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Use of surgical task shifting to scale up essential surgical services: a feasibility analysis at facility… Galukande, Moses; Kaggwa, Sam; Sekimpi, Patrick; Kakaire, Othman; Katamba, Achilles; Munabi, Ian; Runumi, Francis M; Mills, Ed; Hagopian, Amy; Blair, Geoffrey; Barnhart, Scott; Luboga, Sam Aug 1, 2013

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RESEARCH ARTICLE Open AccessUse of surgical task shifting to scale up essentialsurgical services: a feasibility analysis at facilitylevel in UgandaMoses Galukande1*, Sam Kaggwa1, Patrick Sekimpi2, Othman Kakaire3, Achilles Katamba4, Ian Munabi5,Francis Mwesigye Runumi6, Ed Mills7, Amy Hagopian8, Geoffrey Blair9, Scott Barnhart8 and Sam Luboga5AbstractBackground: The shortage and mal-distribution of surgical specialists in sub-Saharan African countries is born outof shortage of individuals choosing a surgical career, limited training capacity, inadequate remuneration, andreluctance on the part of professionals to work in rural and remote areas, among other reasons. This study set outto assess the views of clinicians and managers on the use of task shifting as an effective way of alleviatingshortages of skilled personnel at a facility level.Methods: 37 in-depth interviews with key informants and 24 focus group discussions were held to collectqualitative data, with a total of 80 healthcare managers and frontline health workers at 24 sites in 15 districts.Quantitative and descriptive facility data were also collected, including operating room log sheets to identify themost commonly conducted operations.Results: Most health facility managers and health workers supported surgical task shifting and some health workerspracticed it. The practice is primarily driven by a shortage of human resources for health. Personnel expressedreluctance to engage in surgical task shifting in the absence of a regulatory mechanism or guiding policy. Those infavor of surgical task shifting regarded it as a potential solution to the lack of skilled personnel. Those who opposedit saw it as an approach that could reduce the quality of care and weaken the health system in the long term byopening it to unregulated practice and abuse of privilege. There were enough patient numbers and basicinfrastructure to support training across all facilities for surgical task shifting.Conclusion: Whereas surgical task shifting was viewed as a short-term measure alongside efforts to train and retainadequate numbers of surgical specialists, efforts to upscale its use were widely encouraged.Keywords: Surgical, Task shifting, Uganda, Human Resource for Health crisisBackgroundThe poor availability of surgical services in developingcountries is a long neglected problem that has recentlygained attention [1,2]. Violence, injury, and obstetricemergencies are among leading causes of mortality andmorbidity that can be mitigated through surgical interven-tion [3]. Surgical interventions are often viewed as expen-sive and complex, but many common problems amenableto surgery in resource-limited settings are cost-effectiveand do not require specialized staff and equipment [4].One of the main barriers to surgical care--defined asthe safe provision of preoperative, operative, and post-operative surgical and anesthesia services--in resource-limited settings is the shortage of trained health workers.Africa accounts for 24% of the global disease burdenbut enjoys only 3% of the global health workforce [5]. InUganda there are only approximately 100 general sur-gical specialists for nearly 33 million people [6]. Mean-while reports of surgical output [3,6] i.e. ratios ofoperations/population, are exceedingly low in poor* Correspondence: mosesg@img.co.ug1Department of Surgery, College of Health Sciences, Makerere University,P.O. Box 7072, Mulago Hill Road, Kampala, UgandaFull list of author information is available at the end of the article© 2013 Galukande et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of theCreative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,distribution, and reproduction in any medium, provided the original work is properly cited.Galukande et al. BMC Health Services Research 2013, 13:292http://www.biomedcentral.com/1472-6963/13/292countries. Shortages of surgical human resources arepartially responsible for this low output.Surgery is considered a highly specialized field that re-quires long years of training: in the US, surgeonscomplete a five-year surgical residency before operatingindependently. Indications for surgery are not alwaysstraightforward, patient management decisions can becomplex, and learning the technical skills required toperform major surgery requires committed trainers. Allthis leads to a concern that such complex skills andknowledge cannot be adequately transferred to less-than-fully-trained surgeons in a shortened training course(s).Non-specialist physicians in general hospitals and thehighest level health clinics (HC-IVs) are presumed to beadequately trained and available to handle emergencyand essential surgical care, yet there is a limited scope oflife saving surgery conducted at these units. The mostcommonly performed maternal procedures at districthospitals are cesarean sections and uterine evacuationsfor obstetrics, while the most common general surgicalprocedures) are hernia repairs and wound care for trauma(which may include manipulation of fractures [5]. Withthe advent of mass safe male circumcision for partialHIV prevention, circumcision also will be a commonly-performed surgical procedure [7,8]. These can be safelymanaged by non-surgeons. Highly complicated proce-dures that require the expertise of fully trained surgicalspecialists can then be referred to tertiary Hospitals.Task shifting holds a great promise to contribute to alle-viation of Human Resource for Health crises [9,10].The purpose of this study was to collect the views ofhealth facility managers and clinicians on surgical taskshifting. This paper focuses on the qualitative assessmentof facility staff views of feasibility, practicality and advis-ability of such task-shifting. We conducted this assessmentas a prelude to designing an intervention to build surgicalskills for non surgical physicians (NSPs), under a task-shifting grant from the government of Canada.MethodsOur mixed-method study was conducted in 24 purposivelyand randomly selected facilities; eighteen general hospitalsand six health centre IVs from a list of more than 120Ugandan hospital and health centers made available fromthe Ministry of Health. The qualitative methods includedone focus group discussion in each of the 24 facilities, and37 key informant interviews (KIIs), one or two in each facil-ity. Interviews were conducted with health workers andheads of units at these facilities and heads of units. We useda standard set of focus group and interview questions.The purpose of the focus group discussions and in-terviews was to obtain health workers’ understanding,experiences, and views of surgical task shifting. Amultidisciplinary team, comprising a social scientist andone or two surgeons met with a mixed-cadre group of 6–8health workers from the units studied. A pre-preparedinterview guide was followed along particular themes in-cluding: understanding, practice, acceptability and per-ceived barriers to surgical task shifting. The proceedingswere captured using a voice recorder, this was backed upby taking notes.Respondents were purposively selected to includethose involved in the provision of surgical care servicesin the facilities visited. However, other cadre levels wererepresented in focus group discussions and key informantinterviews.We asked for the definition of task-shifting, how itmanifested, rationale for its practice, the acceptability, theprocedures involved, when it is appropriate, the perceivedbarriers to task shifting it, for how long it should go on, itseffect on patient outcomes and any recommendations.All respondents were informed of the purpose, risks,and benefits of participation in the discussions, and writ-ten informed consent was obtained from all. Discussionswere audio-taped and transcribed verbatim, by the originalinterviewer.The discussions were conducted in English at quiet lo-cations on the premises of the health units, and lasted60 to 90 minutes. IRB approval from Makerere Universitywas obtained before this study was started.Data on the surgical burden of disease, proceduresperformed and resources available for surgical proce-dures were collected from the selected facilities using aStandard (pre tested) questionnaire.In additional to the FGDs and KIIs, we also reviewedthe theater operation logs data from 12 hospitals and 2health centers IVs over a 3 month period November2009 through January 2010 to examine surgical volumes.We limited this review to half of the facilities originallysurveyed due to logistical constraints.Data management and analysisVoice records were transcribed by the original interviewerand harmonized with the notes originally written duringthe discussions. The transcripts were read in their entirety,and themes were developed through an interactive, collab-orative process with the study team, including all of theoriginal interviewers. Matrices were created to trackthemes across participating health care facilities. The find-ings under each theme were attached to illustrative quota-tions and phrases from individual participant’s responses,to illustrate and support the themes. During the analysis,we used numbers to track how many of the 24 focusgroups touched on an identified theme.Data from theatre recordsAll surgical theatre logs were photocopied to allow col-lection of demographic and pertinent care variables,Galukande et al. BMC Health Services Research 2013, 13:292 Page 2 of 7http://www.biomedcentral.com/1472-6963/13/292including: diagnosis, procedures performed and categoryof procedure.ResultsWe conducted 24 focus groups and 37 key informantinterviews at 24 facilities. These included 18 hospitalsas shown in Table 1 (Gombe, Nkozi, Mityana, Mubende,Kalisizo, Kitovu, Kisubi, Bugiri, Rakai, Iganga, Entebbe,Kayunga, Nyenga, Kawolo, Lyantonde, Villa Maria,Kiboga, and Nakaseke) and 6 Health Centre IVs (St.Stephens, Atirir, Serere, Kakira, Kasana and Wakiso).The majority of these facilities had a 100–150 bed cap-acity (Uganda’s Ministry of Health standard for a generalhospital capacity is 100 beds). Patient attendance figuresindicated an average of 80 outpatient visits per day persite. Other statistics for catchment population and staffingare shown in Table 1.In Table 2, the scope and the frequencies of thecommonly performed procedures for the participatinghospitals are shown.Definition of surgical task shiftingOn the whole respondents had a good understandingof the concept of surgical task shifting. Most respon-dents (21/24 focus groups or FGDs) described it as anactive or deliberative process of passing on responsibil-ity to a higher to lower cadre person who had not beenspecifically trained for the task at hand. A few (3/24FGDs) were not familiar with the term.Here are some of the definitions stated by the focusgroup members and key informants:1) Delegation of work particularly from a person withhigher training to one with less training;2) Performing work one is not trained to do;3) Performing activities outside one’s mandate;4) Performing a task on one’s own after recognizing aneed; and/or5) The transfer of tasks among health units i.e. from ahealth centre to a hospital or from a higher healthunit to a lower one.Table 1 Selected Uganda health facilities (hospitals and HC IVs)Hospital Type Bed capacity District Population/Catchment area Distance from Kampala (Km) Health workers numbersDr CO Nur MW1 Bugiri PH 100 24,800 166 5 - 34 122 Gombe PH 100 100,000 68 5 4 23 133 Iganga PH 120 51,800 205 9 - 61 224 Kakira NGH 100 49,000 100 2 27 2 25 Kasana - Luweero HC IV 150 100,000 86 3 - 9 126 Kawolo PH 110 35,500 45 3 - - -7 Kayunga PH 150 23,100 74 2 7 25 188 Kiboga PH 120 16,600 132 4 18 50 159 Kisubi NGH 100 50,000 35 4 4 38 1610 Kalisizo PH 200 32,700 150 4 8 - -11 Mityana PH 120 266,100 77 4 - - -12 Mubende PH 100 436,500 170 2 - - -13 Rakai PH 100 466,300 174 4 7 7 1414 Nakaseke GH 120 100,000 65 5 - - -15 Nkozi NGH 100 100,000 85 2 5 10 716 Nyenga NGH 100 100,000 59 3 5 31 717 Villa Maria NGH 126 500,000 318 6 4 10 -18 Kitovu NGH 220 228,200 140 6 5 40 1419 Wakiso HC IV 30 50,000 40 1 1 - -20 Kabula Lyantonde HCIV 30 25,000 202 3 5 27 1621 Kasana luweero HCIV 30 100,000 86 3 - 9 1222 St Stephen’s HCIV 20 100,000 7 1 2 4 423 Atitir HCIV 34 10,300 299 1 2 5 324 Serere HCIV 30 176,500 205 1 2 8 2PH Public Hospital, HC IV Health center IV, GH General Hospital, NGH Non Governmental hospital, Dr Doctors, CO Clinical Officers, Nur Nurses, MW Midwives.- missing data.Source of data: Uganda task-shifting feasibility study 2012.Galukande et al. BMC Health Services Research 2013, 13:292 Page 3 of 7http://www.biomedcentral.com/1472-6963/13/292One respondent, similar to a few others, describedsurgical task shifting as something almost illicit:“Doing work which you were not supposed to bedoing like performing a Caesarian Section when youare not trained to do it ( for example, a ClinicalOfficer doing a Caesarian Section)” – FGD, in aHospital”Another viewpoint emphasized a delegation of surgicaltasks to low-level personnel:“I think it means shifting a task to someone else whenthe doctor is not around to perform a surgicalprocedure”- FGD in a HospitalAnother respondent characterized it as a facility trans-fer rather than a task transfer:“It can be defined in two ways, a unit shifting the taskto another unit. That is, what work to be done in aparticular unit is shifted to a lower unit, for example,from a hospital to a health centre IV”- FGD in ahospitalJustification for task shiftingSeveral reasons were given to explain why surgical taskshifting took place in the visited health facilities.Understaffing was the main driver for task shifting,most respondents (17/24 FGDs) said so.Most respondents (15/24 FGDs) also noted task shiftingis done for high patient-load reasons, for example when ahigher number of patients need services than the existingnumber of providers can handle. Some (6/24 FGDs)contended that staff resorted to surgical task shifting whenpatients refuse to be referred to other hospitals due to fail-ure to afford services at more distant sites the prohibitivecosts are involved in accessing services at distant sites arecontributed to be transport costs.Understaffing is the main precipitating factor in allinstances, most respondents said.A number of respondents (10/24 FGDs) said task-shifting should be done “to save lives”, with fewer (8/24FGDs) mentioning the benefit to health workers of acquir-ing additional skills or earning extra income, especially inprivate clinics. Participants in a few groups (5/24) saidthis approach could reduce patient waiting time, andsome (3/24 FGDs) also mentioned the scarcity of spe-cialized surgeons as a major driver.One participant, similar to many others, said,“Scarcity of skilled human resource it may notnecessarily mean that, it is the lack of numbers but, theprofessional to perform a particular complex procedureis not around” – FGD in one of the HospitalsA couple of people (2/24 FGDs) discussed the problemsof surgeon absenteeism, while others (in 2/24 FGDs) men-tioned the need to reduce preventable referrals, and two(2/24 FGDs) mentioned the shortage of equipment.“Long distances hinder accessibility of patients toservices, so referrals are not possible, so patients stayhere and we work on them” – FGD in a hospitalPerceived effects of surgical task shiftingAll focus groups included people who were convincedsurgical task shifting would decrease mortality becausecomplications could be averted by the timely manage-ment of surgical emergencies or the need for urgentintervention.However, some respondents feared surgical task shiftingcould increase mortality in instances where incompetenttrainees are left unsupervised. Potential pitfalls of surgicaltask shifting were named; we list them in order of per-ceived importance:1. Possible increase in morbidity and mortality2. Low staff motivation to take on extra loadTable 2 Scope and frequencies of the surgical procedurescommonly performed in selected Uganda health facilitiesbetween November 2009 and January 2010Procedures Sum (%)C- Section 1057 (33)Hernia repair 683 (22)Uterine Evacuation 377 (12)Surgical Toilet & Suture 203 (6.4)Incision & Drainage 202 (6.4)Laparotomy (various indications) 194 (6.1)Circumcision 120 (3.8)Hysterectomies (STAH/TAH) 71 (2.2)Urinary Retention relief 54 (1.7)Superficial skin masses 49 (1.5)Tubal ligation 38 (1.2)Hydrocelectomy 33 (1.0)Closed manipulation of fractures 22 (0.7)Ano rectal conditions 17 (0.5)Appendicectomy 11 (0.4)Cervical Tear repair 11 (0.4)Sequestrectomy 10 (0.4)Vaginal Vesico Fistula repairs 7 (0.2)Breast lump Excision 5 (0.2)Cervical cancer EUA 3 (0.1)Source of data: operating room logs of hospitals in the Uganda task-shiftingfeasibility study 2012.Galukande et al. BMC Health Services Research 2013, 13:292 Page 4 of 7http://www.biomedcentral.com/1472-6963/13/2923. Lack of facilitation, equipment and space4. Medical- legal responsibility for mishaps5. Lack of public acceptance for the concept6. Staff over stepping their boundaries7. Lack of support supervision8. Cost of training and support supervision9. Risk of impersonation (fraud)10.Disincentive for appropriately trained personnel toaccept deployment in rural settings11.Cost of compensation for extra loadChallenges encountered by respondentsThe majority of respondents reported witnessing surgicaltask shifting in district hospitals (20/24 FGDs), and otherssaid they’d seen it in private clinics (7/24 FGDs).The following challenges were reported by a respondentwho had participated in surgical task shifting:“I have done several circumcisions. For the first time,I did it successfully but bleeding was the majorproblem. One of the bleeders was not ligated. Soafter discharging the patient, the area startedbleeding. But the good thing he had my contacts andhe called me. So I have learnt to do it withexperience.”Respondents reported fear resulting from the lack ofsufficient knowledge, skills and experience, as well asthe lack of supervision, legal cover, confidence, orequipment. Prescribing the wrong medicines was alsomentioned.The requirements for making surgical task shifting workare summarized below, as the availability of equipmentand supplies, better remuneration, support supervisionand training. Others included support from specialist sur-geons and better operating room infrastructure.Requirements for surgical task shifting as named byclinical staff at Uganda hospitalsAvailability of equipment and suppliesSalary increment / remuneration for the staff engagedin task shiftingMonitoring and evaluationSupport supervision specialized with ongoing trainingGovernment & MOH supportTraining by non specialist cliniciansPositive attitude of Surgeons to surgical task shiftingFunds to facilitate trainingWillingness of health personnel to be trainedInfrastructure / TheatresSource of data: key informant interviews in the Ugandatask-shifting feasibility study 2012.DiscussionThis study set out to explore perceptions of managersand frontline health workers on surgical task shiftingacross fifteen districts at 24 sites in Uganda. We foundsurgical task shifting was largely supported, although notwithout reservation. In any case, it was taking place atall the facilities we visited to some extent, even in theabsence of guiding Ministry of Health policy.Respondents largely understood the concept of surgicaltask shifting to include the passing on or delegation of aspecified role from an appropriately-trained person in ahigher cadre to a less-trained or less experienced cadre inthe context of shortage of health workers. There were afew who did not grasp the meaning of the term and sug-gested it included referral from a higher level facility to alower level facility in the context of lack of space, facilitiesor personnel at that particular time. There is no officialpolicy framework that articulated the position of surgicaltask-shifting at the national level. At the global healthlevel, WHO has issued guidelines encouraging appropriatedelegation of tasks to lower cadre where it is safe andreasonable [11].Even though surgical task shifting was largely sup-ported, some respondents in our study said they oftenfelt exposed or vulnerable when asked to take on tasksthat are not in their legal scope of practice, especially ina situation where things could go wrong and result in alawsuit or job dismissal. In the absence of regulation,some respondents said some clinical officers may abusethe practice by carrying out procedures away from theirprimary work stations where supervision is not possible.Further, the lack of policy may mean facility staff areasked to take on extraordinary tasks without the con-comitant recognition or appropriate reward or job pro-tections. These factors contribute to resistance to taskshifting.Resistance to task shifting occurs in settings wherethere is a lack of supervision and regulation. Lack ofsupervisor support leaves those engaging in task shiftingwith less on-site training for skill development. Somealso expressed a sense of injustice; the officers delegatingwork get their time freed to go on to do other dutiesthat may be more financially rewarding to them at theexpense of the persons to whom less desirable tasks aredelegated.Other respondents worried the lack of proper documen-tation of these quasi-legal task-shifting operations leads topoor processes and outcomes. Efforts to formalize, andtrack task shifting must not only involve undertaking pro-spective studies but should also aim at improving thecurrent health management information system to in-crease emphasis on surgical data collection.Nearly all respondents acknowledged the need to meetthe demand for surgical services that outpaces the capacityGalukande et al. BMC Health Services Research 2013, 13:292 Page 5 of 7http://www.biomedcentral.com/1472-6963/13/292of health personnel whose scope of services clearly in-cludes surgical procedures. Table 2 gives the sense of thescope and frequencies of procedures encountered in thesestudy sites. There is recognition that other countries inthe region, including Malawi, Mozambique and Tanzania,have had success with the practice [12-16].There is recognition that other countries in the region,including Malawi, Mozambique and Tanzania, have hadsuccess with the practice [12-14]. Health workers inUganda, however, pointed to a lack of country-specificevidence that surgical task shifting is feasible, sustainableand safe. There is also a lack of documentation of thesurgical burden of disease in Uganda [6].In all the facilities we visited, workers tended to sup-port formalizing, supporting and scaling up surgical taskshifting. Their recommendations are similar to thosefound by previous researchers; [9,17,18] that is, the longterm success of task shifting hinges on serious politicaland financial commitments. These include a revisedcompensation scheme, reconfiguration of health teams,changed formal scopes of practice, regulatory frame-works and enhanced training infrastructures. The re-quirements articulated by the study participants asessential for moving task shifting forward to make itformal and safe.What is clear is that surgical task shifting is currentlypracticed widely, even in the absence of regulation. Prac-titioners conceal the practice for fear of legal and profes-sional consequences in the event of a poor outcome.Other barriers include lack of motivation to take on theextra load, poor work environments and a lack of spaceand equipment. These barriers have been articulatedbefore, yet it is critical to pay attention to them [19].The study demonstrates a willingness by managers andclinicians to formally embrace surgical task shifting withthe caveats stated. This willingness is aligned with therealities Uganda faces, in the setting of a population of33 million people with only 100 specialist surgeons whoare mostly found in referral hospitals. Surgeons arerarely located in the rural communities where the majorityof the population lives. Access to specialist care is furtherimpeded by geographical distance, lack of appropriatemeans of transport and a mal-functioning referral system.Limitations of our studyThe study sample represents only health facilities alongthe East-Central axis of the country. Due to logisticalconstraints, it was not possible to include informantsfrom other parts of Uganda. Two sites visited did nothave functional theatres at the time of the visit.No reliable data on the safety of surgical task shiftingwas available from the facilities we visited. Uganda needs awell-designed prospective study in selected sites to establishthe efficacy and safety of surgical task shifting. Consideringthat focus groups had different cadres participating in thesame discussions, (juniors and their supervisors), some re-spondents could have withheld what would have otherwisebeen key or sensitive information for fear of negative conse-quences that could occur after the discussions.In some instances focus group discussions we wereinterrupted by theatre staff being called to attend toemergencies cases.Only one focus group discussion was conducted ineach site.RecommendationsWe recommend the Ministry of Health engage all stake-holders in developing formal surgical task shifting policyguidelines. The policy should address barriers such asresistance from health professionals, low salaries, andpoor working conditions. Training and close supervisionshould be provided to all personnel who are asked toperform surgical procedures for which they did not re-ceive pre-service training. The nation's health manage-ment information system should closely monitor whoperforms surgeries and what the outcomes are. Allhealth personnel should receive health insurance cover-age. As surgical task shifting is a response to a weak andunderstaffed health system, we recommend strengthen-ing health system infrastructure, including workforce.This would include reducing workload, improving re-cruitment and retention through salary improvements,and improving working conditions. It would be helpfulto Uganda and other low-income country settings todocument successful examples of surgical task shifting.ConclusionSurgical task shifting was strongly supported by facilitymanagers and frontline health workers. Surgical taskshifting is informally practiced widely, with varied under-standing of the principles. Formal guidelines are absent.Uganda is ripe for a task shifting support program withformal training and supervision. There is also sufficientdata on which to base a policy framework.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsSL, GB, SB, MG originated concept. MG, SK, PS, OK, AK and SM collected data andparticipated in analysis. GM wrote the first draft. All authors performed reviews ofdrafts for intellectual content. All authors read and approved the final manuscript.AcknowledgementsThis study would not have been possible without the contribution andcooperation of various stakeholders and individuals, including:• IDRC for funding this study through the grant won under number CentreFile: 105968–001 for providing financial assistance and the overalltechnical guidance for this project.Galukande et al. BMC Health Services Research 2013, 13:292 Page 6 of 7http://www.biomedcentral.com/1472-6963/13/292• The Government of Uganda and Ministry of Health, especially theCommissioner for Planning Dr. Francis Runumi Mwesigye for encouragingand facilitating this study.• Evelyn Bakengesa and Aida Namubiru for their administrative and supportto the project.• Health facility managers for accommodating requests for interviews andfocus group discussions who agreed without hesitation.• Key informants and focus group respondents for their time andwillingness to participate in the study. Due to other commitments, manyrespondents made time for interviews after working hours and thisflexibility was greatly appreciated.• Health facilities that participated: Hospitals: Gombe, Nkozi, Mityana,Mubende, Kalisizo, Kitovu, Kisubi, Bugiri, Rakai, Iganga, Entebbe, Kayunga,Nyenga, Kawolo, Lyantonde, Villa Maria, Kiboga, and Nakaseke.• Health Centre IVs: St. Stephens, Atirir, Serere, Kakira, Kasana andWakisoHealth Centre IV: St. Stephens, Atirir, Serere, Kakira, Kasana andWakiso.Author details1Department of Surgery, College of Health Sciences, Makerere University,P.O. Box 7072, Mulago Hill Road, Kampala, Uganda. 2Department ofOrthopaedics, College of Health Sciences, Makerere University, Kampala,Uganda. 3Department of Obstetrics & Gynaecology, College of HealthSciences, Makerere University, Kampala, Uganda. 4Clinical Epidemiology Unit,College of Health Sciences, Makerere University, Kampala, Uganda.5Department of Anatomy, College of Health Sciences, Makerere University,Kampala, Uganda. 6Ministry of Health, Kampala, Uganda. 7University ofWashington, Seattle, USA. 8University of British Columbia, Vancouver, Canada.9University of Ottawa, Ottawa, Canada.Received: 29 December 2012 Accepted: 31 July 2013Published: 1 August 2013References1. Debas H, Gosselin RA, McCord C, Thind A: Surgery. In Disease Controlpriorities in developing countries. 2nd edition. Edited by Jamison DT, BremanJG, Measham AR, Alleyne G, Claeson M, et al. New York: Oxford UniversityPress; 2006:1245–1259. Available: http://www.dcp2.org/pubs/DCP/67/FullText. Accessed 9 April 2009.2. 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Cumbi A, Pereira C, Malalane R, Vaz F, Mc Cord C, Bacci A, Bergstrom S:Major surgery delegation to mid level health practitioners inMozambique: health professionals’ perceptions. Hum Resour Heal 2007,5:27. doi:10.1186/1478-4491-5-27.18. Chandler CI, Chonya S, Mtei F, Reyburn H, Whitty CJ: Motivation, moneyand respect: a mixed method study of Tanzanian non physicianClinicians. Soc Sci Med 2009, 68(11):2078–2088.19. Jackie Wicz W, Tulenko K: Increasing community health work forceproductivity and effectiveness: a review of the influence of the workenvironment. Hum Resour Health 2012, 10:38.doi:10.1186/1472-6963-13-292Cite this article as: Galukande et al.: Use of surgical task shifting to scaleup essential surgical services: a feasibility analysis at facility level inUganda. BMC Health Services Research 2013 13:292.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitGalukande et al. BMC Health Services Research 2013, 13:292 Page 7 of 7http://www.biomedcentral.com/1472-6963/13/292

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