Task shifting: when non-doctors assess

A 52-year-old man arrives at a rural health center for his routine hypertension visit. The person who measures his blood pressure, reviews his medications, asks about new symptoms and decides whether he needs to see a doctor is a nurse, following a protocol printed on the wall. The nearest doctor works in another town, twice a month. The same morning, a health surveillance assistant brings a list of patients who missed their follow-up. The scene is fictional and was written for teaching.

This text is about task shifting, the redistribution of health tasks among teams and communities. The idea is to show what the evidence says, where the strategy works, where it fails and what this changes in the clinical reasoning of whoever is assessing. If you play the case of the day on NEXO, you will recognize the challenge: deciding with the clues in front of you, whatever your badge.

Key points

• Task shifting and task sharing are a way to address the shortage of health professionals worldwide.
• In HIV, non-physician professionals with training and supervision achieved results equal to and sometimes better than those of doctors.
• In hypertension, task sharing reduced systolic blood pressure with nurses, pharmacists, nutritionists and community health workers.
• Training, algorithms and access to medicines help; restrictions on prescribing get in the way.
• In Malawi, health surveillance assistants took on tasks beyond those planned and became overloaded.
• Those who need constant supervision either refer too few or too many patients, and that saves neither time nor money.

What task shifting is

Task shifting and task sharing involve the redistribution of health tasks among teams and communities (Orkin et al., 2021). The authors describe the strategy as a promising way to address the shortage of health professionals worldwide and the insufficient access to care for serious problems, already used effectively in several contexts and conditions.

According to the World Health Organization, cited in a review on the topic, task shifting is a viable solution to expand coverage, making better use of the professionals who already exist and increasing capacity quickly while training and retention programs grow (Seidman and Atun, 2017).

The COATS framework

An international Delphi study, conducted online with experts in knowledge synthesis on the topic, proposed the COATS framework, an acronym for concepts and opportunities to advance task shifting and task sharing (Orkin et al., 2021). Fifty-five potential participants were invited to a series of questionnaires about the purpose of the strategy and the characteristics of the contexts in which it can work.

The framework offers a revised definition and a statement of purpose to guide programs. It describes that opportunities for improvement depend on the implementation context and lists eight conditions, four necessary and four considered important (Orkin et al., 2021). The result is a checklist for planning programs, not a ready-made recipe.

Who receives the tasks

The professionals who take on tasks vary by country and study. In South Africa, primary care nurses began starting and renewing antiretroviral prescriptions (Fairall et al., 2012). In hypertension care, nurses, pharmacists, nutritionists and community health workers appear (Anand et al., 2019), and in Cameroon non-physician clinicians treat hypertension and diabetes (Labhardt et al., 2010). In Sierra Leone, associate clinicians and young doctors entered surgical training (Bolkan et al., 2017). In Malawi, the task fell to health surveillance assistants (Smith et al., 2014), and midwives, nurses, technicians and community health workers already perform point-of-care ultrasound (Abrokwa et al., 2022).

The HIV example

A systematic review on task shifting in HIV treatment in Africa found 2960 articles and included 84 in the main analysis (Callaghan et al., 2010). Five studies showed more access to antiretroviral treatment thanks to greater clinical capacity, two concluded that task shifting had a good cost-effectiveness ratio and nine showed equal or better quality of care. Studies on agreement between decisions by non-physician clinicians and physicians were mixed, with most showing good agreement.

The authors conclude that non-physician professionals, with careful training and supervision, achieve results equal to and sometimes better than those of physicians (Callaghan et al., 2010). They also point out that there is considerable evidence on the possibility of shifting tasks to lay workers or community health workers.

The STRETCH trial

The STRETCH program in South Africa trained nurses to start and renew antiretroviral prescriptions and decentralized care (Fairall et al., 2012). Nurses already handle most primary care in the country. In one of the study groups, viral suppression 12 months after enrollment was equivalent between the intervention group and the control group.

The authors conclude that expanding the role of primary care nurses to start and renew antiretroviral treatment can be done safely and improve outcomes and quality of care, but may not reduce time to treatment initiation or mortality (Fairall et al., 2012).

Quality of those who take on the task

The HIV review issues a warning that applies to any program: the performance of those who take on the task is a central indicator, because professionals who need constant supervision, or who refer too few or too many patients, save neither time nor money and do not improve patients' health (Callaghan et al., 2010). Community health workers in South Africa reported a desire for more training and supervision to cope with the combination of HIV, tuberculosis and poverty.

Hypertension and chronic diseases

A review on task shifting in noncommunicable chronic diseases in low- and middle-income countries found 7176 articles and included 22 (Joshi et al., 2014). Training of non-physician professionals and the provision of algorithms and protocols for screening, treatment and dose adjustment were the main enablers. The availability of medicines also helped. The barriers were restrictions on prescribing and a lack of medicines.

A meta-analysis on hypertension showed that task sharing reduced systolic pressure with different professionals (Anand et al., 2019). The mean difference was 5.34 mmHg lower with nurses, 8.12 mmHg with pharmacists, 4.67 mmHg with nutritionists and 3.67 mmHg with community health workers (Anand et al., 2019). The authors conclude that task sharing is effective for reducing blood pressure.

What the Cameroon program taught

In Cameroon, non-physician clinicians were trained to treat hypertension and diabetes in an integrated way in rural areas (Labhardt et al., 2010). Initial training lasted three days, with one-day refresher courses twice a year, in which the professionals presented the records of new patients. All medicines used were part of the national list of essential medicines and were sold to patients at a relatively low price.

The evaluation, carried out after two years, looked at equipment, professionals' knowledge, number of new patients, retention, patient spending and changes in blood pressure and fasting glucose (Labhardt et al., 2010). Retention of patients treated within one year was 18.1 per 100 (Labhardt et al., 2010).

Where the evidence is still weak

A review of randomized trials on cardiovascular risk reduction in low- and middle-income countries found 2771 articles, and only three met the criteria (Ogedegbe et al., 2014). The three were carried out in health services, two with patients with hypertension and one with diabetes. The authors point to the scarcity of evidence for cardiovascular disease, but consider task shifting feasible.

Primary care in high-income countries

A review of 12 randomized trials, with 22,617 patients and carried out mostly in Europe, compared nurse-led care with physician-led care in primary care (Martínez-González and colleagues, 2015). Nurse-led care was delivered, for the most part, by advanced practice nurses following structured protocols. Most estimates showed no difference compared with physician care, and nurses did better in secondary prevention of heart disease, in dyspepsia and in cardiovascular risk in people with diabetes.

An umbrella review on task shifting in primary care concluded that pharmacists and nurses can take on much broader roles to support physicians, given the change in demand for services (Leong and colleagues, 2021). The review examined five professional groups: nurses, pharmacists, nutritionists, physiotherapists and paramedics.

What the evidence shows taken together

Area	Type of study	What was found	Source
HIV in Africa	Systematic review	Equal and sometimes better results with training and supervision	Callaghan 2010
Antiretroviral	Pragmatic trial	Equivalent viral suppression between groups	Fairall 2012
Hypertension	Meta-analysis	Drop in systolic pressure with several professionals	Anand 2019
Chronic diseases	Systematic review	Training and algorithms help; prescribing restrictions get in the way	Joshi 2014
Primary care	Review of trials	Most estimates with no difference between nurses and physicians	Martínez-González 2015
Primary care	Umbrella review	Much broader roles for pharmacists and nurses	Leong 2021
Economy	Systematic review	A viable option to reduce spending	Seidman 2017

And the money. A review identified 34 studies that analyzed the financial implications of task shifting in low- and middle-income countries, 22 in Sub-Saharan Africa, eight in Asia and four in Central or South America (Seidman and Atun, 2017). The authors conclude that task shifting is a viable option to reduce spending.

Conditions for it to work

The studies repeat a few conditions, under different names. The commentary by Lehmann and colleagues, published during the expansion of HIV treatment, argues that task shifting requires a broad and integrated reconfiguration of teams, changes in scope of practice and in the rules, more training structure and reliable funding, with timelines of 20 to 30 years instead of three to five (Lehmann and colleagues, 2009).

What recurs across the studies

• Training of non-physician professionals (Joshi and colleagues, 2014).
• Algorithms and protocols for screening, treatment and dose adjustment (Joshi and colleagues, 2014).
• Availability of medicines (Joshi and colleagues, 2014).
• Careful supervision (Callaghan and colleagues, 2010).
• Rules that allow the new role (Lehmann and colleagues, 2009).
• Funding for salary, training, supervision and infrastructure (Lehmann and colleagues, 2009).
• Leadership from national governments (Lehmann and colleagues, 2009).

The role of governments

According to the same commentary, task shifting strategies need, above all, leadership from national governments to guarantee favorable rules, lead policies, guide and support training institutions, secure resources and gather the support of the various actors involved (Lehmann and colleagues, 2009). The authors warn that, without this, task shifting risks being one more unsuccessful health sector reform.

Training in surgery

In Sierra Leone, task sharing reached surgery. A prospective observational study, carried out in a consortium of 16 hospitals, followed in-hospital mortality and the productivity of operations performed during and after a three-year surgical training program for five years (Bolkan and colleagues, 2017). The students' progress is tracked through informal mentoring, written assessments, a six-monthly review of surgery records and written and oral exams.

Local surgeons and obstetricians, professors at the country's medical school, assess the final exams, written and oral, after two years. Those who pass receive a diploma in emergency surgery, obstetrics and gynecology (Bolkan et al., 2017). After adjusting for sex, procedure, urgency and hospital, mortality was lower in operations performed by the trainees, with an odds ratio of 0.47 (Bolkan et al., 2017).

Overload and burnout

In Zomba district, Malawi, researchers held focus groups and interviews with 70 health surveillance assistants (Smith et al., 2014). They performed several tasks beyond those in the job description, which created overload, specialization and competing demands. Among the tasks outside the description were nutritional supplementation programs for malnourished children, testing, medicine delivery and review of tuberculosis patients and administration of injectable contraceptives.

Confusion about the role also appeared: 30 of the 70 assistants did not have a copy of the current job description (Smith et al., 2014). The Ministry of Health defines three main roles for the position: promotion, prevention and curative care, community participation and disease surveillance. The authors suggest that managers think about the split between prevention and curative care, between activities in the community and at the health center, and the possible specialization of these professionals.

The clinical reasoning of the person assessing

When a non-physician assesses a patient, clinical reasoning still depends on history, examination, probability and decision. In the cited studies, protocols and algorithms define the scope of each professional (Joshi et al., 2014; Martínez-González et al., 2015). The text on interprofessional clinical reasoning discusses how different professions think about the same patient.

The review on HIV recalls that under-referral or over-referral undermines the gain of the strategy (Callaghan et al., 2010). In the opening scene, the nurse follows the algorithm to adjust the pressure, and the decision to refer to the physician is part of the same reasoning. It is the same principle as diagnostic uncertainty: knowing what you do not know is part of competence.

Tools that extend the examination

Task shifting also reaches examinations. A review of 36 publications showed point-of-care ultrasound performed by midwives, nurses, technicians and community health workers after short training in low- and middle-income countries (Abrokwa et al., 2022). The training included theoretical classes, hands-on practice and supervised and unsupervised examinations. Barriers included the lack of local professionals to lead the programs and high staff turnover.

The text on signs, symptoms and history and the text on clinical decision-making show how each new tool requires knowing what it answers. The text on disaster triage and the text on leprosy and clinical diagnosis bring other situations in which assessment happens far from the specialist.

Step-by-step reasoning in the case

Returning to the 52-year-old man with hypertension, a teaching sequence, built from the facilitators described by Joshi et al. and from the Cameroon program, could be this:

1. Measurement. The nurse measures the blood pressure.
2. Protocol. Follows the local algorithm for treatment and dose adjustment.
3. Medicine. Checks whether the indicated medicine is available at the unit.
4. Prescription. Checks whether local rules allow her to prescribe the adjustment.
5. Referral. Decides whether the case needs the physician.
6. Follow-up. Arranges the next appointment and registers the patient.
7. Record. Notes measurements and decisions for the periodic review.

Steps 3 and 4 correspond to the barriers most often cited in chronic diseases, the lack of medicines and restrictions on prescribing (Joshi et al., 2014). Step 6 recalls the main problem in Cameroon, the low retention of patients treated within one year (Labhardt et al., 2010). Step 7 recalls the refresher courses in which professionals presented the records of new patients.

What to record and pass on

The text on how to organize reasoning in the medical record offers a useful format for exchange between levels, and the text on prognostic reasoning recalls that a referral should also state what is expected for the patient. The text on learning based on clinical cases shows how discussing cases helps consolidate reasoning.

In the referral note, it is worth recording the measurements taken and the time, the medicine in use and the adjustments made under the protocol, the reason for the referral and what is still in doubt.

Safety, access and acceptance

The most common concern about task shifting is patient safety. The studies cited here provide some direct data on this, always in programs with training and supervision.

In the STRETCH trial, a planned subgroup analysis showed slightly lower mortality in the intervention group among patients with a baseline CD4 count between 201 and 350 cells per microliter, with a hazard ratio of 0.73 and a p value of 0.052 (Fairall et al., 2012). Among patients with a baseline CD4 of 200 or less, mortality did not differ between groups. In Sierra Leone, as seen above, adjusted mortality was lower in operations performed by trainees of the surgical program (Bolkan et al., 2017).

Access and acceptance by patients

Among the studies gathered in the review on HIV, a rural cohort in South Africa evaluated the initiation of antiretroviral therapy by nurses in decentralized clinics. Decentralized care increased access and was better accepted by patients, with loss to follow-up of 2 in 100 at the clinics and 19 in 100 at the hospital, for comparable virological and immunological outcomes (Callaghan et al., 2010).

What community health workers have already shown

The Malawi analysis summarizes reviews that show the effect of interventions with community health workers on several fronts: malaria prevention, including distribution of insecticide-treated bed nets, increased vaccination coverage, improved breastfeeding rates and promising benefits in tuberculosis treatment outcomes (Smith et al., 2014).

Other fields of expansion

The umbrella review on primary care recalls that the idea of shifting tasks to pharmacists extended to other areas, such as mental health, and to services such as pharmacist-led warfarin clinics (Leong et al., 2021). In the European review, the 12 trials reported 25 different measures of the course of the diseases studied, which shows the variety of conditions already evaluated (Martínez-González et al., 2015).

How NEXO helps train this reasoning

In NEXO, the case of the day is fictional, with a real clinical presentation and up to six progressive clues, and you propose the diagnosis by searching for the ICD-10 code.

The limits of use of the game are described on the NEXO Economy page. If you research the teaching of clinical reasoning, the page for Researchers explains how to get in touch. Professionals who write or review cases find information under Curator and Creators, and institutions can learn about the proposal on the partnerships page.

Frequently asked questions

Can nurses safely start antiretroviral treatment?

In the STRETCH trial, viral suppression was equivalent between patients started by nurses and by physicians (Fairall et al., 2012).

Do community health workers help control blood pressure?

A meta-analysis showed a drop in systolic blood pressure with task sharing, including with community health workers (Anand et al., 2019).

Do training and protocols make a difference?

Training and the algorithms and protocols were the main facilitators in chronic diseases (Joshi et al., 2014).

Does task shifting depend on context?

An international Delphi study described that opportunities for improvement depend on the implementation context and listed eight conditions (Orkin et al., 2021).

Can the strategy generate savings?

A review of 34 studies in low- and middle-income countries concluded that it is a viable option for reducing spending (Seidman and Atun, 2017).

Take-home messages

• Task shifting and task sharing redistribute health tasks among teams and communities.
• In HIV, non-physician professionals with training and supervision achieved equal and sometimes better results.
• Nurses can safely start and renew antiretroviral therapy.
• Task sharing reduced systolic pressure with several professionals.
• Training, algorithms and available medicines help; restrictions on prescribing get in the way.
• Under-referring or over-referring undermines the gain from the strategy.
• Tasks accumulated beyond the job role caused overload in Malawi.
• The strategy needs leadership from governments so it does not fail.

Want to practice reasoning with progressive clues? Play the case of the day.

References

1. Abrokwa SK, Ruby LC, Heuvelings CC, et al. Task shifting for point of care ultrasound in primary healthcare in low- and middle-income countries-a systematic review. EClinicalMedicine. 2022. PMID 35284806.
2. Anand TN, Joseph LM, Geetha AV, et al. Task sharing with non-physician health-care workers for management of blood pressure in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Glob Health. 2019. PMID 31097278.
3. Bolkan HA, van Duinen A, Waalewijn B, et al. Safety, productivity and predicted contribution of a surgical task-sharing programme in Sierra Leone. Br J Surg. 2017. PMID 28783227.
4. Callaghan M, Ford N, Schneider H. A systematic review of task- shifting for HIV treatment and care in Africa. Hum Resour Health. 2010. PMID 20356363.
5. Fairall L, Bachmann MO, Lombard C, et al. Task shifting of antiretroviral treatment from doctors to primary-care nurses in South Africa (STRETCH): a pragmatic, parallel, cluster-randomised trial. Lancet. 2012. PMID 22901955.
6. Joshi R, Alim M, Kengne AP, et al. Task shifting for non-communicable disease management in low and middle income countries--a systematic review. PLoS One. 2014. PMID 25121789.
7. Labhardt ND, Balo JR, Ndam M, et al. Task shifting to non-physician clinicians for integrated management of hypertension and diabetes in rural Cameroon: a programme assessment at two years. BMC Health Serv Res. 2010. PMID 21144064.
8. Lehmann U, Van Damme W, Barten F, et al. Task shifting: the answer to the human resources crisis in Africa? Hum Resour Health. 2009. PMID 19545398.
9. Leong SL, Teoh SL, Fun WH, et al. Task shifting in primary care to tackle healthcare worker shortages: An umbrella review. Eur J Gen Pract. 2021. PMID 34334095.
10. Martínez-González NA, Tandjung R, Djalali S, et al. The impact of physician-nurse task shifting in primary care on the course of disease: a systematic review. Hum Resour Health. 2015. PMID 26149447.
11. Ogedegbe G, Gyamfi J, Plange-Rhule J, et al. Task shifting interventions for cardiovascular risk reduction in low-income and middle-income countries: a systematic review of randomised controlled trials. BMJ Open. 2014. PMID 25324324.
12. Orkin AM, Rao S, Venugopal J, et al. Conceptual framework for task shifting and task sharing: an international Delphi study. Hum Resour Health. 2021. PMID 33941191.
13. Seidman G, Atun R. Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from low-income and middle-income countries. Hum Resour Health. 2017. PMID 28407810.
14. Smith S, Deveridge A, Berman J, et al. Task-shifting and prioritization: a situational analysis examining the role and experiences of community health workers in Malawi. Hum Resour Health. 2014. PMID 24885454.