South Africa faces chronic healthcare worker shortages and the country's Human Resources for Health Strategy 2030 has warned of an impending healthcare worker crisis. The shortages are particularly acute in some rural areas.
One solution to the shortages that gained some traction in South Africa around 15 years ago was the idea that certain tasks could be shifted from doctors to a new-ish type of mid-level healthcare worker called a clinical associate. The country started training its first clinical associates in 2008 (the course takes three years) and there are now some working both in the public and private sector in South Africa.
But the road for clinical associates has been a rocky one and the potential for this class of healthcare worker to ease the pressure on the public healthcare system arguably remains mostly untapped. The publication of their scope of work was delayed for several years. Some questions also remain over what medicines they may or may not prescribe, and maybe most importantly, they seem not to have been much of a political priority over the last decade. Spotlight previously reported in some depth on the role of clinical associates in South Africa here.
Delivering a keynote address at the Rural Health Conference recently held in Chintsa in the Eastern Cape, Deputy Minister of Health Dr Sibongiseni Dhlomo admitted that as a department they have not really paid much attention to clinical associates. "We just seem to have brushed over it and never really done much on it. I know there are issues that need to be resolved. I promise to listen, but I don't promise to have the answers now. I'm waiting for a report on clinical associates, then I will respond," he told delegates.
'Great improvement'
The role of clinical associates was one of the hottest topics at the conference themed "celebrating rural service". Nomsa Ndaba, a clinical associate and a study coordinator at the University of the Witwatersrand Vaccine and Infectious Diseases Analytics research unit (Wits VIDA), said there is demonstrated improved patient care when healthcare teams include clinical associates.
She said there are four areas where over 90% of healthcare workers agreed in a survey that clinical associates contributed successfully to the overall management of certain conditions. The 45 survey participants included clinical managers, nursing services managers, hospital chief executive officers, and human resource managers.
"Clinical associates succeed in the management of HIV and opportunistic infections, non-communicable diseases, tuberculosis as well as injury and trauma conditions," she said. "The clinical workload of medical practitioners is reduced by sharing tasks with clinical associates. Especially in the rural areas, clinical associates reduced the load on overburdened rural medical practitioners."
Dr Grace Cholimbira, who works in local clinics and at Kuruman Hospital in the Northern Cape, told Spotlight at the conference that she has seen first-hand the value of clinical associates. "Since the inception of the clinical associates programme and their enrolment into clinical practice, we have seen a great improvement in the management of patients, especially in the rural areas. The clinical associates have helped relieve the problem of staff shortages. They provide essential clinical services much needed by the rural health communities and have helped relieve/ reduce health care worker burnout," she said.
She said that in a staff-constrained environment, clinical associates are able to manage patients without supervision as occurred from 2011 to 2013 when a hospital in Kuruman had a dire shortage of clinical personnel and it was run by a team of two medical officers and two clinical associates until they received the much-needed help.
The Rural Health Conference was not just an opportunity for attendees to gain valuable insights into rural healthcare; it was a celebration of unity, diversity, and the shared commitment to improving the health and well-being of rural communities.https://t.co/vBrztUsJDa
-- RHAP (@RHAPnews) September 18, 2023
"This alone is a sign that we cannot ignore the massive impact the clinical associates have in our facilities. Most outpatient departments are run by clinical associates in rural areas and this has significantly reduced patient waiting times. In a nutshell, they have not only added to the staff numbers, but they form the backbone of our rural healthcare service providers," said Cholimbira.
A chapter in the South African Health Review of 2019 stated that as a resource, clinical associates are less costly than doctors and provide good value, but their potential is only fully realised through appropriate supervision and leadership.
Too few clinical associates?
While there seemed to be consensus at the conference over the value of clinical associates, especially in rural areas, there also seemed to be a shared view that this cadre of healthcare worker is underutilised and even somewhat neglected.
Aviwe Mgobozi, Academic Head of the Division of Clinical Associates in the Department of Family Medicine and Primary Care at the University of the Witwatersrand, told Spotlight that the clinical associate programme has not been well marketed by the Department of Health. "There seems to be a lack of political will and leadership by the Department of Health, despite the profession being conceptualised by the Department of Health. As a result, there is a slow uptake to conclude and implement new policies and update existing policies to include practice regulations for clinical associates," she said. She added that the reasons for a lack of leadership, lack of championship, and slow support by the health department are yet to be understood.
According to Mgobozi, there is a rise in specialists wanting clinical associates to function as coordinators of care within their practices, including aiding in patient care, delivery of patient education, and as theatre assistants.
"It is unfortunate that the posts within the public sector are scarce. There is a missed opportunity within the public sector for clinical associates to function optimally within the primary healthcare space to improve access to healthcare and deliver quality healthcare services with the inter-professional teams," she said.
While utilisation of clinical associates has lagged in the public sector, she said, "There is increased uptake of clinical associates within the NGO space where clinical associates are providing HIV/AIDS and voluntary medical male circumcision services to the South African population."
Movement and setbacks
Currently, clinical associates can only prescribe medicine up to schedule 4. According to their scope of practice, they can: "prescribe medicines for common and important conditions according to the primary healthcare 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 medical practitioner. In the case of drugs not on the EDL the prescription must be countersigned by a medical practitioner."
According to Mgobozi, it means that clinical associates still need a supervisor's signature as they are not listed as authorised prescribers in the Medicines and Related Substances Act. She says this can lead to unnecessary delays that impact patient outcomes, especially in emergencies when a script has to be co-signed.
As it stands, the scope of practice authorises them to prescribe the medicine, but the act says otherwise. Mgobozi says prescribing rights for clinical associates must be provided for in the act and they need to be listed as authorised prescribers as stated in the scope of practice and training.
Last year, Professor Parimalaranie Yogeswaran in an article published by Spotlight also bemoaned the fact that although clinical associates do not need a counter signature (unless it's for medicines not on the EDL), "this is still applied differently across facilities".
This, Mgobozi says, is why the lack of clear policies to guide clinical associate practice must be addressed. "The scope of practice is not widely known by the medical community and by the patients, and the Health Professions Council of South Africa (HPCSA) [and we need to] increase awareness of the profession. Stakeholders need to collaborate and work together to develop and implement policies in line with the needs of the provision of health care in South Africa.
The challenges, however, do not end there.
Mgobozi also calls on the health department to create more clinical associates' posts and says there should be more inter-professional education so that professions do not function in silos but rather collaboratively to enhance patient care.
Cholombira echoes this and adds that career and salary progressions are also a challenge. "This has been proved by the lack of further study opportunities by universities which do not have courses tailored to advancing clinical associates. To date, only Wits University has one course in emergency medicine tailored for clinical associates, but what if one is interested in furthering their studies in obstetrics?"
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In 2018, the Professional Association of Clinical Associates in South Africa (Pacasa), in a briefing to MPs in Parliament, said it is time that "a new job evaluation should be done to determine the appropriate salary level". "[Considering] the job description and scope of practice, it can be argued that the current salary level is inappropriately low." At the time, clinical associates were earning less than professional nurses and allied and related health professionals. Pacasa, among others, proposed that "the salary notch and level of clinical associates should increase appropriately according to their level, for example, Clinical Associate First Level, Senior Clinical Associate Second Level, and Principal Clinical Associate Third Level".
Health Minister Dr Joe Phaahla earlier this year in response to a parliamentary question, however, said that discussions are underway to address the occupation-specific dispensation (OSD) for clinical associates, among others. Phaahla, however, cited the prevailing fiscal constraints government is under that may affect this the creation of more clinical associate posts.
Complaints and delays
A ministerial task team was appointed in 2015 to help understand better the issues facing clinical associates and to recommend a way forward. The task team's report was finalised in 2017. However, when, by 2019, the health department had not implemented the recommendations or addressed the issues raised in this report, Pacasa approached the Office of the Public Protector to complain about the department's "delay in processing the report". Due to this delay, Pacasa argued, "the challenges experienced by clinical associates relating to [their] integration within the health system, conditions of service, and their development, continue to persist".
Last week, around six years after the task team finalised its report and two years after the Public Protector's report was released in November 2021, clinical associates were still raising the same issues at the Rural Health Conference, with Dhlomo at least admitting that the department had not afforded the issue proper consideration.
Phaahla, in a parliamentary response earlier this year, said the department is implementing the remedial actions in the Public Protector's report.
