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Background: The aim of this paper was to evaluate the effectiveness and cost-effectiveness of alternative training strategies for increasing access to emergency obstetric care in Burkina Faso. Methods: Case extraction forms were used to record data on 2305 caesarean sections performed in 2004 and 2005 in hospitals in six out of the 13 health regions of Burkina Faso. Main effectiveness outcomes were mothers’ and newborns’ case fatality rates. The costs of performing caesarean sections were estimated from a health system perspective and Incremental Cost-Effectiveness Ratios were computed using the newborn case fatality rates. Results: Overall, case mixes per provider were comparable. Newborn case fatality rates (per thousand) varied significantly among obstetricians, general practitioners and clinical officers, at 99, 125 and 198, respectively. The estimated average cost per averted newborn death (x 1000 live births) for an obstetrician-led team compared to a general practitioner-led team was 11 757 international dollars, and for a general practitioner-led team compared to a clinical officer-led team it was 200 international dollars. Training of general practitioners appears therefore to be both effective and cost-effective in the short run. Clinical officers are associated with a high newborn case fatality rate. Conclusion: Training substitutes is a viable option to increase access to life-saving operations in district hospitals. The high newborn case fatality rate among clinical officers could be addressed by a refresher course and closer supervision. These findings may assist in addressing supply shortages of skilled health personnel in sub-Saharan Africa. © 2009 Hounton et al; licensee BioMed Central Ltd.
The study was conducted in Burkina Faso, one of the poorest countries in the world [11], with a 23% adult literacy rate and a high maternal mortality ratio estimated as ranging from 484 per 100 000 live births [12] to 700 per 100 000 live births [13]. In 2005, the average ratios of specialists, general practitioners and midwives were 1 per 100 000, 1 per 30 000 and 1 per 25 000 inhabitants, respectively [14]. These figures were worse when considering subsets of these health personnel actually providing clinical care (and not involved in other activities). To respond to the scarcity of skilled health providers, the government embarked in the early 1980s in training substitutes for skilled health professionals: training courses for auxiliary midwives (accoucheuses auxiliaires), male midwives (maïeuticiens d’état) and clinical officers (attachés de santé) were created. In addition, a six-month training programme in essential surgery for medical doctors (chirurgie essentielle or essential surgery) was initiated in the early 1990s. Recent process evaluations of this latter programme [15,16] revealed a high turnover of trained doctors due to lack of reward in terms either of an increase in salary or of degree accreditation, a high rate of absenteeism due to lack of motivation, and competing administrative tasks. The study was a retrospective, cross-sectional, facility-based survey. Data for 2004 and 2005 were collected from hospital records and patient case notes during the last quarter of 2007. Because of time and resource constraints, we decided to collect data from all public sector facilities providing caesarean sections in six of the 13 regions of the country (22 hospitals). These six regions were conveniently selected to account for major socioeconomic and cultural differences in the country. Participants in the study were providers of caesarean section, such as specialists (obstetricians or surgeons), trained general practitioners, clinical officers, support staff, policy-makers, and maternal and child health programme managers. Data were collected by a survey team composed of two public health specialists and former district medical officers, three health economists, three sociologists and a midwife. Case extraction forms were used to systematically record data on caesarean sections from operating theatre books and delivery registers. The case extraction forms were pretested in a separate district hospital and pilot-tested before wider use in the selected study areas. Data were collected from each facility on number of caesarean sections, providers, referral status of cases, diagnosis at admission, interventions performed, survival outcomes for mothers and babies, postoperative complications (wound infection, haemorrhage, wound dehiscence), duration of operation, duration of postoperative inpatient days and type of anaesthetic. Data were collected on the costs of putting together surgical teams to perform caesarean sections led by obstetricians, general practitioners or clinical officers. These data included annual salary, allowances, pension, training and deployment, and time spent on surgical tasks. In addition, data were collected from the university on the duration of training and from the Ministry of Health on the number of medical officers trained in emergency surgery at district level. Finally, interviews were conducted with providers and their surgical teams, policy-makers and programme managers on barriers and facilitators for the essential surgery training strategy. The main assumptions made in costing relate to the time of surgical team members and volume of caesarean sections, compared to other medical and surgical interventions, so as to determine the proportion of total costs attributable to caesarean sections (compared to other activities). The proportion of time spent by clinical officers on caesarean sections was approximated by assuming that clinical officers spend their entire time in surgical units and by dividing the number of caesarean sections by the total number of surgeries performed in 2006. A self-administered time allocation form was used to approximate the proportion of time spent by trained physicians on caesarean sections compared to other activities (clinical and administrative). For non-surgical personnel (nurses, midwives, drivers, cooks, guards, etc.) and other hospital costs (mortuary, cleaning, motorcycles, etc.), we used an estimate of 2% to apportion costs to caesarean sections. Finally, the proportion of laboratory and operating theatre costs attributable to caesarean sections was estimated at each facility by dividing the volume of caesarean-related laboratory exams and operations by total laboratory exams and total life-saving surgeries for mothers, respectively. The different discounting periods used are derived from the average times spent in public service after graduation by providers, assuming they remain in public service until retirement. As an example, a nurse could potentially work for 30 years after graduation, since, at the time the survey was conducted, retirement was at 55 years of age or after 30 years of public service. Clinical officers could potentially work 20 years, given that most clinical officers return to further training after an average eight to 10 years of nursing practice. The training of physicians in essential surgery was discounted over five years, because this is the minimum period of public service before they can seek specialized training. None of the trained physicians missed the opportunity to enhance their career by moving to public health training or a clinical speciality. Descriptive statistics were used to compute rates and ratios for each type of provider. Confidence intervals were constructed around each estimate. This was the preferred approach, since we wished to include all caesarean sections from district hospitals in the analysis. Case mixes by each type of provider were assessed by analysing the relationship of the key effectiveness measure with providers, adjusting for reported diagnosis and referral status (a proxy for the severity of cases). We calculated cost estimates of strategies (surgical teams led by obstetricians, trained general practitioners or clinical officers at district hospitals) per selected outcomes, employing a health service perspective. The costing exercise was carried out for 2006. We estimated the costs of caesarean sections carried out by surgical teams led by each of the three providers, since we are seeking to compare strategies, the combinations of provider, surgical team and technical support. This approach was preferred because, apart from patients’ clinical condition at admission, the outcomes of life-saving interventions depend on providers’ skills and the presence of an adequate team, required drugs and functioning equipment. Training costs were annualized, at a discount rate of 3%, so that they could be added to the other health human resource costs to derive a measure of the annual costs of putting together surgical teams to provide caesarean sections. The next step was to apply the appropriate proxies of time of surgical team members so as to determine the proportion of total costs attributable to caesarean sections, compared to other activities. Incremental cost-effectiveness ratios were computed by dividing the differences in average costs of putting in place a surgical team led by one type of provider compared to an alternative option by the differences in newborn case fatality rates associated with each option. Sensitivity analysis was conducted on the major cost categories. We divided the average cost of putting in place an obstetrician/general practitioner/clinical officer-led surgical team by the average number of caesarean sections performed at the district hospitals in 2006. We considered this latter measure the closest approximation of average throughput across the whole country. Implicit in our analysis was that variable costs would be the same for an obstetrician-led team, a general practitioner-led team, and a clinical officer-led team. In fact, the main element of variable costs is the cost of kits and this cost is borne by patients (although subsidized by the government since October 2006) and therefore not included in our costing, which is from a health service perspective. The costing exercise was conducted in West African CFA (Communauté financière d’Afrique – Financial Community of Africa) francs, the currency of Burkina Faso. Key results were then translated into international dollars, which are United States dollars adjusted for differential purchasing power. In 2006, one international dollar equalled 181 CFA.
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