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Mid-Level Providers

May 4-18, 2010

The purpose of this discussion was to share evidence and good practice examples relating to mid-level health workers; address policy and programmatic questions of relevance to the topic; and synthesize existing evidence and provide policy-relevant reflections on the mid-level health workers discourse through the production of appropriate knowledge products.

Discussion Statistics

Number of participants: NA
Number of participants' countries: NA
Number of contributions: 68
% of contributions from developing countries: 18%
Number of countries contributing: 15 countries

Contributing countries: United States (14), India (7), Philippines (8), Uganda (4), Indonesia (2), Rwanda (2), Benin (4), Ecuador (5), Madagascar (1), Mali (2), Bangladesh (7), Burkina Faso (1), Congo (1), Brazil (1), Cambodia (1)

Purpose and Objectives


  • Provide an arena for the discussion of the objectives below.


  • Share evidence and good practice examples relating to mid-level health workers.
  • Address policy and programmatic questions of relevance to the topic.
  • Synthesize existing evidence and provide policy-relevant reflections on the mid-level health     workers discourse through the production of appropriate knowledge products.   


Day 1.  Definition.

  1. Is it necessary to develop a consensus around the definition of mid-level providers? Why?
  2. Does the ILO definition of a paramedical practitioner (reported in the initial statement) adequately capture the work of the mid-level provider?

Emerging themes and issues:

1.    Why do we need consensus around the definition of mid-level providers?
There is a growing movement for countries strengthen and or initiate the use of mid-level providers to increase access to care. This is evident in local human resource strategy documents through to global documents such as the Kampala Declaration and Agenda for Global Action and the Addis Ababa Call to Action on Human Resource for Maternal and Newborn Survival.

In many countries, mid-level providers already function at the forefront of health care provision in health facilities in both developed and developing countries. In the absence of an encompassing definition that spans countries and continents, it is difficult for these providers to organize globally, advocate for their profession or even just be appropriately counted and included in routine surveys – a critical step towards recognition and professional visibility.

And, for very pragmatic reasons, some consensus around this definition is needed given that the term “mid-level providers” is already widely used in the literature – both grey and peer reviewed.

2.    Use of the ISCO-2008 classification.
From the discussions, it is evident that the ISCO-2008 provides a mechanism for mapping the various cadres of mid-level  providers that exist in countries. This classification is based on a distinction between health professionals – who include those who are direct providers of curative, preventive and promotive care, and health associate professionals – who perform the tasks necessary to support diagnosis and treatment of illness. Its utility is in providing a means to aggregate data and information regardless of national variations in training requirements, regulations and nomenclature.

This said, we must be sensitive to the variations in nomenclature that do exist amongst countries, and respectful of the roles that these mid-level providers play in delivering care, often in the most remote areas of these countries.

We are not proposing that countries change the names of their current cadres, but suggest countries make use the classification afforded by ISCO-2008 to map their cadres against that classification, enabling comparison across countries.

3.    Towards a working definition of mid-level providers.
It is evident from the discussions as to who is NOT considered a mid-level provider, and while it is never satisfactory to define anyone in the negative, perhaps we could  very tentatively and sensitively  draw some boundaries around this group of mid-level providers and say that they are neither  doctors, nor community health workers and neither nurses acting under direct supervision or standing orders of others nor health associates who only provide a supportive role to those who directly engaged in curative and preventive care.

Such a definition is really not ideal.   Perhaps more helpful, and also arising from the discussion is a definition of mid-level provider that encompasses the following elements:  A health provider who:
a.    Is trained,  authorized  and regulated to work autonomously   AND
b.    Who receives post school leaving pre-service training at higher education institution for at least a total of 2-3 years  AND
c.    Whose scope of practice includes (but not restricted to) being able to diagnose, manage and treat  illness, disease and impairments (including perform surgery where appropriately trained), as well as engage in preventive and promotive care.

That a definition is needed is evident, but let us not lose sight of the fact that behind this definition are the mid-level providers, without whom millions of people would be denied their basic human right to access health care.
Day 2. Country Experiences and Perceptions.  
  • Is it feasible and desirable to encourage the convergence of the many existing models of mid-level health workers towards an internationally-recognized one?
  • What can be the causes of the resistance to the deployment of mid-level cadres?
  • How to dissipate misplaced perceptions towards these cadres?

Emerging themes and issues: Days 2

From both discussions of day 1 and day 2 the picture that emerges broadly is one of a consensus on the importance and wide use of these health workers. Although there are differences in the understanding and perceptions about some of the issues raised, in general it can be said that there is an agreement on the need of some sort of standardization and international recognition of health professionals who for decades have played a major role in the provision of health care.

Standardization and international recognition have to be addressed as issues with a broad and wide meaning, and not in a narrow and strict sense of having exactly the same curricula, the same training, etc… Or in the sense of giving them “passports to fly away” from their country boundaries.

Even for “traditional” cadres, nurses and doctors, who are internationally-recognized, there are variations from country to country. Curricula and number of years of training vary among countries. There are variations within African countries, within European countries, etc… Nonetheless, if someone says “I am a doctor”, “I am a nurse” s/he is perceived as such, regardless of the existing variations.

The crucial issue is: first of all, can these cadres have an “international” recognition in such a way that they can be perceived as NORMAL and integral part of health systems, rather than “substitute health workers” for (poor) health sectors. Can international institutions, such as WHO, enhance their role in the advocacy for these cadres and take a step forward on concepts such as:

(a)    From mid-level workers, or doctor substitutes, to health workers who have their own role in the respective health systems and not substitute or temporary cadres.

(b)    Task shifting / sharing, to look at the vital role that these cadres have for long played in providing health care, often to the neediest populations.

(c)    By taking some concrete steps, such as when assessing the availability of country health professionals, stopping considering primarily doctor and nurse population ratios and include other professional cadres. Certainly this entails some criteria on which cadre to include, and issues about the quality, etc. But the quality of care should not be raised only when it comes to other health professionals, the “mid-level”. Not all countries provide good training for traditional cadres, such as doctors and nurses. In fact, in many countries there aren’t many studies on the quality of training and care provided for any cadre.

Some standardization may help reduce “the proliferation of MLP job titles” and other factors that some participants judged as contributing to “a poor perception of MLP”. True, it’s neither advisable nor desirable to force a one size fits all. But again, this concern should be applied across the health sector cadres: medical doctors, nurses and others.

Regarding retention of “mid-level” health workers, not all mobility is wrong in itself, many needy countries have benefited from such staff mobility. In the past, Mozambique has benefitted from expatriates of all sorts of health professionals: medical doctors, nurses and some “mid-level” health workers from Guinea Conakry, such as technicien de medicine, technicien de pharmacie and technicien de chirurgie, etc.

And, international recognition may be a step forward into changing perceptions about these cadres.                                                                                                                           
Day 3. Rationale and role of MLP in HRH strategies  

  1. What were the main factors influencing the production of MLP (“auxiliaries”) in the colonial and immediate post-colonial period? How do the factors that have led to the current renewed interest in MLP differ?
  2. What actions are required locally, nationally and internationally to ensure the seamless integration of MLP into a continuum of health service delivery?

Emerging themes and issues:

Several of you have correctly noted that the first ‘wave’ of MLPs in the colonial and immediate post-colonial periods was primarily a response to the severe shortage of health professionals in countries, especially outside the main urban centres/centres of economic activity. The advantages of MLPs were, as you say, that they were much less expensive to train and employ, and also less likely to migrate internally (to urban areas and private practice) or externally. Moreover, some activities required travelling to and working in very difficult settings and gaining community acceptance eg malaria sprayers, smallpox vaccinators. Their association with colonial health policies – and indeed with very hierarchical government arrangements – has sometimes conferred a negative image on these cadres. However, longstanding and mostly positive experience with MLPs, particularly in Africa, and more recently some rigorous studies of their performance, have led to a recognition that MLPs can indeed play a crucial role within health teams. The more recent interest in their contribution (as indeed with Community Health Workers) has been driven by both the above positive assessment of their potential but also by the human resource crisis – especially in Africa – and of course the advent of HIV/AIDS which has imposed a larger workload on health workers.

The need for standard definitions
Some of you have suggested that there should be a standard definition of MLPs, including of their roles, qualifications and training requirements, while others have also referred to a need to define their roles and scopes of practice. In general these are excellent suggestions, for experience reveals that there has often arisen confusion as well as unhealthy competition due to lack of clarity on roles. However, while these principles are crucial, it is also clear that there can be no ‘one size fits all’; different countries have different histories and needs and possess different sets of already existing professionals and also MLPs. So, while in principle there should be some standardization across countries, in the end MLP sub-categories will often be specific to that country and a negotiation about their scopes of practice, relevant to their particular contexts, is often necessary.

The need for regulatory frameworks
Two participants emphasise the importance of establishing regulatory and professional bodies which can govern and presumably also speak on behalf of MLPs, including on issues of remuneration, scopes of practice and the relationship with other professions. As with issues of standardization, a tension exists between such regulation and the desirability to retain the local “fit” of these cadres, whether they have their roots in conventional health professions (i.e. physiotherapy assistants) or have emerged organically in response to country needs (i.e. health assistants). This tension is not easily resolvable and should be addressed in country contexts.

Strengthening the concept of a team approach to health care provision
A number of respondents speak about the importance of thinking about MLPs within a continuum of health care provision and as members of, and integrated into, a health team. This is a topic which is gaining in prominence in human resource discussions, significantly in the context of task-shifting debates. It speaks to two ideas: a) the importance of providing communities with “seamless” care, in which provider roles fit and are integrated with each other; b) the need to dovetail teams, so that MLPs, for example might play a role in supporting and supervising community health workers and medical doctors might play a similar role for MLPs, which would also facilitate their integration into a continuum of care.

Developing the evidence base
One participant reiterates the absence of systematic and robust evidence on the impact of MLP and calls for the generation of such evidence, as well as consultation to overcome skepticism and professional gate-keeping. Of particular importance would be large-scale, prospective effectiveness studies in programme settings to establish optimal categories, structures and models of health service delivery making use of MLPs.
Day 4. Role of MLP in improving distribution and access

  1. Are there better data available that would help establish the current situation with regard to numbers and location (public versus private sector; urban versus rural) of these cadres?
  2. What measures would support the role of mid-level cadres in improving distribution specifically?
  3. Can mid-level cadres be adequately supported in posts where more qualified staff are absent or in severe shortage? What roles can and do they play in these circumstances?

Emerging themes and issues:

1. Are there better data available that would help establish the current situation with regard to numbers, and location (public vs. private sector; urban vs. rural) of these cadres?

Respondents point out that some countries do produce reliable data whereas others do not. Some called for an internationally supported effort to improve data collection, but perhaps the liveliest debate over the past week has concerned the question of defining mid-level providers which would seem to be needed first. If we are going to count something, we had better know what it is we are counting. It may be helpful to define workers according to their length of training but this would not solve problems of discriminating between what they are trained to do, and what starting point is required in terms of years of schooling or further education, or success in those. Without resolution to this, ad hoc data collected from national systems that happen to count something, are likely to remain the only source of information and we are likely to remain unclear as to the importance and role of these cadres beyond specific country narratives.

2. What measures would support the role of mid-level cadres in improving distribution specifically?

Respondents make well supported points. If mid-level cadres are drawn from local under-served populations and if they are trained there, they are more likely to remain. Bonding schemes have been suggested and these have been shown to work in some places, to constrain international nurse migration. However, constraining internal migration is probably more complex. Would the bonded worker be required to stay in a particular job, at a particular facility, in a particular district, or in rural areas more generally? At the extreme end of that continuum, human rights issues loom large - the situation approaches indentured labour (slavery) and the worker would have little protection from exploitation and abuse. If employment were restricted to a district or to designated hard-to-fill posts, there are more practical difficulties – tracking the individual, defining and enforcing penalties. In the end, there is probably no short cut around the third category of recommendation on this point. Mid-level cadres need to be retained in post by adequate pay and conditions and career opportunities.

This raises a new discussion point – how can career opportunities be structured that also retain skilled and experienced workers in hard-to-fill posts? Often there are limited staffing numbers in total in remote facilities and the shallow hierarchy pyramids are characterized by hierarchies among cadres rather than within cadres. Professional rivalries constrain the ability to advance of members of each specific cadre.

3. Can mid-level cadres be adequately supported in posts where more qualified staff are absent or in severe shortage? What roles can and do they play in these circumstances?

Given the imbalances that result from the inability to fill posts in hard-to-staff facilities, it is probably inevitable that all cadres end up undertaking roles for which they have not been trained. This argues for the broadest orientation in training all cadres and against the increasing specialisation that all professional groups see as the route to advancement for their members.

The need for supportive supervision is recognised. Perhaps, rather than emphasising the hierarchy across cadres and expecting that mid-level cadres will be supervised by high-level cadres who are in short supply at district (and sub-district) level as well as at individual facility level, career advancement and supervision goals could be jointly met by promoting more experienced mid-level cadres to more centralised supervisory roles. Perhaps this happens in some contexts but my impression is that this is the exception rather than the rule.
Day 5 Quality of care with MLP.
  1. Should MLPs’ quality of health care be measured on their merit using the above criteria for quality in health care, or should their performance be compared with that of doctors (medical officers/specialists)?
  2. Are there studies done or ongoing in your country measuring the quality of care by MLPs in the process of task shifting?

Emerging themes and issues:

1.    Should MLPs quality of health care be measured on their merit using the above criteria for quality in health care, or should their performance be compared to doctors (Medical Officers/Specialists)?

Respondents have differing views. Contributor from Malaysia feels that MLPs quality of care should be measured on their own merit using the standard criteria proposed (responsive, causing no harm, evidence-based and appropriate, timely, without unnecessary tests and procedures, and non-discriminatory) because MLPs have their given scope of work different from that of Doctors or Specialists. The contributor emphasises the fact that clients in Malaysia are satisfied with the services provided by Assistant Medical Officers.

Contribution from Angola, takes the view that quality of care by MLPs should be the same as that for Physicians and therefore can be compared in spite of different scope of training and practice. The contributor quotes the example of surgical technicians in Mozambique whose quality of care is as good as that provided by Physicians. 

The contributor from Portugal, links the access to care and quality debates through a health economics perspective. In this context Physicians and Specialists who serve urban population do have the largest share of the health budget and would therefore provide better health care quality than MLPs who serve the rural population due to less resources.

The fourth contributor, South Africa brings in structure and outcome as measures of quality. As such MLPs and Physicians will be measured by similar standards.
2.    Are there studies done or ongoing in your country measuring the quality of care by MLPs in the process of task shifting?

Contributors from Malaysia, Angola and Portugal did not know of any such studies. The South African contributor pointed to a completed and ongoing study in Malawi on Mid-level providers in emergency obstetric and newborn health care, factors affecting their performance and retention within the Malawian Health System. 

All agree that providers of health care should be supervised and monitored to make sure they provide the right type of care timely and equally to everybody. If quality of care is measured by the standards listed above, it would not matter whether the provider is MLP or Physician. The comparison of quality of care between MLPs and Physicians/Specialists, becomes necessary only in the context of shifting tasks from Physicians to MLPs.

As for research done or ongoing, it is good to know what Malawi has and is planning to do. However, there is urgent need to measure quality using outcomes of morbidity and mortality. Countries and institutions are encouraged to embark on quality of care  research for MLPs.

Day 6: Education I

  1. What are the entry requirements and the duration of training and internship for MLPs in your country? Are they too permissive, adequate, or too restrictive in relation to your country's context? Are there provisions for making up for fewer years of school or poorer quality basic education for disadvantaged areas?
  2. Is there adequate training capacity, in terms of infrastructure and faculty, for the education of mid-level providers in your country?

Emerging themes and issues:

1.    Entry requirements, duration of training and internship - In the desire to increase numbers, there is a danger of quality dropping because of relaxed academic qualifications, ability to cope with the level of study, etc. This is often cited by professional associations as their main reason for opposition to relaxed entry requirements. However, we should keep in mind the fear by professional groups that increase in numbers will lead to their services being less valued (demand and supply), or increased competition for opportunities in the external labour market. Engagement of various stakeholders and clear political leadership and decision is needed to effect such changes. This was the case in Uganda when the association of nurses and midwives vigorously opposed the introduction of the new cadre of nursing assistants. It took a firm political decision by the then Minister of Health to continue. Some of the examples for flexible or affirmative type action for disadvantaged areas cited by some of the contributors such as; a) allowing experienced in-service personnel to upgrade (Zambia), b) using practicing professionals to contribute to the training of MLP, c) allowing lower entry grades from disadvantaged areas but holding all to the same standard of training and competency requirement (Malaysia),  d) relaxing entry requirements according to need in an area of the country (Tunisia), or e) make up remedial classes for candidates from disadvantaged areas (USA); are all testimonies that innovative means can be used to help increase the numbers of MLP ready to be trained and potentially deployed to serve in the most needy areas. While the concern about decreasing quality of MLP graduates and standards of care and safety are not to be dismissed, there are positive examples of how innovative measures have been taken. The experiences, especially by the private-not-for-profit sub-sector, in using cadres trained on the job, who are often not granted official recognition due to restrictions by professional councils or objections of the professional associations, demonstrate that they can and do provide care of acceptable standard and quality. The literature on these types of evaluations is unfortunately lacking and most information that exists is in unpublished reports or anecdotal. If countries do not adopt such flexible and affirmative measures there may be the risk that increasingly only candidates from "good schools", often located in urban areas or richer regions will send candidates into MLP training, something already happening with higher level professional cadres such as nurses and doctors. Candidates from more elitist backgrounds are not well known for their willingness and readiness to serve in remote or disadvantaged areas.

2.    Training capacity - Capacity for training MLP is inadequate in terms of facilities, faculty, and clinical practice opportunities across many countries. Inadequate training capacity for MLP is not unique only to LMICs. Rigidity to only use formally established training infrastructure or institutions may result in loss of opportunity for innovative training approaches such as; distance education programmes designed by professionals but complemented by local mentors such as qualified professionals practicing in the affected areas. Even existing infrastructure in formal training institutions is often used inefficiently by sticking to the traditional 8 am to 5 pm calendar. It is worth noting that institutions in some countries have started or are introducing distance education programmes or "evening classes", or "extension" programmes conducted for in-service personnel during periods when regular students are on break, etc. Whatever is introduced a critical limiting step is likely to be faculty time as trainees, even on distance programmes, still require faculty to set training materials, conduct sessions, and respond to queries, set and mark examinations, etc. Providing existing practicing professionals training in mentorship and coaching to assist trainees in their localities may be an opportunity worth exploring. Field Epidemiology (FETP) and MPH programmes under the Public Health Schools without Walls (PHSWOW) have done this for over 20 years. Similar approaches could be developed for MLP.

3.    Flexibility and innovation are needed in entry requirements and use of existing capacity if the acute shortage of MLP is to be addressed in the most needy countries. Building new training institution facilities or training dedicated training faculty takes time and resources that most of the countries with urgent need can ill afford. Opportunities to use innovative and flexible strategies to increase numbers of certified MLP exist and some countries are already applying them but are not being adequately exploited. There is room for this even in the context of the current resource levels e.g., using existing practicing professionals to train MLP, increasing clinical practice opportunities to ensure acquisition of competencies, flexible use of the scarce training facilities e.g., allowing different sessions to use the existing capacity and reduce slack time. Critical is the need to increase training faculty who have real and continuing practical experience to ensure training is continuously relevant and updated according to changes in the situation. Faculty involved in training should ideally also have on-going practice in their areas of training to avoid the situation that faculty in training institutions are only doing training and those in practice only practice and do not pass on skills, even when this might be beneficial to trainees located in their areas
Day 7  Education II

  1. What criteria and mechanisms are in place in your country for the identification of priority competencies to be included in the education and qualification of MLP?
  2. What is the appropriate balance between theoretical, classroom-based teaching and practical learning? Are assessments done (formative, during training; and summative, at the end of training) appropriate to ensure that required competencies are being met during training and have been acquired at the end?

Emerging themes and issues:

1. Criteria and mechanisms to identify priority competencies for MLP
First it is worth reminding ourselves that in health care work, like in most professions, we are mostly interested in competencies. Basically you only care that the health care worker, i.e., your doctor, your nurse, your dentist, treats you with respect and attends to the problem that is bothering you, and that you get well as soon as possible. You do not care if the person treating you knows a lot and has published lots of articles in top journals on the subject of tooth ache (has lots of knowledge). You will judge how competent your dentist is by how well he/she has handled you (correct attitude) and attended effectively to your tooth ache (has the right skill to address the problem). Competencies are a function of the right type and amount of knowledge to do a task, the correct attitude one should have in performing the task, and the right skill. You would not want a very knowledgeable and kind dentist to hold the dental drill the wrong way, would you? So all three are important. We say a health care worker is competent when he/she has the right knowledge, i.e., knows how something is done, believes it is right and important to do it (attitude), and knows when to do it for what reasons and in what circumstances. Those of you familiar with the quality assurance literature have heard that "quality is meeting the expectations of your client while meeting expected standards of performance and safety". Others simply put it that quality is "doing the right thing, the right way, at the right time, right away".
An approach that analyses what needs to be done, what sets of skills are needed, and how to go about doing them, utilizing the expertise of peers themselves, is the method known as Developing a Curriculum (DACUM), an occupational analysis methodology. It breaks down the tasks to be done and systematically analyses the knowledge, attitude and skill requirements for the tasks and then identifies the most appropriate way of fulfilling these needs in the trainee. DACUM aims at the achievement of results that may be immediately applied to the development of training curricula (see more information at ).

2. Balance between theoretical and practical learning
MLPs, like all health workers, need both adequate theoretical knowledge and the right attitudes and skills. Health care work is knowledge-based, but is also value based, and skills based. While knowledge can be acquired through didactic classroom teaching, searching for information on the internet, personal reading, or discussions, often trainees will need role models and mentors in order to learn the correct professional attitudes and practical skills. These are best acquired through apprenticeship and internship as part of the pre-qualification process. The amounts of time spent will depend on the particular cadre and country context. What is critical is that the balance to achieve acquisition of competencies should be based on the prevailing needs that the cadre will face in real life. The participant from Mali reminds us very well about this. If most health workers are dealing with mothers dying from preventable obstetric causes, it is reasonable to try to equip them with the skills to deal with this reality as it will take long to have doctors or obstetricians in these places. All participants pointed out that current programmes are often more theoretical with not enough practice. This is probably due to the curricula not having been readjusted to the needs of today.
3. Assessments
In order for MLPs to acquire competencies we need a way of regularly reviewing how well training programmes are leading to delivery of current and appropriate knowledge, trainees come out with the right attitudes to their professions, and have the right set of skills to do what they have to do to deliver effective health care. Training approaches like problem-based learning which aim to turn trainees into life-long learners, equipped to systematically analyse a problem, look for knowledge to solve it, and come out with solutions are appropriate but under-utilised. Many institutions continue to do training and assessment of trainees the way it was done 20 years ago and yet needs and technologies have changed. Traditional exam-only based assessments are inadequate in a changing world where trainees are overloaded with information. What they need more is to be equipped with ways of dealing with a changing world and solving problems on the fly, so to speak. Critical thinking and problem solving skills should equally be considered in assessing how well trainees are likely to perform. It is important to build this assessment throughout the curriculum rather than rely on one end of year examination. Traditional exams put emphasis on knowledge but as we have seen above, this is only one component of producing a competent health worker. A very knowledgeable MLP with a wrong attitude will not deliver effective health care but may create problems instead of offering solutions. A useful way of assessing trainees following a competency based training programme is the Objective Structured Clinical Examination (OSCE), as our colleague from Malaysia has pointed out. More tips on what this is can be found here or in the article by S. McAleer and R. Walker on

To conclude, in the face of resource constraints, many training programmes continue to deliver programmes that were designed in a very different context or modeled along traditional professional lines (as in most African programmes) or according to emerging cadres based on needs (Asia). Once established, training programmes tend to keep doing what they have always done and there may be resistance to change. There is an urgent need to re-evaluate these approaches. Sharing of best practices using a forum such as this one is a good start. We need to generate and/or document these innovative approaches and success stories and share them widely. I thank you all for your contributions.
Day 8: Management of MLP.

  1. What distinctive competencies do mid level workers need?
  2. What should the balance be between recruiting from outside and recruiting from inside (e.g. auxiliary nurses who are already in the system)?
  3. What new selection methods are being used or should be used with candidates who may not have a traditional training background (e.g. skills demonstrations)?
  4. What performance management approaches can be used or should be used for MLP?
  5. How can mid-level cadres get access to promotion and “mainstream” career routes?

Emerging themes and issues:

The following concerns were raised:
•    Having a clear picture of the competences that MLP need to be effective
•    Getting the balance right between internal and external recruitment
•    Using appropriate methods to identify competences in the selection process
•    Using performance management to monitor MLP and support their development
•    Having appropriate career progression routes

For me, the first of these looks like the most important, because it kills two birds with one stone.  A strong competence framework makes it most likely that we will get the best person for the job.  That’s always true, of course, but it’s especially true when the skills requirements are not ones with which we are familiar in the way that we are with the well-established mainstream roles of doctors and nurses etc.  Whether or not we prioritise communicable diseases or skilled birth attendance, or indeed team skills, it is clear that an investment in producing a robust competence framework or frameworks will be valuable. 

Now I must say that I’m not aware of any robust framework which already exists (have I missed something?).  I think the exercise of producing such a framework would be very worthwhile, and I wonder if it is something that WHO could take a lead on.

Several of you talked about career progression for MLP.  Here again competence frameworks are relevant, I think.  If we had such frameworks not only for MLP, but for the mainstream health categories as well, we would then be much better placed to see what the competence gap is between MLP and the mainstream roles.  That in turn will make it possible to specify routes from MLP roles into other mainstream, ‘higher’ roles.  (As someone who comes from outside the health service, one thing that has always struck me is how rigid the different mainstream roles often are, so that it is harder to move between different roles than in many other areas of work.)

Turning to performance management, a robust competence framework will have the added benefit of making performance management of MLP a much more focused affair.  One more point about performance management which I think arises from the discussion is that we have to get the balance right between performance management for monitoring and performance management for development.  I suppose my own view is that performance management should be fundamentally a developmental activity.  Past performance is water under the bridge: we are interested in it in order to learn from it and to IMPROVE in the future.  Also, performance management is perhaps even more important with MLP than with health staff in general because MLP are often coming in from outside the system, and may not have had the work socialisation which ‘mainstream’ health workers have had through their professional training and previous work experience.  They need more support.

I have picked up by no means all the issues that have been raised in the discussion.  In particular, I’m conscious that I’ve said nothing about recruitment and selection.  However, I hope that there has been some value in concentrating on a couple of issues that I think are particularly important. 

I’d like to thank everyone who has taken part in the discussion, both those who have only ‘listened’ as well as those who have ‘spoken’.  My own work with MLP convinces me that they are an innovative way of dealing with the staffing bottleneck that restricts our ability to respond to health needs, even where there is enough money to do so.  Good luck with your efforts to maximise the contribution that these new and potentially very valuable colleagues can make.
Day 9: Regulation and accreditation of MLP .

  1. What country-specific legislation is required to enable mid-level providers to practice in your country?
  2. How is pre-service training for mid-level providers accredited in your country?
  3. Is there a need to register specific cadres to ensure quality?

Emerging themes and issues:
What country specific legislation is required to enable mid-level providers to practice in your country?
World wide there are a range of approaches to legislation that could be used to cover the involvement of MHW either under government departments or though independent ”boards”. For example in Ethiopia there is specific legislation that supports an autonomous nursing regulatory body while in Malaysia there is a Nursing Board for nurses and a Medical Assistant Board for Assistant Medical Officers which define the scope of practice and the registration requirements.

It is important that all cadres of practicing MHW have their scope of practice defined by appropriate legislation in a way that suits the specific country environment. In a number of countries legislation covering MHW is state based, not national which adds a level of complexity in those environments.

How is pre service training for mid-level providers accredited in your country?
This question generated the most interest from participants who shared that although many countries have approaches for accrediting MHW many still do not. Significantly the ongoing dimension of accreditation was raised which is very important not only when considering the accreditation of training institutions but the accreditation and registration of MHW themselves;
 “First, a critical requirement for achieving the intended impact of quality regulation is that the approach must build in mechanisms to ensure that the desired performance or competence is sustained over time. Licensing and certification only at the point of entry into the healthcare market are insufficient to provide assurance to the public and to health sector institutions that providers maintain competency throughout the span of their careers. Time-limited licenses and certificates and clear requirements for renewal are thus essential.”

In resource poor environments the need to appropriately fund accreditation is often overlooked. If appropriate funding and suitably trained staff are not available to monitor and enforce regulations associated with accreditation then… “Regulations that are not enforced, or that are enforced with mild sanctions, do little but contribute to a general disregard of the regulatory authority of the government (World Health Organization 2000).”  A further complicating factor can be the “will” of authorities to enforce not only accreditation standards but health legislation.
The absence of enforcement for any reason reduces the quality of the health care system.

Is there a need to register specific cadres to ensure quality?

It is commonly agreed that most cadres that have the ability in influence patient care should be registered and that this registration should require renewal and where possible a demonstration of current practice or evidence of post service continuing education. Departments who have this responsibility are reminded that “for quality regulation to be effective, regulatory bodies must have the resources and mechanisms needed to exert regulatory authority and must regularly collect and act on monitoring data to verify compliance.”
Program Examples.

Ethiopia: "Every country has to have the capacity of regulatory mechanism for every level of health cadres within the country. For instance, Ethiopia has strong human resource for health regulatory mechanism. Every graduate from any level of a health science teaching institution has to be licensed before starting practicing as a public health or clinical practitioner in the country. The provided license will be renewed every 5 years if without any unethical health practice. Therefore, the Ethiopian Ministry of Health established a health care worker regulatory agency to protect and save the public from unethical nonprofessional practice, and licensure is mandatory for independent practice in public, private and NGO institutions in Ethiopia."
Cross-cutting themes.

Visibility and Recognition of MLPs
  • "In the absence of an encompassing definition that spans countries and continents, it is difficult for these providers to organize globally, advocate for their profession or even just be appropriately counted and included in routine surveys—a critical step towards recognitions and professional visibility."
  • "I think that one of the major problems in health care, even within a specific country or setting, is that our professions (with the probable exception of medical doctors and dentists) are not readily understood by the general population, patients, and even those in the health professions. In nursing in the US, we have LPN/LVNs, RNs, nurse practitioners, nurse-midwives, nurse clinicians, nurse associates, clinical nurse specialists—with variable requirements for education, licensure, and job tasks, Add to this list medical aides, nurses’ aides, medication aides, etc. and "nursing" begins to be seen as a very confusing occupation. Across countries, this becomes even more difficult but very important; the people we serve, those with whom we work and collaborate, governments, and funding sources should understand who we are."

  • "I do not think that it is feasible or desirable to encourage the convergence of the existing models of MLPs. Each particular type of provider has a somewhat different focus; for instance, midwives care for women throughout their lives but particularly during the childbearing years, a geriatric nurse specialist may provide services to the elderly, and a PA may specialize in orthopedics. Personally, I do not see this as a disadvantage (but I do admit it causes confusion). In addition, I think that having one type of general MLP might make the field less desirable to some people."
  • "With the discrepancies between health systems around the world, it would be very difficult to create an internationally recognized model. It’s a bit like trying to ensure a monetary and political union between countries who are at different stages of development with different needs: one size doesn’t fit all. However, some international consensus on minimum requirements for these cadres, perhaps in terms of duration of training, could be useful."  
  • "I am not sure I agree with a common standard for mid-level health workers, even within one region like Africa. We already have the problem of doctors moving from one country to another. If a common model is created for mid-level workers, also clinical officers will do the same. It might be good for us as individuals if we can look for greener pastures abroad, but who will stay behind looking after our people?"

  • "I would suggest also comprehensive HRH study and sharing best experiences and compiling evidence, if any, as input to shape the policy and strategic plan. I would support the idea of pulling to international recognized classification of health workers, training and accreditation and regulation and deployment."
  • "In improving distribution of mid-level cadres specifically, there must be sufficient data on the population of the public vs private sector and the urban vs rural areas."
  • "Good evidence and effective analysis are needed to remove the skepticism and resistance of the traditional professions and other influential communities to effective use of substitutes." Marco Gomes

Providing support to MLPs
  • "The need for supportive supervision is recognised. Perhaps, rather than emphasising the hierarchy across cadres and expecting that mid-level cadres will be supervised by high-level cadres who are in short supply at district (and sub-district) level as well as at individual facility level, career advancement and supervision goals could be jointly met by promoting more experienced mid-level cadres to more centralised supervisory roles. Perhaps this happens in some contexts, but my impression is that this is the exception rather than the rule."  

Competence framework
  • "Type of education and title does not ensure competency, and the length of training is an inappropriate measure of presumed skill. We should rather be talking about what is the minimum standard of care, irrespective of who provides the service. (South Africa is a perfect example where capabilities and training standards for nurses managing antiretrovirals is continually debated—mostly by doctors—yet there has never been standardized requirements for doctors: quality has not been assured, only presumed.)"  
  • "But clinical competencies are not enough. In some cases CO manage small clinics, so they should know also something about public health and management of health services, including reporting, supervision of other staff, etc."  
  • "I think mid-level [providers] should have their competences viewed in a team delivery framework, with clear boundaries or explicit overlapping areas with nurses, doctors, and other types of health workers."
Post-forum survey results


Reports and publications References and resources
Related Resources & References in the community library:
Articles and Materials in French, Spanish.
CycleBeads Inserts in various languages
FAM: Peer Reviewed Journals
SDM Manuals
SDM Peer Reviewed Journals
TDM Articles and Materials

Organizing groups 
HRH Exchange

Contributing experts/facilitators 

  • Dr Isabel Brasil, Director of the Joaquim Venâncio Polythenic Health School /Oswaldo Cruz Foundation, Brazil
  • Mr Andrew Brown, Assistant Professor, University of Canberra, Australia
  • Ms Amelia Cumbi, independent consultant, Mozambique
  • Dr Helen de Pinho, Assistant Professor, Mailman School of Public Health, Columbia University, USA
  • Dr Francis Kamwendo, Consultant Obstetrician/Gynaecologist, Malawi University, Malawi.
  • Dr Willy McCourt, Director, Institute for Development Policy and Management, University of Manchester, UK
  • Prof Barbara McPake, Director, Institute for International Health and Development, Queen Margaret University, UK
  • Prof David Sanders and Prof Uta Lehmann, School of Public Health, University of the Western Cape, South Africa
  • Ms Peggy Vidot, Health Adviser, Commonwealth Secretariat, UK

This discussion was moderated by the Secretariat of the Global Health Workforce Alliance in collaboration with the World Health Organization and the Implementing Best Practices (IBP) Consortium.