Task Shifting and Task Sharing Implementation in Africa: A Scoping Review on Rationale and Scope

Numerous studies have reported task shifting and task sharing due to various reasons and with varied scopes of health services, either task-shifted or -shared. However, very few studies have mapped the evidence on task shifting and task sharing. We conducted a scoping review to synthesize evidence on the rationale and scope of task shifting and task sharing in Africa. We identified peer-reviewed papers from PubMed, Scopus, and CINAHL bibliographic databases. Studies that met the eligibility criteria were charted to document data on the rationale for task shifting and task sharing, and the scope of tasks shifted or shared in Africa. The charted data were thematically analyzed. Sixty-one studies met the eligibility criteria, with fifty-three providing insights on the rationale and scope of task shifting and task sharing, and seven on the scope and one on rationale, respectively. The rationales for task shifting and task sharing were health worker shortages, to optimally utilize existing health workers, and to expand access to health services. The scope of health services shifted or shared in 23 countries were HIV/AIDS, tuberculosis, hypertension, diabetes, mental health, eyecare, maternal and child health, sexual and reproductive health, surgical care, medicines’ management, and emergency care. Task shifting and task sharing are widely implemented in Africa across various health services contexts towards ensuring access to health services.


Introduction
Task shifting and task sharing are being implemented in several countries to efficiently utilize existing health workers to improve the access of the population to quality health services. Access of populations to quality healthcare is essential in achieving Universal Health Coverage (UHC) and the health and health-related Sustainable Development Goals (SDG) [1][2][3]. Task shifting is defined by the World Health Organization (WHO) as "the rational redistribution of tasks among health workforce teams", from trained and qualified health workers to other health workers with shorter training duration to maximize the available health workforce [2]. In task shifting, tasks are delegated or transferred, and in task sharing, tasks are delivered collaboratively by different staff categories [3]. This approach is implemented in many countries globally, including Africa, where there remains a persistent health workforce shortage and deficient access to healthcare [4,5].
Africa faces numerous health workforce challenges that are contributing to the health indices and systems' performance of countries in the continent [6]. These challenges are also impacting negatively on the functionality and the resilience of the health system [7,8], and the attainment of key population outcomes [9]. These challenges, which are quite broad and have contextual specificities, include weak health and health workforce leadership, governance and stewardship mechanisms, and management systems, as well as poor regulation, and evidence generation and use mechanisms [6,10]. Furthermore, there is a Table 1. Population, concept, and context (PCC) framework for the scoping review.

Criteria Component(s) Explanation
Population (P) Population Health workforce Everyone accessing health services. Healthcare workers such as physicians, nurses, midwives, and community health workers that are working as frontline contact in the healthcare system.

Concept (C) Rationale Scope
Usual reasons or the logical explanations for task shifting and task sharing. Extent or range of services that are task-shifted or -shared amongst various categories of health workers.

Context (C) Healthcare services African countries
Healthcare services within essential service packages that are either sought or received by the population at any healthcare service delivery level in both public and private sectors. Any country within the African continent.
We identified relevant studies by applying the search strategy in Table 2 to obtain peer-reviewed papers from the PubMed, Scopus, and CINAHL bibliographic databases. We considered quantitative, qualitative, and mixed-methods studies, as well as review and perspective papers on task shifting or sharing for integrated health service delivery. We also considered articles published from 2010 to 2021 to obtain a wide range of contemporary information. CINHAL TI "task shifting" OR AB "task shifting" OR TI "task sharing" OR AB "task sharing" OR MH "task shifting" OR MH "task sharing" TI" health system*" OR AB "health system*" OR TI" healthcare system*" OR AB" healthcare system*" OR TI" health care system*" OR AB" health care system*" OR TI" healthcare sector*" OR AB" healthcare sector*" OR TI" health facilit*" OR AB" health facilit*" OR TI "hospital*" OR AB "hospital*" OR TI" healthcare" OR AB" healthcare" OR TI "health care" OR AB "health care" OR TI" health service*" OR AB" health service*" OR TI" healthcare service*" OR AB" healthcare service*" OR TI" health cent*" OR AB" health cent*" OR TI" care, health" OR AB" care, health" OR TI "system, health care" OR AB "system, health care" OR TI "systems, health care" OR AB "systems, health care" OR TI "system, healthcare" OR TI "system, healthcare" MH Africa OR TI Africa* OR AB Africa* OR TI Algeria* OR AB Algeria* OR TI Angola*OR AB Angola* OR TI Benin*OR AB Benin* OR TI Botswana* OR AB Botswana OR TI "Burkina Faso*" OR AB "Burkina Faso*" OR TI Burundi* OR AB Burundi* OR TI "Cape Verde*" OR AB "Cape Verde*" OR TI Cameron* OR AB Cameron*OR TI Cameroon*OR AB Cameroon* OR TI Chad* OR AB chad* OR TI Comoros* OR AB Comoros* OR TI Congo* OR AB Congo* OR TI "Cote d'Ivoire" OR AB "Cote d'Ivoire" OR TI "Ivory coast" OR AB "Ivory coast" OR TI Djibouti* OR AB Djibouti* OR TI Egypt* OR AB Egypt* OR TI Eritrea* OR AB Eritrea* OR TI Ethiopia* OR AB Ethiopia* OR TI Gabon* OR AB Gabon* OR TI Gambia*OR AB Gambia* OR TI Ghana* OR AB Ghana OR TI Guinea* OR AB Guinea* OR TI Kenya* OR AB Kenya* OR TI Lesotho* OR Lesotho* OR TI Liberia* OR AB Liberia OR TI Libya* AB Libya* OR TI Madagascar* OR AB Madagascar* OR TI Malawi* OR AB Malawi* OR TI Mali* OR AB Mali* OR TI Maurit* OR AB Maurit* OR TI Morocc* OR AB Morocc* OR TI Mozambiqu* OR AB Mozambiqu* OR TI Namibia* OR AB Namibia* OR TI Niger* OR AB Niger* OR TI Rwanda* OR AB Rwanda* OR TI Senegal* OR AB Senegal* OR TI Seychelles* OR TI Seychelles* OR TI "Sierra Leone*" OR AB "Sierra Leone*" OR TI Somalia* OR AB Somalia" OR TI South Africa* OR AB South Africa* OR TI Sudan* OR AB Sudan* OR TI Swaziland* OR AB Swaziland* OR TI Tanzania* OR AB Tanzania* OR TI Togo* OR AB Togo* OR TI Tunisia* OR AB Tunisia OR TI Uganda* OR AB Uganda* OR TI Zambia* OR TI Zambia* OR TI Zimbabwe* OR AB Zimbabwe* Table 2. Cont.

Source of Literature Task Shifting/Sharing Terms Health System/Services Terms Africa Terms
Scopus "task shifting" OR "task sharing" "health system*" OR "healthcare system*" [tiab] OR "health care system*" OR "healthcare sector*" OR "healthcare industr*" OR "health industr*" OR "health facilit*" OR "hospital*" OR "healthcare" OR "health care" OR "health service*" OR "healthcare service*" OR "health cent*" OR "care, health" OR "system, health care" OR "systems, health care" OR "system, healthcare" TITLE-ABS-KEY ("Africa" OR "Algeria*" OR "Angola*" OR "Benin*" OR "Botswana*" OR "Burkina Faso" OR "Burundi*" OR "Cape Verde*" OR "Cabo Verde" OR "Cameron*" OR "Cameroon*" OR "Chad*" OR "Comoros*" OR "Congo*" OR "Cote d'Ivoire" OR "Ivory coast" OR "Djibou*" OR "Egypt*" OR "Eritrea*" OR "Ethiopia*" OR "Gabon*" OR "Gambia*" OR "Ghana*" OR "Guinea*" OR "Kenya*" OR "Lesotho*" OR "Liberia*" OR "Libya*" OR "Madagascar*" OR "Malawi*" OR "Mali*" OR "Maurit*" OR "Morocc*" OR "Mozambiqu*" OR "Namibia*" OR "Niger*" OR "Rwanda*" OR "Senegal*" OR "Seychelles" OR "Sierra Leone*" OR "Somalia*" OR "South Africa*" OR "Sudan*" OR "Swaziland*" OR "Tanzania*" OR "Togo*" OR "Tunisia*" OR "Uganda*" OR "Zambia*" OR "Zimbabwe*") All articles obtained from the literature search, which was conducted independently by the authors, were downloaded into the Mendeley reference manager, with duplicates removed. The title and abstract were screened independently by the authors, with discrepancies discussed and a consensus reached. Afterwards, the full text was reviewed based on the eligibility criteria for inclusion. The inclusion criteria were: (1) quantitative, qualitative, and mixed-methods studies on task shifting or sharing for integrated health service delivery in Africa, (2) review and perspective papers on task shifting or sharing for integrated health service delivery in Africa, (3) full-text articles are written in the English language and are accessible, and (4) articles were published from 2010 to 2021. The exclusion criteria were: (1) papers written in other languages, (2) full texts were not accessible, and (3) papers were news articles, editorials, commentaries, and letters to the editor that did not involve primary data and did not provide insights into the rationale, scope, and health professions education for task shifting and task sharing in Africa.
The first author (S.C.O.) used a data extraction matrix to extract information on the author and year of publication, country name, study design, study setting, and population. Additionally extracted were the key findings on the rationale and scope of task shifting and task sharing, health service context, and the level of care. As had been carried out in other studies, we extracted text verbatim on themes, concepts, and categories relevant to the research questions [18,19] into the extraction matrix for analysis using the thematic analysis approach. The second author randomly reviewed the charting for 50% of the studies, with an agreement reached on the charting output.
We analyzed the characteristics of the papers based on the extracts using descriptive statistics. We analyzed the qualitative content of the papers using thematic analysis [20,21], with synthesized information described narratively based on information on the rationale and scope of task shifting and task sharing in Africa. We reported the findings using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines Extension for Scoping Review reporting standards (Table A1).

Description of Studies
We identified 926 records from the databases CINAHL (n = 197), PubMed (n = 567), and Scopus (n = 162). After duplicates were removed, 510 records were screened by titles and abstracts, from which 141 articles' full text were assessed for eligibility ( Figure 1). Sixty-one original research papers were included in the final review, with nine (15%) mixed-methods studies, forty-two (69%) quantitative, and ten (16%) qualitative (Table 2). In all, 80 papers Healthcare 2023, 11, 1200 5 of 28 were excluded following the full-text review, with 29 being books, editorials, commentaries, and letters to the editor without primary data, 47 papers providing no insights on the rationale and scope of task shifting and task sharing, and 4 not being conducted in Africa.

Description of Studies
We identified 926 records from the databases CINAHL (n = 197), PubMed (n = 567), and Scopus (n = 162). After duplicates were removed, 510 records were screened by titles and abstracts, from which 141 articles' full text were assessed for eligibility ( Figure 1). Sixty-one original research papers were included in the final review, with nine (15%) mixed-methods studies, forty-two (69%) quantitative, and ten (16%) qualitative (Table 2). In all, 80 papers were excluded following the full-text review, with 29 being books, editorials, commentaries, and letters to the editor without primary data, 47 papers providing no insights on the rationale and scope of task shifting and task sharing, and 4 not being conducted in Africa.

Characteristics of the Included Studies
The main characteristics of the included papers are presented in Table 3, with details in Table 4. The highest proportion of the papers was published in 2017 (18%), with the lowest proportion published in 2019 (3%). Of the included papers, 2 were multi-country, and 22 were conducted in different countries in Africa. Thirteen percent (n = 8) were conducted in Uganda, and ten percent (n = 6) were conducted in Ghana and Kenya. Of the reviewed papers, 87% (n = 53) provided insights on the rationale and scope of task shifting and task sharing, with 11% (n = 7) providing insights on scope only, and 2% (n = 1) on rationale only. Furthermore, 59% (n = 36) of the studies reported task shifting and task sharing practices at the community and primary level of care, with 3% (n = 2) of studies reporting practices at the tertiary level of care.

Characteristics of the Included Studies
The main characteristics of the included papers are presented in Table 3, with details in Table 4. The highest proportion of the papers was published in 2017 (18%), with the lowest proportion published in 2019 (3%). Of the included papers, 2 were multi-country, and 22 were conducted in different countries in Africa. Thirteen percent (n = 8) were conducted in Uganda, and ten percent (n = 6) were conducted in Ghana and Kenya. Of the reviewed papers, 87% (n = 53) provided insights on the rationale and scope of task shifting and task sharing, with 11% (n = 7) providing insights on scope only, and 2% (n = 1) on rationale only. Furthermore, 59% (n = 36) of the studies reported task shifting and task sharing practices at the community and primary level of care, with 3% (n = 2) of studies reporting practices at the tertiary level of care. Table 3. Main characteristics of the included papers.

n %
Year of publication  Primary care level 13 21 Primary and community care level 15 25 Secondary and primary care level 7 11 Secondary care level 13 21 Secondary, primary, and community care level 2 3 Tertiary care level 2 3 All levels 1 2

Main Themes from the Included Studies
The main theme and subthemes are presented in Table 5 and described in subsequent sections.

Rationale for Task Shifting and Task Sharing
Fifty-four studies  included under this theme provided insights on the rationale for the implementation of task shifting and task sharing in Africa, as presented in Table 6. Table 6. Summary of key findings on rationale and scope of task shifting and task sharing in reviewed studies.  Rationale: Severe health worker shortage and a high demand for healthcare services. Scope: Community health workers (CHW) and PLWHA in care and support of AIDS patients, ophthalmic clinical officers conduct cataract surgery, psychiatric clinical officers cover the same scope as the psychiatrists, but are more community-oriented than the psychiatrists, who tend to be mainly hospital-based.
Nurses set IV lines in upcountry due to lack of physicians, midwives conduct manual vacuum extraction, manual removal of the placenta, and manual vacuum aspiration due to shortage of doctors. CHWs and community members involved in delivery of expanded program on immunization (EPI) services, etc.

Optimally Utilize Existing Health Workers
Seven [22,[59][60][61][62][63][64] studies reported the rationale for task shifting and sharing implementation to include the need to optimally utilize the available human resources within a health service level to deliver health services. The study in Benin [59] implemented task shifting to expand the role of existing lay nurse aides to conduct counselling in maternal and newborn care. In a study conducted in Kenya [60], task shifting was implemented in HIV/AIDS care to optimally utilize existing health workers to improve outcomes without increasing resources. A Nigerian study [61] reported the implementation of task shifting to reduce the waiting time for accessing services from doctors by expanding the role of existing nurses. In Zambia [62], the rationale for implementing task shifting and sharing was to utilize existing peer educators in expanding the delivery of health services. A study in Tanzania [63] reported a task shifting implementation in preventing mother-to-child transmission (PMTCT) service delivery to optimally utilize existing health workers by reducing nurses' workload and health system costs.

Expand Access to Health Services
Twelve [22] studies reported the rationale for task shifting and sharing implementation to be to ensure increased access to health services at other levels of care and geographical locations, specifically, rural areas. The countries where an expansion of health services to other levels of care was reported include Ghana, Kenya, Madagascar, Malawi, Namibia, Swaziland, and Uganda. A study in Ghana [68] reported the implementation of task sharing to expand the service delivery of hypertension management and control to lower levels of care. In Kenya [45], the rationale for implementing task shifting was to increase access to non-communicable diseases (NCD) services (hypertension, diabetes mellitus type 2, epilepsy, asthma, and sickle cell) in primary healthcare settings. Another study in Kenya [74] reported implementing task shifting to improve access to mental health interventions at the community level. The study in Madagascar [66] reported that task shifting of the provision of contraceptives was implemented to expand access of community members through community health workers. A study in Malawi [67] reported task shifting of primary mental healthcare to the community level to improve the access of community members. In a Namibian study [73], task shifting was implemented to scale-up point-ofcare CD4+ testing in HIV counselling and testing settings in public health facilities. A study in Swaziland [72] reported the implementation of task sharing to decentralize antiretroviral (ART) provision to improve access. A Ugandan study [71] reported the implementation of task shifting for tuberculosis to improve the access of community members to directly observed treatment short course (DOTS).
Studies from Cameroon, Eswatini, Ethiopia, and Senegal reported the implementation of task shifting and task sharing to expand health services to rural areas. In a study conducted in Cameroon [65], task shifting was implemented to increase the access of the rural population to adequate hypertension and diabetes care. A study in Eswatini [35] reported the implementation of task shifting tuberculosis management to improve access in rural areas. A study in Ethiopia [69] reported the task sharing implementation to improve access to family planning in rural areas. In a study in Senegal [70], task sharing to increase the use of long-acting reversible contraceptives was performed to improve the access to family planning in rural areas.

Scope of Shifted and Shared Tasks
Sixty reviewed studies reported a range of tasks that were either task-shifted or taskshared in various health services contexts in Africa (Table 6).

Hypertension Management
Five studies reported task shifting and task sharing in the management of hypertension. A study conducted in Cameroon [65] reported a task shifting of integrated management of hypertension to non-physician clinicians (nurses) in a rural setting to improve the access to care for hypertension. In Kenya [45], NCD service delivery, including hypertension, was task-shifted to nurses in primary healthcare settings. In a study conducted in the Democratic Republic of Congo (DRC) [31], hypertension management was taskshifted to nurses. In a Ghanian study [68], hypertension management was task-shifted to community health nurses (CHNs) and enrolled nurses (ENs). The study conducted in Mozambique [37] reported that initial screening and initiation of obstetric emergency care for pre-eclampsia/eclampsia was task-shifted to community health workers.

Diabetes Management
Two studies reported task shifting and task sharing in diabetes management. The first study from Cameroon [65] reported a task shifting of integrated management of diabetes to nurses in a rural setting to improve access to type 2 diabetes care. The second study, that was conducted in Kenya [45], reported task shifting of NCD services, including for diabetes mellitus, to nurses in primary healthcare settings.

Mental Health
Ten studies conducted in eight countries reported the scope of shifted or shared tasks to be within the delivery of the mental health services domain. Three studies in Ghana [50,52,53] reported the task shifting of mental healthcare to community mental health workers-community psychiatric nurses (CPNs), clinical psychiatric officers, (CPOs), and community mental health officers (CMHOs). A study in Malawi [67] reported task shifting of primary mental healthcare at the community level to village-based health workers. In a study conducted in Zimbabwe [81], delivery of depression and other common mental disorders (CMD) services, specifically screening and monitoring of CMD and delivery of interventions, were task-shifted to lay workers. The study in Uganda [57] reported task shifting and sharing practices to include psychiatric clinical officers covering the same scope as the psychiatrists. A study in Mozambique [51] reported task shifting of the delivery of psychiatric care to psychiatric technicians due to low numbers of psychiatrists and psychologists. A study in Kenya [74] reported implementing task shifting of communitybased family therapy mental health interventions to lay counsellors. A study in South Africa [36] reported task shifting of psychological treatment for perinatal depression to non-specialist community health workers. Another study in South Africa [82] reported task sharing of mental health counselling to non-specialist facility-based counsellors (FBCs).

Maternal and Child Healthcare
In six studies from four countries, maternal and child health services were either task-shifted or task-shared. The study in Benin [59] implemented task shifting to expand the role of existing lay nurse aides to conduct counselling in maternal and newborn care. A study in Ethiopia [55] reported the task shifting of comprehensive emergency obstetric care (CEmOC) to non-physician clinicians (NPCs). In another study in Ethiopia [43], task shifting of the conduct of the caesarian section to non-physician surgeons (NPS) was reported. In a study in Nigeria [77], detection of early signs of pre-eclampsia was reported to be taskshifted, albeit informally, to community health extension workers. The study in Uganda [57] reported task shifting and task sharing practices to include midwives conducting manual vacuum extraction, manual removal of the placenta, and manual vacuum aspiration due to a shortage of doctors, and community health workers (CHWs) and community members were involved in the delivery of an expanded program on immunization (EPI) services. Another study in Uganda [39] highlighted that due to the absence of physicians in certain locations, midwives were often the main providers of post-abortion care services.

Sexual and Reproductive Health Services
Eight reviewed studies from seven countries reported the task shifting or task sharing of sexual and reproductive health services. A study in Burkina Faso [33] reported task shifting of the provision of oral and injectable contraceptives to community health workers, and implants and intrauterine devices to auxiliary midwives and nurses. A study in Ethiopia [69] reported the implementation of task sharing of the provision of long-acting contraceptive (Implanon) family planning services to health extension workers. A study in Ghana [34] reported the implementation of task sharing of the provision of an intrauterine contraceptive device to community health nurses. The study in Madagascar [66] taskshifted the provision of injectable contraceptives and counselling of patients to community health workers. In a study in Malawi [46], the task of long-acting reversible contraception (LARC) insertion was shifted to community midwife assistants (CMAs). In a study in Nigeria [28], the provision of contraceptive implants was task-shifted to community health extension workers. Another Nigerian study [56] reported the task shifting of the screening for cervical cancer using visual inspection with acetic acid to community health officers and community health extension workers. In a study in Senegal [70], task sharing of longacting reversible contraceptives (LARC), specifically implants and intrauterine devices, was implemented for nurses, non-clinical family planning counsellors, and community health workers.

Eye Care
Task shifting of eye care services was reported in three studies conducted in six countries. A study in Uganda [57] reported task shifting and sharing practices to include ophthalmic clinical officers conducting cataract surgery. A study [75] in Madagascar, Malawi, and Rwanda reported task shifting of primary eye care service delivery to general primary healthcare (PHC) workers (ophthalmic clinical officers). A multi-country study [76] in Kenya, Malawi, and Tanzania also reported task shifting of cataract surgery to nonphysician cataract surgeons.

Tuberculosis Care
The task shifting of tuberculosis-related care was reported in three studies. A Ugandan study reported the task shifting of directly observed treatment short course (DOTS) to laypersons [71] and nurses [25]. A study in South Africa [42] reported the task sharing of multidrug-resistant tuberculosis (MDR-TB) treatment between clinical nurse practitioners (CNPs) and medical officers (MO). A study in Eswatini [35] reported the task shifting of directly observed treatment (DOT) supervision and administration of intramuscular MDR-TB injections to lay health workers (LHWs)/community treatment supporters (CTS) to improve the access in rural areas.

Surgical Care and Procedures
For surgical care and procedures, three studies provided insights into task shifting and sharing practices. A study in Uganda [47] that explored surgical task shifting practices from surgical specialists to non-specialist physicians reported that the practice was already in place. A study in Sierra Leone [48] reported the implementation of task sharing of surgical and obstetric emergencies to associate clinicians/community health officers (CHOs) and junior doctors. In a Kenyan study [54], the conducting of fine-needle aspiration biopsy cytology, bone marrow aspiration, and trephine biopsy was shared by pathologists, medical officers (MO), clinical officers (CO), and technologists.

Medicines' Management
One study from Tanzania [49] reported task shifting of pharmaceutical management to nurses and medical attendants. This was reported to be because of the shortage of pharmaceutical personnel in the country, which impacts negatively on service provision, especially in rural areas.

Emergency Care
One study reported task shifting of emergency care-related services. The study from Uganda [27] reported task shifting of acute care for emergency services in a rural setting to nurses. This was pertinent as 84% of the country's population reside in rural areas and they require access to emergency care.

Discussion
This scoping review synthesized evidence on the rationale for task shifting and task sharing in Africa. The reported rationales in the reviewed papers were health worker shortages, the need to optimally utilize existing health workers, and the need to expand access to health services.
The health worker shortages were reported to be prominent by the level of care and geographical location, especially in rural areas. The finding on the shortage of health workers matches the reported global shortage of health workers, which is projected at 10 million by 2030 [83] and is more prominent in Africa [84] and rural and remote areas [85]. The implementation of task shifting and task sharing to cope with this is consistent with the literature. The suboptimal funding of public health [86], including service delivery and its impact on the quality of health infrastructure, the availability of health workers, and service delivery, is also reported in the literature. Similarly, the weak investment in HRH development has also been widely reported in Africa, and this is suggested to substantially contribute to the shortage of health workers [87]. Contributing to this is the dearth of attraction and retention strategies in countries, which is also compounding the shortages and resulting in poorly motivated health workers that are also inequitably distributed [85].
We also found that the need to optimally utilize existing health workers was another reported rationale for task shifting and task sharing. An important perspective gained in the study from Kenya [60] was task shifting being implemented to improve populations' access to health services without increasing resource needs. This is recommended in instances where evidence exists of varied workloads and availability of certain cadres of health workers with low workloads that can take up additional tasks and relieve those with high workloads [88]. This should, however, be informed by an assessment of the workloads, use of the evidence to explore task shifting and task sharing possibilities [89], and adequate capacity building and provision of relevant incentives to beneficiary cadres, in order to ensure quality service delivery. Another reported rationale for task shifting and task sharing was to expand access to health services to other levels of care and geographical locations, specifically, rural areas. The reported expansion of services to other levels of care and rural areas was implemented in scenarios where the primary cadres responsible for the service delivery were not typically available at the target level of care, based on the service delivery organization model. In the reviewed studies, the reported instances were expanding service delivery to primary [45] and community level settings [66,67,74] and rural areas [35,65,69], for improved access to NCD services, family planning services, and HIV/AIDS and tuberculosis services.
This scoping review also synthesized evidence on the scope of task shifting and task sharing implementation in Africa. Our findings indicate that the health services shifted or shared in 23 countries where reviewed papers emanated include communicable diseases (HIV/AIDS and tuberculosis), NCD (hypertension, diabetes, mental health, and eyecare), maternal and child health, sexual and reproductive health, surgical care, medicines' management, and emergency care. In addition to these conditions and health services being those contributing to the burden of morbidity and mortality in Africa [90,91], some of these areas, especially HIV/AIDS, tuberculosis, maternal and child health, sexual and reproductive health, and medicines' management, have received substantive investments from donors and partners in recent years. Perhaps, this investment promoted the task shifting and task sharing practices that were published in the reviewed studies across all levels of the health system, considering most of the studies were funded by projects.

Implications for Policy and Practice
The health system in Africa will likely continue to be faced with a shortage of health workers until urgent steps are taken. The aim should be to urgently strengthen the health system to become adequately resilient [92] and ensure universal access to qualified, skilled, and motivated health workers that are equitably distributed [93]. Until this is achieved, the persistent health worker shortages call for policies aimed at ensuring that adequate numbers of qualified, skilled, and motivated health workers are available to deliver quality health services at all levels of the system in Africa, based on population health needs. Achieving this also requires apposite contextual policies and interventions to attract and retain health workers, with emphasis given to rural and remote areas.
Task shifting and task sharing implementation to optimally utilize existing health workers or expand service delivery using cadres whose primary function differs should be implemented based on contextual needs. Furthermore, evidence from a needs assessment on scope and competencies should be documented [27] and used to inform the capacity building and the provision of necessary job aids [45,72]. These are pertinent in ensuring quality service delivery.

Limitations
The findings should not be considered to provide a complete view of the rationale and scope for task shifting and task sharing in Africa, as this review was based on peer-reviewed literature that met a set of criteria. There is a possibility that there are ongoing practices that either are not published in the peer-reviewed literature or did not meet the inclusion criteria for this review. Additionally, in alignment with the scoping review methodology, we did not critically appraise the evidence provided in this paper. We may have also missed out on task shifting and task sharing practices not published in English. Lastly, although we rigorously searched three databases, we may have missed out on studies that are available in other databases.

Conclusions
Task shifting and task sharing are widely implemented in Africa across various health services contexts, aimed towards ensuring access to health services. To guide its implementation, populations' needs should be used to inform the capacity building of beneficiary cadres to ensure that they have the required knowledge, skills, competence, and job aids to guarantee quality service delivery.

Rationale
3 Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach. 2, 3 Objectives 4 Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.

Protocol and registration 5
Indicate whether a review protocol exists, state if and where it can be accessed (e.g., a Web address), and if available, provide registration information, including the registration number.
-Eligibility criteria 6 Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale. 4

Information sources 7
Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.
4 Search 8 Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated. 3 Selection of sources of Evidence 9 State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review. 4 Data charting process 10 Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.

Data items 11
List and define all variables for which data were sought and any assumptions and simplifications made. 3 Critical appraisal of individual sources of evidence 12 If done, provide a rationale for conducting a critical appraisal of included sources of evidence. Describe the methods used and how this information was used in any data synthesis (if appropriate). -

Synthesis of results 13
Describe the methods of handling and summarizing the data that were charted. 4, 5