1. Task shifting & HRH Crisis: field experience and current thinking within MSF Mit Philips, Médecins Sans Frontières, Brussels. WHO satelite conference, Kigali June 2007

2. MSF & HRH crisis Not new –Post conflict –Weak public health services ART & AIDS care Two pronged approach –Reduce HRH-intensive workload –Retention & reduce turnover Operations & policy dialogue

3. 4 country report: **Retention central** Question limitations in policy, remuneration & resources allocation

4. Task shifting: one of the measures to reduce HRH-needs for ART Simplification Standardisation Classification patients according clinical needs ‘Streamlining’ Two variations with different implications: –Within profesional staff (medical/ within health system) –Towards lay workers

5. Task shifting necessary HRH gap enormous –National averages underestimate problem –Turn-over high & less experienced staff –AIDS care reinforcement disfavouring PHC HRH gap affecting scale up AIDS care –Patient load increasing: follow-up +++ –Decentralisation: major understaffing periferal health centres & rural areas –Integration: mission impossible without HRH –Most affected: ART initiation > follow up Perspectives for solutions: ?

6. Kayalitsha, South Africa: initiation bottleneck

7. Lesotho: estimated need of nurses for ART over next years

8. Mozambique perspectives WHO standard 75% of WHO standard 50 % of WHO standard

9. Task shifting necessary, but…. Not always easily accepted –Legislation, corporate institutions, ‘insecurity’ Concerns of quality –Need for close supervision –Specialised/polyvalent (integration) Policy concerns –No excuse: still need sufficient qualified staff –Salary of extra workers? On budget?- caps? –Lay workers: in/outside health system? In/off budget?

10. Some positive results Feasibility: yes But… reversibility (Lusikisiki) Results –Overcome bottlenecks –Outcomes at patient level

11. Lusikisiki, South Africa: nurse based ART care in health centres

12. Lusikisiki reversed nurse-based

13. Malawi, Thyolo district Vacant positions: Nursing staff 64% Clinical officers 53% Doctors / Specialists 85-100% Nurse/health facility < 1.5 nurses per health facility in 15/29 districts Doctors/district 10 districts with no MOH doctor. 4 districts have no doctor at all ART Target: 10,000 (+-1000) On ART 5,613 (Dec 2006) ART initiations/Month 400 Initial perspective: target by 2012; with task shifting achieved Nov 2007 Health facilities:  flow tracks” (Nurses/ PLWA’s) Community:  “Group/individual counselling” close to homes (PLWA/“Expert patients”/Community nurses)

14. Task shifting within clinics and beyond Clinics: from “One track” doctor centred to “multiple flow tracks” Screening & track allocation - Nurse. Slow track - Medical assistant Complicated opportunistic infections (OI) Side effects/referred patients Medium track - Nurse Less severe OI (eg candida, diarrhoea) ART initiation /ART follow up (< 1month) Fast track - PLWA counsellor Stable patients & drug refills Doctor/Clinical officer – Supervision and support

15. Community network: Volunteers & PLWA’s –Treatment : diarrhoea, fever, oral thrush…. –Adherence counselling (Cotrimoxazole, TB, ART) –Support to family care givers at home –Referral : drug reactions and “risk signs”. –Cough screening (TB) –Social mobilisation. –Further? Community based drug supply & screening for problems in stable ART patients

16. Counselling & Testing: Average/Month in Thyolo, Malawi “Task shifting” : Nurses to PLWA’s Task shifting increased CT capacity by 5 times

17. Thyolo, Malawi: Number of consultations per month (2 main hospital sites) Partial task shifting to medical assistants Task shifting to medical assistants, nurses & PLWA’s Three health centres ++

18. Thyolo, Malawi: New ART- inclusions per month Three health centres ++ “Partial” task shifting to medical assistants Task shifting to medical assistants, nurses & PLWA’s Task shifting increased ART inclusion capacity by 4 times

19. ART & community support Period Jan 2003-Dec 2004 Total placed on ART 1634 Community care Community care YES NO Placed on ART (n-1634) 895 739 Alive & on ART 856 (96%) 560 (76%) P<0.001 Died 31 (3.5%) 115 (15.5%) P<0.001 Loss to follow up 1 (0.1%) 39 (5.2%) P<0.001 Stopped 7 (0.8%) 25 (3.3%) P<0.001 Relative Risk: 1,26 [1,21-1,32] 0,22 [0,15-0,33] 0.02 [0 - 0.12] 0.23 [0.08 - 0.54]

20. Others Mozambique: problems in policy environment –Counselling by nurses who are already overloaded –PMTCT: Initiation versus regularity –Request tests by MD or TM only: bottleneck Burkina Faso: –Towards patient groups and associations –Drug supply also in community? –Not a high prevalence context Lesotho: –Nurse based but shortage of nurses –PLWAs within HC and in community –Tb: difficult; TB-HIV trainer’s booklet –Cost analysis

21. Task shifting not a panacea Inventory/clarification within MSF projects –What objectives? –Where? High prevalence context only? –What degree? What tasks? Within medical staff? Lay workers? –Tools for analysis, training, method Documentation/ analysis –outcomes/outputs (programmatic/patients) –safety Lay workers: Short term- long term policy?

22. Thank you