Does task shifting among parts of a weak health system help?

In this issue of The Lancet Global Health, Sajid Soofi and colleagues1Soofi S Cousens S Turab A et al.Effect of provision of home-based curative health services by public sector health-care providers on neonatal survival: a community-based cluster-randomised trial in rural Pakistan.Lancet Glob Health. 2017; 5: e796-e806Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar assessed the effectiveness of adding neonatal bag and mask resuscitation and oral antibiotic therapy for suspected newborn infections to a basic preventive and promotive interventions package delivered by community-based lady health workers (LHWs) in rural Pakistan. When LHWs attended births they could successfully resuscitate neonates when necessary. But—and here is the crux—LHWs attended only 14% of all births and resuscitated just 4% of neonates who were reported to be not breathing after birth.1Soofi S Cousens S Turab A et al.Effect of provision of home-based curative health services by public sector health-care providers on neonatal survival: a community-based cluster-randomised trial in rural Pakistan.Lancet Glob Health. 2017; 5: e796-e806Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar This lack of availability of health-care providers severely restricted the effectiveness of the intervention. The authors concluded that health systems need to be strengthened if community-based newborn care is to achieve its full potential. Although the authors do not situate their research in terms of task shifting, insights from published work in that area can help to explain their findings. Task shifting refers to the delegation of skills and responsibilities traditionally held by professional workers to workers with lower qualifications.2Jennings L Yebadokpo AS Affo J Agbogbe M Tankoano A Task shifting in maternal and newborn care: a non-inferiority study examining delegation of antenatal counseling to lay aides supported by job aids in Benin.Implement Sci. 2011; 6: 2Crossref PubMed Scopus (21) Google Scholar, 3Philips M Zachariah R Venis S Task shifting for antiretroviral treatment delivery in sub-Saharan Africa: not a panacea.Lancet. 2008; 371: 682-684Summary Full Text Full Text PDF PubMed Scopus (110) Google Scholar Codified in 1978 as a key component of the Alma Ata declaration on primary health care,4WHODeclaration of Alma-Ata: International Conference on Primary Health Care.http://www.who.int/publications/almaata_declaration_en.pdf?ua=1Date: 1978Google Scholar task shifting has been praised on several fronts for its potential to address health worker shortages, reduce costs for training and remuneration, and shift care to cadres that are more easily retained in rural areas, which might be considered undesirable postings by highly trained staff.5Schneeberger C Mathai M Emergency obstetric care: making the impossible possible through task shifting.Int J Gynaecol Obstet. 2015; 131: S6-S9Crossref PubMed Scopus (19) Google Scholar, 6WHOWHO recommendations: optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting. World Health Organization, Geneva2012Google Scholar WHO has set out extensive guidelines for the operationalisation of task shifting.6WHOWHO recommendations: optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting. World Health Organization, Geneva2012Google Scholar The intervention that Soofi and colleagues assessed was essentially an effort to test whether neonatal resuscitation could be task shifted from expected (but non-existent) facility-based clinicians to minimally trained but existing community-based health workers. Their findings have, perhaps inadvertently, shed light on a more fundamental question: can task shifting address the structural weaknesses in health systems that are responsible in the first place for failure to provide facility-based newborn care? The task-shifting literature suggests that delegation of tasks from one part of a weak health system to another is no more likely to be successful than the status quo unless more fundamental structural changes to strengthen the health system are brought about.3Philips M Zachariah R Venis S Task shifting for antiretroviral treatment delivery in sub-Saharan Africa: not a panacea.Lancet. 2008; 371: 682-684Summary Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 7Berer M Task-shifting: exposing the cracks in public health systems.Rep Health Matters. 2009; 17: 4-8Google Scholar Soofi and colleagues' Article has also highlighted the dangers of developing interventions built on hypothetical assumptions that do not take evidence and on-the-ground realities into account. A common oversight in programme design is failure to account for local contextual sociocultural values and norms. Health systems are culturally embedded social systems, the functioning of which is contingent on norms and ideologies of wider society.8Hawe P Shiell A Riley T Theorising interventions as events in systems.Am J Comm Psych. 2009; 43: 267-276Crossref PubMed Scopus (594) Google Scholar The LHWs' poor attendance at births in Soofi and colleagues' study fits with previous findings that LHWs are as constrained by wider gender values and norms of limited mobility as the community women they are supposed to serve.9Mumtaz Z Salway S Nykiforuk C Bhatti A Ataullahjan A Ayyalasomayajula B The role of social geography on lady health workers' mobility and effectiveness in Pakistan.Soc Sci Med. 2013; 91: 48-57Crossref PubMed Scopus (49) Google Scholar The Pakistani LHW programme was designed to provide doorstep services to women, in acknowledgment of the reality that gendered values of seclusion prevent women from travelling to health facilities. Furthermore, only women could work as community health workers, again because gendered values restrict women's contact to female health-care providers. Research9Mumtaz Z Salway S Nykiforuk C Bhatti A Ataullahjan A Ayyalasomayajula B The role of social geography on lady health workers' mobility and effectiveness in Pakistan.Soc Sci Med. 2013; 91: 48-57Crossref PubMed Scopus (49) Google Scholar has shown that LHWs' ability to deliver domiciliary care of all types is severely restricted because they are required to violate a key gender proscription around women's mobility, with resultant loss of status. According to Haq and colleagues,10Haq Z Iqbal Z Rahman A Job stress among community health workers: a multi-method study from Pakistan.BMC Int J Mental Health Syst. 2008; 2: 15Crossref PubMed Scopus (67) Google Scholar mobility requirements of the job are a source of mental distress for these workers. So, for all practical purposes, LHWs as community-based workers are as unavailable to do their work as are more expensively trained doctors or nurses. A primary assumption of task shifting—ie, that community health workers will be more available in rural areas—stands negated. Task shifting in Soofi and colleagues' study shifted responsibility to a cadre of providers who, although ostensibly present, were restricted in their capacity to provide care. That health systems in many low-income and middle-income countries are fragile and crumbling has become a truism. Under the Sustainable Development Agenda, an opportunity exists to develop mechanisms to design universal, comprehensive health care aligned with local cultural values and norms and delivered by appropriately trained and supported personnel, both in communities and facilities. Without addressing the fundamental health-system weaknesses, task shifting will remain akin to moving the deckchairs on the Titanic. We declare no competing interests. Effect of provision of home-based curative health services by public sector health-care providers on neonatal survival: a community-based cluster-randomised trial in rural PakistanThe reduction in neonatal mortality in intervention clusters occurred against a background of improvements in domiciliary practices for maternal and newborn care. However, the poor reach of LHWs in accessing newborn infants at birth and in the early postnatal period underscores the limitations of tasking community health workers in public sector programmes working in similar circumstances with such complex interventions. Such community-based interventions in health systems should be accompanied by concerted efforts to improve quality of care in facilities and referral systems. Full-Text PDF Open Access

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