Non-physician clinicians in rural Africa: lessons from the Medical Licentiate programme in Zambia

Abstract

BackgroundMost sub-Saharan African countries struggle to make safe surgery accessible to rural populations due to a shortage of qualified surgeons and the unlikelihood of retaining them in district hospitals. In 2002, Zambia introduced a new cadre of non-physician clinicians (NPCs), medical licentiates (MLs), trained initially to the level of a higher diploma and from 2013 up to a BSc degree. MLs have advanced clinical skills, including training in elective and emergency surgery, designed as a sustainable response to the surgical needs of rural populations.MethodsThis qualitative study aimed to describe the role, contributions and challenges surgically active MLs have experienced. Based on 43 interviewees, it includes the perspective of MLs, their district hospital colleagues—medical officers (MOs), nurses and managers; and surgeon-supervisors and national stakeholders.ResultsIn Zambia, MLs play a crucial role in delivering surgical services at the district level, providing emergency surgery and often increasing the range of elective surgical cases that would otherwise not be available for rural dwellers. They work hand in hand with MOs, often giving them informal surgical training and reducing the need for hospitals to refer surgical cases. However, MLs often face professional recognition problems and tensions around relationships with MOs that impact their ability to utilise their surgical skills.ConclusionsThe paper provides new evidence concerning the benefits of ‘task shifting’ and identifies challenges that need to be addressed if MLs are to be a sustainable response to the surgical needs of rural populations in Zambia. Policy lessons for other countries in the region that also use NPCs to deliver essential surgery include the need for career paths and opportunities, professional recognition, and suitable employment options for this important cadre of healthcare professionals.

Evaluation of a surgical training programme for clinical officers in Malawi

“…This study tested an innovative 36‐month surgical training programme for COs, mainly involving practical in‐service training at district hospitals. The findings of the study suggest that on‐the‐job surgical training of COs is effective, as has been reported elsewhere in Africa. Two follow‐up cohorts of COs have already entered Malawi's national BSc in Surgery programme developed by COST‐Africa.…”

“…The training model has proved effective and has been embedded within the mainstream educational programmes offered by the University of Malawi College of Medicine. However, there are serious risks endangering the long‐term success of the model, including the absence of career paths for COs in Malawi after obtaining the BSc in Surgery, which is similar to the situation of other non‐physician clinicians in the region. More research is needed to develop retention strategies for surgically able COs to prevent them from diverting to other professions away from the operating room.…”

“…On the other hand, advocates of task‐shifting point to the lack of alternatives for providing emergency life‐saving surgery in remote and rural areas. Most published studies have reported comparable findings when a limited set of emergency obstetric and general surgical procedures are performed by COs and medical doctors (MDs). However, better evidence is needed regarding the feasibility and conditions for rolling out a safe surgical model based on non‐physician clinician‐performed surgery at district hospitals.…”

Who accesses surgery at district level in sub‐Saharan Africa? Evidence from Malawi and Zambia

“…In Zambia, the higher proportion of general surgical procedures and the more diverse set of surgical procedures, categorised as ‘other’, suggest a greater capacity to deliver a broader range of surgical procedures at Zambia's district‐level hospitals. These are often far from referral hospitals and staffed by surgically active NPCs who have more surgical training and experience than NPCs in Malawi . Zambia's NPCs work alongside Medical Officers who could support decisions to undertake surgery at the district level .…”

“…These are often far from referral hospitals and staffed by surgically active NPCs who have more surgical training and experience than NPCs in Malawi . Zambia's NPCs work alongside Medical Officers who could support decisions to undertake surgery at the district level . In Malawi, district hospital surgical care relies mainly on clinical officers , only some of whom have received formal surgical training .…”