Just over 10 years ago, an entirely new kind of health worker was created for South Africa’s health system. Envisioned as a mid-level health worker, aimed at plugging the state’s doctor shortage crisis, clinical associates began their studies in 2008 amid an atmosphere of hope, excitement and anticipation.

But, after nearly a decade of actually working in the country’s health system, clinical associates say they were “sold a dream” and, in reality, face humiliation and exploitation on a daily basis. Expected to enhance the health system and dramatically improve patient care, and capable of doing so, they said they’ve often ended up being redundant.

One of the biggest barriers, caused by legislative failures from a government who has appeared to have lost interest in clinical associates, is their lack of power to prescribe even the most basic of medications like paracetamol – despite having been trained to do so. 

Not allowed to prescribe

On the 1 January 2017 Thando Bhengu* performed her morning routine hurriedly getting ready for her first day of work as a clinical associate at a public hospital in the heart of Mpumalanga. She was so excited that as she brushed her teeth and got dressed she was unable to stop smiling for more than a few seconds.

She had graduated from the three-year degree at the University of Pretoria (UP) the previous year and, for the first four months of her new job, going to work “was going to a place that I loved”.

“I loved to consult with patients and decide on what tests and treatments they needed. There were three of us then and we were allowed to prescribe any medication up to schedule four,” she told Spotlight.

In South Africa, schedule one and two medicines can be bought over the counter without a prescription, unlike medicines classified under schedules three to six that require a valid script.

But in April, the hospital’s clinical manager informed the three clinical associates working in the facility that he had been informed by the South African Medical Association that clinical associates were not legally allowed to prescribe medicines and would need a counter signature from a doctor on any and all prescriptions they wrote going forward.

Immediately, her work shifted from enjoyable to “horrible”.

“I remember we would come to work very early and see a lot of patients but would have to wait for hours for the doctors to arrive to countersign the scripts. And patients loved us because they told us we were not rude and we spent more time consulting with them and we listened to them to such an extent that sometimes they would get to the hospital and ask for us specifically,” she said.

But having to wait for hours after a consultation, diagnosis and prescribed treatment – especially when they had not had to do this for the past few months – patients quickly grew “annoyed”.

“Patients made noise, sometimes even shouting that they’re hungry and they want to go home, asking what is the reason for this delay and asking why we were even there if we had to wait for doctors,” she said.

“This made me feel useless. I also asked myself: ‘Why am I here?’ I was so humiliated I used to go home and cry every day.”

What made matters worse, she said, was that the doctors at the hospital never questioned her judgment when countersigning the prescriptions she authored and saw the task as an extra burden on their limited time.

Worse in rural areas

Mbuso Mqopi*, a clinical associate working in a district hospital in rural Eastern Cape, agreed and said the problem is exacerbated in rural areas where doctor shortages are even more pronounced.

“The need for counter signatures makes my job very stressful because most of the time there is no medical officer [doctor] around. For example, I saw a patient in the early morning and prescribed her pain medication but had to tell her to wait to get the prescription. She had to wait the entire day. Eventually, I had to get on my knees and beg the pharmacists to dispense the medication because that day the medical officer was nowhere to be found,” he said.

The situation, which is not unique to Mqopi as Spotlight has learnt from other clinical associates, places both pharmacists and clinical associates at great legal risk, not to mention frustrating patients and compromising their care. 

Close to GPs

According to a 2019 paper published in the South African Medical Journal (SAMJ), the National Department of Health (NDoH) introduced this “new health profession” in “response to the chronic shortage of healthcare workers, especially doctors”.

Walter Sisulu University’s (WSU) medical school was the first institution to offer a clinical associates degree, called a Bachelor of Clinical Medical Practice, starting in 2008, followed by UP and the University of the Witwatersrand (Wits). By the end of 2018, a total of 1,070 qualified clinical associates had graduated from these three institutions.

Clinical associates “are professional members of the healthcare system with the necessary skills and knowledge to function effectively mainly in primary care settings such as clinics, community health centres and district hospitals” and, like doctors, are required to be registered by the Health Professions Council of South Africa (HPCSA) to practice, noted the SAMJ article. Nurses and pharmacists, for example, are regulated by their own professional bodies and not the HPCSA.

The article explained that their “level of practice is very close to that of a general practitioner” and that “the general feeling” amongst many other health professionals is that clinical associates are “skilled in making a diagnosis and managing patients”.

But it appears that their potential has been drowned by politics. 

Motsoaledi criticised

*Sandile Capa qualified as a clinical associate in 2013 after studying at Wits and now works at a provincial hospital in the North West.

“This initiative was spearheaded by the then health minister Manto Tshabalala-Msimang who left office before concluding many aspects of the programme including the scope of practice and labour issues such as career progression,” he said.

Capa said that her replacement Dr Aaron Motsoaledi failed to resolve any of these issues in his 10 years in office.

“In fact, he was critical of us and I see many of our current problems as having started in the minister’s office because of his influence. Many of the things he has said about our programme were not so nice,” said Capa.

Motsoaledi told Spotlight that he cannot comment on health matters from his new portfolio and referred us to Dr Terence Carter who was deputy director-general for Hospitals, Tertiary Services and Workforce Management.

Now retired, Carter said Motsoaledi was appointed health minister “in a policy vacuum” and the various issues surrounding the profession were “left for him to resolve”.

“Before clinical associates graduated Dr Motsoaledi made sure to send a circular to provinces [in 2010] instructing them on what to do, how clinical associates would work, at what level they should be appointed, for posts to be made available and what remuneration they should receive,” he said.

“The allegations of a lack of support are not true in terms of the national government, in terms of the Minister of Health and in terms of myself. Personally I felt that, clearly, in a country like ours, with a shortage of health professionals, there is no doubt about the potential role clinical associates could play in terms of access to healthcare, particularly in rural areas.” 

HPCSA blamed

Carter said the delays related to gazetting of the profession’s scope of practice were as a result of the HPCSA. “The HPCSA has 12 different professional boards and for the scope of practice to be approved by the HPCSA they need to get comment from all 12. This literally took years,” he said.

However, gazetted in 2015, even this scope of practice includes the prescribing of medicines, without countersignatures in most cases, as a function of clinical associates: “Prescribing medicines for common and important conditions according to the primary health care level Essential Drug List (EDL) and up to schedule IV, except in emergencies when appropriate drugs of higher schedules may be prescribed. The prescription must contain the name of the supervising registered medical practitioner. In the case of drugs not on the EDL the prescription must be countersigned by a registered medical practitioner.”

The wording on this issue remained the same in the revised scope of practice gazetted in 2016.

He said that clinical associates are not permitted to practice independently because of comments and suggestions submitted by other professional health bodies who objected because they felt clinical associates lacked the skills and knowledge to work unsupervised.

For example, a letter dated 17 August 2015 authored by the South African Society of Anaesthesiologists, recommended that clinical associates “shall not conduct an independent private practice” as “we feel [this] may place the patient AND the clinical associate at risk from the clinical safety point of view”.

Carter said this was the view of the vast majority of professional bodies who made submissions relating to the first gazetted scope of practice.

Even so, the ability to prescribe medicines (up to and including schedule four) was in the initial vision for clinical associates’ role and, as such, they were trained to do so as part of their degree, and still are.

Not a valid prescription

Upon the graduation of the first batch of clinical associates from WSU in 2010, the South African Pharmacy Council issued an official statement that indicated that clinical associates “have not been approved by the HPCSA and the Medicines Control Council (MCC) as authorised prescribers and no scheduled substances have been identified in the schedules to Act 101 [the Medicines and Related Substances Act] for this purpose”.

The MCC has now been replaced by the South African Health Products Regulatory Authority (SAHPRA).

The Council added that “a prescription written by a Clinical Associate is not a valid prescription unless it has been signed in person by a medical practitioner” and pharmacists “may not dispense a prescription that is not valid in terms” of the law.

While meant to be mid-level health workers, between doctors and nurses, the reality is qualified professional nurses are able to prescribe and dispense drugs up to and including schedule four, open up their own practices as well as carry out their work without direct supervision while clinical associates cannot. Professional nurses also earn a higher salary than clinical associates according to Milan Gordahn*, a clinical associate working in Port Shepstone.

“You could be one of the best practitioners – it doesn’t matter when it comes to prescription rights which we don’t have because we have to be countersigned even for drugs like Brufen and Panado which patients can buy themselves over the counter. It is demeaning and, in most cases, we don’t even tell the patient we have to get a script countersigned because that alone will cause a patient to lose trust and faith in your capabilities. They would question themselves and ask: Why does this person need to get countersigned? Can they not prescribe? Are they not smart enough? It raises these types of questions and it makes practising almost impossible,” he said. 

Reducing patient waiting times

The situation has caused many health professionals, especially those working in rural areas, to act outside of the legal bounds, but without any intention of causing harm.

After graduating from UP, Portia Mkwanazi* has been working in a hospital in rural Mpumalanga for the past three years where the number of clinical associates outnumber the number of doctors.

“We had a situation where patients who come from the farms, for example, would arrive early in the morning – before eight. We would consult with them but would find the medical officers are busy in theatre or a meeting which resulted in patients having to wait hours and hours, only able to leave the hospital in the afternoon,” she said.

But, in this case, the hospital’s management made a decision that falls outside the law but was seen by staff as “the only rational solution”.

“Fortunately where I am working our medical staff see potential in us. They trust us. Since 2017 they’ve allowed us to see patients on our own and prescribe medication up to schedule four without a countersignature and gave pharmacists permission to dispense drugs based on this,” she said.

At the end of each work day, the doctors on duty would go over the patient files and evaluate the decisions made by the clinical associates as a control measure and give them feedback.

“This has reduced patient waiting times to less than two hours. Patients are happy and we are happy,” she said.

This is significant because, according to a 2014 study published in the journal Rural Remote Health, 57% of clinical associate students said they intended to work in rural areas compared to just 4.8% of medical students.

And in facilities where the laws are rigorously followed, both patients and clinical associates have been negatively impacted.

Change might be coming

However, after almost a decade of attempting to work within these stifling limits, a well-placed source said moves have been made in an attempt to change the situation.

“The responsible board at the HPCSA has just recently submitted a motivation to SAHPRA to include a range of medicines in the schedules for clinical associates. That motivation is being considered and, based on this, the SAHPRA chief executive officer will then recommend a list of medicines to the Minister of Health for gazetting as schedule amendments as per the Medicines and Related Substances Act,” he said.

SAHPRA’s Momeena Omarjee confirmed that a submission to this effect has been made and that SAHPRA “is currently in the process of reviewing said application and will revert back to the applicant as soon as the review is complete”.

But, according to the well-placed source, this process is expected to be complete within the next three months but “the uncertain period is the final decision by the Minister”.

A big question for clinical associates is if the new Minister of Health, Dr Zweli Mkhize, will support the forward momentum of their profession, unlike his predecessor.

The Professional Association of Clinical Associates in South Africa (PACASA) was established in 2012 with the aim of advocating for the resolution of the various issues faced by the profession.

“We have had direct meetings with the former Minister of Health in 2017 where a discussion around the impracticalities of our current scope of practice were had. One of these impracticalities was the challenge of prescribing medications. This still has not been resolved, another two years later,” explained PACASA’s media officer Martene Esteves.

Spotlight’s attempts to get clarity from the health ministry appear to indicate that little has changed since Motsoaledi’s departure.

Apparently reticent to provide any detailed comment from the minister, and after multiple attempts to get comment, the minister’s spokesperson Popo Maja told Spotlight that “the matter of allowing clinical associates to prescribe certain medicines is a training issue and not a policy one”. Other attempts to gain comment from the NDoH were referred to SAHPRA and the HPCSA.

However, one well-placed source speaking on condition of anonymity said that this is incorrect.

“They’re wrong, as this is both a policy and a legal issue. The policy is clear, but the legal steps have been neglected. But they’re right in one sense: The NDoH has no role in the scheduling process as the Minister does that on the recommendation of SAHPRA,” the source said.

But other recommendations from SAHPRA related to amendments to the schedules have been awaiting ministerial approval since April and there is a concern this backlog will only increase in volume and time.

While Maja said that the profession “is a new discipline that is still finding its feet and is not well understood in the clinical environment”, Sanele Ngcobo, a clinical associates lecturer at UP, said: “There is overwhelming evidence from other countries that has shown the effectiveness of clinical associates in South Africa and many other countries where such a profession exists”.

“One of the biggest weaknesses of our health system currently is the chronic shortage of healthcare workers in general, and doctors in particular,” said Ngcobo. “Clinical Associates are an obvious solution to this particular challenge.”

But, said PACASA’s Esteves: “Sadly it would seem that we are in an endless cycle where we are shunted from pillar to post, without clarification or a positive way forward.”

Sold a dream

Dr Richard Mukondi, a district clinical specialist for Zululand district in KwaZulu-Natal, told Spotlight that in his previous role in a hospital in Durban he found that working with clinical associates was “something beautiful and good and I really think they need support”.

“People who are not involved in their training don’t know their curriculum and what they are capable of. I can liken the qualification almost to the whole of a medical school degree – the only difference is they do it in three years,” he said.

Because the course is practically-based from the very outset, their impact on the health system can be felt even before they have graduated.

“In my own experience, clinical associates who graduate are not people who are lazy because it’s impossible to get through this rigorous course if they are. They work so hard in hospitals and study and write exams at the very same time,” said Mukondi. “In fact, most of them are incredibly brilliant people who missed out on medical school by one or two marks or couldn’t get in because the medical schools were full.”

Mukondi is in favour of allowing clinical associates to undergo a supervisory period and then qualify for independent practice, like doctors, as well as prescribe medicines below schedule five.

“It’s funny how we wanted something and now that it is there, we don’t want to recognise it somehow.”

Mpumalanga’s Bhengu, who described her daily challenges under the current restrictions, said: “We were sold a dream. I applied for medicine but, without a bursary, my family couldn’t afford it. The government gave me a bursary to study to be a clinical associate instead and told us we would be similar to doctors but restricted from some procedures. Even while we were studying they did not tell us about the challenges, about the humiliation we would face. What a disappointment. We were sold dreams through bursaries and false promises.” DM

* These clinical associates asked not to be named out of fear of losing their jobs

This article was produced by Spotlight – health journalism in the public interest