Elsevier

Surgery

Volume 164, Issue 3, September 2018, Pages 553-558
Surgery

Global Surgery
Global surgical, obstetric, and anesthetic task shifting: A systematic literature review

https://doi.org/10.1016/j.surg.2018.04.024Get rights and content

Abstract

Background

Five billion people lack access to safe, affordable, and timely surgical care; this is in part driven by severe shortages in the global surgical workforce. Task shifting is commonly implemented to expand the surgical workforce. A more complete understanding of the global distribution and use of surgical, obstetric, and anesthetic task shifting is lacking in the literature. We aimed to document the use of task shifting worldwide with a systematic review of the literature.

Methods

We performed a systematic review of 10 health literature databases. We included journal articles published between January 1, 1995, and February 17, 2017, documenting the provision of surgical or anesthetic care by associate clinicians (any non-physician clinician). We extracted data for health cadres performing task shifting, types of tasks performed, training programs, and levels of supervision, and compared these across regions and income groups.

Results

We identified 55 relevant studies, with data for 52 countries for surgery and 147 countries for anesthesia. Surgical task shifting was documented in 19 of 52 countries and anesthetic task shifting in 119 of 147. Task shifting was documented across all World Bank income groups. No associate clinicians were found to perform surgical procedures unsupervised in high-income countries (0 of 3 countries with data). Independent anesthesia care by associate clinicians was noted in 3 of 19 countries with data. In low-income countries, associate clinicians performed surgical procedures independently in 2 of 3 countries and independent anesthesia care in 17 of 17 countries with data.

Conclusion

Task shifting is used to augment the global surgical, obstetric, and anesthetic workforce across all geographic regions and income groups. Associate clinicians are ubiquitous among the global surgical workforce and should be considered in plans to scale up the surgical workforce. Further research is required to assess outcomes, especially in low-income and middle-income countries where documented supervision is less robust.

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

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