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GH Workforce Taskshifting: Joseph Babigumira & Lou Garrison
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GH Workforce Taskshifting: Joseph Babigumira & Lou Garrison

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This session focuses on considerations and challenges in meeting the health care needs of a growing global population. Attention will be placed on task shifting – the delegation of health …

This session focuses on considerations and challenges in meeting the health care needs of a growing global population. Attention will be placed on task shifting – the delegation of health interventions to less specialized health workers.


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  • 1. Cost Impact of Task Shifting for ART Treatment Follow-Up in Uganda J. Babigumira, A. Stergachis, L P. Garrison Pharmaceutical Outcomes Research and Policy Program, School of Pharmacy Department of Global Health University of Washington Seattle B. Castelnuovo, M. Lamorde, A. Kambugu and P. Easterbrook Infectious Diseases Institute Makerere University Kampala
  • 2. Introduction
    • Demand for HIV care in Africa is increasing (increasing incidence in some areas, increasing prevalence due to reducing mortality, expanding ART access).
    • HIV care needs specialized health workers.
    • But there are severe health worker shortages in Africa (rapidly expanding populations, poor pay and working conditions, “brain drain”, low levels of new training).
    • Task shifting —delegation of tasks from more specialized to less specialized health workers—has been proposed as one potential solution in Global Forum for Human Resources for Health (Kampala, 2008)
  • 3. Study Aim
    • To evaluate the potential economic impact of task shifting in Uganda in term of:
      • Cost savings
      • Physician full time equivalents
  • 4. Follow-Up Methods
    • Physician follow-up (PF)
      • 12 triage visits, 12 physician visits, and 12 regular PW visits
    • Nurse follow-up (NF)
      • 12 triage visits, 10 ART-trained nurse visits, 2 physician visits, and 12 regular PW visits
    • Pharmacy worker follow-up (PWF)
      • 4 regular PW visits, 8 refill PW visits, 4 triage visits, 2 ART-trained nurse visits, and 2 physician visits
  • 5. Methods 1
    • Aggregate cost model for Uganda societal perspective (includes lost patient time) and payer (MOH) perspective (includes only medical costs)
    • Shared costs (do not differ by follow-up method) were not included e.g. drugs, transport e.t.c
    • Health resource utilization data from the infectious Diseases Institute (IDI), Kampala
    • Unit costs from IDI and the literature
    • Assumed that monthly follow-up optimal
    • Lost patient time valued at GDP per capital for Uganda
    • Detailed data for utilization of personnel obtained by a primary time-motion survey
  • 6. Methods 2
    • National projections based on two assumptions
      • Current access to ART (33%)
      • Universal access to ART
    • Workforce impact in terms of physician full time equivalents (FTEs)
      • Assumed 48 40-hour workweeks for Ugandan health workers
      • Divided by number of doctors currently practicing in Uganda (2,209)
    • Sensitivity analyses performed to examine impact of key estimates on results
  • 7. RESULTS
  • 8. Health Worker Use and Patient Waiting
  • 9. Per Visit Cost for Health Workers
  • 10. Per Visit Cost of Task Shifting (Societal)
  • 11. Per Visit Cost of Task Shifting (Medical)
  • 12. National Projections
  • 13. Physician FTE Analysis
    • Task shift to nurses or pharmacy workers at current access, SAVES:
      • 108 physician FTEs per year (4.9% of national workforce)
      • 0.3 physician FTEs per 100,000 population
    • Task shift to nurses or pharmacy workers at universal access, SAVES:
      • 328 physician FTEs per year (14.9% of national physician workforce)
      • 1.05 physician FTEs per 100,000 population
  • 14. Summary
    • Task shifting could save between $0.5 million and $11.0 million depending on perspective and ART access.
    • Task shifting could reduce current physician needs by between 4.1% and 14.8% of the national physician workforce depending on perspective and ART access.
    • Implications 
      • This frees up scarce physician resources for other uses.
      • From a health system perspective, total medical spending would increase, but from a societal perspective, it would be cost-effective.
  • 15. Limitations
    • Outcomes (morbidity and mortality, quality of care, patient satisfaction) were not addressed in this analysis.
    • Thus, this is a partial economic evaluation (cost-minimization model) in which outcomes are assumed to be the same.
    • Current evidence (In Sub-Saharan Africa) suggests that outcomes are not adversely affected because of task shifting.
      • Bedelu et al. JID 2007:196 (Suppl 3)
      • Dovlo. Human Resources for Health 2004, 2 :7
      • Obuku et al. (Unpublished)
    • Case study clinic (IDI) is better than the average clinic in the national health service: hence, generalizability is an issue.

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