Definition of the scope of work was required to allow cadres to carry out job functions normally performed by higher level cadres, and to avoid untrained workforce delivering care outside their scope with associated complications, costs and legal implications.
Recently, it was questioned whether training of higher level cadres in public health prepared graduates with competencies that are relevant to low- and middle-income countries (LMIC) [ 4- 6], and similarly in high-income countries [ 7, 8].
Indeed in LICs there is often high demand for the services of the few higher level cadres and reports suggest they may be absent from the public sector while providing services in the private sector, especially where policies are relatively permissive [ 7, 42].
However, both the health system and legislature remain unprepared to absorb this higher level cadre causing instances of confusion about the role of FNPs [ 101, 102].
Two major power differentials were recognized by participants in the health centre arena: between health workers and patients, and between higher level cadre health workers and those with lower or no qualifications.
For instance, a cadres career strongly depends on his or her performances and their assessments by upper-level and high-level cadres.
In August , 1978 he was sent to Hanoi for ten months' instruction at the Political Institute of the National Defense Department, a training camp in Marxist-Maoist thought for mid- and high-level cadres.
"At the same time, I would never want to have this experience … We are talking about the most powerful people being subject to an extra-legal regime". Unless officials are cleared, which is rare, and rarer still for high-level cadres, shuanggui is normally followed by a brief investigation by judicial officials.
In many African countries, basic level workers, and even untrained auxiliary staff and community health workers, assume roles and perform activities legally reserved for mid- or high-level cadres of workers [ 1].
The substitution of health workers (e.g. high-level cadres substituted by mid-level cadres) has been suggested in the literature as one of the alternatives to deal with the shortage of health professionals in poor countries at a lower cost [ 10- 12].
