The first component of the 4 S framework relates to “staff”. Here we discuss task shifting, community health workers, and telemedicine as interventions to alleviate human resource constraints during the pandemic. These and other solutions to expand the pandemic healthcare workforce are being actively investigated.
Task shifting is a mechanism employed in resource-constrained settings around the world to increase the effective number of clinical staff available to meet a population’s health demands. During the COVID-19 pandemic, systems from all income levels have strained to maintain an adequate healthcare worker capacity to treat the surge of COVID-19 patients in addition to all other patients.
The World Health Organization defines task shifting as “the rational redistribution of tasks among health workforce teams…from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resources for health.” The WHO recommends that task shifting be undertaken in parallel with efforts to strengthen the healthcare workforce capacity and only after consultation with relevant stakeholders, including patients, to ensure needs are appropriately met. Per WHO guidelines, successful implementation of task shifting requires knowledge of:
the available human resources for healthcare;
the gaps in care provision;
the extent to which task shifting is already taking place;
the quality assurance mechanisms that already exist.
Task shifting is typically regulated by existing institutions (e.g., licensing boards, professional societies, as well as local, state, and national governments). Regulations can be modified – especially during times of crisis – to allow extension of the scope of practice or creation of new cadres within the healthcare system. Existing training and quality assurance programs may be modified to ensure that roles and core competencies are clearly defined for new or expanded positions. Furthermore, supervision by healthcare workers with higher levels of qualification is essential (e.g., an anesthesiologist supervises multiple nurse anesthetists). In this way, more highly qualified healthcare workers are available for cases requiring a higher level of skill or expertise. Finally, essential health services cannot be sustainably provided on a voluntary basis, so it is important to ensure workers are compensated and programs are adequately financed.
By mid-March, Italian hospitals were witnessing surges of COVID-19 patients that overwhelmed their existing capacity. As one mechanism to address the insufficient supply of care providers, Italy expedited graduation for senior medical students so that they could serve where need was greatest. Italy also requested that all Italian doctors who had completed their education in Italy and were practicing abroad return to Italy to work.
Which of these policies from Italy incorporated task shifting? What tasks were shifted, and what qualifications were waived?
As the COVID-19 burden grows exponentially in the U.S., multiple task-shifting measures have been enacted to boost the numbers of healthcare workers and expand their scope of practice. In New York, the U.S. epicenter as of April, an Executive Order from the Governor relaxed a number of restrictions on health professionals’ scope of practice. This order allows nurse anesthetists, physician assistants, specialist assistants, and nurse practitioners to practice without the supervision of a physician. In addition, the state has allowed nurses to order testing for COVID-19 without the need for a signed order from a physician. Plans have also been developed to create ICU teams from non-critical care attending physicians and housestaff to meet surge demand. Attending physicians and residents at high risk for severe COVID-19 have been furloughed and serve as “virtual rounders” who assist with hospital documentation tasks including progress notes and discharge summaries. Medical schools in New York and Massachusetts have accelerated graduation of fourth-year medical students and distributed emergency 90-day limited licenses to increase the number of licensed providers available to care for COVID-19 patients. Early graduation in the U.S. has been implemented in the past: during the 1918 Influenza pandemic, and during World War II.
How would you organize an ICU team from a group of doctors, nurses, mid-level providers, clinical assistants, and technicians who have not worked in an ICU before? Who would provide immediate and ultimate supervision of each member of the team?
Mexico´s fifth-year medical school students are called “medical interns”. According to Mexican Health Regulations, an intern is considered a student who, after finishing the first years four years of medical school, is assigned to study and assist other HCWs in medical institutions as a scholarship holder. Most Mexican public hospitals rely on the workforce these students provide in order to satisfy daily patient demand. As these students are considered nonessential personnel, medical institutions facing shortages of PPE during the first weeks of the COVID-19 public health crisis decided to reserve available equipment; only essential personnel were granted with such resources, forcing medical interns to study and work without adequate protection. As COVID-19 incidence increased, educational authorities decided to withdraw all medical and nursing students from hospital settings, from April 6 to April 30, 2020.
Virtual medical education persisted for these students until public health authorities issued a statement announcing the following: “Undergraduate internal physicians and social service interns from all health careers without risk factors for serious illness due to COVID-19 must rejoin regular activities from May 1, 2020. In the event that its units have been designated for the care of COVID-19 patients, they will be relocated to lower risk areas, determined by health authorities in agreement with the educational institutions of origin, where they continue to support healthcare services or participate in health promotion and prevention tasks.” Risk factors for severe illness due to COVID-19 included in the official list were: pregnancy or lactation, chronic non-communicable diseases (lung, heart, liver, metabolic, morbid obesity, kidney failure, lupus, cancer, diabetes, hypertension) or acquired or drug-induced immunosuppression. Students with any of these risk factors were permanently withdrawn from in-hospital service “during the time of contingency due to the pandemic or until the end of their undergraduate medical internship.” Night shifts were limited by official policies to every third or fourth day.
As the rate of medical interns attending non-COVID medical departments increased, by June 2020, almost every fifth-year medical student had partially or completely resumed their clinical rotations. The decisions taken by the government previously described are evidence of how to ensure the continuity of face-to-face medical education, minimizing the risk of contagion and viral transmission, and how to mitigate the shortage of medical personnel, maintaining quality standards in patient care. The latter was not completely achieved, as the Health Institute for Wellbeing (INSABI, according to its acronym in Spanish) hired 585 Cuban physicians and nurses to help combat COVID-19 in several federal entities. It must be noted that 12 of the most recognized medical associations of the country publicly condemned this decision, arguing that these foreign doctors “transgress the functionality in the assigned hospitals, relegate national healthcare professionals, receive excessive economic remuneration in comparison to better prepared Mexican doctors and disrupt the assignment of limited PPE."
Another important aspect of the urgent plan issued by the Mexican government is the “Hospital Reconversion Guideline.” It was issued in April 2020, seeking to “guarantee that the organization of health care services is executed under the principles of timeliness, quality and efficiency of human, material and financial resources for the benefit of the population and thereby influence the prevention and control of the pandemic caused by the SARS-CoV2 virus disease in Mexico.” It highlights an algorithm created to reduce staff occupation in intensive care units and emergency departments; specifically, it aims to ensure one pulmonologist or internal medicine physician as head of the medical team for every 25 ICU beds, and one emergency physician, general physician, or any other physician not directly trained to be on an ICU for every five beds.
There is no doubt that Mexico has most of the necessary tools to respond to the pandemic, but the lack of prioritization has led to professional burnout and misuse of human resources.
How did the US and Spain manage such situation? Could have Mexico chosen an alternate path? In comparison, the US issued immediate provisional practitioner licenses for fourth-year medical students to assist hospital staff and serve as first-contact doctors during the pandemic. As for January 5, 2021, the Federation of State Medical Boards has 43 States in addition to DC, Guam (GU), Central Northern Mariana Islands (CNMI), United States Virgin Islands (USVI) and Puerto Rico (PR) with medical licenses waivers. On the other hand, in Spain, the second most affected European country at the beginning of the pandemic, a national call was made to all recently graduated physicians and last year medical students to join first response teams. “There was a national call to be on a national roster of healthcare personnel ready to lend a hand when needed, and that was what many peers did and most ended up in community health centers, nursing homes and "COVID hotels,” said Ruben Moreno MD. This strategy optimized triage services and medical attention for hospitalized COVID-19 patients.
A CHW is a community member identified as a point of contact for health needs at the local level, helping to provide basic health and medical care within their own community. Although the terminology of a CHW varies by context (e.g., health worker, community health promoter, etc.) and scopes of practice differ across settings, they are typically capable of providing preventive care, health promotion, and rehabilitative care within their own community.
In many LMIC settings that have historically lacked sufficient medical personnel to meet population health demands, CHWs have helped to fill a crucial gap. Compensation for CHWs varies by context. Some countries provide a salary. Other countries provide recognition for CHWs’ service and offer certain incentives such as access to health insurance or mobile phones. Some level of standardized training is generally offered to equip CHWs to perform their expected duties.
Rwanda, a country of 12 million people in Sub-Saharan Africa, illustrates how a CHW network can be effectively deployed for the COVID-19 response. Much has been written about the growth of Rwanda’s CHW program in light of the gaps it helped to fill following the devastating 1994 Genocide against the Tutsis. As of 2020, there are more than 45,000 village-level CHWs operating who provide the first line of health service delivery. In Rwanda, villages comprise between 100 and 200 households. There are three CHWs in each village: a male-female CHW pair (called binômes) providing basic care and integrated community case management (iCCM) of childhood illness and a CHW in charge of maternal health, called an Agent de Santé Maternelle (ASM). While CHWs are elected by the members of their village, this position is voluntary and considered an honor in Rwanda. CHWs are also provided a series of incentives, including access to the national community-based insurance scheme (Mutuelles de Santé), tools such as a mobile phone with airtime for communication, access to CHW co-operatives, and training by the Ministry of Health. Finally, CHWs receive a nominal amount of financial support through the country’s performance-based financing program.
Due to the distribution of CHWs throughout Rwanda, they are the first contacted at the local level by any person with suspected symptoms of COVID-19. Once a CHW is made aware of a suspected case, they contact coordinating health officials via SMS (with the phones they are provided), who then alert those responsible for contact tracing so that containment efforts are optimized. Also, SMS alerts sent by CHWs are integrated into a national health information technology (HIT) system that allows for real-time national information sharing, which in turn allows smooth coordination by regional and national authorities. The advantage of an SMS-based system is that it is a practical, rapid method for CHWs to notify health officials of emerging cases in real time. Because the Ministry of Health pays the cost linked to the telephone communications, there are no financial charges incurred by the CHWs. Further, the system is not reliant on having a stable internet connection in remote areas, thereby helping to ensure a rapid notification system across the entire country.
Rwanda and many other countries have robust CHW programs that existed prior to the COVID-19 pandemic and are ready to integrate any new threat at the community level. Countries that have not historically relied on a cohesive CHW structure can draw important lessons from these systems as they recruit community members for their own COVID-19 responses. The health network that emerges may be worth sustaining well beyond the current crisis.
As seen in Table 1, CHWs can contribute to the COVID-19 response in a variety of ways, building on their previous tasks in their community. They may be particularly helpful in detecting and tracing suspected cases; educating peers about prevention, quarantine, isolation, and lockdown protocols put in place by public health officials; and continuing chronic disease care. In the U.S., community health care centers have drastically reduced in-person appointments to adhere to social distancing and stay-at-home orders. In some settings, these staff have been redirected to COVID-19 clinical teams, responding to high-risk patients over the phone. CHWs can assess risk for patients and provide appropriate escalation of care. As an example, a partnership between the Massachusetts government and Partners in Health developed a CHW workforce capable of scaling up contact tracing. In the United Kingdom, a model has been proposed to train CHWs to support people in their homes or virtually by assessing food and medication supplies and other needs for vulnerable people. In summary, a novel CHW program serves as a promising method to redistribute human resources in strained healthcare systems that lack adequate capacity for the surge in demand.
Table 1: Potential Roles of Community Health Workers in the COVID-19 Pandemic
Educate communities regarding signs, symptoms, and transmission routes and promote personal protective measures.
Organize hand hygiene stations in communities and health facilities.
Support facility-based infection prevention through triage areas and PPE use.
Support preparation for future interventions like vaccines through outreach.
Identify signs and symptoms in community members and support safe sample collection and rapid transport to reduce risk of nosocomial transmission.
Communicate rapidly and effectively to residents.
Support self-isolation while ensuring critical food, medical, and social support.
Monitor patients for clinical deterioration and rapidly refer when needed.
Support contact tracing, symptom reporting, and access to testing and treatment.
Implement disinfection of high-risk surfaces.
Sustain routine primary healthcare services (vaccines, diarrhea management, malaria management, etc.).
As a final example of how to increase staff availability in the setting of COVID-19, we focus this section on telemedicine. This mechanism for interacting with patients virtually is not a new technology, but its implementation has been variable for multifaceted reasons. Below, we provide an overview of telemedicine, evaluate advantages and disadvantages of this technology, and detail how regulations have been relaxed to promote its use in the COVID-19 response.
Prior to COVID-19, the U.S. had witnessed varying degrees of telemedicine utilization due to complex regulatory, policy, and reimbursement challenges. As discussed in Module 3, in the setting of the pandemic, federal and state policy increased reimbursement mechanisms to ensure that telemedicine could be employed as a mechanism for patients to continue seeking care without having to physically attend appointments. For instance, Jefferson Health in the U.S. has increased their telemedicine visits from a few dozen per week to 500-600 visits per day - a tenfold surge in demand. The U.S. Congress recently passed the CARES Act, which allows Medicare reimbursement for health centers and rural health clinics for the remainder of the crisis and for expansion of telemedicine. In the U.S., HIPAA (a law that provides protections for personal health information among many other things) compliance guidelines for telemedicine have been relaxed. It is now possible to use free or low-cost video communication tools such as Apple FaceTime, Facebook Messenger, Skype, and Zoom. Another example discussed in Module 4 is the use of telemedicine for mental healthcare in China. Major limitations include access to a device with audio and camera, and education in using electronic platforms, which may disproportionately affect patients who lack access to this technology. Additionally, development of guidelines on what will require an in-person visit must be set – for example, a change in condition, requiring a physical exam, or lack of interpreters (although remote phone interpreters have helped to fill this last gap). While there are logistical concerns, patients with difficulty in transportation or accessibility to attend in-person visits may benefit from this rise in telemedicine.
To provide an example from another context of how telemedicine has been utilized in the face of the COVID-19 pandemic, we provide a case study from the Philippines.
As the number of COVID-19 cases grows in the Philippines and strains its health sector, several medical groups and physicians have created a Facebook-based platform for online consultation services called the “Lung Center COVID Ask Force.” It primarily aims to triage patients with possible COVID-19-related complaints. Every Monday to Saturday, around 625 volunteer doctors – with the help of student volunteers from the Ateneo School of Medicine and Public Health – provide online consultation services to the first 1,000 patients who message the Facebook page that day. Additionally, the Lung Center COVID Ask Force also posts infographics based on frequently asked questions. These serve as educational materials that people can easily access without needing to consult a doctor.