An introduction to task shifting

In this article, Professor Hannah Kuper introduces task shifting as a solution to human resource limitations, and Dr Julian Eaton (LSHTM and CBM) and Tracey Smythe (LSHTM) provide two case studies of task shifting (or sharing) in mental health care and clubfoot care.

Introduction to task shifting

Many people with disabilities can benefit from specialist services or rehabilitation to treat their impairment. For instance, a person with glaucoma could be treated by an ophthalmologist to stop the condition from progressing further, and vision from deteriorating more. Or a woman with a hearing impairment could be fitted with a hearing aid to allow her to communicate more effectively.

Shortage of human resources

Shortage of human resources is a well-recognised barrier to scaling up access to these specialist services. For example in many sub-Saharan countries, there is only 1 ophthalmologist per million people.

To make things worse, the great majority of specialists, such as mental health care professionals or rehabilitation experts, tend to work in large cities, and rural areas are particularly poorly served.

Training more specialists is not a short-term solution

Training more specialists is a good ambition, but this takes time and resources and is not a realistic short-term solution. Instead, more radical reform of specialist services is needed, particularly where decentralisation or integration of services into all primary care is necessary to improve access to care.

Task shifting (or task sharing) is a practical approach to addressing such gaps in human resources,¹ where competencies previously held by specialists are taught to other personnel. In this way, essential tasks can be provided by non-specialists, for example, community health workers or general nurses.

We can give two examples of how task-shifting is used in low and middle-income settings: For scaling up mental health services, and for provision of club foot treatment.

Case Study: mental health care

14% of the global burden of disease is attributable to mental health conditions, neurological diseases and substance abuse disorders. The WHO estimates that most of the people affected do not have access to the services that they need. This problem occurs because in many countries in the world there is a massive lack of mental health professionals, and only one psychiatrist is available to provide services per one million people.

There is good evidence that the task-shifting approach can be feasible and result in effective and quality mental health care.^2,3 However, it is important to ensure that there is sufficient ongoing support and supervision provided to maintain motivation and quality.

An example of this is the WHO mental health Gap Action Programme (mhGAP) which provides skills for general nurses or doctors to provide basic first-line mental health care.⁴ This programme focuses on the following conditions: depression, psychoses, epilepsy, child and adolescent mental and behavioural disorders, dementia, disorders due to substance use and self-harm and suicide.

The programme outlines strategies for how these conditions can be identified and managed by non-specialists.

mhGAP

mhGAP describes the main presentation of these different conditions and helps the non-specialist (e.g. general physician, nurse) in their diagnosis and recommends a treatment strategy.

For instance, a manic episode in bipolar disorder may be indicated by a “Loss of normal social inhibitions such as sexual indiscretion” or “Impulsive or reckless behaviours such as excessive spending, making important decisions without planning” lasting at least a week and being severe enough to interfere with everyday life.

A recommended treatment strategy is through the prescription of lithium or antipsychotics. Guidelines are given as to when to refer the person to a specialist, as well as recommendations to provide more holistic rehabilitation and support.

Case study: clubfoot care

A different type of challenge is given by clubfoot, or congenital talipes equinovarus (CTEV), a condition in which the structure and position of the foot are affected. Clubfoot is relatively common and affects 0.5-2/1,000 live births in LMICs.^5,6 Untreated clubfoot results in pain and reduced mobility.

There has been a global paradigm shift in the management of clubfoot from extensive surgical correction to minimally invasive conservative correction, most commonly delivered through the Ponseti method.⁷ This method involves sequential manipulation of the foot and serial casting with plaster of Paris, with or without a complete cut through the Achilles tendon (tenotomy).

This corrective phase is followed by a maintenance phase, in which a foot abduction brace is worn at night until the age of 4-5 years.⁸ Given the lack of specialists in low resource settings, the Ponseti method is often delivered by trained non-physician clinicians, such as physiotherapists, and this has been shown to be highly effective.^9,10,11,12

The challenges of task shifting and sharing

Adequate support and training are needed in task-shifting to make sure that the quality of care is not reduced and that the task-shifting initiative can be scaled up adequately. Training should focus on how to identify and treat the conditions of interest.

However, training alone is not enough, and continued supervision is also needed to make sure that the non-specialist staff are confident in their tasks, carrying them out to a high-quality level, and are able to ask questions as they come up. It is also important to adequately recognise and remunerate the non-specialist staff, to keep them motivated in carrying out their new tasks.

Ultimately, task sharing requires clear communication and mechanisms to support monitoring, supervision and evaluation.