work as a hospitalist and one who has specialized in a clinical field provides advanced medical and surgical care and treatment such as administering anesthesia, performing general or specialised surgery, supervising other health workers and other administrative duties. a clinical officer's scope of practice depends on one's training and experience, jurisdiction and workplace policies. in malawi, for instance, a clinical officer performs all routine surgical and obstetric operations such as exploratory laparatomy, emergency orthopaedics and caesarean section. however, in kenya, tanzania and mozambique one has to undergo further specialized training in order to perform such major operations safely. in rural and small urban health facilities a clinical officer is usually the highest medical care provider and works with minimal resources, relying on the traditional medical history and physical examination, often with little or no laboratory facilities, to make a diagnosis and provide treatment. in bigger and better equipped facilities a clinical officer generally acquires superior knowledge, experience and skills and provides high quality and a wider range of services in district, provincial and national hospitals, universities and colleges, research institutions and private medical facilities. a clinical officer is usually the lowest entry-level cadre in the medical hierarchy but with years of experience and/or further training one can rise to the same or a higher grade than a physician. in most countries, however, wages are usually low compared to training and responsibilities and career progression is usually restricted by awarding terminal degrees and diplomas, training students who have not attained the minimum university entry grade and, in some countries, not awarding any degree or recognition for advanced training. in such countries, this usually results in a demotivated and low quality workforce and resulting poor health indicators. the united states' centers for disease control and prevention and other international health and research institutions make extensive use of cos in their projects in africa and clinical officers have been the backbone of hiv care and treatment enabling the rollout of arvs to even the most rural hard to reach areas in africa. research done by the university of birmingham and published in the british medical journal concluded that the effectiveness and safety of caeserian sections carried out by clinical officers did not differ significantly compared with doctors. better health outcomes including lower maternal mortality rates were observed where cos had completed further specialised training particularly in anaesthesia. in the multi-country study, poor outcomes were observed in burkina faso and zaire - the only countries where the procedure was performed by trained nurses. higher rates of wound infection and wound dehiscence in these countries was thought to be due to the nurses' poor surgical technique and need for enhanced training. ≠ kenya kenya has a comprehensive framework of parallel laws and regulations that govern the medical practice of medical officers and clinical officers. the supreme health policy and medical authorities in the republic are the cabinet secretary of health and the director of medical services who oversee the registration and licensing of medical institutions and the training, registration and licensing of medical practitioners through the medical practitioners and dentists board and the clinical officers council. as a british colony in 1928, kenya started training a select group of natives to practice medicine and care for the local population who were increasingly accepting and seeking western medicine. after independence from britain in 1963, medical training in kenya initially adopted the four-year medical school system used in the us rather than the six-year uk model. this was heavily influenced by the kennedy airlift which followed initial funding by the african-american students foundation (aasf) in 1959 and led to hundreds of young kenyan students getting scholarships to study in american institutions: these students came back to kenya after their studies and joined the civil service in the early post-independence kenya. it was also around this time that the first dos were accepted as medical officers by the us civil service and by 1967 the structure and duration of medical training in kenya was similar to the us md training. when the university of nairobi split from the university of east africa and became the first university in kenya in 1970, it continued to teach the six-year british degree which led to the creation of two statutory bodies: the kenya medical practitioners and dentists board in 1978 which had jurisdiction over medical officers and physicians, and the clinical officers council in 1989 which had jurisdiction over clinical officers. instead of residency for the clinical officer, the higher diploma in paediatrics, ophthalmology and other specializations was introduced in the late 1970s as a post-basic course for those who had worked for three or more years and, after ten years of service, one became a senior clinical officer and qualified for a licence to practice under his own name as a private medical practitioner. the bsc. clinical medicine and surgery degree was later introduced in 2006. clinical officers play a central role in kenya's medical sector today. there were 8,600 clinical officers on the register in 2010 compared to 7,100 medical officers. they are trained by the universities, the kenya medical training college (kmtc), st. mary's school of clinical medicine and other private institutions. the ministry of health, through the clinical officers council (coc) regulates their training and practice, accredits training institutions, and approves the syllabi of the universities and colleges. the kenya medical training college (kmtc), also under the ministry of health, has campuses in regional teaching hospitals and trains the majority of clinical officers. st. mary's school of clinical medicine and st. mary's mission hospital in mumias, owned by the roman catholic diocese of kakamega, was the first private institution to train clinical officers. it admits students who got the minimum university entry grade in high school and have passed a written examination and oral interview. the students sit the same examination as their counterparts at the kmtc and are examined by consultants from the public service. on 28 october 1981 lawmakers addressed the national assembly as follows: mr. orengo: on a point of order mr. deputy speaker sir. is it really in order for the hon. member for butere to impute that this house does not know that clinical officers are not allowed to practice. i think the motion is just after legalizing the position and not saying that they are not allowed to practice. mr. shikuku: mr. deputy speaker, we heard dr. chibule saying that he is going to give us a list of 20 clinical officers who are being refused permission to practice and forced to go back to government practice and this is the thing i am trying to reply to. the hon. member was in the house when dr. chibule said this but i do not know why he did not hear him say so, but nevertheless, let me continue. mr. deputy speaker, sir, the clinical officers helped the government during the recent doctors' strike in the country when we virtually depended on them. now, sir, part (a) of this motion is not the responsibility of the ministry of health because if anybody wants to pursue higher education, even from this house, it is upon him first to make sure he has the prerequisite qualifications to pursue higher studies. so, with that, the ministry is not concerned. part (b) of the motion is the most important. we are requiring the enactment of a law to cover our present clinical officers to allow them to practice and be covered by the law as the doctors are covered. this is the point and the assistant minister for health has produced a paper which is going to be presented before the cabinet after which it will come to the house. now, sir, where do we disagree? there is no place where we disagree. what we are trying to say is that the government is already doing what it is being asked to do, and that is why we are saying that this matter has more or less been overtaken by events. therefore, we are not going to be asked to do what we are already doing. mr. orengo: on a point of order, mr. deputy speaker, sir. mr. shikuku: you can have as many points of order as you like! the dual diploma in clinical medicine and surgery plus an internship year is the standard qualification for clinical officers which is awarded on completion of a four-year training programme which started as various programmes that were used to train medical practitioners in the east africa protectorate in the 1920s and which now resembles the north american four-year md and do medical school programmes (including being structured in 9 trimesters over 3 years to meet the minimum 130 weeks of instruction recommended by the liaison committee on medical education) instead of the more recent six-year mbchb programme that was introduced in the 1970s and is more common in european and commonwealth countries: medical officers training: is a six-year professional degree programme accredited by the medical practitioners and dentists board involving two years of pre-clinical training in medical sciences followed by four years of training in clinical medicine, surgery and community health including a mandatory one-year internship and registration, licensing and gazettment by the medical practitioners and dentists board giving unlimited practice rights with specialisation and private practice allowed and eligible for full professional membership of the kenya medical association (kma) clinical officers training: is a four or five-year professional diploma or degree programme accredited by the clinical officers council involving one year of pre-clinical training in medical sciences followed by three or four years of training in clinical medicine, surgery and community health including a mandatory one-year internship and registration, licensing and gazettment by the clinical officers council giving unlimited practice rights with specialisation and private practice allowed and eligible for full professional membership of the kenya clinical officers association (kcoa) the current training follows international guidelines and the two qualifications are awarded jointly on successful completion of a comprehensive nine trimester programme of full-time study, practicals and examinations which are covered over three years leading to a fourth mandatory year of internship in a teaching hospital. a fifth and sixth residency specialisation years are undertaken after registration by the clinical officers council and three years of work experience in general medicine which leads to the award of a general degree in clinical medicine or a specialist diploma in pediatrics, orthopedics, psychiatry, anaesthesia, reproductive health and other specialties. a clinical officer is therefore able to graduate and join the workforce in a minimum of four calendar years and provides medical services within the full scope of family and emergency medicine or within a narrower scope depending on their area of specialisation. registration by the clinical officers council (coc) entitles one to render medical services in any public or private medical institution or to practice medicine independently as a private practitioner. registration also qualifies one to join and participate in the affairs of the kenya clinical officers association (kcoa), including its annual kcoa scientific conference, and the kenya union of clinical officers (kuco). as per the government's revised scheme of service for clinical personnel (2014) a clinical officer works at any of 8 grades depending on ones seniority. table showing different grades of clinical officers, medical officers and medical practitioners in kenya's public service as gazetted officers all registered clinical officers are legally authorized to prepare, sign, issue and keep safe custody of official state documents such as medical examination reports, sick notes, postmortem examination reports and death certificates and to appear in courts of law as expert witnesses. for this reason, a clinical officer is the officer in-charge of a health center or a district hospital and is part of the medical team in bigger hospitals where one may head a department or work under a senior clinical officer or a physician. clinical officers are direct healthcare providers who manage and administer health institutions, medical schemes and projects in primary healthcare (phc) settings and are frontline stakeholders in universal health coverage in kenya which is one of the key pillars of the government's 5-year development plan under president uhuru kenyatta. the four pillars of the 5-year development plan are 1. manufacturing 2. affordable housing 3. universal health coverage and 4. food security. legal status in