Kieran Walsh: Health systems strengthening: is task shifting the answer to better global health?    

There is a global shortage of doctors and little optimism that this shortage will be made up any time soon. Those responsible for human resources for health have come up with a variety of solutions to this problem—one of which is task-shifting. The concept of task shifting is simple—it involves assigning tasks that would traditionally be undertaken by doctors or fully qualified healthcare professionals to healthcare workers that have been trained to take on these tasks. The training of these healthcare workers is typically shorter than the training of doctors and therefore lower cost. Similarly, the cost to employ these workers is lower and thus also lower cost. Task shifting should certainly work in theory—but what is the evidence for its effectiveness? 

Seidman and Atun have sought an answer to this question—specifically in the domain of low-income and middle-income countries. [1] They also look specifically purposely at cost and value in task shifting. Their findings are striking. They found that “substantial evidence exists for achieving cost savings and efficiency improvements from task shifting activities” related to a range of different communicable and non-communicable diaseases. The evidence exists mainly in primary and community healthcare—which is good news as that is where the majority of healthcare takes place. The reviewers also found that much depends on the context, and that there is no single and universal model of task shifting. 

Undoubtedly there is a need to further examine the role of task shifting in hospital settings and to evaluate whether task shifting could help in non-clinical activities such as supply chain management. The authors also wonder about the dangers of task overload—whereby community healthcare workers are overloaded with work as a result of task shifting—with resultant clinical risks and the potential for burnout. 

However, there is another risk associated with task shifting that the authors do not mention. This is the effect that task shifting has on the healthcare professional from whom the task has been moved. The idea of task shifting is that it should make their job easier. They should spend less time on easy jobs and so have more time to take on more complex tasks that only they can do. However, this can result in task overload of a different kind. This overload is not related to volume of tasks but rather to their complexity. Senior healthcare professionals can be left where their entire job is taken up with managing complicated patients or patients who are severely ill or patients who have complained or patients who do not fit in a single clear-cut category and can therefore be managed according to a protocol. This can be exhausting—physically, cognitively, and emotionally. Could this potentially result in burnout amongst senior healthcare professionals—the very problem that task shifting is meant to overcome? There is remarkably little research on this aspect of task shifting, and so another gap in the evidence base that needs to be fulfilled.  

In the meantime, lets return to the original question. is task shifting the answer to better global health—through health systems strengthening in low-income and middle-income countries? It is likely to be at least part of the answer.  

Kieran Walsh is clinical director of BMJ Learning and BMJ Best Practice. He is responsible for the editorial quality of both products. He has worked in the past as a hospital doctor—specialising in care of the elderly medicine and neurology.

Competing interests: KW works for BMJ which produces a range of clinical decision support and learning resources for different types of healthcare professionals. 


1. Seidman GAtun R. Does task shifting yield cost savings and improve efficiency for health systems? A systematicreview of evidence from low-income and middle-income countries. Hum Resour Health. 2017 Apr 13;15(1):29.