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

2. UKMalawi Population60M13M Health funding / pa$3,000$15 Physicians135,000270 Nurses700,0007,300 Clinical Officers----------- 2,900 Medical Assistants ----------- 330 PLHIV70,000950,000

3. 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

4. The Key is “Keep it simple”

5. ART Plan (2004-2005): ART Plan (2006-2010): 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

6. Progress Public Sector - Malawi MonthSitesEver Started on ART Dec 0393,000 (estimate) Dec 042413, 183 Dec 056037,840 Dec 0610381,821 Dec 07118141,449 Dec 08170215,449

7. 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

8. The Human Resource Issue

9. 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

10. 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

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

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

13. 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

15. The first two years 2004 - 2005 System worked quite well 60 ART clinics, mainly in hospitals, set up 40,000 PLHIV ever started on ART

16. 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

17. 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

18. 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

19. 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

20. By the end of 2008 Over 215,000 PLHIV ever started on ART 76,000 new patients started in 2008 170 sites in public sector delivering ART 84 (50%) sites = health centres

21. Health workers running ART clinics in public sector Dec 06Jun 07Dec 07Jun 08Dec 08 Number on ART 81,821110,075141,449184,405215,449 FTE-Clinician779198133142 FTE-Nurse8689107152163 FTE-Clerk647592129142

22. 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

23. What is the way forward? Treat, train and retain

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

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