Task Shifting and Task Sharing to Strengthen the Surgical Workforce in Sub-Saharan Africa: A Systematic Review of the Existing Literature.

Background: A major constraint to surgical care delivery in low-resource settings is inadequate workforce availability. Surgical task shifting (TShifting) and task sharing (TSharing), in which non-surgeon clinicians (NSCs) are trained to perform select surgical procedures, have been proposed as one solution. However, patterns of safety and efficacy of surgical TShifting/TSharing are not well-established. This study aims to summarize the current literature and assess clinical outcomes and impact of surgical TShifting/TSharing in sub-Saharan Africa.

Methods: A two-tiered systematic, PRISMA-adherent literature review of surgical TShifting/TSharing in sub-Saharan Africa was conducted. Collected data included healthcare settings; types of surgeries performed; attitudes toward NSCs; and categories, training, capacity, clinical outcomes, safety, retention, cost-effectiveness, and supervision of NSCs. A random effects meta-analysis of morbidity and mortality rates between NSCs and surgeons was conducted.

Results: Among the 659 abstracts screened, 31 studies met inclusion criteria and were integrated in the final analysis. Eighteen studies (58%) report on the capacity and aptitude of NSCs, 16 (52%) on clinical outcomes and safety, and seven (23%) on attitudes. NSCs performed 1999 (61%) of 3304 total surgical cases studied. The most common operations reported were hernia repair (n = 12, 57%), acute abdominal (n = 12, 57%), and orthopedic procedures (n = 6, 29%). No differences were found between NSC and surgeon case morbidity [315 (16%) vs. 224 (17%); p > 0.05] and mortality [44 (2.2%) vs. 33 (2.5%); p > 0.05] rates.

Conclusion: NSCs are increasingly performing surgical tasks in regions of sub-Saharan Africa deficient in trained surgeons and appear to have non-inferior safety outcomes in select programs.