The Challenge of Non-Communicable Diseases and Road Traffic ...

64 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa
BOX 13: Supporting PLWH Self-Management Leads to Expanded Services in Tanzania
In the Morogoro Region of Tanzania, the USAID Health Care Improvement project has been working with providers, health
officials, and community-based organization to support a facility-based, peer mentoring program for people with HIV.
PLWH with a record of successful self-management are recruited and trained as expert patients, known as “peer mentors”.
They volunteer at health facilities to support new HIV patients and patients having difficulties in providing good
self-care through group education sessions and individual motivational counseling. Improved self-management support
has resulted in significant increases in adherence, appointment-keeping, and the percentage of patients expressing the
confidence to self-manage themselves. These peer mentors have also assumed many routine clinic tasks, such as: patient
registration, filing, packaging of cotrimoxazole tablets, and assessment of patients’ nutritional status. Consequent
reductions in provider work load have allowed facilities to begin introducing expanded services for HIV patients such as
hypertension screening and treatment.
Source: [422]
Human Resources for Health
Africa has long struggled with acute health workforce
shortages: SAA has 24 percent of the global
burden of disease but only 3 percent of all health
workers, and migration of health workers, both to
positions that do not include patient care and to
clinical positions in higher income countries, is a
significant problem [442]. Furthermore, some see
the growing private health care sector in some countries
as having the potential to siphon off both human
and financial resources [398]. The average physician-to-population
ratio in SSA is 2.2 per 10,000
of the population (ranging from 0.1 in Liberia to 5.7
in Cape Verde). The nursing and midwifery personnel-to-population
ratio is nine per 10,000 population
(ranging from 0.4 in Guinea to 28.4 in Botswana)
[397]. There are relatively few specialist training institutions
in Africa, with some countries completely
reliant on foreign education for specialists.
The severe shortage and imbalanced distribution
of trained health workers (and health promoters)
is not just an obstacle to tackling NCDs but also to
the delivery of good quality clinical services in general,
jeopardizing achievement of the MDGs and
improvement of the overall health of the poor, suggesting
the need to align health sector, civil service,
and macroeconomic policies in finding workforce
solutions [443].
Simply scaling up the production of health workers
is not a good enough fix, as urban unemployment,
rural shortages, health sector attrition, including migration
abroad, as well as absenteeism and low productivity
(labor market leakages and inefficiencies)
will waste investments. Potential solutions need to
identify and address country-specific labor market
leakages and inefficiencies, including through: (1)
monetary and non-monetary incentives; (2) innovative
education models (including rural pipeline
models); (3) increasing opportunities for funding
for human resources for health, particularly in rural
areas; and (4) strengthening management and accountability
systems in frontline facilities [444].
Task Shifting
Innovative strategies to expand health-system capacity
to address HIV and other health challenges
include ‘task-shifting’ in clinical settings so that tasks
performed by physicians (or any higher cadre) are
delegated where appropriate to lower cadre health
workers who have a defined set of skills or been specifically
trained to perform a limited task [445]. Appropriately
trained nurses have been demonstrated
to provide effective care for patients similar to that
provided by doctors, and to achieve positive health
outcomes in chronic disease management, illness
prevention, and health promotion [446-447]. This
approach has been applied in a range of NCDs, such
as asthma, hypertension, and diabetes mellitus, and
with minimal additional resources can also improve
patient retention and satisfaction for chronic disease
management [448-453].
While the rationale behind transferring the tasks is
that the alternative would be no service at all to those
in need, the approach is not without risk. Unless
planned and managed appropriately, there is potential
for fragmentation and decreased quality of care, and