End of Project report for
ETATMBA Quality Management Committee
7th July 2014
1.
Overview of progress
The project began on 1st February 2011 and is due to complete on 31st July 2014. There
have been many challenges to overcome but the results are positive:

100 NPCs have been enrolled and retained across both countries, using robust training
programmes customised to each country’s healthcare needs have been established.
Nurse Midwives trained in anaesthesia have been included as an essential component in
augmenting the service in Tanzania.

NPCs have been trained as local leaders in obstetric and neonatal care to improve
clinical services.

An accredited BSc in Clinical Obstetrics and Leadership has been established for NPCs
in Malawi, with University of Malawi Degrees for Specialist Clinical Officers underway for
Surgery, Obstetrics, Paediatrics, Orthopaedics and General Medicine that should deliver
a sustainable solution in Malawi and act as a beacon for the training of NPCs across
sub-Saharan Africa.

A randomised waiting list design controlled trial has been established to evaluate the
training in Malawi and pre- and post-course qualitative and quantitative research is
underway in Tanzania.

Extensive review of existing guidelines with literature review to ensure that best practice
is employed, together with significant use of audit to trace implementation of guidelines
and to drive further improvements in health care. Action-oriented audit now a routine
tool in health care, in contrast to previous poor application and uptake of this practice.

Accredited degree-level training appropriate to competency and tasks that these NPCs
perform has been established in obstetrics and four further specialties.

A professional support network has been created and is being extended, with a culture of
team working and engagement among NPCs and ‘shared leadership’ initiated.

Publication of protocol paper

Presentations at national and international conferences by the project team.
2.
Training
This is now complete in both Malawi and Tanzania. Malawi has followed a modular
approach, due to the requirement that clinical officers are released by their employer for a
short duration only. Tanzania has been able to train cohorts over a longer period of time,
followed up by further support once the student is back in their place of work. Clinical
Officers were trained in both obstetric and neonatal care and in leadership, so that they
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could in turn both train others and find innovative solutions to the problems of their particular
working environment.
Obtaining a BSc was a priority for the Malawian students and they have completed their final
assignment and are on course to graduate in October 2014. Their initiative and
determination has contributed to the University of Malawi’s acceptance that a BSc should be
available to Clinical Officers in a whole range of disciplines, in order to encourage and
promote the best in the profession.
3.
Research
Research data has been collected in both Tanzania and Malawi and is currently in the
process of analysis. Two masters students in Tanzania are working with a Senior Clinical
Research Fellow to review the data from Tanzania, while a statistician at the University of
Warwick is reviewing the data from Malawi. A process paper is under review with BMJ Open
at present, and the results will also be written up for the final EC report.
Data collection in Tanzania was relatively straightforward due to the robust mechanisms
already in place at Ifakara Health Institution for this exercise. Data collection in Malawi was
more problematic because of the variety in content and completeness across the districts
involved in the study. Two researchers visited the regions to collect information from health
centres and hospitals, which could be supplemented by national data collected on behalf of
the Ministry of Health. The resulting figures still require extensive work before they can be
analysed; this is currently underway.
4.
Research outputs
A paper has already been published describing the protocol of the clinical trial in Malawi:
“The impact of training non-physician clinicians in Malawi on maternal and perinatal
mortality: a cluster randomised controlled evaluation of the enhancing training and
appropriate technologies for mothers and babies in Africa (ETATMBA) project.” David
Ellard, Doug Simkiss, Siobhan Quenby, David Davies, Ngianga-bakwin Kandala, Francis
Kamwendo, Chisale Mhango and Joseph Paul O’Hare. BMC Pregnancy and Childbirth
2012, 12:116.
A second paper entitled “Advanced clinical obstetrics, neonatal and leadership training for
non-physician clinicians in Malawi (The ETATMBA Project): A process evaluation” is
currently under review with BMJ Open.
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A book chapter “Advanced Techniques for Modelling Maternal and Child Health in Africa”by
Ngianga-Bakwin Kandala has been published in “Advanced Techniques for Modelling
Maternal and Child Health in Africa.” Eds Kandala, Ngianga-Bakwin and Ghilagaber,
Gebrenegus. The Springer Series on Demographic Methods and Population Analysis, Vol.
34: Springer Science. Ngianga-Bakwin Kandala provides statistical support for the project.
Several other papers are planned once the research findings have been analysed, covering:
 the results of the quantitative data of the randomised clinical trial
 education and quality in processes in obstetrics and neonatal care in Malawi
 empowerment learning
 values-based practice teaching and the impact on quality improvement and neonatal
care in Malawi
 a realist evaluation of education to improve clinical service in two African countries:
what works for whom and where
 the training schemes in Malawi and Tanzania and the quantitative and qualitative
research data and draw conclusions on how these would inform training programmes
for NPCs in other countries and other specialities in sub-Saharan Africa and lowincome countries.
5.
EC funding
A major difficulty has been the withholding of funds by the EC pending further detail about
the costs. This has combined with a change in the remit of the project which was extensive
enough for the EC to request an external review of the work. Some work packages could
not be completed due to lack of resources (for example the concept of 24-hour telephone
support for clinicians) or due to government priorities (for example adoption of the clinical
guidelines developed by the project were subject to government, rather than project,
timelines and priorities).
The lack of funding caused significant difficulties for both Malawi and Tanzania and these
could only partially be overcome by advancement of funds from Warwick to cover essential
costs. While it is hoped that EC funds will now be sent, their arrival will be too late to provide
any assistance in these final weeks of the project.
6.
Conclusion
The project has accomplished its targets despite severe funding difficulties. The clinical
officers trained in Tanzania and Malawi have made a real difference both to their own
patients’ health and lives and to their colleagues’ expertise as these new leaders pass on
and developed what they have learned.
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