112 The World Health Report 2003 ensure a workforce more closely attuned to country needs. Training of students from devel- oping countries at high-prestige institutions in developed countries is useful only when th is no local or regional alternative. Although there are about twice as many nursing schools as medical schools worldwide, in the African Region there are 38 nursing schools and 64 medi- cal schools. This suggests that too many expensive health workers are produced in places that ight have a greater need for new types of providers with an education more focused on primary health care. The public health workforce also needs strengthening, based on a new approach to in-country or regional training that emphasizes the management of health prob- lems at the district level (18) The workforce of doctors is often complemented by training nurse practitioners,assistant nedical officers"and mid-level professionals. These categories are health professionals who can assume many of the responsibilities previously reserved for those with a full medical degree(see Box 7.4). For example, many studies in developed countries show that nurse prac- titioners can reduce the costs of care without harming, and sometimes actually improving, health outcomes(21, 22). In the Pacific Islands, mid-level practitioners, with various titl such as medex, health assistant, or health officer, play an important role in meeting curative and preventive needs, especially in remote or rural areas(23). In other countries, community health workers are trained in very specific and high-priority activities, making it possible to serve populations that are out of the reach of formal health care services. In the past, primary health care strategies based on community health workers or other alter- native health care providers have been difficult to sustain(24). However, evidence suggests that such strategies can be effective, given appropriate training(25, 26). To be successful, the creation of new types of health worker requires that they be valued for their distinctive con tribution, rather than treated as second-class providers. This means offering them career development prospects, rotation to and from rural and underserved areas, good working conditions, the chance to work as a team with other professionals, and an adequate salary. New cadres can be seen not only as a pragmatic response to current shortages, but as a cohort term to their incorporation in the more highly qualified professional categores. Evidences whose skills can be continually upgraded through in-service training, leading in the longe growing that community members can carry out a wide range of health care tasks, including treatment of more complex conditions(10, 25-28) Migration of health workers Policy-makers in all countries are concerned about"brain drain"of the health workforce within and between countries, although relevant research is still in its infancy (29). The move ment of health professionals closely follows the migration pattern of all professionals. while ox 7.4 Training assistant medical officers: the tecnicos of Mozambique In 1984, a three-year programme was initiated to create assistant medi- rty-six assistant medical officers were trained between 1984 and edures in remote areas where consultants were not available(19). The ing For example, a comparison of 1000 r on quality of care is promis. programme trains middle-level health workers in skills required for three conducted by tecnicos de cirurgia with the same number conducted by broad priority areas: pregnancy-related complications, trauma-related obstetricians or gynaecologists indicated that there were no differences complications and emergency inflammatory conditions. Two years of lec. in the outcomes of this type of delivery or in the associated surgical tures and practical sessions in the Maputo Central hospital are followed interventions (20). Many countries have now started or are considering by a one-year internship at a provincial hospital, under the direct super- similar programmes, based on their claimed cost-effectiveness. The vision of a surgeon. potential impact of this type of health worker on both quality and efficiency of health care must continue to be evaluated112 The World Health Report 2003 ensure a workforce more closely attuned to country needs. Training of students from devel￾oping countries at high-prestige institutions in developed countries is useful only when there is no local or regional alternative. Although there are about twice as many nursing schools as medical schools worldwide, in the African Region there are 38 nursing schools and 64 medi￾cal schools. This suggests that too many expensive health workers are produced in places that might have a greater need for new types of providers with an education more focused on primary health care. The public health workforce also needs strengthening, based on a new approach to in-country or regional training that emphasizes the management of health prob￾lems at the district level (18). The workforce of doctors is often complemented by training nurse practitioners, “assistant medical officers” and mid-level professionals. These categories are health professionals who can assume many of the responsibilities previously reserved for those with a full medical degree (see Box 7.4). For example, many studies in developed countries show that nurse prac￾titioners can reduce the costs of care without harming, and sometimes actually improving, health outcomes (21, 22). In the Pacific Islands, mid-level practitioners, with various titles such as medex, health assistant, or health officer, play an important role in meeting curative and preventive needs, especially in remote or rural areas (23). In other countries, community health workers are trained in very specific and high-priority activities, making it possible to serve populations that are out of the reach of formal health care services. In the past, primary health care strategies based on community health workers or other alter￾native health care providers have been difficult to sustain (24). However, evidence suggests that such strategies can be effective, given appropriate training (25, 26). To be successful, the creation of new types of health worker requires that they be valued for their distinctive con￾tribution, rather than treated as second-class providers. This means offering them career development prospects, rotation to and from rural and underserved areas, good working conditions, the chance to work as a team with other professionals, and an adequate salary. New cadres can be seen not only as a pragmatic response to current shortages, but as a cohort whose skills can be continually upgraded through in-service training, leading in the longer term to their incorporation in the more highly qualified professional categories. Evidence is growing that community members can carry out a wide range of health care tasks, including treatment of more complex conditions (10, 25–28). Migration of health workers Policy-makers in all countries are concerned about “brain drain” of the health workforce within and between countries, although relevant research is still in its infancy (29). The move￾ment of health professionals closely follows the migration pattern of all professionals. While Box 7.4 Training assistant medical officers: the técnicos of Mozambique In 1984, a three-year programme was initiated to create assistant medi￾cal officers (técnicos de cirurgia) to perform fairly advanced surgical pro￾cedures in remote areas where consultants were not available (19). The programme trains middle-level health workers in skills required for three broad priority areas: pregnancy-related complications, trauma-related complications and emergency inflammatory conditions. Two years of lec￾tures and practical sessions in the Maputo Central hospital are followed by a one-year internship at a provincial hospital, under the direct super￾vision of a surgeon. Forty-six assistant medical officers were trained between 1984 and 1999, and the evaluation of their influence on quality of care is promis￾ing. For example, a comparison of 1000 consecutive caesarean sections conducted by técnicos de cirurgia with the same number conducted by obstetricians or gynaecologists indicated that there were no differences in the outcomes of this type of delivery or in the associated surgical interventions (20). Many countries have now started or are considering similar programmes, based on their claimed cost-effectiveness. The potential impact of this type of health worker on both quality and efficiency of health care must continue to be evaluated