Task shifting in Mozambique: cross-sectional evaluation of non-physician clinicians' performance in HIV/AIDS care

Abstract

BackgroundMany resource-constrained countries now train non-physician clinicians in HIV/AIDS care, a strategy known as 'task-shifting.' There is as yet no evidence-based international standard for training these cadres. In 2007, the Mozambican Ministry of Health (MOH) conducted a nationwide evaluation of the quality of care delivered by non-physician clinicians (técnicos de medicina, or TMs), after a two-week in-service training course emphasizing antiretroviral therapy (ART).MethodsForty-four randomly selected TMs were directly observed by expert clinicians as they cared for HIV-infected patients in their usual worksites. Observed clinical performance was compared to national norms as taught in the course.ResultsIn 127 directly observed patient encounters, TMs assigned the correct WHO clinical stage in 37.6%, and correctly managed co-trimoxazole prophylaxis in 71.6% and ART in 75.5% (adjusted estimates). Correct management of all 5 main aspects of patient care (staging, co-trimoxazole, ART, opportunistic infections, and adverse drug reactions) was observed in 10.6% of encounters.The observed clinical errors were heterogeneous. Common errors included assignment of clinical stage before completing the relevant patient evaluation, and initiation or continuation of co-trimoxazole or ART without indications or when contraindicated.ConclusionsIn Mozambique, the in-service ART training was suspended. MOH subsequently revised the TMs' scope of work in HIV/AIDS care, defined new clinical guidelines, and initiated a nationwide re-training and clinical mentoring program for these health professionals. Further research is required to define clinically effective methods of health-worker training to support HIV/AIDS care in Mozambique and similarly resource-constrained environments.

Impact of Socioeconomic Status, Ethnicity, and Urbanization on Risk Factor Profiles of Cardiovascular Disease in Africa

“…Innovative strategies will be needed, building on current strategies on task shifting or task sharing in Rwanda 38 and Mozambique, 39,40 the results of which are encouraging. Although thought to further exacerbate income and healthcare inequality, industry involvement in promoting high-tech imaging, devices, and procedures may be revolutionary.…”

Non-physician Clinicians in Sub-Saharan Africa and the Evolving Role of Physicians

“…4,12 Lastly, physicians must also mentor, supervise, and serve as consultants to NPCs and other midlevel health workers on complex clinical cases. 2,4,20,30,31 In several sub-Saharan countries and for multiple types of surgery, for instance, NPCs perform as well as qualified surgeons within the limited scope of their training or skill level, but only with strong mentoring and supervision by physicians. 3,12 Task-shifting to NPCs enables health systems to function with fewer physicians, but it also creates non-clinical tasks for physicians.…”

“…Paucity of standardized decision-making algorithms and simplified drug regimens (which NPCs typically need more than physicians do) and of curricula and teaching materials tailored to NPCs, 11,12,19 2. NPCs' difficult work conditions, limited career development opportunities, and insufficient professional status and recognition, 8,17,[20][21][22][23][24] 3. Opposition to NPCs from mainstream health professional societies, 3,8,23,25 and occasional conflicts between NPCs and other health workers 11,17,23,26 and, 4.…”

A framework for revising preservice curriculum for nonphysician clinicians: The mozambique experience

“…[9] However, a subsequent evaluation identified significant gaps in TM clinical performance and training. [10] The Ministry of Health responded with a revised scope of practice for HIV care and treatment (see Task Analysis), a revised program of inservice training, and a call to action for the integration of HIV care and treatment skills into the TM preservice curriculum.…”

“…[12] The content of the TM curriculum did not reflect the most prevalent conditions in Mozambique; with too little attention to malaria, malnutrition, HIV/AIDS, tuberculosis and management of chronic diseases. [11,12] As a result of the findings and recommendations from the training institution assessments [11][12][13] and TM performance study, [10] the Ministry of Health Training Department convened a Technical Working Group composed of practicing Mozambican clinicians to identify gaps in TMs' clinical performance and guide the curriculum revision process. The goal of the curriculum revision was to integrate HIV/AIDS content, strengthen overall clinical skills and improve graduates' clinical decision-making.…”