Task Shifting in Malawi around delivery of antiretroviral therapy Anthony D Harries “The Union” Paris, France

UKMalawi Population60M13M Health funding / pa$3,000$15 Physicians135, Nurses700,0007,300 Clinical Officers ,900 Medical Assistants PLHIV70,000950,000

The “medicalised model” in Malawi Doctors to deliver ARV treatment Choice of multiple ARV regimens Mandatory laboratory monitoring “ LFTs, FBC, CD4-counts” will preclude massive scale up of ART

The Key is “Keep it simple”

ART Plan ( ): ART Plan ( ): main elements for the public sector Facilities selected and accredited for scale up Free ART to HIV-positive eligible patients One first-line ART regimen only “Triomune” ART delivery by clinical officers and nurses Standardized system of monitoring/reporting Quarterly structured supervision

Progress Public Sector - Malawi MonthSitesEver Started on ART Dec 0393,000 (estimate) Dec , 183 Dec ,840 Dec ,821 Dec ,449 Dec ,449

Standardised quarterly cohort reporting: Public sector Malawi: outcomes by Dec 2008 Started on ART215,449 Alive on ART (first line ART)142,218 (96%) Dead (% in first 3 months)23,044 (63%) Lost to follow-up23,655 Stopped769 Transferred-out25,763

The Human Resource Issue

2003 ART Guidelines: Doctors and Clinical Officers can initiate ART Nurses and Medical Assistants can follow-up patients PROVIDED They attend the national ART training course And pass the end of course examination with marks of 70% or more

Data Base HIV Department maintains an up-to-date data base on all health care workers formally trained and certified in ART This date base sent to the Medical Council of Malawi and Nursing and Midwives Council of Malawi

Preparing the sites for ART The trained clinician and nurse have to train: 1)ART clerk 2)HIV counsellors 3)Pharmacy technicians

All trainings completed Health facilities formally accredited for ART ARV drugs distributed and ART delivered to patients

Quarterly supervision and mentorship HIV Department and partners provide quarterly supervision with a focus on data validation, cohort analysis and drug stocks Clinical supervisors provide quarterly mentorship with a focus on diagnosis of disease, clinical staging, side effects of ART

The first two years System worked quite well 60 ART clinics, mainly in hospitals, set up 40,000 PLHIV ever started on ART

BUT observations and challenges:- As patient numbers increased, nurses took over a larger role in running ART clinics A strong relationship between good ART clinics and good ART clerks Better patient access and follow-up required decentralisation to health centres where often there were no clinical officers

The new ART Plan: 2006 – 2010: to increase ART access to 250,000 by 2010 Reduce the burden of work in hospitals: Reduce follow-up frequency to 2 or 3-months Decentralise ART follow-up to health centres Decentralise ART initiation to health centres Task shift

ART Guidelines and Human Resources ART Guidelines 2006: Doctors, clinical officers and medical assistants can initiate ART ART Guidelines 2008: Doctors, clinical officers, medical assistants and nurses can initiate ART

The battle was to get nurses approved to initiate ART Nurses and Midwives Council in favour Medical Council not in favour  Negotiations between HIV Department and Medical Council  National stakeholders meetings  Finally, written change in policy that was endorsed by Secretary for Health

By the end of 2008 Over 215,000 PLHIV ever started on ART 76,000 new patients started in sites in public sector delivering ART 84 (50%) sites = health centres

Health workers running ART clinics in public sector Dec 06Jun 07Dec 07Jun 08Dec 08 Number on ART 81,821110,075141,449184,405215,449 FTE-Clinician FTE-Nurse FTE-Clerk

If Malawi continues to increase PLHIV on ART by 75,000 per annum By 2015 (MDG) the country may have 750,000 patients ever started on ART This may require 500 FTE clinicians and 500 FTE nurses to just man ART clinics

What is the way forward? Treat, train and retain

1. Simple ART Delivery Continue to run a simple model of ART delivery and resist calls for a more sophisticated model Focus outcomes on the numbers retained on ART stratified by type of ART regimen

2. Ensure decentralisation is matched with quality delivery Compare performance of health centres against hospitals Compare performance of purely nurse run clinics against clinician-run clinics

FIGURE. Probability of attrition (deaths, loss to follow up and stopped) at hospital and health centres Comparison of ART outcomes in hospital and three health centres, Thyolo, Malawi Massaquoi et al, Trans Roy Soc Trop Med Hyg, 2009

3. Increase the number of ART clerks Recruit from secondary school Formally establish position of ART clerk with clearly defined tasks Emphasise the central importance of data integrity and analysis

4. Consider task shifting to lower levels of health worker Health surveillance assistants: (10-weeks training in general preventive activities such as vaccination and hygiene) In 2006, 3,800 in health sector. GFATM funds to increase this cadre over next 5 years

But, need to assess whether Health Surveillance Assistants can follow up patients on ART One study in Lighthouse, Lilongwe, in 2007 showed that this cadre would miss important and life-threatening side effects

CONCLUSION Human resource issues are crucial for the long-term sustainability of ART delivery Innovative solutions and clear political commitment to establish new positions