Comprehensive emergency obstetric care including major surgery such as caesarean section is a major health system problem in rural areas of poor countries, where there are no doctors. Innovative trainings of mid-level workforce have now demonstrated viable, scientifically valid solutions. Delegation of major surgery to duly trained ‘non-physician clinicians’ – ‘task shifting’ – should be seriously considered to address the human resources crisis in poor countries to cope with current challenges to enhance maternal and neonatal survival.
Nationwide, non-physician clinicians in Mozambique perform approximately 90% of caesarean sections at the district hospital level. A comparison between the outcomes of caesarean sections provided by this category and medical doctors, respectively, demonstrates no clinically significant differences. These mid-level providers have a remarkably high retention rate in rural areas (close to 90%). They are cost-effective, as their training and deployment is three times more cost-effective than that of medical doctors.
Highlights
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Task shifting of major surgery to non-physicians is a safe measure.
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Impressive rural retention of surgically trained non-physicians was observed.
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Cost-effectiveness of non-physicians in obstetric surgery is better than that of physicians.
In the literature, ‘non-physician mid-level providers of care’ is most often referred to as ‘non-physician clinicians’ (with emphasis on ‘clinicians’), abbreviated NPCs or more recently and more adequately without the inherent negation of ‘non-’: associate clinicians (ACs).
Who are these NPCs/ACs? Studies and commentators differ in their inclusion or exclusion of traditional health professional cadres, including nurses, midwives, pharmacists and other allied health professionals, who have distinct and complementary clinical roles to play. We focus here on the role of NPCs/ACs in Comprehensive Emergency Obstetric Care (CEmOC) and other surgical services in sub-Saharan Africa (SSA) in situations characterized by physician shortages. These cadres have been central to the debate about ensuring adequate staffing for essential surgery and other physician-delivered services in such environments, although a growing interest has been expressed in the greater use of midwives and nurse–midwives in obstetric surgery, and countries have been building on their experiences in such expanded uses .
Many indicators demonstrate that surgery will play an increasingly important role in global health in the near future. The so-called epidemiological transition replaces the burden of infectious disease by chronic diseases, and a worldwide increase in technical innovation and road traffic leads to an increase in trauma-related injuries .
The key obstacle to overcoming the prevailing problematic scenario is the scarcity in health staff. SSA is most affected by the global shortage of human resources for health . Two countries to be addressed as examples more in detail here, Mozambique and Tanzania, experienced this crisis some years ago . In other countries, despite years of interventions to overcome the scarcity of doctors, the shortage has worsened as a result of population growth, presenting a major challenge to the ability of these countries to achieve the health-related Millennium Development Goals (MDGs) .
A major reason for SSA’s high maternal mortality is that few infants are born in the presence of skilled attendants. The lack of skilled birth attendants contributes to the five to six million maternal deaths, stillbirths and newborn deaths each year worldwide. Ideally, a skilled birth attendant, also mastering CEmOC, has to undergo training in surgery in order to perform CS safely.
Basic surgical procedures at the district hospital level in low- and middle-income countries (LMICs), according to a recent systematic review, are cost-effective; provision of both emergency and trauma surgery at larger hospitals were found to be highly cost-effective .
The poorest third of the world’s population receive only 3.5% of surgical interventions undertaken worldwide, suggesting huge unmet needs in the surgical disease burden of LMICs . Caesarean section (CS) is the most commonly performed major surgical operation at the district hospital level in the SSA region .
The so-called ‘optimum’ population need for CS is often said to be somewhere between 5% and 10% of all deliveries. This proportion is, however, debatable . Nevertheless, there is no doubt that access to such care is grossly inadequate in many sub-Saharan countries. A study investigating CS rate globally found that 27 sub-Saharan countries had rates below 5%. Among these, 13 countries had rates below 2% . In a household study from Sierra Leone, 25% of respondents reported a surgical condition needing attention, and 25% of deaths of household members in the previous year might have been avoided if timely surgical care had been provided .
The AIDS epidemic in SSA may have aggravated the non-accessibility of CSs by depriving health systems of a significant proportion of their trained staff . SSA accounts for 11% of the world’s population and 24% of the total estimated global burden of disease; yet it has only 3% of the global health workforce , only a small percentage of whom are qualified surgeons. SSA has <1% of the number of surgeons that the United States has, despite having a population that is three times as large .
At the district hospital level, building surgical capacity for CSs is often regarded as the most effective means to improve access to emergency obstetric care and essential surgical care in SSA. The majority of the population in SSA reside in rural areas , and the district hospital provides the point of entry to surgical care for most of these people . Women with obstetric complications may not be able or willing to travel long distances, or they cannot afford the treatment provided at a higher level-facility. The lack of qualified staff is one of the main obstacles towards provision of basic surgical services at district hospitals in SSA .
There are several programmes and policies aiming at improved delivery of emergency obstetric care to rural dwellers, including surgical camps, specialist outreach and decentralization of services . Poor sustainability has been a major concern for many of these alternatives, and it is also an important problem when it comes to employing medical doctors in rural areas.
A well-functioning practice of CEmOC in rural areas requires prospective information about the availability of recently graduated young medical doctors and their career intentions. Burch and colleagues investigating a wide range of SSA countries could show that although 20% of medical students wanted to specialize in surgery, only 4.8% intended to practise in rural areas . As many as 21% of the students planned to relocate outside SSA, in search of better reimbursement and professional opportunities. The authors concluded that the career intentions of African medical students were not compatible with the continent’s health workforce needs. Costs associated with surgery training are high, and most surgeons and anaesthetists are concentrated in urban areas, due to better career options and personal opportunities. The reluctance of physicians, and particularly specialists, to work in rural areas contributes to the severe shortage of skilled staff at the district level .
In Mozambique, the scarcity of human resources for health 30 years ago was alarming; the country had fewer than five physicians per 100,000 people. Our research estimated that, a few years ago, there were 33 registered nurses and midwives per 100,000 people . In Tanzania, the health workforce shortage was disastrous, according to the report of the Joint Learning Initiative (Chen and others 2004). The predominant strategy to address this shortage of physicians in many sub-Saharan countries is the institutionalizing of training of NPCs/ACs, a practice commonly referred to as ‘task shifting’. This phenomenon has attracted widespread attention and been subject to various editorials .
An investigation including 47 SSA countries from 2007 revealed an extensive practice throughout the continent . NPCs/ACs were active in 25 (53%) of the countries, and they served a vital role in many health-care systems. All 25 countries were recognized by the World Health Organization (WHO) to have a critical shortage of health professionals. Whilst 80% of both English-speaking and Portuguese-speaking countries reported having NPCs, this cadre was only found in 30% of French-speaking African countries, reflecting a practice most commonly seen in East Africa.
NPCs/ACs and their role in task shifting of CEmOC
In SSA, the characteristics of the non-traditional cadres of health professionals trained to perform major surgery, including CEmOC, are generally as follows:
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They have been created as a response to the scarcity of medical doctors.
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They have an entry level of education lower than medical doctors.
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They receive a shorter period of pre-service training than medical graduates, with the training often limited to a defined set of clinical skills.
This category of health staff currently serves as the backbone of the health-care system in an increasing number of African countries . The strategy of educating non-physicians to perform tasks originally handled by medical doctors has long traditions in many countries on several continents. In France, officiers de santé provided medical services in rural districts during the 19th century . Historically, in Russia, so-called feldshers , or medical assistants, have played an important role in the country’s medical system since the 18th century (Farmer), whilst in China so-called barefoot doctors have provided improved access to health care for rural communities since the 1950s . It is, however, important to keep in mind that there is a very wide variation in both theoretical and practical training from country to country.
As indicated above, these types of health-care workers have carried various titles during the last centuries, and they are now most commonly referred to as health officers, assistant medical officers (AMOs), clinical officers, physician assistants, nurse clinicians or nurse practitioners. To summarize these categories as ‘barefoot doctors’ is, however, inappropriate.
The history of NPCs/ACs in SSA dates back to the era well before most countries reached national independence. Great Britain engaged in training health workers referred to as apothecaries. They were first set to distribute medicine and assist with additional clinical duties, but in Kenya, after the 1920s, they were even trained in basic surgical care. Already then, this practice posed concerns among the medical profession, who feared such training would result in professional dilution . Ethiopia was one of the first countries to initiate education of NPCs/ACs following independence, where a 4-year training programme was established at the College of Public Health at Gondar in 1954 . In Ghana, the Rural Health Service was established to improve primary health-care delivery following independence in 1957. Health centre superintendents were trained as medical assistants, and they are currently important providers of health care in rural parts of the country .
In Mozambique, an exodus of medical staff, and doctors in particular, during the country’s civil war led to a lack of human resources. At the same time, there was a high demand for surgical, orthopaedic and obstetric skills due to the conflict. As a response to this, an intensive programme to train health workers in order to replace doctors in certain roles was initiated. The programme was upscaled to include surgical services in the early 1980s, following the emigration of some 85% of Mozambique’s doctors .
The training curricula and scope of practice of NPCs/ACs vary across SSA, but some common characteristics can be seen. MDG 5 with its focus on maternal and neonatal survival has been one of the most important driving factors to justify the CEmOC focus of training programmes for NPCs/ACs in most countries where they are active.
The NPCs/ACs are frequently recruited from rural or poor areas, and in comparison with other health workers, their training normally takes place closer to their geographical origin and future workplaces. Costs of training of NPCs/ACs are significantly lower than those of doctors, and in the range of US$ 1000–2000 per year. Nine of 25 SSA countries studied had equally many or even more NPCs than doctors . Plans to upscale training of NPCs/ACs have been elaborated in Zambia (2002), Ethiopia (2009), South Sudan (2015), South Africa (2010), Sierra Leone (2008), Ghana (2009) and Liberia (2007).
The delegation of tasks from one cadre to another, as described above, is commonly referred to as task shifting. Task shifting in health care describes a situation where ‘a task normally performed by a physician is transferred to a health professional with a different or lower level of education and training, or to a person specifically trained to perform a limited task only, without having a formal health education’ . Task shifting in obstetrics/gynaecology and surgery is becoming an increasingly important strategy to strengthen surgical manpower in LMICs. It includes not only delegation of surgical tasks from physicians to NPCs but also such delegation from certified surgeons to non-specialist physicians (NSPs) .
Over the last decade, the concept of task shifting has been widely supported by donors and international agencies. WHO now recommends training of NSPs to perform CSs , and it encourages delegation of tasks to lower cadres when safe and reasonable . The International Federation of Gynaecology and Obstetrics (FIGO) released a report, which supported task shifting in obstetric care in 2012 .
The procedure of selecting candidates for a delegated scope of interventions varies between countries. In Tanzania, clinical officers selected by recommendation and examinations receive a supplementary 2 years of training to become AMOs. This training includes 3 months of surgery and 3 months of obstetrics, and a mandatory performance of at least five CSs. After graduation, they are licensed to perform certain major surgical procedures, mainly emergencies. There are >1300 surgically trained AMOs in Tanzania, most of them working in district hospitals .
In Mozambique, a training programme of so-called ‘ técnicos de cirurgia ’ (TCs) was initiated in 1983/1984 by Mozambican and expatriate surgeons and obstetricians . Nurses and medical assistants working in rural areas had begun teaching themselves basic surgical skills and emergency procedures, as doctors were unavailable. The programme was established as a response to this observation, in order to formalize their training. Trainees had 2 or 3 years of previous medical training as a nurse or medical assistant, and also several years of practice in rural areas. The training consists of 2 years of theoretical and practical instruction followed by 1 year of internship in a provincial hospital . The training is currently reviewed to involve further advancement to the licentiate level.
TCs carry out CSs, appendectomies, strangulated hernia repairs, obstetric hysterectomies and other fairly advanced abdominal operations . They perform as much as 92% of major obstetric surgeries conducted at the district hospital level .
In Malawi, clinical officers have 4 years’ training from any of the Malawi Colleges of Health Sciences, including 1 year of internship. During this period, they have a 3-month rotation in general surgery and obstetrics/gynaecology. At graduation, they should be able to perform minor surgical and obstetric procedures, as well as CSs. The clinical officers provide an important contribution to surgical care, and they carry out interventions such as prostatectomies, strangulated hernia repairs and ventriculo-peritoneal shuntings at the central hospital level, where they work alongside specialists . A study investigating >2000 emergency obstetric operations performed at hospitals throughout the country found that 88% were performed by clinical officers. In government district hospitals, the number was as high as 93% .
For the moment, NPCs/ACs with CEmOC competence and training in major surgery include above all the Tanzanian AMOs, the Malawian clinical officers, the Mozambican técnicos de cirurgia , the Zambian medical licentiate practitioners and the Ethiopian emergency surgery and obstetrics health officers. Clinical officers from South Sudan will soon join this group .
While most SSA countries strive to increase intakes to medical schools, there still exist long-term financial hurdles not only to enhance the production of physician graduates from these schools but also to finance their deployment in national health systems in general and their assignments to rural hospitals in particular. This is a slow and costly process, in which motivational factors to stay on in areas most in need of life-saving skills are – and continue to be – decisive and critical for success or failure.
The African Network of Associate Clinicians (ANAC) has developed a strong system of linkage, and it is currently based at the Chainama College of Health Sciences in Lusaka, Zambia. ANAC implies a significant strengthening of existing (often-weak) national associations of NPCs/ACs from a large number of SSA countries. This development will facilitate the recognition of this category of key health staff for advanced care, including surgery, in rural settings that lack access to physicians.
Task shifting and task sharing
The literature indicates that informal or formal delegation of tasks from one cadre to another is not a new concept. Task shifting implies the delegation of certain medical responsibilities to less specialized health workers . This is the direct substitution of new and different cadres for an existing traditional profession . In surgery, such health workers may provide many of the diagnostic and clinical functions usually performed by physicians. However, opinions have diverged; some experts suggest that task sharing may be a more appropriate concept. These two expressions, however, seem to signify two different realities. Where no physicians are available, the tasks of physicians must be shifted to non-physicians. Where a few physicians are available, their range of tasks may be shared with non-physicians.
Is task shifting in CEmOC a temporary or long-term solution? In most sub-Saharan countries, the use of substitute health workers started as a temporary measure until more doctors could be trained. However, in the face of the persisting human resources crisis, this strategy has become permanent. More of these countries have embarked on the expanded training of mid-level health professionals and non-physician cadres to promote access to care and to contain costs . The trend to delegate surgical procedures to lower cadres has often been met with resistance for various reasons. WHO has established a list of surgical procedures performed at first-level hospitals that facilitates the classification of various interventions and can help training schools establish which essential interventions could be safely shifted to NPCs/ACs . A district- or first-level hospital is usually the most remote, rurally situated hospital with inpatient care and a theatre for limited major surgery interventions, such as CSs, open fractures and bowel resections for strangulated hernias .
In Mozambique, the training of NPCs/ACs in surgery is well structured and is followed by a formal internship. The intention is that graduates should be capable to perform surgery independently (implying task shifting rather than task sharing). The recruitment focus is on candidates with previous job experience in peripheral health units or first-level hospitals . Studies have shown that TCs in Mozambique are well appreciated by other professionals, doctors, nurses and midwives .
Approximately 90% of physicians and other health staff in Mozambique gave positive ratings to the strong practical skills and the critical roles played by NPCs/ACs in saving the lives of mothers and newborns at first-level hospitals. With accumulated surgical experience among TCs, young doctors deployed in rural areas are increasingly being trained in surgery by this category of mid-level providers of care . An assessment of the outcomes of CSs between this category and physicians at the Maputo Central Hospital showed no clinically significant differences between the two cadres .
In Tanzania, AMOs are selected from among the clinical officers who have a minimum of 3 years of working experience in peripheral health units or first-level hospitals. The AMOs are different from the TCs in Mozambique in that the latter are specialized in surgery in theory and practice. Some AMOs (on the job surgically trained after graduation) have initially a role of ‘task sharing’, but they may later on be forced to act surgically without any doctor physically present and accept ‘task shifting’. Studies show no significant differences in the clinical outcomes, risk indicators or quality-of-care indicators for major obstetric operations performed by AMOs and non-specialized physicians . For example, despite logistic and material resource problems in all the hospitals, the aggregate maternal case fatality rate was acceptable at 1–2% .
Ghana initiated its programme for training medical assistants, consisting of 1 year of post-nursing qualification training, in 1969. In 2007, this programme was converted into a physician assistant programme, consisting of 4 years of direct training after high school. The students were trained to perform only limited surgical procedures and tasks. A nurse anaesthetist (now called anaesthetist physician assistant) programme has become the backbone of surgical procedures, even in regional third-level hospitals. The surgical tasks of these cadres remain limited to performing incisions, draining abscesses, suturing wounds and immobilizing fractures. Most obstetric tasks beyond normal delivery were not part of their responsibilities .
In both Mozambique and Tanzania, the real challenge in providing quality care is not primarily in the practical skills in the operating room. The difficult aspect of emergency obstetrics and surgery is rather in obstetric decision-making to choose the optimal management before resorting to CS. Empirically, any health worker, NPC/AC (AMO, clinical officer or other category of mid-level health worker) or physician who has not been trained in properly assisting vaginal delivery in general and in vacuum extraction in particular would tend to solve many obstetric problems by performing a CS without proper justification. Most often – in practice – no one would blame a health-care provider for having performed a CS; however, health care providers would be blamed for not having performed a CS if the mother or the baby dies or suffers a serious complication.
This reality tends to increase the number of medically non-justified CSs and contributes to the ‘pandemic of CS’. The problem has one possible solution: careful post-operative auditing of decision-making before CS . This auditing practice is already routine in recent efforts in parts of Tanzania to reduce maternal mortality. CS auditing has proven to be a necessary corollary to task shifting of major obstetric surgery. The audit scrutinizes the circumstances leading to a CS; it then questions each step by examining the details of the partogramme to determine whether, for instance, oxytocin augmentation of labour should have been undertaken, or whether assisted vaginal delivery should have been considered.
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