Safety, productivity and predicted contribution of a surgical task-sharing programme in Sierra Leone

Background Shortages of specialist surgeons in African countries mean that the needs of rural populations go unmet. Task‐shifting from surgical specialists to other cadres of clinicians occurs in some countries, but without widespread acceptance. Clinical Officer Surgical Training in Africa (COST‐Africa) developed and implemented BSc surgical training for clinical officers in Malawi. Methods Trainees participated in the COST‐Africa BSc training programme between 2013 and 2016. This prospective study done in 16 hospitals compared crude numbers of selected numbers of major surgical procedures between intervention and control sites before and after the intervention. Volume and outcomes of surgery were compared within intervention hospitals between the COST‐Africa trainees and other surgically active cadres. Results Seventeen trainees participated in the COST‐Africa BSc training. The volume of surgical procedures undertaken at intervention hospitals almost doubled between 2013 and 2015 (+74 per cent), and there was a slight reduction in the number of procedures done in the control hospitals (–4 per cent) (P = 0·059). In the intervention hospitals, general surgery procedures were more often undertaken by COST‐Africa trainees (61·2 per cent) than other clinical officers (31·3 per cent) and medical doctors (7·4 per cent). There was no significant difference in postoperative wound infection rates for hernia procedures at intervention hospitals between trainees and medical doctors (P = 0·065). Conclusion The COST‐Africa study demonstrated that in‐service training of practising clinical officers can improve the surgical productivity of district‐level hospitals.

Section: Discussionsupporting

confidence: 69%

Evaluation of a surgical training programme for clinical officers in Malawi

Gajewski

Borgstein²,

Bijlmakers

et al. 2019

“…To increase access to emergency obstetric and surgical services, the Sierra Leone Ministry of Health and Sanitation initiated a surgical task‐sharing training programme. ACs are trained to manage basic emergency surgical and obstetric conditions, including surgery such as caesarean section. Community Health Officers and non‐specialist doctors with a minimum of 2 years of work experience can apply for this 2‐year training.…”

Section: Introductionmentioning

confidence: 99%

Caesarean section performed by medical doctors and associate clinicians in Sierra Leone

Duinen

Kamara

Hagander

et al. 2019

Self Cite

Background Many countries lack sufficient medical doctors to provide safe and affordable surgical and emergency obstetric care. Task‐sharing with associate clinicians (ACs) has been suggested to fill this gap. The aim of this study was to assess maternal and neonatal outcomes of caesarean sections performed by ACs and doctors. Methods All nine hospitals in Sierra Leone where both ACs and doctors performed caesarean sections were included in this prospective observational multicentre non‐inferiority study. Patients undergoing caesarean section were followed for 30 days. The primary outcome was maternal mortality, and secondary outcomes were perinatal events and maternal morbidity. Results Between October 2016 and May 2017, 1282 patients were enrolled in the study. In total, 1161 patients (90·6 per cent) were followed up with a home visit at 30 days. Data for 1274 caesarean sections were analysed, 443 performed by ACs and 831 by doctors. Twin pregnancies were more frequently treated by ACs, whereas doctors performed a higher proportion of operations outside office hours. There was one maternal death in the AC group and 15 in the doctor group (crude odds ratio (OR) 0·12, 90 per cent confidence interval 0·01 to 0·67). There were fewer stillbirths in the AC group (OR 0·74, 0·56 to 0·98), but patients were readmitted twice as often (OR 2·17, 1·08 to 4·42). Conclusion Caesarean sections performed by ACs are not inferior to those undertaken by doctors. Task‐sharing can be a safe strategy to improve access to emergency surgical care in areas where there is a shortage of doctors.

“…For example, subspecialties included in the definition of surgeon are highly variable, and some databases include trainees or non‐physician providers along with specialists. It was also recognized that using the current Commission definition of this indicator under‐represents the workforce contributing surgical care. For the purposes of comparability and benchmarking, a more uniform definition is needed.…”

Section: Discussionmentioning

confidence: 99%

Evaluating the collection, comparability and findings of six global surgery indicators

Holmer

Bekele

Hagander

et al. 2018

102

Background In 2015, six indicators were proposed to evaluate global progress towards access to safe, affordable and timely surgical and anaesthesia care. Although some have been adopted as core global health indicators, none has been evaluated systematically. The aims of this study were to assess the availability, comparability and utility of the indicators, and to present available data and updated estimates. Methods Nationally representative data were compiled for all World Health Organization (WHO) member states from 2010 to 2016 through contacts with official bodies and review of the published and grey literature, and available databases. Availability, comparability and utility were assessed for each indicator: access to timely essential surgery, specialist surgical workforce density, surgical volume, perioperative mortality, and protection against impoverishing and catastrophic expenditure. Where feasible, imputation models were developed to generate global estimates. Results Of all WHO member states, 19 had data on the proportion of the population within 2h of a surgical facility, 154 had data on workforce density, 72 reported number of procedures, and nine had perioperative mortality data, but none could report data on catastrophic or impoverishing expenditure. Comparability and utility were variable, and largely dependent on different definitions used. There were sufficient data to estimate that worldwide, in 2015, there were 2 038 947 (i.q.r. 1 884 916–2 281 776) surgeons, obstetricians and anaesthetists, and 266·1 (95 per cent c.i. 220·1 to 344·4) million operations performed. Conclusion Surgical and anaesthesia indicators are increasingly being adopted by the global health community, but data availability remains low. Comparability and utility for all indicators require further resolution.