Effectiveness of Task Sharing and Task Shifting on the Uptake of Family Planning in Kenya

Background: Contraception is an inexpensive and cost-effective intervention, but health workforce shortages and restrictive policies on the roles of mid and lower-level cadres limit access to effective contraceptive methods in many settings. Task sharing and task shifting are strategies that can be adopted to increase uptake of health services including family planning. Methods: We collected data through online survey, key informant interviews and focused grouped discussions with an intervention group and that implemented the task sharing and task shifting policy guidelines and a control group that did not implement the policy. A total of 434 questionnaires were filled by health workers’ in primary health care facilities to assess effectiveness of task sharing and task shifting on the uptake of family planning services including its strengths and challenges. The questionnaire was designed with the aim of getting data on services provided by the cadres on effectiveness (number of clients, increase in use of methods, access to services), how they perceive these tasks, the bottlenecks and facilitating factors associated with the practice of task sharing and task shifting. Results: We found out that the task sharing and task shifting can expand and increase access to services as stated by 95% of the respondents. Most community health workers provided more of the family planning services at 45% with only 5% of the services of family planning being provided by medical officers. 98% of family planning services were integrated with other services. Task shifting was beneficial to the health care providers as well as the clients and the success of task sharing and task shifting depended on training, supportive supervision and a regulated environ-ment through policies. Conclusion: The study shows that formalized task sharing and task shifting can increase health service


Background
Increasing family planning (FP) uptake and providing universal access to reproductive health in resource poor settings has been severely constrained by a shortage of health workers required to deliver interventions [1]. The World Health Organization (WHO) in the Global Health Statistics Report of 2018 projects a shortfall of 12.9 million health workers by 2035, mostly in low-and lower-middle income countries and recommends a threshold of 34.5 skilled health professionals (midwives, nurses and physicians) per 10,000 population [2]. The shortage is most severe in the poorest countries, especially in sub-Saharan Africa, where health workers are most needed. Kenya like other countries faces strains in meeting demands for provision of health services because of limited human resources for health (HRH). This situation has been exacerbated by the continued "brain drain" of highly trained medical workers and more recently by the increased demand for services [3]. In a health workforce assessment conducted in 2016, Kenya had a total of 31, 412 employed in both public and private sector and classified 13 counties as having critical HRH shortages [4]. These numbers were far much below the required numbers at 138,266 as proposed in the staffing norms and standards [5]. In order to increase access to health services, the country developed a Task Sharing and Task Shifting Policy Guidelines on 2017 to expand roles of existing workforce while also acknowledging the role that can be played by community health workers in increasing access to health services [6] [7]. Currently, Kenyan health workforce density stands at 9.81 health workers per 10,000 population and indeed will take several years to achieve the WHO recommended minimum HRH levels [8]. Task shifting involves rationally moving some tasks from one cadre to another, such as nurses, midwives, or community health workers. Tasks are moved where appropriate to less specialized health workers. By reorganizing the workforce in this way can make more efficient use of the human resources currently available [9], for example, when doctors are in short supply, a qualified nurse could often prescribe and dispense medication. Some informal task sharing and shifting had been going in the country un documented and the development of the TSTSPG would help in reorganizing health service delivery through formalized task sharing and task shifting especially where shortages of HRH are so high to improve intended health outcomes as outlined in the Kenya Health Policy and Vision 2030 [10].
Contraception is an inexpensive and cost-effective intervention [11], but health workforce shortages and restrictive policies on the roles of mid and low- Advances in Reproductive Sciences er-level cadres limit access to effective contraceptive methods in many settings [12]. The growing use of contraceptive methods in recent decades has resulted not only in improvements in health-related outcomes such as reduced unintended pregnancies, high-risk pregnancies, maternal mortality, and infant mortality, but also in improvements in schooling and economic outcomes, especially for girls and women [13]. Beyond the impacts of contraceptive use at the individual level, there are benefits at the population level. From a macroeconomic perspective, reductions in fertility enhance economic growth as a result of reduced youth dependency and an increased number of women participating in paid labour [14]. alongside the condoms and pills in the rural and marginalized areas to increase family planning access. It is against this background that the study sought to determine effectiveness of implementing task sharing and task shifting on the uptake of family planning in selected counties of Kenya. Advances in Reproductive Sciences We set out to assess the effectiveness of task sharing and task shifting on the uptake of family planning selected counties of Kenya. We categorized the counties into two categories; those counties that had authority to implement the Task Sharing and Task Shifting Policy and Guidelines (TSTSPG) of 2017 and those that were not authorized to implement the TSTSPG (2017). Our study aims to add evidence on strategies that increase and optimize available health workers in cases of shortages and provide evidence on the effectiveness of task sharing and task shifting on family planning uptake especially where legal frameworks through policies and policy guidelines exist.

Study Design
The research adopted both qualitative and quantitative methods. While the initial intention of the study was to adopt a quasi-randomized control trial to evaluate the effectiveness of task sharing and task shifting, this was not possible as the control sites had implemented the interventions as well. Therefore a de- Those who responded were more than the sample by 67 giving a total of 434 health workers. Five national county directors at MoH and 10 county reproductive health coordinators from the 10 counties included in the study.

Data collection
The researchers designed and pre tested both closed and open ended questionnaires that were administered online through a Survey Monkey to 424 health well informed about the purpose of the study and why they were being asked to participate. They were also informed that participation was voluntary and they had the right to withdraw from the study at any time of the study even after they had participated. We also assured the respondents of their confidentiality, anonymity, and privacy. We also requested for consent for the audio recordings of the focus group discussions with the MoH directors.

Results
A total of 424 healthcare providers responded by filling in all the questions giving a response rate of 118.3% against the proposed sample of 367. The response rate in this study surpassed the target. The responses were obtained from 10 counties as shown in Figure 1 and Figure 2 showing the distribution of the participants to either the control group (n = 77) or the intervention group (n = 347). Majority of the respondents (37%) were aged between 35 and 44 years old.
Most of the respondents had attained college level of education (43%) and most of them were nurses (45%).
Out of the 424 respondents from the intervention and control groups, 411 (95%) recorded that they were aware of the policy and its role, 12 (3%) were not sure of such policy guidelines' existence and the role they played in the optimization of the staffing numbers. 6 (1%) did not know whether such a policy existed and only 5 (1%) stated that they were not aware of the policy guidelines on task sharing and task shifting in the health sector. The health care providers at all the levels of care registered broad consensus regarding their awareness of the implementation of task sharing and task shifting practices in the country. In relation to this common understanding among informants, they noted the importance of Advances in Reproductive Sciences  the policy guidelines that mandated them to offer particular services.
On effectiveness of task sharing and task shifting through engagement of the CHWs, the study noted that the mainly sought services were short term family planning methods and the preferred providers were the community health workers at 43%. The nurses only provided short terms services to 26% of the clients, 24% by clinical officers 24% and only 5% sought the services from medical officers. Its integration with other services like postpartum services (100%), post-abortion care (92%) and HIV services (78%).
Out of the 133 clients interviewed, 80(60%) preferred the short term acting methods of family planning from the options available in the facilities, followed by 29% (39/133) of clients who preferred long acting methods while 9(7%) preferred natural method. The least preferred methods ((4%) was permanent methods.
Overall, all the groups of the respondents provided benefits of the task sharing and task shifting as shown in Table 1. Majority of healthcare providers (99%) reported that the benefit of task sharing and task shifting was that it enables a wide range of providers to access and increases uptake of FP services, while 100% of directors at MoH reported the potential of the approach to positively contribute to strengthening health systems. 98% of clients reported the approach as having the potential to lower cost per visit since community health volunteers are flexible and would avail themselves without them traveling to the facilities.
On the overall judgment on the effectiveness of task sharing and task shifting as a strategy to increase the uptake on family planning services, (52%) stated task sharing and task shifting was good, followed by 33% who stated that task sharing and task shifting as a practice was very good and 9% judged the strategy as excellent. Only 6% stated that task sharing and task shifting was average as indicated in the trends of increase in family planning uptake.
Effectiveness of task sharing and task shifting is shown in Figure 3 and

Discussion
Kenya's health worker shortage hampers delivery of health services and especially in rural areas. The country has committed to increase access to and use of quality FP services by all and especially by the poor, vulnerable and marginalized populations-and achieves a mCPR of 58% by 2020 and so the TSTSPG is one such strategy under implementation towards that goal. The expansion of roles of nurses and clinical officers and the introduction of community health care workers in providing family planning services in the dispensaries, health centers and community units has tremendously increased access to the women and girls. From the results, the community health care providers appear to reach out to more clients who are far away from the facilities and they are popular with short acting methods. Health workers serving at clinical settings are the link with CHWs, and they foster local ownership of community-based interventions, ensure sustainability, efficiency, and to improve rapport between facility-and community-based health care providers. Health workers continue to provide mentorship and follow up [20] [21] [22].
Findings indicate that CHWs have often shown convincing effects on program outputs, outcomes, and impacts. A review by [23] concludes that "…there is robust evidence that CHWs can undertake actions that lead to improved health outcomes…" while a second commentator states "There is no longer any place for discussion of whether CHWs can be key actors in achieving adequate health care" [24]. However, the same authors also concede that many programs are not successful and call for careful planning and research to identify and overcome problems. Task sharing has been applied for many years in family planning programs as various tasks get shared between doctors and nurses or between nurses and community health workers. The consensus reported in a recent WHO document, "Task Shifting to Tackle Health Worker Shortages", was that task sharing "will positively affect health outcome… Good management, support, supervision and political commitment," are needed for success [25].
To increase family planning uptake in most countries [26] [27] suggest that novel approaches such as integration of family planning with other health services are needed to extend access to family planning services to women and couples who desire to limit or space their childbearing but are not currently using contraceptives.
The study had some limitations. It intended to cover two different sets of counties (the intervention counties and the control counties) in Kenya to compare the results.
1) The counties that had been authorized to implement the TSTSPG due to staffing shortages.
2) The counties that were perceived to have adequate staffing; and thus had restrictions on the use of the TSTSPG.
However, during data collection it was noted that all the counties both implemented the policy due to staffing shortages of one cadre or the other. Therefore, the analysis had no opportunity to separate the intervention counties and the control counties and only recorded the effectiveness of task sharing and shifting on the uptake of family planning in Kenya. Lastly, access to client or beneficiaries of family planning was limited as the targeted numbers could not be reached thus low response. However, the study used the client satisfaction survey reports to fill in the gap. Advances in Reproductive Sciences The results reveal that task sharing and task shifting are beneficial to both the health care providers and the beneficiaries. To the nurses and clinical officers, task sharing and task shifting freed up their time to undertake more complex tasks while the community healthcare workers undertook counselling and provision of short acting family planning methods.
While challenges like commodities stock outs, professional resistance and inadequate remuneration exist; opportunities exist for improving and scaling up task sharing and task shifting. We recommend further studies that compare task sharing and task shifting where policies exist with where no policies formalizing the process exist. Standardization and harmonization of training and supportive supervision are needed to ensure that the new cadres can effectively perform. The supply of family planning commodities should be addressed together with incentives for the success of the task sharing and task shifting strategy.

Conclusion
The study concluded that task sharing and task shifting interventions have the potential in increasing family planning uptake especially where the policy environment is conducive. Delivery of services in the community increases access to the communities due to the flexibility of delivery and community health workers play a critical role in community services, thereby reducing unmet family planning needs. However, standardized training, supportive supervision and incentives are critical to ensure sustainability of the strategy.

Authors' Contributions
All the authors have read and approved the final manuscript.