Reflections from the rural Eastern Cape
By: Sharon Gostino, RHAP intern
During my training as a public health practitioner two years back we learnt about the role of various health cadres but little mention was made of the new health cadre of Clinical Associate that was introduced in South Africa in 2008. This was not by chance – in general little is known in society, and through my internship at RHAP I discovered that the health sector is yet to fully embrace this cadre. That’s a pity as they could help us make a giant leap in improving access to healthcare for people in rural areas. I hereby take the opportunity to share what I have learnt about the value of Clinical Associates hoping it will contribute to greater awaraness and support to this mid-level healthcare worker.
The Clinical Associate profession was introduced into South African tertiary institutions in 2008 through a 3 year Bachelor of Clinical Medical Practice degree. The profession is referred to as physician assistant in many parts of the world or clinical officers in many parts of Africa. The first cohort concluded their training at the end of 2011 at Walter Sisulu University. This was followed by students at the University of Witwatersrand as well as the University of Pretoria. The introduction of the new profession was a way of addressing the continuous and severe shortage of health care workers especially in the public health sector. The new profession is part of the HRH solution needed to achieve the goals of the National Health Insurance (NHI) policy, which aims to ensure access to healthcare for all based on need and equity.
Clinical Associates are qualified to:
- Conduct consultations (history taking and physical examination)
- Order and interprets investigations (lab tests, X-rays)
- Diagnose and treat common conditions
- Perform procedures
- Assist in surgery
- Provide patient education and counselling
- Make appropriate referrals
The profession has a lot to offer South Africa particularly in rural communities where staff shortages are the greatest. However the work of Clinical Associates often goes unnoticed and this needs to be addressed at different levels but particularly at leadership level.
In September 2017, I had the privilege of speaking to Nwabisa Mgobozi, a Clinical Associate from Canzibe Hospital, a rural hospital in the Eastern Cape. As a rural hospital, staffing shortages has been a regular occurrence over the years but in 2017 the doctors’ shortage reached crisis levels, dipping from 7 to 2 doctors. Nwabisa joining Canzibe during this crisis period and having her around made a significant difference. She worked in the out-patient department (OPD) when doctors were in surgery, while queues were long and the need for support was the greatest.
Hailing from Hillcrest, Mthatha in the Eastern Cape, Nwabisa, a graduate from the University of Witwatersrand started working at Canzibe Hospital in March 2017. Despite living and growing up in the same province, working in a rural area of the Eastern Cape has not been easy to navigate particularly for a young, energetic millennial. Canzibe Hospital is far off the beaten track. Coming off the main road from Mthatha, there is a further 26km of gravel, sand, dust and hard driving before arriving at the entrance of the hospital. Many have turned away from this difficult and challenging road, but Nwabisa is responding to the call of duty.
Despite the many challenges confronted by this dynamic clinical associate, Nwabisa adores the fact that she can do many of the functions of a doctor such as giving a diagnosis and working in casualty. She also loves the fact that she is able to help people who are really in need of medical assistance. She explains that she often comes across chronic illnesses such as heart diseases, depression, arthritis, cancer and diabetes. She added that many patients only seek help when they are really sick which is symptomatic of delayed health seeking behaviour.
Rural, remote and underserved areas do not attract a high number of health professionals as their urban counterparts do and it is for this reason that a bigger investment needs to be made in Clinical Associates. A research that was undertaken gives a clear understanding on how the profession will not only be cost-effective for the department but it would also cover the gap of the health workers especially in rural areas. By employing more clinical associates, the quality of health care that is administered in rural areas will improve and enhance equity in the health system. The envisioned plan was to provide for five clinical associates per district hospital. This target has not been met as the annual university intake has been significantly low and insufficient Clinical Associate posts are created.
As mid-level medical workers, clinical associates face challenges in terms of remuneration, career progression, scope of practice and generally a sense of acknowledgement for their great contribution to the health sector.
In 2012, the Professional Association of Clinical Associates in South Africa (PACASA) was established. This is a formal representative board that is aimed at advocating and developing the Clinical Associate profession. The board provides guidance on the cases that are to be handled by the Clinical Associates, requirements for professional progression and licencing issues.
Clinical Associates in rural areas are adequately positioned to provide quality health care services in the Primary Health Care (PHC) system. Clinical Associates are that next generation of health worker that will take public health care to greater and higher levels. As clearly indicated by the work of Nwabisa, Clinical Associates have the capability of making huge difference in our health system.
 Jimba, M., Cometto, G., Yamamoto, T., Shiao, L., Huicho, L., & Sheikh, M. (2010, November). Health workforce: the critical pathway to universal health coverage. In World Health Organization, editor. First Global Symposium on Health Systems Research. Montreux, Switzerland: WHO.
 Hamm, J., Van Bodegraven, P., Bac, M., & Louw, J. M. (2016). Cost effectiveness of clinical associates: A case study for the Mpumalanga province in South Africa. African Journal of Primary Health Care and Family Medicine, 8(1), 1-6.