Task Shifting: Is it Working in Mozambique?
In many parts of the developing world, a shortage of health workers is one of the key factors preventing millions of people from being able to access health care. The WHO estimates that an additional 4.3 million health workers are needed to meet the health-related Millenium Development Goals by 2015.
The HIV/AIDS epidemic has increased the burden on health systems that were already inadequate, and has particularly highlighted the lack of health workforce as a bottleneck to scaling up care. With 33 million people estimated to have HIV, and only about 30% receiving treatment, we have a long way to go in reaching everyone and turning the tide of this disease.
Barriers to Staffing Up
Many countries are looking for ways to scale up their health workforce, but are faced with financing challenges due to macroeconomic policies that limit how much governments can spend to train and hire health workers.
In addition, recipient country governments have little flexibility or predictability in international aid flows to allow them to invest in long-term health worker education or recurrent costs like salaries. In the meantime, health workers migrate either to other countries or to the private sector (including NGOs) within their own country to find higher-paying work. This brain drain results in a loss of institutional knowledge and further erodes morale and capacity in the public sector.
The WHO recommends a focus on a strategy of "treat, train and retain" for health workers: help prevent and treat HIV infection of health workers, provide training for health workers, and develop policies and incentives to retain workers. While this strategy will hopefully expand the health workforce in the longer term, countries with high rates of disease need a faster solution so they can scale up services now.
The Potential of "Task Shifting"
According to the WHO, task shifting is "the rational redistribution of tasks among health workforce teams." This means delegating certain activities from the limited numbers of higher-level health workers such as physicians, to lower-level positions or "cadres." These cadres are potentially valuable for several reasons:
- they require less training and less pay, so it costs the government less to train and hire them;
- there are more training facilities able to train at this level than there are medical schools, so more workers can be produced each year;
- they are often more willing to work in rural areas where physicians may not want to go; and
- their qualifications are not as transferable outside of their country, making brain drain less likely.
The reliance on non-physician cadres expanded rapidly in the 1970s with the push for Primary Health Care, though there has been little uniformity in their training, regulation or titles (health officer, clinical officer, physician assistant, to name a few). The WHO emphasizes that task shifting is just one part of a health workforce strategy and should not substitute for efforts to scale up all levels of health workers.
Has Task Shifting Worked in Mozambique?
Mozambique has had a non-physician clinician cadre, called técnicos de medicina, since the mid-1970s, but the government dramatically expanded training when it began to roll out a national AIDS treatment plan. Numbers of trainees increased rapidly around 2004, and in 2006 the government provided trainings for most existing técnicos on HIV and antiretroviral therapy, or ART. HAI provided mentoring and on-site supervision support after the trainings to make sure staff could put new learnings into practice.
In a country that only graduates 75 doctors per year, these técnicos de medicina have played an important role in scaling up HIV services. In the first year that the técnicos were able to prescribe ART (2006), the number of facilities providing ART services quadrupled, so that every district in the country had a place to access ART. As of the end of 2008, almost 130,000 HIV-positive Mozambicans were receiving care, about one-third of those who are eligible.
Técnicos had clearly improved access to ART, but the question remained as to whether they provided the same quality of care as physicians in the same roles. Existing positive research from high-income countries wasn't necessarily relevant to lower-income settings.
HAI's Technical Advisor for Implementation Research, Kenneth Sherr, is just completing research into the quality question to help the Mozambican Ministry of Health determine how to adjust human resources policies in support of expanding HIV care.
The study looks at patient records from 2004 to 2007 in two provinces in central Mozambique with the highest adult rate of HIV (25-29%). The patient data were grouped by patient's initial provider-those seen by physicians and those seen by técnicos-and then also grouped by characteristics of their provider that likely influence quality of care: provider's sex (male/female), days of HIV training, years of service in the Mozambican health service, and number of clinical consults at the HIV clinic (which indicated experience with HIV care). To determine care quality, patient records were evaluated for care processes, such as whether a CD4 cell count was evaluated at 90-210 days after starting ART, and patient adherence to the ART regimens. In total, data from almost 6,000 patients and 52 providers were included in the study. Approximately 70% of patients saw a técnico de medicina as their first provider, and the study supported the observation that patients did not seem to be assigned to providers based on the severity of illness but more likely on availability.
Preliminary analysis indicates that overall the técnicos provided care of the same quality or better than physicians. Patients who saw técnicos at their first visit were slightly more likely to adhere to ART than those who saw physicians, were more likely to have had a CD4 cell count measured in the year following their start on ART, and were less likely to have been "lost to follow-up" (stopped coming in for care). The study also showed that técnicos tended to see patients with less education, lower socio-economic status, and those who lived further from the clinics.
Several characteristics of providers, either técnicos or physicians, correlated with improved quality of care or patient outcomes:
- Patients with female providers were 18-32% less likely to have CD4 cell counts in the year following their start on ART, and were more likely to be lost to follow-up, than patients of male providers.
- Patients of providers with more experience in the National Health Service were less likely to be lost to follow-up.
Possible explanations for the similarity in quality of care between técnicos and physicians is that both receive training that emphasizes the national standard protocol for HIV care, so there is relatively little variation. Also, as a consistent presence in HIV clinics, técnicos may be better able to build relationships with other staff and spend more time with patients to achieve better outcomes.
A Promising Option
Task shifting is an important option for low-resource countries, especially those facing severe HIV epidemics. Preliminary results from HAI's research into how task shifting is working in Mozambique suggest that lower-level cadres of health workers can be a good resource for expanding HIV services. The Mozambican government, with the partnership of HAI, will continue working to expand all levels of the health workforce, from clinical staff through management. Building this component of the public-sector health system will enable more Mozambicans to receive free HIV services, and lead healthier lives.
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