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Table 1 Details of MLW training and scope of practice in four countries

From: Curriculum and training needs of mid-level health workers in Africa: a situational review from Kenya, Nigeria, South Africa and Uganda

Nigeria Uganda Kenya South Africa
Ratio of physicians per 1000 population (latest available data) a
0.376 (2009) 0.12 (2005) 0.199 (2013) 0.767 (2015)
Maternal mortality ratio, i.e. maternal deaths per 100,000 live births (2015)b
814 343 510 138
Under-five mortality rate i.e. deaths of children under 5 years per 1000 live births (Median estimates, 2016)c
104.3 53.0 49.2 43.3
Nomenclature and scope of practice
Community Health Officers (CHOs) and Community Health Extension Workers (CHEWs)
• CHOs and CHEWs constitute 42% of all human resources in PHC compared to 8% nurses.
• CHOs spend 70% of their time in clinic facilities providing essential health services while CHEWS spend up to 50% of their time in these facilities working under supervision of the CHOs.
• 90% of all deliveries performed in PHC are conducted by CHEWS.
• CHOs can become administrative heads of primary care facilities, or take on other administrative and management roles on the public service.
Clinical officers (COs)
• Most COs work in rural settings in primary care, performing patient assessment, disease management, triage, minor surgical procedures, and referrals to tertiary centres. They participate in community outreach, health education, screening and care coordination.
• COs are not trained to manage emergencies whether obstetric, surgical, paediatric or medical
• COs can undergo specialty training to become Psychiatric COs, Ophthalmic Cos, etc.
Clinical officers (COs)
• COs offer a wide range of preventive and curative medical and surgical services, functioning quite independently at a range of levels in the health service though focussing particularly on clinics, health centres and district hospitals.
Since the late 1970s COs could specialise via 2-year Higher Diploma courses in paediatrics, ophthalmology and other specialties, which has been extended to include ENT, anaesthetics, respiratory health, dermatology and reproductive health
Clinical Associates (ClinAs)
• A new cadre, training of whom started in 2008, working under the supervision of doctors mainly in district hospitals, with a focus on management of common and chronic conditions, emergency care, skilled procedures, and inpatient care.
Pre-entry requirements
• Both CHEWs and CHOs gained entry to study through five credit level passes in the Senior Secondary School Certificate examinations (or equivalent) taken after 12 years in the school system ▪ The minimum entry requirement was the Uganda Advanced Certificate of Education, taken after 12 years of schooling
▪ Qualified nurses could enter at the second year level of the Diploma
▪ The minimum entry requirement was a Kenya Certificate of Secondary Education, taken after completion of 12 years of schooling. ▪ The minimum entry requirement is a university entry exemption in the national senior certificate examination, taken after 12 years of schooling.
Duration of pre-service training
▪ CHEWs: 3 years for National Diploma in Community Health
▪ CHOs were originally trained as nurses who then did post-basic training; a 4-year direct entry diploma was launched in 1990, which was subsequently upgraded to a Higher Diploma with plans to change this to a degree level course.
▪ 3 year Diploma in Clinical Medicine and Community Health
▪ Two year internship
▪ 3 year Diploma in Clinical Medicine and Surgery.
▪ One year of internship
▪ A 4 year BSc in Clinical Medicine was launched in 2010 at Mount Kenya University which expanded to 3 other universities.
▪ 3 year Bachelor of Clinical Medical Practice established in 2008 for training clinical associates
Place of training
▪ Schools for CHOs were affiliated to universities while CHEWs were trained through Schools of Health Technology in each of the 36 states. ▪ 3 private institutions and 3 public schools that have trained large numbers of COs ▪ 27 accredited institutions that provide CO training including the Kenya Medical Training Centre, with its constituent colleges in various districts, five universities private and faith-based colleges ▪ University training through 3 medical schools, with ClinAs trained predominantly at district hospitals
Educational content
▪ Diplomas were reviewed in 2006, with curricula adapted to include communications, ethics, health economics, information systems, human resources, and research methods ▪ Curriculum review in 1997 reoriented training towards preventive health and health promotion in addition to curative care.
▪ Contents include nutrition, health education, principles of PHC, maternal and child health, epidemiology, research methods, management, as well as anatomy, physiology, socio-psychology, dental health, internal medicine and pharmacology.
▪ Gaps in theoretical input on HIV and AIDS management, palliative care, new initiatives in malaria and TB.
▪ Limited practical exposure alongside theoretical teaching, especially in new approaches to common conditions
▪ CO curriculum reviewed in 2007, producing a common set of competencies and learning outcomes to be used across all CO training institutions, aiming to cover the range of medical problems encountered by COs.
▪ Respondents felt the training only prepared the COs for 50% of the conditions and issues dealt with in their actual workload
▪ Areas inadequately covered: basic sciences, research methodology, community health, HIV and AIDS, psychology, sociology and ethics.
▪ Bigger focus on health promotion and disease prevention, management of common conditions, not necessarily what COs were faced with in their workplaces
▪ Outcomes-based training according to a common curriculum framework with core competencies of clinical reasoning, investigative and therapeutic procedures appropriate for district hospitals, emergency care, clinical recordkeeping, ethics and professionalism, communication skills and counselling.
▪ The curriculum framework incorporates a set of common conditions presenting at district hospitals with a list of skills and procedures usually performed in district hospitals for which competency has to be achieved and demonstrated
The trainers
▪ Range of health professionals (doctors, nurses, other MLWs) involved in teaching ▪ Training mainly by senior COs and medical technologists
▪ tutors were expected to teach with minimal resources due to paucity of teaching aids and reference materials
▪ Senior COs were responsible for training;
▪ Doctors involved in specialist training particularly for the Higher Diplomas
▪ Range of health professionals (doctors, nurses, other MLWs) involved in teaching
  1. aAvailable from http://www.who.int/gho/health_workforce/physicians_density/en/
  2. bAvailable from https://data.unicef.org/topic/maternal-health/maternal-mortality/
  3. cAvailable from https://data.unicef.org/topic/child-survival/under-five-mortality/
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