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18 August 2008

Programme Director
MEC for Health in the Eastern Cape
Deans of Faculties
Coordinators of the Programme
Representatives of donors present here
Senior officials from the Departments of Health
Trainees present here today
Ladies and gentlemen

It is my honour and privilege to address you this morning on this important occasion, the official launch of the training of Clinical Associates in South Africa here at Walter Sisulu University, where training began in January 2008 with an intake of 23 students.

The launch of this crucial and progressive programme at this institution tells a story about our commitment to the rights especially the health rights of our people, something that came to define the character and personality of the person after whom this university is named, Walter Sisulu.

This occasion also serves to acknowledge the donors who have participated in the implementation of this very important programme for our country.
Occasions like this are important because they bring us together to celebrate milestones or some achievements and allow us the opportunity to re-dedicate ourselves to the imperative of improving the quality of life of all our citizens.

In March of 2004 at the official launch of the midlevel healthcare worker programme, I mentioned the Department of Health Strategy document on Health Human Resources (The Pick Report), which recommended amongst other things, that the mid level healthcare worker be developed by various health professional groups to facilitate the implementation of the primary health care (PHC) package within our country.

Thus began the long process of discussions, debate, preparation and finally implementation of the training of this cadre of healthcare providers for doctors – the Clinical Associate. We are certain that South Africa's adoption of the policy of a healthcare delivery system based on the Primary Health Care approach will be made stronger by the inclusion of this new cadre of healthcare providers. We still believe that by the training of Clinical Associates, our goal of Health for All will be achieved.

Today, we come to officially launch the training of the Clinical Associates. This is a day certainly worth celebrating! Allow me to take the time to briefly remind you of the challenges we have to provide Primary Health Care to the people of South Africa. Despite the fact that enough young doctors graduate from the eight medical schools in the country, the provision of doctors to all our people remains inadequate.

There are many factors contributing to the mal-distribution of doctors including the migration to the private sector and to countries abroad. The urban bias also skews the picture and impacts negatively on the implementation of primary health care. Apart from this programme, another strategy was the introduction of community service for doctors, which went some way towards addressing the problem but not entirely. Currently, despite all our efforts, there are a variety of health facilities in urban and peri- urban areas, which experience severe shortages of doctors and other healthcare professionals.

Prior to the official launch of the midlevel worker in 2004, the introduction of such a cadre was discussed and endorsed by MINMEC on 6 December 2002. The development of this programme was then further endorsed in subsequent MINMEC meetings. To briefly remind you a delegation comprising officials from both the Department of Health and Health Professions Council of South Africa was commissioned to conduct a study tour of the Unites States of America Tanzania to witness, first hand, the training and utilisation of this cadre of healthcare provider and to benchmark best practices of these countries, which have run these programmes for many years.

In the USA they are referred to as Physician Assistants (PAs) and were developed in the mid 1960's in response to a shortage of doctors in rural areas.  The first group trained were corpsmen from the army, who had large amounts of hands-on emergency clinical experience. PAs were in primary health care only, but later started to work in other medical specialities. The PAs do not function independently but practice in association with physicians. The supervising doctor may not be physically present for a PA to practice, but takes responsibility for the work of a PA. They do routine work performed by doctors, like physical examination, diagnosis, carrying out investigation as well as treatment and prescribing.

In primary healthcare, PAs work with a team of family physicians and nurse practitioners. Training programmes are offered at medical schools, mostly as post-graduate courses. For their selection, substantial experience in the health care field is a recruitment requirement. A typical student would have a bachelor's degree in any discipline with four years' experience in a variety of healthcare activities.

To practice, the PA, upon completion of their studies, must pass a National Certification examination. The PA must then apply to the medical board of the state in which they choose to practice for a practicing license, which is granted once an employing supervising doctor has been identified. The scope of practice of the PA is then linked to the scope of practice of the supervising doctor.

The motivation for developing this cadre was not different in Tanzania.  The Medical Assistant, as they are called in Tanzania, was also developed due to an absolute shortage of medical doctors after that country gained their independence. The assistants were trained as rural medical aides. As the education system developed, the entrance criteria and the level of training increased.

There are currently four levels of mid-level workers in Tanzania:
Rural Medical Aids, the medical assistant, the clinical officer and the Assistant Medical Officer (AMO) all of whom are registered by the Tanganyika Medical Council. The training is overseen by the Tanzanian Department of Health and the non-governmental organisations (NGOs) and is done in training centres throughout the country as opposed to Universities.

Training for both the American and Tanzanian cadres is based on Medical training, with emphasis on understanding and management of common diseases and management of health care, while being oriented towards problem-solution and patient-centred. I would now like to discuss the rationale for the Clinical Associate Programme in South Africa, and our training approach based in part by the guidance of the World Health Organisation (WHO).

As I have said, due to a shortage of health professionals and increasing health care needs, a decision was taken and endorsed by MINMEC to establish a midlevel medical worker. As a country, we have learnt lessons with midlevel health workers like dental therapists and assistant pharmacists. These hard learnt lessons were taken into consideration during the development of the Clinical Associate Programme.

Several years of consultation were embarked upon before coming to a consensus on the South African model of this cadre of healthcare provider. Stakeholders consulted included the HPCSA, South African Medical Association, South African Nursing Council, and educators from the faculties of health science, amongst other. A Ministerial Task Team was also appointed to aid the Department in the process of implementation of the programme.

Consensus was reached that at the end of the training of Clinical Associates, they will be a competent, professional member of the health care team with the necessary knowledge, skills and attitudes to function effectively in the district health system in South Africa, primarily working with and under the supervision of a qualified medical practitioner. The clinical associate’s practice will include medical services within the education, training and experience of the clinical associate delegated by the supervising doctor.

Clinical Associates will be permitted to provide any medical service delegated to them by the supervising registered medical practitioner when such service is within their scope of practice, forms a component of the doctor’s scope of practice, and is provided with supervision by a doctor. The clinical associate will thus be considered the agent of their supervising doctors in the performance of all practice-related activities including the ordering of diagnostic, therapeutic, and other medical services.

Upon completion of their training a three year bachelor's degree – the Bachelor of Clinical Medical Practice (B.CMP) - will be awarded. The registration of the qualified clinical associate will rest with the Medical and Dental Board of the Health Professions Council of South Africa. This decision was reached after long deliberations with relevant stakeholders and was felt to be the best choice for this new cadre of health professionals.

The clinical training will be conducted in district hospitals and their affiliated facilities as it was felt that this setting would provide a well-defined and manageable level of care and will also serve to strengthen our primary healthcare services. A clear link with the university through internal, telemedicine and blocks of learning at the university will be maintained.
Placing the clinical associates in the district hospital also makes it possible to be specific about the scope and limits of practice for this healthcare provider.

The clinical associate's scope of practice is defined by the context and requirements of district hospitals with particular focus on emergency care, skilled clinical procedures and in-patient care. Medical services to be provided by the clinical associate may include, but are not limited to obtaining patient histories and performing physical examinations; ordering and/or performing diagnostic and therapeutic procedures; interpreting findings and formulating a diagnosis for common and emergency conditions; developing and implementing a treatment plan; monitoring the effectiveness of therapeutic interventions; assisting at surgery; offering counselling and education to meet patient needs and making appropriate referrals.

The curriculum will be based on the medical curriculum with the focus on the skilled clinical procedures – both diagnostic and therapeutic and knowledge necessary for the clinical associate to function in a district hospital. A survey of district hospitals was conducted to inform the development of the curriculum for this cadre of healthcare providers and this information was used to create the content of the curriculum.

To be practical, there will be one training site per province at the initial stage. Universities and provincial health departments have collaborated to develop a system that works best for each respective province and university. Selection of students will be done in collaboration with each university, relevant province, and donor organisations; and ideally will come from local communities. Entrance requirements continue to be a National School Certificate with subjects in English, Mathematics, and Biology preferred, with a university exemption.

Let me reiterate that although this new cadre of workers is created to bridge the gap between the urban and rural divide, the well-resourced and under-serviced parts of the country, it is by no means an attempt to replace any cadre of existing qualified health professional. Having provided this detailed context and operational planning let me therefore provided some practical detail in terms of what we are doing and where we are. As I indicated at the beginning, Walter Sisulu University has commenced with the programme with an initial intake of 23 students.

The Universities of Witwatersrand, Limpopo and Pretoria are soon to start with their intake, with Witwatersrand commencing in January 2009 with twice the planned number of students and two sites instead of one. Collectively, the latter three universities will account for 76 students. The issue of funding is another critical element that will determine the success and sustainability of a programme like this. As the Department of Health we have committed ourselves to the funding of this programme through the provision of bursaries covering tuition fees, monthly stipends and student books for the first two cohorts of Clinical Associate students. We have also committed ourselves to the financing of infrastructural renovations that would be required to implement the programme at district level. It is also important that I point out the commitment of provincial health Departments to set aside funding that will ensure the sustenance of this programme. I am happy to announce that provinces have already factored into their budgets this new expenditure item.

Over and above funding from our resources, we are happy organisations such as Department of International Development (DFID), Coega Development Corporation (CDC), European Union (EU) and World Health Organisation (WHO) have all committed themselves to fund the programme. The WHO for instance have committed themselves to fully fund the first cohort of students for three years with an allocation of R4,7 million.

The EU and DFID have committed themselves to funding to the value of R15 million and R4,6 million respectively. The R15 million from the EU is for the year 2008 to March 2009. I also wish to express my thankfulness to the Task Team for working tirelessly to ensure the implementation of this programme. This is why we have to be ever creative and innovative in addressing challenges facing South Africa's health care needs.

I am honoured to officially launch this training on this 18 August 2008, and would like to congratulate Walter Sisulu University for being the first university to start the training of this new cadre of healthcare professionals.

Thank you very much.

Issued by: Department of Health
18 August 2008
Source: Department of Health (http://www.doh.gov.za)