Task sharing and shifting: Can we move beyond effectiveness?

Task-sharing and shifting – The darling of global public health

Last three decades have seen a rise in research on and implementation of task sharing and shifting (TSS) initiatives in response to human resource and other health system constraints. From screening for diverse conditions, providing health education, managing mental health issues and illnesses, to assisting in operative/anesthesia procedures, TSS interventions span across a wide range of tasks and roles in service delivery, across different workforce cadres, and at all levels of healthcare, globally.

What counts as evidence?

The pre-dominant focus of research and policy discourse around TSS has been on the effectiveness and cost-effectiveness of TSS interventions. Topmost global health journals have published abundant observational studies, quasi-experimental field studies, randomized controlled trials, and systematic review and meta-analysis studies questioning whether TSS interventions work and whether it is economically beneficial for the governments to invest in taking up and up-scaling TSS interventions.

Notwithstanding intervention specifics, more or less, the evidence on effectiveness and cost-effectiveness of TSS has been positive across studies, settings, healthcare roles/functions, disease outcomes, and workforce cadres. And so, in the “evidence-based” global public health world, researchers, practitioners, policymakers, funders, etc. have advocated to push TSS further to include more tasks, cadres, conditions, levels of healthcare, etc. In short, global public health loves task shifting and sharing.

Problems with evidence

Dominant focus, especially in global public health research on effectiveness and cost-effectiveness of TSS has meant limited attention to other important questions. While there are several domains of inquiry that have remained unanswered due to disproportionate focus on TSS effectiveness, here, I will illustrate two major problems. Let us consider the following vignette to better exemplify how the problems manifest: Imagine a TSS intervention that shifts certain perioperative tasks from specialist surgeons to non-specialist/generalist physicians and nurses. Such TSS interventions are quite common in several low- and lower-middle income countries (LLMICs) and primarily began in response to lack of skilled surgical specialists in settings such as rural public hospitals.

Not considering health systems constraints

The first problem is that there is limited thinking on how broader health system constraints challenge TSS sustainability. Several studies compiled in systematic reviews, show that the surgical task-shifting in our example is effective and cost-effective across LLMICs. So, it is understandable that policymakers would like to implement and scale-up such an intervention. Scaling up such TSS would work well for settings that have shortages of surgical specialists and have adequate generalist physicians and nurses. However, that is an ideal scenario that researchers ‘force’ in the experimental trial. In the real world, hospitals, districts, states, etc. that have shortage of surgeons also face shortages of generalist physicians and nurses. Health workforce shortage is a downstream effect of poor policymaking, planning, and financing that constrains the overall health system.  For instance, in India, states with higher workloads for specialists (surgical or otherwise) are also the states with higher workloads for generalists and nurses. Even though it may be effective and cost-effective to shift certain tasks from specialists to generalists/nurses, TSS would not be sustainable in the medium-to-long run because it will overburden those to whom the tasks are shifted. In such a case, the quality of care might drop, worker satisfaction would reduce, and the generalists/nurses would be forced to ‘pick and choose’ the tasks they can or want to do. Hence, it is not the TSS intervention itself but the context of broader health system constraints that determines whether an intervention would work.

Not considering political economy

The second challenge is posed by limited focus on issues related to the political economy. In settings that do not have many surgeons or where surgical associations are not established, the proposed TSS intervention would be needed by the people (i.e., the patients) and it would also get support from the small number of surgeons. There are several examples in LICs in Africa and Southeast Asia where success of TSS interventions can be attributed to their need, small number of surgeons who were willing for such interventions, and relatively no real opposition from any corner of the society. However, in settings where there are more surgeons (though not enough to cure shortages) with well-established surgical associations and societies, the political economy context is much different. Specialist surgeons may use their individual and collective influence to prevent the scale-up of a TSS intervention in order to hold on to the power. The power dynamics between different groups of healthcare workers can overpower the evidence on effectiveness and cost-effectiveness. LMICs including India have observed several instances where effective TSS interventions remain under-used or unused because they are controversial among the involved interest-holders. Global public health researchers then proposing one TSS trial after another in such settings are producing evidence with no real policy value, due to their ignorance about local political economy issues.

Conclusion

Global public health owes this outlook of evidence generation and evidence-based policymaking centered around effectiveness and cost-effectiveness to individual-centric clinical medicine that originated in the “Western World” under the sociopolitical and ideological stronghold of capitalism. However, if TSS has to work systematically and sustainably in LLMICs, the evidence-building enterprise must make room for research appreciative of the reality of health systems and the larger sociopolitical contexts.