Evaluation of the Training of Técnicos de Medicina in Mozambique
The Mozambican Ministry of Health (MOH) recently developed a plan for accelerated health care worker training that calls for the training of 950 new técnicos de medicina (TDM) by 2010. After the implementation of a two-week in-service training on antiretroviral therapy (ART) for these mid-level providers, Mozambique’s MOH wanted to assess ART-related TDM clinical performance. The overarching aim of the activity was to guide forthcoming revisions to HIV and AIDS-related training of TDM at both pre-service and in-service levels, and to identify system support gaps that, if addressed, could favorably affect the quality of HIV and AIDS care delivered by TDMs.
In October and November 2007, experienced clinicians (COs) observed patient consultations conducted by randomly selected TDMs nationwide. The COs provided immediate, confidential feedback, with correction of clinical errors where indicated. Standardized instruments were used to record patient history, physical exam, lab results, and clinical decision making. Semi-structured interviews described health facility resources and constraints. Primary analyses (quantitative and qualitative) focused on errors in clinical staging and in management of cotrimoxazole (CTX) prophylaxis and/or ART.
COs and TDMs agreed about staging, CTX, and/or ART management in 20.2% of 127 clinical consultations carried out in 44 health facilities. In the remaining encounters, observed staging errors included: over-staging (misclassification of common illnesses as opportunistic infections OIs); under-staging (failure to detect OIs); down-staging (in patients who had improved with treatment); and premature determination of clinical stage before completion of appropriate patient evaluation. Errors common to both CTX and ART management included: inappropriate initiation (before completion of baseline evaluations, without adherence preparation, in the absence of indications, or in the presence of contraindications); failure to initiate when indicated; inadequate management of adverse drug reactions; and poor coordination of ART and CTX startup. Other errors included premature discontinuation of CTX; failure to discontinue CTX once immune restoration occurred; and failure to recognize ART regimen failure. Interviews suggested the following reasons for observed errors: TDMs had been trained to manage only stable patients, but their actual scope of work included care for complicated cases/ critically ill patients; physicians were often unavailable to provide clinical supervision and backup; there was an absence of laboratory capacity and clear, updated guidelines, which limited TDM capacity to distinguish OIs from other pathologies.
The evaluation methodology identified specific domains in which training had not adequately prepared TDMs for actual clinical responsibilities, or existing health-system resources were inadequate for providing care. In direct response, the MOH is reevaluating the TDM scope of practice, revising ART and OI curricula, and preparing new cadres of clinical mentors for TDMs.