1. Non-physician Clinicians in HIV Service Delivery: Experiences From 47 Sub-Saharan African Countries
XVII International AIDS Conference
Mexico City, Mexico
August 4th , 2008
Seble L. Frehywot MD, MHSA
The George Washington University
Washington, D.C.

2. Content Overview of Non-physician Clinicians in Sub-Saharan Africa…ESR
Non-physician Clinicians in HIV/AIDS Service delivery……country examples
Needed Regulatory Elements in Non-Physician Clinician HIV/AIDS Service delivery
Summary - Non-physician Clinicians Promise and Impediments for Scale-up

3. Overview of Non-Physician Clinicians in SSA
Health care providers with post- secondary school training who to most extent can perform the functions of a physician under or in lieu of a physician supervision.
Trained in basic diagnosis and medical treatment
Deliver a range of personal clinical health services.
Basic schooling: Nurse-based or non -nurse based
Pre-Service education: Mostly 3 years (ranges from 1( for RNs) to 4 years)
Post-basic education (Internship):
Mostly months
Curriculum focused on host country’s
indigenous clinical problems & program developed & run by host government
Stable placement in rural areas
Demonstrated established history of effective clinical care services
Cost: $1,200-$4,000/year (tuition and board)

4. Expanded Service Roles (ESR)
Delegation or
Supervision
Medical Doctor
Non-physician Clinicians
(e.g. AMO, Clinical Officers, Health Officers)
Pre-service training coupled
with additional in-service
training
Regulatory Framework
Diagnostic, Prescriptive
Authority
Expanded Service Roles
(ESR)
SOP include:
Medicine (including HIV AIDS treatment),
minor Surgery, Anesthesia, OBGYN (C/S),
Orthopedics, Ophthalmology,
Dermatology etc.

5. NPC Presence in SSA 25 SSA countries where NPCs are present Angola
Gabon
Liberia
Senegal
Tanzania
Burkina Faso
Ghana
Malawi
Seychelles
Togo
Botswana
Guinea Bissau
Mauritius
Sierra Leone
Uganda
Cape Verde
Kenya
Mozambique
South Africa
Zambia
Ethiopia
Lesotho
Rwanda
Sudan
Zimbabwe
Most common nomenclature: Clinical Officer, Health Officer

6. Distribution According to the Language Spoken

7. Expanded Service Role (ESR) in HIV/AIDS
Medical Doctor
Initiation of staging
and diagnosis
Extra in-service
training given or
training included in
pre-service
program
Initiation of ARV
prescription
Diagnostic
and
Prescriptive Privileges
Regulatory Framework
Delegation/
Supervision
Expanded Service Role
Initiation of OI
Prophylaxis
Management of cases
Country Examples
Malawi, Ethiopia, Tanzania, Zambia are
building ART strategies around the
NPC cadres
Non-physician Clinicians
(e.g. Clinical Officers, Health Officers)

8. Enabling Regulations Country Example of Use of Regulations
Malawi:- Clinical Officers
Ethiopia: Health Officers
MOHP: ART guideline was updated for CO to initiate prescription, initiate diagnosis and staging, manage case
Regulatory Bodies: Medical and Allied Professional Council registers CO. The Medical Practitioners and Dentists Act, No. 17 of was amended to allow CO to do ESR and the Pharmacy, Medicine and Poison Board added HIV drugs on the list of drugs that CO can prescribe
Training Institutions: Curricula was revised to include HIV/AIDS training.
FMOH(FHAPCO): Guideline for Implementation of ARV Therapy was updated for HO to initiate prescription, initiate diagnosis and staging, manage case
FMOH (Registration and Licensing Office) HO registered and licensed the same way like doctors. Gives license like the doctor’s for clinical care
Training Institutions: Now for the new program (5000 HO training) curricula was revised to include HIV/AIDS training

9. Recruitment, Deployment,
Regulatory Elements Needed to be Addressed by Countries Conducting Expanded Service Role for NPCs
Financing &
Sub-national
implementation
Supervision
Mentoring & Mentoring
Working Conditions
Non-physician
Clinicians
Scope of Practice &
Competencies
Recruitment, Deployment,
Promotion, Salary, &
Other HR Issues
Standards of Care
Standard Pre-Service
Education & Training
Standard
In-Service Training &
Certificate
Licensing
Registration &
Certification
Regulatory Approaches: Laws/Proclamation, Regulations, Policies, Guidelines

10. Summary - NPC Promise and Impediments for Scale-Up
NPC Impediments
Established history & effective presence in many countries
Instrumental in addressing the
HRH urban/rural maldistribution
problems
Trained in less time and with less
expense than physicians
Stable rural placement
Less problem with “brain drain”
Demonstrated effective role in ART
& other clinical services
Cost of training and
employment
Insufficient faculty and
infrastructure for training
Medical profession
resistance in some countries
SOURCE: Lancet: Mullan F, Frehywot S. Non-physician Clinicians in 47 Sub-Saharan African countries. June 2007

11. Thank You