Task Shifting Could Help Lower Costs in U.S. Health Care


Hayon Thapaliya/HBR Staff

If you ran a fancy restaurant, would you want the chef also to clean dishes and mop the floor? Of course not. You’d hire others to do these things and let the chef focus on producing delicious food. This simple idea — that one should match the skill level of the individual to the skill requirements of a task — has influenced how many businesses operate. That’s why lawyers are helped by paralegals, professors by teaching assistants, and chefs by sous chefs.

Task shifting of this kind moves routine tasks requiring lower skills away from high-skilled professionals. It must be done judiciously, because if a person is less qualified than a task requires, it will hurt quality and may add to costs if rework becomes necessary. On the other hand, if a person is overqualified for a task, it will increase cost and, counter-intuitively, may lower quality if the person is not as engaged in the task as someone with the right skills. In other words, we want to match perfectly each person’s skills and tasks.

The task shifting logic also applies to health care. For years, nurse practitioners and physician assistants have taken on tasks that doctors once performed. This has saved money, of course, but it has also improved quality, because doctors and paramedics perform tasks that best fit their expertise. However, based on our research in India, we believe there’s a lot more room for task shifting in U.S. health care. Some Indian hospitals have pushed the envelope on task shifting because of intense pressure to make the most of the country’s very limited supply of doctors and specialists, while maintaining quality and keeping costs low. Through a process we’ve termed “reverse innovation” these practices can be brought to other countries, including the United States, where health care costs are out of control. Three task-shifting ideas from India are worth considering.

Create new job categories. The Indian exemplar hospitals we studied have taken task-shifting to new heights by creating entirely new categories of low-cost health-care workers. For instance, when Dr. Govindaswamy founded Aravind Eye Care hospital in south India, he had plenty of patients but too few ophthalmologists and optometrists to treat them. His solution was to hire village women with high-school diplomas and train them for two years to work as “midlevel ophthalmic paramedics.” Over time, these paramedics have made up two-thirds of Aravind’s workforce and perform tasks such as admitting patients, maintaining medical records, counseling patients — and assisting doctors in surgery.

Each Aravind surgeon, for example, has help from six paramedics in the clinical domain and four assistants for administrative and support services. Paramedics go to villages, screen patients, transport them back to the hub hospital, measure their vitals, have tests performed, prepare the patients for surgery, deliver postsurgical care in the ward, transport them back to the village, and provide follow- up care. In addition to being inexpensive, the paramedics bring skills such as cultural competency, loyalty to the organization, strong work ethic, and the ability to connect more deeply with patients and families whose socioeconomic background is similar to their own. The surgeon performs only the actual procedure, which is a small but vital fragment of time to which all other tasks contribute. Aravind’s doctors do what only they can do — diagnose patients and perform surgeries. They are 4-6 times as productive as U.S. surgeons are, not because they are overworked but because of rational task shifting and clever process design.

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