Using mid-level cadres as substitutes for internationally mobile health professionals in Africa

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Excerpt from "Using mid-level cadres as substitutes for internationally mobile health professionals in Africa" | Dovlo D. (2004)

With the very high demand for health workers in developed countries and the continuing economic crisis in African countries, substitute health workers will become essential resources in dealing with the increasing disease burden. Scaling up numbers produced and the scope of practice of substitutes and other mid-level health workers should be a priority consideration. For example, the need to expand access to antiretroviral (ARV) treatment as envisaged by the World Health Organization's "3 by 5 Initiative" will require significant increases in health worker numbers and skills, and this must be achieved quickly with a reduced training lag-time. If substitute health workers are not properly regulated, supervised and motivated, there will be serious limitations to the roles they could play and to the quality of services they provide. It is evident that systematic monitoring and support are currently weak, but even then the results have been positive in terms of comparative out- comes to clients. Recognition and formal appreciation of the roles of these health workers has been limited. Government incentives tend to target doctors, but often leave out these staff. Substitutes have been produced in limited numbers except in Tanzania and Kenya, which did not reflect the expectation that more of these cadres were needed. In general, more investment is needed to expand training capacity and equip training institutions for these cadres, but from the evidence to date, it can be concluded that this would be a quite cost-effective strategy.

Abstract BACKGROUND: Substitute health workers are cadres who take on some of the functions and roles normally reserved for internationally recognized health professionals such as doctors, pharmacists and nurses but who usually receive shorter pre-service training and possess lower qualifications. METHODS: A desk review is conducted on the education, regulation, scopes of practice, specialization, nomenclature, retention and cost-effectiveness of substitute health workers in terms of their utilization in countries such as Tanzania, Malawi, Mozambique, Zambia, Ghana etc., using curricula, evaluations and key-informant questionnaires. RESULTS: The cost-effectiveness of using substitutes and their relative retention within countries and in rural communities underlies their advantages to African health systems. Some studies comparing clinical officers and doctors show minimal differences in outcomes to patients. Specialized substitutes provide services in disciplines such as surgery, ophthalmology, orthopedics, radiology, dermatology, anesthesiology and dentistry, demonstrating a general bias of use for clinical services. CONCLUSIONS: The findings raise interest in expanding the use of substitute cadres, as the demands of expanding access to services such as antiretroviral treatment requires substantial human resources capacity. Understanding the roles and conditions under which such cadres best function, and managing the skepticism and professional turf protection that restricts their potential, will assist in effective utilization of substitutes.

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