Non-physician clinicians in rural Africa: lessons from the Medical Licentiate programme in Zambia

Jakub Gajewski,Eric Borgstein,Leon Bijlmakers,Mweene Cheelo,John Kachimba,Carol Mweemba,Ruairi Brugha,Tracey Mccauley

doi:10.1186/s12960-017-0233-0

Abstract

BackgroundMost sub-Saharan African countries struggle to make safe surgery accessible to rural populations due to a shortage of qualified surgeons and the unlikelihood of retaining them in district hospitals. In 2002, Zambia introduced a new cadre of non-physician clinicians (NPCs), medical licentiates (MLs), trained initially to the level of a higher diploma and from 2013 up to a BSc degree. MLs have advanced clinical skills, including training in elective and emergency surgery, designed as a sustainable response to the surgical needs of rural populations.MethodsThis qualitative study aimed to describe the role, contributions and challenges surgically active MLs have experienced. Based on 43 interviewees, it includes the perspective of MLs, their district hospital colleagues—medical officers (MOs), nurses and managers; and surgeon-supervisors and national stakeholders.ResultsIn Zambia, MLs play a crucial role in delivering surgical services at the district level, providing emergency surgery and often increasing the range of elective surgical cases that would otherwise not be available for rural dwellers. They work hand in hand with MOs, often giving them informal surgical training and reducing the need for hospitals to refer surgical cases. However, MLs often face professional recognition problems and tensions around relationships with MOs that impact their ability to utilise their surgical skills.ConclusionsThe paper provides new evidence concerning the benefits of ‘task shifting’ and identifies challenges that need to be addressed if MLs are to be a sustainable response to the surgical needs of rural populations in Zambia. Policy lessons for other countries in the region that also use NPCs to deliver essential surgery include the need for career paths and opportunities, professional recognition, and suitable employment options for this important cadre of healthcare professionals.

Highlights

Most sub-Saharan African countries struggle to make safe surgery accessible to rural populations due to a shortage of qualified surgeons and the unlikelihood of retaining them in district hospitals
Surgery has for long been neglected in sub-Saharan Africa (SSA) [1], where ratios of less than 1 surgeon per 100 000 population in most countries mean that around 95% of the population has no access to essential surgical services [2]
Medical Licentiate (ML) took much of the burden of work from other cadres, Medical officer (MO), because they were clinically trained and surgical and medical duties could be delegated to them: I can tell you there was a huge difference

Summary

Introduction

Most sub-Saharan African countries struggle to make safe surgery accessible to rural populations due to a shortage of qualified surgeons and the unlikelihood of retaining them in district hospitals. In 2002, Zambia introduced a new cadre of non-physician clinicians (NPCs), medical licentiates (MLs), trained initially to the level of a higher diploma and from 2013 up to a BSc degree. Gajewski et al Human Resources for Health (2017) 15:53 competition [13, 14] Despite these concerns, and because of the lack of alternatives [15], as well as evidence of economic benefits [16], task shifting of the delivery of emergency obstetrical interventions (including caesarean sections) and general surgery to non-physician clinicians (NPCs), working at district hospitals in underserved rural areas, has expanded [17, 18]. Over 200 MLs were trained and in 2013 the programme was upgraded to the level of Bachelor of Science (4 years direct entry programme)

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