Non-physician Clinicians in HIV Service Delivery: Experiences From 47 Sub-Saharan African Countries XVII International AIDS Conference Mexico City, Mexico August 4th , 2008 Seble L. Frehywot MD, MHSA The George Washington University Washington, D.C.

Content Overview of Non-physician Clinicians in Sub-Saharan Africa…ESR Non-physician Clinicians in HIV/AIDS Service delivery……country examples Needed Regulatory Elements in Non-Physician Clinician HIV/AIDS Service delivery Summary - Non-physician Clinicians Promise and Impediments for Scale-up

Overview of Non-Physician Clinicians in SSA Health care providers with post- secondary school training who to most extent can perform the functions of a physician under or in lieu of a physician supervision. Trained in basic diagnosis and medical treatment Deliver a range of personal clinical health services. Basic schooling: Nurse-based or non -nurse based Pre-Service education: Mostly 3 years (ranges from 1( for RNs) to 4 years) Post-basic education (Internship): Mostly 12-18 months Curriculum focused on host country’s indigenous clinical problems & program developed & run by host government Stable placement in rural areas Demonstrated established history of effective clinical care services Cost: $1,200-$4,000/year (tuition and board)

Expanded Service Roles (ESR) Delegation or Supervision Medical Doctor Non-physician Clinicians (e.g. AMO, Clinical Officers, Health Officers) Pre-service training coupled with additional in-service training Regulatory Framework Diagnostic, Prescriptive Authority Expanded Service Roles (ESR) SOP include: Medicine (including HIV AIDS treatment), minor Surgery, Anesthesia, OBGYN (C/S), Orthopedics, Ophthalmology, Dermatology etc.

NPC Presence in SSA 25 SSA countries where NPCs are present Angola Gabon Liberia Senegal Tanzania Burkina Faso Ghana Malawi Seychelles Togo Botswana Guinea Bissau Mauritius Sierra Leone Uganda Cape Verde Kenya Mozambique South Africa Zambia Ethiopia Lesotho Rwanda Sudan Zimbabwe Most common nomenclature: Clinical Officer, Health Officer

Distribution According to the Language Spoken

Expanded Service Role (ESR) in HIV/AIDS Medical Doctor Initiation of staging and diagnosis Extra in-service training given or training included in pre-service program Initiation of ARV prescription Diagnostic and Prescriptive Privileges Regulatory Framework Delegation/ Supervision Expanded Service Role Initiation of OI Prophylaxis Management of cases Country Examples Malawi, Ethiopia, Tanzania, Zambia are building ART strategies around the NPC cadres Non-physician Clinicians (e.g. Clinical Officers, Health Officers)

Enabling Regulations Country Example of Use of Regulations Malawi:- Clinical Officers Ethiopia: Health Officers MOHP: ART guideline was updated for CO to initiate prescription, initiate diagnosis and staging, manage case Regulatory Bodies: Medical and Allied Professional Council registers CO. The Medical Practitioners and Dentists Act, No. 17 of 1987 was amended to allow CO to do ESR and the Pharmacy, Medicine and Poison Board added HIV drugs on the list of drugs that CO can prescribe Training Institutions: Curricula was revised to include HIV/AIDS training. FMOH(FHAPCO): Guideline for Implementation of ARV Therapy was updated for HO to initiate prescription, initiate diagnosis and staging, manage case FMOH (Registration and Licensing Office) HO registered and licensed the same way like doctors. Gives license like the doctor’s for clinical care Training Institutions: Now for the new program (5000 HO training) curricula was revised to include HIV/AIDS training

Recruitment, Deployment, Regulatory Elements Needed to be Addressed by Countries Conducting Expanded Service Role for NPCs Financing & Sub-national implementation Supervision Mentoring & Mentoring Working Conditions Non-physician Clinicians Scope of Practice & Competencies Recruitment, Deployment, Promotion, Salary, & Other HR Issues Standards of Care Standard Pre-Service Education & Training Standard In-Service Training & Certificate Licensing Registration & Certification Regulatory Approaches: Laws/Proclamation, Regulations, Policies, Guidelines

Summary - NPC Promise and Impediments for Scale-Up NPC Impediments Established history & effective presence in many countries Instrumental in addressing the HRH urban/rural maldistribution problems Trained in less time and with less expense than physicians Stable rural placement Less problem with “brain drain” Demonstrated effective role in ART & other clinical services Cost of training and employment Insufficient faculty and infrastructure for training Medical profession resistance in some countries SOURCE: Lancet: Mullan F, Frehywot S. Non-physician Clinicians in 47 Sub-Saharan African countries. June 2007

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