Nigeria already meets all the WHO Guideline recommendations for contracting, career progression, financial motivation etc, as contained in the National TaskShifting Policy of 2014: https://www.psi.org/wp-content/uploads/2016/09/5.-Nigeria-FMOH-Task-sharing-presentation-071116-3.pdf
In Task-shifting and Task-sharing policy for essential health care services in Nigeria by federal ministry of health published in August 2014, the Minister of Health stated in his Foreword which he signed, that
‘Unfortunately, when the older health care workers are retiring, they are not being replaced. Conversely, in some parts of the country, there are many employed but under-utilized health care workers who can be trained to competency and given specific responsibilities for the care of vulnerable Nigerians in hard to reach areas. Community health extension workers belong to this group.
The development of this National Task Shifting and Sharing Policy is a major leap towards the scaling up of access to effective and evidence-based essential health services in Nigeria. It is aimed at increasing access to services currently included in the essential health package in an effort to significantly reduce Nigeria’s unacceptably high mortality ratio/rates and to achieve set Millennium Development Goal (MDG) targets for the country.
Its approval will lead to curriculum changes for pre-service education and in-service trainings of different cadres of staff and production of more knowledgeable and skilled health care workers. For example, female CHEWs ( Community Health Extension Workers) can be trained to provide normal delivery services and to identify and initiate the management of the common complications of pregnancy and childbirth. Midwives can be trained to provide long-acting reversible contraception like intrauterine devices and implants while NYSC doctors can be trained to perform manual removal of a retained placenta. Volunteer health workers can be trained to counsel pregnant women about the benefits of HIV testing in pregnancy and to support those on antiretroviral therapy.
These measures are temporary and are not designed to take away tasks from any professional groups but rather to make the best use of the cadres of staff currently employed and deployed to our health facilities. The implementation of this policy will be reviewed every five years as more health care workers are produced and employed in the sector.”
The minister continued in his Foreword to the document that , â€˜Therefore, the policy focuses on key priority areas in which the CHW shall be trained include (such as ) Family and Reproductive Health, Maternal and Child Health services (RMNCH), as well as HIV, TB, Malaria and other communicable and non-communicable diseases in Essential health services package. The essential health services shall include the following (as itemized in the National Health Strategic Development (NHSDP) 2010-2015: Family Health (Ante-natal care, delivery and new-born care; post-natal care; Family planning; Child health – integrated Management of Childhood Illnesses (IMCI); growth monitoring and essential nutrition; immunization; Adolescent reproductive health); Communicable diseases (Tuberculosis (TB) and leprosy; HIV/AIDS and sexually transmitted infections; Epidemic diseases (including malaria surveillance); rabies); Basic curative care (Treatment of major chronic conditions ); Hygiene (Hygiene, Water-borne diseases); Environmental health; Health education (Health education and communication).
It is important to show that CHW are fully integrated in the Nigeria health system by quoting the Recommendations in the Task Shifting policy of 2014 cited above with provisions for career progression and financial motivation:
Recommendation 1: Nigeria Government through Federal Ministry of Health in collaboration with relevant stakeholders and partners have reached consensus in implementing a National Task Shifting Policy where access to priority health services, are constrained by health workforce shortages. Task shifting in Nigeria is considered as an interim measure, and will be implemented alongside other efforts to increase the numbers of skilled health workers.
Recommendation 2: In all aspects concerning the adaptation of National task shifting policy, relevant parties should endeavor to identify the appropriate stakeholders, including but not limited to health workers associations and regulatory bodies, Civil Society Organizations that promote community health, and others who will need to be involved and/or consulted from the beginning.
Recommendation 3: Task shifting approach in Nigeria, will be supported by a nationally endorsed framework to ensure harmonization and provide stability for the priority services that are provided throughout the public and private sectors.
Recommendation 4: Task shifting implementation will be evidence-based and informed through regular updating of national and states health workforce profiles, also through undertaking periodical HRH situational analysis that will provide information on the demography of current human resources for health in both the public and private sectors; the need for services under priority programmes (FH, RH, MCH,HIV, TB, Malaria and others); the gaps in service provision; the extent to which task shifting is already taking place; and the existing human resource quality assurance mechanisms.
B. Recommendations on creating an enabling regulatory environment for Implementation of national task shifting policy.
Recommendation 5: Task shifting in Nigeria will ensure a thorough assessment and consider using existing health workers regulatory mechanisms and approaches (laws and proclamations, rules and regulations, policies and guidelines) where possible, or undertake revisions as necessary, to enable cadres of health workers to practice according to an extended scope of practice, based on the proposed shifting or sharing of tasks among existing cadres of health workers. The code of ethics of the responsibility that are shifted will apply to the personnel having the new tasks
Recommendation 6: A fast-track strategy will be adopted to produce essential revisions to the regulatory approaches (laws and proclamations, rules and regulations, policies and guidelines) where necessary. If necessary (after a period of 3-5 year implementation of this task shifting policy), based on the outcome of HRH situational analysis, a long-term reform will be pursued to support task shifting on a sustainable basis within a comprehensive and nationally endorsed regulatory framework, that will allow among other measures, where necessary, creation of new mid-level cadres within the health workforce in Nigeria
C. Recommendations on ensuring quality of care
Recommendation 7: As part of task shifting policy implementation Nigeria will adapt human resources for health quality assurance mechanisms to support the task shifting or task sharing approach. These will include processes and activities that define, monitor and improve the quality of services provided by all cadres of health workers.
Recommendation 8: The roles and the associated competency levels required will be defined both for existing cadres that are extending their scope of practice, and for those cadres that are being newly created or assigned additional/new tasks under the task shifting policy approach. These standards should be the basis for establishing or reviewing recruitment, training and evaluation criteria.
Recommendation 9: A systematic approach to harmonized, standardized and competency based training that is needs-driven and accredited will be adopted so that all health workers are equipped with the appropriate competencies to undertake the tasks they are to perform.
Recommendation 10: Training programmes and continuing educational support for health workers will be tied to certification, registration by relevant regulatory agencies and career progression mechanisms that are standardized and nationally endorsed.
Recommendation 11: Supportive supervision and clinical mentoring will be regularly provided to all health workers within the structure and functions of health teams. It will be ensured that Individuals or Staff who are tasked with providing supportive supervision or clinical mentoring to health workers to whom tasks are being shifted will themselves be competent and have appropriate supervisory skills.
Recommendation 12: Systems, mechanisms and guidelines will be adapted to ensure that the performance of all cadres of health workers can be assessed against clearly defined roles, competency levels and standards.
D. Recommendations on ensuring sustainability
Recommendation 13: Measures such as financial and/or non-financial incentives, performance-based incentives or other methods will be introduced as means by which to retain and enhance the performance of health workers with new or increased responsibilities, commensurate with available resources in a sustainable manner.
Recommendation 14: Nigeria recognizes that essential health services cannot be provided by people working on a voluntary basis if they are to be sustainable. While volunteers can make a valuable contribution on a short term or part time basis, trained health workers who are providing essential health services, including community health workers, will receive adequate wages and other appropriate incentives as will be defined by the relevant parties.
Recommendation 15: The Government of Nigeria in collaboration with key stakeholders and partners will ensure that task shifting plans are appropriately cost and adequately financed so that the services are sustainable
E. Recommendations on the organization of clinical care services
Recommendation 16: Nigeria will consider the different types of task shifting practice and will adopt, adapt, or extend, those models that are best suited to its specific country situation (taking into account health workforce demography, disease burden, and analysis of existing gaps in service delivery).
Recommendation 17: Nigeria will ensure that efficient referral systems are in place to support the decentralization of service delivery in the context of a task shifting approach. Health workers will be supported to be knowledgeable about available referral systems and trained to use them.
Recommendation 18: Non-physician clinicians can safely and effectively undertake specific clinical tasks for which they are trained (as outlined in Annex —table 3) in the context of service delivery according to the task shifting approach.
Recommendation 19: Nurses and midwives can safely and effectively undertake a range of clinical tasks under priority programmes as outlined in Annex/Table 3 in the context of service delivery according to a task shifting approach.
Recommendation 20: Community Health Extension Workers, Junior Community Health Extension Workers and Community Health Officers can safely and effectively provide specific services (as outlined in Annex/table 4 ), both in a health facility and in the community in the context of service delivery according to the task shifting approach.
Recommendation 21: People living with HIV/AIDS (and other chronic/long term conditions) who are not trained health workers will be empowered to take responsibility for certain aspects of their own care. People living with HIV/AIDS can also provide specific services that make a distinct contribution to the care and support of others, particularly in relation to self-care and to overcoming stigma and discrimination.
Recommendation 22: Cadres, such as pharmacists, pharmacy technicians or technologists, laboratory technicians, records managers, administrators and others, will be included in a task shifting approach that involves the full spectrum of health services.
F. Recommendations on the Service delivery at the Community Level
Recommendation 23: Nigeria will consider the different types of task shifting practices and will adopt, adapt, or extend, those models that are best suited to its community level situation (taking into account of availability of local resources, disease burden, and community referral to strengthen community-clinic linkages) that would strengthening the health system
HIFA profile: Joseph Ana is the Lead Consultant and Trainer at the Africa Centre for Clinical Governance Research and Patient Safety in Calabar, Nigeria. In 2015 he won the NMA Award of Excellence for establishing 12-Pillar Clinical Governance, Quality and Safety initiative in Nigeria. He has been the pioneer Chairman of the Nigerian Medical Association (NMA) National Committee on Clinical Governance and Research since 2012. He is also Chairman of the Quality & Performance subcommittee of the Technical Working Group for the implementation of the Nigeria Health Act. He is a pioneer Trustee-Director of the NMF (Nigerian Medical Forum) which took the BMJ to West Africa in 1995. He is particularly interested in strengthening health systems for quality and safety in LMICs. He has written Five books on the 12-Pillar Clinical Governance for LMICs, including a TOOLS for Implementation. He established the Department of Clinical Governance, Servicom & e-health in the Cross River State Ministry of Health, Nigeria in 2007. Website: www.hriwestafrica.com Joseph is a member of the HIFA Steering Group and the HIFA working group on Community Health Workers.
Email: jneana AT yahoo.co.uk