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

Abstract

Background: The 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.

Methods: Sixteen 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).

Results: There 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.

Conclusion: This 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 registration: ISRCTN66099597 Registered: 07/01/2014.

Keywords: Clinical officers; Global surgery; Hernia repair; Malawi; Medical licentiates; Non-physician clinicians; Patient outcomes; Surgery; Task-shifting; Zambia.