HIV This Week

Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries. Lancet 2007; [Epub ahead of print].

Many countries have health-care providers who are not trained as physicians but who take on many of the diagnostic and clinical functions of medical doctors. The authors identified non-physician clinicians in 25 of 47 countries in sub-Saharan Africa, although their roles varied widely between countries. In nine countries, numbers of non-physician clinicians equalled or exceeded numbers of physicians. In general non-physician clinicians were trained with less cost than were physicians, and for only 3-4 years after secondary school. All non-physician clinicians did basic diagnosis and medical treatment, but some were trained in specialty activities such as caesarean section, ophthalmology, and anaesthesia. Many non-physician clinicians were recruited from rural and poor areas, and worked in these same regions. Low training costs, reduced training duration, and success in rural placements suggest that non-physician clinicians could have substantial roles in the scale-up of health workforces in sub-Saharan African countries, including for the planned expansion of HIV prevention and AIDS treatment programmes.

Editors’ note: “Clinical Officers” rather than physicians are providing care on the frontlines directly to patients in many countries throughout sub-Saharan Africa, meaning that task shifting has already been underway for many years. As work proceeds to examine provider roles, patients’ needs, and rational deployment of human resources for health, the potential of clinical officers is receiving increasing attention.

Funding for scaling-up antiretroviral treatment (ART) in low-income countries has increased substantially, but the lack of human resources for health (HRH) is increasingly being identified as an important constraint for scaling-up ART. In a clinic run by Médecins Sans Frontières in Siem Reap, Cambodia, Van Damme and colleagues documented the use of doctor-time for ART in September 2004 and in August 2005, for different phases in ART (pre-ART, ART initiation, ART follow-up Year 1, & ART follow-up Year 2). Based on these observations and using a variety of assumptions for survival of patients on ART (between 90 and 95% annually) and for further reductions in doctor-time per patient (between 0 and 10% annually), the authors estimated the need for doctors for the period 2004 till 2013 in the Siem Reap clinic, and in a hypothetical district in sub-Saharan Africa. In the Siem Reap clinic, the authors found that from 2004 to 2005 the doctor-time needed per patient was reduced by between 14% and 33%, thanks to a reduction in number of visits per patient and shorter consultation times. In 2004, 2.06 full-time equivalent (FTE) doctors were needed for 522 patients on ART, and in 2005 this was slightly reduced to 1.97 FTE doctors for 911 patients on ART. By 2013, Siem Reap clinic will need between 2 and 5 FTE doctors for ART. In a district in sub-Saharan Africa with 200,000 inhabitants and 20% adult HIV prevalence, using a similar doctor-based ART delivery model, between 4 and 11 FTE doctors would be needed to cover 50% of ART needs. The authors conclude that ART is labour intensive. Important reductions in doctor-time per patient can be realized during scaling-up. The doctor-based ART delivery model analysed seems adequate for Cambodia. However, for many districts in sub-Saharan Africa a doctor-based ART delivery model may be incompatible with their HRH constraints.

Editors’ note: Physician time considerations in resource constrained settings should prompt consideration of alternate delivery models for scale-up, involving clinical officers, nurse practitioners, nurses and community adherence and support counsellors, among others. Determining the best utilisation of available human resources is a key to achieving favourable outcomes for patients and their families.