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A Shift in Perspective: Task Shifting to Save More

Two of the main challenges in global health are that we have too few skilled health care providers and too few settings equipped to care for the large number of people who lack basic care. Right now, training large numbers of more highly skilled doctors or building many more highly specialized hospitals to care for patients is neither feasible nor the highest priority. One solution to closing this health gap is to task-shift health care to lower-skill-level providers and localized settings.

The goal of task shifting is to create system efficiencies, ease bottlenecks, and increase reach while reducing costs of services (Figure 8). It involves delegating responsibilities for specific tasks to other providers or other settings. The focus in task shifting should be on the ability of the provider or setting to perform specific tasks in ways that maintain quality, improve distribution, and reduce costs.

Task Shifting

Provider-type task shifting typically shifts tasks from providers at upper levels (doctors and others who are highly specialized) to middle (nurses, midwives, and skilled technicians) and lower levels (community workers, family members, and patients). Health personnel can consume up to 70 percent of recurrent health care expenditures in developing countries, so task shifting to lower-cost health care providers not only can save more lives, it can save money.¹ Since higher-level providers are in short supply and expensive, task shifting improves efficiency by moving tasks that can be performed by others who are available in much greater numbers and may be significantly less expensive.

Figure 8 Task Shifting

Task shifting between clinical settings typically shifts tasks from specialized to generalized settings, which may not only include small clinics and pharmacies, but may also include schools, marketplaces, and homes.

Ensuring Success with Task Shifting

A number of system-level changes can help ensure success in task shifting. As tasks are shifted from higher- to lower-level providers, there will be challenges. Lower-level providers need good training and ongoing supervision, monitoring, and support. And as with all clinicians, their newly acquired skills will be lost if they are not used. Good monitoring is needed to ensure that protocols are followed. Such monitoring protects everyone—patients, providers, and supervisors.

If basic support to lower-skilled providers cannot be provided, it may not be in the best interest of the patient to shift tasks. Such basic support includes:

• Appropriate provider training

• Appropriate equipment and supplies to perform new tasks

• Diagnostic algorithms, treatment regimens, and checklists to simplify routine care

• Referral systems in place for advanced care and completed cases

• Ongoing supervision, monitoring, and support

With these essential features in place, task shifting may increase health care access and use while reducing the costs of quality service.

While shifting tasks from specialized health sectors may help scale up care for conditions like HIV or cancer, such a shift will require a level of support similar to that needed when shifting from upper-level to lower-level providers to ensure quality care and good clinical outcomes. Providers in specialized health sectors (for example, HIV or other infectious diseases, cancer, or maternal health) have very specific skill sets developed over years of training and practice. In addition, these sectors often receive more support and funding for training, supplies, and equipment. Such support is often not available in more generalized health sectors.

During the planning stage, all levels of personnel and influential opinion leaders should be engaged in plans to task-shift, so every sector and key stakeholder sees how they will benefit. This may minimize turf battles, professional rivalries, and perceived loss of autonomy and control. Legal or regulatory issues may need to be addressed during planning if regulatory safeguards or restrictions prohibit certain types of tasks from being performed by lower-skilled workers.

Facilitating Task Shifting

Mobile Phones and Telemedicine

Mobile technology can facilitate task shifting by helping supply the kind of quality control necessary for delivery systems to work efficiently. Smartphones can be used to provide checklists for community health workers, track patients, obtain second opinions on complex diagnoses and treatments, and verify drug quality. SMS messaging, for example, can be used to verify if a medication is counterfeit or not.²

Telemedicine has greatly facilitated task shifting in some settings. By using telemedicine to provide second opinions and ongoing training, we can side-step limitations due to poor infrastructure, minimize the financial and time costs associated with seeking care far away, and support lower-level health workers to maintain quality care. It may help create trust in the health care delivery system by the patients who will see that though care is provided by lower-skilled providers, they can be “seen” by highly skilled providers when needed. With telemedicine, the same system is in place without the doctor having to be physically present. More communication is the key to improving health outcomes. The faster and more efficiently we can communicate health information, the better will be our health outcomes.

We must remember, however, that these technologies are facilitators of care, not replacements. There is still a need for face-to-face interactions for good patient care. If used properly, they can help us task-shift to become more efficient and effective and lead to better outcomes.

Bikes and Motorcycles

For task shifting to work well, supply chains must be well managed. Poor infrastructure can place great strains on supply chains serving rural health care providers in developing countries. Having skilled providers to care for the poor is only one part of the solution to bridging the health care gap. These providers must also have appropriate supplies and equipment to do their jobs right.

Clinicians and doctors have donned backpacks and satchels filled with tools to diagnose and treat diseases in rural areas not accessible by car. Some NGOs have tried to move more advanced points of care to the rural poor by using motorcycles and other modes of rapid transportation. Task shifting has the potential to help us reach even more people with even more health care services and products—but only if the workers we are shifting the tasks to can get where they need to go. Vehicles such as motorcycles and bicycles help facilitate the distribution of health care to the poor, and in doing so, help improve health outcomes.

Vehicles can be used to bridge the supply chain gaps that plague many communities in developing countries. Trucks and cars can ensure providers, especially those further down the hierarchy, have consistent access to supply distributors; this becomes especially crucial with illnesses like tuberculosis or HIV/AIDS. Patients with these infections need consistent access to care and treatment to avoid antibiotic and antiretroviral resistance.

Many places can be reached only by small vehicles like motorcycles and bicycles. Riders for Health, an NGO with operations throughout Africa, uses motorcycles to bridge links in strained supply chains in developing countries, allowing health providers to visit more patients, move deeper into rural regions, and respond more rapidly to medical emergencies.⁴ A bicycle can cover four times the distance a person can travel on foot and carry five times the weight.⁵

An innovative partnership between World Bicycle Relief, an international NGO started in the aftermath of the tsunami that hit Indonesia, and World Vision, an international faith-based organization with operations in ninety-seven countries, provided 23,000 bicycles to community-based care workers, prevention educators, and orphans with financial support from USAID.⁶ Bicycle Empowerment Namibia, an NGO based in Namibia, has built and distributed bicycle ambulances to transport sick and injured people in poor, remote areas to clinics and hospitals.⁷

These bicycle and motorcycle programs work because in addition to ensuring access to the vehicles, the programs also train mechanics to fix them when repairs are needed, creating local jobs.⁸ Riders for Health charges health ministries and other NGOs a small fee to train their health care workers in motorcycle repair and to perform regular scheduled maintenance. This model can significantly reduce repair costs and help health care workers consistently reach their patients. Riders for Health enabled the African Infectious Disease Village Clinics (AIDVC), a health care NGO in Kenya, to provide care to more than 90,000 people while operating from a central facility.⁹ It travels to bring care to its customers, rather than expecting the customers to travel to them. Together, by being innovative and entrepreneurial, Riders for Health and AIDVC saved lives.

Checklists

Simple clinical checklists can facilitate task shifting and help improve outcomes by ensuring consistency of care by health care workers. One of the areas where checklists have been shown to improve consistency of care is in pregnancy. Although more women in developing countries are delivering in hospital settings, there still has not been an appreciable fall in mortality.

To address this problem, the World Health Organization (WHO) developed the Safe Childbirth Checklist, which covers twenty-nine basic practices such as washing hands, assessing for postpartum bleeding, and breastfeeding within an hour of birth (Table 3). Consistency in doing these very simple practices helps avoid problems such as infections, uncontrolled bleeding, life-threatening hypertension, obstructed labor, and birth asphyxia. Adoption of the Safe Childbirth Checklist has resulted in a 150 percent improvement of adherence to basic procedures in a study conducted at an Indian hospital.¹⁰

Similarly, another checklist was developed by WHO to increase consistency and reduce complications during any surgery. This checklist covers nineteen basic items applicable to all surgeries.¹¹ Hospitals that tested the surgical checklist saw an increase in the likelihood of compliance with basic standards of care, resulting in dramatic drops in complications and surgical-site infection. Simple checklists like these can help ensure basic procedures are followed and therefore facilitate the shifting of more tasks to lower-skilled workers.¹²

Effectiveness = High Quality

Ensuring that health care products and services are effective is critical to making strides in global health. There is a constant tension between increasing scale and maintaining quality. High quality often requires more resources, which limits the ability to reduce costs and increase scale; however, poor quality can at best result in no improvement, and at worst it can kill.

Maximizing Efficiency & Effectiveness

Efficiency: The Pros and Cons of Specialized Services

Either general or specialized health services can use task shifting. We need both kinds of services, and we need to know when to use each (Table 4). General health services provide care for a diverse patient population and can tackle a variety of common diseases. They may allow care to be more tailored to the specific health needs of patients. Within-system referrals and information communication can be streamlined, allowing for better care for those who have multiple problems. However, improving generalized care and treating a vast array of conditions require a variety of supplies, equipment, and staff skills, potentially creating inefficiencies in the system.

Indeed, many of the disadvantages of general care are the advantages of specialized care. A generalist can perform a wider variety of routine care, but the specialist may perform a more select group of specialized tasks more efficiently and with higher quality. Specialized care for conditions such as cancer, HIV, and other specific medical conditions may help bring not only the benefits of specialization, but also increase efficiency and lower costs.

To maximize efficiencies, systems must balance the need for efficient specialized care and important generalized care. Through partnerships, as well as a robust private sector, system imbalances can be fixed. If an area has enough cases of a particular condition for a specialized service to create value in the system, it may be profitable to create such a service. Otherwise, it may be more advantageous or profitable to offer generalized services.

Table 4 Comparison of General Health Care and Specialized Health Care

It is much more likely that general health care services will be provided by government and that specialized health care services will be provided by for-profits, with NGOs providing both at moderate levels. However, it is possible for any of the three to provide either general or specialized health care. Where there is demand, it will be common to find specialized health care provided by private organizations; where there is less demand for specialized care, it may be more advantageous for private organizations to supply general health care. Indeed, one is much more likely to find more general services in rural areas and more specialized services in urban areas, no matter how wealthy the country.

Elements of both general and specialized health care can be task-shifted to lower level providers, including community outreach workers and microentrepreneurs. Living Goods, an NGO operating in Uganda, and Project Shakti, a program run by Hindustan Unilever, show that networks of microentrepreneurs can distribute a wide variety of general health products. Another organization, VisionSpring, has a network of microentrepreneurs that provide a very specialized set of products, eyeglasses, to low-income communities.

More effective distribution systems help save lives by making disease prevention and medical care more available and accessible to those in need (Table 5). Because global health challenges occur on such a large scale, improved systems need to be cost-effective, scalable, and financially sustainable. To solve the challenge of availability and accessibility, these distribution systems must rely heavily on a sustainable model that integrates and complements governmental and NGO support and facilitates the coordination of products and services. With this approach, increased scale improves cost efficiency, access to products and services, financial sustainability, and societal health and well-being. To treat diseases and prevent their spread, distribution channels must provide education and supplies for treatment and prevention, along with basic, advanced, and emergency treatment.

Education can inform people about many aspects of diseases: how they are transmitted and can be prevented, how health care supplies can help people stay healthy, how to recognize symptoms, and when to seek more intensive diagnosis and treatment. Health supplies—including condoms, sterile delivery kits, soaps, and insecticide-treated bed nets—can help prevent the spread of diseases. Diagnostic tests can help clinicians determine if treatment is necessary and, if so, what type to provide, and thus act to facilitate distribution. Clinicians trained in basic diagnosis and treatment can provide the most care and treatment. Trained providers can safely prescribe basic medications. Each level of the health system provides multiple products and services to address different diseases.

Specialized Hospitals

Hospitals are at the top of the distribution tier. To get more advanced treatment and emergency care, people in low-resource settings need access to hospitals. By shifting some of the burden for basic and routine prevention and care to franchised and other clinics and pharmacies, hospitals can focus their attention on the most complex cases. Doing so relieves stress on the commonly overcrowded and understaffed public hospitals in developing countries.

Table 5 Health Service Distribution

Much of the burden for hospitals in developing countries can be alleviated through more effective distribution systems for products and services, as described earlier. Hospitals must be integrated into the larger distribution system and able to refer patients to micropharmacies, microclinics, and entrepreneurs in patients’ communities if they are to make effective use of their highly trained employees and limited space. As much as possible they must shift the burden of care to others to make the best use of their expensive facilities and skilled personnel. The integrated system we suggest offers many possibilities for such shifts. For example, patients can see clinicians, pharmacists, or even microentrepreneurs for most of their needs; only for the most complex and unusual cases do they need to visit a hospital. Making sure the poor have other available resources for receiving primary health care is an important step toward integrating hospitals into a comprehensive distribution system.

Specialized hospitals focus on a particular disease, condition, or ailment, and their factory-like operations can drive down costs. They also use task shifting within their facilities to match the complexity of the task with the skill level of the employee.

The benefits of specialization have long been known, and specialization among health workers and hospitals has the same kinds of benefits. A specialized hospital can develop an expert staff through the increased number of procedures done per physician, and the fact that they can streamline their processes allows them to do far more procedures than can an average hospital. Economies of scale allow bulk purchasing, which reduces input costs.

Of course, specialization means such hospitals will need skilled laborers. And with specialization you need large numbers of patients to create economies of scale. They will therefore typically be found in urban areas.

To reduce costs, mid-level personnel instead of physicians can be used for basic tasks and telemedicine and/or traveling clinics can be used to reach rural communities. Efficient and effective services are particularly important where there is high demand.

Creating Demand

There is no shortage of simple, inexpensive solutions to solve health problems. Condoms can reduce unwanted pregnancy and the transmission of sexually transmitted infections, including HIV—and are cheap and easily distributed.¹³ Maternal bleeding after childbirth—a major killer of mothers—can be prevented with the use of inexpensive and easy-to-use medication.¹⁴ Breast milk is free, nutritious, and transfers immunity from the mother to her child.¹⁵ Water can be purified with inexpensive and easy-to-use chlorine tablets.¹⁶ Sleeping under a mosquito net greatly reduces the chances of getting malaria.¹⁷ And exercise, a plant-based diet, smoking cessation, and even a daily aspirin can drastically reduce the chance of having a heart attack, stroke, and some cancers.¹⁸ Although these solutions exist, it is critical to create demand for their use if they are to save lives.

Businesses are particularly skilled at creating demand, not only for their own product, but for their particular variety of the product—even when it is nearly identical to competitors’ products. When people buy everything from aspirin to an automobile, most customers don’t just grab the first that they find; they gravitate to a particular one. That is generally because demand has been created for that product. We’ve been convinced that we not only need to have the product, but believe that one brand is superior to the others.

Creating Demand

Businesses have much to teach about demand creation. And their lessons are not lost on those working to create global health impacts.

Creating demand for health care products and services can be accomplished through a variety of channels. Generating awareness and providing clear information on health issues and solutions can help to dispel long-held myths. Public awareness and social marketing campaigns using mass media can improve awareness and knowledge within communities.¹⁹

Although these activities can take place on a regional, national, or international level, studies indicate that interpersonal communication is most effective in creating change and catalyzing action. We are most likely to listen to those we know or believe. For example, people will be more swayed by a message delivered by a community health worker they know well and who lives in their community than one delivered by a health worker who visits just to deliver the health message. Likewise, these same community members are more likely to be influenced by information delivered on a local radio station that specially targets that community than by a national campaign.²⁰

Regardless of the group or population size, there will generally be subgroups or subpopulations. Although the difference between them may not be apparent to people outside the group, to those on the inside the differences are clear and meaningful. As a result, when we attempt to generate demand for a health care project or service, particularly one where the benefit is not readily apparent, the differences between the subgroups can make a tremendous difference, and we may need to approach each group differently.

For example, for a variety of reasons the foreskin increases susceptibility to HIV transmission, and multiple studies have shown that circumcision can reduce a man’s risk for acquiring HIV by 60 percent.²¹ It is a one-time procedure that can offer reduced risk of acquiring HIV for the rest of the person’s life. But creating demand for this procedure, no matter how beneficial, would require particular creativity, as few—exceedingly few—men would be willing to have their foreskin cut off without very persuasive arguments delivered in the right way, by the right person, and at a time they are receptive to both listening to and acting on the information provided.

Consider Nyanza, one of eight provinces in Kenya and home to the third-largest ethnic group in the country, the Luo. Nyanza is a Bantu word for “large mass of water,” for one of the things that makes the province distinctive is that it surrounds Lake Victoria. Unfortunately, it is distinctive in another way as well—the Luo men there have an HIV infection rate nearly twice the rate than the rest of the country.²²

In Kenya, 80 percent of males are circumcised. However, circumcision rates vary highly across cultures and geographies. In Nyaza, 52 percent of the men from the Luo ethnic group were uncircumcised. These men also had the highest prevalence rate of HIV at nearly 15 percent.²³ As a result, the Ministry of Health launched a campaign to offer men voluntary circumcision. They initially engaged traditional leaders and mounted an awareness campaign to educate the community. They received large numbers of men who came in to be circumcised. However, as soon as the campaign ended, so too did high demand. After looking at their data, they realized that the campaign was effective in reaching young men, but not older men.²⁴ In subsequent campaigns, they have been able to reach new subpopulations by making slight changes in the message and outreach.

Demand creation cannot be static. It must be dynamic and changing—just as dynamic as the people they intend to reach and the communities in which they live. Given the subtle but important difference between subgroups and subpopulations and the need to get information out to communities, entrepreneurial community members are often effective at identifying the need and meeting it.

Increasingly NGOs and governments view these populations as customers, even when the product or service they are “selling” is lifesaving and at no cost to the customer. Unless NGOs or governments create demand for a product or service, additional supply will not be used. For example, in many countries over 40 percent of live births are attended by traditional birth attendants, even though traditional birth attendants may have little formal training and poor outcomes, and may even be banned from performing services by the government.²⁵ Many of these traditional birth attendants recognize that their customers have many options—other attendants, as well as NGO and government clinics, many of which are free—so like the entrepreneurs they are, they make their services accessible (in the home), acceptable, and affordable (for example, some may be willing to barter for payment).

Just as customers select options that may not work well, they too often ignore solutions that can save a life. For example, even though a simple salty-sweet solution composed of salt, sugar, water, and a zinc tablet costs only pennies and could prevent many of the 650,000 deaths due to diarrhea in children under five, it is often not used by many mothers in developing countries.²⁶ Entrepreneurs in developed countries, on the other hand, have created huge demand for a similar solution, but for a condition that is rarely life threatening—sweating caused by exercise. Sports drinks like Gatorade, Powerade, and many others are basically oral rehydration solutions—salty-sweet products used by many weekend athletes and others to help rehydrate. These sports drinks generate over $4 billion in annual revenue!²⁷

Most of these products—condoms, chlorine tablets, bed nets, and aspirin—can be distributed right to those who need them using micropharmacies, health extension workers, or even a variety of microentrepreneurs, from door-to-door salespeople to a pharmacist on a bicycle. These methods can bring these easy solutions directly to the people and give entrepreneurs the opportunity to increase their income, improving both community health and wealth.

However, we need more than inexpensive and easy-to-deliver solutions—we need demand for a solution. Without demand, products and services won’t be used, regardless of how inexpensive or readily available they are. People generally demand what they value. That means they must be educated on the value of various health products and services.

Champions

We all have people we admire, people we look up to, people whose opinions matter enough to us so we are willing to change our behaviors. It may be a friend, a teacher, a parent, a leader, or even a celebrity. These champions may be critical in helping to create demand for health products and services. Thus, it is important to have champions at local, regional, national, and international levels to create behavioral changes that will benefit people’s health. These champions must be able to advocate for issues, marshal resources, and break through barriers. They must be able to influence policy and behavior in positive ways. And they must be able to give voice to the issues for those who are not heard and are most vulnerable, those who need interventions the most.

In engaging champions it is important to be clear and specific on the goals to achieve, to have messages coincide with pertinent and relevant events, and to use a variety of ways of getting the message out through a variety of champions. It is critically important that the issue be clearly defined for there to be impact. Champions will need to be provided with the data needed to support their arguments. And it is important for the organization to have a clear message if it is to have champions at many levels repeating that same message effectively.²⁸

Champions should have:

• Focus—know the goal and target

• Clarity—be able to communicate the message clearly

• Credibility—be seen as a reliable source

• Relevance—be able to connect with people in ways that offer solutions to problems that are relevant to their lives

• Good timing—be able to articulate the message at a time when it can be linked to other critical issues and have the maximum impact

• Commitment—be dedicated to the issue and be willing to champion it over time ²⁹

These characteristics can be helpful in creating demand regardless of whether the focus is international or local, within one or multiple organizations.

Vouchers

Vouchers are like grocery store coupons: they can increase interest in a health product or service by reducing costs to the redeemer. The voucher can be used by patients to decide if, when, and where to get care. In addition, patient access to vouchers can increase competition among providers to give low-cost, quality care. Vouchers can create compelling incentives for patients to seek the care they need. While there have been debates about the relative merits of vouchers versus market-based strategies,³⁰ these approaches are influenced by local context and can complement each other.³¹

There are many compelling examples across the globe of effective implementations of vouchers. For example, in Tanzania they increased the use of insecticide-treated nets,³² they have helped increase deliveries with birth attendants in Bangladesh,³³ and increased the use of sexually transmitted disease services for adolescents in Nicaragua.³⁴ In one voucher experiment in Uganda, mothers who were given vouchers to take motorcycle taxies to the clinic for prenatal care, delivery, and postnatal care were more likely to go to the clinic to receive these services. In the intervention, deliveries to clinics increased from 200 per month to 500 per month. In addition, more women came in for four or more prenatal visits.³⁵ In another study in Bangladesh, it was discovered that women with vouchers were 3.6 times more likely to have a skilled health person during delivery, 2.5 times more likely to deliver the baby in a health facility, 2.8 times more likely to receive postnatal care, twice as likely to get prenatal care, and 1.5 times more likely to seek treatment for obstetric complications.³⁶ Similar findings have been found in other voucher studies.³⁷

The Need for Accountability

Accountability is essential. It demonstrates how actions and investment translate into tangible results and better long-term outcomes. Establishing clear goals and targets aligned with an organization’s strategy supports effective decision-making. Regular monitoring and evaluation let leaders identify when an organization’s activities are not on track to meet targets, thereby cueing intervention. Evaluation efforts also help leaders determine the cost-effectiveness of program activities and when to reallocate limited resources.

Accountability

Accountability measures are needed at all levels, from the international community down to individual microenterprises. At the international level, we have seen goal-making and tracking efforts take shape through the Millennium Development Goals. These eight goals, agreed upon by 189 countries in 2000, laid out specific and measurable targets with an explicit deadline of 2015. Through regular monitoring and publishing of reports, international leaders are able to identify when countries or regions are no longer on track to meet targets.³⁸

Breaking the Bottleneck

Shifting tasks from a higher-level provider to a lower-level provider and from one setting to another may increase efficiency, reduce costs, and remove bottlenecks. Task shifting requires that lower-skilled providers be well trained and supported. Simplifying tasks, putting referral systems in place, and providing ongoing supervision can help task shifting be successful. Success in global health will also require maximizing efficiencies and effectiveness of interventions, and creating demand for them as well. Patients must be seen as customers, regardless of who covers the cost of services. Finally, goals, targets, and systems of accountability must be put in place so that we know where we’re going and can tell when we get there. Accountability helps ensure that we measure what matters to achieve impacts in global health.