COMMENTARY: Who will do the caesareans when there is no doctor? Finding creative solutions to the human resource crisis

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The commitment of the 5th Millennium Development Goal (MDG5) is extremely far-reaching: to reduce the maternal mortality ratio by 75% by the year 2015. Of all MDGs this goal is the one least likely to be attained. This goal is particularly problematic because the levels of maternal mortality at the starting point, 1990, suffer from a high degree of uncertainty. Under-reporting of maternal deaths was (and is) a very significant problem and numerous studies have shown this to be a serious problem whatever the setting.1–5 The finding of significant under-reporting in wealthy countries shows how difficult it is to assess the true maternal mortality ratio, even when large amounts of funding are available. For countries with small budgets for health care, the problem of under-reporting is even more marked, making the baselines rates highly unreliable.

Statistical doubts mean that we may never be able to determine whether or not the MDG5 has really been attained. But a far greater worry is that we may not be able to enroll sufficient health workers to reduce maternal mortality at all. Although there are famous examples of maternal mortality reductions both nationally (e.g. Sri Lanka and Malaysia6,7) and locally (e.g. Tanzania8), these examples are the exceptions. Elsewhere the picture is not so good. In Malawi, for example, preliminary data indicate that over the last decade the maternal mortality ratio has almost doubled from around 600 to more than 1100 maternal deaths per 100,000 live births.9

There is one common denominator if we consider the ‘success stories’ mentioned: human resources. This was a crucial factor both in Sri Lanka6 and Malaysia,7 as well as in Kigoma, Tanzania.8 The issue of human resources is increasingly recognised as an issue that was insufficiently contemplated when the MDGs were formulated. In a recent overview article in the Lancet10 focussed on human resources for health, it was noted that current spending patterns on human resources are inefficient and fragmented. The authors emphasise ‘… the legacy of chronic under-investment in human resources. Two decades of economic and sectoral reform capped expenditures, froze recruitment and salaries and restricted public budgets, depleting working environments of basic supplies, drugs and facilities. These forces have hit economically struggling and politically fragile countries the hardest’.10 The authors also measure ‘health worker density’ and use it to demonstrate the correlation between this indicator and survival rates. They calculate that ‘sub-Saharan Africa has a tenth of the nurses and doctors for its population that Europe has: Ethiopia has a fiftieth of the professionals for its population that Italy does’.10 Furthermore, low-density areas have a much higher burden of disease than high-density areas. Dr Tim Evans of the WHO has calculated that Africa has approximately 25% of the burden of the world's diseases but only 1.3% of the world's health work force.11 On a global scale it has been estimated that the global shortage of health workers is more than four million and that sub-Saharan countries must nearly triple their current number of workers by adding the equivalent of one million workers through retention, recruitment and training if they are to come close too approaching the MDGs for health.9 This applies particularly to MDG5 and the target of a drastic reduction in maternal mortality by 2015.

One of the most dramatic examples of the depletion of human resources for health is the emigration of nurses and midwives in Africa. WHO has calculated that there will be a net decline in numbers of physicians, nurses and midwives between 2000 and 2015.11 Furthermore, the simultaneous increase in population means that the number of health work force/population is decreasing even more markedly.11 And this effect is not only seen in Africa. WHO statistics on the number of nurses and midwives who applied for registration in UK between 1998 and 2004 indicate that there was a 100-fold increase in applications from both India and the Philippines. Applications from the Philippines rose from 52 in 1998/1999 to 4338 in 2003/2004 while from India they rose from 30 in 1998/1999 to 3073 in 2003/2004.12

Malawi is one of the countries in Africa most severely affected by ‘brain-drain’. There was a time when it was estimated that there were more Malawian doctors in Manchester (UK) than in the whole of Malawi. Even if this statement is not based on formal statistical assessments, it demonstrates the reality of the human resource crisis in poverty-stricken countries in Africa.

Long term and short term solutions

There is now a plethora of articles, statements and policy suggestions on how to overcome the crisis in human resources for health. All these commitments, suggestions and proposals are obviously needed but will not remedy the acute shortage of doctors, nurses and midwives in the least privileged countries, especially in the rural areas. This situation has led some governments to think radically about how they might provide short term solutions.

Mozambique's long-standing war, which started soon after its independence in 1975, led to a crisis in the provision of human resources for health outside urban areas. As a result the Ministry of Health was forced to take the initiative of creating a new cadre of surgically trained medium level providers of care. These so-called ‘técnicos de cirurgia’ correspond to surgically trained assistant medical officers in other southern and eastern African countries. The training of this category of staff has previously been described13,14 and there is little doubt that this is now considered a ‘success story’ for those low-resource settings, which have insufficient numbers of physicians serving in underprivileged areas. Two studies13,15 have addressed the quality of obstetric care carried out by this category of non-doctors. Both have demonstrated remarkably good post-operative outcomes even in advanced major surgery like caesarean hysterectomies, bowel repair, hysterotomies and emergency caesarean sections. Particularly noteworthy was the finding that the post-operative outcome of almost 2000 caesarean deliveries was similar for obstetric specialists and the ‘técnico de cirurgia’.15

In collaboration with Columbia University, we are currently assessing the benefits of the delegation of surgical emergency obstetric care in several sub-Saharan African countries. Preliminary studies indicate that in Mozambique and Malawi the vast majority of caesarean sections at the district hospital level are carried out by non-doctors, in Mozambique by ‘técnico de cirurgia’ and in Malawi by clinical officers trained for surgery. To our knowledge this is the first large-scale assessment of the quality and success of the delegation of life-saving emergency obstetric care including major surgery, and will help to guide service providers throughout the world.

Delegation of surgery to non-doctors: an interim solution or a sustainable approach for the future?

It is estimated that there is a current deficit of around one million health workers in Africa.11 And with the ongoing double brain-drain (emigration and AIDS-related mortality among health staff) it is increasingly unlikely that a simple remedy can be found for this crisis. In Mozambique it has been calculated that it will take approximately 50 years before the local production of medical doctors will reach the estimated need of the country. And even then it is unlikely that those doctors will automatically settle in the remote, rural areas where the unmet need of human resources for health is most pressing.

In the initial phase (1984) of the training of ‘técnicos de cirurgia’ in Mozambique there was a tangible resistance among clinicians to train non-doctors for major surgery. Gradually, however, and particularly after two formal evaluations,14,15 the resistance has faded. This cadre of health workers is now a much appreciated and prestigious category, and their training has recently been upgraded to an academic degree.

The alarming depletion of human resources in the most deprived countries has forced us to question the traditional roles and responsibilities within the healthcare system. There remains, however, much resistance to the concept of delegation of surgery to non-doctors. For many it is seen as a threat, both to them as individuals and to the medical profession as a whole. But if doctors are going to insist on exclusive rights to surgery, then they may end up being more part of the problem than the solution.

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