Task Shifting - Global Recommendations and Guidelines - unaids

Recommendations on ensuring sustainability
Selected examples of experience/additional resources:
Ecuador’s Ministry of Health tested a number of quality improvement interventions, including job
clarification, standards communication and monthly monitoring of compliance indicators in
secondary care facilities to increase health worker compliance with maternal and child care
quality standards. After 12 months, these interventions produced rapid increases in compliance
with clinical standards in the intervention hospitals versus the control group 148 .
Recommendation 13
Countries should consider measures such as financial and/or
non-financial incentives, performance-based incentives or
other methods as means by which to retain and enhance the
performance of health workers with new or increased
responsibilities, commensurate with available resources in a
sustainable manner.
Comment: This recommendation places high value on retention and performance throughout
the health workforce. Incentives systems should be harmonized across the health sector so
that different scopes of practice and levels of responsibility are recognized within a relative
framework. Incentives must be decided on a country by country basis and cannot be
generalized across countries.
Summary of findings
Many studies note that monetary and non-monetary incentives have a definitive impact on the
behaviour and motivation of health workers and that such incentives are a major factor in health
workforce migration 153-156 . Most importantly in relation to the task shifting approach, extending the
scope of practice and increasing the burden of responsibility of health workers without
commensurate incentives is likely to have a demotivating effect.
To compensate for low salaries, poor working conditions and other factors, health workers rely on
individual coping strategies. These are very well documented in a large number of studies 157-186 .
Many health workers resort to dual or multiple employment. For example, many clinicians
combine salaries from public sector clinical work with a fee-paying private clientele. Some health
workers take on additional work outside the health sector, which can lead to absenteeism.
There is evidence that a variety of different incentives systems can improve retention and
performance 6 187-193 . However, further research is needed to understand the effects of different
incentive systems from a broader health systems perspective that looks at how incentives impact
individual health worker performance and how they affects the ways different providers interact
with each other and the community 63 .
Increasing incentives for health workers is highly complex in terms of fiscal impact and
sustainability. Several countries, including some with severe human resources for health crises
and high HIV burdens, have opted to control their wage bill because of concerns about potential
macroeconomic problems that could result from entering into long-term expenditure
commitments without the certainty of long-term income 63 194-196 .
A range of strategies are also needed to improve the retention of health workers in the public
health sector, especially in the delivery of HIV services. These include improvements to workplace
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