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WHO Guidance on Task-Shifting
A Global Advocacy Case Study
One of the guiding principles behind task-sharing is that no one health provider, or one cadre of providers, can do it all. Allowing a wider range of cadres to offer certain services, when this can be done safely and effectively, is an important way to expand access and improve health care, particularly for rural populations.
Clear and comprehensive guidance from the World Health Organization (WHO) will go a long way in breaking down resistance in many countries to allow more task-sharing for family planning; it has already done so in the area of HIV testing and treatment. After an impressive consultative process in early-to-mid 2012 and coordinated advocacy efforts by the Resource Mobilization and Awareness Working Group (RMAWG), which includes Northern and Southern partners of the Advance Family Planning (AFP) initiative, family planning guidance became a reality when WHO published task-sharing guidelines for maternal and newborn health (MNH) in December 2012. Just as health care cannot be provided by a single health worker, bringing about this change was a shared, group effort. This story shows the power of a unified voice, and how it can lead to greatly expanded access to family planning for women throughout the world.
Task-sharing for family planning
Task-sharing has received increased attention in light of the human resource challenges in health care. However, it is much more than a temporary, emergency response. Rather it is something that any health system should consider for rational health care and efficient use of resources. And it is essential in order to expand access to hard-to-reach and rural populations. One of the barriers encountered by family planning service delivery programs is the fact that many services are restricted to doctors only. A recent Reproductive Health Supplies Coalition (RHSC) report noted that when over 150 partners from 26 countries were asked to identify three main barriers to meeting the unmet need for family planning at the country level, lack of task-sharing was one of the most frequently mentioned [Compernolle and Usher Patel, 2012].
There is a good deal of evidence and experience about the safety, acceptability, and effectiveness of task-sharing for family planning, but this has not been compiled in one place, covering all types of services and the full range of medical cadres. In addition, there is still resistance in many countries, particularly from medical associations and resource-poor government agencies where community health worker programs are not a priority. Comprehensive guidelines from WHO are seen as essential to move things along at the country level: “These changes at the global level help us get traction at the national level,” explains one person involved in these issues in Uganda. “When one is able to quote WHO guidelines in our advocacy, it really helps.” National medical associations tend to be obstacles to task-sharing, but these groups do tend to listen to WHO. As one person stated, “It is rare that they will publicly disagree with WHO best practices.”
Getting good guidelines
The RMA Working Group (RMAWG) developed a more strategic approach and plan for its advocacy efforts in 2011. During this process, they identified task-sharing as a key issue to address. Co-chair of the working group, Leo Bryant, was particularly interested because of the service provider perspective of his institution, Marie Stopes International (MSI), and the RMAWG provided a means to talk about it as part of a wide consensus rather than a solo voice. A group of RMAWG members contacted WHO and found that they were planning to develop guidelines for task-sharing, looking broadly at MNH interventions within the OptimizeMNH project (www.optimizemnh.org). Initially the project planned to include only contraceptive injectables; however, through continued dialogue, there was agreement that this was an opportunity to address task-sharing for family planning comprehensively. Rather than having recommendations for different methods scattered throughout different documents, there would be one definitive resource.
The RMAWG played an important role in the WHO-led evidence review and consultation through its convening power and links to technical expertise. Through its membership and connections and its mailing list, they were able to quickly gather together a group of several agencies with expert experience and evidence from the field. This included representation from FHI360, Population Services International, Pathfinder International, Population Council, IntraHealth International, JHPIEGO and others. Importantly, the AFP initiative had some seed money to initiate development of the guidance within WHO. Leo Bryant, who led the RMAWG effort, explained, “We were speaking as a community with one strong voice. The ability to represent inter-agency consensus in the RHSC on this issue, rather than speaking as just one agency, carried a lot of weight.”
Acting as a coordinated group also helped greatly during the evidence review phase. The technical advisors and RHSC were able to coordinate the evidence submitted. AFP and Population Action International (PAI) provided necessary resources for a consultant, identified by WHO, to review the evidence and to provide modest travel funds related to the consultation. Agreeing on what evidence to include was a significant challenge. Standard WHO procedure is to focus on randomized controlled trials. However, much of the evidence that exists is a result of less rigorous operations research and the fact that task-sharing has been implemented for different cadres by many countries at scale for many years. In the end, consideration of large-scale national programs, as suggested by RMAWG members and others, was part of the evidence review. The lesson of agreeing on other ways to grade and include evidence is important to keep in mind in future development of guidelines and standards. As one expert explained, “otherwise you end up throwing out programmatic evidence and falling back on expert opinion, then you rely on expert opinion which often comes from that very programmatic evidence that you’ve thrown out.”
This all led up to the consultation, which happened in two separate meetings at WHO. The first covered maternal and newborn health interventions and took place in April 2012. WHO and partners decided to hold a separate meeting in June to develop the guidelines for family planning. This worked out well as it allowed a smaller group with extensive expertise in family planning specifically to develop detailed guidelines. There was quite a lot of debate over the details, but in the end participants agreed they produced a good, comprehensive product. As one person involved in the consultation explained, “the outcome of the meeting was everything we could have hoped for.” After the meetings, the group continued to act together to give input to the wording of the guidelines so that task-sharing would be represented as a logical health system intervention rather than an act of crisis management. Leo Bryant explained, “When we submitted comments, acting en masse lent much more credibility and weight to what we sent in.”
Getting the guidelines used
Developing strong, comprehensive guidelines for task-sharing for family planning—with the stamp of approval of WHO—is a significant success. But what matters now is translating this document into actual increased access. Essentially, this was advocacy to produce a powerful tool for decision-makers, service providers, and advocates, a tool that must now be promoted and used.
It will be important to keep people engaged, to not feel as if the work is done now that the guidelines are developed. “There has to be an accompanying plan to push it because there is so much resistance out there,” explained one expert. The RMAWG is a great forum to develop that plan and get donor and country-level interest. The informal group of experts that was formed during the guidelines’ development process is well-placed to work with the RMAWG and their own agencies to move this forward.
What needs to happen? The guidelines are a large document. Advocates and others will need to continue to work with WHO to ensure that a pull-out family planning section is produced and promoted. This will serve as both a user-friendly job aid as well as a tool to promote necessary policy changes. Advocates can use this tool to open up discussions at the global and country level.
Who are the target audiences? At the global level, there will be a need for wide dissemination, via major conferences, list servs, and online discussion forums. Global service delivery and technical assistance agencies should consider taking the guidelines and personalizing them to show how to implement them within their respective organizations. WHO should present these guidelines at its regional meetings and through its country offices. Since obstetricians are often resistant to task-sharing and the family planning guidance, it could also help to have the International Federation of Gynecology and Obstetrics (FIGO) help market the guidelines. In addition, professional organizations for other health cadres, including nurses and midwives, will be essential partners in these efforts.
At the national level, there will need to be work with Ministries of Health. One approach that has been successful is to have exchanges where MOH staff from one country visit other countries to see firsthand the realities of successfully implementing task-sharing efforts. It would good to encourage Ministries of Health (MOHs) to take more of a leadership role. One way to achieve this is to gather MOH staff together at regional conferences and meeting to discuss issues and develop plans; “When you get Ugandan, Kenyan, and Rwandan Ministries together in a peer process, it goes a long way.”
One of the challenges will be to adapt the guidelines to local contexts. During development of the guidelines, there was an underlying challenge of the lack of a uniform definition of a community health worker, which will complicate having clear guidance for implementation. In addition, there are a number of qualifying phrases used in the guidelines, such as referring to providers as “when appropriately trained” or recommending a practice “with targeted monitoring and evaluation.” Some of this will be easier to understand with efforts to differentiate the recommendations in a clear, graphic way using an interactive web-based tool, but it is likely that technical assistance will be needed to provide clarity and tailoring for different countries.
Who should do the advocacy? The RMAWG, AFP, other initiatives and coalitions have a key role to play in developing a coordinated strategy with Southern advocates and providers to promote and utilize the guidelines. Linking global advocacy gains to national-level opportunities will be critical in strengthening country ownership of the family planning agenda in the future. A range of partners should be involved in these efforts, including service delivery organizations, technical assistance agencies, UN agencies, and civil society organizations.
Finally, it is important to view task-sharing in the larger health care context. Task-sharing is important and useful, but significant improvements to the overall human resources situation and national investments in health are imperative.
Four main factors led to this advocacy success, and all four have implications for other advocacy efforts:
- Importance of a coordinated, unified voice from a highly respected group of technical agencies and service providers: “working as a group goes a lot further.”
- Evidence supporting safety, effectiveness and acceptability was a necessary but not sufficient part of this successful advocacy effort.
- Having the convening power to make this happen: Having the AFP and the RMAWG supporting this effort empowered its members to come together and be a persuasive voice with WHO.
- Having the resources to turn it into action: Advocacy needs money, and a little bit of money for advocacy goes a long way. This effort required fairly minimal resources from AFP and PAI, but the outcome of this could be globally significant, potentially leading to thousands of women with greater family planning access for every country that implements more task-sharing.
Interviews with Angela Akol, FHI 360, Uganda; Leo Bryant, Marie Stopes International; Lou Compernolle, Reproductive Health Supplies Coalition; Baker Ndugga Maggwa, FHI 360; John Stanback, FHI 360
Compernolle, Lou and Maggie Usher Patel. 2012. Family Planning Access for All: Policy Change for Action and Accountability – A catalyst for discussion. Reproductive Health Supplies Coalition.
World Health Organization (WHO). 2012. From Evidence to Policy: Expanding Access to Family Planning - Optimizing the health workforce for effective family planning services. Policy brief. WHO/RHR/HRP
World Health Organization (WHO). 2012. WHO recommendations for optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting (Optimize 4MNH). Draft. WHO.
This brief was prepared by Julie Solo, with support from AFP and PAI. AFP is an initiative within the Bill and Melinda Gates Institute on Population and Reproductive Health in the Johns Hopkins Bloomberg School of Public Health. AFP is supported by the Bill & Melinda Gates Foundation, the David and Lucile Packard Foundation and the William and Flora Hewlett Foundation.