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Open Access

Peer-reviewed

Research Article

Task-sharing for non-communicable disease prevention and control in low- and middle-income countries in the context of health worker shortages: A systematic review

  • Azeb Gebresilassie Tesema ,

    Roles Data curation, Formal analysis, Visualization, Writing – review & editing

    a.tesema@unsw.edu.au

    Affiliations School of Population Health, UNSW, Sydney, Australia, The George Institute for Global Health, UNSW, Sydney, Australia

    ⨯
  • Sikhumbuzo A. Mabunda,

    Roles Data curation, Formal analysis, Visualization, Writing – review & editing

    Affiliations School of Population Health, UNSW, Sydney, Australia, The George Institute for Global Health, UNSW, Sydney, Australia, Department of Public Health, Walter Sisulu University, Mthatha, South Africa

    ⨯
  • Kanika Chaudhri,

    Roles Data curation, Formal analysis, Visualization, Writing – original draft

    Affiliation The George Institute for Global Health, UNSW, Sydney, Australia

    ⨯
  • Anthony Sunjaya,

    Roles Data curation, Formal analysis, Visualization, Writing – original draft

    Affiliation The George Institute for Global Health, UNSW, Sydney, Australia

    ⨯
  • Samuel Thio,

    Roles Data curation, Writing – review & editing

    Affiliation School of Population Health, UNSW, Sydney, Australia

    ⨯
  • Kenneth Yakubu,

    Roles Data curation, Writing – review & editing

    Affiliation The George Institute for Global Health, UNSW, Sydney, Australia

    ⨯
  • Ragavi Jeyakumar,

    Roles Data curation, Writing – review & editing

    Affiliation School of Population Health, UNSW, Sydney, Australia

    ⨯
  • Myron Godinho,

    Roles Data curation, Writing – review & editing

    Affiliation Westmead Applied Research Centre, University of Sydney, Australia

    ⨯
  • Renu John,

    Roles Data curation, Writing – review & editing

    Affiliation The George Institute for Global Health, UNSW, Delhi, India

    ⨯
  • Mai Eltigany,

    Roles Validation, Writing – review & editing

    Affiliation World Health Organization, Geneva, Switzerland.

    ⨯
  • Martyna Hogendorf ,

    Roles Validation, Writing – review & editing

    ‡ These authors are joint senior authors on this work.

    Affiliation World Health Organization, Geneva, Switzerland.

    ⨯
  • Rohina Joshi

    Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Project administration, Supervision, Validation, Writing – original draft, Writing – review & editing

    ‡ These authors are joint senior authors on this work.

    Affiliations School of Population Health, UNSW, Sydney, Australia, The George Institute for Global Health, UNSW, Sydney, Australia, Westmead Applied Research Centre, University of Sydney, Australia

    ⨯

Abstract

Health workers are pivotal for non-communicable disease (NCD) service delivery, yet often are unavailable in low- and middle-income countries (LMICs). There is limited evidence on what NCD-related tasks non-physician health workers (NPHWs) can perform and their effectiveness. This study aims to understand how task-sharing is used to improve NCD prevention and control in LMICs. We also explored barriers, facilitators, and unexpected consequences of task-sharing. Databases searched in two phases and included MEDLINE, EMBASE, CENTRAL, CINAHL, Cochrane, and clinical trial registries, and references of included studies from inception until 31st July 2024. We included randomised control trials (RCTs), cluster RCTs, and associated process evaluation and cost effectiveness studies. The risk of bias was assessed using the Cochrane Risk of Bias Tool v2. PROSPERO: CRD42022315701. The study found 5527 citations, 427 full texts were screened and 149 studies (total population sample>432567) from 31 countries were included. Most studies were on tasks shared with nurses (n=83) and community health workers (n=65). Most studies focussed on cardiovascular disease (n=47), mental health (n=48), diabetes (n=27), cancer (n=20), and respiratory diseases (n=10). Seventeen studies included two or more conditions. Eighty-one percent (n=120) of studies reported at least one positive primary outcome, while 19 studies reported neutral results, one reported a negative result, eight (5.4%) reported mixed positive and neutral results, and one reported neutral and negative findings. Economic analyses indicated that task-sharing reduced total healthcare costs. Task-sharing is an effective intervention for NCDs in LMICs. It is essential to enhance the competencies and training of NPHWs, provide resources to augment their capabilities, and formalise their role in the health system and community. Optimising task-sharing for NCDs requires a holistic approach that strengthens health systems while supporting NPHWs in effectively addressing the diverse needs of their communities.

Registration: PROSPERO CRD42022315701.

Citation: Tesema AG, Mabunda SA, Chaudhri K, Sunjaya A, Thio S, Yakubu K, et al. (2025) Task-sharing for non-communicable disease prevention and control in low- and middle-income countries in the context of health worker shortages: A systematic review. PLOS Glob Public Health 5(4): e0004289. https://doi.org/10.1371/journal.pgph.0004289

Editor: Roopa Shivashankar, Indian Council of Medical Research, INDIA

Received: September 10, 2024; Accepted: January 28, 2025; Published: April 16, 2025

Copyright: © 2025 Tesema et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data collected for the study is provided within the manuscript. Additional related documents are available in the supplementary section.

Funding: This review was funded by the World Health Organization (WHO). ME and MH received salaries from WHO. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Background

Low and middle-income countries (LMICs, as defined by the World Bank) have a rising prevalence of non-communicable diseases (NCDs)[1,2]. They have a proportionately younger population, and yet their age-standardised mortality rate for cardiovascular diseases (CVD) is greater than that of higher-income nations[1]. People living with NCDs rely on health systems to deliver a continuum of appropriate, affordable, and high-quality services for preventing, treating, and rehabilitating NCDs. This global trend necessitates that health services transition towards models of care that are patient centred, accessible to communities, and which improve health outcomes[3]. The World Health Organization (WHO) has committed to strengthen and orient health systems to address NCDs through integrated people-centred primary health care, towards achieving universal health coverage (UHC)[4]. A set of cost-effective interventions are further recommended for wide implementation to assist countries in reaching global targets for NCDs[5].

Health workers are pivotal for NCD service delivery, yet often remain the limiting factor in health systems due to shortages or lack of training[6,7]. In order to meet UHC targets, the world needs more than 43 million additional health workers. Estimates suggest that per 10,000 population, countries need at least 20.7 physicians, 70.6 nurses and midwives, 8.2 dental personnel, and 9.4 pharmaceutical workers to achieve an effective coverage index score of 80 out of 100 [8]. The most acute health workforce shortages are experienced in LMICs, particularly in sub-Saharan Africa, South Asia, North Africa and the Middle East[8]. LMICs are faced with critical decisions on how to “shape” the health workforce to be fit-for-purpose, ensuring that future and current health workers have the required competencies, supervision, resources, and motivation to deliver quality care. An emerging approach for addressing this workforce need is ‘task sharing,’ which comprises the redistribution of health care tasks within workforces and communities[9]. According to Orkin et al., this occurs “when tasks are completed collaboratively between providers with different levels of training”[9].

The current evidence on which occupational groups can perform which tasks is limited[10]. Occupational groups with a shorter duration of pre-service education (i.e. community health workers (CHWs), non-physician clinicians, etc.) have seen a continual expansion of their tasks, based on population needs, yet their roles sometimes lack clear definition. Evidence indicates that non-physician health workers (NPHWs) (e.g. community health workers, nurses) can deliver various aspects of healthcare traditionally considered to require a physician. Although, this comes with inadequate regulatory protection, supervision, guidance, training, etc. [11]. A 2019 overview of systematic reviews analysed the barriers and facilitators to the delivery of care for NCDs by NPHWs in LMICs and provided high-level recommendations for health systems considering the adoption of task-sharing approaches [11]. However, being an overview of reviews, this study did not inspect individual interventions to identify their models of care or understand how tools and mechanisms were used to enable task-sharing. Therefore, this systematic review aims to understand the effectiveness of task-sharing and how it is used to improve NCD prevention and control in LMICs. We also explore the barriers, facilitators, and unexpected consequences of task-sharing.

Methods

This systematic review assessed the task sharing for NCDs in LMICs by NPHWs. PROSPERO CRD42022315701.https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022315701

Search strategy and selection criteria

We search MEDLINE, EMBASE, Cochrane, CENTRAL (Cochrane Central Register of Controlled Trials) and CINAHL in two phases; initially from the beginning of each database until 4th March 2022[12] and then updated the search from 1st March 2022 to 31st July 2024. Further studies were obtained from scanning reference lists of relevant studies and citation searching of key papers identified for inclusion. We searched references obtained from Cochrane Database of Systematic Reviews and search trial databases such as Clinicaltrials.gov for relevant studies. A search strategy was developed with the support of a medical librarian. We used Covidence to conduct the review[13]. Search terms are included in S1 Appendix. The following outcomes were assessed:

  1. Which interventions related to prevention and control of NCDs (including prevention, promotion, management, rehabilitation, and palliation) are delivered by non-physician health workers? This included patient related outcomes (e.g., blood pressure control for hypertension related studies) indicating effectiveness of intervention delivery. We also reviewed system-related outcomes (e.g., NPHW workload) and unintended consequences of task-sharing (e.g. any harm caused).
  2. Enablers and barriers for task-sharing for NCD prevention and control

Task-sharing refers to the redistribution of healthcare tasks across providers with varying levels of training to address workforce shortages. This can involve expanding the roles of existing health workers, such as nurses or CHWs or incorporating additional resources like volunteers or faith healers. The approach often utilizes a multidisciplinary team, which may include CHWs, nurses, and, in some cases, physicians [9].

Inclusion criteria comprised health facilities and communities in LMICs. Interventions involved NPHWs delivering prevention, screening, management, referral, rehabilitation, palliation for NCDs (such as diabetes, CVD, respiratory diseases, mental health disorders, cancer). Studies were included if physicians were involved with NPHWs as part of a multidisciplinary team.

This systematic review included randomised control trials (RCTs), cluster RCTs, and their associated process evaluation and cost-effectiveness studies. We included studies published in English, French and Spanish. Articles were excluded if they were not a peer reviewed article, not a report based on empirical research, pilot studies, not reported in English, Spanish or French, and research conducted on non-human subjects. Additionally, studies with fewer than 50 participants were excluded based on the sample size criterion. In both phases of search, two researchers independently reviewed and selected studies and articles against the inclusion criteria. Discrepancies between the reviewers were resolved by consultation with the team led by a third reviewer. In the case of duplicate reports, the paper with the most information was included.

Data management and analysis

The shortlisted articles were exported to Endnote X9 (Thomson Reuters, NY, USA) for storage of study records, abstracts, and full text articles [14]. Data was stored on a password protected server-based platform that was accessible by the reviewers. Covidence, a systematic review platform, was used to streamline the process of reviewing articles. Data were collected using a standardised data extraction form. The form was piloted and optimised by two reviewers using a subset of three randomly selected studies that satisfied the eligibility criteria. Information outlined in the standardised data extraction form was collected by two reviewers independently. Data was cleaned and analysed using narrative synthesis. This was supplemented with tables and figures where appropriate. We used the PRISMA guidelines to optimize the quality of reporting.

Risk of bias assessment

The risk of bias was assessed by two independent reviewers using the Cochrane Risk of Bias Tool v2[15, 16]. The assessment was performed at study level and focused on selection, performance, detection, attrition, and reporting bias. We did not exclude studies with a high risk of bias as we wanted to include all contexts. Furthermore, it is known that adhering to all critical aspects of study design is not always feasible in the health system setting, making some trials more vulnerable to bias[17].

Role of funding source

The funder of the study had no role in study design, data collection, data analysis or data interpretation.

Results

Search and study selection

The search retrieved 4858 potentially relevant studies in the first phase and 669 articles in the second phase, totalling 5527 studies. In the first phase, 1372 duplicates were removed, and five duplicates were removed in the second phase. After an initial screening of title and abstract of 4150 articles (3486 citations (phase 1) and 664 (phase 2)), 427 (399 (phase 1) plus 28 (phase 2)) full text articles were assessed of which 278 (261 (phase 1) plus 17 (phase 2)) did not meet the eligibility criteria. A total of 149 (138 (phase 1) and 11 (phase 2)) studies were included in the final review (Fig 1).

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Fig 1. PRISMA Flow chart of study retrieval and selection.

https://doi.org/10.1371/journal.pgph.0004289.g001

Summary of included studies

One-hundred and forty-nine (149) RCTs representing at least a total of 432,567 patients were included in this review. This is because one study was a cluster randomised controlled trial with the intervention implemented and assessed at household level (29000 households). This current study did not impute the average number of individuals in each household but instead used a ratio of 1:1 for each household and individuals to get the absolute minimum sample size. The smallest study included 50 participants[18] and the two largest studies included 151,538 participants from the same cohort, which we counted once[19, 20]. The third largest studies [21, 22] included 33,995 participants from the same cohort, which we also counted once. Table 1 summarises the characteristics of included studies. Trials were published between 2001[23] and 2023[24–28] in peer reviewed journals. On average, about 10 studies were published each year since 2014-2022, with the highest being 20 published in 2020. Almost two-thirds of the studies were conducted in Asia (64%, 96/149), with 21% (31/149) from Africa, and the rest from Europe (5%, 7/149), South America (9%, 14/149), and 1% (1/149) in each of Oceania and North America. One multi-centre study was done in both Asia and South America[29].

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Table 1. Characteristics of articles.

https://doi.org/10.1371/journal.pgph.0004289.t001

The studies originated from a total of 31 countries and there were five multi-country studies[29–33](Fig 2). Most studies (99%, 147/149) were in English and, one each in Spanish and in French. Fifty percent (75/149) of studies were conducted in urban compared to 26% (38/149) in rural areas, 17 studies (11%) were conducted in both urban and rural areas. The remaining, 13% (19/149) did not specify where they were conducted. Most studies (54%, 80/149) were conducted in the community, and 44% (66/149) were conducted in health centres or hospitals, with five studies in a combination of these settings[29–31,33,34]. Thirteen studies had a published process evaluation, and 11 studies conducted a cost-effectiveness evaluation. Workforce related outcomes (e.g. workload, frustration, satisfaction) were reported by studies that included process evaluations.

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Fig 2. Number of studies extracted in each country. Source of the basemap shape file:

https://datacatalog.worldbank.org/search/dataset/0038272/World-Bank-Official-Boundaries.

https://doi.org/10.1371/journal.pgph.0004289.g002

Workforce involvement in task-sharing interventions

The workforce varied across different studies and contexts with 44% (65/149) interventions employing CHWs, and 56% (83/149) of studies using nurses (Table 2). Four studies included only dietitians or nutritionists [35–37] and three study lay health workers. Interventions included a range of services relating to prevention and health promotion (10%), screening (3%), management (36%), rehabilitation (3%) and palliation (1%). Majority (47%) involved a combination of activities including prevention, screening, management, referral and rehabilitation.

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Table 2. Characteristics and outcomes of the interventions.

https://doi.org/10.1371/journal.pgph.0004289.t002

By comparison, CHWs were mostly involved in health education, screening and referrals. CHWs also conducted management in few studies. Some studies had multidisciplinary teams including the primary healthcare (PHC) team of CHWs, nurses, PHC doctor and a specialist or team of specialists[38–44]. Most studies reported providing training or employed a trained health workforce (69%, 103/149) and 39% (59/149) of studies reported having a supervisory structure for the workforce. None of the studies indicated evidence of harm of task-sharing NCD related interventions.

Uses of digital health in task-sharing

The intervention involved digital health solutions in 15 studies. Four of the digital health studies included nurses[45–48] and six included CHWs[29, 33, 49–51] or lay health workers[52]. Three studies had a team of a doctor with either CHW or nurse, and one study involved a multidisciplinary team of five specialists and a nurse[44]. Twelve out of the 15 studies included management of the condition[29,33,44,48–56], one focussed on rehabilitation[57], one on screening[58], and one focussed on education[46].

Digital health interventions included the use of clinical decision support tools and electronic health records to help the NPHW with diagnosis, treatment and referral[29,33,49,51,53,54]. In one study, a smartphone application was used by the patients to set reminders to improve medicine adherence[24]. Smartphone applications were also used to train CHWs[49, 50, 54], to enable online patient support groups[46] and to correspond with patients[24,52].

Diseases addressed by task-sharing interventions

The diseases or conditions investigated varied between the studies (Table 1). Most studies focussed on cardiovascular disease or its risk factors (32%, 47/149). Of these, studies specifically focused on hypertension (43%, 30/47), ischaemic heart disease (15%, 7/47), heart failure (13%, 6/47), and CVD risk factors in general (32%, 15/47). The second most common condition studied was mental health (32%, 48/149) which included depression, anxiety, and post-traumatic stress. eighteen percent of all studies focussed on diabetes (27/149). Cancer was investigated in 13% (20/149) of the included studies. Of these, interventions specifically focused on breast cancer (55%, 11/20), cervical cancer (30%, 6/20), and gastrointestinal cancer (15%, 3/20). Respiratory conditions included asthma and chronic obstructive pulmonary diseases (7%,10/149). One study focussed on the management of chronic kidney disease (1/149). Seventeen studies (11%) included two or more conditions, and 13 of this included mental health along with another chronic illness.

Was task-sharing effective in improving health outcomes?

Out of the 149 studies, 120 studies (81%) reported a significant primary outcome (or at least 1 significant primary outcome), while 19 studies reported neutral results, and one reported a negative result. Table 1 highlights the effect of each outcome. All the task-sharing studies involving the care for cancer morbidity reported at least one positive primary outcome. Twelve of the 15 task-sharing studies which used a digital health intervention reported at least one positive primary outcome, while three reported non-statistically significant outcomes[48,54,59]. Outcomes of all task-sharing interventions are shown on Table 2. In studies where the primary outcome was not achieved, results demonstrated that task-sharing for NCD prevention and control was acceptable, feasible, and resulted in better treatment uptake[53,60–62].

Moreover, Fig 3 illustrates the distribution of studies across various NCD conditions, types of NPHWs, and their associated primary outcomes. A significant number of studies reported positive outcomes for CVD when CHWs and nurses were involved. Additionally, larger studies highlighted positive outcomes for mental health conditions with CHWs, while nurses showed positive results for diabetes management.

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Fig 3. Number of studies by NCD conditions, types of NPHWs, and primary outcomes.

Footnote. Nurse: Includes all roles involving nurses, midwives, and advanced practice nurses. CHW: Refers to community health workers, lay health workers, and similar roles. Mixed: Combines roles, such as CHWs and nurses, or interdisciplinary teams, including physicians. Other: Encompasses roles that do not fall into the above categories, such as dietitians and researchers.

https://doi.org/10.1371/journal.pgph.0004289.g003

What does process evaluation reveal about task-sharing?

The enablers of these studies included the context in which NPHWs carry out their activities, their relationship and trust with the community, support by the leadership and training provided[52,61,63,64]. Training was determined to be vital for these interventions as it provided NPHWs the necessary skills, knowledge, and confidence to deliver health care for NCDs[61, 62]. Another necessary enabler was the availability of resources such as equipment to measure blood pressure or strips to check blood glucose, and a regular medicine supply[63]. The use of digital health tools demonstrated quality improvement and provided standardised and evidence-based care to communities[53]. The simplicity of the intervention, leveraging existing infrastructure and resources, and a collaborative care model facilitated the intervention’s success[52,63]. Some studies provided free medicines or phones with prepaid data to support the implementation of the intervention. Nonetheless, the sustainability and scale-up of these interventions is debatable[52]. Support from senior managers and leaders was considered critical for the success of task-sharing interventions[63,65]. Legitimising the role of the NPHW to ensure community acceptability, especially as they provide new services for conditions such as NCDs was considered essential[61].

Key barriers included the non-availability and erratic supply of medicines in public health facilities [53,60], distrust in the medicines available [61], a lack of equipment [63] and long waiting times for the PHC[64]. Furthermore, interventions that required space for delivery such as counselling or patient education found that many PHCs prioritised conditions such as HIV over NCDs and did not allocate any space within the health facility[60,62,65]. Some evaluations identified challenges such as poor management processes, poor relationships between PHC workers and conflict with higher level occupational groups[60,63]. NPHWs navigated this barrier with the support of community leaders or influential stakeholders[62]. Transportation for patients to attend the PHC, and health workers to visit patients at home, especially those who did not reside in the same community was identified as another barrier[63, 64]. Nurses also felt the need to improve mechanisms to store patient information at the PHC[63].

Is task-sharing a cost-effective intervention?

Thirteen studies reported the costs involved [31,32,40,52,66–68] or evaluated the cost-effectiveness [28,69–73] of the intervention. Most (7/13) of these studies were conducted for interventions relating to mental health [40,68,72,74], three studies for hypertension [70,71,74], two for diabetes [69,73] and one for cardiovascular disease[66]. Economic assessment for the management of depression demonstrated that the intervention was cost-effective, with the task-sharing intervention costing US$120 less in the intervention arm than in the control arm in public health facilities[40]. A multi-country study on psychosis reported larger reductions in overall healthcare costs in the intervention group than in the control group. The study reported higher cumulative costs over the intervention period (US $627 per patient vs $526 in the control group[31]. The incremental cost-effectiveness ratio for task-shared care in Ethiopia indicated lower cost of –US$299·82 (95% CI –454·95 to –144·69) per unit increase in severe mental disorder clinical symptom severity (calculated using a brief psychiatric rating scale) from the health sector perspective at 12 months[28]. However, one study showed that the treatment was more costly per participant per year (US$117.16, 95%CI 94.05, 140.26) compared to enhanced usual care (US$85.30, 95%CI 55.98, 114.62; p = 0.04) and not cost-effective[68].

Task-sharing interventions for diabetes and hypertension indicated that involved trained NPHWs were cost-effective[69,71,73]. The incremental cost-effectiveness ratio for the CHW intervention for diabetes in American Samoa was calculated at $13,191 per quality-adjusted life year (QALY) gained, which is considered highly cost-effective compared to commonly accepted willingness-to-pay thresholds ranging from $39,000 to $154,353 per QALY in the study context. Some of the studies also measured the costs of intervention[69]. A study in South Asia estimated the cost of scale-up of a CHW task-sharing intervention for hypertension to be US$10.70, US$10.50, and US$4.70 per individual in Bangladesh, Pakistan, and Sri Lanka respectively[32]. Another study which trained CHWs to provide management for CVD estimated costs per individual at high‐risk of CVD for three different models of care at 11 USD (CHW salary, training and physical measurement of CVD risk), 12 USD (basic model and medicines for CVD) and 14 USD (basic model, medicines and physician time)[66].

Unintended consequences of task-sharing

As NPHWs were trained to take on new roles, in some contexts, this generated conflict with other staff[60,75]. For instance, studies in South Africa [60] and India [61] demonstrated that nurses were unhappy with the CHWs likely because their role was indirectly challenged by that of CHWs who were trained to perform tasks similar to theirs. Furthermore, some studies reported challenges relating to insufficient remuneration of the CHWs, especially as they took on new roles[75]. A study which evaluated the management of hypertension at the PHC level where services for chronic disease including HIV are provided, demonstrated that vertically funded programs such as HIV and the poor standards of equipment in clinics compromised the quality of services provided by nurses[76].

Training improved the confidence and communication style and skills of CHWs, though some CHWs offered unsolicited information to patients[65]. Using digital health tools and sharing tasks with the PHC doctor for a common goal to improve health outcomes-built legitimacy for the CHW’s new role[61].

Risk of Bias of individual studies

Overall, over half (57%, 85/149) of studies had a low risk of bias, 8% (12/149) had a high risk of bias, and 35% (52/149) had some concerns with bias. There was a low risk of bias associated with randomisation (115/149), deviations (120/149), missing outcome data (129/149), measurement of outcomes (133/149), and selection of report result (131/149) in most studies. For full reporting of ROB results, please refer to S1 Appendix.

Discussion

Our systematic review included studies that utilised NPHWs to prevent or control NCDs, and explored the barriers, facilitators and unexpected consequences of task-sharing. Our search identified 149 RCTs across 31 countries, of which 81% reported a positive primary outcome, demonstrating that task-sharing is an effective intervention for NCDs. NPHWs included CHWs, nurses, dietitians, nutritionists, and traditional faith healers. A sub-set of these studies which included economic analyses found that task-sharing can reduce the total costs of healthcare of patients with depression, anxiety, hypertension and diabetes and improve health outcomes in public facilities[28,69–72]. One study showed that task-sharing interventions were more costly than usual care [31], owing to the training and equipment required to upskill the workforce for providing quality health services.

Previous reviews on task-sharing have identified that it is effective for screening, prevention, and in some cases, the management of mental health conditions [77], hypertension [78], CVD [79], diabetes [80], cholesterol [81], cervical cancer [82] and other NCDs [11,83] - though effectiveness was not demonstrated for cholesterol-lowering interventions[81]. Task sharing has been achieved either by organising the available health workforce by expanding their current roles to include management of NCDs [53,54,74] or by employing additional resources such as community volunteers [84] or faith healers[31]. These models of care usually employ a multidisciplinary team of CHWs and nurses with or without physicians. Although our review found that 81% of the studies reported positive primary outcomes, indicating that task-sharing is an effective intervention for NCDs, a few studies reported neutral, mixed, and negative (one study) results. Various contextual factors at different levels seem to have contributed to these mixed outcomes. At the health system level, factors such as health infrastructure, the capabilities of NPHWs in implementing interventions, and human resource interventions (e.g., supervision and training) may affect effectiveness. Additionally, patient-level factors, such as engagement with interventions and adherence to treatment, also play a role in shaping the outcomes of task-sharing [48,54,59].

Furthermore, many of the task-sharing interventions were multifaceted, some aided by digital health to provide clinical decision support to the workforce[49,51,54,59], and others by the use of phone calls for health education, follow-up and medication adherence [55,85,86] to improve health outcomes. Some studies focussed on a single disease or risk factor [38,87,88] while others evaluated task-sharing for a range of conditions[46,53,89–93]. Use of technology, training, and supervision of the health workforce were identified as facilitators.

However, the effectiveness of NPHWs in task-sharing interventions for NCDs can be influenced by whether they are dedicated solely to a given intervention or tasked with multiple duties within the broader health system. Studies where NPHWs received focused training and were assigned well-defined roles generally report positive outcomes, as these workers can concentrate on NCD-related tasks without competing responsibilities [54]. While digital health-related interventions improved access to effective health care and improved patient outcomes in most studies, scaling up the intervention would require considerable planning and funding to avoid ‘pilotitis’[94]. Appreciation of the context and system-related issues such as non-availability of medicines or the need for a doctor to initiate treatment, as well as data integration with the sub-national or national health information system are important considerations.

As acknowledged by other reviews[11,83], a key takeaway was the macro-level and systemic barriers such as poor medicine supply, lack of equipment and infrastructure which impeded task-sharing. These issues directly influenced intervention outcomes, with some studies reporting disruptions in medication or equipment that hindered NPHWs’ ability to deliver care [11,83]. Such barriers highlight the need to address systemic challenges, including supply chain inefficiencies. Ensuring a consistent supply of essential drugs, establishing an efficient distribution system, and providing training on proper use are critical steps to enhance the effectiveness of task-sharing interventions, particularly in resource-constrained settings [11].

Additional factors included lack of trust in the ‘free medicines’ provided by the public health system[61], low priority given to NCDs compared to communicable diseases [60,62] and additional costs involved in home visits for follow-up[63]. In fact, a recent assessment of Ethiopia’s Health Extension Program services showed that better HIV program performance by CHWs was associated with lower uptake of NCD preventive services[95]. This finding supports the opinion that integration of new programs to existing service packages may spread resources too thinly[96]. This may jeopardise the success of existing health services resulting in worse health outcomes[95].

Having strong community engagement was found to circumvent some of these barriers[62]. As these multifaceted, complex, task-sharing interventions intrinsically depend on the interpersonal relationships of the healthcare teams, some studies found that if the roles of various team members were not clearly defined, it led to role conflict[60,75]. Other researchers have reported that the non-availability of protocols, lack of job description, differential financial incentives and the display of occupational superiority leads to role conflicts among the non-physician PHC team members[97].

Task-sharing is a well-accepted and an effective model of care which can help address the challenges of workforce shortages and inequities in healthcare access. The model has been embedded in the health system of several LMICs for decades to deliver care for communicable diseases and maternal and child health[98]. However, as communicable diseases require short-term care, adapting this model to address the long-term care needs of individuals with NCDs is essential. Decentralising services through task-sharing enables NPHWs to provide vital care in community settings, improving accessibility and continuity of care—key factors for managing chronic conditions effectively.

Recommendations from this review

S3 Appendix documents detailed evidence about the tasks shared by each category of NPHWs for each type of NCD across the continuum of care (prevention, diagnosis, management, and rehabilitation) of patients with NCDs. Using a systems lens with a focus on task-sharing for NCDs in LMICs, we have the following recommendations. At the macro level, national health policies need to include a specific policy for NCD related prevention, promotion, management, rehabilitation, and palliation. In order to implement these policies, countries need to invest in NCDs and allocate sufficient funds. As these NPHWs are also tasked with delivering additional services other than NCDs, including those related to communicable diseases, there is a need for health systems to focus on effective integration of services and systems.

At the meso level, implementors should ideally move from small scale pilots and trials to scaling up evidence-based solutions such as WHO Best buys through PHC as the platform for NCD care. Evidence demonstrates that digital health tools assist the health workforce to provide quality and standardised care and legitimises the role of CHWs. Availability of equipment, regular medicine supply and adequate space are necessary to build workforce and community trust in the health system. Furthermore, to motivate and retain the workforce, they need to be adequately remunerated.

At the micro level, our review highlights that all occupational groups need to have clear job descriptions with appropriate training and retraining of health workforce, especially NPHWs (e.g. CHWs, nurses) to improve their confidence, knowledge and skill set for basic NCD management at the community level. Accountability and community engagement were found to facilitate services. As team-based care requires close interaction and trust between team members, it is essential to provide guidance about how services will be integrated and how each occupation will function. The capability, opportunity, and motivation (COM-B) theory uses three interrelated domains which are linked to behaviour change. Capability includes physical and psychological capacity to engage in or perform an activity, motivation refers to automated and reflective brain processes that energize and direct behaviour, and opportunity refers to all the factors that lie outside of the control of an individual that influence change [75].

Strengths and limitations

Our review includes all randomised controlled trials on task-sharing for NCD management reported in peer reviewed English, Spanish and French language journals. The strength of our report lies in its comprehensive scope as it is a large review encompassing a range of NPHWs and publications reporting both positive and neutral primary outcomes. It explored the barriers, facilitators, and unexpected consequences of task-sharing to NPHWs in the prevention and control of NCDs. Additionally, the overall risk of bias was low in majority of the studies included.

However, the study is not without limitations, most of which stem from the broader scope of the review, which may have missed specific details and nuances. One is the exclusion of studies published in languages other than English, Spanish, and French, which may have led to missing relevant examples from larger nations where research is conducted in other languages. Another limitation is related to combining all countries under the broad label of “LMICs,” which overlooks critical differences in health systems, economic conditions, and cultural and social environments. A more detailed analysis of how task-sharing varies across specific regions and contexts would further enrich the findings. Additionally, very few RCTs reported process evaluation data, which is essential to understand the contextual factors and fidelity of the intervention. Details about training or retraining of the workforce, their supervision and remuneration was not discussed in the studies. Moreover, the diverse reporting in the included studies meant that we could not report disaggregated outcomes contributed by specific NPHWs. The other limitation of this review is that all the findings are based within a research context, which is usually challenging to scale-up due to a number of reasons including cost, adequate monitoring, health inequities, challenges in implementation due to shortage of workforce[99]. Additionally, the exclusion of implementation research may have led to the omission of important contextual and real-world evidence that could provide valuable insights into the practical application of task-sharing interventions. Furthermore, few studies reported cost-effectiveness data which is important for assessing budget impact and the feasibility of scaling sustainably. Nonetheless, the study successfully attained its objectives as it focused on the task-sharing practices of NPHWs with different levels of training [9].

Conclusions

Our review demonstrates that using task-sharing models of care involving trained NPHWs is effective and cost-effective in LMICs where NCDs are the leading causes of premature deaths and disability. Ultimately, task-sharing, should not be viewed as a task-dumping exercise to the ‘lowest’ occupational group, on the contrary, it ought to be designed and implemented as a team-based approach where all members are motivated, trained, remunerated and have the government and community’s support to deliver their roles to the best of their ability.

Acknowledgments

The Authors would like to acknowledge Giorgio Cometto and Alarcos Cieza for reviewing and commenting on this manuscript.

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