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Experience of Task Shifting in Mozambique: A Response to Limited Human Health ResourcesA Response to Limited Human Health Resources

Nafissa Bique Osman

Department of Obstetric and Gynecology, Eduardo Mondlane University, Central Hospital, Maputo.

XIX FIGO World Congress, 4-9 October 2009, Cape Town

Safe Motherhood and Newborn Health

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Mozambique

• Population: 20 million• Growth rate: 2.4%• Pop in rural area: 70%• P density: 20 inh/km²• Among the 10 poorest countries

in the world• Poverty line: 69.4% below • Life expectancy at birth:

45 years

• Source: 2007census, DHS 2003

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Mozambique

• Children< 5yr: 17% pop• 10-24 yrs: 33% pop• 15-49 yrs: 49% pop• Women 15-49yrs: 25% pop = 5 million• >50 yrs: 9.4% pop• Birth rate: 35.2/ 1000 • Death rate: 21.3/ 1000

Source: 2007census, DHS 2003

Source: 2007census, DHS 2003

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Maternal and neonatal HealthMaternal and neonatal Health

• Worldwide, more than one woman dies every minute, 585.000 women die every year.

Ninety nine percent of these deaths occur in developing countries, demonstrating that they could be avoided if resources and services were available

• Complications of pregnancy and childbirth are the leading causes of death among women of reproductive age in Mozambique

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Maternal HealthMaternal Health

ANCANC- 84% pregnant women -1 visit

Institutional deliveries:Institutional deliveries: 46% (urban- 71%, rural- 29%)

Maternal mortality: 1997- 975/ 100,000 2003- 408/ 100,000

1/3 of Maternal death are < 19 years old

Main causes of MM:Main causes of MM:

75% direct causes75% direct causes: hemorrhage, sepsis, eclampsia, uterine rupturehemorrhage, sepsis, eclampsia, uterine rupture 25%25% indirect causes: HIV, malariaHIV, malaria

Source: DHS 1997 & 2003, Revision of MM study, MOH 1998

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Neonatal and Infant mortality

Neonatal mortality:Neonatal mortality: 1997: 59/1000 live births 2003: 48/ 1000 live births

Main causes:Main causes: preterm delivery, LBW, infections, asphyxia

Infant mortality:Infant mortality:

1997: 147/ 1000 live births 2003:125/ 1000 live births

Source: DHS 1997 & 2003

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Challenges in Safe MotherhoodChallenges in Safe Motherhood

Adolescent pregnancy: Adolescent pregnancy: 40%40% Unwanted pregnancies, early marriageUnwanted pregnancies, early marriage Unsafe abortion: Unsafe abortion: 11% of MM11% of MM Contraceptive rate: Contraceptive rate: 1997: 6% 1997: 6% 2003: 17%2003: 17%

Modern contraceptive rate: 2003: 12%Modern contraceptive rate: 2003: 12% Women knowledge of contraceptives: Women knowledge of contraceptives: 90%90% Syphilis in pregnancy: Syphilis in pregnancy: 7%7% HIV prevalence: HIV prevalence: 16%16%

Source: DHS 1997 & 2003, Epidemiological Surveillance, 2007

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National Health National Health SystemSystem Primary levelPrimary level::

Health post (514) Health post (514) Rural and urban health centers (775)Rural and urban health centers (775)

Secondary levelSecondary level:: Rural and district hospital (31), general hospitals (4).Rural and district hospital (31), general hospitals (4). First referral levelFirst referral level

Tertiary level:Tertiary level: Provincial hospital (7)Provincial hospital (7)

Quaternary level: Central hospital (3)Central hospital (3)

1 health unit/ 15,000 inhabitants1 health unit/ 15,000 inhabitants 1 hospital/ 434,368 inhabitants 1 hospital/ 434,368 inhabitants

Source: MoH, NDH, 2006

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Strategies to decrease MMStrategies to decrease MM

1975 Independence. Universal access to primary health care was a goal but, Independence. Universal access to primary health care was a goal but,

human resources crisis, 80 Moz doctors/14 million;human resources crisis, 80 Moz doctors/14 million;

Intensive training of nurses, midwives, medical officers to replace the doctor;Intensive training of nurses, midwives, medical officers to replace the doctor;

Elementary (1yr training) and basic (20 month training) mother/child nurse-Elementary (1yr training) and basic (20 month training) mother/child nurse-midwives to work at primary care level and also at 2midwives to work at primary care level and also at 2ndnd and 3 and 3rdrd level level

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Task Shifting and Delegation of Task Shifting and Delegation of responsibilitiesresponsibilities

1980 Civil war, increased casualties, unmet need for emergency life saving skills

in war casualties and obstetrics; No surgeons, obstetricians and orthopedics in rural, district hospitals; Long distance and deficient transport network

19841984 Training of assistant medical officers with skills in surgery “técnico de técnico de

cirurgia” (TC); cirurgia” (TC); 3 year training to perform all emergency operations in obstetric, trauma

and surgery. Training of “técnico” of anesthesiologyTraining of “técnico” of anesthesiology

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Evaluation of TC skills in ObstetricsEvaluation of TC skills in Obstetrics

Controversy of delegation of major operations to a non medical doctor;Controversy of delegation of major operations to a non medical doctor; Evaluation after 4 yr of the 1Evaluation after 4 yr of the 1stst group group

19921992 Evaluation of 958 cesarean deliveries performed by TC & 1113 by

obstetricians at Central Hospital in Maputo– found no clinically significant difference in postoperative outcomes. Superficial wound separation more frequent in CS by TC

Source: C Pereira, A Bugalho, S Bergstrom, F Vaz, M Cotiro. A comparative study of cesarean deliveries by assistant medical officers and obstetricians in Mozambique. Br J obstet Gynaecol 1996; 103:508-12

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Task Shifting and Delegation of Task Shifting and Delegation of responsibilitiesresponsibilities

19901990 Medium level mother/child nurse-midwife 30 months training with skills Medium level mother/child nurse-midwife 30 months training with skills

for EmOC (basic)for EmOC (basic)20042004 High level nurse-midwife with university degree: 3 year training- High level nurse-midwife with university degree: 3 year training-

bachelorbachelor 4 year training- licentiate. With training in EmOC (comprehensive) 4 year training- licentiate. With training in EmOC (comprehensive)

including cesarean sectionincluding cesarean section2008 29 were graduated. Now, 1 class of 37 student, in 729 were graduated. Now, 1 class of 37 student, in 7thth semester and 1 semester and 1

class of 35 student in 3class of 35 student in 3rd rd semester semester

Source: Instituto Superior de Ciências de Saúde

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Task Shifting and Delegation of responsibilities

20042004 Revue of TC curriculaRevue of TC curricula 3 yrs training- bacharel3 yrs training- bacharel 4 yrs training- licentiate4 yrs training- licentiate So far 61 TC graduated as bachelor and licentiate degree. So far 61 TC graduated as bachelor and licentiate degree. Retired and died: 11Retired and died: 11 Now, 1 class with 18 students in the 4Now, 1 class with 18 students in the 4thth year training and 1 year training and 1

class with 16 student in the 1class with 16 student in the 1stst year. year.

Source: Instituto Superior de Saúde

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Evaluation of TC skills in ObstetricsEvaluation of TC skills in Obstetrics

2002 2002 Analyses of 12,178 obstetric operations in all 34 public Analyses of 12,178 obstetric operations in all 34 public

hospitals;hospitals; TCs performed 92% of major obstetric surgery at TCs performed 92% of major obstetric surgery at

district/rural hospital;district/rural hospital; TCs compared with physicians, stay longer in rural TCs compared with physicians, stay longer in rural

areas. After 7 years 90% of TCs were still in district areas. After 7 years 90% of TCs were still in district hospitals while no physician remainedhospitals while no physician remained

Source: C Pereira, A Cumbi, R Malalane, F Vaz, C McCord, A Bacci, S Bergstrom. Meeting the need for emergency obstetric care in Mozambique: work performed and histories of medical doctors and assistant medical officers trained for surgery. BJOG 2007; DOI:10.1111/j.1471-0528.2007.01489.

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Human ResourcesHuman Resources

Elementary level health worker- 63%Elementary level health worker- 63% Basic level health worker- 20%Basic level health worker- 20% Medium level health worker- 13%Medium level health worker- 13% High level health worker- 4%High level health worker- 4% 1 doctor & 7 nurses/ 33,000 inhabitants1 doctor & 7 nurses/ 33,000 inhabitants Obstetricians- 42 in provincial & central hospital, being 12 in Obstetricians- 42 in provincial & central hospital, being 12 in

Maputo cityMaputo city

Source:Source: MoH DNRH, 2006MoH DNRH, 2006

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Challenges

Conflict between doctor (GP), TC and midwife

Midwife performing CS, less interested in routine midwifery work at normal delivery

Importance of Team Work: Obstetrician, GP doctor, Midwife and TC

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ConclusionsConclusions

After 20 yr experience of delegation of surgical After 20 yr experience of delegation of surgical interventions to “técnico de cirurgia” and 1 yr to midwives, interventions to “técnico de cirurgia” and 1 yr to midwives, we can say that this strategy is very important to increase we can say that this strategy is very important to increase access to Comprehensive EmOC at first referral level.access to Comprehensive EmOC at first referral level.

It can contribute to reduction of maternal and neonatal It can contribute to reduction of maternal and neonatal mortality in poor countries with shortage of human mortality in poor countries with shortage of human resources resources

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Thank You