After independence in 1975, the country had only 80 doctors to serve a population of 14 million and precious few staff capable of providing emergency obstetric care3. However, starting in 1984 Mozambique began to explore a partial solution to this immediate challenge by training non-medical staff to undertake obstetric surgery.
How it led to productivity improvement
While obstetric surgery is traditionally conducted by gynecologists, many obstetric surgical interventions (such as caesarean sections) can also be performed by trained non-physicians. Starting in 1984, the country began to recruit healthcare workers from rural areas to be trained in performing these kinds of interventions. Candidates were required to have at least a three-year degree as either a nurse or a medical assistant and then had to complete a two-year course, which was followed by 12 month internship under supervision of a surgeon (Kruk et al. 2007). After completing the course, recruits became ‘Tecnicos de cirurgia’ (a role comparable to surgically trained assistant medical officers), and were allowed to perform obstetric surgeries.
Over the years, the Tecnicos have become a vitally important part of the delivery of obstetric care in rural areas of Mozambique. Indeed, according to a 2007 study, fully 92 percent of all obstetric surgeries in all district hospitals were being carried out by Tecnicos de cirurgia (Kruk et al. 2007). Moreover, Mozambique enjoys a high retention rate for these Tecnicos, 88 percent of which were still working in the country seven years after graduation. This achievement is made even more significant when juxtaposed against the retention rate for physicians which had fallen to zero after seven years.
Studies into the Tecnicos success also reveal that, after reviewing 2,071 caesarean sections performed by Tecnicos and gynecologists (Kruk et al. 2007), there had been no clinically significant difference in outcome measures between the two: “decision making and quality of care as gauged by indications for surgery, postoperative deaths, and major complications were comparable to obstetricians” (Kruk et al. 2007).
The Tecnicos initiative also proved to be exceptionally cost-effective. Research shows that the training of one Tecnico cost US$19,465 as compared to US$74,130 per physician. Equally, the annual cost of deployment was also much lower with each Tecnico requiring US$3,859 versus US$10,367 per physician (Kruk et al. 2007). This example shows that by expanding the pool of skilled workers, demand for healthcare can be met without compromising the quality of care. Mozambique’s experience proves that non-traditional measures can reduce healthcare costs and enhance staff retention.
Back to top
*This case illustrates how in developing countries unorthodox solutions have to be found given the immense shortages of skilled healthcare professionals. It is not intended as an example of how every healthcare system should be run, but of how developed countries can learn from developing countries.
3Krkr et al, 2007.