Using a collaborative approach to address task ...

ARC supplement: tanzania

Using a collaborative approach to address task shifting during the HIV epidemic: The Tanzania experience By Thecla W Kohi, Lilian T Mselle, Paul M Mashauri, Clavery Mpandana, Ndementria Vermond and Lena Mfalila

© 2014 MA Healthcare Ltd

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ike many low and middle-income countries, Tanzania suffers from a chronic shortage of trained health care workers (HCWs). Tanzania has less than one physician per 10 000 people (Kaiser Family Foundation, 2012), far less than the minimum of 23 doctors and nurses per 10 000 people recommended by the World Health Organization (WHO) (WHO, 2007). The WHO estimates that providing antiretroviral therapy to 1000 people in resource-limited settings requires one or two doctors, up to seven nurses, three pharmacy staff and a wide range of community workers (WHO, 2007). Thus, the HCW shortage in Tanzania makes it very difficult to provide adequate care and treatment (IntraHealth International, 2013) for 1.5 million Tanzanians who live with HIV and the 1.2 million children who have been orphaned by the epidemic (UNAIDS, 2012). Due to the lack of trained HCWs, particularly in rural and underserved areas where the majority of the population resides, nurses and midwives often provide the HIV services that would normally be the responsibility of physicians (Callaghan et al, 2010). The WHO endorsed this service delivery strategy in 2008, promoting the ‘rational redistribution of tasks among health workforce teams’ in which ‘specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resources for health’ (WHO, 2008). Although originally referred to as ‘task shifting,’ this phenomenon has more accurately been defined as ‘task sharing,’ in which ‘physicians, nurses, dentists, and other health professionals delegate health care responsibilities and relevant knowledge to others, including community health workers…[in order to] make more efficient use of existing human resources and ease bottlenecks in service delivery’ (Institute of Medicine, 2010: 114). According to WHO’s guidelines, nurses and midwives can safely and effectively provide many critical HIV services, including HIV counseling and testing, treatment of sexually transmitted infections, prevention of mother-to-child transmission of HIV, management of tuberculosis coinfection and most opportunistic infections, and prescription of first-line antiretroviral medications (WHO, 2008). Numerous studies of task sharing in sub-Saharan African nations continue to demonstrate that task sharing can be used to safely scale-up HIV care and treatment services without compromising quality of care (Cohen et al, 2009; Morris et al, 2009; Shunbushoet al, 2009; Zachariah et al, 2009; Callaghan et al, 2010; Munga et al, 2012; Emdin et al,

Abstract The shortage of trained health workers is particularly severe in Tanzania. Due to the health worker shortage, many nurses and midwives in Tanzania provide critical HIV services that were formerly provided by physicians. This service delivery strategy, called task sharing, is recommended by the World Health Organization, but it has not yet been formally endorsed by the Tanzanian government. Using a collaborative approach developed by the African Health Profession Regulatory Collaborative (ARC) for nurses and midwives, Tanzanian nursing leaders from four professional sectors, the ‘Quad’, along with in-country partners have successfully advocated for nursing on a number of issues important to the profession. With continued support from ARC and other partners, the Quad is working to advance task sharing in a collaborative, sustainable way, which could be an important example for the rest of the region. 2013). In recent years, task sharing has emerged as an effective strategy to rapidly expand the HCW resource pool in resourcelimited settings with significant implications for HIV-related care (WHO, 2007; Munga et al, 2012). Task sharing in Tanzania is seen as ‘an inevitable coping mechanism’ in the face of few options to address the HCW shortage (Munga et al, 2012). Task sharing takes place within cadres (medical officers, assistant medical officers and clinical officers) and between cadres (i.e. clinical officers and nurses) and at any number of health facilities (Munga et al, 2012). It is therefore ‘not surprising…to find an assistant medical officer

Thecla W Kohi is a Professor, School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Lilian T Mselle is a Professor, School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Paul M Mashauri is the President, Tanzania National Nurses Association, Dar es Salaam, Tanzania; Clavery Mpandana is the Chief Nursing Officer, Ministry of Health and Social Welfare, Dar es Salaam, Tanzania; Ndementria Vermond is the Assistant Director, Nursing Training, Ministry of Health and Social Welfare, Dar es Salaam, Tanzania; Lena Mfalila is the Registrar Tanzania Nurses and Midwives Council, Dar es Salaam, Tanzania

AFRICAN Journal of Midwifery and Women’s Health, April–June 2014, Vol 8, No 2 (Supplement)

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ARC Supplement: tanzania

Chief Nursing Office Tanzania Nursing and Midwifery Council Service Delivery, Health Policies

Pre-Service & Continuing Chief Nursing Office Education Ministry of Health and Social WelfareNursing Training Section

Professional Standards & Compliance

Voice to Government for Members Chief and Nursing Office Tanzania Patients National Nurse Association

Figure 1. African Health Profession Regulatory Collaborative Quad structure (Verani et al, 2011)

working as a district medical officer, a post which is supposed to be held by a fully-trained medical doctor’ (Munga et al, 2012). In facilities where nurses and midwives are not available, lessertrained HCWs such as rural medical aides and maternal child health aides who receive 1 to 2 years of education after primary education, provide many nursing services; in the most remote dispensaries, where there may not be any professionally trained medical staff at all (Kwesigabo et al, 2012). Several studies have shown that training nurses and other HCWs to perform duties typically assigned to physicians can help increase access to and efficient delivery of vital HIV-related services (Nyamtema et al, 2011; Bertrand et al, 2012). One recent project to train Tanzanian nurses to perform voluntary male medical circumcision (VMMC) found that health care providers other than medical doctors (including nurses, clinical officers, and assistant medical officers) already perform the vast majority of VMMC procedures in Tanzania, and they strongly believe that these other personnel—once trained—can adequately perform this procedure in this capacity (Bertrand et al, 2012). Having shown that nurses could safely and efficiently perform VMMC, investigators recommended that more systematic training of non-medical personnel be conducted in order to assist in all aspects of the procedure (Bertrand et al, 2012). Another study that provided competency-based training for nurses, midwives and clinical officers to provide emergency obstetric care in rural Tanzania found that health centers can be upgraded and these HCWs can provide comprehensive emergency obstetric care (Nyamtema et al, 2011). These studies strongly suggest that the Government of Tanzania’s endorsement and support of task sharing is critical to alleviate HCW shortages and safely scale up access to essential health care services countrywide. In 2010, nursing leaders from Tanzania were invited to attend a meeting of the African Health Profession Regulatory Collaborative (ARC) for nurses and midwives. Based on the concept of south-to-south sharing, ARC supports 17 countries in east, central, and southern Africa (ECSA) to expand HIV service delivery through enhanced and harmonised nursing and regulation (McCarthy and Riley, 2012). ARC is a 18

partnership between the US Centers for Disease Control and Prevention (CDC) under the US President’s Emergency Plan for AIDS Relief; Emory University’s Lillian Carter Center for Global Health and Social Responsibility; the Commonwealth Secretariat; the Commonwealth Nurses Federation, and the ECSA Health Community. ARC convenes nursing leadership teams, or ‘Quads’, from ECSA countries for regular regional meetings in which country Quads identify regional priorities for nursing and midwifery regulation, and engage in south-to-south collaboration on common challenges (Gross et al, 2012). Each ARC Quad comprises the following four nursing leaders: the chief nursing officer from the ministry of health, the registrar of the nursing and midwifery council, the president of the professional nursing and midwifery association, and a representative of nursing and/or midwifery academia (Figure 1). In addition, country Quads are invited to submit a proposal for a grant to address a national priority in nursing and midwifery regulation over the course of one year. ARC awards the grants directly to qualifying country Quads and assists them in grant implementation during regional meetings and in-country technical assistance visits. In 2013, the Tanzania Quad received an ARC grant to develop a national framework for continuing professional development (CPD) for nurses and midwives. In 1 year, the Quad developed a draft CPD framework, which will be implemented as a part of ensuring continuing competency with re-licensure.

The Quad at work in Tanzania

In Tanzania, the ARC Quad comprises the chief nurse from the Ministry of Health and Social Welfare (MoHSW), the registrar of the Tanzania Nursing and Midwifery Council, the president of the Tanzania National Nurses Association, and the head of the nursing training sub-unit within the human resource development directorate at the MOHSW. The Tanzania ARC team felt the Quad approach unites nursing leaders from distinct areas of the profession and provides a collaborative approach to problem-solving, thereby eliminating problematic isolation of factions within the profession. The Quad also works with in-country partners to advance the nursing and midwifery? profession. The Tanzania Nursing Initiative (TNI), a twinning project which includes the Muhimbili University of Health and Allied Sciences School of Nursing, Winona State University— Department of Nursing (USA) and World Service of La Crosse (USA), provided technical support to the Quad. Established in 2006, TNI aims to build nursing capacity in Tanzania by focusing on nursing education, nursing school support, faculty development and nurse leadership (TNI, 2013). The Tanzania ARC Quad and partners such as TNI have made important progress on several key regulatory issues. For example, the Tanzanian government’s current scheme of service maintains relatively low salary levels for nurses at the master’s and PhD levels as compared to other health professionals with the same qualifications. The Quad led a united front to advocate for a scheme of service that compensates nurses in accordance with their level of education and training. The Quad is also working to establish a nursing directorate within the MoHSW, which will provide clear leadership for the nursing profession at the national government level. The Quad believes that nurses need a directorate that works both independently and collaboratively to improve the quality of nursing care in Tanzania. Both the Prime


Chief Nursing Office Chief Nursing Office



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Minister and Minister of Health have also expressed interest in exploring the possibility of establishing a nursing directorate. The 2013 annual Tanzania National Nurses Association Meeting and Scientific Conference introduced the concepts of task sharing and implications for nursing practice. In addition, at the first National Human Resources for Health Conference (2013) the issues of task sharing were discussed in-depth. All cadres of health professionals agreed to identify what tasks may be shared and how to implement task sharing among the health care cadres. Task sharing is another issue the Quad and partners are committed to advancing. The Quad is advocating for creating a national task sharing policy and establishing legal frameworks and regulations, as well as addressing the issue of compensation for nurses and midwives who assume additional responsibilities. In order to formalise task sharing in Tanzania, the Quad has identified some key considerations and action steps: Identify the challenges of task sharing and develop a plan to meet the challenges: One identified challenge is resistance from professions and cadres hesitant to delegate tasks that have traditionally been part of their responsibilities Conduct forums with other health professions to decrease resistance and promote collaboration Formulate appropriate scheme of service for all cadres that reflect the new guidelines Reconcile pre-service education standards to reflect expanded schemes of service Consider expanding the scope of nursing practice to include nurse practioner education, a nurse with advanced level of preparation and education that can provide comprehensive health care including HIV care, treatment and support. Through the ARC, the Quad will receive support to ensure the safety and sustainability of task sharing through updated and enabling regulatory frameworks. ARC meetings focus on enhancing HIV service delivery by nurses and midwives, including the latest HIV treatment guidelines and regulations (such as CPD) that can facilitate task sharing; country Quads also share with each other and hear how their neighbours have addressed similar challenges around task sharing. In addition, TNI has supported the Quad since 2012 in trying to improve nursing care and advance the issue of task sharing. The Quad knows to anticipate challenges such as resistance from HCWs who do not wish to perform tasks above and beyond their official job description or undergo additional training or certification. In addition, Tanzanian physicians and higher-level cadres may also resist the institutionalising of task sharing, as it may undermine the ‘professional distinction’ of those who have spent many years to earn such professions (Munga et al, 2012). While important challenges exist, some great signs have already developed: The MoHSW has taken an important initial step by establishing an adhoc committee, which includes the Quad members, to explore how task sharing could be institutionalizsed. The development of the Quad by the nursing profession is a model that the MoHSW is encouraging other health care professions to adopt.

Conclusions

According to WHO, with strong political will, management, supervision and support, task sharing can positively affect health outcomes, particularly for people living with HIV (WHO, 2007). With the continued support of the ARC, and

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