This is a question I have asked on this seemingly endless journey during our navigation as clinical associates through the South African healthcare system. I reflect as a clinical associate pioneer from the first cohort of graduates at the University of Witwatersrand in 2011 and dissect the past 16 years of the clinical associate profession in South Africa.
I am one of the clinical associates in South Africa who was locally trained and one of many mid-level healthcare workers on the African continent who have joined the workforce to improve health outcomes and alleviate the human resources for health shortage.(1) The shortage of health workers is a known global, continental, and local challenge.(2)
Three universities in South Africa, namely the University of Witwatersrand, the University of Pretoria, and Walter Sisulu University, have offered the Bachelor of Clinical Medical Practice since 2008. The competencies and trustable professional activities of the graduate define the clinical associate primarily as a primary health care provider encompassing patient consultations, physical examinations, formulating diagnoses, ordering investigations, and managing patients holistically while also allowing flexibility to branch into other fields. The clinical associate educators within the three academic institutions have played a critical leadership role in the profession's growth and continuously deliberate on optimizing the clinical associate profession in health care systems.(3)
Achievements
Every journey has lessons, memories, and moments to stop and take in, and since the programme's inception, there have been many strides and achievements.(4) The training of clinical associates utilizes the latest educational models, incorporating workplace-based learning, technology-enhanced learning, and curriculum integration. The curriculum is centered around the disease burden in the country, focusing on common conditions, fundamental medical knowledge, skills, and professional behaviour.
Multiple post-graduate opportunities have opened to clinical associates, such as those in public health, health science education, emergency medicine, and diplomas in HIV/AIDS. Boundaries are being pushed as first-time offers are made to clinical associates for master-level emergency medicine and family medicine post-graduate degrees. A major professional milestone was achieved when a clinical associate, Sanele Ngcobo, attained his PhD in 2022.
The 2022/23 Health Profession Council of South Africa (HPCSA) report noted 1152 actively registered clinical associates who have impacted various workspaces. Primary healthcare clinics and district hospitals in multiple provinces are benefitting from the work of clinical associates, as their skill set complements the skills of medical doctors by offering shared generalist services to the population and supports the nursing staff by functioning within the skills gap identified between a medical doctor and a nurse.
Non-governmental organizations (NGOs) such as the Centre for HIV/AIDS and Prevention Studies were the first to pioneer the employment of clinical associates and offer the fertile soil for clinical associates to showcase their adaptability, trainability, procedural skills, and leadership skills. There is a widespread employment of clinical associates in several NGOs, including their role as the backbone of the Community Oriented Substance Users Programme, an essential institution for harm reduction in substance users across South Africa.
There is growing interest in the services of the clinical associate profession within the private health sector. Observing Quro Medical, an innovative company that provides a “hospital at home” service using a multidisciplinary team and clinical associates, is exciting. There have been budding private fee-for-service practices that have hired clinical associates to provide primary health care services. Emergency Departments within the private sector were amongst the first to employ clinical associates to offer urgent care within a multidisciplinary team in the hospital. More specialists, such as cardiologists, surgeons, nephrologists, anaesthetists, and radiologists, are hiring clinical associates. This model takes on the USA structure of physician assistants providing clinical work and administration as the consistent care coordinator within a specialist practice.(5)
Many clinical associates have met influential colleagues, mentors, and seniors who have positively contributed to their medical knowledge, clinical skills, and clinical acumen. This collaboration, inclusion, and acknowledgment of each other results in effective healthcare teams and improved patient outcomes. A team-based approach enhances service, decision-making, and the quality of the patient experience.
The clinical associate concept, however, faces ongoing administration, implementation, and governance challenges.(6)
Challenges
Unfortunately, the plan to integrate the clinical associate profession into the South African healthcare system has overlooked the human needs and experiences of individuals entering this field. Unemployment has been a significant factor in our country, threatening the financial security of graduates. The lack of sufficient posts for clinical associates within the public sector results in the profession being seen as a ‘stepping stone’ into Medicine (MBCHB) and offers the clinical associate programme as a less favourable option for prospective students. Revising remuneration and job descriptions per salary grades would significantly motivate individuals. This would enhance employee satisfaction and performance.
Due to the budding nature of the clinical associate profession in South Africa, the profession's identity is evolving. Identity develops from childhood. Individuals often affiliate with social groups from a young age, whether it be religious, gender, or interest groups etc. This unites an individual's identity with a likened community in which one identifies. Entering an existing community of practice such as the medical fraternity or nursing is less challenging, as the cultures, rituals and norms have been established and the “Godfathers” have paved the way and built systems. In contrast, the clinical associate profession is 15 years old in South Africa. Since the programme's inception, we are constantly asked, “What is a clinical associate?” This lack of understanding of the role of the clinical associate results in rigid professional silos. The lack of social cohesion results in the lack of an established community, and belonging is required for personal and professional development.
The critical elements of a successful program rely on good governance, health systems accountability, and intentional allocation of human resources considering skill sets. Through the changing political climate since the start of the clinical associate profession, there has been wavering political support and will. We certainly require more protection and strategizing from the HPCSA and academic institutions regarding the scope of practice of a clinical associate to match the community needs during these fast-changing times. The scope of practice needs to be fit for the purpose, ensuring that clinical associates can function optimally in the workplace without restriction that impedes patient outcomes.
Due to inadequate role modelling, apprenticeship opportunities, and adequate supervision, the adverse effects of socialization are noticeable. Unintended factors contribute to cognitive identity dissonance among clinical associates, leading to feelings of marginalization and dampening their enthusiasm for serving, healing, and collaborating. Often, clinical associates are left with unsupported potential, passion, and unaided aspirations for growth and development. Cultivating a culture of acknowledgment and accomplishment would ensure recognition for the clinical associate's quality of work. This leads to a practice of good work ethic and well-suited recognition. Neglecting the human experience of clinical associates may lead to an increase in mental health issues and the development of unstable professional identities.
The challenges of the clinical associate profession are not without resolution, and an imperative solution entails dedicated governance and leadership to oversee the implementation of the profession, robust research to document evidence of the value of the contributions made by clinical associates, and continuous review of the practice regulations to suit healthcare needs.
We are in a better position than when we started, but we are not where we would like to be, and we are still on that journey. We must ensure increasing awareness, recognition, and intentional inclusion of the clinical associate profession. We shall reach the target destination when there is optimal utilization of clinical associates in all healthcare sectors, recognition of the clinical associate in their entire identity, acceptance of their skill set, and appreciation of the value they bring to patient care. We shall reach the destination when all stakeholders, namely the National Department of Health, HPCSA, academic institutions, public sector, private sector, and NGO's, acknowledge the profession's potential and strategically plan for their full incorporation into the health care system.
To truly reform the South African healthcare system, we must intentionally utilize each healthcare professional's skill set, interrelatedness, human experience, and the effects of socialization on healthcare workers. We need to capitalize on understanding the patient experience and plan for the involvement of all healthcare professionals through unity and synergy as care becomes more coordinated.
We will continue the journey and educate others that clinical associates are not substitutes for existing healthcare professionals but an important addition. We are an asset to the healthcare team with enormous potential. We are the new teller in a grocery store that increases customer access to services or, likened to the midfielder in a football game, coordinating patient care. Through these analogies, one comprehends the target of Universal Health Coverage. We have been successful in this holistic integration in some sections and regions of the healthcare sector. Nevertheless, the mission to fully integrate the clinical associate profession into the entire healthcare system in South Africa continues to gain momentum. Embracing this integration is pivotal for ensuring equitable access to quality care for all South Africans.