Task Sharing Family Planning Services to Increase Health Workforce Efficiency and Expand Access: A Strategic Planning Guide
This document is intended to lead program managers, planners, and policymakers through a strategic process to determine if and how task sharing family planning (FP) services can be used to help achieve development goals. Task sharing is defined as the systematic redistribution of family planning services, including counseling and provision of contraceptive methods, to expand the range of health workers who can deliver services (WHO, 2017). Task sharing is a safe, effective, and efficient means to improve access to voluntary sexual and reproductive health services and reach national FP goals.
This guide builds on experiential learning from implemented programs and is informed by recognized experts in the field.* When contemplating a task sharing strategy, stakeholders should reflect on the considerations below to ensure the potential strategy will address the specific country context, available resources, and diverse needs of the target population.
Note that this process may not be linear. Task sharing implementation should occur within the framework of a functioning health system and within a family planning program that ensures voluntarism and informed choice.
*Aurelie Brunie, Erin Dumas, Sara Chace Dwyer, Mario Festin, Melissa Freeman, Nancy Harris, Rebecca Husband, Candace Lew, Shawn Malarcher, Erin McGinn, Kathryn Mimno, Tishina Okegbe, Japheth Ominde, Sarah Onyango, Intissar Sarker, Lois Schaefer, Tom Van Boven, James White, Leigh Wynne
Consideration 1: How will task sharing help you achieve your goals?
Task sharing can support a variety of program goals, including improving equitable access to contraceptive services for disenfranchised populations or remote communities, allowing clients to obtain their selected contraceptive method from their preferred service delivery point, and/or increasing health system efficiencies by equipping a wider range of providers to deliver key services. Task sharing can also provide an opportunity for health providers, particularly female providers, to advance their professional roles, expand core competencies, and experience economic empowerment. The impact of evidence-based family planning interventions or High Impact Practices (HIPs) is bolstered when responsibilities for delivering high-quality contraceptive services are optimally shared and distributed across different types of family planning service providers within the health system.
Modeling tools can estimate impacts on health outcomes and answer important questions, such as: If CHWs were supported to offer additional methods (task share), is mCPR likely to increase? (See FP Goals); What is the potential contribution of task-sharing to averting unintended pregnancies, abortions, maternal deaths or unsafe abortions? (See Impact 2 Model); How many clients would pharmacies need to be ready to serve if injectables were task-shared? (See Family Planning Market Analyzer).
Table. Task Sharing Enhances Several High Impact Practices
|High Impact Practice||Task Sharing enhances the practice by …||Example|
|Immediate Postpartum FP||Allowing a broad range of health providers to meet client needs through integrated service delivery—a common strategy to achieve health system efficiencies, provide comprehensive client-centered care, and reach disenfranchised communities that may be less likely to seek stand-alone family planning services.||In India until 2009, only doctors were authorized to provide IUDs post-partum, yet most deliveries were attended by nurses and midwives. Development partners worked with the government to demonstrate that nurses and midwives could safely and effectively provide IUDs during the immediate post-partum period, and therefore offer more comprehensive care as part of delivery care.|
|Social Franchising||Supporting client-centered access to products and services through preferred and convenient service delivery points. Task sharing allows clients to access their preferred contraceptive method through their preferred access point/provider.||Community-level provision of implants in Ethiopia through health extension workers has expanded access to long-acting family planning methods.|
|Social Franchising||Building private sector health care professionals’ capacity to provide a broader range of methods, which expands their client base and can potentially strengthen linkages between the public and private health systems.||Drug shop operators in two Ugandan districts were trained to provide DMPA. Data showed that clients were satisfied with the services received, and nearly half of FP clients preferred accessing services at the drug shop compared to clinics.|
|FP Vouchers||Increasing provider availability/accessibility in communities where financial or information barriers hinder uptake of contraceptive methods.||In Nicaragua, adolescents who received vouchers were three times more likely to visit health centers and twice as likely to use modern contraception delivered by a facility-based provider.|
Abbreviations: DMPA: Depot medroxyprogesterone acetate (injectable contraceptive).
Consideration 2: Defining your task sharing strategy – which family planning services providers and which methods.
The following principles have been identified as important considerations for implementing successful programs at scale (WHO, 2009):
- “Interventions that are backed by locally generated evidence of programmatic effectiveness and feasibility increase the likelihood of being successfully scaled up.” Review evidence from task sharing studies for family planning or other health services conducted previously in your country/region to inform the strategy. WHO guidelines exist on the health worker cadres that can safely and effectively provide specific contraceptives and recommendations on how programs can support self-care to help individuals achieve their fertility intentions. This is a good place to identify opportunities for task sharing and/or a task sharing pilot if required.
- “Scaling up often involves an institution-building phase or step that requires a variety of special technical, managerial, human resource, leadership and financial inputs as well as longer timeframes than typical project cycles.” Are financial and human resources available to implement the task sharing strategy? Is it necessary to advocate for policy change for task sharing to occur? Have individuals been identified to champion the process? Will the strategy change provision of an existing contraceptive method or introduce a new method? Is provision of the identified method by a given level of health care worker acceptable to beneficiaries and their communities?
- “Scaling up must be concerned with sustainable policy and program development, including both institutional capacity and availability of financial and material resources.” Are supportive —policies—including protocols, reporting tools, job aids, competency-based pre-service education and in-service training curricula—in place? Would the task sharing result in regulatory changes, such as the accreditation of health shops or facilities, or require updates to licensure/re-licensure processes performed by health professional associations and councils? What are the anticipated training, supervisory, and clinical mentoring requirements, and remuneration needs for the service provider? Are there adequate government allocations to finance voluntary FP programming?
- “When tested interventions involve a large degree of change in the institutions expected to adopt them, scaling up will require extensive technical support and time.” Are current health worker cadres and family planning service providers adequately trained, deployed, and distributed according to national policies and strategies? How well does the supply chain function to ensure broad distribution of family planning commodities? Are human resources sufficient to provide competency-based trainings and refreshers to the cadre and its supervisors?
- “Adapting health service innovations to changing sociocultural, economic, and institutional contexts in the course of expansion is vital for success.” Is there enough political will to introduce and sustain the task sharing approach? Who are the potential influencers? Who may resist adoption of a task sharing approach?
- “Integrating considerations of gender and human rights into scaling-up task sharing initiatives is essential.” Policies that restrict access to contraceptives may contribute to observed inequities in use and lead to unequal burden of unintended pregnancy among specific population groups. Which cadres are permitted to provide which methods? Does this differ by facility type (clinic or hospital, public or private, drug shops, pharmacies, self-care); geographic setting (rural or urban); or health facility volume (low versus high)?
- “Special attention to monitoring and evaluation is needed as task sharing scaling up proceeds to ensure that results inform strategic adjustments and adaptations.” Monitoring and evaluation enables programs to assess whether the programs are being implemented as planned and to maintain and improve the quality of program services. Mechanisms should be in place to ensure that the health system is accountable to beneficiaries and provides high-quality care.
- Successful task sharing strategies should focus on which cadre(s) and contraceptive method(s) are involved. This determination should be based on the feasibility of the approach, the appropriateness for the country context, and whether it would advance the goals of the family planning program (i.e., increase client satisfaction, increase equity, and/or enhance voluntary uptake of long-term FP methods) while meeting the needs of women and couples.
Consideration 3: Which stakeholders should be involved in developing the task sharing strategy?
A range of stakeholders should be involved in developing the task sharing program to ascertain their potential contributions and/or concerns. This includes high-level decision makers, such as the Ministry of Health and Reproductive Health Units, and other relevant government ministries (e.g., Ministry of Finance, Ministry of Education); private sector health providers; professional associations; regulatory agencies/bodies; beneficiaries; and potential influencers and/or resisters such as husbands/partners, mothers-in-law, religious and traditional leaders, and public figures.
Employing a multi-sectoral approach and soliciting robust stakeholder participation from the onset of planning discussions will ensure that the task sharing approach is developed smoothly. Transparent, collaborative conversations are encouraged and often produce ownership and sustainable results.
Consideration 4: What components are recommended to ensure the cadre is supported by the health system?
A resilient health system contributes to the successful, and sustainable, implementation of a task sharing approach. The task sharing approach should build on and strengthen the current health system without overburdening the task sharing cadre. The cadre should have established links to the health system—for supervision, monitoring and evaluation, client referrals, and data management.
For sustainability, the program should also consider potential difficulties in retaining task sharing cadres. For example, health worker attrition remains high in many contexts. Often, it is beneficial to officially recognize the cadre and its expanded job responsibilities to boost morale and legitimize its role. Further, it is sometimes necessary to ensure the cadre receives adequate incentives and remuneration for its new role and workload.
Consideration 5: How will beneficiaries be informed of task sharing and benefit from service?
As with any significant program change or innovation, newly available services or improvements to existing services must be communicated at the district and county levels, as well as down to the community and individual levels.
Often, pervasive social and cultural norms, including provider bias, dictate whether individuals or couples adopt family planning. Demand generation activities—such as mass media campaigns, mobile health platforms and social media, and community group mobilization sessions—can help to raise awareness about the benefits of family planning, promote the task shared services, and stimulate client demand for services. Determine which information channels, audiences, and messages are most appropriate for the country or regional context.
- Bhadra B, Burman SK, Purandare CN, Divakar H, Sequeira T, Bhardwaj A. The impact of using nurses to perform postpartum intrauterine device insertions in Kalyani Hospital, India. Int J Gynecol Obstet. 2018;143(S1): 33-37. doi: 10.1002/ijgo.12602
- Tilahun Y, Lew C, Belayihun B, Lulu K, Asnake M. Improving contraceptive access, use, and method mix by task sharing Implanon insertion to frontline health workers: The experience of the Integrated Family Health Program in Ethiopia. Glob Health Sci Pract. 2017:5(4):592-602. doi: 10.9745/GHSP-D-17-00215
- Akol A, Chin-Quee D, Wamala-Mucheri P, Namwebya JH, Mercer SJ, Stanback J. Getting closer to people: family planning provision by drug shops in Uganda. Glob Health Sci Pract. 2014:2(4):472-481. doi: 10.9745/GHSP-D-14-00085
- Meuwissen L, Gorter A, Knottnerus A. Impact of accessible sexual and reproductive health care on poor and underserved adolescents in Managua, Nicaragua: A quasi-experimental intervention study. J Adolesc Health. 2006;38(1):56. doi: 10.1016/j.jadohealth.2005.01.009
- World Health Organization (WHO). Practical guidance for scaling up health service innovations. Geneva, Switzerland: WHO, 2009. http://whqlibdoc.who.int/publications/2009/9789241598521_eng.pdf. Accessed September 20, 2019.
- World Health Organization (WHO). Task sharing to improve access to Family Planning/Contraception. Geneva, Switzerland: WHO, 2017. http://apps.who.int/iris/bitstream/10665/259633/1/WHO-RHR-17.20-eng.pdf. Accessed September 20, 2019.
High-Impact Practices in Family Planning (HIPs). Task Sharing Family Planning Services to Increase Health Workforce Efficiency and Expand Access: A Strategic Planning Guide. Washington, DC: USAID; 2019 Sep. Available from: https://www.fphighimpactpractices.org/guides/task-sharing-family-planning-services/
For more information on HIP briefs and on the work of the HIP partnership, please refer to the High Impact Practices in Family Planning website at www.fphighimpactpractices.org or contact the team.