Task-sharing to support paediatric and child health service delivery in low- and middle-income countries: current practice and a scoping review of emerging opportunities

To understand what conditions in the 0–19 years age range might need to be prioritized in LMICs we extracted disability-adjusted life-years (DALYs) of level 3 causes (diseases and injuries) for the age group “ < 20 years” in 2019 from the Global Burden of Disease study [17]. We did this for countries defined by the World Bank as: high-income, upper-middle-income, lower-middle-income, and low-income; using the patterns in the first two as an indication of likely future disease patterns in low-income and lower-middle-income countries that will occur with development. For each category of income-level, we selected the top 20 causes ranked by DALYs, and highlighted those likely to require greater emphasis in developing accessible high-quality paediatric services.

Second, we examined national training policies and professional scopes of practice in five East and Southern African countries (Kenya, Uganda, Tanzania, Malawi and South Africa). All have large gaps in the availability of skilled health professionals [18] and were the common location of research in our scoping review. We characterized the different professionals offering care, the extent of their pre-service paediatric and child health training and opportunities for post-basic training in this field. We focused on physicians, nurses and non-physician clinicians (clinical officers, clinical associates, etc.) as the cadres of interest. We searched for documents or information (e.g. from websites) from approved training institutions, relevant regulatory councils and commissions. We reviewed schemes of service, relevant acts, task-sharing policies, other broad and disease-specific national strategic plans/policies to capture their scopes of practice.

Lastly, we conducted a scoping review [19] of studies examining the design and practice of task-sharing for paediatric and child health services in all LMICs (Additional file 1: Scoping review protocol and PRISMA diagram). In summary, we conducted a systematic search using MEDLINE, Embase, Global Health, PsycINFO, CINAHL and the Cochrane Library to identify relevant articles. We combined terms and phrases related to paediatrics, task-sharing, different cadres commonly involved in task-sharing and the Cochrane LMIC filter [20]. We included all study designs published between 1990 and 2019 in English. Table 1 shows the inclusion and exclusion criteria. After two stages of independent screening by two authors, we charted data from included papers and sorted them into three major groups based on the conditions they examined: acute infectious diseases and malnutrition; surgery (with sub-categories minor surgery, other complex surgery), emergency and intensive care; and chronic conditions (sub-categories complex and chronic conditions, mental health). For included papers we described specific health services and procedures shifted/shared, study country, study design, cadres involved, major inputs and outcomes (health worker knowledge, skill, patient outcome) as originally reported in the included papers.

Focusing on those conditions not typically covered by current strategies and initiatives, Table 2 illustrates how the top-ranking conditions for which services will likely need strengthening will change as countries transition from low income to middle and high income if high-quality paediatric care is to be widely accessible. For all countries, neonatal disorders (preterm, birth asphyxia and trauma, neonatal sepsis, etc.) are the highest-ranked cause. Malaria, lower respiratory infections and diarrheal diseases are the 2nd and 3rd top-ranked causes for low-income and lower-middle-income countries, respectively, but covered by existing task-sharing strategies. Congenital birth defects are ranked 4th and 5th for low-income and lower-middle-income countries, respectively. Lower ranked but likely causes of substantial mortality and morbidity are road injuries, drowning, conflict and terrorism that require emergency and surgical care; and haemoglobinopathies and haemolytic anaemias, asthma, epilepsy and conduct disorder that are considered chronic conditions and require long-term multiple interactions with health services. Most of these conditions are also top-ranking conditions for upper-middle-income countries and high-income countries, which suggests that they will become increasingly important needs as countries develop economically.

Table 3 summarizes the training opportunities and scope of practice related to child health for physicians, non-physician clinicians and nurses/specialist nurses in the five African countries examined. The full list (by country and by cadre) is available in the Additional File 2. This details specific opportunities for child health training, existing child health scopes of practice (where defined) and summaries of national policies and planning documents relevant to child health.

In the countries examined physician training generally lasts 5–6 years and is followed by a 1–2 years pre-licensure internship that includes some months of supervised paediatric work within a hospital. All these countries offer physicians further specialist training in paediatrics and child health and family medicine, however graduates of these specialist medical programmes are few (e.g. 20–25 pa in Kenya). It is implicit in most policies that non-specialist physicians, even if junior, are expected to provide care for chronic and complex paediatric conditions with the exception of major surgery or intensive care. As such they may be expected to supervise, teach or receive referrals from non-physician clinicians and nurses offering primary care paediatric services in the absence of specialist paediatricians.

For non-physician clinicians, most countries have 3–4-year entry-level diplomas or Bachelor’s degrees that include some elements of paediatrics and child health (mostly 3–4 short courses). These diplomas and Bachelor’s degrees also require several months of internship in paediatric wards pre-licensure with a relevant regulator. The scope of practice for non-physician clinicians usually includes prescription of common medication. In schemes of service documents some countries (Kenya, Tanzania, South Africa) also explicitly permit non-physician clinicians to perform certain typically minor surgical procedures. Three countries (Kenya, Uganda, Malawi) have advanced-level courses on paediatrics for non-physician clinicians while all countries have advanced diplomas in other relevant specialties (most commonly family medicine, anaesthesia, ophthalmology, ear nose and throat [ENT]), however this training is not specific to the paediatric age group and numbers of these specialist non-physician clinicians are much smaller than generalists.

Nurses too receive some training in child health as part of entry-level training courses and most countries offer advanced diplomas in neonatal or paediatric and child health nursing, while some also have Master’s-level training which requires a Bachelor’s degree for entry. This arrangement also applies to other relevant specialties that are not specific to paediatrics and child health (e.g. mental health/psychiatric, family medicine, critical care nursing). The scope of practice for nurses in general and often for those with advanced training is more restricted than for non-physician clinicians as in most countries such nurses are usually not authorized to prescribe. However, in primary care settings because of de facto/informal task-sharing nurses may prescribe and in some countries nurses are legally allowed to prescribe selected drugs for acute and chronic illness mostly related to HIV/AIDS and tuberculosis (Kenya) or at primary care level (Malawi). In some countries, malnutrition treatment and/or mental health counselling is within nurses’ scope of practice while in Tanzania for example, nurses are not (officially) allowed to treat severe malnutrition at health centre level.

Table 4 shows the results of the scoping review on research evidence for task-sharing and paediatric and child health service delivery. A total of 83 papers were included for data charting, and 84% of the papers were published before 2010. The included studies covered 24 countries, 20 of which were African, most commonly Malawi (n = 14), Kenya (n = 12), Uganda (n = 12), South Africa (n = 8) and Tanzania (n = 6). Forty-nine studies assessed task-sharing as a new intervention, and 34 studies reported task-sharing as a norm, i.e. mentioned that services were routinely delivered by non-physicians but the study aim was not assessing task-sharing. Sixty-five studies used quantitative approaches (cross-sectional (n = 25), before–after (n = 13), non-randomized trials (n = 9)). Ten used qualitative approaches either interviews (n = 5), case study/review (n = 5), mostly investigating how task-sharing initiatives were implemented and health workers’ perspectives. Another 8 studies used mixed-method approaches. For the outcomes of care that were being shared assessed (n = 73 quantitative and mixed-method studies), 18 studies assessed the lower cadres’ knowledge, 28 studies their skills, and 35 patient outcomes including mortality, length of hospital stay, follow-up and adherence rates and patient satisfaction. We now consider findings organized by the type and complexity of conditions.

We found some training opportunities but rather limited policy opportunities for surgery, emergency and intensive care task-sharing. Non-physician clinicians could receive post-basic training in surgery, anaesthesia and emergency medicine. While most previous research evidence on task-sharing to non-physician clinicians or nurses focuses on adult and obstetrics services [57], research evidence on task-sharing for paediatric surgery has emerged over the past decade on circumcision, burn surgery, orthopaedics and VP shunts. Surgery for more complex cases (e.g. congenital defects) seems restricted to the few trained physicians despite a high disease burden. Similarly, while there are advanced courses on critical care nursing and reasonably well-established short-courses for emergencies, e.g. ETAT/ETAT+ and helping babies breathe (HBB), these short courses do not aim to formally establish new professional roles or expand scopes of independent practice. In the few studies that are done on sharing complex surgery or emergency care the mortality rate of patients managed by unsupervised clinical officers and nurses may be higher compared with patients managed by physicians or supervised clinical officers/nurses. Given the general deficits in the medical workforce especially in paediatric surgery and emergency care specialists [6, 58], it would seem worth exploring a more deliberate effort to develop specific paediatric task-sharing roles at hospital-level as has been practised for adults in Tanzania’s assistant medical officers [59].

Task-sharing for these chronic conditions is likely to occur frequently in primary care to non-physician clinicians and nurses due to the shortage of physicians at this level [6]. Nonetheless, this is not clearly reflected in their training curricula and scopes of practices. Despite some examples of advanced paediatrics and family medicine training that covered most paediatrics subspecialties, the production of such professions is relatively small. For example, in 2018 there were only 255 clinical officers and 119 nurses with higher diplomas or master-level paediatric qualifications in Kenya despite some of these courses being introduced in the late 1970s [7, 60, 61].

Research evidence on task-sharing for chronic conditions is limited. Studies focus on mental health, RHD and epilepsy. Most were reasonably small in scale and examined either focused initial diagnosis (echocardiography for RHD diagnosis), or follow-up treatment in lower-level health facilities provided by clinical officers or nurses alone. The implementation experiences reported for mental health and epilepsy treatment suggest successful task-sharing requires sustained training and supervision, uninterrupted supplies of medications and sometimes support from specialized teams to meet complex medical and rehabilitation needs [50, 53]. The challenges posed are similar to those for other non-communicable diseases and with the potential need for regular, scheduled follow-up countries need to consider how best to deliver this together with effective linkages between system levels.

Countries with very few specialists in paediatrics or family medicine and that rely on these cadres to extend access to paediatric and child health care for more complex and chronic conditions might take decades to achieve this given the challenges of training capacity, duration and cost. Task-sharing to cadres with shorter training could be one solution to this human resources gap. However, several issues need to be highlighted. Providing such paediatric and child health services requires a system-approach with integrated models of care spanning healthcare organizations, communities, patients, and sometimes other stakeholders [62]. For example, long-term disability requires sustained interactions with the medical and rehabilitative services [4, 50, 63]. Careful, strategic thinking on the mix of cadres, their roles, regulation, financing and training and supervision and management of teams and services are needed [64‐66]. To inform this much more might be learned from better evaluation of existing experience. Governments, regulatory councils and training institutions also need to enable changes in education, legislation, policy and financing well in advance of future expansion of service scope and scale as producing the desired mix of professions and skills may take years or even decades [64, 65].

Task-sharing strategies should also be mindful of professional identities and hierarchy [66, 67]. If further sharing of what are traditionally medical doctors and specialists’ professional responsibilities with other cadres is being considered, policy-makers need to win doctors’ endorsement and support to ensure effective task-sharing and the supportive supervision and team work that is needed for quality care. The planning needs to be context-specific, based on countries’ existing structures, available resources, previous experiences of task-sharing and future planning for universal health coverage. There are multiple specific examples of more specialist roles for non-physician clinicians and nurses with post-basic training in paediatrics and child health. However, graduates of such programmes are relatively few and it is not clear that their development is part of broader strategic and holistic thinking of how paediatrics and child health care services might be delivered at scale by teams possibly comprising multiple professions. For example, legal restrictions on nurses’ or non-physicians’ prescribing even after specialist training may undermine efforts to expand coverage. To this end, better research is needed on the outcomes, quality of care and costs associated with task-sharing if it is to be a means of improving coverage and quality of care rather than associated with the provision of “second-rate” services [68, 69].

Our study is not without limitations. Due to data and resource availability, we present secondary data on disease burden for 2019 instead of predicting the DALYs for the future. For the training opportunities and scope of practice review, we only examined five East and Southern Anglophone African countries. Paediatrician density is lowest in sub-Saharan Africa [6] and non-physician clinicians are more common in this region as evidenced by the fact that most identified research was from these countries. For the scoping review, we are only able to search and synthesize evidence reported in the research literature, in some circumstances task-sharing may already happen and become the norm, and therefore may not be reported in research papers. We also focused exclusively on task-sharing to professionals in the health sectors although it is well-known that other carers play a huge role in service delivery for chronic conditions.