WMA Statement on Scope of Practice, Task Sharing and Task Shifting

Adopted by the 60^th WMA General Assembly, New Delhi, India, October 2009
and reaffirmed by the 212^th WMA Council Session, Santiago, Chile, April 2019
and revised by the 76th WMA General Assembly, Porto, Portugal, October 2025 

PREAMBLE

In response to the global health workforce shortages and the increasing health expenditures, different measures have been developed to fill the unmet needs in health care delivery.

During the HIV/AIDS crisis, the WHO, the Joint United Nations Programme on HIV/AIDS (UNAIDS), and President´s Emergency Plan for AIDS Relief (PEPFAR) recommended task shifting with the aim to provide care to all individuals in need. Task shifting was defined as specific tasks that are moved from highly qualified health personnel to health personnel with shorter training and fewer qualifications. However, there are significant risks associated with task shifting, most notably the risk of decreasing the quality of patient care and contributing to the creation of a two-tier system in medicine.

In 2021, the WHO published health workforce-related terminology1. It discouraged the use of the word task shifting as it implies simply shifting tasks in isolation, without any accompanying support measures. Instead, the WHO encouraged task sharing, which it defines as ‘the rational redistribution of responsibilities among health workforce teams. Specific tasks or roles are shared, where appropriate, to less specialised health workers to use the available personnel efficiently. It should be accompanied by appropriate measures in terms of education, supervision, management support, licensing, regulation and remuneration.’

The term scope of practice (or SOP) refers to the limits of a health professional’s knowledge, skills and experience. A scope of practice reflects all tasks and activities undertaken within the context of a health professional’s role.

In multi-disciplinary health care teams physicians and other health personnel (like nurses, physiotherapists, physician assistants or community workers) cooperate to make their unique contribution to the best care of the patient. Such teamwork is to be coordinated by a physician, as the most highly trained team member and the one who generally bears the responsibility for diagnostic and therapeutic decisions. In such teams, it is important that each health personnel works within their scope of practice.

Multi-disciplinary healthcare teams should not be understood as interprofessional collaboration. as described in the World Health Professional Alliance statement on Interprofessional Collaborative Practice. This statement refers to collaboration between health professionals, who are licensed and/or regulated, highly educated and adhere to strict codes of ethics.

Some health care settings or jurisdictions have created new cohorts of healthcare personnel whose function is to assist other health professionals, specifically physicians, as well as new groups trained to independently perform specific tasks with or without physician supervision. If these new cohorts are allowed to perform physicians’ tasks on their own without supervision of a physician, this may decrease the quality of care. There are several risks such as, delayed, incorrect or overdiagnosis, incorrect treatment and inability to deal with complications, fragmented and inefficient service and lack of proper follow up. It may also increase the overall cost of care, as non-physician health personnel are more likely to rely on consultations and diagnostic and other tests to compensate for their lesser education and training compared to physicians. Also, the upholding of the specific ethical rules of the medical profession may be compromised.

All these measures are often implemented as counter measures to the critical shortage of physicians, or for social or economic reasons or by request of other health professionals or as means of lowering cost, under the guise of efficiency, or other unproven claims. In some cases, studies indicate that non-physician practitioners actually increase cost and inefficiency. Cost savings and efficiencies may also be facilitated by other interventions, such as the advancement of medical technology, which can standardize the performance and interpretation of certain tasks and augment the skills and knowledge of physicians and other health care professionals, and efforts to incentivize physicians to practice in rural or underserved areas. Data also shows that non-physicians tend to practice in the same locations as physicians, thus negating the notion that these proposals will solve concerns around access to care. It must also be noted that workforce shortages are not limited to physicians but indeed impact many health care professionals.

It must be recognized that medicine can never be viewed solely as a technical discipline. Patients’ health, rights, quality of care and medical ethics, must be the top priorities.

RECOMMENDATIONS

Therefore, the World Medical Association recommends the following guidelines:

1. Multi-disciplinary team approaches, led and coordinated by a physician, should be viewed as the gold standard. This should involve the development of mutually supportive, interactive health care teams, where each member can make his or her unique contribution to the care being provided, based on their education, competence, area of expertise and scope of practice (as agreed upon by the physician leader).
2. Quality and continuity of care, patient safety and medical ethics must never be compromised and should be the basis for all health workforce reforms and legislation.
3. Respect for the physician’s competence, professional independence and clinical autonomy must be guaranteed in any health workforce reform. Diagnosis, as the basis for any action relating to the patient’s health, and prescribing treatments must remain the sole responsibility of the physician.
4. It is imperative to consult and involve physicians and their professional representative organizations when considering whether to shift tasks away from physicians or opening them to other health professionals or new cohorts. This involvement should be explicit and cover all aspects of ensuring high quality care, particularly in relation to reforms in legislation and regulations. In some health care systems, physicians might themselves consider initiating and training a new cohort of assistants under their supervision and in accordance with principles of safety and proper patient care and with clear regulatory frameworks, to be created if necessary.
5. When tasks are shifted from physicians to other health professionals, the respective clinical responsibility and legal liability must be clearly defined before implementation. These definitions should be included in official policies and made accessible to all relevant stakeholders. In particular, patients should be made aware of which health personnel are treating them. Terms such as ‘doctor’ or ‘physician’ must not be used in ways that confuse patients or imply greater training.’
6. Quality assurance standards and treatment protocols must be defined, developed and supervised by physicians. Credentialing systems should be devised and implemented in order to ensure quality of care. The roles and responsibilities of different health personnel must be clarified. Tasks that can only be performed by physicians, such as responsibility for diagnosis and prescribing treatments, must be clearly defined, and non-physician staff must not be allowed or pressured into operate beyond the bounds of their scope of practice.
7. All health workforce reforms should aim for the development of sustainable, fully functioning health care systems, which promote the quality of professional practice. The aspiration should be to educate and employ as many skilled health personnel as required, including physicians, rather than shifting tasks to less skilled health personnel.
8. Assessments (including structured evaluations) should be made of the impact of the health workforce reforms on patient and health outcomes as well as on efficiency and effectiveness of health care delivery.
9. Healthcare reforms, where tasks are shifted to non-physician health professionals without supervision, should not be undertaken or viewed as a viable cost-saving measure, as the economic benefits of such reforms are unsubstantiated. Cost driven measures are unlikely to produce quality results in the best interest of patients. Credible analysis of the economic benefits of such reforms should be conducted to measure public health outcomes, cost effectiveness and productivity, and should be studied and assessed independently and not under the auspices of those designated to perform or finance these reforms.
10. Health care reforms that change scopes of practice or implement new groups of healthcare personnel should be complemented with incentives for the retention of physicians through means such as increasing salaries and improving working conditions.
11. Such health care reforms should be preceded by a systematic review, analysis and discussion of the potential needs, costs and benefits. It should not be instituted solely as a reaction to other developments in the health care system, and in order for collaborative practice to succeed, training in physician leadership and teamwork must be improved. There must also be a clear understanding of the scope of practice of each healthcare team member, meaning what each person is educated for and capable of doing, a clear understanding of responsibilities and a defined, uniformly accepted use of terminology.
12. The reasons underlying the need for health workforce reforms differ from country to country and therefore solutions appropriate for one country cannot be automatically adopted by others.
13. Research must be conducted to identify training models that have been proven effective for less skilled health personnel. Work should be aligned to various models currently in existence. Research should also focus on the collection and sharing of information, evidence and outcomes. Research and analysis must be comprehensive, and physicians must be part of the process.
14. The WMA shall consider establishing a framework for the sharing of information on this topic where members can discuss developments in their countries and their effects on patient care and outcomes.
15. When developing relevant law and policy, governments and health bodies should ensure that definitions of scope of practice for healthcare professionals are consistent, safe and facilitate the highest quality care, and clearly define which roles and tasks should only be undertaken by physicians and which tasks non-physician healthcare professionals may perform with physician supervision.