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Non-Physician Clinicians in Sub-Saharan Africa

This article builds on a recent publication on the capacity of the existing health workforce in Africa to expand through increasing production of its non-physician clinicians and by suggesting that there are four further issues to be urgently addressed if NPCs are to realize their full potential. [adapted from author]

Exploring the Role of Family Caregivers and Home-Based Care Programs in Meeting the Needs of People Living with HIV/AIDS

Given the limited availability of formal, inpatient programs, households rely upon informal caregivers (e.g. household or family members, friends, community members, or voluntary organizations) and homebased care (HBC) programs for assistance. This summary documents the roles played by household and HBC program caregivers in meeting the needs of the chronically ill.

Intermittent Preventive Treatment of Malaria in Pregnancy: a New Delivery System and Its Effect on Maternal Health and Pregnancy Outcomes in Uganda

The objective of this study was to assess whether traditional birth attendants, drug-shop vendors, community reproductive-health workers, or adolescent peer mobilizers could administer intermittent preventive treatment (IPTp) for malaria with sulfadoxine-pyrimethamine to pregnant women. The study concludes that the use of the guideline with adequate training significantly improved correctness of malaria treatment with chloroquine at home. Adoption of this mode of intervention is recommended to improve compliance with drug use at home. The applicability for deploying artemisinin-based combination therapy at the community level needs to be investigated.

Joint Health Professions Statement on Task Shifting

This statement outlines guiding principles to ensure task shifting is effective.

Task Shifting May Prove Key to Tackling Infectious Diseases

Task shifting, a process whereby medical tasks are delegated to less specialized health-care workers, provides one mechanism to address some of the shortfalls of many health care systems. This article advocates for increased task shifting in health care systems, especially in the developing world. [adapted from author]

Task Shifting: Rational Redistribution of Tasks among Health Workforce Teams

Reorganization and decentralization of health services according to a task shifting approach can help to address the current shortages of health workers. This document provides background on task-shifting and twenty-two guidelines for countries that are considering adopting or extending a task-shifting approach to health workforce teams. [from introduction]

Task Shifting to Tackle Health Worker Shortages

The shortage of well-trained health workers is global, but low- and middle-income countries where HIV and AIDS are taking the greatest toll feel the crisis most acutely. This report provides examples and statistics about the potential for task shifting to help with the problem of health worker shortages. [adapted from author]

Major Surgery Delegation to Mid-Level Health Practitioners in Mozambique: Health Professionals' Perceptions

This study examines the opinions of health professionals about the capacity and performance of the ‘tecnico de cirurgia’, a surgically trained assistant medical officer in the Mozambican health system. Particular attention is paid to the views of medical doctors and maternal and child health nurses. [from abstract]

Safety and Feasibility of Community-Based Distribution of Depo Provera in Nakasongola, Uganda

In both Asia and Latin America, community-based health workers have been trained in safe injection techniques and routinely provide injectable contraception. However, the African continent still resists this service delivery mechanism with the rationale that it is unsafe for clients to receive injections from paramedical personnel. This argument is weakening, however, as non-reusable syringes become the norm and with the recent development of a checklist, based on the latest WHO Medical Eligibility Criteria, for safe provision of DMPA by community-based agents.

Impact of Home-Based Management of Malaria on Health Outcomes in Africa: a Systematic Review of the Evidence

Home-based management of malaria (HMM) is promoted as a major strategy to improve prompt delivery of effective malaria treatment in Africa. The published literature was searched for studies that evaluated the health impact of community- and home-based treatment for malaria in Africa. [from abstract]

Community Workers Key to Improving Africa's Primary Care

In parts of rural Africa, where conflict and neglect have destroyed any remnants of a functioning health system, there is one long-running public-health programme that is not only surviving but thriving—by capitalising on communities’ desires to help themselves. [author’s description]

Expansion of the Role of Nurse Auxiliaries in the Delivery of Reproductive Health Services in Honduras

The nurse auxiliaries who work at the rural health centers (CESARs) of the Honduran Ministry of Health (MOH) are frequently the only source of reproductive health services in the communities they serve. In order to increase access to long-term family planning methods, the MOH and the Population Council’s INOPAL III Project conducted an operations research study from 1997 to 1998 to see if nurse auxiliaries could provide good quality IUD, Depo-Provera and vaginal cytology services without health risks for their clients.

Contribution of International Health Volunteers to the Health Workforce in Sub-Saharan Africa

In this paper, we aim to quantify the contribution of international health volunteers (IHVs) to the health workforce in sub-Saharan Africa and to explore the perceptions of health service managers regarding these volunteers. [from abstract]

People First: African Solutions to the Health Worker Crisis

The health worker crisis is particularly acute in rural and hard to reach areas, where 80% of the population in Africa live. The resultant low capacity at the peripheral level of the health system is a crucial barrier to good health. AMREF believes that developing capable, motivated and supported health workers at all levels of the health system is essential in ensuring the delivery of accessible and effective health care across Africa… This briefing draws on AMREF’s experience to look at three key issues: the importance of appropriate training, task-shifting to lower cadres of worker, and training and supporting community health workers (CHW) in order to bring health care closer to communities.

Bridging the Health Gap in Uganda: the Surgical Role of the Clinical Officer

A scarcity of trained medical personnel impedes Uganda’s ability to deliver healthcare effectively. The role of the Clinical Officer (CO) was established to assist the provision of primary healthcare to rural communities. The primary aim of this study was to explore the role that the CO performs in delivery of primary and secondary healthcare in Uganda. A secondary aim was to determine the resources and facilities that are available to COs in order to carry out these duties. A further aim was to determine the confidence of COs at performing surgical and obstetric procedures. [from introducti

Achieving Child Survival Goals: Potential Contribution of Community Health Workers

This article discusses the potential contribution of community health workers to child survival rates. Several trials show substantial reductions in child mortality, particularly through case management of ill children by these types of community interventions. However, community health workers require focussed tasks, adequate remuneration, training, supervision, and the active involvement of the communities in which they work. This article discusses the need for evaluation of programmes for community health workers. [from summary]

Training Shopkeepers to Improve Malaria Home Management in Rural Kenya

This article discusses the cost-effectiveness of a recent programme that involved training shopkeepers and community mobilisation for treating childhood fevers in the rural Kilifi District in Kenya. The programme offered workshops for shopkeepers on appropriate treatment for malaria in young children and also ran community information activities, with impact maintained through refresher training and monitoring. [author’s description]

Uganda: Delivering Analgesia in Rural Africa: Opioid Availability and Nurse Prescribing

Hospice Africa Uganda introduced palliative medicine to Uganda in 1993 with enough funds to support a team of three clinicians for three months. Training in the medical and nursing schools was introduced in 1994. Since then, Uganda has achieved the three essential components of an effective public health strategy. It has also been the first country to have palliative care described as an essential clinical service and to change the law to allow nurses and clinical officers who complete special training in palliative medicine at Hospice Uganda to prescribe morphine. Palliative care is spreading throughout the districts of Uganda, ensuring that morphine will be available to everyone who needs it. [adapted from publisher’s description]

Guideline for Incorporating New Cadres of Health Workers to Increase Accessibility and Adherence to Antiretroviral Therapy

This guideline is for human resources planners and managers in the health sector and sets out the steps required to extend the health workforce by incorporating lay workers (field officers), especially in the delivery of antiretroviral therapy (ART) to home-based clients.

Non-Physician Clinicians in 47 Sub-Saharan African Countries

Many countries have health-care providers who are not trained as physicians but who take on many of the diagnostic and clinical functions of medical doctors. We identified non-physician clinicians (NPCs) in 25 of 47 countries in sub-Saharan Africa, although their roles varied widely between countries… Low training costs, reduced training duration, and success in rural placements suggest that NPCs could have substantial roles in the scale-up of health workforces in sub-Saharan African countries, including for the planned expansion of HIV/AIDS prevention and treatment programmes. [summary]

Postoperative Outcome of Caesarean Sections and Other Major Emergency Obstetric Surgery by Clinical Officers and Medical Officers in Malawi

Clinical officers perform much of major emergency surgery in Malawi, in the absence of medical officers. The aim of this study was to validate the advantages and disadvantages of delegation of major obstetric surgery to non-doctors. [abstract]

Health Workforce Innovations: a Synthesis of Four Promising Practices

While publications like the World Health Report have described general approaches that can be taken to improve the human resources for health (HRH) situation at the country level, there is a relative paucity of more detailed documentation that describes promising practices that would be useful to HRH leaders and practitioners. As a result, USAID’s Africa Bureau commissioned a study to identify and document promising practices in a way that takes into account the context of the practice, describes lessons learned and puts forth potential implications for replication in other countries. The intent of the promising practices study is to “serve as a practical and much needed resource for governments, partners and donors in promulgating policies and approaches that have successfully mitigated the negative effects of the health workforce crisis.” After consultation within USAID, it was decided that the study would focus on promising practices in four African countries: task shifting in Ghana and Uganda, improving retention in Malawi, and increasing recruitment and rapid deployment in Namibia.

Help Wanted: Confronting the Health Care Worker Crisis to Expand Access to HIV/AIDS treatment: MSF Experience in Southern Africa

This report focuses on the impact of human resource shortages witnessed by MSF teams in four southern African countries - Lesotho, Malawi, Mozambique, and South Africa. While the focus is largely on nurses in rural areas, it should be acknowledged that health staff is lacking across the spectrum - from doctors to laboratory technicians to pharmacists - at all levels of care. In all these cases the need for access to ART, as well as other health needs, is outstripping human resource capacity. [from introduction]

New Role, New Country: Introducing USA Physician Assistants to Scotland

This paper draws from research commissioned by the Scottish Executive Health Department (SEHD). It provides a case study in the introduction of a new health care worker role into an already well established and ‘mature’ workforce configuration. It assesses the role of USA style physician assistants (PAs), as a precursor to planned ‘piloting’ of the PA role within the National Health Service (NHS) in Scotland. The evidence base for the use of PAs is examined, and ways in which an established role in one health system (the USA) could be introduced to another country, where the role is ‘new’ and unfamiliar, are explored.

Incorporating Lay Human Resources to Increase Accessibility to Antiretroviral Therapy: a Home-Based Approach in Uganda

The AIDS Support Organization (TASO) administers a home-based program in Uganda that gives people in poor and rural settings access to antiretroviral therapy (ART) and services. The program’s innovation lies in shifting delivery of most clients’ follow-up activities at home to field officers, a new cadre of degree and diploma holders from the social sciences and education. Field officers ensure adherence to ART, refill clients’ medications and perform various activities, from voluntary counseling and testing to education to promoting family and community support. [from executive summary]

Using Nurses to Identify HAART Eligible Patients in the Republic of Mozambique: results of a Time Series Analysis

The most pressing challenge to achieving universal access to highly active anti-retroviral therapy (HAART) in sub-Saharan Africa is the shortage of trained personnel to handle the increased service requirements of rapid roll-out. Overcoming the human resource challenge requires developing innovative models of care provision that improve efficiency of service delivery and rationalize use of limited resources. We conducted a time-series intervention trial in two HIV clinics in central Mozambique to discern whether expanding the role of basic-level nurses to stage HIV-positive patients using CD4 counts and WHO-defined criteria would lead to more rapid information on patient status (including identification of HAART eligible patients), increased efficiency in the use of higher-level clinical staff, and increased capacity to start HAART-eligible patients on treatment.

Potential of Private Sector Midwives in Reaching Millennium Development Goals

This paper explores the potential for private-sector midwives to provide services beyond their traditional scope of care during pregnancies and births to address shortcomings in less developed countries’ ability to reach MDGs. This paper examines factors that support or constrain private practice midwives’ ability to offer expanded services in order to inform the policy and donor communities about PPMWs’ potential. [from executive summary]

Increasing Access to Reproductive Health Services Through Pharmacists

This issue of Outlook explores the role of pharmacists and non-pharmacist counter staff in primary health care, with a specific emphasis on reproductive health. It also presents programs that build the capacity of pharmacists to provide expanded services, thus improving access to quality reproductive health services. [author’s description]

Cost-Effectiveness of Community Health Workers in Tuberculosis Control in Bangladesh

The objective of this article was to compare the cost-effectiveness of the tuberculosis programm run by the Bangladesh Rural Advancement Committee, which uses community health workers (CHWs), with that of the government program which does not use CHWs. [adapted from author]

Achieving a More Efficient Health Care Workforce

This presentation was part of the 2006 Global Health Mini-University. A key approach to address the global shortage of healthcare providers is to improve the productivity of existing workers, thereby improving the quality and coverage of services. Improving the work environment and task shifting of health functions to different cadres of providers are two promising interventions that are being used for this purpose. This session will describe and discuss these and some of the other innovative solutions to enhance the capacity and productivity of the current workforce and to build coherence into the management of human resources for stronger health systems. [publisher’s description]