„nim art‟, nurses, health systems - tb · pdf fileprofessional nurse statistics, 2010...
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„NIM ART‟, nurses, health systems
Stacie C. Stender
10 August 2011
overview
what
when
who
how
where
why not?
considerations
2
what is „NIM ART‟?
3
when?
2004 ART (schedule 4) introduced in public sector
2005 „new‟ Nursing Act
2007 NSP
2009 Nursing Act of 2005 proclaimed, regulations
STILL outstanding
April 2010, nurses „allowed‟ to prescribe, no
regulations
2011, 1.4 million on ART despite HRH shortages…
4
by who?
who is a „nurse‟?
Nursing Act (No 33 of 2005) Fully proclaimed
Section 4(1)(l)(i) provides that the Nursing
Council determines scope of practice of all
categories of nurses defined in 31(1):
(a) Professional Nurse
(b) Midwife
(c) Staff Nurse
(d) Auxiliary Nurse
(e) Auxiliary Midwife
„sister‟?
Professional Nurse Statistics, 2010
Province
number
registered
with SANC
employed in
public
sector
% working
in public
sector
% of posts
vacant
EC 13 985 8 287 59% 67%
FS 7 550 1 868 25% 47%
GP 30 063 9 393 31% 16%
KZN 24 360 12 463 51% 26%
LP 9 025 7 243 80% 68%
MP 5 714 3 732 65% 27%
NC 2 146 1 258 59% 34%
NW 7 775 3 321 43% 12%
WC 14 626 4 399 30% 34%
TOTAL 115 244 51 966 45% 46%
7Source: HST & SANC
EN & ENA Statistics, 2010
Province
Enrolled Nurses Enrolled Nursing Assistants
number
registered
employed
in public
sector
% in
public
sector
Number
registered
employed
in public
sector
% in
public
sector
EC 3 566 2 377 67% 6 124 5 369 88%
FS 1 846 435 24% 2 951 2 230 76%
GP 13 006 4 975 38% 16 667 6 877 41%
KZN 18 895 9 232 49% 11 489 6 123 53%
LP 4 170 2 732 66% 8 331 4 524 54%
MP 2 276 1 414 62% 3 732 2 103 56%
NC 461 188 41% 1 311 759 58%
NW 2 549 774 30% 4 732 2 730 58%
WC 5 601 2 188 39% 8 135 4 143 51%
TOTAL 52 370 24 315 46% 63 472 34 858 55%
8Source: HST & SANC
of note
9
45% of registered Professional Nurses / Midwives
are 50 years or older
Average age of the ~ 3 000 graduates from 4-
year programs is 30
Average age of ~ 2 650 graduates from bridging
program is 39
1 754 PNs are registered with some type of
certificate in primary health (of 8) 798 pts each?
Only 336 PNs are registered with some type of
certificate in pharmacology (of 5)
National clinic supervision rate is 48% 1 visit/1 month
HCT Update, June 2011
Province
15 Month
Target
Pre-Test
Counseled
Target
Achieved Tested
Testing
RateEastern Cape 2,017,693 1,705,245 72% 1,446,351 85%
Free State 957,889 1,124,321 99% 951,765 85%
Gauteng 3,349,084 3,174,328 93% 3,118,184 98%
KwaZulu-Natal 3,059,234 3,686,267 95% 2,920,433 79%
Limpopo 1,540,604 1,498,031 87% 1,332,651 89%
Mpumalanga 1,095,823 918,816 78% 853,578 93%
North West 998,859 1,291,355 107% 1,066,832 83%
Northern Cape 337,941 298,194 86% 290,214 97%
Western Cape 1,607,592 1,006,226 61% 981,263 98%
SA 14,964,720 14,702,783 87% 12,961,271 88%
Who does HIV Counselling and Testing??
Nurse Nominated for NIMART(Will be directly involved in initiating patients on ART)
Had HIV Basics Training?
Yes No
Confident in HIV Basics?
YesNo
In-Facility NIMART Training (PALSA Plus + NIMART IMCI Component)
Clinical Mentoring(Deemed competent and certified)
HIV Basics Training
HIV Update Training
how?
Source: NDOH HRD ?
where? district status
Province DistrictNo of
FacilitiesFacilities
Initiating ART
Nurses Trained in NIMART
Nurses Initiating ART
EC Alfred Nzo 48 24 76 51
14k Amathole 257 122 152 123
Cacadu 111 53 196 167
Chris Hani 196 67 150 77
Nelson Mandela 76 31 61 50
OR Tambo 173 73 199 191
Ukhahlamba 78 40 67 32
TOTAL 939 410 901 691
Source: NDOH HRD
44% 77%
Province DistrictNo of
FacilitiesFacilities
Initiating ART
Nurses Trained in NIMART
Nurses Initiating ART
FS Fezile Dabi 58 23 133 42
8k Lejweleputswa 66 23 108 48
Motheo 82 27 151 50
Thabo Mofutsanyana
100 25 149 60
Xhariep 31 13 64 23
TOTAL 337 111 605 223
Source: NDOH HRD
33% 37%
Province DistrictNo of
FacilitiesFacilities
Initiating ART
Nurses Trained in NIMART
Nurses Initiating ART
GP Ekurhuleni MM 89 85 304 171
30k Johannesburg MM 121 54 254 67
Metsweding DM 15 15 42 17
Sedibeng DM 40 28 118 57
Tshwane MM 62 49 113 43
West Rand DM 47 47 113 109
TOTAL 374 278 944 464
Source: NDOH HRD
74% 49%
Province DistrictNo of
FacilitiesFacilities
Initiating ART
Nurses Trained in NIMART
Nurses Initiating ART
KZN Amajuba 35 17 127 0
24k eThekwini 217 62 1727 30
illembe 48 32 87 22
Sisonke 55 26 41 17
Ugu 77 56 509 56
uMgugundlovu 79 24 59 31
uMkhanyakude 73 51 73 21
uMzinyathi 59 35 52 15
uThukela 56 24 21 5
uThungulu 75 46 92 22
Zululand 89 56 70 13
TOTAL 863 429 2858 232
Source: NDOH HRD
50% 8%
Province DistrictNo of
FacilitiesFacilities
Initiating ARTNurses Trained
in NIMARTNurses
Initiating ART
LP Capricorn 104 92 125 42
9kGreater Sekhukhune
92 54 146 23
Mopani 106 105 181 77
Vhembe 124 123 193 92
Waterberg 64 43 147 15
TOTAL 490 417 792 249
Province DistrictNo of
FacilitiesFacilities
Initiating ARTNurses Trained
in NIMARTNurses
Initiating ART
MP Ehlanzeni 133 132 234 207
6k Gert Sibande 90 68 216 194
Nkangala 95 76 274 130
TOTAL 318 276 724 531
Source: NDOH HRD
85% 31%
87% 73%
Province DistrictNo of
FacilitiesFacilities
Initiating ART
Nurses Trained in NIMART
Nurses Initiating ART
NC Frances Baard 29 19 44 24
2k JT Gaetsewe 37 8 32 9
Namakwa 32 27 32 30
Pixley Ka Seme 35 35 29 22
Siyanda 29 19 28 19
TOTAL 162 108 165 104
Source: NDOH HRD
67% 63%
Province DistrictNo of
FacilitiesFacilities
Initiating ART
Nurses Trained in NIMART
Nurses Initiating
ART
NW Bojanala 156 20 229 17
8k Dr Kenneth Kaunda 63 28 72 32
Ngaka Modiri-Molema
128 30 189 81
Dr Ruth Segomotsi-Mompati
43 12 107 22
TOTAL 390 90 597 152
Source: NDOH HRD
23% 25%
why not (NIM ART)?
Lack of confidence
No formal system of recognition of competency
Workload: facilities without lay counsellors
Stigmatization and continued verticalization
Mixed messages about initiating children
“PMTCT initiation is low. some Dr said nurses
must send all pregnant women to them and not
initiate them” EC
„Sub-optimal use of partners to support the state
clinicians & systems....‟ NC19
why not (NIM ART)?
Pharmacy: mixed messages
Pharmacy: drug availability at PHC
Pharmacy: pharmacists not dispensing nurse
prescriptions EC, KZN
Pharmacy: registration as prescribers /
authorization processes mystifying
Pharmacy: workload with dispensing
20
why not?: health systems
no support from management EC
„facilities not assessed‟ EC
„… trained most of the nurses, but as there is only 3
ART sites (out of 22 clinics), only a small proportion
are involved in initiating.‟ NW
space
„Doctors are a scarce skill and there is a shortage in
this district - we still have not been able to recruit the
roving teams which were supposed to provide the
mentorship to NIMART trained nurses‟ KZN
21
why not?: mentorship
Lack of experienced
mentors
„no follow-up mentorship
planned‟ MP
„lack of support, mentorship,
and resources‟ NC
„the main problem is really
rural areas… the nurses only
get MO's with very little HIV
experience and they then
have to train the doctors‟ WC
22
„merely anecdotal‟
“I think what has worked very
well is the involvement of
NGO's and community
workers. Without them the
system would have collapsed
a long time ago.”
23
considerations
high index of suspicion: symptom screen
need adequate specificity
revisit curricula of all cadres of nurses
diagnosing EPTB & smear negative TB
integrate in health assessment (?NP) training… FNA,
x-ray interpretation, etc.
initiating TB & MDR-TB treatment (legal
implications?)
role of the private sector
role of staff & auxillary nurses in TB (and HIV)24
considerations: „task sharing‟
because nurses are meant to contribute to the
multidisciplinary team, not be the team. what
next, lab work?
dispensing…. more pharmacy assistants!!
phlebotomy… it works well in private sector
counselling… those at the facility for DOT?
symptom screening…?
sputum collection…?
25
