Transactions of the Royal Society of Tropical Medicine and Hygiene (2009) 103, 549—558
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/trst
Task shifting in HIV/AIDS: opportunities, challenges
and proposed actions for sub-Saharan Africa
R. Zachariaha,∗, N. Fordb, M. Philipsc, S.Lynchb, M. Massaquoid,
V. Janssensa, A.D. Harriese,f
aMédecins Sans Frontières, Medical Department, Brussels Operational Center, 68 Rue de Gasperich,
bMédecins Sans Frontières, South African Medical Unit (SAMU), Johannesburg, South Africa
cAnalysis and Advocacy Unit, Médecins Sans Frontières, Brussels Operational Centre,
dMédecins Sans Frontières, Thyolo District, Blantyre, Malawi
eInternational Union against TB and Lung Disease, Paris, France
fLondon School of Hygiene and Tropical Medicine, London, UK
Received 26 May 2008; received in revised form 26 September 2008; accepted 26 September 2008
Available online 6 November 2008
shortage of health workers. The shortage is compounded by a high burden of infectious dis-
eases; emigration of trained professionals; difficult working conditions and low motivation. In
particular, the burden of HIV/AIDS has led to the concept of task shifting being increasingly
promoted as a way of rapidly expanding human resource capacity. This refers to the dele-
gation of medical and health service responsibilities from higher to lower cadres of health
staff, in some cases non-professionals. This paper, drawing on Médecins Sans Frontières’ expe-
rience of scaling-up antiretroviral treatment in three sub-Saharan African countries (Malawi,
South Africa and Lesotho) and supplemented by a review of the literature, highlights the main
opportunities and challenges posed by task shifting and proposes specific actions to tackle the
challenges. The opportunities include: increasing access to life-saving treatment; improving
the workforce skills mix and health-system efficiency; enhancing the role of the community;
cost advantages and reducing attrition and international ‘brain drain’. The challenges include:
maintaining quality and safety; addressing professional and institutional resistance; sustaining
motivation and performance and preventing deaths of health workers from HIV/AIDS. Task shift-
ing should not undermine the primary objective of improving patient benefits and public health
© 2008 Published by Elsevier Ltd on behalf of Royal Society of Tropical Medicine and Hygiene.
Sub-Saharan Africa is facing a crisis in human health resources due to a critical
∗Corresponding author. Tel.: +352 332515; fax: +352 335133.
E-mail address: firstname.lastname@example.org (R. Zachariah).
0035-9203/$ — see front matter © 2008 Published by Elsevier Ltd on behalf of Royal Society of Tropical Medicine and Hygiene.
550R. Zachariah et al.
‘‘I have been working as a nurse since 1971 and what we
are seeing is an emergency. There are too many patients
for too few clinicians and nurses, and the pressure is too
much. Look at this overcrowded ward, look at all these
patients! Tonight there will be one nurse to look after all
of them. What kind of nursing is this? How can we ever
give patients the care they need? If we are to solve this
problem we will need to have many more health workers,
better conditions of service, better training and incen-
tives. Otherwise nothing will change!’’ (Christian Chingi,
Nurse Coordinator, Thyolo District, MSF Malawi).
At the end of 2006 the WHO estimated that there are 57
countries facing critical shortages of health workers. Over
half of them (36) are in Africa and an additional 2.4 mil-
lion doctors and nurses are needed to meet the Millennium
Development Goals.1In sub-Saharan Africa the situation
constitutes a human resource crisis due to significant emi-
poor salaries; low motivation and a high burden of infectious
diseases, particularly HIV/AIDS, among the workforce.1—3
Sub-Saharan African countries are hardest hit in terms of
emigration of trained health staff, both to South Africa
as well as to countries in the West. Malawi, for example,
has two doctors per 100000 population, which is 10 times
below the WHO minimum standard, while South Africa has
77 doctors per 100000 population. In Western countries that
attract health workers from countries such as Malawi the
availability of doctors is even higher at 256 per 100000 in
the USA, 214 in Canada and 230 in the United Kingdom. Sim-
ilarly, the number of nurses per 100000 population is 59 in
Malawi compared with 937 in the USA, 995 in Canada and
1212 in the United Kingdom.4,5
The scale-up of antiretroviral treatment (ART) in sub-
of delivering and sustaining this life-saving intervention.6—8
Consequently, the delegation of medical and health service
duties from higher to lower cadres or new cadres, known
as task shifting, is increasingly promoted as a coping mech-
anism for general and specific human resource shortages.
Table 1 classifies different types of task shifting commonly
seen in Africa.
The concept is not new and has been employed in
the past to support a range of health service demands.
Examples include surgical technicians in Mozambique;9
nurse-anaesthetists and clinical officers in Malawi, Ghana,
Tanzania and Zambia;2,10and the deployment of community
health workers in multiple countries.11Over half the coun-
tries in sub-Saharan Africa have recourse to non-physician
clinicians.12Recently, task shifting has gained considerable
momentum, with the WHO releasing specific guidelines and
recommendations on task shifting.13In as much as task
shifting raises many potential opportunities for the health
system, there are associated challenges which need to be
addressed in order to ensure that this mechanism does not
undermine the primary goal of improving patient benefits
and public health outcomes.
This paper, drawing on Médecins sans Frontières’ (MSF’s)
experience of scaling up ART in three sub-Saharan African
countries (Malawi, South Africa and Lesotho), and supple-
mented by a review of the literature, highlights the main
opportunities and challenges posed by task shifting and pro-
poses specific actions to tackle the challenges.
2. Opportunities presented by task shifting
2.1. Improves access to life-saving treatment and
The task-shifting process requires the development of stan-
dardized protocols, including simplified clinical guidelines,
simplified recording and reporting systems and simplified
monitoring and evaluation. These measures facilitate the
decentralisation of interventions to lower levels of the
health system, and are associated with improved access,
increased national coverage and better geographical equity,
the latter parameters being of key importance in ART scale-
This is illustrated in Malawi, where the national ART
scale-up plan launched in 2004 involved non-physician clini-
cians providing ART.7,14By September 2007, 130488 patients
had been started on ART at 154 health facilities (Ministry of
Health ART Quarterly Report: Results up to 30 September,
2007). Task shifting, coupled with a simplified and standard-
ized public health approach and strong supervision, made it
possible to scale up ART with acceptable quality standards
resulting in many lives saved.7
In Malawi, Lesotho and in Lusikisiki, South Africa, nurses
initiated and managed ART at rural primary health clin-
ics with support from mobile medical teams who provided
clinical mentoring. This enabled access for patients who oth-
erwise might not have received the treatment they needed.
When task shifting from doctors to nurses was reversed
in Lusikisiki patient enrolment rates dropped precipitously
2.2. Optimizes skills of the health worker team to
cope with growing patient loads
Task shifting stimulates the creation of multidisciplinary
teams with a better strategic skills mix.16For example, a
model of HIV care in which nurses initiate ART and doctors
supervise and manage complex cases is being promoted by
(ART) at clinics in Lusikisiki, South Africa, October 2004—June
Quarterly initiation of antiretroviral treatment
Task shifting in HIV/AIDS in sub-Saharan Africa 551
Types of task shifting commonly seen in Africa13.
Type of task shiftingDefinitionExample
Type I The extension of the scope of practice of
non-physician clinicians in order to enable
them to assume some tasks previously
undertaken by more senior cadres, e.g. doctors
The extension of the scope of practice of
nurses and midwives in order to enable them
to assume some tasks previously undertaken by
The extension of the scope of practice of
community health workers or lay providers in
order to enable them to assume some tasks
previously undertaken by more senior cadres,
e.g. nurses and midwives, non-physician
clinicians or doctors
People living with HIV/AIDS, trained in
self-management to assume some tasks related
to their own care that would previously have
been undertaken by health workers
The extension of the scope of practice of other
cadres that do not traditionally have a clinical
function, e.g. pharmacists, laboratory
technicians, administrators, record clerks
Clinical officers deciding eligibility and
prescribing ART (Malawi)
Nurses treating opportunistic infections and
prescribing ART (Botswana, Ethiopia, Uganda,
Community health workers providing ART
counseling and HIV testing (Uganda, Rwanda,
Provision of basic HIV support, treatment
adherence and psychosocial support
(Botswana, Kenya, Nigeria, South Africa)
Record clerks filling in basic patient
information and measuring body weight at HIV
ART: antiretroviral treatment.
the WHO.13In Botswana,17Mozambique,18Malawi (A.D. Har-
ries, unpublished observations), Lesotho and the Democratic
Republic of Congo (N. Ford, unpublished observations), this
strategy has met with success: nurses have reduced the
dependence on doctors by taking on clinical tasks such as
determining ART eligibility; prescribing first-line regimens;
and managing follow-up and common side-effects of med-
ication, while senior clinicians manage complicated cases.
An overview of how a team of health staff, community work-
ers and people living with HIV/AIDS either changed their
roles or took up new roles within a multidisciplinary team is
given by the HIV/AIDS programme in Lusikisiki, South Africa
2.3. Engages the community to address health
Communities are increasingly recognized as an underex-
ploited resource in the delivery of ART. Community health
workers have had a significant positive impact, particu-
larly on reducing mortality linked to childhood pneumonia,20
malaria21and tuberculosis (TB).22In HIV care the deploy-
ment of lay counsellors has resulted in a dramatic uptake
of HIV testing services in Thyolo, Malawi (Figure 2),23
Lusikiski, South Africa,19and Lesotho.8Communities can
also contribute in a comprehensive manner to ART deliv-
ery as seen in Malawi (Table 3).23,24Community workers
also have a positive influence on health-seeking behaviour
among people with HIV/AIDS, help to reduce stigma and
discrimination24,25and often play a critical role in adherence
support.26People with HIV/AIDS have also been effectively
mobilized as partners in the provision of care. One pro-
gramme that trained people with HIV/AIDS to screen for
signs and symptoms of immune deficiency and to refer peo-
ple to hospital if they were not on prophylaxis resulted in a
40% increase in those receiving co-trimoxazole and flucona-
2.4. May provide cost benefits for patients and
Both the cost of initial training and the remuneration of
medical assistants and clinical officers are lower than for
doctors, especially as the education and pre-service train-
ing periods are shorter. Data from five sub-Saharan African
countries show that training time and costs for non-physician
clinicians are lower than for doctors12and they can be as
on the coverage of HIV testing services, Thyolo District, Malawi,
Impact of task shifting from nurses to lay counsellors
552 R. Zachariah et al.
Traditional roles of health staff in HIV/AIDS care compared with roles of health staff in the Lusikisiki program19.
Category Traditional role Role in Lusikisiki
Management of opportunistic
Do not interact with clinic
Prepare individuals for ART
Monitor ART recipients
Manage drug supply
Mobile visits: see only problem cases
Clinic supervision and mentoring of
Part of multidisciplinary team
Manage opportunistic infections
Perform clinical staging
Initiate and monitor ART
Manage drug supply
Supervise adherence counsellors
Prepare individuals for ART
Empower ART recipients
Run ART support groups
Collect data (ART registers)
Mentor community caregivers
Trace individuals who default
Provide mentoring to pharmacist’s
Manage drug supply
Identify individuals who default
Run HIV support groups
Manage drug supply
Not utilized or play a limited role
(dispense drugs only under strict
pharmacist supervision at the
DOT (recall of individuals who
Support groups; community
committees; activists; people with
Prepare individuals for and monitor
adherence to ART
Health promotion in the community
Recall individuals who default
React to bottlenecks
Advocate for better service delivery
ART: antiretroviral treatment; DOT: directly observed therapy; VCT: voluntary counselling and HIV testing.
much as 10 times less expensive, with comparable perfor-
mance, as seen in Mozambique.9Asimplified approach might
also rationalise the use of diagnostic tests and sophisti-
cated equipment,28although this potential advantage might
be negated by individuals with weaker clinical acumen
who would have an increased reliance on such tests and
equipment. While these costs do not include the cost of
systems adaptations to support task shifting, such as super-
vision and a strong referral system, the overall costs are
likely to remain lower, particularly at the lower end of the
health cadre spectrum.
From a patient perspective, travel and indirect costs
are also expected to be lower since people generally live
a shorter distance from a nurse- or medical assistant-run
facility than a doctor-based facility.2Travel costs have been
associated with a high rate of defaulting from HIV care.29
It should be recognized, however, that cost saving alone is
not a valid reason for task shifting, as in-service training
and supervision may negate much of the saving made by
switching to lower cadres. Above all, compromising on qual-
ity of care should not be tolerated at any cost.
2.5. Increases retention and reduces the risk of
international ‘brain drain’
Task shifting can meet specific needs by establishing new
cadres that are better retained in rural and hardship areas
because their qualifications are generally not recognized
internationally. The ‘brain drain’ of health staff from Africa
to developed countries is a major factor contributing to the
current human resource crisis, and this local specificity sup-
ports staff retention.3A follow-up study of a task-shifting
programme to engage non-physician clinicians in obstetric
care in Mozambique found that after 7 years around 90%
of non-physicians were still working in the district hospi-
tal while almost all of the doctors had left.30Finally, task
shifting can be expected to support the retention of existing
Task shifting in HIV/AIDS in sub-Saharan Africa 553
Community support for antiretroviral treatment (ART) delivery in Thyolo District, Malawi24.
Management of opportunistic infections
Home-based diagnosis and management supervised by
Symptomatic treatment for diarrhoea, fever, oral candida and
common skin conditions
Monthly supply of CTX prophylaxis for individuals too ill to
travel to health facilities
Referral of patients with worsening signs of dehydration
despite oral rehydration, persistent difficulty in swallowing
despite medication for oral thrush, reduced level of
consciousness, progressive worsening of headache, increased
breathlessness despite CTX prophylaxis, cough >3 weeks, focal
palsies, violet discoloration of palate or skin
One-to-one supportive counselling for CTX and ART
Early recognition and referral of individuals having possible
drug reactions to ART, CTX or anti-TB treatment
Active tracing of individuals who do not attend scheduled
follow-up visits or drug collection appointments
Distribution and monitoring of supplementary dry rations to
FCG’s provide HIV education; counselling on ART, CTX and
anti-TB treatment; early recognition of possible drug
reactions; nutritional supplementation and palliative care
Various forms of information, education and communication as
well as vocational and income-generating activities
Recognition and referral of individuals with risk signs
to community nurse or hospital
Counselling on drug reactions and early referral
Support to family caregivers
Community mobilization and awareness
CTX: co-trimoxazole prophylaxis; FCG: family caregivers.
cadres by reducing burnout and increasing morale through
more efficient team management of patient case-loads.
3. Challenges and proposed actions
3.1. Quality of care and safety
Evidence from Lusisiki in South Africa and Thyolo in Malawi
showed that the use of nurses (Type II task shifting)19and
community cadres (Type IV task shifting)24in the delivery of
ART significantly improved overall ART outcomes (Table 4).
Thus, from a public health perspective, the use of task shift-
ing for HIV/AIDS care at two relatively new levels of the
health system (health centres and the community) did not
compromise quality but, on the contrary, was associated
with significantly better ART outcomes.
There is a wealth of supportive evidence from outside HIV
care. In a study comparing medical assistants with doctors
and looking at the quality of child care in Malawi, doc-
tors, medical assistants and nurses were found to have a
similar level of diagnostic ability when examining children
under 5 years of age.31One study looking specifically at
the delivery of HIV services found that the quality of HIV
care provided by non-physician clinicians was similar to that
provided by medical doctors who were HIV experts, and bet-
ter than that provided by medical doctors who were not
HIV experts.32In Mozambique a detailed assessment of over
10000 surgical interventions by medical assistants showed
that quality (measured in terms of complication rates) was
effectively identical to interventions by doctors.9A study in
Benin showed that higher percentages of children with diar-
rhoea received oral rehydration therapy and more children
with fever were appropriately treated with a recommended
antimalarial drug by nursing aides than by nurses (interme-
diate) or physicians (worst performance).33,34
These findings show the important contribution of non-
professional health workers (Type IV task shifting) to
achieving child survival goals, not because they can per-
form clinical tasks better than professionals (they almost
certainly cannot) but because they may adhere more strictly
to simple clinical practice guidelines.
3.1.1. Proposed actions
Patients, health staff and policymakers should be involved in
setting measurable targets and indicators for an acceptable
level of quality for a given intervention. Such targets and
indicators can serve as benchmarks for supervision, moni-
toring and evaluation of specific interventions, which in turn
serve to protect patients and providers. Evidence and expe-
rience suggest that inappropriate curricula, poor supervision
and weak regulatory mechanisms affect the quality of care
provided by any cadre. Examples include the poor ability
of medical and nursing graduates in Ghana and Tanzania
to deliver quality family practice2and medical assistants
persisting with unconventional treatment patterns after in-
Strong supportive supervision and continuous education
are proven strategies to improve patient outcomes.36In
Malawi, Lesotho and Lusikisiki MSF provided theoretical and
practical training for nurses, introduced tools adapted for
nurses and provided on-site clinical mentoring, with good
554 R. Zachariah et al.
Antiretroviral treatment (ART) outcomes involving task shifting at community and health centre levels.
Thyolo district, Malawia,24
Lusisiki, South Africab,19
health workers n (%)
health workers n (%)
centres n (%)
Placed on ART
Alive and on ART
Lost to follow-up
7 (0.8) 25 (3.4)<0.001——
CD4 count at 12 months
Viral load at 12 months
NA: not available.
aThyolo district: patients registered between April 2003 and December 2004.
bLusisiki district: patients registered between January 2004 and June 2005.
associated patient outcomes.8,19,24Accreditation of individ-
uals and sites is one way to ensure that health workers have
the necessary skills and capacity for specific interventions
and that these are maintained over time. If standards are
not met accreditation should be suspended or removed, as
is practiced in Malawi for the delivery of ART.14Registra-
tion of health workers by a licensing or regulatory authority
legitimizes a cadre and ensures institutional responsibility
for the performance of that particular cadre.
3.2. Resistance to task shifting
Experience shows that task shifting may not be readily
accepted by various professions. Doctors and pharmacists
have objected to the delegation of their tasks to what
they perceive as ‘half-baked doctors’;12nurses have resisted
taking on doctors’ roles without commensurate salary
increases;2professional groups have objected to a potential
loss of earnings where remuneration includes a fee-for-
services component;37professional councils and associations
have in some instances resisted delegation of tasks to lower
cadres8,38and finally, the additional supervisory responsi-
bilities that come with shifting tasks from higher to lower
cadres have also met with resistance.
Informal task shifting, as an ad hoc response to need
rather than as an explicit policy, may result in the
proliferation of new cadres with vague or overlapping
responsibilities, which are then questioned by existing staff,
policy-makers and the patients themselves, as seen in
3.2.1. Proposed actions
needed to deliver a particular intervention; which person-
nel currently undertake these tasks; what are their annual
productivity and attrition rates and who could safely do
these tasks instead?
Once tasks have been defined, appropriate training (pre-
ages need to be established.38Inter-cadre relationships can
be improved by consulting with existing cadres prior to and
during the process of task shifting. Clear delineation of
professional boundaries and responsibilities are needed to
Coordination and consultation from the outset with key
regulatory bodies such as medical and nursing councils,
as well as with relevant government ministries (health,
education, labour), are essential. Finally, as legal changes
in regulatory frameworks can take years to be enacted,
approaches that use other policies to create an enabling
environment such as changes in strategic plans, the passing
of ‘executive orders’ or granting ‘temporary pilot status’ to
programmes engaged in task shifting may be more expedi-
ent, especially if the package of services to be delivered
is urgent as is the case for ART. Particularly in rural areas
informal task shifting occurs out of necessity among lim-
ited health staff struggling with an overwhelming burden
of patients. Care must be taken not to ban such initiatives
that may occur outside existing regulatory frameworks but
contribute to delivering effective care.
3.3. Motivation, retention and performance
Poor salaries have been a key factor behind job dissatisfac-
tion and the migration of nurses from sub-Saharan Africa to
Western countries,39—41where one in five nurses trained in
sub-Saharan Africa currently work.
Low salaries also have an impact on patient care. For
example in Malawi, participating in workshops is more lucra-
tive than doing clinical work: by attending a 5 day training
Task shifting in HIV/AIDS in sub-Saharan Africa 555
course a nurse can increase her basic monthly salary by
25—40%. The plethora of workshops and per diems (which
provide untaxed top-ups for low salaries) acts as a perverse
incentive, encouraging absenteeism from health facilities,
which increases the workload for the remaining staff. A sur-
vey in Nigeria found that 45% of staff supplemented their
income privately.42Poor working and living conditions of
staff are also important issues, particularly in rural areas.
In a report from Lusikisiki, South Africa, where a third of all
nursing posts were vacant, only one-third of the 12 exist-
ing clinics had electricity, barely 8% had running water and
half lacked nursing accommodation.8Finally, the lack of sup-
portive supervision and opportunities for professional and
career development affect staff morale, motivation and job
3.3.1. Proposed actions
Health workers must receive a decent salary that constitutes
a living wage and that is commensurate with their responsi-
bilities. Although task shifting may be seen as a pragmatic
method to deal with staff shortages there is a real poten-
tial for exploiting vulnerable workers who might continue
to be paid only for work for which they are qualified. Pay-
ment must therefore be linked to the level of responsibility
and increasing workload associated with task shifting. If this
is not taken into consideration it could affect the long-
term viability of task shifting. There is an urgent need to
lift national spending limits imposed by finance ministries
and international finance institutions such as the Interna-
tional Monetary Fund so that governments can increase
salaries. Performance-related allowances have been shown
to be both feasible and effective44and should be encour-
aged. An incentive package to attract individuals to rural
areas is needed and should include good housing; better
work-related infrastructure and equipment; transport (e.g.
motorcycles); hardship or rural allowances and arrange-
ments or subsidies for school and boarding.
Regular supervision visits are critical for maintaining staff
motivation. The use of token benefits such as certificates of
excellence in ART delivery in Malawi14and the Yellow Star
award programme in Uganda45that recognize performance
according to set standards are highly appreciated by health
staff as indicators of official recognition.
Since the qualifications of substitute health workers may
not be accredited by universities, introducing mechanisms
to advance professionally is essential for motivating lower
cadres of health workers.
3.4. Livelihoods of lay health workers
Lay counsellors and community-based volunteers have
become the backbone of many care and support activities
linked to HIV/AIDS and TB in sub-Saharan Africa, but the
appointment of these cadres is often considered to be a
temporary measure, without any longer-term perspective.46
Where their status remains that of an unpaid volunteer, a
threshold is likely to be reached where the volunteers will
have to choose between time dedicated to service support
and time required to make a living. Most of the exist-
ing evidence demonstrates that lack of payment or other
appropriate commensurate incentive(s) results in progres-
sive deterioration in activity rates and high dropout rates of
community workers.47—49There is virtually no evidence to
show that volunteerism can be sustained for long periods.47
3.4.1. Proposed actions
Community groups should not become a ‘dumping ground’
for responsibilities that should fall under the mandate of
Some countries in sub-Saharan Africa, facing serious
shortages of human resources in the health sector and
high HIV prevalence, have introduced remunerated HIV-
dedicated lay cadres. In Malawi the health surveillance
assistant is a community cadre that has been fully inte-
grated within the national system of service delivery and
receives payment from government. Similarly, the post of
paid community HIV/AIDS worker could be developed to sup-
port the work of community health workers and both cadres
could work together, thus sustaining community health and
HIV-specific activities without jeopardizing the livelihoods
of individuals who live in communities that are living in or
on the limits of poverty.
3.5. Health of medical personnel
Death from HIV/AIDS is a major contributor to healthcare
worker shortages in sub-Saharan Africa.52In Malawi it is esti-
mated that over 10% of all health workers had died of AIDS
by 1997.53A survey carried out in all district and main mis-
sion hospitals in the same country found a 2% annual death
rate among key healthcare workers, with AIDS and TB being
the most common causes.54Death from HIV/AIDS accounted
for up to 40% of all the attrition of nurses in Zambia55and
was the main reason for the attrition of health workers in
3.5.1. Proposed actions
Occupational health services and staff policy guidelines that
cover HIV prevention and care would go a long way towards
keeping staff in good health. Access to voluntary counselling
and HIV testing services; isoniazid prophylaxis for noso-
comial TB; co-trimoxazole prophylaxis; post-HIV exposure
prophylaxis and ART and TB care should be available to all
health staff and their families.
Evidence from Malawi on offering ART to health work-
ers showed that at least 250 health workers’ lives were
saved due to ART, representing the equivalent of 1000 health
worker days per week, the number required to implement
the national ART programme.56An additional benefit is the
reduction in absenteeism due to illness or to attend col-
3.6. Operational research in task shifting
There are limited data and evidence for how task shifting
influences the quality, safety, acceptability, cost, manage-
ment and impact of interventions in sub-Saharan Africa.
Such information is required to inform and guide policy.
3.6.1. Proposed actions
Table 5 lists some of the main operational research priori-
ties for task shifting of HIV/AIDS care in sub-Saharan Africa.
556 R. Zachariah et al.
Operational research priorities for task shifting of HIV/AIDS care in sub-Saharan Africa.
IssueExamples Study approach
Quality and safety
How does task shifting to different
cadres influence the quality of care?
ART initiation and follow-up of adults
and children on first-line regimens by
nurses or nurse assistants
Cohort outcomes: enrolment
rates, adherence, biological
comparative cohort, RCT)
Is task shifting safe for the patient
and health worker?
WHO staging by lay and community
Identification and referral of
complicated cases, including serious
side-effects, to higher-level cadres
comparative cohort, RCT)
Do societal and cultural values and
preferences influence the choice of
cadres for task shifting and skills mix?
Community view on the role of
hospital vs. the health centre and on
the ability of lay workers to perform
Community acceptance of care
managed by non-physicians
How do patients and the
community perceive being treated by
a lower cadre and why?
What are the perceptions of health
staff, particularly in relation to
confidence and satisfaction with a
new skills mix?
Doctor acceptance of nurse initiation
Nurses accepting higher levels of
responsibility in clinical care
Health system impact
Is task shifting cost effective? What is the cost benefit of moving
towards nurse-initiated ART?
To what extent do non-remunerative
incentives support staff retention?
Comparative cost analyses
Assessment of payment and
incentive structure(s) to ensure
commitment and long-term
Cost differences between vertical
and integrated approaches to HIV
Cost benefit of providing HIV care at
primary care level
Comparative cost analyses
Public health impact
Does introducing task shifting
improve earlier access and overall
efficiency of the health system in
delivering ART at a population level?
What is the overall impact of task
shifting on scaling-up HIV/AIDS
Does the introduction of task shifting
increase ART initiation rates and
follow-up capacity and reduce
How does task shifting affect ART
enrolment rates at the population
Comparative analysis of
programme data over time
status at enrolment
Enrolment, retention in
ART: Antiretroviral treatment; RCT: randomized controlled trial.
Countries, organisations and academic institutions need to
make efforts towards finding answers to these pressing ques-
Task shifting must be seen as part of an overall strategy
that includes tangible measures to increase, retain and sus-
tain existing and new cadres of staff.57In addition to task
shifting, the crumbling health systems of sub-Saharan Africa
badly need an increased human resource pool that is flexi-
ble, motivated and able to respond to the increasing disease
burden and the changing landscape of public health needs.
What is demanded of the medical profession is flexible prag-
matism to safeguard both quality and safety and to prioritize
patient needs above those of the profession.
Conflicts of interest: None declared.
Ethical approval: Not required.
Task shifting in HIV/AIDS in sub-Saharan Africa557
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