11

Task-Shifting Regulatory Framework

June 14th, 2007Kigali, Rwanda

The George Washington UniversityJohn Palen PhD, MPH, PAAlan Greenberg MD, MPH

Anne Markus JD, PhD, MHSSeble L. Frehywot MD, MHSA

WHO/OGAC Task Shifting Consultation Meeting

22

Presentation Outline

Project Overview

Regulatory Systems

Application of Regulatory Systems to Task Shifting Levels I – IV

Issues for consideration

33

Project Preview

44

Stages of Project

1. Review existing regulations, develop survey tool • Regulatory and case example inventory • Develop draft regulatory framework • 1st meeting at WHO in February • Refine regulatory framework and develop survey tools

2. Field work – document country-specific regulatory frameworks• Site visits to 2 pilot countries – Malawi, Ethiopia • 2nd WHO Task-shifting stakeholders meeting in Kigali• Additional 5 site visits – Uganda, Namibia, Haiti, Rwanda,

Zambia

3. Finalize the regulatory framework – September-November• Synthesize country data and prepare final report• 3rd and final meeting at WHO

55

Why Map?

To document the existing laws, regulations, guidelines, and policies related to health care workers

To gain knowledge of the unique characteristics of the legal and political system

To use the information for planning and implementation of policy and program changes that support existing or new task shifting activities

66

Regulatory Systems

77

Constitutional Rights and Mandates Related to Health and/or Health Care

Right to Development. The State shall take all necessary measures for the realization of the right to development. Such measures shall include, amongst other things, equality of opportunity for all in their access to basic resources, education, health services, food, shelter, employment and infrastructure.

Economic, Social and Cultural rights. Every Ethiopian national has the right to equal access to publicly funded social services. The State has the obligation to allocate ever increasing resources to provide to the public health, education and other social services. [The Federal Government] shall establish and implement national standards and basic policy criteria for public health, education, science and technology...

88

Constitutional Policy Principles Related to Health and/or Health Care

Principles of national policy. The State shall actively promote the welfare and development of the people of Malawi by progressively adopting and implementing policies and legislation aimed at achieving the following goals:…To provide adequate health care, commensurate with the health needs of Malawian society and international standards of health care.

Social objectives. To the extent the country’s resources permit, policies shall aim to provide all Ethiopians access to public

health and education, clean water, housing, food and social security

99

President & his Cabinet

Supreme Court Parliament

High Court

District Assemblies

DHO(Mini-SWAp)

Lower Courts

Line Ministries

MOGMOAMOE MOJ MOLMOF MOLGMOH

Zones

SWAp(health)

UnionsU. Schools & Colleges

Model 1: Map of Domestic National and Local Framework

Local Governments

MOED

Health Professions Regulatory

Bodies

Civil Service Commission

Associations

NGOs

1010

President

Prime Minister & the Council of Ministers

Supreme Court Parliament

High Courts

State Supreme Courts

Line Ministries

FMoCBFMoE FMoJ MOLFMoFFMoH

Zones

UnionsU. Schools & Colleges

Model 2: Map of Domestic National and Local Framework

Health Professions

Advisory Council

NGOs

Civil Service Agency

State Assemblies State Governments

First Instance Courts

State High Courts

State First Instance Courts

Localities

Districts

RHB RFB REB RJB RLB

Associations

1111

Interaction between Domestic and International FrameworksIMFWB

WHO ILO

Government/Non-GovernmentInternational bi-and multi-lateral funding sources in health sector--------------------------- •GFATM

United States Government

Implementing Partners:International NGO’s

MOH MOF MOL

Nursing and Midwives

Associations

Sub-national governments

PLWHAInternational

Groups

IMWIICNIPA

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

MOU/ Service Agreement

MOU

Nat

iona

lL

evel

Sub-

nati

onal

Lev

el

MOJ

Registration

1212

Scope of Practice & Competencies

Standards of Care

Standard Pre-ServiceMedical, Nursing, Clinical

Education & TrainingLicensing & Registration

Certificate & standardIn-Service Training

Recruitment, Deployment, Promotion, Salary, &

Other Human Resources Issues

Working Conditions

Supervision & Accountability & continual

education (mentoring)

Health Workers

1

2

3

4

5

6

7

9Sub national implementation

8

Task-shifting Process & Components

1313

Application of Regulatory

Systems to Task Shifting I,II,III & IV

1414

Task Shifting Types

Task s

hiftin

g I

Task shifting II

Task shifting III

Task shifting IV

Doctors

Non-physician clinicians(clinical officers, health officers)

Registered Nurses(with BSN, degree, or 3 year diploma)

& nurse mid-wives

Nursing Assistants

&Community

HealthWorkers

Enrolled nurses(with 2 year Diploma)

Expert Patients

REGULATIONSupervision, Delegation,

Substitution,Enhancement, Innovation

1515

Task-shifting I

1616

Tasks Shifted

Medical Doctor

Non-physician Clinicians(e.g. Clinical Officers, Health Officers)

Initiation of staging and diagnosis

Initiation of ARVprescription

Initiation of OI prophylaxis

Ta

sks-shifted

Diagnostic and

Prescriptive privileges

Del

egat

ion

Ex

tra

in

-se

rvic

etr

ain

ing

giv

en

1717

Scope of Practice & Competencies

Standards of Care

Standard Pre-ServiceMedical, Clinical

Education & TrainingLicensing & Registration

Certificate & standardIn-Service Training

Recruitment, Deployment, Promotion, Salary, &

Other HR Issues

Working Conditions

Supervision & Accountability & continual

education (mentoring)

Non-physician Clinicians

(Clinical OfficersMedical Assistants)

Sub national implementation

Task-shifting I -- Model 1 Process & Components

1

2

345

6

7

89

Medical, Dentists& Allied

ProfessionalsCouncil, Pharmacy

Board

MOHP

Medical PractitionersAnd Dentist Act &

Pharmacy, Medicines andPoisons Act

Medical, Dentists &Allied Professionals Council, Physician

Assoc, MOHP, WHO

MOE, MOHP,Colleges of HealthSciences, Medical

Council Medical, Dentists& Allied Professionals

Council

MOHP, Medical, Dentists &Allied Professionals Council, Physician

Assoc

Health Services Commission, MOHPDHRMD, MOF, IMF

MOL&SA, ILO,MOHPPhysician Association

DHO

MOLG &RD, DHO,ZHO, MOHP,

Medical, Dentists & Allied Professionals Council, MOHP,

Physicians

Guideline for the use of ART

Labor Act

1818

NO Scope of PracticeCompetencies

Standards of Care

Standard Pre-ServiceMedical, Clinical

Education & TrainingLicensing & Registration

Certificate & standardIn-Service Training

Recruitment, Deployment, Promotion, Salary, &

Other HR Issues

Working Conditions

Supervision & Accountability & continual

education (mentoring)

Non-physician Clinicians

(Health Officers)

Sub national implementation

Task-shifting I -- Model 2 Process & Components

1

2

345

6

7

89

FMOH

NO Medical Practice or Pharmacy

Act

FMOE, RHB,FMOE,Universities, Teaching Hospitals , Physicians

Civil Services Commission, FMOH

RHB, FMOF&ED,IMF, Int. Donors

MOL&SA, ILO,FMOH

RHB, ZHBMOHP, RHB Physicians

ART ImplementationGuideline

FMOH

FMOH, RHB, REB

FMOH, RHB

Labor Act

1919

Task-shifting II

2020

Tasks Shifted

Medical Doctor

Registered Nurse, Enrolled Nurses(With BSN or degree) (With 3yr diploma)

and Nurse Midwives

Initiation of staging and diagnosis

Initiation of ARVprescription

Initiation of OI prophylaxis

Ta

sks-shifted

Diagnostic and

Prescriptive privileges

Non-physician Clinicians(e.g. Clinical Officers, Health Officers)

Delegation & or Supervision

Ex

tra

in

-se

rvic

etr

ain

ing

giv

en

2121

Scope of Practice & Competencies

Standards of Care

Standard Pre-ServiceNursingl, Clinical

Education & TrainingLicensing & Registration

Certificate & standardIn-Service Training

Recruitment, Deployment, Promotion, Salary, &

Other HR Issues

Working Conditions

Supervision & Accountability & continual

education (mentoring)

Nurses and

Midwives

Sub national implementation

Task-shifting II -- Model 1 Process & Components

1

2

345

6

7

89

Nurses &Midwives CouncilMedical, Dentists

& Allied Professionals

Council, Pharmacy Board

MOHP

Nurses & Midwives Act &Pharmacy, Medicines and

Poisons Act

Nurses &Midwives Council

Nurses Assoc, MOHP

MOE, MOHP,Colleges of Health

Sciences, Universities, Nurses &

Midwives Council,Nurses Association

Nurses &Midwives Council

MOHP, Nurses &Midwives Council

Nurses Association

Health Services Commission, MOHP

DHRMD, MOF, IMFNurses Assoc.

MOL&SA, ILO,MOHPNurses Association

DHO

MOLG &RD, DHO,ZHO, MOHP,

Nurses &Midwives Council, MOHP,

Physicians, Clinical Officers

ART ImplementationGuideline

Labor Act

2222

NO Scope of PracticeCompetencies

Standards of Care

Standard Pre-ServiceNursing, Clinical

Education & TrainingNO LicensingRegistration

Certificate & standardIn-Service Training

Recruitment, Deployment, Promotion, Salary, &

Other HR Issues

Working Conditions

Supervision & Accountability & continual

education (mentoring)

Nurses and

Midwives

Sub national implementation

Task-shifting II -- Model 2 Process & Components

1

2

345

6

7

89

FMOH, FHAPCO

NO Nurses Practice or Pharmacy

Act

,FMOE, RHB,FMOH,

Nursing Colleges,

Civil Services Commission, FMOH

RHB, FMOF&ED,IMF, Int. Donors

MOL&SA, ILO,FMOH, Nurses Assoc.

RHB, ZHB

MOHP, RHB Physicians, Health

Officers

ART ImplementationGuideline

FMOH

FMOH

FHAPCO, InternationalUniversities, FMOH,

RHB

Labor Act

2323

Task Shifting III

2424

Tasks Shifted

Nurses and Midwives

Nurse Assistants and

Community Health Workers( e.g. HEW, Community Counselors)

- HIV Counseling & Testing

- Adherence Counseling

- HIV prevention

Ta

sks-shifted

Su

per

visi

on

Single task-shifting

Multipletask-shifting

- Home-based Care

- Other support services

2525

Scope of Practice & Competencies

Standards of Care

Standard Pre-ServiceMedical, Clinical

Education & TrainingNO Licensing

Registration

Certificate & standardIn-Service Training

Recruitment, Deployment, Promotion, Salary, &

Other HR Issues

Working Conditions

Supervision & Accountability & continual

education (mentoring)

Nurse AssistantsAnd

Community HealthWorkers

Sub national implementation

Task-shifting III -- Mechanism 1

1

2

345

6

7

89

FMOH, CBO, NGO, FBO, Prof

Asscc. Donor

FMOH, CBO/NGO/FBO, WHO, Donor

FMOH, FMOE,REB CBO/NGO, FBO

MOH, RHB, REB

FHAPCO, CBO/NGO/FBO, Donor

FMOH, RHBCivil Services

Commission - CivilService Status

Civil Services Commission, FMOL

RHB, ZHO, DHOFHAPCO,CBO/NGO/FBO

Labor Act

2626

Scope of Practice & Competencies

Standards of Care

Standard Pre-ServiceMedical, Clinical

Education & TrainingLicensing & Registration

Certificate & standardIn-Service Training

Recruitment, Deployment, Promotion, Salary, &

Other HR Issues

Working Conditions

Supervision & Accountability & continual

education (mentoring)

Nurse AssistantsAnd

Community HealthWorkers

Sub national implementation

Task-shifting III -- Mechanism 2

1

2

345

6

7

89

MOH, CBO, NGO, FBO

Variable

MOH, MOE, CBO/NGO/FBO

“Certificate of Attendance”MOH, CBO/NGO/FBO

RHB, DA, DHO

Variable

Variable

Variable

2727

Task Shifting IV

2828

Tasks Shifted

Nurse Assistants and

Community Health Workers

Expert Patients

-Adherence Counseling-Adherence Support-HIV counseling

-Patient Referral-Outreach

Ta

sks-shifted

Su

per

visi

on

Single task-shifting

Multipletask-shifting

2929

Scope of Practice & Competencies

Standards of Care

Standard Pre-ServiceMedical, Clinical

Education & TrainingLicensing & Registration

Certificate & standardIn-Service Training

Recruitment, Deployment, Promotion, Salary, &

Other HR Issues

Working Conditions

Supervision & Accountability & continual

education (mentoring)

Expert Patients

Sub national implementation

Task-shifting IV -- Mechanism 1

1

2

345

6

7

89

MOH, CBO, NGO, FBO, Donor

CBO/NGO/FBO, Donor

CBO/NGO, FBOMOH, CBO/NGO/FBO,

Donor

Health ServicesCommission

Health Services Commission, MOL

RHB, DA, DHOCBO/NGO/FBO

3030

Scope of Practice & Competencies

Standards of Care

Standard Pre-ServiceMedical, Clinical

Education & TrainingLicensing & Registration

Certificate & standardIn-Service Training

Recruitment, Deployment, Promotion, Salary, &

Other HR Issues

Working Conditions

Supervision & Accountability & continual

education (mentoring)

ExpertPatients

Sub national implementation

Task-shifting IV -- Mechanism 2

1

2

345

6

7

89

MOH, CBO, NGO, FBO

Variable

MOH, MOE, CBO/NGO/FBO

“Certificate of Attendance”MOH, CBO/NGO/FBO

RHB, DA, DHO, CBO/NGO/FBO

Variable

Variable

Variable

3131

Issues for Consideration

Countries are likely to vary in fundamental elements of the regulatory system => knowledge of the system is critical

International and national stakeholders and their policies for HRD

Distinguish between short-term (rapid) and mid-to long-term (sustainable) approaches to task shifting I & II and III & IV, and plan accordingly

Upfront planning for the transition of pilot program(s) to a sustainable national scale-up

Importance of engaging pertinent stakeholders at the design, development and implementation phases