Task Shifting: Need for a more Cautious and Nuanced Approach

Abstract

Task shifting refers to the strategic redistribution and decentralization of health care tasks from one group to another
(including lay workers), the latter usually deemed as having lesser training and qualifications, and is an approach that is
utilized to address the shortage and imbalance of the health workforce within a certain geographic area, thereby ensuring a
population’s access to care.¹ Task shifting can involve extending the role of a particular group (enhancement), exchanging work
between groups (substitution/delegation), or creation of new jobs (innovation).² While the primary conceptualization of task
shifting is from professional to lay health workers, it must be stated that task shifting can also involve shifting of tasks from
professionals to patients; from health workers to technology; and between different types of health workers.² Task shifting has
been implemented in a variety of settings and for different programs/conditions, such as HIV/AIDS treatment³, cancer care⁴,
mental health⁵, ultrasonography for antenatal care⁶, surgical care⁷, and non-communicable disease management⁸, similar to the
context of the report by Tamayo and Reyes⁹ in this issue of Acta Medica Philippina. In addition to bridging the health human
resources gap, it has been proposed that task shifting may address health equity by broadening access to essential health services,
contribute to enhancing the quality of care that is aligned with the changing societal needs, and yield cost savings particularly
for the delivery of routine activities.^10,11

Despite its widespread application, touted benefits, and the seeming preference of many organizations to use task shifting
a default solution to the health workforce challenge, three things must be pointed out.

First, task shifting should be properly seen as a temporary solution to the health workforce challenge confronting countries
and health systems.^12,13 Better and more comprehensive planning and management of human resources for health at the system
level is needed so that we can address the underlying problems that resulted to the implementation of task shifting in the first
place – shortage, maldistribution, skill-mix balance, and sub-optimal working conditions that are, in turn, driven, by both health
system and contextual factors.¹⁴

Second, in situations where task shifting is perceived to be the better policy alternative, the program should be implemented
in an ethical manner, considering respect for persons (i.e., free and informed decision making to take part in task shifting,
recognition of recipients of tasks as critical contributors to the health program), justice (i.e., adequate guidance and supervision,
fair remuneration, minimization of undue burden), beneficence (i.e., promoting health and welfare of workers, minimizing
harm to workers and communities), proportionality (i.e., assignment of workload and responsibility commensurate to skills
and resources available), and cultural humility (i.e., cultural competency and humility on the part of dominant institutions),
especially when the recipient of tasks are volunteer community health workers.¹⁵

Lastly, task shifting should be implemented as a comprehensive package of interventions, rather than a single activity.
At the outset, the necessary conditions and important considerations for launching a task shifting program should be present,
as outlined in the Concepts and Opportunities to Advance Task Shifting and Task Sharing (COATS) Framework.¹⁶ The key
elements for successful implementation (i.e., collaboration and coordinated care, financing, patient preference, shared decisionmaking,
provider empowerment, training and competency, clear process outcomes, and supportive organizational system) of
task shifting should also be present.¹⁷ Recommendations on how and when to adopt task shifting as a strategy have also been
published by various organizations such as the World Health Organization1 and the World Medical Association¹⁸.

The success of a task shifting strategy will require, among others, that health workers be actively engaged in the process,
ensuring that the planned task shifting is aligned with their personal values, and creating an enabling environment¹⁹ that will
allow them to carry out their tasks effectively, efficiently, and in a safe manner. In short, one of the requirements is that, as
pointed out in the paper by Tamayo and Reyes9, stakeholders find task shifting an acceptable strategy.