MLW training programs in Africa 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. Expansion of these programs will require greater resources and more trainers, but must also address issues of quality and relevance. Increasing the contributions MLWs make to health care will require significant new investment to be made in their training, including trainers and facilities [4]. WHO has called for transformation and scaling up of health professionals’ education (HPE) through greater alignment between educational institutions and health systems, adapting curricula to evolving healthcare needs, accreditation of HPE programs and innovative expansion of faculty including community-based clinicians as educators [18]. MLWs must be part of that.
Common themes from our data resonate with the WHO recommendations [18]: the need to modernise curricula and incorporate innovative approaches to learning and teaching, to align the content of education programs to the burden of disease faced by MLWs in the workplace and to ensure appropriate accreditation of these programs. Feedback from MLWs and district managers in Kenya, Nigeria and Uganda suggests that there are significant deficiencies in training content and educational methodologies. The MLWs surveyed wanted changes in their training methods, updating of the skills of their trainers and supervisors, upgrading of their training facilities and improvement in hands-on clinical practice during training. Training curricula for doctors have been criticised for not being reflective of emerging population health needs with “insufficient alignment between the priorities and planning of the health and education sectors, (and) imbalanced distribution that disadvantages rural and poor urban populations” [19]. Calls for a transformative approach to medical education, one that is defined by a commitment to social responsibility, inter-sectoral engagement, relevance to disease profiles and emerging public health problems [19], apply equally to training of MLWs. A fundamental shift in educational strategy is essential if health professionals are to acquire the necessary skills in mobilising knowledge and deploying critical thinking to patient care and population health [16].
Alignment of training institutions with health systems
The greater alignment between educational institutions and health systems should extend to MLW training which mainly takes place outside of medical schools in training institutions created by Ministries of Health and Education for this purpose. South Africa is the exception. Participants in our study called for curriculum review and formal accreditation of MLW training, which should be standard processes in all HPE institutions [18], and which could be addressed through more formal incorporation of such training into university or other higher education institutional structures. Medical schools across Africa are adopting innovative, problem-solving, student- centred and community-based approaches to medical education [20, 21], which are equally appropriate for MLW pre-service and in-service training. Developing a regional or continental network of training programs with cross-country comparisons and peer review could provide additional support for this. The move in some countries from diploma qualifications to university degrees for MLWs will help them to link in much more with developments in medical schools, and thus to innovative approaches for HPE overall. This upgrading should be informed by deficits faced by MLWs trained at diploma level so that graduates are able to offer better care. More recently established MLW training programs have opportunities to innovate in the design of their teaching methods and curricula, while older programs can reflect on the achievements of the past, and to reorient their approaches towards achieving their stated goals and objectives.
Compared with medical training, MLW training programs accept individuals with lower levels of schooling, shorter training periods, with less reliance on hospitals and advanced technology [3, 8]. The inclination to lengthen training to address some of the gaps should be resisted since the content and teaching methods are more critical than the length of course. Huicho et al. [22] showed no differences in quality of child health care between health workers with shorter or longer duration of training, although they did not examine the nature of the training and focused on very specific protocol-based tasks. Changing to competency-based education would allow for variable lengths of training, accommodating the skills and abilities of individual learners, and ensuring that trainees are assessed for competency before becoming independent practitioners [23].
Curriculum review
Participants were concerned about the limited focus of their training curricula. Reviews of the content of curricula and training programs have not occurred recently in line with current thinking on health professions’ education, and in-depth analysis of these are clearly needed. The gaps in clinical skills, particularly related to the major causes of disease burden in Africa (maternal and child mortality, infectious diseases, trauma and violence) and newer challenges (HIV/AIDS and emerging chronic diseases), are significant and need to be addressed. Where reviews and changes in curricula have taken place, these have often led to the addition of theoretical content such as in health economics, ethics and research methods, rather than inclusion of problem-solving and case-study methods that prepare MLWs to deal with problems faced at health facilities. The solutions proposed by participants in this study include making the training more fit-for-purpose, with better regulation of training and monitoring progression against established standards. Participants requested that the content of programs be grounded in the disease burden of the populations served and should reflect the range and complexity of conditions they have to deal with at district level facilities. Country-specific morbidity profiles and health care needs should be the basis for addressing deficiencies in knowledge and skills. Teaching of research methods, economics and ethics could flow from the problems arising at facility level, rather than from theory. Benefits for whole health care teams would come from implementing care delivery models that best serve the local population health needs, using interventions known to be cost-effective, and that are taught by those with the appropriate skills and experience of those needs and models [6].
Scope of practice
Limiting the scope of what MLWs are trained to carry out, making them focus on preventive health and minor conditions, while at the same time not providing them with the skills to respond to emergencies, has implications for how useful they can be and to their own sense of efficacy, especially where referral systems are limited. Dovlo points out that limiting MLW training to minor procedures may lead to them becoming a “transit referral point”, and thus a potential bottleneck in emergency care [4]. General surgery at district hospitals is highly cost-effective relative to other interventions in sub-Saharan Africa and in comparison to referral hospitals because of the relatively low input costs related to infrastructure and the high level of the avertable disease and disability burden [24, 25]. Where MLWs work under supervision of district doctors, giving them surgical skills to manage emergency situations and surgical procedures, provides good value for money [26]. Requests for more specialist training and career progression were raised in our study, though some MLWs did have opportunities for further training in a number of disciplines such as otorhinolaryngology, ophthalmology and anaesthetics. In the South African model, competency in emergency medicine and trauma procedures are required for ClinAs.
Sustaining performance and CPD
Managers’ perceptions that MLW performance could improve and be sustained have highlighted the importance of follow-up training and CPD [4], concerns also expressed by MLW participants in this study. Adult learning methods that are life-long, experiential, reflective and linked to career progression, are more effective than didactic teaching when used for CPD. There is now stronger evidence emerging of the importance of training in the location of future work. Rural placements that are well-structured and supervised are better at equipping health professionals to work in the same environments [27]. Specialist outreach also facilitates supervision and mentorship of MLWs training in rural areas [7]. Supportive supervision focused on clinical mentorship rather than mainly on administration at both pre-service and in-service training is critical, yet a review of primary care supervision in developing countries found that clinical supervision (checking diagnostic and/or therapeutic skills) was uncommon [28]. Educators also need updating through CPD since many are out-of-touch with learning techniques and skills required for clinical curative primary care [5]. Many Health Professional Councils or Boards in African countries now have a requirement to demonstrate annual CPD credits for continued registration, which should apply to MLWs as well.
Investments required
Rather than being treated as a stop-gap in primary and secondary health services, MLWs should be recognised for the essential frontline health workers they are. Their training and curricula require improvement to enable them to carry out the functions that they do with greater effectiveness and with regard to better quality care and enhanced outcomes. National governments should take a lead to ensure there is an enabling regulatory and accreditation framework for training, and to resource, guide and support educational institutions to upgrade training (quantity, quality and relevance), at both pre-service and in-service levels [16]. 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 programs.
Development and provision of appropriate trainers is critical in this. The slow growth of the health workforce lags behind population growth and increased health need in Africa [29], with the shortage of senior clinical educators – doctors and nurses – undermining training of all health staff as well as provision of services. Recent developments in many African countries of placing Family Physicians and Family Medicine training at district hospitals could facilitate incorporation of MLWs as valued members of district health teams, allowing them to develop practical skills under supervision, at the same time freeing up doctors for other more complex work [29, 30].
The costs of training MLWs and supporting them in practice should be compared with equivalent costs for physicians, to ensure that interventions are cost-effective, at the same time as being relevant and enhancing quality of care. Such an approach is essential given the significant economic, political, sociocultural and other external forces influencing decision-making in the countries studied, as exemplars of Africa, while recognising that investment in education and job creation in the health sector will contribute to promoting economic growth [31].
The progressive upgrade of MLW training in Africa has led to increasing professionalization and subsequent establishment of degree programs and an international professional association. The creation of the African Network of Associate Clinicians (ANAC) is an important step forward in recognising MLWs as health professionals who are making a significant contribution to primary and secondary health care, rather than being just a stop-gap measure. ANAC could collaborate with the International Academy of Physician Associate Educators (IAPAE)Footnote 2 and through this synergy promote the global recognition of this cadre of health professionals.
Limitations
Our study provides useful insights on the appropriateness and relevance of MLW training in Africa, a topic that has received insufficient attention in the literature to date. However, as a cross-sectional rapid appraisal, the study also had a number of limitations. We were not able to undertake a comprehensive and detailed evaluation of MLW training and training institutions but relied on policy documents, curricula, selected key informant interviews, and surveys with district managers and a sample of MLWs. The study was restricted to four countries, capturing a range of different MLW programs and experiences, but may not reflect all countries in the region. The quantitative survey with MLWs was limited in size, particularly in Nigeria, but with good participation rates indicating that the responses should be representative. Future studies, with more resources, will address these limitations.