Rethinking Professionalism: Freirean Pedagogy for Africa’s Clinical Officers

Across Sub-Saharan Africa, Clinical Associates and Clinical Officers have become the backbone of primary healthcare, delivering essential services in rural clinics and understaffed district hospitals where physicians are scarce. Yet according to a new conceptual analysis published in Frontiers in Medicine, the way these mid-level practitioners are trained to be

The argument advanced by Cele and Sujee arrives at a moment when health workforce planners across the region are rethinking what competence actually means for cadres who were, from their inception, designed to serve communities rather than hospitals. Clinical Officers first appeared in Uganda in 1918 and Kenya in 1928, when colonial administrations confronted the arithmetic of serving vast rural populations with very few physicians. That origin matters for how professionalism is understood today. The cadre was never conceived as a junior version of the doctor but as a distinct clinical practitioner whose legitimacy rests on proximity to communities, practical skill, and the ability to function within health systems that have always been resource-constrained. South Africa’s Clinical Associate programme, formalised more recently as a three-year bachelor’s degree regulated by the Health Professions Council of South Africa, represents a later iteration of the same workforce logic, though with a narrower scope of practice and closer oversight by medical practitioners. Malawi, Tanzania, and Zambia each developed their own variants, producing a family of cadres that differ in training pathways and regulatory arrangements but share a common frontline mandate.

This heterogeneity is one reason the authors resist treating professionalism as a single exportable template. A Clinical Officer in rural Malawi who performs emergency surgical procedures operates under conditions that differ profoundly from those facing a Clinical Associate in a South African district hospital, yet both navigate professional hierarchies in which their authority may be questioned by patients, colleagues, and institutions. Dominant professionalism frameworks, which typically enumerate observable behaviours such as punctuality, honesty, and respectful communication, offer little guidance for negotiating these structural realities. The authors argue that such frameworks, rooted in biomedical and competency-based traditions, individualise what are actually systemic problems. When a practitioner works in a facility without reliable supplies, or when patients arrive with advanced disease because transport and referral systems failed them, lapses that assessment tools might code as unprofessional conduct often reflect the conditions of practice rather than deficiencies of character.

The theoretical core of the paper draws on Paulo Freire, the Brazilian educator whose critique of banking education reshaped adult learning theory in the latter twentieth century. Freire’s central insight was that education either domesticates or liberates: it either transmits knowledge as a deposit to be received passively, or it cultivates critical consciousness, the capacity to perceive and interrogate the social conditions that shape one’s life. Applied to health professions education, this distinction is consequential. A curriculum that teaches professionalism as a checklist of attributes produces practitioners who can perform the role as defined by others. A curriculum grounded in dialogue and praxis, by contrast, invites trainees to examine why their communities carry the disease burden they do, why referral systems fail, and why the health workforce itself is distributed so unevenly. Praxis, in Freire’s formulation, joins reflection with action, meaning that critical understanding is incomplete unless it informs how practitioners actually engage their circumstances.

The authors pair Freire with Ubuntu, the Southern African ethical tradition often summarised in the phrase umuntu ngumuntu ngabantu, roughly rendered as a person is a person through other persons. Where Freire contributes the critical edge, a refusal to accept inequity as natural, Ubuntu contributes the relational foundation: the understanding that identity and moral obligation are constituted through community rather than achieved by individuals in isolation. Bringing these traditions into conversation is not merely decorative. It grounds the proposed reconceptualisation of professionalism in intellectual resources indigenous to the region, which is itself a decolonial move. Professionalism scholarship has been dominated by frameworks developed in North American and European contexts, and importing them wholesale risks reproducing the very hierarchies of knowledge that colonial health systems established. The authors position their framework as relational, contextual, political, and emancipatory, four adjectives that each carry weight. Relational acknowledges that care happens between people embedded in communities. Contextual insists that professional conduct cannot be judged apart from material conditions. Political recognises that health inequities are produced by decisions, not accidents. Emancipatory points toward education that expands rather than constrains what practitioners can perceive and do.

The historical framing the authors provide deserves particular attention. Before colonialism, health and healing across much of the continent were embedded in community life and indigenous knowledge systems, with care inseparable from social relationships and local understandings of wellbeing. Colonial administrations reorganised health services around particular forms of knowledge and authority, creating hierarchies that persist in contemporary systems. Post-independence governments responded with the primary health care movement, emphasising community participation, equity, and accessibility, and training community health workers to reach populations that colonial and, in South Africa’s case, apartheid systems had marginalised. Clinical Officers and Clinical Associates emerged within this lineage as cadres explicitly designed to extend care to underserved communities. Their professionalism, the authors contend, cannot be understood apart from this history, because the very existence of the cadre is a response to structural inequity.

The practical implications the authors identify extend across curriculum design, faculty development, assessment, and professional identity formation. Each of these domains currently operates on assumptions that the critical framework challenges. Curricula that present professionalism as a fixed set of attributes would need to create space for students to analyse the social and political determinants of health they encounter daily in clinical placements. Faculty development would require educators themselves to develop critical consciousness, since teachers steeped in competency-based frameworks may struggle to facilitate dialogue about power and inequity. Assessment poses perhaps the thorniest problem: professionalism is typically evaluated through observable behaviours and standardised instruments, and measuring critical engagement with structural conditions resists the psychometric tools available. The authors do not claim to have solved these measurement challenges, but their conceptual analysis makes visible what current approaches leave unexamined.

It is worth situating this argument within broader currents in health professions education research. Over the past two decades, scholars have increasingly questioned whether professionalism can be reduced to individual attributes, pointing instead to organisational culture, hidden curricula, and systems factors as powerful shapers of conduct. Social accountability has gained traction as a criterion for evaluating medical schools, particularly those serving populations with the greatest health needs. Decolonial critiques of curriculum have moved from the margins to the centre of educational scholarship in the global South, questioning whose knowledge counts and whose epistemologies structure training. The paper by Cele and Sujee contributes to these conversations by applying them to a cadre that has been largely absent from the professionalism literature despite its centrality to frontline care across the region. Mid-level practitioners deliver a substantial share of clinical services in many Sub-Saharan African countries, yet the frameworks guiding their professional formation were largely developed for and by the medical profession in very different contexts.

The emphasis on professional identity formation also carries significance for workforce retention, a persistent challenge in health systems marked by shortages. Practitioners whose training fosters a sense of purpose connected to community wellbeing may be more likely to remain in underserved postings than those whose identity is anchored in aspirations modelled on specialist medicine. If professionalism education helps trainees find meaning in the realities of frontline practice rather than framing those realities as deficits to be overcome, it may contribute to sustaining the workforce that primary healthcare depends on. This connection between identity, meaning, and retention is not the authors’ central claim, but it follows naturally from their argument that professionalism is socially situated.

As a perspective piece, the article advances a conceptual argument rather than reporting empirical findings, and its proposals will require testing in actual training programmes. The questions it raises, however, are answerable through research: how CA/CO students experience professionalism curricula, what happens when dialogue about structural conditions enters the classroom, how assessment instruments might be adapted, and whether graduates trained under critical frameworks practise differently in measurable ways. The authors’ contribution lies in articulating a theoretically coherent alternative and demonstrating that the intellectual resources for such an alternative, Freirean pedagogy joined with Ubuntu, are neither foreign nor abstract but rooted in the educational and ethical traditions of the region the cadre serves. Whether training institutions adopt this reframing will depend on regulatory bodies, faculty capacity, and political will, but the paper establishes that the current frameworks are a choice rather than a necessity, and that another conceptualisation of professionalism is available to those who train the practitioners holding up primary healthcare across Sub-Saharan Africa.

Subject of Research: Critical pedagogy approaches to professionalism in clinical associate and clinical officer training in Sub-Saharan Africa

Article Title: A critical pedagogy approach to reimagining professionalism in clinical associate/clinical officer training in Sub-Saharan Africa

Article References: Cele, E., & Sujee, N. (2026). A critical pedagogy approach to reimagining professionalism in clinical associate/clinical officer training in Sub-Saharan Africa. Frontiers in Medicine, 13, Article 1983787. https://doi.org/10.3389/fmed.2026.1983787

Image Credits: AI Generated

DOI: 10.3389/fmed.2026.1983787

Keywords: clinical associates, clinical officers, critical pedagogy, professionalism, health professions education, Sub-Saharan Africa, Paulo Freire, Ubuntu, social accountability, decolonial theory, primary healthcare, medical education