South Africa, a country of 50 million people at the tip of Africa, was given a wonderful opportunity. The national Department of Health concluded that there was a need for so-called midlevel medical workers and invited a group of healthcare providers to work with them in developing the program of study. We were thus able to learn from the experience of others internationally and to develop an appropriate health professional for the South African context. As a result, we are now producing a uniquely branded health worker—the clinical associate. Some of the lessons from this experience have been documented elsewhere; this commentary focuses on some of the developments and the current situation regarding PAs in South Africa.1
WHAT'S IN A NAME?
In the process of developing the program, deciding what to name this new health profession was a matter of intense debate. We wanted to establish a brand new health professional category for South Africa. The country had a few medical assistants, mainly trained in other African countries during time in exile under apartheid, but there was no training within South Africa and the category was not well known. Colleagues had investigated PA models in North America and clinical officers in other African countries, and we aimed to create a hybrid model.
We wanted to move away from the “assistant” label; although we were clear that these professionals would work with physicians (mainly generalists), and not function independently as they do in many other countries in Africa. In a newly democratic state, we wanted to avoid any sense of subservience, thus the term “associate” was chosen. The role we envisioned was very much within the medical profession, but we wanted to move away from a biomedical model to a more holistic, biopsychosocial approach, so the adjective “clinical” was preferred over “medical.”
Since then, a network of similar workers has been formed in Africa, based in Zambia. This network, of which we are a part, was initially known as the network of nonphysician clinicians, but defining oneself by what one is not is problematic, so it was renamed the African Network of Associate Clinicians (http://associateclinicians.org).
THE ROLE OF THE CLINICAL ASSOCIATE
In the South African public healthcare service, which cares for 80% of the population, primary care is delivered at the health district level by primary care nurse practitioners (NPs) working in clinics and health centers and supported by physicians. One of the challenges is that the shortage of physicians means inadequate support for NPs in primary care, and few patients get to see a physician. Physicians are mainly located in district (level one) hospitals, which are staffed by generalists. Most of the approximately 270 district hospitals are in rural areas and are understaffed. Physicians spend much time on procedures and routine work, leaving little time for primary care support. Clinical associate training, therefore, is focused on preparing these health professionals to work alongside physicians at the district hospital level. By sharing much of the burden of district hospital work, the clinical associates will free physicians up to offer more support to primary care facilities outside of the hospital.
Clinical associates are being trained to provide emergency care, conduct rounds, carry out and assist with diagnostic and therapeutic procedures, and offer holistic care to patients with a range of common acute and chronic conditions. Their scope of practice allows them to assist physicians predominantly (though not exclusively) in district-level healthcare services, with a focus on primary care. The intention is that they will work in the public healthcare service; although they are not prevented from going into the private sector, they cannot work independently and the mechanisms are not yet in place for private practices or hospitals to employ them.
Clinical associates have to work under the continuous supervision of a “registered medical practitioner” (that is, a physician), who must be identified by the service in which the clinical associate is working and must be known to the clinical associate. However, this does not mean that the physician must be physically present with the clinical associate; telephone consultation and later reporting of activities carried out in line with their scope are acceptable.
HOW FAR HAVE WE COME?
Clinical associates complete a 3-year bachelor's degree in clinical medical practice and are registered with the Medical and Dental Professions Board of the Health Professions Council of South Africa. The curriculum framework used for all training was drawn up in a collaborative national process, based on the common conditions seen and procedures carried out in district hospitals. Most of the training occurs in district hospitals.
The first 23 students commenced the program in 2008 at Walter Sisulu University in the Eastern Cape; the University of the Witwatersrand in Johannesburg and the University of Pretoria followed in 2009, with 25 and 56 students, respectively. Although only three institutions offer the course of study, others are planning to come on board in the next few years, and the numbers have increased so that 246 graduates were produced by the end of 2012, with a further 151 at the end of 2013.
Almost all the graduates thus far have been absorbed into district hospitals, mainly in rural areas, with a few working in nongovernmental organizations or, in the case of a couple of the early graduates, teaching in academic institutions. An evaluation of their roles and performance is being carried out, but anecdotal accounts of their contributions are consistently very positive.
Challenges remain, and some have been described elsewhere; this is not surprising given how new this cadre is.2 However, the future is bright. The pioneers of the program have formed the Professional Association of Clinical Associates in South Africa and are working with their training institutions and medical colleagues, particularly the Rural Doctors Association of Southern Africa, to address ongoing issues. As South Africa reengineers primary care in the public service and gears itself up for national health insurance over the next 10 years, we expect the role of the clinical associates to be increasingly important, such that they become an indispensable part of our healthcare service.
1. Doherty J, Conco D, Couper I, Fonn S. Developing a new mid-level health worker: lessons from South Africa's experience with clinical associates. Glob Health Action
2. Doherty J, Couper I, Fonn S. Will clinical associates be effective for South Africa. S Afr Med J
. 2012;102(11 Pt 1):833–835.