Nepal in the pathway of reaching the first 90 of the 90-90-90 goal through task shifting.

Sanjeev Raj Neupane and Dr Imran Muhammad

Many developing countries around the world are facing acute shortage of trained health workforce. For achieving Universal Health Coverage trained and adequate number of health workforce is a must. Achieving universal health coverage is impossible without having the right people; with the right skills, in the right place. Many health programmes are facing serious problem due to shortage of trained health workforce. HIV programmes are also severely affected due to lack of trained health workforce. To tackle the HIV epidemic; the problem of shortage of human resources must be tackled. Without tackling the problem of shortage of human resources; the battle against HIV can’t be won. Production and training of health workforce is not only in the control of health ministries. Besides this the production and training of health workforce needs long time; huge investments and multi-sectoral involvement. We cant wait until there will be adequate human resources to tackle the problem of HIV epidemic. So the concept of “Task Shifting” which has already been used successfully in many other public health programs is being replicated in the field of HIV also.

(Figure Source: WHO HIV/AIDS Programme; Task Shifting to Tackle Health Worker Shortages)
Task shifting is a process of delegation of roles and responsibilities from specialized health workers to less specialized health workers or to the community people. In the absence of specialized physicians some of their tasks could be delegated to Medical officers; some of the tasks of medical officers could be delegated to Nurses; some of the tasks of nurses could be delegated to community health workers and some of the tasks of community health workers could be delegated to People living with HIV (PLHIV) themselves. However this needs to operate in public health approach. Regulation and training must be in the centre in the task shifting process.
To end the AIDS epidemic UNAIDS has come with an ambitious goal of 90-90-90 which simply means by 2020; 90% of all people living with HIV will know their HIV status; 90% of diagnosed HIV positive people will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have HIV viral load suppressed. Once this three part target is achieved 73% of all people living with HIV worldwide will be virally suppressed. Modelling data suggest that achieving these targets by 2020 will enable the world to end AIDS epidemic by 2030, which in turn will generate profound health and economic benefits.
But with the current strategies and current pace it is almost impossible to achieve the ambitious goal of 90-90-90 by 2020. Public health scientists and HIV activists around the world are proposing different fast track strategies and approaches that could help world achieve the ambitious 90-90-90 target. One of the strategy proposed for achieving the first 90 is HIV testing by lay providers (which is often called Community led HIV testing). In 2015; WHO recommended that members of key population who are trained can independently conduct safe and effective HIV testing using rapid diagnostic tests. Many people are currently using similar kind of rapid diagnostic test kits for detection of blood sugar in home just by reading the user manual that comes with the test kit. The rapid diagnostic test kits are also similar so trained member of a key population can perform the HIV screening test accurately.
Since WHO recommended HIV testing by lay providers in 2015; many countries around the world are in the process of adopting this WHO recommendation as per their country epidemic. Nepal has already endorsed in its National HIV Strategic Plan 2016-21 that Nepal will also implement Community led HIV testing. Accordingly Nepal has already developed National Guideline for Community Led HIV testing and Nepal is all set to roll out of HIV testing by Lay providers in next few months. Once this is rolled out Nepal will be the first country in South Asia to implement HIV testing by Lay Providers and hopefully this new approach will help Nepal to reach the first 90 of the lofty 90-90-90 target.
June 10, 2018

Sanjeev Raj Neupane and Dr Imran Muhammad

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Sanjeev Raj Neupane

I was reading an article during lunch break by one of my friend about “Karnali highway and Prosperity Dreams” I was distracted by news about Road Traffic Accident in the western part of Nepal claiming 13 lives and injuring 10 people. I was haunted by the news for a whole day. At the end of the day, I quickly scanned all the online portals; social media; twitter handle of the National media. For everyone, this was like just one more column in their newspaper or one more feed to update in the twitter handle. I don’t know why but as a public health professional I was haunted by this news and the more frustrating for me was the ease with which all of us (media; health professionals, students, teachers, bankers, businessmen, travelers and you and me) showed indifference to this news. We all reacted as if nothing has happened and this is just a normal thing in Nepal. Have we become so selfish that a dozen of innocent people who die in the middle of the road because of someone else’s mistake makes us no difference? Have we become so busy that we scroll the news of people dying in road traffic accident just like every other news on the newsfeed? Or have we become such a pure development worker who needs another workshop in a good hotel to raise this issue?
I googled to see the casualties related to Road Traffic Accident that happen every year in Nepal. I was surprised to see the figures staggeringly high. A newspaper article “Road accident fatalities continue unabated” mentions that on an average there were 28 road accidents and six people die every day in the Fiscal Year 2016/17. According to the statistics published by Nepal Police, a total of 2,385 persons were killed (weren’t they murdered ?) in 10,178 road accidents in the fiscal year 2016/17 and the death toll are on the increasing trend. The Global Burden of Disease by Institute of Health Metrics and Evaluation shows that in 2016 there were 15.9 deaths for every 100,000 population due to Road Injuries in Nepal
The Wikipedia defines “Massacre as a killing, typically of multiple victims, considered morally unacceptable, especially when perpetrated by a group of political actors against defenseless victims”. If we follow the dictionary definition the accident that happened in Western part of Nepal today killing 13 people and injuring many others is not a Road Traffic Accident but a mass massacre. Were there multiple victims ? “Yes”……Was it morally acceptable ? “No. Not at all”. Was it perpetrated by a group of political actors ? “Partially Yes”. [Different transport companies affiliated under different political parties operate in Syndicate which is not yet practically eradicated although the government claims this has been eradicated] and all those dying are the innocent defenseless victims traveling to their destination. So this is no different than a mass massacre but the only difference is that the massacre happens once in ages but the road traffic accident are happening everyday and we don’t care about it. Would we have reacted in the same way if there really had been a real massacre ? Would the newspapers and the online portal would have taken it just like another piece of news if there had been a mass massacre? How vigilant our traffic police and security personnel would have been if there was a real massacre ? How often would the politicians have raised the issue in parliament only if there was a real massacre ? How many protests and demonstrations would have been done by political parties and their affiliations if there had been a real massacre ?  Every massacre don’t happen with bullets; guns; swords, bombs; missiles or other weapons of mass destruction. Currently we are facing mass massacre in the form of Road Traffic Accidents but we don’t care about it. Isn’t this inhuman?

Sanjeev Raj Neupane, Technical Specialist for Global Fund Programs, Save the Children US

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