Effectiveness of educational outreach in infectious diseases management: a cluster randomized trial in Uganda.

BACKGROUND: Integrated Infectious Diseases Capacity Building Evaluation (IDCAP) teams designed and implemented two health worker in-service training approaches: 1) an off-site classroom-based integrated management of infectious diseases (IMID) course with distance learning aspects, and 2) on-site support (OSS), an educational outreach intervention. We tested the effects of OSS on workload and 12 facility performance indicators for emergency triage assessment and treatment, HIV testing, and malaria and pneumonia case management among outpatients by two subgroups: 1) mid-level practitioners (MLP) who attended IMID training (IMID-MLP) and 2) health workers who did not (No-IMID). METHODS: Thirty-six health facilities participated in the IDCAP trial, with 18 randomly assigned to Arm A and 18 to Arm B. Two MLP in both arms received IMID. All providers at Arm A facilities received nine monthly OSS visits from April to December 2010 while Arm B did not. From November 2009 to December 2010, 777,667 outpatient visits occurred. We analyzed 669,580 (86.1 %) outpatient visits, where provider cadre was reported. Treatment was provided by 64 IMID-MLP and 1,515 No-IMID providers. The effect of OSS was measured by the difference in pre/post changes across arms after controlling for covariates (adjusted ratio of relative risks = a RRR). RESULTS: The effect of OSS on patients-per-provider-per-day (workload) among IMID-MLP (aRRR = 1.21; p = 0.48) and No-IMID (aRRR = 0.90; p = 0.44) was not statistically significant. Among IMID-MLP, OSS was effective for three indicators: malaria cases receiving an appropriate antimalarial (aRRR = 1.26, 99 % CI = 1.02-1.56), patients with negative malaria test result prescribed an antimalarial (aRRR = 0.49, 99 % CI = 0.26-0.92), and patients with acid-fast bacilli smear negative result receiving empiric treatment for acute respiratory infection (aRRR = 2.04, 99 % CI = 1.06-3.94). Among No-IMID, OSS was effective for two indicators: emergency and priority patients admitted, detained or referred (aRRR = 2.12, 99 % CI = 1.05-4.28) and emergency patients receiving at least one appropriate treatment (aRRR = 1.98, 99 % CI = 1.21-3.24). CONCLUSION: Effects of OSS on workload were not statistically significant. Significant OSS effects on facility performance across subgroups were heterogeneous. OSS supported MLP who diagnosed and treated patients to apply IMID knowledge. For other providers, OSS supported team work to manage emergency patients. This evidence on OSS effectiveness could inform interventions to improve health workers' capacity to deliver better quality infectious diseases care.

Mid-level health providers (MLHPs) in delivering and improving access to primary health care services - a narrative review.

Background: For primary healthcare systems to bring care closer to the communities, the availability of appropriate human resources is crucial. The primary care workforce in the world is expanding to include non-physician health workers (NPHWs) to increase its capacity. Also, NPHWs as mid-level health providers (MLHPs) are currently being employed in high- and low-income countries to assist doctors and specialists to make up for the scarcity of health professionals. Given the wide prevalence in the deployment of NPHWs as mid-level health providers, this article collates recent evidence on the role of MLHPs in improving access to primary healthcare services, and their enablers and barriers in integrating them in primary care teams. The article also presents gaps in evidence and recommendations for the way forward. Methods: A systematic search of contemporary literature published from January 2012 to September 2022 was undertaken using two bibliographic databases (PubMed and Cochrane) and hand searching the reference list of retrieved papers. Duplicates, papers older than ten years, and whose focus was not on primary healthcare were excluded. The papers finalised for appraisal were scrutinised for key themes and their summaries were collated for analysis. The papers comprised of twenty-four quantitative, twenty-three qualitative, and nine mixed approach study designs (n = 56) due to which a narrative approach was conducted as per guidelines. Results: The review identified and presents the following themes - task shifting and its effectiveness in service delivery, quality of care, enablers and barriers of NPHWs in primary health care in both HIC and LMIC settings. Conclusion: Task-shifting interventions need effective engagement and constant coordination with relevant stakeholders. For this, policymakers, public health researchers, healthcare professionals of all cadres and community members need to be involved across all stages of introduction and absorption of the cadre into the primary healthcare delivery system.

Mid-level health providers for primary healthcare: a rapid evidence synthesis.

Background: Health care services, in many countries, are increasingly being provided by cadres not trained as physicians, but capable of performing several diagnostic and clinical functions. These substitute health workers are referred to as mid-level health providers (MLHPs). The health and wellness centres under India's Comprehensive Primary Health Care programme have teams led by MLHPs who can aid doctors. The objective of this study was to rapidly synthesise evidence on the effectiveness of MLHPs for primary health care. Methods: The review team undertook a rapid overview of systematic reviews that compared MLHPs with doctors and different types of MLHPs involved in the delivery of health care were included, with a perspective on low- and middle-income countries, including India. Results: Seven systematic reviews were included in the final report. Mortality outcomes in relation to pregnancy and childbirth care services showed no significant differences in care provided by MLHPs when compared with doctors. Pregnancy care provided by midwives was found to slightly improve quality of care when compared to care delivered by doctors. The risk of failure or incomplete abortion for surgical abortion procedures provided by MLHPs was twice when compared to the procedures provided by doctors. Moderate to high certainty evidence showed that initiation and maintenance of antiretroviral therapy for HIV-infected patients by a nurse or clinical officer slightly reduced mortality. High certainty evidence showed that chronic disease management by non-medical prescribers reduced some important physiological measures when compared to medical prescribing by doctors. Conclusions: To date, this is the first rapid overview of evidence on MLHPs. Evidence suggests that MLHPs might be suitable to deliver quality care in certain areas of health and they may be relevant and feasible in countries like India. However, the roles and subsequent training and regulation of MLHPs might be different for different care domains.