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Background: Africa's health systems rely on services provided by mid-level health workers (MLWs). Investment in their training is worthwhile since they are more likely to be retained in underserved areas, require shorter training courses and are less dependent on technology and investigations in their clinical practice than physicians. Their training programs and curricula need up-dating to be relevant to their practice and to reflect advances in health professional education. This study was conducted to review the training and curricula of MLWs in Kenya, Nigeria, South Africa and Uganda, to ascertain areas for improvement.

Methods: Key informants from professional associations, regulatory bodies, training institutions, labour organisations and government ministries were interviewed in each country. Policy documents and training curricula were reviewed for relevant content. Feedback was provided through stakeholder and participant meetings and comments recorded. 421 District managers and 975 MLWs from urban and rural government district health facilities completed self-administered questionnaires regarding MLW training and performance.

Results: Qualitative data indicated commonalities in scope of practice and in training programs across the four countries, with a focus on basic diagnosis and medical treatment. Older programs tended to be more didactic in their training approach and were often lacking in resources. Significant concerns regarding skills gaps and quality of training were raised. Nevertheless, quantitative data showed that most MLWs felt their basic training was adequate for the work they do. MLWs and district managers indicated that training methods needed updating with additional skills offered. MLWs wanted their training to include more problem-solving approaches and practical procedures that could be life-saving.

Conclusions: MLWs are essential frontline workers in health services, not just a stop-gap. In Kenya, Nigeria and Uganda, their important role is appreciated by health service managers. At the same time, significant deficiencies in training program content and educational methodologies exist in these countries, whereas programs in South Africa appear to have benefited from their more recent origin. Improvements to training and curricula, based on international educational developments as well as the local burden of disease, will enable them to function with greater effectiveness and contribute to better quality care and outcomes.

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Nursing shortages are a critical health workforce challenge and are likely to be exacerbated in coming years by changing population demographics and healthcare needs. As pressures grow, shortages will intensify the unequal distribution of nurses both within and between countries. Currently, many countries are experiencing a rapid expansion of private nurse training institutions. These institutions have the potential to contribute positively to local and national health systems by increasing the supply of nurses, possibly even in rural areas where shortages are most severe. However, little is known about private training institutions (e.g. their syllabus, the quality of training, how they are regulated), or about the job choices of their graduates. RESYST Consortium has conducted research in Thailand, Kenya and India to compare public and private nurse training institutions, and investigate the extent to which the type of training institution influences their job choices. In March 2016, a meeting was held in Bangkok, Thailand, bringing together researchers and policymakers to share new evidence and exchange experiences on the topic.

This report synthesises the research findings that were shared during the workshop, and outlines recommendations that were jointly developed by researchers and policymakers. It builds on the country-specific research results by integrating the findings into wider discussions and existing knowledge on nursing shortages and strategies to overcome these. The recommendations - for governments, regulatory bodies and educational institutions, are organised into two categories: a minimum package that outlines how countries can plan, regulate and monitor training institutions to ensure nursing standards in light of the expansion of the private sector, and an expanded package of recommendations to ensure that private training institutions contribute positively to national priorities.

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