Module 4: Task Shifting

Training Healthcare Workers to be Surgeons

“Task shifting involves extending the scope of practice of existing cadres of health workers to allow for the rational redistribution of tasks among the health workforce in order to make better use of human resources and ease bottlenecks in the service delivery system.”(1)

There are 0.25 fully trained surgeons per 100,000 people in East Africa, compared to 5.69 per 100,000 in the United States.(2) Due to a dearth of medical specialists in developing countries, there exists a need for surgical task shifting where less specialized healthcare workers undertake certain medical duties and responsibilities to make up for the lack of specialist services. This is necessary to provide coverage of basic surgical care, especially in rural areas. If medical emergencies are not met with timely surgical interventions, ill health and mortality can result. Non-specialists who have received the necessary training are therefore important in resource-limited settings. In sub-Saharan Africa, nearly half of all countries train healthcare workers to become surgeons who can meet local surgical needs. Though surgery is a highly specialized field, certain surgical procedures can nevertheless be performed by trained non-specialists safely and effectively. For instance, procedures such as cesarean sections and the suturing of wounds can have major life-saving impacts, especially in low-resource settings.

Surgical Task Shifting as an Ethical Alternative

It is important to consider the ethics of allowing a non-specialist, even a trained community healthcare worker, perform surgery on a patient in the developing world. In developing countries where trained surgeons are in short supply, surgical task shifting is necessary to save lives. These community health workers are specifically trained to be able to provide high quality care and most always serve under the direction of a physician surgeon. As Dr Ngatia, the Director of Training and Curriculuma t the African Medical and Research Foundation, explains, "We'll need doctors, but we'll not get one doctor for 10,000 people," he says. "But we can get another person, let's call him a medical assistant whom the Western people call a 'pseudo' doctor, a half doctor. They're not going to be certified for the medical council of the U.K. or the United States, but they're for Africa."(3)

Surgical Task Shifting as a Cost-Effective, Sustainable Solution

Surgical training for health workers is shorter and less expensive, and trained health workers can provide their services at a lower cost. Moreover, because their skills are not internationally recognized, they tend to remain in their home country for the majority of their working lives.

International Organizations That Support Surgical Task Shifting

The following international organizations use surgical task shifting as part of their operations:(4)

Case Study: Mozambique

Mozambique has experienced one of the most significant national health workforce shortages worldwide, with less than 3 physicians and 21 nurses per 100,000 inhabitants. Half of the physicians practice in the capital city of Maputo, leaving the rural areas with minimal healthcare coverage.  When an exodus of healthcare professionals occurred after Mozambique’s independence in 1975, Mozambique created a new healthcare provider—tecnicos de medicina—that provided preventive and curative services.  However, cuts in public healthcare due to structural adjustment policies of the 1980s resulted in the elimination of many tecnico positions.  With the HIV/AIDS epidemic, however, there has been renewed interest in the role.  In 2003, the overall adult HIV prevalence in Mozambique was greater than 15%, and less than 1% of the estimated 1.2 million infected individuals were receiving antiretroviral therapy (ART).  With international agencies, the government planned a rapid scale-up of ART, but did not have enough physicians to deliver the treatment. Thus, tecnicos de medicina were trained and employed to help physicians deliver ART and care for those on ART.   With task shifting to the new trained tecnico workforce, and with integration of ART into primary health care (PHC), the number of facilities providing ART tripled within a six month period.  The increases came mostly from the increased distribution of ART through small, rural health centers, 45% of which were run by tecnicos.  This latter fact shows that not only can tecnicos provide medical care, but they can also effectively assume many of the administrative tasks of physicians.  Such task shifting in both clinical and managerial tasks could be a long-term solution to healthcare shortages in Mozambique and other developing countries.(5)

For more information on this topic, see Task-Shifting in the Surgery and Global Health Course. 

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(1) Celletti, Francesca, Anna Wright, John Palen, Seble Frehywot, Anne Markus, Alan Greenberg, Rafael Augusto Teixeira de Aguiar, Francisco Campos, Eric Buch, and Badara Samb. “Can the deployment of community health workers for the deliver fo HIV services represent an effective and sustainable response to health workforce shortages? Results of multicountry study.” AIDS 24(2010): 45-57.

(2) Adapted from Datiko DG,  Lindtjørn B. "Health Extension Workers Improve Tuberculosis Case Detection and Treatment Success in Southern Ethiopia: A Community Randomized Trial." PLoS ONE 4(5): e5443.

(3) As quoted in Wilson, B. "Developing Countries See Health Care 'Brain Drain'." NPR 03 Nov 2005 Web.11 Jun 2009.

(4) Chu K, Rosseel P, Gielis P, Ford N (2009) Surgical Task Shifting in Sub-Saharan Africa. PLoS Med 6(5): e1000078.

(5) Sherr, Kenneth, James Pfeiffer, Antonio Mussa, Ferruccio Vio, Sarah Gimbel, Mark Micek, and Stephen Gloyd. “The Role of Nonphysician Clinicians in the Rapid Expansion of HIV Care in Mozambique.” Journals of Acquired Immune Deficiency Syndrome 52(2009): 20-23.