Assessing Health Systems-level Feasibility of Task-Sharing and -Shifting: Cross-sectional Study from Indian District Hospitals

Introduction: Low and lower middle income countries face chronic deficits in specialist surgeons, particularly in rural and remote settings. Task sharing and shifting (TSS) to other health worker cadres is a remedy supported by effectiveness studies. However, policy adoption depends not only on effectiveness but also on feasibility at the health systems level, especially when personnel deficits co-occur across multiple cadres. We aimed to develop and apply an analytic approach to assess whether co occurring workforce deficits constrain the feasibility of surgical TSS using a pan Indian sample of district hospitals. Methods: We conducted a cross sectional descriptive analysis using administrative staffing data from the National Institution for Transforming India (NITI) Aayog assessment of 707 district hospitals for the 2017 2018 financial year. Cadre wise staffing ratios for specialist surgeons, general doctors, nurses, and paramedics were calculated using Indian Public Health Standards (IPHS) norms. A ratio <1 indicated a staffing deficit. We evaluated TSS feasibility for selected cadre pairs, with target and substituting cadres, using a rule-based categorization of relative staffing adequacy (not needed, possible, strained, unlikely, or not possible). Results: Across 479 hospitals with deficits in specialist surgeons or general doctors included in the analysis. Staffing deficits were widespread across cadres. Only one hospital demonstrated TSS feasibility across all cadre pairs. For general doctors substituting specialist surgeons, TSS was possible in 1.5% of hospitals, strained in 9.0%, unlikely in 78.7%, and not possible in 10.9%. Similar patterns were observed for nurses substituting for specialist surgeons and for those substituting for general doctors. Feasibility was higher when paramedics substituted for general doctors or nurses, but co-occurring deficits were common. Conclusion: Co occurring workforce deficits substantially limit health systems level feasibility of surgical task sharing and shifting in Indian district hospitals. Evaluation of TSS interventions should incorporate system level workforce constraints in addition to evidence of effectiveness.