Health workforce skill mix and task shifting in low income countries: a review of recent evidence
TL;DR: Task 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.
Abstract: Health 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. Studies 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. First, 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. Task 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.
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TL;DR: This commentary reflects on the added value of HPSR underpinning HRH and how it enables HRH to transform from being faceless numbers or units of health producers to the heart and soul of health systems and vital change agents in the authors' communities and societies.
Abstract: Health workers are central to people-centred health systems, resilient economies and sustainable development. Given the rising importance of the health workforce, changing human resource for health (HRH) policy and practice and recent health policy and systems research (HPSR) advances, it is critical to reassess and reinvigorate the science behind HRH as part of health systems strengthening and social development more broadly. Building on the recently published Health Policy and Systems Research Reader on Human Resources for Health (the Reader), this commentary reflects on the added value of HPSR underpinning HRH. HPSR does so by strengthening the multi-disciplinary base and rigour of HRH research by (1) valuing diverse research inferences and (2) deepening research enquiry and quality. It also anchors the relevance of HRH research for HRH policy and practice by (3) broadening conceptual boundaries and (4) strengthening policy engagement. Most importantly, HPSR enables us to transform HRH from being faceless numbers or units of health producers to the heart and soul of health systems and vital change agents in our communities and societies. Health workers' identities and motivation, daily routines and negotiations, and training and working environments are at the centre of successes and failures of health interventions, health system functioning and broader social development. Further, in an increasingly complex globalised economy, the expansion of the health sector as an arena for employment and the liberalisation of labour markets has contributed to the unprecedented movement of health workers, many or most of whom are women, not only between public and private health sectors, but also across borders. Yet, these political, human development and labour market realities are often set aside or elided altogether. Health workers' lives and livelihoods, their contributions and commitments, and their individual and collective agency are ignored. The science of HRH, offering new discoveries and deeper understanding of how universal health coverage and the Sustainable Development Goals are dependent on millions of health workers globally, has the potential to overcome this outdated and ineffective orthodoxy.
15 citations
TL;DR: The largest barrier perceived by healthcare providers in this study was noted to be family consent and administrative burden, which seemed to be affecting healthcare providers and mothers/families alike and improvements perhaps through a shared information system is needed.
Abstract: Objectives Our study investigates the barriers perceived by staff in the referral systems in maternal healthcare facilities across Aceh province in Indonesia. Design With a cross-sectional approach, two sets of surveys were administered during September to October 2016 in 32 sampling units of our study. We also collected referral data in the form of the frequency of ingoing and outgoing referral cases per facility. Setting In three districts, Aceh Besar, Banda Aceh and Bireuen, a total of 32 facilities including hospitals, community health centres, and private midwife clinics that met the criteria of providing at least basic emergency obstetric and neonatal care (BEonC) were covered. Participants Across the 32 healthcare centres, 149 members of staff (mainly midwives) agreed to participate in our surveys. Primary and secondary outcome measures The first survey consisted of 65 items focusing on organisational measures as well as case numbers for example, patient counts, mortality rate and complications. The second survey with 68 items asked healthcare providers about a range of factors including attitudes towards the referral process in their facility and potential barriers to a well-functioning system in their district. Results Overall, mothers’/families’ consent as well as the complex administration process were found to be the main barriers (36% and 12%, respectively). Healthcare providers noted that information about other facilities has the biggest room for improvement (37%) rather than transport, timely referral of mothers and babies, or the availability of referral facilities. Conclusions The largest barrier perceived by healthcare providers in our study was noted to be family consent and administrative burden. Moreover, lack of information about the referral system itself and other facilities seemed to be affecting healthcare providers and mothers/families alike and improvements perhaps through a shared information system is needed.
15 citations
TL;DR: Key main strategies in the model included curriculum reforms, regulation, transformative learning, provision of infrastructure and resources and capacity building, and can be used to prioritise nursing education intervention aimed at improving quality of nursing education in Malawi.
Abstract: Background: Despite a global consensus that nurses and midwives constitute the majority and are a backbone of any country’s health workforce system, productive capacity of training institutions remains low and still needs more guidance. This study aimed at developing a middle-range model to guide efforts in nursing education improvements. Objective: To explore challenges facing nursing education in Malawi and to describe efforts that are being put in place to improve nursing education and the process of development of a model to improve nursing education in Malawi. Method: The study used a qualitative descriptive design. A panel discussion with eight nursing education and practice experts was conducted guided by core concepts derived from an analysis of research report from a national nursing education conference. Two focus group discussions during two quarterly review meetings engaged nurse educators, practitioners and clinical preceptors to fill gaps from data obtained from a panel discussion. A qualitative abductive analysis approach was used for the development of the model. Results: Transforming and scaling up of nursing education emerged as the main concept of the model with nursing education context, academic practice partnership, regulation, competent graduate and nursing workforce as sub concepts. Key main strategies in the model included curriculum reforms, regulation, transformative learning, provision of infrastructure and resources and capacity building. Conclusion: The model can be used to prioritise nursing education intervention aimed at improving quality of nursing education in Malawi and other similar settings.
15 citations
Cites background from "Health workforce skill mix and task..."
...There should be sufficient number and mix of staff, which is fairly distributed (Fulton et al. 2011)....
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TL;DR: High levels of absenteeism attributed to clinicians and health service managers result in work overload and stress for frontline health workers, and unsupervised informal task shifting of clinical workload to nurses, who are the less clinically skilled.
Abstract: Background Achieving positive treatment outcomes and patient safety are critical goals of the healthcare system. However, this is greatly undermined by near universal health workforce absenteeism, especially in public health facilities of rural Uganda. We investigated the coping adaptations and related consequences of health workforce absenteeism in public and private not-for-profit (PNFP) health facilities of rural Uganda. Methods An empirical qualitative study involving case study methodology for sampling and principles of grounded theory for data collection and analysis. Focus groups and in-depth interviews were used to interview a total of 95 healthcare workers (11 supervisors and 84 frontline workers). The NVivo V.10 QSR software package was used for data management. Results There was tolerance of absenteeism in both the public and PNFP sectors, more so for clinicians and managers. Coping strategies varied according to the type of health facility. A majority of the PNFP participants reported emotion-focused reactions. These included unplanned work overload, stress, resulting anger directed towards coworkers and patients, shortening of consultation times and retaliatory absence. On the other hand, various cadres of public health facility participants reported ineffective problem-solving adaptations. These included altering weekly schedules, differing patient appointments, impeding absence monitoring registers, offering unnecessary patient referrals and rampant unsupervised informal task shifting from clinicians to nurses. Conclusion High levels of absenteeism attributed to clinicians and health service managers result in work overload and stress for frontline health workers, and unsupervised informal task shifting of clinical workload to nurses, who are the less clinically skilled. In resource-limited settings, the underlying causes of absenteeism and low staff morale require attention, because when left unattended, the coping responses to absenteeism can be seen to compromise the well-being of the workforce, the quality of healthcare and patients’ access to care.
15 citations
01 Jan 2019
TL;DR: Convergence between doctor's and patients' perceptions of their relationship may enhance trust more than conventional intervention and may ultimately contribute to better health outcomes.
Abstract: RATIONALE
Although they form a dyadic relationship, doctor's and patient's levels of trust in the other have usually been investigated separately. As members of dyadic relationships, they influence each other's behaviors and are interdependent because they share a past history and eventually a common future.
OBJECTIVES
The aim of this paper was to examine the composition of trust in doctor-patients relationship and estimate its association with quality of doctor's communication. One-With-Many analyses (OWM) were used to examine the composition of trust variance into "doctor and patient effects", "relationship effects", and "reciprocity effects," taking into account the interdependence of the data.
METHOD
Twelve General Practitioners (GPs; Mage = 54.16, SD = 12.28, 8 men) and 189 of their patients (Mage = 47.48, SD = 9.88, 62% women) took part in the study. GPs and their patients completed postconsultation questionnaires on trust and quality of communication.
RESULTS
The findings revealed that "doctor" and "patient" effects were significant. However, the most important part of the variance was attributable to the relationship and reciprocity effects, meaning that if a doctor reported high trust in a particular patient, then the patient reported a similarly high level of trust. Higher quality of communication was positively associated to those relationship effects of trust.
CONCLUSIONS
Our study stresses the importance to investigate trust in doctor-patients relationship as a dyadic and interdependent phenomenon applying appropriate methodological design and analysis. Convergence between doctor's and patients' perceptions of their relationship may enhance trust more than conventional intervention and may ultimately contribute to better health outcomes.
15 citations
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01 Oct 1984
TL;DR: In this article, buku ini mencakup lebih dari 50 studi kasus, memberikan perhatian untuk analisis kuantitatif, membahas lebah lengkap penggunaan desain metode campuran penelitian, and termasuk wawasan metodologi baru.
Abstract: Buku ini menyediakan sebuah portal lengkap untuk dunia penelitian studi kasus, buku ini menawarkan cakupan yang luas dari desain dan penggunaan metode studi kasus sebagai alat penelitian yang valid. Dalam buku ini mencakup lebih dari 50 studi kasus, memberikan perhatian untuk analisis kuantitatif, membahas lebih lengkap penggunaan desain metode campuran penelitian, dan termasuk wawasan metodologi baru.
78,012 citations
TL;DR: A systematic review and meta-analysis of placebo-controlled studies examined the efficacy and tolerability of different types of antidepressants, the combination of an antidepressant and an antipsychotic, antipsychotics alone, or natural products in adults with somatoform disorders in adults to improve optimal treatment decisions.
Abstract: BACKGROUND: Somatoform disorders are characterised by chronic, medically unexplained physical symptoms (MUPS). Although different medications are part of treatment routines for people with somatoform disorders in clinics and private practices, there exists no systematic review or meta-analysis on the efficacy and tolerability of these medications. We aimed to synthesise to improve optimal treatment decisions.OBJECTIVES: To assess the effects of pharmacological interventions for somatoform disorders (specifically somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, and pain disorder) in adults.SEARCH METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (to 17 January 2014). This register includes relevant randomised controlled trials (RCTs) from The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). To identify ongoing trials, we searched ClinicalTrials.gov, Current Controlled Trials metaRegister, the World Health Organization International Clinical Trials Registry Platform, and the Chinese Clinical Trials Registry. For grey literature, we searched ProQuest Dissertation {\&} Theses Database, OpenGrey, and BIOSIS Previews. We handsearched conference proceedings and reference lists of potentially relevant papers and systematic reviews and contacted experts in the field.SELECTION CRITERIA: We selected RCTs or cluster RCTs of pharmacological interventions versus placebo, treatment as usual, another medication, or a combination of different medications for somatoform disorders in adults. We included people fulfilling standardised diagnostic criteria for somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, or somatoform pain disorder.DATA COLLECTION AND ANALYSIS: One review author and one research assistant independently extracted data and assessed risk of bias. Primary outcomes included the severity of MUPS on a continuous measure, and acceptability of treatment.MAIN RESULTS: We included 26 RCTs (33 reports), with 2159 participants, in the review. They examined the efficacy of different types of antidepressants, the combination of an antidepressant and an antipsychotic, antipsychotics alone, or natural products (NPs). The duration of the studies ranged between two and 12 weeks.One meta-analysis of placebo-controlled studies showed no clear evidence of a significant difference between tricyclic antidepressants (TCAs) and placebo for the outcome severity of MUPS (SMD -0.13; 95{\%} CI -0.39 to 0.13; 2 studies, 239 participants; I(2) = 2{\%}; low-quality evidence). For new-generation antidepressants (NGAs), there was very low-quality evidence showing they were effective in reducing the severity of MUPS (SMD -0.91; 95{\%} CI -1.36 to -0.46; 3 studies, 243 participants; I(2) = 63{\%}). For NPs there was low-quality evidence that they were effective in reducing the severity of MUPS (SMD -0.74; 95{\%} CI -0.97 to -0.51; 2 studies, 322 participants; I(2) = 0{\%}).One meta-analysis showed no clear evidence of a difference between TCAs and NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.55 to 0.23; 3 studies, 177 participants; I(2) = 42{\%}; low-quality evidence). There was also no difference between NGAs and other NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.45 to 0.14; 4 studies, 182 participants; I(2) = 0{\%}).Finally, one meta-analysis comparing selective serotonin reuptake inhibitors (SSRIs) with a combination of SSRIs and antipsychotics showed low-quality evidence in favour of combined treatment for severity of MUPS (SMD 0.77; 95{\%} CI 0.32 to 1.22; 2 studies, 107 participants; I(2) = 23{\%}).Differences regarding the acceptability of the treatment (rate of all-cause drop-outs) were neither found between NGAs and placebo (RR 1.01, 95{\%} CI 0.64 to 1.61; 2 studies, 163 participants; I(2) = 0{\%}; low-quality evidence) or NPs and placebo (RR 0.85, 95{\%} CI 0.40 to 1.78; 3 studies, 506 participants; I(2) = 0{\%}; low-quality evidence); nor between TCAs and other medication (RR 1.48, 95{\%} CI 0.59 to 3.72; 8 studies, 556 participants; I(2) =14{\%}; low-quality evidence); nor between antidepressants and the combination of an antidepressant and an antipsychotic (RR 0.80, 95{\%} CI 0.25 to 2.52; 2 studies, 118 participants; I(2) = 0{\%}; low-quality evidence). Percental attrition rates due to adverse effects were high in all antidepressant treatments (0{\%} to 32{\%}), but low for NPs (0{\%} to 1.7{\%}).The risk of bias was high in many domains across studies. Seventeen trials (65.4{\%}) gave no information about random sequence generation and only two (7.7{\%}) provided information about allocation concealment. Eighteen studies (69.2{\%}) revealed a high or unclear risk in blinding participants and study personnel; 23 studies had high risk of bias relating to blinding assessors. For the comparison NGA versus placebo, there was relatively high imprecision and heterogeneity due to one outlier study. Although we identified 26 studies, each comparison only contained a few studies and small numbers of participants so the results were imprecise.AUTHORS' CONCLUSIONS: The current review found very low-quality evidence for NGAs and low-quality evidence for NPs being effective in treating somatoform symptoms in adults when compared with placebo. There was some evidence that different classes of antidepressants did not differ in efficacy; however, this was limited and of low to very low quality. These results had serious shortcomings such as the high risk of bias, strong heterogeneity in the data, and small sample sizes. Furthermore, the significant effects of antidepressant treatment have to be balanced against the relatively high rates of adverse effects. Adverse effects produced by medication can have amplifying effects on symptom perceptions, particularly in people focusing on somatic symptoms without medical causes. We can only draw conclusions about short-term efficacy of the pharmacological interventions because no trial included follow-up assessments. For each of the comparisons where there were available data on acceptability rates (NGAs versus placebo, NPs versus placebo, TCAs versus other medication, and antidepressants versus a combination of an antidepressant and an antipsychotic), no clear differences between the intervention and comparator were found.Future high-quality research should be carried out to determine the effectiveness of medications other than antidepressants, to compare antidepressants more thoroughly, and to follow-up participants over longer periods (the longest follow up was just 12 weeks). Another idea for future research would be to include other outcomes such as functional impairment or dysfunctional behaviours and cognitions as well as the classical outcomes such as symptom severity, depression, or anxiety.
11,458 citations
TL;DR: Two studies show SU leading to earlier insulin dependence and a meta-analysis of four studies with considerable heterogeneity showed poorer metabolic control if SU is prescribed for patients with LADA compared to insulin.
Abstract: Background
Latent autoimmune diabetes in adults (LADA) is a slowly developing type 1 diabetes.
Objectives
To compare interventions used for LADA.
Search methods
Studies were obtained from searches of electronic databases, supplemented by handsearches, conference proceedings and consultation with experts. Date of last search was December 2010.
Selection criteria
Randomised controlled trials (RCT) and controlled clinical trials (CCT) evaluating interventions for LADA or type 2 diabetes with antibodies were included.
Data collection and analysis
Two authors independently extracted data and assessed risk of bias. Studies were summarised using meta-analysis or descriptive methods.
Main results
Searches identified 13,306 citations. Fifteen publications (ten studies) were included, involving 1019 participants who were followed between three months to 10 years (1060 randomised). All studies had a high risk of bias. Sulphonylurea (SU) with insulin did not improve metabolic control significantly more than insulin alone at three months (one study, n = 15) and at 12 months (one study, n = 14) of treatment and follow-up. SU (with or without metformin) gave poorer metabolic control compared to insulin alone (mean difference in glycosylated haemoglobin A1c (HbA1c) from baseline to end of study, for insulin compared to oral therapy: -1.3% (95% confidence interval (CI) -2.4 to -0.1; P = 0.03, 160 participants, four studies, follow-up/duration of therapy: 12, 30, 36 and 60 months; however, heterogeneity was considerable). In addition, there was evidence that SU caused earlier insulin dependence (proportion requiring insulin at two years was 30% in the SU group compared to 5% in conventional care group (P < 0.001); patients classified as insulin dependent was 64% (SU group) and 12.5% (insulin group, P = 0.007). No intervention influenced fasting C-peptide, but insulin maintained stimulated C-peptide better than SU (one study, mean difference 7.7 ng/ml (95% CI 2.9 to 12.5)). In a five year follow-up of GAD65 (glutamic acid decarboxylase formulated with aluminium hydroxide), improvements in fasting and stimulated C-peptide levels (20 μg group) were maintained after five years. Short term (three months) follow-up in one study (n = 74) using Chinese remedies did not demonstrate a significant difference in improving fasting C-peptide levels compared to insulin alone (0.07 µg/L (95% CI -0.05 to 0.19). One study using vitamin D with insulin showed steady fasting C-peptide levels in the vitamin D group but declining fasting C-peptide levels (368 to 179 pmol/L, P = 0.006) in the insulin alone group at 12 months follow-up. Comparing studies was difficult as there was a great deal of heterogeneity in the studies and in their selection criteria. There was no information regarding health-related quality of life, complications of diabetes, cost or health service utilisation, mortality and limited evidence on adverse events (studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic episodes).
Authors' conclusions
Two studies show SU leading to earlier insulin dependence and a meta-analysis of four studies with considerable heterogeneity showed poorer metabolic control if SU is prescribed for patients with LADA compared to insulin. One study showed that vitamin D with insulin may protect pancreatic beta cells in LADA. Novel treatments such as GAD65 in certain doses (20 μg) have been suggested to maintain fasting and stimulated C-peptide levels. However, there is no significant evidence for or against other lines of treatment of LADA.
6,882 citations
TL;DR: Despite uncertainties about mortality and burden of disease estimates, the findings suggest that substantial gains in health have been achieved in most populations, countered by the HIV/AIDS epidemic in Sub-Saharan Africa and setbacks in adult mortality in countries of the former Soviet Union.
5,168 citations
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