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Transcript of 1 Task-Shifting Regulatory Framework June 14th, 2007 Kigali, Rwanda The George Washington University...
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