COST-Africa project developed a BSc course for non-doctors in Malawi. The volume of surgical procedures almost doubled between 2013 and 2015 in participating hospitals.
With a population of 18 million, Malawi has the highest rate of rural dwellers in sub-Saharan Africa (84%). The country has only 42 surgeons, all of whom work in the main city hospitals, leaving more than 15 million people with little or no access to surgical care provided by specialists.
Rural communities have to rely on a network of 50 district hospitals to meet their surgical needs. These understaffed and under-resourced hospitals offer mostly obstetric surgery, but some general surgical procedures are also available. The lack of investment in these hospitals cause infrastructure problems, such as water shortages and supply issues, and due to lack of proper training and financial constraints many staff lack confidence and motivation.
This situation has a strong negative impact on the people living in rural areas. Recent studies shown that almost 30% of the population in Malawi lives with a surgically treatable condition, but access to care is minimal. Delays in surgery for hernias and hydroceles, very common conditions, too often result in increased morbidity, disability and even fatalities. Patients are forced to travel to one of the four central hospitals for any complex surgical cases, often resulting in a financial struggle for many of them.
In this challenging context COST-Africa (Clinical Officer Surgical Training in Africa), developed a Bachelor of Science course accredited by the university of Malawi. Through this course non-doctors, called locally clinical officers, are being trained in general surgery. The training blends central training at the College of Medicine in Blantyre and two years of in-service training in district hospitals with fortnightly visits from surgeons.
“Prior to COST-Africa I was not able to do a number of surgical procedures”, explains Maxwell Yambeni, a clinical officer at the Chikwawa District Hospital who was one of the first graduates out of the COST-Africa programme. “COST-Africa came in and beefed my confidence up, my surgical skills, my scientific understanding. It has really helped me a lot”–adds Yambeni.
Hilda Dauti, among the 17 district clinicians who currently hold the BSc in General Surgery, also appreciates the knowledge and experience achieved thanks to the methodology of the training. “We were able to deal with patients rather than just knowing the theory of it”, she remarks. The direct exposure to patient management was possible because the surgical teaching was delivered in the hospitals where the students were working. The trainers were visiting them every two weeks to deliver teaching modules and the hands-on surgical training.
An evaluation report published in 2019 in the British Journal of Surgery reveals that the number of general surgery procedures almost doubled in the hospitals that took part in the COST-Africa project, and majority of the procedures were undertaken by the COST-Africa trainees. Outcomes of surgery were also very good when compared with medical doctors who practiced in the intervention facilities and with surgical specialists from central hospitals. No surgical deaths were recorded in the duration of the project.
‘We are proud to say, that the project developed a sustainable and safe model of delivering surgical care to rural populations in Malawi. Two more cohorts of non-doctor surgeons have already been trained following the model we developed’ –says Dr. Jakub Gajewski, who was the lead researcher on the project.
In many places in the sub-Saharan region of Africa non-doctors are often the main, if not the only, providers of surgical care for rural dwellers. Training of surgical specialists requires longer period of time, and is also more expensive. During the last nine years we have worked to strengthen capacity in sub-Saharan district hospitals to ensure that rural populations have access to safe and quality surgical services. The COST-Africa initiative has shown that surgery can be delivered cost-effectively, safely and bring important health benefits to patients attending district hospitals.