Nurses Help to Alleviate Doctor Shortage in Rwanda
Nurses and a patient at Cor Unum site
Committed to improving the health and welfare of people living with HIV, Rwanda, which has an HIV prevalence rate of 3%, has been treating those infected with HIV/AIDS with antiretroviral drugs since 1999.
Treatment of, and follow-up with, patients on ARVs has historically been the responsibility of medical doctors only. However, with only one medical doctor per 18,000 people (and only one per 80,000 people in rural areas), Rwanda faces a significant challenge. There are approximately 300,000 people living with HIV/AIDS in Rwanda, of which 80,000 are currently receiving antiretroviral treatment, representing a mere 70 percent of those in need. Rwanda has approximately 40 hospitals and 500 health centers and about 550 doctors employed in the public sector. Medical doctors are mainly based at the district hospitals and only visit health centers to provide ARV therapy once a week. There is, however, one nurse per 1,700 people in Rwanda, introducing a practical solution to making treatment more accessible to the poor and to fully integrating it into a health center’s daily care package.
In 2005, the Ministry of Health (MOH), in collaboration with FHI
, led a pilot study on “task shifting” in three health centers. Under the study, many responsibilities that were previously reserved for medical doctors (who were visiting health centers increasingly infrequently) were carried out by nurses instead. Transferred tasks included: first-line ARV treatment; treatment for simple opportunistic infections and STIs therapy; clinical and biological monitoring; and managing side effects related to ARVs. When nurses identified therapeutic failures and other complex cases, they were responsible for referring to a doctor or transferring the patient to a hospital.
Task shifting set the stage for success for another Foundation initiative. In 2006, the Foundation developed a model of care in which non-treatment sites enrolled HIV-positive clients in care services immediately after testing, and continued to follow up with them until they were eligible for treatment. An assessment of these services at Foundation-supported prevention of mother-to-child transmission and voluntary counseling and testing sites indicated that providing pre-ART services at non-ART sites could increase the numbers of eligible patients being referred to treatment and reduce the number of patients who failed to follow-up once they were in treatment. As a result of task shifting, health centers were better prepared to provide the additional pre-ART services.
In 2007, the positive outcomes of the MOH/FHI pilot study, and the Foundation’s model of care assessment were presented to the MOH and other partners. Under the pilot study, the number of patients on ARV treatment increased as more patients were put on ART sooner. Prior to task shifting, patients could only be put on ARVs once a week when the doctor was at the health center. But with nurses able to prescribe ARVs, patients could begin treatment any day of the week. In addition, there was a reduction in the number of patients transferred to the district hospital because patients could receive more services at the health center. This task shifting also allowed health centers to provide pre-ART care services to HIV positive clients who were not yet eligible for ART. Following these successes, the Foundation launched care services for at all of its sites, with a focus on non-ART services. Then in 2009, the MOH instructed health centers throughout Rwanda to implement task shifting.
At the end of last year and the beginning of 2010, meetings were held with the MOH and with all HIV clinical service implementation partners to organize a “train the trainers” event. These courses took place in March, April and May and were spread over two weeks for each district. The course included a theoretical phase and a practical phase. Afterwards, a month-long, field-based mentoring and follow-up phase took place. During this mentoring period, nurses began prescribing ARVs with intensive monitoring by a doctor, before receiving the final authorization to prescribe on their own. Health care workers trained in task shifting have now been deployed across the country to carry out further training of more health providers.
The Foundation, as a partner with MOH, has contributed to the different phases of task shifting at its supported sites by participating in various technical group meetings to prepare for implementation, providing trainers for Foundation-supported districts, and financially supporting trainings in six district hospitals with EGPAF supported clinical services. Since the month of March, the Foundation supported trainings of nearly 131 participants from all it's sites offering PMTCT, VCT and ARV services in six districts: Ngarama, Rwamagana, Gahini, Ngoma, Kiziguro, and Nyamata.
Task shifting is an important step in supporting people living with HIV. It allows more patients timely and better access to care, including reducing their waiting time before being enrolled in both treatment and follow-up. This in turn results in better quality of life and longer life expectancy for people living with HIV.
Dr Jacques Rutabagaya is a Technical Advisor for the Foundation. Based in Rwanda, he is in charge of ART and TB/HIV Program and District support team leader for Gatsibo District.