South Africa faces chronic healthcare worker shortages, particularly in rural areas, with the Human Resources for Health Strategy 2030 warning of an an impending crisis and experts urging the government to reconsider the value of clinical associates, and the huge role they can play, writes writes Tiyese Jeranji in Spotlight.
The solution to the shortages – which 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.
But the road 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 past decade.
Delivering a keynote address at the Rural Health Conference recently in Chintsa in the Eastern Cape, Deputy Minister of Health Dr Sibongiseni Dhlomo admitted the department has not paid much attention to clinical associates.
“We just seem to have brushed over it and never done much. I know there are issues that need to be resolved. I promise to listen, but I don’t promise to have the answers now,” he told delegates.
‘Great improvement’
The issue was also one of the hottest topics at the conference, themed “celebrating rural service”.
Nomsa Ndaba, a clinical associate and study co-ordinator at the University of the Witwatersrand Vaccine and Infectious Diseases Analytics research unit (Wits VIDA), said there was demonstrated improved patient care when healthcare teams include clinical associates.
She said there are four areas where clinical associates contributed successfully to the overall management of certain conditions, and this was confirmed by more than 90% of healthcare workers in a survey. The 45 survey participants included clinical managers, nursing services managers, hospital chief executive officers and HR managers.
“Clinical associates succeed in the management of HIV and opportunistic infections, non-communicable diseases, TB as well as injury and trauma conditions,” she said.
“The clinical workload of medical practitioners is reduced by sharing tasks with these associates. In rural areas, particularly, they reduced the load on overburdened practitioners.”
Dr Grace Cholimbira, who works in local clinics and at Kuruman Hospital in the Northern Cape, told Spotlight that she has seen first-hand the value of clinical associates.
“Since the inception of the programme and their enrolment into clinical practice, we have seen a great improvement patient management, especially in rural regions. They have helped relieve staff shortages, providing essential services much needed by the communities, and reduced healthcare worker burnout.”
She said that in a staff-constrained environment, clinical associates can manage patients without supervision – as happened from 2011 to 2013 when a Kuruman hospital had a dire personnel shortage and was run by two medical officers and two clinical associates until they received help.
“This alone is a sign that we cannot ignore the massive impact they have in our facilities. Most rural outpatient departments are run by clinical associates, which has significantly reduced patient waiting times. In a nutshell, they have not only added to staff numbers, but form the backbone of our rural healthcare service providers.”
A chapter in the South African Health Review of 2019 stated that as a resource, clinical associates are cheaper 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 they are under-utilised and somewhat neglected.
Aviwe Mgobozi, academic head of the Division of Clinical Associates in the Department of Family Medicine and Primary Care at Wits, said the clinical associate programme has not been well marketed by the health department.
“There seems to be a lack of political will and leadership there, despite the profession being conceptualised by the department. So concluding and implementing new policies and updating existing ones to include practice regulations for clinical associates, is very slow,” she said.
According to Mgobozi, there is a rise in specialists wanting clinical associates to function as co-ordinators of care within their practices, including helping with patient care, delivery of patient education, and as theatre assistants.
“It is unfortunate that the posts within the public sector are scarce,” she said.
While utilisation of clinical associates has lagged in the public sector, “There is increased uptake of clinical associates among NGOs, where they are providing HIV/Aids and voluntary medical male circumcision services.”
Movement and setbacks
Currently, clinical associates can only prescribe drugs up to schedule 4. According to their scope of practice, they can: “Prescribe … 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. For drugs not on the EDL the prescription must be counter-signed by a medical practitioner.”
This means they still need a supervisor’s signature, which can lead to delays that affect patient outcomes, especially in emergencies.
As it stands, the scope of practice authorises them to prescribe the medicine, but the Act says otherwise. 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, she added.
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 must collaborate to develop and implement policies in line with the needs of the provision of healthcare.”
The challenges, however, do not end there.
She has urged the health department to create more clinical associates’ posts, saying there should be more inter-professional education so that professions do not function in silos but rather collaboratively, to enhance patient care.
Cholombira echoed this, adding that career and salary progressions were 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 a course in emergency medicine, tailored for them, but what if they want to further their studies in obstetrics, for example?”
In 2018, the Professional Association of Clinical Associates in South Africa (Pacasa), in a briefing to MPs in Parliament, said it was time that “a new job evaluation 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.”
Then, 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”.
Earlier this year, Health Minister Dr Joe Phaahla said discussions were under way to address the occupation-specific dispensation (OSD) for clinical associates, among others. But he cited the state’s fiscal constraints as a stumbling block that might impede the creation of more posts.
Complaints and delays
A ministerial task team was appointed in 2015 to better understand the issues facing clinical associates and to recommend solutions.
A report was finalised in 2017.
However, when, by 2019, the health department had not implemented the recommendations or addressed the issues in the report, Pacasa approached the Office of the Public Protector to complain, arguing that “the challenges experienced by clinical associates relating to [their] integration within the health system, conditions of service, and their development, 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.
2030-HRH-strategy-19-3-2020
See more from MedicalBrief archives:
SA healthcare on collision course with staffing crisis and growing disease burden
Exodus of doctors, nurses pushes up healthcare costs, says expert
Rural students could solve South Africa’s doctor dilemma
Year of the Healthcare Worker: Community health workers must be better supported in 2021
NHI Bill ‘won’t be a silver bullet’ in saving public healthcare in SA