This study set out to explore perceptions of managers and frontline health workers on surgical task shifting across fifteen districts at 24 sites in Uganda. We found surgical task shifting was largely supported, although not without reservation. In any case, it was taking place at all the facilities we visited to some extent, even in the absence of guiding Ministry of Health policy.
Respondents largely understood the concept of surgical task shifting to include the passing on or delegation of a specified role from an appropriately-trained person in a higher cadre to a less-trained or less experienced cadre in the context of shortage of health workers. There were a few who did not grasp the meaning of the term and suggested it included referral from a higher level facility to a lower level facility in the context of lack of space, facilities or personnel at that particular time. There is no official policy framework that articulated the position of surgical task-shifting at the national level. At the global health level, WHO has issued guidelines encouraging appropriate delegation of tasks to lower cadre where it is safe and reasonable .
Even though surgical task shifting was largely supported, some respondents in our study said they often felt exposed or vulnerable when asked to take on tasks that are not in their legal scope of practice, especially in a situation where things could go wrong and result in a lawsuit or job dismissal. In the absence of regulation, some respondents said some clinical officers may abuse the practice by carrying out procedures away from their primary work stations where supervision is not possible. Further, the lack of policy may mean facility staff are asked to take on extraordinary tasks without the concomitant recognition or appropriate reward or job protections. These factors contribute to resistance to task shifting.
Resistance to task shifting occurs in settings where there is a lack of supervision and regulation. Lack of supervisor support leaves those engaging in task shifting with less on-site training for skill development. Some also expressed a sense of injustice; the officers delegating work get their time freed to go on to do other duties that may be more financially rewarding to them at the expense of the persons to whom less desirable tasks are delegated.
Other respondents worried the lack of proper documentation of these quasi-legal task-shifting operations leads to poor processes and outcomes. Efforts to formalize, and track task shifting must not only involve undertaking prospective studies but should also aim at improving the current health management information system to increase emphasis on surgical data collection.
Nearly all respondents acknowledged the need to meet the demand for surgical services that outpaces the capacity of health personnel whose scope of services clearly includes surgical procedures. Table 2 gives the sense of the scope and frequencies of procedures encountered in these study sites. There is recognition that other countries in the region, including Malawi, Mozambique and Tanzania, have had success with the practice [12–16].
There is recognition that other countries in the region, including Malawi, Mozambique and Tanzania, have had success with the practice [12–14]. Health workers in Uganda, however, pointed to a lack of country-specific evidence that surgical task shifting is feasible, sustainable and safe. There is also a lack of documentation of the surgical burden of disease in Uganda .
In all the facilities we visited, workers tended to support formalizing, supporting and scaling up surgical task shifting. Their recommendations are similar to those found by previous researchers; [9, 17, 18] that is, the long term success of task shifting hinges on serious political and financial commitments. These include a revised compensation scheme, reconfiguration of health teams, changed formal scopes of practice, regulatory frameworks and enhanced training infrastructures. The requirements articulated by the study participants as essential for moving task shifting forward to make it formal and safe.
What is clear is that surgical task shifting is currently practiced widely, even in the absence of regulation. Practitioners conceal the practice for fear of legal and professional consequences in the event of a poor outcome. Other barriers include lack of motivation to take on the extra load, poor work environments and a lack of space and equipment. These barriers have been articulated before, yet it is critical to pay attention to them .
The study demonstrates a willingness by managers and clinicians to formally embrace surgical task shifting with the caveats stated. This willingness is aligned with the realities Uganda faces, in the setting of a population of 33 million people with only 100 specialist surgeons who are mostly found in referral hospitals. Surgeons are rarely located in the rural communities where the majority of the population lives. Access to specialist care is further impeded by geographical distance, lack of appropriate means of transport and a mal-functioning referral system.
Limitations of our study
The study sample represents only health facilities along the East-Central axis of the country. Due to logistical constraints, it was not possible to include informants from other parts of Uganda. Two sites visited did not have functional theatres at the time of the visit.
No reliable data on the safety of surgical task shifting was available from the facilities we visited. Uganda needs a well-designed prospective study in selected sites to establish the efficacy and safety of surgical task shifting. Considering that focus groups had different cadres participating in the same discussions, (juniors and their supervisors), some respondents could have withheld what would have otherwise been key or sensitive information for fear of negative consequences that could occur after the discussions.
In some instances focus group discussions we were interrupted by theatre staff being called to attend to emergencies cases.
Only one focus group discussion was conducted in each site.
We recommend the Ministry of Health engage all stakeholders in developing formal surgical task shifting policy guidelines. The policy should address barriers such as resistance from health professionals, low salaries, and poor working conditions. Training and close supervision should be provided to all personnel who are asked to perform surgical procedures for which they did not receive pre-service training. The nation's health management information system should closely monitor who performs surgeries and what the outcomes are. All health personnel should receive health insurance coverage. As surgical task shifting is a response to a weak and understaffed health system, we recommend strengthening health system infrastructure, including workforce. This would include reducing workload, improving recruitment and retention through salary improvements, and improving working conditions. It would be helpful to Uganda and other low-income country settings to document successful examples of surgical task shifting.