task shifting in malawi around delivery of antiretroviral therapy anthony d harries “the union”...
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Task Shifting in Malawi around delivery of antiretroviral therapy
Anthony D Harries
“The Union”
Paris, France
UK Malawi
Population 60M 13M
Health funding / pa $3,000 $15
Physicians 135,000 270
Nurses 700,000 7,300
Clinical Officers ----------- 2,900
Medical Assistants ----------- 330
PLHIV 70,000 950,000
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
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
Progress Public Sector - Malawi
Month Sites Ever Started on ART
Dec 03 9 3,000 (estimate)
Dec 04 24 13, 183
Dec 05 60 37,840
Dec 06 103 81,821
Dec 07 118 141,449
Dec 08 170 215,449
Standardised quarterly cohort reporting:Public sector Malawi: outcomes by Dec 2008
Started on ART 215,449
Alive on ART (first line ART) 142,218 (96%)
Dead (% in first 3 months) 23,044 (63%)
Lost to follow-up 23,655
Stopped 769
Transferred-out 25,763
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
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
Preparing the sites for ART
The trained clinician and nurse have to train:
1) ART clerk
2) HIV counsellors
3) Pharmacy technicians
All trainings completed
Health facilities formally accredited for ART
ARV drugs distributed and ART delivered to patients
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
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
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
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
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
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 meetingsFinally, written change in policy that was
endorsed by Secretary for Health
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
Health workers running ART clinics in public sector
Dec 06 Jun 07 Dec 07 Jun 08 Dec 08
Number on ART
81,821 110,075 141,449 184,405 215,449
FTE-Clinician 77 91 98 133 142
FTE-Nurse 86 89 107 152 163
FTE-Clerk 64 75 92 129 142
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
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
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
FIGURE. Probability of attrition (deaths, loss to follow up and stopped) at hospital and health centres
0.00
0.20
0.40
0.60
0.80
1.00
Att
ritio
n f
rom
car
e
0 2 4 6 8 10 12 14Time in months since starting ART
Hospital
Health centres
Comparison of ART outcomes in hospital and three health centres, Thyolo, Malawi
Massaquoi et al, Trans Roy Soc Trop Med Hyg, 2009
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
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
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