MSI experiences of Task Sharing tubal ligation by clinical officers in Zambia and Uganda

MSI experiences of Task Sharing tubal ligation by clinical officers in Zambia and Uganda

Background to Zambia study Modern CPR among married women in Zambia: 33% Unmet need for family planning: 27% Unmet need among married women for limiting their fertility: 10% Prevalence of tubal ligation among WRA: 1.4% (lower than elsewhere in the region) 2

Tubal ligations in Zambia Currently tubal ligations can be provided by: doctors (medical degree plus internship and possible specialised training) and medical licentiates (diploma in medicine plus two year further training plus internship). Overall shortage of doctors, plus inequitable distribution of clinicians between urban and rural areas plus high attrition of doctors. Rural areas: approximately 200 doctors (23%) to serve over eight million people. Lower level health professionals (e.g. Medical Licentiates and Clinical Officers) are more likely to stay in rural areas 3

Government position The Zambian government aims to increase access to permanent FP methods as part of the method mix achieved through: increasing the health system capacity scaling-up recruitment of health workers introduced new cadres: e.g. Medical Licentiates. Zambian government has shown interest in task-sharing of other procedures, including other FP methods and male circumcision. 4

Rationale for task-sharing Task-sharing is needed in Zambia to increase access to permanent FP methods by: addressing the shortage of health providers who are able to provide tubal ligations, especially in rural areas reducing the burden on the doctors and hospitals making use of existing healthcare providers through affordable, inservice training Uganda tubal ligation task-sharing study similar rationale to Zambia 5

Zambia Study objectives Task sharing of voluntary Tubal Ligation from Doctors/Medical Licentiates to Clinical Officers (diploma in clinical medicine and can undergo semi-specialised training, offer minor surgical procedures) Objective is to show that CO s can feasibly provide tubal ligation in Zambia. Specifically: Operationalization: establish if CO s be trained to conduct tubal ligation procedure to MSI clinical standard? Safety: comparison of adverse event rates for procedures performed by CO s against MSI s quality standards for tubal ligation Acceptability: determine acceptability of tubal ligation by clients when performed by CO s 6

WHO recommendations: tubal ligation [WHO recommendations: Optimizing health worker roles for maternal and newborn health through task shifting. 2012] Lay Health Workers Auxiliary Nurses Auxiliary Nurse Midwives Nurses Midwives Associate Clinicians Advanced Level Associate Clinicians Non- Specialist Doctors Recommend against Consider in context of rigorous research Scoped out (recommend) 7

Study design Zambia and Uganda Participants: eligible clients, who select a tubal ligation, and consent to 1) procedure performed by a CO and 2) being observed /interviewed. Routine monitoring of complications All procedures supervised by an experienced TL provider 8 Zambia Uganda November 2015 - present March - June 2012 Nine-day training (theory plus practical) 2 MSI CO s, 2 MoH CO s 4 MSI CO s Two sites within Lusaka, plus rural outreach sites in two districts 256 women 518 women Data collection on day 1 and follow-ups at day 3 and 7 2 week training (theory plus practical) Mobile outreach sites in rural Uganda Data collection on day 1 and follow-ups at day 3, 7, 45

Study oversight Data safety monitoring board: a group independent of the study who review the data on a regular basis Overall supervision of study by Dr Bellington Vwalika (MSZ MoH) MSI and local ethics review 9

Management of complications (Zambia) Management of complications: training includes management of complications (including: IP, identifying and repairing injuries);; supervisors will intervene where necessary;; clear referral process, including identified referral sites;; clients requiring further treatment accompanied by a MSZ team member and MSZ cover treatment costs standard MSI reporting process for all adverse events (including: all major adverse events reported to in-country CSM, research team, MDT in London and Zambia ERC). 10

Results Initial results for Zambia: All four CO s were successfully trained to provide TL s CO s with experience assisting TL s gained competency more quickly 195 tubal ligations provided so far 1 major adverse event (wound infection) 9 moderate adverse events 48 minor adverse events Results for Uganda: Major adverse event rate: 1.5% (compared to 0.87 24% by physicians in other settings) 99% of women reported having either a good or very good experience 97% would recommend the health services to a friend. 11

Advocacy in Zambia Advocacy activities tailored to Zambia context, based on Uganda study: Early engagement with key decision-makers and influencers Support and involvement of MoH at every stage (design, supervision, write-up, dissemination) Establishment of a Technical Working group on task-sharing of Family Planning (Health Professionals Council Zambia, University Teaching Hospital, USAID, the MCDMCH, key parties identified by MoH) Data Safety Monitoring Board will support dissemination Dissemination in a range of forums (national and international) and methods (peer-reviewed journal, briefing notes, presentations) 12

Advocacy in Uganda MoH is supportive of task sharing but the following concerns need to be addressed: Harmonisation with current policy framework In 2016 the RH standards and guideline came up for review: MSU is working with the Uganda Family Planning Consortium to convene a process to review and feed into the guidelines. Cost effectiveness issues MSU is currently using the task sharing calculator to generate an evidence base for long term task sharing as a cost effective option COs would not be adequately protected against liabilities if something went wrong MSU commissioned a legal review to look at how legal protections could be put in place 13

Challenges I Challenge of low client flow (Ethiopia and Zambia): Studies take longer than planned (momentum with stakeholders;; engagement of study team;; budget) CO s take longer to improve their skills Lack of uptake even once policies are changed Specific challenges of permanent methods: Lack of acceptability to method itself by women and stakeholders (lack of awareness, concerns about risks) 14

Challenges II Advocacy/policy change takes a long time and requires a lot of effort Staff turnover at MoH level Time elapsed since research Requirement of some governments to have findings from their own country (Uganda): Need to repeat expensive research Opposition from other health providers 15

Other MSI task-sharing activities Country Method Cadre Results Uganda Tubal Ligation Clinical Officers Tubal ligation provision by CO s found to be safe and highly acceptable. MSU working with MoH to revise policies and guidelines Sierra Leone Injectables Community Health Workers High acceptability among clients. CHWs reached a high proportion of first-time users as well as young clients. No clinical incidents occurred during the pilot. CHWs able to provide DMPA satisfactorily (supervisor observations). Ethiopia Tubal Ligation Associate Clinicians/ Health Officers Low rate of major adverse events (3%), close adherence to the clinical protocol (96.9% average) and high acceptability (97.5% satisfied clients) Nigeria Implants Community Health Extension Workers Study is ongoing but preliminary analysis found no serious adverse events, slightly higher % of moderate among CHEWs. Burkina Faso Implants and IUDs STMs Nurses, Auxiliary nurses CHWs Early stages, in collaboration with FHI 360 16