The Evolution of the Physician Role in the Setting of Increased Non-physician Clinicians in Sub-Saharan Africa: An Insistence on Timing and Culturally-Sensitive, Purposefully Selected Skill Development

As Eyal et al put forth in their piece, Non-physician Clinicians in Sub-Saharan Africa and the Evolving Role of Physicians, task-shifting across sub-Saharan Africa through non-physician clinicians (NPCs) has led to an improvement in access to health services in the context of physician-shortages. Here, we offer a commentary to the piece by Eyal et al, concurring that physician’s roles should evolve into specialized medicine and that skills in mentorship, research, management, and leadership may create more holistic physicians clinical services. We believe that learning such non-clinical skills will allow physicians to improve the outcome of their clinical services. However, at the risk of a local, clinical brain drain as physicians shift to explore beyond the clinical sphere, we advocate strongly for increased caution to be exercised by leadership over the encouragement of this evolution. In the context of still-present physician shortages across many developing countries, we advocate to analyze this changing role and to purposefully select each new skill according to the context, giving careful consideration to the timing and degree of its evolution.

I n 2006, sub-Saharan Africa held 24% of the disease burden in the world but only a startling 4% percent of the global health workforce. 1 Today, despite advancements in health workforce capacity building, this imbalance remains. 2 It is in this context of strained human resources that Eyal et al take their position in Non-physician Clinicians in Sub-Saharan Africa and the Evolving Role of Physicians, discussing new coverage of once-physician-driven clinical areas by nonphysician clinicians (NPCs) and advocating for increased non-clinical education for doctors to prepare them to enter new roles beyond traditional medical fields. In response to Eyal et al, we stress the need to carefully analyze and weigh the influence of clinician redistribution across non-clinical fields before advocating for the evolution of physicians' roles. A particular focus on the timing and extent of this evolution must be made, so as to capitalize on areas of potential while safeguarding from harmful steps that could challenge progress toward quality clinical care.

Task-Shifting to Non-physician Clinicians
Across many developing countries, NPCs now fill physiciandeficit gaps in healthcare delivery, creating the Eyal et al termed "NPC-cornerstone system, " which the authors claim can function with less physicians. 1 As Eyal et al write, many developing countries in sub-Saharan Africa have artfully used task-shifting and decentralization to capitalize on existing human resource capacity within the health sector. 3 In Rwanda, task-shifting occurs between all health professionals in order to counter shortages across every skilled position. At the community level, nurses manage infectious disease effectively through this decentralized transfer of select medical procedures. 4 This has enabled care to be delivered more efficiently, vastly, and at a lower-cost than the traditional physician-driven system, resulting in the improvement of the healthcare system as a whole. 5 I n a recent contribution to the ongoing debate about the role of power in global health, Gorik Ooms emphasizes the normative underpinnings of global health politics. He identifies three related problems: (1) a lack of agreement among global health scholars about their normative premises, (2) a lack of agreement between global health scholars and policy-makers regarding the normative premises underlying policy, and (3) a lack of willingness among scholars to clearly state their normative premises and assumptions. This confusion is for Ooms one of the explanations "why global health's policy-makers are not implementing the knowledge generated by global health's empirical scholars. " He calls for greater unity between scholars and between scholars and policy-makers, concerning the underlying normative premises and greater openness when it comes to advocacy. 1 We commend the effort to reinstate power and politics in global health and agree that "a purely empirical evidence-based approach is a fiction, " and that such a view risks covering up "the role of politics and power. " But by contrasting this fiction with global health research "driven by crises, hot issues, and the concerns of organized interest groups, " as a "path we are trying to move away from, " Ooms is submitting to a liberal conception of politics he implicitly criticizes the outcomes of. 1 A liberal view of politics evades the constituting role of conflicts and reduces it to either a rationalistic, economic calculation, or an individual question of moral norms. This is echoed in Ooms when he states that "it is not possible to discuss the politics of global health without discussing the normative premises behind the politics. " 1 But what if we take the political as the primary level and the normative as secondary, or derived from the political? That is what we will try to do here, by introducing an alternative conceptualization of the political and hence free us from the "false dilemma" Ooms also wants to escape. "Although constructivists have emphasized how underlying normative structures constitute actors' identities and interests, they have rarely treated these normative structures themselves as defined and infused by power, or emphasized how constitutive effects also are expressions of power. " 2 This is the starting point for the political theorist Chantal Mouffe, and her response is to develop an ontological conception of the political, where "the political belongs to our ontological condition. " 3 According to Mouffe, society is instituted through conflict. "[B]y 'the political' I mean the dimension of antagonism which I take to be constitutive of human societies, while by 'politics' I mean the set of practices and institutions through which an order is created, organizing human coexistence in the context of conflictuality provided by the political. " 3 An issue or a topic needs to be contested to become political, and such a contestation concerns public action and creates a 'we' and 'they' form of collective identification. But the fixation of social relations is partial and precarious, since antagonism is an ever present possibility. To politicize an issue and be able to mobilize support, one needs to represent the world in a conflictual manner "with opposed camps with which people can identify. " 3 Ooms uses the case of "increasing international aid spending on AIDS treatment" to illustrate his point. 1 He frames the I n a recent contribution to the ongoing debate about the role of power in global health, Gorik Ooms emphasizes the normative underpinnings of global health politics. He identifies three related problems: (1) a lack of agreement among global health scholars about their normative premises, (2) a lack of agreement between global health scholars and policy-makers regarding the normative premises underlying policy, and (3) a lack of willingness among scholars to clearly state their normative premises and assumptions. This confusion is for Ooms one of the explanations "why global health's policy-makers are not implementing the knowledge generated by global health's empirical scholars. " He calls for greater unity between scholars and between scholars and policy-makers, concerning the underlying normative premises and greater openness when it comes to advocacy. 1 We commend the effort to reinstate power and politics in global health and agree that "a purely empirical evidence-based approach is a fiction, " and that such a view risks covering up "the role of politics and power. " But by contrasting this fiction with global health research "driven by crises, hot issues, and the concerns of organized interest groups, " as a "path we are trying to move away from, " Ooms is submitting to a liberal conception of politics he implicitly criticizes the outcomes of. 1 A liberal view of politics evades the constituting role of conflicts and reduces it to either a rationalistic, economic calculation, or an individual question of moral norms. This is echoed in Ooms when he states that "it is not possible to discuss the politics of global health without discussing the normative premises behind the politics. " 1 But what if we take the political as the primary level and the normative as secondary, or derived from the political? That is what we will try to do here, by introducing an alternative conceptualization of the political and hence free us from the "false dilemma" Ooms also wants to escape. "Although constructivists have emphasized how underlying normative structures constitute actors' identities and interests, they have rarely treated these normative structures themselves as defined and infused by power, or emphasized how constitutive effects also are expressions of power. " 2 This is the starting point for the political theorist Chantal Mouffe, and her response is to develop an ontological conception of the political, where "the political belongs to our ontological condition. " 3 According to Mouffe, society is instituted through conflict. "[B]y 'the political' I mean the dimension of antagonism which I take to be constitutive of human societies, while by 'politics' I mean the set of practices and institutions through which an order is created, organizing human coexistence in the context of conflictuality provided by the political. " 3 An issue or a topic needs to be contested to become political, and such a contestation concerns public action and creates a 'we' and 'they' form of collective identification. But the fixation of social relations is partial and precarious, since antagonism is an ever present possibility. To politicize an issue and be able to mobilize support, one needs to represent the world in a conflictual manner "with opposed camps with which people can identify. " 3 Ooms uses the case of "increasing international aid spending on AIDS treatment" to illustrate his point. 1 He frames the

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International Journal of Health Policy and Management, 2017, 6(1), 53-55 54 task-shifted-care level, certain areas cannot be transferred and physicians must retain critical, specialized roles. Consider Rwanda's current physician ratio of 678 medical doctors: 191 are specialists, with only 2 oncologists (Ministry of Health of the Government of Rwanda, Unpublished data, 2016). If either of these 2 oncologists fully transitions into a leadership position or a research role, only 1 Rwandan oncologist will be left to treat the country's entire cancer population.

Non-clinical Education Makes More Well-Rounded Physicians
Eyal et al advocate for a parallel evolution in education to prepare doctors for new, non-clinical opportunities. 1 Time gained as a result of task-shifting can now, the authors argue, be used to increase physician training in specialized medical fields as well as non-clinical domains such as: health service delivery, workforce capacity building, research, information systems, health financing, ethics, leadership and governance. Given the physician density across sub-Saharan Africa though, such education would be effective if, and only if, it is directly tied to clinical care. This will empower physicians to understand how to improve service delivery on an individual, team, and facility level and to provide health sector governance leaders with relevant feedback. 6 No longer in clinical silos as they now increasingly lead multidisciplinary teams, physicians' mastering of management skills will ultimately benefit patients as well. 7 Yet in order to teach non-clinical skills that may strengthen physicians' clinical work, a decision about timing and education placement must be made. Here, we disagree with the proposal by Eyal et al for a "reduction in coursework that is [in the authors' opinion] less relevant to health service delivery in resource-poor settings" in order to introduce non-clinical skills. 1 This reduction threatens to create substandard medical education, which would not enable the future system to function at its highest clinical capacity for those it should care for most: the patients. Populations in developing countries face the same medical conditions as developed countries; thus, the same, high-quality specialized care is needed in both. We, therefore, advocate that education in non-clinical knowledge must only be put in place if it improves clinical medical skills and education, in lieu of reducing or replacing it. Human Resources for Health (HRH) exemplifies this notion of a strategic and comprehensive program that strengthens both clinical and non-clinical domains. Building capacity through service delivery and in-service mentorship, while concurrently sustainably evolving select areas in advanced medical education, HRH in Rwanda demonstrates an innovative, welldesigned twinning program in a developing country. 8

Non-physician Clinician-Education: A Need for Standardized, Formal Training
Eyal et al propose that in a NPC-based health system, physicians are well-suited to train NPCs in diagnostic and clinical skills. However, it seems more appropriate and effective to create formal, pre-service NPC Technical and Vocational Education and Training (TVET) programs through the education sector. Such short, cost-effective instruction would ensure standardization and consistency in the quality of NPCs. 9 In Rwanda, this structured education has been done with the Home Base Care Practitioners (HBCP) program, in which the Ministry of Education gives a 6-month TVET education, ensuring standardization, quality, and consistency.

Physicians as Non-physician Clinician Mentors: An Effective Evolutionary Step
Eyal et al put forth the notion that supervision and mentoring may diminish physicians' resistance to NPCs and ensure consistency in the quality of services delivered. In the HBCP-TVET program, specialized physicians and nurses conduct mentorship over the new NPCs. Supervisory standards ensure that task-shifting upholds high clinical standards, diminishing mentorship inconsistencies that could negatively impact patients. Through structured education rather than individualized, physician-led instruction, we can ensure that all NPCs have the same knowledge. Guided supervision and mentorship roles create an opportunity for physicians to take on purposefully selected non-clinical work in a manner that directly impacts clinical care, while also encouraging physician-NPC trust through improved inter-professional relationships. 7

How to Tackle Internal Migration, the Clinical Brain Drain?
Eyal et al highlight two physician "brain drains:" one incountry migration from clinical roles to leadership or private opportunities, and another drain from developing countries to positions aboard with higher pay and increased opportunities. 10 We agree with Eyal et al that the first, in-country brain drain can effectively be countered by the promotion of NPCs to decrease the burnout of the few doctors available. 11 For the second brain drain -from local to international positions -we propose three possible solutions: 1. Continue to increase the number of people receiving quality medical education, so as to train a critical mass of physicians. This will ensure that, in the future, those advanced clinical services that NPCs cannot perform are sufficiently delivered to the population safely and comprehensively. 2. A system of individual incentives must be put in place to retain in-country physicians in the clinical sphere. Government-led programs, such as performance-based financing and tax exemption incentives, have been integrated in Rwanda for this specific purpose. 12

3.
To protect developing countries' human resource development, a system of institutional or countrycompensated penalties, similar to that used by athletic organizations to police recruitment of under-contract personnel, must be put in place. 13 This solution will target both individuals and recruiting nations or companies who use their wealth to incentivize doctors to abandon their clinical practice in developing countries. Through this penalty system, international brain drain will be discouraged, the lost human resource value developing countries experience will be countered, and the financial means for countries to educate new physicians will be availed. 14

Needed Boundaries: Recruiting From Outside the Medical Field
In the midst of these discussions around physician evolution, we must remain keenly aware of current health systems. Across sub-Saharan Africa, physicians with clinical expertise but no formal, non-clinical training are often appointed as Hospital Director or Division Head within Ministries of Health in reaction to management shortages. 15 Rather than taking physicians from already-strained clinical spheres, it would be more advantageous to educate non-clinical professionals through hospital administration or health management advanced degrees. By occupying these positions in this way, the systems would be strengthened without leaving clinical gaps where physicians are still greatly needed. 10 Through a Masters degree in Hospital Administration (MHA) at the University of Rwanda, non-professionals from outside of the traditional medical field can now step into the health sector, bolstering its management and administration and allowing physicians to continue in the medical roles they were trained to fill. 8

A Cautious, Calculated Evolution: A Way Forward
Studies have shown that NPCs can perform certain designated clinical functions at an equally safe and medically sound quality to physicians. We encourage health education across the developing world to adapt and promote NPC education with quality, strict standards such as those present in the TVET for HBCP. 5,9,16 Yet in the context of still-remaining significant physician deficits, we question if NPCs can support the clinical sphere to the degree that would safely allow physicians to move beyond the service domain. There remain far too few physicians available for a percentage to provide and develop clinical practice while concurrently evolving into specialization training and non-clinical areas. 17 The bottom line is clear: future physicians should not exit the clinical space when life-saving clinical skills are still needed most. 2 While we disagree with the proposition by Eyal et al to evolve clinicians across non-clinical fields, we agree with their proposal to evolve physicians in purposefully selected specialized areas. An increase in the number of highly trained specialty physicians is crucial in order to answer to the ever-changing epidemiological shifts occurring in already underserved populations. 5 Around the world, the provision of quality care will only occur if there is collaboration between all qualified healthcare providers and if evolution of any roles takes place in a timely, contextually sensitive manner. Accelerating the attainment of a system in which all people have the right to access and receive the needed quantity of quality health services, this collaboration and sensitivity will encourage systems to be in line with national and international education and medical standards. The development of this integrated health system, in which both physicians and NCPs each have their place in achieving the evolving goal of quality care for all, is, for now, the utmost priority.

Ethical issues
Not applicable.