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Clinical Officer Training Malawi

From ”On the Job” training

in Surgery

towards a

Bachelor of Science degree course

for

Clinical Officers

in Malawi

Clinical Officer Training Malawi

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Clinical Officer Training Malawi

•  MALAWI

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Clinical Officer Training Malawi

16 m. 3% yearly increase, double in 15-20 yrs

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Clinical Officer Training Malawi

More about Malawi

•  The nr 9 poorest country world •  11% HIV pos •  1 Doctor for 50.000 inhabitants •  Few Malawian specialists

•  Braindrain CNN documentary: “More Malawian Doctors in Manchester

than in Malawi”

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Clinical Officer Training Malawi

DOS: Please train COs in surgery

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Clinical Officer Training Malawi

Why? Surgery by COs in the DHs: only 3% Operations in District Hospitals in Malawi in 2003 (total = 28594)

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Clinical Officer Training Malawi

COs and why to train in surgery?

•  Due to lack of Doctors, COs are the BACK BONE of health care •  Training COs is basic: 3 + 1 yr intern ship •  COs lack surgical skills and gain little

surgical experience in hospitals •  Consequently surg. patients referred to

Central Hospitals •  The 4 CHs: overloaded

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Clinical Officer Training Malawi

ON THE JOB. •  Why? Dr Lungu will tell (some handouts) PROGRAM •  2 years training for •  2 selected COs per hospital •  First in the SR, later NR •  Trained 45 COs •  In (17/11) 28 Hospitals

2005 Start COs trainings project

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Clinical Officer Training Malawi

•  Upgrade surgical/ obstetrica/ gynaecological knowledge and skills

•  Care for Trauma patients •  Safe practice of common surgical and

obstetrical procedures in DH/MHs •  To standardize and implement similar

surgical protocols (suture mat, antibiotics, pre-op pat.care, aseptic techniques in theatre et

•  Less referrals to CHs

Goal CO training

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Clinical Officer Training Malawi Teaching Program in 2 years

•  HOSPITAL VISITS Every 3-4 weeks, lasting 1-2 days

by (expatriate) surgeons / 1 gynecologist •  ATTACHMENT WEEKS for Extra Theory and Skills in

- General Surgery - Obstetrics and Gynecology - Trauma and Orthopaedics - Resuscitation - Surgical ENT, Dermatology. Ophthalmology

- Pathology (technique FNA, biopsies) - Basic Ultrasound course

Teachers Att. wks from CoM

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Clinical Officer Training Malawi

Program training is structured

First day •  Morning: Out Patient Department (OPD) •  Afternoon: Ward rounds Second day •  7.30: Attending “Hand over” staff meeting and Presentation surgical topic •  Theatre •  Discuss outcome visit with Hospital Director

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Clinical Officer Training Malawi

Day 1: OPD, selected cases only, plan onlyonoly(max 15)

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Clinical Officer Training Malawi

OPD: which hernia to operate?

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Clinical Officer Training Malawi

OPD: dd Breast tumours. Cancer?

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Clinical Officer Training Malawi

Ward Rounds: All surgical patients

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Clinical Officer Training Malawi

To be presented by COs, bed side teaching

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Clinical Officer Training Malawi

Diagnose? Treatment?

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Clinical Officer Training Malawi

Diagnose? Safe surg.proced. at DHs. Advice?

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Clinical Officer Training Malawi

Snake bite. Danger? Treatment?

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Clinical Officer Training Malawi

Ward rounds: also Trauma patients

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Clinical Officer Training Malawi

DAY 2:Teaching hospital staff

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Clinical Officer Training Malawi

THEATRE: the whole day

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Clinical Officer Training Malawi

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Clinical Officer Training Malawi

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Clinical Officer Training Malawi

DHO: the outcome of hospital visit

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Clinical Officer Training Malawi

6 ATTACHMENT WEEKS

Extra Theory and Skills practicing

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Clinical Officer Training Malawi

Bowel anastomosis, ileo/colostomies

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Clinical Officer Training Malawi

Inserting Thorax drains, Skin grafting

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Clinical Officer Training Malawi

Pin traction in fracture treatment

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Clinical Officer Training Malawi

Primary Trauma Course

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Clinical Officer Training Malawi

Training in Obstetrical emergencies

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Clinical Officer Training Malawi Prof Bowie, England Outcome Quote: •  CO skills have improved •  Patients and Hospital benefitted •  Overwhelming support in and outside Malawi

After 2 years: program Review by CoM

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Clinical Officer Training Malawi

2 studies published: both retrospective Study 1: after already 1 year training - Reduction Post Op. inf. inguinal hernia patients

21% - 8,7%!! Study 2: 1 year AFTER the 2 yrs training

- More MAJOR surgical operations: 8,4 - 17,8% - Less REFERRALS to CHs, but not statistically sign.

Was it useful ?..... Prove it!

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Clinical Officer Training Malawi

Any Problems? •  YES….. some DROP OUTS of COs!

Why ?? Not interested…… Why ? NO CAREER PERSPECTIVE OFFERED (no increase in salary) Why ? MoH did NOT allow a “course” Certificate of attendance only! Why ? MoH: no money paying higher salaries to COs. Considered training Doctors (in those days) more

important.

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Clinical Officer Training Malawi

Meeting with MoH, Teaching Inst, Med Council

Dec 2010: “THE DECISIVE MOMENT” Presented: •  Complete Plan BSc course in Surgery •  Plus Curriculum, and a Budget Duration Program: 3 years -  18 m “On the Job” training -  18 m in Central Hs

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Clinical Officer Training Malawi

TOLD MoH what is known in lit. about COs Studies from MOZAMBIQUE (hand outs) - No difference in surgical outcome Drs and TC(COs): -  For 1/4th of the training costs for Doctors -  For LESS hospital costs per Patient -  For LESS costs per Patient - For A salary 1/10th of the Doctor -  While TC STAY in the rural hospitals and are NOT leaving the country -  While ALL Doctors have left DHs… within 7 yrs! - Gen. opinion: Drs not trained/skilled for work in rural

hospitals! Studies from TANZANIA: Assistant Medical Officer (AMO) Able

to work in all wards. But perform minor surgery only.

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Clinical Officer Training Malawi

Response MoH…..

“We should have started this program 5 - 10 years ago” 6 months later: June 2011 Malawi Government requested CoM to create “SPECIALIST CO clinicians” by offering BSc courses in: 1. Surgery 2. Obst/gyne 3. Medicine 4. Paediatrics 5. Orthopaedics and 6. Anaesthesia

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Clinical Officer Training Malawi

Comments Dr Lungu

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Clinical Officer Training Malawi

Surgery in Malawi •  1995 - District Medical

Officer - Kasungu •  IMF Structural

Adjustment •  Major constraint to

District hospital •  Needed to know how

to do emergency surgery

•  More than just a scapel blade

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Clinical Officer Training Malawi

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EHP in Malawi

•  HIV/AIDS/STI ARIs •  Malaria Diarrhoeal Diseases •  Maternal Health NCDs and Trauma •  TB Malnutrition •  Cancers Vaccinations •  NTDs Eyes and Ears Inf

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Clinical Officer Training Malawi

Why “On the Job” Training ? •  Not to further reduce COs in

the Hosp •  Improve quality of care - CPD •  Supervision provided by

teachers •  Cost Effective •  Encourages innovation - use of

what is available •  Effective use of short timers

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Clinical Officer Training Malawi

On the Job training

•  TELL ME AND I FORGOT •  TEACH ME AND I REMEMBER •  INVOLVE ME AND I LEARN

Benjamin Franklin,1706-1790

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Clinical Officer Training Malawi

Friday 31rst Oct 2014 A historical moment for Malawi, as the very first (46) COs received a Clinical Officers Specialist BSc degree

in Acute Obstetrical and Neonatal care. Trained “On the Job” by Warwick University

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Clinical Officer Training Malawi

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Clinical Officer Training Malawi

”KWACHA”

means “the sun is rising”

for the COs in Malawi,

to the benefit of the patients

Thank you

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Clinical Officer Training Malawi