Elsevier

The Lancet

Volume 370, Issue 9605, 22 December 2007–4 January 2008, Pages 2158-2163
The Lancet

Public Health
Non-physician clinicians in 47 sub-Saharan African countries

https://doi.org/10.1016/S0140-6736(07)60785-5Get rights and content

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 personnel 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 Mozambique the exodus of physicians during war prompted initiation of NPC cadres.13 After independence in Ghana, a commitment to primary health care delivery led to the establishment of the Rural Health Service, which trained health-centre superintendents, who were later known as medical assistants.6 Much of rural health care in northern Ghana is now provided by these medical assistants.14

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).

Section snippets

Non-physician clinicians

NPCs cannot be easily delineated from other health workers with a simple legal or practical test, since many categories of health workers have taken on diagnostic and treatment functions that were traditionally the domain of physicians. We defined NPCs as health workers with training beyond the secondary school level, who have fewer clinical skills than physicians but more than basic nurses. Our definition of NPCs included workers who were trained to deliver a range of personal clinical health

Discussion

NPCs were working in 25 of the 47 countries we surveyed in sub-Saharan Africa. All 25 of these countries with NPCs ranked among the 36 African countries that are recognised by WHO to have a critical shortage of health workers.39 Nine countries had the same or greater numbers of NPCs as physicians, suggesting that they relied heavily on NPCs' contributions to health systems. Many countries were training increasing numbers of these workers.

The growing HIV/AIDS epidemic and the health targets

References (46)

  • AS Resnick

    How do surgical residents and non-physician practitioners play together in the sandbox?

    Curr Surg

    (2006)
  • R Heller

    Officiers de santé: the second-class doctors of nineteenth-century France

    Med Hist

    (1978)
  • S Ramer

    Who was the Russian feldsher?

    Bull Hist Med

    (1976)
  • YB Cheung

    Community mobilization and health care in rural China

    Community Dev J

    (1995)
  • MI Roemer

    Primary care and physician extenders in affluent countries

    Int J Health Services

    (1977)
  • BG Druss et al.

    Trends in care by Non-physician clinicians in the United States

    N Engl J Med

    (2003)
  • D Dovlo

    Using mid-level cadres as substitutes for internationally mobile health professionals in Africa. A desk review

    Hum Resour Health

    (2004)
  • RA Cooper et al.

    Current and projected workforce of non-physician clinicians

    JAMA

    (1998)
  • L Maryinez

    The crisis in human resources for health: a clue in the colonial past through the example of Uganda. Joint Learning Initiative. Global Health Trust

  • A Beck

    A history of the British Medical Administration of east Africa, 1900–1950

    (1970)
  • T Fulop et al.

    Reviewing health manpower development. Public Health Paper 83

    (1987)
  • W Shibesshi

    The role of health officers in Africa. Proceedings of ProCor: Global Conference on Cardiovascular Health

  • Vergara A. Human Capacity Development in Health: Mozambique. Office of the United States Global AIDS Coordination:...
  • Ghana: country report

  • B Wilson

    Developing countries see health care ‘brain drain’. National Public Radio (USA)

  • C Hongoro et al.

    Health workers: building and motivating the workforce

  • Carter Center Ethiopia public health training initiative: accelerated health officer training program

    (1997)
  • P Fenton et al.

    Caesarean section in Malawi: prospective study of early maternal and perinatal mortality

    BMJ

    (2003)
  • F Vaz et al.

    Training medical assistants for surgery

    Bull World Health Organ

    (1999)
  • H Nkumbe et al.

    Report on human resources development for middle level eye-care workers in eastern Africa

    (2005)
  • Stop Africa's brain drain

    (2006)
  • Course guide

    (2002)
  • Cited by (0)

    View full text