Task Shifting

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 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.

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 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]

This article discusses the cost-effectiveness of a recent programme that involved training shopkeepers and community mobilisation for treating childhood fevers in the rural Kilifi District in Kenya. The programme offered workshops for shopkeepers on appropriate treatment for malaria in young children and also ran community information activities, with impact maintained through refresher training and monitoring. [author’s description]

Hospice Africa Uganda introduced palliative medicine to Uganda in 1993 with enough funds to support a team of three clinicians for three months. Training in the medical and nursing schools was introduced in 1994. Since then, Uganda has achieved the three essential components of an effective public health strategy. It has also been the first country to have palliative care described as an essential clinical service and to change the law to allow nurses and clinical officers who complete special training in palliative medicine at Hospice Uganda to prescribe morphine. Palliative care is spreading throughout the districts of Uganda, ensuring that morphine will be available to everyone who needs it. [adapted from publisher’s description]

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]

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]

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]

The most pressing challenge to achieving universal access to highly active anti-retroviral therapy (HAART) in sub-Saharan Africa is the shortage of trained personnel to handle the increased service requirements of rapid roll-out. Overcoming the human resource challenge requires developing innovative models of care provision that improve efficiency of service delivery and rationalize use of limited resources. We conducted a time-series intervention trial in two HIV clinics in central Mozambique to discern whether expanding the role of basic-level nurses to stage HIV-positive patients using CD4 counts and WHO-defined criteria would lead to more rapid information on patient status (including identification of HAART eligible patients), increased efficiency in the use of higher-level clinical staff, and increased capacity to start HAART-eligible patients on treatment.

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]

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]

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 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.

This manual was developed to assist district health management teams in countries where malaria is endemic to improve the quality of malaria treatment given by private clinics, pharmacies, shops and kiosks. It gives step-by-step instructions for how to implement a public health activity that will involve wholesalers in communicating malaria guidelines to retailers and private clinics. [author’s description]

The medical workforce shortage and efforts to maintain the safety and quality of health services are putting acute pressure on the profession. Task transfer or role substitution of medical services is mooted as a potential solution to this pressure. This has the potential to drastically transform the profession. How task transfer will evolve and change medicine depends on the vision and leadership of the profession and a flexible pragmatism that safeguards quality and safety and places patient priorities above those of the profession. [from abstract]

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]

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]

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.

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]

No satisfactory strategy for reducing high child mortality from malaria has yet been established in tropical Africa. The authors compared the effect on under-5 mortality of teaching mothers to promptly provide antimalarials to their sick children at home, with the present community health worker approach. The study concludes that a major reduction in under-5 mortality can be achieved in holoendemic malaria areas through training local mother coordinators to teach mothers to give under-5 children antimalarial drugs. [adapted from abstract]

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]

This news article introduces an approach to HIV/AIDS treatment that has helped Uganda scale up treatment in the midst of limited health workers. The approach, called Integrated Management of Adult and Adolescent Illness (IMAI), has been inspired by successes in Latin America, the former Soviet Union and Africa, where lay health workers who are often relatives, friends or other community volunteers have been trained to help treat tuberculosis patients in poor settings. [adapted from author]

Substitute health workers are cadres who take on some of the functions and roles normally reserved for internationally recognized health professionals such as doctors, pharmacists and nurses but who usually receive shorter pre-service training and possess lower qualifications. This desk review was conducted on the education, regulation, scopes of practice, specialization, nomenclature, retention and cost-effectiveness of substitute health workers in terms of their utilization.