#AMTC_HRH A Call to Action; Accelerated Medically Trained Clinicians and the social determinants of health
Author; Nadia Cobb MS, PA-C
Key reference: Findings from a survey of an uncategorized cadre of clinicians in 46 countries--Increasing access to medical care with a focus on regional needs since the 17th century 3
ATMCs post your photos on instagram AMTC with # : #AMTCin46countries
The ‘invisible health workforce’
“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.” (Dr. Etienne (WHO Regional Director for the Americas at the Third Global Forum on Human Resources for Health 2013) The International Labour Organization recently published the “Global Evidence on inequities in rural health protection: new data on rural deficits in health coverage for 174 countries”1 where they note that ‘while 56% of the global rural lacks health coverage, only 22% of urban populations are not covered’. One of the conclusions of this paper is the call for more skilled health workers who will serve the rural and marginalized populations.
The ‘invisible workforce’ described in the November 14, 2014 blog2 has existed for centuries with a focus on increasing access to care. Often over looked and marginalized in health policy and systems planning because of the lack of a defined category as a health care provider. These clinicians most often serve in the communities as the first line of contact, as the primary care providers.
The Accelerated Medically Trained Clinician, AMTC
The Accelerated Medically Trained Clinician (AMTC) is a new term to describe the health workforce category described in the key reference. These cadres are represented in over 46 countries under the professional titles of: clinical Officer, attache’s desante, attache de sante en chirurgie, health officer, assistant medical, medical assistant, physician assistant, tecnicos de medicina, tecnicos de cirurgia, community health care officer, community health officer, clinical associate, associate medical officer, medical licentiate, associate clinician, sub-assistant community medical officer, baga emch, condensed health assistant, feldsher, physician associate, medex, health extension officer. The umbrella “AMTC” category represents this workforce while respecting the origin and region where they serve.3 The variations in training and titles are not dissimilar to the ‘physician’ and ‘nurse’ categories.
These professionals are trained in the medical model, in a condensed, regionally specific, flexible and cost-effective manner. They are dynamic and responsive to the host health system, as well as population and community needs. They are team based health professionals whose development and curriculum have evolved to fill the gaps in healthcare. They are unique in that they have historical and cultural identities in the countries they serve3. Because of their regional ties and titles they are not able to migrate and are seen as not only critical in the care of communities, but as a strong return on investment from a governmental view.3
Brief history of AMTCs
The AMTC’s beginnings were in the USSR in the 1600’s4. These clinicians (now known as feldshers) provided primary care in the rural and remote areas, often along Peter the Great’s routes. They continue to serve that part of the world, as well as in Mongolia with the Baga Emch serving the nomadic tribes’ primary health care needs as they travel with them5. AMTC’s in Africa also developed out of need for increased access to care in the rural communities in the late 1800’s starting with the Medical Assistants in Malawi.6 Similarly the Medical Assistants in Bangladesh8, Health Assistants in Nepal11, Medical Assistant-Health Extension Officers in Papua New Guinea12, the Health Officer in Tonga12 serve in the rural and remote areas. Countries such as the United Kingdom are more recent in the development of the Physician Associate14, as are the Physician Assistants in Canada15 however they all seek to increase access to care.
In exploring the flexibility of the AMTC Kenya, Malawi, Tanzania, Mozambique and Zambia’s governments developed formal paths for advanced training in emergency obstetric care7 (surgery), ophthalmology and psychiatry. Physician Assistants in India were established in the early 1990’s to help with the brain drain in cardiothoracic surgery13. As India seeks to achieve Universal Health Coverage by 202018 the National Initiative for Allied Health Sciences is exploring the expansion of the AMTC workforce into primary care areas. Physician Assistants in the United States started in the late 1960’s to increase primary care access, through the scaling up of the training of the Medics returning from Vietnam16. Today there are over 100,000 practicing.
The social determinants of health; a call to action
As the post 2015 plans are finalized themes have arisen, many linking back to the need for a health workforce educational agenda focusing on transformative medical education. Through increasing awareness of the social determinants of health, as well as team based care at the community level, future health care providers will grow to understand patient centered care and the critical nature of primary care. A cadre of clinicians – the AMTCs have been on the fringes of health system policy development, but are, for the majority, a shining example of the above.
As the AMTC movement grows next steps will include defining core competencies within training and scope of practice. This will help in the formal recognition of this global workforce trained in the medical model, in an accelerated manner, that is regionally specific, flexible, cost effective and culturally engaged. Through this they will be able to be included in health workforce and health systems planning as recognized and defined members, adding to the ultimate goal of universal health coverage.
1. 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
2.Cobb, N; 2014, “The non-physician clinician- the Invisible Workforce” http://whoeducationguidelines.org/blog/non-physician-clinician-invisible-workforce
3. Cobb, N, Meckel, M, Nyoni, J, Mulitalo, K, Cuadrado, H, Sumitani, J, Kayingo, G, Fahringer, D, (in press) “Findings from a Survey of an Uncategorized Cadre of Clinicians in 46 Countries--Increasing Access to Medical Care with a Focus on Regional Needs since the 17th Century World Health and Population edition ‘The Global Health Workforce: Striving for Equity, Tackling Challenges on the Ground’
4. 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.” World Health Organization Institutional Repository for Information Sharing. http://apps.who.int/iris/handle/10665/39783.
5. World Health Organization & Ministry of Health Mongolia. 2012. Health Service Delivery Profile 2012, http://www.wpro.who.int/mongolia/about/service_delivery_profile_mongolia.pdf
6. Muula, AS. 2009. "Case for clinical officers and medical assistants in Malawi", Croatian Medical Journal, vol. 50, no. 1, pp. 77-78
7. Pereira, C., Cumbi, A., Malalane, R., Vaz, F., McCord, C., Bacci, A. and S Bergström. 2007. “Meeting the need for emergency obstetric care in Mozambique: work performance and histories of medical doctors and assistant medical officers trained for surgery.” BJOG: An International Journal of Obstetrics & Gynaecology, 114: 1530–1533. doi: 10.1111/j.1471-0528.2007.01489.x
8. 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.
9. 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
10. Crisp N and L Chen. 2014. “Global Supply of Health Professionals.” New England Journal of Medicine. 2014;370(10):950-957. doi:10.1056/nejmra1111610.
11. Knoble SJ, Pandit A, Koirala B and L Ghimire 2010. “Measuring the Quality of Rural-Based, Government Health Care Workers in Nepal.” The Internet Journal of Allied Health Sciences and Practice. 8(1).
12. World Health Organization Western Pacific Region.2001. Mid-Level and Nurse Practitioners in the Pacific: Models and Issues. http://whqlibdoc.who.int/wpro/2001/a76187.pdf.
13. Abraham EV, Sundar, G and NM CObb. 2104. “Physician Assistants in India.” Transformative Education for Health Professionals. http://whoeducationguidelines.org/content/physician-assistants-india.
14. Apperly, s and NM Cobb. 2014. “Physician Associates in the United Kingdom.” Transformative Education for Health Professionals. http://whoeducationguidelines.org/content/physician-associates-united-kingdom.
15. I Jones. 2014. “Physician Assistants in Canada.” Transformative Education for Health Professionals. http://whoeducationguidelines.org/content/physician-assistants-canada.
16. Hunt, J and NM Cobb. 2014. “Street medicine, Caring for Homeless Patients Where They Are.” Transformative Education for Health Professionals. http://whoeducationguidelines.org/content/street-medicine-caring-homeless-patients-where-they-are-physician-assistant-role.
17. McKimm, J, Newton, P, Silva, A, Campbell, J, Condon, R, Kafoa, B, Kirition, R, Roberts, G, 2013, “Expanded and extended health practitioner roles: a review of international practice”, Human Resources for Health Knowledge Hub, Sydney, Australia.
18. Hazarika, I., 2013.”Health workforce in India: assessment of availability, production and distribution”, WHO South-East Asia Journal of Public Health, April-June 2(2) 106-112
Nadia Cobb MS, PA-C