The vision of the International Council of Nurses (ICN’s) Leadership for Change programme is that, “Nursing in the 21st century will have nurses at a country and organisational level equipped with knowledge, strategies and strength to lead and manage in health services and in nursing through change and into a healthier future for all populations,” (ICN 2010a). The contribution and leadership of nurses to population health has long been recognised, (Kendall 2008) for example, declared that nurses could “lead the way” in primary health care (PHC). In a review of the contribution of PHC nurses since 1978, Kendall concluded, “Nurses have accepted the challenge and the opportunity to make a real difference to community health,” (Kendall 2008 ). Nurses are the key providers in PHC comprising 60-80% of the total health system workforce and provide 90% of all heath care services (WHO 2008). It is imperative for the reform of PHC that nurses’ skills and abilities are harnessed and maximised and hence the development of Task Shifting as a panacea to address the human resources crises.
Questions then arise on how PHC nursing workforce could be supported to deliver the most effective nursing care for individuals and communities? What factors support/drive effective PHC nursing workforce development? What factors inhibit/restrain such developments? How can PHC nurses be empowered to achieve PHC reform through workforce enhancement? How can workforce enhancement support PHC nurses to contribute to PHC reform?, ( Kendal B, Mogotlane S, 2011).
The Declaration of Alma Ata in 1978 (WHO/UNICEF 1978) arose from a “paradigm shift in thinking about health” (WHO 2008) and focused on the potential of PHC to achieve “health for all”. Primary Health Care Now More Than Ever (WHO 2008), relaunched PHC as the way forward for health care in all countries of the world covering universal coverage reforms to improve health equity (Tudor Hart 1971), secondly, leadership reforms to make health authorities more reliable, public policy reforms to promote and protect the health of communities, and service delivery reforms to make health systems more people-centred (WHO 2008). These reforms paved way for Task shifting.
Task shifting is an approach to help address the shortage of healthcare workers through reallocating human resources but its impact on PHC is unclear. Task shifting involves the rational redistribution of tasks to individuals within the healthcare team with fewer qualifications that conventionally were not within their scope of work, (WHO, 2007). This management technique has been advocated as an important strategy to optimise health system performance, especially in resource poor settings, (Leong S et al 2021). Studies performed to date have shown that task shifting can address healthcare resource shortages and allow physicians in primary care to provide more complex care and expand the healthcare capacity, (Mc Pake B, Mensah K, 2008). Unfortunately, human resource in health is limited, especially physicians working in primary care.
This concept was first developed as a strategy to provide care for individuals with HIV in sub-Saharan Africa where there was shortage of specialised healthcare workers due to the disparity between healthcare services, capacity, and budget, (Fulton B et al 2011). In response to this, the WHO developed a consolidated guideline on using task shifting to tackle health worker shortages, (WHO, 2007). Since then, this concept has been expanded to other disease states such as mental health as well as expanded services, including pharmacist in clinics. Indeed, expanding the roles of healthcare workers have been advocated as one of the strategies to enhance the quality of care towards achieving the Sustainable Development Goal 3 of maintaining good health and well-being, (UNDP, 2020).
Multiple systematic reviews on task shifting to other healthcare workers, including nurses and pharmacist have been published, (Weeks G et al, 2016). However, (Leong S, 2021) argues that there is no comprehensive overview of systematic reviews on task shifting that examined the various roles and responsibilities of health workers in primary care and how these strategies can be implemented optimally. Such evidence is vital for health policy planning, especially in resource poor settings and pandemics such as COVID-19, where healthcare resources are strained.
According to (Lehmann U et al, 2009) the delegation of tasks from one cadre to another, previously often called substitution, is not a new concept. It has been used in many countries and for many decades, either as a response to emergency needs or as a method to provide adequate care at primary and secondary levels, especially in understaffed rural facilities, to enhance quality and reduce costs. However, rapidly increasing care needs generated by the HIV/AIDS epidemic and COVID-19 accelerating human resource crises in many countries and in Botswana have given the concept and practice of task shifting new prominence and urgency.
Recently the Botswana Gazette newspaper carried a story with a title heading, “ Crisis Looms as Nurses threaten to stop working in dispensaries , June 28th 2023. According to the Gazette newspaper, stated that , “ the public health sector nurses and mid-wives will stop working in dispensaries from 1st July 2023 because issuing prescribed drugs and other medication to patients violates their code of ethics and the law”. According to the Gazette newspaper, The Botswana Nurses Union (BONU) has notified the government of this and that dispensing prescribed drugs and medication is the remit of pharmacists. It is stated that BOMU asserts that, “ having nurses and midwives do this specialised work also poses a threat to the safety of patients and that there should be clear distinction in the roles and pharmacists in Botswana’s public health system. Was BONU President Peter Baleseng being dishonest, reckless and economic with the truth?
Questions the arise as to whether task shifting can be more than a short-term solution to address the human resources in health care, dispensing of drugs, HIV/AIDS and post COVID-19 crisis and can contribute to a revival of the primary health care approach as an answer to health systems challenges.
In this piece I argue that, while task shifting holds great promise, any long-term success of task shifting hinges on serious political and financial commitments. It requires a comprehensive and integrated reconfiguration of health teams, changed scopes of practice and regulatory frameworks and enhanced training infrastructure, as well as availability of reliable medium- to long-term funding as argued by (Lehman et al 2009).Task shifting can indeed make a vital contribution to building sustainable, cost-effective and equitable health care systems. Without it, task shifting runs the risk of being yet another unsuccessful health sector reform initiative. Evidence consistently show that delegation of tasks, whether from doctors to non-physician clinicians, including nurses from nurses to nursing assistants or aides or to non-professional or lay health workers and patients can lead to improvements in access, coverage and quality of health services at comparable or lower cost than traditional delivery models.
Task shifting requires careful attention to organization, structure and resourcing of health services. Samb et al. argued, in the context of HIV/AIDS services, that task shifting “must be aligned with the broader strengthening of the health system if it is to prove sustainable”. They called on governments and international and bilateral agencies to help prepare health systems to successfully implement task shifting by ensuring the establishment of appropriate regulatory frameworks and the building of training and management capacity. Given the comparably poor record of initiatives to strengthen health systems and to enhance capacity in many African countries, the question has to be asked: What does this mean?
Task shifting requires the integration of the concept and roles of new cadres, changed scopes of practice and regulatory frameworks, enhanced training infrastructure, etc, into the mainstream health system, and a systematic engagement with all the consequences. Successful task shifting requires a comprehensive and integrated reconfiguration of health teams, particularly at community and primary care levels. Without a health team approach, the introduction of new cadres or delegation of tasks will invariably remain a fragmented and unsustainable “add-on”. Any serious commitment to task shifting requires leadership from national governments. It is national government’s role to ensure an enabling regulatory framework and credentialing system, to drive the implementation of relevant policies and to resource, guide and support training institutions to not only upgrade training but also ensure appropriate initial and continuing education.
The national government must also harness the support of the multiple stakeholders who affect and are affected by the reconfiguration of tasks (such as professional bodies and associations; trade unions; ministries of health, education, finance and public service; non-governmental and community organizations and local health structures). Where this is not the case, task shifting will exist on the political and organizational periphery of the formal health system, exposed to policy and funding fashions, and become fragile and unsustainable.
Task shifting, while driven by the urgencies of conquering the HIV/AIDS epidemic, holds the potential of enabling countries to build sustainable, cost-effective and equitable health care systems, thus moving closer not only to the Sustainable Development Goals 2030, (SDG 2030) but also the elusive Health for All goal. However, the challenge of achieving success cannot be underestimated. It requires a willingness to learn from those with relevant experience.
The challenge of lack of personnel in PHC with unmet needs affects every country in the world, including Botswana. Task shifting should thus be viewed as a part of an overall strategy in human-resources challenges facing which in turn includes measures to increase, retain, and sustain health staff.
*Thabo Lucas Seleke isa final year Doctoral Candidate, Global Health Policy, LSHTM
