Abstract
Background: Low- and middle-income countries (LMICs) are the worst affected by a lack of safe and affordable access to safe surgery. The significant unmet surgical need can be in part attributed to surgical workforce shortages that disproportionately affect rural areas of these countries. To combat this, Malawi has introduced a cadre of non-physician clinicians (NPCs) called clinical officers (COs), trained to the level of a Bachelor of Science (BSc) in Surgery. This study explored the barriers and enablers to their retention in rural district hospitals (DHs), as perceived by the first cohort of COs trained to BSc in Surgery level in Malawi. Methods: A longitudinal qualitative research approach was used based on interviews with 16 COs, practicing at DHs, during their BSc training (2015); and again with 15 of them after their graduation (2019). Data from both time points were analysed and compared using a top-down thematic analysis approach. Results: Of the 16 COs interviewed in 2015, 11 intended to take up a post at a DH following graduation; however, only 6 subsequently did so. The major barriers to remaining in a DH post as perceived by these COs were lack of promotion, a more attractive salary elsewhere; and unclear, stagnant career progression within surgery. For those who remained working in DH posts, the main enablers are a willingness to accept a low salary, to generate greater opportunities to engage in additional earning opportunities; the hope of promotional opportunities within the government system; and greater responsibility and recognition of their surgical knowledge and skills as a BSc-holder at the district level. Conclusion: The sustainability of surgically trained NPCs in Malawi is not assured and further work is required to develop and implement successful retention strategies, which will require a multi-sector approach. This paper provides insights into barriers and enablers to retention of this newly-introduced cadre and has important lessons for policy-makers in Malawi and other countries employing NPCs to deliver essential surgery.
Highlights
Common challenges affecting surgical productivity in lowand middle-income countries (LMICs) are staff shortages, availability of essential infrastructure and supplies, and low priority of surgical care within health policies.[1]
Before starting the Bachelor of Science (BSc) programme 11 CA-clinical officers (COs) were working in district hospitals (DHs), 2 were working in central hospitals, 3 in mission hospitals and 1 in an nongovernmental organisation (NGO)
As shown by the evaluation of the Clinical Officer Surgical Training (COST)-Africa intervention[7] and in other studies,[30] non-physician clinicians (NPCs) such as COST-Africa COs (CA-COs) are essential in scaling up surgery in many sub-Saharan Africa (SSA) countries
Summary
Common challenges affecting surgical productivity in lowand middle-income countries (LMICs) are staff shortages, availability of essential infrastructure and supplies, and low priority of surgical care within health policies.[1] The lack of sufficient numbers of trained surgical providers is among the most significant barriers,[2,3,4,5] in sub-Saharan Africa (SSA).[6] Given the chronic shortage of surgeons in SSA, nonphysician clinicians (NPCs) are trained to perform essential surgical tasks.[7] NPCs are health-workers who have not been trained to the level of a medical doctor but take on some of their diagnostic and clinical functions.[8] They are hailed as an alternative due to low training costs, reduced training duration and better retention rates in rural placements compared to medical doctors.[9] The shifting of tasks to lower cadres, such as NPCs, when safe and reasonable is endorsed and recommended by the World Health Organization (WHO).[10,11]
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