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Task Shifting and Task Sharing: Understanding the Policy By Faruk Umar Abubakar Secretary General/Registrar NMCN
Date Posted: 12/May/2019
.Background to the Task Shifting and Task Sharing Policy
.Shifting and Sharing of Tasks- Observations of the NMCN
.The Way Forward
The WHO(2006) in Population Council(2017) defines task shifting and sharing as the rational redistribution of tasks among health workforce teams. This means that tasks have to be distributed in a balanced and fair manner considering the skills and competencies of the members of the healthcare team. The task shifting and sharing regime according to the policy was to be an interim measure designed not to take away tasks from any professional groups but rather to make the best use of cadres of staff currently employed and deployed to our health facilities. (TS&TS Policy 2014,p.3).
The Task Shifting and Task Sharing (TS&TS)Policy in Nigeria, was approved at the 55th National Council on Health held in Uyo, Akwa Ibom State in 2014. The Federal Government had after careful analysis noted that Nigeria’s health and development indicators are very unsatisfactory. Nigeria contributes only 2.4% to the world population but 14% to the global maternal mortality burden (WHO,2010 in TS&TS Policy,2014). One major barrier of access to essential healthcare services is shortage and misdistribution of appropriate cadres of health workforce to deliver services where they are mostly needed. Shortage of healthcare workers led to poor utilization of health facilities for essential services such as: antenatal, delivery, postnatal, infant welfare, HIV, malaria, tuberculosis care and other basic services.
The TS&TS Policy (2014,p.8), further stated as follows, the increase in numbers of some cadres-in particular nurses and midwives is not keeping pace with population growth. This was due to massive external migration.
Afolabi (2017) stated that the enabling factors for task sharing are:
.Human resources shortage in addition to inequitable distribution
.Higher number of health professionals as compared with others
.Freezing on employment due to funding constraints
.Preference for employment of lower cadres of health professionals due to available and lower remuneration packages
.The Council had observed the main problem of TS&TS Policy, was not that nurses and midwives were not being trained in large number, but embargo on employment of nurses and midwives by many states of the Federation.
.In addition even when employment of some nurses and midwives had occurred they were not posted to the Primary Health Care level with the argument that their salaries are very high. 
According to the FMOH the TS&TS Policy was developed as way of scaling up access to healthcare. The policy specifically stated that, ‘female CHEWs can be trained to provide normal delivery services and to identify and initiate the management of common complications of pregnancy and childbirth’ (TS&TS Policy 2014,p.3).
The WHO’s definition of a skilled birth attendant is aptly  captured in the policy as:
. an accredited health professional such as a doctor, midwife, nurse who has been trained to proficiency in skills needed to manage normal(uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and the newborn (TS&TS Policy,2014,19).     
. This arrangement, the policy stated would be reviewed when adequate human resources for health have been trained, employed and properly distributed particularly to rural communities and hard to reach areas. 
Observations on TS&TS Policy
The NMCN without prejudice observed the intent of the policy and has noted that with proper implementation it could contribute toward improving access to healthcare particularly in underserved communities. Notwithstanding the above, the Council has noted with concern the following:  
. In the provisions of the policy, some of the responsibilities of nurses and midwives where shifted to or share with Community Health Extension Workers (CHEWs) while medical conditions related to LSS where shared by medical doctors with, nurses and midwives. 
. Policy shared with nurses and midwives are in the area of HIV care and management of TB
. For those tasks shifted from nurses and midwives to, or shared with, CHEWs there were no express provisions that the CHEWs shall work under the supervision of the nurse/midwife. 
. For a few that the above provision was stated, in actual practice this is not the case, as CHEWs have constantly insisted that they are to be supervised by their senior colleagues or Community Health Officer.  
. The CHEWs have also received various support for capacity building in line with the TS&TS policy from the numerous Partners at the instance of the FMOH .
. Some tasks shifted to CHEWs were beyond their scope and may be detrimental to public safety particularly if they do not work under the supervisor of the original professionals who have those duties. 
. According to Berdellima (2018), this expert of USAID, noted that WHO recommended that tasks sharing of insertion of implants to CHEWs should be carefully monitored.
The Way Forward
The NMCN had already set up a Committee to study this Policy and the Council is considering their recommendations, NANNM can use this approach, because it is necessary to understand the policy first in order to  be able to make input. The Professional Association, NANNM should actively advocate for the employment and posting of nurses and midwives to Primary Health Centers by State Primary Healthcare Development Agencies, bearing in mind their enormous responsibilities in healthcare and the fact that the TS&TS arrangement was to be an interim measure.   
The NMCN and NANNM should work together to draw the attention of the FMOH to some anomalies observed in this policy in the following areas:
. Supervision: Notification of  the Federal Ministry of Health to come up with a policy document such an official circular clearly mandating nurses and midwives to supervise CHEWs of whatever cadre in the performance of the duties or tasks that were shifted from nurses and midwives to, or shared with them.
. This will ensure that quality of care is maintained and public safety guaranteed as required by the Act establishing the NMCN.  
. Some tasks shifted from Midwives to CHEWs or shared with them are beyond the scope of CHEWs irrespective of the fact that it is included in their curriculum. Some examples are: performing of episiotomy, manual removal of retained placenta. 
. The FMOH needs to weigh this carefully because of public safety.
. NANNM in collaboration with the Council should call on FMOH, SMOHs and PHCDA through appropriate consultations to actively involve nurses and midwives in capacity development in line with the TS&TS policy.
. This will enable nurses and midwives to take up the expanded roles and responsibilities as in developed societies thereby scaling up access to qualitative nursing and midwifery care at all levels of the healthcare delivery system in Nigeria. 
. There is need for rational redistribution of tasks as recommended by WHO. 
. Nurses and midwives should be given some tasks hitherto performed solely by Medical Doctors in the TS&TS arrangement. ie nurses with MSc/PhD in medical-surgical nursing specialty areas.
. This very necessary because Primary Health Care cannot succeed without the active involvement of Nurses and midwives
. Advocacy visit by NMCN/NANNM to relevant stake holders to discuss TS&TS Policy on observations and suggested way forward.
. Nurses should actively participate in the universal health coverage in order to addresses the vision of  health for all more than the original Alma Ata Declaration.
. The Council is looking at updating the Curricula for Nursing and Midwifery education to included tasks to be shifted from medical doctors to nurses and midwives after consultation with the relevant stake holders of the FMOH.
. Nurses and midwives needs to be sensitized using all available platforms, and during trainings programmes to accept responsibilities such as posting to rural communities and should be proactive in playing leadership roles by performing their duties diligently while champion the cause of quality healthcare delivery across board in line with the vision of universal health coverage(UCH)
. The TS&TS Policy is a Federal Government policy with many intricacies and interested parties.
. It is however necessary that in the implementation of this policy quality healthcare and public safety is guaranteed
. It is also important to ensure that the Nursing profession is not either short changed or sidelined but actively carried along as a member of the health team.
. This is a challenge that the Professional Association and Nurses as a whole should rise up to and resolve.
Afolabi, K. (2017) Task Sharing Policy Change and Implementation in Nigeria. Abuja: Federal Ministry of Health
Berdellima, A.(2018) Task Shifting/Sharing: What are the Efficiency Gains? The Case of Nigeria. USAID
Federal Ministry of Health (2014) Approved Task-Shifting and Task-Sharing Policy for Essential Health Care Services in Nigeria
Population Council (2017) Enhancing Frontline Health Workers’ Abilities to Improve MNCH Services in Cross River State


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