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.
Citations
More filters
TL;DR: The pace of reform should be moderated to allow service providers to develop absorptive capacity, and independent, outcome-based monitoring and evaluation by a third-party are essential for mid-course correction of the plans and to make officials and providers accountable.
971 citations
TL;DR: In this paper, the current state of human resources for mental health, needs, and strategies for action are reviewed, and the authors also discuss scale-up costs, human resources management, and leadership for Mental Health, particularly within the context of low-income and middle-income countries.
621 citations
Journal Article•
TL;DR: In this article, the current state of human resources for mental health, needs, and strategies for action are reviewed, and the authors discuss scale-up costs, human resources management, and leadership of mental health in low-income and middle-income countries.
555 citations
TL;DR: Evidence concerning CHW program effectiveness can help policymakers identify a range of options to consider, however, this evidence needs to be contextualized and adapted in different contexts to inform policy and practice.
Abstract: To synthesize current understanding of how community-based health worker (CHW) programs can best be designed and operated in health systems. We searched 11 databases for review articles published between 1 January 2005 and 15 June 2017. Review articles on CHWs, defined as non-professional paid or volunteer health workers based in communities, with less than 2 years of training, were included. We assessed the methodological quality of the reviews according to AMSTAR criteria, and we report our findings based on PRISMA standards. We identified 122 reviews (75 systematic reviews, of which 34 are meta-analyses, and 47 non-systematic reviews). Eighty-three of the included reviews were from low- and middle-income countries, 29 were from high-income countries, and 10 were global. CHW programs included in these reviews are diverse in interventions provided, selection and training of CHWs, supervision, remuneration, and integration into the health system. Features that enable positive CHW program outcomes include community embeddedness (whereby community members have a sense of ownership of the program and positive relationships with the CHW), supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of CHW programs into health systems can bolster program sustainability and credibility, clarify CHW roles, and foster collaboration between CHWs and higher-level health system actors. We found gaps in the review evidence, including on the rights and needs of CHWs, on effective approaches to training and supervision, on CHWs as community change agents, and on the influence of health system decentralization, social accountability, and governance. Evidence concerning CHW program effectiveness can help policymakers identify a range of options to consider. However, this evidence needs to be contextualized and adapted in different contexts to inform policy and practice. Advancing the evidence base with context-specific elements will be vital to helping these programs achieve their full potential.
322 citations
Cites background from "Health workforce skill mix and task..."
...Supervision appears to be effective in combination with other supports • Supervision is critical to maintain quality and motivation [19, 23, 33, 35, 76, 132]....
[...]
TL;DR: These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations.
272 citations
References
More filters
TL;DR: A forecasting model uses a forecasting model to estimate the need for, supply of, and shortage of doctors, nurses, and midwives in thirty-nine African countries for 2015, the target date of the United Nations Millennium Development Goals.
Abstract: This paper uses a forecasting model to estimate the need for, supply of, and shortage of doctors, nurses, and midwives in thirty-nine African countries for 2015, the target date of the United Nations Millennium Development Goals. We forecast that thirty-one countries will experience needs-based shortages of doctors, nurses, and midwives, totaling approximately 800,000 health professionals. We estimate the additional annual wage bill required to eliminate the shortage at about $2.6 billion (2007 $US)—more than 2.5 times current wage-bill projections for 2015. We illustrate how changes in workforce mix can reduce this cost, and we discuss policy implications of our results.
105 citations
TL;DR: Among 1,134 complicated deliveries and 1,072 major obstetrical operations, there were no significant differences between assistant medical officers and medical officers in outcomes, risk indicators, or quality.
Abstract: Five countries in sub-Saharan Africa use nonphysicians to perform major emergency obstetrical surgery. In Tanzania, assistant medical officers provide most of this surgery outside of major cities. Questions about the quality of surgery by nonphysicians have kept most African countries from following this example. We reviewed the records of all patients admitted for complicated deliveries to fourteen district hospitals during four months. Among 1,134 complicated deliveries and 1,072 major obstetrical operations, there were no significant differences between assistant medical officers and medical officers in outcomes, risk indicators, or quality. There were significant differences between mission and government hospitals.
102 citations
01 Jan 2009
TL;DR: In this article, the authors pull together available evidence concerning strategies to improve health services delivery in low and middle-income countries (LMICs), using current methods to assemble a knowledge base and analyze the findings.
Abstract: Decision makers and the public are in need of information to guide their decisions about how to strengthen health services. This book pulls together available evidence concerning strategies to improve health services delivery in low- and middle-income countries (LMICs), using current methods to assemble a knowledge base and analyze the findings. It describes the results of reviews of such strategies, and how such strategies can produce gains for the poor. This type of information is intended to help decision makers in LMICs learn from others and from their own experiences, so that they may develop and implement strategies that will improve health services in their own setting. The book provides some suggestions for what works and how to improve implementation, as the evidence does not hold up for 'blueprint' planning. It finds that there are many ways that can succeed in improving health services. But not nearly enough attention has been paid to demonstrating how to improve services for the poor. Approaches that ask difficult questions, use information intelligently, and involve key stakeholders and institutions are critical to 'learning and doing' practices that underlie successful implementation of health services.
101 citations
TL;DR: IMCI training is associated with much the same quality of child care across different health worker categories, irrespective of the duration and level of preservice training.
96 citations
"Health workforce skill mix and task..." refers background in this paper
...Huicho and colleagues found that the number of years of pre-service training was generally not associated with the appropriate assessment, diagnosis, and treatment of young children in Bangladesh, Brazil, Tanzania, and Uganda [30]....
[...]
...Vasan A, Kenya-Mugisha N, Seung KJ, Achieng M, Banura P, Lule F, Beems M, Todd J, Madraa E: Agreement between physicians and nonphysician clinicians in starting antiretroviral therapy in rural Uganda....
[...]
...Babigumira JB, Castelnuovo B, Lamorde M, Kambugu A, Stergachis A, Easterbrook P, Garrison LP: Potential impact of task-shifting on costs of antiretroviral therapy and physician supply in Uganda....
[...]
...In Uganda, non-physician clinicians (NPC) and physicians had considerable strength of agreement for HIV/AIDS patient assessment, particularly with the final antiretroviral therapy (ART) recommendation, WHO clinical stage assignment, and tuberculosis status assessment [27]....
[...]
TL;DR: Questions are raised about the effectiveness of several interventions commonly used to improve the quality of care given by CHWs in Siaya district, Kenya, which showed CHWs commonly made errors in managing childhood illness.
Abstract: Evaluation of a community health worker (CHW) programme in Siaya district, Kenya, showed CHWs commonly made errors in managing childhood illness. We assessed the effect of multiple interventions on CHW healthcare practices. A sample of 192 ill-child consultations performed by 114 CHWs in a hospital outpatient department between February and March 2001 were analysed. The mean percentage of assessment, classification and treatment procedures performed correctly for each child was 79.8% (range 13.3-100%). Of the 187 children who required at least one treatment or referral to a health facility, only 38.8% were prescribed all treatments (including referral) recommended by the guidelines. Multivariate analyses found no evidence that the intervention-related factors studied (refresher training, supervision, involvement of community women in the CHW selection process, adequacy of medicine supplies, and use of a guideline flipchart during consultations) were significantly associated with overall or treatment-specific guideline adherence. A multivariate linear regression analysis revealed that several non-intervention-related factors, such as patient characteristics, were significantly associated with overall guideline adherence. Given that our study was cross-sectional and our measurement of exposure to several interventions was based on CHW recall, the estimated effects of the interventions should be interpreted with caution. Despite these limitations, however, our results raise questions about the effectiveness, in the setting of Siaya district, of several interventions commonly used to improve the quality of care given by CHWs.
88 citations