Clinical officer

In her books, "Beyond the State: The Colonial Medical Service in British Africa" and "Indian Doctors in Kenya, 1895 - 1940: The Forgotten History", the author Anna Greenwood notes that before 1923 there were twice as many Indian doctors as there were European doctors working in the Colonial Medical Service. The Indian doctors had migrated to British Africa along with the coolies who came to work on the Uganda Railway. The Indian doctors faced discrimination and were not appointed to nor paid at the same rank as medical officers (European doctors). Instead, they were designated as Assistant or Sub-assistant surgeons despite having attended similar 3 - 4 year Indian medical schools that were recognized by the General Medical Council in the UK and performing clinical and administrative duties that were largely identical to those of the European doctors. From the mid-1920s the Indians were removed from the colonial service as they were not deemed to be the proper face of the imperial services in Africa. The Indian Assistant and Sub-Assistant Surgeons were thus replaced with similarly qualified Africans who came to be known as clinical officers when the authorizing legislation was passed in 1988 abolishing the Assistant and Sub-Assistant Surgeon and similar positions.[8]

In Kenya, the origin of the clinical officer can be traced back to around 1888 when Sir William Mackinnon, 1st Baronet founded the Imperial British East Africa Company. The company was granted royal charter by Queen Victoria and was used by the Government of the United Kingdom to establish its influence in the East Africa Protectorate (present day Kenya). As the influence grew a healthcare system developed to meet the medical needs of the colony. In 1901 Kenyatta National Hospital was established as the Native Civil Hospital and later renamed the King George VI Hospital after King George VI of the United Kingdom. In 1958 the European Hospital (present-day Nairobi Hospital) was established in the same area to serve the European settlers. The need for qualified medical staff who would provide preventive, promotive, curative and rehabilitative services in hospitals and communities led to the establishment of the first formal training programme for clinical officers at Kenyatta National Hospital in 1928. The programme initially admitted experienced nurses and took them through a one-year certificate course which prepared them for advanced practice. The nursing pathway was discontinued and new students had to study clinical medicine and surgery and sit and pass continuous assessment tests and final qualifying examinations for three years which covered basic medical sciences, medicine, surgery, paediatrics, obstetrics and gynecology, community health, rural health and health service management before admission into a compulsory one-year hospital internship programme and completion of a further three-year period of clinical supervision..

The training expanded after Kenya's independence in 1962 through to 1970 when the newly created University of Nairobi started its own medical school and also used Kenyatta National Hospital as its teaching hospital. Legislation to regulate medical practice by clinical officers was passed in 1988 thus creating the Clinical Officers Council in 1989. In 1990 the Kenya Medical Training College was established by the government with campuses in all major towns and in 1996 the Roman Catholic Diocese of Kakamega established St. Mary's School of Clinical Medicine at St. Mary's Hospital in Mumias which become the second and third institutions to offer the training in Kenya. By this time clinical officers had to complete an accredited four-year programme of study, practicals and internship in clinical medicine and surgery and have their names entered in the clinical officers register which was cleaned annually and taken to the government printer to be published in the Kenya Gazette. Private practice by clinical officers who had left government service after working for a minimum of 10 years was now allowed.

Professional degrees in clinical medicine and surgery were first offered by Egerton University and other universities as from 2006 and in 2012 the Commission for University Education Act No. 42 of 2012 removed the accreditation role from all regulatory bodies such as the Clinical Officers Council (COC) and the Kenya Medical Practitioners and Dentists Council (KMPDC) making the Commission for University Education (CUE) the only authorized accrediting body for all university degrees in Kenya including the degree in clinical medicine. In 2017 the old legislation was repealed and the Clinical Officers Council reconstituted by the Clinical Officers (Training, Registration and Licensing) Act No. 20 of 2017 which requires each clinical officer, clinic or medical centre to be registered by the council and to maintain a current practice license and a current practising certificate in order to operate legally within the scope of medicine, dentistry, orthopedics or health work. A clinical officer may, with respect to patients - examine, diagnose, order laboratory and imaging investigations, prescribe treatment and perform procedures as per their scope of training. Clinical officers are members of the Kenya Clinical Officers Association and the Kenya Union of Clinical Officers. In June 2020 the Public Service Commission approved the Revised Scheme of Service for Clinical Personnel which was issued by the State Department for Public Service to define the clinical officer's career structure, job description, standards for recruitment, training and advancement, and career planning and succession management within the civil service. The scheme is administered by the Ministry of Health through the Cabinet Secretary and the Principal Secretary in conjunction with the Public Service Commission and the County Chief Officer for Health in each of the 47 Counties of Kenya.

Clinical officer is a professional designation established by the government through the Clinical Officers Council (COC) which has jurisdiction and responsibility for the clinical officer's training, registration and licensing and each officer must (1) study clinical medicine and surgery or clinical medicine and community health for three or four years (2) graduate from a government-accredited medical training college (3) sit and pass a government licensing examination (4) complete an internship year at a teaching hospital (5) be registered as a clinical officer (6) have a medical practice licence (7) complete a three-year period of clinical supervision under a senior clinical officer or a senior medical officer (8) have a practising certificate if they have a private practice which allows one to provide general medical services on their own directly to the public (9) undergo one or two additional years of specialized training (optional) and (10) become a trainer. Clinical Officer (CO) is a protected professional title and its use by unregistered persons is prohibited by law and punishable by up to five years in jail with or without a fine. Globally, the title may not have legal restrictions and can refer to a job grade rather than a medical qualification such as junior assistive clinical staff (e.g. in Zambia and Tanzania), licensed medical professionals (e.g. in Kenya and Malawi) or high-level corporate officers, directors, and managers (e.g. Chief Clinical Officers in Europe and the United States).

A clinical officer observes, interviews and examines sick and healthy individuals in all specialties to determine and document their health status and applies relevant pathological, radiological, psychiatric and community health techniques, procedures and findings needed to classify diseases and related health problems and to establish a provisional or final diagnosis upon which to prescribe, initiate, carry out or terminate treatment or therapy based on their specialized knowledge, skills and experience in clinical pharmacology, use of clinical guidelines, best practices and disease patterns as well as individual patient and community characteristics while being actively pharmacovigilant to prevent, identify, minimize and manage drug reactions, drug errors, side effects and poisoning, overdiagnosis, overscreening, overtreatment and futile care. A clinical officer performs general and specialized medical duties such as diagnosis and treatment of disease and injury, ordering and interpreting medical tests, performing routine medical and surgical procedures, referring patients to other practitioners and managing health departments, institutions, projects and systems.

Clinical officers, medical officers and medical practitioners are the only officers who are gazetted and licensed to practice medicine in Kenya. They work under oath and generate credible health data and information within communities and health institutions and cascade the same to the county and national governments, government agencies and third parties through standard recording and reporting tools from the Ministry of Health which are used to capture data on disease outbreaks, physical injuries and deformities, mental illness, drug resistance, disability, nutritional disorders, births and deaths among others.

To practice medicine and surgery or dentistry as a clinical officer one requires at least four years of full-time medical training, supervised clinical practice and internship at an accredited medical training institution and hospitals and registration with the relevant medical board in their country. After a prescribed number of years in active practice, one may complete a further one or two-year residency programme in order to specialize in any approved branch of clinical medicine and surgery such as anesthesia or pediatrics, or get an advanced medical qualification from the university. There are no pathways (post-basic or post-graduate entry-level conversion programs) for nurses and other health workers hence it takes at least eight years of specialised medical training and experience for a clinical officer to graduate with a post-basic qualification. "Clinical officer" in some countries such as Tanzania and Zambia refers to a different cadre of health workers, comparable to "medical assistants" in Malawi, who have less than three years of training but who may upgrade to a similar level by becoming Assistant Medical Officers (AMOs) or Medical Licentiates (MLs)."medical assistants/Sub Assistant Community Medical Officer" in Bangladesh, a Four Year medical diploma course conducting state medical faculty of Bangladesh under ministry of Health and family welfare.

A clinician can specialize in any other field that is deemed appropriate by them and not just clinical medicine. China also has masters of clinical medicine. In countries like Tanzania, UK, and other countries, clinical medicine is regarded as a medical course and graduates are allowed to apply to masters of medicine specialties.

No significant difference has been demonstrated in studies comparing treatment decisions, patient outcomes, quality of care provided and level of knowledge about diseases between a clinical officer and a medical officer (a non-specialist physician) except in countries where nurses were mistakenly assessed as clinical officers. However, because of the nature of practice, populations served and resources at ones disposal, a clinical officer is less likely to administer expensive treatment, prescribe expensive (but not necessarily better) drugs or engage in futile care.[10]

The success of HIV/AIDS prevention and treatment initiatives in Africa is mostly attributed to use of clinical officers to diagnose the disease and provide comprehensive medical care. Access to emergency obstetric care through greater deployment of the clinical officer is one way of attaining the Millennium Development Goals 4 (reducing child mortality) and 5 (improving maternal health).[11]

Worldwide, patients are seen by many other practitioners other than the traditional doctor such as:

• Osteopathic physicians, Podiatrists, Optometrists and Anesthesiologist assistants in the United States
• Emergency and Clinical Officer Pakistan
• Physician Assistants in the United States, United Kingdom, Netherlands, Liberia and Ghana
• Assistant Doctors in China,[12]
• Surgical Care and Emergency Care Practitioners in the UK,[13]
• Assistant Physicians in Saudi Arabia,[14]
• Health Extension Officers in Papua New Guinea[15]
• medical assistants/Sub Assistant Community Medical Officer in Bangladesh
• Medical Assistants in Fiji
• Assistant Medical Officers in Malaysia
• Surgical Technologists in Mozambique
• Clinical Associates in South Africa.[16]

Kenya has a comprehensive framework of parallel laws and regulations that govern the medical practice of medical officers and clinical officers. The supreme health policy and medical authorities in the republic are the cabinet secretary of health and the director of medical services who oversee the registration and licensing of medical institutions and the training, registration and licensing of medical practitioners through the Medical Practitioners and Dentists Board and the Clinical Officers Council.

As a British colony in 1928, Kenya started training a select group of natives to practice medicine and care for the local population who were increasingly accepting and seeking western medicine. After independence from Britain in 1963, medical training in Kenya initially adopted the four-year medical school system used in the US rather than the six-year UK model. This was heavily influenced by the Kennedy Airlift[18] which followed initial funding by the African-American Students Foundation (AASF) in 1959 and led to hundreds of young Kenyan students getting scholarships to study in American institutions: These students came back to Kenya after their studies and joined the civil service in the early post-independence Kenya. It was also around this time that the first DOs were accepted as medical officers by the US civil service and by 1967 the structure and duration of medical training in Kenya was similar to the US MD training. When the University of Nairobi split from the University of East Africa and became the first university in Kenya in 1970, it continued to teach the six-year British degree which led to the creation of two statutory bodies: the Kenya Medical Practitioners and Dentists Board in 1978 which had jurisdiction over medical officers and physicians, and the Clinical Officers Council in 1989 which had jurisdiction over clinical officers. Instead of residency for the clinical officer, the higher diploma in paediatrics, ophthalmology and other specializations was introduced in the late 1970s as a post-basic course for those who had worked for three or more years and, after ten years of service, one became a Senior Clinical Officer and qualified for a licence to practice under his own name as a private medical practitioner. The BSc. Clinical Medicine and Surgery degree was later introduced in 2006.

Clinical officers play a central role in Kenya's medical sector today. There were 8,600 clinical officers on the register in 2010 compared to 7,100 medical officers.[19] They are trained by the universities, the Kenya Medical Training College (KMTC),[20] St. Mary's School of Clinical Medicine and other private institutions. The Ministry of Health, through the Clinical Officers Council (COC)[21] regulates their training and practice, accredits training institutions, and approves the syllabi of the universities and colleges. The Kenya Medical Training College (KMTC), also under the Ministry of Health, has campuses in regional teaching hospitals 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 clinical officers. It admits students who got the minimum university entry grade in high school and have passed a written examination and oral interview. The students sit the same examination as their counterparts at the KMTC and are examined by consultants from the public service.

On 28 October 1981 lawmakers addressed the National Assembly as follows:

• Mr. Orengo: On a point of order Mr. Deputy Speaker Sir. Is it really in order for the hon. Member for Butere to impute that this house does not know that clinical officers are not allowed to practice. I think the motion is just after legalizing the position and not saying that they are not allowed to practice.
• Mr. Shikuku: Mr. Deputy Speaker, we heard Dr. Chibule saying that he is going to give us a list of 20 clinical officers who are being refused permission to practice and forced to go back to government practice and this is the thing I am trying to reply to. The hon. Member was in the house when Dr. Chibule said this but I do not know why he did not hear him say so, but nevertheless, let me continue. Mr. Deputy speaker, Sir, the clinical officers helped the government during the recent doctors' strike in the country when we virtually depended on them. Now, Sir, part (a) of this motion is not the responsibility of the Ministry of Health because if anybody wants to pursue higher education, even from this house, it is upon him first to make sure he has the prerequisite qualifications to pursue higher studies. So, with that, the ministry is not concerned. Part (b) of the motion is the most important. We are requiring the enactment of a law to cover our present clinical officers to allow them to practice and be covered by the law as the doctors are covered. This is the point and the assistant minister for health has produced a paper which is going to be presented before the cabinet after which it will come to the house. Now, Sir, where do we disagree? There is no place where we disagree. What we are trying to say is that the government is already doing what it is being asked to do, and that is why we are saying that this matter has more or less been overtaken by events. Therefore, we are not going to be asked to do what we are already doing.
• Mr. Orengo: On a point of order, Mr. Deputy Speaker, Sir.
• Mr. Shikuku: You can have as many points of order as you like!

The dual diploma in clinical medicine and surgery plus an internship year is the standard qualification for clinical officers which is awarded on completion of a four-year training programme which started as various programmes that were used to train medical practitioners in the East Africa Protectorate in the 1920s and which now resembles the North American four-year MD and DO medical school programmes (including being structured in 9 trimesters over 3 years to meet the minimum 130 weeks of instruction recommended by the Liaison Committee on Medical Education) instead of the more recent six-year MBChB programme that was introduced in the 1970s and is more common in European and Commonwealth countries:

Medical Officers training:

• Is a six-year professional degree programme accredited by the Medical Practitioners and Dentists Board involving
• Two years of pre-clinical training in medical sciences followed by
• Four years of training in clinical medicine, surgery and community health including a mandatory one-year internship and
• Registration, licensing and gazettment by the Medical Practitioners and Dentists Board giving
• Unlimited practice rights with
• Specialisation and private practice allowed and eligible for full professional membership of the Kenya Medical Association (KMA)

Clinical Officers training:

• Is a four or five-year professional diploma or degree programme accredited by the Clinical Officers Council involving
• One year of pre-clinical training in medical sciences followed by
• Three or four years of training in clinical medicine, surgery and community health including a mandatory one-year internship and
• Registration, licensing and gazettment by the Clinical Officers Council giving
• Unlimited practice rights with
• Specialisation and private practice allowed and eligible for full professional membership of the Kenya Clinical Officers Association (KCOA)

The current training follows international guidelines and the two qualifications are awarded jointly on successful completion of a comprehensive nine trimester programme of full-time study, practicals and examinations which are covered over three years leading to a fourth mandatory year of internship in a teaching hospital. A fifth and sixth residency specialisation years are undertaken after registration by the Clinical Officers Council and three years of work experience in general medicine which leads to the award of a general degree in clinical medicine or a specialist diploma in pediatrics, orthopedics, psychiatry, anaesthesia, reproductive health and other specialties.

A clinical officer is therefore able to graduate and join the workforce in a minimum of four calendar years and provides medical services within the full scope of family and emergency medicine or within a narrower scope depending on their area of specialisation.

Registration by the Clinical Officers Council (COC) entitles one to render medical services in any public or private medical institution or to practice medicine independently as a private practitioner. Registration also qualifies one to join and participate in the affairs of the Kenya Clinical Officers Association (KCOA), including its annual KCOA Scientific Conference, and the Kenya Union of Clinical Officers (KUCO). As per the government's Revised Scheme of Service for Clinical Personnel (2014) a clinical officer works at any of 8 grades depending on ones seniority.

Table showing different grades of clinical officers, medical officers and medical practitioners in Kenya's public service

As[22][23] gazetted officers all registered clinical officers are legally authorized to prepare, sign, issue and keep safe custody of official state documents such as medical examination reports, sick notes, postmortem examination reports and death certificates and to appear in courts of law as expert witnesses. For this reason, a clinical officer is the officer in-charge of a health center or a district hospital and is part of the medical team in bigger hospitals where one may head a department or work under a senior clinical officer or a physician.[24][25][26]

Clinical officers are direct healthcare providers who manage and administer health institutions, medical schemes and projects in primary healthcare (PHC) settings and are frontline stakeholders in Universal Health Coverage in Kenya which is one of the key pillars of the government's 5-year development plan under President Uhuru Kenyatta. The four pillars of the 5-year development plan are 1. Manufacturing 2. Affordable housing 3. Universal Health Coverage and 4. Food security.

Medical care is generally provided by clinical officers who are even capable of providing surgical care. Clinical Officers are trained for 4 years, (3+1 year of clinical internship at designated teaching hospitals). One meta-analysis documented that the provision of caesarean section by clinical officers does not result in a significant increase in maternal or perinatal mortality. In other, words there was no difference whether the operation was done by clinical officers or medical doctor[37]

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, name="AMREF"/>

The graduates supplement the efforts of COs trained in neighboring countries, e.g. Kenya, Uganda and Tanzania, most of whom work for international humanitarian agencies. Since 2014, Juba institute of Health Sciences and Ayii University 2021 have now joined in production of competent cadres in the Health in the Republic of South Sudan.

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.[24]

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 which no longer exist since 2017 so a clinical officer can upgrade by studying a bachelor's degree in clinical medicine in any East African country for three years or study it in Tanzania for four years and graduate as a doctor equivalent to an MD graduate even in salary and job opportunities or can study the Medical Doctor(MD) which is a 5-year course plus 1 internship year making 6 years and can add 1 year to be Medical bachelor and Bachelor in Surgery (MBBS) if interested.

A further two years training from the Clinical Officer level 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.

By 1918, Uganda was training clinical officers who were called medical assistants at the time. The training is under the Ministry of Education and takes place in clinical officer training schools.[38] Postsecondary programs last three years, focusing on medicine and hospice care, followed by a two-year internship.[24]

Kampala International University offers a Bachelor of Clinical Medicine and Community Health.[39] High school graduates take four-and-a-half years to complete this degree while practicing clinical officers take three years.

In Zambia, clinical officers who complete a three-year diploma of Science in Clinical Medicine course are called CLINICAL OFFICER -GENERAL (COG). Those who complete a three-year diploma in clinical psychiatry are called CLINICAL OFFICER -PSYCHIATRY (COP). Currently the upgrade of this diploma is a Bachelor of Science and holders are called medical licentiates. Medical licentiates have advanced skills in medicine and surgery and may be deployed interchangeably with physicians. Medical licentiates 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.[40] They perform routine surgical and obstetric operations as well as providing clinical care in hospitals. The College of Surgeons of East, Central and Southern Africa (COSECSA) is involved in their training to increase their surgical skills through the Clinical Officers Surgical Training (COST) programme.

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.[41]

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 caesarian sections.[41] The observed higher fatality rate pointed to a need for refresher courses and closer supervision of the nurses.

The first medical school in Ethiopia was initially a "health officer" training institution. The training of health officers started at Gonder University in 1954.[26] Health officers training programs across Ethiopia require that students have some of the highest scores in National University Entrance Examination to be admitted. Health officers hold bachelor's degrees and undergo a three-year training program plus one-year internship. Those who complete a 2–3 years master's degree programs provide advanced care (e.g. emergency surgery).[24]

In Ghana, Medical Assistants (MAs) have traditionally been experienced nurses who have undergone an 18-month post-basic course to become MAs. High school graduates can now attend a three-year diploma course to become MAs.[42] In Ghana, from 2012, the nomenclature Medical Assistant had been changed to Physician Assistant..[43] The new name Physician Assistant is not known among most Ghanaians[44] The term Physician Assistant (PA) refers to three distinct groups of health professionals trained on the medical model to practise medicine and dentistry. They are the PA-Medical, PA-Dental and also known as Community Oral Health Officers and PA-Anaesthesia (also known as Nurse Anesthetists). These groups of mid-level health providers were trained exclusively in the past by Health Training Institutions (HTIs) under the Ministry of Health with the aim of extending care to the populace where physician numbers were scanty or not present.[43] Currently, there are eight universities in Ghana offering a 4-year Bachelor of Science degree in Physician Assistantship. The objective of the Bachelor of Physician Assistantship programme is to train graduates who will possess the ability to evaluate the health status of an individual, diagnose and treat acute illness as well as life saving interventions, manage chronic diseases, deliver preventive care and counsel individuals on psychosocial problems in independently or in collaboration with a physician.[45]

In 2016, the PA-Anaesthesia group broke away and became certified registered anaesthetist (CRA) according to the Health Professions Regulatory Acts 857 which addressed them as certified registered anaesthetist.[46] PAs are qualified by graduation from the PA educational programme and certification by the Ghana Medical and Dental Council.[47] Newly qualified PAs who are successful in their licentiate examinations by the MDC are issued with provisional registrations to enable them undertake one-year internship in an accredited institution, a prerequisite for permanent registration which would also serve as national service[48] but without pay for the twelve months.

PA students in all PA training schools belong to the Physician Assistant Association of Ghana (PASAG). In order to foster unity, camaraderie and bond among members of the association, and to promote excellence in the discharge of their professional mandate, quiz competitions are held every year. The maiden edition was won by the Presbyterian University College, Ghana.[49] After permanent certification, among other things, PAs diagnose and treat illnesses, conduct physical examinations, counsel individuals on preventative health issues, and order and interpret laboratory tests.[50] In addition, PAs are first or second assistants in major surgery, and provide pre- and post-operative care, and for that matter are trained and well versed in surgical skills.[47] Thus, PAs play roles in preventive Medicine, as well as in educational, research, and administrative activities.[47] The physician assistant is part of the medical team and is placed above the nurse but below the medical officer[51] They perform tasks originally performed by doctors. Some call PAs as "village doctors" or "chiefs." To the patient, a PA is a doctor, since the PA practises medicine just as a doctor[50][52]

The Ghana Physician Assistant Association-Medical at their last annual delegate congress, voted for a name change from the current name Physician Assistant to Clinical Officer. The members of the association believes that the Assistant attached to their name is limitation to what the PA actually does. The PA is not an assistant but an independent medical professional trained and licensed to practise medicine and dentistry. The association has therefore presented a new job description and the new name clinical officer to the Ministry of Health. The meeting which was chaired by the chief director of the ministry of health Dr. Afisah Zakariah who promised to address the grievances of the PAs soon to be known as Clinical Officers[53]

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.[54]

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.[55]

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.[56] Programs also exist at the University of Pretoria and the University of the Witwatersrand.

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 non-physician providers such as physician assistants.

Physician assistants in the United States train for at least two years at the postsecondary level and can hold an associate, bachelors or master's degree. Most PAs have earned a master's degree. Some institutions offer a Doctor of Science degree in the same. The profession is represented by the American Academy of Physician Assistants.

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. Several UK universities are already offering a post-graduate diploma in Physician Assistant studies. The PAs of the UK are represented by the Association of UK PAs.

The University of Queensland offers a one-and-a-half-year Master of Physician Assistant Studies to those with a bachelor's 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.[57] It has been announced that PAs will be allowed to work in Queensland as fully licensed practitioners in 2014.

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.

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.[58] 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.

Under British rule, India trained licentiate 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.[59]

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 partnership with US universities. PAs in India can pursue masters and doctor of science degrees.[60][61][62]

Mid-label Medical Care Health Human Resources of Bangladesh are Medical Assistant product of Medical Assistant Training School (MATS).3 year Medical Assistant Course Started 1976. Now 4 year Medical Assistant course 3 years academy+1 year internship See Also Sub assistant community Medical Officer

Malaysia started training Medical Assistant in the early 1900s after independence from Britain. This profession has undergone several transformations over the decades in line with the current healthcare development in the country. The current name of this profession is Assistant Medical Officers (AMO), they are trained for three years in an undergraduate academic program (Diploma in Medical and Health Sciences or formerly known as Diploma in Medical Assistant) recognized by the Malaysian Qualifications Agency. In order to practice, all Assistant Medical Officers are compulsory to register under the regulating body of Malaysia Medical Assistant Board (Medical Assistant Act (registration),1977) and serve a compulsory resident posting for six months in Emergency and Trauma Department (Program Penempatan Wajib) under a clinical supervision by an Emergency Physician. Upon completing the compulsory posting, they will be deployed in public hospitals, parastatal institutions (e.g. military, prisons), rural health centers, health clinics, community clinics, aged care centers, or private specialist hospitals.[64] To date, there are five training institutions introduced by the Ministry of Health, Malaysia in the public sectors to train new Assistant Medical Officers;

1. Training Institute of Ministry of Health, Malaysia, Sultan Azalan Syah, Perak
2. Training Institute of Ministry of Health, Malaysia, Johor Bahru, Johor
3. T raining Institute of Ministry of Health, Malaysia, Kuching Sarawak
4. Training Institute of Ministry of Health, Malaysia, Kota Kinabalu, Sabah
5. Training Institute of Ministry of Health, Malaysia, Seremban

A registered Assistant Medical Officer can pursue their sub-specialty training (Post Basic certificates and Advanced Diploma) in various fields such as Emergency Medical and Trauma care, Primary Healthcare, Orthopedic, Cardio thoracic, Clinical Neuro-physiology, Sport Medicine, Anesthesiology, Diabetic care, Infection Control, hemodialysis, and many more. Assistant Medical Officer could also join the MBBS /MD after completing the undergraduate study by applying for those programs in either public or private institutions. Those who want to serve and continue as Assistant Medical Officer could further their study in a special programs for Assistant Medical Officers such as Bachelor of Science in Emergency Medicine with honors and Bachelor of Medical and Health Sciences with honors. Unlike Physician Assistant / Associate (PA) and Clinical Officer (CO), Assistant Medical Officer in Malaysia is also involved in Pre-Hospital Care as part of their job scope. Postgraduate programs available for Assistant Medical Officer includes Master in Medical Science (Public Health), Master in Risk Disaster Management, Master in Medical Science (Emergency Medicine), Master in Hospital Management and Health Economics as well as PhD in clinical or medical sciences fields.

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

• Presbyterian university of East Africa
• 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