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Multipurpose worker or new worker
Skill mix in the form of new worker came into existence to increase the health reach in rural and remote areas, where people do not approach appropriate health services thereby widening the unmet need gap. Support workers from the respective community are used with appropriate training to manage the common ailments, to promote healthy practices in the community and to remove social taboos with regard to health practices.(16) This idea was also extrapolated to include such workers who can take care of supplying drugs to registered and proven cases thereby promoting the general health and productivity in the concerned community. Employing such workers in primary health care setting may be economically beneficial and productive. For example, these workers may be basically skilled for cooking and cleaning, wherein appropriate cross training can employ them as multipurpose workers who can be used for store keeping, records maintenance and patient transport. With training such people can be employed for healthcare delivery in various community level health programmes. In a higher cadre of work, nursing assistants acting as midwives and technicians pitching in as support staff are also examples of new workers.
This process of introducing multipurpose worker has also been done in India earlier but in a different way. As part of the National Health Mission, every village is provided with a trained female community health activist ASHA or Accredited Social Health Activist. The ASHA, selected from the same village, is trained to work as an interface between the community and the public health system. There are norms regarding the educational qualifications, selection process, training and remuneration of ASHAs. Preliminary assessment of competency of ASHA in the field of HIV/AIDS in Andhra Pradesh, India showed excellent results and should act as an incentive to take this forward(17). The various roles and responsibilities of ASHA as envisioned in National Health Mission is summarised in Box 4.(18) Over and above these responsibilities, further areas in which they can be trained include monitoring of drug associated adverse events in relation to treatment of diseases like Tuberculosis and HIV/AIDS. Involving them in contact tracing for early detection of Tuberculosis and HIV and appropriate referral of patients developing long term sequelae and opportunistic infections.
Implementation of skill mix requires inputs from many sources. Achieving adequate support from all involved areas is important for skill mix to succeed. Some of these are outlined in Box 4.
Innovative solutions bank on the advantages they can provide in comparison with the present techniques. Skill Mix came into play because of the number of advantages that it can provide. The basic aim of skill mix is to increase the access to health care without subsequently increasing the cost of health care, in short, increasing the productivity. In addition this also serves in reducing the workload of higher grade staff and subsequently increasing their efficiency in dealing with complicated therapeutics. Studies on skill mix highlight the usefulness and efficacy of skill mix. Studies have also documented that skill mix approach had no adverse effects in patient satisfaction.(19) It has also been found that there is no significant difference in drug prescription or cost benefit ratio but the nurses scored better in patient satisfaction. (20)(21) In well trained settings Nurse practitioners can play pivotal roles in patient care even in acute care situations.(22)
Apart from the patient oriented advantages, skill mix also provides development opportunities for the staff. The health care workers also respond positively towards additional responsibility and the work outcome is also noted to be error free.
Last but not the least, the time taken for a specialist to be trained is also substantially reduced when the job is divided and decentralised. Hence the huge problem of health care provider shortage can be met with appropriate skill Mix. (23)
These advantages of skill mix are summarised in Box 6.
Skill mix has its own set of disadvantages. Though there are many proposed advantages in skill mix, there is not enough evidence to show that skill mix is productively efficient. We have many studies favouring it, which show increased patient satisfaction, narrowing the unmet needs gap. But many of the studies did not measure the cost effectiveness of skill mix. Patient satisfaction, directly related to nurse practitioners listening more patiently than doctors has been taken as an endpoint in many of the studies. Effectiveness in terms of equality regarding a doctors and nurse practitioners prescription, identification of associated diseases, early recognition of complications were not measured. Most of the studies were based on managing simple diseases with defined practice guidelines. Some studies have also showed that better care for hospitalised patients is directly proportional to the number hours of nursing care provided by the registered nurses and the care provided by registered nurses better than that of nursing aides.(24)
Also, role enhancement leads to nurse practitioners demanding a higher salary, negating the cost effectiveness of skill mix.(25) A significant investment is required in the initial phases of training the new recruits, which makes skill mix a difficult subject of introduction in developing countries where the GDP of health expenditure in itself is low(26).
In day to day practice the clear demarcation of roles between different health workers may not be possible(27). Blurring of individual roles may have its effect on team work. Many physicians are not comfortable with the idea of nurse practitioners. The traditional idea of powers of a physician gets diluted when Nurse practitioners or such workers are given the right to prescribe medications; this has been a bone of contention among professional organisations of doctors. Patients have concerns regarding a lower grade staff meeting their problems and may be dissatisfied with the healthcare delivery. The effectiveness of skill mix can also not be generalised to all health departments and different healthcare settings. Effort has to be made to continuously monitor the quality of care provided through skill mix which is one of the hidden costs.(3) The need for ensuring accountability and standard of care also needs adequate emphasis as shown by some studies when newer workers are directly involved in patient management.(28) This is particularly important before we introduce skill mix in critical care or emergency management teams.(29)
In the case of qualified skill mix, where primary health care physicians take on the role of specialists, it should be ensured that patients of doctors working alone or in small groups, specifically in rural areas are not disadvantaged. It should also be seen that referral is not delayed and made more appropriate to the requirements of patients and their health problems. Such a specialisation should not come at the expense of their skills in general practice.(30)
Hence Skill mix can be a success only when it is being used in a controlled setting where the roles of each health care personnel is well defined, where the management and referral of a particular health condition has well defined guidelines, adequate systems are in place for the supervision and accountability, with the health care provider having enough motivation for recruitment and usage of newer staff and expenditure of resources. These various disadvantages are summarised in box 7.
Future directives and the way ahead in South East Asian Region
Skill Mix as discussed above is the innovative modality that arose out of the need for more health workers. Skill Mix though being an advantageous solution, may not be applicable in all situations. Strengthening of the health care services and quality health delivery goes a long way in promoting health care in the community. The possible scope of this concept is summarised in Box 8.
Skill Mix has its maximum utilisation in primary health care settings to increase the health service delivery, especially in developing countries. When the basic and minor health problems are met and dealt with appropriately in the primary level, the referred patients will become a minority thereby reducing the workload in secondary and tertiary settings. Empowering the existing system, role enlargement of existing ASHA workers is a potential area. They can be of help in dealing with follow up patients, like that of HIV/AIDS, Tuberculosis and other chronic conditions wherein they can be trained in appropriate drug delivery and timely referral when complications arise. Such measures reduce a major burden on the health care systems. This system of community health workers or ASHAs can also be adapted in other South East Asian countries especially in prevention, treatment, follow up of HIV/ AIDS population as in Thailand or Tuberculosis control in Nepal.
Skill mix may be utilised in the upcoming field of pharmacovigilance, wherein appropriate and timely drug adverse event monitoring can also be carried out by trained field workers. This may be of prime importance in adverse event monitoring of rampant endemic diseases in the South East Asian region which uses drugs with possible serious and fatal toxic effects like Tuberculosis.
Before promoting skill mix on a large scale, we need adequate evidence to support its role in improving patient care. In the present scenario, we have studies to show that qualified workers in any healthcare setting can improve patient outcome.(31) It is important to replicate the same results in an adequately trained ‘skill mix’ environment.
It should not be forgotten that skill mix is simply not a cost reducing measure. Sufficient monetary and time investment and a dedicated programme are necessary to make it a success.