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Expanding Surgical Provision through Clinical Associate Task Sharing
Scott Smalley, Head of Division of Clinical Associates
University of Witwatersrand, Division of Clinical Associates, Department of Family Medicine
and Primary Care, Johannesburg, South Africa
Conference paper for 26th Wits Biennial Surgical Symposium, 2nd-4th July 2018
Advancing surgical practice through innovation and new technologies
South Africa has a shortage of medical providers with only 60 doctors per 100,000, well below
the global average of 152 per 100,000.[1] This is also true in the surgical specialty with only
1621 registered surgeons in South Africa, one surgeons per 34,000 people.[2] In addition, this
is an aging surgeon population, with one third currently reaching retirement age.[2] Coupled
with this inadequate number of providers, is a continued increase in surgical and trauma cases
in the country. Innovative ideas for increasing the number of providers competent to provide
surgical care, along with surgical task sharing and surgical task relocation must be tested and
implemented to increase surgical access and delivery to support the South African healthcare
needs.
Clinical associates can be a solution to this problem. In 2008, South Africa’s National
Department of Health launched the Clinical Associates (ClinA) Programme to train mid-level
healthcare providers in general medicine adopted from the physician assistant model in the
United States.[3] The ClinA is a competent, qualified health professional able to provide a full
range of medical care including primary health care, emergency, surgery, paediatrics and
obstetrics under the supervision of a doctor.[4] Approximately 70-90% of the medical
education in this 3-year bachelor of clinical medical practice (BCMP) degree program takes
place in the practical setting of district hospitals in the emergency departments, wards,
outpatient departments, including the surgical and trauma units.
Clinical associates are registered with the Health Professions Council of South Africa to
practice medicine. They have a defined scope of practice that includes any medical act
delegated to them by their supervising medical practitioner, including minor surgical
procedures and acting as first assist in theatre.[5] Mid-level providers are a recognized cadre
of health professionals by the World Health Organization with recommendation to be
included in health systems planning.[6] Meta-analysis studies of mid level providers have
found similar outcomes for maternal and child health and communicable and non
communicable disease interventions when compared to doctors.[7] A study from Malawi
compared clinical officers to medical officers and found no significant difference for
postoperative outcomes in maternal health after emergency obstetrics procedures for fever,
wound infection or the need to re-operate.[7]
Mid level providers practice medicine in 46 countries with a variation in the length of training,
supervision and scope of practice.[8] This cadre has different titles in different countries such
as in Malawi they are called clinical officer as well as in Kenya, Tanzania, South Sudan,
Rwanda, Uganda, Zambia and Zimbabwe to name a few. They are named physician assistant
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in Liberia, Ghana, Germany, Netherlands, Canada and the United States as well as other
countries. In the United Kingdom they are termed physician associate.[8]
Regardless of the country where they are located, mid level providers are often at the
forefront of providing healthcare at the primary level.[9] This cadre is ideal to be included in
task sharing and task relocation of surgical access and care. Given the disease burden facing
African countries with limited number of surgeons, it is imperative that a new set of health
workers assist with the delivery of surgical care. Studies indicate 24% of the global disease
burden is in Africa with only 3% of the workforce.[10]
Mid level providers in many African countries have proven their ability to share surgical tasks
with similar outcomes to surgeons, with proper training and resources. A study of five general
hospitals in Uganda reported mid level providers performed 5,000 surgical procedures
annually.[10] 84% of all cesarean sections, obstetric hysterectomies and laparotomies for
ectopic pregnancy in Tanzania are performed by clinical officers.[10] In the United States,
physician assistants have been involved in surgical procedures since their inception. The first
program to train physician assistant surgeons began in 1967.[11] Many of the surgically trained
PAs worked in the area of cardiothoracic surgery making significant contributions to improved
surgical care.[12] Studies confirm the outcomes of task sharing of surgical procedures with
physician assistants is comparable to surgeons. A study of Canadian physician assistants
compared thoracostomy tube placement in trauma patients with no outcome difference for
physician assistants versus trauma surgeons.[13] Another Canadian study found no difference
in complication rates between physician assistants and surgical residents for tracheotomies,
percutaneous endoscopic gastrostomy, central venous catheters and arterial lines.[13]
Two studies in South Africa demonstrate clinical associate competence to perform male
medical circumcisions with no difference in outcomes to doctors.[14,15] One study compared
clinical associates to medical practitioners performance of male medical circumcisions in
three clinics and two hospitals in the Tshwane Metropolitan area. Of the 4 850 circumcisions
performed in the period from January 2014 to April 2015, 88.7% were done by clinical
associates with no difference in the incidence of complications compared to the 11.3% done
by medical practitioners.[14] This demonstrates the potential for clinical associates to support
the delivery of surgical care with appropriate mentorship and supervision.
The Lancet Commission of Global Surgery produced an initial report, Global Surgery 2030
describing the envisioned role of surgical and anaesthesia care to improve individual
health.[16] The overview report laid out five key messages to reach this goal. Clinical associates
could play a role in supporting the first three message areas within South Africa.
The first key message is five billion people lack access to safe, affordable surgical and
anaesthesia care.[16] Clinical associates are already trained to provide surgical and anaesthetic
care under the supervision of a medical provider. Of the 937 graduates since 2010, 456 are
currently working for the National Department of Health in district or regional hospitals. Just
under two hundred are in the private sector, providing mostly primary health, maternal and
assisting in surgical care. Fifty-six clinical associates work for non-governmental organisations
with most of them performing male medical circumcisions (Table 1). Gauteng province has
the greatest distribution of clinical associates followed by Eastern Cape and Mpumalanga
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(Table 2). In 2016, a survey of graduate clinical associates demonstrated 30% were working
in a surgically related discipline of theatre, surgical ward, maternity, emergency department
and/or anaesthesia (Figure 1). Clinical associates are currently supporting this initiative to
provide safe, affordable surgical and anaesthesia care. This effort should be increased with
the National Department of Health creating surgical and anaesthesia posts for clinical
associates.
Figure 1: Distribution of ClinAs in district hospitals
Table 1: Employment location of clinical associates
Employment location of ClinAs
Number of Working ClinAs
Government/Public
456
Private
198
NGOs
56
Universities
14
4
Left profession
31
Studying
37
Other (unknown/unaccounted for)
145
Total
937
Table 2: Distribution of clinical associates by province
Province
Numbers of ClinAs
Eastern Cape
116
Free State
14
Gauteng
438
KwaZulu-Natal
75
Limpopo
12
Mpumalanga
80
North West
47
Northern Cape
6
Western Cape
4
Total
792
The second key message is 143 million additional surgical procedures need to be performed
every year to save lives and prevent disability.[16] Current final year clinical associate students
at the University of Witwatersrand have a five-week long surgical rotation, performing more
than fifty surgically related skills and procedures under the supervision and training of a
surgeon preceptor. The students are involved and participate in more than ten surgical cases
during the rotation. At the University of Pretoria and Walter Sisulu University, the final year
students participate in an anaesthesia clinical rotation. The surgical skills learned during these
clinical rotations include suturing, local anaesthesia, central lines, intubation, intercostal
chest drain, spinal anaesthesia, assisting with caesarian sections, appendectomies,
laparotomies, joint aspirations and fracture reductions to name a few (Table 3).
Table 3: Surgical and anaesthesia skills/procedures performed by clinical associates
Surgical and Anaesthesia related Skills/Procedures
taught in BCMP 3-year ClinA degree
Surgical and Anaesthesia related Skills/Procedures
taught in BCMP 3-year ClinA degree
Surgical sterility technique
Regional Blocks - Ring Blocks (penile, digital)
Suturing & surgical knot hand tying
Male medical circumcision - adult
Local anaesthesia & blocks
Suprapubic Catheter/Aspiration
Trauma Survey (Primary & Secondary)
Foreign Body Removal- Vagina/Anal
Advanced Cardiac Life Support - Adult
Removal breast mass
Paediatric Advanced Life Support
Assist Breech Delivery
Defibrillation, manual
Assist shoulder Dystocia Delivery
Cardioversion, synchronized
Episiotomy/Repair vaginal tear
Sedating a Patient
Assist Spinal Anaesthesia (physician presence)
Rapid Sequence Intubation drug admin
Assist in Epidural Anaesthesia (physician presence)
Oral Endotracheal Intubation
Assist with Caesarean Delivery
Needle & Cricothyroidotomy
Removal of Products of Conception - D&C
Central Line Insertion- Internal Jugular vein
Assist endoscopy, gastroscopy, colonoscopy
Central Line Insertion- Femoral vein
Assist laparotomy
Intraosseous access
Assist hernia repair
Arterial Blood Gas - Radial, Femoral
Assist appendectomy
Suturing complicated - Eyelid, Ear
Assist tubal ligation
Pre-Op Assessment - Surgical Risk
Assist surgical procedures
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Intra-Op Assessment
Assist with closed fracture reduction
Post-Op Observation
Apply Traction Splint (long bone)
Assist general anaesthesia induction
Pelvic immobilisation
Incision of Single Thrombosed Haemorrhoid
Assist Open Fracture Reductions
Lymph Node Biopsy
Removal of K wire
Diathermy/Cautery
Knee Joint Aspiration
Cautery/Excision of Condylomata
Close Surgical Incisions
Skin graph
Pre-Op Surgical Note
Pleural Tap – thoracentesis
Surgical Note
Abdominal paracentesis
Post-Op Progress Note
Death Notification
For clinical associates to make an impact in surgery and anaesthesia to support the Global
Surgery 2030 vision, it is recommended to initiate a postgraduate Honours degrees in these
disciplines. The University of Witwatersrand in 2017 started the first Bachelor of Clinical
Medical Practice Honours in Emergency Medicine. The postgraduate year of study has a
clinical associate placed in the emergency department performing all aspects of the
discipline with direct training and guidance from the emergency consultants. Learning
objectives are clearly defined with students being responsible for producing a student
portfolio. The student’s day to day learning activities are captured on an eLogbook using a
tablet to record all patient interactions, medical conditions treated with skills and
procedures entered, to track overall performance leading to competence. In addition, the
students are required to conduct a research project in the discipline, which can lead to a
publishable research report. This model is serving as a template in early planning stages for
developing a BCMP Honours in Anaesthesia at the University of Witwatersrand. The College
of Anaesthetists of South Africa and The South African Society of Anesthesiologists are
supporting this effort following early discussions.
A postgraduate Honours in Surgery for clinical associates would the next logical degree to
develop for this cadre. The Honours in Surgery would have immediate benefits to improve
surgical access and care with trained clinical associates as part of the surgical healthcare
work force. The curriculum should be designed in partnership with surgeons, academics and
department of health personnel to include the relevant and appropriate theoretical and
practical surgical skills for graduate clinical associates to make the largest impact. A clinically
focused postgraduate programme with students trained in the surgical care setting aligns
with the recommendation of the Lancet Commission of Education of Health Professionals
for the 21st Century.[17] The transformative educational attributes of the current Honours in
Emergency Medicine can be included in the Honours in Surgery; competency based
curriculum, work based education, inter-professional training and eLearning strategies.
The third key message of the Global Surgery 2030 report is the expanding cost of surgery
and anaesthesia each year with 33 million individuals facing catastrophic health
expenditures for surgery and anaesthesia care.[16] Clinical associates are a cost effective
member of the health care team. Their inclusion in surgical and anaesthesia service delivery
could make a significant impact in the reduction of health care costs. A recent report by the
Clinical Associate National Task Team, submitted to the National Department of Health,
demonstrates that 2.3 clinical associates can be trained for the same cost as one medical
practitioner.[18,19] The 3-year clinical associate bachelor degree cost is R316 770 per student.
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Compare this to the average cost to train one medical student for a 6-year bachelor degree
at R737 719.[18,19]
The cost saving goes beyond the training phase. The National Department of Health
2016/17 average annual salary of a clinical associate, with benefits, (total cost to company
over the first ten years of service) is R306 259 (Table 4).[19,20] The average salary of a medical
practitioner over the first ten years of service is R729 786 (Table 5).[19,21] These numbers
demonstrate that 2.4 clinical associates could be hired for the same cost as one medical
practitioner. The Clinical Associate National Task Team recommends for medical
practitioner-clinical associate health care teams to be formed in the clinical sites. One
medical practitioner can supervise, mentor and collaborate with three clinical associates to
meet the patient demands of a busy emergency department, in patient ward, surgical ward
or theatre setting. If sixteen medical personnel are needed to staff a district hospital, four
can be medical officers and twelve can be clinical associates to create four medical
practitioner-clinical associate health care teams. This will be an immediate salary savings of
R8 million (Figure 2).
Table 4: Average salary of clinical associates in South Africa
Clinical Associate
Year Salary level
Full-time salary
1 Apri 2016
With
benefits
(TCE)**
1
PSAP (Non-OSD)* Level 7: no 1
R 211 194
R 288 249
2
PSAP (Non-OSD) Level 7: no 2
R 214 365
R 292 096
3
PSAP (Non-OSD) Level 7: no 3
R 217 584
R 296 002
4
PSAP (Non-OSD) Level 7: no 4
R 220 848
R 299 962
5
PSAP (Non-OSD) Level 7: no 5
R 224 157
R 303 977
6
PSAP (Non-OSD) Level 7: no 6
R 227 520
R 308 058
7
PSAP (Non-OSD) Level 7: no 7
R 230 928
R 312 193
8
PSAP (Non-OSD) Level 7: no 8
R 234 396
R 316 400
9
PSAP (Non-OSD) Level 7: no 9
R 237 909
R 320 663
10
PSAP (Non-OSD) Level 7: no 10
R 241 476
R 324 991
Average salary over ten years
R 226 038
R 306 259
* PSAP (Non-OSD) = PUBLIC SERVICE ACT APPOINTEES NOT COVERED BY Occupation Specific Dispensation 14
** TCE = Total Cost to Employer
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Table 5: Average salary of medical practitioner in South Africa
Medical Practitioner
Yea
r
Occupation Specific
Dispensation (OSD) post
Full-time salary
1 April 2016 (all
inclusive)
1
Medical Officer (Community
Service) R 551 454
2
Medical Officer (Gr 1)
R 686 322
3
Medical Officer (Gr 1)
R 696 624
4
Medical Officer (Gr 1)
R 707 067
5
Medical Officer (Gr 1)
R 717 672
6
Medical Officer (Gr 1)
R 728 436
7
Medical Officer (Gr 2)
R 784 743
8
Medical Officer (Gr 2)
R 796 506
9
Medical Officer (Gr 2)
R 808 455
10
Medical Officer (Gr 2)
R 820 581
Average Salary over ten years
R 729 786
Figure 2: Cost savings for creation of medical officer-clinical associate health care teams in
district hospitals
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Surgical task sharing and expanded surgical training of clinical associates is a novel and
available solution to the surgical burden facing South Africa. Clinical associates are currently
trained to perform surgical and anaesthesia skills under supervision with immediate benefit
to expand this training with development of Honours degrees in surgery and anaesthesia.
Employment of clinical associates has direct cost saving impact and can increase access to
surgical and anaesthetic care. Clinical associates are an available human resource to address
the recommendations of the Global Surgery 2030 vision.
SUMMARY
1. South Africa has a demonstrated shortage of medical practitioners, including surgeons
to meet the health care demands.
2. Clinical associates, a newly created mid level provider since 2010, are the ideal cadre
to incorporate in surgical and anaesthesia task sharing.
3. Clinical associates are cost effective for training as well as in clinical practice with 2.3
clinical associates trained for one medical practitioner and 2.4 clinical associates hired
for the cost of one medical practitioner.
4. Creation of a BCMP Honours in Surgery and a BCMP Honours in Anaesthesia is a
justifiable means to expand the clinical associate skill base to provide increased access
and care for surgical and anaesthetic patients.
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