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

Background: Task-shifting, using non-physician clinicians (NPCs) to perform major surgery in obstetric emergencies is common, though still controversial, in Africa to overcome the crisis of human resources for health.

Aim: To describe the extent to which NPCs in Mozambique and Tanzania contribute to surgical skills to enhance maternal survival. More specifically the focus is on met need of emergency obstetric care and on the outcome of major obstetric surgery in the two countries.

Setting: Hospitals with operation theatres in Mozambique and in Kigoma and Mwanza in Tanzania.

Methods: Hospital records of all deliveries in Maputo Central Hospital during one year were reviewed to assess the outcomes of major obstetric surgery performed by specialists and (técnicos de cirurgia, TCs) (study I). The cost of training and deploying the two cadres of health workers were derived from budget reviews, annual expenditure reports, enrolment registers, accounting statements from training institutions and interviews with directors and administrators (study II). Productivity estimates were based on a hospital survey of physicians and TCs. Cost per major obstetric surgical procedure over 30 years was estimated in 2006 US dollars. In study III, hospital records of all deliveries in 2003 at rural, district, provincial and central hospitals with a theatre were reviewed to determine who was responsible for treatment and outcome for the mother comparing TCs and medical officers. Graduates in the classes of 1987, 1988, and 1997 from the Mozambican medical school and the institute training TCs were traced and interviewed, to determine where they were initially assigned and where they were working two and seven years after graduation. A qualitative study to elucidate attitudes and opinions on the work carried out by TCs was undertaken among health staff (study IV). In studies V and VI all hospitals records in Kigoma and Mwanza regions during four months (2003) were followed prospectively to elucidate the activities in obstetric surgery carried out by assistant medical officers (AMOs).

Results: There were no clinically significant differences in the outcomes of 2,071 consecutive cesarean sections performed in the two groups (TCs and specialists) at Maputo Central Hospital (study I). The cost-effectiveness of TCs performing obstetric surgery, over a calculated lifetime, was three times more favourable for TCs than for medical officers (study II). In 2002, TCs performed 57% of the 12,178 operations for either a caesarean section, ruptured uterus or ectopic pregnancy for all hospitals with a theatre in Mozambique.. In rural (district level) hospitals, they performed 92% of 3,246 operations for these conditions. In provincial and general (urban) hospitals, they performed 34% of 4,175 such operations; and in the three central hospitals, they performed 53% of 4,757. Among medical doctors from the three graduated classes, none remained after seven years, whereas 88% of the TCs were still located at their original post (study III). Health staffs recognize with satisfaction that TCs alleviate the burden for medical officers resulting in a reduction of the need for patient referrals with cost reduction for patients. Important problems remain in the professional status and remuneration of TCs (study IV). UN process indicators calculated in all hospitals in Kigoma and Mwanza regions of Tanzania indicate that there are no significant differences between AMOs and MOs (studies V and VI).

Conclusion: TCs and AMOs carry most of the burden of emergency obstetric surgery in Mozambique and Tanzania. The quality of work is comparable to that of medical officers. In Mozambique they are cost-effective and their retention in rural areas, where they are needed most, reaches almost 90% at seven years after graduation while the corresponding percentage for medical officers is zero.

List of scientific papers

I. Pereira C, Bugalho A, Bergström S, Vaz F, Cotiro M (1996). "A comparative study of caesarean deliveries by assistant medical officers and obstetricians in Mozambique." Br J Obstet Gynaecol 103(6): 508-12
https://doi.org/10.1111/j.1471-0528.1996.tb09797.x

II. Kruk ME, Pereira C, Vaz F, Bergström S, Galea S (2007). "Economic evaluation of surgically trained assistant medical officers in performing major obstetric surgery in Mozambique." BJOG 114(10): 1253-60
https://doi.org/10.1111/j.1471-0528.2007.01443.x

III. Pereira C, Cumbi A, Malalane R, Vaz F, McCord C, Bacci A, Bergström S (2007). "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): 1530-3. Epub 2007 Sep 17
https://doi.org/10.1111/j.1471-0528.2007.01489.x

IV. Cumbi A, Pereira C, Malalane R, Vaz F, McCord C, Bacci A, Bergström S (2007). "Major surgery delegation to mid-level health practitioners in Mozambique: health professionals perceptions." Hum Resour Health 5: 27
https://doi.org/10.1186/1478-4491-5-27

V. Pereira C, Mbaruku G, Nzabuhakwa C, Bergström S, McCord C (2010). "Emergency obstetrical surgery by non-physician clinicians in Tanzania: an inventory of 38,758 deliveries." Int J Gyn Obstet [Accepted]
https://doi.org/10.1016/j.ijgo.2011.05.004

VI. McCord C, Mbaruku G, Pereira C, Nzabuhakwa C, Bergstrom S (2009). "The quality of emergency obstetrical surgery by assistant medical officers in Tanzanian district hospitals." Health Aff (Millwood) 28(5): w876-85. Epub 2009 Aug 6
https://doi.org/10.1377/hlthaff.28.5.w876