ETHIOPIA

Ethiopia has been experiencing serious shortage of gynaecologists and surgeons for several decades. In 2011, the total number of all specialists working in the public health sector was 606 with a ratio of 1 specialist to about 54,000 population. The lack of these professionals for the majority has probably contributed significantly to the relatively high maternal and perinatal mortality and morbidity. Due to the low access to emergency surgery, the number of surgical procedures in 2011 in the Southern Regional Sate varied from 56 to 421 operations per year per 100,000 catchment population; 36% were major surgical operations, and 58% were caesarean sections. All these procedures were performed by either gynecologist or surgeon. The national assessment in 2008 in 797 facilities also identified that the caesarean delivery rate was 0.6%, with regional variation from 0.2% to 9%. This was despite the World Health Organization (WHO) recommendation of 5% to 15% cesarean delivery for the general population.

A narrative synthesis identified that shifting and sharing delivery of obstetric surgery, anesthesia and abortion care tasks to non-physicians may increase access to and availability of maternal and reproductive health services without compromising performance. Taking all these into account, the Ministry of Health of Ethiopia, in collaboration with universities and development partners, has taken the initiative to train non-doctor health professionals in emergency obstetrics and general surgery in 2006. This innovative program has got the attention of several partners. However, since this program was the first of its kind in the world (training health officers with a Bachelor of Science Degree to Master's Degree level), several professionals (particularly surgeons) were questioning the graduates' capacity to handle emergency surgical problems in the rural setting, where surgeons and obstetricians are inaccessible. The back and forth discussion with stakeholders had delayed the initiation of the program by about three years. Lastly, a three-year masters level training curriculum was launched in January 2009 in three universities by admitting health officers with a Bachelor of Science Degree and two or more years of work experience. So far, more than 700 students have been admitted in 12 universities across the country, and several African countries are benchmarking it for similar undertakings. The first batch graduated in early 2012 and has been in service for more than three years. During annual review meetings, regional health bureaus' representatives have been heard expressing their appreciation of the impact the assigned surgical officers are bringing about in their vicinity.

Nevertheless, some still express their concerns regarding the graduates' clinical decision making capacity and surgical skill in the management of emergency surgical cases. Unpublished UNFPA survey report from ten hospitals in 2012 focusing only on emergency obstetric care. However, it has shown that the volume of obstetric and surgical emergency cases managed with surgical procedures have increased, and a significant reduction in maternal mortality has been observed. There was also a 49% reduction in obstetric referral from the studied hospitals. A study again focusing on comprehensive emergency obstetric care in Tigray reported that 63.3% of the obstetric procedures were performed by non-physician clinicians, and there was no significant difference in maternal deaths, fetal deaths and length of hospital stay between the physician and non-physician procedures