"Swaziland is dying. Will the last nurse on duty please turn off the lights?" reads a handwritten note at a clinic in Manzini, the country's AIDS-hit commercial centre, 35km southeast of the capital, Mbabane. The wry note disguises the pain of Swaziland's diminishing number of nurses and hints at the reason why their colleagues have fled the country to offer their services elsewhere.
Human Resources
Swaziland nurses flee the HIV/AIDS frontline
The Integrated Regional Information Networks (IRIN), 11 December 2006
Tackling Malawi's human resources crisis
Palmer D: Reproductive Health Matters: 14 (27): 27-39, 2006
In sub-Saharan Africa, health systems are fragile and staffing is grossly inadequate to meet rising health needs. Despite growing international attention, donors have been reluctant to undertake the significant investments required to address the human resources problem comprehensively, given social and political sensitivities, and concerns regarding sustainability of interventions and risks of rising donor dependency. In Malawi in 2004 the government launched a new health initiative to deliver an Essential Health Package, including a major scale-up of HIV and AIDS related services. Improving staffing levels is the single biggest challenge to implementing this approach. Registration (free of charge) with medscape is required to view the article.
Tanzanian lessons in using non-physician clinicians to scale up comprehensive emergency obstetric care in remote and rural areas
Nyamtema AS, Pemba SK, Mbaruku G, Rutasha FD and Roosmalen JV: Human Resources for Health 9(28), 9 November 2011
To address the shortage of healthcare workers providing comprehensive emergency obstetrical care (CEmOC) in Tanzania, an intensive three-month course was developed to train non-physician clinicians for remote health centres. Competency-based curricula for assistant medical officers' (AMOs) training in CEmOC, and for nurses, midwives and clinical officers in anaesthesia and operation theatre etiquette were developed and implemented in Ifakara. A total of 43 care providers from 12 health centres located in 11 rural districts in Tanzania and two from Somalia were trained from June 2009 to April 2010. Of these 14 were AMOs trained in CEmOC and 31 nurse-midwives and clinical officers trained in anaesthesia. The first eight months after introduction of CEmOC services in three health centres resulted in 179 caesarean sections, an increase of institutional deliveries by up to 300%, decreased fresh stillbirth rate and reduced obstetric referrals. There were two maternal deaths, both arriving in a moribund condition. The authors conclude that the training was a success and their model can be used for further training.
Task shifting in Mozambique: Cross-sectional evaluation of non-physician clinicians' performance in HIV/AIDS care
Brentlinger PE, Assan A, Mudender F, Ghee AE, Torres JV, Martínez PM et al: Human Resources for Health 8(23), 12 October 2010
In 2007, the Mozambican Ministry of Health (MoH) conducted a nationwide evaluation of the quality of care delivered by non-physician clinicians (técnicos de medicina, or TMs), after a two-week in-service training course emphasising antiretroviral therapy (ART). Forty-four randomly selected TMs were directly observed by expert clinicians as they cared for HIV-infected patients in their usual worksites. Observed clinical performance was compared to national norms as taught in the course. In 127 directly observed patient encounters, TMs assigned the correct WHO clinical stage in 37.6%, and correctly managed co-trimoxazole prophylaxis in 71.6% and ART in 75.5%. Correct management of all five main aspects of patient care (staging, co-trimoxazole, ART, opportunistic infections, and adverse drug reactions) was observed in 10.6% of encounters. The observed clinical errors were heterogeneous. Common errors included assignment of clinical stage before completing the relevant patient evaluation, and initiation or continuation of co-trimoxazole or ART without indications or when contraindicated. In Mozambique, the in-service ART training was suspended. The MoH subsequently revised the TMs' scope of work in HIV/AIDS care, defined new clinical guidelines, and initiated a nationwide re-training and clinical mentoring program for these health professionals. Further research is required to define clinically effective methods of health-worker training to support HIV and AIDS care in Mozambique and similarly resource-constrained environments.
Task shifting of antiretroviral treatment from doctors to primary-care nurses in South Africa (STRETCH): A pragmatic, parallel, cluster-randomised trial
Fairall L, Bachmann MO, Lombard C, Timmerman V, Uebel K, Zwarenstein M et al: The Lancet 380(9845): 889-898, 8 September 2012
The authors of this study aimed to assess the effects on mortality, viral suppression, and other health outcomes and quality indicators of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) programme, which provides educational outreach training of nurses to initiate and represcribe ART, and to decentralise care. They undertook a pragmatic, parallel, cluster-randomised trial in South Africa between 28 January 2008 and 30 June 2010, randomly assigning 31 primary-care ART clinics to implement the STRETCH programme (intervention group) or to continue with standard care (control group). A total of 5,390 patients in cohort 1 and 3,029 in cohort 2 were in the intervention group, and 3,862 in cohort 1 and 3,202 in cohort 2 were in the control group. Median follow-up was 16.3 months in cohort 1 and 18 months in cohort 2. In cohort 1, 20% of patients analysed in the intervention group and 19% of patients in the control group with known vital status had died at the end of the trial. Time to death did not differ. In a preplanned subgroup analysis of patients with baseline CD4 counts of 201-350 cells per μL, mortality was slightly lower in the intervention group than in the control group, but it did not differ between groups in patients with baseline CD4 of 200 cells per μL or less. In cohort 2, viral load suppression 12 months after enrolment was equivalent in intervention (71%) and control groups (70%). Interpretation suggests that expansion of primary-care nurses' roles to include ART initiation and represcription can be done safely, and improve health outcomes and quality of care, but might not reduce time to ART or mortality.
Task shifting routine inpatient pediatric HIV testing improves program outcomes in urban Malawi: A retrospective observational study
McCollum ED, Preidis GA, Kabue MM, Singogo EBM and Mwansambo C et al: Public Library of Science ONE 5(3), 10 March 2010
This study evaluated two models of routine HIV testing of hospitalised children in a high HIV-prevalence resource-constrained African setting. Both models incorporated task shifting, namely the allocation of tasks to the least-costly, capable health worker. Two models were piloted for three months each within the paediatric department of a referral hospital in Lilongwe, Malawi between January 1 and June 30, 2008. Model 1 utilised lay counsellors for HIV testing instead of nurses and clinicians, while Model 2 further shifted programme flow and advocacy responsibilities from counsellors to volunteer parents of HIV-infected children, called 'patient escorts'. The strategy presented here in the two models, namely task shifting from lay counsellors alone to lay counsellors and patient escorts, was found to improve programme outcomes greatly, while only marginally increasing operational costs. The wider implementation of this strategy could accelerate paediatric HIV care access in high-prevalence settings.
Task-shifting and prioritization: A situational analysis examining the role and experiences of community health workers in Malawi
Smith S, Deveridge A, Berman J, Negin J, Mwambene N, Chingaipe E, Puchalski-Ritchie L, Martiniuk A: Human Resources for Health 12:24, 2014
The objective of this study was to understand the performed versus documented roles of the HSAs, to examine how tasks were prioritized, and to understand HSAs’ perspectives on their roles and responsibilities. A situational analysis of the HSA cadre and its contribution to the delivery of health services in Zomba district, Malawi was conducted. Focus groups and interviews were conducted with 70 HSAs. Observations of three HSAs performing duties and work diaries from five HSAs were collected. Lastly, six policy-maker and seven HSA supervisor interviews and a document review were used to further understand the cadre’s role and to triangulate collected data. HSAs performed a variety of tasks in addition to those outlined in the job description resulting in issues of overloading, specialization and competing demands existing in the context of task-shifting and prioritization. Not all HSAs were resistant to the expansion of their role despite role confusion and HSAs feeling they lacked adequate training, remuneration and supervision. HSAs also said that increasing workload was making completing their primary duties challenging. Considerations for policy-makers include the division of roles of HSAs in prevention versus curative care; community versus centre-based activities; and the potential specialization of HSAs. This study provides insights into HSAs’ perceptions of their work, their expanding role and their willingness to change the scope of their practice. There are clear decision points for policy-makers regarding future direction in policy and planning in order to maximize the cadre’s effectiveness in addressing the country’s health priorities.
Task-shifting HIV counselling and testing services in Zambia: The role of lay counsellors
Sanjana P, Torpey K, Schwarzwalder A, Simumba C, Kasonde P, Nyirenda L, Kapanda P, Kakungu-Simpungwe M, Kabaso M and Thompson C: Human Resources for Health 7, 2 March 2009
This study was conducted to review the effectiveness of lay counsellors in addressing staff shortages and the provision of HIV counselling and testing services. Quantitative and qualitative data were collected by means of semistructured interviews from all active lay counsellors in each of the facilities, including a facility manager or counselling supervisor, and through focus group discussions with health care workers at each facility. The study found that lay counsellors provide counselling and testing services of quality and relieve the workload of overstretched health care workers, providing up to 70% of counselling and testing services at health facilities. The data review revealed lower error rates for lay counsellors, compared to health care workers, in completing the counselling and testing registers.
Task-shifting to community health workers: Evaluation of the performance of a peer-led model in an antiretroviral programme in Uganda
Alamo S, Wabwire-Mangen F, Kenneth E, Sunday P, Laga M and Colebunders RL: AIDS Patient Care and STDs 26(2) : 101-107, February 2012
In this study, researchers examined the performance of community antiretroviral therapy and tuberculosis treatment supporters (CATTS) in scaling up antiretroviral therapy (ART) in Reach Out, a community-based ART program in Uganda. Retrospective data on home visits made by CATTS were analysed to examine the CATTS ability to perform home visits to patients based on the model's standard procedures. Qualitative interviews conducted with 347 randomly selected patients and 47 CATTS explored their satisfaction with the model. The CATTS ability to follow-up with patients worsened from patients requiring daily, weekly, monthly, to three-monthly home visits. Only 26% and 15% of them correctly home visited patients with drug side effects and a missed clinic appointment, respectively. Additionally, 83% visited stable pre-ART and ART patients (96%) more frequently than required. Six hundred eighty of the 3,650 (18%) patients were lost to follow-up (LTFU) during the study period. Ninety-two percent of the CATTS felt the model could be improved by reducing the workload. In conclusion, the Reach-Out CHW model may be too labour-intensive. Triaged home visits could improve performance and allow CATTS time to focus on patients requiring more intensive follow-up.
TB control and the health workforce
The performance of health care systems is closely related to the numbers, distribution, knowledge, skills and motivation of its workforce, particularly of those individuals delivering the services, says an article in the journal Human Resources for Health. "Improvements in global health are greatly dependent on how well health systems can meet the demands placed on them by governments, programmes, communities and ultimately individuals. Human resources for health (HRH)... constitute a sine qua non of health systems. Therefore, developing HRH and fostering appropriate HR management are crucial steps towards achieving and sustaining improved and equitable health."