1 experience of task shifting in mozambique: a response to limited human health resources nafissa...
Post on 26-Mar-2015
221 Views
Preview:
TRANSCRIPT
1
Experience of Task Shifting in Mozambique: A Response to Limited Human Health ResourcesA Response to Limited Human Health Resources
Nafissa Bique Osman
Department of Obstetric and Gynecology, Eduardo Mondlane University, Central Hospital, Maputo.
XIX FIGO World Congress, 4-9 October 2009, Cape Town
Safe Motherhood and Newborn Health
2
Mozambique
• Population: 20 million• Growth rate: 2.4%• Pop in rural area: 70%• P density: 20 inh/km²• Among the 10 poorest countries
in the world• Poverty line: 69.4% below • Life expectancy at birth:
45 years
• Source: 2007census, DHS 2003
3
Mozambique
• Children< 5yr: 17% pop• 10-24 yrs: 33% pop• 15-49 yrs: 49% pop• Women 15-49yrs: 25% pop = 5 million• >50 yrs: 9.4% pop• Birth rate: 35.2/ 1000 • Death rate: 21.3/ 1000
Source: 2007census, DHS 2003
Source: 2007census, DHS 2003
4
Maternal and neonatal HealthMaternal and neonatal Health
• Worldwide, more than one woman dies every minute, 585.000 women die every year.
Ninety nine percent of these deaths occur in developing countries, demonstrating that they could be avoided if resources and services were available
• Complications of pregnancy and childbirth are the leading causes of death among women of reproductive age in Mozambique
5
Maternal HealthMaternal Health
ANCANC- 84% pregnant women -1 visit
Institutional deliveries:Institutional deliveries: 46% (urban- 71%, rural- 29%)
Maternal mortality: 1997- 975/ 100,000 2003- 408/ 100,000
1/3 of Maternal death are < 19 years old
Main causes of MM:Main causes of MM:
75% direct causes75% direct causes: hemorrhage, sepsis, eclampsia, uterine rupturehemorrhage, sepsis, eclampsia, uterine rupture 25%25% indirect causes: HIV, malariaHIV, malaria
Source: DHS 1997 & 2003, Revision of MM study, MOH 1998
6
Neonatal and Infant mortality
Neonatal mortality:Neonatal mortality: 1997: 59/1000 live births 2003: 48/ 1000 live births
Main causes:Main causes: preterm delivery, LBW, infections, asphyxia
Infant mortality:Infant mortality:
1997: 147/ 1000 live births 2003:125/ 1000 live births
Source: DHS 1997 & 2003
7
Challenges in Safe MotherhoodChallenges in Safe Motherhood
Adolescent pregnancy: Adolescent pregnancy: 40%40% Unwanted pregnancies, early marriageUnwanted pregnancies, early marriage Unsafe abortion: Unsafe abortion: 11% of MM11% of MM Contraceptive rate: Contraceptive rate: 1997: 6% 1997: 6% 2003: 17%2003: 17%
Modern contraceptive rate: 2003: 12%Modern contraceptive rate: 2003: 12% Women knowledge of contraceptives: Women knowledge of contraceptives: 90%90% Syphilis in pregnancy: Syphilis in pregnancy: 7%7% HIV prevalence: HIV prevalence: 16%16%
Source: DHS 1997 & 2003, Epidemiological Surveillance, 2007
8
National Health National Health SystemSystem Primary levelPrimary level::
Health post (514) Health post (514) Rural and urban health centers (775)Rural and urban health centers (775)
Secondary levelSecondary level:: Rural and district hospital (31), general hospitals (4).Rural and district hospital (31), general hospitals (4). First referral levelFirst referral level
Tertiary level:Tertiary level: Provincial hospital (7)Provincial hospital (7)
Quaternary level: Central hospital (3)Central hospital (3)
1 health unit/ 15,000 inhabitants1 health unit/ 15,000 inhabitants 1 hospital/ 434,368 inhabitants 1 hospital/ 434,368 inhabitants
Source: MoH, NDH, 2006
9
Strategies to decrease MMStrategies to decrease MM
1975 Independence. Universal access to primary health care was a goal but, Independence. Universal access to primary health care was a goal but,
human resources crisis, 80 Moz doctors/14 million;human resources crisis, 80 Moz doctors/14 million;
Intensive training of nurses, midwives, medical officers to replace the doctor;Intensive training of nurses, midwives, medical officers to replace the doctor;
Elementary (1yr training) and basic (20 month training) mother/child nurse-Elementary (1yr training) and basic (20 month training) mother/child nurse-midwives to work at primary care level and also at 2midwives to work at primary care level and also at 2ndnd and 3 and 3rdrd level level
10
Task Shifting and Delegation of Task Shifting and Delegation of responsibilitiesresponsibilities
1980 Civil war, increased casualties, unmet need for emergency life saving skills
in war casualties and obstetrics; No surgeons, obstetricians and orthopedics in rural, district hospitals; Long distance and deficient transport network
19841984 Training of assistant medical officers with skills in surgery “técnico de técnico de
cirurgia” (TC); cirurgia” (TC); 3 year training to perform all emergency operations in obstetric, trauma
and surgery. Training of “técnico” of anesthesiologyTraining of “técnico” of anesthesiology
11
Evaluation of TC skills in ObstetricsEvaluation of TC skills in Obstetrics
Controversy of delegation of major operations to a non medical doctor;Controversy of delegation of major operations to a non medical doctor; Evaluation after 4 yr of the 1Evaluation after 4 yr of the 1stst group group
19921992 Evaluation of 958 cesarean deliveries performed by TC & 1113 by
obstetricians at Central Hospital in Maputo– found no clinically significant difference in postoperative outcomes. Superficial wound separation more frequent in CS by TC
Source: C Pereira, A Bugalho, S Bergstrom, F Vaz, M Cotiro. A comparative study of cesarean deliveries by assistant medical officers and obstetricians in Mozambique. Br J obstet Gynaecol 1996; 103:508-12
12
Task Shifting and Delegation of Task Shifting and Delegation of responsibilitiesresponsibilities
19901990 Medium level mother/child nurse-midwife 30 months training with skills Medium level mother/child nurse-midwife 30 months training with skills
for EmOC (basic)for EmOC (basic)20042004 High level nurse-midwife with university degree: 3 year training- High level nurse-midwife with university degree: 3 year training-
bachelorbachelor 4 year training- licentiate. With training in EmOC (comprehensive) 4 year training- licentiate. With training in EmOC (comprehensive)
including cesarean sectionincluding cesarean section2008 29 were graduated. Now, 1 class of 37 student, in 729 were graduated. Now, 1 class of 37 student, in 7thth semester and 1 semester and 1
class of 35 student in 3class of 35 student in 3rd rd semester semester
Source: Instituto Superior de Ciências de Saúde
13
Task Shifting and Delegation of responsibilities
20042004 Revue of TC curriculaRevue of TC curricula 3 yrs training- bacharel3 yrs training- bacharel 4 yrs training- licentiate4 yrs training- licentiate So far 61 TC graduated as bachelor and licentiate degree. So far 61 TC graduated as bachelor and licentiate degree. Retired and died: 11Retired and died: 11 Now, 1 class with 18 students in the 4Now, 1 class with 18 students in the 4thth year training and 1 year training and 1
class with 16 student in the 1class with 16 student in the 1stst year. year.
Source: Instituto Superior de Saúde
14
Evaluation of TC skills in ObstetricsEvaluation of TC skills in Obstetrics
2002 2002 Analyses of 12,178 obstetric operations in all 34 public Analyses of 12,178 obstetric operations in all 34 public
hospitals;hospitals; TCs performed 92% of major obstetric surgery at TCs performed 92% of major obstetric surgery at
district/rural hospital;district/rural hospital; TCs compared with physicians, stay longer in rural TCs compared with physicians, stay longer in rural
areas. After 7 years 90% of TCs were still in district areas. After 7 years 90% of TCs were still in district hospitals while no physician remainedhospitals while no physician remained
Source: C Pereira, A Cumbi, R Malalane, F Vaz, C McCord, A Bacci, S Bergstrom. Meeting the need for emergency obstetric care in Mozambique: work performed and histories of medical doctors and assistant medical officers trained for surgery. BJOG 2007; DOI:10.1111/j.1471-0528.2007.01489.
15
Human ResourcesHuman Resources
Elementary level health worker- 63%Elementary level health worker- 63% Basic level health worker- 20%Basic level health worker- 20% Medium level health worker- 13%Medium level health worker- 13% High level health worker- 4%High level health worker- 4% 1 doctor & 7 nurses/ 33,000 inhabitants1 doctor & 7 nurses/ 33,000 inhabitants Obstetricians- 42 in provincial & central hospital, being 12 in Obstetricians- 42 in provincial & central hospital, being 12 in
Maputo cityMaputo city
Source:Source: MoH DNRH, 2006MoH DNRH, 2006
16
Challenges
Conflict between doctor (GP), TC and midwife
Midwife performing CS, less interested in routine midwifery work at normal delivery
Importance of Team Work: Obstetrician, GP doctor, Midwife and TC
17
ConclusionsConclusions
After 20 yr experience of delegation of surgical After 20 yr experience of delegation of surgical interventions to “técnico de cirurgia” and 1 yr to midwives, interventions to “técnico de cirurgia” and 1 yr to midwives, we can say that this strategy is very important to increase we can say that this strategy is very important to increase access to Comprehensive EmOC at first referral level.access to Comprehensive EmOC at first referral level.
It can contribute to reduction of maternal and neonatal It can contribute to reduction of maternal and neonatal mortality in poor countries with shortage of human mortality in poor countries with shortage of human resources resources
18
Thank You
top related