Task shifting or shifting care practices? The impact of task shifting on patients’ experiences and health care arrangements in Swaziland

History of task shifting

In 2006, during the High-Level Meeting on HIV/AIDS for the United Nations General Assembly, the UN committed to work towards universal access to ART by 2010. At the time, there were glaring health system weaknesses in many of the countries hardest hit by HIV, particularly with regard to human resources. The ‘treat, train, and retain’ plan was devised by WHO [7] as a response. The aims of the plan were quadruple: prevent new infection among health workers, treat infected workers, expand capacity of existing health personnel, and add new cadres of workers [8]. Task shifting was specifically identified as a strategy to resolve the last two issues. The shifting of health care-related tasks to lower cadres of health workers was formally advocated by UNAIDS in the context of HIV treatment scale-up in 2007 [9].

At the time, task shifting in the context of HIV-related health services was already being practiced in Swaziland. Lay health workers, predominantly PLHIV, were taking over some nursing tasks, including HIV counselling, whilst nurses took over some of doctors’ duties to start patients on ART. Beyond the context of HIV, nurses had long performed tasks that were officially reserved for medical doctors, for example administering intravenous medicines and doing sutures.

In 2006 the Swazi Ministry of Health decentralised ART provision to the lowest levels of the health system, which resulted in the need to expand the health workforce. The health system was already facing a formidable human resource crisis due to a combination of factors including ‘brain drain’, with Swazi medical professionals often migrating, and a low health worker output in the country. The total number of nurses graduating annually in Swaziland was only 80, far below the numbers required for treatment expansion. Two years after ART became available for free in public health facilities in Swaziland, Kober and Van Damme [10] examined health-related human resources and found the situation dire: 44% of physician posts, 19% of nurses’ posts, and 17% of nursing assistant posts were vacant. This shortage was all the more poignant in the context of increasing demand for HIV-related testing, counselling, and treatment services that came with the nation’s efforts to promote universal treatment access.

In order to meet these demands, a new cadre of lay health workers, expert clients, was introduced in health facilities. A year after the use of expert clients in task shifting was officially instituted in the country’s ART programmes, Samb and colleagues [8] reported a more promising health workforce landscape with ratios nearing the global recommendations for expanding ART services: 1 doctor to 1,135 patients, and 1 nurse to 64 patients (18 doctors and 320 nurses for the 20,427 HIV-positive persons in care at the time). Although addressing the human resource shortage was not the only change made to the HIV-related medical system, the improved human resource situation significantly benefited the ART programme, which recorded tremendous success within a few years. By 2010, 4 years after the introduction of task shifting and expert client services, 64% of those eligible for treatment were receiving it (Ministry of Health Strategic Information Department. Monitoring the STI, HIV and TB Response Report. unpublished); by the end of 2012, 91% of eligible HIV-positive people were on ART (NERCHA 2014). In 2014, Swaziland was applauded by UNAIDS for making rapid progress toward achieving universal access to ART, and task shifting of key care-related tasks to lay health workers was named as a major factor in achieving that success [11]. Despite this well-deserved praise, some barriers continued to impede treatment uptake among some people, including distance to health facilities, limited infrastructure, and a limited capacity in some ART clinics [9]. While the high enrolment numbers were laudable, we argue that the success concealed the experiences and challenges many patients and health workers faced in the quest to expand treatment access quickly.