Thanks for your contributions to this topic. I have been following the discussion quite closely and I keep on wondering why we forget why these guys the so called mid level health care providers are still ingrained in our societies despite the ill or malpractice that we talk about. We, the well trained and skilled health workers do not want to go down to the levels of where the local communities are and work with them. We would rather cluster in the cities and the more urban like areas and remain there. This has left a big health gap and loopholes for these guys to mushroom.
Reproductive and maternal health
Firstly I must point out that I do not like the language of "mid-level, low level" etc. I think this hierarchical approach defeats our approach to team work where each person is trained to a specified level to bring a set of competencies to care delivery. Second I concur with Toumzghi's general line of thinking in support of non-physician -level community health workers. Suppose we are asked by health policy makers to give our views about the use of "mid-level" health workers in our countries or organisations?
I would like us to digest your corollary. ‘it is better to be attended by no one than by someone likely to do more harm than good’. In what context can we speak that we would rather be attended by no one? Leave it to nature? Take the case of TTBAs [*]. As has been said frequently they don't save lives, they may delay.....etc. etc. To come to the example of TTBAs. The trend in Eritrea as an example is that MoH (not yet a written policy change) would want to have every mother deliver at HF and that TTBAs role who change to more of counsellors and reproductive health promoters (RHPs).
HIFA LUMP I think that the level of training is not a matter of assumption. First, there should be analysis of needs, which should be again distinguished from demands or expectations of the served community. There should be a clear list of health care functions that are needed within the served community. This simply answers the basic question of: What are the healthcare services we supposed to provide to our served community? (in response to their needs).
The question of 'lower cadre staff' is a vexed one. The assertion that 'it is better to be attended by someone than by no one' should have a corollary, namely that 'it is better to be attended by no one than by someone likely to do more harm than good'. A lower level carer who tries to do more than they are qualified or able to do could end up harming someone.
I fully agree with Dr Parkes To further add - we are trying to use EHealth techniques (well actually Tele-education) to convince the specialists to train the rural Health workers (The commonest name in India is 'RMP' - or Registered Medical Practitioner and also 'Dai' i.e. the reproductive health nurse) so that they can do the job more skillfully. And we are facing the same resistance
I am an American-trained family doctor, currently teaching in a medical school in Mozambique. I do not believe that using mid-level providers in any way corresponds to lesser or inferior care. The Chinese use surgical technicians extensively, even to reattach severed limbs. In the US, mid-level providers (nurse practitioners and physicians’ assistants) are used extensively in primary care.
I don't believe that we accept lower standards for care when we promote training of TBAs or any other individual to perform an intervention that they might already perform. For example, if we are treating a post partum hemorrhage, the first intervention is recognizing the problem - and recognizing the problem early enough to intervene with whatever technological intervention we have at our disposal. In my community in Canada, I cannot intervene with a blood transfusion but misoprostel is close and convenient.