Surgical Task Shifting in Sub-Saharan Africa

The poor availability of surgical services in developing countries is a long neglected problem that has recently gained attention [1,2]. Violence, injury, and obstetric emergencies are among leading causes of mortality and morbidity that can be mitigated through surgical intervention. Surgically treatable problems are estimated to account for up to 11% of the world’s disability-adjusted life years [1]. In addition to this massive disease burden there are problems that are seriously debilitating (cataract) or stigmatizing (fistula). Surgical interventions are often viewed as expensive and complex, but many common problems amenable to surgery in resource-limited settings are cost-effective and do not require specialized staff and equipment. The World Health Organization (WHO) has prioritized a list of cost-effective surgical interventions for developing countries including emergency care of trauma, obstetrical complications, and acute abdomens as well as elective care of hernias, clubfoot, cataracts, hydroceles, and otitis media [3]. One of the main barriers to surgical care—defined as the safe provision of preoperative, operative, and post-operative surgical and anesthesia services—in resource-limited settings is the shortage of trained health workers. Africa accounts for 24% of the global disease burden but only 3% of the global health workforce [4]. The reasons for this are well documented and include inadequate salaries and poor working conditions leading to staff attrition, unwillingness of international donors to support financing for human resources [5], an insufficiency of medical schools [6], and the brain drain of health staff to resource-rich countries [4,7,8]. The human resource crisis is most acute at the level of specialists, including surgeons and anesthesiologists [9,10]. In East Africa, there are 0.25 fully trained surgeons per 100,000 persons compared to 5.69 per 100,000 in the United States [11,12]. The actual minimum number of surgeons required is unknown. Given the unlikelihood of even a modest increase in the number of surgeons and anesthesiologists working in Africa in the near future, a number of approaches are being piloted to overcome the skills shortage. These include surgical camps and specialist outreach programs (often supported by international experts) and the mobilization of non-physician clinicians (NPCs) to perform surgical and anesthetic tasks [13]. This latter approach, which involves the shifting of tasks from surgeons and anesthesiologists to nonspecialists, has the greatest potential to provide coverage of basic surgical care, especially in rural areas. Task shifting involves the delegation of certain medical responsibilities to less specialized health care workers. In sub-Saharan Africa, task shifting has recently been promoted and formalized to help address the HIV/AIDS epidemic [14]. This paper discusses some of the experiences of surgical task shifting to date, and outlines lessons from task shifting in the delivery of HIV/AIDS care.