The development and implementation of such a framework must become one of the top priorities in community-based health care planning and implementation. There is ample and strong evidence to support the use of mid-level providers, such as nurse practitioners and midwives, especially in primary care. It has been shown over and over again in many jurisdictions that the care provided by these practitioners, working under the supervision of or in cooperation with physicians, is safe and of high quality. Research has generally shown that it is cost effective to use mid-level providers such as nurse practitioners and midwives. But it should be noted that, with the exception of some studies of nurse practitioners in the 1970s, most of the research in this area has been conducted in other countries whose systems or approaches of health care financing and practitioner remuneration are quite different from those in Canada.
Caution is needed in extrapolating the research evidence to the Canadian context.
Role substitution is not restricted to mid-level providers. Although the amount of evidence available and the strength of the evidence vary from one occupational group to another, it is safe to say that considerable role substitution is feasible and effective when it is done properly. Compared to many other countries, Canada lags behind in using health human resources substitution as a policy tool in health care reform. Use of nurse practitioners in Canada is relatively rare except in isolated communities and in the far north. The official recognition of midwifery has occurred very recently and only in a few provinces.