Task shifting

Task shifting — the rational delegation of health care tasks usually performed by more highly trained health personnel to those with less training — is being widely hailed as a major part of the solution to the health care worker shortage that threatens to cripple further expansion of HIV prevention, care and treatment as well as other essential health services in resource-limited settings.

This should come as no surprise to HATIP’s readership community, many of whom have pioneered the very task shifting activities that WHO and others are now recommending taking to national and/or global scale.

Over the last five years HATIP has described how many activities can be performed quite well by nurses, community health workers, people with HIV or other non-medical staff — such as the home-based AIDS care (HBAC) programme in Uganda, nurse-run clinics in Lesotho, or TB screening by voluntary testing and counselling staff. Many of these innovations were born out of necessity, often initiated by the community itself to facilitate access to essential services.

And according to many presentations at the 2008 HIV Implementers’ Meeting and AIDS 2008, task shifting not only improves access to care, it can be performed without sacrificing quality of care — it may even improve the quality of care —and can get high marks in patient satisfaction. It can also be a more efficient and cost-effective way to provide services — but in the end, there may be little choice, because it may realistically be the only way to provide services needed by people with HIV quickly enough.

“Task shifting, from an economic perspective, is division of labour and the division of labour comes with efficiencies because each healthcare worker is focusing on specific tasks that they do best,” said Dr Kate Tulenko of the World Bank’s Africa Health Workforce Program during a symposium on task shifting at AIDS 2008. “But this is not something that’s exclusive to HIV and AIDS; it’s a health reform that’s been long needed in many countries and finally the emergency of AIDS is pushing it through.”

During a health crisis, the fastest route to staffing the health services will be increasing the number of staff who don’t take long to train. For instance, it can take seven years to produce a doctor, but (depending on the country) a few less years to produce a clinical assistant, less time to produce a nurse, and even less time to produce a community-based worker who may be trained for a few months or less to perform one specialised task — such as HIV testing and counselling, default tracing, adherence support — within a team of other health workers.

So the question is not whether to task shift, but rather which tasks to shift, to whom, and how to do it. The outcomes of task shifting can vary greatly depending on training, support and a number of factors — and there are limits to the tasks that can be shifted. So as more countries begin to scale up task shifting, it is crucial that we set up programmes with appropriate training, guidelines and standards based on what is currently known about task shifting.

Treat Train Retain’s global recommendations and guidelines on task shifting

The new WHO guidelines on task shifting, developed in collaboration with UNAIDS and PEPFAR provide a good place to start.

“Good health service coverage depends on having an adequate number of people, adequately trained to provide services,” Dr Francesca Celletti of WHO’s Department of Human Resources for Health, said during a presentation on the task shifting recommendations at AIDS 2008.

“For people living with HIV, in 94% of the cases, the first contact with health systems is not with a doctor but with a nurse, or a social worker or a community health workers (according to a Partners in Health study in Haiti),” she said. “So the question becomes how to empower those cadres to provide good quality services and to make sure that the service users are safe and the health workers protected.”

The new guidelines grew out of a process to document existing practices of task shifting in several sectors, and to ascertain key lessons learned, asking several key questions about each example of task shifting.

What is the impact of task shifting on the coverage of services and on the quality of the services provided? Was task shifting cost-effective? And was it a practice that is acceptable to the service user?

Coverage: There were many examples where task shifting positively impacted on the coverage of the services. For instance, in Ethiopia, access to HIV testing and counselling jumped dramatically from 500,000 people tested to 1,600,000 in 2007 after community health workers began performing the services. Likewise, in one district in Tanzania, there was a dramatic increase in the use of oral contraceptives when trained community health workers were engaged by the Family Planning Clinic and attendance at the clinic increased nearly five times within the same period.

Quality of services: “We also need to move away from the debate of ‘task shifting as being equal to second class care,’ as task shifting has been widely applied in high income countries like the US, UK, France, New Zealand,” said Dr Celletti, As an example, she mentioned a study from the US where physician’s assistants performed similar to or better than ID physicians or HIV expert general practitioners when delivering ART to people with HIV (Wilson et al, Annals of Internal Medicine, 2005). And in Brazil, community health workers were trained to perform immunisation and provide oral rehydration therapy to children. This resulted in sudden increase in the uptake of these services, with reductions in malnutrition, hospitalization and a profound decrease in the infant mortality rate (Cesar  et al, Social Science and Medicine, 2000).

Cost-effectiveness: “WHO, in its routine monitoring of TB programmes, has shown evidence that a decentralised approach to TB management, provides equal or better outcomes than a doctor-based conventional approach,” said Dr Celletti. “But WHO data also show that a decentralised approach for TB management is cost-effective in Kenya, Malawi, Uganda and South Africa, with the same effectiveness of treatment outcomes at a cost that is at least 50% less”.

Several other speakers at same symposium addressed the issue of cost-effectiveness. It seemed to be an issue with which Dr Louise Ivers of Partners of Health was clearly uncomfortable when talking about task shifting approaches in Haiti.

“We didn’t choose a model of using community health workers because it was a cost-effective model. We didn’t do a cost-effectiveness analysis beforehand. We used that model of care because we knew that in rural, isolated settings this model is going to work. It was going to get services to people who otherwise did not have services and furthermore there were no doctors available to provide the services,” she said.

“In using community health workers and using a model of task shifting, we anticipated that there would be an increase in the total health service use. So task shifting to community health workers should be in no way seen, and is in no way seen, as a cost-cutting exercise. We pay community health workers and we expected that as we provided services, the demand for services would increase. In fact, the objective of our model was that the demand for services would increase,” she said (more on the Partners for Health Project below).

“It’s not a cost-saving measure from an entire health sector point of view, but from a per-patient-visit point of view, it definitely can be cost-effective, said Dr Tulenko. “Because in the task shifting team, you have healthcare workers such as frontline and midline healthcare workers whose salaries are lower than the professional cadres such as physicians and doctors. And because of this, your per-visit cost for a patient will be less. The overall wage bill will be greater because you actually have more employees.”

Satisfaction: Dr Celletti referred to one of Dr Iver’s studies of task shifting in the central plateau of Haiti as an example of high satisfaction with the services provided by community-based workers. In that study, 97% (67% extremely satisfied, 28% very satisfied) of the clients were satisfied by the services provided under a task shifting approach.

These examples are just the tip of the evidence base used to develop the task shifting recommendations (and there were many more reports on task shifting projects reported at the recent conferences, see more below).

The task shifting recommendations

There are 22 recommendations divided into 5 categories, which can be read in full at http://www.who.int/entity/healthsystems/TTR-TaskShifting.pdf.

A)    Adopting task shifting as a public health initiative

Countries should consider implementing or extending task shifting where access to HIV services and other essential services is constrained by staff shortages, in combination with other efforts to increase the workforce. All relevant stakeholders, including the service user (people with HIV) and professional associations, should be engaged in the dialogue from the beginning; and a national framework developed to harmonise and stabilise services across public and other sectors. These efforts should be based on accurate data on human resources for health based on current demographic data, information on available services, gaps in services and existing quality assurance mechanisms.

B)     Creating and enabling regulatory environment for implementation

Existing legislation may need to be revised for cadres to take on other tasks (such as giving nurses the right to prescribe ART) or to create new cadres within the health workforce. Essential/emergency regulatory revisions may need to be fast-tracked while long-term comprehensive reform is underway.

C)    Ensuring quality of c are

Quality assurance mechanisms will need to be adapted or created to support task shifting that can monitor and improve the quality of the services provided. Roles and competency levels have to be clearly defined for each cadre (existing or new) taking on new tasks, and these standards should provide the criteria for recruiting, training and evaluation. Countries should systematically develop standardised competency-based training programmes to meet their needs and to provide accreditation that the health worker is equipped to perform their tasks. Training programmes and continuing education should be tied to standardised, national certification, registration and career progression mechanisms. All health workers should receive ongoing mentorship and supervision within their health teams — and those providing supervision should be competent and have supervisory skills. Finally, it must be possible to assess the performance and competency of each health worker in each cadre.

D)    Ensuring sustainability

Countries should consider providing health workers taking on new or increased responsibilities with incentives, financial or otherwise to encourage retention and enhance performance. Also, while short-term volunteer work can be helpful, a sustainable health programme cannot be based on volunteer workers. Trained health workers, including those who are community-based, who are providing essential services should receive adequate compensation. Task shifting plans should be appropriately costed and adequately financed in order to be sustainable.

E)     The organisation of clinical care services

Countries should choose to adopt, adapt or extend those task-shifting practices that best suit their situation and needs. Functional referral systems need to be in place to support decentralised services that may be task shifted, and health workers need to know the referral systems well and how to use them.

The remaining recommendations refer to the tasks, listed in a long annex in the guidelines, that can be safely and effectively performed by the four or five cadres of workers: 1) non-physician clinicians (clinical officers/medical assistants) 2) nurses/midwives 3) community health workers and nursing assistants, 4) people with HIV and 5) Other cadres, including pharmacists, technicians or records managers who could theoretically be engaged in taking on new tasks as well. 

Essentially, many tasks can be shifted down from the more highly trained cadre to the one just beneath it, until people with HIV are reached, who the guidelines - somewhat weakly - state can be “empowered to take responsibility for certain aspects of their own care” and potentially help support others, particularly in regards to “self-care and stigma and discrimination.”

However, the engagement of people with HIV can do much more than that — historically, they have been responsible for many of the innovations in service delivery that have led to new cadres of health workers, devising adherence support programmes, home-based care programmes, prevention campaigns, etc. Of course, these roles become formalised over time, with training and standards — so that commonly people with HIV become community health workers. But it would have been nice if the guidelines had captured that a bit better.

Defining tasks and how far they can be shifted — the experience in Haiti

As mentioned, the laundry list of tasks that could possibly be shifted are listed in a long annex in the guidelines, but many of these came from a list that Dr Ivers helped compile in Haiti.

There are about 8.5 million people living in Haiti but only 730 doctors and 1013 nurses working in the public sector. Partners in Health works in collaboration with the Ministry of Health and one of its focuses is the delivery of HIV at the primary health care/community level.

“Most of our staff are community health workers; we call them “accompagnateurs” in Creole or in French, meaning “the one who accompanies,” said Dr Ivers. “Accompagnateurs are community health workers from the area where we work, living in the communities where we work, neighbours of our patients and clients who bring medicines to people everyday.”

Incidentally, she added that there is something of a tradition of community health workers in Haiti. There are health agents called ‘Ajan fanm/Ajan sante’ dedicated to the care of women or trained to do vaccinations; there are counsellors drawn from the community and trained; many of the lab technicians are people from the community without a high degree of education, but who have been trained to assist in the labs. Similarly there are pharmacy technicians, x-ray technicians, social work assistants, data clerks and medical records clerks — many drawn from the community to provide services.

WHO commissioned Partners in Health to do a survey into task shifting, in which they asked many HIV service providers about the distribution of HIV care-related tasks and what tasks were usually exclusively performed by certain cadres. They came up with a list of about 140 HIV-related tasks, about 50% of them exclusively done by doctors, about 20% exclusively done by nurses and so on.

“Community health workers were not really featuring at all in the traditional model of HIV care,” she said. “However, when we surveyed our sites in Haiti, we found that our distribution of tasks had really shifted [so that most of the tasks were being] performed by doctors, nurses, community health workers and by other non-clinical staff.”

In fact, only 28% of the tasks were exclusive to doctors or nurses in Haiti.

However, the ART programme is nurse-centred in Haiti, and the tasks are shifted rationally by type, with the largest shift seen in the management of patients just prior to and after starting ART. Nurses are responsible for prescribing and managing patients. Only a few tasks are not done by nurses, including starting TB therapy in patients with HIV/TB coinfection or in smear-negative TB cases; the definitive management of some complicated side-effects and complicated opportunistic infections.

Community health workers handle much of the pre-ART care, and provide facilitated referrals if there are signs of opportunistic infections or side-effects of ART.

“Community health workers provided a support system in the community,” she said. “They referred patients who had side-effects from drugs, they supervised therapy of drugs, they were an advocate for patients coming to the clinic to say ‘My patient is not well.’ Their referrals are taken seriously, they consult with the physicians about their patients, they consult with the nurses formally about their patients; and in those referrals, in consultations, they are respected. They are advocates for their patients. They will come and tell us that the roof is leaking, this person has no food in the house and really far more beyond just delivering medications to the patient everyday.”

How did this affect care in the programme? Although the evidence doesn’t come from a randomised controlled study, it is easy to interpret. In over 3000 people on ART, some started as long as 10 years ago, only 2% have needed to change to second line treatment, and despite significant political instability.

 “This is because the community health workers living in the community, they’re the neighbours, they still go to work everyday regardless of what was happening politically in the country," she said.

In addition, shifting tasks to nurses transformed clinics that were previously non-functional. Before task shifting, these clinics received on average only 10-50 visits per day. There were frequent stock-outs, no ART, absent staff, and HIV testing was only available at one stand-alone site that performed less than 40 tests per year.

Since introducing the nurse-led, community worker-supported model, each clinic receives an average of 200-300 visits per day. There are 50,000 voluntary HIV tests per year, over 8,500 people with HIV being followed and over 3,000 people on ART.

And as already mentioned above, patient satisfaction is very high.

Dr Ivers also stressed that the approach can be scaled up in other settings. Since 2005, Partners in Health began expanding this model to eastern Rwanda. In a short period that programme was able to enrol over 2500 people living with HIV on ART. They trained and hired over 800 villagers as community health workers and had nearly 100,000 visits in 2006, just one year after they started the programme.

MSF calls for scaling up task shifting

In a pre-conference satellite at AIDS 2008, Médecins sans Frontières, the organisation that pioneered delivery of antiretroviral therapy in some of the poorest communities in the world, repeated calls from the World Health Organization for more comprehensive attempts to shift tasks that could be done by community health workers and volunteers away from doctors and nurses.

But task-shifting is still happening inconsistently and has yet to realise its full potential.

If task-shifting is essential in achieving universal access and bringing down treatment waiting lists, Malawi’s Thyolo district illustrates how it could contribute. Thyolo, like the rest of Malawi, has around 1.3 doctors per 100,000 people, compared with the WHO minimum recommendation of 20 doctors per 100,000, and is even shorter of nurses – 17 per 100,000 compared with 28 per 100,000 across Malawi as a whole. WHO recommends a minimum of 100 per 100,000.

Marielle Bemelmans, MSF head of mission in Malawi, described what happened when task-shifting was implemented in Thyolo.

Voluntary testing and counselling was handed over to lay counsellors and the number of testing sites was expanded, leading to an increase in HIV tests from 15,000 in 2003 to 78,000 in 2007.

It has been estimated that somewhere between 9,000 and 12,000 needed antiretroviral treatment in Thyolo district by 2008. By June 2008 13,702 were on treatment – universal access in a rural area with a severe shortage of health care workers. How was this achieved?

Antiretroviral therapy inititiation was handed over to medical assistants, clinical officers and nurses after training, with follow-up by lay counsellors. Drug dispensing was shifted to patient attendants and the number of pre-treatment initiation visits was reduced, as were follow-up visits for stable patients. People with HIV, working as volunteers, have been involved through their support groups in pre-packaging of drugs, patient registration and referral.

Indeed, the only stages of the care pathway now being handled by nurses are clinical screening and staging, the assessment of opportunistic infections and nutritional status, and the initiation of cotrimoxazole prophylaxis. Volunteer usage – currently 5 – 8 people per clinic day – means that the district has needed to employ only 7 extra nurses to accommodate the growing patient caseload, not 27 as originally projected.

New starts on treatment have more than doubled since 2005, with around 40% of patients now being initiated at local health centres. Comparison of outcomes between patients who started treatment at a hospital or a local health centre showed no significant overall difference in retention in care, but higher death rates were seen in health centres and higher loss to follow-up rates in hospital patients.

“It would have taken five years to achieve universal access in the district without the community network,” said Marielle Bemelmans.

Task shifting in Kenya

Another example of task shifting is the recent report from Kenya, summarised in more detail in an aidsmap news report from AIDS 2008, which showed that a system of `express care` could be developed that devolved much of the burden of care of patients on ART to nurses. The model led to better outcomes for patients, the investigators reported.

AMPATH developed its model to deal to deal with two categories of patients utilising clinic resources most intensively - those with CD4 counts below 100 cells/mm³, who tended to be ill more often and have a higher risk of loss to follow-up, and those on ART who were clinically stable.

Express care reduced loss to follow-up, and reduced the risk of death by nearly 50%, demonstrating that task shifting does not have to result in poorer outcomes. By shifting tasks, it may be possible to improve the quality of care for the most vulnerable as well as increasing the volume of patients who can be treated.

Conditions for success of task shifting

Dr Wim Van Damme of the Royal School of Tropical Medicine, Antwerp, told the meeting that his research and analysis shows there is a series of conditions for success – but lessons learned are being ignored in many settings.

Firstly, selection and motivation: are volunteers motivated and committed? Evidence from Malawi, where the government is attempting to recruit 4,000 Health Surveillance Assistants to work at community level suggests that rigorous selection is being sacrificed in the attempt to meet recruitment targets.

Secondly, initial training is key in ensuring quality. In Ethiopia, where community health workers are being recruited as part of a national task-shifting initiative, Health Extension Workers receive one year of training. In Malawi Health Surveillance Assistants are trained for up to ten weeks.

Another condition for success, he said, is the need for standardised protocols and realistic job descriptions. This condition is being met everywhere he has looked.

“Supervision, support and supply of materials to do the job are also important, but support and supervision are very problematic in most treatment programmes. Paid staff don’t have time to supervise volunteers due to their heavy workload, so there’s no way to check that volunteers and community health care workers are following protocols. For example, in Ethiopia, referral to hospital by Health Extension Workers has not ben happening routinely,” he said.

Dr Van Damme also noted career structure and remuneration to be an important condition for success and he identified a number of conditions for scale-up of task shifting:

• Political support and a favourable regulatory framework that allows new cadres to take on tasks of existing health care workers: this is very much the case in Ethiopia and Malawi, but there is a lack of guidance from government in Uganda, leading TASO to establish its own regulatory framework to manage task-shifting in its operations, which provide home-based care in many localities.
• Alignment with broader health systems-strengthening activities such as expanding the doctor and nurse supply by investment in further education and a national plan for generating a long-term increase in the supply of doctors and nurses: once again, happening in Ethiopia and Malawi, but lacking in Uganda.
• Flexibility and dynamism: it remains to be seen whether task-shifting initiatives will permit the need to accommodate rapid changes, such as the move from voluntary counselling and testing to opt-out, provider-initiated testing in many settings over the past two years.

He also noted that task-shifting presents two opportunities for health systems:

• Using the real-life experience of patients, such as people living with HIV.
• Developing chronic care models that focus on adherence and retention in care: these are applicable across many diseases, not just HIV, and here Uganda is leading the way.

Remaining barriers to task shifting

Despite the ground swell of support for task shifting among the HIV community, there are a number of significant hurdles to scaling up task shifting in many settings. For instance, in South Africa, the South African National AIDS Council and a wide range of stakeholders are calling for changes in regulations and legislation that are barriers to task shifting and universal access. For instance, in South Africa lay counsellors are still not permitted to provide HIV tests (even using rapid test kits), and nurse are not yet permitted to initiate people on ART.

At a symposium on task shifting at the HIV Implementers' Meeting, there was a discussion about how professional associations are fighting task shifting in some countries.

“There are many misunderstandings about task shifting,” said one audience member. “Having global guidelines is not enough. There is a need for country-based endorsement and participation of local professional associations to accept the WHO guidelines. Another problem is that the link between the vocations and institutions and professional health services is very weak. And to certificate, to endorse, to promote the application of task shifting - there is a need for improving the link between the vocation and the institutions and health services. Some professional associations are more committed to the global health work force approach but others remain attached, protecting the turf of the professions.”

Others were concerned about the over-burdening of nurses, and that not enough was being done to protect the health of community-based workers particularly those with HIV (a future HATIP issue will address this topic).

Finally, there is a possibility that expectations of task shifting could be too high.

“With task shifting you can improve the efficiency of the work force but you cannot generate the kind of numbers that we need from a comprehensive primary healthcare approach - outside of this room, outside of this conference - we have a debate ongoing about funding for AIDS, funding for health systems and funding for global integrated primary healthcare. And the workforce to deal with this IS NOT there!,” said Dr Jos Perriens, Coordinator of the Systems Strengthening and HIV (SSH) unit in the HIV/AIDS Department at WHO, who moderated the discussion.

“Task shifting is not panacea, it is just one solution to the complex problems that are today causing the human resource crisis. It should be taken up along with other strategies such as the production of more healthcare workers and retention of the existing ones,” said Dr Celletti.

However, it is important that the HIV and TB communities engaging in task shifting perform ongoing operational research and document any quality improvement activities to help expand the evidence base of what does and doesn’t work — and why. Word should go out about task-shifting projects or methodologies that are working particularly well, and people should be advocates for taking their successful programmes up to scale.