TRAINING NON-PHYSICIAN CLINICIANS TO IMPROVE THE SURVIVAL OF MOTHERS AND BABIES IN AFRICA – THE ETATMBA PROJECT DR PAUL O’HARE PROJECT LEAD

ETATMBA: (Enhancing Training and Appropriate Technologies for Mothers and Babies in Africa) Tanzania and Malawi ETATMBA is a European Commission FP7 funded project being delivered in Tanzania and MalawiPartners: The University of Warwick (UK) The University of Warwick (UK) Karolinska Institute (Sweden) Karolinska Institute (Sweden) Ifakara Health Institute, TanzaniaIfakara Health Institute, Tanzania The University of Malawi The University of Malawi The Ministry of Health (Malawi) The Ministry of Health (Malawi) GE Healthcare (UK) GE Healthcare (UK)

600,000 women and 7 million babies die annually in childbirth. When obstetric and neonatal emergencies arise most Sub-Saharan African women face childbirth without access to skilled health workers. Education, training and retention of health professionals is the key to improving healthcare for mothers and babies in Africa. In the modern world this tragedy is unacceptable and largely preventable.

ETATMBA (Enhancing Training and Appropriate Technologies for Mothers and Babies in Africa) Very few Medical Doctors in Malawi and Tanzania –260* approximately 1 Medical Doctor per 50,000 people Similar to other African Countries much of this work is done by: Non-Physician Clinicians (NPCs) *Data from 2009

Non-Physician Clinicians (NPCs) are an effective and retainable health solution for doctor-less rural and many urban areas of Africa. Task-shifting to NPCs needs to be: extended enhanced endorsed and supported by the healthcare community. Karolinska (S.B.), global health lead in advocating and evaluating NPCs. Needs to be developed, scaled up and be sustainable in an African setting. Warwick expertise in scaling up health professional educational delivery.

Peirera & Bergström 2071 Caesarean Sections - Non-Clinician Physicians - Doctors in District hospitals (Medical Officers) No clinically significant difference in outcome Mozambique 2002 – NPCs (TCs) performed 57% of 12000caesarean section ruptured uterus ectopic pregnancy Rural areas 92% of 3246

Retention of DRs in Africa ‘There are more Malawi doctors in Manchester than Malawi’ Newly graduated Malawi doctors are sent to district/rural posts but none remain in these posts after 7 years. 88% of NPCs (TC) are retained in their original post But –Professional Status –Continuing Professional Development –Maintenance and progression of standards –Sustainability of resource –Training in leadership in Health

Non-Physician Clinicians (NPC’s) “The crisis in human healthcare resources disproportionately affects the poorest women in low income countries.” “Are non-physician clinicians a substandard solution to the crisis in human resources for maternal health?” “Evidence suggests that the answer is no.” Bergström, BMJ 2011;342:d2499 doi: /bmj.d2499

“The Warm Heart of Africa”

Facts about Malawi (General) Malawi is miles ( km) in size England is miles ( km) Malawi (formally Nyasaland)Was a British Colony until 1964 Lake Malawi (Lake Nyasa) 3 rd largest in Africa 8 th in world Main language is English (and they drive on the left!) Population is currently about 15 Million Predicted to rise to 45 Million by % are Christian and about 13% Muslim Education: Entitled to 5 years primary education (not compulsory) Uptake is low but improving A resource poor country (some tobacco, sugar, tea etc…) Agriculture, Subsistence farming (Maize being main crop)

Main Health Issues Life expectancy at birth: Total population: 51.7 years Male: years Female: years HIV/AIDS HIV/AIDS –WHO suggest 13% of population but data from 2007 (Just under 1 Million people living with HIV/AIDS ) Malaria Malaria Maternal and Neonatal Mortality Maternal and Neonatal Mortality (2011 estimates WHO)

Healthcare Spend Per Capita (USD) USA, $7,410* UK, $3,399* Malawi, $50* *Source: WHO (Global Health Observatory, 2009)

ETATMBA The project is to train 50 Non- Physician Clinicians (NPCs) as advanced leaders providing them with skills and knowledge in advanced neonatal and obstetric care (over a 24 month period). Training it is hoped that will be cascaded to their colleagues (other NPCs, midwives, nurses). The aim of the project is to try and address the high levels of maternal and neonatal mortality.

Clinical Service Improvement will be developed, implemented and evaluated through: clinical guidelines and pathways, structured education, clinical leadership training and workforce development of NPCs and faculty.

Evaluating the impact of ETATMBA The aim of this study is to: Evaluate the impact on healthcare outcomes of the ETATMBA training in Malawi.Evaluate the impact on healthcare outcomes of the ETATMBA training in Malawi. OUTCOMES (Primary): Perinatal mortality (defined as fresh stillbirths and neonatal deaths before discharge from the health care facility)Perinatal mortality (defined as fresh stillbirths and neonatal deaths before discharge from the health care facility) OUTCOMES (Secondary): Maternal death rates;Maternal death rates; Recorded data (e.g. still births, Post-Partum Haemorrhage, C Section, Eclampsia, Sepsis,Recorded data (e.g. still births, Post-Partum Haemorrhage, C Section, Eclampsia, Sepsis, Neonatal resuscitation);Neonatal resuscitation); Availability of resources (e.g. are drugs/blood available);Availability of resources (e.g. are drugs/blood available); Use of available resources (e.g. are drugs being used).Use of available resources (e.g. are drugs being used).

Design & Methods Cluster Randomised Controlled Trial with a Process Evaluation 8 of the 14 districts from Central and Northern Malawi are randomised to the intervention8 of the 14 districts from Central and Northern Malawi are randomised to the intervention Methods (Mixed) Quantitative (hospital outcome data)Quantitative (hospital outcome data) Qualitative(interviews with key stakeholders)Qualitative(interviews with key stakeholders)

Quantitative data Primary data will be extracted from the maternity log and or the summary reports at the district hospitals All health facilities in a district return this data to the district hospital on a monthly basis Data are to be collected retrospectively at three points in time: 1.For the 12 months leading up to start of project (Baseline) 2.At the end of the first year 3.At the end of the second year

Qualitative data In depth interviews with: NPC’sNPC’s District Medical OfficersDistrict Medical Officers District Nursing OfficersDistrict Nursing Officers Cascades' (who are trained by NPCs)Cascades' (who are trained by NPCs) Supervisors and tutorsSupervisors and tutors Baseline, 12 months and 24 months Exploring attitudes and behaviours Have we made a difference to practice?

TAKE HOME MESSAGES KEY TO IMPROVING SURVIVAL OR MOTHERS AND BABIES IN SUB-SAHARAN AFRICA IS TO TRAIN HEALTHCARE STAFF AT COALFACE NON-PHYSICIAN CLINICIANS ARE KEY TO THIS NOT ONLY A MATTER OF “TASK SHIFTING” OPERATIVE SKILLS NEED TO DEVELOP LEADERSHIP AND PROFESSIONAL SKILLS TO PRODUCE CLINICAL SERVICE IMPROVEMENTS NEED TO TEACH TO CASCADE LEARNING TO OTHER MEMBERS OF TEAM IN THEIR DISTRICTS EVALUATING EFFECT OF INTERVENTION CHALLENGING BUT NECESSARY TO ATTEMPT