Strengthening health systems

Integration of task shifting and task sharing in One Health Systems can address several health system challenges

Strengthening health systems


ne Health Systems are understood as “the wide range of roles and responsibilities and interactions among diverse actors seen in systems that deal with multi-sectoral challenges.” These systems build on the development of processes “that can be used to evaluate existing systems, foster synergies across agencies and improve multi-sectoral preparedness, detection and response to complex One Health challenges.

The building-blocks concept has been adopted by the WHO for human health systems, conceptualising these based on six building blocks: service delivery, health workforce, health information systems, access to essential medicines, financing and leadership/ governance. Since its launch in 2007, this framework has been widely recognised as being instrumental in strengthening human health systems, and as a catalyst for achieving global health targets such as the Sustainable Development Goals.

Attaining health goals depends largely on the knowledge, skills, motivation and deployment of the people responsible for organising and delivering services. Many countries, however, lack the human resources needed to deliver integrated health interventions for a number of reasons, including inadequate planning, limited relevant production capacity, a poor mix of skills and demographic imbalances. For a paradigm shift towards an OHS approach, Pakistan needs to address several workforce challenges with a bearing on the functionality of its One Health Systems, including trends of the burden of disease. These challenges arise from a host of factors, including low capacity for human resource planning, a low assembly line of health workers and a high attrition rate of existing health workers. Other challenges include inequitable distribution of the health workforce, retention of health workers and high workloads.

Strengthened One Health Systems have enhanced One Health workforce capacities, investment and infrastructure at all levels. These challenges can be addressed through task shifting and sharing (TS/ S), which involves redistribution of health tasks within workforces and communities. Specific tasks are moved, shared or delegated, usually from highly trained health workers to those with shorter training or lesser qualifications, including lay people. The generalised purpose statement indicates that TS/ S is intended to reduce morbidity, mortality, and the burden of disease among populations where the inaccessibility of professionalised cadres limits access to effective care.

A conceptual framework for this approach is the Concepts and Opportunities to Advance Task Shifting and Task Sharing (COATS) that spotlights opportunities for One Health System improvement arising from TS/ S programmes.

Shortages of trained health professionals are a key threat to health and health equity worldwide. Health systems and professionals face extra burden to respond to new pressures, such as the Covid-19 pandemic, while maintaining the operation of routine services and care.

Task shifting and task sharing strategies allow for more efficient use of health human resources, especially as health systems worldwide struggle to maintain essential services while responding to challenges like the Covid-19 pandemic. The COATS framework defines the purpose and opportunities arising from TS/ S programme as well as laying down criteria for the implementation of TS/ S programme.

Throughout the COATS framework, the term “intervention” is used to refer to the task that is shifted or shared in the context of a TS/ S programme. Interventions in this context may be preventive, curative, therapeutic, diagnostic or other health actions. Where the WHO defines task shifting as the “rational redistribution of tasks among health workforce teams,” the COATS definition offers a broader concept involving the redistribution or delegation of healthcare tasks within workforce or communities. This reference to communities underscores the role of lay and informal service providers in TS/ S initiatives.

The final section provides criteria for programme developers, policymakers, researchers and other stakeholders to assess if a given condition and context is suited to TS/ S. The conditions that are critical to the success of TS/ S programmes in one setting may be less relevant or absent in others.

The criteria for the implementation of a TS/ S programme are divided into “necessary conditions” and “important considerations.” Necessary conditions refer to features of the available workers, the health problem and the intervention that will generally be needed to be in place to make a TS/ S programme successful. For example, workers willing to be trained to deliver the intervention and workers willing to provide that training will both be prerequisites for any successful TS/ S programme. Programme developers should consider these needs as they conceive of a new TS/ S initiative. Important considerations refer to concepts that will enable success in some settings but may be less relevant in others.

The framework does not prescribe a measure or threshold to establish if the criteria have been met. These criteria are intended for interpretation and adaption to their specific context so that practitioners and programme developers can appraise whether and how the criteria have been addressed in their particular circumstances.

Task shifting and task sharing is a leading and promising health systems strategy to address health workforce shortages, transform healthcare delivery, improve health outcomes and reduce inequities. However, TS/ S is not a universal solution to insufficient or inequitable access to care.

Due to the protracted inequitable distribution of health workers, especially at the primary level of care and the low production rate of skilled health workforce, there is a dire need to develop a National Task Shifting and Sharing Policy in Pakistan. The COATS is a good start towards developing a national policy in Pakistan. The policy should aim to achieve universal health coverage by optimising the use of existing health workforce to deliver essential health services. It should endorse the rational distribution of tasks from service providing workers with a longer duration of training to those with a shorter duration towards ensuring improved access to essential health services at primary healthcare centres. The COATS framework is comprehensive, adaptable and suited to support refinements across a range of TS/ S policy and programmes, including planning, decision-making, implementation, evaluation and research worldwide.

The writer is a senior public health leader from Pakistan with international experience in design and management of health systems strengthening initiatives

Strengthening health systems