Table 2.

Lessons from South Africa's experience of clinical associates for introducing a new mid-level worker

	Positive lessons	Cautions
Taking account of contextual issues	Support advocacy for a new mid-level worker programme by drawing on previous policy documentation, where this exists, and taking advantage of political moments that are favourable to change.	Sometimes policy documents pay lip-service to mid-level workers, which mean that continued advocacy is required to popularise the concept. Highlight the relevance of the concept to new policies as they emerge.
	Seize the opportunity provided by an influential policy champion to drive through the implementation of the programme.	As policy champions may move on with time, make sure to build broad-based support for the concept over time.
Managing actor concerns	Consult widely at the early stages of policy formulation and allay fears through advocacy and adjusting the design of the new mid-level worker programme to take account of stakeholders’ views and interests without sacrificing important policy objectives.	As implementation proceeds, consensus will erode as unexpected problems emerge. Address this through continued consultation and feedback, modifying the policy or implementation approach if appropriate.
	Build strong channels of communication with key implementation agencies. In particular, ensure that Treasury and the ministry of public service administration are brought on board and participate at critical moments in the planning process. Involve local health authorities closely with the process of student selection and development of training sites.	Other government ministries have their own timelines and information requirements. Ensure these are met in order to ensure a smooth flow of activities, such as the release of funding and creation of new post structures, levels and staff complements.
	Where resistance to the new cadre is encountered (for example, on the part of health authorities, training institutions and other health professionals), allow phased introduction of the programme to build support on the basis of demonstrable benefits.	Strong national leadership is required to withstand pressure from other health professionals where this is based on narrow self-interest. Complementary measures to bolster the status of the new cadre may be required.
Building a strong process of policy formulation and implementation	Take time to study the international experience, including visiting best practice sites, and incorporate these lessons into local policy.	Re-visit these lessons over time, especially when preparing for the entry of new graduates into public service, as this is a high-risk moment in the development of a mid-level worker programme.
	Understand health system needs properly, conducting exploratory studies and consulting widely.	Monitor the programme closely in both the initial years of production and deployment, including through consultation, in order to check progress against objectives and detect unexpected problems.
	Create a committed team of experts and other key stakeholders who will drive policy formulation, consultation and implementation, as well as ensure continuity.	Sustain this ‘task team’ into the early phases of deployment of new graduates so that unintended problems can be addressed before they spark resistance. Thereafter, sustained effort is required to ensure that the scaling up of training – and the hiring of new graduates into the public sector – proceeds as planned in order to make a substantial difference to the functioning of the district health system.
	Include implementers’ concerns from the early stages of policy formulation.	The intense energy required to implement a new policy often dissipates once there have been early achievements. Maintain close links with implementers throughout the policy development and implementation process in order to anticipate problems that may derail these early successes.
	Develop a short-term and long-term funding strategy that will secure the start-up of training, allow scaling up of the programme and ensure posts are available for new graduates.	Promised funding does not always materialise or is released out of synchrony with training and service needs. This requires contingency planning and negotiation of interim measures.
	Develop an active strategy for incorporating new graduates into the public health system.	This is one of the most challenging components of implementation and, if not handled properly, can lead to the collapse of a programme. While the creation of new posts is very important, do not neglect ‘softer issues’ such as developing appropriate management systems and teamwork. In particular, strong supervision and support systems are required to realise the potential of the new cadre, which in turn is essential for establishing the cadre as a permanent feature of the health system. Active recruitment and retention strategies, including career pathing, are required to prevent brain drain to the private sector.
Designing an appropriate policy	Take care to describe and delineate the scope of practice well, paying particular attention to meeting well-defined health care gaps and differentiating the new cadre from other health professionals with whom they will work closely.	Assess how the scope of practice plays out in practice and adjust it where appropriate. Efforts to strengthen the health system may need to occur in tandem as it is difficult to realise ideal scopes of practice under sub-optimal conditions.
	Link the curriculum closely to the scope of practice and health system needs. Create a professional that is flexible and adaptable so that he or she may work effectively in typically under-resourced settings.	Implement efforts to standardise training, such as a national curriculum framework, national exams and independent evaluations of courses. Allow some local flexibility in training. In order to prevent brain drain overseas, tailor training specifically to local conditions.
	Conceptualise the new cadre as part of a team whilst also clarifying lines of reporting.	Implement on-going efforts to build teamwork, such as better management and communication processes.
	Recruit students from rural and disadvantaged areas. This is an important strategy for retention.	Develop mechanisms to support these students e.g. bursaries, mentorship to support adjustment to the experience of tertiary training.
	Employ service-based and small-group learning. This requires the appointment and nurturing of locally based training coordinators, including through joint appointments between universities and health authorities.	This is a resource-intensive option but can be used to strengthen district health systems at the same time as producing the new cadre. For example, the creation of District Training Complexes can be used to galvanise improved training for the full range of health professionals and act as a spur to recruiting high calibre staff.