Human resources for health (HRH) is an essential health system pillar according to the World Health Organization (WHO) Health System Building blocks, and the WHO advises health systems have adequate HRH engaged in service delivery to improve population health (1). To attain the Sustainable Development Goals (SDGs), the WHO recommends a health workforce density of 44.5 doctors, nurses and midwives per 10,000 population (2). However, there is a chronic shortage of health workers globally; the Global Strategy on Human Resources for Health: Workforce 2030 reports an estimated global needs-based shortage of over 17 million health professionals, including over 9 million nurses and midwives and 2.6 million physicians, and the remainder includes all other health worker cadres. The greatest shortages are in regions with the highest unmet health needs, such as South East Asia and sub-Saharan Africa (2).
Nurses and midwives represent the largest group of health professionals and account for approximately half of the global HRH shortage (3). According to WHO estimates, the global nursing and midwifery workforce shortage will reduce from 9 million to 7.6 million by 2030 (2). While the global nursing workforce is expected to grow, the nursing and midwifery shortage in Africa is estimated to worsen from 1.8 million in 2013 to 2.8 million in 2030 (4). This outcome will limit access to healthcare services in the regions most adversely affected, thus, prompting health systems in LMICs to focus on alternative strategies.
The chronic HRH shortage challenging health systems makes it difficult to provide universal HIV services, attain the SDGs, and enhance population health. The global burden of disease is increasing as populations are living longer (5). Additionally, low and middle income countries (LMICs) are facing the double-burden of infectious diseases and rising prevalence of non-communicable diseases, leading to an increased demand for access and provision of health services (6). The existing HRH in LMICs, however, is not adequate to meet this increasing demand.
Kenya is not exempt from the global HRH crisis; while there are efforts in place to scale up the national health workforce, the number of active healthcare workers remains far below the current WHO recommendations. As reported in the Kenya Health Workforce Report, there is a total of 53,118 active doctors, clinical officers, and nurses and midwives; thus, the health worker to population ratio in the country is 13.8 providers per 10,000 individuals in the nation’s population (7). This ratio is less than one third the WHO critical threshold recommendation of 44.5 providers per 10,000 individuals. Similar to most LMICs, Kenya’s health workforce is largely comprised of nursing professionals who provide a majority of healthcare services to the population. The nurses, however, are overburdened as there are only 8.3 nurses per 10,000 population compared to WHO’s recommendation of 25 nurses per 10,000 population (7). Given Kenya’s critical shortage of health workers, optimization of task sharing with its health workers cadres (Appendix B) may promote efficient delivery of health services.
Kenya’s nursing workforce is affected by a variety of factors. A significant contributor to the depletion of Kenya’s nursing workforce is outmigration with an estimated 6% of the nursing workforce applying to out-migrate (8). Another growing concern is the rising rate of pre-service attrition between enrollment in a training institution and registration with the nursing council. Pre-service attrition of Kenyan nurses doubled from 4.3% in 1999 to 8.2% in 2004. This is due in part to onerous faculty workloads and insufficient clinical mentorship for students (9) .
Kenya has made strategic investments to scale up the nursing workforce, including increasing the national capacity to train nursing professionals by focusing on the expansion of nurse training institutions. This approach led to a 32.5% increase in the number of nursing schools, from 77 to 102 between 2006 and 2015 (7). This expansion subsequently led to increased student enrollment into nursing programs, either as new entrants or advanced practice (7). Additionally, the United States President’s Emergency Plan for AIDS Relief (PEPFAR) has supported training for thousands of health workers (10). Despite these investments, the healthcare workforce shortage has remained persistent.
While increasing the number of nurses has contributed to addressing the HRH shortage in Kenya, it is still not adequate to meet the needs of the health system. Like most of sub-Saharan Africa, Kenya has a large number of persons living with HIV, which has strained the healthcare system and its workforce. In 2016, there were 1.6 million people living with HIV, 62,000 new infections, and 36,000 AIDS-related deaths (11). Kenya’s HIV prevalence rate is 5.9%; however, some regions have disproportionally higher rates than the rest of the nation. For example, Homa Bay, a county in rural Western Kenya, has a HIV prevalence rate of 26%, which is almost 4.5 times the national HIV prevalence rate (12, 13). The HIV rates in Kenya’s Western region are comparable to eSwatini (formerly known as Swaziland), which is known to have the highest rates of HIV in the world at 27.4% (14).The model of physician run clinics, common in High Income Countries, is not feasible for Kenya and other LMICs, given the scarcity of physicians, and health systems have sought other approaches to delivering HIV care, treatment for other illnesses, as well as health promotion and disease prevention services (15).
In light of the global disease burden, HIV pandemic, and critical shortage of trained health workers, the WHO released guidelines on task shifting as one approach to address HRH concerns and increase access to HIV care and other health services. According to WHO, task shifting is “a process whereby specific tasks are moved, where appropriate, to health workers with shorter training and fewer qualifications”(16). If implemented appropriately, task shifting is intended to improve health care coverage by utilizing more widely available cadres, such as nurses and clinical officers, to improve the efficiency of already existing HRH. When the WHO report was released in 2007, task shifting was a recommended solution to reaching the difficult to attain Millennium Development Goals for health and to achieve universal access to HIV services. Over time the terminology evolved to task sharing and was formally introduced in the scientific literature by the Institute of Medicine (IOM) in 2010. The IOM introduced the concept of task sharing as a strategy for capacity building, prevention, treatment, and care of HIV/AIDS in Africa. Task sharing addresses bottlenecks in the delivery of health services through efficient use of existing HRH, whereby “physicians, nurses, dentists, and other health professionals delegate health care responsibilities and relevant knowledge to others, including community health workers” (17). In addition to encouraging collaboration, the IOM recommended that task sharing focus on the clear delegation of roles and promotion of competency-based training for health workers taking on new tasks.
Task shifting and task sharing are used in a variety of public health settings to meet the demand for health services and address workforce shortages. Although WHO recommended formal task shifting in the context of addressing the HIV epidemic, its application was extended to address other areas such as maternal and newborn health care (18) using WHO’s maternal and newborn task shifting guidelines (19). Other areas where task shifting has been implemented include reproductive health (20) and tuberculosis care (21). The use of task sharing as a model of delivering care is gaining popularity in under-resourced regions (21). However, implementation has often been informal and established organically to adapt to HRH shortages (22). Task sharing is used widely in sub-Saharan Africa, increasing access to healthcare services, and yielding positive health outcomes (23, 24). However, despite the benefits of task sharing, and its informal but widespread use in Africa, there is a scarcity of evidence documenting the process of developing and implementing task sharing guidelines. Guidelines and policies are needed to facilitate the process of task distribution to alleviate the workforce burden among health workers in an organized and systematic manner.
In 2015, Emory University, in collaboration with the Kenya Ministry of Health (MOH), the U.S. Centers for Disease Control and Prevention (CDC), and PEPFAR sought to advance task sharing to promote equitable access to universal health coverage (UHC), including HIV services at the national, county, sub-county and community levels in Kenya. Early in this process, the MOH partnered with several institutions to establish the initial advisory committee overseeing the development of the 2017–2030 Kenyan Task Sharing Policy and Guidelines (TSP) (25). The goals of the TSP were to improve the utilization of human and financial health resources by: (i) Establishing a comprehensive national framework for task sharing, (ii) Equipping health workers with relevant knowledge, skills, and competencies, (iii) Ensuring the delivery of quality health services by all health workers and (iv) Allocating resources to sustain task sharing implementation, monitoring and evaluation. As stated in the Kenya Task Sharing Policy, it is intended to “facilitate enhanced quality service delivery in Kenya through the implementation of an integrated task sharing framework, improving access to essential health services, including HIV/AIDS prevention, care and treatment” (20, 26). This article describes the development process of the Kenya TSP.