Poorly paid and under-recognised Clinical Associates, introduced 15 years ago to help address the shortage of healthcare workers (especially in rural areas), have finally convinced the national Health Department to review their functions and status.
This comes after a probe, promised by Deputy Health Minister Dr Sibongiseni Dlomo at the annual rural health conference in East London in 2023 failed to materialise. Two years earlier, the Professional Association of Clinical Associates (PACASA) complained to the Public Protector whose report, issued in November 2021, supported their concerns, and directed the Department of Health to take remedial action.
PACASA explicitly highlighted the lack of job evaluation and compared their pay unfavourably to that of professional nurses and allied health personnel. They urged the government to establish structured levels, e.g, First Level, Senior, and Principal Clinical Associate, to reflect their scope and responsibilities.
Dr Luvuyo Bayeni, director of human resources in the National Department of Health, said his research division had finally managed to convince Treasury to allocate funds for an independent probe by a health economist after identical unsuccessful bids in the 2023/24 and 2024/25 financial years.
The probe is to be conducted by Professor Gavin George, deputy executive director of the Health Economics and HIV and Aids Research Division (HEARD) and an Associate Professor at the University of KwaZulu-Natal.
George has been sub-contracted by the Health Systems Trust (HST) as part of a three-year contract they have with the national Health Department.
Bayeni confirmed that the probe followed the original PACASA complaint to the Public Protector and said his department was concerned that, ‘we’re not being seen to appoint more clinical associates and that we’re not fully embracing this cohort of healthcare professionals.”
Clinical Associates, (aka mid-level workers), are university-trained medical professionals who work under the supervision of doctors to provide a range of healthcare services, particularly in district hospitals. They play a vital role, managing common illnesses, offering patient consultations, performing procedures, and assisting with surgical procedures. This allows doctors to focus on more complex cases.
Research aired at the rural health conference premised on the founding assumption that CAs would want to work in rural areas proved this to have been correct. CA presenters cited a 2014 study which showed that 68% of first year students and 92.1% of third years’ fell into this category. By comparison, just 4.8% of medical students wanted to work in rural practice.1
They also said that over 90% of circumcisions – a powerful HIV prevention tool – in 2014/15 were done by CAs.2
Clinical associates provide comprehensive healthcare to a wide variety of patients and contribute to task sharing, be it in theatre, the outpatients’ department, or casualty. A 2018 study in Tshwane shows that when a healthcare team includes a CA, their colleagues can spend more time with patients and help reduce patient overload.3
CAs, say they do most of the things a doctor can do, but when it comes to salary scale, they are pegged below nurses although they are doing procedures “way above” nurses who are also preferred over them for managerial posts.
Dr Madeleine Muller, a veteran family physician at Cecilia Makiwane hospital and lecturer at Walter Sisulu University, said her university is developing a post graduate diploma in infectious diseases for CAs and wants to use it as a precedent for more graduate diplomas for CAs.
“There’s also a regulation with the Colleges of Medicine which has created a possible gap to enable CAs to write some of their exams,” she revealed.
However, she added a strong caveat: this would take at least another two to three years due to work pressures by all those involved.
PACASA Deputy President ‘TG’ Lamola “we welcome this long-awaited probe but only if it addresses our long-standing grievances. We don’t care about the political voices trying to silence us. The only question that needs answering is what does our health care system need now? We were created to deal with unnecessary referrals from clinics to district hospitals and provide a bridge between nurses and doctors. It’s about staff shortages, care-giving imbalances and inappropriate care – in other words getting the system to work efficiently within existing limitations”.
Another long-standing ask was to allow CAs to practise privately – not as a threat to GPs but in support of them.
- 1 Moodley et al. (2014), titled “Practice intentions of clinical associate students at the University of Pretoria, South Africa”. It’s part of Rural and Remote Health, Vol. 14, no. 3, under article IDs 2874/2381.
- Ngcobo et al. (2018) conducted a retrospective review of 4,850 VMMC procedures performed over 16 months in the Tshwane District. They found that Clinical Associates performed 88.7% of all circumcisions, while doctors performed 3% Reddit+15doaj.org+15UPSpace Repository+15. Quality metrics (adverse events, procedure time, infection rates) showed no significant difference between CAs and doctors UPSpace Repository+4doaj.org+4PMC+4. A follow-up commentary in a health policy journal further underlined that CAs provided the same quality of care as doctors while doing the vast majority of circumcisions.
- Tshwane Interprofessional Care Coordination Study.