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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TL;DR: This pilot study suggests that task-shifting and mobile technologies can deliver safe and effective community-based care to PLWAs, expediting ART rollout and increasing access to treatment while expanding the capacity of health care institutions in resource-constrained environments.
Abstract: OBJECTIVES: To assess whether community-based care delivered by people living with HIV/AIDS (PLWAs) could replace clinic-based HIV care. DESIGN: Prospective cluster randomized controlled clinical trial. SETTING: Villages surrounding 1 rural clinic in western Kenya. SUBJECTS: HIV-infected adults clinically stable on antiretroviral therapy (ART). INTERVENTION: The intervention group received monthly Personal Digital Assistant supported home assessments by PLWAs with clinic appointments every 3 months. The control group received standard of care monthly clinic visits. MAIN OUTCOMES MEASURED: Viral load CD4 count Karnofsky score stability of ART regimen opportunistic infections pregnancies and number of clinic visits. RESULTS: After 1 year there were no significant intervention-control differences with regard to detectable viral load mean CD4 count decline in Karnofsky score change in ART regimen new opportunistic infection or pregnancy rate. Intervention patients made half as many clinic visits as did controls (P < 0.001). CONCLUSIONS: Community-based care by PLWAs resulted in similar clinical outcomes as usual care but with half the number of clinic visits. This pilot study suggests that task-shifting and mobile technologies can deliver safe and effective community-based care to PLWAs expediting ART rollout and increasing access to treatment while expanding the capacity of health care institutions in resource-constrained environments.
208 citations
"Health workforce skill mix and task..." refers background in this paper
...For example, in Kenya, community-based antiretroviral therapy care was augmented with pre-programmed personal digital assistants with decision support [26]....
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...In Kenya, no significant clinical differences were found between HIV/AIDS patients who received clinic-based antiretroviral therapy care versus primarily community-based care delivered by people living with HIV/AIDS who received pre-programmed personal digital assistants with decision support [26]....
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TL;DR: Psychiatrists' new roles should include designing and managing such programmes, building clinical capacity, supervision and quality assurance, providing referral pathways and research.
Abstract: The great shortage, and inequitable distribution, of psychiatrists in low- and middle-income countries is one of the key reasons for the large treatment gap for people with mental disorders. Psychiatrists need to play a public mental health leadership role in increasing the coverage of mental health care through task shifting of effective interventions to non-specialist health workers. Psychiatrists' new roles should include designing and managing such programmes, building clinical capacity, supervision and quality assurance, providing referral pathways and research.
208 citations
"Health workforce skill mix and task..." refers result in this paper
...Patel V: The future of psychiatry in low- and middle-income countries....
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...While outcomes were not compared to physician specialists and other psychosocial care providers, the study demonstrates the potential to train CHWs in mental health treatments (also see Patel [33])....
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TL;DR: The postoperative outcomes of their procedures are comparable to those of medical officers, which is a crucial component of the health care team in Malawi for saving maternal and neonatal lives given the scarcity of physicians.
Abstract: Clinical officers perform much of major emergency surgery in Malawi, in the absence of medical officers. The aim of this study was to validate the advantages and disadvantages of delegation of major obstetric surgery to non-doctors. During a three month period, data from 2131 consecutive obstetric surgeries in 38 district hospitals in Malawi were collected prospectively. The interventions included caesarean sections alone and those that were combined with other interventions such as subtotal and total hysterectomy repair of uterine rupture and tubal ligation. All these surgeries were conducted either by clinical officers or by medical officers. During the study period, clinical officers performed 90% of all straight caesarean sections, 70% of those combined with subtotal hysterectomy, 60% of those combined with total hysterectomy and 89% of those combined with repair of uterine rupture. A comparable profile of patients was operated on by clinical officers and medical officers, respectively. Postoperative outcomes were almost identical in the two groups in terms of maternal general condition – both immediately and 24 hours postoperatively – and regarding occurrence of pyrexia, wound infection, wound dehiscence, need for re-operation, neonatal outcome or maternal death. Clinical officers perform the bulk of emergency obstetric operations at district hospitals in Malawi. The postoperative outcomes of their procedures are comparable to those of medical officers. Clinical officers constitute a crucial component of the health care team in Malawi for saving maternal and neonatal lives given the scarcity of physicians.
193 citations
"Health workforce skill mix and task..." refers background in this paper
...Clinical officers and medical officers providing obstetric surgery in Malawi produced similar patient outcomes [29]....
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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: The potential offered by technological progress in the information and communication technologies (ICTs) industries for the health sector in developing countries is outlined, some examples of positive experiences in India are presented, and the difficulties in achieving this potential are considered.
Abstract: This paper outlines the potential offered by technological progress in the information and communication technologies (ICTs) industries for the health sector in developing countries, presents some examples of positive experiences in India, and considers the difficulties in achieving this potential. The development of ICTs can bring about improvements in health in developing countries in at least three ways: as an instrument for continuing education they enable health workers to be informed of and trained in advances in knowledge; they can improve the delivery of health and disaster management services to poor and remote locations; and they can increase the transparency and efficiency of governance, which should, in turn, improve the availability and delivery of publicly provided health services. These potential benefits of ICTs do not necessarily require all the final beneficiaries to be reached directly, thus the cost of a given quantum of effect is reduced. Some current experiments in India, such as the use of Personal Digital Assistants by rural health workers in Rajasthan, the disaster management project in Maharashtra and the computerized village offices in Andhra Pradesh and Pondicherry, suggest creative ways of using ICTs to improve the health conditions of local people. However, the basic difficulties encountered in using ICTs for such purposes are: an inadequate physical infrastructure; insufficient access by the majority of the population to the hardware; and a lack of the requisite skills for using them. We highlight the substantial cost involved in providing wider access, and the problem of resource allocation in poor countries where basic infrastructure for health and education is still lacking. Educating health professionals in the possible uses of ICTs, and providing them with access and "connectivity", would in turn spread the benefits to a much wider set of final beneficiaries and might help reduce the digital divide.
187 citations
TL;DR: An inventory of all government hospitals in Mozambique was made so as to document obstetric surgery performed by ‘técnicos de cirurgia’ (TCs) and to elucidate their retention at district level.
180 citations