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


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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.
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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
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
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 12years[1].
Human resources for health (HRH) make up a signifi-
cant portion of health expenditures; in LMICs, spending
on salaried health workers makes up 28.733.2% 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:
Department of Global Health and Population, Harvard T. H. Chan School of
Public Health, 677 Huntington Avenue, Boston, MA 02115, United States of
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( 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
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
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.
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])
(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
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
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
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 interventions
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.
Study selection
We reviewed 791 articles and identified 34 references
which analyzed the cost implications of task shifting in
LMICs22 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 [1324], three
reported results from modeling of hypothetical programs
rather than actual interventions [2527], 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 [3033]. 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.
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 [3541], 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.
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 [4548]. 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].
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
Country Intervention Indicator type Main indicator Result Quality data
Clarke, M.,
et al. (2006)
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
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.
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
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)
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
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
Floyd, K.,
et al. (2003)
Malawi Community-based outpatient treatment for
smear-positive pulmonary patients (instead
of inpatient treatment)
Outcome Cost per patient
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
Islam, M. A.,
et al. (2002)
Bangladesh BRAC TB control program using CHWs,
compared to government-run program
Total annual cost
for TB control
program at the
(thana) level;
Cost per patient
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
Khan, M. A.,
et al. (2002)
Pakistan Comparison of DOTS by health workers at
health centers, DOTS by family members,
and DOTS without direct observation
Outcome Cost per case
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)
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
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)
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)
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
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)
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
societal and
Ministry of Health
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
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
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)
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
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
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
Foster, N.
and D.
(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
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.
(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)
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
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)
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)
Chanda, P.,
et al. (2011)
Zambia Comparison of home management (using
CHW) with facility-based management of
uncomplicated malaria
Output Cost per case
diagnosed and
31% reduction from facility-based
management ($6.12) to home management
100% of cases treated appropriately
through home management, and 43% of
cases treated appropriately in facility
B. M., et al.
(2014) [50]
Zambia Comparison of CHW program to test and
treat malaria with facility-based testing and
Output Total cost per
confirmed case
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)
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
9% increase in costs from health center
care (4093 shillings) to community-based
care (4491 shillings)
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
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)
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
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
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
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)
Myanmar Comparison of costs to treat diarrhea by
CHW, government facility, and private
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)
India Comparison of collaborative caremodel
using full-time physician, lay health worker
(LHW), and mental health specialist with
enhanced usual careby full-time physician
only for treatment of depression and anxiety
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)
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
80% reduction in cost from vertical
surveillance ($17) to PHC surveillance
Surveillance rates and levels of infestation
detection were comparable across
intervention and control arms
Cline, B. L.
and B. S.
(1996) [61]
Cameroon Diagnosis and treatment for schistosomiasis
by CHWs identified by the community
Output Average cost of
diagnosis and
treatment of a
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)
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
86% reduction from facility-based
consultation (105.1 lempiras) to community-
based program (14.67 lempiras)
et al., (2009)
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)
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
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)
Mozambique Comparison of surgically trained assistant
medical officers and specialist physicians
Input/process Cost per major
obstetric surgical
72% reduction in costs using assistant
medical officers ($39) compared to
specialist physicians ($144)
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
81% reduction in costs using CHWs ($0.10)
instead of using mobile teams ($0.55)
Puett, C.,
et al. (2013)
Bangladesh Community-based management of severe
acute malnutrition by CHWs compared to
inpatient treatment
Outcome Cost per DALY
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
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
81% reduction in costs using lady health
workers ($1.46) compared to referred cases
93.4% of cases successfully treated by lady
health workers with a 5-day course of
amoxicillin, and remaining cases referred
for further treatment
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
51% reduction in costs from using
dedicated GIS teams ($60,112) to CHWs
Seidman and Atun Human Resources for Health (2017) 15:29 Page 8 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
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 careteam 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].
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
Seidman and Atun Human Resources for Health (2017) 15:29 Page 9 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
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
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 [7275]). 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
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
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.
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.
ART: Antiretroviral therapy; CHW: Community health worker; DOTS: Directly
observed treatmentshort 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
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
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.
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.
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.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Received: 15 November 2016 Accepted: 29 March 2017
1. Grigoli F, Kapsoli J. Waste not, want not: the efficiency of health
expenditure in emerging and developing economies. IMF Working Papers.
2. Hernandez-Peña P. Health worker remuneration in WHO Member States.
Bull World Health Organ. 2013;91(11):80815.
3. Chisholm D, Evans DB. Improving health system efficiency as a means of
moving towards universal coverage, in World Health Report Background
Paper. Geneva: World Health Organization; 2010.
4. World Health Organization. First Global Conference on Task Shifting. 2008
[cited 2016 March 15]; Available from:
5. Joshi R, Alim M, Kengne AP, Jan S, Maulik PK, Peiris D, Patel AA. Task shifting
for non-communicable disease management in low and middle income
countriesa systematic review. PLoS One. 2014;9(8):e103754.
6. Kredo T, Adeniyi FB, Bateganya M, Pienaar ED. Task shifting from doctors
to non-doctors for initiation and maintenance of antiretroviral therapy.
Cochrane Database Syst Rev. 2014;7:Cd007331.
7. Penazzato M, Davies MA, Apollo T, Negussie E, Ford N. Task shifting for
the delivery of pediatric antiretroviral treatment: a systematic review.
J Acquir Immune Defic Syndr. 2014;65(4):41422.
8. Polus S, Lewin S, Glenton C, Lerberg PM, Rehfuess E, Gülmezoglu AM. Optimizing
the delivery of contraceptives in low- and middle-income countries through task
shifting: a systematic review of effectiveness and safety. Reprod Health. 2015;12:27.
9. Martínez-González NA, Tandjung R, Djalali S, Rosemann T. The impact of
physician-nurse task shifting in primary care on the course of disease: a
systematic review. Hum Resour Health. 2015;13:55.
10. Vaughan K. Costs and cost-effectiveness of community health workers:
evidence from a literature review. Hum Resour Health. 2015;13(1):1.
11. PRISMA. PRISMA: Transparent Reporting of Systematic Reviews and
Meta-Analyses. 2015 [cited 2016 September 6]; Available from:
12. W. K. Kellogg Foundation. Logic Model Development Guide. Michigan:
Battle Creek; 2004.
13. Alam K, Khan JA, Walker DG. Impact of dropout of female volunteer
community health workers: an exploration in Dhaka urban slums.
BMC Health Serv Res. 2012;12:260.
14. Borghi J. Economic assessment of a women's group intervention to improve
birth outcomes in rural Nepal. Lancet. 2005;36 6(9500): 18824.
15. Bowser D, et al. A cost-effectiveness analysis of community health workers
in Mozambique. J Pri Care Commun Health. 2015;6(4).
Seidman and Atun Human Resources for Health (2017) 15:29 Page 11 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
16. Chin-Quee D. Building on safety, feasibility, and acceptability: the impact
and cost of community health worker provision of injectable contraception.
Global Health Sci Pract. 2013;1(3):31627.
17. Chola L. Cost of individual peer counselling for the promotion of exclusive
breastfeeding in Uganda. Cost Eff Resour Alloc. 2011;9(1):1.
18. Onwujekwe O, Uzochukwu B, Ojukwu J, Dike N, Shu E. Feasibility of a
community health worker strategy for providing near and appropriate
treatment of malaria in southeast Nigeria: an analysis of activities, costs
and outcomes. Acta Trop. 2007;101(2):95105.
19. Prinja S, Jeet G, Verma R, Kumar D, Bahuguna P, Kaur M, Kumar R. Economic
analysis of delivering primary health care services through community health
workers in 3 North Indian states. PLoS One. 2014;9(3):e91781.
20. Prinja S, Mazumder S, Taneja S, Bahuguna P, Bhandari N, Mohan P,
Hombergh H, Kumar R. Cost of delivering child health care through
community level health workers: how much extra does IMNCI program cost?
J Trop Pediatr. 2013;59(6):48995.
21. Sabin LL. Costs and cost-effectiveness of training traditional birth attendants
to reduce neonatal mortality in the Lufwanyama Neonatal Survival study
(LUNESP). PLoS One. 2012;7(4):e35560.
22. Conteh L. Cost effectiveness of seasonal intermittent preventive treatment
using amodiaquine & artesunate or sulphadoxine-pyrimethamine in
Ghanaian children. PLoS One. 2010;5(8):e12223.
23. Mahmud N, Rodriguez J, Nesbit J. A text message-based intervention to
bridge the healthcare communication gap in the rural developing world.
Technol Health Care. 2010;18(2):13744.
24. Nonvignon J, Chinbuah MA, Gyapong M, Abbey M, Awini E, Gyapong JO,
Aikins M. Is home management of fevers a cost-effective way of reducing
under-five mortality in Africa? The case of a rural Ghanaian District. Trop
Med Int Health. 2012;17(8):9517.
25. Gaziano TA, Bertram M, Tollman SM, Hofman KJ. Hypertension education
and adherence in South Africa: a cost-effectiveness analysis of community
health workers. BMC Public Health. 2014;14:240.
26. McCordGC,LiuA,SinghP.Deploymentofcommunityhealthworkers
across rural sub-Saharan Africa: financial considerations and operational
assumptions. Bull World Health Organ. 2013;91(4):24453b.
27. Sutherland T, Bishai DM. Cost-effectiveness of misoprostol and prenatal iron
supplementation as maternal mortality interventions in home births in rural
India. Int J Gynecol Obstet. 2009;104(3):18993.
28. Tozan Y, Klein EY, Darley S, Panicker R, Laxminarayan R, Breman JG. Pre-referral
rectal artesunate is cost-effective for treating severe childhood malaria. Am J
Trop Med Hyg. 2009;81(5):305.
29. Fiedler JL. A cost analysis of the Honduras community-based integrated
child care program. Health, Nutrition and Population (HNP) Discussion
Paper. Washington: The World Bank; 2003.
30. Johns B. Assessing the costs and effects of antiretroviral therapy task shifting
from physicians to other health professionals in Ethiopia. J Acquir Immune
Defic Syndr. 2014;65 (4):e1407.
31. Johns, B. and E. Baruwa, The effects of decentralizing anti-retroviral services
in Nigeria on costs and service utilization: two case studies. Health Policy
Plan. 2015;31(2):182191.
32. Mbonye A. Intermittent preventive treatment of malaria in pregnancy: the
incremental cost-effectiveness of a new delivery system in Uganda. Trans R
Soc Trop Med Hyg. 2008;102(7):68593.
33. Hounton SH. A cost-effectiveness study of caesarean-section deliveries by
clinical officers, general practitioners and obstetricians in Burkina Faso.
Hum Resour Health. 2009;7(1):34.
34. Munyaneza F. Leveraging community health worker system to map a
mountainous rural district in low resource setting: a low-cost approach
to expand use of geographic information systems for public health. Int J
Health Geogr. 2014;13:49.
35. Datiko DG, Lindtjorn B. Cost and cost-effectiveness of smear-positive
tuberculosis treatment by Health Extension Workers in Southern
Ethiopia: a community randomized trial. PLoS One. 2010;5(2):e9158.
36. Is lam MA. Cost-effectiveness of community health workers in
tuberculosis control in Bangladesh. Bull World Health Organ.
37. Dick J. Primary health care nurses implement and evaluate a community
outreach approach to health care in the South African agricultural sector.
Int Nurs Rev. 2007;54(4):38390.
38. Okello D. Cost and cost-effectiveness of community-based care for tuberculosis
patients in rural Uganda. Int J Tuberc Lung Dis. 2003;7(9s1):S729.
39. Clarke M, Dick J, Bogg L. Cost-effectiveness analysis of an alternative tuberculosis
management strategy for permanent farm dwellers in South Africa amidst health
service contraction. Scand J Public Health. 2006;34(1):8391.
40. Khan MA. Costs and cost-effectiveness of different DOT strategies for the
treatment of tuberculosis in Pakistan. Directly Observed Treatment. Health
Policy Plan. 2002;17(2):17886.
41. Floyd K. Cost and cost-effectiveness of increased community and primary
care facility involvement in tuberculosis care in Lilongwe District, Malawi.
Int J Tuberc Lung Dis. 2003;7(9):S2937.
42. Prado TN. Cost-effectiveness of community health worker versus home-
based guardians for directly observed treatment of tuberculosis in Vitoria,
Espirito Santo State, Brazil. Cad Saude Publica. 2011;27(5):94452.
43. Sinanovic E. Cost and cost-effectiveness of community-based care
for tuberculosis in Cape Town, South Africa. Int J Tuberc Lung Dis.
44. Yan H. The increased effectiveness of HIV preventive intervention among
men who have sex with men and of follow-up care for people living with
HIV after task-shiftingto community-based organizations: a 'cash on service
delivery' model in China. PLoS One. 2014;9(7):e103146.
45. Fatti G, Monteith L, Shaikh N, Kapp E, Foster N, Grimwood A., A Comparison of
Two Task-Shifting Models of Pharmaceutical Care in Antiretroviral Treatment
Programs in South Africa. J Acquir Immune Defic Syndr. 2015;71(4).
46. Babigumira JB. Cost effectiveness of a pharmacy-only refill program in a large
urban HIV/AIDS clinic in Uganda. PLoS One. 2011;6(3):e18193.
47. Foster N, McIntyre D. Economic evaluation of task-shifting approaches to the
dispensing of anti-retroviral therapy. Hum Resour Health. 2012;10:32.
48. Bemelmans M. Community-supported models of care for people on HIV
treatment in sub-Saharan Africa. Trop Med Int Health. 2014;19(8):96877.
49. Chanda P. Relative costs and effectiveness of treating uncomplicated malaria
in two rural districts in Zambia: Implications for nationwide scale-up of home-
based management. Malar J. 2011;10:159.
50. Hamainza B, Moonga H, Sikaala CH, Kamuliwo M, Bennett A, Eisele TP, Miller J,
Seyoum A, Killeen GF. Monitoring, characterization and control of chronic,
symptomatic malaria infections in rural Zambia through monthly household
visits by paid community health workers. Malar J. 2014;13:128.
51. Patouillard E. Coverage, adherence and costs of intermittent preventive
treatment of malaria in children employing different delivery strategies in
Jasikan. Ghana PloS one. 2011;6(11):e24871.
52. Ruebush 2nd TK. Community participation in malaria surveillance and
treatment. III. An evaluation of modifications in the Volunteer Collaborator
Network of Guatemala. Am J Trop Med Hyg. 1994;50(1):8598.
53. Sikaala CH. A cost-effective, community-based, mosquito-trapping scheme
that captures spatial and temporal heterogeneities of malaria transmission
in rural Zambia. Malar J. 2014;13:225.
54. Jafar TH. Cost-effectiveness of community-based strategies for blood
pressure control in a low-income developing country: findings from a
cluster-randomized, factorial-controlled trial. Circulation. 2011;124(15):161525.
55. Puett C. Cost-effectiveness of the community-based management of severe
acute malnutrition by community health workers in southern Bangladesh.
Health Policy Plan. 2013;28(4):38699.
56. Laveissiere C. Detecting sleeping sickness: comparative efficacy of
mobile teams and community health workers. Bull World Health Organ.
57. Buttorff C. Economic evaluation of a task-shifting intervention for common
mental disorders in India. Bull World Health Organ. 2012;90(11):81321.
58. Kruk ME. Economic evaluation of surgically trained assistant medical
officers in performing major obstetric surgery in Mozambique. Bjog.
59. Sadruddin S. Household costs for treatment of severe pneumonia in Pakistan.
Am J Trop Med Hyg. 2012;87(5 Suppl):13743.
60. Chuit R. Result of a first step toward community-based surveillance of
transmission of Chagasdisease with appropriate technology in rural areas.
Am J Trop Med Hyg. 1992;46(4):44450.
61. Cline BL, Hewlett BS. Community-based approach to schistosomiasis control.
Acta Trop. 1996;61(2):10719.
62. Aung T. Incidence of pediatric diarrhea and public-private preferences for
treatment in rural Myanmar: a randomized cluster survey. J Trop Pediatr.
63. Fiedler JL, Villalobos CA, De Mattos AC. An activity-based cost analysis of
the Honduras community-based, integrated child care (AIN-C) programme.
Health Policy Plan. 2008;23(6):40827.
Seidman and Atun Human Resources for Health (2017) 15:29 Page 12 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
64. World Health Organization. Tuberculosis: Fact Sheet No. 104. 2015
[cited 2016 March 14]; Available from:
65. Kim, J.Y. The burden of tuberculosis: Economic burden (2). 2016 [cited 2016
September 15]; Available from:
66. UNAIDS. Fact Sheet 2016. 2016 [cited 2016 September 16]; Available
67. UNAIDS. Fast-Track Update on Investments Needed in the AIDS Response.
2016 [cited 2016 September 15]; Available from:
68. World Health Organization, Classifying health workers: Mapping occupations
to the international standard classification. Geneva: World Health
69. Jaskiewicz W, Tulenko K. Increasing community health worker productivity
and effectiveness: a review of the influence of the work environment.
Hum Resour Health. 2012;10(1):1.
70. Glenton C, et al. Barriers and facilitators to the implementation of lay health
worker programmes to improve access to maternal and child health:
qualitative evidence synthesis. Cochrane Database Syst Rev. 2013;10:
71. Pallas SW. Community health workers in low- and middle-income countries:
what do we know about scaling up and sustainability? Am J Public Health.
72. Bastawrous A, Giardini ME, Bolster NM, Peto T, Shah N, Livingstone IA,
Weiss HA, Hu S, Rono H, Kuper H, Burton M. Clinical Validation of a
Smartphone-Based Adapter for Optic Disc Imaging in Kenya. JAMA
Ophthalmol. 2016;134(2).
73. Gupta B, Huckman RS, Khanna T. Task shifting in surgery: lessons from an
Indian Heart Hospital. Healthc (Amst). 2015;3(4):24550.
74. Boullé C, Kouanfack C, Laborde-Balen G, Carrieri MP, Dontsop M, Boyer S,
Aghokeng AF, Spire B, Koulla-Shiro S, Delaporte E, Laurent C. Task shifting
HIV care in rural district hospitals in Cameroon: evidence of comparable
antiretroviral treatment-related outcomes between nurses and physicians in
the Stratall ANRS/ESTHER trial. J Acquir Immune Defic Syndr. 2013;62(5):56976.
75. Nash D, Azeez S, Vlahov D, Schori M. Evaluation of an intervention to
increase screening colonoscopy in an urban public hospital setting.
J Urban Health. 2006;83(2):23143.
76. Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African
countries. Lancet. 2007;370(9605):215863.
77. Chu K. Surgical task shifting in sub-Saharan Africa. PLoS Med. 2009;6(5):e1000078.
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... This shows that simple radiological measurements do not have to be performed by radiologists but can also be performed by trained personnel with lower qualifications. This fits in the trend of task shifting to reduce rising healthcare costs, waiting lists, and the reduction of workload of radiologists [30][31][32]. ...
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Objectives: The purpose of this study is to evaluate the value of dual-energy CT (DECT) with virtual non-calcium (VNCa) in quantitatively assessing the presence of bone marrow edema (BME) in patients with diabetic foot ulcers and suspected osteomyelitis. Methods: Patients with a diabetic foot ulcer and suspected osteomyelitis that underwent DECT (80 kVp/Sn150 kVp) with VNCa were retrospectively included. Two observers independently measured CT values of the bone adjacent to the ulcer and a reference bone not related to the ulcer. The patients were divided into two clinical groups, osteomyelitis or no-osteomyelitis, based on the final diagnosis by the treating physicians. Results: A total of 56 foot ulcers were identified of which 23 were included in the osteomyelitis group. The mean CT value at the ulcer location was significantly higher in the osteomyelitis group (- 17.23 ± 34.96 HU) compared to the no-osteomyelitis group (- 69.34 ± 49.40 HU; p < 0.001). Within the osteomyelitis group, the difference between affected bone and reference bone was statistically significant (p < 0.001), which was not the case in the group without osteomyelitis (p = 0.052). The observer agreement was good for affected bone measurements (ICC = 0.858) and moderate for reference bone measurements (ICC = 0.675). With a cut-off value of - 40.1 HU, sensitivity was 87.0%, specificity was 72.7%, PPV was 69.0%, and NPV was 88.9%. Conclusion: DECT with VNCa has a potential value for quantitatively assessing the presence of BME in patients with diabetic foot ulcers and suspected osteomyelitis. Key points: • Dual-energy CT (DECT) with virtual non-calcium (VNCa) is promising for detecting bone marrow edema in the case of diabetic foot ulcers with suspected osteomyelitis. • DECT with VNCa has the potential to become a more practical alternative to MRI in assessing the presence of bone marrow edema in suspected osteomyelitis when radiographs are not sufficient to form a diagnosis.
... 5,6 A key driver of task shifting is in it's ability to expand workforce capacity in an economically sustainable and responsible way. 7 From a society or community perspective, task shifting enhances patient care access and screening for rural patients. 8 On a provider or health-system level, task shifting can reduce provider burnout and increase care delivery. ...
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Background: There has been increasing evidence that “task shifting,” when a provider entrusting specific responsibilities to another member of their team, can increase care access and may lead to better patient care outcomes. This has been particularly underscored in underserved communities throughout the world where task shifting has led to increased healthcare access in areas of provider shortages. Within the profession of pharmacy, pharmacy technicians are the primary pharmacist-assistants and recipients of pharmacist-delegated tasks. Recently, such task delegation has placed the pharmacist in more direct patient care responsibilities beyond medication dispensing – and one such model with a growing evidence base is the Optimizing Care Model. Through task shifting, the Optimizing Care Model has been shown to reduce medication errors and increase the quantity of patient care services offered by the pharmacist. However, means to spread and scale the model have yet to be reported in the literature. Methods: This article describes the development of a package of implementation strategies designed to facilitate implementation the Optimizing Care Model in a single division of nationwide supermarket pharmacy chain. The Implementation Mapping approach was used to systematically develop strategies. Results: The application of the five steps of Implementation Mapping are described in detail. Implementation objectives, models, and strategies are outlined, as well as the final implementation protocol. There was an overall increase in weeks meeting the 10% Optimizing Care Model threshold; 33% at baseline to 83% after the intervention. Conclusions: The implementation mapping process led to development of multi-faceted implementation strategy for implementing the Optimizing Care Model into community pharmacy practice. The strategy improved Optimizing Care Model implementation. Further research is needed to understand which strategies were most impactful.
... We speci ed these three occupational groups to be consistent with the literature estimating desired workforce density in LMICs [14] and for practical considerations, given that data availability for other occupational groups is limited. In addition, we included community health workers (CHW) and a category of health workers that is modi able by end-user, with the default category being clinical o cers (CO), in the end-user tool by applying a productivity multiplier empirically identi ed in the literature [15][16][17][18][19]. ...
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Background: Globally, HIV, TB and malaria account for an estimated three million deaths annually. The Global Fund partnered with the World Health Organization to assist countries with health workforce planning in these areas through the development of an integrated health workforce investment impact tool. Our study illustrates the development of a user-friendly tool (with two MS Excel calculator subcomponents) that computes associations between human resources for health (HRH) investment inputs and reduced morbidity and mortality from HIV, TB, and malaria via increased coverage of effective treatment services. Methods: We retrieved from the peer-reviewed literature quantitative estimates of the relation among HRH inputs and HRH employment and productivity. We converted these values to additional full-time-equivalent doctors, nurses and midwives (DNMs). We used log-linear regression to estimate the relation between DNMs and treatment service coverage outcomes for HIV, TB, and malaria. We then retrieved treatment effectiveness parameters from the literature to calculate lives saved due to expanded treatment coverage for HIV, TB, and malaria. After integrating these estimates into the tool, we piloted it in four countries. Results: In most countries with a considerable burden of HIV, TB, and malaria, the health workforce investments include a mix of pre-service training, full remuneration of new hires, various forms of incentives and in-service training. These investments were associated with elevated HIV, TB and malaria treatment service coverage and additional lives saved. The country case studies we developed in addition, indicate the feasibility and utility of the tool for a variety of international and local actors interested in HRH planning. Conclusions: The modelled estimates developed for illustrative purposes and tested through country case studies suggest that HRH investments result in lives saved across HIV, TB, and malaria. Further, findings show that attainment of high targets of specific treatment coverage indicators would require a substantially greater health workforce than what is currently available in most LMICs. The open access tool can assist significantly with future HRH planning efforts, particularly in LMICs.
... Human resources for health have been considered particularly scarce in Africa and in HIV services [34,35]. A systematic review on low-income and middleincome countries found that task shifting may reduce costs and enhance efficiency in HIV care [36]. Another systematic review concluded that shifting the provision of antiretroviral therapy from doctors to trained lowercadre HCW in Africa was possible without decreasing the quality of care [10]. ...
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Background The global expansion of HIV pre-exposure prophylaxis (PrEP) includes health systems that face a shortage of skilled health care workers (HCWs). We estimated the human resource needs and costs for providing PrEP in nurse-led primary care clinics in Eswatini. Furthermore, we assessed potential cost savings from task sharing between nurses and other HCW cadres. Methods We conducted a time-and-motion and costing study in a PrEP demonstration project between August 2017 and January 2019. A form for recording time and performed activities (“motion”) was filled by HCWs of six primary care clinics. To estimate the human resource needs for specific PrEP activities, we allocated recorded times to performed PrEP activities using linear regression with and without adjusting for a workflow interruption, that is, if a client was seen by different HCWs or by the same HCW at different times. We assessed a base case in which a nurse provides all PrEP activities and five task shifting scenarios, of which four include workflow interruptions due to task sharing between different HCW cadres. Results On average, PrEP initiation required 29 min (95% CI 25–32) of HCW time and PrEP follow-up 16 min (95% CI 14–18). The HCW time cost $4.55 (uncertainty interval [UI] 1.52–9.69) for PrEP initiation and $2.54 (UI 1.07–4.64) for PrEP follow-up when all activities were performed by a nurse. Time costs were $2.30–4.25 (UI 0.62–9.19) for PrEP initiation and $1.06–2.60 (UI 0.30–5.44) for PrEP follow-up when nurses shared tasks with HCWs from lower cadres. Interruptions of the workflow added, on average, 3.4 min (95% CI 0.69–6.0) to the time HCWs needed for a given number of PrEP activities. The cost of an interrupted workflow was estimated at $0.048–0.87 (UI 0.0098–1.63) depending on whose time need increased. Conclusions A global shortage of skilled HCWs could slow the expansion of PrEP. Task shifting to lower-cadre HCW in nurse-led PrEP provision can free up nurse time and reduce the cost of PrEP provision even if interruptions associated with task sharing increase the overall human resource need.
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Background: Rehabilitation is essential to foster healthy ageing. Older adults have unique rehabilitation needs due to a higher prevalence of non-communicable diseases, susceptibility to infectious diseases like COVID-19, injuries, and mental health conditions. However, there is a limited understanding of how rehabilitation is delivered to the ageing population. To address this gap, we conducted a scoping review to describe rehabilitation delivery models used to optimise the ageing population's functioning/functional ability and foster healthy ageing. Methods: We searched Medline and Embase (January 2015 to May 2022) for primary studies published in English describing approaches to provide rehabilitation in people older than 50. Three authors screened records for eligibility and extracted data independently and in duplicate. Data synthesis included descriptive quantitative analysis of study and rehabilitation provision characteristics, and qualitative analysis to identify rehabilitation delivery models. Results: Out of 6,933 identified records, 585 articles were assessed for eligibility, and 283 studies with 69,257 participants were included. We identified six rehabilitation delivery models: outpatient (24%), telerehabilitation (22%), home (18.5%), community (16.3%), inpatient (14.6%), and eldercare (4.7%). These models often involved multidisciplinary teams (31.5%) and follow integrated care principles (30.4%). Most studies used a disease-centred approach (59.0%), while studies addressing multimorbidity (6.0%) and prevalent health problems of ageing, such as pain, low hearing and vision, or incontinence were scarce. The most frequently provided interventions were therapeutic exercises (54.1%), self-management education (40.1%), and assessment of person-centred goals (40%). Other interventions, such as assistive technology (8.1%) and environmental adaptations (7.4%) were infrequent. Conclusions: We provided a comprehensive overview of six delivery models used to provide rehabilitation to the ageing population and highlight research gaps that require further attention, including a lack of systematic assessment of functioning/functional ability, a predominance of disease-centred rehabilitation, and scarcity of programs addressing prevalent issues like pain, hearing/vision loss, fall prevention, incontinence, and sexual dysfunctions. Our research can facilitate evidence-based decision-making and inspire further research and innovation in rehabilitation and healthy ageing. Limitations of our study include reliance on published research to infer practice and not assessing model effectiveness. Future research in the field is needed to expand and validate our findings.
Objective: We evaluate mid-intervention (8-weeks) and short-term (16-weeks) impact of a culturally-adapted multiple family group (MFG) intervention, 'Amaka Amasanyufu', on mental health of children with Disruptive Behavior Disorders (DBDs) and primary caregivers in Uganda. Methods: We analyzed data from the SMART Africa-Uganda study. Schools were randomized to: 1) Control group; 2) MFG facilitated by parent peers (MFG-PP); or 3) MFG facilitated by community health workers (MFG:CHW). All participants were blinded to interventions provided to other participants and study hypotheses. At 8-weeks and 16-weeks, we evaluated differences in: depressive symptoms and self-concept among children and; mental health and caregiving-related stress among caregivers. Three-level inear mixed-effects models were fitted. Pairwise comparisons of post-baseline group means were performed using Sidak's adjustment for multiple comparisons and standardized mean differences. Data from 636 children with DBDs and caregivers (Controls: n=243, n=10 schools; MFG-PP: n=194, n=8 schools; MFG-CHW: n=199, n=8 schools) were analyzed. Results: There were significant group-by-time interactions for all outcomes, and differences were observed mid-intervention, with short-term effects at 16-weeks (end-intervention). MFG-PP and MFG-CHW children had significantly lower depressive symptoms and higher self-concept while caregivers had significantly lower caregiving-related stress and fewer mental health problems than controls. There was no difference between intervention groups. Conclusions: Amaka Amasanyufu MFG intervention is effective for reducing depressive symptoms and improving self-concept among children with DBDs while reducing parental stress and mental health problems among caregivers. Given the paucity of culturally-adapted mental health interventions this provides support for adaptation and scale-up in Uganda and other low-resource settings.
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Background:Global chronic health worker shortages and stagnating routine immunization rates require new strategies to increase vaccination coverage and equity. As trained, trusted members of their local communities, community health workers (CHWs)are in a prime position to expand the immunization workforce and increase vaccination coverage in under-reached communities. Malawi is one of only a few countries that relies on CHWs - called Health Surveillance Assistants (HSAs) in Malawi - to administer routine immunizations, and as such offers a unique example of how this can be done. Case Presentation: We sought to describe the operational and programmatic characteristics of a functional CHW-led routine immunization program by conducting interviews with HSAs, HSA supervisors, ministry of health officials, and community members in Malawi. This case study describes how and where HSAs provide vaccinations, their vaccination-related responsibilities, training and supervision processes, vaccine safety considerations, and the community-level vaccine supply chain. Interview participants consistently described HSAs as a high-functioning vaccination cadre, skilled and dedicated to increasing vaccine access for children. They also noted a need to strengthen some aspects of professional support for HSAs, particularly related to training, supervision, and supply chain processes. Interviewees agreed that other countries should consider following Malawi’s example and use CHWs to administer vaccines, provided they can be sufficiently trained and supported. Conclusions: This account from Malawi provides an example of how a CHW-led vaccination program operates. Leveraging CHWs as vaccinators is a promising yet under-explored task-shifting approach that shows potential to help countries maximize their health workforce, increase vaccination coverage and reach more zero-dose children. However more research is needed to produce evidence on the impact of leveraging CHWs as vaccinators on patient safety, immunization coverage/vaccine equity, and cost-effectiveness as compared to use of other cadres for routine immunization.
Nurses are often suboptimally used in HIV care, due to misalignment of training and practice, workflow inefficiencies, and management challenges. We sought to understand nursing workforce capacity and support implementation of process improvement strategies to improve efficiency of HIV service delivery in Tanzania and Zambia. We conducted time and motion observations and task analyses at 16 facilities followed by process improvement workshops. On average, each nurse cared for 45 clients per day in Tanzania and 29 in Zambia. Administrative tasks and documentation occupied large proportions of nurse time. Self-reported competency was low at baseline and higher at follow-up for identifying and managing treatment failure and prescribing antiretroviral therapy. After workshops, facilities changed care processes, provided additional training and mentorship, and changed staffing and supervision. Efficiency outcomes were stable despite staffing increases. Collaborative approaches to use workforce data to engage providers in improvement strategies can support roll-out of nurse-managed HIV treatment.
Background: With an estimated lifetime prevalence of epilepsy of 7.6 per 1,000 people, epilepsy represents one of the most common neurological disorders worldwide, with the majority of people with epilepsy (PWE) living in low-income and middle-income countries (LMICs). Adequately treated, up to 70 % of PWE will become seizure-free, however, as many as 85% of PWE worldwide, mostly from LMICs, do not receive adequate treatment. Objective: To assess the impact of the presence of a neurologist on the management of PWE in Tanzania. Methods: Two epilepsy clinics in rural Tanzania, one continuously attended by a neurologist, and one mainly attended by nurses with training in epilepsy and supervised intermittently by specialist doctors (neurologists/psychiatrists) were comparatively analyzed by multivariable linear and logistic regression models with regard to the outcome parameters seizure frequency, the occurrence of side effects of antiepileptic medication and days lost after a seizure. Results: The presence of a neurologist significantly reduced the mean number of seizures patients experienced per month by 4.49 seizures (p < 0.01) while leading to an increase in the occurrence of reported side effects (OR: 2.15, p = 0.02). Conclusion: The presence of a neurologist may play a substantial role in reducing the burden of the disease of PWE in LMICs. Hence, specialist training should be encouraged, and relevant context-specific infrastructure established.
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Importance Visualization and interpretation of the optic nerve and retina are essential parts of most physical examinations.Objective To design and validate a smartphone-based retinal adapter enabling image capture and remote grading of the retina.Design, Setting, and Participants This validation study compared the grading of optic nerves from smartphone images with those of a digital retinal camera. Both image sets were independently graded at Moorfields Eye Hospital Reading Centre. Nested within the 6-year follow-up (January 7, 2013, to March 12, 2014) of the Nakuru Eye Disease Cohort in Kenya, 1460 adults (2920 eyes) 55 years and older were recruited consecutively from the study. A subset of 100 optic disc images from both methods were further used to validate a grading app for the optic nerves. Data analysis was performed April 7 to April 12, 2015.Main Outcomes and Measures Vertical cup-disc ratio for each test was compared in terms of agreement (Bland-Altman and weighted κ) and test-retest variability.Results A total of 2152 optic nerve images were available from both methods (also 371 from the reference camera but not the smartphone, 170 from the smartphone but not the reference camera, and 227 from neither the reference camera nor the smartphone). Bland-Altman analysis revealed a mean difference of 0.02 (95% CI, −0.21 to 0.17) and a weighted κ coefficient of 0.69 (excellent agreement). The grades of an experienced retinal photographer were compared with those of a lay photographer (no health care experience before the study), and no observable difference in image acquisition quality was found.Conclusions and Relevance Nonclinical photographers using the low-cost smartphone adapter were able to acquire optic nerve images at a standard that enabled independent remote grading of the images comparable to those acquired using a desktop retinal camera operated by an ophthalmic assistant. The potential for task shifting and the detection of avoidable causes of blindness in the most at-risk communities makes this an attractive public health intervention.
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This study sought to synthesize and critically review evidence on costs and cost-effectiveness of community health worker (CHW) programmes in low- and middle-income countries (LMICs) to inform policy dialogue around their role in health systems. From a larger systematic review on effectiveness and factors influencing performance of close-to-community providers, complemented by a supplementary search in PubMed, we did an exploratory review of a subset of papers (32 published primary studies and 4 reviews from the period January 2003-July 2015) about the costs and cost-effectiveness of CHWs. Studies were assessed using a data extraction matrix including methodological approach and findings. Existing evidence suggests that, compared with standard care, using CHWs in health programmes can be a cost-effective intervention in LMICs, particularly for tuberculosis, but also - although evidence is weaker - in other areas such as reproductive, maternal, newborn and child health (RMNCH) and malaria. Notwithstanding important caveats about the heterogeneity of the studies and their methodological limitations, findings reinforce the hypothesis that CHWs may represent, in some settings, a cost-effective approach for the delivery of essential health services. The less conclusive evidence about the cost-effectiveness of CHWs in other areas may reflect that these areas have been evaluated less (and less rigorously) than others, rather than an actual difference in cost-effectiveness in the various service delivery areas or interventions. Methodologically, areas for further development include how to properly assess costs from a societal perspective rather than just through the lens of the cost to government and accounting for non-tangible costs and non-health benefits commonly associated with CHWs.
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Physician-nurse task shifting in primary care appeals greatly to health policymakers. It promises to address workforce shortages and demands of high-quality, affordable care in the healthcare systems of many countries. This systematic review was conducted to assess the evidence about physician-nurse task shifting in primary care in relation to the course of disease and nurses' roles. We searched MEDLINE, Embase, The Cochrane Library and CINAHL, up to August 2012, and the reference list of included studies and relevant reviews. All searches were updated in February 2014. We selected and critically appraised published randomized controlled trials (RCTs). Twelve RCTs comprising 22 617 randomized patients conducted mainly in Europe met the inclusion criteria. Nurse-led care was delivered mainly by nurse practitioners following structured protocols and validated instruments in most studies. Twenty-five unique disease-specific measures of the course of disease were reported in the 12 RCTs. While most (84 %) study estimates showed no significant differences between nurse-led care and physician-led care, nurses achieved better outcomes in the secondary prevention of heart disease and a greater positive effect in managing dyspepsia and at lowering cardiovascular risk in diabetic patients. The studies were generally small, of varying follow-up episodes and were at risk of biases. Descriptive details about roles, qualifications or interventions were also incomplete or not reported. Trained nurses may have the ability to achieve outcome results that are at least similar to physicians' for managing the course of disease, when following structured protocols and validated instruments. The evidence, however, is limited by a small number of studies reporting a broad range of disease-specific outcomes; low reporting standards of interventions, roles and clinicians' characteristics, skills and qualifications; and the quality of studies. More rigorous studies using validated tools could clarify these findings.
Setting: Guguletu and Nyanga areas of Cape Town, South Africa. Objective: To evaluate the affordability and cost-effectiveness of community involvement in tuberculosis (TB) care. Design: A cost-effectiveness analysis comparing treatment for new smear-positive pulmonary and retreatment TB patients in two similar townships, one providing clinic-based-care with community-based observation options available for its TB patients (Guguletu) and one providing clinic-based care only, with no community-based observation of treatment (Nyanga). Costs were assessed from a societal perspective in 1997 US$, and cost-effectiveness was calculated as the cost per patient successfully treated. Results: TB treatment in Guguletu was more cost-effective than TB treatment in Nyanga for both new and retreatment patients ($726 vs. $1201 and $1419 vs. $2058, respectively). This reflected both lower costs ($495 vs. $769 per patient treated for new cases; $823 vs. $1070 per patient treated for retreatment cases) and better treatment outcomes (successful treatment rate 68% vs. 64% and 58% vs. 52% for new and retreatment patients, respectively). Within Guguletu, community-based care was more than twice as cost-effective as clinic-based care ($392 vs. $1302 per patient successfully treated for new patients, and $766 vs. $2008 for retreatment patients), for similar reasons (e.g., for new cases, $314 vs. $703 per patient treated, successful treatment rate 80% vs. 54%). Conclusion: Community involvement in TB care can improve the affordability and cost-effectiveness of TB treatment in urban South Africa. Expansion in the Western Cape and in similar areas of the country is worthy of serious consideration by planners and policy-makers.
To evaluate the effects, costs, and cost-effectiveness of different degrees of antiretroviral therapy task shifting from physician to other health professionals in Ethiopia. Two-year retrospective cohort analysis on antiretroviral therapy patients coupled with cost analysis. Facilities with minimal or moderate task shifting compared with facilities with maximal task shifting. Maximal task shifting is defined as nonphysician clinicians handling both severe drug reactions and antiretroviral drug regimen changes. Secondary analysis compares health centers to hospitals. The primary effectiveness measure is the probability of a patient remaining actively on antiretroviral therapy for 2 years; the cost measure is the cost per patient per year. All facilities had some task shifting. About 89% of patients were actively on treatment 2 years after antiretroviral treatment (ART) initiation, with no statistically significant differences between facilities with maximal and minimal or moderate task shifting. It cost about $206 per patient per year for ART, with no statistically significant difference between the comparison groups. The cost-effectiveness of maximal task shifting is similar to minimal or moderate task shifting, with the same results obtained using regression to control for facility characteristics. Shifting the handling of both severe drug reactions and antiretroviral drug regimen changes from physicians to other clinical officers is not associated with a significant change in the 2-year treatment success rate or the costs of ART care. As an observational study, these results are tentative, and more research is needed in determining the optimal patterns of task shifting.
Background: The severe shortage of pharmacists is an important limitation to providing antiretroviral treatment (ART) in resource-limited countries. Two task-shifting pharmaceutical care models have been developed to address this in South Africa, namely Indirectly Supervised Pharmacist Assistant (ISPA) and nurse-managed models. This study compared pharmaceutical care quality, patient clinical outcomes, and provider staff costs between these models. Methods: An analysis of pharmaceutical quality audits, patient clinical data and staff costing data collected at seven ISPA and eight nurse-managed facilities was undertaken. Pharmaceutical audits were conducted by pharmacists using a standardized tool. Routine clinical data were collected prospectively at patient visits, and staff human resources costs were analysed. Results: Overall pharmaceutical care quality scores were higher at ISPA sites than nurse-managed sites; 88.8% vs. 79.9%, respectively; risk ratio (ISPA vs. nurse)=1.11 (95% CI: 1.09-1.13; P<0.0001). Mean provider pharmaceutical-related human resources costs per patient visit and per item dispensed were 29% and 49% lower, respectively, at ISPA facilities. At ISPA facilities, patient attrition was observed to be lower and viral suppression higher than at nurse-managed sites. Conclusion: The ISPA model had a higher quality of pharmaceutical care and was less costly to implement. Further expansion of this model or integrating it with nurse-managed ART may enhance the cost-efficient scale-up of ART programs in Sub-Saharan Africa.
We present a case study that illustrates task shifting, the transfer of activities from senior to junior colleagues, in the context of cardiac surgery at the Narayana Health City Cardiac Hospital (NH) in India. The case discusses the factors driving the adoption of task shifting at NH and identifies the implications of task shifting for surgeon training, surgical capacity, and procedure costs. A comparison of the outcomes of two senior surgeons with similar experience, workload, and patient profiles-but varying in their level of task shifting-suggests that shifting of lower complexity tasks by senior surgeons to trained junior colleagues does not negatively impact in-hospital mortality and post-procedure length of stay. The study concludes with a discussion of task shifting's potential to improve access to affordable tertiary care in resource-constrained settings.
Current World Health Organization (WHO) guidelines for severe pneumonia treatment of under-5 children recommend hospital referral. However, high treatment cost is a major barrier for communities. We compared household costs for referred cases with management by lady health workers (LHWs) using oral antibiotics. This study was nested within a cluster randomized trial in Haripur, Pakistan. Data on direct and indirect costs were collected through interviews and record reviews in the 14 intervention and 14 control clusters. The average household cost/case for a LHW managed case was $1.46 compared with $7.60 for referred cases. When the cost of antibiotics provided by the LHW program was excluded from the estimates, the cost/case came to $0.25 and $7.51 for the community managed and referred cases, respectively, a 30-fold difference. Expanding severe pneumonia treatment with oral amoxicillin to community level could significantly reduce household costs and improve access to the underprivileged population, preventing many child deaths. Copyright © 2012 by The American Society of Tropical Medicine and Hygiene.
Public health spending is low in emerging and developing economies relative to advanced economies and health outputs and outcomes need to be substantially improved. Simply increasing public expenditure in the health sector, however, may not significantly affect health outcomes if the efficiency of this spending is low. This paper quantifies the inefficiency of public health expenditure and the associated potential gains for emerging and developing economies using a stochastic frontier model that controls for the socioeconomic determinants of health, and provides country-specific estimates. The results suggest that African economies have the lowest efficiency. At current spending levels, they could boost life expectancy up to about five years if they followed best practices.