Doctors - Nurses Substitution
The demand for health care services has increased in developed and developing countries due to population explosion. In many times the supply of doctors and physicians is limited. One possible solution to this problem is shifting primary health care from doctors and physicians to nurses. This situation is referred to as doctor -nurse substitution. The expectation behind this strategy is to maintain quality health care while reducing cost and physicians workload.
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Developing countries have a big medical brain drain which has caused resulted to formation of some policies like doctor - nurse substitution to curb the shortcake of doctors. Most of this problem is found in Sub-Sahara Africa. Countries in this region include; Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Chad, Congo, Ethiopia, Gabon, Guinea, Kenya, Lesotho and Liberia. In all this countries the doctor -nurse substitution is present. In focusing in a specific country, this paper will look at doctor-nurse substitution in Kenya.
Only major hospitals in Kenya have Doctors. These hospitals are found only in major towns thus don't serve the people living in rural areas. In the rural area there are dispensaries which have nurses as 'physicians' (replacing doctors). The country faces a major disaster of emigration of medical experts after completion of their courses in the country. This is caused by low remuneration the government offers to doctors. The nurses diagnose, prescribe, dispatch medicine to patients while also playing their roles as nurses to patients like administering injections. They don't perform surgeries. Some of the nurses posted to work as doctors in these dispensaries lack adequate experience in medicine which a high risk the country takes on its people. This nurses hardly do they undertake any other medical training so as to substitute doctors. This raises a question on the equality of health services provided by the hospital and dispensaries in the country.
Kenya has tried to solve the problem of doctor - nurse substitution through having a direct substitution of qualified medical personnel. This personnel is less specialized like doctors since they take three years studying medicine unlike doctors who take five years. These medical personnel are called Clinical officers who are found in most of the hospitals upcountry. It is imperative to note that these clinical officers are not found in dispensaries in the rural areas but they help the few doctors in hospitals. Clinical officers do diagnose, prescribe, and administer medicines to patients in the Kenya. Some of them are further trained to do minor surgeries and administer anesthesia.
This strategy which is employed has tried to help in provision of basic medical services to the community but it is not efficient enough because of the huge shortage of doctors in Kenya. After introduction of clinical officers there are many places with nurses substituting doctors. The country needs to do more than the direct substitution method of few clinical officers.
The best solution to the problem is not just to have substitution policy but the best solution of nurse-doctor substitution and lack of enough doctors in developing countries like Kenya is by use of integrated strategies addressing the problem. These strategies of curtailing the problem are;
- Increasing remuneration of the qualified medical personnel
- Emigrant doctors should be given bonuses after they return in their countries
- The country should improve living and working conditions of medical personnel
- Government should reimburse educational expenses in emigration cases
- Governments should make policies which increase sustainability between high qualifies professional and the lower qualified personnel thus making them more polyvalent while reducing the huge gap between the medical professionals.
- Substitution which can be direct or indirect. In direct substitution doctors are substituted with new medical personnel who are less qualified and specialized than the doctors. This substitutes are able to deliver services liken physicians since they are more specialized than nurses e.g. clinical officers in Kenya, Tanzania and Uganda; medical assistants in Malawi, Ghana and Mozambique. The common thing with this kind of medical personnel is that they take three to four years to complete their course unlike doctors who go for five years. They are also trained on other medical specialties like anesthesia, orthalmology, ophthalmology, reproductive medicine and of course the general medicine.
- Indirect substitution can be used but it is highly discouraged since it tends to lower service delivery. Indirect substitution involves authorization of lower and weaker qualifications in carrying out certain duties they do not to qualify to carry. This kind substitution does not involve training different personnel. A good example is the doctor -nurse substitution. In some cases the nurses involve in the indirect substitution undergo some small training (3-6 months) and should be highly experienced in the medical field. This helps in ascertaining that the substitutes can deliver quality services. African countries should have experienced nurse and train short courses to them so that they can effectively substitute doctors.
Studies have shown that good direct substitution policies can reduce emigration of high qualified and specialized medical professionals because most of the health workers in a particular country will have specific qualifications which are less valuable in international standards thus the medical personnel can't seek jobs out of their countries. A good example is of the clinical officers in Kenya. Never the less, for a sustainable primary health care delivery, a country should employ all the suggested solution in this paper.