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Werz MJ, van Duinen AJ, Hampaye TC, van den Broek A, Bolkan HA. Exploring barriers and enabling factors for surgical task sharing with physician assistants in Liberia: a qualitative pre-implementation study. BMJ Open 2024; 14:e081363. [PMID: 39013646 PMCID: PMC11253748 DOI: 10.1136/bmjopen-2023-081363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 06/28/2024] [Indexed: 07/18/2024] Open
Abstract
OBJECTIVES This study explores potential barriers and enabling factors that may influence the acceptance of implementation of a surgical task-sharing initiative targeting physician assistants (PAs) in Liberia. DESIGN A qualitative, pre-implementation study using semistructured interviews. Data was analysed in NVivo V.12 using deductive coding and the consolidated framework for implementation research as a guide. SETTING Liberia has few surgical providers and a poor surgical infrastructure resulting in a very low surgical volume. The research was conducted in the context of an already running surgical task-sharing programme for midwives. PARTICIPANTS In 2019, a total of 30 key stakeholders in the field of surgery and the PAs training programme were interviewed. RESULTS The majority of the stakeholders supported the idea of training PAs in surgery. The high unemployment rate among PAs and the need for career advancement of this cadre were important enabling factors. Resistance against surgical task sharing for mid-level clinicians is multifaceted. The Ministry of Health (MOH) did not share a common vision. Opponents within the MOH believed budgetary constraints within the MOH and the lack of surgical infrastructure is a more pressing problem compared with the surgically trained human resources. Another important group of opponents are medical officers (MOs) and their professional bodies. Many of their negative beliefs around surgical task sharing reflect lessons to be drawn from the current surgical training programme for midwives. CONCLUSION Prior to deciding on implementation of a surgical training programme for PAs, wider support is needed. If surgical task sharing with PAs is to be considered, the intervention should focus on adapting the 'adaptable' periphery of the intervention to broaden the support of the MOH, MOs and their professional bodies. Failing to obtain such support should make the implementors consider alternative strategies to strengthen surgical human resources in rural Liberia.
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Affiliation(s)
| | - Alex J van Duinen
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Trøndelag, Norway
- Clinic of Surgery, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | | | | | - Håkon A Bolkan
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Trøndelag, Norway
- Clinic of Surgery, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
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Morris ME, Brusco NK, McAleer R, Billett S, Brophy L, Bryant R, Carey L, Wright AC, East C, Eckert M, Edvardsson K, Fetherstonhaugh D, Fowler-Davis S, Frederico M, Gray R, McCaskie D, McKinstry C, Mitchell R, Oldenburg B, Shields N, Smith K, Spelten E, Taylor N, Thwaites C, Young S, Blackberry I. Professional care workforce: a rapid review of evidence supporting methods of recruitment, retention, safety, and education. HUMAN RESOURCES FOR HEALTH 2023; 21:95. [PMID: 38093376 PMCID: PMC10720209 DOI: 10.1186/s12960-023-00879-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 11/17/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Across the care economy there are major shortages in the health and care workforce, as well as high rates of attrition and ill-defined career pathways. The aim of this study was to evaluate current evidence regarding methods to improve care worker recruitment, retention, safety, and education, for the professional care workforce. METHODS A rapid review of comparative interventions designed to recruit, retain, educate and care for the professional workforce in the following sectors: disability, aged care, health, mental health, family and youth services, and early childhood education and care was conducted. Embase and MEDLINE databases were searched, and studies published between January 2015 and November 2022 were included. We used the Quality Assessment tool for Quantitative Studies and the PEDro tools to evaluate study quality. RESULTS 5594 articles were initially screened and after applying the inclusion and exclusion criteria, 30 studies were included in the rapid review. Studies most frequently reported on the professional nursing, medical and allied health workforces. Some studies focused on the single domain of care worker education (n = 11) while most focused on multiple domains that combined education with recruitment strategies, retention strategies or a focus on worker safety. Study quality was comparatively low with a median PEDro score of 5/10, and 77% received a weak rating on the Quality Assessment tool for Quantitative Studies. Four new workforce strategies emerged; early career rural recruitment supports rural retention; workload management is essential for workforce well-being; learning must be contextually relevant; and there is a need to differentiate recruitment, retention, and education strategies for different professional health and care workforce categories as needs vary. CONCLUSIONS Given the critical importance of recruiting and retaining a strong health and care workforce, there is an immediate need to develop a cohesive strategy to address workforce shortfalls. This paper presents initial evidence on different interventions to address this need, and to inform care workforce recruitment and retention. Rapid Review registration PROSPERO 2022 CRD42022371721 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022371721.
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Affiliation(s)
- Meg E Morris
- The Victorian Rehabilitation Centre, Academic and Research Collaborative in Health (ARCH), and CERI, La Trobe University, Bundoora, VIC, 3083, Australia
| | - Natasha K Brusco
- La Trobe University, Bundoora, VIC, 3086, Australia.
- Rehabilitation, Ageing and Independent Living (RAIL) Research Centre, Monash University, Frankston, 3150, Australia.
| | - Rachael McAleer
- La Trobe Rural Health School, La Trobe University, Bendigo, 3550, Australia
| | | | - Lisa Brophy
- La Trobe University, Bundoora, VIC, 3086, Australia
| | - Rosemary Bryant
- AO Research Centre, University of South Australia, Adelaide, 5001, Australia
| | - Leeanne Carey
- La Trobe University, Bundoora, VIC, 3086, Australia
- Florey Institute of Neuroscience and Mental Health, Heidelberg, 3084, Australia
| | | | - Christine East
- La Trobe University, Bundoora, VIC, 3086, Australia
- Mercy Health, Richmond, 3121, Australia
| | - Marion Eckert
- Rosemary Bryant AO Research Centre, University of South Australia, Adelaide, 5001, Australia
| | | | | | - Sally Fowler-Davis
- Centre for Health and Care Research, Collegiate Crescent, Sheffield Hallam University, Sheffield, S1 1WB, UK
| | | | - Richard Gray
- La Trobe University, Bundoora, VIC, 3086, Australia
| | - Doug McCaskie
- Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Carol McKinstry
- La Trobe Rural Health School, La Trobe University, Bendigo, 3550, Australia
| | | | - Brian Oldenburg
- La Trobe University, Bundoora, VIC, 3086, Australia
- Baker Heart and Diabetes Institute, Melbourne, 3004, Australia
| | - Nora Shields
- La Trobe University, Bundoora, VIC, 3086, Australia
| | - Karen Smith
- Silver Chain, Bourke Street, Melbourne, VIC, 3000, Australia
| | - Evelien Spelten
- La Trobe Rural Health School, La Trobe University, Bendigo, 3550, Australia
| | - Nicholas Taylor
- Eastern Health Academic and Research Collaborative in Health (ARCH), La Trobe University, Bundoora, 3086, Australia
| | - Claire Thwaites
- The Victorian Rehabilitation Centre and Academic and Research Collaborative in Health (ARCH) La Trobe University, Bundoora, VIC, 3083, Australia
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Ryan I, Shah KV, Barrero CE, Uamunovandu T, Ilbawi A, Swanson J. Task Shifting and Task Sharing to Strengthen the Surgical Workforce in Sub-Saharan Africa: A Systematic Review of the Existing Literature. World J Surg 2023; 47:3070-3080. [PMID: 37831136 DOI: 10.1007/s00268-023-07197-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND A major constraint to surgical care delivery in low-resource settings is inadequate workforce availability. Surgical task shifting (TShifting) and task sharing (TSharing), in which non-surgeon clinicians (NSCs) are trained to perform select surgical procedures, have been proposed as one solution. However, patterns of safety and efficacy of surgical TShifting/TSharing are not well-established. This study aims to summarize the current literature and assess clinical outcomes and impact of surgical TShifting/TSharing in sub-Saharan Africa. METHODS A two-tiered systematic, PRISMA-adherent literature review of surgical TShifting/TSharing in sub-Saharan Africa was conducted. Collected data included healthcare settings; types of surgeries performed; attitudes toward NSCs; and categories, training, capacity, clinical outcomes, safety, retention, cost-effectiveness, and supervision of NSCs. A random effects meta-analysis of morbidity and mortality rates between NSCs and surgeons was conducted. RESULTS Among the 659 abstracts screened, 31 studies met inclusion criteria and were integrated in the final analysis. Eighteen studies (58%) report on the capacity and aptitude of NSCs, 16 (52%) on clinical outcomes and safety, and seven (23%) on attitudes. NSCs performed 1999 (61%) of 3304 total surgical cases studied. The most common operations reported were hernia repair (n = 12, 57%), acute abdominal (n = 12, 57%), and orthopedic procedures (n = 6, 29%). No differences were found between NSC and surgeon case morbidity [315 (16%) vs. 224 (17%); p > 0.05] and mortality [44 (2.2%) vs. 33 (2.5%); p > 0.05] rates. CONCLUSION NSCs are increasingly performing surgical tasks in regions of sub-Saharan Africa deficient in trained surgeons and appear to have non-inferior safety outcomes in select programs.
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Affiliation(s)
- Isabel Ryan
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Keshav V Shah
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Carlos E Barrero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Andre Ilbawi
- Department of Universal Health Coverage, WHO, Geneva, Switzerland
| | - Jordan Swanson
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Bognini MS, Oko CI, Kebede MA, Ifeanyichi MI, Singh D, Hargest R, Friebel R. Assessing the impact of anaesthetic and surgical task-shifting globally: a systematic literature review. Health Policy Plan 2023; 38:960-994. [PMID: 37506040 PMCID: PMC10506531 DOI: 10.1093/heapol/czad059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 06/04/2023] [Accepted: 07/26/2023] [Indexed: 07/30/2023] Open
Abstract
The global shortage of skilled anaesthesiologists, surgeons and obstetricians is a leading cause of high unmet surgical need. Although anaesthetic and surgical task-shifting are widely practised to mitigate this barrier, little is known about their safety and efficacy. This systematic review seeks to highlight the existing evidence on the clinical outcomes of patients operated on by non-physicians or non-specialist physicians globally. Relevant articles were identified by searching four databases (MEDLINE, EMBASE, CINAHL and Global Health) in all languages between January 2008 and February 2022. Retrieved documents were screened against pre-specified inclusion and exclusion criteria, and their qualities were appraised critically. Data were extracted by two independent reviewers and findings were synthesized narratively. In total, 40 studies have been included. Thirty-five focus on task-shifting for surgical and obstetric procedures, whereas four studies address anaesthetic task-shifting; one study covers both interventions. The majority are located in sub-Saharan Africa and the USA. Seventy-five per cent present perioperative mortality outcomes and 85% analyse morbidity measures. Evidence from low- and middle-income countries, which primarily concentrates on caesarean sections, hernia repairs and surgical male circumcisions, points to the overall safety of non-surgeons. On the other hand, the literature on surgical task-shifting in high-income countries (HICs) is limited to nine studies analysing tube thoracostomies, neurosurgical procedures, caesarean sections, male circumcisions and basal cell carcinoma excisions. Finally, only five studies pertaining to anaesthetic task-shifting across all country settings answer the research question with conflicting results, making it difficult to draw conclusions on the quality of non-physician anaesthetic care. Overall, it appears that non-specialists can safely perform high-volume, low-complexity operations. Further research is needed to understand the implications of surgical task-shifting in HICs and to better assess the performance of non-specialist anaesthesia providers. Future studies must adopt randomized study designs and include long-term outcome measures to generate high-quality evidence.
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Affiliation(s)
- Maeve S Bognini
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
| | - Christian I Oko
- Division of Health Research, Lancaster University, Bailrigg, Lancaster LA1 4YW, United Kingdom
| | - Meskerem A Kebede
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
| | - Martilord I Ifeanyichi
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
| | - Darshita Singh
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
| | - Rachel Hargest
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
- University Hospital of Wales, Heath Park, Cardiff CF14 4XN, United Kingdom
| | - Rocco Friebel
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
- Center for Global Development, Abbey Gardens, Great College Street, London SW1P 3SE, United Kingdom
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Pittalis C, Drury G, Mwapasa G, Borgstein E, Cheelo M, Kachimba J, Juma A, Chilonga K, Cahill N, Brugha R, Lavy C, Gajewski J. Using participatory action research to empower district hospital staff to deliver quality-assured essential surgery to rural populations in Malawi, Zambia, and Tanzania. Front Public Health 2023; 11:1186307. [PMID: 37780427 PMCID: PMC10536269 DOI: 10.3389/fpubh.2023.1186307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/30/2023] [Indexed: 10/03/2023] Open
Abstract
Background In 2017 the SURG-Africa project set out to institute a surgical, obstetric, trauma and anesthesia (SOTA) care capacity-building intervention focused on non-specialist providers at district hospitals in Zambia, Malawi and Tanzania. The aim was to scale up quality-assured SOTA care for rural populations. This paper reports the process of developing the intervention and our experience of initial implementation, using a participatory approach. Methods Participatory Action Research workshops were held in the 3 countries in July-October 2017 and in October 2018-July 2019, involving representatives of key local stakeholder groups: district hospital (DH) surgical teams and administrators, referral hospital SOTA specialists, professional associations and local authorities. Through semi-structured discussions, qualitative data were collected on participants' perceptions and experiences of barriers to the provision of SOTA care at district level, and on the training and supervision needs of district surgical teams. Data were compared for themes across countries and across surgical team cadres. Results All groups reported a lack of in-service training to develop essential skills to manage common SOTA cases; use and care of equipment; essential anesthesia care including resuscitation skills; and infection prevention and control. Very few district surgical teams had access to supervision. SOTA providers at DHs reported a demand for more feedback on referrals. Participants prioritized training needs that could be addressed through regular in-service training and supervision visits from referral hospital specialists to DHs. These data were used by participants in an action-planning cycle to develop site-specific training plans for each research site. Conclusion The inclusive, participatory approach to stakeholder involvement in SOTA system strengthening employed by this study supported the design of a locally relevant and contextualized intervention. This study provides lessons on how to rebalance power dynamics in Global Surgery, through giving a voice to district surgical teams.
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Affiliation(s)
- Chiara Pittalis
- School of Population Health, Institute of Global Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Grace Drury
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Gerald Mwapasa
- Deparment of Surgery, College of Medicine, Kamuzu University of Health Sciences (former University of Malawi), Blantyre, Malawi
| | - Eric Borgstein
- Deparment of Surgery, College of Medicine, Kamuzu University of Health Sciences (former University of Malawi), Blantyre, Malawi
| | | | | | - Adinan Juma
- East Central and Southern Africa Health Community, Arusha, Tanzania
| | - Kondo Chilonga
- Department of Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Niamh Cahill
- School of Medicine, University of South Carolina, Greenville, SC, United States
| | - Ruairi Brugha
- School of Population Health, Institute of Global Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Chris Lavy
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Jakub Gajewski
- School of Population Health, Institute of Global Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Gajewski J, Pittalis C, Borgstein E, Bijlmakers L, Mwapasa G, Cheelo M, Juma A, Sardana M, Brugha R. Critical shortage of capacity to deliver safe paediatric surgery in sub-Saharan Africa: evidence from 67 hospitals in Malawi, Zambia, and Tanzania. Front Pediatr 2023; 11:1189676. [PMID: 37325346 PMCID: PMC10265866 DOI: 10.3389/fped.2023.1189676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/18/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Paediatric surgical care is a significant challenge in Sub-Saharan Africa (SSA), where 42% of the population are children. Building paediatric surgical capacity to meet SSA country needs is a priority. This study aimed to assess district hospital paediatric surgical capacity in three countries: Malawi, Tanzania and Zambia (MTZ). Methods Data from 67 district-level hospitals in MTZ were collected using a PediPIPES survey tool. Its five components are procedures, personnel, infrastructure, equipment, and supplies. A PediPIPES Index was calculated for each country, and a two-tailed analysis of variance test was used to explore cross-country comparisons. Results Similar paediatric surgical capacity index scores and shortages were observed across countries, greater in Malawi and less in Tanzania. Almost all hospitals reported the capacity to perform common minor surgical procedures and less complex resuscitation interventions. Capacity to undertake common abdominal, orthopaedic and urogenital procedures varied-more often reported in Malawi and less often in Tanzania. There were no paediatric or general surgeons or anaesthesiologists at district hospitals. General medical officers with some training to do surgery on children were present (more often in Zambia). Paediatric surgical equipment and supplies were poor in all three countries. Malawi district hospitals had the poorest supply of electricity and water. Conclusions With no specialists in district hospitals in MTZ, access to safe paediatric surgery is compromised, aggravated by shortages of infrastructure, equipment and supplies. Significant investments are required to address these shortfalls. SSA countries need to define what procedures are appropriate to national, referral and district hospital levels and ensure that an appropriate paediatric surgical workforce is in place at district hospitals, trained and supervised to undertake these essential surgical procedures so as to meet population needs.
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Affiliation(s)
- Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
- Centre for Global Surgery, University of Stellenbosch, Cape Town, South Africa
| | - Chiara Pittalis
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Eric Borgstein
- Department of Surgery, College of Medicine Malawi, Blantyre, Malawi
| | - Leon Bijlmakers
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerald Mwapasa
- Department of Surgery, College of Medicine Malawi, Blantyre, Malawi
| | - Mweene Cheelo
- Surgical Society of Zambia, University Teaching Hospital Lusaka, Lusaka, Zambia
| | - Adinan Juma
- East Central and Southern Africa Health Community, Arusha, Tanzania
| | - Muskan Sardana
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruairi Brugha
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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Zakhari A, Konci R, Nguyen DB, Amar-Zifkin A, Smith JP, Mansour FW, Krishnamurthy S. Task shifting cesarean sections in low- and middle-income countries: A systematic review and meta-analysis. Int J Gynaecol Obstet 2023; 160:771-782. [PMID: 35965383 DOI: 10.1002/ijgo.14401] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/30/2022] [Accepted: 08/05/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Safe and timely access to cesarean section (CS) in low- and middle-income countries (LMIC) remains a significant challenge. OBJECTIVES To compare maternal and perinatal outcomes of CS by non-physician clinicians (NPCs) versus physicians in LMIC. SEARCH STRATEGY AND SELECTION CRITERIA A systematic search of Ovid MEDLINE, EMBASE, Cochrane Library (including CENTRAL), Web of Science, and LILACS was performed from inception to January 2022. DATA COLLECTION AND ANALYSIS Data were extracted by two independent reviewers and meta-analysis was performed when possible. MAIN RESULTS Ten studies from seven African countries were included. There was no significant difference in maternal mortality for CS performed by NPCs versus physicians (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.56-2.14, P = 0.8, I2 = 70%, P < 0.05, eight studies, n = 20 711) or in perinatal mortality (OR 1.18, 95% CI 0.86-1.61, P = 0.3, I2 = 88%, n = 19 716). Despite heterogeneous clinical settings between providers, there was no difference in the rates of wound infection or re-operation, although there was a higher rate of wound complications (such as dehiscence) in the NPC group (OR 1.89, 95% CI 1.21-2.95, P = 0.005, n = 6507). CONCLUSIONS NPCs have comparable maternal and neonatal outcomes for CS compared with standard providers, albeit with increased odds of wound complication. PROSPERO REGISTRATION CRD42020217966.
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Affiliation(s)
- Andrew Zakhari
- Department of Obstetrics and Gynecology, Royal Victoria Hospital-Glen Site, McGill University Health Center, Montreal, QC, Canada
| | - Rea Konci
- Department of Obstetrics and Gynecology, Royal Victoria Hospital-Glen Site, McGill University Health Center, Montreal, QC, Canada
| | - Dong Bach Nguyen
- Department of Obstetrics and Gynecology, Royal Victoria Hospital-Glen Site, McGill University Health Center, Montreal, QC, Canada
| | - Alexandre Amar-Zifkin
- Master of Library and Information Science, McGill University Health Centre Medical Libraries, Montreal, QC, Canada
| | - Jessica Papillon Smith
- Department of Obstetrics and Gynecology, Royal Victoria Hospital-Glen Site, McGill University Health Center, Montreal, QC, Canada
| | - Fady W Mansour
- Department of Obstetrics and Gynecology, Royal Victoria Hospital-Glen Site, McGill University Health Center, Montreal, QC, Canada
| | - Srinivasan Krishnamurthy
- Department of Obstetrics and Gynecology, Royal Victoria Hospital-Glen Site, McGill University Health Center, Montreal, QC, Canada
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Quality Improvement Models and Methods for Maternal Health in Lower-Resource Settings. Obstet Gynecol Clin North Am 2022; 49:823-839. [DOI: 10.1016/j.ogc.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Rice B, Pickering A, Laurence C, Kizito PM, Leff R, Kisingiri SJ, Ndyamwijuka C, Nakato S, Adriko LF, Bisanzo M. Emergency medicine physician supervision and mortality among patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda: a retrospective analysis of a single-centre training programme. BMJ Open 2022; 12:e059859. [PMID: 35768107 PMCID: PMC9244677 DOI: 10.1136/bmjopen-2021-059859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 06/08/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To assess the association between emergency medicine physician supervision and 3-day mortality for patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda. DESIGN Retrospective cohort analysis with multivariable logistic regression. SETTING Single rural Ugandan emergency unit. PARTICIPANTS All patients presenting for care from 2009 to 2019. INTERVENTIONS Three cohorts of patients receiving care from non-physician clinicians had three different levels of physician supervision: 'Direct Supervision' (2009-2010) emergency medicine physicians directly supervised all care; 'Indirect Supervision' (2010-2015) emergency medicine physicians were consulted as needed; 'Independent Care' (2015-2019) no emergency medicine physician supervision. PRIMARY OUTCOME MEASURE Three-day mortality. RESULTS 38 033 ED visits met inclusion criteria. Overall mortality decreased significantly across supervision cohorts ('Direct' 3.8%, 'Indirect' 3.3%, 'Independent' 2.6%, p<0.001), but so too did the rates of patients who presented with ≥3 abnormal vitals ('Direct' 32%, 'Indirect' 19%, 'Independent' 13%, p<0.001). After controlling for vital sign abnormalities, 'Direct' and 'Indirect' supervision were both significantly associated with reduced OR for mortality ('Direct': 0.57 (0.37 to 0.90), 'Indirect': 0.71 (0.55 to 0.92)) when compared with 'Independent Care'. Sensitivity analysis showed that this mortality benefit was significant for the minority of patients (17.2%) with ≥3 abnormal vitals ('Direct': 0.44 (0.22 to 0.85), 'Indirect': 0.60 (0.41 to 0.88)), but not for the majority (82.8%) with two or fewer abnormal vitals ('Direct': 0.81 (0.44 to 1.49), 'Indirect': 0.82 (0.58 to 1.16)). CONCLUSIONS Emergency medicine physician supervision of emergency care non-physician clinicians is independently associated with reduced overall mortality. This benefit appears restricted to the highest risk patients based on abnormal vitals. With over 80% of patients having equivalent mortality outcomes with independent non-physician clinician emergency care, a synergistic model providing variable levels of emergency medicine physician supervision or care based on patient acuity could safely address staffing shortages.
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Affiliation(s)
- Brian Rice
- Emergency Medicine, Stanford University, Palo Alto, California, USA
| | - Ashley Pickering
- Emergency Medicine, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA
| | - Colleen Laurence
- Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Prisca Mary Kizito
- Emergency Medicine, Mbarara University of Science and Technology, Mbarara, Mbarara, Uganda
- Emergency Medicine, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Rebecca Leff
- Emergency Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Steven Jonathan Kisingiri
- Emergency Medicine, Global Emergency Care, Shrewsbury, Massachusetts, USA
- Public Health, Liverpool John Moores University, Liverpool, Merseyside, UK
| | | | - Serena Nakato
- Emergency Medicine, Global Emergency Care, Shrewsbury, Massachusetts, USA
- Emergency Medicine, Karoli Lwanga Hospital, Rukungiri, Rukungiri, Uganda
| | - Lema Felix Adriko
- Emergency Medicine, Karoli Lwanga Hospital, Rukungiri, Rukungiri, Uganda
| | - Mark Bisanzo
- Emergency Medicine, University of Vermont College of Medicine, Burlington, Vermont, USA
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Access to quality surgical care in Nigeria: A narrative review of the challenges, and the way forward. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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A thematic review of the use of electronic logbooks for surgical assessment in sub-Saharan Africa. Surgeon 2021; 20:57-60. [PMID: 34922837 DOI: 10.1016/j.surge.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/26/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Ensuring that surgical training programmes in low- and middle-income countries (LMICs) provide high quality training, including adequate operative experience, is of crucial importance in meeting the goals set out in the Lancet Global Surgery 2030. Electronic logbooks (eLogbooks) have been adopted to monitor both individual trainee progression and the performance of surgical training programmes. METHODS We performed a thematic review of the current evidence base surrounding the use of eLogbooks for the assessment of surgeons in training in sub-Saharan Africa, with a view to identifying the learning to date and areas for future research. RESULTS Whilst there are multiple papers highlighting the use of surgical eLogbooks in high-income countries, we identified only three papers which discussed their use in sub-Saharan Africa. Four common themes emerged which related to the use of surgical eLogbooks throughout sub-Saharan Africa: ease of analysis, centralised databases, discrepancies in reporting and technology limitations. CONCLUSIONS Robust data to demonstrate trainee progression and the quality of surgical training programmes are of crucial importance in ensuring that surgical training programmes can rapidly scale up to deliver large numbers of well-trained surgical providers to address the unmet patient need in LMICs in the next decade. The limited data on the use of well designed, centralised electronic surgical logbooks indicate that this tool may play an important role in providing key data to underpin these training programmes.
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Broekhuizen H, Ifeanyichi M, Cheelo M, Drury G, Pittalis C, Rouwette E, Mbambiko M, Kachimba J, Brugha R, Gajewski J, Bijlmakers L. Policy options for surgical mentoring: Lessons from Zambia based on stakeholder consultation and systems science. PLoS One 2021; 16:e0257597. [PMID: 34587196 PMCID: PMC8480833 DOI: 10.1371/journal.pone.0257597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 09/03/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Supervision by surgical specialists is beneficial because they can impart skills to district hospital-level surgical teams. The SURG-Africa project in Zambia comprises a mentoring trial in selected districts, involving two provincial-level mentoring teams. The aim of this paper is to explore policy options for embedding such surgical mentoring in existing policy structures through a participatory modeling approach. METHODS Four group model building workshops were held, two each in district and central hospitals. Participants worked in a variety of institutions and had clinical and/or administrative backgrounds. Two independent reviewers compared the causal loop diagrams (CLDs) that resulted from these workshops in a pairwise fashion to construct an integrated CLD. Graph theory was used to analyze the integrated CLD, and dynamic system behavior was explored using the Method to Analyse Relations between Variables using Enriched Loops (MARVEL) method. RESULTS The establishment of a provincial mentoring faculty, in collaboration with key stakeholders, would be a necessary step to coordinate and sustain surgical mentoring and to monitor district-level surgical performance. Quarterly surgical mentoring reviews at the provincial level are recommended to evaluate and, if needed, adapt mentoring. District hospital administrators need to closely monitor mentee motivation. CONCLUSIONS Surgical mentoring can play a key role in scaling up district-level surgery but its implementation is complex and requires designated provincial level coordination and regular contact with relevant stakeholders.
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Affiliation(s)
- Henk Broekhuizen
- Dept. Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
- Dept. Health and Society, Wageningen University and Research, Wageningen, The Netherlands
- * E-mail:
| | - Martilord Ifeanyichi
- Dept. Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
- EMAI Health Systems and Health Services Consulting, Nijmegen, The Netherlands
| | - Mweene Cheelo
- Department of Surgery, Surgical Society of Zambia, University Teaching Hospital, Lusaka, Zambia
| | - Grace Drury
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Chiara Pittalis
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Etiënne Rouwette
- Institute for Management Research, Radboud University, Nijmegen, The Netherlands
| | - Michael Mbambiko
- Department of Surgery, Surgical Society of Zambia, University Teaching Hospital, Lusaka, Zambia
| | - John Kachimba
- Department of Surgery, Surgical Society of Zambia, University Teaching Hospital, Lusaka, Zambia
| | - Ruairí Brugha
- Department of Epidemiology & Public Health, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Ireland
| | - Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leon Bijlmakers
- Dept. Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
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Clarke M, Pittalis C, Borgstein E, Bijlmakers L, Cheelo M, Ifeanyichi M, Mwapasa G, Juma A, Broekhuizen H, Drury G, Lavy C, Kachimba J, Mkandawire N, Chilonga K, Brugha R, Gajewski J. Surgical service monitoring and quality control systems at district hospitals in Malawi, Tanzania and Zambia: a mixed-methods study. BMJ Qual Saf 2021; 30:950-960. [PMID: 33727414 PMCID: PMC8606427 DOI: 10.1136/bmjqs-2020-012751] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/22/2021] [Accepted: 03/07/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND In low-income and middle-income countries, an estimated one in three clinical adverse events happens in non-complex situations and 83% are preventable. Poor quality of care also leads to inefficient use of human, material and financial resources for health. Improving outcomes and mitigating the risk of adverse events require effective monitoring and quality control systems. AIM To assess the state of surgical monitoring and quality control systems at district hospitals (DHs) in Malawi, Tanzania and Zambia. METHODS A mixed-methods cross-sectional study of 75 DHs: Malawi (22), Tanzania (30) and Zambia (23). This included a questionnaire, interviews and visual inspection of operating theatre (OT) registers. Data were collected on monitoring and quality systems for surgical activity, processes and outcomes, as well as perceived barriers. RESULTS 53% (n=40/75) of DHs use more than one OT register to record surgical operations. With the exception of standardised printed OT registers in Zambia, the register format (often handwritten books) and type of data collected varied between DHs. Monthly reports were seldom analysed by surgical teams. Less than 30% of all surveyed DHs used surgical safety checklists (n=22/75), and <15% (n=11/75) performed surgical audits. 73% (n=22/30) of DHs in Tanzania and less than half of DHs in Malawi (n=11/22) and Zambia (n=10/23) conducted surgical case reviews. Reports of surgical morbidity and mortality were compiled in 65% (n=15/23) of Zambian DHs, and in less than one-third of DHs in Tanzania (n=9/30) and Malawi (n=4/22). Reported barriers to monitoring and quality systems included an absence of formalised guidelines, continuous training opportunities as well as inadequate accountability mechanisms. CONCLUSIONS Surgical monitoring and quality control systems were not standard among sampled DHs. Improvements are needed in standardisation of quality measures used; and in ensuring data completeness, analysis and utilisation for improving patient outcomes.
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Affiliation(s)
- Morgane Clarke
- Department of Epidemiology & Public Health, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Leinster, Ireland
| | - Chiara Pittalis
- Department of Epidemiology & Public Health, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Leinster, Ireland
| | - Eric Borgstein
- Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi
| | - Leon Bijlmakers
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Mweene Cheelo
- Department of Surgery, Surgical Society of Zambia, University of Zambia University Teaching Hospital, Lusaka, Zambia
| | - Martilord Ifeanyichi
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Gerald Mwapasa
- Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi
| | - Adinan Juma
- East Central and Southern Africa Health Community, Arusha, United Republic of Tanzania
| | - Henk Broekhuizen
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Grace Drury
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Chris Lavy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - John Kachimba
- Department of Surgery, Surgical Society of Zambia, University of Zambia University Teaching Hospital, Lusaka, Zambia
| | - Nyengo Mkandawire
- Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi
| | - Kondo Chilonga
- Department of Surgery, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Ruairí Brugha
- Department of Epidemiology & Public Health, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Leinster, Ireland
| | - Jakub Gajewski
- Department of Epidemiology & Public Health, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Leinster, Ireland
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Igaga EN, Sendagire C, Ayebale ET. Task Sharing in Global Anesthesia and Surgery: Workforce Concerns. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-020-00433-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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van Heemskerken P, Broekhuizen H, Gajewski J, Brugha R, Bijlmakers L. Barriers to surgery performed by non-physician clinicians in sub-Saharan Africa-a scoping review. HUMAN RESOURCES FOR HEALTH 2020; 18:51. [PMID: 32680526 PMCID: PMC7368796 DOI: 10.1186/s12960-020-00490-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 07/07/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Sub-Saharan Africa (SSA) faces the highest burden of disease amenable to surgery while having the lowest surgeon to population ratio in the world. Some 25 SSA countries use surgical task-shifting from physicians to non-physician clinicians (NPCs) as a strategy to increase access to surgery. While many studies have investigated barriers to access to surgical services, there is a dearth of studies that examine the barriers to shifting of surgical tasks to, and the delivery of safe essential surgical care by NPCs, especially in rural areas of SSA. This study aims to identify those barriers and how they vary between surgical disciplines as well as between countries. METHODS We performed a scoping review of articles published between 2000 and 2018, listed in PubMed or Embase. Full-text articles were read by two reviewers to identify barriers to surgical task-shifting. Cited barriers were counted and categorized, partly based on the World Health Organization (WHO) health systems building blocks. RESULTS Sixty-two articles met the inclusion criteria, and 14 clusters of barriers were identified, which were assigned to four main categories: primary outcomes, NPC workforce, regulation, and environment and resources. Malawi, Tanzania, Uganda, and Mozambique had the largest number of articles reporting barriers, with Uganda reporting the largest variety of barriers from empirical studies only. Obstetric and gynaecologic surgery had more articles and cited barriers than other specialties. CONCLUSION A multitude of factors hampers the provision of surgery by NPCs across SSA. The two main issues are surgical pre-requisites and the need for regulatory and professional frameworks to legitimate and control the surgical practice of NPCs.
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Affiliation(s)
| | - Henk Broekhuizen
- Health Evidence Department, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jakub Gajewski
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruairí Brugha
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leon Bijlmakers
- Health Evidence Department, Radboud University Medical Centre, Nijmegen, The Netherlands
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Gajewski J, Monzer N, Pittalis C, Bijlmakers L, Cheelo M, Kachimba J, Brugha R. Supervision as a tool for building surgical capacity of district hospitals: the case of Zambia. HUMAN RESOURCES FOR HEALTH 2020; 18:25. [PMID: 32216789 PMCID: PMC7098155 DOI: 10.1186/s12960-020-00467-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/11/2020] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Many countries in sub-Saharan Africa have adopted task shifting of surgical responsibilities to non-physician clinicians (NPCs) as a solution to address workforce shortages. There is resistance to delegating surgical procedures to NPCs due to concerns about their surgical skills and lack of supervision systems to ensure safety and quality of care provided. This study aimed to explore the effects of a new supervision model implemented in Zambia to improve the delivery of health services by surgical NPCs working at district hospitals. METHODS Twenty-eight semi-structured interviews were conducted with NPCs and medical doctors at nine district hospitals and with the surgical specialists who provided in-person and remote supervision over an average period of 15 months. Data were analysed using 'top-down' and 'bottom-up' thematic coding. RESULTS Interviewees reported an improvement in the surgical skills and confidence of NPCs, as well as better teamwork. At the facility level, supervision led to an increase in the volume and range of surgical procedures done and helped to reduce unnecessary surgical referrals. The supervision also improved communication links by facilitating the establishment of a remote consultation network, which enabled specialists to provide real-time support to district NPCs in how to undertake particular surgical procedures and expert guidance on referral decisions. Despite these benefits, shortages of operating theatre support staff, lack of equipment and unreliable power supply impeded maximum utilisation of supervision. CONCLUSION This supervision model demonstrated the additional role that specialist surgeons can play, bringing their expertise to rural populations, where such surgical competence would otherwise be unobtainable. Further research is needed to establish the cost-effectiveness of the supervision model; the opportunity costs from surgical specialists being away from referral hospitals, providing supervision in districts; and the steps needed for regular district surgical supervision to become part of sustainable national programmes.
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Affiliation(s)
- Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2, Ireland.
| | - Nasser Monzer
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2, Ireland
| | - Chiara Pittalis
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2, Ireland
| | - Leon Bijlmakers
- Radboud University Medical Centre Netherlands, Geert Grooteplein Zuid 10, 6525, Nijmegen, GA, Netherlands
| | - Mweene Cheelo
- Surgical Society of Zambia, Department of Surgery, University Teaching Hospital, P.O. Box 50110, Lusaka, Zambia
| | - John Kachimba
- Surgical Society of Zambia, Department of Surgery, University Teaching Hospital, P.O. Box 50110, Lusaka, Zambia
| | - Ruairi Brugha
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2, Ireland
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Cometto G, Buchan J, Dussault G. Developing the health workforce for universal health coverage. Bull World Health Organ 2019; 98:109-116. [PMID: 32015581 PMCID: PMC6986219 DOI: 10.2471/blt.19.234138] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 11/07/2019] [Accepted: 11/07/2019] [Indexed: 11/27/2022] Open
Abstract
Optimizing the management of the health workforce is necessary for the progressive realization of universal health coverage. Here we discuss the six main action fields in health workforce management as identified by the Human Resources for Health Action Framework: leadership; finance; policy; education; partnership; and human resources management systems. We also identify and describe examples of effective practices in the development of the health workforce, highlighting the breadth of issues that policy-makers and planners should consider. Achieving success in these action fields is not possible by pursuing them in isolation. Rather, they are interlinked functions that depend on a strong capacity for effective stewardship of health workforce policy. This stewardship capacity can be best understood as a pyramid of tools and factors that encompass the individual, organizational, institutional and health system levels, with each level depending on capacity at the level below and enabling actions at the level above. We focus on action fields covered by the organizational or system-wide levels that relate to health workforce development. We consider that an analysis of the policy and governance environment and of mechanisms for health workforce policy development and implementation is required, and should guide the identification of the most relevant and appropriate levels and interventions to strengthen the capacity of health workforce stewardship and leadership. Although these action fields are relevant in all countries, there are no best practices that can simply be replicated across countries and each country must design its own responses to the challenges raised by these fields.
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Affiliation(s)
- Giorgio Cometto
- Health Workforce Department, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| | - James Buchan
- Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Gilles Dussault
- Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal
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