Task Shifting - Global Recommendations and Guidelines - unaids

Recommendations on adopting task shifting as a public health initiative
Summary of Findings
Task shifting for the delivery of HIV services envisages providing access for everyone, including
poor and hard-to-reach communities. Documented experience shows that a task shifting approach
can increase access and equity while also maintaining the quality of care. However, programmes
that have been successful are those that have adopted the key elements of a public health
approach 12 52-57 . A public health approach involves, among other things, the use of standardized,
decentralized delivery models that include simplified treatment protocols and simplified clinical
monitoring 42 58-59 . Accompanied by standardized training, supportive supervision and wellfunctioning
referral systems, these models can maximize the role of health workers with shorter
training and fewer qualifications 12 60-62 .
Health services based on this model can be delivered by a range of different providers and can
involve both the public and non-state sectors. Indeed, experience indicates that scaling up HIV
services is best achieved through collaboration and coordination between a mix of providers,
including the public sector, private medical providers, private companies and nongovernmental
organizations 12 . However, if the three objectives of access, equity and quality are to be met and
sustained, there must be harmonization and alignment of all the HIV services that are being
delivered across the country 63 .
Studies have described some of the problems that can arise, such as inconsistency in wages for
health workers, when HIV services that are being delivered by different service providers are not
properly integrated with the existing health system and wider health sector plans 12 24 .
Some of the earliest examples of task shifting in the 1970s and 1980s faltered when a lack of
government commitment allowed programmes of varying types, qualities, aims and standards to
proliferate independently of the public sector 12 21 51 57 64-67 .
Efforts to increase access to HIV services at a countrywide level using a task shifting approach
must learn from these lessons. Ensuring that standards are adhered to is a challenge in some
settings, especially where there is a range of service providers 12 . A nationally endorsed
framework will define the organization of service delivery, will support task shifting through an
appropriate regulatory framework and will generate accountability that can help improve quality
through the application of a variety of quality assurance mechanisms. By virtue of a framework,
government can then help ensure that these standards remain constant throughout the healthcare
system regardless of any local-level differences that may exist between service providers.
Advantages:
• A nationally endorsed framework can help ensure harmonization and provide the needed
stability for the delivery of countrywide HIV services that use the task shifting approach.
• Public-private partnerships for the delivery services can contribute to countrywide HIV services
that are sustainable if they are integrated as part of a nationally endorsed framework.
Uncertainties:
• The application of a nationally endorsed framework will require some standardization of any
already existing task shifting practices that are being implemented by non-state sector providers.
• Nongovernmental organizations may resist standardization if they feel that their autonomy will
be undermined.
Selected examples of experience/additional resources:
Malawi faces a high HIV burden and has a very serious shortage of human resources for health.
The country has adopted a public health approach that has been well documented. For example,
the country has adopted one national treatment protocol and one monitoring system for the
delivery of antiretroviral therapy. This is currently being implemented throughout the country by
both the public and non-state sectors 47 68-72 .
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