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. Highly qualified or extensively trained practitioners are taking over functions that have been adequately performed by lower-level personnel. Much of the empirical evidence on role substitution pertains to mid-level providers.
Evidence concerning role substitution in other areas or disciplines is less systematic and abundant.
While more research and evaluation should be encouraged, the relative paucity of empirical evidence must not be used as an excuse to prevent experimentation on more innovative ways of using health human resources. Human resources substitution is a policy instrument that can be used to achieve some of the goals of community-based health care like cost effectiveness, service accessibility and equitable distribution of resources. But it is important to ensure that substitution is adopted not just to save money. Substitution is done because it has been shown or can be demonstrated that the same function can be performed just as competently and efficiently by a provider with less extensive training or without formal credentials. If cost savings can be achieved at the same time, so much the better.