Editor's Comment

A lack of human resources is a significant barrier to improving obstetric care, especially in rural areas. This is true in many low-income and some high-income countries. Emigration of doctors and nurses from many low-income countries contributes to this, as does a widespread unwillingness—for many reasons—to work in rural areas [1]. There are several ways to address this shortage, one of which is task shifting, and this issue of the Keystone Section is devoted to this topic.

Three of the papers [2], [3], [4] focus on the state of Gujarat in western India. Although the fourth paper [5] is ostensibly about using audits to improve the quality of emergency obstetric care (EmOC), the hospital from whence it comes is heavily dependent on task shifting (and expatriate physicians) to meet its human resource needs.

Task shifting involves the rational redistribution 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.

The practice has existed for decades and is widely used in many countries. For example, the United States makes widespread use of nurse anesthetists, emergency medical technicians, physicians' assistants, and nurse practitioners among other cadres. A conference, “Human Resources for Maternal Survival: Task-Shifting to Non-Physician Clinicians,” was held recently in Addis Ababa, Ethiopia (June 29 to July 2, 2009). The conference brought together some 350 health professionals, government officials, development partners, and ministers of health—representing a total of 42 counties, including 29 from Sub-Saharan Africa. The participants examined and shared innovative approaches to addressing the human resource gap in the delivery of lifesaving emergency obstetric and newborn care, with a particular focus on nonphysician clinicians (NPCs) as important and undervalued members of the health care team.

The three papers from Gujarat all describe new programs intended to help meet the human resource needs for EmOC. Two papers [3], [4] describe training programs for medical officers (general practitioners with little or no training beyond medical college) to provide EmOC or anesthesia for EmOC. Both programs are small and both require modifications to be and remain successful. Nevertheless, both are being scaled up to the national level without additional testing. The evaluations of these two programs are rather small, but are probably sufficient to legitimately draw conclusions and make recommendations. Medical officers in Rajasthan were also trained to provide EmOC, but this program was implemented poorly and met with little success. It is, in fact, a little disturbing that a national scale up is planned based on very small evaluation studies and one apparent failure.

The other Gujarat paper [2] describes a public–private partnership where obstetricians from the private sector are paid a fixed rate to provide obstetric care to public sector patients. This program is much larger than the training programs mentioned above and has already had a significant impact. An additional benefit is that the opportunity to supplement their income means that private sector physicians are more likely to remain in rural areas rather than move to cities where earning opportunities are greater.