While it may be hard to pass policies into law, it is much harder to prepare Nigeria’s CHEWs for bigger responsibilities no thanks to the country’s task-shifting policy.
At 6.40 am, 4-year-old Abdul is rushed into the primary health center (PHC) by his mother and some concerned family members. Abdul’s breathing is labored and fast and he is very pale.
His mother says his condition worsened over night, but they had to travel a long distance from Angwa Kacikin to reach this primary healthcare centre (PHC). A ‘nurse’ in their community has been giving Abdul some injections for some days now, but his condition has not improved.
Mr Uthman, the community health extension worker (CHEW) on night duty has admitted Abdul and has given him intravenous fluids with IV hydrocortisone.
At 10.40am when I stop at this clinic for one of my routine visits, my community health officer (CHO) friend asks me to practise being a doctor for once and go with her to review a patient. The patient was Abdul and he was dead when I saw him, with the IV line still leaking Vitamin B-complex flavored fluid into his small still body.
My provisional diagnosis would be congestive cardiac failure from severe anaemia. The severe anaemia would be a result of the malaria he had which may have been poorly treated.
All of this is inconclusive, I agree, but the event vividly illustrated a strain that existed already in this primary healthcare center and in several other PHCs and health posts found in rural, hard-to-reach communities. There are no doctors. There are no midwives. There are no nurses. And community health extension workers are being made to carry a burden greater than the capacity of training they have received in schools or in-service.
This grossly inadequate staffing condition is a nation-wide plague. There is a general scarcity of health workers, but the scarcity is more pronounced among the higher cadres of health workers.
The premise of the task-shifting policy (signed August 2014 and available below) then is this, there are more community health workers available, and somehow, since they are already performing some of the traditional tasks of the doctors and midwives, then they can be capacitated to do more.
TSTS policyThis policy is fantastic. It has the potential to solve some of the most pressing human resource for health challenges immediately and right where it matters the most – within the rural communities.
However, first things first. These health workers must receive thorough skills-based training to perform their new tasks successfully. They must be capacitated with the knowledge and supportive supervision to carry out the work. After all, it took a minimum of 6 months of a skills-based, hands-on approach to learn to rapidly recognize congestive cardiac failure and other emergent paediatric conditions in medical training.
As noted in the task-shifting policy, there is some ‘task-shifting’ already, but these forays by untrained CHEWs have been marked by mismanagement of cases and poor outcomes.
It is then not enough to sign the policy into law, or to adopt at the state level with a party and a round of applause. If the implications of the policy were to be fully accepted and understood, there must be concurrent changes in curricula for training our community health extension workers, with sufficient on-the-job continuous training and supportive supervision systems put in place.
Otherwise, the only thing we would have successfully shifted is the place of death for Nigerians in the rural areas – they would still die but in the hospitals, and from mismanagement.