Table 2. Examples of the impact of the pandemic on strategies for task shifting.

Study	Country of study	Task shifted	HRH delivering services	Key findings
Mental health screening and therapeutic interventions
Singla, DR et al [58]	Multi-country (USA and Canada)	Screening and therapy for perinatal anxiety and depression	Nurses and midwives	SUMMIT trial consists of 6–8 weekly sessions on behavioural activation (BA) therapy offered by trained HRH in-person or online HRH are trained in 4-day courses and monitored during 8-week internships Trial is comparing effectiveness of task sharing among telemedicine specialist, telemedicine non-specialist, in-person specialist and in-person non-specialist Lockdowns led training, supervision, data collection and follow-ups shift online; effectiveness of telemedicine-supported BA is being evaluated
Scazufca, M et al [59]	Brazil	Screening, referring and therapy for depression	CHWs	PROACTIVE is a task-shared psychosocial care intervention for depression in adults aged 60 and more, based on psychoeducation and BA CHWs receive 3 days of training and weekly supervision from clinicians COVID-19 alerted trial implementation Recruitment of new participants ceased Participants who had not completed all sessions were offered 2 telephone sessions substituting in-person programme sessions 8 month and 12 month follow up was done via telephone 62·5% participants in the intervention showed recovery from depression compared to 44·0% in the control group (adjusted odds ratio 2·16 [95% CI 1·47–3·18; p<0·0001]
Jordans, MJD et al [60]	Lebanon	Psychological intervention for children with severe emotional distress	CHWs	Proof-of-concept study evaluated outcomes of competency-driven training (CDT) in improving facilitator quality CDT used pre-training and in-training competency assessment outcome scores to adjust dosage of training, focus on competencies and feedback Lockdowns led training of facilitators move online CDT improved training outcomes by 18% without extending class duration
Dambi, J et al [61]	Zimbabwe	Screening and therapy for depression	Grandmothers	Physical distancing measures led Friendship Bench to shift onto WhatsApp and telephone to deliver therapy and communicate with patients Friendship Bench is piloting Inuka, a chat-based application, to further access and enhance help-seeking behavior A quasi-experimental RCT found Iuka to be feasible and demonstrated a decline in common depressive disorders, depression and anxiety and increase in health-related quality of life Connectivity, app instability, expensive mobile data and power outages were discovered as barriers to scaling up
Nirisha, PL et al [62]	India	Screening and referring patients with alcohol use disorders and mental health for depression	Accredited social health activists (ASHA, who are CHWs)	COVID-19 restrictions led trainings adopt hybrid mode 1-day in-person training method vs 1 day in-person training and digitally-driven 7 online longitudinal training was compared in a trial; screen positives and KAP scores were measured Online trained ASHAs identified significantly higher number of persons with potential alcohol use disorders [83%; p ≤ 0.001] and common mental disorders [4%; p = 0.018], while in-person trained ASHA identified significantly higher number of those with potential severe mental disorders [61.61%; p ≤ 0.001] Mean KAP score increased from 16.76 to 18.57 (p < 0·01) in ASHA mentored online and from 18.65 to 18.84 (p = 0.76) in in-person trained
Philip, S et al [63]	India	Screening and referring patients with substance abuse and mental health for depression	Primary care physicians	114 primary care doctors were trained, monitored and mentored virtually Post training case-bases scenario examinations reported 37% improvements in knowledge scores 80.7% and 47.7% trainees felt confident in identifying mental health issues in patients and their caregivers respectively 52.6% felt they understand when to refer to higher centres 60.5% felt confident in prescribing and managing patients with mental health issues 64.9% respondents felt confident in providing deaddiction services
Rodriguez-Cuevas, F et al [64]	Mexico	Psychosocial support, psychological first aid and grief management	Primary care physicians, community healthcare workers, community mental healthcare workers and non-clinical office staff	Non-profit Compañeros En Salud (CES) trained non-specialist providers on mental health screening, therapy and referrals Increase in number of people faced with stress and anxiety due to COVID-19 led CES’s intervention to reach COVID patients and families To mitigate infection transmission risks to CHWs, undertook home visits using PPE such as three-layered fabric masks, hand sanitisers (regular visits); N95 or KN95 respirator mask, face shield, isolation gown and gloves (visiting suspected had COVID-19 patients) They maintained 1.5 metres distance from patients They met at private ventilated areas other than inside the house, e.g. garden, patio or clinic’s backyard
HIV consultation, testing, counselling and treatment services
Coulaud, P et al [65]	Cameroon	Consultation, counselling and ART	Nurses	Small district hospitals designated to provide HIV services had limited resources and inadequate number of doctors Hospitals with limited HRH and not practicing task-shifting, reported higher HIV transmission risk and ARV stock-outs Tasks shifting is recommended to maintain ART services delivery as financial resources is being increasingly diverted to pandemic relief
Lujintanon, S et al [66]	Thailand	ART initiation	Community healthcare workers	Implementation trial is engaging community-based organisations and key population lay providers to start same-day initiation of ART delivery Lay CHWs are trained in counselling, testing, PrEP, PEP and ART care Clients will be offered teleconsultation with physicians and ART home delivery during the COVID-19 pandemic Success of this trial will help overcome geographical and HRH barriers
Roche, SD et al [67]	Kenya	Consultation, counselling and ART delivery	Hospital staff (not specific)	One-stop shop (OSS) model at HIV clinics allowed relocation of drugs, equipment, patient files and PrEP services at one point of patient contact TS dispensing drugs to lower cadres of care reduced provider movement and patient wait times However, social distancing protocols caused proximal testing points to shut and few to transform into isolation centres OSS moved to farther community clinics; patient preferences were unmet Staff had to travel between centres; wasting productivity
Others: Chronic illnesses including Hypertension, Diabetes; Emergency medical services
Kamvura, TT et al [68]	Zimbabwe	Screening of Hypertension and diabetes	Nurses and community health workers (grandmothers)	The Friendship Bench-based intervention is shifting screening of hypertension and diabetes screening onto trained HRH During lockdowns, grandmothers, nurses and other stakeholders used WhatsApp to disseminate knowledge, advise patients and track referrals
Oikonomidi, T et al [69]	France	Consultations and prescribing drugs for chronic illnesses	Digital technology-supported provision of care	Patients preferred teleconsultations for half of their future consultations Patients would use online symptom-checkers over contacting doctors for 22.0% of new symptoms Patients preferred remote monitoring instead of consultations for 52.3% of their treatment adaptations Prescription renewal and addressing acute or minor complaints were reported as circumstances considered appropriate Patients expressed that they seek quality assurance and supervision of results by doctors
Iwamoto, A et al [70]	Cambodia	Emergency bag-and-mask ventilation, incubator-side tube feeding and temperature measurement	Family caregivers (Fathers and grandmothers)	Asymptomatic infected family members entering neonatal care units risk transmitting COVID infections to patients and staff Thermal scanning and frequent hand hygiene were implemented Implementing a second line of screening through questions on symptoms and contact tracing is recommended Risk of transmitting infections necessitates hiring more nursing staff and adequate training and reducing reliance on family caregivers