E with workplace demands and to FCCP site fulfil the obligation they feel towards their patients. Clearly, this fundamental risk should be considered as part of any task-shifting intervention. Project planners need to recognise that any task-shifting programme is limited by the health system of which it is a part. Accordingly, the intervention must be designed to provide supervision of staff to ensure that they are not stretching the mandates of their new or altered job roles. Staff who are working in positions affected by the intervention should also be trained to be mindful of the limitations of the redesigned structure. Specifically, for interventions in such areas as neonatal care, nurses and paediatricians should be trained to understand the limits of the new cadre, and to ensure that they remain supportive of the new staff, but also watchful of their activity. Category 2 ?Task-shifting programme design should be mindful of the perspective of patients and ensure that key differences in cadre are understood Many health workers conveyed that their patients could not fully tell the difference between doctors, nurses or lay workers. A commonly held perception was that patients either were not aware or did not mind that tasks were being delegated to lower cadres.In the past people (in the villages) used to call us doctors, but with this programme we are real doctors BUdR mechanism of action because we are giving them medicines and I feel happy that I am a doctor. (CHW, Malawi, Study # 2)communities were largely conveyed through the interviews with health staff, managers and policy makers, and therefore provided a rather limited insight. The lack of patient voice captured in the studies reviewed is a significant weakness in the literature and any intervention in neonatal care should be mindful of the role and opinions of mothers of patients (e.g. Coulter et al. 2014).Synthesis StatementThe structure of the health system into which the TS project is introduced should be considered for relative pay scales, career development and potentially better alternatives to task shifting. Category 1 ?To avoid tensions between cadres and illicit charging for services, pay levels must be equitable and adequate Health workers involved in task shifting ranged from local volunteers who received little to no monetary compensation to nurses whose salaries were regulated at the national level. In many studies cadres participating in task shifting assumed higher workload and increased level of responsibility than anticipated, but this was usually not reflected in their remuneration. Managing the expectations of workers involved in task shifting, or affected by it, is essential because where staff feel they are not adequately paid, undesirable outcomes are noted.We expected that after being trained, since we are now part of the curative part, there will be change in our monthly salaries but there is no change . . . (CHW, Malawi, Study # 2)The inability of patients to recognise the difference between health workers is an insight that should not be disregarded. While this fact may mean that patients in some areas appear willing to receive care from new cadres, it also means that patients may not be able to recognise when care is delivered inappropriately ?a reality of the majority of the taskshifting programmes studied. Other studies suggested that patients were naively accepting care from lower skilled workers while believing that they were being looked after by a professional. Views conveyed by.E with workplace demands and to fulfil the obligation they feel towards their patients. Clearly, this fundamental risk should be considered as part of any task-shifting intervention. Project planners need to recognise that any task-shifting programme is limited by the health system of which it is a part. Accordingly, the intervention must be designed to provide supervision of staff to ensure that they are not stretching the mandates of their new or altered job roles. Staff who are working in positions affected by the intervention should also be trained to be mindful of the limitations of the redesigned structure. Specifically, for interventions in such areas as neonatal care, nurses and paediatricians should be trained to understand the limits of the new cadre, and to ensure that they remain supportive of the new staff, but also watchful of their activity. Category 2 ?Task-shifting programme design should be mindful of the perspective of patients and ensure that key differences in cadre are understood Many health workers conveyed that their patients could not fully tell the difference between doctors, nurses or lay workers. A commonly held perception was that patients either were not aware or did not mind that tasks were being delegated to lower cadres.In the past people (in the villages) used to call us doctors, but with this programme we are real doctors because we are giving them medicines and I feel happy that I am a doctor. (CHW, Malawi, Study # 2)communities were largely conveyed through the interviews with health staff, managers and policy makers, and therefore provided a rather limited insight. The lack of patient voice captured in the studies reviewed is a significant weakness in the literature and any intervention in neonatal care should be mindful of the role and opinions of mothers of patients (e.g. Coulter et al. 2014).Synthesis StatementThe structure of the health system into which the TS project is introduced should be considered for relative pay scales, career development and potentially better alternatives to task shifting. Category 1 ?To avoid tensions between cadres and illicit charging for services, pay levels must be equitable and adequate Health workers involved in task shifting ranged from local volunteers who received little to no monetary compensation to nurses whose salaries were regulated at the national level. In many studies cadres participating in task shifting assumed higher workload and increased level of responsibility than anticipated, but this was usually not reflected in their remuneration. Managing the expectations of workers involved in task shifting, or affected by it, is essential because where staff feel they are not adequately paid, undesirable outcomes are noted.We expected that after being trained, since we are now part of the curative part, there will be change in our monthly salaries but there is no change . . . (CHW, Malawi, Study # 2)The inability of patients to recognise the difference between health workers is an insight that should not be disregarded. While this fact may mean that patients in some areas appear willing to receive care from new cadres, it also means that patients may not be able to recognise when care is delivered inappropriately ?a reality of the majority of the taskshifting programmes studied. Other studies suggested that patients were naively accepting care from lower skilled workers while believing that they were being looked after by a professional. Views conveyed by.
