Addressing staff shortages in public hospitals: a role for clinical associates?

Jane Doherty, independent researcher and part-time lecturer at the School of Public Health, University of the Witwatersrand. Formerly Deputy Director of the Centre for Health Policy in the same School. Research interests: health systems and policy research.
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Recent news headlines have highlighted the shortage of doctors in public hospitals, especially in disadvantaged areas. There is no doubt that more doctors need to be trained and recruited into the public sector. But are these strategies sufficient to solve the shortage of hospital staff with skills to diagnose patients’ problems and implement treatment? How long will it take to fill all the public sector’s vacant posts, especially in disadvantaged areas? And how much will it cost?

Developing mid-level health professionals who can complement existing staff is an additional strategy that has been debated since 1994 and incorporated into the government’s recent human resources policy (1). Yet progress in the production of mid-level health workers has been slow. Reasons for this are likely to include competing priorities, the practical difficulties associated with setting up and implementing new training programmes, constraints on absorbing new cadres into the existing health system, tensions between different cadres over role definition and working conditions, and the brain drain into the private sector. More fundamentally, concerns remain about whether mid-level workers are the correct choice for our health system (2,3): Will they be supervised adequately?; Will they be able to work well with other professionals?; Will they become a second-best health care option for poor communities?

Drawing on a rapid assessment that has been published in more detail elsewhere (3,4), it is discussed here how the design and early implementation of a new programme to develop South Africa’s first mid-level medical health professionals took account of these concerns and realities. Also highlighted are the issues that need to be addressed by government in order to ensure that this new programme has a substantial impact on the quality of care delivered in public hospitals.