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Enhancing Human Resources and Use of Appropriate Training for Maternal and Perinatal Survival In Sub-Saharan Africa

Final Report Summary - ETATMBA (Enhancing Human Resources and Use of Appropriate Training for Maternal and Perinatal Survival In Sub-Saharan Africa)

Executive Summary:
Background

Most African women face childbirth without access to skilled health workers when obstetric and neonatal emergencies arise. Providing and retaining skilled health workers is vital in attempts to save the 148,000 pregnant or birthing women and 2.2 million babies who die annually in Africa. In the modern world this tragedy is unacceptable and largely preventable. There is a chronic shortage of medical doctors in many Sub-Saharan African countries and indeed many of these countries have very little to spend on healthcare. A cadre of health workers called Non-Physician Clinicians (NPCs) provide the healthcare for these countries; some specialising in obstetric and neonatal care (EmONC). NPCs are an effective and retainable health solution for sub-Saharan Africa. The ETATMBA project aimed to train NPCs (known as Assistant Medical Officers (AMOs) in Tanzania) as advanced leaders providing them with skills and knowledge in advanced neonatal and obstetric care.

Training
One hundred NPCs were trained in obstetric and neonatal care, leadership and clinical service improvement. Forty-six completed a full, accredited BSc in Malawi. In Tanzania, 54 completed a six-month training course in Tanzania, 36 of whom participated in the research evaluations. In both Tanzania and Malawi an evaluation of impact and a process evaluation were carried out. The primary outcome was perinatal mortality with secondary outcomes of maternal mortality, obstetric complications and birth complications. A before-and-after study took place in Tanzania; a randomised controlled trial in Malawi. Interviews with trainees, district medical officers and colleagues who received training from of the trainees were carried out to assess the implementation of the training.

Results
In Malawi there was no difference found for the primary outcome of neonatal and perinatal mortality. In Tanzania neonatal mortality is not recorded in the detail required so perinatal mortality could not be calculated. There is a decline in maternal mortality in Tanzania and may be a trend in Malawi but this needs further statistical modelling to account for confounders. In Malawi the lack of any change in neonatal or perinatal deaths in intervention districts compared to control may reflect the fact that the NPCs’ BSc studies continued to 2014 and a longer time may be needed to see any effect. It may also be due to enhanced training, such as Helping Babies Breathe, in control districts acting as confounders. The qualitative data strongly supports that in Malawi the trainees applied new skills but baseline differences between groups make it difficult for this to be clear. In Tanzania there was both an increased skill level and demonstration that the students were more strategic in their approach to challenges. In Tanzania the Ministry of Health failed to provide the upgrade in facilities that had been planned, limiting the effectiveness of the ETATMBA training but demonstrating that the trainees assumed leadership in tackling the problems it posed.

Conclusions
This study has demonstrated that up-skilling NPCs with skills and knowledge in obstetrics, neonatal care and leadership is possible in sub-Saharan Africa. The work provides strong evidence that this cadre are an important and integral part of the future of healthcare in sub-Saharan Africa and more should be done to encourage a future well-educated and supported generation who will have the health of nations in their hands and provide a sustainable and retainable solution for many countries in sub-Saharan Africa for the future.
Project Context and Objectives:
Non-physician clinicians (NPCs) in Malawi and Assistant Medical Officers (AMOs) in Tanzania are the group of health care professionals who carry out the work which is normally the province of doctors. In these countries, and in most of sub-Saharan Africa, there are not enough qualified doctors to serve the population so alternative solutions have developed in the last few decades. The NPCs and AMOs, often referred to generally as “clinical officers” are a group which therefore has considerable responsibility, but limited training and professional standing.

One objective of the ETATMBA project was to increase the skills of these clinicians specialising in obstetric and neonatal care so that better outcomes could be achieved within the resource-limited settings where they work. This has been achieved for the 100 clinicians and full qualitative and quantitative evaluation has been undertaken. However, improving skills alone would not be sustainable beyond the lifetime of the project: only the clinical officers who received the training would be able to implement it in their practice and they would be dependent on adequate resourcing within their health care facilities. In order for the outcomes to be sustainable, it was important that the clinical officers were not just practitioners of obstetrics but also leaders of their field with the ability to identify problems and implement solutions.

Addressing the difference between being a competent practitioner and being a leader in that field was the real challenge of the ETATMBA project. The clinical officers were originally trained in a traditional classroom style and were unused to challenging current practice or questioning institutional organisation. Recognising that improved clinical care occurs within a context of increased confidence on the part of the clinician, the most crucial element of the project was to embed the clinical teaching within an expectation of leadership at every level. Thus, students were expected to participate in discussions, to question practices, to review and evaluate evidence. They were expected to put this into practice through scenarios, role-play and team-working exercises to find solutions to longstanding problems through a fresh and creative approach.

The clinical and leadership training was complemented by enhancing the professional status of their work. Clinical officers are a much-needed yet undervalued group and this was addressed in the project. The clinical officers in Malawi were able to complete a BSc, enabling them to apply for more senior positions, while in both Malawi and Tanzania professional groups were established with the intention to form a collective voice for clinical officers and to facilitate continued professional education.

The project’s work packages differentiate the elements of training and leadership but, as described above, in practice these strands were interwoven. In this final report, we have identified the unifying themes common to all work packages and to the ethos of the project as a whole:
• Building capacity and improving services by developing training
• Evidence-based practice and audit
• Empowerment and professional support
• Research and evaluation of effectiveness

Building capacity and improving services by developing training

The clinical officers were trained to diploma level but post-qualification support can be variable and unsystematic. There is no obligation to attend refresher courses or to fulfil membership requirements for a professional register. Many clinical officers have attended courses but often these are sponsored by aid agencies and are of variable value and quality; attendance is at the discretion of employers. The ETATMBA course was designed not only to update and improve current clinical practice, but also to instil a culture of professionalism and good management practice. The project itself could only be finite, but once the clinical officers had learned leadership skills and had witnessed the value of cascading their knowledge to fellow health care workers, they were confident about continuing their own professional development.

The objectives under this theme are:
• WP1:1. To develop and implement a training/structured educational programme for NPCs who can diagnose, prescribe and perform surgery and through mentoring, support and resource turn this healthcare workforce into more advanced leaders in obstetric care.
• WP1:3. To develop the clinical knowledge and skills coupled with training on the use of non-surgical treatments and technology that will enable this workforce to improve outcomes.
• WP3:1. To improve maternal and perinatal morbidity and mortality by improving clinical education, leadership training and the creation of a professional support network.
• WP1:6. To establish academic and managerial rigour in clinical service improvement in maternal and neonatal healthcare by training local medical profession and managers in this new discipline so they can undertake their own local monitoring and redesign to ensure continuous improvement.

Evidence-based practice and audit

Both Malawi and Tanzania had officially-established guidelines already in circulation. The extent to which these were up-to-date and, more pertinently, being practised by clinical officers was less clear. Reviewing and editing the guidelines and making recommendations to the respective Ministries of Health formed one part of the project’s work. The other significant task was to assist the clinical officers in their practice of the guidelines. This was achieved by using the audit cycle to demonstrate how the implementation of best practice makes a real and tangible difference to clinical outcomes. Once the clinical officers had followed the process for themselves, they were sufficiently confident to make changes and to teach colleagues the value of what they had learned.

The objectives under this theme are:
• WP1:4. To improve clinical guidelines and pathways for NPCs that support clinical decision-making, audit and professional development.
• WP2:1. Overall objective is to effectively adapt existing evidence-based clinical guidelines in maternal and newborn health to low resourced health communities.
• WP2:2. To determine appropriate clinical guidelines and pathways for the triage and treatment of emergency maternal and newborn cases.
• WP2:3. To develop guidelines and systems in postnatal care that are grounded in the limitations of available resources and staffing and develop innovative local support mechanisms.
• WP3:5. To effectively implement adapted clinical guidelines in maternal and newborn health with a low cost model of training and certification.
• WP2:4. To design intervention studies and criterion based audit to assess effect of application of guideline technology on clinical practice, perceptions and maternal and neonatal outcomes.

Empowerment and professional support

Implicit in the clinical officers’ training was the belief that they had the professional ability to take the lead in suggesting solutions to local challenges. Their training gave them the tools to generate the evidence and the evidence in turn gave them the confidence to make real changes in their workplace. It was important that this sense of professionalism could be sustained beyond the lifetime of the project so support networks were set up to enable the clinical officers to see each other as a source of expertise and support. While some clinical officers are posted to large hospitals, many are in isolated rural health facilities with little access to training and support from colleagues so these networks are a vital source of informal communication. During the development of training programmes in Malawi and Tanzania a culture of team-working and engagement has been established among the faculty in all partners.

The objectives under this theme are:
• WP1:2. To fully involve the local medical profession in the educational leadership and support of this workforce and in the research to evaluate the evidence.
• WP3:2. To establish a culture of team working and engagement through training and shared educational resources.
• WP3:3. To pilot communications systems to provide professional support for NPCs and outreach health workers in their delivery of emergency obstetric care in remote and rural areas.
• WP3:4. To empower all healthcare professionals to improve reciprocal respect, reduce isolation, enhance standards and improve performance.

Research and evaluation of effectiveness

The work of the project was evaluated through quantitative and qualitative studies. The quantitative work examined whether the training had made an impact on maternal mortality and neonatal mortality and morbidity and obstetric complications and interventions. The qualitative work focused on the experience of the clinical officers as they progressed through their training and began to pass on what they had learned to their colleagues.

The objectives under this theme are:
• WP1:5. To research the benefits for continued clinical education, on the job managerial training and structured continued professional development for NPCs.
• WP2:5. To evaluate the effect of guidelines, training, clinical education and mentorship support of NPCs in changing practice.
• WP2:6. To establish quantitative and qualitative research and build audit capacity in the evaluation of the effectiveness of this intervention programme.
Project Results:
Building capacity and improving services by developing training

• WP1:1. To develop and implement a training/structured educational programme for NPCs who can diagnose, prescribe and perform surgery and through mentoring, support and resource turn this healthcare workforce into more advanced leaders in obstetric care.
• WP1:3. To develop the clinical knowledge and skills coupled with training on the use of non-surgical treatments and technology that will enable this workforce to improve outcomes.
• WP3:1. To improve maternal and perinatal morbidity and mortality by improving clinical education, leadership training and the creation of a professional support network.
• WP1:6. To establish academic and managerial rigour in clinical service improvement in maternal and neonatal healthcare by training local medical profession and managers in this new discipline so they can undertake their own local monitoring and redesign to ensure continuous improvement.

The training programmes were enthusiastically received by all participants and for many the range of methods employed was a novel experience. They participated in group work, role play, leadership scenarios, lecture discussion and self-assessment portfolios. Educational resources around leadership, assessment, guideline development and systems improvement have been shared between partners and implemented into both training programmes.

It was aimed to customise and develop the learning objectives and curriculum from the well-known Gotland courses that have been held annually and pioneered in Sweden. However, due to the different backgrounds of each country in the basic training of their NPCs, it was decided that each country should produce an appropriate training curriculum to address its own major obstetric and gynaecological problems.

The trainees in Tanzania were Assistant Medical Officers, who had undergone a ‘Medical Assistants’ college training of three years. To become an Assistant Medical Officer, these students have to practice for at least three years and then sit for an entrance examination. If successful, they are enrolled onto a further two year-course to become Assistant Medical Officers with a non-university ‘Advanced Diploma’.

In Malawi, candidates undergo a three-year course to become Clinical Officers. There exists no further training for these clinical Officers in Malawi and they exit with a non-university ‘diploma’, a situation that has created a deep sense of grievance as government-sponsored nurse training leads for many to a university degree.

In both countries the Assistant Medical Officers and Clinical Officers are expected to work in Health centres and District hospitals following their graduation. Here they practice as clinicians and are involved in the complete management of patients making diagnoses and providing medical or surgical treatments. Delivery of the courses for the project differed in both countries to fit their needs.

In Tanzania, there was a full-time sixteen weeks of residential training in an accredited institution followed by a two-week Advanced Leadership course. This was consolidated with a four-week residential internship at St Francis Referral General Hospital in Ifakara.

We aimed to select a total of 50 NPCs from both countries (i.e. 25 each) as suitable for training as ‘advanced leaders’. These were to be invited and fully funded for the training to attend the structured educational programme. In Tanzania, the AMO was recruited along with a nurse-midwife and the pair were trained as one unit: the AMO specialised in obstetric and neonatal care; the nurse-midwife specialised in anaesthetics. The national plan (“The Road Map to Reduce Maternal Mortality”) is that even the most remote health centres are able to carry out essential EmONC surgery. Therefore the total number trained was 54, comprising 27 AMOs and 27 midwives. All attended the theoretical courses including the Leadership one but each concentrated on their specific roles when it came to the specific surgical aspects. Thirty-eight of these underwent full qualitative evaluation. The Kigoma cohort (n=16) was not accessible to the evaluating team as it lies in the extreme north-west of Tanzania and was inaccessible at the time of the survey.

The courses were very well accepted, highly appreciated and the candidates became local experts in their own areas, demonstrating more confidence that their skills are being utilised by colleagues. The same has happened in Malawi, as the newly trained Advanced Leaders NPCs are being seen as a model in their individual workplaces. In both countries local faculties have been fully involved. In Tanzania, the Tanzania Training Centre for International health (TTCIH) which is an accredited institution by the Ministry of Health, although not able to accredit university degrees, has a full time and part time staff for training of NPCs and other Continuing Education courses.

In Malawi selected NPCs with a minimum of three years’ experience working in obstetrics were enrolled on the ETATMBA BSc course for three years. The modules of one or two weeks in duration were delivered at six-monthly intervals, followed by assignments and specific on-the-job training.

A significant issue for the clinical officers was that, despite a heavy clinical responsibility, their lack of a BSc qualification meant that they were unable to apply for promotion to more senior health service positions. This was in marked contrast to their colleagues in the nursing profession, whose training leads to a degree qualification. A new BSc course accredited by the University of Warwick was created to address this and it has provided the impetus for the College of Medicine to establish its own degree programme.

The modular content of this programme was created in collaboration with College of Medicine and has been used in the design of the BSc in obstetrics which is now running. We brought together a strong faculty from the University of Warwick, working with, and gradually handing over to, a Malawian faculty. The success of this initiative is reflected in the creation of five BScs (paediatrics, obstetrics, surgery, orthopaedics and internal medicine) which all commenced recruitment in 2014. This is being funded by GIZ (German overseas aid) and CHAM (Christian Hospital Association of Malawi). Given that an earlier attempt to set up a BSc for clinical officers at a Mzuzu university had failed (prior to the ETATMBA project), the success at this time demonstrates how the strong and positive working relationships cultivated by the partners were instrumental in building confidence and achieving in this challenging area.

The leadership element of the training was central and the precepts were embedded in every aspect of the students’ learning. This provided a unifying core to the project’s delivery in both countries, and distinguishes it from other initiatives which focus only on improving skills or providing mechanical or technological support.

In Malawi, the second module ‘Clinical service improvement and leadership in Emergency Obstetric and Neonatal Care’ ran during May/June 2012 in Lilongwe. To promote inter-professional learning in this module, NPCs were trained alongside nurse midwives. This was introduced to the course in Malawi following the reports of beneficial team learning in Tanzania. The module took the students’ clinical audits as the starting point and focused on clinical leadership and clinical systems improvement (CSI), evidence-based practice and values-based practice (V-BP) and change management to look closely at how audits can form the foundation of clinical service improvement.

The innovative curriculum in Module 2 emphasised the need for new ways of thinking about problems in healthcare systems. CSI techniques that have proved successful in the NHS such as problem identification including ‘5 Whys’, Plan-Do-Study-Act (PDSA) and value stream mapping were brought to Malawi possibly for the first time. These patient-centred approaches were combined with evidence-based practice and the new approach of values-based practice, a clinical skills-based approach for working with complex and conflicting values in healthcare. The whole module was set in the context of clinical leadership and the NHS Clinical Leadership Competency Framework (CLCF). Leadership assessment was made in the audits and clinical service improvement projects and the most impressive of these are listed on the project website.

Course assessment included knowledge tests, clinical skills, teaching plans and observations, reflective practice, literature reviews, and clinical audit. Audit has been used effectively as a training and development tool for the NPCs. The focus has been on the major causes of maternal and neonatal deaths: postpartum haemorrhage, puerperal sepsis, eclampsia, obstructed labour and early neonatal deaths. All ETATMBA students have undertaken extensive audits, which counted towards their BSc degrees, thus providing evidence that through the project the students applied the knowledge and skills they have acquired through the training in the project.

They are required to identify a concern within their clinical practice, to detect major contributing factors to the identified problems, to set standards and make recommendations against contributing factors to these problems, and act as clinical leaders with colleagues and the community, following them for improvement and re-audit after 3 months to see if the established standards are having a positive influence on health care quality and if so to sustain it. Reaudit is used to complete the cycle, to find out if the recommendations set in the first audit were successful, to measure the gap between the current practice and the practice after introducing the audit standards (if any improvement in patient care) and to measure changes in maternal and neonatal outcomes.

In Tanzania, leadership training was led by Dr Sidney Ndeki who co-designed and adapted the Warwick leadership module. Dr Ndeki taught courses to students at Ifakara, to produce professionals who will improve healthcare by maximising the resources and potential of their own health care facility.

The leadership training courses in Tanzania were tailored to fit the local situation and began by training in basic underlying principles. These were followed by practical applications in the training venue and then practice in the surrounding areas adjoining the training centres. Core management themes such as communication, problem solving and planning and forecasting were reiterated and emphasised. The trainees were involved fully and appreciated that this was a critical part of their training. They both understood and valued the role of managers in the provision of better health care for communities, an aspect which had been neglected during pre-service medical training.

Furthermore, the importance of application in their individual workplaces emphasised that total care of the patient involves not only the provision of medical approaches of treatment also the communication and integration of care, aspects which are not usually covered during pre-service medical training but which are central in delivering a high quality of health care.

As the Tanzanian students were available in a classroom setting for their eight-week course, the leadership element in all training could be emphasised, just as it permeated all modules in Malawi, not just specifically the Leadership course. The Tanzanian students focused on clinical leadership, critical appraisal and understanding, consolidated during their hospital internships which followed the courses. Collaborations with Dr David Davies and Dr Senga Pemba helped to strengthen the leadership assessments: OSCEs and audits could be refined by reference to both Malawi and Tanzania, producing adaptable and flexible tools which could be developed into a state of the art training package suitable for this cadre across sub-Saharan Africa.

This approach enabled the strengths of each country to be enhanced, while still producing clinical officers who were experts in their own areas, in keeping with the WHO observation that “successful empowering interventions cannot be fully shared or ‘standardised’ across multiple populations rather they must be created within or adapted to local contexts” (WHO 2006).

In both countries, the local medical profession was engaged in the day to day duties of the NPCs which was found to be greatly improved after the training. In fact, in many instances, the NPCs brought in new knowledge in their areas which was found to be very relevant to the myriad of problems occurring at their workplaces. This occurrence was extremely motivating not only to the NPCs themselves but also to the rest of the staff of the particular health facilities. A qualitative evaluation of the local medical staff in both countries has been undertaken and strongly supports the value of staff mentoring and supervision in the district workplace carried out during the ETATMBA project.

Content and teaching materials of the BSc modules are detailed on the project web site here: http://www2.warwick.ac.uk/fac/med/about/global/etatmba/training/malawi/
These resources and any intellectual capital in their creation, are available free to trainers across low income countries.


Evidence-based practice and audit

WP1:4. To improve clinical guidelines and pathways for NPCs that support clinical decision-making, audit and professional development.

WP2:1. Overall objective is to effectively adapt existing evidence-based clinical guidelines in maternal and newborn health to low resourced health communities.

WP2:2. To determine appropriate clinical guidelines and pathways for the triage and treatment of emergency maternal and newborn cases.

WP2:3. To develop guidelines and systems in postnatal care that are grounded in the limitations of available resources and staffing and develop innovative local support mechanisms.

WP3:5. To effectively implement adapted clinical guidelines in maternal and newborn health with a low cost model of training and certification.

WP2:4. To design intervention studies and criterion based audit to assess effect of application of guideline technology on clinical practice, perceptions and maternal and neonatal outcomes.

As a point of departure we chose to use identified, officially-established guidelines in both Tanzania and Malawi and we have critically investigated those guidelines in order to adapt then to enhance them in the district hospital and health centre setting. With the above-mentioned approach we have determined the appropriateness of these guidelines and made necessary adjustments based on currently available best clinical evidence. These guidelines have their focus on both maternal and newborn care during pregnancy, child birth and the postnatal period.

We have introduced regular criterion-based audit sessions in both countries with tentative implementation of guidelines as part of ongoing in-service staff training. We have also developed focus on obstetric process indictors, like facility-based deliveries as a percentage of expected deliveries in an assumed catchment area, percentage of caesarean sections of all facility-based deliveries and also case fertility rates per morbidity. We have achieved a good archive of case notes and partograms, which constitute the very basis of clinical audit and professional projects in clinical service improvement in all facilities where the project has been implemented.

Starting in early 2011, in both Malawi and Tanzania, we investigated and scrutinized the national guidelines and made necessary adjustments based on currently available best clinical evidence. This work has been carried out in close collaboration with the relevant authorities in the Ministry of Health in Malawi and with their counterparts in the Ministry of Health and Social Welfare in Tanzania.

Existing, established clinical guidelines for maternal and neonatal care had by 2011 been revised by the Ministries of Health in both Tanzania and Malawi but we found possibilities to add to the last revision updated clinical evidence, which can make interventions more efficient at an affordable cost.

Malawi Sexual and Reproductive Health Guidelines are generic in that they relate to all levels of health workers in the area of reproductive health. During 2013 these guidelines were increasingly supplemented by practical protocols on the management of various sexual and reproductive health conditions. For the purposes of this project the Department of Reproductive Health decided that the guidelines did not need to change but the protocols needed to be updated to be in line with current thinking and new technologies on the management of reproductive health conditions. ETATMBA and USAID were involved in providing human resource (ETATMBA) and funding for printing and dissemination (USAID).

During 2013 the ETATMBA project in Tanzania has accompanied and given significant input into the updating of Emergency Obstetric Care Job Aid. The tool is intended for several levels of health staff: doctors, assistant medical officers, clinical officers, nurse-midwives and other health professionals responsible for providing emergency obstetric care at the dispensary, health centre and hospital levels.

The neonatal guidelines and guidelines for postnatal care are part of the Malawi obstetric protocols and the Tanzanian Job Aid, and are endorsed by Ministry of Health and based on WHO recommendations by local paediatricians grounded in the limitations of available resources. Innovative local support mechanisms consist of the international initiative of the Helping Babies Breathe programme.

The importance not only of familiarity with the guidelines but also of ensuring that these are at the heart of every clinical care pathway has underpinned all of the training modules in Malawi. The NPCs have been thoroughly grounded in the theory and, crucially, each of their modules included a significant amount of emphasis on the practical application of guidelines. This was effectively taught through the use of role play – a method of teaching unfamiliar to the students but one which they rapidly accepted as a powerful tool to help their planning for the best possible care often in difficult circumstances. The focus on guidelines has thus been shifted from their creation to the internalisation and implementation of the guidelines as a core aspect of clinical practice for the students. They have seen at first-hand how improvements can be made by following best practice, and this has not only improved health care overall but has also empowered the NPCs. They now feel able to challenge poor practice and are confident enough to try new and creative methods to overcome problems, despite their limited resources.

In Tanzania the audit focus was initially on outcome indicators, primarily maternal mortality. Gradually the scope was widened to encompass two more outcome entities listed above: intrapartum fetal deaths and early neonatal deaths, both directly related to substandard quality of intrapartum and early postpartum care. However, audit has also been used to scrutinise circumstances around a specific intervention, for instance caesarean section, vacuum extraction and destructive fetal operations. Audit was also used in a successful way to scrutinise referrals, by which the final outcome of patients referred from a peripheral health facility to a hospital was analysed.

A monthly review of all caesarean sections involves an audit note summarising observations. If there is no partogram and no other information written in the patient’s case notes there is no possibility of knowing whether the caesarean section or assisted delivery was “justified”. The partogram is therefore the most important tool for the audit of these two process indicators although it should be noted that the mere existence of a partogram does not mean that it is completed in a way that is meaningful and action-oriented.

Our results include:
• Extensive review of existing guidelines with literature review to ensure that best practice is employed.
• Significant use of audit and professional clinical service improvement projects to trace implementation of guidelines and to drive further improvements in health care.
• Action-oriented audit now a routine tool in health care, in contrast to previous poor application and uptake of this practice.
• Accredited degree level training appropriate to competency and tasks that these NPCs perform has been established in obstetrics and five further specialties in the College of Medicine in Malawi.

Teaching students the importance of best practice by implementing the guidelines was an essential aspect of the training course and was tailored according to each country’s need and capacity.


Empowerment and professional support

WP1:2. To fully involve the local medical profession in the educational leadership and support of this workforce and in the research to evaluate the evidence.

WP3:2. To establish a culture of team working and engagement through training and shared educational resources.

WP3:3. To pilot communications systems to provide professional support for NPCs and outreach health workers in their delivery of emergency obstetric care in remote and rural areas.

WP3:4. To empower all healthcare professionals to improve reciprocal respect, reduce isolation, enhance standards and improve performance.

During the development of training programmes in Malawi and Tanzania a culture of team-working and engagement has been established among the faculty in all partners. Monthly project teleconference calls have allowed partners to share progress and to seek feedback on the development of training modules. But more importantly partner exchange visits have promoted individual faculty learning from and with each other as previously described.

The training courses in Malawi and Tanzania have been designed and delivered to achieve a sense of empowerment amongst student and staff participants. Mutual respect, team work and quality improvement in healthcare are all key parts of the CLCF that has been used for the framework of leadership training. By involving District Medical Officers and Nurse-Midwives in training sessions, mutual respect and improved team work within a shared framework of values has been fostered. This has been translated to their local healthcare team through audit and project work designed to involve them. As leaders and specialists in emergency obstetric and neonatal care, NPCs have returned to their healthcare teams to enhance standards and improve performance. Learning has been cascaded to other team members and we have measured this through course assessments, particularly in module 6 in Malawi, “Essentials of clinical training” where the emphasis was on a teaching-the-teachers approach. Specific efforts have been made in Tanzania and Malawi to forge collaboration not only with the Ministries of Health but also with the existing senior staff in the district to encourage supervision as one of their major roles in order to support this.

In Malawi a major challenge for reciprocal respect to be created and sustained among other health professionals is for this group of specialist clinical officers to be trained and accredited to degree standard. The project has achieved this and involving the College of Medicine and Ministry of Health produced a sustainable and scalable long-term solution that allows NPCs to progress to degree level as they train to be clinical specialists in Malawi.

In bringing together clinical officers from both Tanzania and Malawi, the project has been a stimulus for them to begin to organise themselves into an organisation, become registered and develop more established structures for career advancement. The professional networks among the clinical officers that have been established for those on the course in Malawi and Tanzania has formed a core for the development of proto-national and pan-African networks. Developing a professional association for clinical officers involved in maternal and neonatal health that evolves from these networks and can be an agent of change to improve the quality, standards and performance of healthcare for mothers and babies in each country. A sub-Saharan Africa clinical officers network meeting took place in November 2012 to further strengthen the links between practitioners in Malawi and Tanzania, and to spread good practice to other sub-Saharan countries.

In Malawi we have evidence from both course assessments and from the qualitative research that the clinical officers collaborate amongst themselves for both coursework but also in practice. This mutual support or networking has been informal, and mediated using existing communication capabilities such as face-to-face, email and telephone including SMS messaging. Mobile phones are ubiquitous in Malawi and Tanzania and the use of SMS messages is commonplace.

The ideal support for healthcare workers would be to have an ‘around the clock’ mobile phone or internet-based communication system, with an expert clinician available to answer the calls. We explored the use of one-to-one professional support in Tanzania. The Vodacom Company had been engaged by the Ministry of Health in order to link all clinicians countrywide. We were able to adapt this arrangement so that a local consultant was available as an expert to answer calls on clinical topics.

Professional support was provided by a system of mentoring through email and phone by members of faculty for the clinical officers on the courses but this was dependent on their personal availability to provide advice. The professional network of clinical officers has encouraged the provision of support from more senior clinical officers to their more junior peers and the cascading of teaching extended these processes to other healthcare staff. Attempts to engage long-term sponsorship from mobile phone networks in Malawi have to date not met with the same degree of success but the network survives through text and email.


Research and evaluation of effectiveness

WP1:5. To research the benefits for continued clinical education, on the job managerial training and structured continued professional development for NPCs.

WP2:5. To evaluate the effect of guidelines, training, clinical education and mentorship support of NPCs in changing practice.

WP2:6. To establish quantitative and qualitative research and build audit capacity in the evaluation of the effectiveness of this intervention programme.

In Malawi by making audit and clinical system improvement part of the degree assessment all 46 completing clinical officers undertook a professional project. In defining the standards around which the audits or professional projects were based, the Malawi guidelines were scrutinised, reviewed in the light of the literature and applied in the setting of the 8 district and central hospitals that the trainees worked in. All projects involved teamwork and most involved designing checklists in the local setting that from the evaluations in most cases were instructive, collaborative and improved both the perception and reality of patient care within the limited resources available to the clinical officers. Developing leadership through the understanding and practical application of guidelines was a major research finding which we believe is of global importance in the future training of health workers. Trainees were encouraged to cover different areas from each other and their first year professional project so that for each district hospital the application and evaluation of guidelines in most of the crucial areas of obstetric practice were covered.

All projects involved the understanding of both international and national guidelines with the innovative application of these guidelines to the local setting and the leadership of the healthcare time to use them to produces clinical service improvement. There are many outstanding projects and these have been posted on the ETATMBA website.

The topics of these projects ranged from hand washing, to development of Modified Early Warning Systems in theatres, neonates and postnatal sepsis, prophylactic use of antibiotics, surgical checklists, screening mothers for HIV, finding anaemia in antenatal setting, use of steroids in pre-term labour, use of misoprostol in abortion, kangaroo mother care, screening for hypertension to reduce eclampsia and pre-eclampsia and detection of high risk pregnancy for PPH with matching of blood donors.

The efficacy of the training was then assessed through both quantitative and qualitative studies. A cluster randomised controlled trial has been completed in Malawi and a retrospective before-and-after-study in Tanzania to explore changes in maternal and perinatal mortality (pragmatically defined as fresh stillbirths and neonatal deaths before discharge from the health care facility) comparing data from before the training was implemented and an endpoint not less than a year after the trainees completed their training.

The qualitative analysis was based on interviews which explored the perceptions of the programme from a number of stakeholders including the trainees, their district medical officers, colleagues to whom they have cascaded ETATMBA skills and their trainers.
This two-pronged approach aimed to capture not only any material changes in mortality but also the change in attitude of the NPCs and other health care personnel, in order to assess how the guidelines detailing best practice have been adopted as a key determinant in individuals’ planning and care.

Collection of follow-up and interview data continued January and February 2014 in Malawi and May-June 2014 in Tanzania. In Malawi the PhD and masters students have conducted the data collection by travelling in person to the districts involved in the study and taking data from labour ward records. In Tanzania, the two research masters students were similarly engaged, with the facility written into their protocol that they might use telephone interviews if necessary, due to the extreme remoteness of some health centres. The 16 Kigoma students were too remote to be included in the in-depth qualitative analysis.

The research collection of all quantitative and qualitative data has followed what was designed for Malawi but was customised for the setting. The masters students in Tanzania will continue not only for the academic year 2013/14 but for 2014/15 and further funds beyond the EC grant from Ifakara Health Institute have been found to finance this.

Qualitative Research Study

Malawi
Semi structured interviews were carried out at three time points. The first set of interviews was undertaken four to five months after the delivery of module 1.

The second set of interviews was undertaken by a researcher during visits to all the intervention districts four to five months after delivery of the second module on clinical leadership, covering the training content and about implementation of what they had learnt from the training in their work place followed by a discussion about challenges and successes in using and sharing these skills in their facilities. Available district medical and nursing officers were also interviewed, exploring how they perceived the training and how it had fitted into their hospital. The researcher also asked the trainees to identify cascadees such as nurses, nurse midwives, or NPCs to whom they had delivered some training. The researcher then sought interviews with available cascadees about the delivery and content of training they had received.

Three researchers carried out a third set of interviews with trainees while they were attending the week long residential delivery of modules five and six. We asked the trainees to provide specific examples of how they had used the training in their clinical work, describing actual cases. At this time, we also interviewed the two obstetricians who had worked alongside the NCPs.

Summary of qualitative results in Malawi
The first set of interviews showed that the trainees had good recall of their training courses, but it is from the second set of interviews that the application of their knowledge becomes apparent.

Focusing on how the trainees work with and transmit new learning to others in their work place, at the second time point, 10 of the 12 interviewed then talked about how the leadership training had helped them work better with those around them. District Health Officers also noted that the trainees were taking leading roles in improving health care practice, while the 10 interviews with cascadees indicated that trainees were sharing their knowledge and skills with those around them. The step-by-step approach of helping a new-born to breathe was reported most commonly as having been taught.

The 39 trainees interviewed at the third time point provide evidence of how they used the various skills and knowledge from their training in clinical practice. They commented on the practical skills such as the use of lower-segment caesarean section, vacuum extraction and neonatal resuscitation, but also contextualised these skills in the wider co-ordination of staff to ensure good management particularly in emergency situations such as post-partum haemorrhage.

Leadership was, without doubt, the part of the training that trainees talked about most and with the most enthusiasm. Many trainees became very animated during the interview when talking about how they had used these skills to bring about change in the clinical care delivered. They learned to be strategic in negotiating for resources, and to work constructively with obstetricians and senior staff. For many it was a revelation that by taking a different approach so much could be achieved.

Tanzania
Interviews with trainees were carried out at or near the health facilities at mutually agreeable times during the researcher’s visit. The researchers in Ifakara conducted most of the interviews in Kiswahili to ensure no loss of meaning in expressions.

Summary of qualitative results in Tanzania
The training was positively received and, as in Malawi, a change in attitude was noted in the time following the initial course. The increased skill level, coupled with the students’ ability to be more strategic in their approach following the leadership training. For example, there was a long-standing difficulty in the working relationship between the clinical officers and the obstetricians, but the ETATMBA training has dissolved the tension and brought cohesion among the two groups; medical doctors now do feel that the clinical officers can perform better after been updated with new skills. The trainees were also more confident about diagnosing difficult cases and referring them promptly, rather than delaying while they tried to cope alone.

The size and isolation of many districts in Tanzania, with inadequate resourcing, was a major difficulty for some of the trainees. The poor transport infrastructure in particular could make hospital transfers impossible. This was a source of frustration for the trainees as they were sometimes unable to implement the skills they had learnt.

Despite such difficulties the leadership training led to some positive results; some trainees reported they were confident to face the management for any request or discussion while previously they thought it was the role of managers to identify problems. They also demonstrated creativity in their problem-solving. In one instance, the clinical officer bypassed the immediate management and appealed to the local Member of Parliament, who was able to address the issue. Other trainees were successful in lobbying local councils and churches for funds to build or improve health centres; this was seen as an aspect of their leadership role and a way in which they could make a difference despite difficult circumstances.


Quantitative Research Study

Malawi
Primary data was extracted from the maternity log at the district hospital (which included data sent by other facilities such as health centres) and rural hospitals in each district by the two research assistants monitored by the local and UK team. We collected baseline data at about 18 months into the project and at the end in January/February 2014 (data collected in total was for 2011, 2012, and 2013).

Summary of quantitative results in Malawi
Fifty-four trainees were recruited, representing 67% (54/81) of the COs working in emergency obstetric and new-born care (EmONC) in the intervention districts. Our primary outcome was to look for reduction in perinatal mortality (defined in this study as fresh stillbirth and neonatal death before discharge from the facility). We noted particularly that there are large variations across districts in perinatal mortality rate: in 2013 rates range from 25+ to 14 per 1000 births. There are no significant differences although it appears the control group districts saw the greatest reduction rates appear to have levelled out at around 20 per 1000 births, although starting with the higher baseline of 29 in 2011. The trend does appear to be downward. We are cautious about the interpretation of these figures as the data quality was variable, with poor recording in some districts.

Maternal mortality was a secondary outcome in this study. Again, we noted huge variation in results. There is a possible trend towards an improvement in many of the intervention districts, with six of the eight with lower numbers but also importantly lower rate. Meanwhile in the control districts maternal mortality appears to worsen with five out of six having an increase in rate. In the totals it is harder to see any improving trend as in the intervention districts: overall the rate has risen from 302.2 to 317.3 per 100,000 births in 2013 with a huge increase in 2012 to 658.9 per 100,000 births. We draw attention to a number of outlier figures, not least Lilongwe district, which are within our results that make a number of the districts look very poor. For example the 2012 – 2013 results in Ntchisi where 84 and 83 deaths are reported in the district when there were only around 4000 and 7000 births respectively, compared to 2 in 2011. Rumphi in 2011 recorded 121 deaths from only 4827 births, data that is hard to believe. When we remove Lilongwe from the totals we see a downward trend from 480.3 in 2011 to 264 (2012) and 255.8 in 2013. This variability in the reported results that appear to be outliers means that more complex multivariate analysis with modelling will need to be undertaken before any firm conclusions can be drawn and further checking of source data in Malawi will need to be undertaken before publication.


Tanzania
The research assistants identified the facilities in which trainees are working and extracted the study variables from the Ifakara database to create an ETATMBA database. Baseline data was data for the facility for the year 2011. The follow-up data will be the same variables for the year 2013. The follow-up data was gathered during the ‘grand tour’.

Summary of quantitative results in Tanzania
We reviewed the key maternal, neonatal and birth complication figures across Tanzania for 2011 and 2013 from the health facilities included. It is important to note here that our primary outcome of neonatal mortality and thus perinatal mortality (defined as fresh stillbirths and neonatal deaths before discharge from the health care facility) could not be collected. Whilst stillbirths are recorded as a matter of course, neonatal death is not recorded at the facilities visited.

There was no significant change in fresh stillbirths. No significant differences were found for any of the key maternal, neonatal and birth complication variables across the lifetime of the project. The number of deliveries seemed to reduce slightly overall (-604) but the number of deliveries in health centres did rise (from 7326 to 7961). There is only a slight increase in overall fresh still births (+16, an increase of 1 case per 1000 births) whilst macerated appear to worsen in health centres (from 8.3 to 13.9 cases per 1000 deliveries). Maternal death shows a downward, improving, trend over the two years (down from 282 to 232 cases per 100,000 deliveries), but this is not significant. There is a reduction in the number of caesarean sections overall down from 80.2 to 77.2 (cases per 1000 deliveries) with the largest reduction indicated in health centres where rates are down from 10.6 to 6.2 (cases per 1000 deliveries). The three birth complication variables collected all show a slight increase overall but each show differing trends in where the complications are reported. The rates of post-partum haemorrhage change little over time whilst obstructed labour rates increased in district hospitals (6.4 to 9.5 cases per 1000 deliveries) but in health centres there was a decrease (6.7 to 2.9 cases per 1000 deliveries). Sepsis follows a similar trend with an increase in hospitals (1.7 to 3.1 cases per 1000 deliveries) and a decrease in health centres (1.6 to 0.5 cases per 1000 deliveries). This could imply earlier recognition and transfer of at-risk mothers from health centres to hospitals as a result of training.

In addition a full facilities audit was carried out by the research team of the effectiveness of the government programme to upgrade the health centres used in the study to full EmMONC standards. Full details of this, with accompanying tables, are given in the Evaluation Report.
Potential Impact:
Building capacity and improving services by developing training

Research capacity building was a challenge which has been met creatively in order to optimise the potential for sustainability. There were difficulties, previously reported, in recruiting PhD students. This was in part due to IHI’s lack of a university degree awarding power. The institution had to rely on local African universities to accredit. Partly driven by the needs of this project, the new link with St Francis University at Ifakara will be an option for the future. Meanwhile, for the project research, the solution was to enrol two masters students through the University of Warwick. Both of these are already employees at IHI with considerable experience of research project work. They have completed data collection for the Tanzanian cohort of trainees and have successfully completed their statutory month of residential training at Warwick for their first year of study. As part of this, the students had to make a formal presentation in order to be assessed for their suitability to continue on the programme: both were approved. One of the students is noted to be particularly able, and it is likely that she will wish to progress to a PhD. The fact that both students have a stable contract with IHI, and plan to continue working there, will enhance research capacity both at the institution itself and within Tanzania as their careers progress. IHI are funding and committed to ensuring the completion of the research MSc at Warwick.

In Malawi one PhD student was recruited at the beginning of the study. As an experienced research assistant, she was able to build on this by joining the project and has continued throughout its duration; she will complete her studies after the end date of the project. A masters student was recruited when it became apparent that a second PhD candidate could not be found in sufficient time to replace the one the Ministry had to remove. This practical solution enabled the collection of the research data for the study, as well as enhancing the research capacity of the University of Malawi with the addition of a formally-trained researcher. To build research capacity we have collected all research data through trainees and not employed experienced research field workers. The fact that African partners in the final year suffered from a cash flow crisis caused by retentions and delays in EC funding caused immense frustration for the clinical scientists on the team, limiting the time and available staff supervision to go into the field with the students to support and refine their efforts in comprehensive data collection.

Warwick has provided research supervision across both Tanzania and Malawi, thereby ensuring consistency of quality for the research and access to support for the students.

The challenge for the ETATMBA team now is to develop the tools so that they can be applied as a package in other sub-Saharan countries. The results will enable the team to identify the core elements of the training programme which can most usefully be applied elsewhere. Further work and collaboration between IHI, Uganda, Warwick and Birmingham University is working on a cost-effective training programme for clinical officers and nurses that includes leadership training, accreditation and supported learning in the workplace and grant applications are presently underway: a multinational team involving four universities held its first meeting in September 2014.

Evidence-based practice and audit

The impact of our achievements in WP 2 (improved, updated guidelines) will potentially be significant in the forthcoming revisions of norms for obstetric management in the Ministries of Health in both Tanzania and Malawi. It is important to underline that inputs to this ongoing process of enhancing quality of care come from a number of different professional sources in both Tanzania and Malawi. Various NGOs and donor agencies might offer support and national academic/clinical circles contribute with their own research results.

In Tanzania, the work undertaken by the ETATMBA team has been submitted to the Safer Motherhood working group, which is collating the inputs of all organisations involved in improving clinical guidelines, and this group will present its findings to the Ministry of Health. Thus the project has contributed in a meaningful way to future government policy, which will ultimately benefit the mothers and babies who will receive health care based on best clinical practice.

This power of audit to identify areas for improvement and to show evidence of improvement after a change, based on best practice from the guidelines, has inspired the clinical officers, their local District Medical Officers and the Ministry of Health as far as Principal Secretary level. As a previously under-valued group, they had little confidence in their own abilities to make changes when their working environments were so challenging and poorly-resourced. Actively following the audit cycle and seeing real improvements in health care in their own hospitals has enabled them to see themselves as leaders who can make a difference. The quality and achievements of their professional projects speak for themselves and the clearest examples are on the website.

Regular, criterion-based audit sessions have been initiated as part of ongoing in-service staff training. A number of obstetric process indictors have been introduced, such as facility-based deliveries as a percentage of expected deliveries in an assumed catchment area, percentage of caesarean sections of all facility-based deliveries and also case fatality rates per morbidity. In Tanzania there is now a good archive of case notes and partograms, which constitute the very basis of clinical audit in all facilities where the project has been implemented.

The value of the leadership training can be seen from the results of the qualitative study. It is apparent that training a few key individuals and ensuring that they cascade their learning and improved practices to colleagues has been highly beneficial. Not only has it increased the clinical officers’ own sense of themselves as a profession, but it has also benefitted their institutions in a positive way by making cultural changes which will ultimately help to drive up standards. The Tanzanian Ministry of Health has recognised the value of the leadership training and is espousing this as a key element for future training courses. The Ministry of Health in Malawi and CHAM has supported the development of the BSc programme, again after seeing the benefits that a fully professional workforce can confer on both individuals and communities. Collaborations with future external funders (GEZ) to act as partners in this development have been established in Malawi by the ETATMBA and COSTA programmes, both EC projects.

Empowerment and professional support

In terms of team working between clinical officers, in Malawi this has also extended beyond the training course. We have previously reported how the course had fostered team working between interprofessional learners through the inclusion of nurses and managers on the leadership and service improvement course. The clinical officers have now organised themselves through the leadership of one or two individuals into using Facebook as a social network through which they share professional and informal advice. They also use this social network as a way of discussing their position as clinical officers, and we believe this has the potential to complement the professional web sites that we also reported previously. The Facebook group is a private group to the NPCs but we hope to learn more about their perceptions of its benefit through the qualitative research that is ongoing. Around 50% of the Malawi clinical officers have also connected via LinkedIn with members of the Warwick faculty. Indeed the Malawi clinical officers’ network set up during ETATMBA was extremely effective during the first year in ensuring they were offered a full BSc and in representing themselves to the Ministry and the Medical Council of Malawi, their registration body.

Although this is another example of an informal network that has sprung up separate to the formal course, it is an example of the professional collegiality that the clinical officers have developed as a result of being brought together by ETATMBA. We need to keep an open mind about the importance and usefulness of professional social networks such as LinkedIn, but the very fact that Malawi NPCs are using this means that they are participants in the exploration of this and that is an important point. We believe that professional empowerment accompanies professional engagement.

We expect that one of the next steps in sustaining the foreground developments in this project is a new initiative to create a portal of open educational resources free at the point of access to all healthcare professionals in some of the Malawi training hospitals. We have started a pilot project in collaboration with SkyBand, one of the main wireless broadband providers in Malawi that if successful will see free wifi access to a health education portal created by ETATMBA. SkyBand have provisionally agreed to waive access to public wifi in these locations as part of their corporate responsibility initiatives. By installing toll-free wifi hotspots in two hospitals, one in Lilongwe and one in Mzuzu, we plant to test the feasibility and demand for access to Internet-based evidence-based learning resources. Open educational resources are of course free to access, but the cost to get online is a barrier for many in Malawi. We have also identified another partner, the University of Edinburgh, which has been working in parallel with the College of Medicine to develop capacity in the creation on online learning resource. We believe that our approaches are complementary and therefore we are planning a new project to share infrastructure and know-how in partnership with the College of Medicine.

In Tanzania this background is also being maintained by the obstetrician mentors in their own time and funds continuing to support their AMO colleagues in their workplaces and to provide 24-hour phone advice through the services of Vodaphone.

Research and evaluation of effectiveness

At the suggestion of the external reviewer, the partners re-considered the previously-unfilled role of Senior Clinical Research Fellow (SCRF). The African partners had originally felt that this role would not be useful to them, and that the funds would be better placed in supporting local faculty staff, but the matter was discussed again following the review.

Through links with Prof Nynke van den Broek of the Liverpool School of Tropical Medicine, who is a member of the ETATMBA External Advisory Board, a suitable candidate was identified. Dr Mselenge Mdegela is a Tanzanian obstetrician with considerable research experience. He was willing to be seconded to the project in June and July 2014 to assist with collating the research findings. He not only completed this role, but also proposed following up the ETATMBA students in both Malawi and Tanzania, to see how they continued to progress the training they had received, and how their careers developed.

Dr Mdegela will undertake this work as a PhD over three years, for which other funding has been secured. It will enable clearer understanding of the issues facing clinical officers, how they develop as individuals and how their professional identity changes in the years following their training. It is also planned that he will follow up the regional quantitative data in Malawi and Tanzania for the next three years to allow us to see if a reduction in maternal and perinatal mortality can be seen from 2013-2015 in Malawi and sustained in Tanzania.

This work will be useful not only for following up the individual clinical officers and their career progression, but will also be of use to training facilities and employers in how they plan staffing and promotions. It will give a clearer sense of the professional identity of the group and show how this identity is constructed and further developed.

The ETATMBA project was ground-breaking and its impact on the training of clinical officers across sub-Saharan Africa is highly significant. The findings indicate that the continued up-skilling of non-physician clinicians in obstetrics and neonatal care is worthwhile and beneficial. However there are also implications which are far wider and which are relevant across all areas of healthcare.

The first of these is that an essential component of any training has to be leadership training (as this gives the skills and confidence to problem-solve). More specifically, the leadership training has to be contextualised in a real, working environment, not just taught as theory. Without this sense of context, the training is at best no more than a set of ideals and at worst could have the opposite effect: disempowerment as individuals feel they cannot possibly achieve positive change with the few resources available to them. By embedding the leadership training within a real, working environment, students learn to optimise what they have and discover that creative solutions suited to local environments are the key to improvements in clinical practice.

The implication of the leadership training is that the clinical officers need to feel valued. They are providing an important service and are often very loyal, staying in local areas and building up trust within communities. Equally, they will accept postings to other regions, and in Malawi the Ministry of Health (the employing authority) has already recognised the value of the ETATMBA training and plans to deploy the clinical officers who attended the courses to other areas which were not part of the project. This is in marked contrast to the supply of medically-qualified doctors who are either severely over-stretched or who simply leave to work in other countries where they are more likely to receive better pay and conditions.

A clear career pathway and recognition is also an essential implication of the study findings. There are some differences between clinical officers in different countries leading to disparity and discontent. For example, in Tanzania the training and career pathways are better-established and the infrastructure is more organized. The students were happy to attend the courses without an externally-recognisable qualification and to consolidate their training with internships. However the situation in Malawi was very different. The Ministry of Health promotional structure is linked to qualifications, so without a degree, they clinical officers could never progress beyond a certain point, no matter how experienced they were. This need for a qualification was such that no-one was willing to come on the courses without assurance that the training would lead to a BSc. Their drive and determination for this was instrumental in formulating not just the Warwick BSc for this cadre, but in the College of Medicine developing its own BSc across several specialities, for the benefit of future cadres. For the first time in 50 years since independence a structured post-qualification system of specialist training has been established in these countries and they will become beacons of excellence that light the way for NPC training across Africa.

Reasonable remuneration for their work is also an issue which affects clinical officers not just in Malawi and Tanzania but across sub-Saharan Africa. This is an added motivation for the workers in this healthcare sector to coalesce and form a clear identity, since their case can be better made if they are a united profession rather than a set of individual national groups.

Whilst all this is under development, good quality national and international support, together with trained local mentors and a support network would benefit the clinical officers and enhance their professional reputation. Such support is partly dependent on resources, but as described above, the use of social networking generated by the clinical officers themselves has been an essential first line of support. The further work planned to follow up the ETATMBA students will be able to investigate what external support might be utilised and whether the leadership skills of the students will help them in accessing it.

Finally, the project has shown that leadership training can make a difference to health care, despite circumstances which might be judged as difficult or even impossible. It highlights the fact that often the solutions to problems are not dependent on high-tech interventions but about ensuring that simple resources are made to work effectively. Thus government improvements in basic infrastructure (roads, communication, fresh running water, diesel and electricity) would be more useful than sponsoring technologically complex initiatives. The clinical officers, when given the opportunity to become leaders, have shown that they can meet this challenge and make a difference to the lives of the women and children in their care.
List of Websites:
www.etatmba.org