Task shifting for cataract surgery in eastern Africa: productivity and attrition of non-physician cataract surgeons in Kenya, Malawi and Tanzania

Abstract

BackgroundThis project examined the surgical productivity and attrition of non-physician cataract surgeons (NPCSs) in Tanzania, Malawi, and Kenya.MethodsBaseline (2008-9) data on training, support, and productivity (annual cataract surgery rate) were collected from officially trained NPCSs using mailed questionnaires followed by telephone interviews. Telephone interviews were used to collect follow-up data annually on productivity and semi-annually on attrition. A detailed telephone interview was conducted if a surgeon left his/her post. Data were entered into and analysed using STATA.ResultsAmong the 135 NPCSs, 129 were enrolled in the study (Kenya 88, Tanzania 38, and Malawi 3) mean age 42 years; average time since completing training 6.6 years. Employment was in District 44%, Regional 24% or mission/ private 32% hospitals. Small incision cataract surgery was practiced by 38% of the NPCSs. The mean cataract surgery rate was 188/year, median 76 (range 0-1700). For 39 (31%) NPCSs their surgical rate was more than 200/year. Approximately 22% in Kenya and 25% in Tanzania had years where the cataract surgical rate was zero. About 11% of the surgeons had no support staff.Factors significantly associated with increased productivity were: 1) located at a regional or private/mission hospital compared to a district hospital (OR = 8.26; 95 % CI 2.89 – 23.81); 2) 3 or more nurses in the eye unit (OR = 8.69; 95% CI 3.27-23.15); 3) 3 or more cataract surgical sets (OR = 3.26; 95% CI 1.48-7.16); 4) a separate eye theatre (OR = 5.41; 95% CI 2.15-13.65); 5) a surgical outreach program (OR = 4.44; 95% CI 1.88-10.52); and 6) providing transport for patients to hospital (OR = 6.39; 95% CI 2.62-15.59). The associations were similar for baseline and follow-up assessments. Attrition during the 3 years occurred in 13 surgeons (10.3%) and was due to retirement or promotion to administration.ConclusionsHigh quality training is necessary but not sufficient to result in cataract surgical activity that meets population needs and maintains surgical skill. Needed are supporting institutions and staff, functioning equipment and programs to recruit and transport patients.

Results and safety profile of trainee cataract surgeons in a community setting in East Africa

“…[202122] Although surgical training and experience are major factors for improved outcomes, factors that have also been shown to impact surgical skills of AMO-Os, include supporting staff and functioning equipment. [23] Against this background is the fact that the AMO-Os provide the much-needed cataract surgical services in the rural areas. It is cheaper and easier to train and maintain the AMO-Os compared to ophthalmologists, who would usually prefer to practice in urban settings and large hospitals.…”

Ciliary sulcus implantation of intraocular lens in manual small incision cataract surgery complicated by large posterior capsule rupture

“…A number of reasons, including chronic shortages of medical materials, mean the only feasible method of treating the complications the occur following cataract surgery is IOL. The majority of patients will be unable to undergo second implantation of IOL, as cost and transport duration pose a formidable barrier (32,33). Furthermore, there are often shortages of cataract surgeons, nurses and equipment in low-and middle-income countries, and the training of new cataract surgeons is not sufficient to meet demand (33,34).…”

“…The majority of patients will be unable to undergo second implantation of IOL, as cost and transport duration pose a formidable barrier (32,33). Furthermore, there are often shortages of cataract surgeons, nurses and equipment in low-and middle-income countries, and the training of new cataract surgeons is not sufficient to meet demand (33,34). In addition, it is often difficult to access optometric services in such countries, therefore all patients following cataract surgery that are unable to undergo implantation, will experience reduced postoperative visual acuity (35).…”

Surgery for children in low-income countries affected by humanitarian emergencies from 2008 to 2014: The Médecins Sans Frontières Operations Centre Brussels experience

“…The perioperative capacity of many hospitals and humanitarian projects in LMICs is extremely limited [15]. As a result, teams often work with few physical resources and rely on task-sharing [47,48]. While the outcomes of projects that rely on task-sharing are similar to projects with a well-trained anesthetist [48], complex cases (e.g., surgery for infants, management of children in extremis) require greater resources, training and experience.…”