Now that you have a clear understanding of the role of

task shifting in the provision of health services.

It's important to assess how this approach has fared in the scientific literature,

especially with regard to maternal and newborn health.

Over the past five years, numerous peer-reviewed studies have

documented comparable or other non-inferior outcomes of task shifted and

task shared services provided by non-physicians.

The studies include HIV care,

as well as reproductive health services in low income countries.

For example, in 2013 researchers from The University of Technology in Sydney,

Australia assessed reproductive clinical services,

such as the delivery of emergency obstetrical care.

Preventing mother to child transmission of the HIV virus or PMTCT.

Obstetric surgery, abortion and

contraception services that were shifted or shared with non-obstetricians,

non-clinical, clinicians, nurses and midwives in over an 11 year period.

Of the 20 papers that met the study's review criteria, most of the research

dealt with obstetrical surgery, anesthesia and manual vacuum ex, aspiration outcomes.

The findings, which were reported in the Journal of Health Policy and Planning.

Indicated that shifting and sharing these tasks may increase access and

availability of maternal and reproductive health services

without compromising a performance or patient outcomes.

The researchers also concluded that task shifting or

task sharing may also be cost effective.

However, they identified specific issues and

barriers that underscore the importance of improved provider in service training,

such as supportive supervision and care, and career progression and

incentive packages in order to support and sustain these practices.

Now with regard to cash shifting and

the provision of pediatric HIV, anti-retroviral treatment.

A 2014 systematic review that was published in

the journal of the acquired immune syndromes assess the results of

healthcare services primarily provided by nurses in ten sub-Saharan countries.

The researchers from the World Health Organization found no significant

difference in outcomes regarding pediatric mortality or

the number of patients retained in care, when compared to clinic sites where

HIV-infected children were exclusively seen by doctors or specialists.

Based on their findings, they concluded that pediatric task shifted HIV care

should be included among those strategies considered for scaling-up services.

This recommendation is particularly important,

since pediatric task shifted care is less understood and

lacks the developed policies compared to the adult HIV infected population.

A third study worth noting is the 2014 Cochrane Systematic Review conducted

by the South African Medical Research Council in Capetown, South Africa.

This study compared doctor and non-doctor task shifted care in initiating and

maintaining anti-retroviral therapy.

The review's object was to evaluate the quality of initiation and

maintenance of task shifted HIV care by assessing the quality of

evidence using the GRADE methodology.

The GRADE acronym refers to Grading of Recommendations Assessment,

Development and Evaluation.

And is an approach that provides a common system for

determining the quality of scientific evidence and

uses that information to characterize the strength of a particular recommendation.

Of the 10 studies that met the review inclusion criteria,

all took place in Africa among adults were followed up for one year.

Key findings from this review include high quality evidence based on

clinical trial data that when nurses initiate and provide HIV therapy, there

is no difference in patient mortality or their loss to follow-up care at one year.

Similarly, moderate quality evidence noted no difference in patient mortality or

their loss to follow-up at one year.

However, lower quality evidence from their review revealed conflicting findings

between two cohort studies with one suggesting that there may be an increased

risk of death for patients whose care was task shifted, but showed no difference

regarding the number of patients who were lost to follow-up at one year.

While a second cohort study documented decreased patient deaths and

reduced number of patients who lost the follow-up at

one year among those whose care was task shifted to nurses.

Taken together, the authors concluded that based on the reviewed findings.

Task shifting HIV care from doctors to adequately trained non-physicians,

produced comparable outcomes and

may actually result in more patients remaining in care.

Complimenting these findings are recent taask shifting documents,

produced by different units within the World Health Organization.

In 2012, their Department of Reproductive Health and

Research in collaboration with other global leaders and research advisers.

Produced an advisory document entitled Optimizing Health Workers Role to

Improve Access to Key Maternal and New Interventions Through Task Shifting.

The documents over our chain objective is to provide recommendations that

maximize health worker roles to the World Health Organization members states.

This guidance which is based on scientific evidence supportive of

universal access to essential and effective newborn interventions.

Identifies and defines eight broad categories of maternal and

newborn health providers.

Including advanced level associate clinicians, associate clinicians,

auxiliary nurses, auxiliary nurse midwives, lay health workers,

midwives, non-specialist doctors, nurses.

And identifies practices most appropriate for

each type of these health professionals.

The recommendations which are similarly based on the GRADE methodology,

characterize specific interventions,

such as those that are appropriate for implementation.

Those that require further monitoring and evaluation.

Those that are limited to settings capable of rigorous research or

those practices that are not recommended at all.

The document intentionally excluded task shifted recommendations pertaining to

HIV infected pregnant women and mothers and children, so

as to avoid proposing potentially conflicting re, recommendations.

In 2013, the World Health Organization published their consolidated guidelines of

the use of antiretroviral drugs for treating and preventing HIV infection.

The impetus for developing these guidelines was to further the goal of

universal access to HIV prevention treatment care and support.

In accordance with the target set forth in the 2006 political declaration on HIV,

AIDS and the 2011 political declaration on HIV a, and AIDS.

Intensifying our efforts to eliminate HIV and AIDS.

Because the maternal and newborn population in sub-Saharan Africa

is particularly impacted by the HIV epidemic.

The guidelines covering PMTCT and

Pediatric HIV Services are highly relevant.

In crafting these guidelines,

the authors identified overarching principles to frame their recommendations.

These principles include contributing to global health goals.

Adopting a public health approach.

Strengthening health systems through innovation and learning.

Increasing effectiveness and efficiency of programs.

Promoting human rights and health equity.

And recognizing that implementation of these guidelines should be

informed by the local context.

Significantly, the consolidated guidelines include a new

section on human resources for health.

Which discusses the need to create capacity of all health

cadres including community health workers.

Using the GRADE methodology,

the guidelines provide three strong recommendations with

moderate quality evidence regarding task shifted HIV treatment and care.

These recommendations are as follows.

Trained non-physicians, clinicians, midwives and

nurse can initiate first line anti-retroviral therapy.

Commonly referred to as A-R-T or ART.

For those unfamiliar with the HIV treatment terminology.

ART refers to the use of a combination of three or

more anti-retroviral drugs to achieve viral suppression.

Also at the beginning of HIV treatment, the combination of

drugs initially prescribed is referred to as first line therapy.

The second recommendation was that trained non-physician clinicians, midwives and

nurses can maintain ART.

The term nurse initiated A-R-T or ART or NIMART is used when referring to

these group of professionals providing this task shifted care.

And the third recommendation was that trained and supervised community health

workers can dispense ART between regular clinical visits.

With regard to maternal and child heath settings,

the consolidated guidelines state that task shifting improves access to A-R-T or

ART to those sites that don't typically have doctors present.

Such as maternal and childhood clinics.

However, specific recommendations regarding pediatric HIV care were not

mentioned and guidance in this area remain unclear.

In light of the fact that the World Health Organization's initial resource guide from

2008, which was called Task Shifting: Global Recommendations and Guidelines.

Did not recommend mid level providers initiate or

prescribed first line ART for children.

With global efforts committed to eliminating mother to

child transmission by 2015.

Including a 90% reduction target of HIV infections among children and

a 50% reduction in AIDS related maternal death.

HIV, AIDS protocol and guidance, regarding maternal and

newborn population are constantly evolving.

And result in accompanying expectations for improved and expanded services.

Changes in health workers roles and protocols,

governing their practice, constitute a critical piece of this picture.

Accordingly, task shifting or task sharing roles and

responsibilities should be seen as a dynamic process capable of

responding to newer and improved program requirements.

The Effectiveness of Task Shifting & Task Sharing

Childbirth: A Global Perspective

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