PREAMBLE : Clinical Medicine is the study and practice of medicine that is founded on the direct scrutiny of patients. It is one of the areas in the medical field/health system that primarily deals with the practice and study of medicine based on the direct examination of the patient. This is in contrast to other science fields that focus more on the theoretical and basics of medical science. In clinical medicine, medical practitioners assess patients in order to diagnose, treat, and prevent disease. Whereas Community health is a major field of study and practice within the medical and clinical sciences that focuses on the maintenance, protection, and improvement of the health status of population groups and communities. It is a branch of public health that focuses on people and their role as determinants of their own and other people’s health. A combination of the two gives rise to comprehensive community/public tailored health service delivery.
World-over, Clinical medicine is a recognized field and in East Africa and Uganda in Particular, Clinical medicine was coupled with Community Health to suit the needs of the region, as a tropical region with various tropical endemic diseases/conditions requiring community/public health interventions to better afford Prevention, as it is better than cure. The cadre was therefore named Medical Clinical Officer or simply Clinical Officer.
Medical Clinical Officer (MCO) performs general and specialized medical duties such as diagnosis (through interview to obtain chief complaint/illness, history of that illness, past medical history including previous hospitalizations, surgeries, injuries, diseases, vaccinations such as the currently ongoing COVID-19, Polio etc, allergies; social, family among others as well as systems inquiry and physical examination using diagnostic methods, devices and tests among others) and treatment of disease and injury, ordering and interpreting medical tests performing routine medical and surgical procedures, referral to other practitioners and managing health departments, institutions, projects and systems among other community based Health interventions including break out investigations and research. Currently, over 11,795 MCOs are registered; with 1: 6325 and 11: 4 MCO: patient and MCO: MO ratio in the country, respectively.
Bachelor of Clinical Medicine and Community Health (BCMCH) is the Undergraduate Medical Dual Degree awarded to Medical Clinical Officers; whereas a Diploma (DCM) in the same in the same, exits. With roots in Uganda at Namirembe/Mengo Hospital, MCO training has undergone evolution majorly in developing countries (especially in the East African Community Countries), as well as middle and some high income countries such as South Africa, USA, Malaysia, UK, People’s Republic of China and Nigeria among others.
The cadre is globally trained and have very close evolutionary resemblances to those variously known as Physician/Medical Associates/Assistants, Community Health Workers, barefoot/clinical Doctors among others. In East Africa, the Professionals are known as Medical Clinical Officers (MCO). And thus these are all under a global umbrella known as Global Association of Clinical Officers and Physician Associates (GACOPA). And Discussions with World Health Organization (WHO) and
International Labour organization (ILO) through World AMTC Network, are ongoing at International level to adopt a Common Training Curriculum, professional title and nomenclature.
Uganda is one of the pioneers in career progression and professional development of Medical Clinical Officers from Diploma (DCM) to Degree (BCMCH) level, which is in efforts to re-tool and improve skills set of the professionals to encounter ever changing and challenging medical field to meet basic, emergency and specialized health care needs of our evolving society. This is equally intended to match desired regional and international labor market skills sets and competence levels, like our counterparts in Kenya, Malawi, Zambia, Ethiopia, Ghana, Tanzania, Rwanda and USA where training of these cadres is streamlined to Masters (specialization) and PhD.
In the East African Community, BCMCH is currently offered by Mount Kenya University, Egerton University, Great Lakes University of Kisumu, and Kabarak University in Kenya, University of Rwanda, and Kampala International University Western Campus in Bushenyi-Ishaka and KIU Tanzania Campus. Whereas in Uganda, National Council for Higher Education (NCHE) with consultations from Allied Health Professionals Council (AHPC)/MOH (U) approved curriculum and standard of training BCMCH as a degree of human medicine and community health currently at KIU, with Direct and Extension program of at least 4 years and 3years respectively, at A’ Level and Diploma entry scheme. Upon graduation, the BCMCH Training standards and Curriculum, Uganda’s Vision 2040 and Internship policy of Inter-Ministerial Committee on internship require all medical degree graduates to undergo at least a one (1) year standard government supervised Internship in approved training Hospitals before being fully registered and licensed for health professional practice.
BACKGROUND TO CLINICAL MEDICINE AND COMMUNITY HEALTH PROFESSION IN UGANDA
The origin of Clinical Officers is traced to the initiatives by Dr. Albert Cook who in 1917 started the first Medical Training School in Uganda for Dressers and Dispensers to facilitate his medical work. It was this medical training which gave rise to the establishment of health training institutions for medical practitioners in Uganda. By 1918, under the Ministry of Health, Uganda was training medical practitioners who were called Medical Assistants at the time.
In 1946, the Uganda protectorate government identified training in health as one of the avenues to absorb the returnees from the 2nd World War and to care and promote their health. It was this year when the current Masaka School of Comprehensive Nursing was established to train Ex-service men and offer some Medical Skills. Ex-service men with good formal education were trained for 2 years to become Medical Assistants (as named then). Other Ex-service men with little formal education were trained for one year to qualify as nursing orderlies. The need for Medical Assistants and Nursing orderlies kept on increasing and Masaka Campus could not cope up with the demand. The Government then decided to transfer the training of Medical Assistants to Mbale and left Masaka to continue training Nurses.
In view of the need for a Hospital in the Training of Medical Assistants (as called then), the current Mbale COHES which was initially training Environmental Health Assistants and Inspectors was later in 1950 converted to train Medical Assistants because of its vicinity to Mbale Hospital. The School
was under the Ministry of Health and together with Mbale School of Hygiene; they were being supervised by the Medical Superintendent of Mbale Hospital.
In 1960, the administration of the Medical Assistant Training School of Mbale was handed over to a Ugandan after a White Nurse Tutor. Drafted a Curriculum in 1970 which officiated by 1975. Later in 1996; the name/qualification title was changed and modified; evolving from Medical Assistant to Clinical Officer after adding Community Health to Clinical Medicine Training and Practice to cater for Public Health priorities as put forth in the 1978 in Karzakistan and later the 1990s MDGs Development which called for Community based interventions including community participation in Health promotion, care and especially preventive medicine. similarly, BCMCH development was brought on board to supplement the MDGs which ended in 2015 and currently the BCMCH suits the UN SDGs pursuit by being further trained to cater for the Community through research based interventions, Breakout Investigations including Pandemics like the current Covid-19, Measles, Rubella as well as the endemic conditions like TB, Malaria, among others like zoonoses such as Anthrax.
RELEVANCE OF A MEDICAL CLINICAL OFFICER IN THE HEALTH SYSTEM
The Conventional Clinical Officers (with a diploma in Clinical Medicine & Community Health) have continued to play vital roles [champions in implementation of UNAIDS 90-90-90 (currently 95-95- 95), MDGs, Malaria Elimination projects, Infectious Diseases among other NGOs’ projects which are normally implemented at Sub-county and Village basis] as clinicians and managers not only in Rural Health Facilities but also in the running of health sub district, district and Regional Referral Hospitals and Africa-wide they have been documented to have championed the fight against HIV/AIDS and in the implementation of MDGs and pursuit of the Minimum Health package (Whose priority areas focus on Community Health and at Community level) since inception. However, according to 2019, public service problem analysis of the Local Government Health Facilities, Health Systems as a whole and service delivery in pursuit for Universal Healthcare Coverage (UHC); showed a professionals’ a limited skills and competences in Clinical, Community Health and Research expertise by nature of the training at Diploma level. And further showed that the efforts conferred could not match with the ever increasing emerging and re-emergency of diseases and health needs of the communities which they served thus needed to upgrade to BCMCH which is Public Health Oriented and Research facts based.
Over the years, there has been a significant increase in the number of cases of Non Communicable Diseases such as Diabetes, Hypertension & Cancer, and high prevalence of preventable infectious diseases such as malaria, Tuberculosis & HIV/AIDS. And these have always been endemic in Africa among other conditions (especially infections) like malaria in which Uganda together with other countries contributed up to 80% of the morbidity and mortality. Furthermore, the emergence of the COVID-19 global pandemic has as well demonstrated the urgent need for Health Care Systems to prioritize Primary Health Care (Community Health) which mainly involve disease prevention & Health Promotion not better treatment or Surgical skills but sensitization and research to establish motivating factors for a better Community and facts based interventions. This is a role illustrated to be played well by over 11,000 conventional clinical officers of Uganda with only a Diploma in
Clinical Medicine and Community Health and this is projected to be a better played role with upgraded (Degree holder) Clinical Officers.
Global and National Health Care (Uganda National Health Policy) priorities have been disease prevention at community level, where Clinical Officers have evidently done a tremendous work to realize UHC and SDG 3. Going forward, almost all public HC IIIs across the country are being managed by Clinical Officers. Therefore, improving their technical skills and competence is essential to improve the quality of health care (Mostly Community health) service delivery in the country, besides streamlining their professional advancement/career path as recommended by Public service in 2019 and various WHO press conferences and publications/recommendations.
REGULATION OF MEDICAL CLINICAL OFFICERS IN UGANDA
In Uganda, the professional practice of Clinical Officers is currently being regulated, registered and licensed by the Allied Health Professionals’ Council, in accordance with the Allied Health Professionals Act, Cap 268 of 1996. Additionally, the same act defines Clinical Medicine as an independent Profession thus mandated to profession development as deem due. It should also be noted that health care delivery is accomplished by team work involving various professionals and each professional’s contribution is unique and equally essential. By acquiring a Degree, a clinical officer is trained to be a better team player at his/her level of deployment for a better Health Service Delivery.
Current Developments among the Clinical Medicine Profession
The Allied Health Professionals’ Council and the National Council for Higher Education both; finalized the approval and accreditation process of the Bachelor of Clinical Medicine and Community Health program (which started in 2006) offered by Kampala International University, on 23rd May 2019 under MIN 44/05/19 and on 7th June 2019 under MIN 311/51/2019 respectively, after fulfilling and meeting the minimum standards and defining the need, niche and/or justification/rationale for the same. Subsequently, several stakeholders’ consultative meetings were held with regard to BCMCH, including among others a meeting held on 18th August, 2018 at Sports View Hotel, Kireka. The accreditation of BCMCH followed Clearance and recommendation for the same by the Inter
ministerial committee on Human Resource for Health, Health Policy Advisory Committee of MOH recommended the program for accreditation partly as a way of awarding the Conventional Clinical Officers (11000 plus Diploma Holders) with a University Degree hence improving their training in Biomedical Sciences, Pathology, Public Health/Community Health and Clinical Sciences to enable them meet the ever changing disease patterns both in communicable and Non-Communicable Diseases in order to provide effective Primary Health Care in the Country.
Last but not least, it is worth noting that ever Since the inception of Higher Education Students’ Financing Board (HESFB) in 2014, the government of Uganda through this Board has been sponsoring over 400 students pursuing Bachelor of Clinical Medicine and Community Health at Kampala International University. These sponsored started graduating by 2019; and their training fully completes, for licensing to practice after Internship for to serve their Country and Contribute to the Economy of the Country; A healthy population translates to an empowered Community economically.
In Summary; –
1. Clinical Medicine and Community Health Profession is not only unique with Uganda but all over the world especially East African countries, Africa at large, Europe, UK, America, China, India among other countries where such cadres of that type have evolved and are now part of medical teams providing quality medical care and especially Community based health services across the globe. Thus Affiliation of Clinical schools to Universities could possibly extend Clinical medicine to extensively be taught in Uganda.
2. The rationale of Clinical Officers (especially at Degree level, BCMCH) especially during this time when the world is battling with this pandemic and the need for scientists (especially Community health trained Cadres) has almost tripled, to enforce the SOPs among other WHO Recommendations and Public Health a whole. Similarly, due to continued challenges and emergency of various non communicable and communicable diseases including Covid-19 pandemic, Ebola among others and ever changing and scientific advancement in medical Care, just like universities are supposed to solve problems in a community, Health Policy Advisory committee of MOH recommended the program to improve skillset and enable the cadre to meet the ever changing disease patterns both in communicable and non communicable diseases in order to provide effective primary health care in the country. Government of Uganda through Ministry of education and sports through HESFB provided financial support and it’s still giving support through loans to economically underprivileged students who qualify for university studies but couldn’t afford to acquire this degree in BCMCH program.
3. As a sector, Pharmacists, Medical Clinical Officers and Medical officers; Nurses and midwives, Laboratory, Radiology/Imaging among other Allied Health Professionals need to continue to work as a team in supporting our health system both in the public and public health sector at various levels of serving including but not limited to PNFP NGOs as well as Community Health Teams against Infectious diseases. Thus the MOH and the East African Community, need to harmonize systems in the EAC so as to experience a better health service delivery, across the member states.
Last but not least, I believe that; embracing a one health model (Starting with fair recruitment procedures of the health workforce, in reasonable numbers per profession and role) in pursuit of UHC, SDGs, and most importantly the priority areas as laid down in the National Health Policy and National Action Plan for Health Security 2019-2023; is more likely to bring trust in the health systems and across the country like Kenya where MCO and many other health sector players are used to the fullest.
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The Author; Dr. Kachwano Alex is the National Leader/Representative BCMCH Graduates Society of Uganda,
Deputy Secretary General Medical Clinical Officer Professionals, Uganda (MCOPU) and
Country Representative/Focal Person, World AMTC Network
Tel: +256752294160 (WhatsApp & Telegram), @kachwano (Twitter), drkachwano@yahoo.com
