1. 1 WHO / OGAC In-country: MoH & WHO Academic Institutions: Institute of Tropical Medicine, Antwerp, Belgium Partners in Health / Harvard Medical School Task Shifting “Clinical Mapping” Multi-country study

2. 2 Approach Desk work: –Previous experiences with « delegation of clinical tasks to non-doctors » in Primary Health Care programs (mainly 1980s) –Conceptualisation of task shifting –Tools for field visits Field visits: to document experiences with innovative provider cadres in HIV care: Malawi, Uganda, Ethiopia, Haiti & Rwanda

3. 3 Results from desk work  Framework  Types of task shifting  Evaluations done  Conditions for successful task shifting

4. 4 Professional level Mid-levelAuxiliaryWithout diploma (=Lay persons) Kind of “diploma”  Disciplines ↓ University degreeDiploma from School of Health Sciences Certificate from nursing school (or equivalent) Trained on-the-job, or through a short course (<1 year?) Clinical staff Nursing staff Pharmacy / dispensing Laboratory Educator / counsellor

5. 5 Universal Professional level Mid-levelAuxiliaryWithout diploma (=Lay persons) Kind of “diploma”  Disciplines ↓ University degreeDiploma from School of Health Sciences Certificate from nursing school (or equivalent) Trained on-the-job, or through a short course (<1 year?) Clinical staffMedical doctor Nursing staffRegistered nurse Enrolled nurse Pharmacy / dispensing Pharmacist LaboratoryLab technician Educator / counsellor

6. 6 Malawi Professional level Mid-levelAuxiliaryWithout diploma (=Lay persons) Kind of “diploma”  University degreeDiploma from School of Health Sciences Certificate from nursing school (or equivalent) Trained on-the-job, or through a short course (<1 year?) Clinical staffMedical doctorClinical officer Medical assistant (Lay provider) Nursing staffNurse with university degree Registered nurse Enrolled nurseNurse aid Pharmacy / dispensing PharmacistPharmacy technician Pharmacy assistant LaboratoryLaboratory technician Laboratory assistant Person trained on-the-job Educator / counsellor Counsellor with relevant university degree Lay counsellor

7. 7 4 main types of task shifting Type I: from doctors to non-physician clinicians (clinical officers, medical assistants, physician-assistants, nurse-practitioners, …) Type II: from clinicians to nurses Type III: … to nursing aids, lay providers (including counsellors), community health workers Type IV: self-management by PLHAs

8. 8 Type III Need to further separate Type III: –Depending on prior diploma: range: university graduates – primary school –Counsellors, becoming a new professional group –Nursing tasks –Clinical tasks = Lay providers, including « expert patients »

9. 9 Professional level Mid-levelAuxiliaryWithout diploma in health (=Lay persons) Clinical staffMedical doctorClinical officer Medical assistant Lay provider Nursing staffNurse with university degree Registered nurse Enrolled nurse Nurse aid Educator / counsellor Counsellor with relevant university degree Lay counsellor Type I Type II Type III

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11. 11 Prior experience? Type I: non-physician clinicians in primary health care (PHC) Type II: = happening in many (peripheral) places Type III: –Community health workers = lay providers –Counsellors = quite new to HIV/AIDS –Expert patients = quite new… Type IV: self-management (diabetes &c)

12. 12 Evaluations of task shifting Non-physician clinicians = very positive Community health workers (study UWC) can work « under certain conditions! » Still less firm evidence for recent innovations e.g. –« Nurse-based ART delivery » –« Expert patients »

13. 13 Task shifting: 4 basic conditions Initial training –Basic diploma –Specific pre-service training Guidelines / protocoles (simplification) Continuing education –Supervision –Coaching –Refresher courses Remuneration / career structure

14. 14 Multi-country study Main objective: documenting ‘best practices’ in task shifting for clinical HIV care In each country: –Inventory of all types of health cadre + training –General information on HIV, health system, HRH, AIDS programme, … –Selection of ART delivery sites: ‘best practices’ (+ ‘routine practices’)

15. 15 Field visits to ART sites Questionnaires: For different cadre: detailed documentation of which cadre is actually performing which tasks (mainly interview, some observation) For each facility: –info on patients, on outcomes, … –Inventory of staff + FTE for ART

16. 16 Expected results? Detailed insight in task shifting: –Which tasks? by whom? –Consistent? –Priorities? Workload (FTE staff) for ART Conditions for enabling task shifting Outcomes? (with task shifting)

17. 17 « Bonus » material

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