Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland.
Faculty of Health, Medicine and Life Science, Maastricht University, Maastricht, The Netherlands.
Int J Health Policy Manag. 2022 Mar 1;11(3):354-361. doi: 10.34172/ijhpm.2020.142.
Low- and middle-income countries (LMICs) are the worst affected by a lack of safe and affordable access to safe surgery. The significant unmet surgical need can be in part attributed to surgical workforce shortages that disproportionately affect rural areas of these countries. To combat this, Malawi has introduced a cadre of non-physician clinicians (NPCs) called clinical officers (COs), trained to the level of a Bachelor of Science (BSc) in Surgery. This study explored the barriers and enablers to their retention in rural district hospitals (DHs), as perceived by the first cohort of COs trained to BSc in Surgery level in Malawi.
A longitudinal qualitative research approach was used based on interviews with 16 COs, practicing at DHs, during their BSc training (2015); and again with 15 of them after their graduation (2019). Data from both time points were analysed and compared using a top-down thematic analysis approach.
Of the 16 COs interviewed in 2015, 11 intended to take up a post at a DH following graduation; however, only 6 subsequently did so. The major barriers to remaining in a DH post as perceived by these COs were lack of promotion, a more attractive salary elsewhere; and unclear, stagnant career progression within surgery. For those who remained working in DH posts, the main enablers are a willingness to accept a low salary, to generate greater opportunities to engage in additional earning opportunities; the hope of promotional opportunities within the government system; and greater responsibility and recognition of their surgical knowledge and skills as a BSc-holder at the district level.
The sustainability of surgically trained NPCs in Malawi is not assured and further work is required to develop and implement successful retention strategies, which will require a multi-sector approach. This paper provides insights into barriers and enablers to retention of this newly-introduced cadre and has important lessons for policy-makers in Malawi and other countries employing NPCs to deliver essential surgery.
中低收入国家（LMICs）受到安全和负担得起的安全手术机会缺乏的影响最为严重。这种巨大的未满足的手术需求在一定程度上可以归因于外科劳动力短缺，这些国家的农村地区受到的影响尤为严重。为了解决这个问题，马拉维引入了一批非医师临床医生（NPCs），称为临床医生（COs），他们接受了相当于科学学士（BSc）水平的外科培训。本研究探讨了马拉维首批接受 BSc 水平外科培训的 COs 认为在农村地区医院（DHs）留住他们的障碍和促进因素。
采用纵向定性研究方法，对 16 名在 DHs 工作的 COs 进行了访谈，他们在接受 BSc 培训期间（2015 年）接受了访谈；在他们毕业后（2019 年）又对其中 15 人进行了访谈。对两个时间点的数据进行了分析，并使用自上而下的主题分析方法进行了比较。
在 2015 年接受采访的 16 名 COs 中，有 11 人打算毕业后在 DH 担任职务；然而，只有 6 人后来这样做了。这些 COs 认为，留在 DH 职位的主要障碍是缺乏晋升机会、其他地方更有吸引力的薪酬；以及外科领域内职业发展不明确和停滞不前。对于那些仍然在 DH 岗位工作的人来说，主要的促进因素是愿意接受低工资，创造更多机会从事额外的收入机会；希望在政府系统内获得晋升机会；以及作为持有 BSc 的人在地区一级更大程度地认可和认识到他们的外科知识和技能。
马拉维接受过外科培训的 NPCs 的可持续性尚不能确定，需要进一步努力制定和实施成功的留用策略，这将需要多部门的方法。本文提供了对新引入的这一人员队伍的留用障碍和促进因素的见解，为马拉维和其他国家的决策者提供了重要的经验教训，这些国家正在利用 NPC 提供基本手术。
