Table 3 Potential intended and unintended effects of task shifting for HIV on the health system as a whole
Effect | Sub-system involved |
|---|---|
Health outcomes | |
Better adherence to treatment and reduced loss to follow up[11]. | Service delivery |
Good clinical outcomes and better survival rates [11]. | Service delivery |
Crowding out of other services where health workers or facilities shift their attention to the new tasks [20, 21]. | Service delivery; HRH; Health information |
Supply side | |
Staff burnout due to workload, for example, due to maldistribution of trained health workers, or additional time to fill HMIS records [20, 22]. | HRH; Governance; Health information |
Lack of motivation or staff turnover due to lack of incentives (financial or non-financial) for staff to expand their role [21–23]. | HRH; Financing; service delivery; Governance |
Staff turnover due to lack of career path (e.g., promotion or certification of acquiring the new skills) to address motivation and retention [12]. | HRH; Governance |
Low performance due to selecting health workers (for the training) who are not motivated or interested in the strategy [12]. | HRH; Governance; service delivery |
Job satisfaction due to acquiring new skills and responsibilities. | HRH |
Tension within health teams about roles and responsibilities and hierarchies, especially with newly developed health cadres [11]. | Governance; HRH |
Staff lack of confidence in performing additional tasks due to insufficient training or supportive supervision. | Governance-HRH-service delivery |
Staff insecurity when staff do not have legal backing for the additional tasks, impeding them from taking new responsibilities [7, 23]. | Governance; HRH |
Professional protectionism due to concerns for being undermined [7, 11, 23, 24] | Governance; HRH |
Staff frustration due to unavailability of medicines and supplies for diagnostic tests. | Medicines and technology; HRH; Governance; health information |
Cost implications due to the required supportive supervision and need for new or refresher training to ensure good quality care [7, 11, 22, 25]. | Financing; HRH |
Inefficiencies and poor performance due to over referral, higher use of resources (ordering more lab tests) or lower productivity (longer consultation time) [7, 11]. | Financing; service delivery; HRH |
Efficiencies through saving time of senior staff to spend on non-HIV patients or HIV patients with complications and increased utilization at same costs [11]. | Financing; HRH; service delivery |
Implications on financing of health care due to top up of salaries or hiring new cadres. | Financing; HRH |
Demand side | |
Better services for patients due to immediate attention, longer consultation including counselling [7]. | Service delivery; HRH |
Patient satisfaction due to reduction in waiting time [11]. | Service delivery |
Better access to HIV services due to services close to home [11]. | Governance; Service delivery |
Inequitable access to HIV care if plans to scale up are not well distributed or do not target remote and rural areas. | Governance; Service delivery |
Implications on financing of health care due to change in out of pocket expenditures [26]. | Financing |