The Struggle for Task Shifting: South Africa’s reluctance to allow nurses to perform VMMC

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Randomized Control Trials conducted in South Africa, Kenya and Uganda have shown that male circumcision can reduce the risk of contracting HIV by 60%. Voluntary Medical Male Circumcision (VMMC) has since been scaled-up in many sub-Saharan African countries with high HIV prevalence and low circumcision rates in order to reduce the spread of HIV.

Task-shifting is the process of delegating certain tasks from the physician level to the lower cadre health workers, typically at the nurse level. This allows the physicians to focus on urgent tasks at the facility, and in the case of VMMC services, task shifting helps address the lack of human resources in low resource settings.  In order to reach population-wide HIV prevention benefits from VMMC goals have been set by UNAIDS to reach 80% of the adolescent male population in just a few years. With these huge targets, it is not practical for physicians alone to provide these services.

http://www.jhpiego.org/content/free-voluntary-medical-male-circumcision-program-hiv-prevention-hits-100000-milestone-client

Registered Nurse and VMMC Provider in Tanzania for Jhpiego

Task-shifting is a proven method for increasing the efficiency of VMMC service delivery and many sub-Saharan African countries have moved to this model. Studies have shown that the adverse event rate for nurses is similar to that for physicians, and therefore there is no reason to not have this task shift policy implemented.  The World Health Organization and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) have recommended task-shifting as a best practice, and this is included in the Models for Optimizing Volume and Efficiency (MOVE) to optimize staff.

There are only two remaining governments in the VMMC target countries in sub-Saharan Africa that have not yet implemented this policy, and the Republic of South Africa is one of them. This policy is needed to increase the necessary VMMC scale-up, and ultimately avert thousands of HIV infections in South Africa.

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3 Responses to “The Struggle for Task Shifting: South Africa’s reluctance to allow nurses to perform VMMC”

  1. mayasvenkat Says:

    Task-shifting is indeed a hot topic in health systems throughout the world- one that often arises out of necessity/moments of human resource “crisis” (as you describe here, a situation in which the shortage of physicians who have historically performed male circumcision is juxtaposed with a push to achieve high rates of circumcision).

    Even in these moments of “crisis”, task-shifting may be begrudgingly accepted by those higher-level providers who may feel that their position/role is being threatened by the introduction of “lower-level” providers or the expansion of the roles of these providers. I wonder if in South Africa, this has been one of the barriers to task-shifting in VMMC?

    In the US, I’ve seen that task-shifting is more readily embraced by all the members of a care team when all members of the team are actively involved in identifying issues requiring task-shifting and planning how these tasks may be shifted/redistributed. For example, in my primary care clinic, increasing responsibilities have been shifted to nurses and medical assistants (such as engaging them in patient counseling including asking patients about vaccinations, etc), and the new roles have been readily accepted by all providers (physicians, nurses, MAs) by virtue of the the fact that they themselves defined the new roles!

    Also, I think one of the keys in task-shifting in health care is what you so clearly outlined: quality of care should not suffer as a result. It appears, as you described, that care quality (as measured by complications of the procedure) is roughly the same in the task-shifted model as compared to the physician-only model. I have found that often the “opposition” you may find from different team members often also arises from a concern about the quality of care delivered to the patient (this statement from the AAP regarding nurse practitioner and physician assistant roles in inpatient settings invokes this argument in part: http://pediatrics.aappublications.org/content/103/5/1052.full.pdf).

    Ultimately, members of a care team all want the same for the patient they serve: that the patients will become healthier through the provision of high-quality, respectful care.
    Open conversations of how task-shifting may achieve this ultimate goal, conversations that are not colored by provider “ego” or self-interest, are thus very important.

  2. mislam21 Says:

    Reblogged this on shahidulsemee and commented:

    Thanks for this excellent post. It is very important to shift the task of male circumcision (MC) to female nurses to reach 80M adolescent in South Africa for circumcision. Changing social behavior is the key component of such task shifting. In South Africa, many people have limited understanding of the role of male circumcision in HIV transmission and also males are not usually very comfortable to have the circumcision by a female professional. If social awareness about the role of MC in reducing HIV transmission is created and community people are sensitized about MC by female nurses that will expedite this task shifting. Here, I like to add two points that are very important to focus while promoting the MC. The benefits of MC often fade out due to risk compensation. People often become less aware of the taking protection during sex with the perception that after the circumcision, they are more protected against HIV that increases the risk of HIV transmission. Second, sometimes people resume sex prior to healing the wound of MC. That also increase the rate of HIV transmission.

  3. Eifelginster Says:

    There is no medical reason for routine circumcision of boys or men.

    The primary zones of male erotogenous sensitivity are the frenulum and the ridged band. These zones are orgasmic triggers. Most people are surprised to learn that the glans penis is one of the least sensitive parts of the entire body. We therefore see: so-called voluntary medical male circumcision (VMMC) in fact is genital mutilation.

    There is no evidence that lack of circumcision is a risk factor for HIV infection. Quite the contrary, male circumcision may increase male-to-female transmission of HIV.

    CONDOMS protect against HIV, circumcision does NOT.

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