More clinical associates are needed to transform healthcare in SA — we should support them
South Africa is among the most unequal countries in the world with a huge quadruple burden of disease and to address this we need hands. Professor Parimalaranie Yogeswaran argues that we should maximise the untapped potential of clinical associates to beef up the clinical health workforce.
They are called by many names — clinical associates in South Africa, physician assistants in the US, assistant medical officers in some Asian countries, and assistant medical practitioners in other countries and yet — across the world — the value they add to health systems is indisputable.
Many health workers themselves are not clear on what these clinical associates are and our understanding of their role impacts their contribution to the health system. For example, when one talks about a doctor, everyone the world over, immediately knows what that is. If one mentions a clinical associate in Malaysia, however, they would not make the connection since it is called something else there. So, if you look at the title for the cadre who has this same job description — they all have different names and that’s our first problem. Hence, we must educate health workers on the contribution clinical associates can make.
There is a perception that clinical associates are a type of mid-level medical worker and are only for poorer countries or low- to middle-income countries. This is not true. There are huge numbers in the US, Africa, Europe, and Australia where these mid-level medical workers have been embraced.
By 2020, one study found that there were over 132,000 of these health practitioners (Physician Assistants) in 18 countries across the world. In South Africa, by 2021, we had 11 cohorts of clinical associates that have graduated and who are now contributing to the health system. Currently, we are training about 150 clinical associates per year at three universities, adding to the 1 500 graduates that are in the country.
What are clinical associates?
Clinical associates are mid-level medical workers who are trained for three years whereafter they receive a Bachelor’s Degree in Clinical Medical Practice. Training in South Africa started in 2008 and the first cohort graduated in 2010 from Walter Sisulu University.
The actual scope of practice for this programme was only published by the minister of health in 2016. Until then, however, there was much confusion and many were wondering if they are legitimate, and if they are legal. The confusion mainly stemmed from the fact that they were a category of healthcare worker who did not have a published legal scope of practice.
Luckily that changed when the minister published the scope of practice eventually, but not everyone has moved on from that mindset.
When the curriculum was designed for clinical associates, the aim was clear — we were developing graduates who are going to function in a primary healthcare and district health system, therefore, the skills and knowledge they’re supposed to get in those three years, were planned accordingly. They were expected to provide promotive, preventative, curative, and palliative care, and whatever procedures and clinical skills they needed at a district hospital level, they were trained for. They were trained in managing illnesses and diseases that were common in the country and this included consultation, counselling, clinical procedures, surgical assistance, and pharmaco-therapy.
They were also trained in many emergency conditions. Most of their training over the three years was also done in district hospitals. From the first year onwards, they are trained in clinical spaces working with doctors and patients. At the end of the three years, they have a national exit exam to make sure they have all the necessary competencies for them to provide services.
So, what is their scope of practice?
Simply put, most clinical services provided in district hospitals are within the scope of practice of clinical associates. For example, they can prescribe up to essential drug list level 4. They do not need a counter signature but write the name of the doctor who is supervising and if there is an emergency, they can actually prescribe higher levels and it will be signed especially for a critical patient.
Although they do not need a counter signature, this is still applied differently across facilities while we await a formal instruction from the Pharmacy Council. (Spotlight reported on this issue in 2019.)
One worry many people have when they want to employ a clinical associate is that they think they must be supervised. The scope of practice is clear — the first two years that they are working as clinical associates, they must be supervised. This is hands-on supervision where they work with a doctor. But the scope of practice also says once the clinical associate is competent, the doctor may delegate any duty to the person. Once they have two to four years of continued work as a clinical associate, then they don’t need a doctor next to them and after four years they can work independently, provided that someone is telephonically or physically available if there’s a need.
We need hands
There are some critical issues facing our country. We are among the most unequal countries in the world, we have a huge quadruple burden of disease and to address this we need hands. We are aspiring toward universal healthcare for all our citizens — something we want to achieve by 2030. That will need hands — healthcare workers. So, we will have to increase the efficiency of the health system to be able to achieve that and for quality healthcare, we need healthcare workers who are trained and who can offer that.
In this respect, clinical associates have much to contribute.
We have a huge shortage of healthcare workers and we live in a country where the health system itself is skewed — not just skewed in terms of the public and private health sectors but also the rural and urban divide. These are often two different worlds in terms of healthcare services. For example, with about 40% of the population living in rural areas, only about 12% of medical doctors work there.
During our first pandemic — the HIV pandemic — we all learned task-shifting for the first time. We all had to figure out how to move doctor-based tasks to nurses. We are at the same moment now — to take what we have learned thus far and put it into practice for the future.
Clinical associates work in both the public and private health sectors where they can make a huge difference. In the public sector, they have been working in outpatient and in-patient units, emergency, community health, paediatrics, and made a big difference during the Covid-19 pandemic.
According to the National Task team report on Clinical associates of 2017, only 47% of graduates are in the public sector and 21% were in the private sector. In 2015, the number in the private sector was 2%. So, it’s growing very fast.
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District hospitals often are short of hands, queues get long, and the mammas come from far away rural areas and they still need to get back home, so you can’t just ask them to go and come back the next day. Clinical associates then become a godsend because they can help relieve that pressure. The reality is that in rural areas there are only a few doctors and community service doctors come and go. They know they will be there for one year and they often leave after. With clinical associates, however, when you develop and train them, they stay — so you are establishing skills and a person with the confidence to manage for years to come.
South Africa has the highest HIV burden and also the biggest ART treatment programme in the world. What we need is continuity. Yes, we need doctors, but we all know it’s difficult to recruit doctors, especially in rural hospitals. That’s why we must make sure we make use of these clinical associates so that we can provide the needed services.
For example, there are times in a district hospital when there’s a critical patient brought to emergency and the doctor is in theatre with another patient. The nurses do the initial work but somebody has to clinically assess, make a diagnosis, and start treatment. Even if it’s high-level drugs — they’re allowed to prescribe. They’re able to resuscitate. So, they are trained in all those things. They admit patients, they discharge them, they do rounds, and when the doctor is not there and there’s a critical problem, they’ll call. So, they can do the ward work — the doctors can share some of the responsibilities and some responsibilities can be done instead of the doctor.
There is also a list of common medical procedures clinical associates can perform. For example, if you’re a doctor having to do a lumber puncture or draw blood, it’s going to take you time. Clinical associates can step in. They also do a lot of circumcisions and their performance is equal and sometimes even better because it’s a skill — it’s mechanical so when you do it frequently, you can become better than the doctor who’s doing it infrequently.
Working in rural areas
Apart from the work they can do in emergency medical care and clinical work, the majority of clinical associates express a desire to work in rural areas. There were actually 59% of clinical associates studying who wanted to go to rural areas and of medical students, there were only 4% who indicated they want to work in a rural area.
If we want to strengthen primary healthcare and district health services, we need continuity. Because there are so few healthcare workers wanting to work in rural areas, many get burned out and leave after a while so we need these additional hands.
There is also the cost-effectiveness element to consider.
A recently published systematic review looked not only at costs of care but also quality and accessibility of care provided by clinical associates providing health services. In SA, for every doctor, we can employ two to three clinical associates. So, if we have vacant doctors positions you can appoint two clinical associates and you will have more clinicians, which makes life easier.
Recognise their contribution
We must recognise and appreciate clinical associates’ contribution and respect them for the value they add to the health system.
How do we do that?
As a start, we should provide the enabling conditions for their professional development. We have not yet done or developed enough postgraduate clinical training. There’s only one for emergency medicine. The others are generic like public health and health professions education. So, it’s often a shock for those coming into this profession and people end up taking another route to clinical health professions like studying medicine.
There is still no career path or career progression horizontally or vertically but currently, the health department is talking to stakeholders about this.
We are also producing too few clinical associates.
The National Department of Health’s National Task team on clinical associates’ report of 2017 showed clearly — for us to achieve UHC by 2030, we will need to produce 11,500 clinical associates by 2030. This report was submitted to the health department in 2018 and talks on implementing the recommendations of this report is still ongoing. At the moment, we are producing 150 per year. Do the maths — 150 graduates for eight years will only get us 1,200 which is not getting us close to the numbers needed.
So what needs to be done?
We must scale up the production of these graduates and sort out their career opportunities otherwise they will move on to other professions.
In the workplace, doctors and nurses should look at task-shifting and task-sharing and need to understand the scope of practice of clinical associates so that we are able to work as a team and have better patient outcomes. Getting all healthcare workers to understand what can be done by clinical associates is an important aspect of getting the full potential from this profession.
Advocacy for this profession is also important. As with any new profession, there are only a few at first — so the rest of us health workers, especially those of us passionate about working in rural areas, must advocate. We must join hands and advocate for clinical associates to help work towards healthcare delivery for our communities far away from the big cities. We must see this as a social investment.
At the moment as a country we are not optimising the contribution this profession can make to the health system. If we are really serious about providing primary healthcare to every person, we really have to work on ourselves first as health workers and support, encourage, and mentor and as their managers give them confidence, trust them, respect them, and delegate, share, and do task-shifting. We need to get this right. We need to see clinical associates as an important investment in our health system and only then we can have a good chance to give every South African better healthcare by 2030. DM/MC
*Yogeswaran is a Professor and recently retired Head of the Department of Family Medicine and Rural Health at Walter Sisulu University. The article is based on a keynote address at the Rural Health Conference in September.
*This article was published by Spotlight – health journalism in the public interest.