Task shifting: successes from Mozambique and Rwanda

Non-physician clinicians and nurses can take over many of the tasks in providing HIV care and treatment (including ART) in some resource-limited settings according to a number of reports at both the HIV Implementer’s Meeting in Kampala, Uganda and AIDS 2008 in Mexico City — and shifting tasks to them can free up doctors' time, and reduce the impact of HIV/AIDS programmes on the health system as a whole. Several of these studies also reported that the care was at least as good as that provided by doctors — with high client satisfaction.

However, for such task shifting to be sustainable, non-physician clinicians and nurses will need to be adequately compensated for their increased responsibilities, and some of their less usual tasks (paperwork, counselling, etc) will need to be shifted to less highly trained health workers. And such task shifting will not be the cure-all for most countries’ human resource crises — they will still need to train and engage more health care workers of all types.

The human resources for health crisis

There is a global shortage of medical professionals, such as doctors and nurses, that is especially severe in resource-limited settings. Doctors are in particularly high demand — too few are being produced, they take longest to train, and they are the most likely to accept positions for better pay in the private sector or move abroad to work in better resourced countries.

In many countries, doctors are the only cadre of health care workers allowed to prescribe antiretroviral therapy (ART), so the virtual absence of doctors in some areas (especially rural settings in poorer countries) makes it difficult or impossible to provide universal access to ART. Since it takes about seven years to produce new doctors, the only way in underserved areas to save potentially millions of lives is to empower cadres with less training to provide ART.

Non-physician clinicians

Non-physician clinicians go by a variety of names in different places, but “have established a history and effective presence in many countries,” according to Dr Seble Frehywot of George Washington University, who presented a survey at AIDS 2008 on the presence and use of non-physician clinicians in sub-Saharan Africa, with a special focus on how they can be employed in HIV programmes.

In the United States, non-physicians are called physician’s assistants or nurse practitioner, but in resource-limited settings, the most common nomenclature is clinical officer or health officer. Regardless of the name, these non-physician clinicians - healthcare providers with less post-secondary school training than a doctor but more than registered nurses - can to some extent do the work of a physician (sometimes without the supervision of a physician). They are trained in basic diagnosis and medical treatment to deliver a range of personal clinical health services.

Dr Frehywot said that their basic schooling takes one of two forms. Some countries take registered nurses or nurses with four-year degrees and add one or two years more training and then call them either nurse clinicians or nurse practitioners. Other countries take students right out of high school, give them three to four years of training, and an internship of 12 to 18 months. In the end, however, their function is essentially the same as those produced by the nurse model.

However, their curriculum is often defined by the local government, and tailored to the host country’s indigenous clinical needs. Because their training and certification is specific to each country, they cannot easily find positions abroad — and are much less susceptible to brain drain.

In addition, said Dr Frehywot, “we found, that when these clinicians are placed within the rural communities, they stay there.”

As for the cost for a work force comprised of non-physician clinicians, she said it was difficult to calculate in Africa because the data are not available. “What we have found is that mostly the cost ranges from US$1200 to US$4000 per year but this includes only their individual tuition and board.”

Non-physician clinicians are more commonly found in Anglophone Africa, although they do also exist in some French and Portuguese-speaking countries.

For instance, in Mozambique non-physician clinicians are called Tecnicos de Medicina.

“In Mozambique, we have three physicians to 100,000 patients,” said Dr Catherine McKinney of the US Centers for Disease Control speaking at the HIV Implementers' Meeting, “for a population of around 20 million.” She said that the Tecnicos de Medicina were introduced around the time of independence (33 years ago) but quickly took on increased responsibilities. “About 75% of the physicians left the country at the time of independence, so there was no upper echelon of health care, at that time, so clinical officers became the upper echelon,” she said.

This pattern has been repeated throughout sub-Saharan Africa.

Expanding the use of non-physician clinicians in HIV/AIDS

Most recently, Dr Frehewot said, “non-physicians have demonstrated an effective role in HIV and AIDS services,” with some countries such as Malawi, Ethiopia, Tanzania and Zambia building their ART strategies upon these cadres. In general, they are being used to perform HIV disease staging and diagnosis, to initiate preventive medicine for opportunistic infections, and to manage most of the uncomplicated clinical cases. Finally, they can initiate ART.

“But all this requires some kind of regulatory framework,” said Dr Frehywot. In other words, to shift the tasks from doctors to non-physician assistants, a number of changes must be made to the relevant laws/proclamations, regulations, policies, and guidelines in each country.

“There are a quite few things that the countries have to take into consideration,” Dr Frehywot said, including: the scope of practice and competencies for these healthcare workers; standards of care to be provided; the standard pre-service education and training that will be required, along with in-service training and certification; licensing registration and certification; supervision, mentoring and monitoring to make certain a high quality of care is provided; regulations about working conditions, how will they be recruited, deployed, and promoted, what they will be paid and other human resource issues; and finally, sub-national implementation, since many of these workers will be deployed in rural areas.

The same would hold true for shifting these tasks to nurses.

There are some barriers to increasing reliance on non-physician clinicians. “The cost is a still a little bit high and there are insufficient faculties and infrastructure for training these cadres. Finally, in some countries the medical profession shows resistance,” said Dr Frehywot, but she reiterated that non-physician clinicians can provide a high quality of care, and are a cadre of health workers that can be trained and deployed much more quickly than doctors, with a much higher rate of retention.

Tecnicos de Medicina provide high level of HIV service in Mozambique

There are currently only 600 Tecnicos de Medicina (TdMs) in Mozambique, but they prove a disproportionate part in clinical care. “These non-physician clinicians represent an effective strategy given their ease of deployment, longevity at post, shorter training time, more established training capacity, and lower cost for training and maintaining,” said Dr Kenneth Gimbel-Sherr of the University of Washington and Health Alliance International, at another presentation at AIDS 2008.

Dr Gimbel-Sherr said that evidence from US suggests mid-level non-physician clinicians perform as well as or better than MDs (including for HIV care) (Wilson), but that evidence from resource-limited settings was mostly anecdotal.

“This lack of evidence leads to continued reticence among policymakers to allow non-physicians to prescribe ART and provide continued care for patients on ART,” he said. “Much of this reticence centres around concerns about quality of care, and the lack of mentoring and ongoing support provided to NPCs – many of whom work in isolated health facilities.”

So Dr Gimbel-Sherr and colleagues performed a retrospective cohort analysis of outcomes among patients in the ART programme over a 3.5-year period (starting with the initiation of the national ART programme in July 2004) attending two HIV clinics along the Beira corridor in central Mozambique, the area with the highest and most mature epidemic in the country. The study compared outcomes in patients who were attended by TdMs and doctors.

The clinics both have a high patient load, with an average of over 900 new HIV-positive enrollees per month, an average of over 225 patients initiating ART per month, and nearly 5,000 clinical consultations per month across the clinics. There are more doctors (28) than TdMs (14) but the TDMs were more likely to be present in the clinics. So, out of the nearly 6,000 patients included in the analysis, most (69.4%) were treated by TdMs and only 30.6% by doctors. There were no significant differences in baseline characteristics (gender, baseline weight, CD4, clinical stage, etc).

Likewise, the outcomes seemed similar. Those patients seen by TdMs were more likely to be lost to follow-up, but less likely to have died, but these outcomes were again insignificant in the adjusted analysis. However, patients seen by TdMs were significantly more likely to have had a quarterly visit with a clinician for at least three out of four quarters after starting ART — probably because the TdMs were more likely to be present in the HIV clinics— and significantly more likely to have optimal adherence six months after starting ART initiation, as defined by pharmacy records.

The study has a number of considerable limitations. For instance, as one statistician in the audience pointed out, it doesn’t meet the standards of a randomised controlled clinical trial. However, it represents a start in documenting the quality of service that can be provided by supervised non-physician clinicians, which Dr Gimbel-Sherr concluded seems “equivalent to or slightly better than that provided by MDs.” However, he added that “results from large centralised sites with more supervision may not apply to smaller remote sites with less supervision.”

The information should be reassuring to Mozambique, which in 2006 embarked on a plan to produce thousands of TdMs to be deployed by 2010.

Shifting tasks to nurses in Rwanda achieves good results

However, it still takes quite a while to produce this new cadre of health workers, and for most countries to scale up ART programmes quickly, they have to turn to the health staffing resources they have — which is most commonly nurses.

Fortunately, “nurses can effectively perform when optimal conditions are met – and here we talk about good preparation, better tools, and consistent MD support,” said Dr Fabienne Shumbusho of Family Health International speaking at the HIV Implementers' Meeting in Kampala. She described a successful pilot programme in rural Rwanda in which nurses were trained and mentored by MDs to prescribe first-line ART for treatment-naïve adult patients at three primary health centres.

In most of Rwanda, the HIV programme is physician-centred. Doctors perform the physical exams, order CD4 count measurements, prescribe ART and provide follow-up of patients before and after starting ART. Nurses perform a supportive role, including requesting CD4 counting in some sites, and ordering refills of ART.

In the Family Health International pilot project, all the doctor’s primary tasks, except for the management of complex cases (including children) and the provision of mentoring and supervision, were shifted to the nurses who completed a course in HIV care and treatment. The pilot project, which ran from September 2005 to March 2008, included over one thousand patients, 435 of whom were started on ART by nurses.

The outcomes were very similar to what is observed in other settings in Rwanda where care is physician-centred with nearly 88% of alive patients on ART in March 2008, 6.7% dead and less than 3% lost to follow-up —with no cases of stopped treatment. At 18 months the probability of retention in care is 91%, and the median CD4 cell increase at six months was 140 cells, 166 cells at 12 months and 251 cells at 24 months.

The study also evaluated several aspects of nurse performance including:

• Was eligibility for ART correctly determined? Yes, the nurses didn’t put anyone on ART who wasn’t eligible, and only missed 4.2% of cases who should have been started on ART.
• Was the correct ART prescription made? Yes, with no patients put on drugs that were contra-indicated.
• Were ART patients adequately monitored through lab controls and clinical exams? Initially yes, though with longer follow-up, there was a decreasing amount of data.

“At the same time, we found that the level of completeness in this pilot compares favourably with data from a national evaluation conducted in 2004-2005 in Rwanda,” said Dr Shumbusho.

“There is room for improvement,” she concluded, but she recommended that the programme be scaled up nationwide. “We can achieve universal access to AIDS treatment by improving the skills of nurses to their full capacity and potential,” she said.

Task shifting to nurses frees up physician time and reduces impact of HIV programme on general health services

Indeed, a mathematical model presented at both the HIV Implementers’ Meeting and AIDS 2008, Joyce Chung, of the Center of Strategic HIV Operations Research and the Clinton Foundation HIV/AIDS Initiative found that if the nurse task shifting model was scaled up throughout Rwanda, it would dramatically increase the time that the country’s physicians have to tackle more complex cases.

The model included 976 patients from the FHI centres (only those patients enrolled by December last year). The model compared schedules and consultation times at one pilot clinic and one conventional clinic. Details of how the simulation model works can be found in Chung’s extra slides, in her powerpoint presentation on the AIDS 2008 site (use this link to download the presentation)

But overall, between September 2005 and December 2007, prescribing nurses expended a total of 942 hours, saving 737 hours of physician time. “This is equivalent to 6 months of a physician working 30 hours per week”, said Chung, “with one hour worked by a prescribing nurse saving approximately 47 minutes of physician time.”

This freed up time for more complex cases, such as treating children with HIV, and for work in non-HIV areas.

The latter finding is of critical importance because HIV programmes have been accused of stealing time away from general health services. By employing this task-shifting model however, even with ongoing scale-up of ART, Chung calculated that there would be increased physician capacity for the system as a whole.

“If we assume expansion to 59,000 people on treatment at the end of 2008, to deliver care in line with national guidelines would require around 9,300 hours of physician consultation time per month, or roughly 77 physicians providing direct patient care for 30 hours per week,” she said. “Since there are only about 150 physicians providing patient care in the public sector, this means that HIV care and treatment will absorb about 51% of the total physician capacity of the government of Rwanda by the end of this year.  But the application of task shifting nationwide over the course of the year would result in a 78% decrease in physician demand to just 17 physicians working 30 hours per week, or just 11% of the total public physician capacity. The amount of physician capacity available for complicated cases or non-HIV care is 183% higher with task shifting!”

Concerns and caveats

Despite the positive findings reported in the above studies some audience members at each conference expressed concerns that task shifting would be tantamount to second-class care. At the symposium in Mexico City, Dr Frehewot insisted this is not the case.

“If their pre-service training is really beefed up regarding psychology, pathology, medicine, microbiology, then they do give really good service. I can give an example: I’ve been living in the United States for about 15 to 17 years now. When I am sick — and I’m a medical doctor — I don’t like to treat myself. So I go to my family practitioner and most of the time, I see a nurse practitioner.  I’m a medical doctor but I’m seen by a nurse practitioner, which is excellent. Their training and everything is excellent. I have a five-year old daughter and when she has a cold or diarrhoea problem, and we go to a doctor’s office, most of the time we see a nurse practitioner or a physician assistant. We don’t see medical doctors — and this is in the United States,” she said.

Finally, another concern is that shifting these tasks to clinical officers and nurses would lead to over-burdened health workers — and some of their routine tasks “falling off the table.”

“That means, the work that nurses have done previously, is now not going to be done,” said one audience member from Malawi at the Implementers’ Meeting. “It’s really important to realise that task shifting — net gains from task shifting — can only happen if we manage to pull additional bodies into the system  —that’s shifting tasks to non-healthcare professionals who will then start to do HIV services.”

Chung emphasised that her study merely focused on clinician time saved by shifting tasks to nurses. But the model could similarly be used to assess the time saved to nurses by shifting tasks to community-based health workers trained to perform counselling and testing, recording and reporting and other tasks.

Dr Shumbusho stressed that nurses currently spend too much of their time doing paperwork that could be done by less highly trained staff. Thus shifting tasks to them doesn’t necessarily have to result in a heavier burden on them, and many nurses are only too happy to be doing more interesting work that they have, after all, been trained to do: “Nurse are already trained to do clinical examinations — we are not teaching them to do something they have never done.  We are just giving them the tools that will ease their tasks — and we are recognising what they are already doing,” she said.