Skip to main content

Applying systems thinking to task shifting for mental health using lay providers: a review of the evidence

  • D. Javadi (a1), I. Feldhaus (a2), A. Mancuso (a3) and A. Ghaffar (a1)

This paper seeks to review the available evidence to determine whether a systems approach is employed in the implementation and evaluation of task shifting for mental health using lay providers in low- and middle-income countries, and to highlight system-wide effects of task-shifting strategies in order to better inform efforts to strength community mental health systems.


Pubmed, CINAHL, and Cochrane Library databases were searched. Articles were screened by two independent reviewers with a third reviewer resolving discrepancies. Two stages of screens were done to ensure sensitivity. Studies were analysed using the World Health Organization's building blocks framework with the addition of a community building block, and systems thinking characteristics to determine the extent to which system-wide effects had been considered.


Thirty studies were included. Almost all studies displayed positive findings on mental health using task shifting. One study showed no effect. No studies explicitly employed systems thinking tools, but some demonstrated systems thinking characteristics, such as exploring various stakeholder perspectives, capturing unintended consequences, and looking across sectors for system-wide impact. Twenty-five of the 30 studies captured elements other than the most directly relevant building blocks of service delivery and health workforce.


There is a lack of systematic approaches to exploring complexity in the evaluation of task-shifting interventions. Systems thinking tools should support evidence-informed decision making for a more complete understanding of community-based systems strengthening interventions for mental health.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Applying systems thinking to task shifting for mental health using lay providers: a review of the evidence
      Available formats
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Applying systems thinking to task shifting for mental health using lay providers: a review of the evidence
      Available formats
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Applying systems thinking to task shifting for mental health using lay providers: a review of the evidence
      Available formats
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
*Address for correspondence: Dena Javadi, Alliance for Health Policy and Systems Research, WHO, Geneva, Switzerland. (Email:
Hide All
Abas, M, Bowers, T, Manda, E, Cooper, S, Machando, D, Verhey, R, Lamech, N, Araya, R, Chibanda, D (2016). 'Opening up the mind': problem-solving therapy delivered by female lay health workers to improve access to evidence-based care for depression and other common mental disorders through the Friendship Bench Project in Zimbabwe. International Journal of Mental Health Systems 10, 39.
Adam, T, Hsu, J, De Savigny, D, Lavis, JN, Rottingen, JA, Bennett, S (2012). Evaluating health systems strengthening interventions in low-income and middle-income countries: are we asking the right questions? Health Policy and Planning 27(Suppl 4), iv9iv19.
Agyapong, VI, Osei, A, Farren, CK, Mcauliffe, E (2015a). Task shifting – Ghana's community mental health workers’ experiences and perceptions of their roles and scope of practice. Global Health Action 8, 28955.
Agyapong, VI, Osei, A, Farren, CK, Mcauliffe, E (2015b). Task shifting of mental health care services in Ghana: ease of referral, perception and concerns of stakeholders about quality of care. International Journal for Quality in Health Care 27, 377383.
Agyapong, VI, Osei, A, Mcloughlin, DM, Mcauliffe, E (2016). Task shifting-perception of stake holders about adequacy of training and supervision for community mental health workers in Ghana. Health Policy and Planning 31, 645655.
AHPSR (2009). Systems Thinking for Health Systems Strengthening. World Health Organization: Geneva.
Ali, BS, Rahbar, MH, Naeem, S, Gul, A, Mubeen, S, Iqbal, A (2003). The effectiveness of counseling on anxiety and depression by minimally trained counselors: a randomized controlled trial. American Journal of Psychotherapy 57, 324336.
Ali, NS, Ali, BS, Azam, IS, Khuwaja, AK (2010). Effectiveness of counseling for anxiety and depression in mothers of children ages 0–30 months by community workers in Karachi, Pakistan: a quasi experimental study. BMC Psychiatry 10, 57.
Atif, N, Lovell, K, Rahman, A (2015). Maternal mental health: the missing ‘m’ in the global maternal and child health agenda. Seminars in Perinatology 39, 345352.
Baker-Henningham, H, Powell, C, Walker, S, Grantham-Mcgregor, S (2005). The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Archives of Disease in Childhood 90 (
Bolton, P, Lee, C, Haroz, EE, Murray, L, Dorsey, S, Robinson, C, Ugueto, AM, Bass, J (2014). A transdiagnostic community-based mental health treatment for comorbid disorders: development and outcomes of a randomized controlled trial among Burmese refugees in Thailand. PLoS Medicine 11, e1001757.
Buttorff, C, Hock, RS, Weiss, HA, Naik, S, Araya, R, Kirkwood, BR, Chisholm, D, Patel, V (2012). Economic evaluation of a task-shifting intervention for common mental disorders in India. Bulletin of the World Health Organization 90 (
CASP (2016). Critical Appraisal Skills Program: Making Sense of Evidence. UK (http://www.Casp-Uk.Net/Casp-Tools-Checklists).
Chatterjee, S, Naik, S, John, S, Dabholkar, H, Balaji, M, Koschorke, M, Varghese, M, Thara, R, Weiss, HA, Williams, P, Mccrone, P, Patel, V, Thornicroft, G (2014). Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial. Lancet (London, England) 383 (
Chibanda, D, Cowan, FM, Healy, JL, Abas, M, Lund, C (2015). Psychological interventions for common mental disorders for people living with HIV in low- and middle-income countries: systematic review. Tropical Medicine & International Health 20, 830839.
Chowdhary, N, Sikander, S, Atif, N, Singh, N, Ahmad, I, Fuhr, DC, Rahman, A, Patel, V (2014). The content and delivery of psychological interventions for perinatal depression by non-specialist health workers in low and middle income countries: a systematic review. Best Practice & Research: Clinical Obstetrics & Gynaecology 28, 113133.
Eaton, J, Mccay, L, Semrau, M, Chatterjee, S, Baingana, F, Araya, R, Ntulo, C, Thornicroft, G, Saxena, S (2011). Scale up of services for mental health in low-income and middle-income countries. Lancet 378, 15921603.
Fulton, BD, Scheffler, RM, Sparkes, SP, Auh, EY, Vujicic, M, Soucat, A (2011). Health workforce skill mix and task shifting in low income countries: a review of recent evidence. Human Resources for Health 9, 1.
GHWA (2007). Systems Support for Task-Shifting to Community Health Workers. Technical Briefing. Global Health Workforce Alliance: Geneva.
GHWA (2013). Joint Commitment to Harmonized Partners Action for Community Health Workers and Frontline Health Workers: Moving from Fragmentation to Synergy Toward Universal Health Coverage. Third Global Forum on human resources for Health, Global Health Workforce Alliance: Brazil.
Hanlon, C, Luitel, NP, Kathree, T, Murhar, V, Shrivasta, S, Medhin, G, Ssebunnya, J, Fekadu, A, Shidhaye, R, Petersen, I, Jordans, M (2014). Challenges and opportunities for implementing integrated mental health care: a district level situation analysis from five low-and middle-income countries. PLoS ONE 9, 17.
Hung, KJ, Tomlinson, M, Le Roux, IM, Dewing, S, Chopra, M, Tsai, AC (2014). Community-based prenatal screening for postpartum depression in a South African township. International Journal of Gynaecology and Obstetrics 126, 7477.
Iheanacho, T, Kapadia, D, Ezeanolue, CO, Osuji, AA, Ogidi, AG, Ike, A, Patel, D, Stefanovics, E, Rosenheck, R, Obiefune, M, Ezeanolue, EE (2016). Attitudes and beliefs about mental illness among church-based lay health workers: experience from a prevention of mother-to-child HIV transmission trial in Nigeria. International Journal of Culture And Mental Health 9, 113.
Joshi, R, Alim, M, Kengne, AP, Jan, S, Maulik, PK, Peiris, D, Patel, AA (2014). Task shifting for non-communicable disease management in low and middle income countries--a systematic review. PLoS ONE 9, e103754.
Jotheeswaran, AT, Dias, A, Philp, I, Beard, J, Patel, V, Prince, M (2015). Identifying common impairments in frail and dependent older people: validation of the COPE assessment for non-specialised health workers in low resource primary health care settings. BMC Geriatrics 15, 114.
Kakuma, R, Minas, H, Van Ginneken, N, Dal Poz, MR, Desiraju, K, Morris, JE, Saxena, S, Scheffler, RM (2011). Human resources for mental health care: current situation and strategies for action. Lancet 378, 16541663.
Kessler, RC, Aguilar-Gaxiola, S, Alonso, J, Chatterji, S, Lee, S, Ormel, J, Ustun, TB, Wang, PS (2009). The global burden of mental disorders: an update from the WHO World Mental Health (WMH) surveys. Epidemiologia e Psichiatria Sociale 18, 2333.
Kumakech, E, Cantor-Graae, E, Maling, S, Bajunirwe, F (2009). Peer-group support intervention improves the psychosocial well-being of AIDS orphans: cluster randomized trial. Social Science & Medicine (1982) 68 (
Larson-Stoa, D, Jacobs, GA, Jonathan, A, Poudyal, B (2015). Effect of counseling by paraprofessionals on depression, anxiety, somatization, and functioning in Indonesian torture survivors. Torture 25, 111.
Levin, C, Chisholm, D (2015). Cost-effectiveness and affordability of interventions, policies, and platforms for the prevention and treatment of mental, neurological and substance use disorders. In Disease Control Priorities 3: Mental, Neurological, and Substance Use Disorders (ed. Jamison, D. T., Nugent, R., Gleband, H., Horton, S., Jha, P., Laxminarayan, R. and Mock, C.), pp. 114. World Bank: Washington.
Lorenzo, T, Van Pletzen, E, Booyens, M (2015). Determining the competences of community based workers for disability-inclusive development in rural areas of South Africa, Botswana and Malawi. Rural and Remote Health 15, 2919.
Magidson, JF, Lejuez, CW, Kamal, T, Blevins, EJ, Murray, LK, Bass, JK, Bolton, P, Pagoto, S (2015). Adaptation of community health worker-delivered behavioral activation for torture survivors in Kurdistan, Iraq. Global Mental Health (Cambridge) 2, 110.
Mendenhall, E, De Silva, MJ, Hanlon, C, Petersen, I, Shidhaye, R, Jordans, M, Luitel, N, Ssebunnya, J, Fekadu, A, Patel, V, Tomlinson, M, Lund, C (2014). Acceptability and feasibility of using non-specialist health workers to deliver mental health care: Stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda. Social Science & Medicine 118, 3342.
Murray, CJ, Barber, RM, Foreman, KJ, Abbasoglu Ozgoren, A, Abd-Allah, F, Abera, SF, Aboyans, V, Abraham, JP, Abubakar, I, Abu-Raddad, LJ, Abu-Rmeileh, NM, Achoki, T, Ackerman, IN, Ademi, Z, Adou, AK, Adsuar, JC, Afshin, A, Agardh, EE, Alam, SS, Alasfoor, D, Albittar, MI, Alegretti, MA, Alemu, ZA, Alfonso-Cristancho, R, Alhabib, S, Ali, R, Alla, F, Allebeck, P, Almazroa, MA, Alsharif, U, Alvarez, E, Alvis-Guzman, N, Amare, AT, Ameh, EA, Amini, H, Ammar, W, Anderson, HR, Anderson, BO, Antonio, CA, Anwari, P, Arnlov, J, Arsic Arsenijevic, VS, Artaman, A, Asghar, RJ, Assadi, R, Atkins, LS, Avila, MA, Awuah, B, Bachman, VF, Badawi, A, Bahit, MC, Balakrishnan, K, Banerjee, A, Barker-Collo, SL, Barquera, S, Barregard, L, Barrero, LH, Basu, A, Basu, S, Basulaiman, MO, Beardsley, J, Bedi, N, Beghi, E, Bekele, T, Bell, ML, Benjet, C, Bennett, DA, Bensenor, IM, Benzian, H, Bernabe, E, Bertozzi-Villa, A, Beyene, TJ, Bhala, N, Bhalla, A, Bhutta, ZA, Bienhoff, K, Bikbov, B, Biryukov, S, Blore, JD, Blosser, CD, Blyth, FM, Bohensky, MA, Bolliger, IW, Bora Basara, B, Bornstein, NM, Bose, D, Boufous, S, Bourne, RR, Boyers, LN, Brainin, M, Brayne, CE, Brazinova, A, Breitborde, NJ, Brenner, H, Briggs, AD, Brooks, PM, Brown, JC, Brugha, TS, Buchbinder, R, Buckle, GC (2015a). Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition. Lancet 386, 21452191.
Murray, LK, Dorsey, S, Haroz, E, Lee, C, Alsiary, MM, Haydary, A, Weiss, WM, Bolton, P (2014). A common elements treatment approach for adult mental health problems in low- and middle-income countries. Cognitive and Behavioral Practice 21, 111123.
Murray, LK, Skavenski, S, Kane, JC, Mayeya, J, Dorsey, S, Cohen, JA, Michalopoulos, LT, Imasiku, M, Bolton, PA (2015b). Effectiveness of trauma-focused cognitive behavioral therapy among trauma-affected children in Lusaka, Zambia: a randomized clinical trial. JAMA Pediatrics 169, 761769.
Murthy, RS (2011). Mental Health Services in Low- and Middle-Income Countries. Oxford Textbook of Community Mental Health. Oxford University Press: Oxford.
Neuner, F, Onyut, PL, Ertl, V, Odenwald, M, Schauer, E, Elbert, T (2008). Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: a randomized controlled trial. Journal of Consulting and Clinical Psychology 76, 686694.
Niekerk, V (2008). Task shifting or power shedding? South African Medical Journal 98, 327.
Nimgaonkar, AU, Menon, SD (2015). A task shifting mental health program for an impoverished rural Indian community. Asian Journal of Psychiatry 16, 4147.
Olaniran, A, Smith, H, Unkels, R, Bar-Zeev, S, Van Den Broek, N (2017). Who is a community health worker? – a systematic review of definitions. Global Health Action 10, 113.
Padilla, E, Molina, J, Kamis, D, Calvo, M, Stratton, L, Strejilevich, S, Aleman, GG, Guerrero, G, Bourdieu, M, Conesa, HA, Escobar, JI, De Erausquin, GA (2015). The efficacy of targeted health agents education to reduce the duration of untreated psychosis in a rural population. Schizophrenia Research 161, 184187.
Patel, V, Araya, R, Chatterjee, S, Chisholm, D, Cohen, A, De Silva, M, Hosman, C, Mcguire, H, Rojas, G, Van Ommeren, M (2007). Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet 370, 9911005.
Patel, V, Maj, M, Flisher, AJ, De Silva, MJ, Koschorke, M, Prince, M (2010a). Reducing the treatment gap for mental disorders: a WPA survey. World Psychiatry 9, 169176.
Patel, V, Thornicroft, G (2009). Packages of care for mental, neurological, and substance use disorders in low- and middle-income countries: PLoS medicine series. PLoS Medicine 6, e1000160.
Patel, V, Weiss, HA, Chowdhary, N, Naik, S, Pednekar, S, Chatterjee, S, Bhat, B, Araya, R, King, M, Simon, G, Verdeli, H, Kirkwood, BR (2011). Lay health worker led intervention for depressive and anxiety disorders in India: impact on clinical and disability outcomes over 12 months. British Journal of Psychiatry 199, 459466.
Patel, V, Weiss, HA, Chowdhary, N, Naik, S, Pednekar, S, Chatterjee, S, Silva, MJ, Bhat, B, Araya, R, King, M, Simon, G, Verdeli, H, Kirkwood, BR (2010b). Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial. Lancet (London, England) 376 (
Paudel, S, Gilles, N, Hahn, S, Hexom, B, Premkumar, R, Arole, S, Katz, C (2014). Impact of mental health training on village health workers regarding clinical depression in rural India. Community Mental Health Journal 50, 480486.
Peters, DH (2014). The application of systems thinking in health: why use systems thinking? Health Research Policy and Systems 12, 51.
Petersen, I, Ssebunnya, J, Bhana, A, Baillie, K (2011). Lessons from case studies of integrating mental health into primary health care in South Africa and Uganda. International Journal of Mental Health Systems 5, 8.
Philips, M, Zachariah, R, Venis, S (2008). Task shifting for antiretroviral treatment delivery in sub-Saharan Africa: not a panacea. Lancet 371, 682684.
Pradeep, J, Isaacs, A, Shanbag, D, Selvan, S, Srinivasan, K (2014). Enhanced care by community health workers in improving treatment adherence to antidepressant medication in rural women with major depression. Indian Journal of Medical Research 139, 236245.
Rahman, A, Fisher, J, Bower, P, Luchters, S, Tran, T, Yasamy, MT, Saxena, S, Waheed, W (2013). Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis. Bulletin of the World Health Organization 91, 593601I.
Rahman, A, Malik, A, Sikander, S, Roberts, C, Creed, F (2008). Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet (London, England) 372 (
Richters, A, Rutayisire, T, Slegh, H (2013). Sexual transgression and social disconnection: healing through community-based sociotherapy in Rwanda. Culture, Health & Sexuality 15, S581S593.
Robbins, RN, Mellins, CA, Leu, CS, Rowe, J, Warne, P, Abrams, EJ, Witte, S, Stein, DJ, Remien, RH (2015). Enhancing Lay Counselor Capacity to Improve Patient Outcomes with Multimedia Technology. AIDS and Behavior 19(Suppl 2) (
Rotheram-Borus, MJ, Tomlinson, M, Le Roux, I, Stein, JA (2015). Alcohol use, partner violence, and depression: a cluster randomized controlled trial among urban South African mothers over 3 years. American Journal of Preventive Medicine 49, 715725.
Schneider, H, Lehmann, U (2016). From community health worker to community health system: time to widen the horizon? Health Systems and Reform 2, 112118.
Thurman, TR, Kidman, R, Taylor, TM (2014). Does investment in home visitors lead to better psychological health for HIV-affected families? Results from a quasi-experimental evaluation in South Africa. AIDS Care 26, S2S10.
Tomlinson, M, Doherty, T, Jackson, D, Lawn, JE, Ijumba, P, Colvin, M, Nkonki, L, Daviaud, E, Goga, A, Sanders, D, Lombard, C, Persson, L, Ndaba, T, Snetro, G, Chopra, M (2011). An effectiveness study of an integrated, community-based package for maternal, newborn, child and HIV care in South Africa: study protocol for a randomized controlled trial. Trials 12 (
van Ginneken, N, Tharyan, P, Lewin, S, Rao Girish, N, Meera, SM, Pian, J, Chandrashekar, S, Patel, V (2013). Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database of Systematic Reviews (
Wang, PS, Aguilar-Gaxiola, S, Alonso, J, Angermeyer, MC, Borges, G, Bromet, EJ, Bruffaerts, R, De Girolamo, G, De Graaf, R, Gureje, O, Haro, JM, Karam, EG, Kessler, RC, Kovess, V, Lane, MC, Lee, S, Levinson, D, Ono, Y, Petukhova, M, Posada-Villa, J, Seedat, S, Wells, JE (2007). Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet 370, 841850.
Weinmann, S, Koesters, M (2016). Mental health service provision in low and middle-income countries: recent developments. Current Opinion in Psychiatry 29, 270275.
Whiteford, HA, Degenhardt, L, Rehm, J, Baxter, AJ, Ferrari, AJ, Erskine, HE, Charlson, FJ, Norman, RE, Flaxman, AD, Johns, N, Burstein, R, Murray, CJ, Vos, T (2013). Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet 382, 15751586.
WHO (1997). Intersectoral action for health: a cornerstone for health-for-all in the twenty-first century. In (ed. WHO), International Conference on Intersectoral Action for Health, Halifax, Canada. WHO.
WHO (2006). World Health Report 2006: Working Together for Health. World Health Organization: Geneva.
WHO (2007a). Everybody's Business: Strengthening Health Systems to Improve Health Outcomes. World Health Organization: Geneva.
WHO (2007b). Joint WHO/OGAC Technical Consultation on Task Shifting: Key Elements of a Regulatory Framework in Support of In-country Implementation of Task Shifting. World Health Organization: Geneva.
WHO (2008). mhGAP Mental Health Gap Action Programme: Scaling Up Care for Mental, Neurological, and Substance Use Disorders. World Health Organization: Geneva.
WHO (2009). Improving Health Systems and Services for Mental Health. World Health Organization: Geneva.
WHO (2010). Monitoring the Building Blocks of the Health System. World Health Organization: Geneva.
WONCA (2008). Integrating mental health into primary care: a global perspective . In (ed. WHO), Singapore World Health Organization; World Organization of Family Doctors: Geneva, Switzerland.
Wright, J, Chiwandira, C (2016). Building capacity for community mental health care in rural Malawi: findings from a district-wide task-sharing intervention with village-based health workers. International Journal of Social Psychiatry 62, 589596.
Yaya Bocoum, F, Kouanda, S, Kouyate, B, Hounton, S, Adam, T (2013). Exploring the effects of task shifting for HIV through a systems thinking lens: the case of Burkina Faso. BMC Public Health 13, 997.
Zachariah, R, Ford, N, Philips, M, Lynch, S, Massaquoi, M, Janssens, V, Harries, AD (2009). Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa. Transactions of the Royal Society of Tropical Medicine and Hygiene 103, 549558.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Global Mental Health
  • ISSN: -
  • EISSN: 2054-4251
  • URL: /core/journals/global-mental-health
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed