Task-sharing for the prevention and control of non-communicable diseases
Authors: Rohina Joshi, David Peiris
Journal: The Lancet Global Health (2019)

The UN's Sustainable Development Goal 3.4 aims to reduce premature mortality due to non-communicable diseases by a third by 2030. To achieve this goal, WHO estimated in 2013 that an additional 17·4 million health workers were needed worldwide, with the greatest shortage in southeast Asia (where 6·9 million workers are needed), followed by Africa (which needs 4·2 million workers).1WHOHealth workforce requirements for universal health coverage and the sustainable development goals.https://www.who.int/hrh/resources/health-observer17/en/Date: 2016Date accessed: March 31, 2019Google Scholar In order to address this shortage and improve access to care, low-cost, disruptive health-care delivery models are emerging. Task-sharing is one key element of these models and has been adopted by several low-income and middle-income countries, driven by shortages of physicians, unbalanced workforce distribution in rural versus urban areas, and financial constraints. Certain tasks are shared among health-care teams (task-sharing) or moved from highly qualified health workers to workers with shorter training (task-shifting) in order to use the available human resources efficiently and provide better access to care. In The Lancet Global Health, T N Anand and colleagues describe the findings of a systematic review and meta-analysis of the effectiveness of task-sharing interventions for blood pressure control among adults in low-income and middle-income countries.2Anand TN Joseph LM Geetha AV Prabhakaran D Jeemon P 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; 7: e761-e771Summary Full Text Full Text PDF PubMed Scopus (74) Google Scholar They reviewed studies in which non-physician health workers (including nurses, community health workers, pharmacists, and allied health professionals) implemented a range of interventions to lower blood pressure. The study had two key findings: first, there are several studies (63 in their narrative review, and 31 randomised controlled trials in the meta-analysis) that have shown the effectiveness of task-sharing for blood pressure control in this setting. Second, delivering interventions to lower blood pressure through non-physicians is effective. The overall reduction in systolic blood pressure, irrespective of the type of non-physician health worker involved, was −4·85 mm Hg (95% CI −6·12 to −3·57) and for diastolic blood pressure it was −2·92 mm Hg (–3·75 to −2·09). The biggest reduction in systolic blood pressure was for interventions involving pharmacists (–8·12 mm Hg, −10·23 to −6·01). Interventions involving community health workers also resulted in significant but more modest reductions in systolic blood pressure (–3·67 mm Hg, −4·58 to −2·77). The study therefore supports growing evidence about the effectiveness of using community health workers for interventions related to non-communicable diseases, at least for blood pressure treatment and control.3Neupane D Kallestrup P McLachlan CS Perry H Community health workers for non-communicable diseases.Lancet Glob Health. 2014; 2: e567Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar Task-sharing gained popularity during the peak of the HIV/AIDS epidemic when a WHO high-level meeting in June, 2006, endorsed such a strategy to address unmet health-care needs.4WHOTask shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines. World Health Organisation, Geneva2008Google Scholar Since then, task-sharing strategies have evolved in complexity and become highly heterogeneous (ranging from deployment of highly skilled nurses and allied health professionals through to village-based lay community health workers). These models have been used in several high-income countries to improve disease outcomes, and team-based care involving multiskilled health workers (physician assistants, diabetes educators, palliative care nurses, and non-dispensing pharmacists) is increasingly promoted as an essential part of care for chronic conditions.5Rinker J Dickinson JK Litchman ML et al.The 2017 Diabetes Educator and the Diabetes Self-Management Education National Practice Survey.Diabetes Educ. 2018; 44: 260-268Crossref PubMed Scopus (34) Google Scholar, 6Maier CB Aiken LH Task shifting from physicians to nurses in primary care in 39 countries: a cross-country comparative study.Eur J Public Health. 2016; 26: 927-934Crossref PubMed Scopus (161) Google Scholar Most of the evidence of benefit in low-income and middle-income countries thus far has related to better access and improved health outcomes for maternal and child health (eg, higher immunisation rates) and some infectious diseases (eg, improved adherence to treatment for tuberculosis and HIV/AIDS).4WHOTask shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines. World Health Organisation, Geneva2008Google Scholar For non-communicable diseases, there is less evidence. However, on the basis of a small number of high-quality studies, improvements have been noted for mental health conditions, chronic respiratory disease, cardiovascular disease, and cancer.7Joshi 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; 9: e103754Crossref PubMed Scopus (293) Google Scholar, 8Ogedegbe 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; 4: e005983Crossref PubMed Scopus (89) Google Scholar The question of whether task-sharing works or not should no longer be the primary focus. The priority now is to identify sustainable and scalable task-shifting models that can be embedded in existing health systems rather than as a part of isolated research studies. The Ethiopian Health Extension Program is one such example of an embedded task-sharing model that is now being expanded to include non-communicable diseases.9Wang H Tesfaye R Ramana GNV Chekagn CT Ethiopia Health Extension Program An Institutionalized Community Approach for Universal Health Coverage. World Bank, Washington, DC2016Crossref Google Scholar When thinking of implementation at scale, different questions arise relating to how various cadres are recruited, regulated, trained, remunerated, supervised, and how systems are implemented to improve the quality of care delivered. It is also essential to assess the community's trust in the expanding role of non-physicians and acceptability of the non-physician's responsibilities by other cadres of the workforce. When considering how task-sharing models can achieve large-scale system-wide transformations, the future research agenda needs to go beyond asking whether such models are effective and tackle these many broader health system questions. We declare no competing interests. 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-analysisTask-sharing interventions are effective in reducing blood pressure. Long-term studies are needed to understand their potential impact on cardiovascular outcomes and mortality. Full-Text PDF Open Access