NAIROBI, 30 October 2009 (IRIN) - The use of mid-level health workers rather than doctors to prescribe antiretroviral treatment (ART), a strategy called task-shifting, has enabled Mozambique to triple the number of facilities providing medication within six months, according to a new study.

The report, published in the in the latest edition of the Journal of Acquired Immune Deficiency Syndromes, by Kenneth Sherr from the University of Washington and officials in Mozambique's Health Ministry, found that patients from rural and disadvantaged areas could also access quality ART services as a result of the task-shifting.

Shortly after independence in 1974, the majority of physicians - mostly Portuguese nationals - departed from Mozambique, leaving fewer than 80 physicians to care for a population of 10.6 million.

Since then the country has largely relied on 'técnicos de medicina' - non-physician clinicians who undergo training for 30 months - to provide the clinical and managerial tasks ordinarily carried out by doctors.

Political instability and economic structural adjustment programmes in the 1980s hit Mozambique's health system hard, forcing the closure of up to 50 percent of public health centres. HIV prevalence reached 15 percent in 2003, yet only one percent of people had access to treatment; the government again looked to técnicos to fill the gap.

Rapid expansion

"Because the numbers of existing physicians were inadequate to cover the large number of facilities in the rapid scale-up, the national plan included a renewed effort to train new técnicos as an essential element of workforce expansion for HIV care," the report noted.

By mid-2006, the first wave of newly graduated técnicos had been deployed at health facilities; about a year later 167 health centres covering 147 Mozambican districts and municipalities were providing treatment.

The scale-up also integrated ART into public healthcare, so physicians and técnicos would attend to all patients, not only those infected with HIV.

"Deployment of newly trained técnicos provides opportunities to staff rural and smaller urban clinics with clinical cadres that are more likely to continue to work in public healthcare. Furthermore, training, salaries, and benefits cost less for técnicos than for physicians," the authors said.

"Supported by the integrated care approach, the number of facilities with ART tripled over a six-month period, including predominately small, rural, and peri-urban health centres, 45 percent of which were managed by a técnico de medicina."

A continuing effort

Mozambique is also increasing its number of trained physicians; student intake at the country's main medical school has doubled, and two new medical schools have been opened. According to the study, the quality of care provided by técnicos is equivalent to or better than that provided by medical doctors.

However, an evaluation of the técnicos' training found that they were not sufficiently prepared for actual clinical responsibilities, especially where health system resources were inadequate, and the health workforce would have to be multiplied several-fold to achieve the United Nations Millennium Development Goals.

Nevertheless, the report concluded that "Using a mix of physicians and responsible task-shifting to non-physician providers, the Mozambique health system can maintain its momentum in ART scale-up while strengthening the wider public healthcare system."

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