SUMMARY BRIEF
Task sharing to improve access to Family Planning/Contraception
Summary information Problem: Poor access to family planning services due to inadequate numbers of health workers or their uneven distribution
RECOMMENDATIONS ON FAMILY PLANNING RELATED TO CADRES OF PROVIDERS • The WHO recommends that family planning services and methods can be safely and effectively provided by different health worker cadres, under specified circumstances. • Community health workers can safely and effectively provide the following contraceptive services: education and counselling, information on SDM, 2Day Method, and LAM; oral contraceptives and condoms; and hormonal injectables, under targeted monitoring and evaluation. • Auxiliary nurses and auxiliary nurse midwives can safely and effectively provide education and counselling, information on SDM, 2Day Method, and LAM, oral contraceptives, condoms, hormonal injectables, and contraceptive implants; and (for auxiliary nurse midwives) IUDs. • Nurses and midwives can safely and effectively provide education and counselling, information on SDM, 2Day Method, and LAM, oral contraceptives, condoms, hormonal injectables, contraceptive implants, and IUDs. • WHO recommends further research on the safety and effectiveness of nurses and midwives delivering tubal ligation and vasectomy. • Operators of retail outlets such as drugs shops and pharmacies and can safely and effectively provide contraceptive services commensurate with their clinical qualifications according to the cadres listed in this document.
Option: Enabling additional cadres of health workers to provide family planning services through competency-based training
Comparison: Method delivered by other ‘higher’ clinical cadres or no method delivered
Setting: Lower level and community/primary health care settings
Benefits of task sharing of contraceptive services: • Offering contraception through a wide range of providers enables access and availability • Evidence and experience support that various types of providers can safely and effectively provide contraception • Sharing routine tasks with lower level cadres allows higher cadre clinicians more time to use their specialized skills. • Access to contraception is part of a comprehensive sexual and reproductive health and rights package for women and men • Policies are enforced to allow effective use of defined skills and competencies of the health workforce
Background Globally, governments, civil society, multilateral organizations, donors, the private sector, and the research and development community have committed to enable 120 million more women and girls to use contraceptives by 2020. Furthermore, the Sustainable Development Goals (SDGs) aim to meet 75% of the global demand for contraception by 2030. To meet these goals, national programs will need to bring together many components, including social and behavior change, a gender and rights perspective, commodities, and quality service provision by adequately trained health providers. However, in many countries, the numbers of properly trained health providers are not sufficient to address the need for contraception , and their distribution can mean women living in remote or hard to reach areas may lack access. Human resource shortages in the health sector are widely acknowledged as threats to the attainment of health related Sustainable Development Goals (SDGs). Contraception is an inexpensive and cost-effective intervention, but health workforce shortages and restrictive policies on the roles of midand lower-level cadres limit access to effective contraceptive methods in many settings. Expanding the provision of contraceptive methods to other health worker cadres can significantly improve access to contraception for all individuals and couples. Many countries have already enabled mid- and lower-level cadres of health workers to deliver a range of contraceptive methods, utilizing these cadres either alone or as part of teams within communities and/or health care facilities. The WHO recognizes task sharing as a promising strategy for addressing the critical lack of health care workers to provide reproductive, maternal and newborn care in low-income countries. Task sharing is envisioned to create a more rational distribution of tasks and responsibilities among cadres of health workers to improve access and cost-effectiveness. The WHO recommendations on task sharing FP services are based on the identified priority questions and critical outcomes, and the retrieval, assessment and synthesis of evidence. These are presented in the two documents: Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting (published in December 2012) and Health worker roles in providing safe abortion care and post-abortion contraception (published in July 2015), both of which have recommendations on task sharing for contraceptive services by different cadres. These guidelines documents made 48 recommendations on which contraceptive methods can be delivered safely and effectively by various health worker cadres.
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Task sharing to improve access to Family Planning / Contraception
The processes of enabling additional cadres to provide a specific health intervention is referred to here as ‘task shifting’ and ‘task sharing’, which are defined below:
distribution of tasks among health workforce teams. Specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications to make more efficient use of the available human resources for health. Reorganizing the workforce in this way through task shifting usually presents a viable solution for improving health care coverage by making more efficient use of the human resources already available and by quickly increasing capacity while training and retention programmes are expanded. http://www.who.int/healthsystems/TTRTaskShifting.pdf?ua=1
Task shifting – refers to a process of delegation or rational
providers who can appropriately deliver health services. The term is used to emphasize the common performance of the entire clinical task, or key components of it, among teams of different cadres of health workers. Tasks are not taken away from one cadre and given to another, but rather that additional cadres are given the capacity to take on identified tasks. Task sharing enables this expansion to lay and mid-level healthcare professionals – such as nurses, midwives, clinical officers and community health workers– to safely provide clinical tasks and procedures that would otherwise be restricted to higher level cadres. It can be a vital strategy in overcoming the shortage of higher level providers in many settings. Even in well resourced health systems, task sharing can offer a means of providing services more efficiently, more cost effectively and in a less medicalized environment. http://www.ghspjournal.org/content/3/3/327
Task sharing – refers to an expansion of the levels of health
They both reflect the same intention – to include cadres who do not normally have competencies for specific tasks to deliver them and to thereby increase levels of health care access. Both emphasize the need for training and continued educational support of all cadres of health workers in order for them to undertake the tasks they are to perform. The recommendations stated in this document generally would apply to task sharing or task shifting programmes.
Summary Brief
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Cadres of health workers included in the Task Sharing Guidelines The health worker types considered in the guidelines are described in Table 1. The descriptions draw on a variety of sources including definitions used in the OptimizeMNH task-shifting guideline (1), and Health worker roles in providing safe abortion (2) and other WHO publications (3–8). Descriptions have been adapted to be generic enough to apply across settings (see Annex 1). They are indicative and illustrative and are not intended to substitute formal definitions of professional bodies or those used in specific countries and are not official WHO definitions.
Table 1. Summary table of cadres included in task shifting/sharing guidelines Health Worker Type Specialist doctor Non-specialist doctor Advanced associate and associate clinician Midwife Nurse Auxiliary nurse midwife (ANM) and auxiliary nurse Doctor of complementary systems of medicine (mainly in South Asia) Pharmacist Pharmacy worker Lay health worker User / self
Illustrative examples Gynaecologist, obstetrician Family doctor, general practitioner Assistant medical officer, clinical officer, medical licentiate practitioner, health officer, physician assistant, surgical technician, non-physician clinician, medical assistant, nurse practitioner Registered midwife, midwife, community midwife, nurse-midwife Registered nurse, clinical nurse specialist, licensed nurse, BSc nurse Auxiliary midwife, auxiliary nurse, ANMs, family welfare visitor Ayush doctor, Ayurvedic physician, non-allopathic physician
Pharmacist, chemist, clinical pharmacist, community pharmacist Pharmacy assistant, pharmacy technician dispenser, pharmacist aide Community health worker, village health worker, traditional birth attendant, female community health volunteer Woman, client
There are many variations in terms and definitions used for various cadres of providers of contraception. For any report or research on task sharing or human resources in health, these standard terms can be used, based on the local context, and can provide definitions of usual standards of practice, and if possible, descriptions of the prior training and accreditation procedures, whenever applicable. This would allow some flexibility in determining which guideline recommendation to follow, and for comparability across other reports and research.
Drug shops, pharmacies and other retail outlets: Retail outlets such as drugs shops have been identified as important points of service provision in many settings, and can usually provide commodities including contraceptives. Drug shops are operated by a variety of cadres of providers for these services, ranging from physicians, nurses, midwives, pharmacists, pharmacy assistants, to lay health workers. The recommendations for providing contraception in these outlets are determined by the cadre of provider delivering the service, not the nature of the outlet.
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Task sharing to improve access to Family Planning / Contraception
Table of guideline recommendations for task sharing of contraception
FP Methods and Services Typically Offered by Cadre of Service Provider
National policies and service delivery guidelines dictate which cadres of providers can offer specific FP services. The chart below shows the FP methods that are typically offered by these cadres of providers based on recommendations from WHO. Pharmacy Workers Pharmacist Auxiliary Nurse Auxiliary Nurse Midwife Nurse Midwives Associate/ Advanced Associate Clinicians Nonspecialist doctors Specialist doctors
Contraceptive Service
Lay Health Workers (e.g., CHWs)
• Informed choice counselling • Combined oral contraceptives (COCs) • Progesterone-only oral contraceptives (POPs) • Emergency contraceptive pills (ECPs) • Standard Days Method and TwoDay Method • Lactational amenorrhea method (LAM) • Condoms (male & female), barrier methods, spermicides
• Injectable contraceptives (DMPA, NET-EN or CICs)
• Implant insertion and removal
R R R R R R R Recommended in the context of rigorous research Recommended in specific circumstances
• Intrauterine device (IUD)
• Vasectomy (male sterilization)
R R Recommended Considered within typical scope of practice, evidence not assessed.
• Tubal ligation (female sterilization)
Considered outside of the typical scope of practice; evidence not assessed.
Recommended against
Summary Brief
All of the recommendations above assume that the assigned health workers will receive task specific training prior to implementation. The implementation of these recommendations also requires functioning mechanisms for monitoring, supervision, and referral.
The recommendations are applicable in both high- and low- resource settings. They provide a range of types of health workers who can perform the task safely and effectively. The options are intended to be inclusive, and do not imply either a preference for or an exclusion of any particular type of provider. The choice of specific health worker for a specific task will depend upon the needs and conditions of the local context.
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Adapted from the WHO World Health Organization guidelines: Optimizing health worker roles to improve access to key maternal and newborn interventions through task shifting and Health worker roles in providing safe abortion care and post-abortion contraception.
Summary of guideline recommendations for task sharing of contraception The following lists the recommendations from the Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting (published in December 2012) and Health worker roles in providing safe abortion care and post-abortion contraception (published in July 2015).
• General counselling and sharing information on contraception • Distribution of condoms (male and female), other barrier methods. • Initiation and distribution of combined oral contraceptives, progestin only oral contraceptives, and emergency contraception • General instructions for using Standard Days Method, TwoDay Method®, and Lactational Amenorrhea • Can be provided by all cadres within their established competencies. This includes the lay health workers. No additional reviews were performed or needed. NOTES: Provision of contraception by doctors of complementary systems of medicine is recommended only in contexts with established health system mechanisms for their participation in other tasks related to maternal and reproductive health. This option is feasible and may promote continuity of care for women and can increase access in regions where such providers form a significant proportion of the health workforce. Provision of Emergency Contraception is not yet specified in these recommendations. Although emergency contraceptive pills are very safe and have few restrictions, evidence on their provision by lay health workers is lacking or has not been reviewed.
• Delivery of injectable contraceptives using a standard syringe with needle for IM injection or for subcutaneous injection • Can be provided by nurses, midwives, associate clinicians and doctors, as part of their established competencies
• Recommended that these may be provided by auxiliary nurses, auxiliary nurse midwives
• Recommended that these may be provided by doctors of complementary medicine in specific circumstances
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Task sharing to improve access to Family Planning / Contraception
• Recommended that pharmacists may provide injectable contraceptives –– Administering injections is within the typical scope of practice of pharmacists, and would require minimal additional training needs. • Recommended that pharmacy workers may provide injections in specific circumstances –– Administering injections is within the typical scope of practice for trained pharmacy workers, and thus would need minimal additional training needs. This practice could be under the direct supervision of pharmacists. • Recommended that lay health workers may provide this with targeted monitoring and evaluation –– There needs to be more rigorous evidence about the effectiveness or acceptability of lay heath workers providing injectable contraceptives in various contexts or conditions, especially when being considered for implementation and scaling up. Particular attention must be given to specific issues such as risks or harms for which little or no relevant information is available. • If to be given by the woman or client, self-injection is recommended only in specific circumstances, particularly in contexts where mechanisms to provide the woman with appropriate information and training exist, referral linkages to health care providers are strong, and where monitoring and follow-up can be ensured. NOTES: The administration of an injectable involves using a standard syringe and may be intramuscular or subcutaneous. Compact pre-filled auto-disable devices are still not widely available. For self-injection, the following are important considerations when making the self-injection option available:
++ adequate arrangements for storage and for keeping sharps safely at home; ++ training in and the provision of mechanisms for the safe and secure disposal of used injectable contraceptives (especially in settings with high HIV prevalence); ++ ensuring a way to procure injectable contraceptives on a regular basis without needing to repeatedly visit a health-care facility.
• Insertion and removal of IUDs • Can be provided by associate clinicians and doctors as part of the established competencies
• Guidelines recommend that these can be provided by auxiliary nurse midwives, nurses and midwives
Summary Brief
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R
• Guidelines recommend that these can be provided by auxiliary nurses only in the context of rigorous research
• Guidelines recommend that these can be provided by doctors of complementary systems of medicine in specific circumstances
• Guidelines do not recommend that these be provided by LHWs, pharmacists and pharmacy workers
• Insertion and removal of contraceptive implants • Can be provided by associate clinicians and doctors as part of the established competencies
• Guidelines recommend that these can be provided by nurses and midwives
• Guidelines recommend that these can be provided by auxiliary nurses and auxiliary nurse midwives under monitoring and evaluation
• Guidelines recommend that these can be provided by doctors of complementary systems of medicine under specific circumstances
• Guidelines do not recommend that these be provided by pharmacists and pharmacy workers
R
• Guidelines recommend that these be provided by LHWs in the context of rigorous research and with LHWs with higher appropriate levels of training –– This is to be determined at the country level and the research on the role of lay health workers be limited to those who deliver care within a facility with sterile conditions.
NOTES: The removal of implants can require higher and other skills than insertion, and any health worker trained to independently insert implants should also be trained in removal.
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Task sharing to improve access to Family Planning / Contraception
• Provision of tubal ligation • Can be provided by associate clinicians and doctors as part of the established competencies
R
• Guidelines recommend that when these are provided by nurses and midwives it should be in the context of rigorous research
• Guidelines considered this as outside of the typical scope of practice and competencies of lay health workers, pharmacy workers, pharmacists, and doctors of complementary medicine. The evidence was not reviewed.
• Provision of vasectomy • Can be provided by associate clinicians and doctors as part of the established competencies
R
• Guidelines recommend that when these are provided by nurses, midwives, auxiliary nurses and auxiliary nurse midwives that it should be in the context of rigorous research • Guidelines recommend against the provision by lay health workers; it is outside of their established competencies.
General implementation considerations: The option of task shifting/sharing in family planning services is recommended for consideration in the following situations or settings: • Access to services is limited by either overall shortage of health workers qualified to provide specific methods or their uneven distribution across a country or region; • There are difficulties in ensuring staff retention of higher cadres in certain settings such as rural areas; • The lower salary levels of mid- or lower-cadre health workers can reduce the budgetary cost of providing family planning services without compromising client safety; or • There is a need to free the time of higher cadre health workers so that they may better focus the provision of services requiring a higher level of technical proficiency.
Summary Brief
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Considerations for recommendations on cadres of family planning providers Maintaining quality and safety of services is paramount when implementing task shifting/sharing. The skill set for which different cadres are trained and equipped varies across countries, which means that the support structures and training required to enable a cadre to take on the provision of an additional family planning service will also vary. In some cases these changes may be minimal; while in others, more substantive training and support programmes may be necessary. In some settings, the demand for some services may be so low that task sharing may not be necessary, (e.g., for some permanent methods), but planning for other strategies like mobile services by usual providers may be an alternative. Key considerations for enabling a cadre of providers to provide an additional intervention safely include: • Initial and ongoing training requirements for both service providers and their supervisors and trainers to maintain competence and confidence; • Supplies of drugs and other commodities; • Supervisory responsibilities; • Lines of referral for management of complications; • Monitoring and evaluation systems; • Necessary changes to protocols, regulations and curricula in order to support the relevant cadre’s new scope of practice; and • Salaries or remuneration to reflect changes in the relevant cadre’s scope of practice. Health system arrangements and specific sociocultural and political system factors will shape the implementation of these recommendations in particular settings. These factors need to be considered to improve the chances of successful implementation. The following link provides programmatic recommendations that were developed for task shifting for HIV and may further provide other considerations when preparing programmes in task sharing for contraception. http://www.who.int/healthsystems/TTR-TaskShifting.pdf?ua=1
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Task sharing to improve access to Family Planning / Contraception
Key policy and programme actions on optimizing the health workforce for effective family planning services. (From HRP 12.19.) Recommended policy actions • Implement sound international and national strategies to increase the number of skilled health workers trained and allowed to provide family planning services, with specific focus on underserved areas and population groups. • Adapt WHO guidelines in developing and implementing locally appropriate task shifting/ sharing policies for family planning counselling and services. To facilitate this, the guidelines should describe a package of technical resources for dissemination and implementation, that includes new and existing job aids, counselling tools, information sheets, sample training packages and post-training support, that must be adapted to the local context. • Adopt and strengthen public–private partnerships to optimize the capacity of health workers in the non-governmental sector and to transfer skills rapidly across the health system.
Recommended programme actions • Undertake a systematic approach to standardized, competency-based training that enables health workers to provide quality family planning services, with adequate supervision and monitoring, and clear protocols for referrals. –– The WHO USAID UNFPA Family Planning Training Resource Package has been developed to be an online resource for training modules on various contraceptive methods and tools. It is available at the link below: http://www.fptraining.org. • Emphasize quality of care through counselling by all cadres of providers. All services and guidelines should be centred in a rights-based approach that respects individual needs and preferences. –– The document Ensuring human rights in the provision of contraceptive information and services: Guidance and recommendations would be useful for this action. It is available at the following link. http://www.who.int/reproductivehealth/publications/family_planning/ human-rights-contraception/en/ • Trained health workers, including community health workers, providing family planning services should receive appropriate recognition, support and remuneration.
Recommended research actions • Undertake further rigorous studies to determine the safety and effectiveness of the recommendations such as: auxiliary nurses performing IUD insertion and removal, and nurses and midwives performing male and female sterilization procedures. • Evaluate the policy and programmatic considerations for task sharing of providing emergency contraception by other cadres. • Undertake studies to evaluate the cost-effectiveness of programmes of various cadres of health providers in family planning service provision. • Carry out social science and implementation research to understand, and strengthen, the dynamics and organization of health systems and contraceptive services delivery. NOTES: A workbook on contextualising and implementing the guidelines is available at: www.optimizemnh.org/Annexes/Annex_8_Contextualizing_Workbook.pdf Summary Brief 11
References: WHO Recommendations: Health worker roles in providing safe abortion care and post-abortion contraception Geneva: World Health Organization; 2015 (http://apps.who.int/iris/bitstream/10665/181041/1/9789241549264_eng.pdf?ua=1&ua=1) WHO recommendations: OptimizeMNH: optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting. Geneva: World Health Organization; 2012 (http:// www.optimizemnh.org/, accessed 12 June 2015). Classifying health workers: mapping occupations to the international standard classification. Geneva: World Health Organization; undated (http://www.who.int/ hrh/statistics/Health_workers_classification. pdf?ua=1, accessed 12 June 2015). Technical notes – global health workforce statistics database. Geneva: World Health Organization; undated (http://www.who.int/ hrh/ statistics/TechnicalNotes.pdf, accessed 12 June 2015). Africa Health Workforce Observatory. Definitions of the 23 health workforce categories. Geneva: World Health Organization; 2007 (http:// apps.who.int/ globalatlas/docs/HRH_HWO/HTML/Dftn.htm, accessed 12 June 2015). ICM international definition of the midwife. The Hague: International Confederation of Midwives; 2011 (http://www. internationalmidwives.org/ assets/uploads/ documents/CoreDocuments/CD2011_001%20 ENG%20Definition%20of%20the%20 Midwife.pdf, accessed 12 June 2015). WHO recommendations: optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting. Annex 1: Cadre definitions used in the project. Geneva: World Health Organization; 2012 (http://www.who. int/reproductivehealth/ publications/maternal_ perinatal_health/Annex_1_Cadre_definitions. pdf, accessed 12 June 2015). Renfrew MJ, Homer CSE, Downe S, McFadden A, Muir N, Prentice T, et al. Midwifery: an executive summary for The Lancet’s series. The Lancet Series on Midwifery. Lancet. 2014 (http://www.thelancet.com/pb/assets/raw/ Lancet/stories/series/midwifery/midwifery_ exec_summ.pdf, accessed 19 June 2015). Task shifting to improve access to contraceptive methods http://www.who.int/reproductivehealth/publications/family_planning/task_ shifting_access_contraceptives/en/ (accessed 07 Feb. 17) Task Shifting: Global Recommendations and Guidelines. http://www.who.int/healthsystems/task_shifting/en/ (accessed 07 Feb. 17)
Additional information Conflict of interest: None. Acknowledgements The original summary was prepared with support from the Norwegian Knowledge Centre for the Health Services (NOKC); The Norwegian Agency for Development Cooperation (NORAD); and Marie Stopes International with partners Advance Family Planning, FHI360, Population Council and the Reproductive Health Supplies Coalition (RHSC).
For more information, please contact: Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, CH-1211 Geneva 27, Switzerland. E-mail: reproductivehealth@who.int www.who.int/reproductivehealth
WHO/RHR/17.20 © WHO 2017. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license.