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Task Shifting


April 28-May 8, 2009
http://my.ibpinitiative.org/global/HRHExchange

The purpose of this discussion was to:

  • Share perspectives on the applicability of task-shifting in different country situations.
  • Develop recommendations to inform policy/decision-making.
  • Discuss lessons learnt and challenges faced in the implementation of task-shifting.
  • Suggestions as to how the Alliance's can contribute to addressing the critical gaps and imbalances in the health workforce.
  • Compile an action-oriented summary of the discussions for use at the country level.
  • Establish continuing dialogue on task–shifting.


Discussion Statistics


Number of participants: 246
Number of participants' countries: 56
Number of contributions: 92
Number of countries contributing: 21 countries

Contributing countries: United States (14), India (7), Philippines (8), Uganda (4), Indonesia (2), Rwanda (2), Benin (4), Ecuador (5), Madagascar (1), Mali (2), Bangladesh (7), Burkina Faso (1), Congo (1), Brazil (1), Cambodia (1)



Purpose and Objectives

  • Share perspectives on the applicability of task-shifting in different country situations.
  • Develop recommendations to inform policy/decision-making.
  • Discuss lessons learnt and challenges faced in the implementation of task-shifting.
  • Suggestions as to how the Alliance's can contribute to addressing the critical gaps and imbalances in the health workforce.
  • Compile an action-oriented summary of the discussions for use at the country level.
  • Establish continuing dialogue on task–shifting.
                                                                                                                                   
Day 1. 
Questions:

  1. Is task-shifting a viable solution to the human resource for health crisis?
  2. Philips et al., Lancet 371:682-684 (2008), stated that, "Task shifting should not be viewed as a panacea for the human resource challenges facing sub-Saharan Africa". If so, what is the role of task-shifting as a public health initiative in the human resource for health crisis, and what other strategies are needed?

Emerging themes and issues:

A contributor from Israel believes that task shifting is the way forward given the insufficient number of and inaccessibility to health care providers. While a participant from Nigeria believes that task shifting should only be implemented in times of extreme emergencies such as wars and natural disasters. The contribution from Zambia included a paper on ways of achieving best practices. He went on further to state that we need to discuss the gaps and how to solve it in a structured way. The questions posed seemed to raise further questions in the mind of our final respondent, who is from India, and asks "how will the health manpower planners address the issue of quality care and equity for all patients?" Our Indian contributor thinks that poor infrastructure in rural areas discouraged medical personnel from being willing to stay in these areas. As a consequence, much of the tasks must be shifted to health volunteers and community workers who may not have the competency and skill of medical personnel.

                                                                 
                                                       
Day 2. 
Question:
  
  • What are the critical elements of a successful task-shifting policy? 
  • What issues should be considered when implementing task-shifting in order to ensure sustainable human resource development?

Emerging themes and issues: Days 2

Respondents comments on the critical elements needed for a successful task shifting policy ranged from promotion of buy-in by all stakeholders and team building in the health care system, and a concern for the need for mutual respect and understanding of the skills brought to the 'table' by all involved in health care. In keeping with that trend of thought, a contributor from Uganda speaks to the need to keep service to the patient as uppermost in health planning. Our respondent from India makes a Day 2 contribution in saying that he believes in an extensive cadre of non-physicians. A respondent from Nigeria sees as critical elements, regular system review and strict supervision and goes on to say that the curriculum of all the institutions involved in training the health workers needs to reviewed to reflect the task that may be shifted to them if the need arises. One contributor from Uganda states that there are indeed no easy answers. Finally, a contributor from the Ministry of Health in Thailand and brings up the issue of legality and protection for individuals involved in task shifting. She also sees task shifting as a short-term solution for health care delivery in resource constrained environments.
                                                                                                                               
Day 3. 
Questions:

  1. For countries implementing task-shifting, which tasks are usually shifted or which areas and which cadres are mainly involved?
  2. What is it that countries have done in the following areas so that the quality of the services provided is not compromised?
  3. What has been the role of the Ministry of Health in this initiative?
  4. What are the experiences particularly with regulatory bodies in the implementation of task-shifting initiative?
  5. Any lessons learnt, and, if so, what are they?

Emerging themes and issues:

Today, we want to focus on the three (3) vibrant responses received based on the questions posed by our expert advisor of the day, Immaculate Chamangwana.

The replies to her first question on which tasks are normally shifted, in which areas, and by which cadres brought interesting reading. From India, a contributor illustrates the role adopted by Accredited Social Health Activists who deliver primary medical care with an emphasis on preventive care. Another participant related that the tasks of diagnosis, prescriptions and treatments normally performed by doctors have been shifted. A contributor from the U.S.A. describes pilot studies carried out in Uganda and Madagascar by Family Health International (FHI), which looked at shifting provision of injectable contraceptives to community-based distribution (CBD) agents.

In putting forward the question of uncompromised quality of service, patient safety was uppermost for all, along with adhering to the code of practice. A Nigerian contributor believes that in developing countries with no checks and balances safety has been compromised although though the code of practice may be observed.

Respondents indicated that Ministries of Health were the primary movers in adopting task shifting. In India the National Rural Health Mission (NRHM) is funded and supported by the Ministry of Health and Family Welfare (MoHFW). From Nigeria, a contributor states that the Ministry of Health regulatory policies are ambiguous, delaying and creates bottle-necks. Both in Uganda and Madagascar, the Ministries of Health were instrumental in giving approval for the studies and scaling up programs based on study recommendations.

Experiences with the regulatory bodies vary with a contributor telling us that India has the medical council and the nursing councils acting as guardians. The major problem with regulatory bodies states Our Nigerian contributor shares that Nigeria is poor record keeping and statistical information thus impending health disasters due to task shifting may not be easily averted. In June, 2009, a review of the work conducted in Uganda and Madagascar will be conducted by technical experts from FHI, USAID & WHO declares a contributor from Family Health International. Conclusions drawn will treat with research and programmatic recommendations.

Finally our respondents considered "lessons learnt".  Our contributor from India saw that success could be realized with a well researched programme and little political interference at the grassroots level. Our Nigerian contributor saw the need for legal protection and adequate remuneration for those involved in task shifting. Our contributor from FHI speaks to a strong existing cadre of community workers, government support, finding champions (advocacy) and continued evidence -based work.

                                                                 
                                                       
Day 4.
Questions:

  1. In light of the global shortage of health workers, task-shifting has been under discussion globally, regionally and nationally. What do you think are the educational implications for imparting skills, knowledge and ensuring appropriate competences of health workers in your context for an effective contribution towards attaining the Millennium Development Goals (MDGs)? 
  2. Health-worker professional groups operate under a legal framework that determines their scope of practice. How would task-shifting be addressed under the current legal framework in your country?
  3. Implementing task-shifting entails systematic planning involving all concerned parties, as it may have implications for conditions of service, including career paths and supervision. What is your opinion on how best to address these issues?

Emerging themes and issues:

In speaking to the educational implications of task shifting, contributors mentioned having a basic minimum content for training, believing that most medical personnel have a common and
basic medical training that allows for task shifting,, while another contributor does not believe that there is need for task shifting at all.

All contributors saw the need for a legal framework. A contributor from Nigeria informs that the current Nigerian legal framework does not allow for task shifting. Another contributor from  Israel, promotes enacting of legislation that would allow physicians, nurses, pharmacists, dentists, to carry out task shifting 'duties' such that they support patient care. Our Nigerian contributor states that different legal framework for professional groups in the healthcare system is a big challenge to effective task shifting.

The issue of a career path and supervision in task shifting brought responses ranging from there is no need for career development in taskshifting since he (C'Fine Olorochukwu, Nigeria), envisions for example, difficulties in identifying the skilled and unskilled where persons may
be performing the same task. Continuing education was seen as an avenue to career growth in task shifting. Our Nigerian respondent commented that there should be uncompromising
entry requirements, basic skills development requirement which includes training to recognize the limitations of such training and the wherewithal to make appropriate referrals.


                                                                 
                                                       
Day 5.
Questions:
  1. What minimum capacity is required at the central level (within the HR department) and at the district/provincial level (in terms of training capacity) to effectively promote, roll out, manage, and monitor and evaluate task-shifting?
  2. What mechanisms are needed to assure quality once -shifting has taken place. Is task-shifting also an opportunity to strengthen local accountability mechanisms for health service quality?
  3. Can informing communities of the extended role of health workers, and of their need for support and feedback, be a way of increasing community engagement in monitoring the quality of service delivery?
  4. •    What strategies are there for overcoming professional resistance to task-shifting? Creating an evidence base on service quality to counter arguments that task-shifting “dumbs down” service delivery.
  5. What regional or sub-regional capacity might be needed to support the development/implementation of task-shifting at the country level?
  6. Is task-shifting about making more effective use of existing cadres of workers, or is it about creating new cadres of workers?
  7. What tasks can be shifted to community health workers? Is there a basic set of qualifications/skills that community health workers need to participate effectively in a task-shifting process.
  8. Can tasks be shifted to volunteer workforces, or are we expecting too much of voluntary community health workers (CHWs). Does task-shifting require a higher level of compensation/remuneration for CHWs to make it work effectively?

Emerging themes and issues:

Today's questions speak to the inclusion of task shifting in strategic planning and to full-scale, well-constructed plans at all levels of public health planning and implementation prompted seven (7) varied contributions including anecdotal responses from a contributor from Croatia who related his experiences in Sri Lanka after the tsunami of 2004.

All contributors agreed that appropriate systems must be established; systems which recognise the task shifting worker, rights and responsibilities, etc. A contributor from India spoke to the 'feeling' that task shifting simply moves work from the senior to the junior and stressed the need for HR to be completely involved in task shifting planning, while a contributor from Nigeria mentioned effective regulatory controls. A contributor from the U.S.A., believes that volunteer health workers should be recognized in health care through their paid inclusion in health planning strategies. A contribution from Thailand states that task shifting has been used for a while, albeit under various names and that the process of task shifting should be so designed as to empower communities.


Day 6.
Questions:

  1. Regulation is often perceived as a barrier to change. How can regulation meet its purpose of public protection and at the same time ensure appropriate expansion of the role of the health care worker?
  2. What models/frameworks are currently in use to ensure appropriate supervision as well as delegation of tasks to the unlicensed health care worker?
  3. There are many perspectives on task-shifting. It is seen as a solution to workforce shortages, through the delegation of simple tasks, and also as an opportunity for health professionals to focus on patients with more complex health care needs. What will be the effect of task-shifting on the quality of services provided?


Emerging themes and issues:

Contributors from Uganda, Nigeria and the USA all speak of the need for regulations being an important part of any task shifting planning, helping to ensure quality of service, and protect workers and patients.

While our contributors did not identify specific models/frameworks they did state that appropriate models/frameworks should include standardized training material, registration and de-registration of health workers along with proper documentation and terms of reference. Our contributor from Nigeria believes strongly that maintaining statistics will help to improve areas of health care delivery and also sees that there will be a difference in the 'output' of work between a health professional and those involved in task shifting. A contributor from the USA spoke to the 'health promoter' model used in Mexico and Latin America, and the Partners in Health model used in Haiti and further makes mention, of a 'first responders' model being implemented in the Global South which trains truck drivers to give aid in accidents.

When considering the impact of task shifting on the quality of patient care, our contributors seemed to focus on current quality of care and care without task shifting. We read of not only a lack of resources, but the means to create/sustain primary health care, the need for community support, and the quality of service provided by paid staff and current gaps in current teaching and training centres.

Of interest are the contributions who have responded in terms of putting additional questions 'on the table'. One contributor articulated the educational standards of public health and task shifting and another asked us to consider risk-based approach as opposed to the evidence-based approach to task shifting and public health policy development in general.

                                                                 
                                                       
Day 7.
Questions:

  1. Are non-physician clinicians trained for surgery competent to provide major surgery in emergency obstetric care (EmOC)?
  2. Does non-physician clinicians' work contribute significantly to saving the lives of mothers?
  3. What is the cost of their training and deployment?
  4. How is their surgical work accepted by other health workers?
  5. What are the advantages of training these cadres?


Emerging themes and issues:

While it was acknowledged by one contributor that midwives are used in many countries for obstetric care and by extension are therefore faced with dealing with emergency situations, our contributors felt that non-physicians clinicians would lack the in-depth knowledge or the training to handle emergency obstetric care. Another contributor acknowledged that non-physician clinicians play a great role in saving the lives of mothers especially in conflict and post-conflict arenas where others may not wish to go. Their roles become even more significant given the issue of migration of gynaecologists. In considering question 3, our contributor from Uganda speaks more to deployment and retention of trained staff. He states that money for training exists. In terms of acceptance of their surgical work one gets the impression from our contributors that there is little acceptance, except in emergency settings. Our contributor from India speaks to the strong physicians' lobby of India which does not promote other cadres performing what has been traditionally doctors' duties. One contributor does concede that in Uganda non-physician clinicians manage health centres and are received well by the community (ies). Our contributor from Israel sees nothing but financial gain in training non-physician clinicians, while another contributor points out training of individuals in areas of health gaps would be of benefit and may encourage increased collaboration between stakeholders and governments and ultimately redound to the community(ies). To assist in our understanding of the role of task shifting in daily health care, Our contributor from India proposes country studies that analyses various public health jobs and attendant responsibilities.

                                                                 
                                                       
Day 8.
Questions:

  1. ”Task-shifting” is used to describe a variety of situations, e.g. for the delegation of tasks from doctors to nurses; but also for delegation of tasks to community-health workers or lay providers. Which form of task-shifting is used in your settings?
  2. Are there stakeholders who are rather opposed to task-shifting in your setting?
  3. Task-shifting may involve the creation of new cadres of health workers. This, then, often raises issues of recognition and pay. Do you have experience with debates around these issues?


Emerging themes and issues:

We are told by Howard Rice of the non-existence of task shifting in Israel, although one gets a sense that it will be on the scene in the near future. Other contributors speak of task shifting occurring at the formal and informal levels (Indrajit Hazarika, India), and in various
health-care related disciplines (Dawn Surratt, USA). We are further informed that task shifting has been in place in Iran for more than thirty (30) years (Sara Javanparasat, Australia) and according to Babu Ram Marasini, in Nepal for near 13 years. Boris Budosan, Croatia tells
us about task shifting in mental health care in Sri Lanka and Indonesia and speaks to its significance after the tsunami of 2004.

Opposition to task shifting is evident. In Israel where Howard Rice tells us task shifting does not exist, this opposition is implied in Howard Rice's contribution but he points out the need to keep in mind the health and welfare of the patient. Mit Philips, Belgium speaks to the various types of opposition based not on concerns of quality of care but on what she terms "gate-keeping" and it seems, hierarchy in its various forms. Even with the existing opposition, we are told of situations in which much of this, the opposition, was overcome. In general, negativity displayed towards task shifting is overcome in situations of emergency or staff shortages (Sri Lanka and Indonesia), and where there is national government support (Iran, India, Nepal). Indrajit Hazarika gives us Indian examples in the form of ANMs and sputum microscopists. The Community Health Workers (CHWs) of Iran are shown as being very significant in rural health development (Sara Javanparast, Australia). Dawn Surratt, USA and Babu Ram Marasini of Nepal speak to resistance to task shifting being broken down where there are strong, well-defined work structures.

In terms of the acceptance of this new cadre of worker, we are shown that this acceptance is not always a continuous acceptance. Indrajit Hazarika speaks to new cadres being supportive in the present crisis but is unsure about their contribution/acceptance within the health system for the long term. From Nepal, we see Babu Ram Marasini's contribution shows that acceptance exists for those involved in reproductive health. Finally, both Dawn Surratt and Mit Philips speak to situations of acceptance into the general work culture that is, being part of a government service or a unionized environment where benefits are realized and respect is gained and their existence and contribution is a planned one.

                                                                 
                                                       
Day 9.
Questions:

  1. Is task-shifting a local implementation issue, and should it be considered in national HRH policy and planning processes?
  2. What evidence is there that task-shifting contributes to alleviation of the HRH crisis and also progress towards the MDGs and universal access goal? 
  3. Is the term ‘task-shifting’ appropriate for advocating the practice? If not, how should it be defined, what is and what is not to be considered ‘task-shifting’? (E.g. is the use of medical assistants/clinical officers instead of MDs and/or enrolled instead of registered nurses considered task-shifting? What is to be included under this definition?

Emerging themes and issues:

With regard to question one, we received a mixed bag of contributions, with both Howard Rice, of Israel believing that task shifting should only be at an international level and put into effect during times of disaster and C'Fine Okorochukwu, Nigeria stating that task shifting should be an alternative aspect of national planning, to be used where nothing else can be implemented. Stacie C. Stender, South Africa sees it as a local implementation issue which must be adapted to suit the specific local environment. Three of our contributors Charles Senessie, Switzerland, Dora Shehu, Ghana and Babu Ram Marasini believe that task shifting needs to be approached at both levels, local and national with each giving full details as to their reasoning.

Evidence of the beneficial effects of task shifting and its role in easing of the HRH crisis, supporting the MDGs and Universal access goal was presented by most contributors. Howard Rice spoke to the use of para-medics by the Red Cross. Stacie Stender declared that there is of a "plethora of evidence" and by example cited a recent article on the subject, while our contributor from Switzerland spoke to his experience in Sierra Leone and other African countries and the Nepalese experience was touched on.

What did our contributors think of the name "Task Shifting"? Suggestions were made as to the terminology that should be used, task sharing (Stacie Stender, South Africa) to what the position should be named, clinical assistant (C'Fine Okochukwu, Nigeria) but what is clear is that there is some more work to be done by public health practitioners in this area.

                                                                 
                                                       
Cross-cutting themes and issues. 

1. Workforce shortages and capacity building
•    "It is my humble submission that the task-shifting is the worst thing that happens to the health sector and hence should not be encouraged except during extreme emergencies such as war and natural disasters. With good policy we can increase the training centres for different cadres of health workers, at the same time making the jobs attractive. While I totally disagree on the idea of task-shifting, I suggest that the government should employ more health workers”. 
•    "The problem in most developing countries like Nigeria is the underutilization of health professionals cum underemployment/unemployment. This is to say that in a country like Nigeria what we have is an apparent or virtual shortage of health workers. This is occasioned by poorly organised health care financing systems—for example, the low level of coverage by the national health insurance scheme, taking care of the elite class and leaving the majority of poor masses uncovered. This group of people (poor masses) spends so much for health care but receives low quality health care services because the health care delivery system is poorly organised. However, the burden of task-shifting is low in a well organised society with a good health care delivery and financing system; hence, it is evident that the needs for task-shifting will be less in developed countries. The emphasis should be good health care delivery and health care financing system development instead of task-shifting". 

2. Patient-focused care
•    "Task-shifting is done without any additional payment or incentive. This is taken as one of the roles and responsibilities and part of the job description. One is taken through the training and orientation of these additional responsibilities".. 

3. Resistance from health care professionals
•    "I believe that the most critical element of successful task-shifting is acceptance/buy-in from all stakeholders --community, government and professional bodies--that the best health care practices will only be accomplished using extensive cadres of non-physicians. The idea that “in a pinch” we can use community health workers, traditional birth attendants, nurses, pharmacists, but what we really want is many more physicians, will be self-defeating. Developing the team approach, carefully planned for realistic goals and sustainability, is at least half the battle in task-shifting. Any prominent "players" among the primary stakeholders who oppose the ideals and potential of the process can easily sabotage its implementation".

•    "I think that mutual respect is key, as well as recognition by every member of the health care team that the contributions and skill sets of everyone are vital to the goal of providing quality patient care. However, some groups of medical professionals have over-inflated egos and are driven by power and privilege that they will not give up easily…". 

•    "The other observation I have is that resistance to task-shifting tends to be quite selective and not always in line with reality. In some countries task-shifting is allowed in rural areas but not in urban, better staffed areas. I think this is a very questionable approach. Either task-shifting (for specific tasks, specific staff and with specific pre-conditions and support) is safe for patients and provides effective health care, or it is not. One cannot just adapt to the constraints and disregard real concerns for quality of care. Neither can one argue that nurses cannot provide ART in capitals/urban areas because we have these MDs available; if the nurses provide good quality care, we should not keep this care by nurses from patients waiting for their AIDS treatment". 

4. Preventive care
•    "...I think task-shifting is a short-term solution for delivering care in such resource-constrained countries. When the situation changes and tasks have become overlapping, we will face strong oppositions from professional bodies. The sustainable task-shifting approach should be focused more on shifting from curative service to preventive services. As for preventive service, we have plenty of health workforce in the community, i.e. village health volunteers, traditional healers, etc. With proper support and management, they can contribute to a healthy society with a cost-effective and sustainable approach". 

5. Rural-urban divide
•    "Task-shifting should be seen as an effort to demystify the technicalities of medicine and pharmaceuticals. Since the cost of producing an allopathic doctor is high and the process of medical education alienates the trainee from far–off. peripheral regions, public health has to shoulder the onerous responsibility to prepare a band of task force which may carry out the desired functions in the remote location. The challenge in this strategy is to demarcate the lines of functions and referrals at various levels for which continuous research as well as dialogue between health system research and service apparatus is mandatory". 

                                                                 
                                                       
Program Examples.

From FHI: “To expand the existing body of knowledge gathered from studies in Asia and Latin America, Family Health International (FHI) completed two pilot studies in Africa on shifting provision of injectable contraceptives to community-based distribution (CBD) agents, one in Uganda 2004-5 and one in Madagascar 2006-8. “CBD agents in both countries are paramedical workers selected from existing community-based programs and had to receive high scores on a pre-test of family planning knowledge in order to be eligible for training. In Uganda they also had to meet certain other criteria, including being respected in the community, mature (over the age of 18 years), trustworthy, educated (at least seven years of schooling), interested in family planning and demonstrated to be good counsellors. CBD agents in Madagascar were selected based on literacy, past CBD work performance, recommendations from community health supervisors, community acceptance, acceptance of modern family planning methods, location, physical capability and enthusiasm. “Both studies showed that provision of injectables by this cadre was safe, feasible and acceptable.”
                                                               
                                                       
Post-forum survey results

N of surveys completed   -  NA
% who have passed content to others  -  NA
% who have or will use in their work  -  NA
% very satisfied with forum content  -  NA
                                                              
                                                       
Key Points

  1. Planning - task shifting must be considered as only one aspect of structured, costed national and local levels HRH & overall health care planning. 
  2. Grass roots involvement - a bottom-up approach in local level planning  to ensure what is demanded is indeed supplied and supported by the community.
  3. Adaptability - there is no one size fits all for task shifting thus implementation must be determined in context - situation, resources, types of tasks to be shifted.
  4. Education & Training -  a minimum level of education and well structured training programmes can assist successful implementation of tasks.
  5. Quality Control - standards of professionalism must be created, monitored and maintained.
  6. Systems Development - task shifting should take place within a proper functioning system to ensure smooth functionality. 
  7. Regulations - to ensure that equity, respect, and uniformity of personhood is brought to the persons who are part of the new cadres of workers.  Legal frameworks that would support task shifting must be put into place.  Task shifting should not be considered cheap labour.
  8. Retention - solutions must be found that will ensure that individuals remain i) not only within the health care system, but ii) within their own countries' health care system and in iii) the areas (regional and district) where demand for services is greatest. Thus career paths must be set,  incentives created and acknowledgements introduced.
                                                               
                                                       
Reports and publications Organizing groups 
The Global Health Workforce Alliance, the World Health Organization (WHO), and the Implementing Best Practices (IBP) Consortium

Contributing experts/facilitators 

  • Ms Tana Wuliji, Project Manager, Human Resources and Pharmacy Education, International Pharmaceutical Federation (FIP), The Netherlands
  • Mrs Immaculate Chamangwana, Deputy Director, Nursing Services, Ministry of Health, Malawi
  • Dr Erica Wheeler, Knowledge Officer, Global Health Workforce Alliance 
  • Dr Neil Squires, Human Development Advisor, Department for International Development (DFID)
  • Ms Anne Morrison, Consultant, Nursing and Health Policy, International Council on Nursing, Switzerland
  • Dr Wim van Damme, Senior Lecturer, Institute of Tropical Medicine, Belgium
  • Dr Eileen Petit-Mshana, Technical Officer, WHO, Switzerland

Other acknowledgements
  • Implementing Best Practice Knowledge Gateway (IBP)/WHO:
  • Ms Maggie Ushar-Patel, Scientist, WHO, Switzerland
  • Ms Catherine Richey. Technical Officer, WHO, Switzerland
  • Dr Alena Petrakova, Technical Officer, WHO, Switzerland

Moderators
Jeannelle Bernard, Research Officer and Dr Erica Wheeler, Knowledge Officer, both of the Global Health Workforce Alliance