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The development of task sharing policy and guidelines in Kenya

Authors:
  • Emory University Kenya health workforce project

Abstract

Background The global critical shortage of health workers prevents expansion of healthcare services and universal health coverage. Like most countries in sub-Saharan Africa, Kenya’s healthcare workforce density of 13.8 health workers per 10,000 population falls below the World Health Organization (WHO) recommendation of at least 44.5 doctors, nurses, and midwives per 10,000 population. In response to the health worker shortage, the WHO recommends task sharing, a strategy that can increase access to quality health services. To improve the utilization of human and financial health resources in Kenya for HIV and other essential health services, the Kenya Ministry of Health (MOH) in collaboration with various institutions developed national task sharing policy and guidelines (TSP). To advance task sharing, this article describes the process of developing, adopting, and implementing the Kenya TSP. Case presentation The development and approval of Kenya’s TSP occurred from February 2015 to May 2017. The U.S. Centers for Disease Control and Prevention (CDC) allocated funding to Emory University through the United States President’s Emergency Plan for AIDS Relief (PEPFAR) Advancing Children’s Treatment initiative. After obtaining support from leadership in Kenya’s MOH and health professional institutions, the TSP team conducted a desk review of policies, guidelines, scopes of practice, task analyses, grey literature, and peer-reviewed research. Subsequently, a Policy Advisory Committee was established to guide the process and worked collaboratively to form technical working groups that arrived at consensus and drafted the policy. The collaborative, multidisciplinary process led to the identification of gaps in service delivery resulting from health workforce shortages. This facilitated the development of the Kenya TSP, which provides a general orientation of task sharing in Kenya. The guidelines list priority tasks for sharing by various cadres as informed by evidence, such as HIV testing and counseling tasks. The TSP documents were disseminated to all county healthcare facilities in Kenya, yet implementation was stopped by order of the judiciary in 2019 after a legal challenge from an association of medical laboratorians. Conclusions Task sharing may increase access to healthcare services in resource-limited settings. To advance task sharing, TSP and clinical practice could be harmonized, and necessary adjustments made to other policies that regulate practice (e.g., scopes of practice). Revisions to pre-service training curricula could be conducted to ensure health professionals have the requisite competencies to perform shared tasks. Monitoring and evaluation can help ensure that task sharing is implemented appropriately to ensure quality outcomes.
Kinuthiaetal. Human Resources for Health (2022) 20:61
https://doi.org/10.1186/s12960-022-00751-y
CASE STUDY
The development oftask sharing policy
andguidelines inKenya
Rosemary Kinuthia1* , Andre Verani2, Jessica Gross2, Rose Kiriinya4, Kenneth Hepburn1, Jackson Kioko3,
Agnes Langat2, Abraham Katana2, Agnes Waudo4 and Martha Rogers1
Abstract
Background: The global critical shortage of health workers prevents expansion of healthcare services and universal
health coverage. Like most countries in sub-Saharan Africa, Kenya’s healthcare workforce density of 13.8 health work-
ers per 10,000 population falls below the World Health Organization (WHO) recommendation of at least 44.5 doc-
tors, nurses, and midwives per 10,000 population. In response to the health worker shortage, the WHO recommends
task sharing, a strategy that can increase access to quality health services. To improve the utilization of human and
financial health resources in Kenya for HIV and other essential health services, the Kenya Ministry of Health (MOH) in
collaboration with various institutions developed national task sharing policy and guidelines (TSP). To advance task
sharing, this article describes the process of developing, adopting, and implementing the Kenya TSP.
Case presentation: The development and approval of Kenya’s TSP occurred from February 2015 to May 2017. The
U.S. Centers for Disease Control and Prevention (CDC) allocated funding to Emory University through the United
States President’s Emergency Plan for AIDS Relief (PEPFAR) Advancing Children’s Treatment initiative. After obtaining
support from leadership in Kenya’s MOH and health professional institutions, the TSP team conducted a desk review
of policies, guidelines, scopes of practice, task analyses, grey literature, and peer-reviewed research. Subsequently, a
Policy Advisory Committee was established to guide the process and worked collaboratively to form technical work-
ing groups that arrived at consensus and drafted the policy. The collaborative, multidisciplinary process led to the
identification of gaps in service delivery resulting from health workforce shortages. This facilitated the development
of the Kenya TSP, which provides a general orientation of task sharing in Kenya. The guidelines list priority tasks for
sharing by various cadres as informed by evidence, such as HIV testing and counseling tasks. The TSP documents were
disseminated to all county healthcare facilities in Kenya, yet implementation was stopped by order of the judiciary in
2019 after a legal challenge from an association of medical laboratorians.
Conclusions: Task sharing may increase access to healthcare services in resource-limited settings. To advance task
sharing, TSP and clinical practice could be harmonized, and necessary adjustments made to other policies that regu-
late practice (e.g., scopes of practice). Revisions to pre-service training curricula could be conducted to ensure health
professionals have the requisite competencies to perform shared tasks. Monitoring and evaluation can help ensure
that task sharing is implemented appropriately to ensure quality outcomes.
Keywords: Task sharing, Task shifting, Policy, Guidelines, Human resources for health, Health workforce shortage,
Universal healthcare, Kenya, Sub-Saharan Africa
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Open Access
*Correspondence: rkinuth@emory.edu
1 Department of Nursing, Emory University, 1520 Clifton Road, Atlanta, GA
30322, USA
Full list of author information is available at the end of the article
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Kinuthiaetal. Human Resources for Health (2022) 20:61
Background
Human resources for health (HRH) is an essential
health system building block, and the World Health
Organization (WHO) advises that health systems have
adequate HRH engaged in service delivery to improve
population health [1]. To attain the Sustainable Devel-
opment Goals (SDGs), the WHO recommends a health
workforce density of 44.5 doctors, nurses, and midwives
per 10,000 population [2]. However, there is a chronic
shortage of health workers globally; the Global Strategy
on Human Resources for Health: Workforce 2030 reports
an estimated global needs-based shortage of over 17
million health professionals, including over 9 million
nurses and midwives and 2.6 million physicians. e
greatest shortages are in regions with the highest unmet
health needs, such as South East Asia and sub-Saharan
Africa [2].
e chronic HRH shortage makes it difficult to provide
universal HIV services, attain the SDGs, and enhance
population health. e global burden of disease is
increasing as populations are living longer [3]. Addition-
ally, low- and middle-income countries (LMICs) are fac-
ing the double-burden of infectious diseases and rising
prevalence of non-communicable diseases, leading to an
increased demand for access and provision of health ser-
vices [4].
In Kenya, the number of active healthcare workers
remains far below the current WHO recommendations.
As reported in the Kenya Health Workforce Report, Kenya
has 53,118 active doctors, clinical officers, and nurses and
midwives; thus, the health worker to population ratio in
the country is 13.8 providers per 10,000 individuals in the
nation’s population [5]. is ratio is less than one third
the WHO critical threshold recommendation of 44.5
providers per 10,000 individuals. As in many LMICs,
Kenya’s health workforce largely comprised nursing pro-
fessionals; Kenya has 8.3 nurses per 10,000 population
compared to WHO’s recommendation of 25 nurses per
10,000 population [5].
Kenya has made strategic investments to scale-up the
nursing workforce, including increasing the national
capacity to train nursing professionals by focusing on the
expansion of nurse training institutions. is approach
led to a 32.5% increase in the number of nursing schools,
from 77 to 102 between 2006 and 2015 [5]. is expan-
sion subsequently led to increased student enroll-
ment into nursing programs, either as new entrants or
advanced practice [5]. Additionally, the United States
President’s Emergency Plan for AIDS Relief (PEPFAR)
has supported training for thousands of health workers
[6]. Despite these investments, Kenya’s healthcare work-
force shortage has persisted.
Kenya has a large number of people living with
HIV (PLHIV), which has strained the healthcare sys-
tem and its workforce. In 2016, when the 2017–2030
Kenya Task Sharing Policy and Guidelines (TSP) [7].
were being developed, there were 1.6 million PLHIV,
62,000 new infections, and 36,000 AIDS-related
deaths in Kenya [8]. Given the scarcity of physicians,
the model of physician run clinics, common in high
income countries, is not feasible for Kenya and other
LMICs [9].
In light of the global disease burden, HIV pandemic,
and critical shortage of trained health workers, in
2007 the WHO released guidelines on task shifting as
one approach to address HRH concerns and increase
access to HIV care and other health services. Accord-
ing to WHO, task shifting is “a process whereby spe-
cific tasks are moved, where appropriate, to health
workers with shorter training and fewer qualifica-
tions” [10]. If implemented appropriately, task shift-
ing is intended to improve health care coverage by
utilizing more widely available cadres, such as nurses,
clinical officers, and community health workers, to
improve the efficiency of already existing HRH. After
the release of WHO’s task shifting guidelines, the term
task sharing was formally introduced in the scientific
literature by the Institute of Medicine (IOM) in 2010.
The IOM introduced the concept of task sharing as
a strategy for capacity building, prevention, treat-
ment, and care of HIV/AIDS in Africa. Task sharing
addresses bottlenecks in the delivery of health services
through efficient use of existing HRH, whereby “phy-
sicians, nurses, dentists, and other health profession-
als delegate health care responsibilities and relevant
knowledge to others, including community health
workers” [11]. In addition to encouraging collabora-
tion, the IOM recommended that task sharing focus
on the promotion of competency-based training for
health workers taking on new tasks.
Task shifting and task sharing are used in a variety of
public health settings to meet the demand for health
services and address workforce shortages. Although
WHO initially recommended task shifting in the con-
text of addressing the HIV epidemic, its application
was extended to address other areas such as maternal
and newborn health care [12] with WHO’s maternal
and newborn task shifting guidelines [13]. Task shift-
ing has been implemented to support reproductive
health services [14] and tuberculosis care [15]. e use
of task sharing as a model of delivering care is gaining
popularity in under-resourced regions [15]. However,
implementation was often informal and established
organically to adapt to HRH shortages [16]. Task
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Kinuthiaetal. Human Resources for Health (2022) 20:61
sharing is used widely in sub-Saharan Africa, increas-
ing access to healthcare services, and yielding positive
health outcomes [17, 18].
However, despite the benefits of task sharing, and its wide-
spread use in across Africa, there is a scarcity of evidence
documenting the process of developing and implementing
task sharing policies and guidelines. Guidelines and poli-
cies, informed by stakeholders, may facilitate the process of
task distribution and alleviate the workforce burden among
health workers in an organized and systematic manner.
Policy development has been described in the public
policy literature as one of multiple stages in the policy
cycle [19]. Policy adoption, policy implementation, and
policy evaluation are examples of other stages in the pol-
icy cycle which sequentially follow policy development.
e process of policy advancement is relevant to HIV
services and health generally [20], as exemplified by the
case of task sharing policy development in Kenya.
Stakeholders have been defined as, “the individu-
als, organizations, and even governments involved in
policy-making, the processes related to policy develop-
ment and implementation, and the interactions between
them” [21]. A key principle in health policy is that of
stakeholder engagement, as summarized here: “Success-
ful implementation of healthcare interventions relies on
stakeholder engagement at every stage” [22]. However,
the practice of stakeholder participation is complex and
challenging [23].
Case presentation
is section describes the multi-year process whereby
the Government of Kenya, with stakeholder participa-
tion, drafted then adopted Kenya’s Task Sharing Policy
and Guidelines. Several of us were active participants in
this process; we hope that by sharing insights into the
TSP development process, others will be better informed
to advance task sharing.
As public health practitioners, our purpose was to sup-
port drafting and adoption of task sharing by the Gov-
ernment of Kenya, in order to advance pediatric HIV
treatment, other HIV services, and additional health
services as appropriate. It is important to note that pub-
lication in a peer-reviewed journal was a secondary con-
sideration, which we only embarked upon after the TSP
was adopted and disseminated for implementation. is
has implications for the approach described in this arti-
cle. For example, our desk review on task sharing was
conducted rapidly in time for an in-person meeting of
stakeholders as opposed to being conducted over several
months with greater detail and methodological rigor as
might be more common for the purpose of publication.
In short, this article describes the TSP development and
implementation process as it played out on the ground in
Kenya from 2015 to 2019.
In 2015, Emory University, in collaboration with the
Kenya Ministry of Health (MOH), the U.S. Centers for
Disease Control and Prevention (CDC), and PEPFAR
sought to advance task sharing to promote equitable
access to universal health coverage (UHC), including
HIV services at the national, county, sub-county and
community levels in Kenya. Early in this process, the
MOH partnered with several institutions to establish the
Project Advisory Committee (PAC) overseeing the devel-
opment of the TSP. As stated in the TSP, it is intended
to “facilitate enhanced quality service delivery in Kenya
through the implementation of an integrated task sharing
framework, improving access to essential health services,
including HIV/AIDS prevention, care and treatment”
[14, 24].
e process of development, adoption, and implemen-
tation of the Kenya TSP occurred in five phases which are
described in detail below.
Phase 1 (February 2015–September 2015)—funding
andpartnering
CDC allocated funding through the PEPFAR Advanc-
ing Children’s Treatment initiative to facilitate devel-
opment of Kenya’s TSP, since the lack of advanced
practitioners trained and authorized to provide HIV
treatment to children had been identified as a bar-
rier to PEPFAR’s HIV treatment coverage for children
in Kenya. In February 2015, CDC Kenya and Kenya’s
nursing professional leaders began to conceptualize
the formalization of task sharing (as recommended
by WHO) to address HRH challenges in the country.
In August 2015, the Emory University Kenya Health
Workforce Project met with the Kenyan Director of
Medical Services (DMS) from the MOH who provided
high-level support to develop the TSP guidelines and
policy. The Kenya MOH then identified key mem-
bers for the establishment of a Policy Advisory Com-
mittee (PAC) to steer the initiative. PAC stakeholders
included but were not limited to the Kenya MOH,
Kenya’s National AIDS and STI Control Programme
(NASCOP), county governments (which implement
health services under Kenya’s Constitutionally man-
dated devolution), training institutions, health pro-
fessional regulatory bodies for nurses, physicians,
clinical officers, laboratorians, and other cadres, non-
governmental organizations (NGOs) and faith-based
organizations (FBOs), and partner agencies such as
the WHO, United States Agency for International
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Page 4 of 12
Kinuthiaetal. Human Resources for Health (2022) 20:61
Development (USAID), and CDC (see Appendix A for
a comprehensive list of PAC members).
Phase 2 (September 2015–October 2015)—stakeholders
set outprocess andpolicy scope
In September 2015, the PAC held its first meeting to
identify the best approach for the development of the
task sharing guidelines and policy. e PAC worked col-
laboratively to ensure PAC representation of key stake-
holders, as well as to identify the desired scope of the task
sharing policy, the best approach for policy development,
and the level of approval needed in the Kenya MOH.
In preparation for the first meeting of the PAC, Emory
and CDC collaboratively conducted a rapid desk review
which included evidence-based guidance from WHO,
recent task sharing policies in other neighboring coun-
tries (including scopes of practice for various healthcare
cadres), and peer-reviewed research, as well as a mapping
exercise of health workers and unmet ART needs. Mate-
rials reviewed were in English and Portuguese.
e mapping exercise utilized data from Kenya’s
Human Resources Information System (HRIS), an inter-
operable database connecting several health profes-
sional regulatory bodies with their members to facilitate
registration, licensing, continuing professional develop-
ment (CPD), and other regulatory functions [27]. Over-
all, the proportion of nurses per population was found
to be three times that of clinical officers which in turn
was double that of medical officers. With six times more
nurses than physicians, the importance of nurses to HIV
treatment and the country’s inability to rely on physi-
cians alone or in conjunction with clinical officers who
are also far outnumbered by nurses, became clear to the
stakeholders present. Complementary data sources were
the 2010 Kenya Service Provision Assessment [25], which
showed that fewer than 40% of nurses in Kenya were pre-
scribing ART.
e rapid desk review summarized key points from
WHO task shifting guidelines [10], national guidance
and policies (e.g., guidelines for antiretroviral therapy
in Kenya [26]), and peer-reviewed publications on task
sharing/shifting. WHO task shifting recommendations
that were highlighted in the rapid desk review are sum-
marized in Table1.
To further ground the rapid desk review in the
national and regional policy reality, recent scopes of
practice or schemes of service were reviewed from
nearby countries including the 2014 Tanzania Nursing
and Midwifery Council Scope of Practice for Nurses and
Table 1 WHO task shifting recommendations included in the desk review
WHO
recommendation
number
Area of focus Recommendation
#1 Strengthening task sharing Implementing a task shifting approach is recommended in
countries where access to healthcare services is limited due to
health workforce shortages
#3 National harmonization A nationally endorsed framework is recommended for countries
opting to implement task sharing
#16 Types of task sharing Countries that implement a task sharing approach should adopt
task sharing models that are best suited to the context
#17 Efficient referral systems There should be efficient referral systems in place to facilitate
implementation of task sharing and the health workforce should
be trained to use the referral systems appropriately
#18 Safe and effective delivery of clinical tasks by non-physician
clinicians Some clinical tasks can be conducted effectively by trained non-
physician clinicians
#19 Safe and effective delivery of clinical tasks by nurses and
midwives Nurses and midwives can undertake HIV clinical services includ-
ing ART initiation and management
#20 Safe and effective delivery of HIV counseling, education, and
other services by community health workers (CHWs) CHWs and PLWHIV can provide HIV services in health facilities
and community settings
#21 Self-care and support for others by people living with HIV PLWHIV can be empowered to take responsibility for their care
and also support their peers
#22 Task shifting of diagnostic and dispensing services Pharmacy, laboratory professionals, and non-clinical staff such as
record managers and administrators can provide health services
and should be included in task sharing
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Kinuthiaetal. Human Resources for Health (2022) 20:61
Midwives [27], the 2014 Uganda Scope of Practice for
Nurses and Midwives [28], the 2012 Scope of Practice
for Nurses in Kenya [29], and 2011 Guidelines for ART
in Kenya [26], which describes the roles and responsi-
bilities of clinical officers. Highlights included: (i) Tan-
zania’s general authorization of registered and enrolled
nurses to prescribe and administer medicines according
to their specific scopes of practice, (ii) Uganda’s indica-
tion that nurses and midwives should not perform tasks
outside their respective scopes of practice, (iii) Kenya’s
clinical officer scope of practice authorizing all 10 grades
of public sector clinical officers to initiate and manage
ART, and (iv) Kenya’s nursing scope of practice generally
authorizing prescription of drugs for acute and chronic
illnesses. Concurrently, the 2011 Kenya ART guidelines
acknowledged that actual staffing varies from staffing
norms and that task shifting allows for best use of avail-
able health staff, all of whom it called for to be trained in
HIV care and treatment. Being more specific with regard
to who could provide ART, Malawi’s 2011 integrated
HIV service guidelines [30] stated that, “all certified clin-
ical PMTCT/ART providers are authorized to prescribe
and dispense ART (Doctors, Clinical officers, Medical
Assistants, Registered Nurses, Nurse/Midwife Techni-
cians)”. Other policies supportive of task sharing were
reviewed from the Democratic Republic of the Congo,
Eswatini, and Mozambique.
Published, peer-reviewed data presented to the PAC
in the rapid desk review included: a systematic review
finding equal or improved HIV clinical outcomes with
nurse managed care [31], positive stakeholder perspec-
tives on task sharing such as reduced waiting times and
improved access [32], reduced patient out-of-pocket
costs with a task shifting home-based care model [33],
a survey finding 11 of 15 countries in east and south-
ern Africa practicing nurse-initiated and managed
ART with Kenya being one of the four in the minority
[34], and over 70% of community members surveyed in
Malawi and Uganda supporting task shifting from doc-
tors to nurses and from nurses to community health
workers [35]. In sum, the review identified gaps in the
existing models used to deliver healthcare in Kenya and
identified opportunities to utilize the competency and
skills of various cadres more effectively through task
sharing.
At its first meeting, the PAC decided to develop a task
sharing policy inclusive of HIV care and other health ser-
vices essential for UHC. is initial decision to develop
a task sharing policy that included but was not limited
to HIV services led to a lengthier, more complex process
involving stakeholders across diseases and conditions in
order to produce policy and guidelines documents highly
relevant to Kenya’s overall goal to achieve UHC, as well
as PEPFAR’s more focused goal to expand HIV services.
e PAC subsequently established five technical work-
ing groups (TWGs) and suggested TWG members to
advance the development of the Kenyan TSP within their
respective thematic areas. Table2 provides a summary
of the five TWGs and their roles in the development of
the TSP. TWG members included representatives from
the national MOH, county level health offices, health
professional regulatory bodies including those for phy-
sicians, clinical officers, nurses, pharmacists, and labo-
ratorians, as well as health training institutions, FBOs,
NGOs, Emory, USAID, CDC, and WHO. To emphasize
the importance of the TSP, the Kenya Principal Secretary
Table 2 Summary of the technical working groups and assigned roles
Technical working group (TWG) Role
TWG #1: Introduction and Evidence Conducted a mapping exercise and focused on reviewing evidence and background information regarding task
sharing policy in Kenya’s health system. This group worked together to provide the aim and objectives of the TSP
and to conduct a situational analysis
TWG #2: Legal and Regulatory Researched and analyzed existing laws, regulations, and policies pertinent to task sharing and recommended
harmonization of national laws, policies, regulations, and guidelines in support of task sharing
TWG #3: Training Focused on identifying requirements to equip health workers with the necessary knowledge, skills, and compe-
tencies to provide essential healthcare services. Stakeholders conducted a task analysis of each cadre, identifying
their training needs, then collaborating to explore best practices to promote quality healthcare through pre-
service, internship, in-service training, CPD
TWG #4: Service Delivery Worked together to identify key service areas and ensure the service delivery guidelines were comprehensive for
all six levels of Kenya’s healthcare system
TWG #5: Implementation, Monitor-
ing and Evaluation Applied evidence-based principles of monitoring and evaluation to develop an implementation checklist, identify
data collection methodologies, and develop indicators to monitor the progress of TSP implementation
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Kinuthiaetal. Human Resources for Health (2022) 20:61
for Health officially launched the TWGs in September
2015. e PAC recommended areas of concentration for
the TWGs informed by the desk review.
Phase 3 (October 2015–May 2016)—technical working
groups draft theTSP
e TWGs convened periodically over the course of
a year to develop the TSP. e groups utilized an itera-
tive process involving three collaborative rounds of in-
person meetings and online communication to develop
the policy. Round 1 of the TWG meetings took place
from October 27th to November 4th, 2015. During this
time, the groups developed a draft outline for the policy.
Round 2 of the TWG meetings, which took place from
December 1st to 9th, 2015, resulted in the development
of an initial draft of the TSP policy, with each TWG
drafting its respective section. Revision of the initial draft
took place from February 2nd to 9th, 2016 during round
3 of the TWG meetings. For about three months after
the round 3 meetings, the team collaborated to complete
several activities that led to finalizing the policy. ese
activities included: finalizing the comprehensive TSP
guidelines, reviewing of the guidelines with healthcare
workers (HCW) who were members of the PAC, revision
of policy using feedback from HCWs, and convening of
the PAC to finalize the policy. PAC members reviewed
the TSP to ensure integration and coherence, since the
policy was drafted section-by-section by the respective
TWGs. e final TSP policy and guidelines were submit-
ted to the Kenya MOH on May 15th, 2016.
Phase 4 (May 2016–May 2017)—nalization andadoption
byGovernment ofKenya
After the PAC’s submission of the draft documents to the
MOH and finalization by MOH staff, the MOH Cabinet
Secretary and DMS reviewed, and approved the TSP.
MOH finalization included division of the draft TSP into
two separate documents: (i) an overarching policy docu-
ment, and (ii) a more detailed and operationally focused
guidelines document. To further emphasize the impor-
tance of the task sharing policy and guidelines, an offi-
cial launch took place during a ceremony involving the
MOH’s highest leadership, CDC Kenya officials, county
health officials, health professional regulatory board rep-
resentatives, and other stakeholders. ereafter, the pol-
icy and guidelines were disseminated to the counties.
Phase 5 (May 2017–April 2019)—implementation ofpolicy
andguidelines
e fifth phase of the process is implementation, moni-
toring, and evaluation. Activities to facilitate this final
phase included Emory University in collaboration with
the MOH disseminating the TSP and guidelines. TSP
sensitization to increase awareness of the policy and
guidelines initially took place in 10 select counties, with
plans to sensitize health representatives from all 47
Table 3 Summary of the Kenya 2017–2030 task sharing policy and guidelines
Chapter Description of chapter
Chapter 1: Introduction Presents background information on Kenya’s health indicators, overview of the health system, and
the health worker shortage crisis; thus, making a case for why introducing task sharing in Kenya
would be beneficial to addressing the workforce shortages. The chapter also discusses the global
evidence-based recommendations for task sharing from the WHO
Chapter 2: Legal, Regulatory and Policy Framework Highlights various Kenyan laws, regulations and policies, and reviews whether they enable or
restrict the implementation of task sharing in the country, while urging harmonization of Kenya’s
laws, regulations, and other policies in support of task sharing
Chapter 3: Training and Education Presents an overview of health training in Kenya and summarizes the training provided to select
cadres and addresses the need for specialized training and continuing education for these cadres
to facilitate implementation of task sharing
Chapter 4: Task Sharing by Cadre and Level Presents targeted cadres and a large number and variety of tasks that may be shared by each cadre
after ensuring competency to perform the task. See Appendix B for a list of cadres targeted for task
sharing
To facilitate implementation, the information is presented in tables that are easy to read and inter-
pret. These tables constitute approximately half of the entire document, as several hundred tasks
are listed alongside the evidence base for sharing each task with each cadre. These tasks include
HIV rapid testing, HIV treatment, HIV Pre-Exposure Prophylaxis, medical male circumcision, TB case
identification, malaria rapid diagnostic testing, micronutrient supplementation, and provision of
immunizations, among many others. See Appendix C for an example of the HIV testing and coun-
seling table included in the TSP document
Chapter 5: Monitoring and Evaluation (M&E) Describes the areas that M&E of the TSP will cover as well as the guiding principles and M&E frame-
work of the TSP
Chapter 6: Recommendations Makes suggestions for the way forward, centering around five key areas: (i) adoption and imple-
mentation, (ii) harmonization of laws, policies and regulations, (iii) training, (iv) service delivery, and
(v) monitoring and evaluation of TSP implementation
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Kinuthiaetal. Human Resources for Health (2022) 20:61
counties in Kenya. However, in June of 2017, only one
month after the TSP was launched by the Government
of Kenya, the Association of Kenya Medical Laboratory
Scientific Officers (AKMLSO) asked Kenya’s High Court
to stop its implementation. It is not the purpose of this
paper to delve into the legal arguments made either by
the AKMLSO or the Kenya MOH. Although it is impor-
tant to note that the High Court decided to stop TSP
implementation in its decision of April 2019 [7].
Task sharing policy andguidelines
e TSP development process resulted in the devel-
opment of the Kenya 2017–2030 task sharing policy
and guidelines [7] that were briefly implemented then
stopped by the judiciary. e policy document provides
a brief general orientation to task sharing and key aims
of task sharing policy. e guidelines list priority health-
related task sharing activities by cadre with references to
the evidence base. e guidelines are organized into six
chapters which are summarized in Table3.
Discussion
e process of developing the TSP guidelines and pol-
icy encouraged collaboration and consensus among the
stakeholders. Consensus was promoted by convening
broadly representative groups of stakeholders with vary-
ing roles in Kenya’s health care system (PAC and TWGs),
through high-level MOH leadership delegating responsi-
bility to the PAC and TWG members for policy develop-
ment, and by frequent in-person meetings of the TWGs
over the course of a year. Email was used for communica-
tion in between in-person meetings; however, in-person
meetings were more effective than virtual communica-
tions at advancing consensus and policy development.
As noted earlier, stakeholder participation is an impor-
tant principle than can be difficult to put into practice.
As seen with Kenya’s TSP, each context in which policy
development and stakeholder consensus takes place
exerts a unique influence on the outcome. In Kenya, vari-
ous stakeholders participated in agreeing on the need for
a policy, scoping the policy, and developing the policy.
However, one stakeholder group challenged the policy
after it had been adopted and effectively stopped its
implementation through the courts, at least temporar-
ily. In hindsight, a systematic stakeholder analysis at the
beginning of the process might have mitigated such a
risk.
As noted in the TSP, there are several pending items to
be addressed to advance task sharing. Revision of certain
legislation in Kenya may be considered to lift restrictive
laws prohibiting the sharing of certain tasks. For exam-
ple, as noted in the guidelines document, the Public
Health Act restricts disease reporting to medical officers
even though many health facilities in Kenya lack even
one medical officer. Further, e Clinical Officers Act
does not authorize HIV treatment by private sector clini-
cal officers.
Revision of scopes of practice and schemes of service
for the various cadres delivering healthcare services may
also be considered. Tasks that can be performed com-
petently may nevertheless not be covered by the cadre’s
scope of practice. Regulatory authorities could, there-
fore, work collaboratively to address how all cadres can
practice to the full scope of their training. In some cases,
cadres in under-resourced areas are practicing beyond
their official scope of practice because of clients’ needs;
however, there may be the risk of liability for performing
certain tasks, even if performed competently.
Capacity development of stakeholders is key for suc-
cessful task sharing implementation [36]. Ideally, capacity
building would take place across public and private sector
workplaces, professional association forums, and train-
ing institutions. For already credentialed health workers,
training institutions could consider incorporating CPD
and continuing medical education (CME) to increase
knowledge, skills, and competencies to facilitate task
sharing. To meet the needs of the future healthcare work-
force, the TSP encourages training institutions to revise
the existing training curricula at all levels to include new
tasks supportive of task sharing.
Many challenges arose during the process of TSP
development, adoption, and implementation. e TSP
policy and guidelines development demanded time,
resources, and dedication of key individuals from the
MOH. e MOH is faced by many competing priorities,
some of which had potential to be impacted by TSP pro-
cess. However, adequate preparation by parties interested
in furthering task sharing prior to the meeting with the
MOH facilitated buy-in. In addition, TSP project cham-
pions with prior experience in the MOH secured key
meetings to gain support and advance policy develop-
ment with MOH leadership.
As with other collaborative processes, engaging all
stakeholders and coordinating the logistics to iden-
tify meeting times suitable to all parties is challenging.
Oftentimes, senior officials involved in the TWGs had
competing tasks and could not participate in meetings.
Some leaders designated their assistants as delegates in
their absence. Individuals unable to join received meet-
ing briefings. Although health professional member asso-
ciations were not directly involved in the development of
the policy, the councils responsible for regulating varied
health professionals (including physicians, clinical offic-
ers, pharmacists, nurses, and medical laboratorians) were
directly involved in TSP development.
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Kinuthiaetal. Human Resources for Health (2022) 20:61
e process of developing the task sharing policy and
guidelines was complex and rigorous, requiring dedica-
tion and commitment from all stakeholders. A major
barrier during the policy development process was
the nationwide nurses and doctors strikes that lasted
for months. e strikes took attention away from the
TSP and some of the TWG meetings had to be delayed
because MOH senior management representatives were
dealing with the strike issues.
An ongoing challenge is the Kenyan court ruling in
April of 2019 in the case brought by the AKMLSO against
the MOH wherein the Kenya High Court stopped imple-
mentation of the TSP [37]. Despite evidence-based WHO
guidance supporting task sharing of diagnostic services
with other trained health workers including clinical offic-
ers, nurses, and community health workers (as detailed
above), the legal challenge from a laboratorian profes-
sional association has stopped the TSP.
During the TSP development process, many lessons
were learned that may provide insights to inform task
sharing policy development, adoption, and implementa-
tion in other countries. High-level political will from the
MOH and involvement of a wide range of stakeholders
from the health sector promoted ownership and buy-in.
During the collaborative process, participating stake-
holders identified that sharing roles among the TWGs
ensured a focused and faster process. To advance col-
laboration, the TSP team shared progress reports with
the human resources for health interagency coordinat-
ing committee in Kenya, on which the counties are rep-
resented, helping to further secure essential county level
input.
e TSP PAC engaged the MOH review team early in
the process and received orientation on the flow of gov-
ernment policy, which enhanced the efficiency of the
policy development process and enabled the PAC to meet
the time constraints discussed above. While technology
facilitates remote meetings in many parts of the world,
the TWGs found that meeting in person was most pro-
ductive, and much progress was made during the in-per-
son meetings.
Conclusions
e development of a national task sharing policy estab-
lished a framework in Kenya for innovative and dif-
ferentiated service delivery models for essential health
services. e TSP (if implementation is allowed to
resume by the Kenyan courts) could help to advance task
sharing in Kenya and address the workforce shortages.
Crucial to renewed implementation would be to follow-
up on revisions of legislation, scope of practice, capacity
building, schemes of service and curricula.
Appendix A
Comprehensive list ofPAC members
Member Institute of Affiliation
Dr. Nicholas Muraguri Kenyan Ministry of Health (MOH)
Dr. Izaq Odongo Kenyan Ministry of Health (MOH)
Dr. Hannah Wamae K enyan Ministry of Health (MOH)
Mr. Joseph Mirereh Kenyan Ministry of Health (MOH)
Dr. Santau Migiro Kenyan Ministry of Health (MOH)
Dr. Pacifica Onyancha Kenyan Ministry of Health (MOH)
Dr. Rachel Nyamai Kenyan Ministry of Health (MOH)
Dr. Martin Sirengo National AIDS and STIs Control Program
(NASCOP)
Dr. Irene Mukui National AIDS and STIs Control Program
(NASCOP)
Dr. Peter Kimuu Kenyan Ministry of Health (MOH)
Dr. Jackson Kioko Kenyan Ministry of Health (MOH)
Professor Issaac Kibwage University of Nairobi (UoN)
Mr. David Njoroge Kenyan Ministry of Health (MOH)
Dr. Andrew Mulwa County Executives Committee (CEC) for Health
Dr Jack Magara County Directors of Health Services (CDHS)
Mrs. Agnes Waudo Emory Kenya Health Workforce Project
Mr. Sylvester Kimaiyo Academic Model Providing Access to Health-
care (AMPATH)
Mr. Meshack Ndolo IntraHealth International
Dr. Janet Muriuki I ntraHealth International
Mr. Mathew Thuku IntraHealth International
Mr, Mark Hawken International Center for AIDS Care and Treat-
ment Program (ICAP)
Mrs. Susan Otieno Kenyan Ministry of Health (MOH)
Mr. Andre Verani Centers for Disease Control and Preven-
tion (CDC) Atlanta
Mr. James Kwach Centers for Disease Control and Prevention
(CDC) Kenya
Dr. Abraham Katana Centers for Disease Control and Prevention
(CDC) Kenya
Dr. Elly Odongo Centers for Disease Control and Prevention
(CDC) Kenya
Mr. Peter Waithaka United States Agency for International Devel-
opment (USAID) Kenya
Mrs. Edna Tallam Kimaiyo Nursing Council of Kenya (NCK)
Mr. Micah Kisoo Clinical Officers Council (COC)
Mr. Daniel Yumbya Kenya Medical Practitioners and Dentists
Board (KMPDB)
Dr. Samuel Mwenda Christian Health Association of Kenya (CHAK)
Ms. Jacinta Mutegi Kenya Conference of Catholic Bishops (KCCB)
Ms. Firdaus Omar Supreme Council of Kenya Muslims (SUPKEM)
Mr. Peter Tum Kenya Medical Training College (KMTC)
Dr. Jane Karonjo Mt. Kenya University
Professor Barasa Otsyula Kenya Methodist University (KeMU)
Mrs. Jessica Gross Emory University/ Centers for Disease Control
and Prevention (CDC) Atlanta
Custodia Mandlhate World Health Organization (WHO) Kenya
Dr. Nduku Kilonzo National AIDS Control Council (NACC)
Dr. Celestine Mugambi National AIDS Control Council (NACC)
Prof. Sylvia Ojoo University of Nairobi
Dr. Agnes Langat Centers for Disease Control and Prevention
(CDC) Kenya
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Kinuthiaetal. Human Resources for Health (2022) 20:61
Appendix B
See Fig.1.
Fig. 1 Cadre abbreviations. Reprinted from Task Sharing Policy Guidelines 2017–2030 (p. 53) by Kenya Ministry of Health, Nairobi, Kenya. Copyright
2017 by the Principal Secretary, Ministry of Health, Kenya. Reprinted with permission
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Page 10 of 12
Kinuthiaetal. Human Resources for Health (2022) 20:61
Appendix C
See Fig.2.
Abbreviations
HRH: Human resources for health; WHO: World Health Organization; SDG:
Sustainable Development Goals; LMICs: Low- and middle-income countries;
PLHIV: People living with HIV; IOM: Institute of Medicine; MOH: Ministry of
Health; CDC: Centers for Disease Control and Prevention; UHC: Universal
health coverage; TSP: Task sharing policy and guidelines; PEPFAR: President’s
emergency plan for AIDS relief; DMS: Director of medical services; PAC: Policy
advisory committee; USAID: United States Agency for International Develop-
ment; TWG : Technical working groups; NASCOP: National AIDS and STI Control
Programme; CPD: Comprehensive continuing professional development;
HCW: Healthcare workers; CME: Continuing medical education.
Acknowledgements
We would like to acknowledge PEPFAR and CDC for their financial support
of the project. We also thank the Kenya Ministry of Health for commissioning
this work, members of the policy advisory committee and technical working
groups for their participation in the TSP process and working tirelessly to
ensure the success of this project.
Disclaimer
The findings and conclusions in this report are those of the authors and
do not necessarily represent the official position of the Centers for Disease
Control and Prevention.
Author contributions
RK, AW, JG, and AV contributed to the conception and development of the
manuscript. All authors were involved in drafting the manuscript and all the
authors contributed by their comments of improvement in several revisions to
reach a final manuscript. All authors read and approved the final manuscript.
Funding
This work was funded under the terms of the cooperative agreement number
U36OE000002 with funding from the U.S. President’s Emergency Plan for AIDS
Relief (PEPFAR) through the United States Centers for Disease Control and
Prevention, Division of Global HIV &TB.
Fig. 2 HIV testing and counseling tasks that may be conducted with adequate training and supervision. Reprinted from Task Sharing Policy
Guidelines 2017–2030 (p. 85) by Kenya Ministry of Health, Nairobi, Kenya. Copyright 2017 by the Principal Secretary, Ministry of Health, Kenya.
Reprinted with permission
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Kinuthiaetal. Human Resources for Health (2022) 20:61
Availability of data and materials
The data that support the development of the Kenya TSP documents are
available from the Kenya Ministry of Health. Summaries of the findings were
published in the TSP documents, which are publicly available and can be
accessed via the following hyperlink: https:// www. hesma. or. ke/ wp- conte nt/
uploa ds/ 2017/ 02/ Task- Shari ng- Guide line- 2017. pdf
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
All the authors have reviewed the final manuscript and provide consent for
publication.
Competing interests
There are no commercial associations that might pose a conflict of interest in
connection with this manuscript.
Author details
1 Depar tment of Nursing, Emory University, 1520 Clifton Road, Atlanta, GA
30322, USA. 2 U.S. Centers for Disease Control and Prevention, 1600 Clifton
Rd, Atlanta, GA 30333, USA. 3 Kenya Ministr y of Health, Afya House, Cathedral
Road, P.O. Box:30016-00100, Nairobi, Kenya. 4 Emory University Kenya Health
Workforce Project, Nairobi, Kenya.
Received: 9 December 2021 Accepted: 30 May 2022
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Background One of the potential strategies to improve health care delivery in understaffed low-middle income countries (LMIC) is task sharing, where specific tasks are transferred from more qualified healthcare cadre to a lesser trained cadre. Dyslipidaemia is a major risk factors for cardiovascular disease but often it is not managed appropriately. Objective We conducted a systematic review with the objective to identify, and evaluate the effect of task sharing interventions on dyslipidaemia in LMIC. Methods Published studies (RCTs and observational studies) were identified via electronic databases such as PubMed, EMBASE, Cochrane Library, PsycINFO, and CINAHL. We searched the databases from inception to September 2016 and updated till 30 June 2017, using search terms related to task shifting, and cardiovascular disease prevention in LMIC. All eligible studies were summarised narratively, and potential studies were grouped for meta-analysis. Results Although our search yielded 2938 records initially and another 1628 in the updated search, only 15 studies met the eligible criteria. Most of the studies targeted lifestyle modification, and care-coordination by involving nurses or allied health workers. Eight RCTs were included in the meta-analysis. Task sharing intervention were effective in lowering LDL- c (-6.90 mg/dl; 95% CI ⁻11·81- ⁻1·99) and total cholesterol (-9.44 mg/dl; 95% CI ⁻17·94- ⁻0.93) levels with modest effect size. However, there were no major differences in HDL-c (-0·29 mg/dl; 95% CI ⁻0·88- 1·47) and triglycerides (-14·31 mg/dl; 95% CI ⁻33.32- 4·69). The overall quality of evidence based on GRADE was either ‘low’ or ‘very low’. Conclusion Available data are not adequate to make recommendations on the role of task sharing strategies for the management of dyslipidaemia in LMIC. However, the studies conducted in LMIC demonstrate the potential use of this strategy especially in terms of reduction in LDL-cholesterol and total cholesterol levels. Our review calls for the need of well-designed, and large-scale studies to demonstrate the effect of task sharing strategy on lipid management in LMIC.
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Background One of the key strategies to successful implementation of effective health-related interventions is targeting improvements in stakeholder engagement. The discrete choice experiment (DCE) is a stated preference technique for eliciting individual preferences over hypothetical alternative scenarios that is increasingly being used in health-related applications. DCEs are a dynamic approach to systematically measure health preferences which can be applied in enhancing stakeholder engagement. However, a knowledge gap exists in characterizing the extent to which DCEs are used in implementation science. Methods We conducted a systematic literature search (up to December 2016) of the English literature to identify and describe the use of DCEs in engaging stakeholders as an implementation strategy. We searched the following electronic databases: MEDLINE, Econlit, PsychINFO, and the CINAHL using mesh terms. Studies were categorized according to application type, stakeholder(s), healthcare setting, and implementation outcome. ResultsSeventy-five publications were selected for analysis in this systematic review. Studies were categorized by application type: (1) characterizing demand for therapies and treatment technologies (n = 32), (2) comparing implementation strategies (n = 22), (3) incentivizing workforce participation (n = 11), and (4) prioritizing interventions (n = 10). Stakeholders included providers (n = 27), patients (n = 25), caregivers (n = 5), and administrators (n = 2). The remaining studies (n = 16) engaged multiple stakeholders (i.e., combination of patients, caregivers, providers, and/or administrators). The following implementation outcomes were discussed: acceptability (n = 75), appropriateness (n = 34), adoption (n = 19), feasibility (n = 16), and fidelity (n = 3). Conclusions The number of DCE studies engaging stakeholders as an implementation strategy has been increasing over the past decade. As DCEs are more widely used as a healthcare assessment tool, there is a wide range of applications for them in stakeholder engagement. The DCE approach could serve as a tool for engaging stakeholders in implementation science.
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Background Treatment success rates for multidrug-resistant tuberculosis (MDR-TB) in South Africa remain close to 50%. Lack of access to timely, decentralized care is a contributing factor. We evaluated MDR-TB treatment outcomes from a clinical cohort with task-sharing between a clinical nurse practitioner (CNP) and a medical officer (MO). Methods We completed a retrospective evaluation of outcomes from a prospective, programmatically-based MDR-TB cohort who were enrolled and received care between 2012 and 2015 at a peri-urban hospital in KwaZulu-Natal, South Africa. Treatment was provided by either by a CNP or MO. Findings The cohort included 197 participants with a median age of 33 years, 51% female, and 74% co-infected with HIV. The CNP initiated 123 participants on treatment. Overall MDR-TB treatment success rate in this cohort was 57.9%, significantly higher than the South African national average of 45% in 2012 (p<0·0001) and similar to the provincal average of 60% (p = NS). There were no significant differences by provider type: treatment success was 61% for patients initiated by the CNP and 52.7% for those initiated by the MO. Interpretation Clinics that adopted a task sharing approach for MDR-TB demonstrated greater treatment success rates than the national average. Task-sharing between the CNP and MO did not adversely impact treatment outcome with similar success rates noted. Task-sharing is a feasible option for South Africa to support decentralization without compromising patient outcomes. Models that allow sharing of responsibility for MDR-TB may optimize the use of human resources and improve access to care.
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We also expanded the database of vital registration, survey, and census data to 14 294 geography-year datapoints. For GBD 2015, eight causes, including Ebola virus disease, were added to the previous GBD cause list for mortality. We used six modelling approaches to assess cause-specific mortality, with the Cause of Death Ensemble Model (CODEm) generating estimates for most causes. We used a series of novel analyses to systematically quantify the drivers of trends in mortality across geographies. First, we assessed observed and expected levels and trends of cause-specific mortality as they relate to the Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility. Second, we examined factors affecting total mortality patterns through a series of counterfactual scenarios, testing the magnitude by which population growth, population age structures, and epidemiological changes contributed to shifts in mortality. Finally, we attributed changes in life expectancy to changes in cause of death. We documented each step of the GBD 2015 estimation processes, as well as data sources, in accordance with Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). Findings: Globally, life expectancy from birth increased from 61·7 years (95% uncertainty interval 61·4-61·9) in 1980 to 71·8 years (71·5-72·2) in 2015. Several countries in sub-Saharan Africa had very large gains in life expectancy from 2005 to 2015, rebounding from an era of exceedingly high loss of life due to HIV/AIDS. At the same time, many geographies saw life expectancy stagnate or decline, particularly for men and in countries with rising mortality from war or interpersonal violence. From 2005 to 2015, male life expectancy in Syria dropped by 11·3 years (3·7-17·4), to 62·6 years (56·5-70·2). 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Task shifting in various forms has been adopted extensively around the world in an effort to expand the reach of lifesaving services to the women, newborns, and families who need them. The emerging global literature, as well as Jhpiego's field experiences, supports the importance of addressing several key components that facilitate effective task shifting in maternal and newborn health care. These components include: (1) policy and regulatory support; (2) definition of roles, functions, and limitations; (3) determination of requisite skills and qualifications; (4) education and training; and (5) service delivery support, including management and supervision, incentives and/or remuneration, material support (e.g. commodities), and referral systems. Jhpiego's experiences with task shifting also provide illustrations of the complex interplay of these key components at work in the field. Task shifting should be considered as a part of the larger health system that needs to be designed to equitably meet the needs of mothers, newborns, children, and families. Copyright © 2015. Published by Elsevier Ireland Ltd.
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Background: Task shifting is a common strategy to deliver antiretroviral therapy (ART) in resource-limited settings and is safe and effective if implemented appropriately. Consensus among stakeholders is necessary to formulate clear national policies that maintain high-quality care. We sought to understand key stakeholders' opinions regarding task shifting of HIV care in Mozambique and to characterize which specific tasks stakeholders considered appropriate for specific cadres of health workers. Methods: National and provincial Ministry of Health leaders, representatives from donor and non-governmental organizations (NGOs), and clinicians providing HIV care were intentionally selected to represent diverse viewpoints. Using open- and closed-ended questions, interviewees were asked about their general support of task shifting, its potential advantages and disadvantages, and whether each of seven cadres of non-physician health workers should perform each of eight tasks related to ART provision. Responses were tallied overall and stratified by current job category. Interviews were conducted between November 2007 and June 2008. Results: Of 62 stakeholders interviewed, 44% held leadership positions in the Ministry of Health, 44% were clinicians providing HIV care, and 13% were donors or employed by NGOs; 89% held a medical degree. Stakeholders were highly supportive of physician assistants performing simple ART-related tasks and unanimous in opposing community health workers providing any ART-related services. The most commonly cited motives to implement task shifting were to increase ART access, decrease physician workload, and decrease patient wait time, whereas chief concerns included reduced quality of care and poor training and supervision. Support for task shifting was higher among clinicians than policy and programme leaders for three specific task/cadre combinations: general mid-level nurses to initiate ART in adults (supported by 75% of clinicians vs. 41% of non-clinicians) and in pregnant women (75% vs. 34%, respectively) and physician assistants to change ART regimens in adults (43% vs. 24%, respectively). Conclusions: Stakeholders agreed on some ART-related task delegation to lower health worker cadres. Clinicians were more likely to support task shifting than policy and programme leaders, perhaps motivated by their front-line experiences. Harmonizing policy and programme managers' views with those of clinicians will be important to formulate and implement clear policy.
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