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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 dis<strong>allo</strong>wed 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”.
5. Human resources for health (HRH): a crucial element for achieving international MDGs. 65Two further subtypes are identified.• Partial substitutes, who carry out only limited and circumscribed tasks ofdoctors and refer other tasks to doctors. Medical assistants in Ghana andclinical officers in Zambia are examples of such substitutes.• True or full substitutes, who carry out significant segments of the scope ofpractice of doctors. Assistant medical officers in Tanzania and surgical/obstetrictechnicians (tecnicos de cirurg?a) in Mozambique independentlyperform surgery and are examples of this type of substitution.Intra-cadre skills delegation, i.e. delegating some specific, special tasks to lesstrainedcadres from the same professionTasks normally carried out by specialists are delegated to general practitionerswith or without additional training. The West Africa Post-GraduateMedical College determined a gap in certain specialties in the region – psychiatry,ophthalmology, ENT and anesthesia – and had provided 18-monthpractical diploma courses for general practice physicians to undertake enhancedroles in these specialties. General practice nurses have been used asoperating room nurses without the appropriate qualification.Task delegation, i.e. delegation of some non-technical tasks to relieve professionalsof unwarranted workloadClerical tasks in wards, such as administration of patient reports, can be delegatedto ward clerks working closely with nurses. The health sector in Ghanarecently authorized the creation of “health aides” aimed at relieving professionalnurses of the more menial tasks on wards, such as lifting or bedbathingpatients,A basic underlying factor in all substitutions is that the worker to whom thetasks are delegated is not trained to the same level or qualification as the cadrewho normally carries out these tasks. Laws or regulations should normallyformalize substitution, but it is also recognized that substantial informal skilldelegation exists because of unfilled needs in rural and remote areas.Good governance and overall policy frameworkThe scaling-up of priority interventions is intimately linked to ongoing reformsin the health sector. Decentralization, the promotion of private practice,new financing and payment schemes, hospital and/or pharmaceutical reformsare currently promoted in many countries as a means to improve performanceand outcomes of national health care systems. The development of
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