Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from low-income and middle-income countries

Abstract

Background
Task shifting has become an increasingly popular way to increase access to health services, especially in low-resource settings. Research has demonstrated that task shifting, including the use of community health workers (CHWs) to deliver care, can improve population health. This systematic review investigates whether task shifting in low-income and middle-income countries (LMICs) results in efficiency improvements by achieving cost savings. Methods
Using the PRISMA guidelines for systematic reviews, we searched PubMed, Embase, CINAHL, and the Health Economic Evaluation Database on March 22, 2016. We included any original peer-review articles that demonstrated cost impact of a task shifting program in an LMIC. ResultsWe identified 794 articles, of which 34 were included in our study. We found that substantial evidence exists for achieving cost savings and efficiency improvements from task shifting activities related to tuberculosis and HIV/AIDS, and additional evidence exists for the potential to achieve cost savings from activities related to malaria, NCDs, NTDs, childhood illness, and other disease areas, especially at the primary health care and community levels. Conclusions
Task shifting presents a viable option for health system cost savings in LMICs. Going forward, program planners should carefully consider whether task shifting can improve population health and health systems efficiency in their countries, and researchers should investigate whether task shifting can also achieve cost savings for activities related to emerging global health priorities and health systems strengthening activities such as supply chain management or monitoring and evaluation.

Full text

R E S E A R C H Open Access
Does task shifting yield cost savings and
improve efficiency for health systems? A
systematic review of evidence from
low-income and middle-income countries
Gabriel Seidman
*
and Rifat Atun
Abstract
Background: Task shifting has become an increasingly popular way to increase access to health services, especially
in low-resource settings. Research has demonstrated that task shifting, including the use of community health
workers (CHWs) to deliver care, can improve population health. This systematic review investigates whether task
shifting in low-income and middle-income countries (LMICs) results in efficiency improvements by achieving cost savings.
Methods: Using the PRISMA guidelines for systematic reviews, we searched PubMed, Embase, CINAHL, and the Health
Economic Evaluation Database on March 22, 2016. We included any original peer-review articles that demonstrated cost
impact of a task shifting program in an LMIC.
Results: We identified 794 articles, of which 34 were included in our study. We found that substantial evidence
exists for achieving cost savings and efficiency improvements from task shifting activities related to tuberculosis and
HIV/AIDS, and additional evidence exists for the potential to achieve cost savings from activities related to malaria,
NCDs, NTDs, childhood illness, and other disease areas, especially at the primary health care and community levels.
Conclusions: Task shifting presents a viable option for health system cost savings in LMICs. Going forward,
program planners should carefully consider whether task shifting can improve population health and health
systems efficiency in their countries, and researchers should investigate whether task shifting can also achieve
cost savings for activities related to emerging global health priorities and health systems strengthening activities
such as supply chain management or monitoring and evaluation.
Keywords: Task shifting, Community health workers, Health systems, Efficiency, Cost-effectiveness, Systematic
review
Background
Efficient and effective health systems are critical for man-
aging healthcare costs, addressing rising burden of disease,
and providing sustainably universal health coverage. The
efficiency of health spending has major implications for
the health of the population. In low-income and middle-
income countries (LMICs) of Africa, Asia, and the Middle
East, increasing the efficiency of health spending could in-
crease health-adjusted life expectancy by 1–2years[1].
Human resources for health (HRH) make up a signifi-
cant portion of health expenditures; in LMICs, spending
on salaried health workers makes up 28.7–33.2% of
total health expenditure [2]. Improving the efficiency of
spending on HRH can improve the efficiency of health
systems, which can free up financial and other resources
and ultimately improve health coverage [3].
According to the World Health Organization (WHO),
task shifting “presents a viable solution for improving
health care coverage by making more efficient use of
the human resources already available and by quickly
increasing capacity while training and retention pro-
grams are expanded”[4]. Task shifting can produce
* Correspondence: Gabriel.seidman@gmail.com
Department of Global Health and Population, Harvard T. H. Chan School of
Public Health, 677 Huntington Avenue, Boston, MA 02115, United States of
America
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Seidman and Atun Human Resources for Health (2017) 15:29
DOI 10.1186/s12960-017-0200-9
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equivalent or superior outcomes for many diseases and
health interventions including non-communicable dis-
eases [5], HIV/AIDS [6, 7], contraceptive distribution
[8], and others [5, 9].
Given the high spend on HRH, the evidence for task
shifting as a way to improve population health, and the
prominence of task shifting on the global policy agenda,
policymakers should understand the cost and efficiency
implications of this approach to health systems strength-
ening (HSS). Therefore, our systematic review aims to
answer the following question: Does task shifting result
in cost savings and efficiency improvements for health
systems or patients in LMICs?
To our knowledge, only one literature review has
addressed a similar question so far [10]. That review
found that community health workers (CHWs) are
cost-effective for treating TB and select other disease
areas, such as reproductive, maternal, newborn, and
child health (RMNCH). Our review builds on the im-
portant initial review conducted by Vaughan et al. in
three ways. First, our search strategy takes a broader
scope in that it reviews other forms of task shifting be-
sides the use of CHWs (e.g., shifting the work of physi-
cians to nurses or the work of nurses to pharmacy
technicians), which may contribute to HSS.
Second, our review looks at evidence for efficiency
improvements achieved by shifting tasks from one
cadre of workers to another, rather than whether an
intervention using a specific type of health worker
meets a cost-effectiveness threshold. Although cost-
effectiveness thresholds (e.g., cost/unit of health im-
provement above or below a pre-defined benchmark)
are an important criterion for prioritizing interventions,
cost-effectiveness as measured by an actual reduction
in costs without a reduction in programmatic quality is
particularly salient for policymakers trying to improve
the efficiency of the health system. Therefore, we re-
view whether studies found changes in cost per input/
process, output, or outcome as a result of task shifting.
Whereas cost savings on inputs/processes are very
likely since the wage for a lower-skilled worker will
almost always be lower than that of a higher-skilled
worker, cost savings on outputs and outcomes are not as
guaranteed since lower-skilled workers might operate
less efficiently. A reduction in cost per output or out-
come can be interpreted as an improvement in efficiency
and therefore a true savings to the health system (with
changes in cost per outcome as the stronger indicator),
but a reduction in cost per input/process can only be
interpreted as an efficiency improvement if it is accom-
panied by the documentation of no change (or an im-
provement) in clinical or programmatic quality.
Third, following from the previous point, our review
also captures and reports evidence of changes in
programmatic or clinical quality as a result of task shift-
ing for each included reference, which Vaughan et al.
do not systematically report. Reporting programmatic
quality outcomes is important for determining whether
a reduction in costs actually indicates an improvement
in health systems efficiency.
Methods
This systematic review follows the criteria and method-
ology described in the PRISMA guidelines on systematic
reviews [11].
Search process and criteria
This search relied on an internal protocol developed by
both authors, with the support of a Harvard University
librarian specializing in systematic reviews. The protocol
was not registered externally. We searched PubMed,
Embase, CINAHL, and the Health Economic Evaluation
Database. The main search that was conducted on
March 22, 2016, was as follows (for PubMed), with an
additional search term for LMICs, and any publication
from before that data was eligible for our review:
(task shift*[tiab] OR balance of care[tiab] OR non-
physician clinician*[tiab] OR nonphysician clinician*
[tiab] OR task sharing[tiab] OR community care giver*
[tiab] OR community healthcare provider*[tiab] OR
cadres[tiab] OR “Community Health Workers”[Mesh])
AND
(“Cost Savings”[mesh] OR “Cost Benefit Analysis”
[mesh] OR “Efficiency”[mesh] OR cost[tiab] OR costs
[tiab] OR efficienc*[tiab] OR economies of scale[tiab]
OR economies of scope[tiab] OR productivity[tiab] OR
absenteeism[tiab] OR “Absenteeism”[Mesh])
We also conducted several additional searches based
on a review of citation lists from relevant publications,
and based on recommendations from public health
researchers.
Study selection and eligibility criteria
After conducting our search, all titles were reviewed
for relevance. After excluding irrelevant titles, we read
all abstracts and, when appropriate, full articles to de-
termine the relevance of the article for our research
question. In order to be included in the study, the pub-
lication had to meet the following criteria:
Report on an effort, such as a program or policy
intervention, involving task shifting of a clinical
activity or health systems-related activity
Report a comparison of program costs from the
task shifted model for conducting the activity or
service to a comparable activity in a model that
does not involve task shifting.
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Report results from an actual intervention, rather
than a computer model or simulation
Report results from a low-income or middle-income
country
Be original research about an intervention published
in a peer-reviewed format (as opposed to an editorial,
literature review, opinion piece, interview, etc.)
Have a complete article available (as opposed to
just an abstract)
Be published in English
Data collection process
In order to extract data for this review, we piloted an
Excel-based data collection tool that was used to capture
results from a preliminary search, the results of which
were presented at the Harvard Ministerial Leadership Pro-
gram in the summer of 2016. Based on our experience
with this initial process, we modified the tool accordingly
and finalized a tool which collected the following informa-
tion: author, year, title, publication, abstract, country, con-
tinent, description of the intervention, main indicator,
result on relevant indicator, and data on programmatic
quality changes resulting from the intervention. Studies
were not excluded if they did not have relevant quality
comparisons. Results which did not provide evidence of
cost changes, such as baseline costing studies, were ex-
cluded. GS conducted a first review of all references in the
search, and the list was reviewed by RA and other public
health researchers in order to identify missing references
or references which had been improperly included.
We also retrospectively categorized the included refer-
ences based on whether the main indicator documented
changes in cost per input/process, output, or outcome,
using the following definitions: [12].
Inputs/processes: resources required to conduct an
activity, or a discrete activity such as a patient visit
with a clinician
Outputs: direct products of program activities, such
as number of individuals treated
Outcomes: changes in health status as a result of
theprogram,suchasnumberofpatientscuredor
number of deaths averted
Risk of bias
As with any systematic review, the references and data
sources for this review contain the possibility for bias.
At the level of individual references, authors are more
likely to report cost data if their program resulted in cost
savings, especially if costing/cost-effectiveness was not
the primary purpose of the study.
Across all studies, there is also a risk of publication
bias and selective reporting within studies, especially if
authors more frequently chose to report positive
outcomes (such as cost savings). Of course, the decision
to implement task shifting in a given context would re-
quire extensive analysis of that particular intervention’s
potential impact, and we caution researchers and policy-
makers not to interpret the findings from this review as
indicative of the results that they can expect to achieve.
Results
Study selection
We reviewed 791 articles and identified 34 references
which analyzed the cost implications of task shifting in
LMICs—22 in sub-Saharan Africa, eight in Asia and four
in Central or South America. See Fig. 1 for the study se-
lection for inclusion in this systematic review. Of the 32
studies included in the review by Vaughan et al., we ex-
cluded 17 and included 15, which means that our review
also included an additional 19 studies not included in
Vaughan et al. Of the 17 references included by Vaughan
et al. that we excluded, 12 were excluded because they
did not provide comparison of costs between the task
shifted model and another model of care [13–24], three
reported results from modeling of hypothetical programs
rather than actual interventions [25–27], one reference
did not have a full article available [28], and one refer-
ence reported the same data from the same program as
another reference already included in our review [29].
Of the 34 studies included in our review, 30 found evi-
dence of a reduction in health costs either to the health
system or the patient, and four had a mixed impact, an in-
crease in costs, or no changes in costs [30–33]. Almost all
the studies focused on the effects of shifting clinical or
public health tasks related to a specific disease or disease
area, while one study focused on task shifting a HSS
activity (mapping of village geographic coordinates) [34].
Only two studies examined task shifting within a hospital,
whereas all others examined task shifting from the hos-
pital to the primary health care (PHC) or community
levels, or task shifting within the PHC/community level.
Of the 30 studies that found evidence of cost savings,
10 reported a cost savings per outcome, 13 reported a
cost savings per output, and 3 reported a cost savings
per input/process coupled with a corresponding main-
tenance or improvement in programmatic quality. Al-
though cost savings on inputs/processes do not indicate
efficiency improvements as strongly as savings on out-
puts or outcomes, the combined body of evidence from
these 26 studies suggests that task shifting yields cost
savings that result in efficiency improvements to the
health system, especially at the PHC and community
levels. The four citations which reported cost savings on
an input/process and which did not report changes in
clinical or programmatic quality all reported on tasks re-
lated to different disease areas/HSS activities.
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The full list of references meeting inclusion criteria
can be found in Table 1.
Tuberculosis
Nine studies demonstrated cost savings with task shift-
ing for identification, diagnosis, and treatment of tuber-
culosis. Strategies for reducing costs included task
shifting treatment supervision to health workers in the
community [35–41], to home guardians or close rela-
tives [42], laypersons [43], and in one case entrusting pa-
tients to take medicine without direct supervision [13].
Programmatic and clinical indicators, such as treatment
success rate, treatment completion rate, and case finding
rate, also indicate that task shifting programs maintained
programmatic quality comparable or superior to trad-
itional models of care.
HIV/AIDS
Studies in this review revealed cost savings from task
shifting prevention and care for a high-risk group (men
who have sex with men (MSM)) to community-based
organizations [44], and dispensing of ART from pharma-
cists to Indirectly Supervised Pharmacist Assistants
(ISPA), adherence clubs, or other pharmacy-only refill
programs [45–48]. Programmatic indicators, such as pa-
tient retention, viral load, and mortality also indicate that
these programs maintained high quality of care. These
findings indicate that the dispensation of ARTs, especially
to clinically stable patients who are very familiar with
the routine of taking these drugs, is suitable for task
shifting in low-resource (and possibly other) settings.
One study examining task shifting of ART dispensation
to clinics found both an increase of costs in one state
and a decrease in another state [31], and one study
examining the task shifting initiation and management
of ART treatment found no statistically significant dif-
ferences in costs [30].
Malaria
Our review identified five articles that identified cost
savings related to task shifting for malaria-related pro-
grams: CHW management of malaria [49, 50], village
health worker (VHW) administration of IPT [51],
community-based surveillance and treatment of malaria
[52], and community-based surveillance and trapping of
mosquitoes for vector control [53]. Indicators of program
and clinical quality, such as administration of appropriate
treatment, treatment completion rate, and average time
from examination to initiation of treatment, indicate that
the programs also maintained or improved programmatic
quality. One study found a minor (9%) increase in the cost
of administration of IPT during pregnancy when shifting
to a community-based model. Although the evidence is
less robust than that for TB or HIV/AIDS, these findings
suggest that many malaria-related tasks can achieve cost
savings from task shifting.
Other disease areas and activities
Our review identified 11 additional studies which pro-
vided evidence of cost savings from task shifting for
activities related to other diseases or health systems
strengthening. These activities included controlling
Fig. 1 Study selection for inclusion in systematic review
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Table 1 Full list of citations included in systematic review
Author and
year
Country Intervention Indicator type Main indicator Result Quality data
TB
Clarke, M.,
et al. (2006)
[39]
South Africa Training of lay health workers (LHWs) to
support treatment and management of TB
on farms, instead of clinic nurses or enrolled
(non-professional) nurses
Input/process Cost per minute
of health worker
time
91% reduction in cost from clinic nurses
($0.12 per minute) to LHWs ($0.01 per
minute) and 87.5% reduction from enrolled
nurses ($0.08 per minute) to LHWs
Farms with LHWs supporting had 42%
better case finding rate and 10% better
cure rate
Datiko, D. G.
and
B. Lindtjorn
(2010) [35]
Ethiopia Comparison of Health Facility-based DOT
(HFDOT) program for TB compared with
community DOT (CDOT) program using
health extension workers
Outcome Cost per
successfully
treated patient
63% reduction in costs from HFDOT model
($16.19) to CDOT model ($6.07)
74.8% cure rate for CDOT compared with
68.2% for HFDOT
Dick, J.,
et al. (2007)
[37]
South Africa Evaluation of a lay health worker project
overseen by primary healthcare nurses
aimed at treating TB on farms
Outcome Cost per case
detected and
cured
74% cost reduction to the District Health
Authority on farms with LHW program
compared to control farms (absolute cost
figures not reported)
Treatment completion rate for smear-
positive TB patients 18.7% higher in
intervention group compared to controls
(p<.05)
Floyd, K.,
et al. (2003)
[41]
Malawi Community-based outpatient treatment for
smear-positive pulmonary patients (instead
of inpatient treatment)
Outcome Cost per patient
cured
62% reduction from hospital-based
treatment ($786) to community-based
treatment ($296)
Cure rate was 68% for community-based
strategy and 58% for hospital-based
strategy
Islam, M. A.,
et al. (2002)
[36]
Bangladesh BRAC TB control program using CHWs,
compared to government-run program
Input/process;
outcome
Total annual cost
for TB control
program at the
subdistrict
(thana) level;
Cost per patient
cured
31% reduction in total annual costs from
government program ($10,697) to BRAC
program ($7,351); 32% reduction in cost
per patient cured
84.1% cure rate in BRAC TB program
compared to 82.2% in government
program
Khan, M. A.,
et al. (2002)
[40]
Pakistan Comparison of DOTS by health workers at
health centers, DOTS by family members,
and “DOTS without direct observation”
Outcome Cost per case
cured
45% reduction from health center DOTS
($310) to CHW DOTS ($172); unsupervised
DOTS cost $164
Cure rates were 62% for unsupervised
DOTS, 55% for family member DOTS,
67% for CHW DOTS, and 58% for Health
Center DOTS
Okello, D.,
et al. (2003)
[38]
Uganda Comparison of conventional hospital-based
care with community-based care for DOTS,
including management by a sub-county
public health worker
Outcome Cost per smear-
positive patient
successfully
treated
57% reduction in costs from conventional
care ($911) to community-based care ($391)
Treatment success rate for smear-positive
cases was 56% for conventional care and
74% within community-based care
Prado, T. N.,
et al. (2011)
[42]
Brazil Comparison of DOTS overseen by guardians
with standard of care treatment by CHWs
Output Total cost for
DOTS course
28% reduction in costs from CHW DOTS
($547) to guardian-supervised DOTS ($389)
98% treatment completion in guardian-
supervised DOTS compared to 83%
treatment completion with CHW-
supervised DOTS (p= .01)
Sinanovic, E.,
et al. (2003)
[43]
South Africa Comparison of clinic-based care with
community-based observation by lay
person with community-based care for
smear-positive pulmonary and retreatment
TB patients
Outcome Cost per patient
successfully
treated
62% reduction in costs for new smear-
positive patients from clinic-based care
($1302) to community-based care ($392);
62% reduction in costs for retreatment
patients from clinic-based care ($2008) to
community-based care ($766)
80% treatment success rate for community-
based care, compared to 54% treatment
success rate for clinic-based care
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Table 1 Full list of citations included in systematic review (Continued)
HIV
Babigumira,
J. B., et al.
(2011) [46]
Uganda Comparison of a Pharmacy-only Refill
Program (PRP) to Standard of Care for
treatment for HIV/AIDS patients
Output Cost per person
peryearfrom
societal and
Ministry of Health
perspective
21% reduction in societal costs from
Standard of Care ($665) to PRP ($520)
and 17% reduction in MoH costs from
Standard of Care ($610) to PRP ($496)
No statistically significant difference in
favorable immune response among
patients in two groups
Bemelmans,
M., et al.
(2014) [48]
South Africa Adherence club for ARVs led by lay
counselor and offered to all clinically stable
patients who had been on ARVs for greater
than 12 months; Club met every 2 months
for essential medical tasks (e.g., weighing
and health assessment) and distribution of
ARVs
Output Cost per patient
per year
46% reduction from mainstream model
of care ($108) to ARV club model ($58)
<1% mortality at 40 months, and 2.8% loss
to follow up at 40 months in ARV club
Fatti, G.,
et al. (2015)
[45]
South Africa Indirectly Supervised Pharmacist Assistant
(ISPA) program compared to nurse-managed
models for providing ARTs
Input/process Human resource
costs and costs
per item
dispensed
29% reduction in human resource costs
from nurse-managed program ($1.89 per
patient visit) compared to ISPA model
($1.35 per patient visit); 49% reduction
in cost per item dispensed from nurse-
managed program ($0.83) to ISPA model
($0.43)
Cumulative attrition lower at ISPA sites
(20.7% compared to 31.5%); proportion of
patients achieving virological suppression
higher at ISPA sites (89.6% compared to
85.9%)
Foster, N.
and D.
McIntyre
(2012) [47]
South Africa Indirectly Supervised Pharmacist Assistant
(ISPA) program and nurse-managed models
compared to full-time pharmacist for
providing ARTs
Input/process Cost per patient
visit
43% reduction in cost from nurse-driven
model ($10.16) to ISPA model ($5.74) and
12% reduction in cost from full-time
pharmacist model ($6.55)
Johns, B.
and E.
Baruwa
(2015) [31]
Nigeria Comparison of hospital-based distribution
of ART (by doctors) with clinic-based
distribution of ART (by nurses and/or
community pharmacists) for stable
patients who had been on ART for at
least 1 year, in two states aiming to
decentralize health services
Output Total cost per
person per year
Total costs increased in one state by 31%
and decreased in one state by 32%; In
both cases, the largest difference in costs
between the hospital and clinic sites was
staff cost/patient visit
Few statistically significant differences
found in service utilization indicators
between patients going to clinic sites
versus hospital sites; Patients in the state
that achieved cost savings had 3.7× more
visits per year than in hospitals (p< .01)
Johns, B.,
et al. (2014)
[30]
Ethiopia Comparison of minimal, moderate, and
maximal task shifting for ARV responsibilities
away from physicians with hospital-based
ARV distribution . Minimal = nonphysicians
clinicians (NPC) monitor ART; Moderate =
NPC initiate and monitor ART; Maximal =
NPCs initiate, monitor, treat side effects, and
switch ARTs
Output Cost per patient
year
No statistically significant changes in
cost/patient per year between models of
task shifting or between all task shifting
models and hospitals
Almost no statistically significant
differences in patient retention from
different levels of task shifting
Yan, H.,
et al. (2014)
[44]
China Evaluation of shifting HIV preventive
intervention and care for men who have sex
with men (MSM) from government facilities
to community-based organizations (CBOs)
Outcome Unit cost per HIV
case detected
97% reduction in cost from government
health facilities ($14,906) to community-
based organizations ($315)
Within 4 years, total % of HIV cases
reported increased from ~10 to ~50%,
despite “a very low share of HIV tests by
CBOs out of the total HIV tests performed
each year during the pilot,”which
indicates effective targeting of HIV
patients for tests by CBOs
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Table 1 Full list of citations included in systematic review (Continued)
Malaria
Chanda, P.,
et al. (2011)
[49]
Zambia Comparison of home management (using
CHW) with facility-based management of
uncomplicated malaria
Output Cost per case
appropriately
diagnosed and
treated
31% reduction from facility-based
management ($6.12) to home management
($4.22)
100% of cases treated appropriately
through home management, and 43% of
cases treated appropriately in facility
Hamainza,
B. M., et al.
(2014) [50]
Zambia Comparison of CHW program to test and
treat malaria with facility-based testing and
treatment
Output Total cost per
confirmed case
treated
60% reduction in cost from facility-based
approach ($10.75) to CHW approach ($4.34)
78% of CHW contacts received
appropriate testing and treatment, while
53% of facility-based patients received
appropriate testing and treatment based
on guidelines
Mbonye, A.,
et al. (2008)
[32]
Uganda Community-based administration of
intermittent preventive treatment (IPTp) for
malaria by traditional birth attendants, drug-
shop vendors, community reproductive health
workers, and adolescent peer mobilizers
Output Cost per patient
of providing a
full regimen of
IPTp
9% increase in costs from health center
care (4093 shillings) to community-based
care (4491 shillings)
Patouillard,
E., et al.
(2011) [51]
Ghana Comparison of IPT administration by village
health workers (VHWs), facility-based nurses
working in outpatient departments of health
centers or EPI outreach clinics
Outcome Economic cost
per child fully
covered and
fully adherent to
treatment
11% reduction from using facility-based
strategy ($8.51) to VHW strategy ($7.56)
69.1% of children in VHW strategy
completed course, 63.8% of children in
facility-based strategy completed course
Ruebush, T.
K., 2nd,
et al. (1994)
[52]
Guatemala Change to the supervision and distribution
model of unpaid Volunteer Collaborators
(VC) in the surveillance and treatment of
malaria, including treatment for malaria
without taking a blood smear, removal of
literacy requirement for VC, and reduced
supervision from once every 4 weeks to
once every 8 weeks
Output Cost per patient
treated
75% reduction in cost per patient treated in
modified model of VCs ($0.61) versus
control network of VCs ($2.45)
Average time from examination to
initiation of treatment was 6.6 days in
modified model areas, compared to
14.6 days in control areas
Sikaala, C.
H., et al.
(2014) [53]
Zambia Community-based (CB) mosquito surveillance
andtrappingusinglighttraps(LT)and
Ifakara tent traps (ITT) compared to centrally
supervised quality assurance (QA) trapping
teams, including human-landing catch (HLC)
teams, for the prevention of malaria
Output Cost per
specimen of
Anopheles
funestus
captured
96% reduction in costs from using QA-LT
($141) to CB-LT ($5.3); 83% reduction in
costs from using QA-ITT ($168) to CB-ITT
($28); QA-HLC method cost $10.5
Other diseases and health systems strengthening activities
Aung, T.,
et al. (2013)
[62]
Myanmar Comparison of costs to treat diarrhea by
CHW, government facility, and private
provider
Input/process Total patient cost
for consultation
and correct ORS
7% reduction from private providers ($5.40)
to CHWs ($5) and 67% reduction from
government facilities ($15) to CHWs
CHWs provided appropriate ORS and
amount of drinking water in 57.6% of cases,
private providers in 47.1% of cases, and
government facilities in 71.4% of cases
Buttorff, C.,
et al. (2012)
[57]
India Comparison of “collaborative care”model
using full-time physician, lay health worker
(LHW), and mental health specialist with
“enhanced usual care”by full-time physician
only for treatment of depression and anxiety
disorders
Output Average annual
cost per subject
23% reduction in costs from collaborative
care model ($177) compared to physician-
only care model ($229)
Patients in collaborative care improved
3.84 points more on the Revised Clinical
Interview Schedule (to measure psychiatric
symptoms) compared to physician-only
care model
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Table 1 Full list of citations included in systematic review (Continued)
Chuit, R.,
et al. (1992)
[60]
Argentina Surveillance to reduce transmission of
Chagas disease using Primary Health Care
(PHC) agents compared to a vertically
oriented program run by trained
entomological professionals
Output Cost of
surveillance per
house
80% reduction in cost from vertical
surveillance ($17) to PHC surveillance
($3.40)
Surveillance rates and levels of infestation
detection were comparable across
intervention and control arms
Cline, B. L.
and B. S.
Hewlett
(1996) [61]
Cameroon Diagnosis and treatment for schistosomiasis
by CHWs identified by the community
Output Average cost of
diagnosis and
treatment of a
child
90% reduction in cost from treatment at
nearest pharmacy (approx. $15) to CHW
model ($1.50)
7% prevalence in school children after
participating in program, compared to
71% in children who did not participate
in program
Fiedler, J. L.,
et al. (2008)
[63]
Honduras Community-based integrated child care
(AIN-C) program that uses volunteers to
help mothers monitor and maintain
adequate growth of young children
Input/process Cost for one
child growth
and
development
consultation
86% reduction from facility-based
consultation (105.1 lempiras) to community-
based program (14.67 lempiras)
Hounton
et al., (2009)
[33]
Burkina Faso Training of obstetricians, general
practitioners, and clinical officers to lead
surgical teams for caesarian sections
Outcome Incremental cost
of one newborn
life saved
Compared to clinical officers, one
newborn life saved cost $200 for general
practitioners, and $3,235 for obstetricians
Higher newborn and maternal case fatality
rates among clinical officers than other
types of practitioners
Jafar, T. H.,
et al. (2011)
[54]
Pakistan Home-health education (HHE) by CHWs,
home-health education plus general
practitioner (GP) supervision (combined
group), or general practitioner-supervision
only to control blood pressure
Output Total cost per
patient over
2 years for each
group
7% reduction in costs from GP-only group
($537) to combined group ($500); 27%
reduction in costs from GP-only group to
HHE-only group ($393)
Decline in systolic BP was highest in the
combined group (p= .001)
Kruk, M. E.,
et al. (2007)
[58]
Mozambique Comparison of surgically trained assistant
medical officers and specialist physicians
Input/process Cost per major
obstetric surgical
procedure
72% reduction in costs using assistant
medical officers ($39) compared to
specialist physicians ($144)
Laveissiere,
C., et al.
(1998) [56]
Cote d'Ivoire Detection of sleeping sickness using
conventional mobile teams compared to
integration of activity into CHW duties
Output Cost of
surveillance per
person
81% reduction in costs using CHWs ($0.10)
instead of using mobile teams ($0.55)
Puett, C.,
et al. (2013)
[55]
Bangladesh Community-based management of severe
acute malnutrition by CHWs compared to
inpatient treatment
Outcome Cost per DALY
averted
98% reduction in costs/DALY averted from
observed inpatient treatment costs ($1344)
to community treatment ($26) and in
costs/death averted from observed
inpatient treatment costs ($45,688) to
community treatment ($869)
91.9% of children in community treatment
area recovered, compared to only 1.4% in
inpatient treatment
Sadruddin,
S., et al.
(2012) [59]
Pakistan Comparison of home treatment of severe
pneumonia by lady health workers with
referred cases treated by other practitioners
Output Cost per
treatment of
severe
pneumonia
81% reduction in costs using lady health
workers ($1.46) compared to referred cases
($7.60)
93.4% of cases successfully treated by lady
health workers with a 5-day course of
amoxicillin, and remaining cases referred
for further treatment
Munyaneza,
F., et al.
(2014) [34]
Rwanda Use of CHWs and nurses to collect
geographic coordinates using GIS systems
instead of trained and dedicated GIS teams
Input/process Total cost of
mapping
activities
51% reduction in costs from using
dedicated GIS teams ($60,112) to CHWs
($29,692)
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blood pressure through a combination of general prac-
titioner and CHW activities [54], community-based
management of severe acute malnutrition [55], inte-
gration of the detection of sleeping sickness intro rou-
tine CHW activities [56], treatment for mental health
problems by a “collaborative care”team that included
a lay health worker and mental health specialist [57],
administration of major obstetric procedures by assist-
ant medical officers instead of physicians [58], home-
based treatment of severe pneumonia by lady health
workers [59], integration of surveillance to reduce
transmission of Chagas disease by Primary Health Care
agents instead of specially trained professionals [60],
diagnosis and treatment of schistosomiasis by CHWs
[61], treatment of diarrhea by CHWs [62], community-
based integrated child care using volunteers to moni-
tor and maintain growth [63], and geo-mapping acti-
vities by CHWs and nurses instead of dedicated GIS
teams [34].
Discussion
This review aimed to identify whether task shifting can
result in cost savings and efficiency improvements to
health systems. Our results indicate that task shifting is
a promising approach to achieving cost savings and im-
proving efficiency in LMICs, and our results build on
previous work which concluded that task shifting can be
an effective way to improve population health. These
findings have significant policy implications, discussed
below, as well as important limitations.
1. Task shifting can help achieve cost savings and
improve efficiency for activities related to top global
health priorities, emerging global health issues, and
neglected tropical diseases, but the evidence base is
mostly limited to PHC and community-based care
The most robust body of evidence found in this
study is for achieving cost savings from task shifting
activities related to TB and HIV/AIDS. Given the
high burden of these diseases in LMICs and the
longitudinal nature of preventing, treating, and
managing these diseases, interventions that can
reduce both their economic and health burdens
simultaneously are particularly important for the
future of global health. Each year there are 1.5
million new cases of tuberculosis, mostly in
LMICs, and the global burden of TB amounts to
approximately $12 billion annually [64,65]. As of
2015, 36.7 million people were living with HIV, and
meeting UNAIDS targets will require nearly $20
billion annually [66,67]. TB treatment using DOTS
is a relatively routine activity that occurs over
many months and can take place in the community
(when the infection is not drug-resistant).
Dispensation of ART to clinically stable patients
who know and follow their drug regimens is also a
relatively routine process. Therefore, these activities
are well-suited for task shifting, and health systems
can likely improve their efficiency by undertaking
such efforts.
Outside of TB, HIV/AIDS, and malaria, the evidence
for cost savings from task shifting was spread across
many disease areas, making it difficult to conclude
that task shifting activities for a specific disease
could result in cost savings. Nonetheless, the fact
that programs achieved cost savings from such
a diverse set of diseases and across multiple
geographies indicates that policymakers and
program planners should consider task shifting
as one of many potential approaches to improve
efficiency in their health systems. The evidence
for cost savings came from disease areas such as
childhood illnesses, non-communicable diseases
(which are receiving increased priority at the global
level due to the Sustainable Development Goals),
and neglected tropical diseases (NTDs).
Almost all studies identified shifted tasks to or
within the context primary health care (PHC) or
community-based care. Although several citations
identified cost savings by shifting tasks from hospitals
to PHC or community care, only one citation found
cost savings by shifting tasks within the hospital
setting [58]. One additional study within the hospital
setting found that shifting surgical care from
physicians to clinical officers did not yield cost
savings, but it did not analyze the cost-effectiveness
of shifting surgical tasks from surgeons to other
physicians [33]. While the body of evidence in this
review suggests that task shifting can improve
efficiency across multiple disease at the PHC and
community levels, more research is needed on the
effects of task shifting within secondary, tertiary,
and highly specialized care.
2. Models of task shifting involve more than transferring
clinical care to CHWs
CHWs play a key role in reducing costs and
increasing access to care in the health system.
Nonetheless, this research shows that many
models of task shifting exist outside of a simple
transfer of clinical care to a CHW. Of course,
many types of associate health professionals exist,
such as pharmacy technicians, lay counsellors,
and medical assistants, and the references included
in this study reflect this diversity of health
professions [68]. In particular, the use of different
models for dispensing ART to HIV-positive patients
was documented in multiple studies. In addition,
several studies used models where CHWs or other
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lower-skilled workers collaborated with clinicians
in order to provide a new model of care for the
patient [54,57].
Interestingly, only two studies identified cost savings
from task shifting non-clinical activities: geo-mapping
by CHWs and community-based mosquito trapping
and surveillance. Given the importance that many
non-clinical health systems functions have on
improving population health (e.g., supply chain,
monitoring and evaluation), research and program
planners should consider the potential that task
shifting could have for other health systems-related
activities. For example, it is possible that lower-skilled
professionals could perform routine tasks related to
monitoring the supply chain or tracking patient data
without compromising the quality of the activity.
3. The design and benefits of task shifting interventions
will vary based on the context
Policymakers and program planners must recognize
that task shifting is not a panacea for improving
health and efficiency, but rather one of many tools
to use in order to improve the efficiency of the
health system. This review identified a range of task
shifting models which resulted in different types of
cost savings. Of course, without proper design, task
shifting may actually increase system costs or reduce
efficiency, such as by worsening overall population
health due to poor clinical quality or increasing the
number of staff in the health care system without
changing care-seeking patterns among patients.
Interestingly, one study found that the same model
of task shifting resulted in both cost increases and
cost decreases in two different regions of the same
country [31]. Further, task shifting can also result in
task overload for health workers, which could also
reduce productivity and worsen health population
health outcomes [69].
The breadth of task shifting models covered in this
review is consistent with other findings from the
literature which also indicate the need to adapt task
shifting models to local contexts and health systems.
For example, one systematic review notes a number
of factors which can impact the success of lay health
worker programs, including acceptability of the
model to patients, implementation challenges
such as problems with training, and health systems
bottlenecks such as challenges with payment [70].
Another systematic review specifically identified
strong management of CHW programs as the
most important factor in their scale-up [71]. This
body of evidence therefore suggests that designing
appropriate task shifting models requires a thorough
investigation of the local context, disease burden,
and program goals.
Limitations of the evidence, risks, and future directions
for research
There are several limitations to the research and its find-
ings. First, this study includes citations that measure
changes in cost and efficiency very differently. Of course,
looking strictly at cost-effectiveness thresholds, rather
than cost savings and programmatic indicators as a proxy
for cost-effectiveness, would have helped to standardize
these findings to make them more comparable. However,
limiting our analysis to cost-effectiveness thresholds
would also have negatively altered the evidence base in
our review by (1) eliminating studies which demonstrated
savings but did not have a formal cost-effectiveness
analysis and (2) including studies that may have achieved
some level of cost-effectiveness but which did not actu-
ally achieve savings (i.e., those in which an intervention
by a specific cadre of health worker met a cost-
effectiveness threshold). By researching the impact of
task shifting on costs to the health system as a proxy
measure for efficiency improvements, we have focused
on a key aspect of decision-making directly relevant to
policymakers.
Second, unlike systematic reviews looking at health
outcomes from highly specified clinical protocols, this re-
view cannot predict the implications of a new task shifting
program. Numerous factors in a given context will affect
the outcomes of task shifting, including the burden of dis-
ease, the existing human resources for health, previous
task shifting efforts, the social determinants of health, and
the political economy of health. We caution that re-
searchers and policymakers should not treat this review as
a guarantee that future task shifting efforts will result in
cost savings; rather, they should see this review as provid-
ing compelling evidence that task shifting can achieve cost
savings if there is a need for such an intervention, and it is
implemented appropriately.
Third, our search only identified two citations suitable
for inclusion that examined task shifting within a hos-
pital setting. Our search did not exclude programs that
delivered services at a specific level, and the search in-
cluded other citations focused on hospitals or specialty
care that failed to meet inclusion criteria for other rea-
sons (see select citations for examples [72–75]). This
result suggests that the absence of evidence for task
shifting within hospitals is likely due to the limited re-
search on this topic to date. Nonetheless, LMICs have
implemented programs to task shift hospital-based
care, such as surgical services [76, 77]. Future research
should examine models of task shifting within hospitals
and their impacts on health outcomes, costs, and other
relevant indicators.
Finally, as already discussed, the methodology of this
review is limited by biases in reporting and publication
of individual references.
Seidman and Atun Human Resources for Health (2017) 15:29 Page 10 of 13
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Going forward, we feel that researchers, program plan-
ners, and policymakers should continue to collaborate to
understand both the financial and health impacts of task
shifting. Many new task shifting efforts are underway
globally, and ensuring that all these programs report on
cost-effectiveness thresholds and changes in costs to the
system will increase the evidence base surrounding this
important topic. In particular, more programmatic re-
search is needed to confirm the preliminary findings that
task shifting for activities related to NCDs, NTDs, and
health systems strengthening can result in cost savings,
and to understand the role that task shifting can play in
hospital and specialty settings. At the same time, re-
searchers should also carefully examine the risk of task
overload from task shifting and design ways to prevent
and mitigate this risk.
Conclusions
This review examined the evidence for task shifting in
improving health systems efficiency in LMICs. The evi-
dence indicates that task shifting for activities across a
broad range of diseases, including TB, HIV/AIDS, malaria,
childhood illness, NCDs, and NTDs, can result in cost
savings without compromising clinical or programmatic
quality. This review also revealed that countries have used
different approaches to introduce task shifting for man-
agement of different conditions and that task shifting
takes on many forms besides simply transferring clinical
activities to CHWs. Going forward, researchers, program
planners, and policymakers should carefully examine their
local context in order to determine whether task shifting
can improve health systems efficiency while also maintain-
ing or improving population health.
Abbreviations
ART: Antiretroviral therapy; CHW: Community health worker; DOTS: Directly
observed treatment—short course; HSS: Health systems strengthening;
ISPA: Indirectly supervised pharmacist assistant; LMIC: Low-income and middle-
income countries; MSM: Men who have sex with men; NCD: Non-
communicable disease; NTD: Neglected tropical disease; PHC: Primary health
care; RMNCH:
Reproductive, maternal, newborn, and child health; TB: Tuberculosis;
VHW: Village health worker; WHO: World Health Organization
Acknowledgements
We thank Michael Sinclair and Brian Dugan from the Harvard Ministerial
Leadership Program for their support in preparation of this report. We thank
Paul Bain at Harvard University for assistance with designing the search
strategy.
Funding
An original draft of this paper was commissioned by the Harvard Ministerial
Leadership Program, a joint initiative of the Harvard TH Chan School of
Public Health, Harvard Kennedy School of Government, and the Harvard
Graduate School of Education in collaboration with Big Win Philanthropy,
and with the support of the Bill and Melinda Gates Foundation, Bloomberg
Philanthropies, the GE Foundation, and the Rockefeller Foundation.
Availability of data and materials
Key information from original dataset included in Table 1 is in the manuscript.
The original dataset is available from the corresponding author upon request.
Authors’contributions
GS and RA jointly conceived of the research question, concept, and
methodology for this paper. GS developed the data collection tool,
reviewed all articles, and drafted and revised the manuscript. RA provided
revisions and additional references for review. Both authors read and
approved the final manuscript.
Authors’information
GS is a DrPH candidate at Harvard T. H. Chan School of Public Health. RA is
the director of the Global Health Systems Cluster at Harvard T. H. Chan
School of Public Health.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
Not applicable.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Received: 15 November 2016 Accepted: 29 March 2017
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