Guidelines

1
Task Shifting and New Cadres

• Vision
• The Context
• WHO's Position
• Evidence
• Recommendations
• Future Directions

2
Our vision

• "We need to ensure access to a motivated, skilled
  and supported health worker by every person, in
  every village, everywhere."

Dr LEE Jong-wook WHO Director-General 2003-2006
3
Our vision. Let's get it right

• Right people
• Right places
• Right competencies and skill mix
• Right resources and support

4
The context
5
Better health outcomes occur when a higher
density of health workers are engaged in care.
Source WHO (2006). The World Health Report 2006
Working Together for Health. Geneva, World
Health Organization
6
The reality critical shortages and poor
distribution of health workers.
57 countries with fewer than 2.5 doctors, nurses
and midwives per 1000 population
Source WHO (2006). The World Health Report 2006
Working Together for Health. Geneva, World
Health Organization
7
Maldistribution within countries creates pockets
of shortages even where there is no crisis.
Urban vs. Rural Distribution of Health Workers
Doctors
Nurses
Others
WHR, 2006
8
Imbalances in competencies or "skill mix"
Number of doctors and nurses in selected countries
WHR, 2006
9
Current and predicted shortages of some cadres in
many countries

• For Example
• Nurses in the USA
• Doctors in Canada
• Nursing and Care Workers in Norway

10
Appearance of "mid-level" or "substitute" cadres

• For Example
• Physician's Assistants in the USA
• Clinical Officers in Zambia
• Medical Assistants in Ghana
• Assistant Medical Officers in Tanzania

11
Need for more investment, resources and support

• For Example
• Few countries in the African Region allocate at
  least 15 of the national budget to health (Abuja
  target)
• Poorly equipped facilities and shortages of
  commodities (e.g. drugs, diagnostic tests)
• Sporadic supervision of staff, especially in
  remote areas
• Limited, long-term investment in pre-service
  education and continuing professional development

12
Partnerships agencies and mechanisms to fight
HIV/AIDS in Tanzania.
http//www.sciencemag.org/cgi/content/full/311/575
8/162/F7, accessed on 20 Feb 200CREDIT J.
COHEN/SCIENCE,
13
The challenges to scale up services for HIV, TB,
and malaria
World Malaria report
Global Plan to stop TB
HIV/UA assessment report

• Inadequate financing
• HR crisis
• Affordable commodities
• Stigma, discrimination
• - Accountability

• Partnership alignment
• Inadequate financing
• Laboratory capacity
• HR crisis
• Quality drugs

• Drug efficacy
• Information system
• Inadequate financing
• HRH and Community services
• - ME

14
Is there a magic bullet?

• NO!

15
Our position
16
A range of strategies is needed

• Strategies to improve, for example
• Retention
• Working conditions
• Education and training
• Recruitment
• Remuneration and incentives
• Regulation
• Investment
• The labour market
• Skill mix (task shifting and new cadres)

17
Working life span
ENTRYPreparing the workforce Planning Educatio
n Recruitment
WORKFORCE PERFORMANCE
WORKFORCE Enhancing worker performance Supervis
ion Compensation Systems support Lifelong learning
Availability Competence Responsiveness Productivit
y
EXITManaging attrition Migration Career
choice Health and safety Retirement
Source WHO (2006). The World Health Report 2006
Working Together for Health. Geneva, World
Health Organization
18
Critical success factors at national level for
scaling up education and training

• Political commitment and good governance
• Sustained government commitment and support
• Collaboration around a country-led health plan
• Significant financial investment
• Health workforce planning
• Commitment to short and long-term health
  workforce planning
• Commitment to produce appropriately-trained
  workers to meet health needs
• Significant expansion of pre-service education
  programmes
• Enabling environment
• Good information systems for health workforce and
  education, with monitoring and evaluation
• Effective management and leadership
• Labour market capacity and policy to absorb and
  sustain additional health workers

19
Evidence
20
Task shifting

• A process whereby specific tasks are moved, where
  appropriate, to health workers with shorter
  training and fewer qualifications.
• The key questions
• Impact on coverage?
• Impact on quality of services?
• Cost-effective?
• Acceptable by service users?

21
First contact with health system for people
living with HIV
22
How confident and satisfied are you with the
services provided by CHWs?
Not satisfied
Fairly satisfied
3
3
28
67
Very satisfied
Extremely satisfied
WHO commissioned study on Task Shifting, Central
Plateau, Haiti
23
Task shifting and HIV counselling and testing
coverage in Ethiopia
1 600 000
Number of people tested for HIV
1,500,000
CHWs performing HIV TC
1 ,000,000
500 000
500,000
436 854
2006
2007
2005
MOH Ethiopia, 2007
24
Ceará's programme of community health agents,
Brazil
1987
1992
1994

• 7,300 CHAs and 235 half-time nurse supervisors
• Served 65 of Ceará's population
• 32 drop in infant mortality
• a substantial increase in exclusive breastfeeding.

National government adopted the Cearà programme
and integrated it into the newly created Family
Health Programme.

• Disaster event gt the government led the
  development of a job-creation programme
• CHAs trained for 3 months
• Providing monthly visits to 50-250 households

Source Macinko et al, 2006
25
Selected child health indicators in Brazil
4 year
3 year
2 year
1 year
Baseline
1 year
3 year
Baseline
2 year
Cesar et al, Social Science and Medicine, 2000
26
Neonatal mortality rate in India
Bang et al., Journal of Perinatology, 2005
27
TB treatment in hospitals and communities
WHO, 2003
28
Cost-effectiveness of task shifting in TB care
WHO, 2003
29
Recommendations
30
Documents leading up to the task shifting
recommendations and guidelines for HIV/AIDS

• 3X5 Report March 06
• Universal Access Assessment Report March 06
• Treat Train and Retain Plan May 2006
• PEPFAR and UNAIDS (on task shifting)

31
Development of the Task Shifting Global
Recommendations and Guidelines for HIV/AIDS

• July 07- Dec 07
• Consultative process
• Identification of the needs/scope
• Development of partnerships and technical
  collaboration
• Review of published and grey literature
• Gathering of expert opinion
• Identification of evidence gaps
• Additional research in countries
• Drafting and review of guidelines and
  recommendations

32
The consultative events
- Geneva, Feb 07 - Kigali, June 07 - Geneva, Sep
07 - Kampala, 1-2 Oct 07 - Geneva, 4-5 Oct 07 -
Ethiopia, 8 Oct 07 - Washington, 10 Oct 07 -
Washington, 11-12 Oct 07 - Geneva, 3 Dec 07 -
Geneva, 4-6 Dec 07
33
The Document www.who.int/healthsystems/task_shift
ing

• Background
• Scope
• Methods
• Recommendations
• Task shifting as public health initiative
• Creating an enabling regulatory environment
• Ensuring quality of care
• Ensuring sustainability
• Organization of clinical care services
• Annexes
• HIV Tasks analysis by cadres
• Definitions
• Implementation
• Evaluation
• Electronic Annexes
• Evidence tables
• Reports of consultations
• WHO commissioned studies

34
Future directions

• WHO Regional Office for Africa is organizing a
  consultation in June 2008 on the adaptation of
  WHO Guidelines on Task Shifting
• WHO is eager to exercise its convening role with
  the Professional Associations and the Health
  Professions Alliance to define changes in health
  professions regulation related with delegation
  and education of new cadres
• Discuss with partners the need for an
  international instrument to tackle with these new
  trends in delegation and education
• To monitor and evaluate existing practices in
  delegation and utilization of new cadres

35
Recommendations on adopting task shifting as a
public health initiative

• Consider when access to health services is
  constrained by health workforce shortages, along
  side other initiatives to increase numbers of
  skilled workers
• Identify appropriate stakeholders who will need
  to be involved from the beginning
• Define a nationally endorsed framework that can
  ensure harmonization and stability of services
• Undertake or update a human resource analysis on
  the current human resources for health, the need
  for services, the gaps in service provision, the
  extent to which task shifting is already taking
  place, and the existing human resource quality
  assurance mechanisms

36
Recommendations on creating an enabling
regulatory environment

• Assess and then consider using existing
  regulatory approaches where possible, or
  undertake revisions as necessary, to enable
  cadres of health workers to practise according to
  an extended scope and to allow the creation of
  new cadres
• Consider adopting a fast-track strategy to
  produce essential revisions to regulatory
  approaches where necessary.

37
The regulatory framework
Working conditions
Supervision Accountability continual
education
Financing Sub- national Implementation
Recruitment, career path
Scope of practice
Health Workers
Standards of care
Standardization of In- service training and
certification
Standardization Of Pre-service training
Licensing and Registration
38
Recommendations on ensuring quality of care

• Adapt existing, or create new, human resource
  quality assurance mechanisms to support task
  shifting.
• Define roles and associated competency levels
  required both for existing cadres that are
  extending their scope of practice, and for newly
  created cadres.
• Adopt a systematic approach to harmonized,
  standardized and competency-based training that
  is needs-driven and accredited.
• Training and continuing education should be tied
  to certification, registration and career
  progression mechanisms.
• Supportive supervision and clinical mentoring
  should be provided to all health workers within
  the structure and functions of health teams.
• Ensure that the performance of all cadres of
  health workers can be assessed against clearly
  defined roles, competency levels and standards.

39
Recommendations on ensuring sustainability

• Consider measures such as financial and/or
  non-financial incentives or other methods as a
  means for retaining and enhancing the performance
  of health workers with new or increased
  responsibilities.
• Recognize that essential health services cannot
  be provided by people working on a voluntary
  basis.
• Ensure that task shifting plans are appropriately
  costs and adequately financed so that the
  services are sustainable.

40
Recommendations on the organization of clinical
care services

• Consider the different types of task shifting
  practice and elect to adopt, adapt or extend
  models that are best suited to the specific
  country situation.
• Ensure that efficient referral systems are in
  place to support the decentralization of service
  delivery in the context of task shifting.
• Non-physician clinicians can safely and
  effectively undertake a majority of clinical
  tasks.
• Nurses and midwives can safely and effectively
  undertake a range of clinical services.
• Community health workers can safely and
  effectively provide specific services, both in a
  health facility and in the community.
• People living with HIV/AIDS, who are not trained
  health workers, can be empowered to take
  responsibility for certain aspects of their own
  care, and the care of others.
• Other cadres, such as pharmacists, laboratory
  technicians and administrators could be included
  in a task shifting approach.

41
Types of task shifting I, II, III, IV
42
Costing Task Shifting I, II
43
Costing Task Shifting I, II, III
44
Cost estimate summary of findings

• Our estimate is that in the 61 countries with the
  highest HIV burden, it will cost a minimum of US
  7-9 billion over the next 10 years to implement
  the Task Shifting approach
• - These estimates correspond to an annual per
  capita cost of 3-7 in the countries concerned,
  representing 10 to 25 of current health
  expenditures typically found in low income
  countries.

45
Workforce shortages are most severe where the
burden of disease is highest.
Source WHO (2006). The World Health Report 2006
Working Together for Health. Geneva, World
Health Organization
46
What do we know today about CHWs programmes?
"Evidence strongly suggests that, particularly
in poor countries, CHW programmes are not an easy
investment, but nonetheless a good one, since the
alternative in reality is no care at all for the
poor living in geographically peripheral areas."
World Health Organization, 2007
47
Our vision. Access plus.

• Access Competence Resources Support
• Positive Health Outcomes