Does higher performance in a national licensing examination predict better quality of care? A longitudinal observational study of Ethiopian anesthetists.

BACKGROUND: Ethiopia made a national licensing examination (NLE) for associate clinician anesthetists a requirement for entry into the practice workforce. However, there is limited empirical evidence on whether the NLE scores of associate clinicians predict the quality of health care they provide in low-income countries. This study aimed to assess the association between anesthetists' NLE scores and three selected quality of patient care indicators. METHODS: A multicenter longitudinal observational study was conducted between January 8 and February 7, 2023, to collect quality of care (QoC) data on surgical patients attended by anesthetists (n = 56) who had taken the Ethiopian anesthetist NLE since 2019. The three QoC indicators were standards for safe anesthesia practice, critical incidents, and patient satisfaction. The medical records of 991 patients were reviewed to determine the standards for safe anesthesia practice and critical incidents. A total of 400 patients responded to the patient satisfaction survey. Multivariable regressions were employed to determine whether the anesthetist NLE score predicted QoC indicators. RESULTS: The mean percentage of safe anesthesia practice standards met was 69.14%, and the mean satisfaction score was 85.22%. There were 1,120 critical incidents among 911 patients, with three out of five experiencing at least one. After controlling for patient, anesthetist, facility, and clinical care-related confounding variables, the NLE score predicted the occurrence of critical incidents. For every 1% point increase in the total NLE score, the odds of developing one or more critical incidents decreased by 18% (aOR = 0.82; 95% CI = 0.70 = 0.96; p = 0.016). No statistically significant associations existed between the other two QoC indicators and NLE scores. CONCLUSION: The NLE score had an inverse relationship with the occurrence of critical incidents, supporting the validity of the examination in assessing graduates' ability to provide safe and effective care. The lack of an association with the other two QoC indicators requires further investigation. Our findings may help improve education quality and the impact of NLEs in Ethiopia and beyond.

Health care managers' perspectives on workforce licensing practice in Ethiopia: A qualitative study.

BACKGROUND: Professional licensing bodies are valuable sources for tracking the health workforce, as many skilled health-care providers require formal training, registration, and licensure. Regulatory activities in Ethiopia were not effectively implemented due to poor follow-up and gaps in skilled human resources, budget, and information technology infrastructure. OBJECTIVE: The aim of this study was to explore and describe the lived experiences and challenges faced by health care managers in health professionals' licensure practices in Ethiopia. METHODS: A cross-sectional study design with a phenomenological approach was employed between March 26 and April 30, 2021, to collect qualitative data. We conducted in-depth interviews with a total of 32 purposively selected health system managers. An interview guide was prepared in English, translated into Amharic, and then pretested. Audio recorded data was transcribed verbatim, translated, and analysed manually by themes and sub-themes. A member check was done to check the credibility of the result. RESULTS: The data revealed four major themes: awareness of licensing practices, enforcement of licensing practices, systems for assuring the quality of licensing practices, and challenges to licensing practices. Lack of awareness among managers about health workforce licensing was reported, especially at lower-level employers. Regulators were clear on the requirements to issue a licence to the health workforce if they are competent in the licensing exam, while human resource managers do not emphasise whether the employees have a licence or not during employment. As a result of this, non-licenced health workers were employed. Health care managers mentioned that they did not know any monitoring tools to solve the issue of working without a licence. Fraudulent academic credentials, shortage of resources (human resources, finance, equipment, and supplies), and weak follow-up and coordination systems were identified as main practice challenges. CONCLUSIONS: This study reported a suboptimal health professionals' licensing practice in Ethiopia, which is against the laws and proclamations of the country that state to employ all health workers only with professional licenses. Challenges for health professionals' licensing practice were identified as fraudulent academic credentials, a shortage of resources (HR, finance, equipment, and supplies), and a weak follow-up and coordination system. Further awareness of licensing practices should be created, especially for lower-level employers. Regulators shall establish a reliable digital system to consistently assure the quality of licensing practices. Health care managers must implement mechanisms to regularly monitor the licensing status of their employees and ensure that government requirements are met. Collaboration and regular communication between regulators and employers can improve quality practices.

Impact of anesthetist licensing examination on quality of education in Ethiopia: a qualitative study of faculty and student perceptions.

BACKGROUND: Ethiopia drastically increased the anesthesia workforce density by training 'associate clinician anesthetists' as a task-shifting and sharing strategy. However, there were growing concerns about educational quality and patient safety. Accordingly, the Ministry of Health introduced the anesthetist national licensing examination (NLE) to assure the quality of education. However, empirical evidence is scarce to support or refute the overall impact of NLEs, which are relatively costly for low- and middle-income settings. Therefore, this study aimed to explore the impact of introducing NLE on anesthetists' education in Ethiopia. METHODS: We conducted a qualitative study using a constructivist grounded theory approach. Data were prospectively collected from ten anesthetist teaching institutions. Fifteen in-depth interviews were conducted with instructors and academic leaders, and six focus groups were held with students and recently tested anesthetists. Additional data were gathered by analyzing relevant documents, including versions of curricula, academic committee minutes, program quality review reports, and faculty appraisal reports. Interviews and group discussions were audiotaped, transcribed verbatim and analyzed using Atlas.ti 9 software. RESULTS: Both faculty and students demonstrated positive attitudes toward the NLE. Student motivation, faculty performance, and curriculum strengthening were the three primary changes that emerged, resulting in three subsequent spin-offs on assessment, learning, and quality management practices. Academic leaders' dedication to evaluating examination data and turning these into action led to changes that improved education quality. Increased accountability, engagement, and collaboration were the predominant factors facilitating change. CONCLUSION: Our study indicates that the Ethiopian NLE has prompted anesthesia teaching institutions to improve their teaching, learning, and assessment practices. However, more work is required to improve exam acceptability among stakeholders and drive broader changes.

Evaluating the effect of interventions for strengthening non-physician anesthetists' education in Ethiopia: a pre- and post-evaluation study.

BACKGROUND: Access to safe surgery has been recognized as an indispensable component of universal health coverage. A competent anesthesia workforce is a prerequisite for safe surgical care. In Ethiopia, non-physician anesthetists are the main anesthesia service providers. The Government of Ethiopia implemented a program intervention to improve the quality of non-physician anesthetists' education, which included faculty development, curricula strengthening, student support, educational resources, improved infrastructure and upgraded regulations. This study aimed to assess changes following the implementation of this program. METHODS: A pre-and post-evaluation design was employed to evaluate improvement in the quality of non-physician anesthetists' education. A 10-station objective structured clinical examination (OSCE) was administered to graduating class anesthetists of 2016 (n = 104) to assess changes in competence from a baseline study performed in 2013 (n = 122). Moreover, a self-administered questionnaire was used to collect data on students' perceptions of the learning environment. RESULTS: The overall competence score of 2016 graduates was significantly higher than the 2013 class (65.7% vs. 61.5%, mean score difference = 4.2, 95% CI = 1.24-7.22, p < 0.05). Although we found increases in competence scores for 6 out of 10 stations, the improvement was statistically significant for three tasks only (pre-operative assessment, postoperative complication, and anesthesia machine check). Moreover, the competence score in neonatal resuscitation declined significantly from baseline (from 74.4 to 68.9%, mean score difference = - 5.5, 95% CI = -10.5 to - 0.5, p < 0.05). Initial gender-based performance differences disappeared (66.3% vs. 65.3%, mean score difference = - 1.0, 95% CI = - 6.11-3.9, p > 0.05 in favor of females), and female students scored better in some stations. Student perceptions of the learning environment improved significantly for almost all items, with the largest percentage point increase in the availability of instructors from 38.5 to 70.2% (OR = 3.76, 95% CI = 2.15-6.55, p < 0.05). CONCLUSION: The results suggest that the quality of non-physician anesthetists' education has improved. Stagnation in competence scores of some stations and student perceptions of the simulated learning environment require specific attention.

Identifying gaps in the practices of rural health extension workers in Ethiopia: a task analysis study.

BACKGROUND: Health extension workers (HEWs) are the frontline health workers for Ethiopia's primary health care system. The Federal Ministry of Health is seeking to upgrade and increase the number of HEWs, particularly in remote areas, and address concerns about HEWs' pre-service education and practices. The aim of this study was to identify gaps in HEWs' practices and recommend changes in their training and scope of practice. METHODS: A cross-sectional descriptive task analysis was conducted to assess the work of rural HEWs who had been in practice for six months to five years. One hundred participants were invited from 100 health posts in five regions of Ethiopia. HEWs self-reported on 62 tasks on: frequency, criticality (importance), where the task was learned, and ability to perform the task. Descriptive statistics, including frequencies and percentages, were computed for each variable. Task combinations were examined to identify tasks performed infrequently or for which HEWs are inadequately prepared. RESULTS: A total of 82 rural HEWs participated in the study. Nearly all HEWs rated every task as highly critical to individual and public health outcomes. On average, most HEWs (51.5%-57.4%) reported learning hygiene and environmental sanitation tasks, disease prevention and control tasks, family health tasks, and health education and communication tasks outside of their pre-service education, primarily through in-service and on-the-job training. Over half of HEWs reported performing certain critical tasks infrequently, including management of supplies, stocks and maintenance at the facility and management of the cold chain system. Almost all HEWs (95.7-97.2%) perceived themselves as competent and proficient in performing tasks in all program areas. CONCLUSION: HEWs were insufficiently prepared during pre-service education for all tasks that fall within their scope of practice. Many learned tasks through in-service or on-the-job training, and some tasks were not learned at all. Some tasks that are part of expected HEW practice were performed infrequently, potentially reducing the effectiveness of the Health Extension Program to provide preventive and basic curative health care services to communities. Findings should alert policy makers to the need to review HEWs' scope of practice, update pre-service education curricula and prioritize in-service training modules.