National strategies for improved access to Human Resources for Health

The Department of Health has identified a wide range of short, medium and long-term strategies that together need to ensure, “a workforce fit for purpose to meet South Africa’s health needs”1. The development and employment of new health cadres is part of the roadmap to better health for all. This Rural Health Update focuses on the role of the clin-ical associate (ClinA) in addressing the country’s health workforce shortages. The role of ClinAs is often not well understood by different stakeholders, including by health man-agement and health care workers, and a number of challenges impede the successful introduction and expansion of this health workforce cadre.

History of Clinical Associates

Physician assistants, as they are known in many parts of the world, or clinical officers, as they are frequently called in Africa, are found in developed and developing countries. Following a National Health Council decision to develop this kind of health worker in South Africa, subsequently called clinical associates, the National Department of Health requested the Family Medicine Education Consortium (FaMEC), a collaboration amongst the eight university Departments of Family Medicine in the country, to take on the task of planning the training programme and curriculum2, based on reviews of programmes in other countries and national needs. South Africa began the production of clinical associ-ates in small numbers in 20083. The first cohort of ClinAs in South Africa completed their training at the end of 2011 at Walter Sisulu University and these were followed by students of the University of the Witwatersrand as well as the University of Pretoria.

1 National Department of Health. (2011). Human Resources for Health, South Africa. HRH Strategy for health sector 2012/13 – 2016/17. Pretoria: National Department of Health .

2 Doherty, J., & Conco, D. (2009). Mid-Level medical Workers in South Africa: Situation Analysis. 3 Doherty, J., Conco, D., Couper, I., & Fonn, S. (2013). Developing a new mid-level health worker: lessons from South Africa’s experience with clinical associates. Global

Health Action. 6:1-10. doi: 10.3402/gha.v6i0.19282. Available at http://www.globalhealthaction.net .

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KEY QUESTION: WHAT IS THE ROLE OF THE NEW MEDICAL CADRE OF CLINICAL ASSOCIATES IN

IMPROVING ACCESS TO QUALITY HEALTH CARE FOR ALL RURAL COMMUNITIES?

IMPROVING ACCESS TO HR4RH: THE ROLE OF CLINICAL ASSOCIATES

A d v o c a c y P r o j e c tR u r a l H e a l t hR u r a l H e a l t hR u r a l H e a l t hR u r a l H e a l t hR u r a l H e a l t hR u r a l H e a l t h

Rural Health Update - No.1

Dalton Dingelstad

The Role and Place of Clinical Associates

ClinAs are being placed in district hospitals to strengthen health care services in the district and to address the shortage of doctors at district hospital and community health centre level. ClinAs work alongside doctors to enhance efficiency and efficacy of clinical work. A ClinA:

•conducts consultations (history taking and physical examination)

• orders and interprets investigations (lab tests, X-Rays)

•diagnoses and treats common conditions

•performs procedures

•assists in surgery

•provides patient education and counselling

•makes appropriate referrals.

“The district hospital is considered to be the ideal setting for the ClinA due to its well-defined and manageable level of care where it is possi-ble to be specific about the scope and practice limits for the ClinA. The ClinA will be part of a team in different units in the district hospital (emergency unit, outpatient departments, med-ical and surgical units, and maternity). In oper-ating theatres, the ClinA will assist the doctor in basic procedures. The scope of practice of the CA is intended to fill the gap that exists in dis-trict hospitals where a large proportion of the clinical work of doctors is related to emergency care, diagnostic and therapeutic procedures and in-patient care.”

Decentralised Training

Clinical Associates are required to earn a Bachelor of Clinical Medical Practice degree from an accredited university to qualify for reg-istration with the Health Professions Council of South Africa. Rooted in problem-based learn-ing, this three-year course of study emphasises the acquisition of hands-on clinical skills that ClinAs need to take their place in the multi-dis-ciplinary health care team. A defining charac-teristic that differentiates this programme from

others is the idea of decentralised learning. For the majority of their training, students are out in their clinical sites, and learning and being hands on in the hospital settings.

“Some mid-level worker programmes have failed, not because the concept is flawed, but as a result of ‘. . . weaknesses relating

to poor teamwork, competing market forces, [poor] production processes and employment

opportunities, as well as a lack of synergy between involved role players and the

processes of regulation, production and employment’.”

(Doherty et al, 2013, citing Hugo, J. et al, 2005)

Mid-level medical workers (collec-tively known as associate clinicians) are established members of the health workforce in countries such as Kenya, Uganda, Tanzania, Malawi, USA and Canada.

Financial disadvantage and rural career intentions are among the selection criteria used by some of the universities.

ClinAs graduate with a Bachelor of Clinical Medical Practice (BCMP) after three years of training.

There are approximately 250 ClinA graduates in the country.

ClinAs are trained in clinical sites. These are often rural, hereby provid-ing an extra resource to understaffed facilities and preparing the ClinA to the rural health care context. This model follows international good practice, where rural-based training is part of the rural recruitment and retention strategy.

The ClinA competencies in basic clinical skills free up time of the doctor who can attend to more complex clinical cases and conduct outreach services to clinics, hereby supporting the PHC drive to bring health care closer to communities.

The scope of practice of the ClinA differs from that of the Primary Health Care Nurse Practitioner where first contact care, chronic care and illness prevention are most important.

Once doctors are trained in supervi-sion and teamwork with ClinAs, their performance reviews will include assessment of their supervision and support.

Little is mentioned in NHI policy state-ments about the ClinAs, reflecting the need for better understanding of their role in addressing the health workforce shortages.

The Professional Association of Clinical Associates in South Africa was launched in September 2012.

Quick Facts

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Challenges impeding short and long term impact of the Clinical Associate Programme

According to the National Department of Health’s Human Resources for Health Strategy there needs to be 1,350 Clinical Associates employed in district hospitals around South Africa by the year 2028, which means five Clinical Associates per district hospital. If this quota is met by the set time frame, then ClinAs would have contributed significantly towards addressing the health workforce shortage in rural healthcare. The successful scale-up of this new cadre is impeded by a number of challenges:

“The international experience suggests that mid-level health workers have played an important role in addressing human

resource shortages and improving health care access and equity, especially in low-

and middle-income countries”

(Doherty et al, 2013)

Dalton Dingelstad

Professional Association of Clinical Associates South Africa – PACASAPACASA Clinical Associates founded the Professional Association of Clinical Associates in South Africa in 2012. Visit www.clinicalassociates.co.za for more information, or email PACASA Chair, Edwin Leballo, at Edwin.leballo@gmail.com

Professional Association of Clinical Associates South Africa – PACASA

Labour related problems

Labour issues are centred on the scope of practice, the subject of a regulatory stand-off between the Health Professions Council of South Africa, the Pharmacy Council and the Medicines Control Council. The vagueness of the initial scope of practice regarding pre-scriptions by the ClinAs led the Pharmacy Council to issue a national memorandum stating that pharmacists may not dispense medicines prescribed by the ClinAs without a medical practitioner’s signature until the required regulations have been promulgated.

ClinAs are yet to be placed in the organogram of the clinical set-ting in which they work. The confusion has left some health workers unsure where exactly they fi t in relation to ClinAs and this has caused unnecessary tensions between health cadres working in the same facility.

Undefi ned career pathways

Growth within the profession, as a recruitment and retention strategy, is hampered by a stagnant remuneration package from the National Department of Health and a current lack of further training and pro-motion opportunities. A ClinA who has worked for three years is

currently on the same salary scale as a newly graduated ClinA. The career growth through training will however be addressed from 2015 onwards when different universities start their postgraduate programmes for ClinAs.

Supervision

ClinAs are trained to work under the supervision of medical practi-tioners. However, a lack of understanding of the role of ClinAs have led to their ineffi cient use; ClinAs do not have to work in the physical presence of a doctor at all times, but must have a named supervisor available, who should be consulted whenever needed.

Low priority by policymakers and lack of cost-effectiveness / impact studies

Policymakers and government offi cials have thus far not played their role as well as they should. The evidence lies in the recent unsavory event of newly graduated ClinAs who could not fi nd employment for three months as the Gauteng Provincial Department of Health had not created ClinA posts, despite paying for their bursaries and the conspicuous need for health care workers.

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Rural Doctors Association of Southern AfricaC e n t r e f o r R u r a l H e a l t h

Contact details:Email: info@rhap.org.za | Phone: 011 356 4100 |

Fax: 011 339 4311 | www.rhap.org.zaPhysical Address:

SECTION27 (Incorporating the AIDS Law Project)23 Jorissen street, Braamfontein, Johannesburg

Postal Address: RHAP c/o SECTION27

PO BOX 32361, Braamfontein, 2017

Priorities to make CAs

work for Rural and National

Health

• Integration of ClinAs in policy initiatives such as PHC Re-engineering and NHI• Marketing of the ClinA Programme by the DoH Scaling-up of the production of ClinAs to meet

the national target• Suffi cient funding for the expansion of the training programme• Development of training facilities in rural districts• Career pathways for ClinAs• Funded posts created by Provincial Departments of Health • Induction of management and clinicians at district hospitals on the role and contribution of

ClinAs• Studies into the impact of the ClinAs cadre including cost-benefi t analyses.