SOUTH SUDAN — I am in South Sudan for the next few weeks and have been fortunate enough to observe the training of a new kind of health professional.
They are called clinical associates, and they are given a bachelor degree when they complete their training program. The clinical associates are not medical doctors but are trained to do surgery in their home villages. The United Nations funds the program.
Many of these people were trained as clinical officers, and now they are stepping up to become clinical associates.
The African Medical and Research Foundation, or AMREF, launched in 1957 by three doctors and is in South Sudan and other places in Africa. In South Sudan, AMREF explains: “There is only one doctor for every 150,000 people, compared to the U.S., which has one doctor per 270 people. The few doctors that do exist mainly work in private clinics, leaving most of the population without access to any kind of health care. To help alleviate this crisis, they train clinical officers to serve in rural areas, helping educate communities on how to maintain their own health. These clinical officers are able to perform 70 percent of the work of a doctor, but can be trained in half the time at one-fifth the cost.”
Publicity has focused on clinical associates in South Africa, but they are very present in South Sudan.
Professor Khaya Mfenyana, executive dean, faculty of health sciences at Walter Sisulu University, and another center director in South Africa, said: “In the Eastern Cape, where our clinical associates are working, patients often travel great distances to go to a hospital because local healthcare clinics are so understaffed. The clinical associates will help the doctors by relieving their workload, which will allow doctors to focus on more complex cases. Patients will be treated sooner and closer to their homes, and that will help reduce the disease burden in South Africa and help improve overall patient outcomes.
Professor Ian Couper, director of the Center for Rural Health at the University of the Witwatersrand, said: “Clinical associates will play a vitally important role in rural health care. From the outset, rural doctors have welcomed this new cadre of workers and have looked forward to working with them. Their support of the team in rural district hospitals will ensure better care for patients and will also enable doctors to engage in greater outreach to clinics.”
Depending on who you talk to, clinical associates were initially trained as part of President George W. Bush’s PEPFAR program (President’s Emergency Plan for AIDS Relief) to prevent AIDS in Africa, but it has been operated by the United Nations. Now, during the first year, clinical associates learn the following:
1) Obtaining patient histories;
2) Performing physical exams;
3) Ordering diagnostic or therapeutic procedures;
4) Interpreting findings and diagnosing common emergency conditions;
5) Developing and implementing a treatment plan;
6) Monitoring efficacy of therapeutic interventions;
7) Assisting with surgeries;
8) Providing patient education and counseling; and
9) Making appropriate referrals for specialized care.
Some of these clinical associates have training as clinical officers and have been trained in these topics before. For others, this is a new area. They have exams in all aspects of medical training, including anatomy and obstetrics. South Sudan has been known to have the highest maternal mortality rate in the world. Therefore, having a competent practitioner to deliver a child, especially when there are complications, is crucial to preserve the lives of the unborn child and the mother.
Watching the training of the clinical associates in South Sudan is impressive. The students know so many of the World Health Organization, or WHO, ways of diagnosing problems. They have written, along with UNFPA (United Nations Population Fund) and UNICEF, many ways of delivery of care in many different areas. For instance, the students knew the 4 Ts – tone, tissue, tear/trauma, thrombin – developed by WHO.
Without the WHO teaching and clear “how to” instructions, students in the clinical associates programs wouldn’t know what to do or how to do it. These guidelines govern the treatment of women with special needs as well as women with HIV and instructions and education in postpartum care.
We are focused on training physicians in the United States, but not every country has the resources to train enough physicians. The clinical associate, a new kind of health professional, is one answer to this problem. The United Nations has stepped up to the plate with great results.