• Govt refuses to pay them for non-nursing duties, disregards expert advise
• 'Separate nurses, teachers from rest of civil service' – Malaysian consultant
• The ratio of doctors and nurses per 1,000 population is 1.94 and 9.81 respectively
The protracted battle between Government and nurses over the latter's performance of 'non-nursing' duties is far from over, despite the Ministry of Health and Wellness (MoHW) and Directorate of Public Service Management (DPSM) sitting on recommendations from consultants to resolve the impasse.
A draft policy on task sharing is gathering dust at the MoHW ever since it was submitted as far back as June 2016. Long before the former Permanent Secretary Shenaz al Halabi left for Geneva to join WHO in December 2017, her ministry received recommendations from a study commissioned to explore opportunities for, barriers to, difficulties with and experiences of task sharing and task shifting for nurses and midwives in Botswana. Using the findings of the study a team comprising representatives from Nursing and Midwifery Council of Botswana (NMC), Botswana Nurses Union (BONU), Dr Magowe from UB School of Nursing, independent consultants and other stakeholders developed a draft policy and submitted it to MoHW in 2016 for finalisation. To date nothing has happened. Ruth Maphorisa was recently appointed to replace al Halabi as new PS. Sources say the issue was recently highlighted to Maphorisa in a meet and greet with stakeholders. "We await her schedule to ventilate the issue further," a source said.
Obonolo Rahube, the president of BONU says nurses are crying out loud because some jobs at local level have been shifted to them without any benefit. He said this happens despite that professionals doing the same tasks earn decent scarce skills allowance. For example pharmacists get 25%, lab technicians get 30% while dental therapists and doctors earn a whopping 40% scarce skills allowance for the same job done by nurses for 0% where such professionals are not available in most health facilities. "We were hopeful that a new policy will improve the fortunes for nurses,” he said.
The Patriot on Sunday can also confirm that nurses are pinning their hopes on the adoption of a new pay structure for civil servants by Government. Part of the recommendations from the Malaysian firm [Permandu Consultants], engaged to review civil service salaries, which are kept a closed secret, is that Government should introduce a separate pay structure for nurses and teachers because of the uniqueness of their work environment.
The Masisi administration is anticipated to adopt the recommendations, as part of efforts to appease the civil service and thaw relations with public officers going forward. The relationship between Government and civil servants deteriorated to an all-time low when the Khama administration adopted a hard-line stance at the height of the infamous 2011 nationwide strike. Khama refused to meet trade unions leaders labelling them unpatriotic and promptly fired thousands of civil servants that had hastily been declared essential service personnel. The end result was strengthening relations between public sector trade unions and sympathetic opposition political parties, which culminated in the formation of the Umbrella for Democratic Change (UDC) that almost toppled the ruling Botswana Democratic Party (BDP) in 2014 polls. The anger among civil servants was cited as one of the reasons why for the first time in history, the popular vote for the BDP fell to just 46 percent.
The study, whose findings were passed to the Ministry of Health and Wellness as far back as 2016, was conducted by University of Botswana health academics and experts from WHO, UNDP in partnership with nurses' representatives from BONU. NMC in collaboration with the BONU and researchers from the University of Botswana were funded to conduct a study aimed at exploring the experiences of nurses and midwives with tasks shifted to them or shared with other health care professionals. The aim of the study was to inform a policy for task sharing and task shifting for nurses and midwives in Botswana.
The funders of the project were the Centres for Disease Control and Prevention Botswana through the Public Health Informatics Institute which is part of the USA Task Force for Global Health. The project manager was Dr Maureen Kelley from Emory University based in Atlanta; and project consultant was Ms Jill Iliffe from the Commonwealth Nurses and Midwives Federation based in London. The nursing and midwifery leadership managing this project in Botswana was the Botswana African Regulatory Collaborative (ARC) team.
From a total of 480 nurses interviewed in the study some 54.6% of respondents reported sharing tasks with other nurses all the time and 40.8% said they shared tasks with other nurses often making a total of 95.4% of respondents sharing tasks with other nurses. With regard to tasks shifted to them from other cadres, 334 out of 475 (70.3%) received tasks shifted from other health cadres, however a majority 436 from 496 (87.9%) said they did not shift tasks to other non-nursing cadres. According to respondents 57.4% (of 359) experienced some conflict over who should perform the task, while 192 (42.6%) said they did not experience conflict.
Over 50% of respondents only performed 13 of the 42 HIV and AIDS related activities listed. The most performed activities cited by respondents were: routine screening and testing; risk or exposure screening; pre and post-test counselling; infant feeding and counselling; on-going care for HIV positive mothers; family planning; contraceptive and STD counselling and testing; dispensing; cervical cancer screening; interpreting CD4/VL results; and interpreting haematology and chemistry results.
There were concerns expressed about the need to monitor quality of care; the supply and demand for all cadres; and the need to ensure patient safety. Training, mentoring, coaching, supervision, monitoring and evaluation were emphasized as a pre-requisite to the introduction of task sharing to ensure high quality services.
The need for a framework which is supported by law and congruent with professional expectations was emphasized. Additionally, interview respondents suggested the need for adequately set boundaries for the protection of all professionals involved. Legal tools that support task sharing and shifting implementation should be developed (Acts, regulations policies, guidelines, and standards). Interview respondents enumerated tasks that they considered could be shared among health care professionals. These included out-patient consultations; medication prescriptions; dispensing medications; taking and maintaining stock inventories; sexual and reproductive health care activities; expanded HIV and AIDS activities such as medication renewal; management of patients with uncomplicated HIV or AIDS; HIV and AIDS counselling; community education; linking communities to services; and expanding access to services.
Interview respondents also outlined the benefits of task sharing and task shifting as: personal and professional development; personal motivation; acquiring new skills; contributing to the community; and being part of the solution to the problem. According to the interview respondents, task sharing and task shifting saves costs and enhances team work collaboration among health care professionals. Additionally, some interview respondents said task sharing and task shifting increases access to health care services and improves equitable distribution of health resources. HIV and AIDS care related benefits mentioned were: increasing access to counselling and testing services; expanding outreach and follow-up programs; and providing community education.
Health Workforce Issues
The world is faced with a chronic shortage of health workers making health the most pressing global health issue and Botswana is no exception. Health care workers are regarded as the heart and soul of health care systems. Health service providers constitute about two thirds of the global health workforce, with an estimated 59.2 million full-time paid health workers worldwide (WHO, 2015). Globally, there is an estimated shortfall of 7.2 million health workers and the gap is expected to increase to 12.9 million by 2035 if no interventions are made (WHO, 2013). Strategies suggested by the World Health Organization to address workforce shortages include task sharing and task shifting; approaches that have been successfully used by many countries.
The study found that Botswana is experiencing a shortage of health care workers, especially nurses, midwives, pharmacy and laboratory personnel, and doctors. The shortage of these personnel has resulted in some of their traditional tasks being ‘shifted’ to nurses and midwives. The ratio of doctors and nurses per 1,000 population is 1.94 and 9.81 respectively. Several innovations have been implemented to ease the health workforce shortages in Botswana. These include an increase in the number of training institutions for nurses and midwives; an increase in the number of nurses and midwives trained annually; the development of new medical schools; and the proposed upgrading of educational programs from diploma to degree level. However the shortages continue to escalate due to migration; the increasing burden of disease; insufficient training numbers; and ageing of the workforce leading to retirement from the workforce.
The shortage of personnel has resulted in the shifting and sharing of tasks between health workers, especially nurses and midwives as they are more numerous than other health cadres. There has not been however any formal research that has explored health worker shortages in Botswana, neither has there been any policy development to guide the implementation of task sharing and task shifting to justify or support what is happening in practice.
Generally results seemed to favour the terminology of task sharing rather than that of task shifting. While some tasks are shifted to nurses, nurses are already sharing a considerable number of tasks with other professionals such as doctors. However, some concerns and pre-requisites were raised so that task sharing can be implemented fairly and safely.