Is Task Shifting an Alternative Option of HIV Care in East Africa - Literature review Example

Is Task Shifting an Alternative Option of HIV Care in East Africa? The Effectiveness and its Economic Implications: А Literature Review Name Instructor Date Literature review Introduction Human resources shortage according to Mdege and Chindove (2013) possess a major challenge to rollout of ARV therapy for HIV-infected patients in Sub-Saharan Africa. The present challenge as a result of shortage of human resources is evident in studies by Callaghan, Ford, and Schneider (2010), Zachariah et al, (2008), and Kosgei et al, (2010). As a result, attending to HIV/AIDs patients is in large part, challenging because of shortage of healthcare workers. A study by the World Health Organization in 2006, recognized that, decreased access to care for HIV/AIDs patients was proportionate of health workers shortages. In order to promote increased access to HIV care in health facilities, WHO suggested the use of task shifting. Evidence suggests that the use of task shifting in addressing human resource constraint is effective for not only improving accessibility to care, but also a cost-effective approach that does not compromise health outcomes. In global healthcare, task shifting is accepted as a strategic means of improving access to care meeting demands for managing ARV therapy. In 2003, the WHO proposed consolidated guidelines advocating for keeping HIV-infected patients healthy, thus, emphasizing the significance of equitable access to ARV therapy. In addition to WHO guidelines, the UN program on HIV/AIDS recommends a scale-up of HIV treatment and prevention. The goal is to reach the 95% awareness level, where people explicitly know their status. The UN goal also sought to reach 95% ARV therapy coverage in order to achieve 95% virologic suppression by 2030. As such, it becomes important to increase the provision of ARV therapy while ensuring patients are undergoing care. The UN recommends task shifting and decentralization as pillars of public health that can successfully increase ARV therapy (ART) in resource-limited settings. Task shifting by definition refers to the practice of transferring tasks to healthcare workers who have do not serve these tasks as part of their health profession. The health workers have not conventionally performed such tasks in their scope of practice. However, the health workers who would be providing these new tasks are readily available. They will have few qualifications and have completed a short training. In task shifting, healthcare workers are provided with specific skills based training, and assigned clearly outlined tasks. In addition, health workers receiving specific training may be assigned to perform limited task. According to Crowley and Mayers (2015), the aim of the process is to make efficient use of the available human resources in healthcare in order to reduce delays in health delivery, while at the same time, observing standard of care. Particular emphasis is given to improving health of extremely vulnerable populations. The WHO defines task shifting as the process of delegating healthcare functions from specialized to less specialized health care workers. There is sufficient evident of efficiency of application of task shifting in increasing care delivery, as well as, prompting wider access to care. For instance, in Tanzania, the health system sought to increase care delivery through task shifting. To achieve this goal, they upgraded clinical officers into assistant medical officers. The resultant was a widened scope of practice, allowing them to perform tasks of medical officers such as general surgery and emergency obstetric surgery. In Zambia, the Nurses Act of 1997 allowed nurses to carry out a greater set of tasks, consequently increasing the scope of practice for midwives and nurses. The Act empowered nurses to perform physical examinations, resuscitation, and insertion and removal of intrauterine devices. As a result, patients seeking such healthcare would access it readily from local healthcare facilities. In East Africa, Kenya and Tanzania trains clinical officers who serve as doctor-substitute cadres. Particularly, Tanzania trains nurses in disciplines of general medicine and surgery. On the other hand, Kenyan nursing training equips nurse with knowledge in disciplines of reproductive health, orthopedics, pediatrics, and ophthalmology. Such training allows nurses to have general skills to perform these tasks. Trends in task shifting Studies by Callaghan, Ford, and Schneider (2010), Zachariah et al, (2008), and Kosgei et al, (2010), evidence that many countries in Sub-Saharan Africa are implementing task shifting as an alternative to resolve the problem of human resource constrain, while at the same time expand HIV programs. In East Africa, task-shifting practice seems to be including broader health functions instead of HIV services alone. Task shifting is practiced in almost all health care facilities (Crowley and Mayers, 2015). For instance, health care facilities are providing a number of health care services such as surgery, midwifery, as well as non-communicable disease management, evidence that health systems are gearing towards task-shifting approach to care. However, the extent of implementation of task shifting seems to reflect specific health needs in the society, with consideration of health system capacity. In the scope of HIV services, doctors, nurses, non-physician clinicians, and midwives tend to provide phlebotomy as well as counseling services to HIV patients, an evidence levels of task shifting. In addition, they are providing training to lay health workers, in a bid to increase the lay health workers’ mandate in care provision. Evidence-based studies by Braton et al, (2013); and Jacob, McKenna, and D’Amore (2015) show that the lay health care workers are increasingly dispensing disease prevention care, as well as, health promotion, home-based care, counseling, and treatment support services. Further, a systematic review into the role of community health care workers in provision of HIV services reveals that such health workers are instrumental in promoting delivery of HIV care (Mwai et al, 2013). The presence of community health care workers in health clinics contributed to reduce waiting times for patient seeking HIV services (Crowley and Mayers, 2015). In addition, it helped reduce workload for health workers. Swartz et al (2014), argued that most community workers live within area which they serve, consequently reducing challenges of language and cultural competence. An empirical study in South Africa shows that large infrastructure of lay workers has in the past increased to meet the demand of HIV epidemic. According to Schneider, Holpe, and Van Rensburg (2008), 40,000 lay workers supplemented the existing professional nurses in dispensing HIV care in public sector, consequently doubling the number of health care workers offering HIV services. Training such lay workers with special education on HIV management in a bid to allow them to dispense HIV care aimed at meeting the growing demand of HIV care. The program was successful, but expensive. Owing to the growing treatment burden of HIV care, provision of HIV services has gradually shifted from hospitals to decentralized healthcare facilities. In sub-Saharan Africa, a further decentralization has seen HIV care; expand into community-supported care for stable patients (Bemelmans et al, 2014). In Kenya, for instance, lay workers are offering community-based care, consequently reducing clinic visits for HIV patient without compromising quality of care and health outcomes (Selke et al, 2010). Munga, Kilima, Mutlemwa, and Kisoka (2012) point out that task shifting in HIV treatment and care fits well within contexts of care delivery. However, it may not be exactly the same for other non-HIV services. Probably, this is because of the emphasis given by the WHO, specifically recommending task shifting as solution to addressing HIV pandemic in East Africa. Nonetheless, potential for wider application is recognized. The effectiveness of task shifting in addressing human resource constraints and improving patient outcomes has gained momentum in the recent past. Several studies investigate the effectiveness and appropriateness of task shifting in addressing human resource constraints. However, there is a deficit in number of studies exploring effectiveness of the same in the context of HIV care. Existing studies, however, concur that task shifting improves access to care and resolves the problem of inadequacy of human resources. In East Africa, the expansion of the ARV therapy programs has led to improved access to care despite pervasive human resource constraints. This has been possible because of liberal task shifting strategies embraced. The success has been paramount without significant increases in human resources (Emdin and Millson, 2012). Systematic reviews exploring the effect of task shifting have been conducted in various East African countries including Kenya, Uganda, and Tanzania among other sub-Saharan countries. The findings of these reviews suggest that task shifting can offer cost-effective and high quality care to patients than a physician-centered care (Callaghan, Ford, and Schneider, 2010). In addition, task shifting seems to draw acceptance of patients. In the context of HIV care, services offered by non-physicians, including lay health workers is similar to care provided by physicians. However, in the case of physician-provided care, in absence of task shifting amounts to huge work burned contributing to loss of follow-up services. Therefore, the adoption of task shifting reduces loss-to-follow-up rates, in turn improving patient satisfaction (Emdin, Chong, & Millson, 2013). Kredo et al (2013), in their studies, argues that reduced rate of loss to follow up may be resulting from decentralization linked with task shifting since patients are receiving care closer to their homes. Refuting this claim is a study by Grismsrud et al (2014) that argued that objects task shifting and decentralization of health care acts as a remedy for improving patient outcomes. According to the study, loss to follow-up is evident in settings that have adopted decentralized care. In decentralized HIV care, models used in care delivery do not explicitly consist of health outcomes of patient. The argument put forth by studies is task shifting, may be effective in improving quality of care since services rendered by nurses are replica of services rendered by lay health workers. There is no lesser of a profession when it comes to care delivery. According to Rashidian et al (2013), task shifting may even lead to better retention in healthcare workforce, particularly, in remote areas East African villages, where it provides career opportunities to staff of lower cadres. There is sufficient research evidence supporting trend of adoption of task shifting for addressing HIV treatment, in East Africa. In fact, the existing evidence advocates for expansion of policies on task shifting. Nonetheless, the studies caution such implementation to follow thorough training to ensure delegation of tasks serves the right purpose and is appropriately implemented by the lay health workers. In practice, the process of task shifting is complex because it may be implemented in dissimilar forms owing to variation in the cadre, competency of health workers, and training. Therefore, it becomes important to make comparisons of success of the practice. However, evidence suggests that task shifting leads to improved access to care. In this sense, many patients in remote areas, in East Africa, would not receive treatment were it not for task shifting. Economic implications of task shifting According to Callaghan, Ford, and Schneider (2010), task shifting is not the solution for dysfunctional health system. Instead, task shifting requires human resource and systems support. Studies concur that task shifting is appropriate for improving and utilizing care services as well as reducing cost of care. However, this is not necessarily true, as implementation of task shifting in South Africa proved to be expensive. Cost increases in task shifting are attributable to cost of supporting training and mentoring, which in turn limits the potential of saving (Braton et al, 2013). Jacob, McKenna, and D’Amore (2015), however, suggest that training and hiring professional nurse and doctors is more costly than employing lay workers. In addition, skilled and experienced workers tend to deliver better patient outcomes, which comes in as relief of employing better-qualified healthcare workers. Economic and financial constraints limit the ability to employ large number of professional, thereby leaving task shifting as a viable option for addressing demand at substantially lower costs (Munga, Kilima, Mutalemwa, & Kisoka, 2012). Furthermore, long-term success of task shifting rests on financial commitment and reorganization of health systems, with regulatory and training support (Lehmann et al, 2009). Health care workers trained to provide HIV care are experiencing heavy workload in an already constrained health care system. This means that with no task shifting, health care workers will continue experiencing heavy workload, which may prompt fatigue and loss of quality care. To curb this shortcoming, it becomes appropriate to train lay health workers in a bid to expand their scope, which in turn improves accessibility and quality of care. In this case, there is a need for adequate supportive supervision of lay health workers. However, because of need to meet the increasing demand, tasks may be shifted in absence of supportive supervision (Munga, Kilima, Mutalemwa, & Kisoka, 2012). Cost implications of task shifting include training and support costs. These costs are inevitable if quality care is to be realized. Nonetheless, in order to understand if the option is economically viable or rather establish the cost implication of the same, it becomes necessary to compare cost of hiring new nurses and doctors, against the cost of training lay health workers. After all, the cost of adding up new health workers goes hand-in-hand with setting up new care facilities, which tends to be costly that task shifting. The major limitation of task shifting is high staff turnover. Orner, Cooper, and Palmer (2011) established that lack of health system support and resources, as well as inadequate infrastructure, posed as barriers to implementation of task shifting. Resolving these barriers has an attached economic cost. Additionally, the shortage of nurses working in primary health care facilities presents a barrier to efficiency of task shifting, as these nurses would be appropriate in training lay health workers as well as candidates for taking up new tasks. Munga, Kilima, Mutalemwa, & Kisoka, (2012); Orner, Cooper, and Palmer (2011), and Kedro et al (2013) report that there is no existing structured system for supervision after training. As such, efficiency of task shifting cannot be realized. In Ethiopia, increasing ARV therapy was possible through task shifting alongside a range of other interventions. The health system of Ethiopia adopted a system of community mobilizing, health system strengthening, patient information systems, and case management support. These initiatives were instrumental to scale up of ARV therapy. The cost implication for such scale up was reported to be minimal compared to other alternatives evaluated such as employing extra nurses (Assefa et al, 2014). In Malawi, regular peer-based support was adopted for all health care workers as well as their mentors. The system was successful mainly because they linked training to continuous professional development, which prompted and strengthened training uptake (Sodhi et al, 2014). Conclusion Sufficient evidence shows implementation of task shifting, in East Africa, is challenging mainly because of lack of structures and frameworks, particularly in resource-constrained countries. Furthermore, the adoption of task shifting in isolation is likely to undermine the long-term sustainability of the approach. Therefore, it becomes necessary to develop standardized method that serve as frameworks for guiding adoption of task shifting. In addition, lack of sufficient studies exploring task shifting with respect to HIV care makes it important to instigate further research. Crowley and Mayers (2015) recommend that further research on intervention needs for support of personnel be conducted. The duo suggests the inclusion of task shifting in interdisciplinary team approach with the central focus on patient-self management. Vast research conducted in East African countries suggests that task shifting is an effective alternative to providing life-saving treatment to a large number of patients. Thus, it serves as a key strategy for complementing human resources in health. Lack of implementation of task shifting comprises need to deliver care and impact on large population of patients in need for health services. Nonetheless, the implementation of task shifting in absence of system strengthening can lead to failure. The implementation of task shifting in East African countries evidences lack of fidelity to WHO guidelines, specifically on supportive supervision, and regulatory frameworks. Perhaps this is the reason why sufficient success has not been achieved in the area. In addition, studies recommend participation of professional regulatory bodies in task shifting decision-making process as key for success of the program. Time costs are significantly lower in intervention consisting of task shifting as compared to other methods (Buttorf et al, 2012). However, additional resources are necessary to ensure health care workers are well equipped to offer HIV care services. The present research, therefore, indicates that task shifting can reduce total cost of care to patients with HIV and improve health outcomes in public health facilities. Intervention of such approach is thus cost-effective. References Assefa Y, Alebachew A, Lera M, Lynen L, Wouters E, Van Damme W., (2014). Scaling up antiretroviral treatment and improving patient retention in care: Lessons from Ethiopia, 2005–2013. Global Health. 10(43) PubMed Burtorff C., Hock R., Weiss H., Naik S., Araya R. Kirkwood B., & Chisholm D., (2012). 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