Bridging the human resource gap in surgical and anesthesia care in low-resource countries: a review of the task sharing literature.

Task sharing, the involvement of non-specialists (non-physician clinicians or non-specialist physicians) in performing tasks originally reserved for surgeons and anesthesiologists, can be a potent strategy in bridging the vast human resource gap in surgery and anesthesia and bringing needed surgical care to the district level especially in low-resource countries. Although a common practice, the idea of assigning advanced tasks to less-specialized workers remains a subject of controversy. In order to optimize its benefits, it is helpful to understand the current task sharing landscape, its challenges, and its promise. We performed a literature review of PubMed, EMBASE, and gray literature sources for articles published between January 1, 1996, and August 1, 2016, written in English, with a focus on task sharing in surgery or anesthesia in low-resource countries. Gray literature sources are defined as articles produced outside of a peer-reviewed journal. We sought data on the nature and forms of task sharing (non-specialist cadres involved, surgical/anesthesia procedures shared, approaches to training and supervision, and regulatory and other efforts to create a supportive environment), impact of task sharing on delivery of surgical services (effect on access, acceptability, cost, safety, and quality), and challenges to successful implementation. We identified 40 published articles describing task sharing in surgery and anesthesia in 39 low-resource countries in Africa and Asia. All countries had a cadre of non-specialists providing anesthesia services, while 13 had cadres providing surgical services. Six countries had non-specialists performing major procedures, including Cesarean sections and open abdominal surgeries. While most cadres were recognized by their governments as service providers, very few had scopes of practice that included task sharing of surgery or anesthesia. Key challenges to effective task sharing include specialists' concern about safety, weak training strategies, poor or unclear career pathways, regulatory constraints, and service underutilization. Concrete recommendations are offered.

Coverage, compliance, acceptability and feasibility of a program to prevent pre-eclampsia and eclampsia through calcium supplementation for pregnant women: an operations research study in one district of Nepal.

BACKGROUND: Calcium supplementation during pregnancy has been shown to reduce the incidence of pre-eclampsia/eclampsia among women with low calcium intake. Universal free calcium supplementation through government antenatal care (ANC) services was piloted in the Dailekh district of Nepal. Coverage, compliance, acceptability and feasibility of the intervention were evaluated. METHODS: Antenatal care providers were trained to distribute and counsel pregnant women about calcium use, and female community health volunteers (FCHVs) were trained to reinforce calcium-related messages. A post-intervention cluster household survey was conducted among women who had given birth in the last six months. Secondary data analysis was performed using monitoring data from health facilities and FCHVs. RESULTS: One Thousand Two hundred-forty postpartum women were interviewed. Most (94.6 %) had attended at least one ANC visit; the median gestational age at first ANC visit was 4 months. All who attended ANC were counseled about calcium and received calcium tablets to take daily until delivery.79.5 % of the women reported consuming the entire quantity of calcium they received. The full course of calcium (300 tablets for 150 days) was provided to 82.3 % of the women. Consumption of the full course of calcium was reported by 67.3 % of all calcium recipients. Significant predictors of completing a full course were gestational age at first ANC visit and number of ANC visits during their most recent pregnancy (p < 0.01). Nearly all (99.2 %) reported taking the calcium as instructed with respect to dose, timing and frequency. Among women who received both calcium and iron (n = 1,157), 98.0 % reported taking them at different times of the day, as instructed. Over 97 % reported willingness to recommend calcium to others, and said they would like to use it during a subsequent pregnancy. There were no stock-outs of calcium. CONCLUSIONS: Calcium distribution through ANC was feasible and effective, achieving 94.6 % calcium coverage of pregnant women in the district. Most women (over 80 %) attended ANC early enough in pregnancy to receive the full course of calcium supplements and benefit from the intervention. High coverage, compliance, acceptability among pregnant women and feasibility were reported, suggesting that this intervention can be scaled up in other areas of Nepal.

Preparing the next generation of maternal and newborn health leaders: the maternal and newborn health champions initiatives.

A champion in health care can be defined as any health professional who has the requisite knowledge and skills in a relevant health field, who is respected by his/her peers and supported by his/her supervisors, and who takes the lead to promote or introduce evidence-based interventions to improve the quality of care. Jhpiego used a common approach during two distinct initiatives to identify individuals in Africa, Asia, and Latin America and the Caribbean whose expertise in their clinical service area and whose leadership capacity could be strengthened to enable them to serve as champions for maternal and newborn health (MNH). These champions have gone on to contribute to the improvement of MNH in their respective countries and regions. The lessons learned from this approach are shared so they can be used by other organizations to design leadership development strategies for MNH in low-resource countries.

Reproductive health services in Malawi: an evaluation of a quality improvement intervention.

OBJECTIVE: this study was to evaluate the impact of a quality improvement initiative in Malawi on reproductive health service quality and related outcomes. DESIGN: (1) post-only quasi-experimental design comparing observed service quality at intervention and comparison health facilities, and (2) a time-series analysis of service statistics. SETTING: sixteen of Malawi's 23 district hospitals, half of which had implemented the Performance and Quality Improvement (PQI) intervention for reproductive health at the time of the study. PARTICIPANTS: a total of 98 reproductive health-care providers (mostly nurse-midwives) and 139 patients seeking family planning (FP), antenatal care (ANC), labour and delivery (L&D), or postnatal care (PNC) services. INTERVENTION: health facility teams implemented a performance and quality improvement (PQI) intervention over a 3-year period. Following an external observational assessment of service quality at baseline, facility teams analysed performance gaps, designed and implemented interventions to address weaknesses, and conducted quarterly internal assessments to assess progress. Facilities qualified for national recognition by complying with at least 80% of reproductive health clinical standards during an external verification assessment. MEASUREMENTS: key measures include facility readiness to provide quality care, observed health-care provider adherence to clinical performance standards during service delivery, and trends in service utilisation. FINDINGS: intervention facilities were more likely than comparison facilities to have the needed infrastructure, equipment, supplies, and systems in place to offer reproductive health services. Observed quality of care was significantly higher at intervention than comparison facilities for PNC and FP. Compared with other providers, those at intervention facilities scored significantly higher on client assessment and diagnosis in three service areas, on clinical management and procedures in two service areas, and on counselling in one service area. Service statistics suggest that the PQI intervention increased the number of Caesarean sections, but showed no impact on other indicators of service utilisation and skilled care. CONCLUSIONS: the PQI intervention showed a positive impact on the quality of reproductive health services. The effects of the intervention on service utilisation had likely not yet been fully realized, since none of the facilities had achieved national recognition before the evaluation. Staff turnover needs to be reduced to maximise the effectiveness of the intervention. IMPLICATIONS FOR PRACTICE: the PQI intervention evaluated here offers an effective way to improve the quality of health services in low-resource settings and should continue to be scaled up in Malawi.

Pre-eclampsia in low and middle income countries.

Pre-eclampsia and eclampsia are leading causes of maternal and perinatal morbidity and mortality worldwide. The exact prevalence, however, is unknown. The majority of pre-eclampsia related deaths in LMIC occur in the community and therefore, interventions must be focused at this level. There are a number of unique challenges facing LMIC but the principles of care for women with pre-eclampsia remain the same as in well resourced settings. Three primary delays lead to an increased incidence of maternal mortality from pre-eclampsia- delays in triage, transport and treatment. There are a number of other challenges facing LMIC and the health care worker shortage is particularly significant. Task shifting is a potential strategy to address this challenge. Community health care workers, specifically lady health care workers, are an integral part of the health care force in many LMIC and can be employed to provide timely care to women with pre-eclampsia. Prevention strategies should be applied to every pregnant woman since we cannot predict who will develop pre-eclampsia given the limitation in resources. Aspirin and calcium are the only two recommended therapies at this time. Measuring blood pressure and proteinuria is challenging in LMIC due to financial cost and lack of training. A detection tool that is affordable and can be easily applied is needed. Magnesium sulfate is the drug of choice for the prevention and treatment of eclampsia but it is underutilized due to barriers on multiple levels.

Expanding uterotonic protection following childbirth through community-based distribution of misoprostol: operations research study in Nepal.

OBJECTIVE: To determine feasibility of community-based distribution of misoprostol for preventing postpartum hemorrhage (PPH) to pregnant woman through community volunteers working under government health services. METHODS: Implemented in one district in Nepal. The primary measure of performance was uterotonic protection after childbirth, measured using pre- and postintervention surveys (28 clusters, each with 30 households). Maternal deaths were ascertained through systematic health facility and community-based surveillance; causes of death were assigned based on verbal autopsy. RESULTS: Of 840 postintervention survey respondents, 73.2% received misoprostol. The standardized proportion of vaginal deliveries protected by a uterotonic rose from 11.6% to 74.2%. Those experiencing the largest gains were the poor, the illiterate, and those living in remote areas. CONCLUSION: Community-based distribution of misoprostol for PPH prevention can be successfully implemented under government health services in a low-resource, geographically challenging setting, resulting in much increased population-level protection against PPH, with particularly large gains among the disadvantaged.

Where there is no obstetrician--increasing capacity for emergency obstetric care in rural India: an evaluation of a pilot program to train general doctors.

BACKGROUND: Maternal mortality continues to be high in rural India. Chief among the reasons for this is a severe shortage of obstetricians to perform cesarean delivery and other skills required for emergency obstetric care (EmOC). In 2006, the Government of India and the Federation of Obstetric and Gynecological Societies of India (FOGSI) with technical assistance from Jhpiego, instituted a nationwide, 16-week comprehensive EmOC (CEmOC) training program for general medical officers (MOs). This program is based on an earlier pilot project (2004-2006). OBJECTIVE: To evaluate the pilot project, and identify lessons learned to inform the nationwide scale-up. METHODS: The lead author (CE) visited trainees and their facilities to evaluate the project. Eight data collection tools were created, which included interviews with informants (program/government staff, regional/international experts, trainees and trainers), facility observation, and facility-based data collection of births and maternal/newborn deaths during the study period. RESULTS: More trainees performed each of the basic EmOC skills after the training than before. After training, 10 of 15 facilities to which trainees returned could provide all signal functions for basic EmOC whereas only 2 could do so before. For comprehensive EmOC, 2 facilities with obstetricians were providing all functions before and 2 were doing so after, even though the specialists had left those facilities and services were being provided by CEmOC trainees. Barriers to providing, or continuing to provide, EmOC for some trainees included insufficient training for cesarean delivery, lack of anesthetists, equipment and infrastructure (operating theater, blood services, forceps/vacuum, manual vacuum aspiration syringes). CONCLUSION: Although MOs can be trained to provide CEmOC (including cesarean delivery), without proper selection of facilities and trainees, adequate training, and support, this strategy will not substantially improve the availability of comprehensive EmOC in India. RECOMMENDATIONS: To implement a successful nationwide scale-up, several steps should be taken. These include, selecting motivated trainees, implementing the training as it was designed, improving support for trainees, and ensuring appropriate staff and infrastructure for trainees at their facilities before they return from training.

Cervical cancer screening using visual inspection with acetic acid: operational experiences from Ghana and Thailand.

Thailand in 2000 and Ghana in 2001 initiated cervical cancer prevention programmes using a single-visit approach with visual inspection with acetic acid (VIA) with cryotherapy for pre-cancerous lesions. This service was integrated into existing reproductive health services, provided by trained nurses. The providers maintained a high level of competence and performance, including after the withdrawal of external funding. In Ghana, independent co-assessments revealed a high level of agreement in diagnosis between providers and a Master Trainer. In Thailand, high quality performance was associated with quality assurance mechanisms such as peer feedback and review of charts and service statistics. Provider performance was maintained at a high level in both countries: an average of 74% of providers from both countries met 85% or more of performance standards. The successful transition from a demonstration project to a national programme in Thailand was dependent on a strong commitment from government health bodies and health professionals. In contrast, the lack of health infrastructure and political will has prevented scale-up to a national programme in Ghana. However, this study shows that a single-visit approach with VIA and cryotherapy is programmatically feasible and sustainable and should be considered in national investments to control cervical cancer.