Evaluation of a surgical training programme for clinical officers in Malawi.

BACKGROUND: Shortages of specialist surgeons in African countries mean that the needs of rural populations go unmet. Task-shifting from surgical specialists to other cadres of clinicians occurs in some countries, but without widespread acceptance. Clinical Officer Surgical Training in Africa (COST-Africa) developed and implemented BSc surgical training for clinical officers in Malawi. METHODS: Trainees participated in the COST-Africa BSc training programme between 2013 and 2016. This prospective study done in 16 hospitals compared crude numbers of selected numbers of major surgical procedures between intervention and control sites before and after the intervention. Volume and outcomes of surgery were compared within intervention hospitals between the COST-Africa trainees and other surgically active cadres. RESULTS: Seventeen trainees participated in the COST-Africa BSc training. The volume of surgical procedures undertaken at intervention hospitals almost doubled between 2013 and 2015 (+74 per cent), and there was a slight reduction in the number of procedures done in the control hospitals (-4 per cent) (P = 0·059). In the intervention hospitals, general surgery procedures were more often undertaken by COST-Africa trainees (61·2 per cent) than other clinical officers (31·3 per cent) and medical doctors (7·4 per cent). There was no significant difference in postoperative wound infection rates for hernia procedures at intervention hospitals between trainees and medical doctors (P = 0·065). CONCLUSION: The COST-Africa study demonstrated that in-service training of practising clinical officers can improve the surgical productivity of district-level hospitals.

'I think we are going to leave these cases'. Obstacles to surgery in rural Malawi: a qualitative study of provider perspectives.

OBJECTIVES: Surgical services at district level in Malawi are poor, yet the majority of the population resides in rural areas. This study aimed to explore the perceived obstacles to surgery from the perspective of the cadre directly responsible for surgical service delivery at district hospitals. METHODS: Qualitative interviews were conducted with 16 clinical officers (COs) receiving surgical training in eight public district hospitals and their 12 trainers. Thematic analysis of data was conducted using a top-down coding method. RESULTS: Despite readiness of the COs to conduct operations, other staff essential for surgery were sometimes unavailable to support them. Respondents attributed this to lack of skills, weak motivation or poor work ethic of their colleagues. Lack of commitment to do surgery, passiveness, lack of initiative in problem-solving and 'laziness' of surgical team members were among the reasons provided by study participants, accounting for unnecessary cancellations of elective surgery and inappropriate referrals of emergency cases. Other factors included infrastructure breakdowns and stock-outs of surgical supplies. There were instances where COs, and their supervisors, showed initiative in finding solutions to problems resulting from poor district hospital management practices. CONCLUSIONS: This study demonstrates how the motivation of surgical team members is a key factor in deciding whether or not to perform operations; and that shortages of supplies or infrastructure need not be an absolute obstacle to service delivery. Scale-up of surgical services at district level requires investments to improve surgical and anaesthetic skills, to strengthen human resources and facility management, and to ensure the availability of reliable infrastructure and essential supplies.

Leadership and the functioning of maternal health services in two rural district hospitals in South Africa.

Maternal mortality remains high in Eastern Cape Province, South Africa, despite over 90% of pregnant women utilizing maternal health services. A recent survey showed wide variation in performance among districts in the province. Heterogeneity was also found at the district level, where maternal health outcomes varied considerably among district hospitals. In ongoing research, leadership emerged as one of the key health systems factors affecting the performance of maternal health services at facility level. This article reports on a subsequent case study undertaken to examine leadership practices and the functioning of maternal health services in two resource-limited hospitals with disparate maternal health outcomes. An exploratory mixed-methods case study was undertaken with the two rural district hospitals as the units of analysis. The hospitals were purposively selected based on their maternal health outcomes: one reported good maternal health outcomes (pseudonym: Chisomo) and the other had poor outcomes (pseudonym: Tinyade). Comparative data were collected through a facility survey, non-participant observation of management and perinatal meetings, record reviews and interviews with hospital leadership, staff and patients to elicit information about leadership practices including supervision, communication and teamwork. Descriptive and thematic data analysis was undertaken. The two hospitals had similar infrastructure and equipment. Hospital managers at Chisomo used their innovation and entrepreneurial skills to improve quality of care, and leadership style was described as supportive, friendly, approachable but 'firm'. They also undertook frequent and supportive supervisory meetings. Each department at Chisomo developed its own action plan and used data to monitor their actions. Good performers were acknowledged in group meetings. Staff in this facility were motivated and patients were happy about the quality of services. The situation was different at Tinyade hospital. Participants described the leadership style of their senior managers as authoritarian. Managers were rarely available in the office and did not hold regular meetings, leading to poor communication across teams and poor coordination to address resource constraints. This demotivated the staff. The differences in leadership style, structures, processes and work culture affected teamwork, managerial supervision and support. The study demonstrates how leadership styles and practices influence maternal health care services in resource limited hospitals. Supportive leadership manifested itself in the form of focused efforts to build teamwork, enhance entrepreneurship and in management systems that are geared to improving maternal care.

Progressive realisation of universal health coverage: what are the required processes and evidence?

Progressive realisation is invoked as the guiding principle for countries on their own path to universal health coverage (UHC). It refers to the governmental obligations to immediately and progressively move towards the full realisation of UHC. This paper provides procedural guidance for countries, that is, how they can best organise their processes and evidence collection to make decisions on what services to provide first under progressive realisation. We thereby use 'evidence-informed deliberative processes', a generic value assessment framework to guide decision making on the choice of health services. We apply this to the concept of progressive realisation of UHC. We reason that countries face two important choices to achieve UHC. First, they need to define which services they consider as high priority, on the basis of their social values, including cost-effectiveness, priority to the worse off and financial risk protection. Second, they need to make tough choices whether they should first include more priority services, first expand coverage of existing priority services or first reduce co-payments of existing priority services. Evidence informed deliberative processes can facilitate these choices for UHC, and are also essential to the progressive realisation of the right to health. The framework informs health authorities on how they can best organise their processes in terms of composition of an appraisal committee including stakeholders, of decision-making criteria, collection of evidence and development of recommendations, including their communication. In conclusion, this paper fills in an important gap in the literature by providing procedural guidance for countries to progressively realise UHC.

Professionalism, patient satisfaction and quality of health care: experience during Zimbabwe's structural adjustment programme.

In 1991, Zimbabwe embarked on a structural adjustment programme. In the health sector, collection of fees was enforced and fees were later increased. Utilisation subsequently declined. This paper examines the perceptions of both government nurses and health care consumers regarding the impact of adjustment on overall quality of care, including nurse professionalism, the nurse-client relationship and patient satisfaction with care. These issues were explored in a series of focus group discussions held in December 1993, about three years after policy reforms. The discussions suggested many areas of shared concern (fees, drug availability, waiting times), but divergent views regarding the process of care. Nurses were concerned mainly with overwork and patient ingratitude, and failed to recognise nurse behaviour as a major source of patient dissatisfaction. Community women saw nurses as hardened and indifferent, especially in urban areas. These differences are rooted in the perceived class differences between nurses and the communities they serve, but appear to have sharpened during the period of structural adjustment.

Health systems research in leprosy control--what contributions can it make?

The paper describes a Health Systems Research (HSR) training programme which took place at the All Africa Leprosy, Tuberculosis and Rehabilitation Training Centre (ALERT) in Ethiopia. The training consisted of three stages: an initial workshop focussing on protocol development, followed by a fieldwork period and a data analysis and report writing workshop. Twenty participants, divided over four groups, took part in the training and carried out the research alongside their day-to-day professional commitments. Three of the projects were concerned with prevention of disabilities, one with integration of the leprosy programme into the general health services. Based on the findings of their research, each group produced a set of recommendations and a plan of action for the implementation of these recommendations. The contribution of HSR to leprosy control is discussed.

Directory of socio-behavioural research on HIV infection and AIDS in Zimbabwe.

In July-August 1992, a directory was made of research projects on socio-behavioural aspects of HIV infection and AIDS in Zimbabwe. A total of 92 research projects were identified, most of which were already completed. Whilst there was a wide variety of topics, populations and geographical areas covered, there was a strong bias towards AIDS awareness and knowledge, attitudes and practices (KAP) studies. Many of these were not linked with any specific AIDS prevention programme or with policy making. Suggestions are given to make better use of existing scientific information. A call is made upon researchers to conduct action-oriented studies and to consult HIV/AIDS programme implementers when specifying 'researchable' problems, so as to increase the likelihood that the study results will indeed have an impact on policy making and programme implementation.

PIP: During July-August 1992, a public health consultant compiled a directory of research on sociobehavioral aspects of HIV infection and AIDS in Zimbabwe. The consultant reviewed journals and the Health and Disease Research Databank of the Medical Research Council of Zimbabwe to identify completed, ongoing, or planned research. The consultant also spoke to people at the University of Zimbabwe, training and research institutes, the Ministry of Health, and other institutions. Field names for each record were author(s), institution(s), documentation/publication, key words, funding agency, status/time, population, objective, methodology, major findings, recommendations, and (expected) utilization of results. 65 (71%) of the 92 research projects were completed research. 17 (18%) and 10 (11%) were ongoing and planned research, respectively. The University of Zimbabwe was linked to 45 (49%) research projects. Nongovernmental organizations were involved in 19 (21%) projects. The most frequent study site was Harare (26), followed by the entire nation (14). Populations studies included adults, women, pupils, factory/farm workers, patients, students, traditional healers, people with HIV/AIDS, men, adolescents, health workers, teachers, prostitutes and clients, pregnant women, and blood donors. The leading research topics were knowledge, attitudes, and practices (23%); education/educational needs (22%); AIDS awareness (20%); sexual behavior (14%); and condom use and acceptance (11%). 71% of the studies were not linked to specific interventions or decision making. 15 of the 27 studies that did make such a linkage were baseline surveys, i.e., done before implementing any interventions. 28 articles were published in scientific journals. 3 research projects were presented at the 8th International Conference on AIDS in Amsterdam. Researchers should do more action research and consult with HIV/AIDS prevention program managers to identify and define problem statements.