The table to the left shows the despair some countries suffered in providing sufficient clinician capital for the HIV pandemic*. In Malawi, for example, there were over 7000 HIV+ patients per doctor, while in Moçambique, there were over 6800 HIV+ patients for each doctor. The ratios were better, but still unacceptable, for the number of patients per nurse. (For comparison, see the rations in the USA and UK at the bottom of the table.)
The explosion of thirty years of a simmering pandemic exacerbated the push/pull dynamics of the health care brain-drain in these countries. Countries tried numerous strategies, including incentivizing native clinicians, attracting foreign ones and quite creatively, 'task-shifting' - the concept that in areas of need, important tasks are handled by less formally trained staff.
The need for task-shifting is represented in the above table. For example, the initiation of anti-retroviral medicine is essentially a physician's role here in the US. But emulating this restriction in either Malawi or Moçambique is a fool's errand - there just aren't enough hours in a day to treat all the patients. And so through protocols, close supervision and available referrals for consultations, nurses can diagnose HIV and start medications. Meanwhile, for patients with more complicated illnesses, physician assistants (aka clinical officers) take over management. And if the physician assistant needs assistance, there's the potential of referring the patient to the consultant physician.
How well does task-shifting work? Here's the punch-line from a 2010 review:
We found 2960 articles, of which 84 were included in the core review. 51 reported outcomes, including research from 10 countries in sub-Saharan Africa. The most common intervention studied was the delegation of tasks (especially initiating and monitoring [HIV medications]) from doctors to nurses and other non-physician clinicians. Five studies showed increased access to HAART through expanded clinical capacity; two concluded task shifting is cost effective; 9 showed staff equal or better quality of care; studies on non-physician clinician agreement with physician decisions was mixed, with the majority showing good agreement.
Yet the conceit of 'task-shifting' isn't simply a desperation of circumstance. It's the belief that the number of talented clinicians isn't exactly equal to the exact number of doctors. If there are 500 physicians in Malawi, it's not the case that there are only 500 people capable of doing a doctor's work. Especially in countries with destroyed/fledgling/non-existent educational systems, there are lots more individuals who could have been and want to be doctors. Utilizing these individuals isn't just necessary, it's elegant.
*2004 WHO data, published in the New England Journal of Medicine