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Research Article
Revised

Mid-level health providers for primary healthcare: a rapid evidence synthesis

[version 2; peer review: 2 approved]
PUBLISHED 10 May 2021
Author details Author details
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REVIEWER STATUS

This article is included in the Health Services gateway.

Abstract

Background: Healthcare services, in many countries, are increasingly being provided by cadres not trained as physicians, and these substitute health workers are referred to as mid-level health providers (MLHPs). The objective of this study was to rapidly synthesise evidence on the effectiveness of MLHPs involved in the delivery of healthcare, with a perspective on low- and middle-income countries.
Methods: The review team performed an overview of systematic reviews assessing various outcomes for participants receiving care from MLHPs. The team evaluated systematic reviews for methodological quality and certainty of the evidence. Also, the review team consulted relevant stakeholders in India.
Results: The final report included seven systematic reviews, with six assessed as moderate to high methodological quality. Mortality outcomes concerning pregnancy and childbirth care services showed no significant differences in care provided by MLHPs when compared with doctors. Pregnancy care provided by midwives was found to improve the quality of care slightly. The risk of failure or incomplete abortion for surgical abortion procedures provided by MLHPs was twice when compared to the procedures provided by doctors. Moderate to high certainty evidence showed that initiation and maintenance of antiretroviral therapy for HIV-infected patients by a nurse or clinical officer slightly reduced mortality. High certainty evidence showed that chronic disease management by non-medical prescribers reduced some important physiological measures compared to medical prescribing by doctors.
Conclusions: To date, this is the first rapid overview of the evidence on MLHPs. Low-quality evidence suggests that MLHPs might be suitable to deliver quality pregnancy care. Moderate and high-quality evidence from trials suggests that MLHPs are helpful for chronic disease management and initiation and maintenance of antiretroviral therapy in people with HIV/AIDS. However, the roles and subsequent training and regulation of MLHPs might be different for different care domains.

Keywords

Rapid review, rapid evidence synthesis, systematic reviews, mid-level health providers, MLHPs, low- and middle-income countries

Revised Amendments from Version 1

Major differences between the previously published version and the new version of the article relate to the abstract and the discussion sections. The changes in the discussion relation were about the context, the comparison of similar or contrasting review findings with existing literature available on the topic. The new version also includes additional citations to support the additional information. The revised abstract reflects the changes done in the main text. There were some minor changes in the introduction and methods section in the revised version, mainly concerning the context of the review and information on stakeholder engagement.

See the authors' detailed response to the review by Guido Bendezu-Quispe
See the authors' detailed response to the review by Shradha S. Parsekar

Introduction

There is a growing momentum worldwide to improve access to healthcare and provide efficient and cost-effective primary healthcare (PHC)1. Mid-level health providers (MLHPs) are currently being used in high- and low-income countries to assist doctors and specialists or render services independently, particularly in resource-poor settings, to make up for the scarcity of health professionals. Countries with poor economies and weak healthcare infrastructure have inadequate human resources for health. There is a growing movement for countries to strengthen and initiate the use of MLHWs to increase access to services2. However, MLHPs have been used for many years in Africa and Asia2, p.9. Their role has been progressively expanding and receiving attention, particularly in low- and middle-income countries (LMICs), as a strategy to overcome health workforce challenges and improve access to essential health services2.

A cornerstone of India’s current health systems reform efforts is the flagship Ayushman Bharat (AB) program. Primarily, the program has an insurance component (Pradhan Mantri Jan Arogya Yojana, PMJAY) and the development of Health and Wellness Centres (HWCs) as strategies to advance on the path to universal health coverage2.

Ayushman Bharat’s HWC sub-strategy, the comprehensive primary healthcare (CPHC), conceives MLHPs as a key focal point for service organisation and delivery, performing a range of screening, diagnostic and clinical functions and improve health systems at the frontline. The program conceptualises 12 different packages for the CPHC reforms3. One key pillar of rolling out the AB-HWC component is implementing a new health cadre trained and accredited for a set of skills/competencies related to PHC and public health. Further, one of this programme’s aims is the transformation of existing sub-health centres and PHCs to HWCs, with teams led by MLHPs.

The National Health Systems Resource Centre (NHSRC), the technical support agency of the National Health Mission, is responsible for developing the curriculum for MLHPs. We received a request from the NHSRC for a rapid review of evidence on the effectiveness of MLHPs in the PHC context of low- and middle-income countries (LMICs) to understand the role MLHPs can play in different packages. We host a rapid evidence synthesis (RES) platform, which provides RES products in various formats to public agencies. RES or rapid review is an emerging form of evidence synthesis that is increasingly being promoted by the WHO and employed by governments to inform decision making4. The need to meet the time-sensitive demands and the availability of fewer resources necessitated a RES. We thus synthesised evidence related to the effectiveness of MLHPs in the PHC context of LMICs.

Methods

Approach for RES

We conducted a rapid overview of systematic reviews (SRs) of evidence on the effectiveness of MLHPs within a span of about eight weeks and in all domains corresponding to the CPHC package in Ayushman Bharat. The 12 CPHC packages are: pregnancy and childbirth; neonatal and infant health services; childhood and adolescent health services; family planning, contraceptive services and other reproductive care services; communicable diseases (prevention and management); non-communicable diseases; elderly and palliative care; oral healthcare; ophthalmic and ear, nose and throat (ENT) care; mental health and emergency medical services3.

The World Health Organization (WHO), defined MLHP as “a health provider who is trained, authorised and regulated to work autonomously, receives pre-service training at a higher education institution for at least 2–3 years and whose scope of practice includes (but is not restricted to) being able to diagnose, manage and treat illness, disease, and impairments (including performing surgery, where appropriately trained), prescribe medicines, as well as engage in preventive and promotive care”1, p.8. However, MLHPs in various countries have been variously referred to as substitute health workers, auxiliaries, non-physician clinicians, and include cadres such as clinical officers, medical assistants, physician assistants, nurse practitioners, and surgical technicians. Institutions and researchers worldwide use alternate or less well-specified definitions, and therefore MLHP as defined in the SRs was considered for this review. Therefore, we used broad criteria for the rapid overview wherein we accepted the definition of MLHPs as defined by the SR authors. The overview of SRs is an appropriate study design for our research because we intended to summarise the evidence for multiple conditions in different disease/condition domains for the same type of intervention and on similar health systems, clinical and public health outcomes.

Inclusion criteria

Participants. The RES considered SRs assessing outcomes for participants receiving care from MLHPs in LMICs, including India.

Intervention and comparators. SRs that compared service delivery provided by MLHPs with doctors or other types of MLHPs were included. The MLHPs included were midwives, nurses, auxiliary nurses, nurse assistants, non‐physician clinicians, and surgical technicians.

Outcomes. The following outcomes were considered for inclusion based on the initial discussions with the requester: healthcare and clinical outcomes (mortality, morbidity, outcomes associated with care delivery, and physiological measures); access to care; and quality of care (including patient or client satisfaction with care).

Study design. SRs including studies of any quantitative study design, irrespective of whether they have or have not conducted meta-analyses and irrespective of whether they have or have not used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to assess the certainty of evidence were included. Qualitative SRs were not considered.

Context. The review considered SRs with a focus on and including studies from LMICs. SRs that included studies conducted in both HICs and LMICs were considered for inclusion, with no pre-specified criteria for the percentage of studies included from LMICs.

Stakeholder engagement. As part of the RES process, the review team and NHSRC jointly convened a policy dialogue to consult with relevant stakeholders on an interim draft of the MLHP policy brief. The final draft of the policy brief incorporated feedback from the consultation. The stakeholders included key stakeholders, including policymakers, health system managers and researchers.

Search strategy

Given time constraints, the search was limited to published and indexed articles, and those published in the English language. The following databases were searched (from database inception up until March 2019): Cochrane Database of Systematic Reviews; Medline (PubMed); EMBASE; Health Systems Evidence; and CINAHL. An additional search was conducted from April 2019 to April 2020 to update the review findings for recency and relevancy. Search strategies (for both the periods) are provided separately for each database (see Extended data)5.

Data collection and analysis

The lead reviewer (SM) independently screened the titles and abstracts of studies for inclusion, following which full-text examination of eligible studies was conducted for potential inclusion. A second reviewer (SB) randomly verified the results of the study selection process during both the screening stages. For each domain of interest, where multiple SRs were available, only one SR was included based on its comprehensiveness, recency, and quality. Each SR was independently assessed for methodological quality by using established standardised criteria (A MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 checklist)6. Data from included reviews was extracted using a pre-defined template, which included variables such as review type, review question, countries/settings, participants characteristics, interventions, outcome measures and review conclusions. The lead author (SM) independently extracted all relevant outcome data, with random verification of 20% of the included studies by another author (SB).

Summary of findings

The GRADE approach was used to assess the certainty of the evidence using a transparent framework for developing and presenting the summary of findings tables710. The GRADE of evidence was synthesised with respect to a PHC setting and in an LMIC context to make the product locally relevant9,10.

Stakeholder engagement

As part of the RES process, the RES team and NHSRC jointly convened a policy dialogue to engage and consult with relevant stakeholders to present an interim draft of the MLHP policy brief. The stakeholders included policy makers (key stakeholders from government agencies and collaborators), health system managers, and researchers from more than eight states in India.

Results

Search results and study selection

The search for evidence identified 5171 studies (Figure 1 – Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram). Following the study screening process, full-text articles were retrieved for 30 potentially relevant studies. In cases where there were multiple SRs for the same domain, the SR that was the most recent and provided comprehensive information (as per authors’ (SM, SB) consensus) was selected and included. Following full-text examination, 23 out of 30 SRs were excluded. An additional 717 records were identified in an updated search. However, following the study selection process, none of the reviews were found to be relevant to the topic of interest (Figure 2 – PRISMA flow diagram (updated search)). Overall, seven SRs were included in the RES.

7a481123-8bdb-48e8-ba41-fd2b75a4c4af_figure1.gif

Figure 1. PRISMA study flow diagram.

Search conducted from database/s inception up until March 2019.

7a481123-8bdb-48e8-ba41-fd2b75a4c4af_figure2.gif

Figure 2. PRISMA study flow diagram (updated search).

Updated search from April 2019 to April 2020.

Characteristics of included SRs

The majority of the studies included in the SRs were randomised controlled trials (RCTs), with some quasi-experimental study designs and observational studies. Key characteristics of the included SRs are provided in the Extended data file5. The studies related to HIV/AIDS were mostly conducted in sub-Saharan African countries11,12. Most studies compared care provided by midwives or auxiliary nurse midwives or nurses with that provided by doctors working in a team along with midwives or nurses.

Methodological quality of included SRs

The AMSTAR-2 checklist6 was used to assess the methodological quality of SRs included in the report. The checklist is a 16-item questionnaire. The critical appraisal results of the included SRs are provided in the Extended data file5. Six out of seven SRs were of moderate to high methodological quality and well reported. Almost all the SRs did not refer to a priori protocol and publication bias was not assessed. One SR by Chaudhary et al. was of poor quality, as assessed by the checklist11.

Summary of findings tables for each domain of interest

Key findings. The key findings from the included SRs have been categorised based on the various healthcare domains of interest in the CPHC package3. The quality of evidence for the main outcomes is summarised using the GRADE approach and ‘Summary of Findings’ tables710. The Summary of Findings tables aid in recording results, outcomes, and outcome risks in a structured synthesis format.

MLHPs for care in pregnancy and childbirth. An SR compared the effectiveness of care provided by MLHPs, particularly midwives and auxiliary nurse midwives with doctors providing care in a team with midwives13. The review included patients receiving pregnancy and childbirth services including antenatal care. The majority of the studies were conducted in tertiary care settings and developed countries. Most of the evidence was assessed as low certainty. It was found that the use of intrapartum analgesia and episiotomies were less likely with care provided by midwives when compared with that provided by doctors working along with midwives. Also, no significant difference in rates for performing caesarean section, postpartum haemorrhage, and preterm births were reported.

No significant difference in the likelihood of an incomplete abortion was reported between groups of patients treated by auxiliary nurse midwives compared to those cared for by doctors. However, the likelihood of a complication during or an adverse event after manual vacuum aspiration was significantly greater with care provided by auxiliary nurse midwives. There was very low certainty evidence to suggest that pregnancy care provided by clinical officers reduced the likelihood of early neonatal death or postoperative maternal health outcomes, such as fever and wound infections. Table 1 provides a summary of findings and certainty of evidence related to pregnancy and childbirth care provided by midwives, auxiliary nurse midwives and clinical officers with that provided by doctors in a team with midwives.

Table 1. Summary of findings for care provided by MLHPs for pregnancy and childbirth.

OutcomesRelative effect
(95% CI)
No of
participants
Certainty
of the
evidence
(GRADE)
Plain language summary
Midwives alone versus doctors along with midwives
Randomised Controlled Trials (RCTs)Rate of
performing
caesarean
sections
RR 0.94

(0.81 to 1.06)
12144
(8 RCTs)
⨁⨁◯◯
Low1
Pregnancy care provided by
midwives may slightly reduce the
rate of performing caesarean
sections (low certainty evidence)
Postpartum
haemorrhage
RR 0.53

(0.25 to 1.14)
8604 (6 RCTs)⨁⨁◯◯
Low1,2
Pregnancy care provided by
midwives may reduce postpartum
haemorrhage (low certainty
evidence)
Preterm birthsRR 0.87

(0.73 to 1.04)
9210 (5 RCTs)⨁⨁◯◯
Low1
Pregnancy care provided by
midwives may slightly reduce
preterm births (low certainty
evidence)
Use of
intrapartum
regional
analgesia
RR 0.87

(0.81 to 0.93)
9415 (8 RCTs)⨁⨁◯◯
Low1
Pregnancy care provided by
midwives may slightly reduce
the use of intrapartum regional
analgesia (low certainty evidence)
EpisiotomiesRR 0.85

(0.78 to 0.92)
13205 (8 RCTs)⨁⨁◯◯
Low1
Pregnancy care provided by
midwives alone may slightly
reduce in episiotomies (low
certainty evidence)
Quality of care
(QoC)
RR 1.23

(1.10 to 1.37)
826 (1 RCT)⨁⨁◯◯
Low1,3
Pregnancy care provided by
midwives may slightly improve
quality of care (low certainty
evidence)
Mortality and
Access to care
---No studies were found that
examined these outcomes
Auxiliary nurse midwives versus doctors
RCTsIncomplete
abortion
RR 0.93

(0.45 to 1.90)
1032 (1 RCT)⨁⨁◯◯
Low1,3
Pregnancy care provided by
auxiliary nurse midwives may
make little or no difference in
the likelihood of an incomplete
abortion (low certainty evidence)
Complications
during conduct
of manual
vacuum
aspiration
RR 3.07

(0.16 to 59.1)
2789 (1 RCT)⨁⨁◯◯
Low1,3
Pregnancy care provided by
auxiliary nurse midwives may
make little or no difference in
complications during manual
vacuum aspiration. However,
the wide 95% confidence
interval includes the possibility
of both increased and reduced
complications (low certainty
evidence)
Post-operative
adverse event
RR 1.36

(0.54 to 3.40)
2761 (1 RCT)⨁⨁◯◯
Low1,3
Pregnancy care provided by
auxiliary nurse midwives may
increase post-operative adverse
events; however, the 95%
confidence interval includes the
possibility of both increased and
reduced postoperative adverse
events (low certainty evidence)
Clinical officers versus doctors
Observational studiesLikelihood of
early neonatal
death
RR 1.40

(0.51 to 3.87)
(1
observational
study)
⨁◯◯◯
Very low4
It is uncertain whether pregnancy
care provided by clinical officers
reduces the likelihood of early
neonatal death as the certainty of
the evidence has been assessed
to be very low
Postoperative
maternal health
outcomes, such
as fever, wound
infection, the
need for
re-operation
and maternal
death, after
emergency
obstetric
procedures
RR 0.99

(0.95 to 1.03)
(1
observational
study)
⨁◯◯◯
Very low4
It is uncertain whether pregnancy
care provided by clinical
officers reduces the effect on
postoperative maternal health
outcomes as the certainty of the
evidence was assessed to be
very low

1Downgraded one level due to serious risk of bias and another two levels due to indirectness (almost all the studies were conducted in tertiary care centres and high-income countries).

2Downgraded one level due to serious inconsistency (considerable heterogeneity was found).

3Downgraded one level due to imprecision (single study with a small sample size yielding wide confidence intervals spanning line of no effect).

4Quality of evidence was downgraded from Low (observational study design) to Very low due to a very serious risk of bias.

CI, confidence interval; GRADE, Grading of Recommendations, Assessment, Development and Evaluations; RR, risk ratio; RCT, randomised controlled trial; QoC, quality of care; MLHPs, mid-level health providers.

MLHPs for neonatal and infant health care services. The effectiveness of midwives/nurses delivering care for neonatal and infant healthcare services was compared with that provided by doctors or obstetricians in a team with midwives in a SR13. The population included patients receiving neonatal and infant health services. The majority of the studies were conducted in tertiary care settings and developed countries. The certainty of the evidence was assessed as low quality. The review results showed that there was no significant difference between the groups in foetal or neonatal death rates. None of the studies included in the review reported on clinical outcomes, and outcomes related to quality of care and access to care. Table 2 presents the review findings in plain language format and the certainty of the evidence for the relevant outcome.

Table 2. Summary of findings for care provided by MLHPs for neonatal and infant health care services.

OutcomesRelative
effect (95%
CI)
No of
participants
Certainty
of the
evidence
(GRADE)
Plain language
summary
Midwives versus obstetrician or doctor in team with midwives
RCTsFoetal or
neonatal death
RR 0.94

(0.56 to 1.58)
11562 (6 RCTs)⨁⨁◯◯ Low1Care provided by
midwives alone
may result in little
to no difference in
foetal or neonatal
deaths (low certainty
evidence)
Clinical
outcomes;
quality of care &
access to care
---No studies were
found that examined
these outcomes

1Downgraded one level due to serious risk of bias and two levels due to indirectness (almost all the studies were conducted in tertiary care centres).

CI, confidence interval; GRADE, Grading of Recommendations, Assessment, Development and Evaluations; RR, risk ratio; RCT, randomised controlled trial; MLHPs, mid-level health providers.

MLHPs for family planning, contraceptive and other reproductive health care services. Another SR by Barnard et al. evaluated the safety and effectiveness of surgical and medical abortion procedures administered by MLHPs compared to doctors14. The review included various MLHPs who included nurses, midwives, doctor assistants, and physician assistants delivering care for patients requesting abortion procedures, either surgical or medical. The majority of the studies were conducted in PHC settings and LMICs. Much of the evidence was of low or very low quality. The review found that the evidence for surgical abortion procedures provided by MLHPs was lacking. Further, evidence from cohort studies suggested that there was an increase in the risk of failure or incomplete abortion for surgical abortion procedures when provided by MLHPs. However, no statistically significant differences in complications alone, immediate complications or delayed complications were reported when surgical abortion was provided by MLHPs. Concerning medical abortion procedures, the review results suggested MLHPs could safely and effectively carry out these procedures. No significant differences were reported for abortion failure or incomplete abortion. None of the studies included in the SR examined other outcomes of interest such as mortality, quality of care, and access to care. Table 3 presents a summary of findings on various outcomes related to surgical and medical abortion procedures provided by MLHPs compared to doctors.

Table 3. Summary of findings for care provided by MLHPs for family planning, contraceptive and other reproductive health care services.

OutcomesRelative
effect (95%
CI)
No of
participants
Certainty
of the
evidence
(GRADE)
Plain language summary
Nurses, midwives, doctor assistants, and physician assistants versus doctors
Surgical abortion procedures
RCTsFailure/incomplete
abortion
RR 2.97

(0.21 to 41.82)
2789 (2 RCTs)⨁⨁◯◯
Low1
Care provided by MLHPs may increase the
chance of the abortion being ineffective
or incomplete (more than twice the risk of
failure or incomplete abortion for surgical
abortion procedures provided by MLHPs
when compared to the procedures
provided by doctors) (low certainty
evidence)
ComplicationsRR 0.99

(0.17 to 5.7)
2789 (2 RCTs)⨁⨁◯◯
Low1
Care provided by MLHPs may make little
or no difference in complications (low
certainty evidence)
Total
complications*
RR 3.07

(0.16 to 59.08)
2789 (2 RCTs)⨁⨁◯◯
Low1
Care provided by MLHPs may increase
total complications. However, the wide 95%
confidence interval includes the possibility
of both increased and reduced risk of total
complications (low certainty evidence)
Observational studiesFailure/incomplete
abortion
RR 2.2

(1.34 to 3.6)
13,715 (3
observational
studies)
⨁◯◯◯
Very low1,2
It is uncertain as to whether care provided
by MLHPs reduces the risk of
failure of incomplete abortion as the certainty of the
evidence has been assessed as very low
ComplicationsRR 1.38

(0.7 to 2.72)
13,715 (3
observational
studies)
⨁◯◯◯
Very low13
It is very uncertain whether care provided
by MLHPs reduces complications as
the certainty of the evidence has been
assessed as very low
Total complications*RR 1.36

(0.86 to 2.14)
16,173 (4
observational
studies)
⨁◯◯◯
Very low13
It is very uncertain about the effect of
care provided by MLHPs on the risk of
total complications.
Mortality; quality
of care; and access
to care
---No studies were found that examined
these outcomes
Medical abortion procedures
RCTsFailure/ incomplete
abortion
RR 0.81

(0.48 to 1.36)
1892 (2RCTs)⨁⨁⨁◯
Moderate
Care provided by MLHPs may slightly
reduce the risk of failure/ incomplete
medical abortion when compared with that
provided by doctors (moderate certainty
evidence)
Observational studiesFailure/incomplete
abortion
RR 1.09

(0.63 to 1.88)
1164 (1
study)
⨁◯◯◯
Very low13
It is very uncertain about the effect of care
provided by MLHPs on failure/incomplete
abortion as the quality/certainty of the
evidence has been assessed as very low
Mortality; quality
of care; and access
to care
---No studies were found that examined
these outcomes

*Total complications - incomplete or failed abortion and complications

1Downgraded one level due to imprecision and additional one level due to indirectness as studies included were not from the primary healthcare context.

2Downgraded two levels due to risk of bias and one level for imprecision (wide confidence intervals)

3Downgraded one level due to serious risk of bias

CI, confidence interval; GRADE, Grading of Recommendations, Assessment, Development and Evaluations; RR, risk ratio; RCT, randomised controlled trial; MLHPs, mid-level health providers.

MLHPs for communicable diseases. Two SRs examined the effectiveness of the delivery of antiretroviral therapy (ART) provided by MLHPs in HIV-infected patients11,12. The reviews included studies mainly conducted in primary healthcare settings and LMICs. The studies included in the reviews compared ART provided by nurses or clinical officers with doctors. The certainty of the evidence varied for different outcomes, from high to very low quality. However, the evidence for various outcomes was based on relatively few studies. The review reported that there was no significant difference in mortality, with lower rates of losses to follow up at 12 months. Further, no difference in death or number of patients lost to follow up at 12 months was reported when doctors initiated therapy and nurses provided follow-up. The reviews suggested that shifting tasks from doctors to MLHPs may help in potentially reducing costs of ART provision, without compromising on the quality of care and patient outcomes. Table 4 provides a summary of findings reported in the SRs for outcomes related to the initiation and maintenance of ART in HIV-infected patients.

Table 4. Summary of findings for care provided by MLHPs for HIV/AIDS and ART.

OutcomesRelative
effect (95%
CI)
No of
participants
Certainty of the
evidence
(GRADE)
Plain language summary
Nurses or clinical officers versus doctors
RCTsInitiation and
maintenance
of ART
mortality
follow-up: 12
months
RR 0.96

(0.82 to 1.12)
2770

(1 RCT)
⨁⨁⨁⨁
High
Initiation and maintenance of ART by a nurse or
a clinical officer slightly reduces mortality (high
certainty evidence)
Maintenance
of ART death
follow-up: 12
months
RR 0.89

(0.59 to 1.32)
4332

(2 RCTs)
⨁⨁⨁◯
Moderate1
Maintenance of ART by a nurse or a clinical
officer makes little or no difference in mortality
when ART had previously been initiated by a
doctor (moderate quality/certainty evidence)
Observational studiesInitiation and
maintenance
of ART death
follow-up: 12
months
RR 1.23

(1.14 to 1.33)
39160
(2 observational
studies)
⨁⨁◯◯
Low2
Evidence suggests that there may be an
increased risk of death when ART is initiated
and maintained by a nurse or a clinical officer
when compared to a doctor’s care (low certainty
evidence)
Maintenance
of ART death
follow-up: 12
months
RR 0.19

(0.05 to 0.78)
2772

(1 study)
⨁◯◯◯
Very low3
It is uncertain whether nurse-led care reduced
mortality as the quality/certainty of the evidence
has been assessed as very low
Quality of
care and
access to
care
---No studies were found that examined these
outcomes

1 Downgraded by one level for imprecision due to a wide confidence interval

2 Rated low because of observational study designs. Not downgraded for risk of bias

3 Downgraded by one level for imprecision due to low event numbers

CI, confidence interval; GRADE, Grading of Recommendations, Assessment, Development and Evaluations; RR, risk ratio; RCT, randomised controlled trial; MLHPs, mid-level health providers; HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency syndrome; ART, antiretroviral therapy.

MLHPs for non-communicable diseases. Two reviews compared the effectiveness of care provided by non-physician health workers (NPHWs) for patients with non-communicable diseases in primary and secondary healthcare settings15,16. The NPHWs included nurses, pharmacists, allied health professionals, and physician assistants. The care provided by NPHWs was compared to that provided by doctors for various physiological measure outcomes, health-related quality of life, and access to care. The evidence assessed was of moderate to high quality. The findings from the two reviews suggested that care provided by NPHWs with varying but high degrees of autonomy and with support was comparable to that provided by doctors for various relevant outcomes. Care prescription by NPHWs significantly improved outcomes such as systolic blood pressure, glycated haemoglobin and low-density lipoprotein levels. Also, the care provided by NPHWs improved health-related quality of life (physical component). However, the mental health-related quality of life was reduced with the care provided by NPHWs compared to that provided by doctors. There was a lack of conclusive evidence on outcomes related to access to care. Table 5 presents a summary of findings for various relevant outcomes related to chronic diseases.

Table 5. Summary of findings for care provided by NPHWs for non-communicable disease management.

OutcomesMean
difference
(MD)
(95% CI)
No of
participants
Certainty
of the
evidence
(GRADE)
Plain language summary
Non-medical (non-physician health workers (NPHWs)) prescribing compared to medical (doctors) prescribing for chronic disease
management in primary care
RCTs
Systolic blood
pressure

(mmHg) at 12 months
MD -5.31
mmHg

lower (-6.46 to
-4.16 lower)
4229

(12 RCTs)
⨁⨁⨁⨁
High
Chronic disease management by non-medical
prescribers probably reduces systolic blood pressure
(high certainty evidence)
Glycated
haemoglobin

(HbA1c, %) at 12
months
MD -0.62

(-0.85 to
-0.38)
775

(6 RCTs)
⨁⨁⨁⨁
High
Chronic disease management by non-medical
prescribers reduces the glycated haemoglobin levels
(high certainty evidence)
Low-density
lipoprotein

(mmol/L) at 12
months
MD -0.21

(-0.29 to
-0.14)
1469

(7 RCTs)
⨁⨁⨁◯
Moderate1
Chronic disease management by non-medical
prescribers probably reduces low-density lipoprotein
levels (moderate certainty evidence)
Health-related quality
of life measured with
SF-12/36 – Physical
component
MD 1.17

(0.16 to 2.17)
2385

(8 RCTs)
⨁⨁⨁◯
Moderate2
Chronic disease management by non-medical
prescribers probably improves the health-related quality of
life (moderate certainty evidence)
Health-related quality
of life measured with
SF-12/36 – Mental
component
MD 0.58

(-0.40 to 1.55)
2246

(6 RCTs)
⨁⨁⨁◯
Moderate1,2
Chronic disease management by non-medical
prescribers probably reduces health-related quality of
life (mental component) (moderate certainty evidence)
Mortality ---No studies were found that examined this outcome
Access to care---Several studies reported improved access to healthcare
at the community level, although the metric to evaluate
access was often not described. Data was not reported,
and the evidence was not assessed according to GRADE
criteria.

1Downgraded one level due to serious inconsistency (considerable heterogeneity was found)

2Downgraded one level due to indirectness (prescribing component effect on quality of life difficult to determine)

CI, confidence interval; GRADE, Grading of Recommendations, Assessment, Development and Evaluations; MD, mean difference; RCT, randomised controlled trial; NPHW, non-physician health worker.

MLHPs for mental health. One SR compared the effectiveness of delivery of care provided by non-specialist health workers (NSHWs) to that provided by mental health specialists in women with perinatal depression17. The NSHWs included midwives, nurses, and community health workers. The studies included in the review were conducted in primary health settings and LMICs. The review found that the NSHWs could effectively deliver psychological interventions for perinatal depression in low-resource settings, particularly where specialist services are both scarce and expensive. The review did not examine other relevant outcomes such as mortality, quality of care, and access to care. The review lacked proper reporting and hence it was not possible to assess the certainty of evidence by GRADE. The SR included nine RCTs involving a total of 14,555 participants. Table 6 briefly presents a narrative summary of the findings reported in the review.

Table 6. Summary of findings for care provided by NSHWs for women with perinatal depression.

OutcomesImpactPlain language summary
Non-specialist health workers (NSHWs) (midwives, nurses and community health workers) versus mental health specialists
Perinatal depression assessed using
Edinburgh Postnatal Depression Scale
(EPDS), the Center for Epidemiological
Studies Depression Scale (CES-D), Beck
Depression Inventory (BDI), the General
Health Questionnaire (GHQ), Hamilton
Depression Rating Scale (HDRS) Follow
up: range 6 weeks to 3 years
All nine studies reported statistically
significant improvements in perinatal
depression in the intervention groups
compared with control groups. The
estimates were presented differently
for different measurement scales and
at different followup periods.
Only narrative synthesis was conducted
for the systematic review and no pooled
estimate was available. The results
suggested that NSHWs can feasibly
provide mental health services leading
to improvement in perinatal depression
scores, particularly in low-resource settings
where specialist services are both scarce
and expensive. Certainty of evidence by
GRADE was not assessed for it due to the
paucity of information in the published SR.
Mortality; quality of care and access to
care
-No studies were found that examined these
outcomes

NSHW, non-specialist health worker; EPDS, Edinburgh Postnatal Depression Scale; CES-D, Center for Epidemiological Studies Depression Scale; BDI, Beck Depression Inventory; GHQ, General Health Questionnaire; HDRS, Hamilton Depression Rating Scale; GRADE, Grading of Recommendations, Assessment, Development and Evaluations; SR, systematic review.

MLHPs for other packages of care. This RES did not identify any SRs that assessed the role of MLHPs in the provision of following health services.

  • MLHPs for childhood and adolescent health services

  • MLHPs for ophthalmic and ENT conditions

  • MLHPs for elderly and palliative healthcare

  • MLHPs for emergency medical services

Discussion

In this rapid overview of SRs, we examined the evidence on the effectiveness of care provided by MLHPs in LMICs for various healthcare domains of India’s CPHC package3. We contextualised the certainty using the GRADE approach7. We found that there is some evidence that MLHP-led care may be appropriate in patients for management of various outcomes in different healthcare domains of interest such as maternal and child health, neonatal and infant health, and communicable and non-communicable disease management when compared to a physician or doctor-led care. Still, the certainty of the evidence for this was mostly low or moderate (barring a few exceptions). As such, while MLHPs can be considered as an alternative to medical professionals for some domains, the certainty of evidence implies the need for building an evidence base and careful evaluation of programs.

Low-quality evidence suggests that MLHPs might be suitable to deliver quality pregnancy care. In their review18, indicated that shifting tasks or sharing them with MLHPs could lead to increased service provision and improved patient outcomes in the provision of emergency obstetric care and family planning services. Studies from India and Nepal suggest that MLHPs found task-shifting of medical abortion provision to mid-level providers to be acceptable, and women were happy with the service provided19,20. Moderate and high-quality evidence from trials suggests that MLHPs are helpful for chronic disease management and initiation and maintenance of ART in people with HIV/AIDS. As reported in a review that focussed on sub-Saharan Africa, task-shifting from physicians to nurses and midwives is a viable and cost-effective option for the management of HIV-AIDS21.

Other studies that investigated the effects of MLHPs support our review findings1,22. However, similar to our review, previous reviews were limited by the quality of included studies. 23 examined the evidence for the effectiveness of MLHPs in poor resource settings and found them to be an effective option in improving the delivery of health services.

We did not find any synthesised evidence in the form of SRs for childhood and adolescent health services, ophthalmic and ENT conditions, elderly and palliative health care, or emergency medical services. There is a need for conducting well-designed primary studies on these domains to inform future plans for rolling out of MLHPs to improve the delivery of health services in LMICs. The shortage and unbalanced distribution of the health workforce is a significant obstacle in achieving better health outcomes for maternal and child health, neonatal and infant health, and communicable and non-communicable disease management in LMICs24.

Judging relevance to low-income countries is sometimes tricky, and we are aware that evidence from high-income countries is not directly generalisable to low-income countries. We based our judgments on assessing the likelihood that MLHP-lead care considered in the review address a problem that would be feasible and would be of interest to decision-makers in LMICs, regardless of where the included studies took place. While we looked at global evidence, the use of GRADE enabled us to contextualise evidence to India. A detailed examination of contextual factors specific to the Indian context would have provided extensive contextualised evidence; however, exploration of specific contextual factors was not the focus of this overview. We utilised a robust, transparent and comprehensive search strategy to identify all relevant SRs. We used a standardised checklist for methodological quality assessment of included SRs. Having a wide scope covering multiple CPHC domains enabled the identification of knowledge gaps that could inform relevant stakeholders at the national and state levels.

As part of the RES process, we presented the interim policy brief to engage with key stakeholders to ensure that the product was robust, relevant, and valuable to the target audience. The stakeholders deliberated on the policy brief and provided feedback on the usefulness, relevance, format, and GRADE use. Following deliberations with the stakeholders, we made several changes to the policy brief regarding the use of standardised definitions, the use of more plain language statements, and contextualising evidence to the Indian setting. The inclusion of SRs provided more high-level insight into synthesised evidence around MLHPs. We did not update the reviews, and as such, we acknowledge the limitation of evidence from recently published primary studies.

We found several gaps in current research on MLHPs. Evidence from SRs of randomised controlled trials is important. Still, this approach may not be the most appropriate, as they are unlikely to yield data to inform such a complex intervention. Primary research on outcomes related to access to care and quality of care is required. Future studies may consider addressing the implementation aspects as part of the existing healthcare system and the cost-effectiveness in LMICs. There is a lack of empirical studies in primary healthcare settings in LMICs.

There is limited evidence on strategies and facilitators for implementing universal healthcare policies and the provision of equitable healthcare through MLHPs in India. A study in Chhattisgarh that assessed the clinical competence of non-physician clinicians and physicians in the delivery of primary healthcare services found comparable levels of competency25. Another study conducted in Chhattisgarh reported that physicians and nonphysician clinicians performed similarly in patient satisfaction, trust, and perceived quality26. In Assam, a three-year rural health practitioner course was developed and implemented to select, train and deploy Rural Health Practitioners (RMPs, a type of MLHP) in sub-centres, which showed significant improvements in the number and the range of services delivered27.

Conclusion

In conclusion, and based on our findings, utilisation of MLHPs for care provision for certain healthcare domains may be applicable, relevant, and feasible in LMICs, including in India. MLHPs such as nurse practitioners, physician assistants, and community health officers will be required for primary care to fill the gaps in access and quality in health services. However, the roles and subsequent training and regulation of MLHPs might be different for several CPHC packages. There is a need for embedded research and robust evaluations in the future.

Data availability

Underlying data

All data underlying the results are available as part of the article and no additional source data are required.

Extended data

Figshare: Extended data.docx. https://doi.org/10.6084/m9.figshare.12401525.v25

This project contains the following extended data:

  • - Appendix 1: Search strategies (since database inception up until March 2019)

  • - Appendix 2: Updated search strategies (April 2019 to April 2020)

  • - Appendix 3: Key characteristics of the included SRs

  • - Appendix 4: Critical appraisal results of included systematic reviews assessed using the AMSTAR-2 checklist

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

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Moola S, Bhaumik S and Nambiar D. Mid-level health providers for primary healthcare: a rapid evidence synthesis [version 2; peer review: 2 approved]. F1000Research 2021, 9:616 (https://doi.org/10.12688/f1000research.24279.2)
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Version 2
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Reviewer Report 25 Jun 2021
Guido Bendezu-Quispe, Universidad Privada Norbert Wiener, Lima, Peru 
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The revisions ... Continue reading
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Bendezu-Quispe G. Reviewer Report For: Mid-level health providers for primary healthcare: a rapid evidence synthesis [version 2; peer review: 2 approved]. F1000Research 2021, 9:616 (https://doi.org/10.5256/f1000research.56486.r84982)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 31 Mar 2021
Guido Bendezu-Quispe, Universidad Privada Norbert Wiener, Lima, Peru 
Approved with Reservations
VIEWS 21
Abstract (Introduction: Provide only necessary information to inform the context of the study. 
Methods: There is insufficient information about the study methods (quality of the included studies, stakeholder engagement, others). Results: no results are presented on the evaluation of the ... Continue reading
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CITE
HOW TO CITE THIS REPORT
Bendezu-Quispe G. Reviewer Report For: Mid-level health providers for primary healthcare: a rapid evidence synthesis [version 2; peer review: 2 approved]. F1000Research 2021, 9:616 (https://doi.org/10.5256/f1000research.26786.r81670)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 10 May 2021
    Sandeep Moola, George Institute for Global Health, Vishakhapatnam, India
    10 May 2021
    Author Response
    Dear Guido, 

    Thank you for taking out time to review the paper and for your valuable comments. We will revise and upload a new version of the article based ... Continue reading
  • Author Response 10 May 2021
    Sandeep Moola, George Institute for Global Health, Vishakhapatnam, India
    10 May 2021
    Author Response
    Abstract (Introduction: Provide only necessary information to inform the context of the study.
    Methods: There is insufficient information about the study methods (quality of the included studies, stakeholder engagement, others). ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 10 May 2021
    Sandeep Moola, George Institute for Global Health, Vishakhapatnam, India
    10 May 2021
    Author Response
    Dear Guido, 

    Thank you for taking out time to review the paper and for your valuable comments. We will revise and upload a new version of the article based ... Continue reading
  • Author Response 10 May 2021
    Sandeep Moola, George Institute for Global Health, Vishakhapatnam, India
    10 May 2021
    Author Response
    Abstract (Introduction: Provide only necessary information to inform the context of the study.
    Methods: There is insufficient information about the study methods (quality of the included studies, stakeholder engagement, others). ... Continue reading
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26
Cite
Reviewer Report 18 Jan 2021
Shradha S. Parsekar, Public Health Evidence South Asia, Public Health Evidence South Asia, Manipal, Karnataka, India 
Approved
VIEWS 26
Thank you for providing me opportunity to review this piece of work. 
Considering the lack of qualified doctors in some of the resource limited settings like India, mid-levels health providers can be an alternative. I must appreciate authors for ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
S. Parsekar S. Reviewer Report For: Mid-level health providers for primary healthcare: a rapid evidence synthesis [version 2; peer review: 2 approved]. F1000Research 2021, 9:616 (https://doi.org/10.5256/f1000research.26786.r76144)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 10 May 2021
    Sandeep Moola, George Institute for Global Health, Vishakhapatnam, India
    10 May 2021
    Author Response
    Dear Reviewer, 
    Thank you for taking out time to review the paper and for your valuable comments. Sincere apologies for the delay in replying. Will revise and upload a new ... Continue reading
  • Author Response 10 May 2021
    Sandeep Moola, George Institute for Global Health, Vishakhapatnam, India
    10 May 2021
    Author Response
    The focus of the rapid overview of systematic review was on LMICs, however some of the SRs included studies conducted in high income countries (e.g., Barnard et al., 20151 included ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 10 May 2021
    Sandeep Moola, George Institute for Global Health, Vishakhapatnam, India
    10 May 2021
    Author Response
    Dear Reviewer, 
    Thank you for taking out time to review the paper and for your valuable comments. Sincere apologies for the delay in replying. Will revise and upload a new ... Continue reading
  • Author Response 10 May 2021
    Sandeep Moola, George Institute for Global Health, Vishakhapatnam, India
    10 May 2021
    Author Response
    The focus of the rapid overview of systematic review was on LMICs, however some of the SRs included studies conducted in high income countries (e.g., Barnard et al., 20151 included ... Continue reading

Comments on this article Comments (0)

Version 2
VERSION 2 PUBLISHED 16 Jun 2020
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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