Table 1 Barriers to surgery performed by NPCs in SSA identified in the literature

I. Primary outcomes (28 articles)

1. Surgical output

A.1 Range and volume of surgical procedures performed by NPC

1. Inadequate surgical skills (n = 8)

(n = 3)

[14,15,16]

(n = 5)

[17,18,19,20,21]

2. Inadequate diagnostic skills (n = 6)

(n = 3)

[22,23,24]

(n = 3)

[18, 25, 26]

3. Insufficient opportunities to practise after training (n = 2)

(n = 1)

[27]

(n = 1)

[17]

2. Surgical outcome

A.2 Surgical outcomes of surgical procedures performed by NPC

4. Low-quality care of NPC, without comparison to MD (n = 9)

(n = 8)

[15, 28,29,30,31,32,33,34]

(n = 1)

[18]

5. Worse surgical outcome compared to MD (n = 4)

(n = 2)

[35, 36]

(n = 2)

[37, 38]

3. Surgical information

A.3 Availability and quality of information on surgical output/outcomes

6. Ambiguous or incomplete evidence on NPC (n = 8)

(n = 5)

[27, 31, 36, 39, 40]

(n = 3)

[2, 17, 25]

II. NPC workforce (40 articles)

4. Training

B.1 Quality and amount of education and training

8. Inadequate pre/in-service training in basic surgical operations (n = 10)

(n = 8)

[14,15,16, 30, 35, 41,42,43]

(n = 2)

[18, 44]

9. Insufficient opportunities for practising during training; inappropriate practice setting (n = 6)

(n = 3)

[14, 27, 45]

(n = 3)

[2, 25, 46]

10. Inadequate infrastructure or supplies at training facilities (n = 4)

(n = 4)

[42, 47,48,49]

-

-

B.2 Standardization

11. Poor coordination of training (n = 9)

(n = 4)

[14, 15, 27, 40]

(n = 5)

[19,20,21, 25, 50]

B.3 Financial support

12. High expenses and inadequate funding for training or education (n = 4)

(n = 2)

[30, 45]

(n = 2)

[2, 8]

5. Supervision in the field

B.4 Availability of supervision and support for supervision

13. Poor quality of supervision (n = 2)

(n = 2)

[15, 40]

–

–

14. Lack of (financial) support and availability of MD for supervision (n = 8)

(n = 7)

[14, 22, 30, 47, 51,52,53]

(n = 1)

[50]

6. Composition of surgical team

B.5 Availability of team members

15. Staff shortages (n = 12)

(n = 11)

[14, 15, 24, 27, 40, 42, 49, 54,55,56,57]

(n = 1)

[25]

7. Career development

B.6 Career path

16. Absence of career progression (n = 10)

(n = 6)

[14, 27, 58,59,60,61]

(n = 4)

[2, 18, 19, 25]

17. Behavioural problems due to lack of career progression (n = 4)

(n = 3)

[14, 30, 59]

(n = 1)

[21]

8. Employment conditions

B.7 Remuneration

18. Insufficient remuneration (n = 8)

(n = 7)

[14, 27, 30, 54, 58, 60, 62]

(n = 1)

[2]

19. Financial competition between MD and NPC (n = 2)

(n = 1)

[51]

(n = 1)

[8]

B.8 Prestige, professional status

20. Insufficient professional recognition or status (n = 4)

(n = 4)

[14, 60,61,62]

–

–

9. Workload

B.9 Burden of work

21. High workload (n = 7)

(n = 5)

[14, 15, 30, 51, 52]

(n = 2)

[2, 19]

10. Retention

B.10 Retention at rural level

22. Difficulties to retain at rural level (n = 6)

(n = 3)

[22, 30, 47]

(n = 3)

[17,18,19]

III. Regulation (27 articles)

11. Regulation

C.1 NPC professional profile

23. Absence of a standardized, legal framework for NPC (n = 15)

(n = 10)

[14, 30, 33, 34, 40, 41, 51, 52, 58, 63]

(n = 5)

[8, 19, 25, 64, 65]

C.2 Coordination

24. Inadequate coordination and support of NPC practising surgery (n = 7)

(n = 3)

[27, 30, 40]

(n = 4)

[2, 18, 25, 50]

25. Absence of a regulating body for NPC (n = 3)

(n = 2)

[58, 61]

(n = 1)

[64]

26. Unsuitable clinical protocols (n = 4)

(n = 3)

[15, 40, 51]

(n = 1)

[64]

12. Acceptability

C.3 Attitudes of policymakers, health workers, and patients towards NPC

27. General resistance (n = 16)

(n = 8)

[14, 27, 30, 47, 52, 53, 59, 61]

(n = 8)

[2, 8, 19, 25, 46, 64,65,66]

28. Fear for loss of power by MD; competition between MD and NPC (n = 8)

(n = 5)

[22, 27, 34, 52, 59]

(n = 3)

[2, 8, 25]

29. Concerns on quality of care, ethical reservations (n = 7)

(n = 4)

[14, 30, 52, 59]

(n = 3)

[2, 20, 64]

C.4 Attitude of NPC themselves

30. Negative attitude of NPC (n = 4)

(n = 2)

[14, 52]

(n = 2)

[2, 25]

IV. Environment and resources (26 articles)

13. Infrastructure and supplies

D.1 Availability of infrastructure, basic amenities, and equipment

31. Inadequate theatre rooms (n = 4)

(n = 4)

[27, 47, 52, 57]

–

–

32. Challenging environmental factors (n = 4)

(n = 4)

[55, 58, 67, 68]

–

–

33. Shortages of equipment (n = 13)

(n = 11)

[15, 22, 30, 40,41,42, 47,48,49, 57, 69]

(n = 2)

[17, 25]

D.2 Availability of supplies

34. Supply shortages (n = 10)

(n = 8)

[30, 40, 47, 48, 54, 55, 63, 69]

(n = 2)

[17, 19]

14. Health information system

D.3 Availability/quality of health information systems

35. Insufficient data recording systems (n = 5)

(n = 4)

[52, 70,71,72]

(n = 1)

[64]

160

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