Task Sharing, Not Task Shifting: Team Approach Is Best Bet for HIV Care

This post was originally published on the IntraHealth International blog.

By developing a more rational division of labor among HIV/AIDS health workers in developing countries, we can go a long way in “Overcoming the Last Barrier to Universal Access,” and nurses have a significant role to play in that effort.

That was the ambitious premise and title of a presentation by Dr. Kate Tulenko, senior director for health systems innovation for IntraHealth International (and CapacityPlus deputy director for clinical services and service delivery strengthening), at a satellite session I attended at the XIX International AIDS Conference in Washington, DC.

“There is a complete mismatch between where HIV exists and where health workers are,” said Dr. Tulenko. “If HIV/AIDS care is to be delivered, it has to be delivered with nurses.”

Nurses were the focus of the larger satellite event “Nurse Models of HIV Care and Treatment: Addressing Health Workforce Shortages for Long-Term Sustainability,” and several speakers made the point that HIV/AIDS cannot be defeated without nurses. “Nurses deliver 90% of all health care services worldwide,” said Dr. Jason Farley, assistant professor at Johns Hopkins University School of Nursing.

Dr. Tulenko also made that point and emphasized that a “team approach” to HIV prevention, treatment, and care produces greater efficiency, with higher productivity from each worker, lower per-visit cost, lower investment costs, and time savings.

She defined “team-based care” as “medical care provided to a patient by a set group (team) of different health professionals with different roles that maximize the skills and abilities of each team member. Team-based care differs from traditional care in which a physician was either the only or the primary point of contact with the patient. Team-based care is designed to enable different health professionals to achieve their full potential and improve quality, reduce costs, and increase access to health services. Team-based care includes inter-professional training both at the pre-service education level and the continuous professional development level.”

From task shifting to task sharing
This focus on team approaches is a move away from “task shifting,” which the World Health Organization defined a few years ago as “the rational re-distribution of tasks among health workforce teams” in which specific tasks are moved from highly qualified health workers to those who have fewer qualifications in order to make more efficient use of available resources.

But Dr. Tulenko and other speakers made it clear that task shifting is no longer the answer, if it ever was. “I prefer the ‘team approach,’” she said. “The care isn’t physician-centered anymore.”

“It’s about task sharing, not task shifting,” said Dr. Carmen Portillo of the University of California at San Francisco. “Task shifting never resonated with me. Task sharing is needs-based; it’s not hierarchical or territorial.”

Dr. Portillo said task shifting is controversial because of the compensation packages of the categories of different health workers: some lower-paid health workers feel they are getting a lot of new work without commensurate compensation.

The argument for task sharing, or a team-based approach, seems logical and laudable in situations where multiple health workers are present, but that is far from the reality in much of the developing world. What about those places where people don’t have access to even one health worker? How are we supposed to get a team of health workers to them?

Cost-effectiveness: The need for evidence
Several speakers talked about the cost-effectiveness of nurses, but there is not a lot of research to prove that to be the case.

Dr. Tulenko cited a Cochrane Review from 2009: “In primary care, it appears that appropriately trained nurses can produce as high quality care and achieve as good health outcomes for patients as doctors. However, the research available is quite limited.”

In fact, she said there’s been no peer-reviewed research published on the cost-effectiveness of nurse-delivered HIV/AIDS care since 2008.

“We [nurses] are all cost-effective interventions,” stated Dr. Farley. “But we need more cost-effectiveness data, and we will go out and get it.”

The session ended with a spirited tribute to nurses worldwide and a call for more recognition and involvement of nurses in HIV/AIDS policy decisions.

The Association of Nurses in AIDS Care (ANAC), the organizer of this event, demanded a more visible nursing presence in planning, policy, and practice and more education, engagement, and support of nurses.

“Nurses remain largely invisible at decision-making tables in national capitals and international agencies,” as stated in the ANAC’s call to action, passed out at the session. “Their absence constitutes a global health crisis.”

Dr. Farley chided the International AIDS Society (IAS), the organizer of the conference, for not including nurses more in the biennial meeting. “Nurses must have a seat at the table,” he said. “IAS, where are your nurses?...We believe an AIDS-free generation is possible, but it will not happen without nurses.”

New issues, new questions
This session illuminated several issues for me and raised new questions:

• Issue: The apparent fall from favor of task shifting and the rise of task sharing (or team-based approaches). Question: Isn’t phasing out one approach and adopting another overly simplistic, and should we not be using both approaches (and hybrids of both) depending on the specific health care worker situation in question?

• Issue: The lack of research data on the cost-effectiveness of nurses in HIV/AIDS prevention, care, and treatment. Question: Why is there such a dearth of this research, and what can be done to generate more research of this type?

• Issue: Although I must confess I never thought about it before, it now seems obvious to me that the indignant nurses were right to complain about a lack of representation in global health decision-making fora given the global role of nurses in delivering health care. Question: What can be done to rectify that, starting with IAS?

What do you think about these three issues? We welcome your comments.

This is a report from a satellite session entitled, “Nurse Models of HIV Care and Treatment: Addressing Health Workforce Shortages for Long-Term Sustainability,” at the XIX International AIDS Conference in Washington, D.C. on July 23, 2012.

David J. Olson is an independent global health communications and policy consultant with more than 25 years of experience in Africa, Asia, and Latin America. Follow him on Twitter @davidjolson.