Module 5: Task-Shifting

Due to the significant shortage of doctors and trained surgeons in lower-income countries, many surgical procedures are conducted by mid-level providers in what is formally called task shifting. “Task-shifting implies the delegation of certain medical responsibilities to less specialized health workers. In surgery, such health workers are capable of carrying out many of the diagnostic and clinical functions of medical doctors in emergency obstetric care, including major surgery.”(1) Many surgical interventions can be provided, and some life-saving operations, such as caesarean section, can be performed by trained non-physicians.(2)

The use of non-physician clinicians (NPCs), or other mid-level health workers to provide specific surgical interventions is widespread throughout Africa. “Capacitating lower health cadres to undertake specific surgical tasks aims to maximize benefits while minimizing harm in settings where the unmet need of surgical care is great.” (3) Almost half of all countries in sub-Saharan Africa use NPCs to perform minor surgical procedures. A recent review found that mid-level providers work in 25 of 47 sub-Saharan African countries. These providers performed minor surgery in 12 of these 25 countries, major surgery (including cesarean sections and orthopedic procedures) in 7, and anesthesia in 4 of these countries.(4) In Tanzania and Mozambique, 84% and 92% (respectively) of cesarean sections, obstetric hysterectomies, and laparotomies for ectopic pregnancy are performed by NPCs. In Malawi, 90% of cesarean sections at district hospital level are performed by surgical clinical officers.(5) In addition to increasing access to care, another benefit of NPCs is that they are more likely to understand the local customs and language, and to remain in their home country because their training is not internationally recognized.(6) It is also less expensive to train NPCs than physicians. “The World Health Assembly, in 2006, established the Task Force for Scaling Up Education and Training for Health Workers. It reported the average cost of educating physicians in Africa was 5 times greater than the cost of educating community health workers, such as clinical officers, making the avenue of training nonphysicians even more attractive.” (7) Thus, overall, the essential role of mid-level providers as a solution to the crisis in human resources for health has been recognized. Task-shifting has been promoted as a cost-effective strategy to increase access to essential surgical care. It has been effectively utilized by Malawi, Tanzania, Mozambique, and other countries where non-physicians have been trained to treat specific surgical conditions. Evaluations in these countries show that 85% of operations can be adequately performed by general doctors and/or paramedical staff with the appropriate surgical training and supervision. (8)

Examples and Outcomes

Mozambique: Mozambique has one of the most studied programs for training mid-level health providers.  In 1975, the country suffered a civil war that left only 80 Mozambican doctors for a population of 14 million people, resulting in a huge unmet need for obstetric emergency care as well as war injuries. To fill this gap, the country began training non-physician surgeons (técnicos de cirurgia) in 1984. The técnicos de cirurgia must already have a three-year degree as a nurse or medical assistant, and then must go through two years of classroom training followed by one year of internship under a surgeon. (9) The program has since trained 61 técnicos, and 55 are still in active practice. The técnicos focus on providing emergency obstetrical care and trauma care, and also receive training in performing craniotomies, bowel resections, skin transplants, splenectomies and war surgery.(10)

A 1996 review of 2,071 caesarean sections performed by técnicos and physicians showed that técnicos’ “decision making and quality of care as gauged by indications for surgery, postoperative deaths, and major complications were comparable to obstetricians.” (11) Similarly, a study on non-physician clinicians at Maputo central Hospital in Mozambique found that “there were no clinically significant differences in the outcomes of 2,071 consecutive cesarean section performed in the two groups” (técnicos and specialists).(12) Even other health workers recognize the importance of the técnicos’ work. A study on health workers’ perceptions of técnicos found that “health workers at all levels voiced satisfaction with the work of the técnicos de cirurgia. They stressed the life-saving skills of these cadres, the advantages resulting from a reduction in the need for patient referrals and the considerable cost reduction for patients and their families.” (13) In addition to increasing access to surgical care, the retention rates for the técnicos are better than those of the medical doctors. After 7 years, about 90% of nonphysicians were still working in district hospitals, while almost no physicians remain.(14) Training técnicos de cirurgia is also cost effective. The total cost including all training was $19,465 per student, as compared to $74,130 for one specialist physician. The annual cost of deployment was $3,859 and $10,367 respectively.(15) “The cost-effectiveness of TCs performing obstetric surgery, over a calculated lifetime, was three times more favourable for TCs than for medical officers.” (16) Thus, técnicos are capable of providing cost effective surgical care and are now widely accepted in the Mozambican health system. They currently perform over 90% of all obstetric surgeries at the district hospital level in Mozambique.(17)

Niger: In 2005, surgical programs were launched at the district hospital level in Niger by training general practitioners in basic surgery for 12 months. In emergent surgeries, the obstetric interventions represented 77.8% of the activities and had a mortality rate of 6.25% (compared to a mortality rate of 5.7% in the regional hospital where fully trained surgeons provided care). “The results from this study of rural surgery performed by generalists trained in surgical procedures are promising and encouraging. Mortality and morbidity is low for both emergent and elective procedures, and referrals to the regional hospital have been reduced drastically.” (18)

Malawi: Malawi suffers from one of the lowest doctor-to-population ratios in the world, with 1 doctor per 62,000 people. Malawi faces this critical shortage of human resource mainly because of the high cost of training medical doctors, and the migration of health professionals to high income countries. Thus, in order keep up with the health demands of its population, in 1976, Malawi introduced a cadre of mid-level health providers called clinical officers. The clinical officers are non-doctors who are trained for three years, complete a year-long internship at a central or district hospital, and then are licensed to perform major and elective surgery. A study on the 2,131 emergency obstetric operations performed in Malawian hospitals found that 88% were done by clinical officers, while 12% were done by physicians. The outcome figures were similar in the two groups, and there was no significant difference in the number of days required for hospitalization between the two groups. The authors of the study concluded that “clinical officers constitute a key category of health workers to save women’s lives by providing advanced emergency obstetric care. They perform the bulk of the emergency obstetric operations at district hospitals in Malawi. The postoperative outcomes of their procedures are comparable to those of medical officers.” (19)

Anesthesia

It is critical to have trained anesthesia providers in order for surgery to be a safe and cost-effective public health intervention.  “The situation of anesthesiology in sub-Saharan Africa is unique in that nowhere else in the world has the absolute numbers of anesthesiologists decreased during the nineties… experienced anesthesiologists are now so few that, in most countries, the critical mass of knowledgeable specialists no longer exists to train new anesthesia professionals.” (20) Because of these shortages, a number of resource limited countries, such as Malawi and Togo, have reported high avoidable anesthesia-related mortality rates, and a study on maternal deaths in South Africa identified anesthesia as one of the top four causes of avoidable deaths. Though having trained anesthesiologists is critical to preventing these deaths, resource-limited countries have very few anesthesiologists. Some African countries have as few as one anesthesiologist per million residents. “Benin is relatively privileged with 15 specialists practicing in the country in 2006 (up from 8 in 2001), while at the other extreme Chad counts on only one indigenous anesthesiologist (plus one expatriate) for over 8 million inhabitants, and the Central African Republic (8.9 million inhabitants) recently lost its last specialist.” (21) In order to fill this gap, many countries have implemented task shifting. In the absence of specialists, non-physician anesthetists have been trained and mobilized to perform anesthesia in many resource-limited settings. A recent survey found that 107 of 200 countries reported using non-doctors to administer anesthesia, and they have been found to be as effective as doctors at their task. A study in Haiti of 330 procedures conducted by nurse anesthetists found that the perioperative mortality rate was 0.3% (1/330), and there was no association between death and lack of supervision by an anesthesiologist.  Thus, the authors of the study concluded that “training non-physician anesthetists in a resource limited setting is a feasible and important way to scale up delivery of safe surgical services.” (22)

Footnotes

(1) Pereira, C. (2010). Task-shifting of major surgery to midlevel providers of health care in Mozambique and Tanzania: A solution to the crisis in human resources to enhance maternal and neonatal survival. Institutionen för folkhälsovetenskap/Department of Public Health Sciences.

(2) PLoS Medicine Editors, “A Crucial Role For Surgery in Reaching the UN Millennium Development Goals.” PLoS Medicine. 5.8 (2008): 1165-1167.

(3) Chu, K., Rosseel, P., Gielis, P., and Ford, N. “Surgical Task Shifting in Sub-Saharan Africa.” PLoS Medicine. 6.5 (2009).

(4) Kruk, M., et. al. “Human Resources and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective cross-Sectional Survey.” PLoS Med. 7.3 (2010).

(5) Chu, K., Rosseel, P., Gielis, P., and Ford, N. “Surgical Task Shifting in Sub-Saharan Africa.” PLoS Medicine. 6.5 (2009).

(6) Ibid.

(7) Kushner, A. “Addressing the Millennium Development Goals From a Surgical Perspective. Essential Surgery and Anesthesia in 8 Low- and Middle- Income Countries.” Archives of Surgery. 145.2 (2010): 154-159.

(8) Luboga, S., Galukande, M., and Ozgediz, D. “Recasting the role of the surgeon in Uganda: a proposal to maximize the impact of surgery on public health.” Tropical Medicine and International Health. 14.6 (2009): 604-608.

(9) Kruk, M., et. al. “Economic evaluation of surgically trained assistant medical officers in performing major obstetric surgery in Mozambique.” BJOG. 114 (2007): 1253-1260.

(10) Pereira, C. “Using Tecnicos de Cirurgia to delivery Emergency Obstetrica Care in Mozambique: Safety, Retention, and Cost.” PowerPoint.

(11) Kruk, M., et. al. “Economic evaluation of surgically trained assistant medical officers in performing major obstetric surgery in Mozambique.” BJOG. 114 (2007): 1253-1260.

(12) Pereira, C. (2010). Task-shifting of major surgery to midlevel providers of health care in Mozambique and Tanzania: A solution to the crisis in human resources to enhance maternal and neonatal survival. Institutionen för folkhälsovetenskap/Department of Public Health Sciences.

(13) Cumbi, A., et. al. “Major surgery delegation to mid-level health practitioners in Mozambique: health professionals’ perceptions.” Human Resources for Health. 5.27 (2007).

(14) Pereira, C., et. al. “Meeting the need for emergency obstetric care in Mozambique: work performance and histories of medical doctors and assistant medical officers trained for surgery.” BJOG. 114.12 (2007).

(15) Kruk, M., et. al. “Economic evaluation of surgically trained assistant medical officers in performing major obstetric surgery in Mozambique.” BJOG. 114 (2007): 1253-1260.

(16) Pereira, C. (2010). Task-shifting of major surgery to midlevel providers of health care in Mozambique and Tanzania: A solution to the crisis in human resources to enhance maternal and neonatal survival. Institutionen för folkhälsovetenskap/Department of Public Health Sciences.

(17) Kruk, M., et. al. “Human Resources and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective cross-Sectional Survey.” PLoS Med. 7.3 (2010).

(18) Sani, R., et. al. “The Impact of Launching Surgery at the District Level in Niger.” World J Surg. 33. (2009): 2063-2068.

(19) Chilopora, G., et. al. “Postoperative outcome of caesarean sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi.” Human Resources for Health. 5.17 (2007).

(20) Lokossou, T. “Anesthesia in French-speaking Sub-Saharan Africa: an overview.” Acta Anaesth. Belg. 58. (2007):197-209.

(21) Ibid.

(22) Rosseel, P., et. al. “Ten Years of Experience Training Non-Physician Anesthesia Providers in Haiti.’ World J Surg. 34. (2010): 453-458.