WHO: Lack of new antibiotics threatens global efforts to contain drug-resistant infections (6) Task shifting (1) Practical Approach to Care Kit (PACK)

20 January, 2020

Dear All, [in response to Kenneth Iregbu, Nigeria: http://www.hifa.org/dgroups-rss/who-lack-new-antibiotics-threatens-globa... ]

Some of us used to think that Task Shifting was impossible especially in our context in LMICs with the very weak health systems. The doubt about Task shifting is fueled by a myriad of reasons, that also varies from country to country: lack of understanding of task shifting/ task mixing; fear of loss of professional clout; desire to maintain practice turf; existing disharmony between doctors on onside and the other health workers on the other side; belief that other professionals cannot be taught to take on tasks performed by the other profession; etc.

However, the fact is that most of the indicators of quality and safe care cannot be achieved, and UHC and SDG are not attainable in LMICs unless workable solutions are found, now, to address the serious challenge posed by inadequate numbers and skewed distribution of doctors and other health workers in general.

As I said above, we shared the doubts about Task shifting in Nigeria with colleagues, because of all the reasons mentioned above, until we saw The PACK Programme for primary health care (the 4+1 pillars) which is originally produced KTU University of Cape Town, South Africa about 20 years ago. (PACK = Practical Approach to Care Kit for primary health care) (currently in use in Ethiopia, Brazil, Botswana, etc etc).

Our discovery of PACK Programme coincided with the release of the service delivery indicator (SDI study) in PHC in Nigeria in 2014 by Wirkd Bank Nigeria and FMOH, which showed some shocking results, especially low clinical competence of PHC clinical cadres that leads to very low diagnosis and treatment accuracy rates. No wonder, according to Health Reports from various global bodies, Nigeria continues to lead the world in maternal, newborn, child mortality and other poor health indices for decades.

We took the PACK Programme to Nigeria, assembled a multidisciplinary team that fully localized the content, line by line, with evidence provided by BMJ and WHO, and aligned the guide and training materials to over 14 extant guidelines, policies and protocols in use in PHC in Nigeria, including the latest Standing Order 2015 which is used by community health practitioners ( CHPs) since 1995. And including the National Task shifting Policy 2014 of Nigeria, the curriculum for pre service training of CHPs, nurses and midwives and medical doctors. The pilot/ intervention received ethical approval from the National HREC of the FMOH, and was supported by FMOH, NPHCDA, the relevant regulatory bodies ( CHPRB, NMCN, MDCN), the NSHIP states ( 3 states at the time). etc.

This quality improvement tool (PACK Nigeria Programme) was then piloted over 6 months in 2017. The outcome was massive, and provided point-of-care-derived evidence of improvement in all the indicators of quality raised by the SDI study cited above. And more.

We are converts to the benefits of Task shifting and mixing especially in LMICs with such dearth of doctors and other health workers, not only in total but also their skewed distribution from urban to suburban, rural and difficult to reach parts of a country.

We have been seeking to recruit more converts to the benefit of evidence based tools like PACK Programme because it solves the concerns about Task Shifting while maintaining total quality and safety in patient care.

We hope to share the published report on PACK Nigeria Programme pilot at the various professional meetings this year to help dispel the fears and doubts about targeted, evidence informed and guided Task Shifting. We are really pleasantly surprised that All cadres working in PACK-enabled facilities in the pilot, work in harmony and complied to their prescribed limit of practice.

Over 90% of the users wrote that ‘before PACK I did not know my limit but with it I now know my limit of competence when to stop and refer to the next higher cadre’. Which means that In our pilot Community health extension workers did not become nurses / midwives and the nurses and midwives did not be one medical doctors.

Data from the pilot has been used to demonstrate that PACK Programme ensures antibiotics stewardship and reduces polypharmarcy and reduces inappropriate multiple laboratory testing. Gains made from this better prescribing, diagnosis and treatment guarantees that the Programme after the initial investment, can be cost effective and sustainable in the medium and long term.

Finally given the weak state of health systems in LMICs it should be clear that achieving Universal Health Coverage and/or SDG by 2030 is not possible. Strategic and structured Task shifting is imperative.

Joseph Ana

HIFA profile: Joseph Ana is the Lead Consultant and Trainer at the Africa Centre for Clinical Governance Research and Patient Safety in Calabar, Nigeria. In 2015 he won the NMA Award of Excellence for establishing 12-Pillar Clinical Governance, Quality and Safety initiative in Nigeria. He has been the pioneer Chairman of the Nigerian Medical Association (NMA) National Committee on Clinical Governance and Research since 2012. He is also Chairman of the Quality & Performance subcommittee of the Technical Working Group for the implementation of the Nigeria Health Act. He is a pioneer Trustee-Director of the NMF (Nigerian Medical Forum) which took the BMJ to West Africa in 1995. He is particularly interested in strengthening health systems for quality and safety in LMICs. He has written Five books on the 12-Pillar Clinical Governance for LMICs, including a TOOLS for Implementation. He established the Department of Clinical Governance, Servicom & e-health in the Cross River State Ministry of Health, Nigeria in 2007. Website: www.hriwestafrica.com Joseph is a member of the HIFA Steering Group and the HIFA working group on Community Health Workers.



Email: jneana AT yahoo.co.uk