Developing a new mid-level health worker: lessons from South Africa's experience with clinical associates

Abstract

Background : Mid-level medical workers play an important role in health systems and hold great potential for addressing the human resource shortage, especially in low- and middle-income countries. South Africa began the production of its first mid-level medical workers – known as clinical associates – in small numbers in 2008.

Objective : We describe the way in which scopes of practice and course design were negotiated and assess progress during the early years. We derive lessons for other countries wishing to introduce new types of mid-level worker.

Methods : We conducted a rapid assessment in 2010 consisting of a review of 19 documents and 11 semi-structured interviews with a variety of stakeholders. A thematic analysis was performed.

Results : Central to the success of the clinical associate training programme was a clear definition and understanding of the interests of various stakeholders. Stakeholder sensitivities were taken into account in the conceptualisation of the role and scope of practice of the clinical associate. This was achieved by dealing with quality of care concerns through service-based training and doctor supervision, and using a national curriculum framework to set uniform standards.

Conclusions : This new mid-level medical worker can contribute to the quality of district hospital care and address human resource shortages. However, a number of significant challenges lie ahead. To sustain and expand on early achievements, clinical associates must be produced in greater numbers and the required funding, training capacity, public sector posts, and supervision must be made available. Retaining the new cadre will depend on the public system becoming an employer of choice. Nonetheless, the South African experience yields positive lessons that could be of use to other countries contemplating similar initiatives.

• mid-level medical workers
• human resource policy and production
• district hospitals
• South Africa
• policy analysis

Acknowledgements

This article is based on a study funded by the Consortium for Advanced Research and Training in Africa through a grant from the Bill and Melinda Gates Foundation. The Consortium is co-directed by the African Population and Health Research Centre in Kenya and the School of Public Health, University of the Witwatersrand, South Africa.

Notes

^#Supplement Editor Sharon Fonn has not participated in the review and decision process for this paper.

¹In South Africa, district hospitals are staffed by generalist doctors and operate at sub-district level, providing support to primary health care services.