title: What does the literature tell us about health workers' experiences of task-shifting projects in sub-Saharan Africa? A systematic, qualitative review.
abstract: OBJECTIVE
  To review systematically, qualitative literature covering the implementation of task shifting in sub-Saharan Africa to address the growing interest in interventions of this kind. This review aims to distil the key practical findings to both guide a specific project aiming to improve the quality of neonatal care in Kenya and to contribute to the broader literature.
  
  
  BACKGROUND
  Task-shifting programmes aim to improve access to healthcare by delegating specific tasks from higher to lower skilled health workers. Evidence suggests that task-shifting programmes in sub-Saharan Africa may improve patient outcomes, but they have also been criticised for providing fragmented, unsustainable services. This systematic review of qualitative literature summarises factors affecting implementation of task shifting and how such interventions in sub-Saharan Africa may have affected health workers' feelings about their own positions and their ability to provide care.
  
  
  METHODS
  Following literature search, a modified Critical Appraisal Skills Program (CASP) framework was used to assess quality. Thereafter, analysis adopted a thematic synthesis approach.
  
  
  METHODS
  A systematic literature search identified qualitative studies examining task -shifting interventions in sub-Saharan Africa. Thematic synthesis was used to identify overarching themes arising from across the studies and infer how task-shifting interventions may impact on the health workers from whom tasks are being shifted.
  
  
  RESULTS
  From the 230 studies screened, 13 met the inclusion criteria. Overarching themes identified showed that task shifting has been associated with jurisdictional debates linked to new cadres working beyond their scope of practice, and tension around compensation and career development for those taking on tasks that were being delegated.
  
  
  CONCLUSIONS
  Based on the qualitative data available, it appears that task shifting may negatively impact the sense of agency and the ability to perform of health workers' from whom tasks are shifted. The potential implications of task shifting on all health workers should be considered prior to implementing task-shifting solutions.
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK.|McMaster University Children's Hospital, Hamilton, Ontario, Canada.
authors.forename: Hana
authors.initials: H
authors.lastname: Mijovic
authors.affiliation: Oxford Health Systems Collaboration - Africa (OHSCAR), Nuffield Department of Medicine, University of Oxford, Oxford, UK.
authors.forename: Jacob
authors.initials: J
authors.lastname: McKnight
authors.affiliation: KEMRI Wellcome Trust Research Programme, Nairobi, Kenya.|Nuffield Department of Medicine, University of Oxford, Oxford, UK.
authors.forename: Mike
authors.initials: M
authors.lastname: English
mesh_terms: D017954:Africa South of the Sahara; D003695:Delivery of Health Care / Q000458:organization & administration*; D006801:Humans; D036301:Qualitative Research; D016526:Workload
keywords: capacity issues; neonatal care; neonatal nurseries; nursing workforce; sub-Saharan Africa; task-shifting