Task shifting and task sharing in the health sector in sub-Saharan Africa: evidence, success indicators, challenges, and opportunities

¹Department of Statistics, Faculty of Physical Sciences, University of Nigeria, Nsukka, Nigeria, ²Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa, USA, ³Department of Sociology, Faculty of Humanities, University of Johannesburg, Johannesburg, Auckland Park, South Africa, ⁴Department of Population and Behavioral Sciences, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana, ⁵Department of Epidemiology and Biostatistics, Fred N. Binka School of Public Health, University of Health and Allied Science, Hohoe, Ghana, ⁶Department of Economics, Faculty of Economics and Management Sciences, University of Bamenda, Bamenda, Cameroon, ⁷Yale School of Public Health, Yale University, New Haven, Connecticut, United States of America, ⁸Intellectual Consortium LLC, Tampa, Florida, United States of America, ⁹School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa, ¹⁰Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria, ¹¹Institute of Human Virology, Abuja, Nigeria, ¹²International Development Research Centre, IDRC, Ottawa, Canada

^&Corresponding author
Brenda Mbouamba Yankam, Department of Statistics, Faculty of Physical Sciences, University of Nigeria, Nsukka, Nigeria

Essay    

Defining task shifting and task sharing: there is an ongoing global dearth of skilled healthcare professionals, and more than four million people are needed in the global health workforce, which is a critical shortage in many parts of sub-Saharan Africa (SSA), Asia, and the Americas [1-4]. Task shifting and task sharing were developed as an ideal solution to the shortage of skilled healthcare workers [5]. Task shifting is the practice of giving specific tasks to healthcare workers who have not typically done them as part of their scope of practice [4,6]. It entails assigning tasks to healthcare workers who are more readily accessible, have less skills or narrowly tailored training, and have fewer qualifications [6,7]. Task shifting, according to the World Health Organization (WHO), is "a process whereby specific tasks are moved, where appropriate, to less-skilled healthcare workers in order to make more efficient use of the available human resources for health and by rapidly increasing capacity while training and retention programs are expanded" [4,6].

In 2010, the Institute of Medicine (IOM) officially introduced task sharing in the scientific literature to develop African capacity for HIV/AIDS prevention, treatment, and care [4,8]. Task sharing is described by WHO [6] as "an increase in the number of healthcare workers who can provide appropriate health services". The idea illustrates how teams of healthcare professionals from various cadres work together to complete the full clinical task. The capacity to carry out specific tasks is granted to extra cadres rather than being transferred from one cadre to another. As stated by Robertson [9], task sharing involves collaborating teams of experts and less-qualified cadres who share clinical responsibility and rely on iterative communication and training to keep high-quality results. It can be a critical strategy in many settings to address the shortage of higher-level providers. Task sharing can deliver services more effectively and affordably, even in health systems with ample resources [10]. Despite differences in sharing models between countries, published evidence shows that having many healthcare workers to provide essential care can greatly increase access to healthcare services [11].

Task shifting and sharing aim to efficiently use human resources to improve the health of extremely vulnerable populations and increase cost-effectiveness. These strategies stress that all health worker cadres must receive training and ongoing educational support to accomplish the required tasks [6,10,12,13].

Effectiveness of task shifting and sharing - evidence from the literature: task shifting and sharing have been successfully used to improve health in various settings and times, including the COVID-19 pandemic, to address global health workforce shortages and inadequate access to care for critical health issues [4,14-17]. Some studies have shown that task sharing and shifting are efficient and effective methods for assisting healthcare workers in completing duties not previously within their purview and increasing human resource for health (HRH) and quality outcomes [14-18]. For instance, Amani et al. [17] implemented task shifting in Central Africa Republic in 2022 to increase COVID-19 vaccination uptake and observed that the administration of injectable COVID-19 vaccines by CHWs were highly effective and widely accepted as vaccination coverage of COVID-19 tripled from 9% in January 2022 to 29% by August 2022. Gibson et al. [16] conducted a task-shifting study in which CHW cadres dispensed vaccines in 20 countries with established community health worker (CHW) programs and recorded improved access to immunization rates in zero-dose communities.

Furthermore, the scoping review by Okoroafor and Christmals [18] revealed that many African countries had received substantive investments from donors and partners in recent years to shift and share task in the health sector ensuring access to health services which prove effective. Dawson et al. [19], indicated that delegating and sharing duties might improve patient outcomes or performance while also increasing access to maternal and reproductive health (MRH) services. Additionally, if ongoing investments are made in the healthcare system, collaboration with community members and healthcare professionals at all levels has the potential to implement MRH interventions successfully [19].

Moreover, Farley et al. [8] indicated that task sharing can promote decentralization in South Africa without negatively affecting patient outcomes. It may be possible to make the best use of human resources and increase access to treatment with models that permit sharing duties for multidrug-resistant tuberculosis (MDR-TB).

Additionally, some studies have shown the efficacy of task-sharing interventions for controlling blood pressure in low-and-middle-imcome countries (LMICs) and found that including non-physician healthcare workers in lowering blood pressure is a useful option in LMICs, leading to task-sharing intervention's efficacy [20]. Enhancing efficacy must be evaluated considering the surrounding conditions and the need to consider the quality, acceptability, and feasibility of care [5,21].

Theoretical frameworks/conceptual models on responsible task shifting and sharing in SSA

The WHO global recommendations and guidelines on task shifting and sharing: the World Health Organization (WHO) has devised global recommendations and guidelines on task shifting and sharing to support and guide the expansion of healthcare initiatives and workforce organization in countries [7,22]. The framework aims to establish conditions for safe, equitable, efficient, effective, and sustainable task shifting. Implementation of these guidelines aims to achieve key outcomes such as strengthening healthcare workforce capacity, improving access to services, enhancing program implementation, and bolstering health systems for high-quality treatments. The guidelines propose that countries facing healthcare workforce shortages consider adopting and enhancing task-shifting strategies in collaboration with stakeholders, alongside efforts to increase qualified healthcare workers. The importance of involving stakeholders from the outset is highlighted to ensure shared responsibility, active partnership, and alignment with national needs. The guidelines recommend a consistent national agenda for healthcare services across public and private sectors, defining roles of diverse healthcare providers and updating analyses with demographic and quality data. Task shifting and sharing should be tailored to individual country requirements, as underscored by the guidelines [22].

Concepts and Opportunities to Advance Task Shifting and Sharing (COATS) framework: the COATS framework is a comprehensive and adaptable model that can be used to improve task shifting and sharing in creating policy, programs, assessment, and analysis. The COATS framework consists of three elements, and this includes:

Definition and purpose of task shifting and sharing programs: the COATS framework expands WHO's task shifting and sharing concept, effective for healthcare in resource-limited communities [22,23]. Task shifting optimizes labor by redistributing tasks, easing service bottlenecks [10]. It shifts tasks from skilled to less-trained personnel [24], often prompting broader healthcare system changes. The goal is to reduce disease burden and mortality by deploying less-trained professionals for efficient interventions [10,22]. Effective implementation of task shifting and sharing requires funding, planning, training, and education, enhancing resource-constrained health systems [24-26].

Opportunities arising from task shifting and sharing programs: the COATS framework (Figure 1) outlines four task shifting and sharing opportunities to enhance healthcare systems, tailored to program context. These include diversifying care options, redistributing responsibilities to highly trained workers, culturally/contextually suitable care via peers/CHWs, and expanding interventions by altering provider hierarchies [4,10].

Implementation criteria for task shifting and sharing programs: program developers, policymakers, and stakeholders can use the COATS framework's criteria to determine whether a particular situation and setting are appropriate for task shifting and sharing. "Necessary conditions" and "important considerations" constitute the criteria for putting into practice a task shifting and task-sharing program [10]. Necessary conditions that must exist for a task shifting and sharing program to succeed in achieving its goals and objectives include the characteristics of the staff that is accessible, the health issue, and the intervention. Important considerations signify ideas that might not always be relevant and will help the program succeed in some circumstances.

Examples and outcomes of task shifting and task sharing interventions: a summary of interventions and outcomes of task shifting and task sharing is shown in Table 1.

Factors that lead to effective task shifting and sharing: task shifting and sharing are used to increase and guarantee access to vital health services by utilizing the current medical care personnel to their fullest potential. Some of the factors which lead to effective task shifting and sharing are:

Motivation/optimism: effective healthcare services through task shifting and sharing require motivated workers and confident, prepared clients, fostering successful provider-client relationships and improved outcomes [1,27]. Feiring and Lie [27] identified motivation and optimism factors: beliefs about task shifting's impacts, job satisfaction, esteem, and organizational culture. Norway's 1:4 doctor-to-nurse ratio led them to advocate task shifting as an effective HRH utilization strategy, especially for flexible team members [27]. Provider skills and self-efficacy, nurtured within task shifting interventions, are pivotal. These attributes attract clients by enhancing their perception of provider expertise. Improved skills yield better results, elevating provider self-efficacy, trust-building, and influence for meaningful change [28]. Learning about task shifting enhances readiness for new roles and responsibilities, amplifying intervention effectiveness [27]. Ultimately, the combination of motivated providers, equipped with refined skills, and confident clients fosters successful task shifting and sharing interventions.

Organizational factors: these factors are an essential component in task shifting and task sharing, which, if well managed, will result in effective and efficient task distribution, as it is thought between physicians and nurses to foster teamwork by reinforcing a supportive environment [5,27]. Effective collaboration involving an existing network that connects the different healthcare workers to support the health system is an effective factor that leads to the delivery of task-shifting and task-sharing interventions successfully. For instance, the ability to send patients to specialists and other care providers was made possible by the existing provider networks. Therefore, it leads to effective task shifting and sharing when well implemented.

Societal factors: they encompass socio-economic conditions, cultural norms, and historical context, can substantially hinder task sharing and shifting interventions in terms of access, involvement, and delivery [1]. Sociocultural norms pose significant challenges. Dutch medical doctors' resistance to technology adoption was linked to historical perceptions, as indicated by de Haan et al. [5]. Similar findings were observed in Mangochi, Malawi, by Kok et al. [29]. Certain medical fields, like intensive care, embraced technological changes and expanded clinical technologist roles, whereas acceptance varied among specialties, such as surgery and rheumatology [5].

Key barriers in task shifting and sharing: task shifting and sharing are implemented by policymakers in many countries globally. It is an effective strategy for delivering healthcare services in many countries to improve treatment costs, availability, and safety [5]. Despite recent studies reporting the safety and cost-effectiveness of task shifting and task sharing [3,7,18], some notable barriers to implementation are discussed below [1-2,5].

Trust, responsibility, and accountability: these are factors affecting the success of task shifting and task sharing [2]. Colvin et al. [26] reported that doctors voiced anxiety about accountability and responsibility when midwives were assigned tasks with doctors. The fear frequently results from ignorance of midwifery education and practice, the impression of variation in midwife skill and experience, and ambiguous legal guidelines governing liability in these situations. Additionally, caregivers shared the same worries.

Organizational factors: effective healthcare delivery and minimal inter-professional cooperation depend on each cadre of healthcare professionals having a clearly defined task. However, inaccuracy in task distribution and description can result in dishonesty, interpersonal disputes among healthcare professionals, and inefficiency in task distribution when providing customers with healthcare services [7]. According to Le et al. [1], the provision of time slots for healthcare workers to perform additional shared tasks was insufficient, resulting in lower engagement, especially for patients whose financial status restricted their ability to attend rendezvous, lowering the quality of care. Moreover, physical space limitations in health clinics presented a major obstacle to task-sharing intervention, making it difficult to achieve privacy for private counselling sessions with clients [1].

Client characteristics: client characteristics are another major barrier to task shifting/sharing intervention [1]. A study conducted by Le et al. [1] on the barriers to adopting evidence-based task-sharing mental health interventions in low- and middle-income countries (LMICs) showed that the demographics of the clients influence their level of trust in the service being provided by CHWs involved in task sharing intervention. For instance, the more educated or higher-income clients were hesitant to receive a health service from a CHW instead of a registered nurse.

Success indicators for task shifting and sharing: the effectiveness of task-shifting and sharing interventions depends on a variety of indicators. These indicators are presented in Table 2.

The main criteria for task shifting and sharing: several indices determine if task shifting and sharing are viable options in any given work environment. These conditions influence the decision of when and if shifting and sharing of tasks should be adopted, the intention being to arrive at success ultimately.

Insufficient manpower: task shifting and sharing are strategic responses to address manpower shortages in healthcare settings. These approaches involve reallocating tasks among different cadres based on effectiveness rather than qualifications. They help maximize team outcomes despite workforce deficits, making them suitable in scenarios of inadequate manpower. In regions like Africa with marked human resource gaps, exploring task shifting and sharing becomes crucial, though they should not substitute skilled staff recruitment. Additionally, task sharing becomes pertinent when rapid response is essential due to insufficient trained personnel. The need for swift healthcare reactions driven by limited qualified workforce underscores the rationale for task shifting and sharing. This interplay between manpower scarcity, rapid response, and efficient resource allocation shapes the application of task sharing and shifting.

Complexity of care: in the health sector, this necessitates the need to share different tasks. Take, for instance, in the surgical context, tasks will be shared among surgeons/clinicians who have the capacity and have been trained to perform surgery in order to boost output, address the burden of new tasks, improve access, and solves human resource shortages [9].

Sustainability: this is another key factor in task delegation and sharing. In initiatives like Nigeria's Reproductive, Maternal, Newborn, and Child Health (RMNCH), community health extension workers (CHEWs) are preferred due to lower remuneration, addressing resource constraints [15]. Some countries can't afford full remuneration for higher-skilled healthcare workers, leading to task shifting and sharing as alternatives. These strategies compensate for staff shortages by employing less-skilled workers who won't demand full remuneration packages, ensuring sustainability in healthcare provision. A summary table of when we should task shift and task share is presented in Table 3.

Success criteria for effective task shifting and sharing: the advantages of task shifting and sharing may not be immediately apparent for health workers. Some criteria for evaluating the effectiveness of task shifting and sharing are shown in Table 4.

Improved quality of patient care: primarily, task sharing and shifting should result in more seamless, enhanced patient care. This is due to eliminating the bottlenecks that typically bedevil the patient care system, increasing collaboration between healthcare workers, entrenching a person-centered approach to healthcare, and introducing more healthcare workers. Thus, one indicator that task shifting and sharing has successfully been carried out is an improved quality of patient care. This could be in the form of reduced wait time, increased access to counseling/care, and reduced patient mortality rate [8].

Efficient use of resources/cost effectiveness: task shifting and task sharing can be motivated by economic incentives, that is, the need to use resources effectively. This is because the process sees the better utilization of available manpower and eliminates the need to outsource tasks. Furthermore, physicians can concentrate more on complicated cases thanks to task shifting, which also lowers the cost of personnel management. In light of this, a substantial decrease in the overall cost of maintaining the healthcare system is frequently a sign that task shifting and sharing are successful. In a review of 34 studies on the possible cost savings of task shifting, 30 studies revealed a drop in health costs due to the adoption of task shifting and task sharing, both to the health system and the client [13].

Ethical considerations for task shifting and task sharing

Justice principle: respect is a concept that shapes the principle of justice. The principle of justice states that everyone must be handled fairly and given the same opportunity to be listened to and considered. Justice makes sure that everyone has an equitable opportunity to participate in legal proceedings [30]. Although higher-educated healthcare worker cadres are required to provide CHWs with adequate guidance, supervision, and management, CHWs are often given limited chances to provide feedback in HIV programs [30]. As a result of institutional policies that have consistently prohibited them from taking part in HIV initiatives, this draws attention to procedural justice violations. Since CHWs may believe they have few chances to provide feedback within the delivery of HIV care, this problem may impact motivation and retention rates.

Respect for persons: according to the principle of respect for persons, all persons should be respected. It is critical that healthcare professionals, including CHWs, physicians, and nurses, receive enough knowledge to exercise their full autonomy while making wise decisions. This is crucial for CHWs since they frequently find themselves in precarious situations because their level of education is low compared to other members of the medical community. Despite this, several CHWs have claimed they were enlisted for interventions without receiving the necessary instruction or knowledge about carrying out their duties [30]. It is important to give prospective CHWs detailed instructions on their responsibilities throughout the recruitment process to get around this conundrum. Additionally, they should be informed upfront if they will be paid for their labor and if there are any chances for professional progression. Each of these initiatives can help CHWs do their duties with greater knowledge.

Beneficence: according to the concept of beneficence, promoting benefits to human welfare and health should be a goal of healthcare delivery [30]. This idea minimizes possible harm while promoting the welfare of individuals and communities. The welfare gains may include health gains and social benefits like neighborhood empowerment. This idea is especially pertinent to HIV initiatives. For instance, when providing HIV services, CHWs may be forced to conduct home HIV tests without the proper safety precautions, putting their health at risk. Therefore, precautions should be taken to prevent these problems, and sufficient welfare should be offered. For instance, Governments and pertinent organisations can ensure CHWs have access to the right tools, like latex sleeves, when performing HIV testing that would help CHWs maintain their health [30].

Proportionality: the principle of proportionality asserts that moral considerations and public health benefits hold equal importance [30]. It dictates that positive aspects should be balanced against negatives in decision-making, vital for task shifting and sharing interventions. This principle guides assessment of options and helps decision-makers choose the least disruptive approach by considering personal gains alongside societal well-being.

Cultural humility: in order to foster greater collaboration and partnership-building during task-shifting and sharing interventions, cultural humility highlights the significance of stakeholders being receptive to exchanging cultural knowledge and skills throughout healthcare delivery [30].

Conclusion and recommendations: task shifting and sharing are potential interventions for expanding healthcare within LMICs and increasing human resources for health. In this article, we have been able to discuss its evidence, challenges, and opportunities in sub-Saharan Africa, and as a result, we recommend that LMICs should: consider implementing, extending, and strengthening task shifting or task sharing methods in areas where health staff shortages are impeding the availability of HIV and other health services. Task shifting should be implemented alongside other initiatives aimed at increasing the number of qualified health workers [4]. Analyze a framework for researching task shifting or task sharing in order to address other important public health issues. In addition, LMICs should perform a human resource analysis to provide data on the demographics of current HRH in both the public and private sectors. Examine and think about using current regulating methods, such as laws, proclamations, rules, regulations, policies, and guidelines, to permit cadres of health workers to practice within a wider range of practice and to permit the emergence of new cadres within the health workforce. Specify the responsibilities and corresponding competency levels needed for both newly established cadres created due to the task shifting/task sharing approach and current cadres expanding their practice areas.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Brenda Mbouamba Yankam and Luchuo Engelbert Bain designed the study. Brenda Mbouamba Yankam, Oluwafemi Adeagbo, Hubert Amu, Robert Kokou Dowou, Beryl Gillian Mbouamba Nyamen, Samuel Chinonso Ubechu, Pascal Georges Félix, Ngwayu Claude Nkfusai, Oluwaseun Badru, and Luchuo Engelbert Bain developed the protocol. Brenda Mbouamba Yankam, Robert Kokou Dowou, Beryl Gillian Mbouamba Nyamen, Samuel Chinonso Ubechu, Pascal Georges Félix, Ngwayu Claude Nkfusai, Oluwaseun Badru and Luchuo Engelbert Bain wrote the manuscript. Oluwafemi Adeagbo, Hubert Amu, Oluwaseun Badru and Luchuo Engelbert Bain provided substantial comments to the writing of the manuscript. All authors read and approved the final manuscript.

Acknowledgments     

We would like to express our gratitude to Professor L.E.B for his time, patience, and advice throughout this project. He checked the work for quality and made significant contributions from the beginning to the end.

Tables and figure     

Table 1: summary of findings

Table 2: success indicators for task shifting and task sharing

Table 3: what are the main criteria for task shifting and task sharing? (when should we task shift/task share?)

Table 4: success criteria for effective task shifting and task sharing?

Figure 1: a conceptual framework for task shifting and sharing (source: Orkin et al. [10])

References