Workforce and Cost Implications of Substituting Nurses and Pharmacy Workers for Doctors in the Follo

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Workforce and Cost Implications of Substituting
Nurses and Pharmacy Workers for Doctors in the
Follow-up of HIV/AIDS Patients in UgandaThe
Economic Impact of Task Shifting

• Joseph B. Babigumira
• Pharmaceutical Outcomes Research and Policy
  Program
• School of Pharmacy
• University of Washington
• Friday April 4th 2008
• The 2008 Berkeley Conference on the Global Health
  Workforce
• From Evidence and Research to Public and Health
  Care Industry Policy

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Co-authors

• Infectious Diseases Institute, Makerere
  University, Kampala, Uganda
• Barbara Castelnuovo MBChB, MMed
• Mohammed Lamorde MBBS
• Andrew Kambugu MBChB, MMed
• Philippa Easterbrook PhD
• University of Washington, Seattle, WA
• Andy Stergachis PhD
• Louis P. Garrison PhD

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HIV/AIDS in Uganda

• 1 million (850,0001.2 million) infected
• 132,000 new infections in 2005
• Faltering prevention despite early success
• Decreasing mortality without a cure (need for
  life-long therapy)
• Ever increasing pool of patients needing
  HIV/AIDS-specific care
• Health care system faces major challenges as a
  result, especially sustainability of drug
  supplies, infrastructure capacity and an acute
  shortage of health workers

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Workforce Shortages

• Uganda, like other sub-Saharan African countries,
  faces an acute shortage of health workers due to
  brain drain, poor working conditions, and low
  capacity for training.
• HIV/AIDS exacerbates the problem due to its
  direct impact on the health workforce.
• The health worker crisis especially affects
  HIV/AIDS care because antiretroviral therapy
  requires large numbers of skilled health workers.
• Task shifting--a process of delegating tasks from
  more specialized health workers to health workers
  with lower qualification--has been proposed as a
  solution to this crisis.
• The potential economic impact of task shifting
  from a governmental (Ministry of Health) or a
  societal perspective is not known.

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Study Objective

• To quantify the workforce and cost
  implications of substituting nurses and pharmacy
  workers for doctors (i.e., task shifting from
  doctors to nurses and pharmacy workers) in the
  follow-up of patients with AIDS on ART in Uganda

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Study Setting

• The study was conducted at the Infectious
  Diseases Institute (IDI) at Makerere University
  in Kampala, Uganda.
• The IDI is a regional center of excellence in
  HIV/AIDS treatment, prevention, training and
  research in Africa .
• It maintains and runs a large urban outpatient
  HIV/AIDS clinic, which has registered 20,000
  patients since it opened.
• Currently, about 10,000 patients are actively
  followed up with more than half of these on ART.
• IDI has been implementing different forms of
  patient follow-up as a way to cope with
  increasing demand for doctors.

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Follow-up methods

• There are three different and unique forms of
  patient follow-up at IDI
• Doctor-intensive follow-up (DIF)
• Nurse-intensive follow-up (NIF)
• ART-trained nurses who in addition to their usual
  training have undergone special training to
  administer ART perform NIF.
• Pharmacy worker-intensive follow-up (PIF)
• Pharmacy workers are usually trained as nurses or
  pharmacy technicians and perform the duties of
  pharmacists including the dispensing of
  medications.
• PIF is organized through the pharmacy-only refill
  program, an innovation started in 2006 in the
  wake of increasing demand for follow-up doctor
  visits.

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Personnel requirements for follow-up at IDI
Grey-shaded boxes indicate that the specific
health worker visit occurs at that month
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Methods

• We performed a cost analysis from governmental
  (MOH) and societal perspectives.
• We included personnel costs and the opportunity
  cost of lost patient time.
• Other costs such as overhead costs, drug costs
  and patient transportation are identical by
  follow-up method and were excluded from the
  analysis. Therefore, the costs estimated in this
  study are incremental costs.
• The WHO encourages monthly visits for ART
  follow-up that can be combined with drug
  dispensing, as they are useful opportunities to
  reinforce adherence.
• Our analysis is based on the premise that monthly
  follow-up is optimal and often more practical
  given the irregularity of drug supplies.
• Analyses of patient flow survey data were
  performed in STATA, and the cost analysis was
  performed in Microsoft Excel.

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Estimating Health Worker Utilization and Lost
Patient Time

• A time-motion survey was performed on Monday,
  August 20, 2007.
• Records of each patient who was scheduled to
  attend the clinic on the day were identified and
  a structured questionnaire to track the time in
  and time out for different services was
  attached.
• Different cadres of health worker were asked to
  record time in when the patient entered their
  room or appeared at their post and time out
  when they finished their consultation.
• Time spent with a particular cadre of health
  worker or HWU time (time out minus time in)
  and time spent waiting for that particular cadre
  or waiting time (time in minus time out at
  previous post) were calculated.
• Waiting time was added to HWU time to obtain an
  estimate of lost patient time.

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Costs

• Unit health worker wage data were obtained from
  IDI human resources department.
• Unit wages due to lost patient time was estimated
  based on per capita gross domestic product (GDP)
  as proxy for societal wage.
• Unit wages were multiplied by times to obtain
  personnel and lost patient time costs per visit
  for each cadre.
• Annual cadre-specific costs were computed and
  added to those from other cadres needed to
  implement a particular follow-up method.
• Projections to the national level made by
  multiplying the resulting mean per patient annual
  cost of follow-up for different methods with the
  current number of patients in Uganda who need ART
  and would be followed up under two alternative
  assumptions
• the status quo (current levels of access to
  ART)99,000 per year
• universal access to ART300,000 per year.

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Results 1 Health worker utilization (HWU) and
patient waiting times (hours) for services at the
IDI
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Results 2 Total cost per visit for different
cadres of health workers at IDI
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Results 3 Annual societal costs of different
follow-up methods at IDI
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Results 4 Annual medical (wage) costs of
different follow-up methods at IDI
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Results 5 Annual per patient societal and
medical costs of follow-up of AIDS patients at IDI
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Results 6 Projected national annual societal and
medical costs of follow-up of AIDS patients at IDI
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Results 7 Projected National Workforce Impact

• Substitution of pharmacy workers for doctors
  (using PIF rather than DIF) at the current level
  of access to ART would reduce the need for
  doctors by 90 (80103) full-time-equivalent (FTE)
  doctors per year.
• According to the WHO, there are 2209 doctors
  practicing in Uganda. Therefore, the task
  shifting would save an equivalent to 4.1
  (3.64.7) of the total doctor workforce in
  Uganda.
• If there were universal access to ART, the task
  shifting from doctors to pharmacy workers would
  reduce physician workforce costs by 273 (243313)
  FTE doctors per year or 12.4 (11.014.1) of
  the current national doctor workforce.
• The use of NIF versus DIF would reduce physician
  requirements even moreby about 20but at a
  higher total personnel cost.

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Discussion

• Our study suggests that task shifting achieves
  cost savings in terms of health worker wages and
  from the perspective of society in general.
• Prior research at IDI and elsewhere in Africa
  suggests no adverse impact on outcomes of task
  shifting to pharmacy workers and nurses in the
  short term.
• Nurses and pharmacy workers (who are usually
  trained as nurses) are currently in greater
  supply, are cheaper to train, and can be trained
  relatively quickly.
• This evidence suggests that task shifting may be
  a viable policy option in the short term as well
  as the long term.

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Limitations

• Our study does not measure the effect of PIF and
  NIF methods on quality of care which is one of
  the main concerns to task shifting.
• Although there are suggestions that quality of
  care may not be adversely affected, there is
  reason for caution.
• Other important outcomes such as patient
  acceptance and long-term mortality, morbidity,
  and adherence.
• Before these new follow-up methods are
  implemented broadly, further qualitative and
  quantitative research is required to determine
  their impact on long-term outcomes,
  acceptability, and quality of care of task
  shifting.

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Conclusion and Recommendation

• The two task shifting regimens for ART
  follow-upPIF and NIFhave the potential for
  making a substantial economic impact at the
  national level in Uganda.
• Task shifting to more efficiently use health care
  personnel may improve the motivation of the
  existing workforce and overall system performance
  in terms of health outcomes.
• We therefore recommend that HIV/AIDS clinics in
  sub-Saharan Africa, in the face of the current
  healthcare worker crisis, begin to consider and
  further evaluate these alternate follow-up
  methods, discussing their adoption and
  optimization as a way to best use the available
  scarce health workforce.