Non-physician medical providers, task-shifting and Africa

By Maggie Sullivan Moderator | 19 Jan, 2014

On the HIFA2015 site there is somewhat of a debate between task-shifting to non-physican health care providers versus focusing on increased physician training. This is not the main thrust of the discussion (it's more about developing the primary care infrastructure in general) but there's a side thread that got me thinking. There are some who view non-physician health care providers as inadequate and of poor quality, there are others who view them (us) as indespensable to rehabilitating primary care, and others still who see us as a Western import. I'll include a few of the resources mentioned in this conversation, as well as a few exerpts.

A few of the HIFA comments include:
 - "It should be task delegation. Someone is still responsible for those tasks being delegated to others. As pointed out...Community Health Extension Workers are all over the place venturing into areas they were forbidden from getting into. No one is asking questions, and no one is evaluating their output. Nigeria is a peculiar country, and we cannot run away from this fact. Until we are able to sort out the mess in the health sector occasioned by ill-informed laws, unnecessary competitions, encroachment into areas people had no training on, economically-induced elongation of training programmes to 'meet up' and the lack of political will on the part of our leaders, any attempt to add another group of non-physicians to the field will only add fuel to a raging fire. Let us be careful."

 - "I will never subject my health to a non-physician, I will also not allow even my enemy to be touched by them. Those who probably have obtained grants to run those programmes should please think of something more useful to do with the money or return them to their owners....we have chosen that which is compatible with our cultures, beliefs and sensibilities. That is the way to go; we must not import everything foreign into our land. No more room for non-physicians other than the little they are permitted to do now."

 - "Part of the problem with that programme today is that those trained to anchor it are no longer interested in doing that; every body wants to come into the hospital and function there; no one wants to remain at the primary level except a few patriotic ones. Unfortunately, government is not helping matters...The community health extension workers were developed to serve the rural communities, but government, through corrupt practices, has elevated them to the highest level in civil service (director), for which reason they all are now seeking employment in the main centers and Ministries where they can become directors. There is no longer any middle level cadre staff in Nigeria's health sector.

"Moving forward Nigeria must recreate the middle level workforce in the health sector, politics must be separated from health matters. It is for this reason the Nigerian Medical Association has been advocating for the establishment of the office of Surgeon General to insulate health from the vagaries of politics. It is also for the same purpose of improving the health of the people and guarantee them a minimum health package that NMA has been at the forefront of the campaign for the passage and signing into law of the National Health Bill. Unfortunately, other health workers whose only interest in health sector is personal welfare have been against these two noble advocacies. They have ganged up to work against any initiative by doctors, no matter how excellent the initiatives might be. Government of Nigeria need to be strong and resolute if things must improve."

 - "...[others], instead of providing leadership by supporting primary care (much of which is routineizable and fully within the scope of non-doctors), while concentrating their expertise on the provision of excellent secondary and tertiary (specialist) care, chose to view his concepts as some kind of colonialist trick to consign the population to permanent second class care! (Many US doctors have been comparably short sighted in opposing midwives and nurse practitioners, despite their excellent education and the preponderant evidence of the excellence of the care they provide!)."

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Maggie Sullivan Moderator Replied at 1:27 PM, 19 Jan 2014

Would love to hear anyone's thoughts on this topic - and it doesn't need to be limited to Africa only. -Maggie

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Sarah Gimbel Replied at 12:11 AM, 20 Jan 2014

Thanks for the encouragement to write. A lot of us are looking to the role of NPC as the only feasible way to increase access to healthcare. For option B+ alone the role of nurses is critical. Yet, resources are not being allocated to ensure that the training is adequate and supervision is ongoing for nurses to improve their clinical management capacity. In Sofala province, Mozambique where I am working, in preparation for the partial introduction of Option B+ services, the MOH took a 2 week MD level training on ART management, gave it to MDs, tecnicos de medicina and ANC nurses. But due to limitations in costs and also staffing issues at health centers nurses were only allowed to attend one week of the course, despite the fact that they are now expected to independently manage ART treatment for pregnant women. I believe NPC (be they tecnicos or nurses) can be trained to provide and manage care but resources need to be allocated in order for them to do so.

Find attached some previous articles on task shifting from our experiences in Mozambique

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chris macrae Replied at 10:10 AM, 20 Jan 2014

I'm from the segment who'd always want to connect () with non-physician are absolutely indispensible but I am coming from a change system viewpoint that value's open education as youth's greatest ever liberator

imagine if first aid and basic health was a schools curriculum from age 8 up- and why wouldnt such a curriculum be as attractive as maths at khan academy; this is not to devalue the expert trained but I dont know of a health goal that wouldnt be accelerated by a deeper community base of basic knowhow; add in such communities demanding smart mobile apps, and web-dynamics designed to reduce degrees of separation on life critical information

- why isnt health knowhow the number 1 linkin context of anything that claims to be a social media? why doesnt public broadcast media do more programming on how to do health? in my home country UK this could have been such a natural follow up of the Olympics opening where nurses were celebrated as somewhat more valuable to communities than sportstars; incidentally last wee the EU's annual youth summit was led by an entrepreneur network that creates thousands of jobs for youth who dont quite make star status by bringing what healthy sports bodies know how to exercise that every age group can learn from
anyhow the viewpoint of everyone's livelihood connects with open health education is an issue we are hoping youth summits will massively brainstorm by sending postcards to each other to viralise the good news of such extraordinary entrepreneur solutions as nearly free nursing colleges that banglaldesh and haiti are already accelerating back from the future of affordable accessible health solutions by and for all

suzanne willard Replied at 10:35 AM, 20 Jan 2014

I am a non physician provider. I have been certified by medical societies and nursing boards. I have been at meetings and conferences with my physician colleagues keeping up to date on they latest advances. I read journals routinely I write prescriptions I make diagnosis I collaborate with other health care providers including physicians to insure quality health outcomes for the patients that I see. Research has shown that my outcomes are similar to my physician colleagues. Collaborative practice models are the most economically appropriate as well as provide quality services.
I am an advanced practice nurse. Many nurses throughout the globe do what they need to do to get what their patients need. We need to support them.


Elizabeth Glaser Moderator Emeritus Replied at 4:15 PM, 20 Jan 2014

Many nurses have heard these arguments against task shifting before. This is purely speculation, but I would like to sketch out a a few ideas about why these attitudes still prevail and would love to hear other people's impressions as well, especially from nurse practitioners or dispensing nurses. The scenarios below are possibilities, not certainties , for why we might encounter the proffered comments. And it these are not arguments confined to lower resource settings. For context, in Massachusetts, the US state where GHDonline is based, advanced practice nurses have long fought for the right to practice independently. The opinions expressed by the establishment here are more measured in tone, but the underlying idea that nurses cannot practice independently, remains.

1. Lack of exposure to mid level providers or other care extenders.
NPs and PAs or CHWs have become a vital part of some health care models , but not others. In this scenario, the comments Maggie highlighted , while sounding hostile, come from a genuine concern about the welfare of patients.

2. Lack of adequate nursing education incountry.
This is is something that physician colleagues have mentioned to me- that the nurses they work with in their own country are not adequately trained to do basic assessments, much less advanced practice. That is an argument for better basic nursing but not necessarily for denying task shifting or advanced practice.

3. Experience only within hierarchical systems.
Again, I have heard this from physicians as well as nurses, "someone has to be in charge", and based on education, it should be a physician. It is not an unreasonable argument but how is this to be achieved? We need task shifting because there are not adequate numbers of physicians and nurses, they may not take assignments in rural areas, may not show up to work at all , or may do private practice during periods when they are assigned to a government post. How are doctors to be in charge where there are no doctors?

4. Fear of competition.
If nurses and community health workers can do so much essential care, what is left for physicians? Lots.
However in markets with more private sector participation, midlevel providers with shorter and less costlier training, could end up posing competition to physicians if midlevel provider outcomes were as good as or better than physician outcomes. And if CHWs can work as well as nurses, why advocate for more nursing education?

5. Threat to identity and role
Task shifting also requires a shift in mentality - this can be open up wonderful opportunities for some but overlapping roles can be seen by others as a threat to identity. Providers with lesser training do sometimes outstep their scope of practice. Again better supervision should help, but if we had enough well trained physicians and nurses and could afford to pay them, would we want to continue use community health workers or would we want to shift tasks back to doctors and nurses?

The hierarchical nature of health systems may reflect social hierarchies and role identities. Doctors are perceived as people who have earned that place. However,in some societies children of the upper class are expected to become a lawyer , a physician ,a business person or perhaps a civil servant. Their class dictates what work they can do and by extension those in the upper class do not work in lesser roles, such as nurses or community health workers. In this case, external hierarchy is as important as that of the health system, so cultural shaping is at play.

What else - ? Look forward to hearing from you.


suzanne willard Replied at 8:16 PM, 20 Jan 2014

Great comments elizabeth!

Karen A Wolf Replied at 9:33 PM, 20 Jan 2014

When you move out of a US perspective, the issues is not between advanced practice nurses and physicians, but rather, preparing and using nursing resources in many countries. Educational preparation may lack standardization and the limited resources of baccalaureate nurses. In some case, the education is directed less as the national health system, then at supporting the production of nurses for export. I am aware that the lack of educational foundation may limit the development of advanced practice nurses, but it also reminds me of when it was still illegal in states in the US for nurses to provide patient education. Knowledge and technology are central to the medical dominance. Another significant point alluded to was is that Nursing has historically been stigmatized for a variety of reasons, from the proximity to patient care and bodily functions, to the larger class differentiation between nursing medicine. This stigmatization continues globally- yet the flip side of the this is often the privilege of intimacy and trust that patients hold for nurses.

Elizabeth Glaser Moderator Emeritus Replied at 9:59 PM, 20 Jan 2014


Elizabeth Glaser Moderator Emeritus Replied at 10:29 AM, 21 Jan 2014

How can can we convince the providers, the ones who Maggie quoted, that non-physician providers are a vital part of the health system, as is task-shifting, and that health knowledge should not be an exclusive domain of one group?
What would you say or do to help bring about change?


EMILIA IWU Replied at 10:57 PM, 21 Jan 2014

Very interesting comments!
It is unfortunate the degree of resistance expressed in the quotes Maggie presented. It is even more surprising they all came from Nigeria. My experience with Task shifting implementation in Nigeria is that patient safety is the paramount goal and non physician providers have definitely improved access to needed health services. from tertiary, to secondary and primary health facilities.
However, reading those quotes, I sensed more of a turf protection than anything else. None of the quotes proffered solutions to access to care other than "a wish for abundant numbers of physicians". With ongoing struggle to overcome poor health outcomes and increasing disease burden in Nigeria, this is the time to maximize every health worker's clinical potential instead of limiting them. 
I challenge these physicians to visit sites providing task shifting; seek opinions of their colleagues working with Nurses, Midwives and Community Health Workers  rendering task shifted services. I guess these and scientific evidence from the field are ways to convince them though I have my doubts if that is what's needed. My concern however is when "...we have chosen that which is compatible with our cultures, beliefs and sensibilities..." without the interests of health consumers at heart.
Thanks Maggie for sharing.
Emilia Iwu MSN, APNC

Barbara Waldorf Moderator Emeritus Replied at 6:26 PM, 29 Jan 2014

This is a very interesting conversation and important topic. I really appreciate the logical framework of your breakdown Elizabeth, and feel that this is the way to be able to address the multiplicity of issues that exist here. It is important to understand the motivation for such comments, as that is the way to really be able to work together to provide the best patient care.
Thank you to all who posted,
Barbara Waldorf BSN, MPH

EMILIA IWU Replied at 1:44 AM, 30 Jan 2014

Hi All,
I am doing my dissertation project on NIMART and want to find out the main components and duration of NPC training in the counties you work in.

Elizabeth Glaser Moderator Emeritus Replied at 3:06 AM, 30 Jan 2014

Hi Emily,
To clarify do you wish to know what countries do Nurse Initiated ART? At the time of publication of the 2013 articles from JAIDS
( below) only South Africa, Lesotho and Malawi had implemented national policies allowing the ARV prescription by nurses.

If this is repetition for you , I apologize , but I do like to search around and through the literature to find out what's going on in a certain area. Health , Policy and Planning , 2013 :The effectiveness and cost implications of task-shifting in the delivery of antiretroviral therapy to HIV-infected patients: a systematic review. In two trials of NIMART in South Africa, Fairall et al. (2011) and Sanne et al. (2010), both studies suggested that NIMART was not inferior to physician initiated ART, in fact there were little or no differences in primary outcomes between the groups.

In Emdin CA, Chong NJ, Millson PE. (2013) Non-physician clinician provided HIV treatment results in equivalent outcomes as physician-provided care: a meta-analysis.J Int AIDS Soc. 2013; 16(1): 18445, the ending paragraph is a keeper - especially in light of the comments made by the HIFA2015 providers:
"This meta-analysis of the result of a combined 59,666 subjects found that non-physician-provided HIV treatment results in the same outcomes as traditional physician-provided treatment and may result in reduced LTFU rates. Patients were more likely to be satisfied by care provided by non-physicians, which was attributed to the perception that nurses provided more holistic care and that nurse-led clinics were closer to patients’ homes. These results support the current expansion of task shifting policies in sub-Saharan Africa and suggest that countries that have not implemented such policies may be unnecessarily rationing their care. Future research should be conducted into evaluating training programmes for non-physicians as well as identifying barriers that are inhibiting the expansion of task shifting policies."

GIven the attitudes voiced in the HIFA discussion, how can we use the studies noted here and others to create more support for task shifting and nurse initiated ART? Because we should be shouting it from the rooftops - task shifting works!


Winnie Nhlengethwa Replied at 11:47 AM, 30 Jan 2014

Swaziland is also conducting training on NIMART. I will have to check the ART Unit of which model they use.

Molotsi Monyamane Replied at 12:11 PM, 30 Jan 2014

Task shifting with supportive supervision with leadership and
accountability will help access to Healthcare at Primary Level. Awareness
Immunisation Diarrhoeal diseases treatment and HIV Testing have all been
supported by trained non Medical Staff, this has increased coverage and
adherence to treatment.

Winnie Nhlengethwa Replied at 12:36 PM, 30 Jan 2014


That's very true, especially in this part Africa where nurses are the
backbone of the health care system.

TSERETSE MAPHOSA Replied at 12:53 PM, 30 Jan 2014

In Zimbabwe ,task sharing is in the in thing,nurses are leading OI/ART clinics.nurses are trained to initiate and follow up clients who are on ART

EMILIA IWU Replied at 2:01 PM, 30 Jan 2014

Thanks Elizabeth,
You are absolutely right, Task Shifting works and we must continue to flaunt the evidence as well as document it.

So far, I have come across one or two publications that presented the types of training (content plus duration) utilized to prepare nurses to either initiate or maintain patients on ART. Many more countries are implementing and I am interested finding out more what is covered during their training, how long nurses were trained, mentored etc.
Thanks for your time.

Elizabeth Glaser Moderator Emeritus Replied at 5:21 PM, 30 Jan 2014

Dear Winnie,
Is there any clinical trial or evaluation associated with it?


Sarah Gimbel Replied at 12:04 AM, 31 Jan 2014

please refer to Sherr's articles on NPC in Mozambique in both JAIDS and AIDS

Sherr K, Micek M, Gimbel S, Gloyd S, Hughes J, John-Stewart G, Manjate R, Pfeiffer J, Weiss N. Quality of HIV care provided by non-physician clinicians and physicians in Mozambique: a retrospective cohort study. AIDS. 2010;24:S59-66

Sherr K, Pfeiffer J, Mussa A, Vio F, Gimbel S, Micek M, Gloyd S. The role of non-physician clinicians in the rapid expansion of HIV care in Mozambique. J Acquir Immune Defic Syndr. 2009;52:S20-23

Milka Ogayo Moderator Replied at 6:06 AM, 31 Jan 2014

Thank you Maggie for this interesting discussion. I come from a region where task shifting has succeeded.

Elizabeth Glaser Moderator Emeritus Replied at 9:45 AM, 31 Jan 2014

Hi Milka,

Can you tell us more about your experience with task-shifting in Kenya?


Elizabeth Glaser Moderator Emeritus Replied at 10:24 AM, 31 Jan 2014

First - I forgot to mention that our colleague Sheila Davis at PIH prefers to use the term " task-sharing" instead of "task-shifting" as this may be a less competitive and more accurate description of the practices involved and the goals.

Second- I found a number of articles on NIMART at African Journals OnLine (AJOL) ,"the world's largest collection of peer-reviewed, African-published scholarly journals", many are open access - this is a good place to visit! If you search for "Nurse Initiated Management of Antiretroviral Treatment " many papers come up, such as the one linked below. This article was from the South Africa Medical Journal. It was a phone survey of nurses in 7 provinces approximately 2 months post NIMART training. They reported that 62% of the nurses had initiated adults on ART, but only 7% had initiated children. The main barriers were physical space to meet with patients and having to do other tasks in the clinic as a result of staff shortages.

For me, this paper raised questions about limitations on task-sharing for initiation of ART - once trained, they need the opportunity to practice.

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EMILIA IWU Replied at 8:16 PM, 1 Feb 2014

Thanks Elizabeth. I appreciate all the comments, links and questions.

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