Task shifting in the management of epilepsy in resource‐poor settings

To the Editors: Sub-Saharan Africa (SSA) has an estimated shortfall of health workers equivalent to a need to more than doubling its current workforce. The time required to train new professionals, the inadequate number of training facilities, and the pressing demand emphasize the need for innovative short-term approaches to health care in SSA. Task shifting has been recognized as one of such approaches (World Health Organisation 2007, 2008). Task shifting is a process of delegation whereby tasks are moved, where appropriate, to less specialized health workers (World Health Organisation, 2008). Through this reorganization, available human health resources are used efficiently. Task shifting is already the basis for infectious diseases care in SSA, and has been implemented for chronic diseases. Relevant contributions for epilepsy were published in Epilepsiain 2008 (Kendall-Taylor et al., 2008; Kengne et al., 2008a) together with accompanying commentaries (Birbeck, 2008; Odermatt et al., 2008; Selassie, 2008). Kengne et al. suggested that their nurse-led epilepsy care experience was the first documented in Cameroon (Kengne et al., 2008a). Following this, Njamnshi (2009) argued that nurse-led care for epilepsy has been implemented elsewhere in Cameroon. However, he referred to a model of care wherein patients with epilepsy were followed by general practitioners and neurologists (Dongmo et al., 2003). It is important to note that only neurologists were allowed to modify the treatments. The task shifting claimed by Njamnshi does not fit within the model he tends to describe. It is completely out of the scope of task shifting to lower-grade human health resources. His study was based on 44% less participants than that of the study of Kengne et al., and he did not provide clear definitions of processes of care and monitoring. Therefore, further comparison may be misleading. Njamnshi also referred to a model we developed to integrate chronic diseases care with the health system in Cameroon. The diabetes component of the model was published both in “Diabetes International” (Awah et al., 2007) and “Diabetes Voice” (Njamnshi et al., 2006). Building on this diabetes model to develop a national plan for epilepsy in Cameroon is a sound idea, since approaches to chronic diseases are transferable. However, care choices for chronic diseases in SSA must probably favor integrated models over single-disease ones. Single-disease programs are inefficient in a number of respects, given that many such programs involve the same patient populations, settings, or provider. We have demonstrated in Cameroon that integrated chronic diseases care was achievable at the primary level through task shifting. In addition to providing care for epilepsy (Kengne et al., 2008a), within the same package, the same nurses provided acceptable care for asthma (Kengne et al., 2008b), diabetes, and hypertension (Kengne et al., 2009). However, implementing the integrated approach to chronic care in SSA would require collaborative efforts, which would require that specialist physicians see beyond artificial boundaries of specific organ diseases. Therefore, the diabetes model in Cameroon, in addition to informing plans for other chronic diseases, could potentially serve as the foundation and backbone for a comprehensive national chronic diseases program. We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. None of the authors has any conflict of interest to disclose.