Task Shifting for Non-Communicable Disease Management in Low and Middle Income Countries – A Systematic Review

Abstract

BackgroundOne potential solution to limited healthcare access in low and middle income countries (LMIC) is task-shifting- the training of non-physician healthcare workers (NPHWs) to perform tasks traditionally undertaken by physicians. The aim of this paper is to conduct a systematic review of studies involving task-shifting for the management of non-communicable disease (NCD) in LMIC.MethodsA search strategy with the following terms “task-shifting”, “non-physician healthcare workers”, “community healthcare worker”, “hypertension”, “diabetes”, “cardiovascular disease”, “mental health”, “depression”, “chronic obstructive pulmonary disease”, “respiratory disease”, “cancer” was conducted using Medline via Pubmed and the Cochrane library. Two reviewers independently reviewed the databases and extracted the data.FindingsOur search generated 7176 articles of which 22 were included in the review. Seven studies were randomised controlled trials and 15 were observational studies. Tasks performed by NPHWs included screening for NCDs and providing primary health care. The majority of studies showed improved health outcomes when compared with usual healthcare, including reductions in blood pressure, increased uptake of medications and lower depression scores. Factors such as training of NPHWs, provision of algorithms and protocols for screening, treatment and drug titration were the main enablers of the task-shifting intervention. The main barriers identified were restrictions on prescribing medications and availability of medicines. Only two studies described cost-effective analyses, both of which demonstrated that task-shifting was cost-effective.ConclusionsTask-shifting from physicians to NPHWs, if accompanied by health system re-structuring is a potentially effective and affordable strategy for improving access to healthcare for NCDs. Since the majority of study designs reviewed were of inadequate quality, future research methods should include robust evaluations of such strategies.

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“…1 Task shifting rehabilitation activities to unpaid caregivers may offer a sustainable alternative to conventional rehabilitation, and provide an affordable strategy in meeting the health demands in high and LMICs. [2][3][4][5] India, with one sixth of the world's population, only has approximately 35 stroke units, located mainly in urban centres. 6,7 Consequently most people have no access to specialised stroke care and little access to conventional rehabilitation programs.…”

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“…31 Task-shifting from physicians to NPHWs, if accompanied by the restructuring of the health system, is a potentially effective and affordable strategy. 28 Specifically, successful task-shifting should include workforce skill-mix changes, worker incentives and an increase in training capacity and supportive oversight.…”

“…8 Task-shifting strategies have the potential to meet the demands of NCD programmes since management principles for these diseases are based on screening, health promotion, initiation of treatment and referral of high-risk patients to physicians. 28 Proponents of task-shifting point to significant positive outcomes for patients with HIV, obstetric care requirements, mental health issues and malaria. 8,10,13,20 Trained 7 Task-shifting interventions by nurses and nursing assistants in LMICs have reportedly helped to reduce the burden of CVDs and there is considerable evidence supporting the effectiveness of task-shifting implementation for chronic disease management.…”

“…20 Successful task-shifting interventions are potentially effective and affordable; some of the benefits include mitigation of the health workforce shortage by increasing the number of NPHWs and thus providing increased access to life-saving treatment, improving health workforce skills and increasing the efficiency and sustainability of healthcare delivery. 28 These elements form the core principles of primary NCD management.…”