Nairobi — Surgery performed by associate clinicians or medical professionals who are not qualified surgeons are as safe and effective as those performed by doctors, and should be promoted in Sub-Saharan Africa, a study suggests.
Faced with a growing shortfall of surgeons, the 68th World Health Assembly passed a resolution in 2015 to promote so-called task shifting in hospitals globally. The term refers to the sharing of clinical tasks among specialist and non-specialist medical doctors and mid-level health care workers, or associate clinicians, whose educational qualifications are between that of a nurse and a physician.
According to the study, groin hernia — a bulging of contents of the belly through a weakened stomach wall — affects more than 200 million people worldwide, with 20 million hernia repairs performed each year. However, evidence that hernia operations performed by associate clinicians are effective and safe had been inconclusive.
Researchers therefore decided to examine the rates of recurrence of hernias following operations performed in Sierra Leone between October 2017 and February 2018. They analysed outcomes within one year of surgery on 114 patients by five physicians, and 115 patients by six associate clinicians.
“The associate clinicians were non-inferior to the medical doctors,” says Michael Ohene- Yeboah, a co-author of the study and an associate professor of surgery at the University of Ghana. “The associate clinicians had a recurrence rate of 0.9 per cent and the medical doctors had a recurrence rate of 6.9 per cent. We conclude that task sharing with associate clinicians in the study setting is safe and effective.”
Ohene-Yeboah tells SciDev.Net that hernia operations are the most commonly performed general surgical procedure but the gap between surgical volume and surgical need is immense. Task sharing has been implemented as a solution to the health workforce crisis in surgery in most countries in Sub-Saharan Africa, he added.
The study published in JAMA Network Open in January involved a randomised clinical trial with adult male patients aged at least 18 years old with groin hernias and no significant medical problems that would make surgery inappropriate.
“After one year, all patients reported fewer symptoms from the groin than before the operation, and 208 patients (99 per cent) were satisfied with the result of the operation,” the study adds.
According to Ohene-Yeboah, there are 70-times as many surgical workers per 100,000 people in high-income countries compared with low-income countries.
“There is an urgent need to increase the surgical work force in Sierra Leone and other African [countries],” he says. “Policymakers may take advantage of the key findings of this study to train more associate clinicians and increase the surgical workforce.”
The shortage of surgeons in Sierra Leone and other African countries, he explains, are mostly due to inadequate investment in training personnel and the migration of doctors to high-income countries.
“The study highlights that it is the training that the surgical providers have received that is most important, [and] not the title,” Yeboah says.
But Mohammed Bailor Barrie, a physician and strategic advisor to Partners in Health Sierra Leone, says that many medical doctors in the country do not like the idea of community health officers being trained to do basic surgery because they will pose as surgeons when they are not, and attempt to perform complex operations which can lead to complications.
“I believe that there are many people who these community health officers can save if trained well to perform basic surgeries,” he tells SciDev.Net, adding that task shifting can take away the burden of surgeons so that they can focus on doing the complicated surgeries.
“African countries should look at their health systems, their burden of disease and their capacity to handle basic surgeries. Countries that lack the capacity to do basic surgeries, I would recommend them to adopt this [as a] policy”.
This piece was produced by SciDev.Net’s Sub-Saharan Africa English desk.
 Thomas Ashley and others Outcomes after elective inguinal hernia repair performed by associate clinicians vs medical doctors in Sierra Leone (JAMA Network Open, 11 January, 2021)
 World Bank Surgical care – an overlooked entity in health systems (World Bank, February 14, 2018)