Obstetrical and abdominal emergencies, and trauma, much of it affecting children, represent a major and neglected part of Africa’s burden of disease. Countries cannot train and retain sufficient specialist surgeons (doctors) to address these priorities. We propose a surgical training intervention targeted at Clinical officers (COs), who are trained non-physician clinicians that form the backbone of Africa’s district hospital services. Lacking medical degrees, COs have fewer opportunities for emigration. Surgical training of non-clinician physicians has been tried and reportedly worked well in African countries. It has never been rigorously evaluated, nor been subject to economic and population impact assessments. Two different 2 year training models are proposed: district hospital in-service training in Malawi and centralised training in Zambia. Before-and-after and randomized controlled trial evaluations are planned. The latter is the strongest study design for evaluating an intervention. Outcomes will include direct health benefits to patients, including morbidity and mortality averted; improved provider knowledge, skills and performance; direct (surgical) and indirect (management and other services) improvements in district hospital performance. Cost-effectiveness analyses and population impact assessments will be conducted.
Clinical Officer training has for long been a feasible and acceptable model to African national policy makers; and COST-Africa has already elicited high level expressions of support. There will be an ongoing interaction with national stakeholders in both countries to ensure attractive career paths, salaries and retention strategies are in place for the graduates. A proven model for training and retaining a new cadre of non-physician surgical officers has the potential to provide a standard of life-saving surgical care often denied to African populations; tackle major rural:urban inequities; and transform district hospital care. Without such a resource, Africa has no hope of reaching MDG 5 on maternal mortality; and reduced hope for MDG 4 on childhood mortality.
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