Coping with health worker shortages: lessons and limits
© Gideon Mendel
Task-shifting: a delicate balance
Task-shifting has been used by governments and NGOs as a coping mechanism in the face of shortages and unequal distribution of professional health care workers. Results from MSF and other programmes that rely heavily on taskshifting demonstrate satisfactory outcomes for patients.24
Lay counsellors, especially people living with HIV/AIDS, have helped to improve uptake of HIV testing and counselling, ART adherence support, and treatment literacy. Shifting of these and other tasks (from nurses to counsellors) is essential to getting more people on ART sooner. But task-shifting is not a panacea.
People accessing ART often suffer from complicated medical conditions that may require management by skilled nurses or doctors. These can include diagnosis of smear-negative and extra-pulmonary TB, inpatient care of severe opportunistic infections, management of ARV sideeffects and drug interactions, and provision of care for specific groups such as children.
Task-shifting for rapid scale-up must be balanced against the need to provide quality care and should not become an alibi for accepting shortages of skilled staff.
Donors are quick to support initiatives involving lay health workers, but often refuse to fund measures to recruit and retain health professionals. Ultimately, chronic shortages of health workers can only be addressed with increased production and retention of health staff, and this requires mobilisation of national and international resources.
In order to expand access to HIV/AIDS treatment, MSF teams have simplified and decentralised HIV care, particularly in rural areas. Simplification has included use of fixed-dose combinations, reduced reliance on laboratory monitoring, and simplified approaches to care.18 Decentralisation has meant moving care from hospitals to primary health care clinics and community health outposts. Through decentralisation, access to ART is increased both by reducing bottlenecks in central facilities and bringing care closer to people who need treatment.
National policies (government and professional councils) play a determining role in the extent to which strategies to decentralise care can be implemented. Whether or not a government will allow nurses to initiate and prescribe ARVs, for example, determines the pace of decentralisation and scale-up of ART.
The sections below summarise strategies used by MSF teams and local partners to overcome human resource constraints and describe some of the main barriers and dilemmas faced in the process.
Hiring supplemental staff
In southern Africa, expanding access to ART to ensure "universal access" will be virtually impossible with the existing number of health workers. As an international organisation, MSF is able to bring external resources to address health and humanitarian emergencies. However, MSF is an interim actor, filling gaps and supporting local authorities and organisations to take full responsibility for programmes.
In Thyolo district in Malawi, MSF has been working with the government to reach more than 10,000 people on ART by the end of 2007. To reinforce the Ministry of Health staff, MSF has employed 11 clinical officers, 48 nurses, and three medical assistants in addition to two expatriate doctors, three nurses, and one lab technician.
The hiring of local staff by international NGOs, including MSF, can inadvertently add to human resource shortages, and has to be managed carefully to avoid unfair competition for scarce health care workers. Furthermore, while NGOs can overcome institutional barriers in the short-term because they can hire and pay their own staff, these additional staff cannot always be absorbed into the public sector. This is especially problematic in countries facing "wage bill caps" which limit the number of people that can be employed in the civil service.
Task-shifting means re-allocating tasks between available staff. For example, doctors focus on providing care at hospitals for inpatients and complicated cases as well as supervising clinics via mobile teams rather than handling all clinical management of patients; nurses assess patients to diagnose and treat opportunistic infections and initiate and monitor ART rather than exclusively supporting doctors; while lay workers provide testing and counselling, ART adherence support, and assist with general clinic support.
In Lusikisiki, shifting the task of initiating ART to nurses has been central to achieving high coverage. This approach was considered by some as a radical divergence from accepted norms, but, at the provincial level there was an understanding that decentralisation would have failed without these changes. In April 2006, the Department of Health passed instructions to the clinics insisting that ART initiation must be done by doctors. This resulted in bottlenecks and fewer people being treated every month (see graph). Confronted with this negative trend, the Eastern Cape Department of Health reversed the decision six months later. Now nurse-initiated ART has been recognised at the national level as key to scaling up treatment.22
Task-shifting is often limited by national policies and those of professional medical or nursing councils; sometimes the issue is more a matter of how policies are interpreted than what they actually allow. In South Africa, for example, nothing in national rules prevents nurses from initiating and prescribing ARVs,23 but there is a great deal of confusion surrounding this among ARV site managers. In many sites initiating and prescribing ARVs is limited to doctors, creating unnecessary bottlenecks.
There is considerable divergence between countries regarding what tasks can be performed by whom. Governments and relevant professional councils will need to clarify, and in some cases reverse, policies that hinder task-shifting, to ensure that health care workers, managers, and supervisors all receive explicit guidance. Furthermore, task-shifting alone is not enough. Significant increases in responsibility and workload must be accompanied by appropriate salary increases and access to training and career advancement opportunities.
"Last year, my brother took me on a horse to the clinic because I was too sick to walk. Now I am on ARVs and I take my tablets every day. Since September 2006, I have been a lay counsellor. My role here is to give counselling to all HIV-positive people and teach patients about the importance of adherence. My other crucial role is that of being a drug dispenser, especially for ARVs. I think my job is very important and it reduces the heavy workload on the nurses."
- Joseph Ramokoatsi, 35, Lay Counsellor, St Rodrique Health Centre, Lesotho
Creating new capacity
MSF's efforts to scale up HIV/AIDS treatment have relied heavily upon mobilising new categories of health workers, particularly "lay" counsellors and community-based "volunteers." Lay/community workers have become the backbone of most programmes profiled in this report and scale up could not be achieved without them. As such, they must be recognised and compensated properly over the longterm either within the health system or outside of it.
Facility-based lay counsellors
In Lesotho, MSF has trained nearly 40 "HIV/TB lay counsellors" to work at the district hospital and health centres it supports. Lay counsellors provide HIV testing and counselling, ART counselling and adherence support, as well as general clinic support. These counsellors are also being trained to provide TB treatment education and adherence counselling.
The increase from approximately 100 people tested per month to more than 500 in June is a direct result of the introduction of lay counsellors at Scott Hospital and the four busiest clinics. The second increase in September - a doubling of the number of people tested - reflects the introduction of lay counsellors at eight additional clinics (see graph).
At present, financing for the lay counsellors is subsidised by MSF and administered by Scott Hospital, but discussions are underway for the Ministry of Health and Social Welfare to accredit and compensate lay counsellors as a new cadre of the health system. But there are concerns about what salary they will be able to offer and whether new civil service posts can be created.
In Mozambique, MSF and other NGOs have advocated for the creation of a polyvalent counsellor/educator to provide HIV and other rapid tests, TB and ART adherence counselling, nutrition and hygiene counselling, and range of other, non-HIV tasks. After lengthy negotiations, the Ministry of Health accepted the concept of a polyvalent counsellor/educator, but has insisted these tasks be done by nurses due to concerns about scope of practice. This defeats the purpose of reducing the workload of professional medical staff.
In Malawi and elsewhere, community-based workers - whether volunteer or paid - are highly motivated and have come to play an essential role in supporting service delivery and increasing general awareness about HIV prevention and treatment and, importantly, promoting openness about HIV.
In Thyolo, Malawi, community home-based caregivers are volunteers chosen by their village. There are 600 such volunteers working with the programme in Thyolo district alone. In the past several years, their work has been transformed from providing end-of-life care to assisting community nurses with diagnosis and management of common HIV-related conditions, preparing and supporting people on ART, and tracing defaulters, among other tasks (see table). Clinical outcomes in Thyolo have been shown to be better when community caregivers are involved in the provision of services.25
In Chiradzulu, Malawi, MSF is piloting the use of "community ARV dispensers" to provide ARV refills to stable patients.