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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 200-205

Identification of family health care provider challenges in comprehensive health centers

Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman

Date of Submission14-Dec-2019
Date of Decision21-Dec-2019
Date of Acceptance18-Feb-2020
Date of Web Publication23-Jul-2020

Correspondence Address:
Dr. Farzaneh Doosty
Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNMS.JNMS_58_19

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Context: Task shifting is one of the human resource development methods that can strengthening the spirit of job while developing employee's multidimensional perspective. Coinciding with beginning of Health care Reform Plan nationally at Mashhad University of Medical Sciences, the title of hygiene/midwifery expert in organizational chart changes to family health-care providers (as task-shifting staff).
Aims: This study was conducted with the aim of identification of family health-care provider challenges in comprehensive health centers.
Setting and Design: This is a qualitative study that was conducted in comprehensive health centers affiliated to Mashhad University of Medical Sciences in 2018.
Materials and Methods: Interviews were conducted with 18 family health-care workers working at least for 5 years who experience the work condition prior to implementing health-care reform plan. The first participants through purposeful sampling and subsequent based on the findings of the research were selected. Data collection was implemented by a deep semi-structured interview. The average time of interviews was 55 min.
Statistical Analyze Used: Data were analyzed by qualitative content analyzed method.
Results: After summarizing and categorizing the items from the viewpoint of family health-care providers, five main theme (include: attitudinal, educational, motivational, management, and structural challenges) and 15 sub-theme were extracted as challenges of task shifting plan.
Conclusions: Attention to the structural challenges and educational needs of family health-care providers, as well as improvement of management and their attitude and motivation are needed to increasing the quality of services and satisfaction in comprehensive health centers.

Keywords: Comprehensive centers of health, Family health-care providers, Hygiene expert, Midwifery expert, Task shifting

How to cite this article:
Doosty F, Rasi V. Identification of family health care provider challenges in comprehensive health centers. J Nurs Midwifery Sci 2020;7:200-5

How to cite this URL:
Doosty F, Rasi V. Identification of family health care provider challenges in comprehensive health centers. J Nurs Midwifery Sci [serial online] 2020 [cited 2022 Aug 12];7:200-5. Available from: https://www.jnmsjournal.org/text.asp?2020/7/3/200/290543

  Introduction Top

Task shifting is one of the human resource (HR) development method that can strengthening the spirit of work while developing employees' multidimensional perspective.[1] It can help to effectively achieve the mentioned goals and each of the motivational and developmental job's factors and since having a flexible workforce will facilitate business and save time and resources.[2] Of course, there are several types of task shifting, such as replacing professional staff, delegating tasks to less educated professionals (creating a new staff cader), and delegating tasks to nonprofessionals or a combination of these options.[3] Furthermore, task shifting is one of the most important types of employee in service-training because in advanced organizations it is believed that the quality of staff is the most important factor for success and this is achieved through high quality in-service training and the task shifting leads to the same kind of training.[4]

However, when decision-makers planning to task shifting employees, should consider the opportunity cost of a turnover because these staff have less time to doing his primary duties. Therefore, utilizing of cost-effectiveness analyses before implementing task shifting plans can be one way to avoid of created problems in implementation phase. For example, some researchers conclude that in Burkina Faso the cesarean delivery rate is higher when care is provided by clinical staff (198–1000) than when care done by general practitioners (125–1000) or gynecologists (99–1000). On the other hand, the measuring of the cost-effectiveness ratio showed that the cost of performing 1000 cesareans by the general practitioner was $ 200 more than when the cesarean was performed by clinical staff and increased around 11,757/1000 births, when the cesarean was performed by obstetricians (dollar price assumed in 2006).[5]

Some researchers believe that implementing such projects will lead to increased efficiency (cost and time saving) and that after the task shifting is implemented, time saving is achieve for senior managers because of duties delegation.[6]

Despite these researchers, some believe that task shifting may lead to cost-effectiveness rather than cost savings and require strong government leadership to ensure that there are enough resources for implementation, training, and funding the plan.[7] While there is ample evidence of increased efficiency and potential productivity of multitasking employees in terms of task shifting plans, this plan faces many challenges and its results are not always desirable.[8] Based on the advantages and disadvantages that a worker's task shifting might bring to the organization, and given that this plan was started at Mashhad University of Medical Sciences from 2014 and simultaneously, the title of hygiene/midwifery expert in organizational chart changes to family health care providers (as task-shifting staff). These staff were trained in a 150 h in person and 600-h virtual training course with written and practical tests to accept their new multitask role. Given that most start-ups are faced with problems that usually occur during implementation, this study aimed to identify the challenges of health-care providers in comprehensive health centers affiliated to Mashhad University of Medical Sciences.

  Materials and Methods Top

This study was a qualitative study carried out in content analysis approach in 2018. In this study, the challenges of the task shifting plan from the perspective of health-care workers in the comprehensive health centers of Mashhad University of Medical Sciences were studied.

The first participants through purposeful sampling and subsequent based on the findings of the research were selected. After interviewing 18 family health-care workers, the data were sutured.

Questions were asked after that interviewees were assured about the confidentiality of the information and obtained the informed consent form for recording their voice. The method of data collection was a deep and semi-structured interview. One of the questions was “do you think what differences happen to your duties after implementing task shifting plan?” The average time of interviews was 55 min. During the last three interviews, the researchers concluded that no new information on the content analysis of the quality of the interviews was obtained and reached the data saturation. In order to increase the accuracy of the data collection process, the conversations were recorded by one of the researchers and then word-by-word was written on paper. The initial codes based on similarity and proportionality were classified into the main categories after detailed examinations and multiple read outs. These themes were named abstractly on the basis of the concept and nature and finally for each main theme, the subthemes were obtained.

To assess the reliability and accuracy, four criteria provided by Lincoln et al. including credibility and transferability, dependability, and confirmability were used.[9]

For reach to these criteria, at first, the researchers got official permit for referred to the comprehensive health centers affiliated to Mashhad University of Medical Sciences. Furthermore, researchers tried to carefully select the informed people, long-term contact with the participants for attain their trust, using combine data collection methods (such as interviews, writing the participants opinions simultaneously), using of the interview guide, sufficient time allocation for interviews, constant review and comparison of extracted main and sub codes in terms of similarities and differences, restore the data analysis result for the interviewees for final approved and entering the codes into the study after their approval.

Ethical considerations

Written consent was obtained from participants before the commencement of work; before starting the study, the participant was informed about the aim and method of the study and the volunteers' personal information was protected. Participation in the research did not create any financial burden for the participants. Code of Ethics Committee of Research of Iran University of Medical Sciences: IUMS/SHMIS-1395/9221532203.

  Results Top

After interview with participants (include 16 women and 2 men in the ages 26–53 that three of them had associate's degree and the rest had a bachelor's degree also, three of them were between 20 and 30, 10 were between 10 and 20, and 5 were under 10 years experiences), summarizing and sorting out the issues and problems raised by them, 5 main theme and 15 sub-theme were extracted as the main challenges of the task shifting plan from the viewpoint of family health-care providers [Table 1]. The main challenges were: (a) attitudinal; (b) educational; (c) motivational; (d) management, and (e) structural challenges.
Table 1: Challenges of task-shifting health-care providers affiliated to Mashhad University of Medical Sciences

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  1. Attitudinal challenges: in the case of this challenge, the subthemes extracted from the text of the interviews were as follows:

    • The distrust of pregnant mothers to provide maternal care by hygiene experts: because of the more experience of midwives in delivery counseling and caring services to pregnant mothers especially the high risk one, they preferred to get midwifery services
    • Low hygiene expert's self-esteem in the care of mothers, especially encounter to high risk mothers: health-care providers who had a degree of hygiene and did not attend pregnancy-related maternity care courses, especially practical course in the maternity ward, faced to lot of difficulty in deciding when dealing with high-risk mothers
    • Midwifes low level regard to maternal and child hygiene care: most midwives were reluctant to do hygiene care because they thought that midwifery is a specialized work that nobody could do but even staff without academic education can do the hygienic care.

  2. Educational challenges: in the case of this challenge, the subthemes extracted from the text of the interviews were as follows:

    • Insufficient training course that held for family health care providers for taking a new task: according to health-care providers interview, the training provided by the hygiene deputy to convert hygiene staff and midwives into health-care providers was inadequate and did not adequately address the quality of education and learning
    • Lack of midwifery practical training courses during the student period for hygiene staff: according to health-care providers believes, university courses, especially internships in the maternity ward, are very helpful in dealing with many cases, especially high-risk mothers, courses that hygienist did not benefit from
    • Abortion of long time for past professional educational course that deliver to midwife and hygiene experts based on needs assessment: according to health care provider's viewpoints, the effectiveness of previously specialized and individualized training hours that held for each of the midwifery and hygienist has been called into question by the new plan.

  3. Motivational challenges: in this regard, the topics raised by the interviewees included three items, which are referred to below in each sub code and an example of the text of the interview:

    • Midwife' unwillingness and their low motivation for doing maternal and child health care and other duties as family health-care providers: according to participant's interview, midwives are unwilling to doing hygiene care and because of the high sensitivity of maternal care, especially high-risk pregnant mothers, and the opposite of the routine and less risky hygiene care, midwives tend to spend much time on materiality care
    • Unwillingness of experienced staff' to learn new duties because of nearing the end of career: According to participant's interview, these changes in the field of revolution in health care system in recent years are very problematic for some employee that have a lot of experience and are nearing to retirement, and they are less inclined to adapt whit these changes
    • Unmotivated hygiene expert for doing pregnant women care due to distrust of mothers to their abilities: participated family health-care providers claim that even if the hygienist makes every effort to provide high quality services to pregnant mothers, they don't trust us and sometimes Instead of showing gratitude, they behave inappropriately.

  4. Management challenges: in this regard, the issues raised by the interviewees included three items, which are referred to below in each sub code and an example of the text of the interview:

    • Reducing management and discipline ability in employees after delegate new tasks to them: In the view of participants, ordering and managing tasks when tasks were professionally divided was much easier than multitask delegation
    • Lowering staff concentration due to force to doing multiple tasks: the staff believed that the focus on doing the main job was reduced by performing many tasks outside of our expertise
    • Weakness of precise monitoring and control of the work by the supervisors due to multiple tasks.

  5. Structural challenges: in this regard, the topics raised by the interviewees included 3 items, which are referred to below in each sub theme and an example of the text of the interview:

    • Not decreasing need for staff after implementing the new plan: according to family health care provider's viewpoints, the need for HRs has not changed since their conversion to multitask health care provider
    • Increasing midwife and hygienist expert's workload: new projects are always aimed at improving current affairs and quality, but the only tangible result for health-care providers since the implementation of the plan has been increased workload and confusion for staff
    • Subtle appropriate outcomes of implementing plan: Since the implementation of the plan, leading to a lack of confidence in the effectiveness of these changes, dissatisfaction of refers and health-care providers have increased.

  Discussion Top

Based on the findings of this study, the challenges of executing task shifting include motivational, educational, structural, and management challenges. Overall, a review of related literature shows that there is no general consensus among researchers, and HR experts on the implementation of a task shifting plan, and there are many uncertainties in this regard.[10] Among the studies that were align with the findings of the present, can be cited on the result of one study that shows because multitask health-care providers have many different responsibilities, from diagnosis to treatment of pediatric illnesses, they do not have the capacity to manage all tasks of the right quality.[11] Concerning structural challenges, the results of the one study are in line with the findings of the present study, as if they pointed to the structural challenges of the task shifting plan in their research. The researchers believe that although it was expected that the need for physicians would decrease after changes the role of nurses to performed the physician's duties, the results did not support the assume that task shifting lead to decrease in number of needed physicians. In line with the findings of the present study, confirms that the results of implementation of the task shifting plan in structural challenges are not enough tangible.[12]

The findings of the one study are consistent with the attitudinal challenges that identified in the present study. The researchers concluded that after the task shifting, widespread tension between nurses and community health workers due to increased ambiguity in their new roles happened.[13] Hence, it seems negative attitude toward new roles in task shifting is a challenge in such programs. Thus there is need to use appropriate management and increase motivation to improve attitude of health workers. Despite the challenges mentioned above that outline the results of relevant studies in support of the findings of the present study, some studies have pointed to the positive aspects of implementing a task shifting plan. For example, the findings of one study showed that increasing in a number of multitask staff, have direct effect on improving efficiency in the delivery of healthcare, increase accessibility to care, promote the quality of care, and health outcomes.[14] A finding of another study showed that multitask staffing plans are effective in Nigerian and Chinese primary health-care organizations, and they believe that task shifting plans in many health-care centers are also applicable and feasible that it is inconsistent with the findings of the present study.[15] Based on the result of some study, implementing task shifting has had positive results that this may have been due to how the plan was implemented.[16],[17],[18]

A limitation of this study was lack of time for health-care providers to conduct interviews whit them due to the large number of the referred customers that researchers attempted to done interviews as late as possible during office hours when fewer were referred to comprehensive health centers.

Since most researchers in the medical sciences are very interested to doing their studies in the field of hospital and the field of hygiene is almost neglected, it is recommended that researchers pay more attention to the problems and challenges in this important and widespread field.

  Conclusions Top

In general, it can be said that in consistent with the results of other studies, the barriers to implementing a task-shifting plan were: lack of policies and laws designed to delegate new duties to staff, lack of organizational structure to define the new role of staff as multitask staff, failure to anticipate proper referral system as multitask staff support in the face of complex issues, lack of proper infrastructure to collect performance data and information to monitoring trend of task shifting plan to omitting deficiencies and improving the service delivery process. It seems that given the many benefits gained after implementing task shifting plans in different countries, resolving the challenges of the plan can be an effective step in enhancing employee satisfaction and consequently improving the quality of service delivery by them.

Conflicts of interest

There are no conflicts of interest.

Authors' contribution

Farzaneh Doosty conceived of the presented idea. Vahid Rasi developed the theory and performed the computations. Farzaneh Doosty verified the analytical methods and encouraged to investigate [a specific aspect] and supervised the findings of this work. Both authors discussed the results and contributed to the final manuscript.

Financial support and sponsorship

This research is part of Ph.D. thesis of first author in Iran University of Medical Sience that financial by grant number IUMS/SHMIS-1395/9221532203.


This research was part of PhD thesis in the field of administrative of healthcare of first author in the field of healthcare manager that financial by grant number IUMS/SHMIS-1395/9221532203.

  References Top

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Mokhtari H. Optimization of job rotation system based on jobs ergonomic risk factors. IOHJ 2017;14:26-13.  Back to cited text no. 2
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Hariry N, Sh E. Effect of task shifting on staff productivity (case study: National library of Iran). Vol. 26. National Library Studies and Information Organization Studies; 2016. p. 75-90.  Back to cited text no. 4
Dawson AJ, Buchan J, Duffield C, Homer CS, Wijewardena K. Task shifting and sharing in maternal and reproductive health in low-income countries: A narrative synthesis of current evidence. Health Policy Plan 2014;29:396-408.  Back to cited text no. 5
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Lincoln YS, Guba EG, Schwandt TA. Judging interpretations: But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New Dir eval J 2007:114;11-25.  Back to cited text no. 9
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Buchan J, Calman L. Skill-Mix and Policy Change in the Health Workforce: Nurses in Advanced Roles. OECD Health Working Papers, No. 17. NJI; 2005.  Back to cited text no. 12
Brentlinger PE, Assan A, Mudender F, Ghee AE, Vallejo Torres J, Martínez Martínez P, et al. Task shifting in Mozambique: Cross-sectional evaluation of non-physician clinicians' performance in HIV/AIDS care. Hum Resour Health 2010;8:23.  Back to cited text no. 13
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