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


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          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.


          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.


          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.


          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.

          Electronic supplementary material

          The online version of this article (10.1186/s12913-018-3362-9) contains supplementary material, which is available to authorized users.

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          Most cited references20

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          Using mid-level cadres as substitutes for internationally mobile health professionals in Africa. A desk review

          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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            A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas.

            The shortage of healthcare professionals in rural communities is a global problem that poses a serious challenge to equitable healthcare delivery. Both developed and developing countries report geographically skewed distributions of healthcare professionals, favouring urban and wealthy areas, despite the fact that people in rural communities experience more health related problems. This review provides a comprehensive overview of the most important studies addressing the recruitment and retention of doctors to rural and remote areas. A comprehensive search of the English literature was conducted using the National Library of Medicine's (PubMed) database and the keywords '(rural OR remote) AND (recruitment OR retention)' on 3 July 2008. In total, 1261 references were identified and screened; all primary studies that reported the outcome of an actual intervention and all relevant review articles were selected. Due to the paucity of prospective primary intervention studies, retrospective observational studies and questionnaire-driven surveys were included as well. The search was extended by scrutinizing the references of selected articles to identify additional studies that may have been missed. In total, 110 articles were included. In order to provide a comprehensive overview in a clear and user-friendly fashion, the available evidence was classified into five intervention categories: Selection, Education, Coercion, Incentives and Support - and the strength of the available evidence was rated as convincing, strong, moderate, weak or absent. The main definitions used to define 'rural and/or remote' in the articles reviewed are summarized, before the evidence in support of each of the five intervention categories is reflected in detail. We argue for the formulation of universal definitions to assist study comparison and future collaborative research. Although coercive strategies address short-term recruitment needs, little evidence supports their long-term positive impact. Current evidence only supports the implementation of well-defined selection and education policies, although incentive and support schemes may have value. There remains an urgent need to evaluate the impact of untested interventions in a scientifically rigorous fashion in order to identify winning strategies for guiding future practice and policy.
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              Substitution of physicians by nurses in primary care: a systematic review and meta-analysis

              Background In many countries, substitution of physicians by nurses has become common due to the shortage of physicians and the need for high-quality, affordable care, especially for chronic and multi-morbid patients. We examined the evidence on the clinical effectiveness and care costs of physician-nurse substitution in primary care. Methods We systematically searched OVID Medline and Embase, The Cochrane Library and CINAHL, up to August 2012; selected and critically appraised published randomised controlled trials (RCTs) that compared nurse-led care with care by primary care physicians on patient satisfaction, Quality of Life (QoL), hospital admission, mortality and costs of healthcare. We assessed the individual study risk of bias, calculated the study-specific and pooled relative risks (RR) or standardised mean differences (SMD); and performed fixed-effects meta-analyses. Results 24 RCTs (38,974 participants) and 2 economic studies met the inclusion criteria. Pooled analyses showed higher overall scores of patient satisfaction with nurse-led care (SMD 0.18, 95% CI 0.13 to 0.23), in RCTs of single contact or urgent care, short (less than 6 months) follow-up episodes and in small trials (N ≤ 200). Nurse-led care was effective at reducing the overall risk of hospital admission (RR 0.76, 95% CI 0.64 to 0.91), mortality (RR 0.89, 95% CI 0.84 to 0.96), in RCTs of on-going or non-urgent care, longer (at least 12 months) follow-up episodes and in larger (N > 200) RCTs. Higher quality RCTs (with better allocation concealment and less attrition) showed higher rates of hospital admissions and mortality with nurse-led care albeit less or not significant. The results seemed more consistent across nurse practitioners than with registered or licensed nurses. The effects of nurse-led care on QoL and costs were difficult to interpret due to heterogeneous outcome reporting, valuation of resources and the small number of studies. Conclusions The available evidence continues to be limited by the quality of the research considered. Nurse-led care seems to have a positive effect on patient satisfaction, hospital admission and mortality. This important finding should be confirmed and the determinants of this effect should be assessed in further, larger and more methodically rigorous research.

                Author and article information

                +27 21 9389186 , icouper@sun.ac.za
                +263 778303439 , sunanda28@hotmail.com
                +27 11 7173422 , Duane.Blaauw@wits.ac.za
                +254 720804606 , gngwena@hotmail.com
                +254 722703364 , lucy.muchiri@uonbi.ac.ke
                +254 722 344312 , erenoyungu2002@yahoo.co.uk
                +234 8033230457 , omigbodun@yahoo.com
                +234 8034784402 , imranmorhasonbello@gmail.com
                +256 772437351 , cibingira@gmail.com
                +256 772494120 , kabaleimc@gmail.com
                +27 117172502 , Daphney.Conco@wits.ac.za
                +27 11 7172707 , Sharon.fonn@wits.ac.za
                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central (London )
                16 July 2018
                16 July 2018
                : 18
                : 553
                [1 ]ISNI 0000 0001 2214 904X, GRID grid.11956.3a, Ukwanda Centre for Rural Health, , Stellenbosch University, ; PO Box 241, Cape Town, 8000 South Africa
                [2 ]ISNI 0000 0004 1937 1135, GRID grid.11951.3d, Centre for Rural Health, , University of the Witwatersrand, ; Johannesburg, South Africa
                [3 ]ISNI 0000 0004 0572 0760, GRID grid.13001.33, Department of Community Medicine, College of Health Sciences, , University of Zimbabwe, ; PO Box A178, Avondale, Harare, Zimbabwe
                [4 ]ISNI 0000 0004 1937 1135, GRID grid.11951.3d, School of Public Health, , University of the Witwatersrand, ; Johannesburg, South Africa
                [5 ]ISNI 0000 0004 1937 1135, GRID grid.11951.3d, Centre for Health Policy, School of Public Health, , University of the Witwatersrand, ; Private Bag 3, Johannesburg, 2050 South Africa
                [6 ]GRID grid.442486.8, Maseno University School of Medicine, ; PO Box 333, Maseno, Kenya
                [7 ]ISNI 0000 0001 2019 0495, GRID grid.10604.33, Department of Human Pathology, School of Medicine, College of Health Sciences, , University of Nairobi, ; P.O. Box 19676, Nairobi, 00202 Kenya
                [8 ]ISNI 0000 0001 0495 4256, GRID grid.79730.3a, School of Medicine, , Moi University, ; PO Box 4606, Eldoret, 030100 Kenya
                [9 ]ISNI 0000 0004 1794 5983, GRID grid.9582.6, College of Medicine, , University of Ibadan, ; Ibadan, Nigeria
                [10 ]ISNI 0000 0004 1764 5403, GRID grid.412438.8, Department of Obstetrics and Gynaecology, , University College Hospital, ; Ibadan, Nigeria
                [11 ]ISNI 0000 0004 1794 5983, GRID grid.9582.6, Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine, , University of Ibadan, ; Ibadan, Nigeria
                [12 ]ISNI 0000 0004 0620 0548, GRID grid.11194.3c, College of Health Sciences, , Makerere University, ; PO Box 7072, Kampala, Uganda
                [13 ]ISNI 0000 0004 0620 0548, GRID grid.11194.3c, Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, , Makerere University, ; P.O. Box 7072, Kampala, Uganda
                [14 ]ISNI 0000 0004 1937 1135, GRID grid.11951.3d, School of Public Health, , University of the Witwatersrand, ; Wits Education Campus, 27 Saint Andrews Road, Parktown, Johannesburg, 2193 South Africa
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                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                : 27 April 2018
                : 5 July 2018
                Funded by: FundRef http://dx.doi.org/10.13039/100000865, Bill and Melinda Gates Foundation;
                Award ID: 51228
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                © The Author(s) 2018

                Health & Social care
                healthcare providers,healthcare workers,mid-level workers,primary healthcare,educational models,quality of healthcare,curricula,africa


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