African mid-level health workers need better training

Professor Ian Couper

This is one of the major findings of a study carried out simultaneously by researchers in Kenya, Nigeria, South Africa and Uganda. It was published recently in the journal BMC Health Services Research.

“Africa’s health systems rely on services provided by mid-level health workers and it is therefore important to update their training programmes and curricula so that they can continue to help relieve the burden of disease, function with greater effectiveness and contribute to better quality care and outcomes,” says Professor Ian Couper, director of Ukwanda Centre for Rural Health in the Faculty of Medicine and Health Sciences at Stellenbosch University, who part of the South African research group.

The study reviewed the training and curricula in the aforementioned countries to determine which areas needed improvement. These countries were chosen on the basis of an existing collaboration between their researchers, and because they represent Western, Eastern and Southern Africa which has a range of experience of training mid-level health workers.

These workers provide general diagnoses and treatment in primary care clinics, health centres, and outpatient departments of district and mission hospitals. Those with specialist training may provide care in specific disciplines such as surgery, anaesthesia, psychiatry, and HIV services.

As part of the study, professional associations, regulatory bodies, training institutions, labour organisations and government ministries were interviewed in each country, and policy documents and training curricula were reviewed for relevant content. A total of 421 district managers and 975 mid-level health workers (excluding South Africa as there were no clinical associates qualified at the time of the study) at urban and rural government district health facilities completed self-administered questionnaires regarding the training and performance of these health workers.

Additional skills

Couper says the study showed that although up to 85% of practicing mid-level health workers considered their basic training to be adequate for their work, more than 50% indicated the need to change the training approach. Almost 65% wanted training in additional skills, with 18% calling for improved training institutions.

“Significant concerns regarding skills gaps and quality of training were raised. Mid-level health workers and district managers indicated the need for updated training methods with additional skills offered. These workers also wanted their training to include more problem-solving approaches and practical procedures that could be life-saving.”

“A recurring theme was that the educational content of training sessions was not aligned with the disease burden of the populations served and the kinds of conditions commonly presenting at rural health facilities. The training did not include methods of coping with day-to-day problems such as staff shortages, lack of equipment and medications.”

“Mid-level health workers and educators also highlighted the need for follow-up training and continuing professional development,” adds Couper.

He says there’s a definite need to modernise curricula and incorporate innovative approaches to learning and teaching, to align the content of education programmes to the burden of disease faced by these workers and to ensure appropriate accreditation of these programmes. Couper adds that South Africa was able to learn from the experience of the other African countries as well as international developments in medical education when implementing the clinical associates training programme.

“Training programmes for mid-level health workers offer an important avenue for scaling up human resources to meet health needs of communities as part of achieving universal health coverage, developing clinicians who are able to provide diagnostic and therapeutic services with lower entry qualification requirements and shorter training periods than for physicians.”

Couper says national governments, including South Africa, should help ensure there is an enabling regulatory and accreditation framework for training, and should resource, guide and support educational institutions to upgrade training (quantity, quality and relevance) at both pre-service and in-service levels.

He adds that greater resources and more trainers are needed to increase the numbers of mid-level health workers in Africa.

Targeted investments in infrastructure, faculty and training are necessary, and early collaboration with appropriate, socially accountable medical and nursing faculties could provide the necessary support for new programmes. “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.”

Instead of treating mid-level health workers as a stop-gap in primary and secondary health services, they should be included in health workforce planning and their roles formally regulated, adds Couper.