Implementation Guidance Note

Implementation Guidance Note

American College of Nurse-Midwives (ACNM) Averting Maternal Death and Disability (AMDD) Program Chainama College of Health Sciences (CCHS) College of Medicine, Malawi (COM) Community Health Promotion, Kenya (CHPK) Muhimbili University of Health and Allied Sciences, Tanzania (MUHAS) East Central and Southern Africa Health Community (ECSA HC) URC through the USAID TRAction Project

Significant human resource crisis impacting health in SSA 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed Innovative approaches to HRH crises have been employed in SSA for decades: Associate Clinicians In some countries Associate Clinicians perform up to 80% of all surgeries

Proportion of population without access to safe, affordable surgery and anaesthesia

Many programs and strategies have been implemented to address inequitable distribution and safe provision of surgical care: Performance based financing Use of foreign doctors Task Sharing Surgical camps Changing retirement age/employing retired surgeons

The Guidance Note on Task sharing on the performance of Caesarean Section by Associate Clinicians is being developed to guide countries seeking to implement task sharing programs for caesarean section or to strengthen the implementation of such programs in countries already implementing such programs. It expands on areas pointed out in the WHO Optimize MNH recommendations as areas that planners need to take into considerations when starting task shifting programs.

A professional clinician with basic competencies to diagnose and manage common medical, maternal, child health and surgical conditions. They may also perform minor surgery. The prerequisites and training can be different from country to country. However, associate clinicians are generally trained for 3 to 4 years postsecondary education in established higher education institutions. The clinicians are registered and their practice is regulated by their national or subnational regulatory authority. Clinical officer (e.g. in Tanzania, Uganda, Kenya, Zambia), medical assistant, health officer, clinical associate, nonphysician clinician 11/02/2016 7

ADVANCED A professional clinician with advanced competencies to diagnose and manage the most common medical, maternal, child health and surgical conditions, including obstetric and gynaecological surgery (e.g. caesarian sections). Advanced level associate clinicians are generally trained for 4 to 5 years post-secondary education in established higher education institutions and/or 3 years post initial associate clinician training. The clinicians are registered and their practice is regulated by their national or subnational regulatory authority Assistant medical officer, clinical officer (e.g. in Malawi), medical licentiate practitioner, health officer (e.g. Ethiopia),physician assistant, surgical technician, medical technician, non-physician clinician 11/02/2016 8

11/02/2016 9

The Guidance Note is informed by an implementation research conducted in four ECSA- HC member states. Specifically for the research, the objective was to identify the barriers and facilitating factors for scaling-up task shifting/sharing approaches, which seek to expand access to caesarean section services in low-income countries and ultimately improve maternal, newborn and child health There the research explored and identified salient issues of what worked and what didn t in terms of the implementation of a new or upgraded cadre in the study countries.

Kenya, Zambia, Tanzania and Malawi Data collection methods: Focus group discussions Key Informant Interviews Record reviews (in Zambia and Tanzania) Informant types: AACs, MDs, Hospital Administration, OB teams, training institutions, regulatory bodies, Ministry representatives, interns, District and Medical managers, NGOs supporting the training, professional associations, and others as other country-specific stakeholders

Cadre Medical Licentiate Practitioners (MLP) - Zambia Clinical Officer Reproductive Health Specialty - Kenya Assistant Medical Officer - Tanzania Year Established Years Training 2002 Clinical Officer + 2 years training 1 year internship 2002 Clinical Officer + 1.5 years training 6 mos internship 1963 Clinical Officer + 2 years training Clinical Officer - Malawi 1974 Certificate (name?) + 1.5 years training 6 mos internship Award Received Advanced Diploma* BSc - NEW Advanced Diploma BSc - PLANNED Advanced Diploma Diploma BSc in specialty

Malawi: Clinical Officer (CO) 1976 56 KIIs & 4 FGDs Task Sharing for Caesarean Section in Malawi: A case study Tanzania: Assistant Medical Officer (AMO) 1964 40 KIIs & 4 FGDs Task sharing for caesarean section delivery by Assistant Medical Officers in Tanzania; A case study Kenya: Clinical Officer of Reproductive Health Specialty (CORH) 2002 38 KIIs (smaller study) Expanding access to comprehensive emergency obstetric care focusing on CS: A rapid assessment of the Kenyan CORH Specialty Zambia: Medical Licentiate Practitioner Program (MLP) 2002 58 KIIs Provider survey with 76.4% response rate (of all currently practicing MLPs) Medical Licentiate Practitioners: Implementation of a Task Shifting Programme in Zambia 14

All four country case studies were completed Teams came together to discuss findings, identify higher level findings per domains + additional categories that emerged through the analysis Drafted Guidance Notes as a team Conducted a GN Validation Workshop in Tanzania with various representatives from Ministries of Health, WHO Afro Region and other stakeholder groups

Introduction Brief picture of four country AC cadres Implementation considerations related to specific domains: Stakeholders Regulation and Statutory Environment Training and Education Human and Capital Resource Management Human Resource Management Role Distribution Referral Infrastructure, Equipment and Medical Supplies Incentives

Domain specific components Hardware and software components Country examples to illustrate what worked or did not work with the implementation

The curriculum should be adapted regularly to reflect feedback from students, consultants, and trainers, as well as changing burden of disease. Key considerations for implementation: Are there existing processes by which curricula for other cadres are reviewed, and if so, can these be adapted for use by AC training programs? a.how are changing disease patterns going to be included in the curricula review? Whatmechanismsexist to collect feedback from stakeholders? The students, consultants/lecturers and supervisors (facility based) should be able to provide feedback on the ultimate readiness of the graduates to manage obstetric complications/emergencies and have that information inform improvements and adjustments in the training. Who would be responsible for managing and funding the curriculum review? If there are both public and private training institutions, how do they work together to ensure that the same curriculum is being taught and held to the same high standards? How are curriculum revisions that alter scope of practice communicated to health facilities receiving the graduating ACs, and to national regulatory bodies? There is no such a thing like a curriculum, the one we found has been there for a long time and we are still using it up to date. Because AMO was initiated in the year 1999 or so, and up to date we are still using the same curriculum,there has been no othercurriculumthat has been created recently (KI-AMO training college).

Institutions responsible for advanced AC training programs should be represented at the national level to be a part of the national conversation around decisions being made and have an active voice; this should take place through existing platforms. Key considerations for implementation: What current platform exists? This will largely depend upon whether the training program is located within the Ministry of Education, or the Ministry of Health, and existing relationships between these two bodies. In some cases, there is a national medical education council, whereas others allow for professional associations/regulatory bodies/training institution administrators to represent the cadre. If there is already a platform, this may be the group to link with for the issue of national representation taking from them their current networks, relationships, etc. Within the current platform, how can the cadre create their own distinct organization/association? They should not be included into a larger group rather, be a distinct group within the larger unit. Does the current representative body have experience in the rural areas? Do those speaking on behalf of the cadre and training institution at the national level know about the cadre, know about the circumstances, in the rural areas, etc.?

Establish and clearly articulate the place of the cadre within the health system with attention to their clinical and administrative supervision as well as their clinical practice vis-à-vis other cadres. Associate Clinicians are often misunderstood as far as where they fit within the larger health system and specifically within the HR structures. However, a clear organizational chart can explain the clinical and administrative supervisory roles that can prevent confusion at a moment when an AC may need to have clear levels of authority. These are all issues better off discussed before the AC arrives at a facility. The following are some questions to guide decision-making:

Clinical and administrative supervision: What is the supervision and support structure? When the AC has a clinical question or wants to consult with someone more senior or experienced, who provides clinical support (on-site or via phone)? When there are administrative supervision/management questions, who is he/she to report to? (Nurse, Midwife?) If this is not clear, the reporting channels need to be strengthened. Who would the new/upgraded ACs supervise in turn? Specific consideration should be given to situations where a supervisee has a higher level degree or is less experienced, for example the AC supervising an intern or newly qualified MD. Informal supervision and mentoring also took place when senior clinicians were not available or non-responsive to their role as supervisor: In Tanzania, it was found that there was a form of attachment to senior AMOs for all new AMOs fresh from school; the lack of supervision guidelines provided room for non-uniform supervision in performance of Caesarean section by AMOs. In some places the supervision was done by experienced AMOs even without a guideline.

Three possible ways to operationalize the Guidance notes: 1. Countries currently training, deploying and supporting AACs can use this to strengthen their existing programs Kenya: CORH created their own professional association Zambia: MLP and training college advocated for changes to posting 2. Countries in the region who are interested in utilizing AACs as one part of their strategy to increase access to surgery, can use this to guide them throughout the planning and implementation processes. 3. ECSA HC s role in owning and sharing this document: The Guidance Notes will be hosted on ECSA s website and shared in global forum ECSA-HC to work with member states interested in implementing an AAC cadre to operationalize the document