Task Shifting: Maximizing Healthcare in Low-Resource Countries

1 Dec 2010

Low-resource countries often carry the heaviest disease burden and maintain the smallest health workforce. The deadly cholera epidemic in Haiti is only the most recent example of how the time for 'task shifting' has arrived.

Amidst dwindling health resources and a frightening lack of health personnel internationally, the World Health Organization (WHO) and other health policy experts are working to develop new strategies to meet the overwhelming healthcare needs in low income countries. With primary care in dismally short supply in many parts of the world, and resources to mitigate crises equally difficult to come by, minimizing the cost of care can mean increasing access to it.

One strategy for providing more comprehensive healthcare coverage in the face of severely restricted resources is external pagetask shifting, "a process whereby specific tasks are moved, where appropriate, to health workers with shorter training and fewer qualifications." The goal of task shifting is to "make more efficient use of existing human resources and ease bottlenecks in service delivery."

Human resources - doctors, nurses and other healthcare personnel - make up external page70 percent of healthcare costs, so in low-resource settings, where funding is tight, minimizing the amount spent on each health worker can free up funds to employ more personnel, and to pay for more advanced equipment and medicines, with the end goal of providing more comprehensive coverage.

'Brain drain' poses a challenge, however, to employing more personnel in pursuit of comprehensive coverage. Internationally, countries with the highest healthcare burdens often have the fewest health care personnel per capita. Africa carries external page24 percent of the international disease burden but only has external pagethree percent of the world's health workers. Difficult working conditions and low pay often motivates citizens with advanced degrees to flee the country. For example, at least external page83 percent of Haitian doctors work outside the country. This has left lower-level health workers who do not have the resources to leave with increased responsibilities. By employing task shifting in a regulated manner, the WHO and local health providers hope to address this need.

Task shifting was originally developed to confront the HIV epidemic. The idea was that health workers with lower qualifications could perform tasks originally delegated to higher-level workers. Under external pagethe strategy of task shifting, "nurses may become involved in prescribing drugs, lay counselors involved in testing, new cadres may be introduced to perform specific tasks, and patients may be engaged to take over some elements of their own care."

After the WHO produced external pagethe manual on task shifting in 2008, several follow up studies have demonstrated its effectiveness. external pageA review of task shifting for HIV treatment and care in Africa published this year concludes, "Task shifting offers high-quality, cost-effective care to more patients than a physician-centered model." A case study in Malawi showed, "district-wide access to ART [Anti Retroviral Therapy] using a non-physician model of care was achieved for an additional $2.5 per capita, well within the estimated minimal basic health package costs."

Task shifting has been shown to increase efficiency and access to healthcare, while reducing costs.

Given the successes with task shifting to combat HIV, researchers are exploring the applicability of the model to other health epidemics and general health needs. Already task shifting has been suggested as a means to expand access to anesthesia. A external pageWHO bulletin published in August asserts, "The anesthesia services required at the first referral level facilities can mostly be delivered by trained non-physician anesthetists."

Task shifting for cholera in Haiti

Haiti is facing a massive cholera outbreak, with external pageestimates of up to 375,000 cases. While the epidemic has already spiraled out of control in some areas of the country, health professionals from the Haiti Epidemic Advisory System (HEAS), a network of health workers confronting the disease, suggest that training lower-level health workers to provide treatment and care could mitigate the impact of cholera in areas not yet in the emergency phase. HEAS reported in an anonymous post that "There is now no more time to train Haitians to train others for many parts of northern and central Haiti." But they hold out hope that in the areas least affected task sharing may still take hold: "Perhaps this may be done in the relatively nascent South."

Medecins Sans Frontieres (MSF) has been leading the cholera response effort and has set up over 20 treatment centers. But they say the epidemic exceeds their capacity, and they have raised a call for any available doctors, nurses and even last-year medical students to come forward and join the effort. Stefano Zannini, head of MSF in Haiti, released a external pagestatement 11 November saying, "More medical staff are arriving, but there's a chronic lack of personnel here in Haiti and we are close to being overwhelmed."

Early in the epidemic, when Haitian officials hoped a temporary slowdown in cases meant the situation had stabilized, Dr Gabriel Timothee, director general of the Haitian ministry of public health said that international doctors did not need to flock to the country; rather nurses and equipment were a priority. This makes sense given that most cases of cholera can be easily treated by lower-level healthcare workers administering an oral rehydration serum. Severe cases require intravenous rehydration and antibiotics. Since the epidemic has ballooned, the calls have expanded, and the UN external pagereleased an appeal for $164 million dollars this month, particularly highlighting the need for additional health workers.

The lack of adequate personnel has severe consequences. HEAS external pagereportedin an anonymous post, "in the original epicenter of St Marc, we have reports in the Haiti MPHISE [medical and public health information sharing environment] that clinics have run completely out of personnel and supplies, leaving many to die unassisted."

Cholera is now a part of Haiti's health landscape, joining malaria, dengue fever and tuberculosis as endemic diseases afflicting the population. The Pan American Health Association external pageestimatesthat the case load may reach 800,000. To face the long-term scope of the disease, it may prove essential that task shifting is employed to meet the healthcare needs of the population given funding shortages and limited personnel.

Health policy experts in Haiti recognize that all levels of health workers must be engaged to combat the epidemic. The implementation of task shifting may prove essential in this particular health crisis, and if properly documented could lay the groundwork for broadening healthcare access for other epidemics and general health needs.  

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