Global SurgeryGlobal surgical, obstetric, and anesthetic task shifting: A systematic literature review
Introduction
Five billion people lack access to safe, affordable surgical care when needed.1 This is driven, in part, by severe shortages in the global surgical workforce.2 Task shifting (TS), defined by the WHO in 2008 as “the rational redistribution of tasks among health workforce teams … from highly qualified health workers to health workers with shorter training and fewer qualifications,” is a commonly implemented yet often contentious strategy to expand the workforce. Criticisms include that the practice is frequently unregulated and is an often unassessed intervention.3, 4, 5, 6, 7, 8, 9 Still, many advocate for its use to scale up the surgical workforce to decrease the gap between patients and access to care. An estimated 1,272,586 new surgical workforce providers are needed to achieve a global surgical workforce density of 20 surgeons, anesthetists, and obstetricians per 100,000 people by 2030, costing US$71–146 billion; increased “task sharing” has been proposed as a way of decreasing cost and training times to reach this goal.10
Before the debate on surgical TS can be advanced, some fundamental questions need clarifying, which includes understanding the current scope of TS globally. While separate regional studies of the use of surgical and anesthetic TS and a global survey of the use of nurse anesthetists have been performed,3, 4,11, 12 an updated global view of the use of TS in the surgical and anesthetic disciplines is currently lacking in the literature. Understanding how and where TS is employed to bend the cost curve of health care expenditure while simultaneously expanding access to care is a first step in an informed discussion regarding policies on the needs in the global surgical workforce across all income settings.
In this review, we describe the current use of surgical and anesthetic TS as it is reported in the literature throughout the world. This review includes a description of the tasks shifted, the health workers involved in TS, and the role of supervision in TS. This review will serve as a more complete and updated expansion of our preliminary findings presented as an abstract in 2015.13
Section snippets
–Task shifting
For the purposes of this review, we used the WHO definition of TS (“the rational redistribution of tasks among health workforce teams … from highly qualified health workers to health workers with shorter training and fewer qualifications”) with the added modification that we also included situations in which surgical and anesthetic tasks were performed by associate clinicians (ACs) before and/or more frequently than by physicians, even though said tasks had not been redistributed from
Results
Our search strategy resulted in 8,084 distinct articles, of which 43 met our inclusion criteria, and 12 additional articles were included through references (Fig. 1 shows study flow diagram and online appendix shows full list of included review references). Data on surgical and anesthetic TS were obtained from 52 and 147 countries, respectively. The practice of surgical TS was reported in 19 of 52 countries (37%) with available data and the practice of anesthetic TS in 119 out of 147 countries
Discussion
In this review, we demonstrated that TS for surgery, obstetrics, and anesthesia occurs throughout the world across all regions and income levels. TS was most heavily used in sub-Saharan Africa the United States, and the United Kingdom. While the economic constraints on health systems in sub-Saharan Africa are substantially greater than in the US and the UK, all these regions regardless of budget may use ACs as surgical and anesthetic providers to fill a human resource gap that would otherwise
Conclusion
TS is used to augment the global surgical, obstetric, and anesthetic workforce across all geographic regions and income groups. Independent practice among ACs in anesthesia was found to be highly prevalent in LMICs but was rarely reported among HICs. Data on supervision of AC-provided surgery were also scarce. Further research is required to evaluate the effect of supervision on patient outcomes, especially for health systems where supervision is less robust. Future research might also include
References (33)
- et al.
Global access to surgical care: a modelling study
Lancet Global Health
(2015) - et al.
Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development
Lancet
(2015) - et al.
Non-physician clinicians in 47 Sub-Saharan African countries
Lancet
(2007) - et al.
Physician Assistants—a solution to wait times in Canada? Healthcare management forum / Canadian College of Health Service Executives = Forum gestion des soins de sante /
College canadien des directeurs de services de sante
(2007) - et al.
The scale-up of the surgical workforce
Lancet
(2015) - et al.
Global surgical and anaesthetic task shifting: a systematic literature review and survey
Lancet
(2015) - et al.
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement
Journal of Clinical Epidemiology
(2009) - et al.
Initial audit of a basic and emergency neurosurgical training program in rural Tanzania
World Neurosurgery
(2010) - et al.
Task shifting and sharing in Tigray, Ethiopia, to achieve comprehensive emergency obstetric care
International Journal of Gynaecology and Obstetrics
(2011) - et al.
Countries where anesthesia is administered by nurses
AANA Journal
(1996)
A cost-effectiveness study of caesarean-section deliveries by clinical officers, general practitioners and obstetricians in Burkina Faso
Human Resources for Health
Rural general practitioner surgeons in Australia
ANZ Journal of Surgery
Meeting the need for emergency obstetric care in Mozambique: work performance and histories of medical doctors and assistant medical officers trained for surgery
BJOG
World Health Organization., PEPFAR, UNAIDS. Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines
Composition of the anaesthesia team: a European survey
European Journal of Anaesthesiology
Anaesthesia workforce in Europe
European Journal of Anaesthesiology
Cited by (33)
Cost-Effectiveness Analysis of Inguinal Hernia Repair With Mesh Performed by Surgeons and Medical Doctors in Ghana
2022, Value in Health Regional IssuesCitation Excerpt :The IPQ is a 7-level scale in which a score of 1 represents no pain, 2 to 3 indicates mild pain that does not interfere with daily activities, 4 to 5 indicates pain that is moderate and debilitating, and 6 to 7 represents severe pain, which prevents daily activities completely.39 Disability weights (DWs) were determined by matching the IPQ score for each patient with DWs used for inguinal hernia in the Global Burden of Disease Study 2017 (Table 221,22).40 Patients with no pain preoperatively were assigned a DW of 0.011 as we considered the presence of the hernia a disability.
The development and evaluation of a nurse anaesthesia model for practice in South Africa
2022, International Journal of Nursing SciencesCitation Excerpt :In South Africa, there is currently no professional nurse anaesthetist registration where a nurse is permitted to independently provide anaesthesia services to patients [2–5]. There is a severe shortage of surgery, obstetrics, and anaesthesia providers in low- and middle-income countries like South Africa [6,7]. There is an average of 1.36 physician anaesthesia providers per 100,000 population in Africa.
Keep it simple – Effective training in obstetrics for low- and middle-income countries
2022, Best Practice and Research: Clinical Obstetrics and GynaecologyCitation Excerpt :Both pre- and in-service training can contribute to task shifting/sharing which has been successfully implemented in many LMIC. Examples include the uptake and performance by nurses/midwives of tasks usually performed by medical doctors and the ability of mid-level providers to carry out obstetric surgery including caesarean sections (CS) [22,36,37]. Strengthening the performance of health systems depends on more than just increasing the numbers of health workers, actions for assessing and strengthening their recruitment, distribution, retention, and productivity are also important.
Increasing access to pediatric surgical care: Assessing district hospital readiness in rural Rwanda
2024, World Journal of Surgery