Sharing and Shifting Tasks to Maintain Essential Healthcare During COVID-19 in Low Resource, non-US settings
- Task shifting and task sharing reflect the same intention – to allow cadres who do not normally have competencies for specific tasks to deliver them and thereby increase levels of medical care access.
- Task shifting and task sharing approaches allow for more efficient use of available human resources working in overburdened health systems during the COVID-19 pandemic.
- Task shifting and task sharing can be used to expand and ensure access to essential health services by optimizing the use of the existing medical care workforce.
- Task shifting and task sharing approaches can be adapted to meet the needs of specific health care programs. Task shifting allows tasks to be shifted from highly qualified healthcare workers (HCWs) to HCWs with less training and less qualifications. Task sharing allow tasks to be shared between equally qualified HCWs. This allows for more efficient use of available human resources working in overburdened health systems during the COVID-19 pandemic.
- Before implementing a task shifting or task sharing approach, health facilities should determine whether task shifting or sharing is an appropriate intervention, create an enabling regulatory environment for implementation, create an implementation plan that ensures quality of care, and develop a monitoring and evaluation system.
Summary of Recent Changes
- Sources of information have been updated to the most recent
- Reference links are inserted within the guidance document
- Reference list has been updated
The coronavirus disease 2019 (COVID-19) pandemic has placed a substantial burden on many medical care systems worldwide as they struggle to treat both COVID-19 patients and maintain essential primary care services. The burden may be even greater in low-resource non-US settings, where healthcare systems are often already overtaxed and struggling to provide services to patients in need due to a shortage in the healthcare workforce. The World Health Organization (WHO) outlines two approaches to expand and ensure access to essential health services by optimizing the use of the existing healthcare workforce: task shifting1 and task sharing2
Task shifting and task sharing reflect the same intention – to allow staff who do not normally have competencies for specific tasks to deliver them and thereby increase levels of health care access. Both emphasize the need for training and continued educational support of all cadres of health workers in order for them to undertake the tasks they are to perform. Additionally, routine supportive supervision and a well-functioning referral system are essential preconditions for success.
Task shifting1 is the process of delegation whereby tasks are moved, where appropriate, to less specialized HCWs. This reorganization of the workforce, along with expanded training and retention programs, can allow a health system to more efficiently use the existing workforce3 easing bottlenecks in service delivery, while expanding workforce capacity4 (additional examples are provided below in the “Task Shifting and Sharing Examples by Medical Service” section).
Task sharing2 increases the categories of HCWs who can deliver certain health services. With task sharing, tasks are not taken away from one cadre or set of HCWs and given to another, but they are shared across groups. Task sharing enables low- and mid-level health professionals, such as CHWs, auxiliary nurses, midwives, and other frontline health workers, to perform tasks and procedures that would normally be restricted to higher level health professionals, thereby freeing up time for these higher-level providers within a health system to deliver more emergent needed services (additional examples are provided below in the “Task Shifting and Sharing Examples by Medical Service” section).
Task shifting and task sharing are part of a larger strategy to expand and strengthen health system capacity to increase access to COVID-19 care while maintaining essential health services. Additionally, these strategies can help protect and maintain the health and wellbeing of the healthcare workforce5 by reducing their workload and strategically using staff who are at higher risk of severe illness from COVID-19 in a way that decreases their risk of exposure to the virus that causes COVID-19.
Ultimately, the goal of task shifting and sharing in the era of the COVID-19 pandemic is to standardize, simplify, and decentralize systems to maximize the role of primary health care and community-based care as it relates to the provision of COVID-19 clinical care. Good management, supportive supervision, and political will are important for ensuring successful outcomes from task shifting and sharing.
The suggestions in this document are intended for countries where access to basic essential health services is constrained due to the COVID-19 pandemic, that have an underlying health workforce shortage, and that are considering implementation of a task shifting or sharing approach to strengthen and expand the health workforce for the delivery of COVID-19 care and other essential health services. Primarily this document is aimed at health care/medical care policy makers, program managers and staff in Ministries of Health who manage human resources for health along with local and international organizations providing essential health services that have been affected by the pandemic.
Given the urgent need to keep essential health services functional during the COVID-196 pandemic, the steps below take into consideration the following: the demand placed on health systems by COVID-19, the legal/ regulatory environment, characteristics of the health system involved, possible resource constraints in low income settings, and what to consider when developing an implementation plan. These steps and considerations have been generalized to be applicable to most situations.1,5 Given the uniqueness of each environment in which these steps could be implemented, additional considerations specific to that environment may need to be considered.
- Determine whether task shifting and/or sharing is an appropriate intervention
- Assess health system ability to provide COVID-19 and essential health services.
- Identify appropriate stakeholders to be involved and/or consulted from the beginning.
- Develop a nationally endorsed framework for implementation that can ensure harmonization and provide stability for essential primary health care services provided through public and private sectors during the pandemic.
- Conduct human resource inventory and assessment to determine demographics at risk of severe COVID-19 symptoms among HCWs working in public and private sectors.
- Assess gaps in essential primary health care services provision and the extent to which task shifting and/or sharing may already be taking place along with existing quality assurance mechanisms.
- Assess whether resources are available to support hiring of additional human resources.
- Create an enabling regulatory environment for implementation
- Assess existing regulatory approaches (laws, regulations, policies and guidelines) to determine appropriateness in implementation.
- Undertake revisions as necessary to enable extending scope of practice of different cadres of HCWs and to allow creation of new ones.
- Consider adoption of fast-track strategy to produce necessary revisions to regulatory approaches (such as countries that may have regulations in place that allow for the establishment of new cadres during periods of national emergency).
- Create an implementation plan that ensures quality of care
- Adapt existing human resource quality assurance mechanisms to support task shifting and/or sharing approaches.
- Define roles and competency levels needed for existing and newly added cadres.
- Use standards for recruitment, training, and evaluation.
- Develop a systematic accredited approach to standardized competency training based on needs.
- Ensure all staff are trained on infection prevention and controland appropriate use of personal protective equipment.
- Consider different types of task shifting and sharing practices and adopt/adapt practices based on local context.
- Determine which providers in outpatient and inpatient settings are underutilized due to cancellations of outpatient visits, non-COVID-19 hospitalizations, and elective procedures. These providers could be shifted to provide alternate services.
- Consider shifting tasks requiring direct patient care from HCWs with underlying medical conditions (high risk) to those with no underlying medical conditions (low risk).
- Establish efficient referral systems to support decentralization of service delivery.
- Ensure HCWs are trained on existing referral systems.
- Digital technologies may help deliver some health care components by offering training, providing digital tools for diagnosis, guiding treatment, facilitating supervision, and integrating services.
- Develop a monitoring and evaluation system
- Provide routine supportive supervision and clinical mentoring using health team model. Performance should be assessed against defined roles and competency levels.
- Develop and implement a standardized and structured evaluation to establish and recognize the ability of HCWs to perform compared to competency-based standards.
- Evaluation and outcomes research is important to establish whether tasks that have been shifted or shared result in positive outcomes (i.e. safety and quality of care).
The following section describes of tasks under specific health programs that may be shifted or shared. It is assumed that shifting and/or sharing of these tasks comes with adequate training, monitoring, and supervision as described in this document.
- Human immunodeficiency virus (HIV) prevention and treatment
With countries moving toward the WHO’s “Treat All”7 recommendation, there is a need to initiate more HIV-infected persons into antiretroviral therapy (ART). In resource-limited settings, task shifting is an approach that can address clinician shortages.
According to the WHO1, CHWs can: 1) distribute refills of ART to adults, adolescents, and children living with HIV through home visits, community pick-up points, community adherence groups, etc;1 2) implement community-based education, preventive interventions;1 3) provide combined HIV and tuberculosis observed treatment; and 4) offer psychosocial support to patient and family. Non-physician clinicians, midwives, and nurses can conduct the point-of-care viral load testing,8 initiate first-line ART or post-exposure prophylaxis,9 and maintain ART. CHWs and health facility staff can be mobilized, trained, and engaged in delivering the WHO endorsed, Interpersonal Psychotherapy (IPT-G) for Postpartum Adolescent (PPA) mothers living with HIV.10
- Tuberculosis(TB) prevention and treatment
CHWs can screen for TB by identifying people with symptoms (e.g. coughing for more than 2 weeks, coughing up blood, fever, night sweats, unintentional weight loss). Medical doctors, non-physician clinicians, or nurses1 may initiate TB treatment after the first episode of pulmonary or extra-pulmonary TB based on clinical symptoms, while awaiting, in lieu of, or in addition to sputum results. They can also monitor TB response to treatment and recognize medication side effects.
WHO issued evidence-based recommendations11 to facilitate universal access to key, effective maternal and newborn interventions through the optimization of health workers’ roles. One way of facilitating universal access is to mobilize available human resources and provide short periods of additional training for health workers to take on activities they have not undertaken before.
Maternal and Newborn
CHWs, auxiliary nurses, and midwives can promote appropriate health-related behaviors and conduct home visits to measure the blood pressure12 of pregnant women. CHWs can be trained to identify main danger signs13 of pregnancy complications and refer obstetric emergencies to a higher level of care. CHWs and auxiliary nurses may administer misoprostol to prevent or treat postpartum hemorrhage (PPH) before referral. Auxiliary nurses may administer intravenous fluids for resuscitation and administer oxytocin as part of PPH treatment. Auxiliary nurse midwives may deliver neonatal resuscitation.
The coverage of maternal and neonatal care interventions, including antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC) can be increased14 by strengthening CHWs.
CHWs can identify and treat children who have uncomplicated pneumonia, diarrhea or malaria, identify young infants with serious illness and improve early health facility care seeking.15
- Non-communicable diseases (NCDs) such as hypertension, diabetes, obesity, asthma, and kidney disease
Studies show that task shifting from physicians to other health care workers, including CHWs, nurses16 and nurse practitioners, is an effective strategy for improving access to health care17 for NCDs, especially when coupled with health system restructuring. They provide counseling for patients and family members on medication adherence, address any general concerns,18 and screen patients with confirmed COVID-19 for a history of preexisting hypertension, diabetes, obesity, asthma, and kidney disease. CHWs can deliver interventions to diagnose and treat,19 using blood pressure monitoring devices, glucometers, pulse oximeters, and nebulizers.
Integrating mental health services into primary care20 and shifting the provision21 of evidence-based psychosocial treatments to non-specialist health workers such as community health workers, lay persons, and other frontline health workers has emerged as a highly promising approach.
The “task sharing” in mental health can be achieved either by mobilizing the human resources currently available by expanding their current roles to include counselling (termed the “designated approach”) or by re-distributing funding to allow for the employment of additional counsellors (termed the “dedicated approach” by the WHO in 2007).22
According to WHO6 CHWs, nurses, psychosocial workers, or community social workers in humanitarian settings can raise awareness about use (MNS) care and refer people with MNS conditions to seek help at a clinic. CHWs, nurses, psychosocial workers or community social workers in humanitarian settings can also provide psychological first aid, brief psychological treatments, facilitate self-help groups, and teach stress management.
- Surgery and Anesthesia
Task sharing in surgery and anesthesia23 can enhance access to safe and cost-effective surgery. Task sharing is preferred24 to task shifting to maintain safety of surgical procedures in low-resource settings. Most task-sharing25 targets non-physician clinicians and non-specialist physicians. Approaches to task sharing may include: engaging nursing, physician, and other health provider groups in the planning and implementation of task sharing activities from the initial stages to delineate roles and ameliorate inefficiencies arising from role overlap among cadres; constructing a portfolio of priority procedures and develop a framework that stratifies them by complexity, learning curve, and risk to facilitate the identification of procedures that may be safely and effectively performed by non-specialists with appropriate training and mentorship; placing training centers and clinical residencies (or substantial phases of training) in areas where resources and limitations match those in the areas to which the workforce will be deployed to assure that training is attuned to the local needs and circumstances; and designing and implementing system for supervision and mentorship to both enhance patient safety and foster professional development and collaboration.
- World Health Organization, PEPFAR & UNAIDS. Task shifting : rational redistribution of tasks among health workforce teams : global recommendations and guidelines. World Health Organization . [Online] 2007. https://apps.who.int/iris/handle/10665/43821.
- World Health Organization. Summary Brief: Task Sharing to Improve Access to Family Planning/Contraception. [Online] 2017. Task sharing to improve access to Family Planning/Contraception (who.int)
- Foster and McIntyre. Economic evaluation of task-shifting approaches. Human Resources for Health 2012, 10:32 http://www.human-resources-health.com/content/10/1/32
- Seidman, Gabriel and Atun, Rifat. Does Task Shiftin Yield Cost Savings and Improve Efficiency for Health Systems? A Systemic Review of Evidence from Low-Income and Middle-Income Countries. 29, April 13, 2017, Human Resources for Health, Vol. 15.
- Ariadne Labs, “News: Tackling the Covid-19 Human Resource Emergencyexternal icon,” Ariadnes Labs, June 2020. [Online]. [Accessed June 2020].
- WHO and UNICEF, Community-based health care, including outreach campaigns, in the context of the COVID-19 pandemic: Interim guidance, May 2020, Geneva: World Health Organization and United Nations Children’s Fund, 2020. Community-based health care, including outreach and campaigns, in the context of the COVID-19 pandemic (who.int)
- Mitruka K, Bamrotiya M, Agarwal R, et al. Implementation of the Treat All Policy Among Persons with HIV Infection Enrolled in Care But Not on Antiretroviral Therapy — India, May 2017–June 2018. MMWR Morb Mortal Wkly Rep 2018;67:1305–1309. DOI: http://dx.doi.org/10.15585/mmwr.mm6747a2
- Jani IV, Meggi B, Loquiha O, Tobaiwa O, Mudenyanga C, Zitha A, Mutsaka D, Mabunda N, Vubil A, Bollinger T, Vojnov L, Peter TF. Effect of point-of-care early infant diagnosis on antiretroviral therapy initiation and retention of patients. AIDS. 2018 Jul 17;32(11):1453-1463. doi: 10.1097/QAD.0000000000001846. PMID: 29746301. https://pubmed.ncbi.nlm.nih.gov/29746301/
- Sekiziyivu BA, Bancroft E, Rodriguez EM, Sendagala S, Nasirumbi MP, Najjengo MS, Kiragga AN, Musaazi J, Musinguzi J, Sande E, Brad B, Dalal S, Byakika-Jayne T, Kambugu A. Task Shifting for Initiation and Monitoring of Antiretroviral Therapy for HIV-Infected Adults in Uganda: The SHARE Trial. J Acquir Immune Defic Syndr. 2021 Mar 1;86(3):e71-e79. doi: 10.1097/QAI.0000000000002567. PMID: 33230029; PMCID: PMC7879828. https://pubmed.ncbi.nlm.nih.gov/33230029/
- Yator O, Kagoya M, Khasakhala L, John-Stewart G, Kumar M. Task-sharing and piloting WHO group interpersonal psychotherapy (IPT-G) for adolescent mothers living with HIV in Nairobi primary health care centers: a process paper. AIDS Care. 2021 Jul;33(7):873-878. doi: 10.1080/09540121.2020.1801981. Epub 2020 Aug 11. PMID: 32781831. https://pubmed.ncbi.nlm.nih.gov/32781831/
- WHO recommendations Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting https://apps.who.int/iris/bitstream/handle/10665/77764/9789241504843_eng.pdf?sequence=1
- Charanthimath U, Vidler M, Katageri G, Ramadurg U, Karadiguddi C, Kavi A, Joshi A, Mungarwadi G, Bannale S, Rakaraddi S, Sawchuck D, Qureshi R, Sharma S, Payne BA, von Dadelszen P, Derman R, Magee LA, Goudar S, Mallapur A, Bellad M; and the Community Level Interventions for Pre-eclampsia (CLIP) India Feasibility Working Group, Bhutta Z, Naik S, Mulla A, Kamle N, Dhamanekar V, Drebit SK, Kariya C, Lee T, Li J, Lui M, Khowaja AR, Tu DK, Revankar A. The feasibility of task-sharing the identification, emergency treatment, and referral for women with pre-eclampsia by community health workers in India. Reprod Health. 2018 Jun 22;15(Suppl 1):101. doi: 10.1186/s12978-018-0532-5. PMID: 29945662; PMCID: PMC6019995. https://pubmed.ncbi.nlm.nih.gov/29945662/
- Sevene E, Boene H, Vidler M, Valá A, Macuacua S, Augusto O, Fernandes Q, Bique C, Macete E, Sidat M, von Dadelszen P, Munguambe K; CLIP Feasibility Working Group. Feasibility of task-sharing with community health workers for the identification, emergency management and referral of women with pre-eclampsia, in Mozambique. Reprod Health. 2021 Jul 6;18(1):145. doi: 10.1186/s12978-021-01192-x. PMID: 34229709; PMCID: PMC8259411. https://pubmed.ncbi.nlm.nih.gov/34229709/
- Jacobs C, Michelo C, Chola M, Oliphant N, Halwiindi H, Maswenyeho S, Baboo KS, Moshabela M. Evaluation of a community-based intervention to improve maternal and neonatal health service coverage in the most rural and remote districts of Zambia. PLoS One. 2018 Jan 16;13(1):e0190145. doi: 10.1371/journal.pone.0190145. Erratum in: PLoS One. 2018 Jul 2;13(7):e0200324. PMID: 29337995; PMCID: PMC5770027. https://pubmed.ncbi.nlm.nih.gov/29337995/
- Zhao Y, Hagel C, Tweheyo R, Sirili N, Gathara D, English M. Task-sharing to support paediatric and child health service delivery in low- and middle-income countries: current practice and a scoping review of emerging opportunities. Hum Resour Health. 2021 Aug 4;19(1):95. doi: 10.1186/s12960-021-00637-5. PMID: 34348709; PMCID: PMC8336272. https://pubmed.ncbi.nlm.nih.gov/34348709/
- Some D, Edwards JK, Reid T, et al. Task Shifting the Management of Non-Communicable Diseases to Nurses in Kibera, Kenya: Does It Work?. PLoS One. 2016;11(1):e0145634. Published 2016 Jan 26. doi:10.1371/journal.pone.0145634 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4727908/
- Joshi R, Alim M, Kengne AP, et al. Task shifting for non-communicable disease management in low and middle income countries–a systematic review. PLoS One. 2014;9(8):e103754. Published 2014 Aug 14. doi:10.1371/journal.pone.0103754 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4133198/
- World Health Organization. Maintaining essential health services: operational guidance for the COVID-19 context, interim guidance, 1 June 2020 https://www.who.int/publications/i/item/WHO-2019-nCoV-essential_health_services-2020.2
- World Health Organization. WHO Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Care, Brochure and Flyer. 7 September 2020. WHO package of essential noncommunicable (PEN) disease interventions for primary health care
- Hoeft TJ, Fortney JC, Patel V, Unützer J. Task-Sharing Approaches to Improve Mental Health Care in Rural and Other Low-Resource Settings: A Systematic Review. J Rural Health. 2018 Dec;34(1):48-62. doi: 10.1111/jrh.12229. Epub 2017 Jan 13. PMID: 28084667; PMCID: PMC5509535. https://pubmed.ncbi.nlm.nih.gov/28084667/
- Raviola G, Naslund JA, Smith SL, Patel V. Innovative Models in Mental Health Delivery Systems: Task Sharing Care with Non-specialist Providers to Close the Mental Health Treatment Gap. Curr Psychiatry Rep. 2019 Apr 30;21(6):44. doi: 10.1007/s11920-019-1028-x. PMID: 31041554. https://pubmed.ncbi.nlm.nih.gov/31041554/
- World Health Organization . Integrating mental health into primary care: a global perspective. Geneva: WHO; 2008 https://apps.who.int/iris/bitstream/handle/10665/43935/9789241563680_eng.pdf?sequence=1&isAllowed=y
- Ashengo T, Skeels A, Hurwitz EJH, Thuo E, Sanghvi H. Bridging the human resource gap in surgical and anesthesia care in low-resource countries: a review of the task sharing literature. Hum Resour Health. 2017;15(1):77. Published 2017 Nov 7. doi:10.1186/s12960-017-0248-6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5688799/
- 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 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7164328/
- Falk, R., Taylor, R., Kornelsen, J. et al. Surgical Task-Sharing to Non-specialist Physicians in Low-Resource Settings Globally: A Systematic Review of the Literature. World J Surg 44, 1368–1386 (2020). https://doi.org/10.1007/s00268-019-05363-7