Curriculum and training needs of mid-level health workers in Africa: a situational review from Kenya

Curriculum and training needs of mid-level health workers in Africa: a situational review from Kenya, Nigeria, South Africa and Uganda

Ian Couper1,2* , Sunanda Ray3,4, Duane Blaauw5, Gideon Ng’wena6, Lucy Muchiri7, Eren Oyungu8, Akinyinka Omigbodun9,10 , Imran Morhason-Bello11 , Charles Ibingira12, James Tumwine13 , Daphney Conco14 and Sharon Fonn14

Abstract Background: Africa’s health systems rely on services provided by mid-level health workers (MLWs). Investment in their training is worthwhile since they are more likely to be retained in underserved areas, require shorter training courses and are less dependent on technology and investigations in their clinical practice than physicians. Their training programs and curricula need up-dating to be relevant to their practice and to reflect advances in health professional education. This study was conducted to review the training and curricula of MLWs in Kenya, Nigeria, South Africa and Uganda, to ascertain areas for improvement. Methods: Key informants from professional associations, regulatory bodies, training institutions, labour organisations and government ministries were interviewed in each country. Policy documents and training curricula were reviewed for relevant content. Feedback was provided through stakeholder and participant meetings and comments recorded. 421 District managers and 975 MLWs from urban and rural government district health facilities completed self-administered questionnaires regarding MLW training and performance. Results: Qualitative data indicated commonalities in scope of practice and in training programs across the four countries, with a focus on basic diagnosis and medical treatment. Older programs tended to be more didactic in their training approach and were often lacking in resources. Significant concerns regarding skills gaps and quality of training were raised. Nevertheless, quantitative data showed that most MLWs felt their basic training was adequate for the work they do. MLWs and district managers indicated that training methods needed updating with additional skills offered. MLWs wanted their training to include more problem-solving approaches and practical procedures that could be life-saving. Conclusions: MLWs are essential frontline workers in health services, not just a stop-gap. In Kenya, Nigeria and Uganda, their important role is appreciated by health service managers. At the same time, significant deficiencies in training program content and educational methodologies exist in these countries, whereas programs in South Africa appear to have benefited from their more recent origin. Improvements to training and curricula, based on international educational developments as well as the local burden of disease, will enable them to function with greater effectiveness and contribute to better quality care and outcomes. Keywords: Healthcare providers, Healthcare workers, Mid-level workers, Primary healthcare, Educational models, Quality of healthcare, Curricula, Africa Excerpt:

Achieving universal health coverage requires a well-trained and motivated health workforce, delivering a range of services. International experience suggests that mid-level health workers (MLWs) play an important role in addressing human resource shortages and improving health care access and equity, especially in low- and middle-income countries [1–5]. Africa’s health systems are dependent on services provided by MLWs, with initiation of new training programs in some countries and expansion of numbers of MLWs being trained in others in order to implement priority health programs. In 2007 this category of health care provider was identified in 25 out of 47 countries in sub-Saharan Africa [3]. Despite being the most cost-effective providers of primary and secondary health services, MLWs are often not included in health workforce planning and in some countries their roles are not formally regulated [5, 6]. They have been called doctor-substitutes, those who compensate for the scarcity of doctors especially in rural and underserved areas [3–5]. However, compared to doctors, they have higher retention in underserved areas, shorter training courses and lower dependence on expensive technology and investigations [4]. Whether MLWs are well-equipped to fulfill their responsibilities however, is uncertain. There have been several calls to review and update the curricula and training of MLWs, to ensure they gain the competencies necessary to make a significant impact in addressing twenty-first century healthcare needs [7–11].

Clinical MLWs include a range of cadres that carry out diagnostic and treatment functions convention- ally thought of as the responsibility of doctors, usually in primary and secondary healthcare settings. They include clinical officers, health officers, medical assistants, téchnicos de medicina and téchnicos de cirugia, clinical associates and others who are trained to diagnose and manage common medical, maternal and child health (MCH) and surgical conditions [12]. Where nurses take on “medical” tasks such as making diagnoses, initiating treatment or performing anaesthesia, they may also be considered MLWs [5, 9]. Recently the term “associate clinician” has been adopted by MLWs1 as a unifying term in the professional development of this cadre [12]. Training programs for physician assistants, a profession with comparable concepts of clinical delegation and patient management, started in the USA in the mid-1960s, and have now been established in Europe, Australia and North America [13]. A recent systematic review of quality of care found that outcomes of numerous interventions in the areas of MCH, communicable and non-communicable diseases were similar whether carried out by MLWs (including midwives) or doctors, albeit that the level of evidence was low [6]. A Cochrane review similarly found that appropriately trained nurses could produce as high quality care as primary care doctors, with as good health outcomes for patients [14]. A more recent review found that nurse substitution for doctors in primary care has a positive effect on patient satisfaction, hospital admission and mortality [15]. The reviews emphasize the importance of good supervision and training relevant to purpose, based on an under- standing that there is a chain that links effective learning to high-quality services and thus to improved health [16]. It is therefore important to examine the training of MLWs in Africa, to assess whether it is fit-for-purpose and whether improvements can be made to training and thus to quality of care. The training programs for African MLWs were mainly developed in the mid-twentieth century to address physician shortages during colonial and immediately post-colonial periods of African history, based on the medical model of education at that time. Kenya for ex- ample has trained clinical officers since 1928, though the original certificate course was replaced with a three-year diploma in 1967 [17]. Globally the literature is silent on the appropriateness and relevance of curricula, teaching methodologies and training personnel for MLWs, though there is some indication that curricula and teaching methods may not be tailored to the practice of these workers to meet needs of the communities they serve [5]. The Lancet Commission on the Education of Health Professionals for the twenty-first Century did not specifically discuss the training of MLWs. With regard to medical, nursing, and public health training it noted that professional education has not kept pace with current health challenges. This was attributed to “fragmented, outdated, and static curricula that produce ill-equipped graduates” characterised by a mismatch of competencies to health needs, poor teamwork, and a narrow focus on technical, individual and hospital-oriented care [16]. The same criticism is likely to apply to the training of MLWs, but there is a paucity of literature that critically appraises the relevance or appropriateness of MLW training, aside from descriptions of focused training for specific, narrowly defined roles.

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