Substitute Health Workers

A recent online discussion aimed to share evidence and good practice examples of the impact of mid-level providers and offer policy-relevant reflections. This report has been developed based on statements provided by the expert advisers and contributions made by participants as part of the discussion, complemented by a selective literature review. [from foreword]

The objective of this study was to assess the effectiveness of these adherence support workers in adherence counseling, treatment retention for people on antiretroviral therapy and addressing inadequate human resources at health facilities. [from abstract]

This report will address the need to expand the global healthcare workforce and international emergency medical response mechanisms. It will also analyze the current mechanisms and channels that mobilize and coordinate healthcare volunteers in response to international disasters. The report will provide several collaborative pathways through which non-governmental organizations can coordinate their international emergency response efforts with volunteer teams of healthcare providers. [from introduction]

Increasing interest has been shown in the use of lay health workers (LHWs) for the delivery of a wide range of maternal and child health (MCH) services in low and middle income countries. However, robust evidence of the effects of LHW interventions in improving MCH delivery is limited. The objective of this document is to review evidence from randomized controlled trials on the effects of LHW interventions in improving MCH and addressing key high burden diseases. [adapted from abstract]

In Mozambique, a country with a high HIV burden and a staggering workforce deficit, the Ministry of Health looked to past experience in workforce expansion to rapidly build ART delivery capacity, including reliance on existing nonphysician clinicians (NPC) to prescribe ART and dramatically increasing the output of NPC training. [from abstract]

The objective of this study was to assess the skills of community health volunteers in diagnosing active trachoma, the world’s leading cause of preventable blindness, and distributing azithromycin treatment in the Northern Region of Ghana. [adapted from author]

The physician assistant (PA) profession is a nationally recognized medical profession in the United States of America. The authors examined the 1980-2007 US census data to determine the demographic distribution of the PA workforce and PA-to-population relationships. Maps were developed to provide graphical display of the data. [adapted from abstract]

This report presents research findings on the potential for making contraceptives, and in particular injectable contraceptives, widely available through using a community-based distribution approach which would expand the cadre of providers authorized to provide contraceptives to include health surveillance assistants and community-based distribution agents. [adapted from summary]

This article details the results of a South African study assessing the feasibility of utilizing volunteers in tracing patients who had defaulted from scheduled psychiatric clinic appointments. [adapted from introduction]

This article provides an overview of how new research in India and Nigeria offers innovative strategies to improve health care provider performance.

In the face of medical workforce shortages, governments are looking to displace doctors with alternative health care providers like nurse practitioners, physician assistants, and other health professionals such as psychologists and pharmacists to relieve bottlenecks in health care delivery. Displacing doctors in this way, or role or task substitution as it is also termed, has been actively pursued in the United Kingdom and United States. How should the medical profession react to these developments? [from author]

This document discusses China’s long struggle with rural coverage for health care through the barefoot doctors program, which was introduced as a national policy focused on quickly training paramedics to meet rural needs. [adapted from author]

The current global tuberculosis (TB) epidemic has pressured health care managers, particularly in developing countries, to seek for alternative, innovative ways of delivering effective treatment to the large number of TB patients diagnosed annually. One strategy employed is direct observation of treatment for all patients. In high-burden settings innovation with this strategy has resulted into the use of lay community members to supervise TB patients during the duration of anti-TB treatment.

This review aims to support efforts to integrate, plan and manage mid-level health workers by collating what we know about experiences with mid-level cadres in low-income countries in Africa, south-east Asia and the Pacific, regions that heavily rely on them. It interrogates the existing evidence on the evaluation of different types of mid-level workers and their impact on health outcomes and it identifies knowledge gaps. The review focuses specifically on the role of mid-level workers as independent practitioners in areas that suffer from severe shortages of professionals. [adapted from execu

This article builds on a recent publication on the capacity of the existing health workforce in Africa to expand through increasing production of its non-physician clinicians and by suggesting that there are four further issues to be urgently addressed if NPCs are to realize their full potential. [adapted from author]

Given the limited availability of formal, inpatient programs, households rely upon informal caregivers (e.g. household or family members, friends, community members, or voluntary organizations) and homebased care (HBC) programs for assistance. This summary documents the roles played by household and HBC program caregivers in meeting the needs of the chronically ill.

The nurse auxiliaries who work at the rural health centers (CESARs) of the Honduran Ministry of Health (MOH) are frequently the only source of reproductive health services in the communities they serve. In order to increase access to long-term family planning methods, the MOH and the Population Council’s INOPAL III Project conducted an operations research study from 1997 to 1998 to see if nurse auxiliaries could provide good quality IUD, Depo-Provera and vaginal cytology services without health risks for their clients.

In this paper, we aim to quantify the contribution of international health volunteers (IHVs) to the health workforce in sub-Saharan Africa and to explore the perceptions of health service managers regarding these volunteers. [from abstract]

This guideline is for human resources planners and managers in the health sector and sets out the steps required to extend the health workforce by incorporating lay workers (field officers), especially in the delivery of antiretroviral therapy (ART) to home-based clients.

Many countries have health-care providers who are not trained as physicians but who take on many of the diagnostic and clinical functions of medical doctors. We identified non-physician clinicians (NPCs) in 25 of 47 countries in sub-Saharan Africa, although their roles varied widely between countries… Low training costs, reduced training duration, and success in rural placements suggest that NPCs could have substantial roles in the scale-up of health workforces in sub-Saharan African countries, including for the planned expansion of HIV/AIDS prevention and treatment programmes. [summary]

This paper draws from research commissioned by the Scottish Executive Health Department (SEHD). It provides a case study in the introduction of a new health care worker role into an already well established and ‘mature’ workforce configuration. It assesses the role of USA style physician assistants (PAs), as a precursor to planned ‘piloting’ of the PA role within the National Health Service (NHS) in Scotland. The evidence base for the use of PAs is examined, and ways in which an established role in one health system (the USA) could be introduced to another country, where the role is ‘new’ and unfamiliar, are explored.

The AIDS Support Organization (TASO) administers a home-based program in Uganda that gives people in poor and rural settings access to antiretroviral therapy (ART) and services. The program’s innovation lies in shifting delivery of most clients’ follow-up activities at home to field officers, a new cadre of degree and diploma holders from the social sciences and education. Field officers ensure adherence to ART, refill clients’ medications and perform various activities, from voluntary counseling and testing to education to promoting family and community support. [from executive summary]

This paper explores the potential for private-sector midwives to provide services beyond their traditional scope of care during pregnancies and births to address shortcomings in less developed countries’ ability to reach MDGs. This paper examines factors that support or constrain private practice midwives’ ability to offer expanded services in order to inform the policy and donor communities about PPMWs’ potential. [from executive summary]

The objective of this article was to compare the cost-effectiveness of the tuberculosis programm run by the Bangladesh Rural Advancement Committee, which uses community health workers (CHWs), with that of the government program which does not use CHWs. [adapted from author]

Human resources for health are non-existent in many parts of the world and the outer islands of Marshall Islands in Micronesia are prime examples. While the more populated islands with hospital facilities are often successful in recruiting qualified health professionals from overseas, the outer islands generally have very limited health resources, and are thus less successful. In an attempt to provide reasonable health services to these islands, indigenous people were trained as Health Assistants (HA) to service their local communities.

This study investigates the experiences of informal caregivers of people living with HIV in two semi-rural communities in South Africa. It is argued that a thorough understanding of how home-based care undermines the physical health and psychological wellbeing of already vulnerable women is crucial for informing policies on home-based care. Thus, there is a need to incorporate gender perspectives when planning and implementing home-based care programs. [from abstract]

Women health workers have been vital in improving the health of women and children in Pakistan. Inspired by its neighbor’s experience, Afghanistan is embarking on a similar program to encourage women to work in the health sector. [author’s description]

Achieving significant reductions in maternal and newborn morbidity and mortality will be facilitated by developing a comprehensive approach to address the social and health system issues in the community, and at both peripheral and district-level facilities. This integrated approach to community and facility based maternal and newborn programming and implementation is called the Household-to-Hospital Continuum of Care. [from author]

The medical workforce shortage and efforts to maintain the safety and quality of health services are putting acute pressure on the profession. Task transfer or role substitution of medical services is mooted as a potential solution to this pressure. This has the potential to drastically transform the profession. How task transfer will evolve and change medicine depends on the vision and leadership of the profession and a flexible pragmatism that safeguards quality and safety and places patient priorities above those of the profession. [from abstract]

In Thailand, family practice was developed primarily through a small number of self-styled family practitioners, who were dedicated to this professional field without having benefited from formal training in the specific techniques of family practice. In the context of a predominantly hospital-based health care system, much depends on their personal motivation and commitment to this area of medicine. The purpose of this paper is to compare the responsiveness, degree of patient-centredness, adequacy of therapeutic decisions and the cost of care in 37 such self-styled family practices, i.e. practices run by doctors who call themselves family practitioners, but have not been formally trained, and in 37 conventional public hospital outpatient departments (OPDs), 37 private clinics and 37 private hospital OPDs.