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WHO Recommendations: Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions Through Task Shifting. Geneva: World Health Organization; 2012.

Cover of WHO Recommendations: Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions Through Task Shifting

WHO Recommendations: Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions Through Task Shifting.

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Many WHO Member States have attempted to increase access to effective interventions. One way of facilitating improvement is to give available cadres short periods of additional training and then to allow them to take on particular activities they have not undertaken before. This process is known as ‘task shifting’ or ‘task sharing’ and is one of several strategies that can potentially improve the utilization of health system resources. Ultimately, task shifting can also improve health system performance and outcomes. The terms that are used to describe these change processes often lack precise definitions and tend to be used interchangeably, but they reflect the same general intention: to train cadres who do not normally have competencies for specific tasks to deliver them and thereby increase levels of health care access. In this document, we use the term ‘optimizing the delivery of key, effective interventions’ to reflect a focus on increasing access to interventions that have been shown in clinical studies to be effective in improving health outcomes.

Many low- and middle-income countries (LMICs) are seeking to optimize the delivery of key effective maternal and newborn interventions in order to improve maternal and newborn health. The WHO supports the efforts of its Member States to increase skilled birth attendance and thereby improve intrapartum care. Task shifting strategies can play an important complementary role in achieving these objectives and in accelerating improvements in maternal and newborn outcomes through increases in access to specific interventions.

This project forms part of a comprehensive Knowledge-to-Action framework implemented by the WHO Department of Reproductive Health and Research in 2009. This approach, known as the GREAT project (Guideline-driven, Research priorities, Evidence synthesis, Applicability of evidence, Transfer of knowledge) (, includes the development of evidence-based guidelines that are in accordance with the standards set by the WHO's Guidelines Review Committee (GRC). In addition, the project aims to actively develop adaptation strategies and facilitate the implementation of this guidance.

The global health workforce crisis

Widespread crises in the health workforce are impacting on the realization of the health-related MDGs. According to a 2006 World Health Report, 57 countries face chronic human resource shortages in the health sector. Typically, such countries are LMICs and are nations with the highest burden of health problems such as HIV/AIDS and maternal and newborn mortality (3).

Such problems are compounded by global and national imbalances in the distribution of the health workforce. Notably, 36 of the 57 countries currently facing health-related human resource crises are in sub-Saharan Africa. This region contains 11% of the world's population but bears 24% of the global disease burden. It also has only 3% of the global health workforce and accounts for just 1% of global health expenditure. In contrast, the Americas region (predominantly the United States of America and Canada) is home to 14% of the world's population but bears only 10% of the world's burden of disease, contains 37% of the global health workforce and accounts for approximately 50% of the world's health expenditure (4).

Within-country inequalities in health workforce distribution are also common, especially in low-income countries. Estimates indicate that 24% of physicians and 38% of nurses work in rural areas even though these regions contain half of the world's population (3). Imbalances exist not only in the number and geographical distribution of available health workers, but also in the range of health worker skills. Most countries still have too few specialist doctors (such as surgeons, obstetricians and anaesthetists) relative to the health needs of their population.

Human resource gaps in maternal and newborn health

The low proportion of women assisted by skilled birth attendants is an important indicator of the global personnel shortage in the health sector. Approximately 60 million births each year occur in settings other than health facilities and 52 million of these births take place without the support of a skilled birth attendant (5). While skilled birth attendance is provided at almost all births in most industrialized countries, fewer than 50% of births in the majority of countries in South Asia and sub-Saharan Africa receive such support (6). In 2008, the WHO estimated that the average proportion of births attended by a skilled health worker was 33.7% in East Africa and 46.9% in South Central Asia (WHO Fact Sheet, Given that coverage in developing nations is improving at a rate of less than 0.5% per year, even by 2015 fewer than 50% of all births will have the support of a skilled birth attendant (7).

There is often an inverse association between neonatal mortality and the availability of skilled birth attendants: countries with very high neonatal and maternal mortality rates typically have very low numbers of births supported by skilled birth attendants, very few caesarean deliveries, and low levels of physician density. In contrast, nations with the lowest neonatal mortality rates and maternal mortality rates typically have the highest level of skilled birth attendance, a higher number of caesarean deliveries, and higher levels of physician density (7;8). Closing existing gaps in health coverage and improving maternal and newborn health outcomes will therefore require active human resource policy interventions by those countries affected.

Optimizing the roles of health workers through task shifting: Overarching principles

National health strategies help to facilitate both improved levels of access and good quality care. Following the global endorsement of the MDGs, further efforts have been made in low- and middle-income countries to improve maternal and newborn health by improving levels of skilled birth attendance and institutional birth coverage. Attempts have also been made to establish universal access to sexual and reproductive health and rights.

The recommendation that skilled birth attendants should support all births has been universally acknowledged and endorsed and, overall, progress is being made in raising national rates of coverage. Many countries have also developed innovative strategies to enhance access to other key interventions to further improve maternal and newborn health, especially in remote areas. Some countries, for example, have trained lay health workers (LHWs) to administer specific interventions, utilizing them either alone or as part of teams within communities and health care facilities. LHWs are defined as those who perform functions related to health care delivery, have been trained in some way in the context of the intervention, but who have received no formal professional or paraprofessional certificate or tertiary education degree (9). The term ‘lay health worker’ is necessarily a broad one and includes (amongst others cadres) community health workers, village health workers and treatment supporters.

LHW programmes are often created to provide health promotion and counselling services and the inclusion of LHWs in the delivery of maternal and newborn health interventions should therefore be considered within the wider set of roles for which they are trained. In some settings, for example, traditional birth attendants (TBAs) have been recruited and trained to deliver individual interventions, including the promotion of basic newborn care, as part of wider programmes to improve access to care. Professional cadres have also been offered additional training to deliver interventions that were not necessarily within the competencies that formed part of their initial training: in some settings, auxiliary nurses, auxiliary nurse midwives, nurses and midwives have even been taught how to perform minor surgical procedures. To reflect the changes that task shifting can entail, new cadres (such as ‘non-physician clinicians’ or ‘NPCs’) have been created in certain instances to offer formal recognition to those who have gained advanced surgical competencies1.

The purpose of this WHO guidance is to offer recommendations for optimizing the delivery of key interventions. An initial list of effective maternal and newborn clinical interventions was based on existing clinical guidance and evidence from systematic reviews. The recommendations for each intervention have been evaluated in terms of whether the intervention could be delivered safely and effectively by the relevant health provider category (either by LHWs or professional health worker cadres). It has been assumed that training more health cadres to deliver certain interventions will lead to an increase in intervention access and utilization. Further methodological detail can be found in Chapter 3.

The interventions detailed in this document can be implemented successfully only if health care workers are supported by other interrelated health systems components (Figure 1). These elements are presented and evaluated in Chapter 5 (‘Implementing task shifting programmes’) and Chapter 6 (‘Contextualizing guidance’) which discuss the dissemination and implementation of the interventions. Chapter 4 (‘Evidence and recommendations’) presents wider implementation considerations for each of the recommendations.

Figure 1. The WHO health systems building blocks.

Figure 1

The WHO health systems building blocks. Source: (20)

The basic emergency obstetric care (BEMOC) and comprehensive emergency obstetric care (CEMOC) signal functions are indicators of a full package of emergency obstetric care and specifically relate to capacity at a facility level ( However, the recommendations made in this document regarding which health workers are suitable for the safe and effective delivery of a range of maternal and newborn health interventions do not imply a preference for particular care settings or types of facilities. In most cases, it has been assumed that health workers are undertaking their job alone within a community or in primary care, rather than in teams which include several cadres and professional health workers.

It is acknowledged that the implementation of these recommendations will depend on many political, financial and health system factors. For example, the existence of a cadre which is able to take on one or more new tasks, compared to the decision to initiate a programme to create a new cadre, present two very different scenarios both for health systems and for policy-makers. These political, financial and health system factors are further examined in Chapter 6 (‘Contextualizing guidance’). The recommendations made in this document are compatible with other WHO GRC-approved guidelines which are referred to in Chapter 4 (‘Evidence and recommendations’) where relevant.


The objective of this guidance is to provide evidence-based recommendations to facilitate universal access to key, effective maternal and newborn interventions through the optimization of health worker roles. This guidance is intended for use by health policy-makers, managers and other stakeholders at a regional, national and international level. By providing this broad guidance internationally, the WHO assumes that countries will adapt and implement these recommendations while taking into account the context of the political and health systems in which they operate.



Note: The cadre name ‘non-physician clinician’ is not always used consistently. In this document, we have used the terms ‘associate clinician’ and ‘advanced level associate clinician’ when referring to this cadre. A complete list of the cadre categories used in this guidance document can be found in Annex 1.

Copyright © 2012, World Health Organization.

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Bookshelf ID: NBK148510


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