Using the open-ended survey results and the analysis tool, we summarize our findings in Table 2. Responses were coded to address the indicators and variation in practice. The information in parentheses provides guidance used to interpret open-ended responses. Table 2 shows that all five countries indicate that there are national standards for accreditation of AMTCs (indicator 3-1), that accreditation mechanisms were in place (indicator 3-2), that there are socially accountable standards (indicator 3-3), and those socially accountable standards are effectively implemented (indicator 3-4). In these five countries, there was general agreement on standards (indicator 3-7) and continuing professional development (indicator 3-8).
There was more variation in responses for the remaining indicators. Specifically, respondents reported that standards concerned with social determinants of health (indicator 3-5) were partly implemented in Malaysia and Mongolia. This was due to respondents’ interpretation of the role of community health in the standards for training in their respective countries. This was not the case in Ethiopia, Kenya, Ghana, and Malaysia, where community medicine and public health was more clearly the focus of training. For example, in Ethiopia, this cadre is trained to meet the needs of rural and remote communities. The same is true in Kenya, Ghana, Ghana, and Malaysia; the cadre is seen as fit-for-purpose because of accelerated training and the focus on primary care.
Responses varied regarding standards for interprofessional education (indicator 3-6). In Ghana, interprofessional education is embedded in the undergraduate training curriculum of Physician Assistants (PA) whereby PA students study other professional courses and collaborate in teams with other professional students such as nursing, pharmacy, medical laboratory, and medical students during clinical attachments, clerkship, and preceptorship as part of preservice training. The title ‘physician assistant’ refers to three different groups of health professionals (17) trained in the medical model to provide medical and dental care: PA-medical including medical assistants; PA-dental, known as community oral health officers; and PA-anaesthesia, otherwise called nurse anaesthetists.
In Malaysia, interprofessional education (IPE) is not a national education policy, but the concept of IPE is implemented in several higher educational institutions. For example, the National University of Malaysia (UKM), a public university, has implemented IPE in the medical faculty where medical and nursing students study in the same class for certain courses. The primary goal of IPE is to prepare students to work in interprofessional teams and apply this knowledge, skills, and attitudes into their future practice, ultimately providing interprofessional patient care as part of a collaborative team and focusing on improving patient outcomes (19).
In Mongolia, training of feldshers ended in 2012 in Ulaanbaatar, in 2016 in Dakhan province, in 2017 in Dornogovi province, and 2018 in Gobi-Altai province, by order of the Ministry of Health. Currently, there are 2,410 in active practice. According to the UNDP report, the number of the smallest administrative unit, bags increased: in 2007 there were 1,539 bags, which increased to 1,668 in 2019, of which only 965 bags (58%) were where feldshers were frontier health specialists providing health and medical services to rural area populations. In Kenya, the evolution of the clinical officer cadre has meant that interprofessional education was essential as there is considerable work with medical officers (physicians) and nurses, particularly as part of in-service training. Currently, there is an independent regulator, the Clinical Officer Council, which may affect the extent to which interprofessional education curricula are used.
For indicator 3-9, there was some variation in the responses. In Ethiopia, standards have been reviewed and revised for additional training and the scope of practice. Recommendations have been submitted to the regulatory authorities. Training for emergency surgical services is also provided in Ethiopia for Integrated Emergency Surgical Officers. In Mongolia, the training of feldshers has ended, but graduates of the programmes continue their professional development in different fields mostly in public health: biostatistics and epidemiology.
In Kenya, clinical officers are currently developing an automated digital platform for the acquisition of new knowledge and updated professional information geared towards improving professional practices across its sub-specialities. In this regard, it is the responsibility of each individual within the profession to acquire the minimum continuing professional development (CPD) points required before the renewal of each individual’s professional practising license. The accounting for CPD points has been done manually since 2016 using signed booklets provided by the Clinical Officers Council. The growing population of professionals and their specialities has necessitated the development of an automated digital platform for this purpose. To do this effectively, the Clinical Officers Council and other stakeholders are currently working with the World Continuing Education Alliance (WCEA) that is already providing the same services to the Kenyan nurses, midwives, and doctors. There are other existing providers of CPD points for clinical officers, other than WCEA. In Ghana, in terms of continuing professional development programs, PAs can pursue PA speciality and subspecialty programs in psychiatry and clinical dermatology.
In Malaysia, assistant medical officers / medical assistants are encouraged to pursue continuing education programs to enhance their knowledge and skills in the respective field of medicine they work. Accordingly, they must earn a minimum of 40 CPD points as a prerequisite for renewing their Annually Practising Certificate (APC). Renewal of APC can be done online using the Business Licensing Electronic Support System. For continuing professional education, accreditation practices varied as well. In some of the countries, respondents thought that this additional training was part of speciality training. Also, the cadre has the opportunity to pursue in-service training for post-basic or advanced diploma programs (6-12 months) in various areas of specialities such as emergency medicine, orthopaedics, respiratory medicine, critical care, cardiovascular care, renal care, ophthalmology, otorhinolaryngology and many more. The courses are conducted by the Ministry of Health training institutions or private institutions (20).
The open-ended data provided were quite rich and provided insights regarding accreditation processes that go beyond the indicators that are part of the NHWAs. Table 3 provides additional information regarding accreditation of pre-service and in-service training, the establishment of accreditation, and who is responsible for accrediting programs. The organizations responsible for the accreditation of training for these health professionals are national in origin. For the most part, ministries of education and health are responsible for the accreditation of pre-service training. Based on the responses, these government agencies are responsible for regular curriculum review, coordination of site visits, and establishment of training standards for pre-service training. For in-service training, this responsibility shifted to the licensing authority in the country. Kenya was the exception; this country has a regulatory body (the Clinical Officers Council; COC) that is specific to the Clinical Officers as a cadre.