The Context

Why mid-level providers?

Mid-level providers already exist in most countries in Africa. They include those cadres of health professionals who are not doctors, but who have been delivering essential clinical and surgical services in their countries for decades. They are variously known as clinical officers, medical assistants, assistant medical officers or surgical technicians and also include nurse practitioners, midwives and physician assistants.

Yet mid-level providers are seldom the focus of human resource strategies, are almost never counted – especially at global level, and there are few indications of efforts to expand their training and scope of practice. In some countries, this lack of attention is compounded by professional turf issues and assumptions in some quarters that these mid-level providers must necessarily be delivering second rate care.

But the evidence challenges this assumption. Initial research reports that mid-level providers expand cost-effective quality services to under-serviced areas and play a critical role as part of a team of health workers providing care. Their presence is regarded as a positive and stabilizing factor in health services, providing access to life saving care for rural and peri-urban communities.

With the right training, and working in appropriate enabling environments as part of a comprehensive workforce system, mid-level providers have been shown to produce similar outcomes to doctors, and have excellent retention rates especially in districts and rural areas. In Mozambique, Tanzania and Malawi, over 80% of all Caesarean sections at the district hospital level are carried out by mid-level providers.

Although human resource deficits and imbalances in distribution are not new in Africa, the search for effective, affordable solutions has taken on new urgency. Traditional ideas about the training and organization of human resources must now be carefully re-considered if the health MDGs are to be met. Without immediate and bold action, the current situation represents only the beginning of the crisis.