Physician assistants and nurse practitioners have made a great contribution to the American health care system especially in rural areas where the need is greatest, and many African countries have developed similar programs.

Africa suffers from “brain drain,” losing many educated doctors and nurses to other countries. This has served as the impetus for developing a cadre of paramedical professionals, who work in rural areas in their respective countries, where the need for health services is greatest. Uganda, Zambia, Kenya, Ghana, Liberia, Malawi, and Ethiopia are just some of the countries that rely on paramedical professionals to meet health-care needs.

South Africa is in dire need of health-care professionals. Although it has more than many of its African neighbors, the country’s needs are more intense. Not only does it have an HIV rate close to 21%,1 South Africa has many of the same health-care issues that are seen in some of the poorest African countries, especially among the nonwhite residents, who represent the majority of the population.2

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In 2008, South Africa developed a three-year Clinical Associate program in one of the most disadvantaged regions of South Africa, Eastern Cape. The goal of the program was to recruit students from rural underserved areas and to place the graduates in these regions upon completion of the program to serve in these communities.

Creating the Clinical Associate program was a huge step toward addressing the country’s health-care needs. But how is the program going now, six years later? How are the students faring? And is it accomplishing the goal of creating a health-care workforce willing to work in the most underserved regions of South Africa?

Shabalala Ayanda a student at Walter Sisulu University in Mthatha Eastern Cape, South Africa, where I taught for one year, shared her experiences with Global Health Rounds.

Shabalala’s Story

Shabalala first applied to medical school in South Africa, but was not accepted and decided to apply to the Clinical Associate program, where she is now in her third year. Although initially disappointed, Shabalala said she prefers the hands-on training style of the Clinical Associate program, where she has had much earlier clinical exposure to patients than her peers in medical school. She now feels very confident in her medical skills because of her training.

Clinical Associate students start seeing patients a year and a half into their training. In the second year, they are able to prescribe medications with a cosignature and perform many procedures. Although these students are functioning independently and making huge contributions to the hospitals where they work, they have full back up from Medical Doctors if they need help with a case. Having the opportunity to independently come up with a diagnosis and plan, and then receive feedback from physicians creates highly functioning Clinical Associate practitioners.

Despite the many positive aspects of the profession, not all of Shabalala’s classmates are as satisfied as her. Because the Clinical Association profession is still poorly understood in South Africa, many are tempted to apply to medical school when they finish their training, due to the promise of being more readily accepted as a member of the medical community.  “No one knows who we are and what we can do,” Shabalala said.  

This is a huge loss to the South African health-care system. Not only is it losing much-needed potential rural health-care providers, but also it costs the government more to educate students in both programs.

One of the biggest challenges is that hospital staff are not familiar with Clinical Associates and do not know how the profession fits into the bigger health-care system, Shabalala explained. In regional hospitals where both medical students and Clinical Associates train, medical students sometimes have an air of superiority that can create a barrier to the two groups working together and learning from each other.

However, in other settings, such as the rural district hospitals where Shabalala trained, Clinical Associates enjoy an immense amount of respect and receive great training from MDs. Here Clinical Associates are well accepted, because the doctors understand the significant impact the profession has on productivity in the outpatient clinic. Here they take the time to train the students well, because they see the benefits of this investment in terms of creating a more balanced workload for the staff.