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Developing a new mid-level health
worker: lessons from South Africa’s
experience with clinical associates
Jane Doherty
1
*, Daphney Conco
1
, Ian Couper
2
and
Sharon Fonn
1#
1
School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa;
2
Division of Rural Health, Faculty of Health Sciences, University of the Witwatersrand,
Johannesburg, South Africa
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.
Keywords: mid-level medical workers; human resource policy and production; district hospitals; South Africa; policy analysis
Received: 3 August 2012; Revised: 3 October 2012; Accepted: 10 October 2012; Published: 24 January 2013
A
chieving universal coverage requires strong dis-
trict health systems that reach even the most
disadvantaged and remote communities (1).
However, attracting staff to work in such settings is a
perennial problem (2). The international experience
suggests that mid-level health workers have played an
important role in addressing human resource shortages
and improving health care access and equity, especially in
low- and middle-income countries (35). A review of mid-
level workers found that they are a world-wide phenom-
enon, playing a variety of roles in both developed and
developing countries, from augmenting the work of
doctors to independent practice (6). They are present in
large numbers in Southeast Asia and are the backbone of
the primary care system in East Africa, with more than
10,000 clinical officers trained in Uganda, Tanzania, and
Kenya alone. They are being introduced, or their roles are
being expanded, in the United Kingdom, Canada, and
Australia. There is evidence that, ‘with appropriate
and adequate training ... and provided with continued
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#
Supplement Editor Sharon Fonn has not participated in the review and decision process for this paper.
æ
BUILDING NEW KNOWLEDGE SUPPLEMENT
Glob Health Action 2013. # 2013 Jane Doherty et al. This is an Open Access article distributed under the terms of the Creative Commo ns Attribution-
Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction
in any medium, provided the original work is properly cited.
147
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support and supervision, [mid-level workers] can indeed
provide care comparable to medical professionals’
(6: 305). However, some mid-level worker programmes
have failed, not because the concept is flawed, but as a
result of ‘ ... weaknesses relating to poor teamwork,
competing market forces, [poor] production processes
and employment opportunities as well as a lack of
synergy between involved role players and the processes
of regulation, production and employment’ (7, p. 7).
This article describes how South Africa embodied the
international experience in the way it conceptualised and
introduced a new mid-level medical worker known as
a clinical associate. The creation of this new cadre forms
part of a broader strategy to strengthen district health
systems and extend health care coverage by dealing with
South Africa’s own human resource shortages. These
shortages are considerable when compared to other
middle-income countries, with 60,000 additional doctors
required to reach ratios equivalent to those in Brazil (8, 9).
The article draws lessons from South Africa’s early
implementation of the clinical associate programme to
inform the efforts of other countries seeking to expand the
range of mid-level workers deployed in their health
systems.
Methods
This article is based on a rapid assessment that used a
qualitative approach and was conducted in 2010 (10).
Prior to commencement, ethics approval was obtained
from the University of the Witwatersrand Committee
for Research on Human Subjects (clearance certificate
M090674).
The study consisted of a document review and a set of
semi-structured interviews. The document review was
purposive in nature and looked at 19 local policy
documents, reports of government and university plan-
ning meetings, preparatory studies, and published opinion
pieces that reflected on the development of the clinical
associate strategy and were easily accessible. Eleven
interviews were conducted with a purposive sample of
stakeholders integrally involved in the mid-level medical
worker programme through policy development, plan-
ning, or training (i.e. national and provincial ministries of
health, the national Treasury, training institutions, and
professional councils).
The issues that were investigated through both the
document review and interviews included the reasons for
the programme and its objectives; the history of the
programme, including the process of stakeholder engage-
ment; the roles and attitudes of the various stakeholders;
the key design features of the programme and the reasons
for these; the successes and challenges of early imple-
mentation and the reasons for these; and future problems
anticipated. These themes were developed on the basis of
lessons from international literature as well as the
authors’ personal knowledge of South African and
international mid-level worker programmes.
Prior to the interview, each key informant was pro-
vided with an information sheet and consent forms.
Two senior researchers using semi-structured interview
guides and a recorder conducted interviews. All interviews
were transcribed. The anonymity of key informants was
protected by using number codes for interview transcripts.
A thematic analysis was conducted on the document
reviews and interview transcripts based on the pre-
identified themes. Information that could be triangulated
because it appeared in several sources (whether docu-
ments or interviews) formed the basis of our findings,
although sometimes we had to formulate findings on the
basis of single sources of information (in which case these
findings are indicated as tentative). During write-up, Walt
and Gilson’s Policy Analysis Triangle (11) was used to
group themes: this approach makes explicit the complex
interaction between actors (at the centre of the triangle)
and context, process and policy design (at the points of
the triangle), aiding understanding of why and how a
policy has an impact.
The final draft of the study report was sent to key
informants who were given several months to provide
feedback. Seven people submitted comments, providing
another opportunity for triangulation, and these were
incorporated into the final version of the report.
A limitation of the study was that not all of the
stakeholders who were initially identified by the research-
ers were available for interview during the study’s time-
frame. However, the most relevant stakeholders were
interviewed and key informants provided some informa-
tion on other stakeholders’ positions. Very little new
information came to light during the final interviews,
which suggested that some measure of saturation had
been achieved and that the interviews were able to
capture the main dimensions of policy-makers’ and
implementers’ experience.
Results
Key features of the clinical associate programme
The overall purpose of South Africa’s clinical associates
is to strengthen health care at district hospitals
1
as
integral members of the health care team, in the context
of revitalising primary care at district level. They take
over some of the tasks of doctors so that their time is
freed up to perform higher-level functions. Some of these
tasks are currently being performed by nursing staff
though they are outside of their scope of practice,
a form of task-shifting that is common in resource-poor
1
In South Africa, district hospitals are staffed by generalist doctors
and operate at sub-district level, providing support to primary
health care services.
Jane Doherty et al.
148
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settings (12). By allowing other cadres to focus on their
own roles and fulfil them better, and strengthening a level
of hospital care that suffers severe staff shortages in
South Africa, clinical associates will provide better
access to care for marginalised communities and reduce
the need for referral.
Clinical associates are required to work under the
supervision of doctors. Their scope of practice includes
patient consultation and physical examination, routine
diagnostic and therapeutic procedures, assisting with
emergencies and inpatient care, and counselling. Their
skills are generalist rather than specialist. It is anticipated
that clinical associates may develop more specialised
skills as they gain clinical experience but this will depend
on the particular needs of the hospital, the interests of the
supervising doctor, and the capabilities of the individual
clinical associate.
Three main features distinguish the clinical associate
from nurses who have developed specialised clinical
competencies (traditionally known in South Africa as
primary health care nurses). First, these nurses are
registered nurses who have completed basic training
through a 4-year degree (or diploma) and then obtained
a post-basic diploma. Therefore, their training takes at
least 5 years compared to the 3 years it takes to train a
clinical associate. Second, unlike clinical associates, these
nurses are independent practitioners and therefore do not
have to work under the supervision of a doctor. Their
competencies also include prescribing and issuing drugs
on the primary health care essential drugs list (schedules
one to four) (13). Finally, these nurses are trained to
diagnose and treat patients who are appropriately seen in
an outpatient setting and do not have significant training
in conducting the diagnostic and therapeutic procedures
typically required of an inpatient setting.
Training of the first cohort of clinical associates began
in 2008. The bachelor’s degree course is offered by
three of the country’s eight medical schools. A national
curriculum framework guides participating universities
and ensures a common standard while allowing local
differences and protecting university autonomy.
Students are mainly recruited by the four provincial
health authorities participating in the programme (and,
more recently, the South African Military Health Ser-
vices), with a special emphasis on identifying students
from remote areas. Students are offered provincial
bursaries in return for undertaking to work in the
provincial health services immediately after qualifying
for as many years as they received the bursary.
The teaching approach is small-group learning with
maximum practical experience. Class sizes began rela-
tively small, ranging from the mid-twenties to mid-fifties,
although more recently one medical school has settled on
a class size of 80. Students receive some early training on
the main university campus but within weeks spend most
of their time in selected district hospitals that have
received some physical upgrading for training purposes.
Training is coordinated locally by small teams of two
to three staff who mostly have ‘joint appointments’
(where the incumbent has both academic responsibilities
towards a university and service responsibilities towards
the public health sector). In one province, the aim is to
have 12 clinical associate students per district hospital in
each year of study (so that there are 36 students at each
hospital at any one time), with two training staff for every
12 students and one administrative person for all 36
students. District Training Complexes are evolving at
some sites: these allow for the training of medical and
other undergraduates, medical interns, family medicine
registrars, and primary health care nurses alongside
clinical associates.
Thus far, training has proceeded relatively smoothly
and is reportedly of good quality. Pass rates for the first
student cohorts were approximately 95% or more and
new graduates have demonstrated confidence and com-
petence in their new workplaces. There are anecdotal
accounts that staff in training facilities appreciated the
contribution made by students in relieving their work-
load, and there appears to be a demand for new
graduates. However, a formal evaluation of the quality
of graduates has still to be performed as well as an
assessment of the manner in which the first graduates
have been received by the wider health workforce since
their entry into the job market in 2011.
Factors accounting for the early success of the
clinical associate programme
The initial success of the clinical associate programme
was due to savvy policy-making and training implemen-
tation processes, underpinned by favourable contextual
factors. These enlisted the support of key stakeholders
(or at least diffused resistance from potential antagonists)
and resulted in a clinical associate programme tailored to
the country’s needs.
Thus, for example, the political context supported the
introduction of clinical associates. The African National
Congress, the majority party in government since the first
democratic elections, had always endorsed the concept of
mid-level workers while one minister of health was
particularly instrumental in driving the implementation
of the clinical associate programme.
Initial opposition to the concept from some quarters
was dissipated through a process of consultation with a
range of stakeholders, including primary health care
nurses and their trainers, rural doctors and family
physicians, provincial and national ministries of health
and politicians, the ministry of education, medical
schools, professional organisations of doctors and nurses,
and professional councils. Accommodating stakeholder
concerns in the formulation of the new cadre’s scope of
Developing a new mid-level health worker
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practice (e.g. through focusing on procedures and requir-
ing a doctor’s supervision) was important to achieving
stakeholder buy-in, especially among doctors and nurses.
Growing awareness of the human resource crisis facing
South Africa helped in this regard.
Committed and technically expert family physicians
were carefully identified to support government planners.
Together they reviewed international evidence, conducted
country visits, determined the nature of health conditions
that could be dealt with by a mid-level medical worker at
district hospital level, developed the clinical associate
concept, and produced the national curriculum frame-
work. During this process, a Ministerial Task Team was
formed to provide guidance and impetus to policy for-
mulation and early implementation: this provided stabil-
ity in the early years of the programme. Further, some
members were also responsible for developing the clinical
associate course at their home universities, lobbying for
support among their colleagues, and developing a sense
of ownership among university faculty. The health autho-
rities and professional council encouraged this by allowing
each university to develop its own course within the overall
national framework.
Implementers’ viewpoints were incorporated in the
early stages of policy development. This happened partly
through working closely with university-based course
developers who were very familiar with the needs of
remote district hospitals and the challenges of providing
training in these settings, and had already established
good working relationships with some district hospital
staff. Further, provincial-level health officials were in-
volved in all stages of the process: this developed a sense
of commitment to the programme in the provinces and
led to them becoming instrumental in advertising, select-
ing students, awarding bursaries, assisting in the refurb-
ishment of sites, creating ‘joint appointment’ posts for
training staff, and weathering implementation obstacles,
especially funding shortages.
Table 1 provides more detail on how the design of the
clinical associate programme accommodated contextual
factors, stakeholders’ concerns, and implementers’ advice
whilst retaining the original objectives of the clinical
associate programme and wider human resource policy,
namely the extension of health care coverage and
improvement of the quality of care at the district level,
especially in rural communities (9).
Challenges to the sustainability of the clinical
associate programme
While key informants felt that the early curriculum
development and training of clinical associates had
been successful, many pointed out that these achieve-
ments were precarious. One government respondent
ascribed this to ‘rapid implementation which, in my
opinion, overwhelmed our administrative capacity to
actually manage that implementation’.
For example, start-up funding for course development
and training the first cohorts of students was expected
from donor sources but was never properly secured
because of the difficult economic climate faced by donor
countries and banking delays in transferring funds. This
was aggravated by an apparent miscommunication be-
tween the ministry of health and Treasury around
planning and releasing special allocations for the start-
up of the clinical associate programme.
The funding shortfall meant that universities largely
had to draw on their existing resources, leaving teaching
faculty stretched to the maximum. Hospital managers
also found it difficult to pay for new training posts and
other related training costs out of their existing budgets;
provincial directors faced the same problem with funding
bursaries. This raises questions about the prospects
for expansion of the clinical associate programme.
The currently low levels of production will not have
a substantial impact on the health care needs of the
country and considerable scaling up is required to meet
the minimum target of 1,350 clinical associates, equiva-
lent to five per district hospital (9), let alone the 1620
clinical associates per hospital that some key informants
estimated are actually required.
While regular ministry of education subsidies to
universities kick in as students begin to graduate, there
will inevitably be a mismatch between these subsidies and
training costs as class sizes expand, new student cohorts
are added, and more universities participate in the
programme. This threatens the ability of universities to
preserve the high quality of training that was made
possible in the early days of implementation through the
participation of a few highly committed and skilled
teaching faculties and the availability of adequately
resourced district training sites.
The first cohorts of graduates are still working back
their bursaries in the public sector but soon their
obligations will be met. Poor working conditions and
management systems in the public sector contribute to
poor staff retention, especially in rural areas (14). These
conditions may be expected to impact on the aspirations
of clinical associates also, although it is hoped that the
rural origin of clinical associates, and their training in
rural facilities, will equip them better for rural practice
(15). Nonetheless, several key informants felt that the
private sector would ‘snap up’ clinical associates once
they are free to leave the public sector.
Insufficient posts in the public sector could hasten this
brain drain, as has been the experience with other forms of
mid-level workers in South Africa who have migrated to
the private sector. Until now, participating provinces have
used vacant posts for other health professionals to
Jane Doherty et al.
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Table 1
. Design features of the clinical associate programme that contributed to initial successes
Design feature Potential value*
Linkage to training and regulation of doctors
Training of clinical associates is located within medical schools
as a 3-year degree course
Regulation of the cadre is through the medical and dental
board
Confers status on the new cadre
Fosters synergy between clinical associates and doctors who have
to work closely together
Training is quicker and less costly than for a doctor, and there will
not be a brain drain overseas as the degree is not recognised
internationally
Enables post-graduate training which supports career progression
National curriculum and exam
A national curriculum framework guides the courses at different
universities
Students face both a local and national final exam
Ensures comparable training and maintains standards
Allows local flexibility and innovation
Clearly defined position within the district hospital health care team
The clinical associate is conceptualised as part of a collabo-
rative district-level clinical team that includes the doctor
working with a primary health care nurse at the clinic and
health centre level, and the doctor working with the clinical
associate at the district hospital level
The scope of practice of the clinical associate is tailored to the
specific context and needs of the district hospital
There is an emphasis on generalist skills and flexibility in
response to the particular situation of the individual hospital
and health worker
In tandem with policies to improve district management capacity,
supports the development of a particularly weak level of the district
health system (i.e. the district hospital) and relieves the workloads of
nurses and doctors
Responds to the patient profile at district hospitals (district hospitals
do not have enough patients with complex conditions that warrant
full-time specialist clinical associates, such as an anaesthetic
assistant)
Clarifies differences in scopes of practices and reporting lines and
avoids overlap of roles with primary health care nurses
Diffuses concerns of other health professionals
Encourages a sense of belonging to a team
Creates a ‘pluri-potential’ person who is not locked into specific
tasks and is able to adapt to different tasks during their working day
and longer-term career
Rural recruitment and training
Students are recruited from rural and other disadvantaged areas
The bulk of training is in rural facilities
Creates a new route of entry into the medical field, especially for
students from marginalised communities
Produces health workers who can communicate with patients in
their home language
Enhances retention in rural areas
Supervision by doctors
Adequate supervision and support is ensured through making
the presence of a doctor integral to the functioning of a clinical
associate
Strengthens quality of care
Alleviates concerns about the ability of clinical associates to deliver
quality care
Service-based learning
Service-based learning
Creation of District Training Complexes
Provides plenty of opportunities for practical learning
Allows students to become familiar with local circumstances, the
district hospital setting and community in which they will one day
work
Students demonstrate their usefulness to other staff by immediately
relieving their workload
Helps to realise the goal of decentralised, multi-disciplinary
training that makes health workers better equipped for, and more
responsive to, community needs
Allows the development of teaching approaches that can be applied
to other categories of health professional
Provides additional motivation and support for staff, improving
recruitment and retention
*This is the value identified by key informants. Whether the potential has been fully realised needs to be determined by a more
comprehensive evaluation.
Developing a new mid-level health worker
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accommodate new clinical associate graduates, but this
will become increasingly difficult as production continues.
Confrontations between the new cadre and existing
health professionals around the boundaries of scopes of
practice and prescription competencies are also looming.
In the meantime, clinical associates have been stopped
from prescribing by the Pharmacy Council, at least until
new regulations are promulgated, while recently qualified
clinical associates are beginning to challenge their salary
scales, given the extensive amount of work they are
taking over from doctors. It is the international experi-
ence that it is difficult to clarify and protect the
boundaries between the scopes of practice of different
health professional categories, especially in settings that
are hugely under-resourced, as tasks have to be shared by
whoever is on duty (12). It is also likely in South Africa
that clinical associates in some hospitals will be expected
to perform their duties without the required supervision
as doctors are not always available, as has been the
experience with newly graduated doctors working
through their community service commitments (16).
These trends may undermine the carefully negotiated
support of this new cadre by health professional associa-
tions and create aspirations for greater recognition and
remuneration among clinical associates in a context
where the impact on the quality of care whether positive
or negative remains unmeasured.
Immediate priorities for securing the future of the
clinical associate programme
Treasury and the ministries of health and education will
have to find mechanisms to expand and stabilise funding
for the training of clinical associates. The elements of the
training programme requiring funding are summarised in
Box 1. Short-term funding solutions are required at the
start-up of new training programmes and during rapid
expansion, such as special allocations by Treasury, but a
long-term solution would be something like a national
training grant combined with contributions from pro-
vinces’ regular budgets, although these are highly con-
strained in the current economic climate. To reach this
point, the ministry of health needs to present Treasury
with clear documentation that puts the case for clinical
associates, sets targets, and lays out in detail the plans for
scaling up production and deployment: these negotia-
tions are quite urgent given the long lead time involved in
the annual budgeting cycle. Another possible response to
the funding crisis is to improve the efficiency of the
current training programmes which one respondent
characterised as using ‘models of teaching [that] tend to
be very expensive’.
Equally importantly, posts need to be created in the
public sector to absorb new graduates. This is not purely
a technical exercise. There is much professional sensitivity
involved in the issue, relating to how different lengths and
sophistication of training and clinical experience are
recognised and remunerated. This means involving the
ministry of public service administration, one of the few
stakeholders that was not an integral part of earlier
consultations.
More ‘joint appointment’ training posts are also
required. Respondents identified these as critical in
sustaining the quality of clinical associate training at
district hospitals, especially as the number of hospitals
involved in the training programme expands. Partner-
ships between rural facilities and universities also help to
attract good calibre staff (thereby helping to strengthen
the district health system as a whole) and are integral to
realising decentralised training of many other categories
of health worker (17).
Tensions between the different members of the health
care team also need to be actively managed. Whilst a
considerable amount of effort was put into this initially,
there still remains a risk that clinical associates will be
received with suspicion, especially in facilities that were
not involved in training. Orienting managers and other
health professionals to the role of the new cadre, and
advertising the fact that successful relationships have
already emerged between students, staff, and patients in
training facilities, are strategies that may alleviate anxiety
about clinical associates. Clarifying opportunities for the
career progression of clinical associates including post-
graduate training, becoming trainers, and entry into
management echelons is another strategy. A wide array
of interventions to improve staff recruitment and re-
tention for all staff categories, including clinical associ-
ates, is also required to improve the attractiveness of
district-based practice, especially in disadvantaged areas
(3, 15).
Box 1. Costs associated with mounting a new clinical
associate training programme
Salary package for course coordinator.
Salary and other costs related to the design and
approval of the new curriculum and the development
of new teaching materials.
Salary packages for teaching staff (mainly joint
appointees based at district hospitals).
Associated office costs and overheads.
Salary packages for administrative staff.
Infrastructure development, including refurbishment
of district teaching hospitals and district-based
teaching sites.
Accommodation and food for students.
Transport for students.
Bursaries for marginalised students to cover student
fees. (including materials, access to services such as
libraries, etc.)
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Table 2
. Lessons from South Africa’s experience of clinical associates for introducing a new mid-level worker
Positive lessons Cautions
Taking account of
contextual
issues
Support advocacy for a new mid-level worker
programme by drawing on previous policy
documentation, where this exists, and taking
advantage of political moments that are favourable
to change.
Sometimes policy documents pay lip-service to
mid-level workers, which mean that continued advocacy
is required to popularise the concept. Highlight the
relevance of the concept to new policies as they
emerge.
Seize the opportunity provided by an influential policy
champion to drive through the implementation of the
programme.
As policy champions may move on with time, make sure
to build broad-based support for the concept over time.
Managing actor
concerns
Consult widely at the early stages of policy
formulation and allay fears through advocacy and
adjusting the design of the new mid-level worker
programme to take account of stakeholders’ views and
interests without sacrificing important policy objectives.
As implementation proceeds, consensus will erode as
unexpected problems emerge. Address this through
continued consultation and feedback,
modifying the policy or implementation approach if
appropriate.
Build strong channels of communication with key
implementation agencies. In particular, ensure
that Treasury and the ministry of public service
administration are brought on board and participate at
critical moments in the planning process. Involve local
health authorities closely with the process
of student selection and development of training sites.
Other government ministries have their own timelines
and information requirements. Ensure these are met in
order to ensure a smooth flow of activities, such as the
release of funding and creation of new post structures,
levels and staff complements.
Where resistance to the new cadre is encountered
(for example, on the part of health authorities,
training institutions and other health professionals),
allow phased introduction of the programme
to build support on the basis of demonstrable
benefits.
Strong national leadership is required to withstand
pressure from other health professionals where this
is based on narrow self-interest. Complementary mea-
sures to bolster the status of the new cadre may be
required.
Building a strong
process of
policy
formulation and
implementation
Take time to study the international experience,
including visiting best practice sites, and incorporate
these lessons into local policy.
Re-visit these lessons over time, especially when
preparing for the entry of new graduates into public
service, as this is a high-risk moment in the development
of a mid-level worker programme.
Understand health system needs properly,
conducting exploratory studies and consulting widely.
Monitor the programme closely in both the initial years of
production and deployment, including through consul-
tation, in order to check progress against objectives
and detect unexpected problems.
Create a committed team of experts and other
key stakeholders who will drive policy formulation,
consultation and implementation, as well as ensure
continuity.
Sustain this ‘task team’ into the early phases of
deployment of new graduates so that unintended
problems can be addressed before they spark
resistance. Thereafter, sustained effort is required to
ensure that the scaling up of training and the
hiring of new graduates into the public sector
proceeds as planned in order to make a substantial
difference
to the functioning of the district health system.
Include implementers’ concerns from the early stages
of policy formulation.
The intense energy required to implement a new
policy often dissipates once there have been
early achievements. Maintain close links with
implementers throughout the policy development
and implementation process in order to
anticipate problems that may derail these early
successes.
Developing a new mid-level health worker
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Finally, it is unclear whether national-level support for
the clinical associate concept is as enthusiastic now as it
was previously. The ministry of health is absorbed in
implementing two other massive and challenging reforms
(i.e. primary health care re-engineering and national
health insurance). Policy-makers and planners have not
highlighted the part that clinical associates could play in
realising the objectives of these reforms, even though
the latest national human resource policy states very
clearly that the production of more clinical associates is a
priority (9).
Lessons learnt from the clinical associates
programme
The specific findings described above yield some general
lessons around how to take contextual factors into
account when developing a mid-level medical worker
programme, manage actor concerns, build a strong
process of policy formulation and implementation, and
design an appropriate policy. Using the policy analysis
approach of Walt and Gilson (11), we group these lessons
for other countries in Table 2. Also included in the table
are cautions around issues that, in our analysis of the
Table 2 (Continued)
Positive lessons Cautions
Develop a short-term and long-term funding strategy
that will secure the start-up of training, allow scaling up
of the programme and ensure posts are available for new
graduates.
Promised funding does not always materialise or is
released out of synchrony with training and service
needs. This requires contingency planning and
negotiation of interim measures.
Develop an active strategy for incorporating new
graduates into the public health system.
This is one of the most challenging components of
implementation and, if not handled properly, can lead to
the collapse of a programme. While the creation of new
posts is very important, do not neglect ‘softer issues’
such as developing appropriate management systems
and teamwork. In particular, strong
supervision and support systems are required to realise
the potential of the new cadre, which in turn is essential
for establishing the cadre as a permanent feature of the
health system. Active recruitment and retention strate-
gies, including career pathing, are required to prevent
brain drain to the private sector.
Designing an
appropriate
policy
Take care to describe and delineate the scope of
practice well, paying particular attention to meeting
well-defined health care gaps and differentiating the new
cadre from other health professionals with whom they
will work closely.
Assess how the scope of practice plays out in
practice and adjust it where appropriate. Efforts to
strengthen the health system may need to occur in
tandem as it is difficult to realise ideal scopes of practice
under sub-optimal conditions.
Link the curriculum closely to the scope of practice and
health system needs. Create a professional that is
flexible and adaptable so that he or she may work
effectively in typically under-resourced settings.
Implement efforts to standardise training, such as a
national curriculum framework, national exams and
independent evaluations of courses. Allow some local
flexibility in training. In order to prevent brain drain
overseas, tailor training specifically to local conditions.
Conceptualise the new cadre as part of a team whilst
also clarifying lines of reporting.
Implement on-going efforts to build teamwork,
such as better management and communication pro-
cesses.
Recruit students from rural and disadvantaged areas.
This is an important strategy for retention.
Develop mechanisms to support these students e.g.
bursaries, mentorship to support adjustment to the
experience of tertiary training.
Employ service-based and small-group learning.
This requires the appointment and nurturing of locally
based training coordinators, including through
joint appointments between universities and health
authorities.
This is a resource-intensive option but can be used to
strengthen district health systems at the same time
as producing the new cadre. For example, the creation of
District Training Complexes can be used to galvanise
improved training for the full range of health profes-
sionals and act as a spur to recruiting high calibre
staff.
Jane Doherty et al.
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interviews and documents, seem to have been dealt with
less adequately in the South African context. Some of
these were raised as concerns in the early days of
formulating the clinical associate policy (18) and many
resonate with accounts in the international literature
(4, 1921). This suggests that internationally, and in
South Africa, strong national leadership and action are
required to preserve the gains made by mid-level medical
programmes. These lessons and recommendations remain
tentative, however, until a more formal and comprehen-
sive evaluation of the South African clinical associate
programme can be conducted.
Conclusion
South Africa has introduced a new form of mid-level
medical worker to contribute to the quality of district
hospital care. Only small numbers have entered the health
system to date, and it is too soon to tell whether this new
category of health professional will achieve its full
potential. Immediate and significant challenges are scaling
up production, creating funded public sector posts to ab-
sorb new graduates, dealing with tensions between differ-
ent members of the health care team around scopes of
practice, managing the career aspirations of the new cadre
as they gain experience, and preventing a brain drain to the
large and attractive private sector. Assessing the impact of
the new cadre on the quality of care will soon become a
new priority, given general concerns about the quality of
management and clinical supervision at district hospitals.
The mid-level medical worker programme has made a
strong start, however. Technical experts and policy-
makers drew on international experience in the develop-
ment and implementation of the new health worker
programme in order to pre-empt some of the problems
encountered in other settings. They also investigated
South Africa’s own experience of the introduction of
other types of mid-level worker to learn from past
mistakes. This led to buy-in from other health profes-
sionals, integral support and involvement by participat-
ing provincial health authorities, the recruitment of good
quality students from disadvantaged areas, standardised
and good quality training, and possibly allevia-
tion of other health professionals’ workloads. Central to
the success of the programme was a clear definition and
understanding of the interests of various stakeholders.
This experience adds to the considerable international
evidence on the strengths and challenges of developing
mid-level workers and yields some additional lessons that
could be of use to other countries contemplating similar
initiatives.
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.
Conflict of interest and funding
There are no conflicts of interest.
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*Jane Doherty
School of Public Health
Faculty of Health Sciences
University of the Witwatersrand, Johannesburg
7 York Road, Parktown 2193
South Africa
Email: dohertyj@telkomsa.net
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