Transformative Education
for Health Professionals

The Non-Physician Clinician - the Invisible Workforce

The Global Health Workforce Alliance estimates that by 2035 the global shortage of healthcare providers will be 12.9 million1. Current estimates are that over 1 billion people do not have access to health care providers today.2  

The non-physician clinician (NPC) plays an important role in the health workforce globally. They are rapidly trained under the medical model, region specific clinicians that increase access to health care with focus on health equity.  They have been termed ‘agents of change’ as they often serve in the most rural and impoverished areas in interdisciplinary teams. However, they are often ‘invisible’ in the human resources for health (HRH) ‘count’ as they vary in title, scope, accreditation and regulation. This leads to confusion and fragmentation in the midlevel health worker cadre. It is critical that health teams serve in a collaborative manner with a clear understanding of each other in order to maximize the scope of care. The International Labour Office does not have a distinct classification for the NPC, which adds to the challenge in HRH policy and planning.

NPCs have been in existence for many decades in developing and developed countries and have continued to evolve to meet the local population needs. They are known under many names such as physician assistants, assistant medical officers, clinical officers, medical licentiates practitioners, health assistants, associate clinicians, health officers, feldschers, physician associates and technical de cirurgia.  

Innovation in skills mix and task sharing has taken a stronghold in many nations. The findings of the Global Health Workforce Alliance (GHWA) systematic review on mid-level health workers (MLHW) showed outcomes in care were no different than that of physicians, and in some cases even better.3 However, the authors note that the low level of evidence and limited numbers of studies should lead to further studies and deeper evaluation.

The GHWA review includes nurses, midwives, auxiliary nurses/auxiliary nurse midwives, non-physician clinicians and surgical technicians in its definition of the mid-level health workforce. It defines the MLHW “as group of cadres who are trained 2-5 years to acquire basic skills in diagnosing, managing common conditions, and preventing disease.”3  The review describes the non-physician clinician (NPC) as a provider that is “not trained as a physician but who is capable of many of the diagnostic and clinical functions of a medical doctor and who have more skills than a nurse. They usually provide advanced advisory, diagnostic, curative… and preventive medical services. The requisites and training can be different from country to country, but often include three to four years of post-secondary education in clinical medicine, surgery and community health”3

The International Standard Classification of Occupations 2008 (ISCO-08) through the International Labour Office (ILO) has some mention, however no single definitive classification for the NPC type worker. Medical Assistants/Clinical Assistants are represented in Major Group 3.  Technicians and Associate Professionals are listed under Minor Group 325, Unit Group 3256. Clinical Officers are listed in the group of Professionals (Major Group 2) under Minor Group 224, Unit group 2240 in the Paramedical Practitioner area. Examples of the paramedical practitioner category are given as advanced care paramedic, clinical officer, feldscher, primary care paramedic and surgical technician.

With the World Health Organization and other global health policy leaders using the ILO as a reference tool for professionally designated workforces it is critical that the NPC type clinician be recognized in a comprehensive and clearly defined role. This will help facilitate the health care system structure with team development for the post 2015 era. 

As an ILO designated occupation the NPC cadres could engage more easily in national policy for accreditation, regulation and standardization of national training programs. This would only add to the oversight and quality of care provided. In the quest for Universal Health Care Coverage shifting the paradigm and helping nations and communities embrace team based care will enable the health workforce to work to the top of its’ capability and expand access to care.

Understanding the workforce skills mix capabilities is critical in planning and seeking solutions to a rising crisis in access for all to health care. Having globally defined and accepted health workforce cadres will help guide this process.






  1. 2013/en/index.html
  2. Crisp, N., Chen, L., Global Supply of Health Professionals, N Engl JMed, 20144:370:950-7
  3. Global Health Workforce Alliance, Mid-level health workers for delivery of essential health services –a global systematic review and country experiences. WHO/hss/hwa/mlp2013/ENG.
  4. International Standard Classification of Occupations 2008 (ISCO-08)
  5. Dovlo, D. Using mid-level cadres as substitutes for internationally mobile health professionals in Africa: A desk review, Human Resources for Health, 204, 2:7
  6. Lehman, U Mid-level health workers-the state of evidence on programmes, activities, costs and impact on health outcomes: a literature review, Geneva, World Health Organization, 2008.
  7. Mullen, F., Frehywot, S., Non-physician clinicians in 47 sub-Saharan countries, Lancet, 2007;370:2158-63
  8. Multak, N., An Update on Feldsher Training and Practice in the Ukraine , The Journal of Physician Assistant Education, 2010 Vol 21 No 3






















Area of intervention: