Task-Shifting and Task-Sharing in Neurosurgery: An International Survey of Current Practices in Low- and Middle-Income Countries and Global Perspectives

Abstract

Background: Nearly 5 million essential neurosurgical cases go untreated each year, and over 23,000 more neurosurgeons are needed to bridge this treatment gap, particularly in low- and middle-income countries (LMICs). Consequently, there is a growing interest in delegating neurosurgical tasks to non-specialists, task-shifting and task-sharing (TS/S). However, TS/S is highly controversial, and the current breadth of practice is poorly understood. This research investigated current practices and perceptions of neurosurgical TS/S to elucidate whether it is a permissible, temporary solution to the workforce deficit. Methods: Two separate surveys were conducted between July 2018 – January 2019. The Capacity survey explored TS/S practices in LMICs. The Perspectives survey inquired about perceptions on neurosurgical TS/S in both high-income countries (HICs) and LMICs. Data were analyzed by descriptive statistics and univariate regression of Likert-scale scores. Results: The Capacity survey yielded 126 responses from 46 LMICs; 21 countries (45.7%) reported ongoing TS/S. The majority of TS/S procedures involved emergency interventions; the top three being burr holes, craniotomy for hematoma evacuation, and external ventricular drain. A majority (65.0%) believed that their Ministry of Health does not endorse TS/S (24.0% unsure), and only 11% believed that TS/S training was structured. There were few opportunities for TS/S providers to continue medical education (11.6%), maintenance of certification (MOC; 9.4%), or receive remuneration (4.2%). The Perspectives survey obtained returns from 105 of 194 WHO member countries (54.1%; 391 respondents, 162 from HICs, 229 from LMICs). The most agreed-upon statement was that task-sharing is preferred to task-shifting. There was broad consensus that both task-shifting and -sharing should require competency-based evaluation, standardized training endorsed by governing organizations, and MOC. When perspectives were stratified by income class, LMICs were significantly more likely to agree that task-sharing can address the global shortage of neurosurgery providers, and quickly increase capacity while training and retention programs are expanded. Importantly, LMICs were also significantly more likely to agree that task-shifting is professionally disruptive to traditional training, task-sharing should be a priority where human resources are scarce, and call for additional TS/S regulation, such as MOC, and formal consultation with a neurosurgeon (in-person or electronic/telemedicine). Conclusion: TS/S is ongoing in many LMICs without substantial structure or oversight, which is concerning for patient safety. Both LMIC and HIC countries agreed that task-sharing should be prioritized over task-shifting, and that additional recommendations and regulations could elevate the level of care. This data represents a call to action for future discussions on policy and training programs and has helped inform the upcoming Peshawar Global Neurosurgery Recommendations: “Comprehensive Policy Recommendations for Head and Spine Injury Care in LMICs.”