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Task-Shifting Regulatory Framework

Task-Shifting Regulatory Framework. WHO/OGAC Task Shifting Consultation Meeting. June 14th, 2007 Kigali, Rwanda The George Washington University John Palen PhD, MPH, PA Alan Greenberg MD, MPH Anne Markus JD, PhD, MHS Seble L. Frehywot MD, MHSA. Presentation Outline. Project Overview

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Task-Shifting Regulatory Framework

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  1. Task-Shifting Regulatory Framework WHO/OGAC Task Shifting Consultation Meeting June 14th, 2007 Kigali, Rwanda The George Washington University John Palen PhD, MPH, PA Alan Greenberg MD, MPH Anne Markus JD, PhD, MHS Seble L. Frehywot MD, MHSA

  2. PresentationOutline Project Overview Regulatory Systems Application of Regulatory Systems to Task Shifting Levels I – IV Issues for consideration

  3. Project Preview

  4. 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

  5. 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

  6. Regulatory Systems

  7. 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 allin their accessto 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...

  8. 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

  9. Model 1: Map of Domestic National and Local Framework President & hisCabinet Supreme Court Parliament Civil Service Commission LineMinistries High Court Health Professions Regulatory Bodies MOH MOF MOE MOLG MOJ MOL MOA MOG MOED U. Schools & Colleges Unions Associations SWAp (health) Zones District Assemblies Local Governments Lower Courts NGOs DHO (Mini-SWAp)

  10. Model 2: Map of Domestic National and Local Framework President Prime Minister & the Council of Ministers Supreme Court Parliament Line Ministries High Courts Health Professions Advisory Council First Instance Courts FMoH FMoF FMoE FMoJ MOL FMoCB Civil Service Agency U. Schools & Colleges NGOs Unions Associations State Assemblies State Governments State Supreme Courts State High Courts RHB RFB REB RJB RLB State First Instance Courts Zones Localities Districts

  11. Interaction between Domestic and International Frameworks IMF WB WHO ILO • Government/ • Non-Government • International bi-and multi-lateral funding sources in health sector • --------------------------- • GFATM IMWI ICN IPA PLWHA International Groups MOH MOF MOJ MOL National Level Nursing and Midwives Associations United States Government MOU Registration - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Implementing Partners: International NGO’s Sub-national Level Sub-nationalgovernments MOU/ Service Agreement

  12. Task-shifting Process & Components Supervision & Accountability & continual education (mentoring) Sub national implementation 8 9 7 Working Conditions Health Workers 1 Scope of Practice & Competencies Recruitment, Deployment, Promotion, Salary, & Other Human Resources Issues 6 Standards of Care 2 Certificate & standard In-Service Training 5 Standard Pre-Service Medical, Nursing, Clinical Education & Training 3 Licensing & Registration 4

  13. Application of Regulatory Systems to Task Shifting I,II,III & IV

  14. Task Shifting Types Task shifting II Registered Nurses (with BSN, degree, or 3 year diploma) & nurse mid-wives Non-physician clinicians (clinical officers, health officers) Task shifting III Task shifting I Enrolled nurses (with 2 year Diploma) REGULATION Supervision, Delegation, Substitution, Enhancement, Innovation Doctors Nursing Assistants & Community Health Workers Task shifting IV Expert Patients

  15. Task-shifting I

  16. Tasks Shifted Medical Doctor Initiation of staging and diagnosis Extra in-service training given Delegation Diagnostic and Prescriptive privileges Initiation of ARV prescription Tasks-shifted Initiation of OI prophylaxis Non-physician Clinicians (e.g. Clinical Officers, Health Officers)

  17. Task-shifting I -- Model 1 Process & Components Medical, Dentists & Allied Professionals Council, MOHP, Physicians MOLG &RD, DHO, ZHO, MOHP, Medical Practitioners And Dentist Act & Pharmacy, Medicines and Poisons Act Supervision & Accountability & continual education (mentoring) 9 Sub national implementation 8 MOL&SA, ILO,MOHP Physician Association DHO Medical, Dentists & Allied Professionals Council, Pharmacy Board Scope of Practice & Competencies Working Conditions 1 Labor Act 7 Non-physician Clinicians (Clinical Officers Medical Assistants) MOHP Guideline for the use of ART Health Services Commission, MOHP DHRMD, MOF, IMF Recruitment, Deployment, Promotion, Salary, & Other HR Issues Medical, Dentists & Allied Professionals Council, Physician Assoc, MOHP, WHO Standards of Care 2 6 Certificate & standard In-Service Training Standard Pre-Service Medical, Clinical Education & Training Licensing & Registration 3 5 4 MOE, MOHP, Colleges of Health Sciences, Medical Council MOHP, Medical, Dentists & Allied Professionals Council, Physician Assoc Medical, Dentists& Allied Professionals Council

  18. Task-shifting I -- Model 2 Process & Components RHB, ZHB MOHP, RHB Physicians NO Medical Practice or Pharmacy Act Supervision & Accountability & continual education (mentoring) 9 Sub national implementation 8 MOL&SA, ILO, FMOH FMOH NO Scope of Practice Competencies Working Conditions Labor Act 1 7 Non-physician Clinicians (Health Officers) Civil Services Commission, FMOH RHB, FMOF&ED, IMF, Int. Donors ART Implementation Guideline Recruitment, Deployment, Promotion, Salary, & Other HR Issues 2 Standards of Care 6 FMOH Certificate & standard In-Service Training Standard Pre-Service Medical, Clinical Education & Training Licensing & Registration 3 5 4 FMOE, RHB,FMOE, Universities, Teaching Hospitals , Physicians FMOH, RHB FMOH, RHB, REB

  19. Task-shifting II

  20. Tasks Shifted Medical Doctor Non-physician Clinicians (e.g. Clinical Officers, Health Officers) Initiation of staging and diagnosis Delegation & or Supervision Diagnostic and Prescriptive privileges Initiation of ARV prescription Tasks-shifted Extra in-service training given Initiation of OI prophylaxis Registered Nurse, Enrolled Nurses (With BSN or degree) (With 3yr diploma) and Nurse Midwives

  21. Task-shifting II -- Model 1 Process & Components Nurses & Midwives Council, MOHP, Physicians, Clinical Officers MOLG &RD, DHO, ZHO, MOHP, Nurses & Midwives Act & Pharmacy, Medicines and Poisons Act Supervision & Accountability & continual education (mentoring) 9 Sub national implementation 8 Nurses & Midwives Council Medical, Dentists & Allied Professionals Council, Pharmacy Board MOL&SA, ILO,MOHP Nurses Association DHO Scope of Practice & Competencies Working Conditions Labor Act 1 7 Nurses and Midwives ART Implementation Guideline Health Services Commission, MOHP DHRMD, MOF, IMF Nurses Assoc. MOHP Recruitment, Deployment, Promotion, Salary, & Other HR Issues Standards of Care 2 Nurses & Midwives Council Nurses Assoc, MOHP 6 Certificate & standard In-Service Training Standard Pre-Service Nursingl, Clinical Education & Training Licensing & Registration 3 5 4 MOE, MOHP, Colleges of Health Sciences, Universities, Nurses & Midwives Council, Nurses Association MOHP, Nurses & Midwives Council Nurses Association Nurses & Midwives Council

  22. Task-shifting II -- Model 2 Process & Components RHB, ZHB MOHP, RHB Physicians, Health Officers NO Nurses Practice or Pharmacy Act Supervision & Accountability & continual education (mentoring) 9 Sub national implementation 8 MOL&SA, ILO, FMOH, Nurses Assoc. FMOH, FHAPCO NO Scope of Practice Competencies Working Conditions Labor Act 1 7 Nurses and Midwives Civil Services Commission, FMOH RHB, FMOF&ED, IMF, Int. Donors ART Implementation Guideline Recruitment, Deployment, Promotion, Salary, & Other HR Issues 2 Standards of Care 6 FMOH Certificate & standard In-Service Training Standard Pre-Service Nursing, Clinical Education & Training NO Licensing Registration 3 5 4 ,FMOE, RHB, FMOH, Nursing Colleges, FHAPCO, International Universities, FMOH, RHB FMOH

  23. Task Shifting III

  24. Tasks Shifted Nurses and Midwives Single task-shifting - HIV Counseling & Testing - Adherence Counseling Supervision Tasks-shifted - Home-based Care - HIV prevention - Other support services Multiple task-shifting Nurse Assistants and Community Health Workers ( e.g. HEW, Community Counselors)

  25. Task-shifting III -- Mechanism 1 FHAPCO,CBO/NGO/FBO RHB, ZHO, DHO Supervision & Accountability & continual education (mentoring) 9 8 Sub national implementation Civil Services Commission, FMOL FMOH, CBO, NGO, FBO, Prof Asscc. Donor Scope of Practice & Competencies Working Conditions 1 Labor Act 7 Nurse Assistants And Community Health Workers FMOH, RHB Civil Services Commission - Civil Service Status Recruitment, Deployment, Promotion, Salary, & Other HR Issues FMOH, CBO/NGO/FBO, WHO, Donor Standards of Care 2 6 Certificate & standard In-Service Training Standard Pre-Service Medical, Clinical Education & Training NO Licensing Registration 3 5 4 FMOH, FMOE,REB CBO/NGO, FBO FHAPCO, CBO/NGO/FBO, Donor MOH, RHB, REB

  26. Task-shifting III -- Mechanism 2 Variable RHB, DA, DHO Supervision & Accountability & continual education (mentoring) 9 Sub national implementation 8 MOH, CBO, NGO, FBO Variable Scope of Practice & Competencies Working Conditions 1 7 Nurse Assistants And Community Health Workers Recruitment, Deployment, Promotion, Salary, & Other HR Issues Variable Variable 2 Standards of Care 6 Certificate & standard In-Service Training Standard Pre-Service Medical, Clinical Education & Training Licensing & Registration 3 5 4 MOH, MOE, CBO/NGO/FBO “Certificate of Attendance” MOH, CBO/NGO/FBO

  27. Task Shifting IV

  28. Tasks Shifted Nurse Assistants and Community Health Workers Single task-shifting • Adherence Counseling • Adherence Support • HIV counseling Supervision Tasks-shifted • Patient Referral • Outreach Multiple task-shifting Expert Patients

  29. Task-shifting IV -- Mechanism 1 CBO/NGO/FBO RHB, DA, DHO Supervision & Accountability & continual education (mentoring) 9 8 Sub national implementation Health Services Commission, MOL MOH, CBO, NGO, FBO, Donor Scope of Practice & Competencies Working Conditions 1 7 Expert Patients Health Services Commission Recruitment, Deployment, Promotion, Salary, & Other HR Issues CBO/NGO/FBO, Donor 2 Standards of Care 6 Certificate & standard In-Service Training Standard Pre-Service Medical, Clinical Education & Training Licensing & Registration 3 5 4 CBO/NGO, FBO MOH, CBO/NGO/FBO, Donor

  30. Task-shifting IV -- Mechanism 2 Variable RHB, DA, DHO, CBO/NGO/FBO Supervision & Accountability & continual education (mentoring) 9 Sub national implementation 8 MOH,CBO, NGO, FBO Variable Scope of Practice & Competencies Working Conditions 1 7 Expert Patients Recruitment, Deployment, Promotion, Salary, & Other HR Issues Variable Variable 2 Standards of Care 6 Certificate & standard In-Service Training Standard Pre-Service Medical, Clinical Education & Training Licensing & Registration 3 5 4 MOH, MOE, CBO/NGO/FBO “Certificate of Attendance” MOH, CBO/NGO/FBO

  31. 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

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