Programme Director, Honoured Guests, Ladies and Gentlemen, all protocols observed.

It is my honour and privilege to address you this morning on this important occasion, the official launch of the midlevel workers programme.

Occasions like this are important not only because they bring us together to celebrate milestones or some achievements but also because they offer us some opportunity to refocus our thoughts, share experiences and aspirations and re dedicate ourselves to the imperative of improving the quality of life of all our citizens.

On behalf of our government, I would like to recognise our guests from Atlanta, Washington DC in the USA and Tanzania who opened their arms to the delegation of the Department of Health during their exploratory study tour in their quest to investigate training and utilisation of the midlevel cadres for medical doctors, the Medical/ Physician Assistants.

I would also like to extend a hearty welcome to all our honoured guests who have responded positively to our invitation today.

I am encouraged by the fact that they have set aside time to come and deliberate with us in our endeavour to improve on the human resource aspects of our health care delivery system. We are gathered here to officially launch the Medical Assistant Programme.

South Africa chose to adopt the policy of a health care delivery system based on the Primary Health Care Approach.

This was deemed the most achievable method through which the goal of Health for All could be achieved for all our population.

This is the program that will increase access to quality health care for all by strengthening Primary Health Care delivery.

This is a day worth celebrating.

Provision of Primary Health Care to the people of South Africa has always been a challenge. Despite the fact that enough young doctors graduate from the 8 medical schools in the country, the provision of doctors is inadequate.

Let me point out that there are many factors contributing to the mal-distribution of doctors amongst other the migration to the private sector as well as to countries abroad.

The urban bias also skews the picture and impacts negatively on the implementation of primary health care. Needless to say there are a variety of health facilities in urban and peri- urban areas, which experience severe shortages of doctors and other health professionals.

All this necessitates us to find creative ways of addressing the challenges mentioned here.

The Department of Health Strategy document on Health Human Resources (The Pick Report) recommended amongst others that the mid level worker cadres be developed by various health professional groups to facilitate the implementation of the primary health care package (PHC) within the country.

For medical doctors this translates into medical / physician assistants.

The introduction of such a cadre was discussed and endorsed by MINMEC on 06 December 2002. The development of this programme was further endorsed in subsequent MINMEC meetings.

Another strategy was the introduction of community service for doctors, which went some way towards addressing the problem but not entirely. To facilitate implementation of this programme, a delegation comprising of officials from Department of Health and Health Professions Council of South Africa was commissioned to conduct a study tour of the USA and Tanzania to witness, first hand, the training and utilisation of this cadre and to benchmark best practices of these countries, which have run these programmes for many years.

I will not pre-empt presentations from our invited guests but will highlight a few issues on what medical assistants are about.

In the USA such a cadre is referred to as Physician Assistants (PAs).

This cadre developed during the mid 1960's due to shortage of doctors in rural areas.

PA's were in primary health care only but later started to work in other medical specialities.

The PA's do not function independently but practise in association with physicians.

The doctor may not be physically present for a PA to practise, but takes responsibility for the work of a PA.

They do routine work performed by doctors, like examination, diagnosis, carrying out investigation as well as treatment and prescribing.

In primary health care, PAs work with a team of family physicians and nurse practitioners. Training programmes are offered at medical schools. For their selection, substantial experience in the health care field is a recruitment requirement.

A typical student would have a bachelor's degree and 4 years experience in health care activities.

South Africa however does not intend to have the medical assistant programme as a post-graduate course.

This cadre will be located in the district hospitals in the South African context as a pilot.

To practise the PA must pass the National certificate examination by the National Board of Medical Examiners.

The PA must then apply to a state medical board for a practising licence and appoint a supervising medical doctor.

The PAs are employed in hospitals, group or solo practices, community health centres and rural clinics.

The motivation for developing this cadre is not different in Tanzania because this mid-level medical worker also developed due to absolute shortage of medical doctors after their independence.

The assistants were trained as rural medical aides.

As the education system developed, the entrance criteria and the level of training increased.

There are three levels of mid-level workers in Tanzania.

Rural Medical Aids, the medical assistant, the clinical officer and the Assistant Medical Officer (AMO).

AMO are registered within the Tanganyika Medical Council. The mid-level workers work for the government and NGO's.

Training of mid-level workers in Tanzania is done in the training centres throughout the country and not at Universities.

It is run by the Department of Health and the NGOs.

Training is based on Medical training, with emphasis on understanding and managing common diseases and management of health care.

I will leave the details to our speakers from Tanzania to do justice to this subject.

An interesting question to ask is "Why are Clinical Officers and Physician Assistants willing to work in rural areas in their countries"?

This is probably due to the fact that the PA or a clinical Officer is usually a person from the local community with local culture, normally chosen to do the work.

This makes them less mobile because they are fulfilled with a local life.

This is an important point to consider when establishing the medical assistant programme in South Africa.

I would now like to come nearer home and discuss the rationale for Medical/Physician Assistant programme in South Africa and our envisaged approach. Due to absolute shortage of health professionals and increasing health care needs, a decision was taken and endorsed by MINMEC to establish a midlevel medical worker.

As a country, we have learnt lessons with midlevel health workers like dental therapists.

These hard learnt lessons will be taken into consideration in the development of the medical assistant programme.

We envisage ladies and gentlemen that in the initial phase of the plan this cadre will be located in the district hospitals to strengthen our primary health care services.

This will be evaluated before further phases are developed. A district hospital is ideal in the sense that it is a well-defined and manageable level of care.

Placing the medical assistant in the district hospital makes it possible to be specific about the scope and limits for this midlevel worker.

The Medical / Physician Assistant will be part of a team in different units in a district hospital, that is, the Emergency Unit, Maternity, Out patient Departments, Medical and Surgical Units.

In the operating theatres, the Medical/ Physician Assistant will assist the doctor in basic procedures like incisions, drainage and evacuations.

The regulation of the Medical Assistant will rest with the HPCSA. That is why the HPCSA participated in the exploration.

Education and training of medical assistants will be close to the place where the Medical Assistant will function. Most learning will take place at a district hospital.

The curriculum will be based on the medical curriculum with the focus on the skills and knowledge necessary for the Medical Assistant to function in a district hospital.

A clear link with the university through internal, telemedicine and blocks of learning at the university will be maintained.

Training will be three years followed by an internship in the district hospital.

To be practical there will be one training site per province with 12 students per site per year at the initial stage.

More training sites will be developed within the next 5 years.

The developments will depend on how the universities and provincial departments of health collaborate and what works best for each province and each university.

Recruitment will in principle not be done from other health professional groups.

Ideally, students should be nominated by local communities with a minimum of a matric with a university exemption.

People with basic degree in science or arts may be good candidates, especially in the early stages of the programme.

Let me hasten to assure you that a process of consultation, discussion and openness will be critical in ensuring that there is a common understanding on the objective of this programme.

A task team has already started initiating this process and I urge you to enrich this process by giving your valuable inputs. This new cadre of workers is created to bridge the gap between the urban and rural divide, the well-resourced and under-serviced parts of the country.

It is by no means an attempt to replace any cadre of existing qualified health professionals.

We know that the full team of health workers are important especially in primary health care and we want to strengthen this team. In particular, we will be building on the much appreciated experience of clinician nurses who have done a wonderful work in the provision of health services.

The realities of South Africa with its liberal constitution are such that there are no obvious means of enforcing equitable distribution of health human resources based on need.

In the foreseeable future, it is most likely that we shall continue to have conglomeration of health professionals in the great metropolitan areas as before.

This is why we have to be ever creative and innovative in addressing challenges facing South Africa's health care needs.

I am honoured to officially launch this programme on this 29th day of March 2004.

As you go forward with the process let us all strive for excellence.

I thank you ladies and gentlemen!