Task Shifting - Global Recommendations and Guidelines - unaids

Recommendations on creating an enabling regulatory environment for implementation
Comment: This recommendation places high value on the need for governments to assess
and identify the extent to which any existing mechanisms designed to guide and regulate the
delivery of health services will, or will not, support the implementation of task shifting. Any
changes must be in accordance with broader national policies, such as decentralization,
labour, human resource management and financing and should include the active
participation of people living with HIV/AIDS.
Summary of findings
The main objective of health-care regulation is to ensure a degree of accountability that will
provide safety for service users and protection of health workers. Through regulatory approaches
such as laws and proclamations, rules and regulations or policies and guidelines, countries are
able to protect service users from malpractice and to foster conditions of trust between health
workers and those they serve 84 85 .
Task shifting involves organizing health-service delivery in new ways, which include changes to
scopes of practice and the creation of cadres of health workers. These new ways of working may,
or may not, be consistent with existing national regulations that pertain to the provision of health
care.
The steps that are required to ensure that task shifting can be properly accommodated and
supported within an appropriate regulatory framework will vary depending on the details of the
existing regulatory approaches in any given country.
Regulatory approaches may range in level of government versus non-government involvement 86 .
At one end of this spectrum professional associations operate as primary regulatory institutions.
They control the scope of practice, determine standards for good practice and oversee the
conduct of members. They also provide expert guidance for legislators and administrators. At the
other end of the spectrum is an institutional model of regulation that gives the lead role to the
state to regulate health-care professionals.
The differences between these two main types of regulation of health workers will have significant
implications for countries seeking to change or adapt regulatory frameworks to support task
shifting.
However, adapting the regulatory framework to accommodate task shifting need not necessarily
involve extensive changes in policy and legislation. Indeed, some countries may find that they
have sufficient scope to implement task shifting within their existing laws and proclamations, rules
and regulations, policies and guidelines. The degree of regulation required will also vary
considerably depending on the types of task shifting that a country wishes to adopt or that are
already taking place.
There is considerable evidence in the literature of the ways in which certain high-income
countries, such as Canada, Sweden and the United Kingdom, have adapted their regulatory
frameworks to allow nurses to prescribe medication, a task that has traditionally been the
responsibility of medical doctors 87-89 . There are also studies from resource-constrained countries
on the extension of the role of nurses to include prescription privileges 62 90 91 92 93 .
However, the use of mid-level cadres has proliferated, particularly in Africa, and appropriate
adjustments to the regulatory framework have not always accompanied these changes to
methods of service delivery 24 51 94 95 . Studies of community health worker programmes also note
frequent failure to provide adequate systems support, including an appropriate regulatory
framework 62 90 91 93 .
The WHO-Commissioned Study on Task Shifting sought to assess and analyse the regulatory
approaches used by a number of countries that are implementing task shifting in various forms
Annex a
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