Task Shifting

This presentation was part of the 2006 Global Health Mini-University. A key approach to address the global shortage of healthcare providers is to improve the productivity of existing workers, thereby improving the quality and coverage of services. Improving the work environment and task shifting of health functions to different cadres of providers are two promising interventions that are being used for this purpose. This session will describe and discuss these and some of the other innovative solutions to enhance the capacity and productivity of the current workforce and to build coherence into the management of human resources for stronger health systems. [publisher's description]

This article discusses the potential contribution of community health workers to child survival rates. Several trials show substantial reductions in child mortality, particularly through case management of ill children by these types of community interventions. However, community health workers require focussed tasks, adequate remuneration, training, supervision, and the active involvement of the communities in which they work. This article discusses the need for evaluation of programmes for community health workers. [from summary]

A scarcity of trained medical personnel impedes Uganda’s ability to deliver healthcare effectively. The role of the Clinical Officer (CO) was established to assist the provision of primary healthcare to rural communities. The primary aim of this study was to explore the role that the CO performs in delivery of primary and secondary healthcare in Uganda. A secondary aim was to determine the resources and facilities that are available to COs in order to carry out these duties. A further aim was to determine the confidence of COs at performing surgical and obstetric procedures. [from introducti

This issue of the HST Update contains articles on: overview of nursing in South Africa, transforming nursing education towards primary health care, problems in nursing today, nursing summit charters a way forward, placement of nurses, nurse training in Mount Frere health district, and the quest for rational drug use.

The integration of HIV-prevention activities into care has received little attention within or outside formal healthcare settings. The contribution of community home-based care services in facilitating disclosure of HIV status and reducing stigma have also not been described. This study examines the community impact of an integrated community home-based care (ICHC) programme on HIV-prevention efforts and disclosure of status. Quantitative data was collected from 363 people living with HIV (PLHIV) and 1 028 members of their micro-communities. [from abstract]

In parts of rural Africa, where conflict and neglect have destroyed any remnants of a functioning health system, there is one long-running public-health programme that is not only surviving but thriving—by capitalising on communities' desires to help themselves. [author's description]

This research brief presents results from a cost analysis of an adolescent reproductive health intervention that found that using community health workers was less expensive than using doctors for provision of reproductive health services to young women. [from publisher]

Over the past four decades there has been a trend for pharmacy practice to move away from its original focus on medicine supply towards a more inclusive focus on patient care. The role of the pharmacist has evolved from that of a compounder and supplier of pharmaceutical products towards that of a provider of services and information and ultimately that of a provider of patient care. This introductory handbook sets out a new paradigm for pharmacy practice. Its aim is to guide pharmacy educators in pharmacy practice, to educate pharmacy students and to guide pharmacists in practice to update their skills.

Evidence Update is a two-page summary of a Cochrane Review of healthcare interventions relevant to people in low-income and middle income-countries. This issue reviews whether lay health workers improve health care delivery and health care outcomes.

The nurse auxiliaries who work at the rural health centers (CESARs) of the Honduran Ministry of Health (MOH) are frequently the only source of reproductive health services in the communities they serve. In order to increase access to long-term family planning methods, the MOH and the Population Council’s INOPAL III Project conducted an operations research study from 1997 to 1998 to see if nurse auxiliaries could provide good quality IUD, Depo-Provera and vaginal cytology services without health risks for their clients. The study concluded that auxiliaries could provide these services and that, in addition, the cost-effectiveness of the strategy was appropriate.

A number of ART projects are trying to tackle the HRH problematic by delegating certain tasks from medical doctors to other cadres. While this task-shifting is certainly an important step, we contend that it will not be enough for scaling up ART in the high HIV-prevalence countries with the most severe HRH shortages. In the present report we argue that an altogether different approach to HIV/AIDS care and treatment might be required for overcoming the HRH bottleneck. [from summary]

While publications like the World Health Report have described general approaches that can be taken to improve the human resources for health (HRH) situation at the country level, there is a relative paucity of more detailed documentation that describes promising practices that would be useful to HRH leaders and practitioners. As a result, USAID's Africa Bureau commissioned a study to identify and document promising practices in a way that takes into account the context of the practice, describes lessons learned and puts forth potential implications for replication in other countries. The intent of the promising practices study is to "serve as a practical and much needed resource for governments, partners and donors in promulgating policies and approaches that have successfully mitigated the negative effects of the health workforce crisis." After consultation within USAID, it was decided that the study would focus on promising practices in four African countries: task shifting in Ghana and Uganda, improving retention in Malawi, and increasing recruitment and rapid deployment in Namibia.

This report focuses on the impact of human resource shortages witnessed by MSF teams in four southern African countries - Lesotho, Malawi, Mozambique, and South Africa. While the focus is largely on nurses in rural areas, it should be acknowledged that health staff is lacking across the spectrum - from doctors to laboratory technicians to pharmacists - at all levels of care. In all these cases the need for access to ART, as well as other health needs, is outstripping human resource capacity. [from introduction]

Home-based management of malaria (HMM) is promoted as a major strategy to improve prompt delivery of effective malaria treatment in Africa. The published literature was searched for studies that evaluated the health impact of community- and home-based treatment for malaria in Africa. [from abstract]

The AIDS Support Organization (TASO) administers a home-based program in Uganda that gives people in poor and rural settings access to antiretroviral therapy (ART) and services. The program's innovation lies in shifting delivery of most clients' follow-up activities at home to field officers, a new cadre of degree and diploma holders from the social sciences and education. Field officers ensure adherence to ART, refill clients' medications and perform various activities, from voluntary counseling and testing to education to promoting family and community support. [from executive summary]

This issue of Outlook explores the role of pharmacists and non-pharmacist counter staff in primary health care, with a specific emphasis on reproductive health. It also presents programs that build the capacity of pharmacists to provide expanded services, thus improving access to quality reproductive health services. [author's description]

The WHO IMAI guidelines support the rapid expansion of access to ART by supporting the shifts of key tasks to multi-purpose health workers at first-level facilities located in the community (health centres and clinics). By preparing nurses and clinical aids to provide acute care to adults, many opportunistic infections can be treated and the patient stabilized for ARV treatment without referral to district clinic. Management of patients near their home is important for equity and to achieve high levels of ARV adherence. [adapted from publisher's description]

The objective of this study was to assess whether traditional birth attendants, drug-shop vendors, community reproductive-health workers, or adolescent peer mobilizers could administer intermittent preventive treatment (IPTp) for malaria with sulfadoxine-pyrimethamine to pregnant women. The study concludes that the use of the guideline with adequate training significantly improved correctness of malaria treatment with chloroquine at home. Adoption of this mode of intervention is recommended to improve compliance with drug use at home. The applicability for deploying artemisinin-based combination therapy at the community level needs to be investigated.

This statement outlines guiding principles to ensure task shifting is effective.

This study examines the opinions of health professionals about the capacity and performance of the 'tecnico de cirurgia', a surgically trained assistant medical officer in the Mozambican health system. Particular attention is paid to the views of medical doctors and maternal and child health nurses. [from abstract]

The health worker crisis is particularly acute in rural and hard to reach areas, where 80% of the population in Africa live. The resultant low capacity at the peripheral level of the health system is a crucial barrier to good health. AMREF believes that developing capable, motivated and supported health workers at all levels of the health system is essential in ensuring the delivery of accessible and effective health care across Africa... This briefing draws on AMREF's experience to look at three key issues: the importance of appropriate training, task-shifting to lower cadres of worker, and training and supporting community health workers (CHW) in order to bring health care closer to communities.

Clinical officers perform much of major emergency surgery in Malawi, in the absence of medical officers. The aim of this study was to validate the advantages and disadvantages of delegation of major obstetric surgery to non-doctors. [abstract]

This paper explores the potential for private-sector midwives to provide services beyond their traditional scope of care during pregnancies and births to address shortcomings in less developed countries' ability to reach MDGs. This paper examines factors that support or constrain private practice midwives' ability to offer expanded services in order to inform the policy and donor communities about PPMWs' potential. [from executive summary]

Training private drug retailers can improve early treatment of malaria at home. As well as giving important health benefits, improvements could support over-stretched public health resources, reduce household economic costs and potentially play a role in reducing the rate of development of drug resistance for OTC anti-malarial medications. [author's description]

This study analyzed and compared the knowledge base of trained community health workers with that of doctors and nurses in Afghanistan to determine the differences in their abilities to provide healthcare and health information to patients.

This paper aims to provide an overview of the current evidence and opinion of the workforce implications of regulation, competency development and role definition. These three elements are inextricably linked to each other and are fundamental to the practice of nursing in today’s environment. [from introduction]

In both Asia and Latin America, community-based health workers have been trained in safe injection techniques and routinely provide injectable contraception. However, the African continent still resists this service delivery mechanism with the rationale that it is unsafe for clients to receive injections from paramedical personnel. This argument is weakening, however, as non-reusable syringes become the norm and with the recent development of a checklist, based on the latest WHO Medical Eligibility Criteria, for safe provision of DMPA by community-based agents. Has the time come for community-based provision of DMPA in Africa?

Various tools and approaches can help accelerate the process of providing health care workers with the skill sets needed to tackle current health care needs. To this end, the Capacity Project has identified and categorized existing tools and approaches that support health cadres in learning new skills, especially in the area of HIV/AIDS. In this paper, we briefly describe and give examples of these potential resources, providing web links (where available) in the appendices. [from introduction]

Based on a review of the literature and country examples, the brief describes why task shifting is important and highlights some key steps in planning for, developing and supporting cadres involved in task shifting. [author's description]

Task shifting should not be viewed as a panacea for the human resources challenges facing sub-Saharan Africa. Rather, it must be part of an overall strategy that includes measures to increase, retain, and sustain health staff. [from author]