FRONTESPIZIO - Cooperazione Italiana allo Sviluppo

64 Carlo Resti, Yohannes Tadessesure that new cadres have access to continuing education opportunities andcan upgrade their skills and educational levels. Skill substitution or skill delegationis not but at an early discussion stage in Ethiopia, while there aresome experiences in other African countries.To face the challenge of shortage of HRH, the use of substitute health workersis quite common in Africa, but reviews and non anedoctal evidences arenot published.There are four main forms of substitution of health care workers in Africa,(D. Dovlo, 2004).Indirect substitution/task delegation (task shifting), i.e. substitution using an existingbut different professionAn example of this occurs when tasks carried out by physicians are taken upby nurses. Several examples of this type of substitution were found. InGhana, the “Life Saving Skills Training Project” trained midwives in rural areasto carry out delivery-related tasks normally undertaken by doctors. SouthAfrica (Choice on Termination of Pregnancy (CTOP) Act 1996) and Zambiahave changed their abortion laws and given new roles to nurses and midwives,including tasks normally restricted to physicians. White et al. (1987)report that in the Congo in the 1950s, nurses were trained to perform surgeryand in Malawi, Ghana, Tanzania and Zambia, nurse anesthetists providedanesthesia for surgical operations. These skill substitutions also enhancethe roles of these existing cadres and so are rather forms of task delegation.Informal substitution often occurred when nurses and other mid-level healthworkers in rural areas performed procedures normally disallowed by the regulations.Nurses in rural areas in Ghana, for example, delivered breech presentationsand performed episiotomies, even without additional training anddespite restrictions that these tasks be performed by physicians or underphysician supervision.Direct substitution: i.e. substituting an existing profession with new and differentcadresMany African countries have created country-specific cadres to carry outtasks that are internationally recognized as those of other professionals. Thisis a common form of substitution in Africa, where in most countries thesesubstitutes are no longer “new”, having been in place for over two decades.Examples include substitution for doctors using “clinical officers”, “medicalassistants”, “assistant medical officers” and “surgical or obstetric technicians”.