Table 3.

Potential intended and unintended effects of task shifting for HIV on the health system as a whole

Effect	Sub-system involved
Health outcomes
Better adherence to treatment and reduced loss to follow up[11].	Service delivery
Good clinical outcomes and better survival rates [11].	Service delivery
Crowding out of other services where health workers or facilities shift their attention to the new tasks [20,21].	Service delivery; HRH; Health information
Supply side
Staff burnout due to workload, for example, due to maldistribution of trained health workers, or additional time to fill HMIS records [20,22].	HRH; Governance; Health information
Lack of motivation or staff turnover due to lack of incentives (financial or non-financial) for staff to expand their role [21-23].	HRH; Financing; service delivery; Governance
Staff turnover due to lack of career path (e.g., promotion or certification of acquiring the new skills) to address motivation and retention [12].	HRH; Governance
Low performance due to selecting health workers (for the training) who are not motivated or interested in the strategy [12].	HRH; Governance; service delivery
Job satisfaction due to acquiring new skills and responsibilities.	HRH
Tension within health teams about roles and responsibilities and hierarchies, especially with newly developed health cadres [11].	Governance; HRH
Staff lack of confidence in performing additional tasks due to insufficient training or supportive supervision.	Governance-HRH-service delivery
Staff insecurity when staff do not have legal backing for the additional tasks, impeding them from taking new responsibilities [7,23].	Governance; HRH
Professional protectionism due to concerns for being undermined [7,11,23,24]	Governance; HRH
Staff frustration due to unavailability of medicines and supplies for diagnostic tests.	Medicines and technology; HRH; Governance; health information
Cost implications due to the required supportive supervision and need for new or refresher training to ensure good quality care [7,11,22,25].	Financing; HRH
Inefficiencies and poor performance due to over referral, higher use of resources (ordering more lab tests) or lower productivity (longer consultation time) [7,11].	Financing; service delivery; HRH
Efficiencies through saving time of senior staff to spend on non-HIV patients or HIV patients with complications and increased utilization at same costs [11].	Financing; HRH; service delivery
Implications on financing of health care due to top up of salaries or hiring new cadres.	Financing; HRH
Demand side
Better services for patients due to immediate attention, longer consultation including counselling [7].	Service delivery; HRH
Patient satisfaction due to reduction in waiting time [11].	Service delivery
Better access to HIV services due to services close to home [11].	Governance; Service delivery
Inequitable access to HIV care if plans to scale up are not well distributed or do not target remote and rural areas.	Governance; Service delivery
Implications on financing of health care due to change in out of pocket expenditures [26].	Financing