Clinical officer

Clinical officers (COs) are health care providers who are trained and licensed to practice modern medicine. They practice independently but may be supervised by a physician in some settings. COs supplement the work of doctors in Sub-Saharan Africa by performing general medical duties such as diagnosis and treatment of disease and injury, ordering and interpreting medical tests, performing routine medical and surgical procedures, and referring patients.

They usually perform their duties at the level of a junior doctor. COs are trained to handle routine every-day medical care that 80 percent of patients need and carry out treatment that is out of the nurses' scope. No significant difference has been demonstrated in studies comparing treatment decisions, patient outcomes, quality of care provided and level of knowledge about diseases between clinical officers and non-specialist doctors (medical officers)[6]. Because of the nature of their practice, populations they serve and resources at their disposal, COs are less likely to administer expensive treatment, prescribe expensive (but not necessarily better) drugs, or to engage in futile care. This makes them particularly appropriate for Africa.

Their training and practice is based on the old medical maxim that common things occur commonly - sometimes with unusual symptoms - and rare things rarely occur. COs are therefore trained to understand local epidemiological patterns, accurately diagnose (or rule out) common diseases and competently manage them using national medical guidelines. They can diagnose any disease and, if necessary, provide initial treatment to patients before referring them to appropriate practitioners.

Training programs usually involve three or four years of undergraduate education, award of a diploma or a bachelors degree, and completion of an internship year. The training differs from a traditional medical degree by the shorter time spent in biomedical training and emphasis on clinical practice. Students usually complete their biomedical coursework in the first year but spend as much time as doctors - up to three years - in clinical training studying diseases, their causes, diagnosis, treatment and prevention and undergoing supervised clinical practice. Their training is therefore shorter than a full medical degree and requires less resources. Because of their focus on local health systems' needs, their qualification may not be directly transferable to other countries - making them cost-effective clinicians who are more likely to stay in their home country (see brain-drain).

Clinical officers take the Hippocratic oath and are registered by the same or different statutory medical body as doctors depending on jurisdiction. The general nature of their training prepares them to work at all levels of the health care system. Most work in primary care and casualty departments in hospitals where they diagnose and treat a wide range of common diseases, including serious and life-threatening ones, in all age groups; and stabilise then admit, discharge or refer emergency cases. In smaller hospitals they work as hospitalists and those who specialise in a clinical field provide advanced medical and surgical care and treatment such as administering anaesthesia, performing general or specialised surgery, supervising other health workers and other administrative duties.

Their scope of practice depends on one's training and experience, jurisdiction and workplace policies. In Malawi, for instance, COs learn to perform common surgical and obstetric operations such as laparatomy and Caesarean section whereas in Kenya, Tanzania and Mozambique they must undergo additional formal training before undertaking such responsibility.

In poor rural and urban areas, where most people in sub-Saharan Africa live, COs work with minimal resources and rely on the traditional medical history and physical examination, often with little or no laboratory facilities, to make a diagnosis and provide treatment to mostly impoverished populations. Those who work in bigger and better equipped facilities generally can order routine and more sophisticated tests to make or confirm their diagnosis e.g. in district, provincial and national hospitals, universities and colleges, research institutions and private medical institutions.

Clinical officers play an important role in increasing access to essential health care in areas with few doctors. The success in HIV/AIDS prevention and treatment on the continent has been attributed to use of COs to supplement physicians' work by providing diagnostic and comprehensive medical care. Access to emergency obstetric care through greater deployment of COs may also be part of the solution to meeting Millennium Development Goals 4 (reducing child mortality) and 5 (improving maternal health).

The United States' Centers for Disease Control and Prevention and other global health and research institutions make extensive use of COs in their projects in Africa.

Similar health workers are physician assistants in the United States, Assistant Doctors in China, Surgical Care Practitioners in the UK, Assistant Physicians in Saudi Arabia, Health Extension Officers in Papua New Guinea, surgical technologists in Mozambique, and clinical associates in South Africa.

Overview

Countries train and utilise COs in different ways depending on their needs and resources. Against a backdrop of an acute shortage of physicians, Tanzania, Malawi and Zambia train complete physician substitutes who have advanced skills in all medical and surgical specialties including performing major surgery. They are utilised interchangeably with medical doctors.

Elsewhere, COs are more medical-oriented (like in Kenya where physicians perform most major emergency surgery and COs can only perform major surgery within a specialty e.g. cataract surgery, orthopedics and reproductive health); or more surgical-oriented (like surgical technologists in Mozambique who perform major and emergency surgery across specialties). Some countries like Burkina Faso and Ghana train nurses to practice like COs.

Research done by the University of Birmingham and published in the British Medical Journal concluded that the effectiveness and safety of caeserian sections carried out by clinical officers did not differ significantly compared with doctors. Better health outcomes including lower maternal mortality rates were observed where COs had completed further specialised training particularly in anaesthesia.

In the multi-country study, poor outcomes were observed in Burkina Faso and Zaire - the only countries where the procedure was performed by trained nurses. Higher rates of wound infection and dehiscence in these countries was thought to be due to poor surgical technique and need for enhanced training.

Kenya

Clinical officers have been an integral part of Kenya's healthcare system since 1928 when she was still a British colony. The profession probably developed because of segregation laws in pre-independent Kenya. White doctors were probably not allowed to attend to natives; instead, their African assistants, who had amassed considerable medical knowledge and skills from years of shadowing the white doctors, gradually took over that role.

In due course a certificate programme was developed for the medical/hospital assistants. After independence the original certificate course evolved to incorporate formal medical training and was finally phased out in 1967 and replaced with a three-year diploma in clinical medicine and surgery. The Higher Diploma course in paediatrics, ophthalmology and other specialisations was introduced in the late 1970s and the Bachelor of Clinical Medicine and Community Health in 2006.

Although the country went on to establish the University of Nairobi in 1970 and the first medical school, clinical officers continue to play a central role in the country's medical sector.

Today COs are trained by universities, the Kenya Medical Training College (KMTC), St. Mary's School of Clinical Medicine and other private institutions. COs study the same medical books that medical students study and, in the teaching hospitals, they attend the same wardrounds and learn from the same consultants. Those who qualify are also required to follow the same regulations and guidelines that doctors follow. Three senior doctors appointed by the minister of health also sit on the Clinical Officers Council and are involved in all policy and regulatory matters regarding COs.

The Ministry of Health, through the Clinical Officers Council (COC), regulates their training and practice, accredits training institutions, and approves the syllabi of the universities and colleges. The Kenya Medical Training College, also under the Ministry of Health, has campuses attached to public teaching hospitals all over the country and trains the majority of clinical officers. St. Mary's School of Clinical Medicine and St. Mary's Mission Hospital in Mumias, owned by the Roman Catholic diocese of Kakamega, was the first private institution to train COs in Kenya. Students sit the same examination as their counterparts at the KMTC and are examined by consultants from the public hospitals.

The Clinical Officers (Training, Registration and Licensing) Act Cap 260

Clinical officers are legally recognized as qualified medical practitioners. They are required to see, examine and treat patients, sign legal documents such as medical certificates, death certificates and P3 legal forms, and to present medical evidence in a court of law, for instance, in cases of rape and assault.

The Clinical Officers (Training, Registration and Licensing) Act Cap 260 of 1988 of the laws of Kenya is the legal basis for the practice of Clinical Officers. It establishes the Clinical Officers Council whose functions are:

• To assess the qualifications of Clinical officers
• To ensure the maintenance and improvement of the standards of practice by clinical officers and to supervise the professional conduct and practice of clinical officers
• To register and license clinical officers for the purposes of this act
• To collaborate with other bodies such as the medical practitioners and dentists board, the central board of health, the nursing council of Kenya, the pharmacy and poisons board, in the furtherance of the functions of the council and those bodies; and
• To consider and deal with any matter pertaining to clinical officers including prescribing badges, insignia or uniforms to be worn by clinical officers.

Before this act there were many sub-cadres within the profession such as registered clinical officer (RCO), certified clinical officer (CCO), medical assistant, etc., who had different kinds and levels of education. All these were abolished by the act in 1989, in favour of a uniform Clinical Officer (CO) cadre. However the title Registered Clinical Officer (RCO), who were the creme of the profession at one time, has persisted even in official publications.

Training

The first university to train clinical officers was Egerton University in 1999. Programs also exist at Jomo Kenyatta University of Agriculture and Technology, Kenya Methodist University (KEMU) and Mt Kenya University. The diploma in Clinical Medicine and Surgery takes three years to complete on a trimester system. The Bachelor of Clinical Medicine and Community Health lasts four years and is offered as a direct entry, or a top-up degree for diploma holders.

The training follows the medical model. In the first year students learn human biology through in-depth lectures in Anatomy, Physiology, Biochemistry, Pathology etc. The second year involves intensive lectures in the clinical subjects i.e. Medicine, Surgery, Paediatrics, and Obstetrics and Gynecology. The last year concentrates on bedside lectures in a teaching hospital where they rotate in every department. They attend consultants' ward rounds, clerk patients and present medical histories, perform deliveries and act as first assistants in major surgery. They also attend clinical meetings and write prescriptions which at this stage must be counter-signed by a supervising clinician.

There is special emphasis on primary care with modules on community health taught throughout the course. In the third year students must spend at least one month in a Provincial Rural Health Training Centre where they immunise children, examine pregnant women and offer family planning services in mother and child health clinics. They treat in-patients and out-patients under the guidance of qualified Clinical officers. They also organise outreach services where they venture into remote rural villages, seeing patients and immunising children. During this time they complete a project in community diagnosis.

They also learn Health Service Management which prepares them for their management and leadership roles in health centres and other institutions.

Internship and registration

All clinical officers must work as full-time interns for one year at an approved public or mission hospital before getting a license to practice medicine. On passing the final qualifying examination, they take the hippocratic oath then apply for provisional registration by the Clinical Officers Council, the statutory body that regulates the practice of clinical officers in the country. The internship involves supervised rotations in the major clinical departments namely casualty, medicine, paediatrics, surgery, obstetrics and gynecology. They are supervised by consultants in the respective fields. The consultants ensure that they can practice clinical medicine safely before signing them off for registration. An internship booklet duly signed by the consultants is required for registration.

Advancement

The Kenya Medical Training College offers post-basic courses to COs with three years experience. These last twelve to eighteen months leading to a specialised Higher Diploma qualification in paediatrics, reproductive health, anaesthesia, ENT, ophthalmology and cataract surgery, orthopaedics skin and chest diseases, epidemiology and Community health. They are then able to provide advanced medical and surgical care including invasive procedures in their specialisation such as caeserian section, cataract surgery, tonsillectomy and administering anaesthesia.

Many COs hold advanced degrees and diplomas in Biochemistry, Microbiology, Counselling psychology, Management, Statistics, Sociology, Public Health, etc. A good number go on to medical school.

Famous clinical officers

• Karisa Maitha, the late former member of parliament for Kisauni and foreign affairs minister
• Ole Kiu, former Chief Clinical Officer, Ministry of Health
• Mohamed Abdi Haji Mohamed, Member of Parliament for Mandera West.

Burkina Faso

In Burkina Faso, as elsewhere in sub-Saharan Africa, the use of non-physician clinicians began as a temporary measure while more doctors were trained, but has become a permanent strategy in the face of a crisis in health human resources. Different training alternatives have been used. Two-year advanced training programs in surgery were developed for registered nurses. Clinical officers (known as attachés de santé en chirurgie) were district medical officers trained with an additional six-month curriculum in emergency surgery.

Many studies show that trained COs provide quality medical and surgical care with outcomes similar to physicians' providing similar care in the same setting. However, nurses re-trained to become COs have been associated with more adverse outcomes as shown in a study using 2004-2005 hospital data from six regions of Burkina Faso, which associated them with higher maternal and neonatal mortality when they performed caeserian sections. The observed higher fatality rate pointed to a need for refresher courses and closer supervision of the nurses.

Ethiopia

The first medical school in Ethiopia was initially a “health officer” training institution. The training of health officers started at Gonder University in 1954 due to the shortage of physicians. Health officers hold bachelors degrees and undergo a three-year training program plus one-year internship. Those who complete the masters degree provide advanced care e.g. emergency surgery.

Ghana

In Ghana, Medical Assistants (MAs) have traditionally been experienced nurses who have undergone a one-year post-basic course to become MAs. High school graduates can now attend a three-year diploma course to become MAs.

Liberia

In Liberia, the Tubman National Institute of Medical Arts (TNIMA) was established in 1945. In 1965, the physician assistant (PA) programme was established as a joint venture between the Liberian government, WHO and UNICEF. Initially it was a one-year course, but currently it is a three-year diploma course accredited by the Liberia National Physician Assistant Association (LINPAA) and the Liberia Medical and Dental Association Board. In order to legally practice medicine as a PA one must sit and pass a state exam administered by the medical board.

Malawi

In Malawi, where physicians are in short supply and concentrated in the urban areas, clinical officers perform the vast majority of major surgical procedures in district and central hospitals. Clinical officers train for three years and undergo one year internship in order to be able to carry out all the routine functions of a doctor, including minor surgery, obstetric operations such as Caesarean sections, orthopedic care, dermatology and ophthalmology.

Medical assistants can enrol for an 18 month upgrading course to become specialised clinical officers; the upgrading course takes place at Malamulo and Malawi College of Health Sciences.

Mozambique

See also: Surgical technologist

In Mozambique, tecnicos de cirurgia, or surgical technologists, are experienced Clinical Officers who undergo further residential training in surgery under the supervision of senior surgeons lasting two years at Maputo Central Hospital, and a one-year internship at a provincial hospital. They are trained to carry out emergency surgery, obstetrics and traumatology and are deployed to the district hospitals where they are usually the sole surgical care providers.

South Africa

See also: Clinical associates

South Africa trains clinical associates for three years and awards them the Bachelor of Clinical Medical Practice degree. The first program was launched by the late Health Minister Tshabalala Msimang on 18 August 2008 at the Walter Sisulu University in Mthatha. The first class graduated in December 2010. Programs also exist at the University of Pretoria and the University of the Witwatersrand.

Sudan

Southern Sudan separated from the Arab North (Sudan) in July 2011 after years of civil war that left much of the southern part in ruins. The healthcare system is almost non-existent. AMREF started training clinical officers by setting up the Maridi National Health Training Institute.

The graduates supplement the efforts of COs trained in neighboring countries, e.g. Kenya, Uganda and Tanzania, most of who work for international humanitarian agencies.^{[citation needed]}

Tanzania

In Tanzania, training is under the Ministry of Health. There are numerous clinical officer training schools and programs last three years. Internship is not required for registration.

Experienced clinical officers may enrol for an advanced diploma in clinical medicine which takes two years to complete. This qualification is regarded as equivalent to a first degree in medicine by universities and the Ministry of Health in the country. The graduates are known as Assistant Medical Officers. A further two years training leads to a specialist qualification in anaesthesia, medicine, surgery and radiology etc.

Kampala International University has opened a campus in Dar es Salaam where it is now offering its Bachelor of Clinical Medicine and Community Health.

Uganda

In Uganda, the training is under the Ministry of Education and takes place in clinical officer training schools. Postsecondary programs last three years, focusing on medicine and hospice care, followed by a two-year internship.

Kampala International University offers a Bachelor of Clinical Medicine and Community Health. High school graduates take four-and-a-half years to complete this degree while practicing clinical officers take three years.

Zambia

In Zambia, clinical officers (with an advanced diploma) outnumber general physicians (with university degree) across all regions, with the ratio ranging from 3.8 COs per physician in Lusaka to 19.3 in the Northwestern provinces. They perform routine surgical and obstetric operations as well as providing clinical care in hospitals.

International

The specialised nature of medical training in the developed world has created a shortage of general practitioners and runaway expenditure on healthcare by governments. primary care is increasingly being provided by mid-level providers such as physician assistants.

United States

Main article: Physician assistant

Physician assistants in the United States train for at least two years at the postsecondary level and can hold an associate, bachelors or masters degree. Some institutions offer a Doctor of Science degree in the same. According to Money magazine, this is currently one of the best careers in the US. The profession is represented by the American Academy of Physician Assistants.

United Kingdom

The United Kingdom has in recent years employed physician assistants from the United States on a trial basis as it plans to introduce this cadre into their health care system.^{[citation needed]} Several universities are already offering a post-graduate diploma in Physician Assistant studies. However there are already other mid-level care providers known as Emergency Care Practitioners and Operating department practitioners.

Australia

The University of Queensland offers a one-and-a-half-year Master of Physician Assistant Studies to those with a bachelors degree. Those with a post-secondary healthcare qualification such as registered nurses and paramedics can access the programme via a Graduate Certificate in Physician Assistant Studies; as long as they have at least five years full-time working experience.

China

China has about 880,000 Rural Doctors and 110,000 assistant doctors who provide primary care to rural populations where they are also known as barefoot doctors. They typically have about one year of training; those who sit and pass government examinations qualify to be rural doctors. Those who fail become community health workers. However, there is a government move to have all rural doctors complete three years training.^{[citation needed]}

Fiji

Africa and the rest of the world are perhaps following a well trode path. In 1879, a group of Indians arrived in Fiji by ship having survived cholera and smallpox en route. During a period of crew quarantine, a small group was trained in vaccination. The experience was considered so successful that a few years later, in 1885, a group of young Fijian men started a three-year training program at the Suva Medical School, now known as the Fiji School of Medicine. The title given to the professional practice has had many names over the years, including Native Medical Practitioner, Assistant Medical Practitioner, Assistant Medical Officer, and Primary Care Practitioner (PCP). By 1987, the PCPs were training for three years before going back to their communities to serve one-year internship, followed by another two years of study after which they were awarded a MBBS degree.

India

Under British rule, India trained licenciate doctors for three years. They were then registered with the General Medical Council of Britain. Most of them worked among the rural population providing medical care.

After independence, and on the recommendation of the bhore committee in 1946, the training of licentiate doctors was stopped and their qualifications converted to MBBS degrees. They were then grandfathered into the Medical Council of India.

The plan was to train enough doctors who would serve the whole country. However, the plan has not borne fruit and doctors generally leave their rural posts after their internship for more lucrative and glamorous careers in the big cities.

As of 2009, the Indian government plans to introduce a three-and-a-half-year Bachelor of Rural Medicine and Surgery (BRMS) degree to train doctors who will work in remote Indian villages. On graduation they will undergo a one year internship period at a regional hospital before being licensed. Those with five years experience will qualify for post-graduate studies on equal standing with their MBBS counterparts.

In India, the Madras Medical Mission in Chennai, collaborating with Birla Institute of Technology and Frontier Lifeline has since 1992 offered a bachelor of science degree in Physician Assistant studies. The program duration is four years, comprising three years classroom and laboratory coursework then one year compulsory internship. Several other universities offer similar courses in patnership with US universities. PAs in India can pursue masters and doctor of science degrees. .

Malaysia

Malaysia started training medical assistants in the early 1900s after independence from Britain. Also known as Assistant Medical Officers, they are trained for three years in an undergraduate academic program recognized by the Malaysian Qualifications Agency in order to practice. They are mainly deployed in public hospitals, parastatal institutions (e.g. military, prisons), rural health centres, aged care centres, or private specialist hospitals.

See also

• Allied health professions
• Healthcare in Kenya
• Assistant Medical Officers
• Surgical technologists
• Clinical associates in South Africa
• Feldsher in countries of the former Soviet Union

External links

• Clinical officers - Ministry of Health, Kenya
• Kenya Medical Training College - Clinical Medicine Department
• Kilimanjaro Christian Medical College- Tanzania
• Egerton University (Kenya) - Diploma in Clinical Medicine and Surgery
• Kenya Methodist University - Department of Clinical Medicine
• Mt. Kenya University
• Malawi College of Health Sciences
• Maridi National Health Training Institute- Maridi
• Indian Association of Physician Assistants
• The Clinical Officers Council