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: 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]....
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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
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01 Jan 2009
659 citations
TL;DR: Task shifting is an effective strategy for addressing shortages of HRH in HIV treatment and care and offers high-quality, cost-effective care to more patients than a physician-centered model.
Abstract: Background
Shortages of human resources for health (HRH) have severely hampered the rollout of antiretroviral therapy (ART) in sub-Saharan Africa. Current rollout models are hospital- and physician-intensive. Task shifting, or delegating tasks performed by physicians to staff with lower-level qualifications, is considered a means of expanding rollout in resource-poor or HRH-limited settings.
598 citations
"Health workforce skill mix and task..." refers result in this paper
...This finding is supported by other recent reviews of task shifting, including HIV/AIDS treatment and care provided by lay and community health workers in Africa, maternal and child health care as well as the management of infectious diseases by lay health workers, and doctor-nurse substitution in primary care in developed countries [22-24]....
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...Additional file 1: Studies analyzed [2,5,16,20-23,25-30,32,36-38,40-42,5666]....
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TL;DR: Serious concerns exist about the quality and productivity of the health workforce in low income countries and among available strategies to address the problems, expansion of the numbers of doctors and nurses through training is highly constrained.
431 citations
Additional excerpts
...Additional file 1: Studies analyzed [2,5,16,20-23,25-30,32,36-38,40-42,5666]....
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TL;DR: Generally patients consulting nurse practitioners were significantly more satisfied with their care, although for adults this difference was not observed in all practices, and the wider acceptance of the role of nurse practitioners in providing care to patients requesting same day consultations is supported.
Abstract: Objective: To ascertain any differences between care from nurse practitioners and that from general practitioners for patients seeking “same day” consultations in primary care.
Design: Randomised controlled trial with patients allocated by one of two randomisation schemes (by day or within day).
Setting: 10 general practices in south Wales and south west England.
Subjects: 1368 patients requesting same day consultations.
Main outcome measures: Patient satisfaction, resolution of symptoms and concerns, care provided (prescriptions, investigations, referrals, recall, and length of consultation), information provided to patients, and patients' intentions for seeking care in the future.
Results: Generally patients consulting nurse practitioners were significantly more satisfied with their care, although for adults this difference was not observed in all practices. For children, the mean difference between general and nurse practitioner in percentage satisfaction score was −4.8 (95% confidence interval −6.8 to −2.8), and for adults the differences ranged from −8.8 (−13.6 to −3.9) to 3.8 (−3.3 to 10.8) across the practices. Resolution of symptoms and concerns did not differ between the two groups (odds ratio 1.2 (95% confidence interval 0.8 to 1.8) for symptoms and 1.03 (0.8 to 1.4) for concerns). The number of prescriptions issued, investigations ordered, referrals to secondary care, and reattendances were similar between the two groups. However, patients managed by nurse practitioners reported receiving significantly more information about their illnesses and, in all but one practice, their consultations were significantly longer.
Conclusion: This study supports the wider acceptance of the role of nurse practitioners in providing care to patients requesting same day consultations.
422 citations
TL;DR: The World Health Report 2006 - Working together for health contains an expert assessment of the current crisis in the global health workforce and ambitious proposals to tackle it over the next ten years starting immediately as mentioned in this paper.
Abstract: The World Health Report 2006 - Working together for health contains an expert assessment of the current crisis in the global health workforce and ambitious proposals to tackle it over the next ten years starting immediately The report reveals an estimated shortage of almost 43 million doctors midwives nurses and support workers worldwide The shortage is most severe in the poorest countries especially in sub-Saharan Africa where health workers are most needed Focusing on all stages of the health workers career lifespan from entry to health training to job recruitment through to retirement the report lays out a ten-year action plan in which countries can build their health workforces with the support of global partners
403 citations