Cadres, roles and task shifting

BARBARA MCPAKE: Hello, there. I’m now going to talk about cadres, roles, and task shifting. The health workforce is made up of multiple different health professionals, such as midwives, dentists, radiographers, lab technicians, paramedics, and many others. These are known as cadres. The labels used for different cadres have much in common between countries. For example, I haven’t come across a country that doesn’t have professionals known as doctors or nurses. On the other hand, not all countries have a separate professional category of midwife.

In many countries, this is a specialism within nursing and other cadres, such as medical or clinical officers, medical assistants, nurse practitioners– have been devised in specific countries to respond to identified needs for different combinations of skills than the traditional cadres have. Even where a cadre label, like doctor, is in near universal use, the definition and the role played can vary quite a lot. What defines a doctor? In part, it could be argued that a doctor is defined by what she is trained to do. So an examination of the variation between curricula from one country to another can help to clarify the differences between cadres.

But what people are trained to do and what they actually do can also be very different. Since life as any kind of health professional is really a continuous learning process, which only starts with the formal pre-service training program, doctors may be further defined by the real nature of the work they undertake from day-to-day. And that means that even within a single country, there are many different definitions of doctor or any other health professional. Consider the difference between a Cuban general physician and an American one. The Cuban doctor’s training is focused on primary health care, preventative and promotive health interventions at community level, and the treatment of common conditions that can be managed with basic interventions.

An American general physician is far more likely to have focussed on hospital level care provision, to largely deliver treatment for existing health conditions, and to operate from a hospital outpatient clinic rather than a community setting. But within both countries, there are many exceptions and variations. Because of the importance of lifelong learning and sometimes processes of deskilling that arise from the lack of opportunities to regularly practise something once learned, a detailed understanding of the roles played by cadres, needs to be understood as one of continuing evolution, even where curricula change little to reflect that evolution. Environments evolve in many respects and the roles of different cadres of health worker evolve with them.

Consider a situation in which doctor-nurse ratios are rising because of greater investment in medical schools than nursing schools. Health care teams will evolve so that doctors’ roles become less specialist. They will start to take on roles that were formerly those of nurses. And nurses will become more specialist, focussing on things only they can do. The figure shows how widely nurse-doctor ratios vary, even within the OECD. In Finland, where there were 4.7 nurses for every doctor in 2013, you would expect the doctors would have very specialist roles, with nurses taking on those tasks that might be done by either.

In Greece, where there is only one nurse for about one and a half doctors, you expect doctors to take on those tasks. The idea of task shifting is a more deliberate attempt to manage the process by which roles change in response to shifting needs and staff availability. Traditional role designations seem to have assumed greater availability of each successive level of seniority in the health workforce than has been achieved in most countries. That has meant that it has frequently been judged appropriate to reallocate roles– as the figure shows– successively down the hierarchy and even onto patients themselves, sometimes using the label expert patient.

In lots of contexts, evaluations of task shifting suggest that it can be done safely and with improved population level outcomes. And it’s often the case that those cadres taking on new roles outperform their more senior colleagues in these roles. There are a number of reasons why that might be. We may be comparing people whose training in the task is more recent than those who used to perform the roles. They may be more highly motivated to demonstrate their competence. Or it may be that as tasks are shifted down the hierarchy, they are shifting from a more complex, overall task portfolio to a simpler one.

Whatever the explanation, there are few examples of evaluations that suggest that any specific competency cannot be shifted down the hierarchy safely, at least to some degree. Despite the strong evidence that task shifting is safe and effective for many roles in many settings, the importance of the centre of WHO’s figure can’t be overlooked. The evaluated experiences have required effective training and regulation. And as part of those functions, effective supervision and mentoring. The programs have been carefully designed. Logically, there is a limit to what can be passed down the hierarchy– how far and to what extent.

There are concerns about the capacities of those to whom tasks are shifted to take on more and more roles as each is judged suitable to be shifted. There might be an excess total burden or it might be that the diversity of tasks is itself a challenge to the cadre to whom tasks are shifted. In other words, while each individual task may be something the new cadre can do safely and effectively, that might not be the case after that same person is expected to take on multiple tasks.

There is some debate about whether it is better to have specialist, mid-level, and lower cadres for this reason or multivalent, mid-level, and lower cadres who can respond more flexibly to the needs in front of them. And as with any innovation, it cannot overcome problems of underfunding or lack of political commitment.