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Workforce Innovations to Expand the Capacity for Surgical Services

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  • 307
    Workforce Innovations to Expand the
    Capacity for Surgical Services
    Staffan Bergström, Barbara McPake,
    Caetano Pereira, and Delanyo Dovlo
    Surgical interventions are often considered complex
    procedures to be undertaken by highly trained surgeons,
    but such specialists are rare in many low-income coun-
    tries (LICs). However, many common surgical problems
    in resource-limited settings do not require the inter-
    vention of specialized staff. Significant documentation
    demonstrates that cost-effective surgical interventions
    can be undertaken in LICs with the innovative use and
    deployment of trained staff, including emergency care
    for trauma and obstetrical needs. Despite this docu-
    mentation, surgical workforce innovations that use
    nonspecialized cadres often meet with resistance from
    established surgeons and their professional associations.
    The most important barrier to the safe provision of
    preoperative, intraoperative, and postoperative surgical
    and anesthesia services in LICs is the shortage of trained
    staff. The well-documented reasons for this scarcity
    include the following (Chu and others 2009; FAIMER
    Institute 2008):
    Low number of medical school graduates
    Inadequate initial and ongoing training
    Poor salaries and working conditions
    Inability to motivate and retain staff in remote and
    rural areas
    Staff attrition due to retirement, death, or resignation,
    and the consequences of brain drain
    The reluctance of governments to invest in human
    resources compounds the effects of these factors. Current
    financial constraints, such as those in Tanzania, for
    example, have forced governments to announce freezes
    in employing new human resources for health.
    Sub-Saharan Africa is most affected by the global
    shortage of human resources for health (Chankova,
    Muchiri, and Kombe 2009; Mills and others 2008;
    WHO 2006). Two countries profiled in this chapter,
    Mozambique and Tanzania, experienced this crisis some
    years ago (Liese and Dussault 2004; Mills and others
    2008; Smith and Henderson-Andrade 2006). In other
    countries, despite years of interventions to overcome
    the scarcity of doctors, the shortage has worsened as
    the result of population growth, presenting a major
    challenge to the ability of these countries to achieve the
    health-related Millennium Development Goals (MDGs)
    (Anand and Barnighausen 2004; Liese and Dussault
    2004) (box 17.1). Available doctors tend to concentrate
    and work in urban areas and in regional or even national
    hospitals, limiting access for rural populations, who
    often constitute up to 75 percent of national populations.
    A major reason for Sub-Saharan Africas high mater-
    nal mortality is that few infants are born in the presence
    Corresponding author: Staffan Bergström, MD, PhD, Karolinska Institutet, staffan.bergstrom@ki.se
  • 308 Essential Surgery
    of skilled attendants. The lack of skilled birth atten-
    dants contributes to the 5 million to 6 million maternal
    deaths, stillbirths, and newborn deaths each year world-
    wide. In 19 of the 52 Sub-Saharan African countries
    that reported data, fewer than 50 percent of births were
    attended by skilled health personnel. The World Health
    Organization (WHO) estimates that 80 percent of births
    need to be attended by an adequately equipped and
    skilled birth attendant to reach the fifth MDG target of
    reducing maternal mortality by three-quarters (UNECA,
    African Commission, African Development Bank, and
    UNDP n.d.).
    One colleague in Tanzania expressed his frustrations
    in the following way:
    … [We] are fed up with the government’s commitments
    and the politicians’ alleged devotion to the problem
    of maternal deaths in Tanzania. Our work burden is
    increasing tremendously, but there are no signs of real
    support. Imagine: If I am up during the night to make
    one to two cesarean sections, I have to work the full day
    the morning after. We are entitled to a symbolic call
    allowance of US$6 (six!) per night, but we do not receive
    even that! The government says “there is no money.
    This is not true.
    The AIDS epidemic in Sub-Saharan Africa may have
    aggravated this crisis by depriving health systems of a
    significant proportion of their trained staff (Chen and
    others 2004). Sub-Saharan Africa has 11 percent of the
    world’s population and 24 percent of the total estimated
    global burden of disease; yet it has 3 percent of the global
    health workforce (Chen and others 2004), only a small
    percentage of whom are qualified surgeons. Sub-Saharan
    Africa has less than 1 percent of the number of surgeons
    that the United States has, despite having a population
    that is three times as large (Ozgediz, Riviello, and Rogers
    2008). Expanding the human workforce is clearly essen-
    tial to improving the performance of health systems (de
    Bertodano 2003; Chankova, Muchiri, and Kombe 2009;
    Liese and Dussault 2004; WHO 2000; World Bank 2004)
    and improving outcomes, even under difficult circum-
    stances (Chu and others 2009; EQUINET 2007; FAIMER
    Institute 2008; Mills and others 2008).
    In Mozambique, the scarcity of human resources
    for health 30 years ago was alarming; the country had
    fewer than 5 physicians per 100,000 population. Our
    research estimated that there are 33 registered nurses
    and midwives per 100,000 population (Pereira 2010). In
    Tanzania, the health workforce shortage was disastrous,
    according to the report of the Joint Learning Initiative
    (Chen and others 2004). A study by the London School
    of Hygiene and Tropical Medicine suggests that the
    number of health care providers would need to increase
    by more than 58,000 to provide necessary interven-
    tions to meet the health-related MDGs for Tanzania
    (Anyangwe and Mtonga 2007).
    In most countries in Sub-Saharan Africa, the scarcity of
    human resources for health existed before independence,
    as a result of colonial training policies and, in some cases,
    the massive exodus of colonial professionals after indepen-
    dence (Ministry of Health, Mozambique 2008; Ozgediz
    and others 2008). In Mozambique, a civil war provoked by
    neighboring South Africa in the early 1980s worsened the
    situation. Both Mozambique and Tanzania suffered from
    the consequences of the brain drain, either externally as
    health professionals moved to high-income countries
    (HICs) or internally as they migrated from rural to
    urban areas (Dodani and LaPorte 2005; McKinsey and
    Company 2006; Mullan and Frehywot 2007).
    The literature uses a number of terms to describe cate-
    gories of health professionals who may serve as substi-
    tutes for physicians in providing health care. The most
    common are nonphysician clinicians (NPCs)—nowadays
    referred to as associate clinicians—and midlevel providers
    (MLPs), although others such as substitute health work-
    ers have been used (Dovlo 2005).
    The terms appear to be used interchangeably, although
    there is inconsistency across the literature in the ways in
    which the terms are used. In the Sub-Saharan African
    Box 17.1
    Millennium Development Goals (MDGs) for Health
    Goal 4: Reduce the under-five mortality rate by two-thirds
    between 1990 and 2015.
    Goal 5: Reduce the maternal mortality ratio by three-
    quarters; achieve universal access to reproductive health.
    Goal 6: Have halted and begun to reverse the spread of
    HIV/AIDS by 2015; achieve universal access to treatment
    for HIV/AIDS by 2010 for all those who need it; have halted
    and begun to reverse by 2015 the incidence of malaria and
    other major diseases.
    A review of progress on the MDGs is available at http://
    / hrh-statistics.html.
    Source: United Nations, http://www.un.org/millenniumgoals.
  • Workforce Innovations to Expand the Capacity for Surgical Services 309
    literature, the characteristics of the nontraditional cadres
    of health professionals are generally as follows:
    They have been created as a response to physician
    They have a lower initial level of education.
    They receive a shorter period of preservice training
    than physicians, with the training often limited to a
    specific set of clinical skills.
    These cadres include the Tanzanian assistant medical
    officers (AMOs) and the Mozambican técnicos de cirurgia
    (TCs), whose experiences particularly inform this
    chapter. Other countries use the terms medical assis-
    tants (Ghana) or clinical officers (Kenya and Uganda) to
    denote similar cadres.
    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 com-
    plementary clinical roles to play. For example, Warriner
    and others (2006, 1) define MLPs as “health care pro-
    viders who are not doctors, such as nurses, midwives,
    and doctor-assistants” in their review of the options
    for providing induced abortion services in South Africa
    and Vietnam. Similarly, the American Osteopathic
    Association, Division of State Government Affairs
    (2003), based in the United States, counts both new and
    traditional health professional cadres in the definition
    of the term NPC. In contrast, Bradley and McAuliffe
    (2009, n.p.) define MLPs as “cadres of health workers
    who undertake roles and tasks that are more usually
    the province of internationally recognized cadres, such
    as doctors and nurses, implying that nurses are not
    included among MLPs. This definition is similar to that
    of NPCs according to Mullan and Frehywot (2007), who
    list health officers, clinical officers, physician assistants,
    nurse practitioners, and nurse clinicians as the labels by
    which NPCs are known.
    This chapter focuses on the role of NPCs or MLPs—
    AMOs and TCs in particular—in surgical services
    in Sub-Saharan Africa in situations characterized by
    physician shortages. These cadres have been central to
    the debate about ensuring adequate staffing for essen-
    tial surgery and other physician-delivered services in
    such environments, although 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
    (Berer 2009; Warriner and others 2006).
    In recent years, a welcome terminological shift has
    occurred, from the NPC concept (which actually is a
    negation) to the concept of associate clinician. A growing
    network—the African Network of Associate Clinicians
    (ANAC)—has developed and is based at the Chainama
    College of Health Sciences in Lusaka, Zambia,
    a lower-middle-income country. The ANAC is signifi-
    cant; for the first time, differently titled MLPs from a
    large number of Sub-Saharan African countries have
    formed a major international association. This develop-
    ment will facilitate the recognition of this category of key
    health staff for advanced care, including surgery, in rural
    settings that lack access to physicians.
    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 medi-
    cal responsibilities to less specialized health workers
    (McCord and others 2009). This is the direct substitution
    of new and different cadres for an existing traditional
    profession (Pereira and others 2007; Pereira and others
    2011). In surgery, such health workers may provide many
    of the diagnostic and clinical functions usually per-
    formed 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 physi-
    cians are available, the tasks of physicians must be shifted
    to nonphysicians. Where a few physicians are available,
    their range of tasks may be shared with nonphysicians.
    Training for Safe and Effective Care
    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 midlevel health
    professionals and nonphysician cadres to promote access
    to care and to contain costs (Dovlo 2004; Ministry of
    Health, Mozambique 2008; Pereira and others 2011).
    This trend to delegate procedures to lower cadres
    has often met with resistance for various reasons.
    Surgery is considered a highly specialized field that
    requires several years of training; hence, it is impor-
    tant to define the boundaries of surgical task-shifting
    considered essential to ensure quality of care. The
    WHO has established a list of surgical procedures per-
    formed at first-level hospitals that facilitates the classi-
    fication of various interventions and can help training
    schools establish which essential interventions could
    be safely shifted to NPCs (Lehmann, Dieleman, and

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Workforce Innovations to Expand the Capacity for Surgical Services

Workforce Innovations to Expand the Capacity for Surgical Services Discusses how the lack of highly trained surgeons affect health care in many low-income countries (LICs) leading to the recommendation that governments invest in training nonphysician clinicians (NPCs) or associate clinicians (sometimes called assistant medical officers) for task-shifting of diagnostic and clinical functions. The World Health Organization (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 can be safely shifted to NPCs. In Mozambique, assistant medical technicians called técnicos de cirurgia (TCs), despite acceptance by the medical community, express dissatisfaction with working conditions that combine heavy workloads and low pay. Initiatives to improve the capacity to provide adequate supervision and management can improve work satisfaction, performance, and quality of work in remote settings. NPCs are trained for two years in surgery, and general practitioners receive six months of training to perform emergency surgery in rural areas. These personnel are cost-effective compared with specialists.

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