PS020 - Task Shifting: The Solution for Healthcare Worker Shortages?

"There are negative and positive lessons to be learned from task shifting," emphasized David Benton, nursing and health policy consultant at the International Council of Nurses.

Regarding the positive lessons, literature review on task shifting show an increase in coverage and equity of access to care in underserved communities, and growing evidence that community health workers can undertake interventions that lead to improved health outcomes. Audience members contributed country specific success examples, such as Ethiopia, where maternal mortality was curbed due to CHWs being trained in performing cesarean sections. Seble Frehywot, member of the George Washington University Department of Health Policy and Global Health, identified NPCs in 25 of 47 Sub-Saharan African countries studied. These were trained in specialist activities such as cesarean section, ophthalmology and anesthesia.

Regarding negative lessons, the problem with task shifting is volunteerism cannot be sustained for a long period of time, and poor health care workers expect and require income. In addition volunteerism does not provide a sustainable solution because CHWs cannot engage in other work, like tending to the field.

The 12 principles endorsed by the World Health Professionals Alliance (WHPA) - which can be found detailed at www.icn.ch/statement_12_principles.pdf - also address the problem of volunteerism. The 12 principles also outline other problems of task shifting in three ways. Firstly, it increases demand on health professionals by increasing their responsibilities as trainers and supervisors, taking scarce time away from their other tasks. Secondly, successful task shifting requires higher numbers of assistive personnel to take care of the new patients. Lastly, health professionals will be faced with patients who have more complex health needs and require more sophisticated analytical, diagnostic and treatment skills, since the simpler cases will be covered by task shifting.

Frank Nyonator, from the Policy Planning Monitoring and Evaluation Division of the Ghana Health Service, starkly portrayed the negative effects of task shifting experienced in Ghana, where migration of health care workers has increased the workload for mid-level cadres, leading to a reduction in time available per patient, and has decreased the quality time patients receive from health workers. Patients, aware of long waiting times, are seeking alternative care.

The audience illuminated other problems encountered with task shifting like resistance - for instance in India there is a shortage of anesthetics and task shifting to NPCs is resisted by the Association of Anesthetics - and the problem of definitions and scope of practice.

"If you talk to five people in a room, you'd get different definitions of 'community worker'," said Mr. Benton. The problem with task shifting as a solution is that health care workers do not know where their scope of practice starts and finishes. However, it has been stressed that where outcomes have been less positive they are due to the failure of the health system and professionals within that system, to provide necessary support for CHWs.

"This can be solved by having a regulatory framework," said Frehywot. Task shifting can be a solution if scope of practice is defined, competence based models of education and practice are applied, recruitment is put into operation, regular performance appraisal is practiced, supervision and delegation is executed, and services and education accreditation are arranged.

Audience members also suggested a need for change in curricula. The change of curricula would go as far as reviewing the current carbon copy curriculum taken from the North and applied in the South; instead it would be based on needs assessment. Audience members also reiterated that task shifting was not really a solution because it takes one profession away, leaving "a gaping hole that needs to be filled." Other audience members differed and suggested that task shifting be viewed as not 'the' solution, but one among many: "part of the slate of solutions."

"It's one thing to say 'let's shift tasks'; it's another thing to say 'let's shift quality', quipped Frehywot. Therefore, a need for other quality solutions, designed for short-term, mid-term and long-term must be probed. Mr. Nyonator recommended development of a policy to increase intake and reduce barriers to professional practice, as an alternative quality solution instead of task shifting. "This can be achieved by redefining functions, reforms in staffing and refocusing on in-service training," he added.

With other solutions in mind, Mr. Benton framed the conclusion drawn by the audience and panellists: "Task shifting is not a total solution and must not replace the development of sustainable, fully functioning health care systems".