4 - 5 - Video 3.5 The Effectiveness of Task Shifting & Task Sharing (10 55), Childbirth A Global Perspective
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Now that you have a clearunderstanding of the role oftask shifting in the provisionof health services.It's important to assess how this approachhas fared in the scientific literature,especially with regard to maternal andnewborn health.Over the past five years,numerous peer-reviewed studies havedocumented comparable or othernon-inferior outcomes of task shifted andtask shared servicesprovided by non-physicians.The studies include HIV care,as well as reproductive healthservices in low income countries.For example, in 2013 researchers fromThe University of Technology in Sydney,Australia assessed reproductiveclinical services,such as the delivery ofemergency obstetrical care.Preventing mother to child transmissionof the HIV virus or PMTCT.Obstetric surgery, abortion andcontraception services that were shiftedor shared with non-obstetricians,non-clinical, clinicians, nurses andmidwives in over an 11 year period.Of the 20 papers that met the study'sreview criteria, most of the researchdealt with obstetrical surgery, anesthesiaand manual vacuum ex, aspiration outcomes.The findings, which were reported inthe Journal of Health Policy and Planning.Indicated that shifting and sharingthese tasks may increase access andavailability of maternal andreproductive health serviceswithout compromising a performance orpatient outcomes.The researchers also concludedthat task shifting ortask sharing may also be cost effective.However, they identifiedspecific issues andbarriers that underscore the importanceof improved provider in service training,such as supportive supervision andcare, and career progression andincentive packages in order to support andsustain these practices.Now with regard to cash shifting andthe provision of pediatric HIV,anti-retroviral treatment.A 2014 systematic reviewthat was published inthe journal of the acquired immunesyndromes assess the results ofhealthcare services primarily providedby nurses in ten sub-Saharan countries.The researchers from the World HealthOrganization found no significantdifference in outcomes regardingpediatric mortality orthe number of patients retained in care,when compared to clinic sites whereHIV-infected children were exclusivelyseen by doctors or specialists.Based on their findings, they concludedthat pediatric task shifted HIV careshould be included among those strategiesconsidered for scaling-up services.This recommendation isparticularly important,since pediatric task shiftedcare is less understood andlacks the developed policies comparedto the adult HIV infected population.A third study worth noting is the 2014Cochrane Systematic Review conductedby the South African Medical ResearchCouncil in Capetown, South Africa.This study compared doctor and non-doctortask shifted care in initiating andmaintaining anti-retroviral therapy.The review's object was to evaluatethe quality of initiation andmaintenance of task shifted HIVcare by assessing the quality ofevidence using the GRADE methodology.The GRADE acronym refers to Gradingof Recommendations Assessment,Development and Evaluation.And is an approach thatprovides a common system fordetermining the quality ofscientific evidence anduses that information to characterize thestrength of a particular recommendation.Of the 10 studies that metthe review inclusion criteria,all took place in Africa among adultswere followed up for one year.Key findings from this review includehigh quality evidence based onclinical trial data that when nursesinitiate and provide HIV therapy, thereis no difference in patient mortality ortheir loss to follow-up care at one year.Similarly, moderate quality evidence notedno difference in patient mortality ortheir loss to follow-up at one year.However, lower quality evidence from theirreview revealed conflicting findingsbetween two cohort studies with onesuggesting that there may be an increasedrisk of death for patients whose care wastask shifted, but showed no differenceregarding the number of patients whowere lost to follow-up at one year.While a second cohort study documenteddecreased patient deaths andreduced number of patientswho lost the follow-up atone year among those whose carewas task shifted to nurses.Taken together, the authors concludedthat based on the reviewed findings.Task shifting HIV care from doctorsto adequately trained non-physicians,produced comparable outcomes andmay actually result in morepatients remaining in care.Complimenting these findingsare recent taask shifting documents,produced by different units withinthe World Health Organization.In 2012, their Departmentof Reproductive Health andResearch in collaboration with otherglobal leaders and research advisers.Produced an advisory document entitledOptimizing Health Workers Role toImprove Access to Key Maternal andNew Interventions Through Task Shifting.The documents over our chain objectiveis to provide recommendations thatmaximize health worker roles to the WorldHealth Organization members states.This guidance which is based onscientific evidence supportive ofuniversal access to essential andeffective newborn interventions.Identifies and defines eightbroad categories of maternal andnewborn health providers.Including advanced level associateclinicians, associate clinicians,auxiliary nurses, auxiliary nursemidwives, lay health workers,midwives, non-specialist doctors, nurses.And identifies practicesmost appropriate foreach type of these health professionals.The recommendations which are similarlybased on the GRADE methodology,characterize specific interventions,such as those that are appropriate forimplementation.Those that require further monitoring andevaluation.Those that are limited to settingscapable of rigorous research orthose practices thatare not recommended at all.The document intentionally excluded taskshifted recommendations pertaining toHIV infected pregnant women andmothers and children, soas to avoid proposing potentiallyconflicting re, recommendations.In 2013, the World Health Organizationpublished their consolidated guidelines ofthe use of antiretroviral drugs fortreating and preventing HIV infection.The impetus for developing theseguidelines was to further the goal ofuniversal access to HIV preventiontreatment care and support.In accordance with the target set forthin the 2006 political declaration on HIV,AIDS and the 2011 politicaldeclaration on HIV a, and AIDS.Intensifying our effortsto eliminate HIV and AIDS.Because the maternal andnewborn population in sub-Saharan Africais particularly impactedby the HIV epidemic.The guidelines covering PMTCT andPediatric HIV Servicesare highly relevant.In crafting these guidelines,the authors identified overarchingprinciples to frame their recommendations.These principles includecontributing to global health goals.Adopting a public health approach.Strengthening health systemsthrough innovation and learning.Increasing effectiveness andefficiency of programs.Promoting human rights and health equity.And recognizing that implementationof these guidelines should beinformed by the local context.Significantly, the consolidatedguidelines include a newsection on human resources for health.Which discusses the need tocreate capacity of all healthcadres including community health workers.Using the GRADE methodology,the guidelines provide threestrong recommendations withmoderate quality evidence regardingtask shifted HIV treatment and care.These recommendations are as follows.Trained non-physicians,clinicians, midwives andnurse can initiate first lineanti-retroviral therapy.Commonly referred to as A-R-T or ART.For those unfamiliar withthe HIV treatment terminology.ART refers to the use ofa combination of three ormore anti-retroviral drugs toachieve viral suppression.Also at the beginning of HIV treatment,the combination ofdrugs initially prescribed isreferred to as first line therapy.The second recommendation was that trainednon-physician clinicians, midwives andnurses can maintain ART.The term nurse initiated A-R-T orART or NIMART is used when referring tothese group of professionalsproviding this task shifted care.And the third recommendation was thattrained and supervised community healthworkers can dispense ART betweenregular clinical visits.With regard to maternal andchild heath settings,the consolidated guidelines state thattask shifting improves access to A-R-T orART to those sites that don'ttypically have doctors present.Such as maternal and childhood clinics.However, specific recommendationsregarding pediatric HIV care were notmentioned andguidance in this area remain unclear.In light of the fact that the World HealthOrganization's initial resource guide from2008, which was called Task Shifting:Global Recommendations and Guidelines.Did not recommend mid levelproviders initiate orprescribed first line ART for children.With global efforts committedto eliminating mother tochild transmission by 2015.Including a 90% reduction target ofHIV infections among children anda 50% reduction in AIDSrelated maternal death.HIV, AIDS protocol and guidance,regarding maternal andnewborn populationare constantly evolving.And result in accompanying expectationsfor improved and expanded services.Changes in health workers roles andprotocols,governing their practice, constitutea critical piece of this picture.Accordingly, task shifting ortask sharing roles andresponsibilities should be seenas a dynamic process capable ofresponding to newer andimproved program requirements.
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