Filling the gaps

Introducing substitute health workers in Africa

Massive shortages in trained health care professionals in sub-Saharan Africa have led to an examination of substitute health workers as an immediate response to the workforce crisis.

Two Kenyan health workers in the video 'Haki Yako' ('It’s Your Right'), the story of a couple who seek family planning after the birth of their second child
© 1994 John Riber, Courtesy of Photoshare

For many countries these substitute health workers (SHWs) are not new. They already play various minor roles in health services, especially in rural and deprived areas.

In Tanzania, Malawi and Mozambique, assistant medical officers are used as substitutes for doctors. They perform surgery and a variety of other tasks. Ghana uses community health officers to improve access to health care and Ethiopia is planning large numbers of health extension workers.

Resistance from the health professions, such as doctors and midwives, to retain their status limits the numbers of SHWs trained and the roles that they are assigned. In the 1980s and 1990s many countries in sub-Saharan Africa, led by the professions, banned the training of enrolled nurses which restricted the numbers available.

Given the shortage of personnel available to respond to priorities such as antiretroviral treatment, the World Health Organisation estimates that sub-Saharan Africa urgently needs up to one million more health workers to be able to meet the health Millennium Development Goals. This urgency suggests that substitutes have a critical role to play.

SHWs are trained for specific roles, may not be internationally tradable and are more easily retained within the country. Other possible advantages of SHWs are:

• Training of SHWs can be easier and faster than for specialist staff. Training for assistant medical officers in Mozambique and Malawi takes half the time of that for doctors. All training is local and practical, whilst academic entry requirements are lower. Training also costs less. In Ghana it costs US$12,000 to train a SHW compared to US$ 60,000 for a doctor.
• Many SHWs accept postings and are likely to remain in rural and deprived areas. They may relate better with communities by being less elitist and more integrated. In Tanzania 75 percent of SHWs work in rural areas.
• Pay and incentives for SHWs are lower than for the staff they are replacing.

However, there may be disadvantages to SHWs:

• Quality of care may suffer with poor clinical decision-making or limited supervision of SHWs. Increasing the numbers of SHWs may mean a similar expansion in the numbers of professional supervisors.
• SHWs may neglect ethical issues whilst practice regulation can be absent. In Tanzania a medical board regulates training but not practice.
• The potential lower costs may be offset by poor treatment. In Ghana medical assistants often give the wrong doses of drugs to treat malaria.
• Eventually SHWs demand pay and incentives similar to the staff they replace. Conflict between professions and demotivation may occur.
• The use of SHWs needs to be investigated so further evidence can be obtained. For SHWs to be a sustainable solution:
• The skepticism and resistance of the traditional professions must be tackled.
• SHWs must receive support and supervision. In-service training is needed to reinforce correct practice and to develop a culture of ethics and leadership.
• Significant new investment in SHWs training facilities is required.

Given the rising emigration of health workers, the use of SHWs should be sustained and planned to fit a country’s health workforce needs. SHWs should be allowed to progress, acquire more advanced skills, be entrusted with more complicated tasks, and eventually even qualify as health care professionals.

Delanyo Dovlo
PO Box CT5203
Cantonments
Accra
Ghana
dovlod@yahoo.com

See also

Using mid-level cadres as substitutes for internationally mobile health professionals in Africa. A desk review, Human Resources for Health 2(7), by D. Dovlo, 2004
www.human-resources-health.com/content/2/1/7

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