Health workforce skill mix and task shifting in low income countries: a review of recent evidence

Abstract

BackgroundHealth workforce needs-based shortages and skill mix imbalances are significant health workforce challenges. Task shifting, defined as delegating tasks to existing or new cadres with either less training or narrowly tailored training, is a potential strategy to address these challenges. This study uses an economics perspective to review the skill mix literature to determine its strength of the evidence, identify gaps in the evidence, and to propose a research agenda.MethodsStudies primarily from low-income countries published between 2006 and September 2010 were found using Google Scholar and PubMed. Keywords included terms such as skill mix, task shifting, assistant medical officer, assistant clinical officer, assistant nurse, assistant pharmacist, and community health worker. Thirty-one studies were selected to analyze, based on the strength of evidence.ResultsFirst, the studies provide substantial evidence that task shifting is an important policy option to help alleviate workforce shortages and skill mix imbalances. For example, in Mozambique, surgically trained assistant medical officers, who were the key providers in district hospitals, produced similar patient outcomes at a significantly lower cost as compared to physician obstetricians and gynaecologists. Second, although task shifting is promising, it can present its own challenges. For example, a study analyzing task shifting in HIV/AIDS in sub-Saharan Africa noted quality and safety concerns, professional and institutional resistance, and the need to sustain motivation and performance. Third, most task shifting studies compare the results of the new cadre with the traditional cadre. Studies also need to compare the new cadre's results to the results from the care that would have been provided--if any care at all--had task shifting not occurred.ConclusionsTask shifting is a promising policy option to increase the productive efficiency of the delivery of health care services, increasing the number of services provided at a given quality and cost. Future studies should examine the development of new professional cadres that evolve with technology and country-specific labour markets. To strengthen the evidence, skill mix changes need to be evaluated with a rigorous research design to estimate the effect on patient health outcomes, quality of care, and costs.

Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition

“…[10][11][12][13][14][15][16][17] Additionally, shifting of delivery of a range of services from doctors to nurse practitioners, or from health workers to lay providers (who have received only short periods of formal training), can eff ectively expand coverage without jeopardising chil dren's survival, health, and nutrition. [29][30][31][32] These fi ndings are particularly important in view of the absence of robust evidence for interventions that aim to improve the distribution and retention of health professionals in rural areas, and are in line with the principle that services should be delivered at the lowest eff ective level of care. Scale-up of the use of cadres of health workers with less formal training and lay health workers should therefore receive greater attention in frameworks that aim to overcome health system bottlenecks.…”

“…This strategy has the potential to both improve the effi ciency and expand the capacity of the delivery channel. [29][30][31] A review 32 of four African studies showed that nurses and medical assistants could provide some obstetric services, including caesarean deliveries, cost eff ectively. Another multi country study 30 showed that health workers with shorter training in assessment, classifi cation, and management of routine childhood illnesses, and counselling of caregivers, were as eff ective as those with longer training.…”

“…For example, reviews that considered strategies' eff ects on equity and found promising pro-poor eff ects included those assessing expanded roles for community health workers, 10,11,16 task shifting, 31,32 the expanded use of private service providers, 23,34 strategies to reduce fi nancial barriers to access, 37 and strategies to increase humanresource availability and geographical access. 38,39,43 The other paper in this Series 6 builds on our recommendations and uses data from 15 low-income and middleincome countries to describe how a UNICEF modelling team developed and applied a model that simulates the potential eff ect of implementation of the most promising of these strategies in the context of an equity-based approach to health and nutrition programming.…”

Analyzing the Determinants of Health Worker Performance

“…Task shifting is another important dynamic of the labor market for health workers (Ferrinho et al 2011;Fulton and Scheffler 2009;Fulton et al 2011). One example is where tasks normally performed by a surgeon are shifted to a surgery technician.…”

Shining a Light on Task-Shifting Policy: Exploring opportunities for adaptability in non-communicable disease management programmes in Uganda

“…5,8,9 In 2015, 31 countries in sub-Saharan Africa reported an increased need for trained health personnel. 10 As there is a direct relationship between the health worker-to-population ratio and NCD health outcomes, this is a serious concern. 7,[11][12][13] In Uganda, the increasing demand for healthcare services, a steadily growing population and the continued burden of morbidity and mortality from infectious diseases have led to significant health workforce shortages.…”