Joint Special Issue E.21: Training front-line health workers for tuberculosis control in developing countries: lessons from Nigeria and Kyrgyzstan
Authors:*Niyi Awofeso1,2, Irina Schelokova3, Dalhatu Abubakar4
1Faculty of Health Sciences, National Open University of Nigeria, Abuja, Nigeria.
2**School of Public Health and Community Medicine, University of New South Wales, Sydney 2052, Australia
3Specialist Tuberculosis Physician, Bishkek, Kyrgyzstan
4Senior Health Tutor, National Tuberculosis and Leprosy Training Centre, Nigeria.
*Corresponding author
**Address for correspondence
Type of article: Commentary
Word count of text: 1560
Word count of abstract:213
Tables: 1
References: 31
E-mail of corresponding author:
E-mail of first co-author:
E-mail of second co-author:
Competing interests: The authors declare that they have no competing interests.
Authors’ contributions: The original idea was that of the corresponding author NA. IS and AD provided valuable local data, and critiqued the original draft.
Abstract
Background
Efficient human resources development is vital for facilitating tuberculosis control in developing countries, and appropriate training of front-line staff is an important component of this process. Africa and Central Asia are over-represented in global tuberculosis statistics. Although the African region contributes only about 11% of the world population, it accounts for at least 25% of annual TB notifications, a proportion that continues to increase due to poor case management and the impact of HIV/AIDS. Central Asia’s estimated average tuberculosis prevalence rate of 240/100,000 is significantly higher than the global average of 217/100,000.
Methods
With increased resources currently becoming available for African and Asian countries to improve tuberculosis control, it is important to highlight context-specific training benchmarks, and propose how human resources deficiencies may be addressed, in part, through efficient(re)training of frontline tuberculosisworkers. This article compares the quality, quantity and distribution of tuberculosis physicians, laboratory staff, community health workers and nurses in Nigeria and Kyrgyzstan.
Conclusions
Major inadequacies in quality, quantity and distribution are evident in all cadres of frontline staff in Nigeria, and such trends are mirrored in most countries in sub-Saharan Africa. In Kyrgyzstan, as in most of Central Asia and Eastern Europe the major training issue is in relation to developing an optimal mix of front-line tuberculosis staff. Strategies for addressing identified shortcomings are proposed.
Keywords: Tuberculosis, Training, Health Workers, Nigeria, Kyrgyzstan.
Joint Special Issue E.21: Training of front-line health workers for tuberculosis control in developing countries: lessons from Nigeria and Kyrgyzstan
Introduction
The World Health Organization (WHO) acknowledges that the main human resource issues affecting tuberculosis control are insufficient quality, quantity and distributionof health workers.[1]According to the Stop TB Partnership, $US250 million is required annually to provide training to tuberculosis endemic regions. Apart from training, other influences on productivity of tuberculosis health workers include adequate remuneration and professional advancement opportunities.[2] A 2005 WHO study determined that poorly developed human resources information systems impaired the reliability of data on tuberculosis workforce, and thatwide variation in training course duration and staff numbers were poorly correlated with tuberculosis programs’ performance.[3] Undergraduate and post-basic training for tuberculosis control is inadequately funded by most developing country governments, and financially-rewarding training programs sometimes divert front-line staff away from tuberculosis control duties for considerable periods.[4,5]
Nigeria has the fourth highest estimated TB burden worldwide. Kyrgyzstan has the second highest TB burden in Central Asia. The training system for tuberculosis control workers in Nigeria exemplifies tuberculosis training programs in sub-Saharan Africa, while training programs for Kyrgyzstan’s tuberculosis workers exemplify training programs in Eastern Europe and Central Asia Selected TB-related statistics for Nigeria and Kyrgyzstan are shown in Table 1.[6]
Table 1: TB profiles for Nigeria and Kyrgyzstan, 2005
Nigeria / KyrgyzstanPopulation / 131.5 million / 5.3 million
Estimated Incidence (all cases/100,000 population/year) / 371,642 (283/100,000 population) / 6,346 (121/100,000 population)
Estimated Prevalence (all cases/100,000 population/year) / 704,388 (536/100,000) / 7013 (133/100,000)
Estimated Mortality (deaths/100,000 population/year) / 99,938 (75/100,000 population/year) / 927 (18/100,000 population/year)
Estimation proportion of TB patients with HIV co-infection / 27% / 10%
DOTS case detection rate / 22% / 91%
DOTS treatment success rate / 73% / 85%
Non-Governmental Organizations (NGO)preferentially fund vertical or combined tuberculosis control andtraining programs despite their limitations.[7,8] As leprosy prevalence in Nigeria continues to decline, ‘reverse integration’ of tuberculosis services and some general health services into better funded leprosy control programs has been occurring in many projects.[9] At Nigeria’s National Tuberculosis and Leprosy Training Centre(NTBLTC) in 2006, only 284 outpatient consultations were undertaken for patients with leprosy, compared with1463 tuberculosis consultations and20,493 general health consultations.[10] In Kyrgyzstan,plans are underway to combine tuberculosis training with tobacco and HIV in line with WHO-supported initiatives.[11,12] There is as yet no international consensus regarding the relative emphasis that should placed on the training of physicians, nurses, laboratory technicians and community health workers in order to produce an optimal human resources mix for tuberculosis control.[13] In this article, differences in quality, quantity, and distribution of front-line tuberculosis staff inNigeria and Kyrgyzstan tuberculosis control programs are used to highlight the above training-related issues, and to propose improvements for tuberculosis (re)training in developing countries.
Quantity
The 2004 WHO Joint Learning Initiative Report used three categories to identify the density of health workers as low, medium or high: less than 2.5, 2.5–5.0 and 5.0 or more health workers respectively per 1000 population.[14]The authors recommenda mix of 0.125 physician (1: 24), 0.25 nurse (1:12), 0.125 laboratory technician (1:24) and 0.5 tuberculosis control supervisor (1:6) working as frontline tuberculosis staff per 1,000 patients as an optimum human resources mix for tuberculosis control in developing countries. The TB doctor-patient ratio for Kyrgyzstan documented in a 2005 World Bank report was one doctor per 17 tuberculosis patients.[15]
Recent estimates indicate that Africa has, on average, 2.3 health workers per 1,000 inhabitants, and that 36 of 57 countries experiencing shortage of health workers are in Africa.[16]Nigeria is currently critically deficient in meeting its workforce requirements in relation to physicians (0.3: 1,000), nurses (1.7: 1,000), community health workers (0.9: 1,000) and laboratory health workers (0.005: 1,000). The proportion ofNigeria’s health staff working in tuberculosis controlis significantly less than the above ratios. For instance, WHO estimates that the TB physician per population ratio in Nigeria is between 1: 160,000 and 1: 400,000.[17]In contrast, Kyrgyzstan has 3.0 doctors per 1,000 population, 6.1 nurses per 1,000 population, 3.7 laboratory workers per 1,000 population but practically no tuberculosis control supervisors. A comparable proportion of Kyrgyzstan’s physicians, nurses and laboratory specialists are employed in tuberculosis control.[15,18]
Nigeria continues to lag behind in its target oftraining at least one nurse or community health worker as Local Government Area tuberculosis and leprosy control supervisor/coordinator for each of its 774 Local Government Areas. Unfortunately, the biggest funding shortfall in Nigeria’s government tuberculosis budget has consistently beenin the area of training front-line staff to improve case detection and cure rates.[17,19,20]
Quality
Although concerted efforts have been made by WHO to improve the quality of tuberculosis training activities such as laboratory support, developing countries have not benefited adequately from such initiatives.[21,22] It is suggested that national training curricula for frontline tuberculosis staff at undergraduate and post-graduate levels should be developed (and revised regularly) in consultation with WHO, International Union Against Tuberculosis And Lung Disease (IUATLD) and the respective regulatory bodies for the training of physicians, doctors, community health officers and laboratory technicians. Also pertinent is the need to develop standard, multi-disciplinary training programs for quality assurance of tuberculosis control programs.[23] Assurance of long-term funding for training activities by government and NGO is important for quality assurance.
Quality of tuberculosis training should be monitored at participant learning, job behaviour and organizational levels. Participant feedback, pre-test, post-test and performance tests (e.g. role play and evaluation of reports during training) are useful quality tools at participant learning level. Tools for assessing quality of training at job behaviour level include questionnaire studies of participant’s impressions of how the training is impacting on job performance, and formal site visits by trainers to observe participants at work settings. At the organizational level, quality of training may be indirectly assessed by its impact on case detection, treatment outcome and validity of reports.
Kyrgyzstan’s National Tuberculosis Institute (NTI) coordinates post-graduate physician training, which typically lasts 12 months. Tuberculosis physicians are required to undertake government-funded mandatory update courses at the NTI once every three years. In addition, nursing and laboratory workers also have the opportunity to undertake high quality training programs funded by NGOs involved with tuberculosis control, such as the WHO MDR-TB management coursein Latvia
Distribution
Since failure of control measures is an important determinant of the distribution and spread of tuberculosis,[24]it is important to focus trained human resources in areas of high tuberculosis prevalence. In developing countries, two geographical areas in which tuberculosis prevalence outstrips distribution of competent tuberculosis health workers are poor rural areas and prisons. Enhancement of quality of rural experiences during undergraduate postings, and promoting the challenges and lifestyle of rural practice to health workers play important roles in encouraging tuberculosis workers to work in, or return to, underserved rural areas.[25,26] In Kyrgyzstan generous incentives such as 30% enhanced basic salary for front-line TB workershave influenced improvements in the quantity and distribution of TB staff.
Tuberculosis training programs may be used as an incentive to influence health workers’ distribution patterns, such as by preferentially allocating funded tuberculosis training places to eligible applicants from geographical regions with relatively high disease burden, and by making fully-funded tuberculosis training conditional on trainees working in a tuberculosis high prevalence region for a specified period. Given the difficulties that specialist staff are likely to face with regards to living conditions in some high tuberculosis prevalence settings such as prisons and rural areas, it may be prudent to factor ‘prison/rural posting package’ costs into employment contracts in order to enhance staff retention and motivation.[5,27]Because Kyrgyzstan has adequate numbers of tuberculosis workers, and because the vast majority are employed within the public sector, ensuring adequate distribution through government employment policies and directives have so far been relatively successful, although problems remain in relation to staff motivation and treatment outcomes.[28,29]Nigeria’s national and State tuberculosis programs currently lack sufficient incentives and authority to influence the distribution of frontline tuberculosis staff.
Conclusion
This review underscores the need for tuberculosis policy makers and NGOs working in developing countries to address the following training-related issues:
- Trained human resources operate in a “productivity mix” comprising other factors such as adequate motivation and tuberculosis control infrastructure. As more funds become available for training, it is important to pay attention to other factors of the “productivity mix”, so as not to reinforce the limitations and weaknesses of current training practices in developing countries. As shown in a study of tuberculosis workers in Malawi, improvements in TB cure rates are achievable not only by improved training, but also local analysis of tuberculosis procedures, improved supervision and decentralization of drug supplies.[30]
- Planning for training needs of tuberculosis control programs requires a good human resources information system, which is currently poorly developed in countries with high burden of tuberculosis.[3] It is important to adopt an internationally coordinated approach to addressing this deficiency, and to fund human resources information systems with comparable datasets across developing countries.
- Since most developing countries inadequately fund post-basic training of tuberculosis workers, there is large room for improvement in the quality of tuberculosis training in the basic curriculum of nurses, doctors, community health officers and laboratory technicians. A system for evaluating the quality of tuberculosis training at this level also needs to be developed.
- NGOs have strong influence on the structure of TB training, as well as the mix of health worker cadres that will be trained in order to efficiently undertaken tuberculosis control services. Training opportunities strongly influence the distribution of tuberculosis health workers in developing countries. However, it is important to minimise the adverse impact of training on the availability of health workers in high-need areas by developing, funding and promoting distance learning and on-site training programs.[31]
- Evaluation should occur not only during training, but also within 12 months following training programs, as well as through long-term evaluation of tuberculosis program outcomes, with particular attention to improvements in case detection rates and cure rates.
Declaration of competing interests
'The authors declare that they have no competing interests”
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