Doctors and non-physician clinicians (NPC)

There is a severe shortage of trained health staff in rural Africa. We try to solve this issue by using doctors and non-physician clinicians (NPC). A recent problem we have seen in south Ethiopia is that these two categories of health personnel do not collaborate.

As non-physician clinicians (NPC) take over doing surgical tasks, the doctors withdraw from this important part of the work. General practitioners work on internal medicine and paediatrics, leaving surgery and obstetrics to NPC. In one hospital we have also seen the physician, who has only one year of clinical experience, leave the hospital when the non-physician clinician (NPC) started work.

This is a trend that worries us, and we need to find mechanisms to promote the collaboration between the two professions.

Any suggestions to solve this unhealthy competition?

Sustainability and task shifting in Africa

Recently Kathryn Chu and colleagues  wrote  a very good discussion on the topic of using non-physician clinician in emergency surgery (see Chu K, Rosseel P, Gielis P, Ford N (2009) Surgical Task Shifting in Sub-Saharan Africa. PLoS Med 6(5): e1000078. doi:10.1371/journal.pmed.1000078)

In a response to their paper, I wrote a comment on PLoSMedicine:

Kathryn Chu and colleagues are to be commended for their paper on “Surgical Task Shifting in Sub-Saharan Africa”.

I work on a project to train non-physician clinicians (NPC) in Emergency Obstetrics and surgery in south Ethiopia. The Ministry of Health collaborates and recognizes the training. It is a programme for public institutions, and it consists of four months basic training, followed by two months of supervisory visits to their home institutions. An important part of the project is also to support the peripheral institutions with essential equipment.

Our experience is similar to those from Mozambique and shows that using NPC for essential surgery and obstetrics is workable. Complication rates are low. As expected, we see that staff with some years of clinical experience perform better that those coming directly from school.

As many institutions have only one trained NPC, their sustainability is often threatened, and work might be discontinued during week-ends, vacations and needed travels. Each institution needs more than one team to become sustainable.

Too often, staff receive training and acquire basic skills to return to their home institution where it is not possible to do the tasks they trained for because of lack of follow up, surgical equipment or materials. For programmes to succeed, we think it is important to continue supporting the peripheral institutions.

As most peripheral hospitals and health centres are public, and to ensure sustainable performance, we believe the national or regional health authorities should own or be a part of the programme. This would allow for needed professional and political recognition, provision of necessary incentives and continued recruitment of essential staff.

Non-physician clinicians

We have good experience from sub-Saharan Africa, that task shifting from doctors to non-physician clinicians can address the HIV/AIDS treatment, improve tuberculosis control and manage health problems in children (IMC). Similarly, some operations usually done by surgeons and anaesthesiologists can be safely done non- specialists.

Surgical care is the safe provision of preoperative, operative, and post-operative surgical and anaesthesia services. Unfortunately, there are too few surgeons in Africa, and it is unlikely that a modest increase in the number of surgeons and anaesthesiologists will occur.

In HIV care, we recognized the Western model of care with medical specialists in secondary and tertiary hospitals, could not be copied in Africa. By adapting and selecting treatment protocols and task shifting, it was possible to treat millions of patients received antiretroviral drugs. Similarly, it is important in the surgical fields to avoid creating “islands of excellence in a sea of under provision”.

By enabling non-physician clinicians to do some essential operations, we may increase benefits while lessening harm among populations where the unmet need of surgical care is great.

Please also see a very good discussion on this topic written by Chu K, Rosseel P, Gielis P, Ford N (2009) Surgical Task Shifting in Sub-Saharan Africa. PLoS Med 6(5): e1000078. doi:10.1371/journal.pmed.1000078

For more information about our training programme in Ethiopia click here.

Better tuberculosis control

One of the main strategies to control tuberculosis is to find and treat people with active disease. Unfortunately, the case detection rates remain low in many countries. Thus, we need interventions to find and treat sufficient number of patients to control tuberculosis.

We investigated whether involving health extension workers (HEWs: trained community health workers) in tuberculosis control improved smear-positive case detection and treatment success rates in southern Ethiopia.

We carried out a community-randomized trial in southern Ethiopia. Involving community health workers in tuberculosis control improved the case detection and treatment success rates for smear-positive patients and for women in particular.

We think our approach improved service access, and recommend this could be applied in settings with low health service coverage and a shortage of health workers.

Datiko DG, Lindtjørn B (2009) Health Extension Workers Improve Tuberculosis Case Detection and Treatment Success in Southern Ethiopia: A Community Randomized Trial. PLoS ONE 4(5): e5443. doi:10.1371/journal.pone.0005443

ART programme and task shifting

The use of antiretroviral drugs, and HIV counselling and testing in Ethiopia has increased in Ethiopia. Dr Degu Dare, who was among the first to start ART at rural hospitals in Ethiopia, is the co-author of a recent paper in PLoS Medicine (1).

Has this expansion of ART affected the performance of other health programmes such as tuberculosis and maternal and child health services is the question they asked.

Very interestingly, the authors document task shifting to the health officers, nurses, and health extension workers, and that this might be responsible for the successes of the ART programme in Ethiopia. However, HIV prevention interventions and management of chronic care patients are lagging behind. This may be because doctors leave the public sector to work for NGOs.

1. Assefa Y, Jerene D, Lulseged S, Ooms G, Van Damme W (2009) Rapid Scale-Up of Antiretroviral Treatment in Ethiopia: Successes and System-Wide Effects. PLoS Med 6(4): e1000056. doi:10.1371/ journal.pmed.1000056