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Revisiting the need for Multi-tasking /Task shifting/ putting into practice the learnt skills
Dr. Himanshu Bhushan
Advisor & Head
PHA, NHSRC
Concept
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Task Shifting: Process of delegation whereby tasks are moved, where appropriate, to less specialized HCWs. Promotes efficient use of existing workforce
Individual Accountability
Task Sharing: Process of completion of tasks collaboratively between providers with different levels of training.
Tasks are not taken away from one cadre or set of HCWs and given to another, but they are shared across groups
Team Accountability
Purpose is to reduce morbidity, mortality and burden of disease among populations where a shortage & inaccessibility of highly professionalized health workers limits access to effective care
Purpose can be achieved by positioning providers with less training to deliver effective interventions, thereby improving access to and coverage to those interventions without compromising standards of care
Opportunities through Task Sharing/ Shifting
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Diversify care options and modes of delivering care. For eg: Nurse Practitioners (USA Model offering choice of treatment), SBA training), etc
Redistribute responsibilities within health workforce teams. For eg: Clinical & Managerial Services.
Deliver more culturally or contextually appropriate care. For eg: by utilizing community health workers for screening, etc.
Permit scale-up of essential interventions by positioning more providers to deliver those interventions. For eg: Population based screening for detecting NCDs.
Change conventional hierarchies between health providers, where highly trained professionals work as partners & mutual respect with providers with less training.
Tamil Nadu: Vision and Mission
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“Government of Tamil Nadu is totally committed in building healthy people, not only by making available quality medical care facilities at the doorstep of every citizen in the remotest corner of the State, but also by providing medical facilities of the highest order, keeping pace with rapid technological developments in the field of medicine. Government of Tamil Nadu provides preventive, curative and promotive care to all classes of the society.”
Tamil Nadu as Pioneer State
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Some Key Achievements
Some Key Achievements
Key Policy Decisions promoting Task Shifting/ Sharing in Tamil Nadu
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Operationalized 24*7 PHCs (1997-2004) by placing staff nurses for round the clock services. Later adopted by GoI.
Training MBBS doctors for EmOC & LSAS for operating FRUs and conduct good quality ANCs/ PNCs. Also utilized for FP services.
Training MBBS doctors for MVA to operate block level PHCs.
Organized screening for CA Cervix and LA Breast by training nurses in VIA.
Models of Task Sharing were extended over to the persons in administration, community, etc, like…
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Conducting maternal death audits by involving both community, clinicians, district officials, etc
Training nurses for skills like PPH, active management of 3rd Stage of labor, etc
Training nurses on syndromic management of RTIs & STIs
Thus, task shifting/ sharing was widely utilized for RMNCH+A services which yielded positive results not only in achieving MDGs but going beyond SDGs
Although MMR has reduced & 100% Institutional Deliveries achieved but….
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Source: NFHS 5 and NHA 2018-19
Total percentage of C-sections is higher than the WHO’s standard (10-15%); and out of the total reported C-sections, about 52.2% are conducted at private facilities in the State.
Deliveries at Different Levels of Facility
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Source: Apr 2022- Nov 2022, HMIS Real Time Report
Delivery & its Management (in Numbers)
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Level of Facility | Total Delivery | Complicated Pregnancies | C-Sections |
DH | 81,469 (15.05%) | 12,831 (14.1%) | 40,735 (50.76%) |
SDH | 1,90,005 (35.1%) | 53,760 (25.6%) | 90,404 (47.58%) |
CHC | 2,30,063 (42.5%) | 9,246 (3.6%) | 1,19,060 (51.63%) |
PHC | 38,163 (7.03%) | 2,903 (7.08%) | 2,080 (5.4%) |
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Assuming All Deliveries are taking Place in Public health Facilities (N= 5,00,000)
Total Deliveries | Percentage | number | Remaining |
Deliveries at PHC | 15% | 75000 | 4,25,000 |
Deliveries at CHC & SDH | 60% | 2,55,000 | 1,70,000 |
C- sections at CHC & SDH | 20% | 51000 | 2,04,000(2,55,000-51,000) |
C sections at DH & tertiary care | 30% | 51,000 | 1,19,000(1,70,000-51,000) |
Total C section %age | 20.4% | 1,02,000 | 3,98,000 |
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Assuming Deliveries are being shared between public and private health Facilities (N= 500000)
Public (N= 300000) | Private (200000) | |||||
Place | Percentage | number | Remaining | Percentage | number | Remaining |
Deliveries at PHC | 10% | 30000 | 270000 | | | |
Deliveries at CHC & SDH | 60% | 162000 | 108000 | | | |
C- sections at CHC & SDH | 20% | 32400 | 129600 | | | |
C sections at DH & tertiary care | 30% | 32400 | 97200 | 40% | 80,000 | 1,20,000 |
Total C section %age | 21.6% | | | | | |
Nutritional Status among Women & Children in Tamil Nadu
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With Changing Burden of Disease
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Source: https://vizhub.healthdata.org/gbd-compare/india (2019)
SDG Target
Current Performance of TN with respect to SDG & National Goals
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Indicator | SDG by 2030 | NHP 2017 | India | Tamil Nadu |
MMR | 70/ Lakh | 100/ Lakh LB | 97 (SRS 2018-20) | 54 (SRS 2018-20) |
U5MR | 25/ 1000 LB | 25/ 1000 LB by 2025 | 41.9 (NFHS 5) | 22.3 (NFHS 5) |
IMR | - | 28/ 1000 LB by 2019 | 35.2 (NFHS 5) | 18.6 (NFHS 5) |
NMR | 12/ 1000 LP | 16/ 1000 LB by 2025 | 24.9 (NFHS 5) | 12.7 (NFHS 5) |
AIDS, TB, Malaria/ NTD | End Epidemic | HIV/ AIDS- 90:90:90 TB- Elimination by 2025 | TB Prevalence- 304/ 1 Lakh (India TB Report 2022) HIV Prevalence- 0.22% (India HIV estimation 2019) | TB Prevalence- 953/ 1 Lakh (India TB Report 2022) HIV Prevalence- 0.23% (India HIV estimation 2019) |
NLEP | | <1 per 10,000 | Prevalence 0.57 per 10,000 (Annual report 2019-20) | Prevalence 0.37 per 10,000 (Annual report 2019-20) |
OOPE | Substantial Decrease | Decrease in catastrophic HE by 25% by 2025 | 48.2 % of THE (NHA 18-19) | 44.3% of THE (NHA 18-19) |
Proportion of GDP spent | 5.99 (Globally) | Increase in State sector health spending to > 8% of their budget by 2020 | 5.5 % Budget Estimate (RBI State Finances Report 2021-22) | 5.7 % Budget Estimate (RBI State Finances Report 2021-22) |
Evolving modes of Health Care Delivery in Tamil Nadu
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Comprehensive Primary Health Care
Curative/ Super-Speciality Care
India
Tamil Nadu
Specialized Care Centers initiated in Tamil Nadu
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Tamil Nadu STEMI (ST Elevation & Myocardial Infraction) project
Tamil Nadu Accident & Emergency Care Initiative Centers
Comprehensive Emergency Care Centers
Cancer Care Hospitals
Trauma Care Centers
Pediatric blood and marrow transplant center in Children's hospitals
Regional Eye Care Center
Centres of Excellence for Stroke, Poisoning, etc
Healthcare Needs of a District
Fig. Increase Burden of NCDs
4520 surgeries per 100000 population
90400 surgeries per 20,00,000 population
124 surgeries per day
Fig. Increasing surgical need per 20 lakh population
Approx. 340 lakh patients require haemodialysis per year in India
132 haemodialysis per day per 20,00,000 population in a district
Dialysis unit with 20 beds is capable to cater 80 patients per day at SDH/DH Level
Remaining 52 patients seek care from medical college/private facility
Fig. Dialysis need per 20 lakh population
Specialist Availability at CHC level
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Requirement of specialists at CHC level not being fulfilled despite 7700 MBBS & 4430 specialists passing out every year (NHP 2021)
As per IPHS 2022, specialists required at:
Source: Data as on 31st March 2021, RHS 2020-21
Specialist Availability at DH/ SDH Level
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As per IPHS 2022, specialists required at:
Skill Based MO Required at:
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Do we need to shift more focus on primary care?
Do we need to give more focus on District level Health Plans?
Do we want to strengthen Block headquarters CHC as the Hub?
Whether Tamil Nadu needs Task Shifting/ Sharing in current scenario?�
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Task Sharing & Skill Building for Specialized Services
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As shortfall observed, the MBBS doctors can be trained for specialized care
Policy Decision can be taken where the specialized services to be delivered i.e. at lower level (CHC) for a community centered approach or higher level (DH/ Super- Specialty Centers)
Task Sharing & Skill Building for Non-Specialized Preliminary Care
Policy decision for nurse practitioners ???
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Clinical & Professional Non-Clinical Skills
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Management roles like supply-chain management, financial management, recruitment of human resource is specialized job but done by medical professionals
Triage at emergency facilities can be done by Nurses/ Trained EMTs
Public health surveillance, forecasting of epidemics can be done by any trained professional
Tamil Nadu being a Visionary State can decide on Strategic Task Shifting/ Sharing
Task shifting
Task Sharing
Task Sharing
Policy Decisions at National Level for Improving HR Availability
1. Indian Public Health Standards 2022
The situations varies from State to State and depending on the requirement of the individual State, task shifting/ sharing shall continue to be needed.
Utilizing various provisions under IPHS for Task Sharing & Shifting
2. Public Health Management Cadre
Creation of management cadres for different level of service provisions as defined under PHMC
Aligning visionary approach beyond NHP 2017 & going beyond SDGs
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Take Home Message
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State needs to prioritize more investment in primary healthcare.
District wise analysis of health needs of the community
Comprehensive DHAP encompassing community needs.
Developing Block as a health hub for both clinical and public health services.
Decision on the need to reform HR Policies
Tertiary care more for superspecialist services and teaching/training, capacity building, clinical mentoring, research, evidence generation etc
To Conclude
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State has still to traverse a long and tortuous public health journey where every number counts for reducing not only the burden of disease but other public health challenges.
To achieve Universal Health Coverage, the state needs to take policy decisions to further widen the affordable access to quality public health services within reach to the community.
Task sharing/skill building, and Task shifting are low-cost interventions, gives good output if utilized judiciously with adequate mentoring.
THANK YOU
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