Shining a Light on Task-Shifting Policy Exploring opportunities for adaptability in non-communicable disease management programmes in Uganda *

In terms of disease burden, many lowand middle-income countries are currently experiencing a transition from infectious to chronic diseases. In Uganda, non-communicable diseases (NCDs) have increased significantly in recent years; this challenge is compounded by the healthcare worker shortage and the underfunded health system administration. Addressing the growing prevalence of NCDs requires evidence-based policies and strategies to reduce morbidity and mortality rates; however, the integration and evaluation of new policies and processes pose many challenges. Task-shifting is the process whereby specific tasks are transferred to health workers with less training and fewer qualifications. Successful implementation of a task-shifting policy requires appropriate skill training, clearly defined roles, adequate evaluation, an enhanced training capacity and sufficient health worker incentives. This article focuses on task-shifting policy as a potentially effective strategy to address the growing burden of NCDs on the Ugandan healthcare system.


N
early 80% of the nine million deaths worldwide among individuals under 60 years old occur in low-and middleincome countries (LMICs). 1 In these developing countries, non-communicable diseases (NCDs) have emerged relatively unnoticed while the international community focused on combating human immunodeficiency virus (HIV), acquired immune deficiency syndrome (AIDS), malaria and tuberculosis. 2Furthermore, NCDs have long been under-recorded and were omitted from the Millennium Development Goals. 2 Consequently, there are numerous knowledge, policy, and implementation gaps regarding the treatment of NCDs. 2,3As a result, strategies for the treatment and management of NCDs have traditionally struggled to gain significant financing.In general, NCDs share common risk factors (e.g.tobacco use, excessive alcohol consumption, unhealthy diets and physical inactivity) and socioeconomic determinants of health (e.g.poverty, lack of education and urbanisation) with cardiovascular diseases (CVDs). 2,4,5n Uganda, a low-income country in east sub-Saharan Africa, the double burden of both communicable diseases and NCDs is a challenge to the underfunded health system administration. 2,3,6Over the last decade, the prevalence of NCDs in Uganda has increased significantly, with NCDs estimated to account for 27% of total deaths. 2The World Health Organization (WHO) estimates that CVDs account for 9% of total deaths in Uganda. 1 Recent statistics have also shown an increase in mortality from cancers (5%), chronic respiratory diseases (2%), type 2 diabetes mellitus (1%), injuries (13%) and other NCDs (10%); chronic, communicable, maternal, perinatal and nutritional conditions are responsible for 60% of all deaths. 3][4][5] While sub-Saharan Africa accounts for 11% of the world's population and 24% of the global burden of disease, only 3% of the world's health workers are based in this region. 7In 2008, the WHO noted a regional critical shortage of more than four million trained health workers. 5,8,9In 2015, 31 countries in sub-Saharan Africa reported an increased need for trained health personnel. 102][13] In Uganda, the increasing demand for healthcare services, a steadily growing population and the continued burden of morbidity and mortality from infectious diseases have led to significant health workforce shortages. 8][16] These issues have significantly affected the delivery of healthcare services in Uganda and highlight the need for the implementation and development of policies that consider both an efficient and effective use of existing human resources through planned resource allocation. 8,10,17,18][19] This article examines task-shifting policy in Uganda within the current political and economic context.

Healthcare Structure and Delivery
Currently, Uganda has a population of more than 36 million people, although only 22.5% of the population is between 30-70 years old. 2 The majority of Ugandans live in rural provinces and only 15.6% live in urban areas. 2 Healthcare services in Uganda are provided through both governmental and non-governmental resources.In Uganda, the decentralised healthcare system is categorised by the level of healthcare delivery; public healthcare is provided at the local, district, regional and national levels.The district health service is responsible for all healthcare structures within that district, except for the national and regional referral hospitals.Health centre I is the name given to the most basic level of healthcare provision in Uganda, operating within villages.A health centre II is the first physical centre at which a patient can be seen; from here, patients are referred to a health centre III, which can then refer patients to a health centre IV.Communities and facilities served at the health centre IV level make up a health sub-district.The fifth level of care is provided at a district or general hospital, which then refers patients to regional hospitals, and from there to national referral hospitals.
As yet, Uganda has no evidence-based national guidelines, protocols or standards for the management of major NCDs. 2,5Healthcare professionals manage NCD patients with minimal local epidemiological data, as few studies include sub-Saharan African populations in determining optimal medications for specific NCDs. 3Considering the lack of NCD surveillance systems and inadequate financial resources, addressing and reporting NCDs to meet the nine global NCD targets of the WHO will continue to pose a challenge. 2,5Given its limited resources, the government of Uganda has set in place an operational unit within the Ministry of Health to address the health burden caused by NCDs. 3 This will require moving away from siloed programmes towards diagonally oriented and integrated health service delivery platforms. 11ganda continues to face problems in the recruitment and retention of trained health workers to serve its growing population and the healthcare worker shortage is characterised by an inadequate number of personnel with the required skills, low motivation, poor performance and high attrition rates. 8,10,13,17uring the 2010-2011 fiscal year, only 56% of approved positions in the public sector at the national level were filled by trained health professionals, which is well below established norms. 20Currently, over 51% of all staff positions at all levels of the healthcare delivery system in Uganda are unfilled. 21,22Uganda's National Development Plan for 2010/2011-2014/2015 estimated the health worker-to-population ratio to be 1:1,298; this is much higher than the ratio in most countries in the East African region. 23In 2010, data showed that the doctor-to-patient ratio in Uganda was 1:24,725 while the nurse-to-patient ratio was 1:1,000. 23n 2011, data collected by the Ugandan Ministry of Health indicated significant gaps in health staffing at all levels [Table 1]. 24Staff shortages were reportedly more acute in rural health facilities.As such, a large proportion of the available health workforce is urbanbased while the majority of Uganda's low-income population lives in rural areas. 14ccording to the Uganda Nurses and Midwives Council (UNMC), the national licensing body for nurses and midwives, there are 11,673 nurses and midwives in Uganda, 6,405 of whom have attained a certificate level of nursing education. 25Fewer nurses obtain a specialised nursing education as there are only three graduate nursing programmes available in Uganda. 25Other factors affecting staff recruitment and retention include a lack of promotion opportunities, unequal remuneration of healthcare workers compared to other professionals, inadequate training/facilities, poor leadership, inadequate staff accommodation and staff fatalities due to HIV/AIDS, accidents and malaria. 14,16,26,27sk-Shifting Policy Fulton et al. define task-shifting as the delegation of tasks to an existing or new cadre of health workers with either less training or disease-/skill-specific training. 10The WHO describes task-shifting as the process whereby specific tasks are transferred, in a structured manner, to health workers with less training and fewer qualifications than normally required to provide a certain service or perform a specific task. 8ask-shifting strategies have the potential to meet the demands of NCD programmes since management principles for these diseases are based on screening, health promotion, initiation of treatment and referral of high-risk patients to physicians. 28Proponents of task-shifting point to significant positive outcomes for patients with HIV, obstetric care requirements, mental health issues and malaria. 8,10,13,20Trained Adapted from Uganda Ministry of Health.Human resources for health bi-annual report: Improving HRH evidence for decision making -April-September 2011. 249][30] Additionally, NPHWs can also encourage medication adherence among patients requiring chronic care. 7Task-shifting interventions by nurses and nursing assistants in LMICs have reportedly helped to reduce the burden of CVDs and there is considerable evidence supporting the effectiveness of task-shifting implementation for chronic disease management. 9,19e WHO recommends task-shifting as a strategy for LMICs to address the global human resource crisis. 8ithout a policy on task-shifting, Uganda may not attain the benefits and viability of NCD programme implementation reported by other countries. 20Taskshifting has been present in Uganda for decades as nurses have been known to undertake a range of tasks that were formerly the responsibility of doctors. 14,20owever, at the national level, there are no policies on task-shifting to address the growing burden of NCDs. 2,5Although task-shifting is not a new concept, it has faced criticism due to its unstructured approach and lack of systematic follow-up and monitoring. 17,20 qualitative study on task-shifting in Uganda found NPHWs were perceived by health managers and policy-makers as incompetent, overworked and lacking support or supervision. 14Barriers to taskshifting in Uganda include, but are not limited to: reluctance to change; protection of professional 'turf '; institutional regulations; heavy workloads; lack of time to provide necessary supervision and training; and the high disease burden. 20Other challenges include poor planning, inadequate guidelines and high unemployment rates, as well as the lack of taskshifting advocates in Uganda. 20uccessful task-shifting interventions are potentially effective and affordable; some of the benefits include mitigation of the health workforce shortage by increasing the number of NPHWs and thus providing increased access to life-saving treatment, improving health workforce skills and increasing the efficiency and sustainability of healthcare delivery. 28hese elements form the core principles of primary NCD management. 14At the same time, challenges to task-shifting implementation need to be identified and addressed.These challenges include the identification of the right health workers with the necessary competencies, effective supervision of NPHWs and sufficient support from policy-makers, professional bodies and managers.

Political and Legal Environment
Analysis of the Ugandan National Development Plan 2010/2011-2014/2015 revealed many existing gaps in achieving its intended results. 23,31However, the Ugandan Government, private partners and donor agencies are all committed to solving the on-going human resource crisis. 3132,33 The majority of trained healthcare providers are educated in state-sponsored universities; thus, a loss of trained personnel is an investment loss on the part of the government. 21It is therefore imperative for the Government of Uganda, healthcare leaders and policy-makers to extend their political commitment to support and allocate adequate budgets for training, incentivising, hiring and retaining healthcare workers in the public sector.
Currently, several policies are being implemented in various sectors, including agriculture, health and education.Within the health sector, the National Development Plan and national health policies have been put in place to guide the achievement of health indicators. 23,24Professional councils and licensure bodies in Uganda are responsible for controlling health worker professional practices, with published codes of conduct; 23,25 however, no specific guidelines exist regarding task-shifting in the management of NCDs in Uganda.In addition, no policies have been developed to stop the emigration of healthcare providers. 34As such, it is recommended that healthcare professional councils work in collaboration with universities or institutions and other government agencies in Uganda to institute a formal legal framework that will support contractual employment for retention purposes. 14It is important that policies and standards for managing NCDs, considering the barriers to taskshifting implementation, are established. 17The WHO recommends that countries facing a growing NCD burden, as well as a human resource crisis, undertake a fast-track strategy to produce essential revisions to their regulatory policies, enabling existing healthcare staff to work with an extended scope of practice without compromising quality or patient safety. 8

Social and Economic Influences
Disparities in salaries are strongly linked to health workforce shortages, leading to a significant maldistribution of healthcare providers and inequitable healthcare service provision. 21,31In the public sector, attrition among health workers and low productivity have reportedly led to low salaries and delayed payments. 31Research indicates that Uganda's budget allocation for the health sector is inadequate to provide liveable salaries for health workers serving in the public sector. 14,30Consequently, the remaining healthcare providers are overworked, resulting in some choosing to leave the profession altogether. 34ther healthcare providers often look for additional employment to supplement their wages, causing uncontrolled absenteeism. 31These factors have significantly affected the provision of high-quality healthcare services. 22,31,33,35The World Bank reported absenteeism as the single largest waste factor in the public sector, leading to an estimated loss of 26 billion Ugandan Shillings. 23,31Similarly, social pressure and increased responsibilities have forced more healthcare providers in rural areas to leave their families and work in urban areas. 21,31National reports in Uganda indicate that healthcare providers in the public sector and in rural settings are more likely to work without incentives or motivation compared to their private sector counterparts, leading to a significant maldistribution of healthcare workers. 14,21Rural areas do not have the capacity to attract and retain health workers; as such, recruitment efforts should be focused on these regions. 14e term 'brain drain' is used to describe the phenomenon whereby highly trained personnel migrate to another country, usually for social and/or economic reasons.Due to the high cost of living, many healthcare workers from Uganda emigrate in an effort to attain a better quality of life. 31Tsolekile et al. found that 22% of medical school graduates from sub-Saharan Africa had migrated outside of Africa five years post-graduation. 7To address this challenge, health trainees sponsored by the government should be contractually obligated to serve the Ugandan health sector for a five-year period before receiving their academic transcripts and certificates. 14n order for NCD management programmes to be both successfully implemented and sustainable, social and economic factors affecting healthcare provider retention and efficiency need to be addressed through improved salary packages, including allowances for housing, transportation to work facilities and other social amenities. 30Such benefits could result in major improvement to the lives of healthcare workers in rural settings and thus contribute to their retention. 14n opportunity that may present with a NCD taskshifting policy is the potential to create demand for better pay for NPHWs who accept these new roles. 15urthermore, the Government of Uganda should increase budget allocations to purchase the drugs required for the management of NCDs.

Adapting Task-Shifting Strategies to Non-Communicable Disease Programmes
In order for Uganda to pursue its goal of improving the health of its population, both the existing health workforce crisis as well as the growing burden of NCDs need to be addressed. 31Task-shifting from physicians to NPHWs, if accompanied by the restructuring of the health system, is a potentially effective and affordable strategy. 28Specifically, successful task-shifting should include workforce skill-mix changes, worker incentives and an increase in training capacity and supportive oversight.
w o r k f o r c e s k i l l -mix c h a n g e s Notably, task-shifting in NCD programmes requires the skill mix of various healthcare providers working collaboratively with regards to management, screening, prevention, lifestyle modification health education, treatment and referrals for specialised care. 30gandan nurses are among those envisioned to take up the task-shifting role in the detection and management of NCDs; as a result, these nurses will require additional training in NCD management as well as supportive supervision, mirroring the use of NPHWs in the detection and management of HIV. 9,14,15,18,26,29Unfortunately, the scope of practice for nurses and midwives often limits their roles.At present, only midwives in Uganda are allowed to administer drugs during obstetric care.The UNMC is currently developing a scope of practice for all cadres of nurses and midwives in Uganda which will extend their prescriptive role. 25Policies governing prescriptive roles need to be put in place and disseminated nationally to protect and facilitate the NPHW's extended role in treatment.Encouraging consensus among the relevant stakeholders within the Ugandan healthcare sector would be beneficial in successfully implementing NCD programmes. 3

t r a i n i n g c a pa c i t y a n d s u p p o r t i v e o v e r s i g h t
Focused training and intensive support of NPHWs by experienced health workers is essential to maintain quality standards. 14,17,28Healthcare workers taking up new roles in identifying and managing NCDs need to be adequately prepared through formal training, enabling them to successfully carry out their new duties. 8Adequate training, evaluation, clinical mentoring and supportive supervision will also counteract the number of health workers leaving the country. 8owever, training health workers to meet the current demands of both communicable diseases and NCDs poses a significant challenge to many countries. 8,36raining NPHWs to take up expanded roles will require introducing them to evidence-based guidelines, protocols and strategies in the management of NCDs; 37 approved treatment algorithms may be useful in this respect.Re-training, supportive supervision and mentoring of NPHWs need to be considered as quality-monitoring approaches to the implementation of an effective task-shifting policy.
h e a lt h w o r k e r i n c e n t i v e s Considerable evidence suggests that incentives play a significant role in increasing the retention, productivity and motivation of health workers. 8,14he WHO advises healthcare policy-makers to consider both financial and non-financial incentives predicated on performance-based measures, particularly with respect to encouraging NPHWs in their new or increased responsibilities. 8,37However, these incentives should be matched with available resources to ensure sustainability. 8,17Similarly, it has been suggested that incentivising health workers enhances their responsiveness to patient needs and is associated with improved healthcare outcomes. 8

Further Recommendations
In addition to the above recommendations, further operational research is needed to understand barriers to the successful implementation of task-shifting policies in Uganda.The role of incentives and remuneration in retaining an optimal health workforce should not be underestimated.Further investigation is necessary to understand how role expansion for NPHWs might affect patient safety.Moreover, additional studies are needed to assess the acceptance of existing task-shifting strategies among communities and professionals.

Conclusion
In Uganda, the growing NCD burden is complicated by a severe shortage of healthcare personnel.Taskshifting may potentially be an effective model for the management of NCDs.Successful implementation of the task-shifting model of care requires policy changes to include standardised protocols, enhanced training capacity and the incentivisation and integration of NPHWs as part of a multidisciplinary team of health workers.Further studies are needed to assess the Shining a Light on Task-Shifting Policy Exploring opportunities for adaptability in non-communicable disease management programmes in Uganda e164 | SQU Medical Journal, May 2016, Volume 16, Issue 2

Table 1 :
Number of units and percentage of staffing positions filled at various health facilities in Uganda