Task-shifting and task-sharing for surgical workforce sustainability in sub-Saharan Africa: A narrative review of cost-effectiveness and retention evidence

Sub-Saharan Africa (SSA) carries a disproportionate share of the global surgical disease burden against a severely constrained surgical, obstetric, and anesthesia workforce. Task-shifting and task-sharing, the delegation of selected surgical tasks to non-physician clinicians (NPCs), have been widely promoted as a pragmatic response, and existing systematic reviews report broad clinical non-inferiority of NPC-performed procedures relative to specialist-performed equivalents. Far less attention has been paid to whether task-shifting represents a fiscally and organizationally sustainable long-term workforce strategy rather than a stopgap measure. This review synthesizes the existing evidence on the cost-effectiveness and workforce sustainability (retention, attrition, regulatory durability) of surgical task-shifting in SSA, reframing the discussion from a clinical-safety question to a health-systems sustainability and financing question. A purposive search of PubMed and Google Scholar was conducted for English and French language studies published between 2007 and 2026, using terms including “task-shifting,” “non-physician clinician,” “surgical workforce,” “cost-effectiveness,” “retention,” and “sub-Saharan Africa,” supplemented by manual searching of reference lists from identified reviews. Disability-adjusted life year-based costing studies place several NPC training programs among the most cost-effective health interventions documented in low-income settings. However, the retention literature points to attrition driven by inadequate remuneration, unclear career progression, and weak regulatory recognition, factors that, if unaddressed, erode the long-run cost advantage that makes task-shifting attractive. Task-shifting is best understood not as a permanent low-cost substitute for specialist surgical care, but as a conditionally sustainable strategy whose financial advantages depend on parallel investment in retention, regulation, and career pathways.