Table 8 Advantages and disadvantages of using substitute health workers (SHWs)

1. Substitutes are country-specific, not internationally "tradable", and are more easily retained within the country

2. Emoluments and incentives for such cadres are significantly lower than for cadres substituted for

3. Pre-service training costs are also much lower

4. Academic entry requirements into technical training are less problematic and training is accessible to a wider range of entrants from all segments of society

5. All training is local and practical

6. Substitute cadres accept postings into rural/hardship areas and are retained there

7. Substitutes may reduce other service costs by requiring fewer diagnostic tests and less sophisticated equipment and by prescribing generic medications

8. They may relate better with communities by being less elitist and more integrated

1. Quality of care may suffer with poor clinical decision-making or poor supervision of their practice (they still require supervision by a professional)

2. Ethical considerations may be less strong in new cadres who don't have existing traditions and norms. Practice regulation is absent for many such cadres

3. The perceived low costs may be offset by poor treatment results and outcomes to patients and high morbidity

4. Scaling up the numbers of substitutes to achieve higher coverage will mean similar expansion in the numbers of professional cadres required for supportive supervision

5. Eventually cadres carrying out similar tasks want remuneration and incentives similar to those of the original cadres. Interprofessional conflict and demotivation may ensue