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Non-physician clinicians in 47 sub-Saharan African countries http://www.alphagalileo.org/index.cfm?_rss=1&fuseaction=readrelease&releaseid=521222 Summary Many countries have health-care providers who are not trained as physicians but who take on many of the diagnostic and clinical functions of medical doctors. We identified non-physician clinicians (NPCs) in 25 of 47 countries in sub-Saharan Africa, although their roles varied widely between countries. In nine countries, numbers of NPCs equalled or exceeded numbers of physicians. In general NPCs were trained with less cost than were physicians, and for only 3-4 years after secondary school. All NPCs did basic diagnosis and medical treatment, but some were trained in specialty activities such as caesarean section, ophthalmology, and anaesthesia. Many NPCs were recruited from rural and poor areas, and worked in these same regions. Low training costs, reduced training duration, and success in rural placements suggest that NPCs could have substantial roles in the scale-up of health workforces in sub-Saharan African countries, including for the planned expansion of HIV/AIDS prevention and treatment programmes. Introduction Many nations have a history of health-care provision by staff who are not trained as physicians but who are capable of many of the diagnostic and clinical functions of medical doctors. In the 19th century, the French deployed officiers de santé (health officers)1 for rural medical services; in the 20th century Russian feldshers and Chinese barefoot doctors were active.2,3 These types of health workers are now known as health officers, clinical officers, physician assistants, nurse practitioners, or nurse clinicians. We will describe them as non-physician clinicians (NPCs). Non-physician clinicians deliver health services in both developed4,5 and developing countries.6 For example, more than 300 000 non-physician clinicians practise alongside physicians in the USA.7 NPCs were present in sub-Saharan Africa during the colonial era; the British in particular trained health workers known as apothecaries, who dispensed medicines and often assumed additional clinical duties (Kadama P; Ministry of Health, Uganda, and WHO Health Policy and Strategic Planning; personal communication). In Uganda, an African Native Medical Corps was formed in 1918, with training programmes at the government hospital in Mulago.8 In Kenya, from the 1920s, health workers known as dressers and dispensers were trained to provide basic surgical and medical care, respectively.9 Agents sanitaire were trained in the Congo and elsewhere in French-speaking colonial Africa.10 The rationale for development of NPC programmes before and after independence was the need for person-nel to deliver medical services in poorly served regions.11 But despite the practical benefits of educating Africans for increasingly senior clinical duties, some physicians were concerned that training of such personnel would result in professional dilution.9 This tension was evident in the titles used to designate African NPCs between the 1920s and 1960s, which included subassistant surgeon, subdispensary attendant, senior native medical assistant, senior African medical assistant, medical assistant, medical auxiliary, and clinical officer.9 Ethiopia initiated
education of health officers at the University of Gonder in 1954.12 In
countries such as Robust information on national health workforces is not available in many countries. Reasons for this include different data collection agencies for trainees and workers; employment by both governments and non-governmental organisations; the difficulty of tracking retirements, deaths, and emigration; and the cost of maintaining accurate workforce data. To obtain primary data about NPCs, we used a key informant tree, whereby we surveyed individuals in all 47 countries, including officials in ministries of health and education, academicians, health programme directors, local government officials, and members of non-governmental organisations and faith-based organisations. NPC registries were also available in seven countries (Ethiopia, Ghana, Kenya, Malawi, Tanzania, Uganda, and Zambia). We investigated the background, role, and status of NPCs in the 47 countries of sub-Saharan Africa (Angola, Benin, Botswana, Burkina Faso, Burundi, Central African Republic, Cameroon, Cape Verde, Chad, Comoros, Côte d'Ivoire, Djibouti, Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, The Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritius, Mozambique, Namibia, Niger, Nigeria, Republic of the Congo, Rwanda, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, Sudan, Sao Tome & Principe, Swaziland, Tanzania, Togo, Uganda, Zambia, and Zimbabwe). References 1 Heller R. Officiers
de santé: the second-class doctors of nineteenth-century France.
Med Hist 1978; 22: 25-43. Please credit www.kubatana.net if you make use of material from this website. This work is licensed under a Creative Commons License unless stated otherwise.
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