COMMENTARY

Task Shifting: A Solution for the Health Worker Human Resource Crisis?

Larry W. Chang, MD, MPH

Disclosures

July 14, 2009

Task Shifting

Low-resource settings (LRS) face numerous barriers to the successful implementation of important health services. Lack of equipment and medications are common in many countries, but recognition is growing that the most significant challenge to improving health outcomes in LRS is the healthcare human resource crisis. The dramatic shortage of physicians, nurses, pharmacists, and other clinicians and health personnel makes traditional models of healthcare delivery (eg, physician-centered) an unrealistic option in many settings. In response to this crisis, task shifting has been increasingly promoted and studied as one strategy to address this major global health problem.

What Is It?

What exactly is task shifting, and what is the evidence supporting it? In their inaugural guidelines on task shifting, the World Health Organization (WHO) described task shifting as the rational redistribution of tasks among health workforce teams.[1] When feasible, healthcare tasks are shifted from higher-trained health workers to less highly trained health workers in order to maximize the efficient use of health workforce resources. The 4 main cadres of workers among whom tasks can be shifted are:

  • Medical doctors;

  • Nonphysician clinicians;

  • Nurses; and

  • Community health workers.

Largely driven by necessity, task shifting has been occurring in many forms and for many functions prior to these WHO guidelines, but the recent emphasis on task shifting by the global health community has raised new questions and presented unique opportunities.

Zachariah and colleagues offer an excellent overview of the many challenges, opportunities, and evidence-based needs of task shifting, and they provide vivid examples from experiences in the field.[2] This article emphasizes the need for ensuring quality of care and safety as task shifting is undergone, and for paying careful attention to motivation, retention, and performance issues of the workers to whom tasks are shifted. It also strongly emphasizes the need for further operational research to inform policy and practice. Indeed, evidence is often scarce for many of the recommendations for task shifting, with expert opinion, case studies, and observational reports more common than comparative studies or trials. This need for more research is acknowledged by the WHO guidelines, which recommend that "continuous monitoring and evaluation must therefore be established as an integral component of the implementation process for task shifting...and operational research should be developed alongside this implementation process.[1]" Therefore, although evidence will often lag behind interventions in crisis situations, future studies will no doubt add beneficial heft to current global and national recommendations.

Paradigm Applications Across Specialties

Most prior reports and current guidance on task shifting have focused on medical and maternal health applications, with a particularly strong emphasis on the role of task shifting in scaling up care in those with HIV.[3] However, the persistent surgical workforce crisis requires immediate and sustained action. For example, the entire continent of Africa has about 1% of the number of US surgeons, although basic surgical services have reported cost-effectiveness results comparable to some vaccinations and better than antiretroviral therapy for HIV.[4] Surgical task shifting guidance, quality assurance, and research is still a young and evolving field. Surgical task shifting is already happening in many countries, such as Mozambique, where 57% of major obstetric surgeries are performed by nonphysician clinicians known as técnicos de cirurgia.[5] A strong and urgent need therefore exists for additional high-quality studies on surgical task-shifting outcomes and for organizations to establish standards of training and care.[6]

As shown by surgical task shifting, it is clear that this concept does not have to be limited to traditional applications. The task-shifting paradigm is now being applied to many fields. For example, a shift of mental health interventions to nonspecialist health personnel in LRS has been advocated. (It will be no surprise to note that mental health professionals are also in short supply in most LRS.[7]) Some have argued that psychiatrists' new roles in LRS should be focused on designing and managing mental health programs, rather than seeing each patient individually.[7]

This concept is not dissimilar in some respects to the concept of the "medical home" being advocated by many in the United States as one solution to the fragmented US healthcare system. The medical home, in which a primary care physician coordinates a team to facilitate healthcare for patients, applies in many ways the concepts behind task shifting.[8] Indeed, the idea of the medical home was driven in large part by the shortage of primary care physicians. The idea of a "teamlet" approach, whereby physicians shift many traditional wellness tasks to health coaches (specially trained nurses, medical assistants, or community health workers), takes this concept of task shifting in the US healthcare system even further.[9] The human resource crisis then, whereas most pronounced in LRS, is not limited to LRS, and the global shortage of professionally trained healthcare personnel has encouraged novel applications of task shifting.

Potential Challenges

Task shifting is not without its critics; indeed, constructive criticism is needed to help improve the implementation of task shifting. Concern has been raised that traditional cadres of workers and professional societies will be hesitant to turn over their traditional roles to less highly trained workers.[2] Critics have also noted that the emphasis on task shifting has overshadowed persistent challenges with training and retaining high-quality traditional cadres of healthcare workers.[10] It seems appropriate, therefore, to emphasize that "above all, task shifting...must be aligned with the broader strengthening of health systems if it is to prove sustainable.[3]" The reauthorization of the US President's Emergency Plan for AIDS Relief (PEPFAR) in 2008 recognized the important concept of improving health system capacity by incorporating into the reauthorization training and in-country deployment of 140,000 new health professionals and paraprofessionals.[11]

Future Role in Global Health

The first Global Forum on Human Resources for Health was held last year in Kampala, Uganda, and ended with the Kampala Declaration that called upon all countries to work collectively to address current and anticipated global health workforce shortages.[12] As global health continues to receive welcome attention and resources, the issue of who will do the work of healthcare will likely remain at the forefront of debates on how best to improve health for the global community. Perhaps with persistence and adequate resources, the lofty goals of the Kampala Declaration will begin to be reached, and a health workforce that is able to deliver essential healthcare to all will become a reality.

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