Human Resources for Health in Maternal, Neonatal and - HRH ...

Substitution
Substitution is different from task shifting in that it involves the enhancement of existing
work roles by the: substitution of one type of worker for another, delegation of functions up
or down the traditional role ladder; innovation in designing new jobs, transfer or relocation of
particular roles or services from one health care sector to another (Krupp and Madhivanan
2009)
Research suggests that the quality of care is maintained and in cases improved when of
nurses is subsisted for doctors. In addition organisational costs are maintained or reduced by
increasing the role and deployment of clinical nurse specialists, nurse practitioners and
clinical nurse-midwives.(Brown 1995; Kinnersley 2000; Dovlo 2004). Patient outcomes as
well as and care processes were found to be similar for nurses and doctors however patients
were more satisfied with care from nurses than from doctors.(Horrocks S 2002). However
Lewin and Dick caution against the use of lay health professionals instead of professionals
stating that the evidence is mixed with different outcomes favouring either professional or
LHW interventions (2009). More research is therefore required in this area.
A study in PNG indicates that the CHW is being viewed by some health managers as a
substitute for the nurse aide (Ashwell and Freeman 1995). The CHW has been trained
specifically to improve the access to essential primary health care services of people living in
rural areas, especially in preventive and maternal and child health care. The research found
that they were not all practicing in this capacity and as a result were not utilising their skills.
Only 8% of the CHWs studied used all the skills obtained in their basic training. This
substitution is problematic as it leaves a gap at the community level in MNRH care and
services. The use of CHWs at facility level has left Aid Posts unstaffed leading to their
closure. This situation is being addressed through a revitalisation of community health posts
through increased intakes of CHW, focused MNRH training and re deployment at the
community level (Government of Papua New Guinea 2009).
Guidance on the delegation of tasks and functions in MNRH at community level is provided
by Nasah (1992). The general principles in delegation of responsibility are reviewed and the
functions to be delegated are presented together with minimal criteria for training to acquire
required skills. Problems arising from delegation are reviewed as well as possible solutions
which include modification of some standard procedures. Conclusions are drawn from case
studies that effective delegation needs strong leadership of maternal health teams sustained
by national political, professional, and community support.
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