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Walking in Other People’s Shoes

Task shifting in low-resource settings means transferring tasks from one health care worker to another—and it comes with challenges.

I just completed an evaluative survey about an email-based community of practice—Healthcare Information For All by 2015. It occurred to me that one of the critical values of the community is that it enables me to ‘hear’ diverse opinions on health care-related issues. For example, earlier this month, one of the correspondents wrote about the challenges of introducing task shifting in low-resource settings. It wasn’t the challenges of training or safety that captured his attention but the inflexibility of health professionals that can prevent task shifting. Nigerian professor of surgery Shima Kaimom Gyoh wrote:

“They regard it as a degradation of their profession and an act that would further reduce the little resources governments devote to the development of their professions.”

Task shifting in low-resource settings means transferring tasks from one health care worker to another. It is often a transfer from a higher to a lower cadre worker, who is then specially trained to take on the new task. Interestingly, in both the United Kingdom (UK) and the United States (US), the transfer of tasks from physicians to nurse practitioners and physicians’ assistants has been common over the last 40 years. But it has not been without professional challenges, as one profession fears erosion of its role by another.

When I was a nurse practitioner, many years ago, I thought physicians were terribly unreasonable to protest about the extent of my training and the care I gave. That was until the day that a paramedic came into my clinic to tell me that he did not agree with my diagnosis because he had listened to the patient’s chest. Then I understood my physician colleagues as I thought to myself: “What is this paramedic thinking? Listening to a chest?” Of course, it is now commonplace for paramedics in the UK and USA to do this, and it has saved many lives. But, then, it was task shifting, and I considered it a threat to my professional role.

How easily we forget.

Recently, I was working on health workforce development, and I suggested to the nurses’ professional association in one low-resource country that the best thing they could do was introduce health care assistants. These assistants could take on many tasks in hospitals and thus free up the nurses for more and different work. It was as though I had asked them to work as volunteers; they were horrified. The argument they used was exactly the same as Dr. Shima Gyoh—if they hired assistants, the government would want to invest in the cheaper cadre, and the nurses might lose their jobs. My logical and evidence-based answer was well and truly ditched!

Evidence-Based Decision Making

Sitting on the sidelines, as it were, it seems a simple solution is to look at evidence on the effectiveness of task shifting and then suggest implementing it because it works. Of course, task shifting makes sense to some but not to everyone. Negotiating good solutions means listening and understanding other people’s views, even when they are vastly different from our own or from the evidence of what will work, then finding a path that can make as many people as possible feel like winners. This is why we seek to convene stakeholder groups—people who each hold potentially different views about the same issue. In health workforce development in general—not only task shifting—the number of interested parties that have to be satisfied can be daunting.

Several years ago, I worked on finding solutions to the problem of health worker migration from poorer to richer countries. I rapidly discovered that although this seemed, to the international community, to be harmful to the poorer countries, to the migrants and their families, it could be a choice that enabled them to escape dreadful working conditions and low salaries. Migration gave them a chance at prosperity for themselves and their families, through the money they sent home and the opportunity to work in well-equipped hospitals with more room for professional development. When we are trying to find ways of influencing health workers to behave as we want them to—that is to stay in rural areas, not leave the country, or stay in the health sector—it is essential to acknowledge that each health worker is making an individual choice, based on a set of options that are a combination of economic, social, and psychological factors and family choices.[1] The views of the Minister of Health will differ considerably from those of the health worker. The minister’s imperative is to provide equitable health services to the whole population—a mission that will be compromised by not having enough health workers in the country. And even though the World Health Organization has developed guidelines to help countries control health worker migration, those guidelines will not factor into the choices of individual health workers.

Having an Influence

It is easy to feel defeated by the challenge of trying to influence a large group of individuals to make certain choices, and this does account for at least some of the complexity of workforce development, be it task shifting, retention, or deployment of health workers. We are, after all, working with quite a crowd—politicians, policy makers, public and private organizations, health workers and their associations, and with the users of health services: communities, families and individuals. Yet, if we are to achieve real, long-lasting change, we need to find a way to listen to all the views and to develop appropriate responses. If we do not, change will be much slower, and there could be rebellion.  

Convening stakeholder groups has almost become a ritual—it happens at the beginning of every project and is included in every proposal. But it could be the most important event that happens in a project: we need to pay more attention to that process and set up meaningful dialogue, where we learn to think together creatively towards the solutions that we all want and will work for.

[1] Connell J., Brown R. 2004. The remittances of migrant Tongan and Samoan nurses from Australia. Human Resources for Health 004;2:2. Available at: