Content uploaded by Paulo Ferrinho
Author content
All content in this area was uploaded by Paulo Ferrinho
Content may be subject to copyright.
Available via license: CC BY 2.0
Content may be subject to copyright.
RES E AR C H Open Access
Task-shifting: experiences and opinions of health
workers in Mozambique and Zambia
Paulo Ferrinho
1*
, Mohsin Sidat
1,2
, Fastone Goma
3
and Gilles Dussault
1
Abstract
Background: This paper describes the task-shifting taking place in health centres and district hospitals in
Mozambique and Zambia. The objectives of this study were to identify th e perceived causes and factors facilitating
or impeding task-shifting, and to determine both the positive and negative consequences of task-shifting for the
service users, for the services and for health workers.
Methods: Data collection involved individual and group interviews and focus group discussions with health
workers from the civil service.
Results: In both the Republic of Mozambique and the Republic of Zambia, heal th workers have to practice beyond
the traditional scope of their professional practice to cope with their daily tasks. They do so to ensure that their
patients receive the level of care that they, the health workers, deem due to them, even in the absence of wri tten
instructions.
The “out of professional scope” activities consume a significant amount of working time. On occasions, health
workers are given on-the-job training to assume new roles, but job titles and rewards do not change, and career
progression is unheard of. Ancillary staff and nurses are the two cadres assuming a greater diversity of functions as
a result of improvised task-shifting.
Conclusions: Our observations show that the consequences of staff deficits and poor conditions of work include
heavier workloads for those on duty, the closure of some services, the inability to release staff for continuing
education, loss of quality, conflicts with patients, risks for patients, unsatisfied staff (with the exception of ancillary
staff) and hazards for health workers and managers. Task-shifting is openly acknowledged and widespread, informal
and carries risks for patients, staff and management.
Background
In many African countries, basic level workers, and even
untrained auxiliary staff and community health workers,
assume roles and perform activities legally reserved for
mid- or high-level cadres of workers [1]. This is informally
acknowledged, but rarely documented, and it is generally
ignored in human resources for health (HRH) planning.
We describe the task-shifting between different cadres
in health centres (HC) and in district level hospital set-
tings in the Republic of Mozambique and the Republic
of Zambia, and present the perceptions of health work-
ers of their skills in relation to their actual tasks.
This type of information is important for policy and
planning purposes because it serves to verify the exist-
ence of informal task-shifting, allowing a clearer idea of
the baseline situation to be changed through scaling-up
efforts.. Also, the perceptions of health workers of the
various dimensions of their work are a determinant of
their willingness to change their scope of work and re-
sponsibilities. To know the opinions of health workers is
important because they are active agents, faced with
many competing incentives and constraints, in dynamic
labour markets [2].
The first section of the paper is a brief description of the
health workforce situation in Mozambique and Zambia,
two countries which were selected for their recent
health workforce planning efforts in which the authors
participated [3,4]. The methods used to collect and
* Correspondence: pferrinho@ihmt.unl.pt
1
International Public Health & Biostatistics Unit and CMDT, WHO
Collaborating Centre for Health Workforce Policy and Planning, Instituto de
Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
Full list of author information is available at the end of the article
© 2012 Ferrinho et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Ferrinho et al. Human Resources for Health 2012, 10:34
http://www.human-resources-health.com/content/10/1/34
analyse data are presented followed by the results and
their discussion.
Country contexts
Mozambique and Zambia are countries covering large
areas, with estimated populations of 22 and 13 million,
respectively. They have similar levels of urbanization,
health and HRH indicators (Table 1). There are import-
ant political and cultural differences: Mozambique is a
former Portuguese colony and is recovering from a civil
war that followed an armed struggle for independence.
Zambia, a former British colony, gained independence
peacefully and never experienced civil war.
Zambia’s health policy was formulated in the National
Health Strategic Plan (NHSP 2006–2010 ) [5]. The Min-
istry of Health estimates that its health workforce corre-
sponds to less than half of the requirements to deliver
basic services [5,6]. HRH issues are identified as a prior-
ity, which the Human Resources for Health Strategic
Plan 2006–2010 addressed [6].
In Mozambique, health policy directions are formu-
lated in the Plano Estratégico do Sector Saúde (Health
Sector Strategic Plan [7]), which identifies the deficit of
skilled health workers as a major challenge for the im-
plementation of the health policy. In response, the gov-
ernment has adopted a plan for human resources
development (Plano de Desenvolvimento de Recursos
Humanos) for 2008–2015 [8].
In both countries, in addition to limited funding [4],
the greatest obstacle to increasing the workforce is the
insufficient capacity for training new workers. This is
why task-shifting is regarded as a realistic, efficient and
rapid way to scale-up access to qualified services, at a
much lower cost than training more physicians and
nurses [9].
Two sets of questions triggered our research. First,
does task- shifting exist, and if so, to what extent and in
what form? Second, how great is health workers’ willing-
ness to perform expanded functions and how do they as-
sess their competencies to do so? What are the views of
managers of health services on task-shifting?
Methods
We conducted individual and group interviews with key
health personnel and focus group discussions with
health workers from the civil service (Additional file 1:
Annex I – downloadable file), with a view to gather in-
formation of experiences of task-shifting and on percep-
tions of workers and managers on their competencies
and on their working conditions in general.
We first selected HC and district hospitals (DHs) to
ensure a representation of urban and rural facilities
and of all levels of services: we included at least one
Table 1 Country profile: Mozambique and Zambia (2009–2010)
Mozambique Zambia
Area (km
2
) 801 590 752 618
Population 22 million (2008) 13 million (2008)
Urbanisation rate 37% 35%
Gross national product/purchasing power parity per capita (int $) 770 1230
Population living on < $1/day 74.7% 64.3%
Human Development Index (2010) (both countries are below the Sub-Saharan Africa average) 0.317, 0.425,
Adult literacy (2000–2007) 44% 71%
Health indicators Life expectancy at birth (years) 42.1 42.4
Maternal mortality/100 000 live births 520 830
Infant mortality/1000 live births 90 92
Malaria mortality/100 000 population 92 121
Tuberculosis in people positive for HIV/100 000 population 36 18
Prevalence of HIV in people 15–49 years of age 12.5% 15.2%
Human resources for health situation Assisted deliveries 48% 47%
Physicians/10 000 population <0.5 1
Nurses and midwives/10 000 population 3 7
Pharmaceutical personnel/10 000 population <0.5 <0.5
Dental personnel/10 000 population <0.5 <0.5
HIV: human immunodeficiency virus.
Source: WHO . World Health Statistics 2010 and hdrstats.undp.org/en/countries/profiles/.
Ferrinho et al. Human Resources for Health 2012, 10:34 Page 2 of 8
http://www.human-resources-health.com/content/10/1/34
facility from each area of great isolation. This selec-
tion was done with the support and approval of Min-
istry of Health officials. All facilities contacted by
telephone agreed to participate. The managers of each
facility assumed the responsibility to mobilize their
staff (we do not have information on staff refusal to
participate).
On average, two focus groups were conducted by each
facility: one with technical staff and one with ancillary
staff. Where the number of technical staff allowed it, we
organized focus groups for a specific cadre (e.g. nurses)
(Additional file 2: Annex II – downloadable file). In the
case of managers, individual interviews or interviews
with two respondents were conducted.
Interviews (Additional file 3: downloadable file for
interview schedule) and discussions shared the same set
of issues for discussion and were recorded with the con-
sent of the participants, transcribed and subjected to
open, qualitative content analysis [10].
Results
Experiences and opinions of health facilities’ staff and
managers
In the following sections, we describe experiences of
task-shifting and present opinions expressed by man-
agers, technical staff and non-professional ancillary staff
working in hospitals and HCs.
Experiences of task-shifting
Health facility managers
In both countries, health facility managers experience
a significant staff deficit at all levels of care. But, in
Mozambique it is felt that the deficit situation is improv-
ing, particularly in the urban areas, therefore less use is
made of non-professional ancillary staff for clinical acti-
vities. In district health facilities, staff deficits are reported:
... in Mitande [Niassa] there is only one nurse... he
does dental chores ... con ducts labours ... consults
with patients besides doing his own nursing work ...
He runs the dispensary, ...
We have some health posts where the only staff
present is auxiliary midwives and a maid. In the
absence of the auxiliary midwife the maid t akes over
... even antenatal care ...
Task-shifting is described by managers as very frequent
in the health facilities of both countries:
... [we cope] because people are doing more than their
job description ... like the maids ... the maid may
help the nurse at the end of the day. Even helping to
take bodies to the mortuary... (Lusaka HC)
Making use of underskilled or unskilled personnel to
ensure the running of a health facility is part of the diffi-
culty in improving the quality of the services provided:
There are situations where other people, mostly
helpers, do nurses’ ... They may help with preparing
bodies for the mortuary, bed making, registration in
OPD and cleaning instrument s in theatre ... when
doctors are not there [Clinical Officers are asked to
assist] with the ward rounds... There are even
situations when patients are clerk ed by nurses because
there were no clinical officers ... Nurses may also have
to do other doctors’ jobs, like withdrawing of blood
(Kafue DH)
In labour room ... maids are mobilized to assist
[skilled nurses].. . (Niassa Regional Hospital (RH)
... besides, they do not value confidentiality ... (Gaza RH)
Managers gave other examples of task-shifting:
For example ... because we lack trained counsellors,
antiretroviral counselling is con ducted by a dental
technician and a physiotherapy tech nician .. . Another
example is that of the radiology technician who is also
head of the financial department, for lack of someone
else (Nampula RH)
... we have one nurse who helps in the radiology
department and another in .. . in charge of pharmacy
... the nurse working at the pharmacy, she is there the
whole time...but other nurses come to help out at the
pharmacy as well .. . in the X-ray department ... may
be 20% or 25% of the time (Mpanshyia Hospital)
In situation s of chronic deficit of personnel, nurses
“will train their ancillary staff to assume clinical chores
”
(Nampula HC).
Managers acknowledge that this task-shifting is usually
unplanned, but when it is, it is never done in writing:
“... the allocation of new tasks to the health workers is
made verbally ...” (Nampula HC).
Care providers
The experiences of care providers coincide, to a large ex-
tent, with those of managers.
Except for Maputo HCs, where the situation was
considered acceptable, all technical staff interviewed
complained of lack of staff and of being compelled to as-
sume a diversity of extra tasks.
As enrolled nurses, we are not supposed to be
delivering (in the labour room, but we do it). We are
Ferrinho et al. Human Resources for Health 2012, 10:34 Page 3 of 8
http://www.human-resources-health.com/content/10/1/34
also doing [patient] screening [in OPD] ... MCH
activities [which] are supposed to be done by a
qualified person .. . suturing and doing cannulations
... minor surgery – I&D [incision and drainage]...
giving IV drugs...we even do death certification [on
behalf of the clinical officer]. We also do the
counselling and testing for HIV... and also testing for
Hb, RPR and RDT [rapid diagnostic tests] for malaria
... administrative work ... we don’t even know our job
description These other extra duties take most of our
time” (Zambian Rural HC)
... the cleaners ... do chores such as damp dusting,
bed making, weighing babies and mothers in MCH,
taking temperatures and other vit als, etc.... with no
training other than ... on-the-job. They learnt by
doing alongside the nurses...[but even with their help
we, nurses] are not enough (Lusaka HC)
A number of nurses and of other health personnel say
that their initial training prepared them to some of the
task-shifting they assume:
... when we are at nursing school, we get exposure to
some of these areas like we go for clinics, we also work
in the ward s, so that whatever small experience we
have, when we come in the field, we are not surprised,
we find the situation as bad as we were told, we just
fit in (Zambian Rural HC),
We, general nurses, learn everything ... if you take me
now and place me in maternity I will be prepared to
work there. I can screen. I can handle some small
surgery. I can work in the wards. We are really taught
a bit of everything [during our initial training]
(CS Maputo)
This does not seem to apply to some midwives :
I am a midwife, after losing the general nurse [at the
HC] I had to assume tasks for which I felt I was not
prepared. Therefore I referred a lot ...(Niassa HC)
In addition to lack of preparation, the absence of
adequate equipment causes another major bottleneck:
There are things that the dental therapist wants to do
but cannot do them because the equipment is not
adequate ...(Lusaka HC).
In fact, this releases staff from the duties they were
trained for to assume other tasks that are shifted to
them.
Some of the task-shifting observed takes place because
of the lack of transport to refer patients:
... when there are difficulties with transport to take
the patient to the referral hospital we are forced to
take on some very complex tasks ... (Nampula HC)
Technical staff show s openness to scaling-up the com-
petencies of untrained personnel and relatives of
patients, as a way to increase the capacity to cope with
heavy workloads:
... in the wards the relatives there really assist us in
taking care of the patient (Mpanshyia RH)
In Maternal and Child Health, we have community
health workers ... who help weigh babies at the
under-5 clinic and ... mothers at the ante-natal clinic
(Mpanshyia RH)
General non-professional ancillary staff
These staff members clean, do the laundry and cook. In
day-to-day life, on a need to do basis, they assist with a
number of tasks, for which they have no training.
I am an indoors cle aner. I help the nurses do most of
their work. I do bed-making, bring bed-pans to the
patients, monitor temperatures, and also wait on
patients. I help cooking for the patients, and
sometimes I go to help in the lab to do finger pricks for
the slides, and do tests such as RPR, pregnancy tests. I
also help with growth monitoring. I also look after the
stores for World Food Programme “food-for-work”
project. I keep records of the food in the stores and do
stores controlling. Sometimes you just arrive, before
you start cleaning up, you have to make beds, go to
collect linen, etc. ... These take three quarters of my
time (Zambian rural HC)
When I was in the district, my nurse had to go away
for one month and was not replaced. I was all by
myself ... I had to do dressings, suture wounds, drip
patients, assist women in labour, and still do my own
cleaning job (Gaza HC)
I was not trained. But as I saw so many being done I
did it myself. I thought it was normal (Niassa HC)
At Maputo General Hospital (GH), Mozambique, a
different situation is observed. Only occasionally do an-
cillary staff members support the midwives, handing
over the equipment for example, but they never con-
duct any clinical work on their own. Most received
Ferrinho et al. Human Resources for Health 2012, 10:34 Page 4 of 8
http://www.human-resources-health.com/content/10/1/34
some training before starting their work in the hospital.
They are happy with their situation. This contrasts with
what is observed in all other hospital facilities visited,
where they assume all sorts of tasks including clinical
ones,
In registry, there is also work which is not supposed to
be done by us, but you find yourself maybe tallying
diagnosis or other treatment [of data]... when a
patient comes ... unable to walk or talk, you are
forced to get the patient to OPD ... there you find
there is no nurse, maybe she’s somewhere else, you will
be forced to do the nurse’s job, for the sake of assisting
that patient because you can’t just leave him collapse
(Kafue RH)
I helped in maternity. I conducted deli veries. I did
that to help the nurse. Let’s suppose that five or six
mothers come all in labour. Then the nurse would
ask for my help. I had to help. I could not let the
mothers push out the baby on the floor. Of cour se, I
would put on my gloves and would run to help the
nurse (Nampula RH)
Perceptions and expectations regarding task-shifting
One district health director in Niassa, Mozambique,
considers that, compared with other provinces, the level
of staffing in his district can be considered reasonable
(“in the district head office we have enough staff to re-
spond to the flow of work ...”), but bad management of
the continuing education of his staff by the provincial
head office creates disruptions:
... the staff who remains in the health centre may be
overloaded by work ... continuing education
initiatives occur spontaneously, unplanned, cre ating
service constraints ...
...[In] Mitande ... the situation gets really serious
when [the single nurse on duty] is called for continuing
education ...
The most important deficit observed is for maternal
and child health nurses and auxiliary clinical officers
(agentes de medicina). The director considers that the
major obstacle in placing staff in isolated rural areas is
related to the lack of accommodation; this aggravates
the staff deficit that leads to task-shifting.
HC managers are usually health professionals (most
frequently nurses) who cumulate management and clin-
ical tasks, spending most of their time on the latter, thus
neglecting managerial activities, for which they are not
prepared:
... the HC should have an administrator ... some of
the administrative activ ities are difficult ... experience
is not enough to carry them out adequately .. . human
resources management has been most difficult ...
(Niassa HC )
Hospital managers cumulate management functions
with district management and clinical duties:
We have to care for pa tients in the wards and to see
them as outpatients. In practice this means that
administrative work is done in late afternoons, except
in days when I have to participate in the activities of
District Government ... which pushes my ward
visiting times to after 6 pm (Gaza RH).
Management and administration are seen as a burden
for which hospital managers feel ill prepared:
I was frustrated at the beginning, because my training
was as a MCH nurse and not in administration ...
with time I got used ... I spend 65% of my time with
administration and 35% with nursing duties ... Iam
not happy with this situation. I would rather spend all
my time with clinical chores ... I have difficulty with
statistical reports and I should have a computer to
help me with my work (Maputo GH)
This overload could be reduced if there were more
and better trained administrative personnel. In their ab-
sence, highly trained staff members have to spend their
time doing general basic chores:
We should have more administrative staff ... There
are chores that do not need to be done by myself but I
have to get involved because the staff available is not
skilled enough... (Niassa RH)
“The main skills lacking in the hospital are nursing
and midwifery. These are compensated by the use of
part time nurses and by nurses in the establishment
who do calls ... but even so the y are not enough to
cover all the night shifts (Kafue DH)
According to the managers, the situation of deficit
prevents proper in-service training:
... the problem is that we are so short of staff that
even training is difficult, in-service training which was
supposed to be routine is lacking becau se there is no
time to remove staff from their posts, but we know
that, that is the only way to overcome the quality crisis
... (Mpanshyia Hospital)
Ferrinho et al. Human Resources for Health 2012, 10:34 Page 5 of 8
http://www.human-resources-health.com/content/10/1/34
Managers report absenteeism for illness as a problem:
...because of staff members that are frequently ill, we do
have occasional shortages of non-professional ancillary
staff and of other health workers (Maputo HC)
They consider that, in general, the situation is more
difficult in rural than in urban health centres: “...we are
supposed to have three doctors but we only have one...”
(Lusaka HC).
Managers acknowledged that informal task-shifting
involves risks for them:
...when we had maternal deaths, it wasn’t only the
nurses who were asked to write a report, even the
sister in-charge, even the nurses who wer e there when
the mother died, they also wrote the report. So
management is also liable [for the hazards re sulting
from task-shifting] (Lusaka HC)
Most who work overtime or assume new functions are
not rewarded financially as this is not allowed by the
rules of the Ministries of Health:
... maybe the lack of financial rewards is not the
worst of it. Also, there is a lack of recognition of the
add-on work that they assume... (Maputo GH)
Managers consider that, overall, staff members are un-
happy, “We notice that workers are not happy...”
(Maputo GH).
As with their experience of task-shifting, the percep-
tions and expectations of care providers coincide, to a
large extent, with those of managers.
Again, excepting for Maputo HCs, where the situation
was considered acceptable, technical staff feel compelled
to assume a diversity of extra tasks out of comrade-
ship—or on instruction from management, “... the Pro-
vincial Health Direc tor just told me to do it, to assume
the responsibility for the expanded programme of
immunization” (Niassa HC), and, “Orders are orders ...”
(Nampula HC).
Care providers consider there to be several conse-
quences of staff deficit and the poor conditions of work:
a heavier workload on the staff on duty; the closure of
services, and its consequent reduction of access; the in-
ability to release staff for continuing education; poorer
quality and po orer efficiency as qualified staff has to per-
form menial tasks; conflicts with patients; and increased
risks for health workers and users of services. Hospital
technical staff considers that the staffing shortage in
hospitals is critical and affects skilled and unskilled staff
categories, resulting in significant shifts of tasks among
different categories of health workers,
“We have five staff members involved with patient
screening. We see so many patients, too many patients.
I believe that each day each one of us sees up to 75 or
even 85 patients. That is too much ...” (Maputo HC),
“There are not enough staff members. Therefore we are
forced to close some sectors, because of this lack of
staff ...” (Maputo HC),
“... so there is a problem, we are not being looked
after properly [as far as continuing education is
concerned] when there is any new program on board
...” (Lusaka HC),
“if you are overworked, your care will lack quality
”
(Zambian rural HC),
“... sometimes I have to interrupt what I should be
doing [consulting with patients] to assist with
dressings, injections ... Patients get very angry when
they have to wait for a long time until I resume
consulting them ...” (Nampula HC),
“... you are alone in labour ward.. . and there are 10
women about to deliver, so the risk of infecti ng each
other is high. People would rather put on four pairs of
gloves and just keep on remov ing the top ones. And for
example you find 2 or 3 mothers are pushing, then the
babies are there on the vulva, which one do you get
first? If you get that one, maybe that other one will
drop on the floor, again you will be the one to
answer for that” (Lusaka HC),
“At the X-rays ... we are supposed to have dosage
monitoring badges, so we have requested from the
district and the regulation protection board ... we
have been working for almost a year but we don’t
have those badges” (Lusaka HC)
“because of shortage of staff ... our dental officer is in
charge of tuberculosis and leprosy control, even if he
is not competent to run those programmes ...”
(Nampula RH)
“... when I come in the morning I find there are few
cleaners at the hospital and they are held up
somewhere, in that case I just get the broom and clean
my department and then I start working because I
won’t wait for that cleaner to come and clean for me
to start, I have patients waiting. So, I was trained as
a physiotherapist but I sweep ...” (Kafue RH).
Ferrinho et al. Human Resources for Health 2012, 10:34 Page 6 of 8
http://www.human-resources-health.com/content/10/1/34
“I am a clinical officer for anaesthesia ... in the
theatre there are the three of us, so when the
procedure is going on, everything that is needed I have
to do it. I am a circulating nurse, I am a runner,
a porter ...” (Kafue RH),
Suggested solutions include:
... training the ancillary staff in routine duties such
as feeding patients, taking BP, temperature and other
vitals, so as to be more effective ... (Zambian rural HC);
Continuing education programmes have to be
decentralized to the periphery (Niassa RH);
[as the] auxiliary nurse carries almost the same task s
as a mid-level nurse ... it would be right if that
auxiliary nurse could be promoted to mid-level nurse
by a distance learning course (Nampula RH).
Discussion
Our results are consistent with other studies from Mo-
zambique and Zambia in terms of the extent of task-
shifting and sharing we have observed [11,12]. Our stud-
ies further specify the type of task-shifting and document
the opinions of staff about the situation.
In Mozambiqu e, a recent stu dy on nurs ing has
shown that auxiliary n urses tend to ass ume nursing
responsibilities above their level of training, particu-
larly in isolated settings of lesser complexity. There
was a significant overlap of tasks between nurses (all
levels) and clinical officers and auxiliary clinical offi-
cers [12]. This is consis ten t with our findings. This
suggests that existing auxiliary le vel staff could be
upgraded to mid-level professional skills. Another
consideration is that the training of new auxiliaries
should probably be abandoned in favour of mid-level
workers.
The delegation of tasks from one health care provider
to another, advocated in the 2006 World Health Report
[13], has been used in many countries on a routine basis
for decades, especially in understaffed rural facilities, to
enhance access and to reduce costs [14]. One of the
earliest and most systematic studies was undertaken in
the 1970s and 1980s in the Democratic Republic of the
Congo (then Zaire) [15].
It was recognized, from the time of Mozambican
[16,17] and Zambian independe nce [18], and even before
[19-21], that there was a need to develop health services
with less skilled trained cadres, such as auxiliary health
workers or even traditional personnel such as traditional
birth attendants [22,23]. This justification was that many
activities of doctors and nurses could be carried out at a
lower cost by persons with shorter training, which allows
for faster entry into the labour market and is signifi-
cantly cheaper.
This re cognition did not come easily, nor was it always
the result of systematic planning, and not all stake-
holders supported it. In most instances, task-shifting
occurs in the absence of adequate support, such as ac-
cess to means of communication, supervision and
mechanisms of referral. It also often takes place in an
environment in which basic amenities—housing, water,
electricity and sanitation—are lacking. Even so, some
cadres, like clinical officers in Zambia and surg ical tech-
nologists in Mozambique [24], are examples of effective
formal processes of task-shifting.
Another form of task-shifting is observed when work-
ers are trained beyond their legal scope of practice, as a
strategy to facilitate the implementation of specific pro-
grams. For example, in Zambia this is done for nurses
and environmental health technologists: during their
pre-service training they are taught to screen patients
and to prescribe for the most common conditions. Also
in Zambia, an Integrated Competence-based Training
programme has been developed for those already work-
ing in the system. It gives front-line health cadres (clin-
ical officers, nurses, environmental health technologists)
basic competencies in the delivery of the entire health
care package at subdistrict le vel. These initiatives pre-
pare Zambian health workers to substitute other cadres
when the need arises [5,6]. In Mozambique, all categor-
ies of health workers receive training in minor surgical
procedures, injections, and management of a febrile pa-
tient etc. The training of clinical officers as surgical tech-
nologists (técnicos de cirurgia) is another example from
Mozambique [24].
Conclusions
The consequences of the staff deficit and the poor con-
ditions of work include a heavier workloads for the staff
on duty, the closure of some services reducing patient
access, the inability to release staff for continuing educa-
tion, poorer quality, conflicts with patients, risks for
patients, unhappy staff (with the exception of ancillary
staff) and hazards for health workers and managers.
Task -shifting alone cannot respond to the needs of poor
countries, especially if other issues are not addressed at the
same time: inadequate facilities, lack of or faulty equip-
ment, lack of transport for field work and for patient
evacuation, unreliable electrical power supply, inadequate
refrigeration facilities, lack of accommodation for staff, and
inadequate continuing education efforts, among others.
Solutions cannot ignore the extent of the crisis, the
maldistribution of resources [25,26], the insufficient
training capacity, the imbalance of skills and the ancil-
lary staff “reser ve for rapid expansion of the skills base”
Ferrinho et al. Human Resources for Health 2012, 10:34 Page 7 of 8
http://www.human-resources-health.com/content/10/1/34
within the public sector facilities. This paper shows that
workers have clear ideas about how to improve the avail-
ability of services; it remains to be seen if decision-
makers will listen to them.
Additional files
Additional file 1: Annex I Data collection sites.
Additional file 2: Annex II Characterization of study participants.
Additional file 3: Interview/focus group schedule of topics for
discussion.
Competing interests
The authors declare no competing interests.
Authors’ contributions
PF, MS and FG participated in the design of the study, in the data collection
and analysis, and carried out the drafting of the manuscript. GD participated
in the manuscript drafting. All authors read and approved the final
manuscript.
Acknowledgments
The field work for this research was supported by the World Bank. We
further acknowledge support received from Fátima Ferrinho in different
phases of the preparatory work for this article. Jim Buchan commented an
advanced draft of this paper.
Author details
1
International Public Health & Biostatistics Unit and CMDT, WHO
Collaborating Centre for Health Workforce Policy and Planning, Instituto de
Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal.
2
Faculty of Medicine, Universidade Eduardo Mondlane, Maputo,
Moçambique.
3
Faculty of Medicine, University of Lusaka, Lusaka, Zambia.
Received: 10 October 2011 Accepted: 17 June 2012
Published: 17 Septemb er 2012
References
1. Buchan J, Dal-Poz MR: Skills mix in the health care workforce: reviewing
the evidence. Bulletin of the World Health Organization 2002, 80:575–580.
2. Grepin KA, Savedoff WD: 10 best resources on health workers in
developing countries. Health Policy and Planning 2009, 24:479–482.
3. Sidat M, Fernandes B, Mussa A, Ferrinho P: Recursos humanos da saúde
em Moçambique: evidências actuais e desafios futuros [Human
resources for health in Mozambique: current evidence and future
challenges]. Revista Médica de Moçambique 2010, 10(suplemento):1–2.
4. Tyrrell A, Russo K, Dussault G, Ferrinho P: Costing the scaling-up of human
resources for health: lessons from Mozambique and Guinea Bissau.
Human Resources for Health 2010, 8:14.
5. Republic of Zambia, Ministry of Health: National health strategic plan (NHSP
2006–2010). Lusaka: MoH; 2005.
6. Republic of Zambia, Ministry of Health: Human resources for health strategic
plan 2006 – 2010. Lusaka: MoH; 2005.
7. República de Moçambique, Conselho de Ministros: Plano estratégico sector
saúde (PESS) 2001-2005-(2010) [Strategic Health Sector Plan 2001-2005-(2010)].
Versão aprovada em 24 de Abril. Maputo: RCM; 2001.
8. de Moçambique R, da Saúde M: Plano de desenvolvimento de recursos
humanos 2008–2015 [Plan for human resource development 2008-2015].
Departamento de Recursos Humanos: Maputo; 2008.
9. Tjoa A, Kapihya M, Libetwa M, Schroder K, Scott C, Lee J, Mc-Carthy E:
Meeting human resources for health staffing goals by 2018: a
quantitative analysis of policy options in Zambia. Human Resources for
Health 2010, 8(1):15.
10. Graneheim UH, Lundman B: Qualitative content analysis in nursing
research: concepts, procedures and measure to achieve trustworthiness.
Nurse Education Today 2004, 24:105–112.
11. de Moçambique R, da Saúde M: Direcção Nacional de Recursos Humanos,
Departamento de Formação: Análise situacional da carreira de enfermagem
em Moçambique [Situational analysis of the nursing career in Mozambique].
Relatório Técnico: Maputo; 2010.
12. Wlash A, Ndubani P, Simbaya J, Dicker P, Brugha R: Task sharing in Zambia:
HIV service scale-up compounds the human resource crisis. BMC Health
Services Research 2010, 10:272.
13. World Health Organization: The World Health Report 2006 - working together
for health. Geneva: WHO; 2006.
14. Gish O, Hill KR, Elliot K: Health, manpower and the medical auxiliary.
Intermediate Technology Group Ltd: London; 1971.
15. World Health Organization: Taking stock: task-shifting to tackle health worker
shortages. Geneva: WHO; 2007.
16. de Moçambique R, da Saúde M:
Les soins de santé primaires au Mozambique
[Primary health care in Mozambique]. Republique Populaire du Mozambique/
Ministére de la Santé: Maputo; 1977.
17. Walt G, Melamed A: Mozambique: towards a people’s health service. Zed
Books, Ltd: London; 1983.
18. Kalusa W: Language, medical auxiliaries and the re-interpretation of
missionary medicine in colonial Mwinilunga, Zambia, 1922–51. Journal of
Eastern African Studies 2007, 1(1):57–58.
19. Ferrinho H: O interesse dos aspectos sociais no desenvolvimento rural. Série
Economia e Social, n 1 [The relevance of social aspects of rural development.
Social and Economic Series, No. 1]. Moçambique: Instituto do Algodão de
Moçambique; 1964.
20. Ferrinho H: Fomento algodoeiro e promoção social. Série Economia e Social, n
2 [Development of cotton culture and social advancement. Social and
Economic Series, No. 2]. Moçambique: Instituto do Algodão de
Moçambique; 1965.
21. Martins H: Porquê Sakrani? Memórias dum médico duma guerrilha esquecida.
[Why Sakrani? Memoirs of a doctor in a forgotten guerrilla]. Maputo: Editorial
Terceiro Milénio; 2001.
22. Gloyd S, Floriano F, Seunda M, Chadreque MA, Nyangezi JM, Platas A:
Impact of traditional birth attendant training in Mozambique: a
controlled study. Journal of Midwifery and Women’s Health 2001,
46(4):210–216.
23. Thomas WW: Impact of traditional birth attendant training in
Mozambique: a controlled study. Journal of Midwifery and Women’s Health
2002, 47(1):65– 66.
24. Kruk ME, Pereira C, Vaz F, Bergstrom S, Galea S: Economic evaluation of
surgically trained assistant medical officers in performing major obstetric
surgery in Mozambique. BJOG: an international journal of obstetrics and
gynaecology 2007, 114(10):1253–1260.
25. Ferrinho P, Siziya S, Goma F, Dussault G: The human resource for health
situation in Zambia: deficit and maldistribution. Human Resources for
Health 2011, 9:30.
26. Ferrinho P, Martins J, Sidat M, Conceição C, Dalpoz MR, Ferrinho F, Tyrell A,
Neves C, Dreesch N, Mussa A, Dussault G: A força de trabalho e a política
de saúde em Moçambique.[Health workforce and health policy in
Mozambique]. Revista Médica de Moçambique 2010, 10(suplemento):3–12.
doi:10.1186/1478-4491-10-34
Cite this article as: Ferrinho et al.: Task-shifting: experiences and
opinions of health workers in Mozambique and Zambia. Human
Resources for Health 2012 10:34.
Submit your next manuscript to BioMed Central
and take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit
Ferrinho et al. Human Resources for Health 2012, 10:34 Page 8 of 8
http://www.human-resources-health.com/content/10/1/34
