This paper reports original in-depth findings on the feasibility of, and the actual benefits and obstacles to, implementing a surgical specialist supervision model as a means of improving surgical skills at DLHs in sub-Saharan Africa. The findings suggest that the model is an effective way of ensuring clinical supervision of remotely located mid-level surgical providers through a programme of regular visits by surgical specialists.
Surgical outreach campaigns that enable specialists to intermittently or occasionally deliver services to rural populations have served a similar purpose to the COST-Africa supervision model and have often resulted in good outcomes . The main concern, however, is that such campaigns seldom incorporate training and supervision of the district-level staff who provide regular and accessible services to these communities, as well as their lack of sustainability . To avoid this, COST-Africa introduced a combined training and supervision approach to make surgical expertise available in a sustainable way in Zambia’s rural communities, both through surgical specialists making regular quarterly supervisory visits and being available for phone consultations. The use of local surgical specialists, developing and strengthening their relationships with the surgical teams at the district hospitals that manage and refer patients to the specialist hospital, is one component of a sustainable, surgical quality of care intervention. Making regular surgical supervision sustainable was enhanced by the central involvement of the research principle investigator (JK) and two of the project’s surgical supervisors in the development of Zambia’s National Surgical, Anaesthesia and Obstetric Plan (NSOAP) . The cornerstone of the national plan, building on a 10-year national programme of deploying surgically trained MLs to DLHs , is the tested programme of regular surgical supervision provided by the COST-Africa research .
In an earlier paper, we discuss the importance of a participatory implementation research approach that brings together local researchers, supported by external researchers, in informing the development of NSOAPs. This research team continues to work on refining and evaluating the supervisory model, under the follow-up SURG-Africa project  in close collaboration with the Ministry of Health in Zambia. This close collaboration, which started in 2011, increases the likelihood that the supervisory model will form part of a sustainable national programme. Modifications were made to the intervention based on the lessons learned from the supervision model tested in COST-Africa. Other specialists were included in in the supervisory visits (obstetricians, anaesthesiologists and OT nursing specialists) aiming to provide training and supervision for other DLH essential staff to the provision of safe surgical services. The focus is on the skills of individuals involved in surgery and how they work together (teamwork). This is one of the ways in breaking the barriers between MLs and MDs in particular, identified in this study, by making them work together under the supervision of specialists.
This paper also aims to contribute to a broader understanding of how to optimise supervisory models for NPCs working at DLHs in sub-Saharan Africa (SSA). Although similar initiatives have been implemented in other countries , to date, NPC supervision is still irregular or often lacking in rural health care systems [15, 29], and there is little evidence about the practical implementation of NPC supervision models. This study to our knowledge was the first one to explore these dimensions in practice. It provides evidence to illustrate the additional role that specialist surgeons can play, bringing the benefits of their expertise to rural populations, where such surgical competence would otherwise be unobtainable. Given the concerns that have been expressed, it adds to evidence  showing that the benefits of NPC-delivered surgery in rural areas outweigh the risks such as sub-optimal quality of surgery or ‘task creep’ , if effective surgical systems (including specialist supervision) are in place.
DLHs are at the frontline of the provision of surgical care for the majority of the population in Zambia and SSA, but often lack sufficient capacity, especially in staff surgical skills, to meet the needs of rural populations . The study identified several direct benefits that ensued due to the supervision model, ranging from individual-level developments in the MLs’ surgical capabilities to wider institutional-level advancements experienced by the DLHs. On an individual clinician level, the supervision resulted in self-reported increased confidence and skills among the MLs which confirms the effectiveness of this method observed in other studies [33, 34]. Through the support of their assigned supervising surgeons, the majority of MLs expressed increased confidence in their surgical capabilities, as well as the ability to take on more complex procedures.
The surgeons also played a role in improving the working environment at intervention hospitals by strengthening relationships between MLs and MOs. It has previously been documented that in the district hospital setting, although medical doctors (MDs) have higher medical education than MLs, the consistent exposure of MLs to surgery while in training has led to their skills exceeding those of the doctors at times . Tension revolving around seniority, role definition and the scope of decision-making/practice boundaries are some work environment issues in the relationship between the two cadres that have previously been reported in other studies [4, 6, 35]. Although most MOs in this study appreciated the MLs’ surgical capabilities, some surgeons reported they had resolved disputes between MLs and MOs which, if left unresolved, could have potentially affected the delivery of surgery or even compromised patient care.
The supervision also improved the functional dynamics of DLHs on an institutional level. By improving the individual-level skill sets of MLs and establishing communication channels between DLHs and central hospitals, the local surgical teams were able to undertake more cases  and avoid unnecessary referrals to the central hospitals. Interviewed cadres also reported the cost benefits of reducing such referrals, confirming findings from other studies with other studies carried out in the SSA region [35,36,37,38]. Additionally, these communication channels between the hospitals also contributed to the overall safety of surgical practice at rural hospitals.
The newly created communication channels proved to be life-saving during the management of complex cases, especially in situations where urgent intervention was required. Moreover, the interviewed surgeons reported the importance of periodically placing provincial surgeons in rural areas in terms of lobbying and advocating. Due to the severe shortage of consultant surgeons in Zambia , their influential power at a provincial level is yet to be utilised. Considering almost all cadres reporting the issue of limited surgical supplies, a frequently occurring phenomenon in the SSA region , the exposure of DLHs to provincial surgeons also appeared to be effective in that sense.
Although this intervention provided promising outcomes, the study identified several instances where surgeons were incapable of mentoring the MLs due to the unavailability of equipment, such as anaesthetic monitors, or key surgical staff. For example, since the effective management of surgical cases must include preoperative, intraoperative and postoperative care, supervising surgeons refused to carry out procedures if these aspects of patient care were to potentially be undermined. Not only do such barriers waste the surgeons’ invaluable visits and lead to missed opportunities, but also compromise the standard of surgical practice altogether.
Since MLs account for a very large proportion of the surgical workforce at DLHs , the concurrent inadequacy of developmental opportunities for these cadres leaves the quality and safety of their practice open to question . In order to ensure ongoing clinical competency and ethically acceptable standards of care at DLHs, consistent schemes for NPC supervision and education must be integrated into a regulatory framework . It is plausible that there were other system-wide effects, whereby regular visits by surgical specialists to DLHs benefitted other clinical services and hospital management more broadly, but such effects were not measured. The Zambia National Health Sector Strategic Plan 2011–2015  called for the development of outreach programmes from technical supervision of regional referral hospitals by specialists at national tertiary hospitals; our findings suggest there is a scope for the supervision to be extended to the district level, focusing initially on essential surgery.