The contribution of non-physician clinicians to the provision of surgery in rural Zambia\u2014a randomised controlled trial

Jakub Gajewski,Leon Bijlmakers,Mweene Cheelo,John Kachimba,Ruairi Brugha,Chiara Pittalis

doi:10.1186/s12960-019-0398-9

Abstract

BackgroundThe global shortage of surgeons disproportionately impacts low- and middle-income countries. To mitigate this, Zambia introduced a ‘task-shifting’ solution and started to train non-physician clinicians (NPCs) called medical licentiates (ML) to perform surgery. The aim of this randomised controlled trial was to assess their contribution to the delivery of surgical care in rural hospitals in Zambia.MethodsSixteen hospitals were randomly assigned to intervention and control arms of the study. Nine MLs were deployed to eight intervention sites. Crude numbers of selected major surgical procedures between intervention and control sites were compared before and after the intervention. Volume and outcomes of surgery were compared within intervention hospitals, between NPCs and surgically active medical doctors (MDs).ResultsThere was a significant increase in the numbers of caesarean sections (CS) in the intervention hospitals (+ 15.2%) and a drop by almost half in the control group (− 47%) (P = 0.015), between the two time periods. There were marginal shifts in the numbers of index procedures: a small drop in the intervention group (− 4.9%) and slight increase in the control arm (+ 4.8%) (P = 0.505). In all pairs, MLs had higher mean number of CS and other major surgical cases done in the intervention period compared with MDs. There was no significant difference in postoperative wound infection rates for CS (P = 0.884) and other major surgical cases (P = 0.33) at intervention hospitals between MLs and MDs.ConclusionThis study provided evidence that the ML training programme in Zambia is an effective and safe way to bridge the gap in rural hospitals between the demand and the limited availability of surgically trained workforce in the country. Such evidence is greatly needed as more developing countries are developing national surgical plans.Trial registrationISRCTN66099597 Registered: 07/01/2014

Highlights

The global shortage of surgeons disproportionately impacts low- and middle-income countries (LMICs) [1,2,3]
We compared the share performed by Medical doctor (MD) with the share performed by medical licentiates (ML) (Table 4)
Surgically active MLs were outnumbered by surgically active MDs

Summary

Introduction

The global shortage of surgeons disproportionately impacts low- and middle-income countries (LMICs) [1,2,3]. To mitigate chronic health workforce shortages, some countries train non-physician clinicians (NPCs) to perform functions normally carried. Studies comparing rates of postoperative complications between doctors and NPCs have found no significant differences [21,22,23]. The global shortage of surgeons disproportionately impacts low- and middle-income countries. Zambia introduced a ‘task-shifting’ solution and started to train non-physician clinicians (NPCs) called medical licentiates (ML) to perform surgery.

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Conclusion