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“Fit for Purpose and Fit for Practice:” Mid-Level Providers to Bridge Gap in Human Resources for Health

By: Helen de Pinho, Associate Director, Averting Maternal Death and Disability (AMDD) Program, Columbia University; Shanon McNab, Senior Program Officer, Averting Maternal Death and Disability (AMDD) Program, Columbia University

This post is part of our “Supporting the Human in Human Resources” blog series co-hosted by the Maternal Health Task Force and Jacaranda Health.

With the post-2015 maternal mortality goals set, and a global commitment to achieving universal health coverage and ending preventable maternal deaths, the conversation must now turn to who is going to deliver this care, especially in the most remote regions.

An often under-represented cadres in these conversations are Associate Clinicians (AC). Previously referred to in the literature as “non-physician clinicians,” these cadres include clinical officers, medical licentiates, assistant medical officers, tecnicos de cirugia, etc. They are trained clinicians, coming from and returning to rural areas to provide services where few medical doctors will go to stay. Their training is shorter than that of physicians, is predominantly clinical skills based, and varies according to the country—ranging from emergency surgery to provision of primary care. The training programs are two to four years post-secondary education and most include internships.

As countries are struggling with their HRH needs, ACs have taken on several roles in their countries’ health systems. Within the context of expanding access to maternal and newborn health services, advanced ACs with additional training provide comprehensive emergency obstetric care, including cesarean sections and other emergency surgery. This care is provided close to the community, at district hospitals and appropriately equipped health centers. But our research has shown that despite expanding access to care, ACs are not being properly utilized, acknowledged, supported or fairly compensated for their work. Their lack of voice and representation at global, regional and often national levels results in their exclusion from critical policy and budgetary discussions.

ACs are present in over 49 countries in Sub-Saharan Africa, and this number is growing. But their presence is not limited to LMICs, as similar mid-level providers, such as physician assistants and nurse practitioners, are extending access to care in the United States. As task shifting continues to be a growing solution for achieving universal healthcare, a deeper look at who is providing these services is necessary.

At facility level, ACs work closely with nurses and midwives and are regarded as vital and integral parts of the health care team by their colleagues. However, at the national level, the picture is somewhat different. Our research reveals a lack of systematic recognition of ACs, or mid-level providers, which results in exclusion from national planning, second-rate training facilities, salaries and benefits below their level of responsibility and a lack of clear career pathways. Some advanced cadres have been around for decades, as in Tanzania, Malawi and Mozambique, while others are new and struggling with the challenges of integrating as a new cadre with emergency obstetric skills into an existing health system, as in Ethiopia, Zambia and Kenya. Regardless of their history, all cadres of mid-level providers face similar challenges: lack of representation and a collective voice to provide them support, value, and integration in the health system.

And yet, despite their often ignored or misunderstood roles, dedicated ACs continue to work in difficult settings and remain highly motivated at their posts. In Zambia, several of the medical licentiates (advanced ACs) described what motivated them to continue to work in a remote area with limited clinical support, inconsistent supplies and salaries often not commensurate with their training and responsibility. They talked enthusiastically about working for their communities; managing women with complications who would no longer have to be referred, thereby reducing the financial burden on the woman and her family; being appreciated by fellow facility staff and, of course, helping women bring healthy babies into the world. But these factors cannot sustain a cadre for generations to come without systemic support, integration and recognition. Factors needed for sustainability include, amongst others, strengthening AC training programs, improving regulatory systems, supporting the development of national and regional professional associations and including ACs in critical policy discussions. As countries introduce new health cadres and task-shifting to meet their human resources for health challenges, lessons learned from the successes and challenges of ACs should be applied to new programs and existing AC cadres.

To this end, the Africa Network for Associate Clinicians (ANAC), based in Lusaka, Zambia, was formed to support regional engagement on the development and deployment of ACs and to advocate for recognition and support of these integral members of ACs—a human resource solution. It will be through associations like ANAC and other emerging regional champions that ACs themselves will begin to contribute to the conversation about universal health coverage and the provision of quality maternal and newborn health care.

Learn more about the role of Associate Clinicians by checking out the following links:

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