Task Shifting:

Faced with a major global shortage of healthcare workers which may prevent the world from achieving several of the Millennium Development Goals and providing universal access to HIV/AIDS services, the World Health Organization (WHO) launched a major initiative called “Treat Train, Retain” (TTR) in August 2006. This initiative aims to address the human resource crisis by creating policies that call for treatment of health workers living with HIV, training of new and existing staff, and the creation of environments in which staff retention is improved.

As part of the TTR project, WHO wanted to understand how existing human resources could be used in a way that allows for a “rational redistribution of tasks among health workforce teams…a process whereby specific tasks are moved, where appropriate, to health workers with shorter training and fewer qualifications.” The model was called “task shifting.”

	A community health worker distributes medicine to an HIV patient in Haiti

Based on Partners In Health’s (PIH) experience in community-based delivery of HIV and TB care, we were invited to join a technical consulting team for the development of international guidelines entitled Task Shifting: Global Recommendations and Guidelines. The project is funded by UNAIDS, the Italian Ministry of Foreign Affairs, the Norwegian Agency for Development Cooperation and the US Office of the Global AIDS Coordinator.  Representatives from several other non-profit organizations, universities and WHO collaborated in the development of these guidelines. 

For our contribution to the task-shifting project, PIH conducted a bi-national study mapping the distribution of HIV-related clinical tasks among different cadres of healthcare workers in our programs and also participated in the development and writing of the guidelines. We found the study process itself to be quite informative, and we were pleased that we were able to play a significant role in the shaping of the guidelines on key points of interest to us, such as the role of trained and paid community health workers and the importance of comprehensive services.  Below are a few descriptions and direct quotes from the guidelines illustrating how key parts of PIH’s model have been integrated into them.

Fair Compensation

“Task shifting” is a process that naturally evolved at our sites through our local partners’ wisdom to utilize the talents and skills of local community members in caring for their neighbors and relatives.  As our medical work has expanded, it has become a cornerstone of our healthcare model.  Other healthcare staff and community health workers (CHWs) are routinely assigned tasks in HIV and TB care that traditionally were considered “doctor” tasks.  One issue that we and our partners have continuously is an “old school” perspective that local residents should be willing to volunteer their time for health and development projects that benefit the community at large.  However, PIH has consistently made it a priority to provide monetary compensation to all staff members, including community health workers, which is beneficial for the employees, communities, local economies and our projects’ acceptability. 

After working with the other stakeholders in this project, we now have the WHO, PEPFAR and UNAIDS agreeing on the following statement: 

“Countries should recognize that essential health services cannot be provided by people working on a voluntary basis if they are to be sustainable.  While volunteers can make a valuable contribution on a short-term or part-time basis, trained health workers who are providing essential health services, including community health workers, should receive adequate wages and/or other appropriate and commensurate incentives.”

Community health workers are integral parts of health care
and enhance the quality of care
At clinics, but most often in the community, CHWs are performing critical tasks to bring care to patients in their homes. Examples of services provided by CHWs in the community include:  HIV counseling and testing; HIV test interpretation; identifying and referring HIV and TB patients to clinics for care; following stable patients on first-line antiretroviral (ARV) therapy; and adherence support.  In addition, in the clinics many CHWs are recruited as X-ray technicians, laboratory and pharmacy assistants and data clerks.

Research performed by PIH in Haiti for the WHO study shows that patients in our HIV program are very satisfied with the healthcare they receive. At all PIH sites we strive for the highest quality of care and CHWs are a key part of that.  Task-shifting should never lead to a decline in quality, but instead should improve quality for all patients.

“…people living with HIV/AIDS reported a high level of satisfaction with the health care they were receiving from community health workers. In a survey of 200 people living with HIV/AIDS, the great majority were satisfied or extremely satisfied with their assigned community health worker.” 

The fundamental role of the CHW is highlighted:

“…delegation to cadres of health workers with no formal clinical training can increase access to health care and improve quality of care.”

Increasing the total number of health workers
PIH has advocated strongly that involving CHWs and other health workers in health systems is not a “cheap solution” to the healthcare worker crisis, and should not be viewed as such. Task shifting is not a substitute for training an increased number of highly trained health workers such as physicians and nurses and as mentioned above, CHWs must be paid for their work. This is emphasized by the WHO and highlighted throughout the guidelines.  Community health workers are essential members of our teams but are not expected to replace more highly-paid, highly trained members.  PIH was pleased to see this belief outlined in the WHO guidelines:

“Task shifting should not be viewed as a cost-cutting strategy. In fact, a successful task shifting programme which decentralizes and expands access to HIV services at the community level is likely to increase the total number of health-service users, including increasing the demand for other health services.”

Increasing access to comprehensive health care
The guideline authors propose that “successful task shifting should increase access to health services and increase utilization of the health system generally.” This has proven to be the case at every site PIH has helped open in every country that we are working in.  Increasing outreach to communities, in most cases with initial funding for HIV-specific services, brings crowds to clinics for all health problems.  Therefore, clinics and health systems should be strengthened and outfitted to provide comprehensive services.  

The Task Shifting Guidelines were launched at a conference in January 2008 which was attended by health ministers, other senior government officials, opinion leaders and representatives of several NGOs and UN agencies.  Many countries are now changing regulatory codes, instituting new training courses and shifting tasks from overburdened doctors and nurses to other cadres of health workers in order to remediate the crushing health care worker shortages. PIH looks forward to sharing our model with these countries and ensuring that paid community health workers become integral parts of many more projects around the world so that everyone has access to the highest standard of healthcare, even those in the poorest places on earth.

[published February 2008]