COST-Africa (Clinical Officer Surgical Training in Africa), 2011-15, is a randomised controlled trial that seeks to measure the health impact and cost effectiveness of training clinical officers to undertake major surgery at district hospitals in Malawi and Zambia. In its first two years it has provided additional surgical training to 30 clinical officers in Zambia who were completing a 3-year Medical Licentiate training programme. In Malawi, a BSc in surgery for clinical officers has been accredited by the University of Malawi and 17 candidates started training in 2013. In both countries, district hospitals have been randomly allocated to intervention and control arms and clinical officers have been selected for allocation to the intervention hospitals. Tools for measuring surgical outputs have been developed and tested and the evaluation has commenced in Zambia.
African countries have surgeons trained to top international standards, but too few to tackle the burden of disease that is amenable to surgery, especially in rural areas. Obstetrical emergencies, trauma and abdominal contribute to much higher rates of morbidity and mortality than in Europe or the U.S. Maternal mortality in Africa, most of it avoidable, ranges from 200 to 2,000 per 100,000 deliveries, compared with rates between 3 and 20 per 100,000 in Europe. Less attention has been given the surgically avoidable unmet need due to major trauma and acute abdominal emergencies.
Poor health outcomes are due to poorly functioning district hospitals, which lack adequately trained and remunerated health professionals with the knowledge, skills and resources to deliver safe and effective district level emergency surgery. Clinical Officers are a cadre of formally trained and qualified health professionals in Africa who have no counter-part in Europe or the US, making emigration difficult for them. They already undertake life-saving emergency caesarean sections in many African countries.
The hypothesis underlying this project is that Clinical Officers are capable of being trained to safely and effectively undertake life-saving major surgery for the emergencies, which commonly present to district hospitals in Africa.
These treatable conditions include:
To design, implement and evaluate, at the district hospital level, the impact and cost-effectiveness of an ethical surgical training intervention for clinical officers; and to work with national policy makers to put in place career paths that will retain clinical officers, working in district hospitals in Africa.
Results expected – evidence of:
The project will provide a fully costed and tested model that provides African countries with a trained and retainable health professional, appropriate to their needs. It will also demonstrate the potential for a two-fold role for Africa’s scarce resource of highly trained surgeons – as specialists and as trainers – which would increase the likelihood of retaining them in Africa.
Where existing health professionals obtain enhanced expertise and additional roles, these need to be supported by incentives and attractive career paths. These are being put in place at the start of the project, instead of at the end. COST-Africa has high level support in Malawi and Zambia – at the level of Permanent Secretaries and national programme directors – which will facilitate and support national roll out of lessons learned. The Project will work with policy makers across the ECSA [East, Central and Southern African] Region, and with the College of Surgeons of East, Central and Southern African (COSECSA), to develop Clinical Officer retention strategies and support roll out of lessons learned across sub-Saharan Africa, supported by conference and journal publications.