1Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
2Division of Global Health Equity, Brigham and Women’s Hospital, and Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
3School of Medicine, University of Rwanda, Butare, Rwanda
4Institute for Ethics, History, and the Humanities, Faculty of Medicine, Geneva University, Geneva, Switzerland
Responding to critical shortages of physicians, most sub-Saharan countries have scaled up training of nonphysician clinicians (NPCs), resulting in a gradual but decisive shift to NPCs as the cornerstone of healthcare delivery. This development should unfold in parallel with strategic rethinking about the role of physicians and with innovations in physician education and in-service training. In important ways, a growing number of NPCs only renders physicians more necessary – for example, as specialized healthcare providers and as leaders, managers, mentors, and public health administrators. Physicians in sub-Saharan Africa ought to be trained in all of these capacities. This evolution in the role of physicians may also help address known challenges to the successful integration of NPCs in the health system.
World Health Organization (WHO). The world health report 2006: Working together for health. Geneva: WHO; 2006.
World Health Organization (WHO). Treat Train Retain. Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines. Geneva: WHO; 2008.
Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries. Lancet. 2007;370(9605):2158-2163.
World Health Organization (WHO). Optimize MNH: Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting. Geneva: WHO; 2012.
Wilhelm TJ, Thawe IK, Mwatibu B, Mothes H, Post S. Efficacy of major general surgery performed by non-physician clinicians at a central hospital in Malawi. Trop Doct. 2011;41:71-75.
Emdin CA, Chong NJ, Millson PE. Non-physician clinician provided HIV treatment results in equivalent outcomes as physician-provided care: a meta-analysis. J Int AIDS Soc. 2013;16:18445.
Chilopora G, Pereira C, Kamwendo F, Chimbiri A, Malunga E, Bergstrom S. Postoperative outcome of caesarean sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi. Hum Resour Health. 2007;5:17.
Fonn S, Ray S, Blaauw D. Innovation to improve health care provision and health systems in sub-Saharan Africa - promoting agency in mid-level workers and district managers. Glob Public Health. 2011;6(6):657-668. doi:10.1080/17441692.2010.489905
Shumbusho F, van Griensven J, Lowrance D, et al. Task shifting for scale-up of HIV care: evaluation of nurse-centered antiretroviral treatment at rural health centers in Rwanda. PLoS Med. 2009;6(10):e1000163. doi:10.1371/journal.pmed.1000163
Gopinathan U, Lewin S, Glenton C. A review of large-scale programmes for scaling up human resources for health in low- and middle-income countries--study in progress (Annex 7: Evidence base). WHO recommendations--optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting. Geneva: WHO; 2012:35-42.
Chu K, Rosseel P, Gielis P, Ford N. Surgical task shifting in Sub-Saharan Africa. PLoS Med. 2009;6(5):e1000078. doi:10.1371/journal.pmed.1000078
Africa Network for Associate Clinicians (ANAC) Community of Practice (COP). Strategic plan, 2013-2017 (draft 3), May 2012.
Sherr K, Pfeiffer J, Mussa A, et al. The role of nonphysician clinicians in the rapid expansion of HIV care in Mozambique. J Acquir Immune Defic Syndr.. 2009;52 Suppl 1:S20-S23. doi:10.1097/QAI.0b013e3181bbc9c0
South African Department of Health. Strategic plan 2014/15-2018/19. Pretoria: Minstry of Health; 2014. Accessed July 20, 2015.
Johns B, Asfaw E, Wong W, et al. Assessing the costs and effects of antiretroviral therapy task shifting from physicians to other health professionals in ethiopia. J Acquir Immune Defic Syndr. 2014;65(4):e140-147. doi:10.1097/QAI.0000000000000064
Callaghan M, Ford N, Schneider H. A systematic review of task- shifting for HIV treatment and care in Africa. Hum Resour Health. 2010;8:8. doi:10.1186/1478-4491-8-8
Bergstrom S. Training non-physician mid-level providers of care (associate clinicians) to perform caesarean sections in low-income countries. Best Pract Res Clin Obstet Gynaecol. 2015;29(8):1092-1101. doi:10.1016/j.bpobgyn.2015.03.016
Samb B, Celletti F, Holloway J, Van Damme W, De Cock KM, Dybul M. Rapid expansion of the health workforce in response to the HIV epidemic. N Engl J Med. 2007;357(24):2510-2514. doi:10.1056/NEJMsb071889
Brentlinger PE, Assan A, Mudender F, et al. Task shifting in Mozambique: cross-sectional evaluation of non-physician clinicians' performance in HIV/AIDS care. Hum Resour Health. 2010;8:23. doi:10.1186/1478-4491-8-23
Chen LC. Striking the right balance: health workforce retention in remote and rural areas. Bull World Health Organ. 2010;88(5):323. doi:10.2471/BLT.10.078477
Sprague C, Chersich MF, Black V. Health system weaknesses constrain access to PMTCT and maternal HIV services in South Africa: a qualitative enquiry. AIDS Res Ther. 2011;8:10. doi:10.1186/1742-6405-8-10
Colvin CJ, de Heer J, Winterton L, et al. A systematic review of barriers and facilitators to the implementation of task-shifting in midwifery programmes. WHO recommendations. Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting. Annex 7: Evidence base. Geneva: WHO; 2012:20-24.
Huicho L, Scherpbier RW, Nkowane AM, Victora CG. How much does quality of child care vary between health workers with differing durations of training? An observational multicountry study. Lancet. 2008;372(9642):910-916. doi:10.1016/S0140-6736(08)61401-4
Yakam JC, Gruenais ME. Involving new actors to achieve ART scaling-up: difficulties in an HIV/AIDS counselling and testing centre in Cameroon. Int Nurs Rev. 2009;56(1):50-57. doi:10.1111/j.1466-7657.2008.00680.x
Lutalo IM, Schneider G, Weaver MR, et al. Training needs assessment for clinicians at antiretroviral therapy clinics: evidence from a national survey in Uganda. Hum Resour Health. 2009;7:76. doi:10.1186/1478-4491-7-76
Lehmann U, Van Damme W, Barten F, Sanders D. Task shifting: the answer to the human resources crisis in Africa? Hum Resour Health. 2009;7:49. doi:10.1186/1478-4491-7-49
Hirschhorn LR, Oguda L, Fullem A, Dreesch N, Wilson P. Estimating health workforce needs for antiretroviral therapy in resource-limited settings. Hum Resour Health. 2006;4:1. doi: 10.1186/1478-4491-7-49
Wilson IB, Landon BE, Hirschhorn LR, et al. Quality of HIV care provided by nurse practitioners, physician assistants, and physicians. Ann Intern Med. 2005;143(10):729-736.
Moosa S, Mash B, Derese A, Peersman W. The views of key leaders in South Africa on implementation of family medicine: critical role in the district health system. BMC Fam Pract. 2014;15:125. doi:10.1186/1471-2296-15-125
Royal College of Physicians and Surgeons of Canada (Jason R. Frank). The CanMEDS 2005 Physician Competency Framework. Ottawa; 2005.
World Health Organization (WHO). Systems Thinking for Health Systems Strengthening. Geneva: WHO; 2009.
World Health Organization (WHO). Every Body's Business: Strengthening Health Systems to Improve Health Outcomes WHO's Framework for action. Geneva: WHO; 2007.
Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health. 2006;4:12. doi:10.1186/1478-4491-4-12
Burch VC, McKinley D, van Wyk J, et al. Career intentions of medical students trained in six sub-Saharan African countries. Educ Health (Abingdon). 2011;24(3):614.
Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923-1958. doi:10.1016/S0140-6736(10)61854-5
Dwyer J, Paskavitz M, Vriesendorp S, Johnson S. An urgent call to professionalize leadership and management in health care worldwide. Management Sciences for Health Occasional papers No. 4; 2006.
WHO Regional Committee for Africa. Road Map for Scaling up the Human Resources for Health for Improved Health Service Delivery in the African Region 2012–2025. Luanda; 2012.
Eyal N, Hurst SA. Physician brain drain: can nothing be done? Public Health Ethics. 2008;1(2):180-192.