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. In nine countries, numbers of NPCs equalled or exceeded numbers of physicians. In general NPCs were trained with less cost than were physicians, and for only 3–4 years after secondary school. All NPCs did basic diagnosis and medical treatment, but some were trained in specialty activities such as caesarean section, ophthalmology, and anaesthesia. Many NPCs were recruited from rural and poor areas, and worked in these same regions. 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.
Human Resources
Most sub-Saharan African countries struggle to make safe surgery accessible to rural populations due to a shortage of qualified surgeons and the difficulty in retaining them in district hospitals. In 2002, Zambia introduced a new cadre of non-physician clinicians, medical licentiates, trained initially to the level of a higher diploma and from 2013 up to a Bachelor of Science degree. Medical licentiates have advanced clinical skills, including training in elective and emergency surgery, designed as a sustainable response to the surgical needs of rural populations. This qualitative study aimed to describe the role, contributions and challenges surgically active medical licentiates have experienced. Based on 43 interviewees, it includes the perspective of medical licentiates, their district hospital colleagues—medical officers, nurses and managers; and surgeon-supervisors and national stakeholders. In Zambia, medical licentiates play a crucial role in delivering surgical services at the district level, providing emergency surgery and often increasing the range of elective surgical cases that would otherwise not be available for rural dwellers. They work hand in hand with medical officers, often giving them informal surgical training and reducing the need for hospitals to refer surgical cases. However, medical licentiates often face professional recognition problems and tensions around relationships with medical officers that impact their ability to utilise their surgical skills. The paper provides new evidence concerning the benefits of ‘task shifting’ and identifies challenges that need to be addressed if medical licentiates are to be a sustainable response to the surgical needs of rural populations in Zambia. Policy lessons for other countries in the region that also use non-physician clinicians to deliver essential surgery include the need for career paths and opportunities, professional recognition, and suitable employment options for this important cadre of healthcare professionals.
Access to good-quality health services is crucial for the improvement of many health outcomes, such as those targeted by the Millennium Development Goals (MDGs) adopted by the international community in 2000. The health-related MDGs cannot be achieved if vulnerable populations do not have access to skilled personnel and to other necessary inputs. This paper focuses on the geographical dimension of access and on one of its critical determinants: the availability of qualified personnel.
The objective of this study was to determine the percentage of South African nurses initiating new HIV-positive patients on therapy within two months of attending the Nurse Initiation and Maintenance of Antiretroviral Therapy (NIMART) course, and to identify possible barriers to nurse initiation. A brief telephonic interview using a structured questionnaire of a randomly selected sample (126/1736) of primary care nurses who had attended the NIMART course between October 2010 and 31 March 2011 at primary care clinics in seven provinces. Outcome measures were the number of nurses initiating ART within two months of attending the FPD-facilitated NIMART course. Results showed that, of the nurses surveyed, 62% (79/126) had started initiating new adult patients on ART, but only 7% (9/126) were initiating ART in children. The main barrier to initiation was allocation to other tasks in the clinic as a result of staff shortages. In conclusion, despite numerous challenges, many primary care nurses working in the seven provinces surveyed have taken on the responsibility of sharing the task of initiating HIV-positive patients on ART. The barriers preventing more nurses initiating ART include the shortage of primary care nurses and the lack of sufficient consulting rooms. Expanding clinical mentoring and further training in clinical skills and pharmacology would assist in reaching the target of initiating a further 1.2 million HIV-positive patients on ART by 2012.
In a recent article in the South African Medical Journal, Nicki Fouché of the Division of Nursing and Midwifery at the Faculty of Health Sciences at the University of Cape Town warned that the haemorrhaging of professional nursing staff would have a catastrophic effect on the delivery of health care in South Africa over the next decade. She added that it was estimated that there are 2 300 registered nurses working overseas and that they receive about 200 applications per month for overseas registration. In 1999, 3 300 nurses left South Africa.
The promise of higher salaries and better working conditions lures about 20,000 African nurses and other health-care workers annually to richer countries. The brain drain makes it even harder for African countries to treat diseases such as AIDS, tuberculosis and malaria, which kill millions each year, experts say. But with the United States facing its own nursing shortage, some on Capitol Hill want to make it easier for foreign nurses to immigrate to America. The article describes policies that have facilitated this change.
A nurses' strike has shut down most of Swaziland's health care system, drawing attention to financial and technical shortcomings, and the problems besetting the nursing profession. "While we continue our strike action, doctors and orderlies will have to take care of patients," said the president of the Swaziland Nurses Association, Masitsela Mhlanga, at a press conference. Nurses are striking over the government's inability to pay salaries on time, back pay and salary increases.
Nurses in the public health sector would receive increases of between 20 percent and 88 percent on their starting salaries, Health Minister Manto Tshabalala-Msimang said. The increases, which would be retrospectively introduced from July this year, comes as part of the occupational specific dispensation which would see substantial improvements in the salaries of professionals in the health department and the rest of the civil service over the next few years.
There is growing concern globally at the current flows of nurse migration, particularly from low-income to middle and high-income countries. Recruitment practices of many countries such as Ireland are thought to be fuelling this rate of migration. This paper aims to establish the perceptions and opinions of those involved in the recruitment process on their role in recruitment and the effects recruitment has on both source and destination countries. A purposive sample of 12 directors of nursing, from major academic teaching hospitals in Dublin and hospitals in South Africa and the Philippines were recruited.
This review examines the experiences of nurses, community health workers, and home carers in health systems from a gender analysis. With respect to nursing, current discussions around delegation take place over layers of historical struggle that mark the evolution of nursing as a profession. Female community health workers also struggle to be recognized as skilled workers, in addition to defending at a personal level the legitimacy of their work, as it transgresses traditional norms proscribing morality and the place of women in society, at times with violent consequences. The review concludes by exploring the characteristics of, and challenges faced by, home carers, who fail to be recognized as workers at all. A key finding is that these mainly female frontline health workers compensate for the shortcomings of health systems through individual adjustments, at times to the detriment of their own health and livelihoods. So long as these shortcomings remain as private, individual concerns of women, rather than the collective responsibility of gender, requiring public acknowledgement and resolution, health systems will continue to function in a skewed manner, serving to replicate inequalities in the health labour force and in society more broadly.