Experiences with substitution in Africa
Production of substitute cadres
The training of substitute cadres varies between countries in terms of entry qualifications, training duration and content of training. According to key informants, Mozambique had three levels of doctor substitutes, described as basic and middle-level "health technicians", and a "specialist" level. For the basic level, the requirement was a 10th-grade high school certificate for a pre-service training of 30 months. The cadres must work for two years before becoming eligible to be selected for a further 18-month course to become specialized.
CEDHA indicated that Tanzania provides a multi-step system, starting with the "clinical officer" (entry with grade 12) and ending at the assistant medical officer (AMO) specialist level. Kenyan Medical Training Center's clinical officers are trained for three years and registered after a year's "internship". A further 18 to 24 months' training confers a "higher diploma" and specialist grade in specific subjects such as anesthesia, ophthalmology and cataract surgery, reproductive health (with caesarean skills), and orthopedics.
Malawi's College of Health Sciences (MCHS) graduates clinical officers with certificates in "clinical medicine" after three years' training. Another year of training leads to postbasic qualifications in "clinical medicine" and "ophthalmology" as well as other specialties. MCHS also has a three-year diploma in pharmacy technology and with similar postbasic qualifications for pharmacist substitutes.
In the countries studied, the ministries of health were directly responsible for training institutions and not tertiary educational institutions. Tables
3,
4 and
5 provide a summary of training and staff production information from countries that responded to a questionnaire. If all the stages are taken together, the duration of education may be the same as for training a doctor, or nearly so