Bachelor of Science degree course

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1 Clinical Officer Training Malawi From On the Job training in Surgery towards a Bachelor of Science degree course for Clinical Officers in Malawi 1

2 Clinical Officer Training Malawi MALAWI 2

3 Clinical Officer Training Malawi 16 m. 3% yearly increase, double in yrs 3

4 More about Malawi Clinical Officer Training Malawi The nr 9 poorest country world 11% HIV pos 1 Doctor for inhabitants Few Malawian specialists Braindrain CNN documentary: More Malawian Doctors in Manchester than in Malawi 4

5 DOS: Please train COs in surgery Clinical Officer Training Malawi 5

6 Clinical Officer Training Malawi Why? Surgery by COs in the DHs: only 3% Operations in District Hospitals in Malawi in 2003 (total = 28594) Dilatation & curettage Caesarian Section Other Suture of wound Abscess drainage Manipulation of fracture Cataract removal Hernia repair Debride wound Laparotomy Osteomyelitis surgery Arthrotomy Debridement of open fracture Insertion of skeletal traction pin Tenotomy Skin graft Osteotomy Internal fixation of fracture Club foot correction Burr Hole 6

7 COs and why to train in surgery? Clinical Officer Training Malawi Due to lack of Doctors, COs are the BACK BONE of health care Training COs is basic: 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 7

8 2005 Start COs trainings project 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 8

9 Clinical Officer Training Malawi Goal CO training 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, preop pat.care, aseptic techniques in theatre et Less referrals to CHs 9

10 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 Clinical Officer Training Malawi 10

11 Program training is structured Clinical Officer Training Malawi 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 11

12 Clinical Officer Training Malawi Day 1: OPD, selected cases only, plan onlyonoly(max 15) 12

13 OPD: which hernia to operate? Clinical Officer Training Malawi 13

14 OPD: dd Breast tumours. Cancer? Clinical Officer Training Malawi 14

15 Ward Rounds: All surgical patients Clinical Officer Training Malawi 15

16 Clinical Officer Training Malawi To be presented by COs, bed side teaching 16

17 Diagnose? Treatment? Clinical Officer Training Malawi 17

18 Clinical Officer Training Malawi Diagnose? Safe surg.proced. at DHs. Advice? 18

19 Snake bite. Danger? Treatment? Clinical Officer Training Malawi 19

20 Ward rounds: also Trauma patients Clinical Officer Training Malawi 20

21 DAY 2:Teaching hospital staff Clinical Officer Training Malawi 21

22 THEATRE: the whole day Clinical Officer Training Malawi 22

23 Clinical Officer Training Malawi 23

24 Clinical Officer Training Malawi 24

25 Clinical Officer Training Malawi DHO: the outcome of hospital visit 25

26 6 ATTACHMENT WEEKS Clinical Officer Training Malawi Extra Theory and Skills practicing 26

27 Clinical Officer Training Malawi Bowel anastomosis, ileo/colostomies 27

28 Clinical Officer Training Malawi Inserting Thorax drains, Skin grafting 28

29 Pin traction in fracture treatment Clinical Officer Training Malawi 29

30 Primary Trauma Course Clinical Officer Training Malawi 30

31 Clinical Officer Training Malawi Training in Obstetrical emergencies 31

32 Clinical Officer Training Malawi After 2 years: program Review by CoM Prof Bowie, England Outcome Quote: CO skills have improved Patients and Hospital benefitted Overwhelming support in and outside Malawi 32

33 Was it useful?... Prove it! 2 studies published: both retrospective Clinical Officer Training Malawi 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. 33

34 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. 34

35 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 35

36 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 36 to work in all wards. But perform minor surgery only.

37 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 37

38 Comments Dr Lungu Clinical Officer Training Malawi 38

Clinical Officer Training Malawi Surgery in Malawi 1995 - District Medical Officer - Kasungu IMF Structural

39 Clinical Officer Training Malawi Surgery in Malawi 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 39

40 Clinical Officer Training Malawi EHP in Malawi HIV/AIDS/STI Malaria Maternal Health TB Cancers NTDs ARIs Diarrhoeal Diseases NCDs and Trauma Malnutrition Vaccinations Eyes and Ears Inf 40

CPD Supervision provided by teachers Cost Effective Encourages

41 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 Clinical Officer Training Malawi 41

42 On the Job training Clinical Officer Training Malawi TELL ME AND I FORGOT TEACH ME AND I REMEMBER INVOLVE ME AND I LEARN Benjamin Franklin,

43 Friday 31rst Oct 2014 Clinical Officer Training Malawi 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 43

44 Clinical Officer Training Malawi 44

45 KWACHA Clinical Officer Training Malawi means the sun is rising for the COs in Malawi, to the benefit of the patients Thank you 45

46 Clinical Officer Training Malawi 46

EMERGENCY CARE SYSTEMS

EMERGENCY CARE SYSTEMS OVERVIEW Emergency and Trauma Care Systems The DCP emergency components of essential packages WHO Emergency Care System Framework Emergency Care System Assessment Tool PREVENTION PREHOSPITAL & TRANSPORT