The WHO defines task shifting as a process which involves the rational redistribution of tasks among health workforce teams whereby specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resources for health [182]. Task shifting thus expands the pool of HRH and in so doing increases access to services. Reorganization and decentralization of services using task shifting could promote universal access through increasing access to services at the peripheral levels of care [182].
From the existing evidence task shifting can be classified broadly into four types, as follows:
Task shifting type I – The extension of the scope of practice of non-physician clinicians in order to enable them to assume some tasks previously undertaken by more senior cadres (e.g.
medical doctors).
Task shifting type II – The extension of the scope of practice of nurses and midwives in order to enable them to assume some tasks previously undertaken by senior cadres (e.g. non-physician clinicians and medical doctors).
Task shifting type III – The extension of the scope of practice of community health workers (often called non-professional health workers or lay providers), including people living with HIV/AIDS, in order to enable them to assume some tasks previously undertaken by senior cadres (e.g. nurses and midwives, non-physician clinicians and medical doctors).
Task shifting type IV – People living with HIV/AIDS, trained in self-management, assume some tasks related to their own care that would previously have been undertaken by health workers.
In the classification of task shifting, the defining factor for task shifting types is the cadre that assumes the new task. For example, any extension of the scope of practice of
nurses and midwives is defined as task shifting type II [182]. Figure 9 below provides a graphic illustration of the concept of task shifting.
Figure 9: Graphic illustration of the concept of Task shifting to expand the pool of human resources for health
Source: WHO 2007
4.5.1. Task shifting type 1:
The Ministry of Health (MoH) in Zambia scaled-up HIV/AIDS care and treatment services at the primary care clinics using predominantly physician clinicians [184, 185]. Non-Physician Clinicians play crucial roles in the decentralization of ART. They have been trained to diagnose, prescribe, initiate and follow up patients on ART in Ethiopia, Kenya, Malawi and Uganda [104, 147, 186, 187].
4.5.2. Type shifting type II:
Shifting ART initiation to nurses has been central in the rapid scale-up of HIV treatment and care with high coverage at the primary health care level in the Lusikisiki sub-district (Eastern Cape Province of South Africa). The National Strategic Plan predicted that by 2011 most people in need of ART would receive their treatment from nurses at the primary healthcare clinics and not from doctors in hospitals [188]. In 2004 when the health authorities in
Botswana realized that a physician-centred ART delivery model was not feasible, a nurse-centred ART delivery model: where ART-trained nurses clinically manage stable ART patients was piloted in two projects. The findings show increased access reflected in shortening of waiting lists [137, 158].
4.5.3. Task shifting type III:
Medecins Sans Frontieres (MSF) in the Thyolo district of Malawi piloted community participation in HIV care, treatment and support by involving community caregivers. Their findings have shown clinical outcomes to be better when community caregivers were involved in the provision of services [189]. Partners in Health (USA) and a Haitian Organization (Zanmi Lasante) working together to provide ART have integrated ART into the primary health care delivery services. Using the Directly Observed Therapy Short Course (DOT) approach for both TB and ART patients, community health workers (accompagnateurs) provide ART at the community level with supervision. Patient outcomes have been reported to be good and adherence, impressive [137, 190].
4.5.4. Task shifting is not new
Historically, many nations both rich and poor have used health care providers who were not trained as physicians but who are capable of many of the diagnostic and clinical functions of medical doctors. Depending on the countries or regions and roles of the health cadres involved, they may be known as Non-Physician Clinicians, “mid-level cadres”, “substitute health workers”, Community Health Workers and others [137, 182, 186, 187, 191-193]. The Alma Ata Declaration of 1978 [50], the Kasongo project of the Institute of Tropical Medicine (Antwerp) and the expert patients concepts provide further examples of the involvement of non-professional health workers in the provision of health care [165, 194, 195].
4.5.5. Why the renewed interests in task shifting practice?
Task shifting is promising and appears most pragmatic given the current HRH crisis and HIV/AIDS scenario in SSA [135, 179, 196]. The renewed interests call for research to explore further the potentials of task shifting as an innovative strategy in finding solutions to the mismatch between HRH crisis and health services utilization in SSA.
4.5.6. In summary, what can be said about Task shifting?
Task shifting may be promising, but that potential will be better harnessed when there are clearly established career development pathways for non-professional health workers to
and a formal recognition. In that way, task shifting may serve as an entry point for interested but non-professional health workers to become professional health workers. Consequently, task shifting may serve the dual purpose of expanding the pool of non-professional as well as professional workers, while promoting the rational redistribution of the few skilled professionals.