“I would like to invite you to come with me to my mother’s kitchen in rural Zimbabwe.”  Nyaradzayi Gumbonzvanda, General Secretary of the World YWCA, shared this compelling invitation with participants two weeks ago at InterAction’s Forum 2013. Gumbonzvanda, a Zimbabwean human rights lawyer and activist, went on to describe her mother’s kitchen and the powerful impact it has had on her life. She described how her mother always managed to put food on the table, and to welcome hungry neighbors, no matter how little she had. She described her mother as a true innovator.

“We have to remember that we don’t bring innovation to rural communities,” she said. “They are inventing and innovating every day to get on with life.”

She went on to explain that necessity breeds innovation, and that people in need come together and share tasks because they need to—not because someone told them to share tasks, or authorized them to do so.

In the global health community, we talk about task sharing a lot. How can teams of health workers best provide services by dividing up tasks? We often draw from evidence, examine official scopes of practice, and carefully plan appropriate training before official changes are made. But her captivating words got me thinking: is task sharing a science—like we typically treat it—or an art, or both?

Shifting or sharing

A few years ago, the World Health Organization (WHO) defined task shifting as “the rational re-distribution of tasks among health workforce teams” in which specific tasks are moved from highly qualified health workers to those who have fewer qualifications in order to make more efficient use of available resources. At IntraHealth International, we—along with others in the global health community—think that the term task sharing is more pertinent, because it takes a team approach to offer high-quality health services.

The WHO and others are working diligently to ensure that guidelines around task sharing (and shifting) are available to countries to help them determine which cadre of health worker should be eligible to perform which level of service in areas such as family planning, maternal and child care, and HIV/AIDS care and treatment. It is important that such guidelines are evidence-based—but it’s equally important that they be adapted to local contexts.

The art of task sharing in Mali

One of the strongest examples I know of necessity breeding innovation in health service delivery, and perhaps of task sharing as an art, comes from Mali. Starting in 2005, IntraHealth worked with Mali’s Ministry of Health and others to train nurse midwives in a technique—active management of the third stage of labor—to help prevent postpartum hemorrhage. Postpartum hemorrhage is the single most significant cause of maternal death worldwide, accounting for half of all maternal deaths that occur after childbirth and 24% of overall maternal mortality. Approximately 130,000 women die each year from complications from pregnancy and childbirth; 99% of women who die are in low-income countries.

Most cases of hemorrhages occur during the third stage of labor, after the baby has been delivered. Active management of the third stage of labor has been shown to significantly reduce the risks of a woman bleeding to death. The “active management”  has three main components: 1) administration of an uterotonic drug within one minute of birth to induce a strong contraction of the uterus (after ensuring there is not another baby in utero); 2) controlled cord traction of the umbilical cord with counter-traction to the uterus; and 3) massage of the uterine fundus through the abdomen. The technique shortens the time it takes to deliver the placenta and leads to a decrease in uterine distress, which is associated with 90% of postpartum hemorrhages.

In Mali, nursing assistants, or matrones, deliver most babies, even those born in health facilities. In many health centers, matrones get the night shift, and often face deliveries without the backup of a nurse midwife or doctor. However, when we trained nurse midwives in Mali in the active management of the third stage of labor, matrones were not authorized to receive the training, primarily because they were not allowed to administer injections.

What happened?  IntraHealth began to notice that although the matrones were not officially allowed to practice active management of the third stage of labor, many matrones observed the trained midwives using the technique—and learned it themselves on the job. They began to help the trained midwives, and then even to use the technique on their own when midwives were not present. The number of cases of hemorrhages plummeted. Working with the Malian Association of Midwives, we advocated for a policy change—and the Ministry of Health changed the guidelines to allow matrones to officially practice what they had already learned to do through observation and determination.

To me, what happened in Mali shows that task sharing is somewhat of an art, often emerging through the organic processes of teamwork. Midwives in Mali originally agreed that matrones should not be allowed to administer injections, and only by observing that they were indeed capable, changed their minds. Thanks to the seamless teamwork of midwives and matrones in health facilities and the lives it saved, Mali’s Ministry of Health changed the policy.

Innovations in the field

At the Women Deliver 2013 conference in Malaysia next week, I will be talking about task sharing, and some innovative solutions that different countries have implemented to meet their own health care challenges.

The WHO, in a groundbreaking 2006 report, found that 57 countries are “health workforce crisis countries” with strikingly low access to health workers. Interestingly, among these countries, there are vast differences in common health indicators such as family planning use, deliveries in health facilities, and immunization coverage. Why are come countries doing so well despite their health workforce crises, and what can other countries learn from them?

Health workers included in the WHO’s estimates of health workers and health worker needs are generally limited to doctors, nurses, and nurse midwives. By only counting these “officially recognized” health professionals, we tend to under-emphasize the roles other health workers—especially community health workers and others on the front lines of care—play. The countries with the best results—including Ethiopia, Rwanda, and others—have developed strategies that allow and encourage task sharing, and make the best use of a variety of health workers. In many cases, task sharing started at the grassroots level out of necessity, and then informed national strategies and policies.

As we learned in Mali, and as Nyaradzayi Gumbonzvanda learned in her mother’s kitchen in rural Zimbabwe, sometimes task sharing is, indeed, both an art and a science.