May 17, 2020

The Global PA Phenomenon

6 min
The Global PA Phenomenon.jpg
Written By Ruth Ballweg, MPA, PA-C The Global PA Phenomenon While we often define ourselves as nationalities in ways that emphasize our differences fro...

Written By Ruth Ballweg, MPA, PA-C 

The Global PA Phenomenon

While we often define ourselves as nationalities in ways that emphasize our differences from other population groups, science has demonstrated that we are all in fact quite alike. Studies of the human genome have revealed all humans share 99.9 percent of common DNA. As it turns out, the world’s countries also share the same health care challenges: increasingly unhealthy populations, shortages of qualified providers (especially in rural areas) and the like. There are region-specific challenges, to be sure, but with so many challenges in common, it stands to reason that we would find the same solutions to be useful as well.

As long as there have been physicians, there have been non-physicians fulfilling physician-like tasks. In the last fifty years, a clear trend in the spread of a particular type of non-physician health care provider has emerged in North America, Europe, Australia, Africa and Asia.

These new clinicians are called different things in different countries. In the U.S., they are called physician assistants (PAs). The PA concept has spread around the globe as U.S.-trained PAs have been deployed on military assignments, participated in humanitarian and religious missions and other international projects, and joined other health care providers around the world to respond to epidemics and health crises.

Of course, while human DNA may be almost identical from one population group to another, those country-specific health issues do come into play with realities of economics and politics. Thus, the U.S. PA model is not a one-size-fits-all approach. Countries around the world are adapting the concept to fit their specific needs.

North America

In the U.S., the PA profession has been established and growing since the 1960s and today boasts more than 90,000 nationally certified PAs. In partnership with physicians, those PAs practice in every state, specialty and setting, providing a wide range of patient care across the broad spectrum of diseases, disorders and medical conditions.

To the north, the Canadian Forces initially developed a similar PA role to respond to the needs of troops. During the last decade, three PA educational programs have developed in Canada, two in Ontario and one in Manitoba.  Canada also boasts a national certification exam and a process for maintenance of certification, and today PAs practice in the Canadian Forces and in Manitoba, Ontario and Alberta.                                                                                                   


The Netherlands boasts the most well-established PA profession in Europe. Ten years after that country accredited its first PA training program, 800 PAs are in practice providing a range of care that approaches the breadth of the PA’s role in the U.S. The development of PAs in The Netherlands represents an astonishing rate of progress in terms of gaining broad-based support and establishing enabling legislation, and regulations in that first decade. PAs in Netherlands are trained in five masters-level programs that include a significant amount of hospital-based education. In practice they are supporting physician partners by taking responsibility for a large percentage of more routine medical care, including diagnosis and treatment, and performing medical and surgical procedures within a scope of practice established by the national government

The United Kingdom (U.K.) is another country well on its way to establishing a PA profession (though in the U.K. the preferred terminology is now physician associate). The first U.K. PAs were Americans, participating in several Ministry of Health pilot projects. Later other PAs came to the U.K. through arrangements with individual physician practices.  Beyond that, four PA educational programs were developed in the U.K. in the last ten years and have graduated approximately 150 PAs; however,

regulatory delays have been barriers to progress, and two programs have at least temporarily closed doors. The U.K. physicians and PAs leading this movement continue to address issues of regulation and assessment, and as those issues are resolved, the expectation is that new PA programs and practice will again expand in the U.K.

Australia also chose “pilot” projects to introduce PAs in several states. Queensland’s pilot – sponsored by the Ministry of Health – tested the utility of the PA concept as a solution to Australia’s needs in rural and remote centers, as well as in urban hospitals.

South Australia used a pilot to test out hospital-based roles in surgery and pediatrics.

Two PA programs were created in Queensland, and one remains while practice and reimbursement roles are more clearly defined by governmental agencies. As a country that recently implemented national licensure for health professionals, educational and practice opportunities are predicted to expand as regulatory mechanisms develop.

In nearby New Zealand, PA development has been sponsored by Health Workforce New Zealand, which initially worked with a teaching hospital to explore inpatient roles on a surgical service. A second pilot has recently begun to demonstrate the value of PAs in primary care and emergency room settings in small communities.


Many African countries developed new clinical roles similar to PAs during the many African revolutions in the 1970s when, faced with the return of European doctors to their home countries, Africa was left with a very small physician workforce and had to develop solutions to meet basic health care needs.  Many of those roles remain, and a number of U.S. PA programs are working with African countries to update training and oversight processes for these clinicians. Simultaneously, the PA concept is emerging in new areas throughout the continent.

South Africa has three educational programs in the PA model training “clinical associates” to provide care in rural areas in response to a critical shortage of physicians. Clinical associates complete a three-year training program of post-secondary education, with the majority of that training conducted in hospital settings. Here, too, the aim is to have clinical associates take on more routine medical exams, diagnostics, and treatment plans so that physicians can focus on the more complex cases and highly specialized tasks. The South African government has established a minimum target of placing five clinical associates in every district hospital.

PAs in Ghana have two models, one that emerged by upgrading health worker training programs and a second university-based academic training model. Recognizing the great need for health care in their country, the government is now working to integrate both models into the country’s health care system.


The PA profession is also emerging in Asia, where in India PAs are assisting in complex surgeries in for-profit hospitals, and Saudi Arabia has worked with a US hospital system to create a PA program within the military system.  

Elsewhere, on a province by province basis, China is considering many possible roles for physician assistants.  One role, for example, would be to care for the large migrant worker population of rural residents who move into large urban centers to staff high tech and clothing factories. Japan is also interested in engaging physician assistants to increase the efficiency of surgeons in high tech specialties such as cardiac surgery.


The emergence of PAs around the globe is not a coincidental happenstance. Thought leaders from many countries and every continent are exchanging ideas, coming together to share successes and talk through challenges. Thanks to their efforts, around the world physician services are being extended through partnerships with PAs, and access to care is improving.

About the author

Ruth Ballweg, MPA, PA-C, leads international outreach efforts on behalf of the National Commission on Certification of Physician Assistants (NCCPA) and is professor and director of the MEDEX Northwest Physician Assistant Program at the University of Washington.

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Jun 13, 2021

How healthcare can safeguard itself against cyberthreats

Jonathan Miles
6 min
Jonathan Miles, Head of Strategic Intelligence and Security Research at Mimecast, tells us how the healthcare sector can protect itself from attacks

One of the most fundamental lessons from the COVID crisis is that health should always be a priority.  In a similar fashion to the human body that frequently fights off viruses and foreign invaders that intend to cause it harm, the sector itself is now a prime target for another type of external threat: cyberattacks.

The figures speak for themselves: between December and January this year, hospitals in the UK were at 89% capacity, with 7,000 fewer available beds than there usually are. As the pandemic increased pressure on hospitals, clinics, and research facilities to create a treatment for patients globally, it has left the sector exposed to hackers who, like a virus, have been targeting it relentlessly and evolving their tactics. 

From patient records being held ransom, to fake emails claiming to originate from the UN WHO, the NHS, or vaccine centres, through to attacks on the cold supply chain to find out the secret formula of the COVID vaccine, the healthcare industry is facing constant cyberattacks and struggling to cope. This threat is unlikely to go away anytime soon – and as such, the industry needs to take a proactive, preventative stance to stay safe in a dynamic digital world. 

Going digital 

The responsive nature of healthcare – particularly of hospitals – means that efficiency is crucial to the industry’s standard operations. To support this, the sector has been embracing technological advancements that can improve the quality of work, enabling staff to meet pressing deadlines, and enhancing patient care. For example, the industry has been digitising records and improving its ways of working through digital means over the past few years. 

This shift is critical to offer high quality patient care; yet, it also means the sector has become more dependent on IT, which can come with a risk if cybersecurity processes employed are deemed as inadequate. 

Without the correct security measures in place, the desired efficiency gains realised, can be easily lost in a heartbeat. Simply put, an elementary glitch in the system can have a tremendous ripple effect on many areas, from accessing patient records and conducting scans, to maintaining physical security and protecting the intellectual property of experimental treatment development.

To prevent this, healthcare organisations need to ensure they’re considering cybersecurity as part of their overall digital transformation strategy – and setting the right foundations to create a culture where safety goes hand in hand with patient care. 

Strengthening defences

Before implementing cybersecurity process, healthcare organisations need to assess the potential risks they face. Depending on how much confidential data the trust has, where it is stored, who has access to it and via which means, the cybersecurity strategy and associated solutions will change. 

It’s fair to say that a medical device start-up where all employees have a corporate-sanctioned laptop and access data via a VPN will have radically different needs to a large hospital with hundreds of frontline workers connecting to the hospital’s Wi-Fi using their personal device. 

These requirements will pale by comparison to a global pharmaceutical giant with offices in multiple locations, a large R&D department researching new treatments for complex diseases and a fully integrated supply chain. Considering the existing setup and what the organisations is looking to achieve with its digital transformation strategy will therefore have an immediate impact on the cybersecurity strategy.

Despite this, there are fundamentals that any organisation should implement: 
Review and test your back-up policy to ensure it is thorough and sufficient – By checking that the organisation’s back-up is running smoothly, IT teams can limit any risks of disruption in the midst of an incident and of losing data permanently.

In our recent State of Email Security report, we found that six out of ten organisations have been victims of ransomware in 2020. As a result, afflicted organisations have lost an average of six days to downtime. One third of organisations even admitted that they failed to get their data back, despite paying the ransom. In the healthcare industry, this could mean losing valuable patient records or data related to new treatments – two areas the sector cannot afford to be cavalier about.

Conduct due diligence across the organisation’s supply chain – Healthcare organisations should review their ways of working with partners, providers and regulatory institutions they work with in order to prevent any weak link in their cybersecurity chain. Without this due diligence, organisations leave themselves exposed to the risks of third party-led incidents. 

Roll out mandatory cybersecurity awareness training - Healthcare organisations shouldn’t neglect the training and awareness of their entire staff – including frontline workers who may not access the corporate network on a regular basis. According to our State of Email Security report, only one fifth of organisations carry out ongoing cyber awareness training.

This suggests it is not widely considered as a fundamental part of most organisations cyber-resilience strategy, despite the fact many employees rely on their organisation’s corporate network to work. By providing systematic training, healthcare organisations can help workers at all levels better understand the current cyberthreats they face, how they could impact their organisation, the role they play in defending the networks, and develop consistent, good cybersecurity hygiene habits to limit the risks of incidents. 
Consider a degree of separation – Information and Operational Technology (IT and OT) networks should be separated.

Although mutually supported and reliance on each other, employees shouldn’t be accessing one via the other. This should be complemented by a considered tried and tested contingency and resiliency plan that allows crucial services to function unabated should there be a compromise. Similarly, admin terminals should not have internet access to afford a degree of hardening and protection for these critical accounts.

As the sector becomes a common target for fraudulent and malicious activity, putting cybersecurity at the core of the organisation’s operations is critical. It will help limit the risks of disruption due to cyberattacks, reduce time spent by the cybersecurity team to resolve easily avoidable errors, and ensure that institutions can deliver patient care, safe in the knowledge that their networks are safe.  

Fighting future threats

With technology continuing to change the face of healthcare, the surface area and vectors available for attacks by malicious actors is constantly increasing. With the introduction of apps, networked monitoring devices, and a need for communication, the attack vector is ever expanding, a trend that needs to be monitored and secured against.

To prevent any damage to patients, staff, or the organisation they are responsible for, healthcare leaders must put security front and centre of their digital transformation strategy. Only then can the sector harness the full benefits of technology. Doing this should include implementing cybersecurity awareness training to challenge misconceptions around security, encourage conversation, and to ensure employee knowledge of the security basics and threats faced. 

This ultimately allows healthcare organisations to do what they do best: provide the highest standard of patient care, safe in the knowledge that their operations, patients, and data are safe.

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