Spotlight: Task-shifting in nursing and midwifery in low- and middle-income countries
By Michal Kawka
The shortage of trained healthcare professionals is a global problem, but it is most profound in low- and middle-income countries (LMIC). In some areas, levels of staffing can be as low as 50%, which directly affects healthcare delivery. One of the solutions proposed to tackle this issue is task-shifting – utilising existing workforce to deliver healthcare which involves transferring and sharing some of the responsibilities from doctors to non-physician clinicians (e.g. physician associates), from non-physician clinicians to nurses/midwives and from nurses /midwives to nursing associates (Figure 1).
WHO has recommended the implementation of this strategy to help with workforce gap, however, there have been reports of this approach being counterproductive, requiring more recourses that recruitment of new healthcare workers . In this article, we’re going to have a closer look at the advantages and disadvantages of task-shifting in nursing and midwifery in LMICs.
Figure 1 – Diagrammatic representation of task-shifting (adapted from WHO, 2007. Task-shifting to tackle health worker shortages 
Task-shifting is the mainstay of Uganda’s healthcare system, especially in areas of preventative and home-based treatment of malaria, family planning services and HIV/AIDS patient triage for antiretroviral therapy (ART). One of the biggest challenges for Uganda’s healthcare system is the disparity between rural and urban settings – most doctors (75%) were located or based in urban centres whereas about 86% of the population in Uganda was located in rural areas – as found in 2014 scoping review of task-shifting . The main findings of this study were that focused on training, support and supervision is key to ensure the productivity of staff and patient safety. Moreover, it was found using clear job descriptions and defined responsibilities can allow for effective use of human resources. Negative perceptions of task-shifting were associated with concerns over resource allocation and competency.
The problems encountered by Rwanda with regards to task-shifting are similar to those of Uganda . The study by Shumbusho et al. in 2009 has reported 1 physician per 50,000 inhabitants and 1 nurse per 3,900, a situation which yields itself to task-shifting. The study investigated ART prescribing by nurses in a nationally coordinated manner and has found nurses can safely and effectively prescribe ART. The study highlighted the need for training, supervision and data collection in task-shifting efforts. The case of Rwanda exemplifies that strong policy, education and clear transfer of responsibilities enable effective task shifting.
Deller and colleagues  reported extensive adoption of task-shifting in midwifery services worldwide in countries such as Guinea, Kenya, Malawi and South Africa. Midwives and nurses gain additional responsibilities such as caesarean deliveries, contraceptive implants and manual vacuum aspiration. The authors stress the importance of identification of missing services in each of the regions, as well as making sure that competency-based service is delivered. Both of these aspects are crucial elements of effective policies on local and national levels, to maximise the strategic value of task-shifting.
When talking about task-shifting it is crucial to remember an important point, made by Afolabi and colleagues, in their 2019 letter – task-shifting must recognise the professional role of nurses and midwives . Their professional competencies are key to achieving sustainable development goals, however, empowerment of nurses and midwives needs to be done in a way that recognises their skill and leadership. While task-shifting offers a unique solution to health workforce problems in LMICs, shifting responsibilities must be done in a regulated manner, to ensure patient safety and human resources are utilised to their most, while unique skillset of nurses and midwives is respected and appreciated.
Baine and Kasangaki, 2014. A scoping study on task shifting; the case of Uganda
WHO, 2007. Task-shifting to tackle health worker shortages
Shumbusho et al., 2009. Task shifting for a scale-up of HIV care: Evaluation of Nurse-Centered Antiretroviral treatment at rural health centres
Deller et al., 2015. Task shifting in maternal and newborns healthcare: Key components from policy to implementation
Afolabi et al, 2019. Task-shifting must recognise the professional role of nurses.