Challenges of Implementing the Task Shifting Strategy in the context of Health Systems and How to overcome the challenges.

Introduction:

Task-shifting is officially accepted and further suggested by World Health Organization during 2007 and developed global recommendations and guidelines on its website on Task-shifting: rational redistribution of?tasks among?health workforce?teams: global?recommendations?and?guidelines (Aithal?S et al, 2017).

Task shifting has been practiced in many countries for years as a means to address the shortage of higher-skilled health workers. Shortage of higher-skilled health workers is a global quandary. It is worst in low- and middle-income economies (including Kenya) (Baine S. et al, 2018).

Task-shifting can?be?regarded?as?an?Optimum?Patient?Survival?Management?Strategy?for?Health-care?Organizations?in Developing Countries where there is an acute shortage of trained professionals. The healthcare sector is facing the crisis in certified healthcare professionals due to a critical shortage of such trained people. (Aithal?S et al, 2017).

Strategy in management is a process of identifying and realizing the both short term and long term goal while solving a problem by using optimum resources and efforts. It is a short-cut way of ensuring success in a given task. There are many types, methods of implementation of strategies by managers and leaders depending ?on?the?type?of?problems,?objectives,?circumstances,?privileges,?preferences,?advantages,?constraints?and opportunities (Aithal?S et al, 2017).

According to the World Health Organization (WHO), task shifting “presents a viable solution for improving health care coverage by making more efficient use of the human resources already available and by quickly increasing capacity while training and retention programs are expanded” . Task shifting can produce equivalent or superior outcomes for many diseases and health interventions including non-communicable diseases (Seidman G et al, 2017).

Task-shifting is an innovative?concept or?an alternative?survival?strategy?in?the healthcare?sector in?many?countries where?the medical care?task is shifting between healthcare?workers. The idea of Task-shifting is developed to promote rapidly required human resource capability. Such process is also referred as the delegation of health and medical service responsibilities from upper to lower cadre or from one cadre to another cadre of health staff, and in some cases even to non-professionals. The delegation of tasks from one cadre to another, previously often called substitution, is not a new concept (Aithal?S et al, 2017).

The causes are complex and range from failure to train adequate numbers of skilled health workers, failure to attract and retain them, deaths, and migration, to complex political-socio-economic contexts. Poor work conditions, benefit packages, and job satisfaction cause migration of health workers in search of better packages from other countries, the private sector within countries, and others exit the health sector (Baine S. et al, 2018).

Regarding types of task shifting, Manongi?et al.?had coined ‘vertical’ and ‘horizontal’ task shifting as most common concepts associated with task shifting. Further sub-divided into ‘vertical’ task shifting into ‘upward’ and ‘downward acting’ to reflect how it is actually practiced. ‘Horizontal’ task shifting is also practiced, although is more widespread than ‘vertical’ task shifting (Munga MA et al, 2012).

?Challenges faced in task shifting

?Challenges faced in task shifting included

1.?????Quality of care and safety

There is evidence that?show the important contribution of non-professional health workers (task shifting) to achieving patient survival, not because they can perform clinical tasks better than professionals (they almost certainly cannot) but because they may adhere more strictly to simple clinical practice guidelines (Zachariah R. et al, 2008). Task-shifting makes use of already available human resource by delegating tasks requiring high skills to health workers with lower qualification (E. Okyere et al, 2017). The higher-skilled health workers off-loading a lot of their responsibilities to less-skilled health workers at the cost of quality and safety of care (Baine S. et al, 2018). Doubts/lack of satisfaction regarding treatment among the general public may be also seen. In some cases, quality of treatment might get compromised as some health workers may be less experienced and might have less knowledge/expertise on areas outside of their expertise (Sandesh Adhikari, 2018). Changes in the characteristics of patients and in the opportunities to intervene have been an important driver of change in several countries including Kenya (European Commission, 2019).

Proposed actions

Proposed actions

Patients, health staff and policymakers should be involved in setting measurable targets and indicators for an acceptable level of quality for a given intervention. Such targets and indicators can serve as benchmarks for supervision, monitoring and evaluation of specific interventions, which in turn serve to protect patients and providers (Zachariah R. et al, 2008). Create an implementation plan that ensures quality of care

2.?????Difficulty in identification of the less skilled health workers

Difficulty in identification of less-skilled health workers who could take on additional responsibilities from higher-skilled health workers is one of the challenges facing task shifting strategy (Baine S. et al, 2018).

Proposed actions

Maintain a database and pool of health workers with the motivation to take up additional roles. Provide incentives to motivate the workers.

3.?????Scarce of resources

Scarcity of resources to facilitate mentorship, in-service training, and support supervision is also a challenge (Baine S. et al, 2018). For task shifting, training of the staffs and health workers is required, which can in turn increase the immediate cost/investment (Sandesh Adhikari, 2018).

Proposed actions

Management and the leadership of health care organizations must morbilize resources to ensure availability of the available resources to achieve the task shifting strategy.

4.?????Resistance to task shifting

Experience shows that task shifting may not be readily accepted by various professions. Doctors and pharmacists have objected to the delegation of their tasks to what they perceive as ‘half-baked doctors’; nurses have resisted taking on doctors’ roles without commensurate salary increases; professional groups have objected to a potential loss of earnings where remuneration includes a fee-for-services component; professional councils and associations have in some instances resisted delegation of tasks to lower cadres and finally, the additional supervisory responsibilities that come with shifting tasks from higher to lower cadres have also met with resistance (Zachariah R. et al, 2008).

Resistance of higher-skilled health workers and decision and policy makers to task shifting was based on the premise that certain procedures could not be shifted to less-skilled health workers since they were not well-trained to offer them unsupervised (Baine S. et al, 2018).

Proposed actions

Job scope should be clearly defined to facilitate transitioning into the COVID-19 workforce, seeking consultation for complex cases, and prevention of “task creep,” acting beyond permissible guidelines (Robertson F. et al, 2020). Once tasks have been defined, appropriate training (pre-or in-service), clear job descriptions and remuneration packages need to be established. Inter-cadre relationships can be improved by consulting with existing cadres prior to and during the process of task shifting. Clear delineation of professional boundaries and responsibilities are needed to foster teamwork and cooperation Coordination and consultation from the outset with key regulatory bodies such as medical and nursing councils, as well as with relevant government ministries (health, education, labour), are essential (Zachariah R. et al, 2008).

5.?????Policy and regulatory environment

Task-shifting requires engagement with policy-makers, health professionals and community members. At the health system level, it is essential to establish clear roles with detailed job descriptions and adequate remuneration for the tasks performed (Joshi?R et al, 2018). The lack of a national policy and frameworks to guide implementation of task shifting and protection of less-skilled health workers against legal actions in courts of law in case of unintentional errors (Baine S. et al, 2018). While the regulatory environment in some countries is permissive of task shifting, the cadre has no legal protection for additional tasks if anything was to go wrong. Some countries still have outdated policies or laws that prevent lower level cadres from carrying out particular tasks (AMREF, n.d)

Proposed actions

Legal changes in regulatory frameworks can take years to be enacted, approaches that use other policies to create an enabling environment such as changes in strategic plans, the passing of ‘executive orders’ or granting ‘temporary pilot status’ to programmes engaged in task shifting may be more expedient (Zachariah R. et al, 2008).

6.?????Motivation, retention and performance

Poor salaries have been a key factor behind job dissatisfaction and the migration of nurses from sub-Saharan Africa to Western countries, where one in five nurses trained in sub-Saharan Africa currently work. Low salaries also have an impact on patient care (Zachariah R. et al, 2008). Most doctors are not willing to be deployed to rural areas and the public sector, where the impact of the shortage is most felt. Task shifting is therefore still seen as a government ploy to avoid paying the right people to do their rightful jobs (AMREF, n.d). Health workers lack incentives to expand their roles. CHWs are not paid and reimbursement systems of other health workers do not provide incentives for appropriate delivery of costeffective interventions. Non-financial incentives are also inadequate (Harriet Nabudere et al, 2010). Continuous supervision is most to ensure quality treatment (Sandesh Adhikari, 2018).

Proposed actions

Health workers must receive a decent salary that constitutes a living wage and that is commensurate with their responsibilities. Although task shifting may be seen as a pragmatic method to deal with staff shortages there is a real potential for exploiting vulnerable workers who might continue to be paid only for work for which they are qualified. Payment must therefore be linked to the level of responsibility and increasing workload associated with task shifting (Zachariah R. et al, 2008). Short-term priorities include ensuring that the newly trained staff thrives for as long as needed, with an adequate supply of PPE and timely dissemination of new information. Addressing the impact of physical, emotional, and moral stress on providers given isolation and care rationing should be incorporated (Robertson F. et al, 2020).

7.?????Training challenge

Waiting for enough new workers to graduate through the conventional systems will mean lengthy delays in providing urgently needed services. This means that measures to raise recruitment rates and expand training facilities, although important, are not the whole solution. In addition to these measures, alternative and simplified models need to be developed that can quickly expand the capacity of the current health workforce (WHO, 2006)

Proposed actions

Conduct integrated training and continuous professional development for all health care workers.

8.?????Professional protectionism?

In many instances doctors feel that their many years of training count and not just anyone can do their work. Nurses too feel that their profession is being invaded by nursing aides. As a result, community health workers are not embracing task shifting (AMREF, n.d). Shifting of responsibilities from higher level professional to lower level can create conflicts in between the professionals. Clash of ego is quite common (Sandesh Adhikari, 2018).

Proposed actions

Involvement of the cadres from the beginning to foster acceptance in line with established guidelines or regulatory and policy framework

9. Gaps in leadership, planning, monitoring and evaluation

Task shifting strategies require leadership from national governments to ensure an enabling regulatory framework; drive the implementation of relevant policies; guide and support training institutions and ensure adequate resources; and harness the support of the multiple stakeholders. With such leadership and a willingness to learn from relevant experience task shifting can indeed make a vital contribution to building sustainable, cost-effective and equitable health care systems (Lehmann U et al, 2009). The task shifting that has occurred has been without a clear policy, planning, or monitoring and evaluation (Harriet Nabudere et al, 2010).

Proposed actions

Involvement of the leadership in getting the buy in to support and view the task shifting a shorter close gap measure that bridges the current shortcomings and the future better situation.

10. Ethical Concerns

The guidelines from the WHO regarding task shifting delineate basic practice standards and ethical principles. However, there is no body or association that will regulate this task force. There is no clear delineated code of conduct. Ethical concerns of utilizing a non-specialist task force to deliver health care services have not been researched (Philip, S et al, 2018).

Proposed actions

Regulatory authority to clearly state the code of conduct and ethical consideration?in practice of task shifting for consistency?and uniformity within various cadres in health care.

12. Legal Concerns

Another concern is from the legal perspective on task shifting. Here is a cadre of nonprofessionals who have been tasked to provide some aspects of health care. In case of any adverse events arising in this context, how would liability be adjudged? Would it lie solely on the trainer/liaising organization (Philip, S et al, 2018).

Proposed actions

Regulatory authorities have discouraged the introduction and use of lower skilled professionals in providing care let alone during Covid 19 situation. Legislation should be put in place to ensure the regulatory bodies take cognizance of the shortage and the ability of the employers to meet the norms and standards in the spirit of the common good of the populace.

Conclusion

Task-shifting has been shown to be effective in high-income countries whereby appropriately trained and well supervised lower-level cadres perform delegated tasks well or better than the trained ones.

The state must legislate and implement the ministry of health task shifting plan already documented.

References

1.?????Aithal, Sreeramana & Aithal P, Architha. (2017). Task Shifting – An Alternative Survival Strategy for Health-care Organizations.. International Journal of Scientific Research and Modern Education (IJSRME). 2. 34-48. 10.5281/zenodo.995627.

2.?????AMREF.(n.d). Amref Health Africa’s Position Statement on Task Shifting . Retrieved from: https://amref.org/position-statements/amref-health-africas-position-statement-on-task-shifting-3/#gsc.tab=0

3.?????Baine, S.O., Kasangaki, A. & Baine, E.M.M. Task shifting in health service delivery from a decision and policy makers’ perspective: a case of Uganda.?Hum Resour Health?16,?20 (2018). https://doi.org/10.1186/s12960-018-0282-z

4.?????Eunice Okyere?, Lillian Mwanri, Paul Ward. (2017). Is task-shifting a solution to the health workers’ shortage in Northern Ghana? https://doi.org/10.1371/journal.pone.0174631

5.?????European Commission (2019). TASK SHIFTING AND HEALTH SYSTEM DESIGN :Report of the Expert Panel on effective ways of investing in Health (EXPH)

6.?????Harriet Nabudere, Delius Asiimwe,?Rhona Mijumbi (2010). An Evidence Brief for Policy Task shifting to optimise the roles of health workers to improve the delivery of maternal and child healthcare. Retrieved from https://www.who.int/evidence/resources/country_reports/TaskShiftingfullreport2010.pdf

7.?????Joshi?R,?Thrift?AG,?Smith?C, et al Task-shifting for cardiovascular risk factor management: lessons from the Global Alliance for Chronic Diseases BMJ Global Health?2018;3:e001092

8.?????Lehmann U, Van Damme W, Barten F, Sanders D. Task shifting: the answer to the human resources crisis in Africa?.?Hum Resour Health. 2009;7:49. Published 2009 Jun 21. doi:10.1186/1478-4491-7-49

9.?????Munga MA, Kilima SP, Mutalemwa PP, Kisoka WJ, Malecela MN. Experiences, opportunities and challenges of implementing task shifting in underserved remote settings: the case of Kongwa district, central Tanzania.?BMC Int Health Hum Rights. 2012;12:27. Published 2012 Nov 2. doi:10.1186/1472-698X-12-27

Philip, S., Chaturvedi, S.K. Musings on Task Shifting in Mental Health.?J. Psychosoc. Rehabil. Ment. Health?5,?103–107 (2018). https://doi.org/10.1007/s40737-018-0121-5

11.?Robertson FC, Lippa L, Broekman MLD. Editorial. Task shifting and task sharing for neurosurgeons amidst the COVID-19 pandemic [published online ahead of print, 2020 Apr 17].?J Neurosurg. 2020;1-3. doi:10.3171/2020.4.JNS201056

12.?Sandesh Adhikari (2018). Task Shifting: What Is Task Shifting and Why is it Needed?. Retrieved from https://www.publichealthnotes.com/task-shifting-what-is-task-shifting-and-why-is-it-needed/

13.?Seidman, G., Atun, R. Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from low-income and middle-income countries.?Hum Resour Health?15,?29 (2017). https://doi.org/10.1186/s12960-017-0200-9

14.?WHO. 2006. Task shifting to tackle health worker shortages.https://www.who.int/healthsystems/task_shifting/TTR_tackle.pdf?ua=1

15.?Zachariah, Rony & Ford, N & Philips, Mit & Lynch, Sharonann & Janssens, V & Harries, Anthony. (2008). Task shifting in HIV/AIDS: Opportunities, challenges and proposed actions for sub-Saharan Africa. Transactions of the Royal Society of Tropical Medicine and Hygiene. 103. 549-58. 10.1016/j.trstmh.2008.09.019.