ICTworks

The World Health Organization estimates that we need 18 million more frontline health workers (FLHWs) by 2030 to achieve the SDG targets and other global health aspirations. It’s a complicated problem with a dizzying array of solutions – but all fundamentally align with just three strategies:

1. Get more – Bring more FLHWs into the workforce, whether it be by increasing the throughput of pre-service training institutions, or by upskilling and accrediting existing informal workers so they can be officially counted, or by increasing the number of funded health worker posts
2. Lose less – Do a much better job of supporting the existing workforce to retain the FLHWs we already have
3. Do more – Work smarter with the FLHWs we already have, so that health worker teams can cover a larger proportion of the population while still providing quality care

The Johnson & Johnson Center for Health Worker Innovation is exploring all three of these strategies, but this post will focus only on the third: boosting the reach and productivity of the existing health workforce.  Task shifting between health cadres is an established approach to increase the efficiency of health service delivery, but increasingly task shifting to virtual services is an opportunity for health systems to do more with the FLHWs they currently have.

What is Task Shifting?

The WHO defines task shifting as the rational redistribution of tasks among health workforce teams to maximize efficiency and health worker productivity. Each health worker operates within a scope of practice that fully utilizes his/her skills and capacity, with seamless patient referral to the next appropriate cadre of health worker whenever the required task falls outside this scope.

This is easy to imagine, but challenging to implement as it requires health workers to function effectively within distributed, interprofessional teams that span both community-based and facility-based care, and primary through tertiary services. Our work on Tech-supported Teams explores how digital health can support this process.

Task Shifting to Virtual Services

But task shifting can go even further. Some health worker tasks can be shifted to lay workers (including staff of call centers, help desks and hotlines), directly to the client, or to full automation.

We’ve been seeing this in healthcare for decades in small ways (e.g., use of an automated blood pressure cuff vs manual blood pressure readings) but now we’re also seeing an explosion of virtual health education, counselling, monitoring, testing and reminder services using mobile messaging, hotlines and call centers, chatbots, apps, home testing kits and wearables.

The challenge, however, is that most of these virtual services exist in parallel to brick ‘n’ mortar health services with little to no integration (there are some notable exceptions, particularly national hotlines offering triaging services like the NHS 111 service in the UK).

The academic literature focuses on individual health outcomes such as increased health literacy, adoption of healthy behaviors, or improved medication adherence – with very little research focused on the health system impacts of such services, barring some discussion of demand generation with increased uptake of services.

This lack of integration creates some important shortcomings. It is very difficult to appropriately escalate patients from virtual services to face-to-face care (and vice versa) when required. Virtual services are seldom a tool that an individual health worker can usefully deploy during patient care to alleviate his/her workload.

It is near impossible to quantify the full contribution of virtual services to overall health service delivery, meaning these services cannot be practically factored into health workforce planning when addressing the projected health workforce shortage.

Integrated Virtual Services

Imagine, instead, a future scenario where virtual services are seamlessly integrated into the health worker’s daily workflow:

1. A community health worker (CHW), Ajitha, visits a household and confirms that her patient Swati is pregnant. Ajitha is immediately able to register Swati for a package of weekly mobile messages with information for pregnancy, the port-partum period and early childhood.
2. Ajitha is guided to check in on Swati by an automated workflow system. Updates to Swati’s health record automatically customize her weekly mobile messages. Ajitha’s manager uses the workflow system to make sure all pregnant women in the catchment area are seen on a regular basis, with enough time for each visit to be effective.
3. Several months later Swati reads a mobile message noting that headaches and blurred vision are symptoms of concern in pregnancy. She immediately contacts a helpdesk, engaging first with an automated bot but later with a human operator based on the content of her query and her health record.
4. The human operator opens a helpdesk ticket, which automatically activates a task for Ajitha, Swati’s CHW, to conduct an urgent home visit. Ajitha’s examination confirms symptoms warranting a hospital referral. When Ajitha marks her visit with Swati as complete, this automatically updates the helpdesk ticket, Swati’s health record, and Ajitha’s workflow system.
5. Swati is seen at the facility and her health record speeds up the diagnosis of pre-eclampsia. She is escalated to an emergency cesarean section. When she is discharged, Ajitha activates an additional short package of mobile messages for Swati with warning signs for wound infection and other post-operative complications. She invites Swati to join a post-partum WhatsApp support group.

In this scenario, the virtual services become another useful tool for the health worker – a ‘digital prescription’ that can be offered alongside any physical therapies. They may also allow Ajitha to serve more households because she is not required to manually respond to every one of Swati’s medical queries – alongside the queries of the many other mothers and families in her catchment area.

These ideas are not new. We are all familiar with customer service models in other sectors that use ticketing systems to blend fully automated services like chatbots with call center/helpdesk agents and face-to-face interaction in order to triage incoming queries and provide quality customer service at scale with a limited workforce. These sectors provide an example of how we can harness technology more deliberately to bridge health worker gaps.

Through the Johnson & Johnson Foundation, we have supported the evolution of virtual services in low- and middle-income countries for a decade, working with partners like Praekelt.org, VillageReach, ARMMAN, UNICEF and Jacaranda Health. Our work began with content development and investments to support one-way mobile messaging in maternal and child health and has evolved to interactive messaging and chatbots, AI-powered helpdesks and call centers. These programs have grown to national scale, served millions of users, and demonstrated improved health outcomes.

But when we ask ourselves what role this work has played in helping to reduce the FLHW coverage gap, there is no easy way to quantify the impact.

For our team, this is the next frontier for investment and inquiry in this field: the pursuit of seamlessly integrated virtual services to measurably support our over-burdened frontline workforce in their efforts to provide universally accessible, patient-centered care. We’re seeing movement in this direction such as the newly-launched mothers2mothers Virtual Mentor Mother service and an integration between Turn.io and OpenSRP.

We call this body of work Health in Your Hand, and we invite other interested funders, implementers and researchers to join us in this conversation and share their insights.

By Joanne Peter, Johnson & Johnson Center for Health Worker Innovation