Abstract

With the United Nations Development Programme (UNDP) Post-2015 Development Agenda upon us, it is increasingly important to address the worldwide deficit of human resources for health. Ironically, there is a unique subset of regionally trained healthcare providers that has existed for centuries, functioning often as an “invisible” workforce. These practitioners have been trained in an accelerated medical model and serve their communities in over 46 countries worldwide. For the purpose of this paper, “medical model” is defined as the evidence-based and scientific manner of training and practice that defines physicians globally.

Inconsistent nomenclature, however, has resulted in these workers practicing as a virtually unidentified and disjointed cadre on the margins of health policy planning. We use the term Accelerated Medically Trained Clinician (AMTC) here as a categorical designation to encompass these professionals who have been referred to by various titles.

We conducted an exploratory, systematic review for AMTCs in over 70 counties to asses if there is such a cadre, the name or title of their cadre, period of and curricula of training and existence of credentialing. This paper reports our findings and aims to serve as a springboard for future, in-depth studies on how we can better categorize and utilize these clinicians. 

Introduction 

The escalating global crisis of the health workforce shortage is alarming. The Global Health Workforce Alliance (GHWA) estimates that by 2035, the global shortage of healthcare providers will be well over 12.9 million (Global Health Workforce Alliance Strategy 2013-2016 2012). Current estimates indicate that over one billion people do not have access to healthcare providers today (Crisp and Chen 2014). The paucity of appropriately trained healthcare providers worldwide limits access to fit-for-purpose healthcare. Maldistribution and migration of skilled healthcare workers, as well as limited-skills training, also contribute to the current health workforce deficit. The International Labour Organization (2015) recently published Global Evidence on Inequities in Rural Health Protection: New Data on Rural Deficits in Health Coverage for 174 Countries, noting that the “fundamental rights to health and social protection remains largely unfulfilled for rural populations.” It goes on to note, “while 56% of the global rural population lacks health coverage, only 22% of urban populations are not covered.” They estimate that “23% of the worlds’ health workforce are sent to rural areas, while more than 50% of the population live there.” One of the most significant inferences of this paper is a worldwide call for additional fit-for-purpose health workers to meet this basic fundamental right (Scheil-Adlung 2015). The importance of a more harmonized system for data collection of human resources for health was also a key point. 

Figure 1. Global distribution of AMTCs as reported in this study

Dots denote country of confirmed AMTC

To promote quality-driven, efficient healthcare, we must make best use of existing assets. Limited resources necessitate a collaborative approach and a clearer understanding of the roles and scope of practice of clinicians. For decades, Accelerated Medically Trained Clinicians (AMTCs) have existed worldwide under various titles: physician assistant, clinical officer, medical assistant, associate clinician, health assistant, medex, community health officer, feldshers and so on, depending on where they practice. These professionals are trained in a medical model framework, typically focused on diagnostic, therapeutic and preventive care in a condensed time frame of study that is regionally specific, flexible and cost-effective. Accelerated and regionally specific trained clinicians are responsive to their host health system, which makes them invaluable to the community they serve. 

AMTCs are trained to perform various functions traditionally under the purview of physicians, but their training is shorter in duration. It stresses medical science and clinical decision-making with a focus on patient history, physical examination, diagnosis and treatment. In many countries, the focus of education has been on primary care, as this is where they often practice as the only providers. Their education often includes public health, epidemiology and medical practice management. In some countries, the training focus narrows rapidly during their clinical training to the specialty area of practice. For example in India, they have become vital team members in subspecialty surgery, where they can be seen in surgical roles as first assist as well as coordinators in areas such as transplant. In some African countries, career ladders have been developed to provide services closer to the rural population needs, and AMTCs are further trained in emergency obstetric care, surgery, ophthalmology and psychiatry. They are trained to work within teams to maximize team member roles and increase access to care. While their scope of practice has broadened globally, they share a common training in the medical model. 

Designating a categorical title for a cadre of clinicians, one must consider what already exists. The categories “physician” and “‘nurse” are globally recognized, and yet, can vary widely in training, scope and title. Table 1 displays examples of physician and nurse training and titles in several countries. Yet, despite the variation in training and titles, physicians and nurses are categorically linked and recognized by the public and policymakers, allowing their clinical capacity to be considered within health systems planning. 

Table 1. Examples of physician and nurse training and titles

Country Education Degree/title awarded
Global examples of training/titles for cadre = physician 
New Zealand 
6-year undergraduate 
MBBS=Bachelor of Medicine, Bachelor of Surgery 
2-year rotations 
House Officer/House Surgeon/Intern 
FY1/FY2/PGY1/PGY2/RMO/junior doctor 
3+-year training program 
Registrar/Resident/Registrar Medical Officer 
Specialist or consultant 
Specialist Medical Officer/Specialist/Consultant 
Medical Officer/MOSS/Staff Grade/Board Eligible 
US*** 
Post 4-year undergraduate degree 
4 years medical school 
Medical Doctor – MD 
Residency/fellowship: 3–8+ years 
Medical Doctor – MD 
Doctor of Osteopathy – DO/Chiropractic Doctor – DC all recognized as “doctor” 
India 
5.5 years undergraduate 
MBBS=Bachelor of Medicine, Bachelor of Surgery 
 
3 years post grad 
Doctor of Medicine – MD 
General practice 
 
2–3 years post MD 
Doctor of Medicine – DM 
Super specialty 
 
3 years post grad 
Master of Surgery – MS Surgery 
 
2-3 years post MS 
Magister Chirurgiae – MCh Super specialty surgery 
 
Allopathy, Homoeopathy, Siddha, Naturopathy and Unani all recognized as “doctor” 
Global examples of training/titles for cadre = nurse 
USA 
1 year program vocational/technical school/ community colleges 
Licensed Practical Nurse: LPN* 
Licensed Vocational Nurse: LVN* 
 
2 years 
Associate Degree Nursing: ADN 
 
Assoc + 2 years or 4 years 
Bachelor of Science in Nursing: BSN 
 
BSN + 2 years** 
Master of Science in Nursing: MSN 
 
Variable 2-4+ years 
DNP 
2 years post MSN 
3-4 years post BSN 
PhD 
3-7 years post MSN or other MS degree 
Advanced Practice Nurses: nurse-midwives, nurse anaesthetists, clinical nurse specialist 
Also Doctoral: DNP 
DP – focus on evidence-based practice [EBP] research, stress physical assessment skills 
Typically sought as terminal degree for APNs 
PhD – research and nursing science-based education 
Considered more academic, scholarly with strong research 
India 
India Nursing Council 
Training in College of Nursing 
Graduate 12th class + 2 years 
Multi Purpose Health Worker Female training (ANM or MPHW-F) 
 
Graduate 10th class 
+ 1.5 years 
Female Health Supervisor training (HV or MPHS-F) 
 
Graduate 12th class 
3.5 years = 2 years practice/1 year community health nursing and midwifery/6 month administration or 6 months research 
General nursing and midwifery (GNM) 
 
4 years 
Bachelor of Nursing Course – B.Sc Nursing 
 
Regular: GNM + 2 years 
Distance: GNM +3 years 
Bachelor of Nursing Course (post certificate) Regular B.Sc (post basic) 
Distance B.Sc (post basic) 
 
BSc + 1 year exp/ BSc + nursing post certificate 
Master of Nursing MScN Nursing 
Medical Surgical Nursing, ob/gyn nursing, pediatric nursing, mental health nursing, community health nursing 
 
Full time 1 year with thesis 
Master of Philosophy Program in Nursing -MPhil 
 
3 years 
Doctorate of Philosophy in Nursing – PhD in Nursing 
Ghana 
Graduate 12th class 
+ 3 years 
RN (diploma) 
 
Graduate 12th class + 4 years 
RN (bachelor’s degree) 
 
Graduate 12 class + 3 years 
Registered Psychiatric Nursing (RPN) 
 
Graduate 12th class 
+ 2 years 
Community Health Nurse (CHN) 
 
Graduate 12th class 
+ 3 years 
Registered Midwife 
 
RN +3 years working experience 
+1.5 years 
Post Basic Diploma: critical care, operating room, ophthalmic nursing, ENT nursing, psychiatric 
 
RN + 2 years 
Post Basic University Diploma: nursing education, nursing management 
 
RN + 1st degree/diploma 
+ 2 year sandwich course 
Master’s degree in: education, management 
 
RN + 2 years 
Registered Psychiatry Nurse – RPN 
 
Graduate 12th class +RN + 2 years 
Registered Midwife – RM (post RN) 
 
Graduate 12th class +2 years CHN training + 2 years 
Registered Midwife (post enrolled CHN) 

*LPN /LVN are non-professionals with limited scope of practice and brief training
**US select BSN programs offer accelerated BSN to PhD program
***US growing number of medical students earn a master’s in Public Health or PhD as part of their medical education

AMTCs are unique in that they have historical and cultural identities in the countries they serve. Many have originated independently out of need, yet are remarkably similar in the services they are trained to provide. In the majority of African countries, they are the front-line clinician and the link between rural and the next level of care. Often referred to as “non-physician clinicians” or “mid-level workers” (Dovlo 2004; Cobb et al. 2015; Lehman 2008; Global Health Workforce Alliance 2013; McKimm et al. 2013; Mullan and Frehywot 2007), there is much uncertainty surrounding the training, scope and global representation of this cadre of health workers. In some instances, these terms combine nursing professionals and AMTCs. This increases ambiguity; leads to fragmentation, underutilization and inadvertent omission of an already existing core of skilled medical personnel, in the human resources for health “count”; as well as calls for increased numbers of fit-for-purpose clinicians. 

AMTCs have been termed “agents of change,” as they often were introduced, and in many regions organically developed, as a health workforce to serve in the most rural and impoverished areas. Historically, AMTCs can be appreciated as early as the 17th century, when Peter the Great introduced them into the Russian armies to provide primary care to rural areas (Zdravoohranenija et al. 1974). Today, they continue to be recruited for training from areas of need in the hope that they will return to serve their home communities. Regionally specific training and titles often prevent AMTCs from migrating across borders, where a neighbouring country lacking in resources could utilize their skills. There have been no international recognition or educational standards developed for these clinicians, unlike physicians and nurses, so the exodus from developing to developed countries does not apply to this cadre. 

The WHO (2008) reports that the literature on outcome studies on mid-level health workers is sparse. While Mullan and Frehywot (2007) and Dovlo (2004) studied the use of the non-physician clinician, their research was limited to Africa and included nurse-based clinicians. McKimm et al. (2013) explored the “expanded and extended healthcare workforce” in the Pacific region, separating out the non-nurse and nurse mid-level practitioners. They agreed that the “one size fits all” approach for these clinicians is not appropriate and that regional and community diversity will necessitate unique approaches. The distinctions between professional Advanced Practice Nurses (APNs) and AMTCs are their distinct practice frameworks and education and training. APNs are educated and trained within a nursing science framework. Nursing science views patients as unique individuals, in constant interaction with their environment. This “systems approach” views disease and illness as deviations from health. Nursing interventions aim to promote and return patients to a maximum state of health. Nurses use a holistic approach in their practice, as they assess, plan, intervene and evaluate their patients’ needs and responses to care disease and illness. APN curricula prepare nurses for more independent practice and include physical assessment, pharmacology and care management, typically for a specialty practice such family health, mental health or paediatrics. AMTCs are trained in a model based on physician training. In the United States, they are the only other profession, other than physicians (MD and DO), licensed to “practice medicine.” While there is lack of standardization of curricula for these clinicians, flexibility often facilitates training responsive to regionally specific needs (Lehman 2008), while compounding the lack of consistent categorization of these practitioners. 

This study inventoried the global distribution of AMTCs across 46 countries and describes the various regional titles, when the profession was established, the duration of training, scope of practice and the governing regulatory body by region. The research attempts to identify and unite an existing clinical workforce and categorizes them to enable them to be distinguished and fully utilized within the healthcare team and health systems. 

Methods 

This descriptive, exploratory study systematically reviewed the education, training, scope of practice and credentialing of a group of front-line clinicians workforce that has not been consistently designated. We conducted a literature review using the following databases: Pubmed, Medline and Google Scholar. Keyword search terms included assorted AMTC nomenclature: “non-physician clinician,” “midlevel clinician,” “health workforce,” “physician assistant,” “clinical officer,” “medical assistant,” “health assistant,” “clinical associate,” “feldsher,” “human resources for health (HRH) strategy,” “auxiliary health worker” and “medex”. Source inclusion criteria encompassed publications in peer-reviewed journals, country reports by the World Health Organization and World Bank and other country reports from well-known international professional bodies. Literature within a maximum time frame of 10 years from (2005 to 2015) was included, except when researching the history of a specific assembly of workers, in which case the time frame was extended. We included only published works written in English. The literature search revealed matches of various AMTC analogues in over 45 countries. 

We accessed contacts in the 46 countries, primarily through government health professionals and websites, country-specific health professional associations and websites and the professional networking service LinkedIn®. The contacts included AMTCs who served as clinicians, educators and AMTC organization representatives. Regional and national policy makers also provided assistance. Data were collected through communication by email or phone and queried for: (1) title of the profession, (2) year it was established, (3) education and training, (4) scope of practice, (5) regulation and (6) number of AMTC professional cohorts in each respective country. One researcher verified the accuracy of the data collected. 

We used a snowball sampling technique to continue gathering information about AMTCs by country and region. We used this technique, as it was difficult to locate subjects who practice in remote rural areas. Researchers asked subjects whether they would be willing to recommend other potential contacts. They were informed that they had the right to decline to provide this information. 

In the event that an in-country contact was not identified or available, the researchers gathered data from resources such as WHO or local government reports on health professionals. For two countries, researchers uncovered a health workforce that was previously operational, but now defunct. WHO in-country offices and the country’s Ministry of Health confirmed these findings. 

We cleaned the data using a three-step process involving repeated cycles of screening, assessing and editing data with suspected abnormalities. In the screen step, data were evaluated for lack/excess of data and inconsistencies. In the assessment step, data were evaluated for errors as well as true extremes or norms. In the final editing step, data were corrected, deleted or left unchanged. Data were then assembled by query question: (1) title of the profession, (2) year profession was established, (3) education and training, (4) scope of practice, (5) regulation and (6) number of AMTC professional cohorts in each respective country to allow comparison of the AMTCs across countries that were surveyed. 

Findings 

Africa (See Table A

Africa has 20 AMTC-type providers. The titles vary widely on this continent and include health officer, medical assistant, clinical officer, physician assistant, community health officer, community healthcare officer, clinical associate, associate clinician and medical licentiate. The earliest noted AMTCs in Africa are Malawi’s Medical Assistants, established in the 1890s (Muula 2009). Next, the Ugandan medical assistant was introduced in 1918 and the Kenyan Clinical Officer was introduced in 1928 by the British colonial government to provide health services in remote and less developed rural areas (Clinical Officer Council, website 2015). Overall, AMTC training in African countries is a minimum of three years, with some countries, such as Kenya, Malawi, Tanzania and Zambia, having formal paths for more advanced training that include surgery (emergency obstetric), ophthalmology and psychiatry. Gabon’s Assistant Medicals are trained in neighbouring countries such as Togo and return to practice in their communities in Gabon. There is a varied range of degree- as well as non-degree-granting educational processes; however, all are focused on the allopathic medical model of education in both public and private AMTC training institutions. 

Generally, the scope of practice for African AMTCs is primary care, with the majority of AMTCs working in rural areas or with marginalized populations in community health centres. In larger cities, AMTCs can be found working in secondary and tertiary care centres providing specialized care in more progressive settings. In many African countries, AMTCs are not only responsible for providing primary care for entire villages but they are also responsible for organizing and managing the resources necessary to oversee their local community health structure. Regulation of AMTCs, although varied, was existent in all African countries surveyed. 

Asia (See Table B

Asia has over 13 AMTC-type providers. Titles of the AMTC in Asia include the feldsher, baga emch, physician assistant, medical assistant, sub-assistant community medical officer and health assistant. The earliest known AMTCs began in the USSR in 1600s as apprentice physicians or physician assistants (Farmer et al. 2003). The feldsher training schools were established in the 1870s (Farmer et al. 2003). Russia, Armenia, Kazakhstan, Kyrgyzstan, Mongolia and Uzbekistan have continued to utilize feldshers/baga emchs since the fall of the USSR (Kulzhanov and Healy 1999.; Hakobyan et al. 2006; Roberts et al. 2011; World Health Organization and Ministry of Health Kyrgyzstan 2005; World Health Organization and Ministry of Health Mongolia 2012; World Health Organization and Ministry of Health Uzbekistan 2007). Training ranges from two to four years, with some training programs awarding degrees upon completion. The scope of practice in Afghanistan, Bangladesh, Nepal, Russia, Armenia, Kazakhstan, Kyrgyzstan, Mongolia and Uzbekistan is most often providing primary care in rural communities. India’s AMTCs were established secondary to the brain drain of Indian cardiothoracic physicians over 20 years ago, and have largely served in specialty care since then. There is a resurgence of primary care focus for the Indian AMTCs currently (Abraham et al 2014). Of the Asian countries surveyed, AMTCs have regulatory oversight, except in Afghanistan, India and in the Kingdom of Saudi Arabia, where it is pending. 

Europe/North America/South America (See Table C

Europe has over four AMTC types working in Germany, The Netherlands, Ukraine and the United Kingdom, recently including in Scotland. In North America, both the United States and Canada employ AMTCs. Although programs vary, most offer two to three years of postgraduate training and award master’s degrees. Most functioning AMTCs in Europe, Canada and South America work in the primary care capacity, with the exception of The Netherlands, where AMTCs function in the surgical capacity. All have oversight bodies. 

Most recently, the UK’s Faculty of Physician Associates at the Royal College of Physicians assumed this function (July 2015). 

The United States has over 100,000 physician assistants practicing in all areas of medicine. In the United States, the AMTC profession was developed when highly skilled medics returned from war in Vietnam to civilian life. The medics, with relatively little training, were positioned to provide effective and efficient much-needed primary care. 

In South America, Guyana has AMTCs called medex, who, with governmental oversight, serve the primary care needs of the country (Goede 2014). While there are mentions of “community health technicians” in Colombia, Mexico and Peru (Yokwe Online 2011), the authors were unable to confirm the current practice, training, scope or regulation of such practitioners. 

Oceania (See Table D

Oceania has at least six AMTC types that have been identified. The AMTCs provide primary care in the remote regions and outlying islands (Lane 2008). Their titles include physician assistants, physician associates, health extension officers, health assistants, health officers and medex (Keni 2006; Lassi et al. 2013; Lehman 2008; World Health Organization Western Pacific Region 2001). Training in the medical model varies from 18 months to 4 years. Owing to limited resources, some AMTC students are trained in neighbouring countries before returning to their home country to work. The University of Hawaii was training AMTCs in the medex model for Chuuk, Kiribati, Pohnpei and the Marshall Islands (Lassi et al. 2013). Regulation of Australia’s AMTCs is pending, while Fiji is currently utilizing nurse practitioners after phasing out the use of medical assistants in 1984. The AMTCs in New Zealand, Papua New Guinea and Marshall Islands have processes in place for regulation. The literature surveyed was limited and often more than 10 years old at the time of this publication. Countries that were unable to be verified were not included in the tables. 

Discussion 

It is critical to account for and understand the variations across cadres of the health workforce. Effective and regionally fitting health systems planning requires a clear understanding of the workforce in terms of stock, skill-mix and distribution. While the roles of physicians, nurses, midwives, pharmacists and dentists are clearly defined by entities such as the Global Health Workforce Statistics database (WHO), International Labour Organization and the International Standard Classification of Occupations, they often vary in training, regional titles and scope of practice. Cadres trained in an accelerated medical model that encompass the AMTC category have historically been either excluded or placed in categories that do not adequately represent their training and skills. Many of them have served on the margins of the health sector and their contributions to healthcare delivery continue to be largely overlooked. As countries strive to strengthen and reconstruct their health systems, it is critical to include AMTCs as vital members of the global health workforce. They are a flexible workforce that can rapidly and cost-effectively be morphed based on the health system’s needs that they are part of. They work within teams and are culturally engaged within the countries they serve. 

For centuries, the AMTC workforce has provided primary care services to rural and marginalized populations (Cobb et al. 2015; Crisp and Chen; 2014; Dovlo 2004; Global Health Workforce Alliance 2013; Lehman 2008; Mullan and Frehywot 2007). In 1978, the International Conference of Primary Health Care and the WHO issued the Declaration of Alma-Ata, expressing the need for “all governments and the world community to protect and promote the health of all the people of the world” (Global Health Workforce Alliance 2013; Lehman 2008; Health Bulletin 2013.) The Third Global Forum on Human Resources for Health (2013) was the largest attended convening to date focused on HRH. Dr. Etienne (WHO Regional Director, Americas) highlighted that “One of the challenges for achieving universal health coverage is ensuring that everyone – especially people in vulnerable communities and remote areas – has access to well-trained, culturally-sensitive and competent health staff…The best strategy for achieving this is by strengthening multidisciplinary teams at the primary health care level… Training of health professionals must be aligned with the health needs of the country.” 

Overall, AMTCs are valued in high- to low-income countries alike – from the 2,000 medical licentiates who serve in Zambia (doctor to population ratio 0.1/1,000) to the 100,000 physician assistants who serve in the United States (doctor to population ratio 2.5/1,000) (World Bank 2015). Their places in health systems are in line with the Declaration of Alma-Ata and The Third Global Forum on HRH. 

While the midlevel workforce has been broadly documented in Africa (Dovlo 2004; Lehman 2008; Mullan and Frehywot 2007), and more recently in the Pacific region (McKimm et al. 2013), comparing titles, education, scope of practice and regulation produces discordant findings. By identifying and clarifying this “invisible” global workforce, governments, policymakers and communities can begin to unite and mobilize these healthcare providers to meet the current health worker crisis. Broad and non-descriptive nomenclature such as “non-physician clinician” or “mid-level” has also contributed to the obscure classification of AMTCs (Lassi et al. 2013; Lehman 2008). The ambiguity of this profession is further compounded because of variations in training, degrees procured, scope of practice and the presence (or absence) of a regulatory body. This overview sought to differentiate and define the AMTC with the initiation of a census. 

The training outlined in Tables A through D  provides basic information on topical focus within AMTC training. They include basic diagnosis, treatment and prescriptive ability. The majority of programs offer post-secondary education, ranging from 18 months to 4 years. Those programs that offered training in less than two years generally drew from an existing pool of clinically experienced nurses. Of note, African AMTCs have been vocational pioneers, offering progressive training in emergency obstetric care, ophthalmology, psychiatry and dermatology to individuals seeking career advancement. However, as Lehman (2008) and Mullan and Frehywot (2007) note, fragmentation in training necessitates standardization of international AMTC core competencies to further unite and advance these health professionals. Similar work is ongoing, yet much advanced, within the nursing and physician professions (Royal College of Physicians and Surgeons Canada 2015; World Health Organization 2009). 

Understandably, ever-changing political climates and lack of infrastructure sometimes necessitate that AMTCs receive training from nearby countries. This non-nationally-based training can not only leave a void in regulatory processes, but can lead to a lack of support for the AMTC, as he/she returns to home communities to meet a critical healthcare need. Gabon is facing such challenges, as their Assistant Medical Officers are trained in Togo. In Fiji (Keni 2006; World Health Organization Western Pacific Region 2001), the profession was not maintainable and ended nine years after its establishment. 

Regulation and management of AMTCs vary widely. In some countries, the Ministry of Health guides both training and practice oversight. In others, it is the Ministry of Education that is engaged in the clinician’s didactic training, but provides no regulation for practicing AMTCs. Some countries have non-governmental professional bodies involved in training and practice supervision. Ghana began regulation of its AMTCs (physician assistants) through the Medical and Dental Council 40 years after the AMTCs were established and were providing primary care services to populations in rural communities (Adjase and Cobb 2014; Cobb et al. 2009). Countries like India and Sierra Leone are seeking authoritative medical supervision after the AMTCs have been a part of the workforce for more than five years. 

Physician involvement and oversight of the AMTC is variable and merits further exploration. In some countries (United States, Canada, The Netherlands and South Africa, for example), AMTCs function under the supervision of a physician. Globally (particularly in the rural areas where AMTCs serve), direct physician supervision may not always be feasible owing to the shortage of physicians, geographical location and resources available in the clinical setting. 

In the post-2015 era, integrating AMTCs into health systems will provide a vital addition, in building a health workforce to meet current and future population needs.

Study Limitations 

There were many challenges collecting data for this study. The peer-reviewed literature and websites that provide information on ATMC training and regulation are sparse. There is a general paucity of published information for many of these professions, particularly in resource-poor countries. Published information utilized for this study was not always available from primary sources, but instead came from external sources such as WHO country documents, non-governmental organization aid agency reports and foreign journal articles. There is simply not enough published primary source information regarding this cadre of health professionals within respective countries. 

Verification of existing AMTCs reported in literature was challenging, as the information was often outdated. Accurately identifying comparable AMTCs was difficult owing to the numerous country-specific titles given to this workforce. Inconsistent designations could suggest a gross under-representation of actual personnel available. There were several limitations to the snowball sampling technique. First, the researchers had to rely on the recommendations from their existing contacts. Therefore, representativeness of this cadre of healthcare workers was not guaranteed. Next, there was a concern for sampling bias. As the researchers’ contacts tended to nominate people they knew well, it was possible that the nominees obtained only a small subgroup of the existing cadre. 

The challenges of desk research are numerous, especially in terms of validity and timeliness. Primary in-country data collection would allow for a broader informational structure. Primary research and data gathering would allow for greater understanding of the skills and contribution of AMTCs as healthcare providers and their capacity to positively impact and improve national health indicators. 

Recommendations: The Way Forward 

The GHWA “Global Key Messages” (January 2014) forecasts a global deficit of 12.9 million health workers by 2035 using an arbitrary threshold of 34.5 skilled health professionals per 10,000 population. Their proposed solutions are critical when considering the AMTC workforce. 

  • “Health begins with health workers” – the support and empowerment of all health workers is essential. 
  • Assembly of a health workforce is a priority. 
  • “The role of the mid-level and community health workers should be maximized in order to make frontline health services more accessible and acceptable in support of Universal Health Coverage (UHC) plan.” 
  • Improved HRH databases are critical and will aid in the planning and improvement the workforce. 

The GHWA Board (February 2015) statement on the post-2015 health workforce agenda stresses that “substantive and strategic investments in HRH are needed in order to ensure the right to universal access to safe and quality healthcare, a life of dignity for all, and to attain the health, education, employment, equity, gender and wider development targets under consideration in the Sustainable Development Goals (SDGs).” AMTCs are ideally suited to contribute to the post-2015 agenda, expansion of universal health coverage and equity. They function as members of an interprofessional, multi-cadre team, and are rapidly and medically trained and regionally specific with skills and competencies that can contribute to improving population health while they bridge the socio-cultural dynamics of the local healthcare systems. 

Identifying and clarifying the various roles within the health workforce is key to moving forward to meet the challenge posed by the Declaration of the Alma-Ata. Engaging WHO’s Department of Human Resources for Health or GHWA to request member countries to participate in comprehensive human resources for health studies could dramatically assist in broadening the global understanding of available resources. This could be particularly important to reinforce the post-2015 agenda of the WHO, and the United Nations Sustainable Development Goals, which will serve all countries. As we seek to improve and strengthen current health systems, we are reminded of countries like Liberia who, during the Ebola crisis, suffered unimaginable losses, as 150 Liberian physicians struggled to give adequate care to a population of 4.3 million. Sadly, there was little mention of the over 1,000 Liberian AMTCs who served and continue to serve in the most remote parts of their country. 

This research not only inaugurates a current census of global AMTC categories of health workers, but also aims to propose an official designation for AMTCs as the “encompassing” classification for this professional workforce. While the “Accelerated Medically Trained Clinician” terminology is primarily descriptive of the training process, it considers the regional titles these professionals have held for years, while acknowledging core similarities. Future work needs to establish regulatory parameters for education, training and competencies. A categorical designation can enable conversations with stakeholders around these aims and facilitate policymakers, stakeholders and national officials to fully utilize AMTCs as vital members of regionally specific healthcare teams, especially when exploring existing resources for health and health systems planning. 

The Future Considerations table (Table 2) provides examples of the various stages and processes for sample regions with AMTCs. Regional, national and global organizations should bring forward best practices, lessons learned and work as advocates. As this process occurs, the ability to track and collect data in a thoughtful manner that encompasses each of the variables listed in Table 2 and assess the economic and health impacts realized by scaling up of this cadre will help guide future regulatory policy. 

The post-2015 agenda calls for a paradigm shift to increase access to care, with a focus on primary care that is patient-centred and personal. Care across the life span with attention to the social determinants of health starting with health teams at the very most rural community level will not only empower the communities, but will enable them to be more productive. This will ultimately increase their socioeconomic status, opportunities for their children and development of a less divided society. 

Table 2. Future considerations

 Pre-training  

Education  

Scope  

Regulation  

Student, faculty recruitment from areas of need – to return to area 

Global/ regional competencies 

Regionally specific, driven by health system they are in 

Accreditation and standardized of regional curricula 

Public awareness of the AMTC so applicants understand profession 

Regional accreditation of educational programs 

Adequate support (experts, physicians) available 

Regulation of practice, regionally/nationally 

Development of bridge-type programs to enable success in formal training program for students from rural, marginalized populations 

Social determinants of health and primary care at core of training to enable this workforce to be versatile in where they work 

In-service training opportunities 

Access to continuing medical and professional education 

Formal organizations at regional, national and global levels 

Team-based training with interdisciplinary learners, faculty and practitioners 

Career ladder options 

Advocacy at policy levels for health teams with integration of social determinants of health 

Community-engaged transformational experiences throughout training 

   

Consider degree levels of training globally 

   

Scholarly activities led by the AMTC cadre 

Scholarly activities led by the AMTC cadre 

Scholarly activities led by the AMTC cadre 

Scholarly activities led by the AMTC cadre

Indeed, AMTCs have broad impact and provide proven quality healthcare with global and regional variation. They are well-aligned and must be included in the post-2015 global health workforce agenda. It is vital that this essential cadre within the health team is summoned from the fringes of the health sector, categorized and fully utilized. To achieve universal health coverage and be part of the solution to the current health workforce crisis and the development of future health systems, it is time for AMTCs to rise and be regarded. 

 

 

 

About the Author

Nadia Cobb, MS, PA-C
Associate Professor 
Office for Promotion of Global Health, Equity, Division of Physician Assistant Studies University of Utah School of Medicine, Salt Lake City, UT
Director, International Office of Physician Associate Educators
President, International Academy of Physician Assistant Educators
 
Marie Meckel, MS, PA-C, MPH
Physician Assistant, Baystate Medical Center, Springfield, MA
 
Jennifer Nyoni, BA, MPA
Technical Officer, Human Resources for Health Management, Health Systems & Services Cluster, WHO Regional Office for Africa, Republic of Congo
 
Karen Mulitalo, MPAS, PA-C
Associate Professor
Director University of Utah Physician Assistant Program, 
University of Utah School of Medicine, Salt Lake City, UT
Co-Director Communications, International Office of Physician Associate Educators
 
Hoonani Cuadrado, MSPAS, PA-C
Assistant Professor, DeSales University, Center Valley, PA
 
Jeri Sumitani, MMSc, PA-C
Physician Assistant, Pretoria, South Africa
 
Gerald Kayingo, PhD, MMSC, PA-C
Assistant Clinical Professor
University of California-Davis, Sacramento, CA
 
David Fahringer MSPH, PA-C
Associate Professor/Physician Assistant, International Academy of Physician Associate Educators – Trustee
Associate Director of Physician Assistant Studies, Director of Clinical Education, University of Kentucky, Lexington, KY
 
Correspondence may be directed to: 
Nadia Cobb

Email: nadia.m.cobb@utah.edu 

Acknowledgment

(by country) 

Africa: Dr. Delanyo Dovlo, Jennifer Nyoni; Angola: Dr. Richard Isidore Kiniffo; Australia: Sandi Lear, Al Forde; Bangladesh: Shafiqur Rahman; Burkina Faso: Dr. Zampaligre; Canada: Ian Jones; Cape Verde: Dr. Yolanda Estrela; Ethiopia: Samson Tekeste; Gabon: Dr. Aboubacar Inoua; Germany: Samantha Keller; Ghana: Dr. ET Adjase; Guinea-Bissau: Mr. Malam Drame; India: Ebin Abraham, Gomathi Sundar, VG Prasad; Kenya: Manaseh Bocha; Liberia: Jerry Kollie; Malawi: Charles Mulilima; Mauritius: Mr. Ajoy Nundoochan; Mongolia: Dr. Orgilmaa Regzedmaa; Mozambique: Dr. Hilde Rene S De Graeve; Myanmar: Dr. Nay Soe Maung, Dr. Htin Saw Soe, Dr. Aye Sanda Mon; Nepal: Anil Stha; The Netherlands: Luppo Kuliman; Oceania: Andrew McDonnell, Andrew Langi, Afa Palu; Republic Southern Sudan: David Manana; Rwanda: Emmy Bushaija; Saudi Arabia: Dr. Naveed Ahmed; Senegal: Dr. Sall; Sierra Leone: Abu Conteh, Donald Bash-Tagi, Sei Coleman; South Africa: Sanele Ngcobo; Tanzania: Senga Pemba; Togo: Dr. Pekele, Dr. Drave; Uganda: Emoit Ekol, Nicholas Ssewankambwe, Susan Nalugo; UK/Scotland: Shane Apperley, Philip Begg; Zambia: David Lusale.

References

Physician Assistants in India. Transformative Education for Healthcare Professionals. Retrieved July 25, 2015. <http://whoeducationguidelines. org/content/physician-assistants-india>. 

Adjase, E. and N. Cobb. 2014. The Physician Assistant Profession in Ghana. Transformative Education for Healthcare Professionals. Retrieved July 25, 2015. <http://whoeducationguidelines. org/content/physician-assistant-profession-ghana>. 

Central Intelligence Agency. 2015. The World Factbook. Retrieved August 31, 2015. <https:// www.cia.gov/library/publications/the-world-factbook/index.html>. 

Clinical Officers Council. 2015. “A Brief History.” Retrieved July 25, 2015. <http://clinicalofficerscouncil.org/profile/brief-history/>. 

Cobb, N.M., R. Bailey, E. Abraham, D. Lusale, S. Lear and S. Apperly. 2015. “Expanding Health Equity through the Mobilization of Non-Physician Clinicians – 5 Continent Examples.” Prince Mahidol Awards Conference, Bangkok, Thailand. 

Cobb, N.M., J. Antwi and E.T. Adjase. 2009. “Educating for Service: The MA Profession in Ghana”. Journal of Physician Assistant Education 20(3): 44–47. 

Crisp, N. and L. Chen. 2014. “Global Supply of Health Professionals.” New England Journal of Medicine 370(10): 950–57. doi:10.1056/ nejmra1111610. 

Dovlo, D. 2004. “Using Mid-Level Cadres as Substitutes for Internationally Mobile Health Professionals in Africa. A Desk Review.” Human Resources for Health 2(1). doi:10.1186/1478-4491- 2-7. 

Farmer, R.G., A.Y. Sirotkin, L.E. Ziganshina and H.M. Greenberg. 2003. “The Russian Health Care System Today: Can American-Russian CME Programs Help?” Cleveland Clinic Journal of Medicine 70(11): 937–38. doi:10.3949/ ccjm.70.11.937. 

Global Health Workforce Alliance. 2015. South Sudan. Retrieved July 25, 2015. <http://www. who.int/workforcealliance/countries/ssd/en/>. 85 

Global Health Workforce Alliance. 2013. Mid-Level Health Workers for Delivery of Essential Health Services a Global Systematic Review and Country Experiences. Geneva: World Health Organization. 

Global Health Workforce Alliance. 2012. The Global Health Workforce Alliance Strategy 2013–2016 Advancing the Health Workforce Agenda within Universal Health Coverage. Geneva: World Health Organization. 

Global Health Workforce Alliance. 2014. Global Key Messages. Retrieved July 25, 2015. <http:// www.who.int/workforcealliance/media/key_ messages_2014.pdf?ua=1>. 

Goede, H. 2014. “Mapping and Analysis of Primary Care Models in South American Countries: Mapping PHC in Guyana.” Auctorial document on PHC in South American Countries. Rio de Janeiro. Retrieved July 25, 2015 <http:// www.isags-unasur.org/uploads/eventos/ev[328] ling[1]anx[298].pdf>. 

Government of the People’s Republic of Bangladesh, Ministry of Health and Family Welfare. 2014. Health Bulletin 2013. Dhaka: Management Information System Directorate General of Health Services. 

Hakobyan, T., M. Nazaretyan, T. Makarova, M. Aristakesyan, H. Margaryants, E. Nolte et al. 2006. “Armenia Health System Review.” Health Systems in Transition 8(6): 1–180. Retrieved July 25, 2015 <http://www.euro.who.int/__data/ assets/pdf_file/0004/96430/E89732.pdf>. 

Keni, B. 2006. “Training Competent and Effective Primary Health Care Workers to Fill a Void in the Outer Islands Health Service Delivery of the Marshall Islands of Micronesia.” Human Resources for Health 4(27). doi:doi:10.1186/1478-4491-4- 27. 

Kulzhanov, M. and J. Healy. 1999. “Health Care Systems in Transition: Kazakhstan.” Copenhagen: World Health Organization Regional Office: European Conservatory on Health Care Systems. 

Lane, J. 2008. “The Need for Effective Licensure Laws for Mid-Level Health Care Providers in Countries Facing Chronic Physical Shortage: As Case Study of the Marshall Islands’ Health Assistants.” Pacific Rim Law & Policy Journal 17(3): 767–94. 

Lassi, Z.S., G. Cometto, L. Huicho and Z.A. Bhutta. 2013. “Quality of Care Provided by Mid-Level Health Workers: Systematic Review and Meta-Analysis.” Bulletin of the World Health Organization 91(11): 824–33. doi:10.2471/ blt.13.118786. 

Lehman, U. 2008. “Mid-Level Health Workers. The State of the Evidence on Programmes, Activities, Costs and Impact on Health Outcomes: A Literature Review”. Geneva: World Health Organization Department of Human Resources for Health. 

McKimm, J., P. Newton, A. Silva, J. Campbell, R. Condon, B. Kafoa et al. 2013, Expanded and Extended Health Practitioner Roles: A Review of International Practice. Sydney, Australia: Human Resources for Health Knowledge Hub. 

Mullan, F. and S. Frehywot. 2007. “Non-Physician Clinicians in 47 Sub-Saharan African Countries.” The Lancet 370(9605): 2158–63. doi:10.1016/ s0140-6736(07)60785-5. 

Multak, N. and N.M. Cobb. 2015. “Feldshers in the Ukraine.” Transformative Education for Health Professionals. <http://whoeducationguidelines.org/ content/feldshers-ukraine>. 

Munjanja, O., S. Kibuka and D. Dovlo. 2005. “The Nursing Workforce in Sub-Saharan Africa.” International Council of Nurses ISBN: 92-95040- 27-9. 

Muula, A.S. 2009. “Case for Clinical Officers and Medical Assistants in Malawi.” Croatian Medical Journal 50(1): 77–8. 

Ritsema, T.S. 2014. Results of the 2014 UK Association of Physician Assistants Annual Census. www.ukapa.co.uk

Roberts, G., W. Irava and J. Tuiketei. 2011. “The Fiji Island Health System Review. Asia Pacific Observatory on Health Systems and Policies.” Health Systems in Transition. (1). Retrieved July 25, 2015 <http://www.wpro.who.int/asia_pacific_ observatory/hits/series/Fiji_Islands_Health_ Systems_Review.pdf>. 

Scheil-Adlung, X. 2015. Global Evidence on Inequities in Rural Health Protection: New Data on Rural Deficits in Health Coverage in 174 Countries. Extension of Social Security International Labour Office: International Labor Organization. 

Tekeste, S., M. Meckel and N.M. Cobb. 2014. “Ethiopia’s Health Officers.” Transformative Education for Health Professionals. Retrieved July 25, 2015 <http://whoeducationguidelines.org/ content/ethiopia’s-health-officers>. 

World Bank. 2015.World Health Organization's Global Health Workforce Statistics, OECD, supplemented by country data. Retrieved August 31, 2015. <http://data.worldbank.org/indicator/ SH.MED.PHYS.ZS>. 

World Health Organization and Ministry of Health Mongolia. 2012. Health Service Delivery Profile. Retrieved July 25, 2015 <http://www. wpro.who.int/mongolia/about/service_delivery_ profile_mongolia.pdf>. 

World Health Organization. 2013. “Mongolia Health System Review.” Health Systems in Transition 3(2). 

World Health Organization. 2009. Global Standards for the Initial Education of Professional Nurses and Midwives. WHO/HRH/HPN/08.6. WHO: Geneva.

World Health Organization and Ministry of Health, Kyrgyzstan. 2005. Integrated Management on Emergency and Essential Surgical Care (IMEESC). Bishkek, Kyrgyzstan Retrieved July 25, 2015 <http://www.who.int/surgery/Report_ Kyrgyzstan_Facilitators_workshop.pdf>. 

World Health Organization and Ministry of Health, Uzbekistan. 2007. Assessment of the Mental Health System in Uzbekistan. Tashkent, Uzbekistan: World Health Organization. Retrieved July 25, 2015 <http://www.who.int/mental_health/ evidence/uzbekistan_who_aims_report.pdf>. 

World Health Organization, Western Pacific Region. 2001. Mid-Level and Nurse Practitioners in the Pacific: Models and Issues. Geneva: World Health Organization. 

Yokwe Online. 2011. “Marshall Islands’ Cabinet Approves 17 New Health Assistant Positions.” Yokwe Online. Retrieved July 25, 2015 <http:// www.yokwe.net/index.php?module=News>. 

Zdravoohranenija, M, Union of Soviet Socialist Republics, World Health Organization. 1974. “The Training and Utilization of Feldshers in the USSR : A Review (Prepared by the Ministry of Health of the USSR for the World Health Organization)”. 56: 56. Geneva: World Health Organization.