Task Shifting and Task Sharing Implementation in Africa: A Scoping Review on Rationale and Scope

The impact of surgical task-sharing in Sierra Leone: a nationwide longitudinal observational study on surgical workforce and volume, 2012-2023

BACKGROUND

A surgical task-sharing programme was initiated by the Sierra Leonean Ministry of Health in 2011 to enhance public surgical capacity and equalise access between urban and rural populations by redistributing surgical tasks within a limited healthcare workforce.

METHODS

This longitudinal nationwide study, involving all healthcare facilities with an operating theatre in Sierra Leone, analysed changes in volume and population rates of surgery and distribution of surgical resources before (2012), 5 (2017) and 10 years after (2023) the initiative was introduced.

RESULTS

Surgical volume rates increased from 400 to 505 procedures per 100 000 population between 2012 and 2023. The public sector became the main provider, performing 56.0% of all operations in 2023, up from 39.6% in 2012. Rural surgeries increased by 77.6% over the decade, almost two times more than in urban areas. In rural areas, there was a transition from non-specialised physicians performing 46.2% of operations in 2012, to task-shared associate clinicians performing 55.1% (95% CI 49.5% to 60.7%) in 2023, making them the main surgical provider. Nationwide caesarean section rates increased from 1.4% (2012) to 5.3% (95% CI 4.6% to 6.0%) (2023). Caesarean sections were in 2023 mostly performed in public facilities (81.3%, 95% CI 80.1.0% to 82.5%) by associate clinicians (57.6%, 95% CI 53.2% to 61.9%).

CONCLUSIONS

Over the last decade, Sierra Leone has seen a shift in surgical care, with a transition from general to obstetric surgeries, from private to public institutions, and an expansion of surgical care in rural areas, with associate clinicians as the leading provider. The introduction of a nationwide surgical task-sharing initiative to strengthen the surgical workforce at district governmental hospitals in 2011 has emerged as the major contributor to the change in surgical activity and output observed in Sierra Leone over the last decade.

South African midwife specialists practice: Medico-legal experts' experiences

Background

Medical litigations are rising and becoming a global challenge. The multilayered demands of midwifery-related conditions and the multiple responsibilities of the midwifery team contribute to possible litigations. Midwife specialists in South Africa are trained to provide specialised midwifery care to improve outcomes for patients with midwifery-related complications. While midwife specialists are equipped with specialised knowledge and skills, no specific practice regulations exist to protect them against possible medical litigations.

Aim

The study aimed to explore and describe medico-legal experts' experiences of midwife specialists optimally utilising their knowledge and skills.

Setting

The context of the study is the public and private sectors of South Africa.

Methods

A qualitative, descriptive and contextual research design was employed. Six medico-legal experts identified through a snowball sampling technique participated in virtual, semi-structured interviews. Data were analysed using Collaizi's descriptive method.

Results

Three themes with subthemes emerged. Results confirmed that medico-legal experts recognised the midwife specialists' expanded knowledge and skill set. The medico-legal experts experienced a disconnect between training regulations and the current practice regulations. Midwife specialists' practice was experienced as being guided by a moral obligation rather than prescribed regulations.

Conclusion

Midwife specialists are yet to receive full legal recognition in South Africa, challenging midwife specialists' assumption of autonomous and independent roles.

Contribution

Midwife specialists face potential risk of involvement in medical litigations under the current legislative framework. The findings of this study may guide the formulation of a scope of practice (SOP) that legally guides midwife specialists' practice in South Africa.

Evaluating Access Improving Interventions: An Economic Evaluation of Surgical Task-Shifting for C-Sections in Sierra Leone

BACKGROUND

Access to safe, timely and affordable surgical care is lacking globally. Less than 6% of all surgical operations are carried out in low- and middle-income countries, where over a third of the world's population lives. CapaCare, an NGO operating in Sierra Leone, have developed a surgical training programme (STP) for Associate Clinicians based on principles of task-shifting to improve access. Interventions to increase healthcare access have the same value evidence requirements as new technologies but their evaluation presents methodological challenges as access is not routinely incorporated explicitly in economic evaluations.

OBJECTIVE

To evaluate the cost-effectiveness of surgical task-shifting in Sierra Leone, implemented through the CapaCare STP, to increase provision of caesarean section (C-section).

METHODS

We evaluated the impact of the STP on the provision of C-section and subsequent maternal and child outcomes, measured in disability-adjusted life-years (DALYs), relative to the costs using a healthcare system perspective and decision-tree model parameterised using data from surgical logbooks, national data, and the literature.

RESULTS

Results indicate that the surgical task-shifting programme in Sierra Leone would be considered cost-effective in increasing provision for C-section. It is cost saving (USD - 16.77) and results in 2.14 DALYs averted, per women with an indication for C-section, due to avoidance of maternal and child deaths as well as reduced complications.

CONCLUSION

Investment in surgical task-shifting initiatives should be considered by policymakers as a potentially cost-effective way to increase access to quality surgical services. Future evaluations of access-increasing interventions should seek to capture the distributional impact of this strategy and system benefits.

Assessing Task-Shifting Progress in Obstetrics and Gynecology: A Nationwide Survey of Japanese Obstetricians and Gynecologists

Background/Objectives: This study identified tasks suitable for delegation and gathered insights on how task shifting might affect medical care quality and working hours. Methods: A questionnaire survey was conducted among obstetricians and gynecologists working in hospitals nationwide. A multivariate logistic regression analysis was conducted. Then, opinions were collected on the individual tasks that should be task-shifted and the impact that task-shifting promotion would have on medical care quality and working hours. Results: Valid responses were obtained from 1164 doctors (16.3% of the 7127 obstetricians and gynecologists) working in hospitals. An analysis of the characteristics of the 31.2% of doctors who thought that task shifting had hardly progressed at their workplace showed that the odds of working 60-80 h were significantly higher (1.72, 95% CI: 1.06-2.77, p = 0.03) than those working <40 h and 3.50 (95% CI: 1.19-10.25, p = 0.02) for those working ≥100 h. Most obstetricians said that the only items "transferred" were "moving patients (e.g., from the operating room to the ward)", "collecting blood culture samples", and "ensuring chemotherapy lines", revealing that task shifting had not progressed. Regarding the impact on medical care quality, if obstetricians and gynecologists promoted task shifting, most doctors said that the quality of care would improve, while 13% said that it would decrease. Conclusions: This study provides a comprehensive assessment of task shifting among OBGYNs in Japan, revealing its limited progress despite physician work reform efforts. Findings indicate that expanding task shifting could improve efficiency without compromising medical care quality, reinforcing its potential as a strategy for reducing physician workload.

Cultural adaptation of a brief psychological intervention for PTSD in severe mental illness: a Botswana context

High rates of trauma exposure among patients with severe mental illness (SMI) in Botswana highlight the need for appropriate interventions. Culturally adapted interventions have been reported to be more acceptable, effective and feasible. This study aimed to culturally adapt the Brief Relaxation, Education and Trauma Healing (BREATHE), a brief psychological intervention to treat post-traumatic stress disorder (PTSD) among people with SMI in Botswana. The cultural adaptation process followed the steps outlined by previous research. They included a community assessment to identify needs, selecting an appropriate intervention and consultations with experts and stakeholders. Individual interviews and focus groups were conducted with patients living with SMI and mental health professionals, respectively, to inform domains of the intervention to be adapted. BREATHE was adapted to be culturally congruent to Botswana by following the ecological validity model framework and using data from the interviews. Examples of the adaptation include language that was translated to Setswana, and spoken English and the content that was revised to reflect the traumatic experiences and demographics of the Botswana population. The study underscores the utility of using evidence-based frameworks to culturally adapt interventions. The adaptation process resulted in a culturally relevant BREATHE for patients with comorbid PTSD and SMI in Botswana.

Understanding healthcare providers' perspectives on barriers to accessing stroke care at a resource-limited hospital in East Africa: A qualitative study from Mnazi Mmoja Referral Hospital in Zanzibar

Timely and appropriate care reduces the risk of mortality and disability after stroke. Despite high stroke incidence, little is known about the specific barriers to accessing stroke care in Zanzibar, East Africa. The aim of this study was to investigate healthcare providers' perspectives regarding the barriers to stroke care at the main referral hospital in Zanzibar. We used a phenomenological approach and conducted 14 individual semi-structured interviews with healthcare providers at Mnazi Mmoja Referral Hospital in Zanzibar. The interviews took place from April through September 2022. Thematic network analysis was applied to analyse and interpret the data. Three broad themes and eleven sub-themes were identified, relevant at specific stages in the patient's care pathway from deciding to seek care over receiving acute stroke care in hospital to accessing post-stroke care. These themes include health system barriers (medical supplies and equipment; staff shortages; attitudes and teamwork; organization of services; health education); patient-level factors (health literacy; relational factors; worries and feeling hopeless; financial constraints); and cultural context (stroke as a spiritual malady; trust, mistrust and power). Some of the sub-themes of barriers were similar to findings from other studies in both high and low-resource settings, such as shortages of medical supplies, equipment and staff, and sub-optimal organization of care. Other sub-themes were unique findings to low-resource settings, such as Zanzibar, and included relational factors and patients' perception of stroke as a spiritual malady. Interventions to improve stroke care should be informed by all these findings. Otherwise, focus only on removing barriers related to availability of stroke treatment in hospital may divert attention from significant cultural factors that affect health care seeking behaviour.

Advancing Sustainable HIV Services Through Integration in Primary Healthcare in Sub-Saharan Africa: A Perspective on Practical Recommendations

Sub-Saharan Africa continues to bear a disproportionate burden of the global HIV epidemic. Integrating HIV services into primary healthcare is a crucial strategy to accelerate progress towards ending the epidemic. However, several challenges hinder effective integration, including underfunding, human resource shortages, infrastructure limitations, weak health systems, and sociocultural factors. With this perspective, we discuss strategies to address these challenges. A comprehensive, multi-faceted approach is necessary to overcome these barriers. Investing in human resources, improving infrastructure, and strengthening health information systems are essential for strengthening the health system. Implementing patient-centered care, integrated service delivery models, and community engagement can optimize service delivery. Utilizing digital health tools, such as mobile health applications and electronic health records, can enhance service delivery and data management. Mobilizing for an increase in domestic resources, aligning donor funding, and using cost-effective approaches are crucial for effective financing. Finally, robust monitoring and evaluation systems are necessary to track progress, identify challenges, and inform decision-making. With these strategies, among many others, sub-Saharan African countries can significantly improve the integration of HIV services into primary healthcare, leading to better health outcomes for people living with HIV and more sustainable HIV programs.

Surgical Practice in Resource-Limited Settings: Perspectives of Medical Students and Early Career Doctors: A Narrative Review

Introduction

Surgical practices in low-resource countries often fail to meet established standards. Both doctors and medical students have limited exposure to surgical cases, which hinders training and the development of surgical specialization. This study highlights the current state of surgical practice from a trainee's perspective, explores existing gaps in training and capacity building, and recommends practical solutions.

Methods

We conducted a literature search on PubMed, Google Scholar, and other scientific databases using search terms such as "surgical practice," "doctors' perspectives in surgical practice," "surgery in low- and middle-income countries," and "solutions to surgical inadequacy." We included studies published from 2015 to 2024, with exceptions for a few highly relevant studies published prior to 2015.

Results

We outline the limitations identified in the literature concerning surgical training and healthcare in low- and middle-income countries. Many centers lack adequate infrastructure, human resources, and training. These challenges negatively affect the skills and quality of surgical care. However, some centers demonstrate that surgical practice is feasible through collaboration with institutions established in higher-income contexts.

Conclusion

Telesurgery, task shifting and sharing, high-impact, low-cost surgeries, and collaborations with more developed health systems could effectively bridge the gap in surgical availability in LMICs.

Health System Factors Influencing the Integration of Pre-Exposure Prophylaxis into Antenatal and Postnatal Clinic Services in Cape Town, South Africa

INTRODUCTION

Oral pre-exposure prophylaxis (PrEP) is an effective and safe option to prevent HIV acquisition and vertical HIV transmission in pregnant and breastfeeding women. Understanding health system factors influencing the integration of PrEP into care for pregnant and breastfeeding women is key to increasing access. We explored managers' and health care workers' (HCWs) experiences with integrating PrEP into antenatal care and postnatal care services in primary health care clinics in Cape Town, South Africa.

METHODS

This exploratory qualitative study used codebook thematic analysis, where HCWs were purposively, heterogeneously sampled from an implementation science study. Semistructured individual interviews were conducted with 9 managerial-level staff, and 3 focus group discussions were conducted with HCWs (nurses, midwives, and HIV counselors) providing PrEP (6-7 HCWs per group) between November 2022 and January 2023 (N=28). Interview guides covered health system facilitators, barriers, and recommendations. The Health Systems Dynamics framework guided data analysis and presentation of results.

RESULTS

PrEP integration into antenatal care services was described as acceptable and feasible; however, changes to HIV testing policy and indicators in breastfeeding women are needed to integrate PrEP into postnatal clinics, together with identification of mother and baby as a dyad in visits. Results showed that supportive policies facilitated wider, simplified PrEP provision. The availability and accessibility of prescribing nurses and lay HIV counselors, PrEP (both within facilities and in communities), and information about PrEP for implementers and pregnant and breastfeeding women will be pivotal to facilitating integration.

CONCLUSION

Facilitators for PrEP integration include task-shifting PrEP education and identification of women for PrEP initiation to HIV counselors, changes to national guidelines defining who can prescribe PrEP, revision and integration of PrEP training for HCWs, community-level interventions for PrEP demand creation and stigma reduction, and provision of differentiated PrEP delivery options.

The practice, nature, and impact of nurse-led type 2 diabetic foot prevention services and educational programs in Sub-Saharan Africa: a scoping review

Objective

The objective of this study is to assess the scope of existing practice, nature, and impact of nurse-led type 2 diabetic foot prevention services and educational programmes in Sub-Saharan Africa (SSA).

Introduction

Type 2 diabetes mellitus (T2DM) in SSA imposes a heavy burden on current healthcare services. Complications such as foot ulcers can have a significant impact on patient care and healthcare resources. It is imperative to identify patients at risk of developing diabetic foot complications and empower them with diabetes self-management education and support from specialised foot clinics is crucial. However, the availability of such programmes and services in SSA is limited.

Inclusion criteria

Studies of nurse-led diabetic foot prevention services and/or educational programmes in low- or middle-income countries in SSA for adults with T2DM, written in English, between August 2013 and March 2024 were considered.

Methods

Following the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for conducting and reporting scoping reviews, searches were conducted on four electronic databases (CINAHL, ProQuest, MEDLINE, and Scopus) and Google Scholar. The titles and abstracts were scrutinised. All eligible papers were retrieved and screened for full text.

Results

The review included ten studies (across 14 papers), all of which focused on nurse-led diabetes self-management education (DSME) programmes in SSA. There are no specific educational programmes or services led by nurses that focus exclusively on diabetic foot prevention. The analysis highlighted the components of successful nurse-led DSMEs that led to positive glycaemic control and self-care behaviors, including the focus on behavior change and the DSME should be co-produced with service users. The theoretical aspects of the DSME include evidence-based, structured, interactive, culturally and linguistically appropriate group-based activities. The DSME should be delivered over a period of several weeks, and sessions should last between 1.5 and 2 h. Barriers to delivery and participation include the rainy season, stockouts, time and resources needed, and a DSME that meets diverse levels of literacy and education.

Conclusion

There is a heightened need for nurse-led, co-produced, culturally congruent, frugal, and sustainable education interventions or programmes. There is also a need for diabetic foot screening and foot ulcer prevention services that can operate sustainably alongside these educational interventions through task-shifted, simple, and frugal initiatives.

Clinically sound and person centred: streamlining clinical decision support guidance for multiple long-term condition care

The care of people with multiple long-term conditions (MLTCs) is complex and time-consuming, often denying them the agency to self-manage their conditions-or for the clinician they visit to provide streamlined, person-centred care. We reconfigured The Practical Approach to Care Kit, our established, evidence-based, policy-aligned clinical decision support tool for low-resource primary care settings, to provide consolidated clinical guidance for a patient journey through a primary care facility. This places the patient at the centre of that journey and shifts the screening, monitoring and health education activities of multimorbidity care more equitably among the members of the primary care team. This work forms part of a study called ENHANCE, exploring how best to streamline MLTC care in South Africa with its high burden of communicable, non-communicable and mental health conditions. This practice paper describes the four steps of codeveloping this clinical decision support tool for eleven common long-term conditions with local stakeholders (deciding the approach, constructing the content, clinical editing, and design and formatting) along with the features of the tool designed to facilitate its usability at point of care. The process highlighted tensions around prioritising one condition over another, curative over preventive treatment and pharmacological therapies over advice-giving, along with the challenges of balancing the large volume of content with a person-centred approach. If successful, the tool could augment the response to MLTC care in South Africa and other low-resource settings. In addition, our development process may contribute to scant literature around methodologies for clinical decision support development.

Investing in health workers: a retrospective cost analysis of a cohort of return-of-service bursary recipients in Southern Africa

BACKGROUND

Return-of-service (RoS) schemes are investment strategies that governments use to increase the pool of health professionals through the issuing of bursaries and scholarships to health sciences students in return for service after graduation. Despite using these schemes for many years, Eswatini, South Africa, Botswana and Lesotho have not assessed the costs and return on investment of these schemes. This study aimed to assess the costs and relative rates of contract defaulting in these four Southern African countries.

METHODS

A retrospective cohort study was carried out by reviewing databases of RoS beneficiaries for selected health sciences programmes who were funded between 2000 and 2010. Costs of the schemes were assessed by country, degree type and whether bursary holders completed their required service or defaulted on their public service obligations.

RESULTS

Of the 5616 beneficiaries who studied between 1995 and 2019 in the four countries, 1225 (21.8%) beneficiaries from 2/9 South African provinces and Eswatini were presented in the final analysis. Only Eswatini had data on debt recovery or financial repayments. Beneficiaries were mostly medical students and slightly biased towards males. Medical students benefited from 56.7% and 81.3% of the disbursement in Eswatini (~US$2 million) and South Africa (~US$57 million), respectively. Each South African medical student studying in Cuba cost more than five times the rate of medical students who studied in South Africa. Of the total expenditure, 47.7% and 39.3% of the total disbursement is spent on individuals who default the RoS scheme in South Africa and Eswatini, respectively.

CONCLUSIONS

RoS schemes in these countries have loss of return on investment due to poor monitoring. The schemes are costly, ineffective and have never been evaluated. There are poor mechanisms for identifying beneficiaries who exit their contracts prematurely and inadequate debt recovery processes.

Gaining consensus on a protocol for general surgery physician assistants in the management of non-compressible abdominal haemorrhage in military austere environments: a Delphi study

BACKGROUND

Non-compressible abdominal haemorrhage (NCAH) is a potentially preventable cause of death due to injury. Limited exploratory laparotomy by a non-surgeon is a temporary intervention to sustain life until definitive surgical intervention by trauma surgeons can be obtained. This study aims to establish consensus on a protocol for general surgery physician assistants performing limited exploratory laparotomy to manage NCAH in an austere environment.

METHOD

This study included anonymised trauma surgeons and general surgery physician assistants from military and civilian backgrounds. Participants were recruited from various professional surgical organisations, including direct interaction with trauma surgeons and surgical physician assistants. Participants used a modified Delphi survey with a 9-point Likert scale in two rounds. The two surveys were categorised into three parts: protocol for NCAH (part A), the potential role of general surgery physician assistants (part B) and measures of success (part C). A total of 24 statements were voted on and assessed. Votes were divided into three zones: agreement (median 7-9), uncertain (median 4-6) and disagreement (median 1-3). To reach a consensus, 70% agreement was required within a zone. If more than 30% of the votes fell outside of a specific zone, consensus was not achieved. After consensus, the original protocol was revised in an online meeting with experts.

RESULTS

The initial analysis involved 29 participants. After 2 survey rounds, 19 out of 24 statements reached a consensus. Part A: 10 statements gained consensus, including in austere environments, controlling NCAH can be challenging. A qualified general surgery physician assistant should intervene. A focused assessment with sonography for trauma examination can be used for screening. Bleeding can be managed with packing and pressure. After managing the haemorrhage, the abdominal wall should be left open with a temporary closure technique. Part B: nine statements gained consensus, including in austere locations, a licensed general surgery physician assistant with a minimum of 3 years of experience working under the supervision of a trauma/general surgeon can perform interventions for limited exploratory laparotomy for patients with NCAH. Part C: general surgery physician assistants will be required to have the same success rates as any qualified surgeon.

CONCLUSION

Gaining consensus and implementing a revised protocol for managing NCAH by general surgery physician assistants is attainable. General surgery physician assistants will need formal training to manage NCAH. With the support of trauma surgeons who provide direct and indirect supervision, general surgery physician assistants can develop a comprehensive understanding of the necessary skills and make sound decisions when treating patients with this condition. This teamwork can also increase surgical capacity and potentially decrease mortality rates for patients with NCAH in austere environments.

Global survey on point-of-care ultrasound (pocus) use in child surgery

PURPOSE

To undertake a global assessment of existing ultrasound practices, barriers to access, point-of-care ultrasound (POCUS) training pathways, and the perceived clinical utility of POCUS in Child Surgery.

METHODS

An electronic survey was disseminated via the GICS (Global Initiative of Children's Surgery) network. 247 anonymized responses from 48 countries were collated. 71.3% (176/247) worked in child surgery.

RESULTS

Ultrasound was critical to practice with 84% (147/176) of requesting one daily or multiple times per week. Only 10% (17/176) could access emergency ultrasound < 1 h from request. The main barrier was a lack of trained personnel. HIC surgeons were more likely to have ultrasound training (24/29; 82.8%) compared with LMICs (74/147; 50.3%) (p = .001319; CI 95%). Self-perceived POCUS competence was associated with regularity of POCUS use (p < 0.001; CI 95%). Those who already practice POCUS most commonly use it for trauma, intussusception, and ultrasound-guided procedures. Majority (90%; 159/176) of child surgeons would attend formal POCUS training if available.

CONCLUSIONS

Ultrasound is critically important in children's surgery globally, however, many surgeons experience barriers to timely access. There is a strong interest in learning POCUS for relevant pediatric surgical applications. Further research is needed to evaluate the best methods of training, accreditation, and governance.

Task sharing for increasing access to obstetric ultrasonography: a formative qualitative study of nurse-led scanning with telemedicine review in Kenya

The informal settlements of Nairobi have higher neonatal and infant mortality rates than the average for Nairobi. Universal access to important diagnostics like ultrasonography is poor and inequitable due to the high cost of devices and limited availability of skilled sonographers. Recent advances of mobile ultrasound probes connected to smartphones, with or without artificial intelligence support, have improved access to devices; but skills to perform and interpret scans continue to be limited. The SonoMobile intervention involved training nurse-midwives to conduct point-of-care obstetric ultrasound scans in antenatal care clinics in urban informal settlements. Scan data and images were shared, using telemedicine technology, with remote sonographers, who reviewed scan images and data, and provided reports. This study of 61 respondents from diverse stakeholder groups describes the acceptability, utility and considerations for sustainability of nurse-led, point-of-care obstetric ultrasonography with telemedicine review. Perceived value of nurse-led obstetric ultrasonography includes improving access and affordability of obstetric ultrasonography services, timely identification and referral of high-risk pregnancies, and improving awareness of appropriate antenatal care among underserved populations. The relative affordability of SonoMobile was described as a critical enabler for a business model targeting low- and middle-income segments of the population, and for increasing quality and equity of antenatal care coverage. Areas highlighted for improvement include strengthening supervision of nurse trainees, broadening the scope of nurse training and development of clear regulatory guidelines for nurse-led obstetric ultrasonography. The study highlights the complex task shifting required to provide universal access to a life-saving technology in a low- and middle-income country health system.

Scaling training facilities for patent and proprietary medicine vendors in Nigeria: insights and lessons learned for policy implication and future partnerships

Patent and proprietary medicine vendors in Nigeria play a very integral role in providing primary health care services and are an important source of care for the poor. They are located close to communities and are often the first source of care for hygiene and family planning (FP) products and treatment of child illnesses. Since 2017, Pharmacy Council of Nigeria (PCN) has partnered with Society for Family Health through the IntegratE project to address the poor quality of services by patent and proprietary medicine vendors (PPMVs) and reposition them for better service delivery through piloting the three-tier accreditation system. The partnership has engendered innovation for human resource for health, and considering the peculiarity of their situation, new emerging methods and arrangements to deliver the training to PPMVs in diverse geographical locations within their catchment areas are developed. In this study, we aimed to discuss the role of patent and proprietary medicine vendors in the provision of quality health delivery and provide key lessons and recommendations which have been learned from the pilot scaling of training facilities for PPMVs in Nigeria through the IntegratE project. From the lessons learnt, we propose that, for a successful scale-up of implementation of the three-tier accreditation of PPMVs, PCN will have to establish a budget line for accreditation. In addition, the government should also consider supporting this training through the Basic Healthcare Provision Fund as a way of strengthening human resources at the primary healthcare level. Other alternative sources of funding include licensing and registration fees and other dues generated internally by PCN.

Nurse prescribing and dispensing in South Africa: Gaps in the current legislative framework

Background

Nurse prescribing and dispensing are central to ensuring universal health access in South Africa.

Objective

To describe the historical development of the legal enablements of nurse prescribing and dispensing in South Africa and highlight gaps in the current legislative framework.

Method

This is a discussion article.

Results

We emphasise significant deficiencies in the current legislative landscape that pose challenges to these vital nursing practices and call for urgent revisions of the legislative framework, particularly the revision of Section 56 of the Nursing Act (33 of 2005) and its related regulations, to formalise authorisation of specialist nurse prescribers in public and private practice. This will also entail an application to the South African Health Products Regulatory Authority (SAPHRA) for the scheduling of substances by authorised nurse prescribers in the defined professional nurse and specialist nurse categories by the Minister of Health.

Conclusion

There is a necessity for prompt legislative revisions to address identified deficiencies.

Contribution

The contribution of this article lies in its advocacy for changes to the regulatory framework to further enable nurses to deliver safe and comprehensive health care.

A review of twenty-first century developments in paediatric surgery in Africa

This review explores the significant advancements in paediatric surgery in Africa during the twenty-first century, with a particular focus on capacity-building, education, infrastructural development, and research. Historically, paediatric surgery has been an overlooked sector, especially in low-and-middle-income countries in Africa. However, recent years have seen considerable progress. Collaborative efforts such as the Global Initiative for Children's Surgery, and the formation of the Pan African Paediatric Surgery Association, the College of Surgeons of East, Central and Southern Africa and the West African College of Surgeons have facilitated knowledge sharing, collaboration, and advocacy for enhancing surgical standards. Local training programmes, including Master of Medicine programmes and fellowships, have been instrumental in building a skilled workforce. These initiatives have been complemented by infrastructural developments through non-governmental organisations like Kids Operating Room, which have expanded access to paediatric surgical care. Technological advancements, particularly in telemedicine, have further enhanced accessibility. Task-sharing strategies, where non-specialist physicians are trained in paediatric surgical skills, have also been utilised to address the shortage of specialised surgeons. Research in paediatric surgery has experienced an upswing, with local health professionals taking the lead. Research has been crucial for understanding the epidemiology of paediatric surgical conditions, and developing prevention strategies, and is increasingly leading to the inclusion of paediatric surgery in national health plans. Despite the progress, challenges remain, including the need for sustainable funding, continued investment in infrastructure, and training and retention of healthcare professionals. The review emphasises the importance of ongoing efforts in community engagement, innovative technologies, and health systems strengthening for the sustainable development of paediatric surgical services in Africa.

Acceptance of virtual patients as a continuous professional development approach among practicing nurses in primary health care settings in a low-income country: a quasi-experimental posttest setup design

BACKGROUND

Virtual patients are an educational technological approach used in healthcare education. Its distinctive features have rendered virtual patient technology appealing for the training of medical and healthcare students, particularly in the enhancement of clinical reasoning. Virtual patients are less often applied for continuous professional development for practicing healthcare providers, and there is a scarcity of studies exploring this possibility. This study aimed to assess the acceptability of nurses for using virtual patients as a continuous professional development approach.

METHOD

The study used a quasi-experimental posttest setup design. The study was conducted in ten primary healthcare settings in Rwanda. Among 76 nurses who consented to participate in the study, 56 completed the intervention and responded to the study questionnaire. Following a one-week program of continuous professional development on four non-communicable diseases, the study used a self-administered questionnaire based on the Technology Acceptance Model 3 to collect data. Descriptive analysis served as the primary method for analyzing participants' responses. The study also used a correlation test to assess the relationship of variables.

RESULTS

Across all items in the questionnaire, the median response tended towards either agree or strongly agree, with only a minority number of participants expressing strong disagreement, disagreement, or neutrality. The results indicated a significant positive correlation between perceived usefulness and behavior intention (p < 0.001).

CONCLUSION

The findings indicate an acceptability and behavioral intention of adopting virtual patients as an alternative continuous professional development approach among nurses working at health centers in Rwanda or other locations with similar contexts.

Rethinking headache as a global public health case model for reaching the SDG 3 HEALTH by 2030

The 2030 Agenda for Sustainable Development sets out, through 17 Sustainable Development Goals (SDGs), a path for the prosperity of people and the planet. SDG 3 in particular aims to ensure healthy lives and promote well-being for all at all ages and includes several targets to enhance health. This review presents a "headache-tailored" perspective on how to achieve SDG 3 by focusing on six specific actions: targeting chronic headaches; reducing the overuse of acute pain-relieving medications; promoting the education of healthcare professionals; granting access to medication in low- and middle-income countries (LMIC); implementing training and educational opportunities for healthcare professionals in low and middle income countries; building a global alliance against headache disorders. Addressing the burden of headache disorders directly impacts on populations' health, as well as on the possibility to improve the productivity of people aged below 50, women in particular. Our analysis pointed out several elements, and included: moving forward from frequency-based parameters to define headache severity; recognizing and managing comorbid diseases and risk factors; implementing a disease management multi-modal management model that incorporates pharmacological and non-pharmacological treatments; early recognizing and managing the overuse of acute pain-relieving medications; promoting undergraduate, postgraduate, and continuing medical education of healthcare professionals with specific training on headache; and promoting a culture that favors the recognition of headaches as diseases with a neurobiological basis, where this is not yet recognized. Making headache care more sustainable is an achievable objective, which will require multi-stakeholder collaborations across all sectors of society, both health-related and not health-related. Robust investments will be needed; however, considering the high prevalence of headache disorders and the associated disability, these investments will surely improve multiple health outcomes and lift development and well-being globally.

An Ultra-Brief Proxy Measure for Early Mental and Substance Use Disorders and Suicide Risk Case Detection at the Community and Household Level: An Efficient and Feasible Clinical and Population-level Service Needs Screening Tool

Valid mental and substance use disorders and suicide risk screening tools are needed for community case finding of individuals who may not otherwise seek care. We evaluated the Proxy Mental Wellness Tool-3 (mwTool-3-proxy) a three-item screener that asks about the mental health of another adult, against a diagnostic gold standard in Mozambique and South Africa. The mwTool-3-proxy adapts the three items of the Mental Wellness Tool-3, developed in Mozambique using Mini International Neuropsychiatric Interview diagnoses as the criterion standard, regression modeling and expert consultation to determine the best three items for identifying any mental disorder. The Mental Wellness Tool-3 has been validated in South Africa, Spain and the United States, and is being validated in three countries in the Asia-Pacific and Israel. Pairs of adults in South Africa and Mozambique at primary and tertiary healthcare facilities were separately screened with the mwTool-3-proxy and diagnosed using the Mini International Neuropsychiatric Interview. We calculated the sensitivities and specificities for predicting any mental and/or substance use disorder and suicide risk among the proxy individual. We performed additional analyses restricted to respondents who were relatives of one another and who lived in the same household. The prevalence of any Mini International Neuropsychiatric Interview-diagnosed disorder among the 229 pairs in both countries was 35.6% (38.5% in Mozambique; 32.9% in South Africa). The pooled sensitivity of the mwTool-3-proxy for identifying any disorder among the proxy individual was 73.01 (95%CI: 65.5-79.65) - 70.24 (95%CI: 59.27-79.73) in Mozambique and 80.00 (95%CI 69.17-88.35) in South Africa. The mwTool-3-proxy is a culturally-relevant, ultra-brief valid measure that can improve mental and substance use disorders and suicide risk case detection with strong sensitivity at the community and household level and offer a means to efficiently and feasibly collect clinical and population-level service needs data.

Predictors of cessation of exclusive breastfeeding according to the Cox regression model: survey of mothers of children aged 6-12 months, Thiès, Senegal

Introduction

even though exclusive breastfeeding (EBF) for up to six months is recognised as essential infant care, it is still insufficiently practiced. The objective of this study was to identify predictors of EBF cessation in Thiès.

Methods

this was a survival analysis of data collected using a cross-sectional procedure. Data collection took place from 2nd December 2019 to 21st January 2020. The study population consisted of mothers of children aged 6 to 12 months residing in Thiès and seen at the reference health centre of the Thiès Health District during infant vaccination sessions. The number of subjects was 400 mothers recruited using a systematic survey, with a sampling interval equal to two. Data were collected through a face-to-face interview. Predictive factors were identified using the Cox regression model. The adjusted hazard ratio (AHR) and its 95% confidence interval (95% CI) are calculated.

Results

the average age of the mothers was 27.08 ± 6.34 years. The proportion of mothers who breastfed their child within one hour of birth was 29.25%. The proportion of those who practiced EBF was 41.50%. The incidence density of EBF cessation was 14 person-months per 100 breastfeeding mothers. The median duration of EBF was 5 months. Lack of advice on EBF during antenatal care (AHR=1.42; 95% CI =1.08-1.85), sources of information other than health professionals (AHR =1.51; 95% CI =1.05-2.19), late initiation of EBF, i.e. breastfeeding beyond 24 hours after birth (AHR =1.53; 95% CI =1.02-2.28) and low level of knowledge about EBF (AHR =1.46; 95% CI =1.11-1.92) were significantly associated with early termination of EBF.

Conclusion

the promotion of EBF for up to six months will necessarily involve the promotion of prenatal consultations during which professionals should raise awareness among future mothers.

Task shifting and task sharing in the health sector in sub-Saharan Africa: evidence, success indicators, challenges, and opportunities

This review explores task shifting and task sharing in sub-Saharan African healthcare to address workforce shortages and cost-effectiveness. Task shifting allocates tasks logically, while task sharing involves more workers taking on specific duties. Challenges include supply chain issues, pay inadequacy, and weak supervision. Guidelines and success measures are lacking. Initiating these practices requires evaluating factors and ensuring sustainability. Task shifting saves costs but needs training and support. Task sharing boosts efficiency, enabling skilled clinicians to contribute effectively. To advance task shifting and sharing in the region, further research is needed to scale up effective initiatives. Clear success indicators, monitoring, evaluation, and learning plans, along with exploration of sustainability and appropriateness dimensions, are crucial elements to consider.

Optimizing the roles of health workers to improve access to health services in Africa: an implementation framework for task shifting and sharing for policy and practice

BACKGROUND

Globally, countries are taking actions to ensure that their population have improved access to people-centred and integrated health services. Attaining this requires improved access to health workers at all levels of health service delivery and equitably distributed by geographical location. Due to the persistent health worker shortages, countries have resorted to implementing task shifting and task sharing in various settings to optimally utilize existing health workers to improve access to health services. There are deliberations on the need for an implementation framework to guide the adoption and operationalization of task shifting and task sharing as a key strategy for optimally utilizing the existing health workforce towards the achievement of UHC. The objective of this study was to develop an implementation framework for task shifting and task sharing for policy and practice in Africa.

METHODS

A sequential multimethod research design supported by scoping reviews, and qualitative descriptive study was employed in this study. The evidence generated was synthesized into an implementation framework that was evaluated for applicability in Africa by 36 subject matter experts.

RESULTS

The implementation framework for task shifting and task sharing has three core components - context, implementation strategies and intended change. The implementation strategies comprise of iterative actions in the development, translation, and sustainment phases that to achieve an intended change. The implementation strategies in the framework include mapping and engagement of stakeholders, generating evidence, development, implementation and review of a road map (or action plan) and national and/or sub-national policies and strategies, education of health workers using manuals, job aids, curriculum and clinical guidelines, and monitoring, evaluation, reviews and learning.

CONCLUSION

The implementation framework for task shifting and task sharing in Africa serves as a guide on actions needed to achieve national, regional and global goals based on contextual evidence. The framework illustrates the rationale and the role of a combination of factors (enablers and barriers) in influencing the implementation of task shifting and task sharing in Africa.