Likewise, Ethiopia has adopted a standardised approach to HIV care based on task shifting, but at the same time has ramped up the production of healthcare workers, along with improvements in the health systems to boost retention and monitor the quality of care being delivered.
“We tried to identify the human resources we needed based on the programmes we have, based on the priorities we have and we tried to train enough of that,” said Dr Adhanom.
An emphasis on primary care provided by health service extension officers
He stressed that most of the care that needs to be given to people in Ethiopia, including people with HIV, is preventive primary care — which can be addressed by professional healthcare workers with less training “who are not affected by brain drain.”
To fill this need, Ethiopia has created a cadre of health service extension officers (HSEOs), whose role is to bridge the gap between health facilities and where people live in the community. According to Mr Lencha’s presentation, the HSEOs focus on four key areas, by delivering:
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A prevention and control package for the major communicable diseases: HIV/AIDS, malaria and TB
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A family healthcare package
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A hygiene & environmental health package
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Health education (providing essential health information and behaviour change communication)
The government worked closely with regional and local partners to develop curriculum and training materials and to pilot the project.
The communities take part in selecting the trainees, who have to have completed school grade 10, and who, for the most part, are women (except in pastoral areas). Mr Lencha said this was for a couple of reasons including their traditional roles in Ethiopia as family caregivers and because it is more culturally acceptable for a woman to go into homes and to talk frankly about health matters, especially with another woman. “For a man, it would be difficult,” he said.
Training lasts for a year, a quarter of which is theoretical, while the rest of the year is practical, based in the community and households. The HSEOs are then deployed to their own community, paid by the government and theoretically at least, are supposed to deliver service house-to-house. In fact, the goal is to provide universal access to home and community-based care by 2009. So far, 80% of the kebeles (Ethiopia’s smallest administrative unit) are covered.
“We have targeted to train 30,000 and we have trained and deployed 24,000 and the remaining 6,000 will be trained by December 2008," said Dr Adhanom. “So this cadre will work on prevention, not only for HIV, for other programmes as well. We use the HIV money, the money from PEPFAR and Global Fund, to use this cadre of professionals, and they are actually serving [all of] their communities.”
Ethiopia expects a lot out of these workers, whose role is to “create a social transformation,” Mr Lencha said. But they also fill a potential gap in services as more technical tasks are shifted to nurses.
Note, the HSAs in Malawi are supposed to fulfil a similar function, providing the essential health packages in villages, and the country has set a target of engaging 1 HSA per 1,000 people.
Accelerated training of health officers and doctors
Tasks such as ART and most curative services have been assigned to health officers (clinical officers in Ethiopia) and to a lesser extent nurses.
“More than 90% of our patients just need the attention of health officers and nurses. They do not need more highly skilled professionals,” said Dr Adhanom.
So the Ministry of Health has launched a training programme to produce 5,000 health officers by 2010. Training takes place in five universities and at 21 training hospitals, involving one year at university and two years in practical training at the hospitals, leading to a bachelors of medicine. By June this year, the programme had graduated 1000 health officers, with another 4200 currently enrolled. 5000 are to be deployed by 2010 to enable health centres through-out the country to provide universal access.
But Ethiopia has also dramatically increased the number of doctors being produced as well.
“Before 2008, the average annual intake of medical officers was only 200 and now we have increased this to 1,000,” said Mr Lencha. By 2009, this is supposed to increase to 1,800. Annual enrolment is planned to increase to 8,000 by September 2009 at 21 universities and 40 hospitals so that Ethiopia can increase its number of hospitals from 143 currently to 800 by 2013 (to service a population of around 80 million).
Maintaining high quality with mentorship via the health network model
As tasks are being shifted from more highly trained staff to health workers with less training, Ethiopia is setting up a formal system of clinical mentoring using the health network model. In other words, larger facilities support smaller ones, and doctors should be providing support to the clinical officers, the clinical officers to the nurses and so on. The cadres of case managers, community-based workers providing HIV testing and counselling, and adherence support counsellors also require supervision. There is a goal of setting up routine meetings and seminars within each catchment area.
But already, there have been reports that more mentorship and supervision may be necessary, at least at the HSEO level. Preliminary research showed that communities were generally pleased by the services the workers were offering, but home visits were less frequent than had been planned, and the communities’ basic health knowledge was still quite poor (Negusse). “The reasons for this clearly need to be ascertained, but anecdotal accounts suggested a lack of administrative support and monitoring may be partly responsible,” the authors wrote.
Maintaining a consistently high quality of service will doubtless be a moving target, but it may be possible to improve supervision as more highly trained health workers come online.
Monitoring and evaluation (M&E) and information management systems
To recognise such problems sooner and improve the health systems performance with strategic information, Ethiopia is also scaling up the production of M&E officers and health management and information services (HMIS) technicians (8,000 this year) to eventually be appointed at each level of administration throughout the health service (hospitals, health centres, districts, and regions).
Improving retention and motivation within the health service
“We also have to have mechanisms to retain and motivate the workers,” said Mr Lencha. So the Ministry of Health has designed a career development structure, which includes bonding — tying opportunities for training or promotions to a minimum number of years of service in the health service. In addition, the country is working on hospital reform to improve the work environment and there are efforts to provide housing at remote rural hospitals and improve remuneration.