Table 3.

Characteristics of included studies, surgical task-shifting

Study name, country	Study design	Healthcare facility characteristics	Procedures	Lead surgical providers and number of procedures	Training and level of supervision of non-specialists	Outcomes assessed	Mortality	Other clinical outcomes
Ashley et al., 2021. Sierra Leone (sub-Saharan Africa). Low-income economy.	Single-blind, parallel, non-inferiority randomized clinical trial. Data were collected between October 2017 and February 2019.	Single-centre study. First-level district hospital, serving an entirely rural catchment population of 200 000 people.	Surgical task-shifting. Anterior inguinal hernia repair with mesh. Major surgical procedure; elective.	Associate clinicians (ACs): non-physicians. ACs operated on 115 patients. Medical doctors (MDs): non-specialist physicians. MDs operated on 114 patients.	Background training: 3-year Diploma in Community Health and 2 years of work experience as Community Health Officers (CHOs). 3-year surgical training programme (including 1 year of internship), organized by CapaCare. ACs routinely performed hernia repair using tissue techniques as part of their jobs. Study training: inguinal hernia mesh repair training programme (1-day theoretical module + hands-on practice performing the surgeries under supervision, 1–3 days). Supervision: ACs in the study operated independently.	Primary outcomes: mortality and hernia recurrence (1 year after the operation). Secondary outcomes: postoperative complications (any, pain, impaired wound healing, wound infection, haematoma and reoperation) (2 weeks after surgery). Fewer groin symptoms, Inguinal Pain Questionnaire score, patient satisfaction and Self-Assessed Health Status (1 year after surgery).	No difference in mortality rates between ACs and MDs.	Hernia recurrence (1-year post-surgery): 0.9% (ACs) vs 6.9% (MDs), P < 0.001. ACs and MDs were equivalent for all other morbidity outcomes measured at 2 weeks and 1-year post-surgery.
Attebery et al., 2010. Tanzania (sub-Saharan Africa). Lower-middle-income economy.	Retrospective audit review. Data were collected between January 2006 and September 2007.	Single-centre study. Rural referral hospital, serving 11 000 patients and vastly funded by the Norwegian Ministry of Health.	Surgical task-shifting. 51 patients underwent basic and emergency neurosurgical procedures (including burr hole surgery, craniotomy, skull fracture repair, ventriculo-peritoneal shunting (VP-shunting), myelomeningocele repair, laminectomy and exploratory biopsies).	Assistant medical officer (AMO): non-physician. The AMO operated on 38 patients. American neurosurgeon: specialist physician who either operated independently or alongside the AMO (task-sharing). 11 patients were operated on by the American neurosurgeon in conjunction with the AMO (task-sharing); 3 patients were operated on by the American neurosurgeon alone.	The non-physician was a qualified AMO. He routinely performed general surgery at Haydom Lutheran Hospital. Study training: a condensed training programme for neurosurgical procedures led by the American neurosurgeon. Level of supervision: in the intervention group, the AMO operated as the ‘lead surgeon’, but the degree of supervision received is unclear.	Mortality.	No significant difference in mortality rates between the AMO and the neurosurgeon.
Beard et al., 2014. Tanzania (sub-Saharan Africa). Lower-middle-income economy.	Retrospective records review. Data were collected in 2012.	Multi-centre study. 7 district, regional and mission hospitals.	Surgical task-shifting. Non-obstetric major surgical procedures and laparotomies for ruptured ectopic pregnancies. The five most common procedures were elective inguinal hernia repair, prostatectomy, exploratory laparotomy, hydrocoelectomy and emergency inguinal hernia repair. Major surgery; emergency and elective procedures.	Non-physician clinicians (NPCs): clinical officers (COs) or AMOs. NPCs performed 948 procedures. Physicians: 20 medical officers (MOs) (non-specialists) and 5 surgeons (specialists). Physicians performed 750 procedures.	Background training: COs were secondary school graduates who had completed 3 years of training and were qualified to practise medicine and perform minor surgeries. Although COs are not usually licenced to practise major surgery in Tanzania, they routinely performed major surgical procedures in one of the study sites. AMOs: 3 years of CO training + further 2-year training in common major obstetric and general surgical procedures. They are licenced to practise medicine and surgery in Tanzania. Supervision: NPCs operated independently.	Mortality (in-hospital). Morbidity (30 days postoperatively): all, wound infection; anaemia requiring blood transfusion; reoperation and readmission. Subgroup analysis: mortality and ‘all’ morbidity events were reported separately for the five most common surgical procedures (elective inguinal hernia repair, prostatectomy, exploratory laparotomy, hydrocelectomy and emergency inguinal hernia repair).	All major surgical procedures: no difference in mortality rates between NPCs and physicians. Subgroup analysis: no difference in mortality rates between NPCs and physicians for elective inguinal hernia repair, prostatectomy, exploratory laparotomy, hydrocelectomy and emergency inguinal hernia repair.	All major surgical procedures: NPCs and physicians were equivalent for all morbidity measures. Subgroup analysis: no difference in ‘all’ morbidity rates between NPCs and physicians for elective inguinal hernia repair, prostatectomy, exploratory laparotomy, hydrocelectomy and emergency inguinal hernia repair.
Beard et al., 2019. Ghana (sub-Saharan Africa). Lower-middle-income economy.	Prospective cohort study with non-inferiority design. Data were collected between February 2017 and September 2018.	Single-centre study. Referral hospital under the management of the Ghana Health Service (public hospital).	Surgical task-shifting. Anterior tension-free mesh hernia repair, according to the Lichtenstein technique. Major surgical procedure. Elective surgery.	MDs: non-specialist physicians. MDs operated on 119 patients. General surgeons: specialist physicians. The general surgeons operated on 123 patients.	Background training: medical school and a 2-year general internship. MDs did not have formal training in surgery. Study training: 2-week theoretical course by the Ghana Hernia Society followed by hands-on practical training, performing hernia repairs with mesh under the supervision of consultant surgeons. The performance of MDs was evaluated by two trainers to determine their competence. Level of supervision: upon completion of the training programme, MDs were qualified to perform hernia repairs independently.	Primary outcomes: mortality and hernia recurrence (1-year post-surgery). Secondary outcomes: postoperative complications (any, impaired wound healing, superficial infection, haematoma/seroma, severe pain, other complications and intervention for complications) (2 weeks post-surgery). Fewer symptoms, Inguinal Pain Questionnaire score, patient satisfaction, and Self-Assessed Health Status score (1-year post-surgery).	No difference in mortality rates between MDs and general surgeons.	Hernia recurrence (1-year post-surgery): 0.9% (MDs) vs 2.8% (general surgeons), P < 0.001. No difference between MDs and general surgeons for all other morbidity outcomes measured 2 weeks and 1-year post-surgery.
Bevis et al., 2008. Kansas (USA). High-income economy.	Single-centre study. Level I trauma hospital, intensive care unit or operating room. Data were collected between June 2003 and December 2003.	Single-centre study. Level I trauma hospital (intensive care unit or operating room).	Surgical task-shifting. 71 tube thoracostomies, performed on 51 patients. Major, emergency procedure.	Advanced practice providers (APPs): non-physicians. APPs performed 38 tube thoracostomy insertions on 24 patients. Trauma surgeons: specialist physicians. Trauma surgeons performed 33 tube thoracostomy insertions on 27 patients.	APPs were trained to perform tube thoracostomies through courses led by attending surgeons. Each APP performed 10 tube thoracostomy placements under direct supervision to establish competency. Upon completion of the training, APPs were qualified and licenced to perform tube thoracostomy placements under indirect supervision in Kansas.	Death as a result of the tube thoracostomy procedure and hospital length of stay. Incorrect tube placement: tube kinking, lateral drainage port extrapleural, tube extending caudad from the insertion site, abutment to mediastinum, intrafissure placement, intra-abdominal or transdiaphragmatic placement. Insertion complications: bleeding, re-expansion pulmonary oedema, loss of pulse and vasovagal phenomena. Outcome complications: dislodgement of chest tube, empyema, video-assisted thoracotomy or thoracoscopic surgery, need for chest tube reinsertion and reinsertion <5 hours after removal.	No death occurred as a direct result of tube thoracostomies.	Tube extending caudad from insertion site: 2.6% (APPs) vs 21% (surgeons), P = 0.02. No other significant differences in incorrect tube placement parameters. No insertion complications occurred during the study period and there were no differences in outcome complications between APPs and surgeons. The duration of hospital length of stay was equivalent between APPs and surgeons.
Bolkan et al., 2017. Sierra Leone (sub-Saharan Africa). Low-income economy.	Prospective observational study. Data were collected between January 2011 and July 2016.	Multi-centre study. 16 partner hospitals, comprising district hospitals run by private not-for-profit organizations and government district hospitals. All hospitals had the adequate surgical capacity and 24-hour availability of MDs to perform surgery.	Surgical task-shifting. Surgical and obstetrical procedures. Procedures included caesarean section, hernia repair, laparotomy, appendicectomy, dilatation and curettage and hysterectomy. Minor and major surgeries; elective and emergency operations.	Trainees of the Capacare Surgical Training Programme and Surgical Assistant Community Health Officers (SACHOs). Trainees were CHOs (non-physicians) and junior MDs (non-specialists). SACHOs were CHOs who had graduated from the Capacare Surgical Training Programme (non-physicians). Trainees performed 4715 procedures under indirect supervision; SACHOs performed 2369 procedures. Trainers and supervisors were qualified MDs (non-specialists) and specialist surgeons or obstetricians. During the training period, supervisors performed 4515 operations. Following the training, supervisors performed 114 procedures.	Background training: CHOs have a 3-year basic medical diploma training and 2 years of postgraduate clinical practice. Junior MDs have to complete medical school and an internship to be eligible for the CapaCare Surgical Training Programm. CapaCare surgical training: 2-year training course. Introductory 6-month course (theoretical and practical training); three 6-month surgical rotations in district hospitals, engaging in all aspects of care of surgical patients. Trainees undergo refresher training at Masanga hospital. CHOs have to complete a further 1-year internship in a tertiary surgical and maternal hospital, before being appointed as SACHOs. Supervision: All trainees and SACHOs are indirectly supervised by an unscrubbed MD when performing surgical and obstetrical procedures.	Crude in-hospital mortality. Mortality rates following trainees’ and SACHOs’ indirectly supervised operations are compared with the mortality rates of ‘observed operations’ (performed by trainers and supervisors).	Trainees: no significant differences in mortality rates between trainees and trainers. SACHOS: no significant differences in mortality rates between SACHOs and physicians.
Buwembo et al., 2011. Uganda (sub-Saharan Africa). Low-income economy.	Programme evaluation (prospective study). Data were collected between May 2006 and May 2010.	Healthcare clinics.	Surgical task-shifting. 5152 male surgical circumcisions, using the dorsal slit or sleeve surgical resection methods. Minor surgical procedure; elective surgery.	COs: non-physicians. COs performed 3218 male circumcisions. Trained and certified general physicians: non-specialists. Physicians performed 1934 male circumcisions.	During the study, COs were trained by a consultant urologist to perform male circumcisions. No details of the background training of COs were specified. COs operated independently.	Safety: moderate or severe adverse events related to the surgery and wound healing. Moderate adverse events were those requiring medical treatment; severe adverse events required surgical intervention. Outcomes were measured 24–48 hours post-surgery, 7–9 days post-surgery and 4 weeks post-surgery. Efficiency: operative time from first skin incision to wound closure and dressing.		Physicians experienced a higher rate of adverse events than COs (1.5% vs 0.6%, P = 0.007). There was no overall difference in operative duration between physicians and COs.
Chu et al., 2011. Somalia (sub-Saharan Africa). Low-income economy.	Prospective study. Data were collected between October 2006 and December 2009.	Single-centre study. A private hospital supported by Médecins Sans Frontièrs (MSF).	Surgical task-shifting. 2086 surgical interventions, performed on 1602 patients. Elective and emergent procedures (70% of interventions were emergent); minor and major surgeries. 1591 interventions were trauma related.	Doctor with surgical skills (non-specialist physician) and surgical nurse (non-physician). They operated on patients between January 2008 and December 2009: the doctor performed 1119 procedures and the surgical nurse performed 314 procedures. The doctor performed 89% of elective cases; the surgical nurse performed 46% of all caesarean sections. Expatriate surgeons from MSF: specialist physicians. They operated on patients between October 2006 and January 2008. They performed 653 surgical operations.	Training of generalist MD: Background: the generalist doctor was ‘extremely competent, especially in trauma surgery’. He had gained surgical skills with the International Committee of the Red Cross and International Medical Corps and he had attended several training seminars. Study training: 2 years of training under MSF expatriate surgeons. The MSF programme included technical training in surgical and anaesthesia skills. Surgical nurse: Background training: the nurse had acquired surgical skills through informal, on-the-job training.	Operative mortality.	0.2% (non-specialists) vs 1.7% (expatriate surgeons), P < 0.001.	Study training: surgical and anaesthesia skills acquired through the MSF training programme prior to January 2008. Level of supervision: the generalist doctor and the surgical nurse operated without supervision between 2008 and 2009.
Cometto et al., 2012. South Sudan (sub-Saharan Africa). Low-income economy.	Retrospective review. Data were collected between 2005 and 2010.	Multi-centre study. The programme was implemented in Primary Healthcare Centres, supported by the Italian non-governmental organisation (NGO) Comitato Collaborazione Medica.	Surgical task-shifting. 1543 patients underwent an operation during the surgical missions of Comitato Collaborazione Medica. Minor and major surgical procedures. Surgical procedures included hernia repairs (42%); skin, abscesses, lipomas and burns (17.76%); proctology (8.49%); Ob/Gyn and breast surgery (8.43%); thyroid and neck surgery (5.18%); urology (5.12%); digestive tract surgery (5.06%) and others (7.97%). The majority were elective procedures.	Surgical technicians: non-physicians. They performed 216 surgical operations. Visiting expatriate consultant surgeons: specialist physicians. They performed 1327 surgical operations.	Training: surgical technicians had a level of background training between nurses and physicians. They were trained through the Comitato Collaborazione Medica training programme and through the War Wounded Referral Hospital (Kenya) managed by the International Committee of the Red Cross. They developed competencies in perioperative surgical care and in performing minor and major surgery. Level of supervision: surgical technicians were supervised by surgeons when performing caesarean sections and hernia repairs.	Mortality.	No differences between surgical technicians and expatriate surgeons.
Ellens et al., 2019. Michigan (USA). High-income economy.	Retrospective cohort study. Data were collected between January 2012 and September 2016.	Single-centre study. Level I trauma centre, intensive care unit or emergency department.	Surgical task-shifting. External ventricular drain (EVD) placement, taking place in the intensive care unit or in the emergency department.	Mid-level practitioners (MLPs): non-physicians. MLPs first-attempted EVD placement in 238 patients. Neurosurgeons: specialist physicians. Neurosurgeons first-attempted EVD placement in 70 patients.	Training and supervision: MLPs received on-the-job training to perform EVD placement. They had to place at least five EVDs under the direct supervision of senior MLPs or experienced neurosurgeons prior to operating independently. MLPs were allowed to operate independently solely after the authorization of a neurosurgeon.	Glasgow Coma Scale score (pre-procedure and post-procedure), number of passes of the catheter per procedure, the accuracy of placement and complications (all haemorrhages, intraventricular haemorrhage, intraparenchymal haemorrhage, subdural haemorrhage and subarachnoid haemorrhage, infection and cerebrospinal fluid leak).		No differences between MLPs and neurosurgeons in placement accuracy, Glasgow Coma Scale scores and complication rates. 18 patients operated on by MLPs required multiple passes; in 14 cases, MLPs abandoned the procedure after three failed passes.
Enriquez-Marulanda et al., 2018. Massachusetts (USA). High-income economy.	Retrospective cohort comparative study. Data were collected between June 2007 and June 2017.	Single-centre study. Neurosurgical service at an academic and teaching hospital.	Surgical task-shifting. 203 patients underwent EVD placement in patients with acute subarachnoid haemorrhage. Emergency procedures (91.2%). Major surgery.	Advanced practitioners [nurse practitioners (NPs) and physician assistants]: non-physicians. Advanced practitioners performed 87 (36.5%) EVD placements. Neurosurgeons or subspeciality clinical fellows: specialist physicians. They performed 151 (63.5%) EVD placements.	Training and supervision: advanced practitioners had to perform five successful EVD placements with little or no assistance in order to qualify to operate unsupervised. Attending neurosurgeon backup was available when intraprocedural complications occurred or if three failed attempts occurred without obtaining cerebrovascular fluid drainage.	Primary: EVD tract haemorrhages and accuracy of catheter tip placement. Secondary: number of catheter placement attempts, intraprocedural complications, EVD infection, EVD obstruction/non-functional EVD, catheter dislodgement, need for repositioning and replacement and duration of EVD catheter.		EVD obstruction or non-functional EVD: 21.8% (advanced practitioners) vs 11.9% (neurosurgeons), P = 0.04. No differences in primary outcomes between provider types. No significant differences in the number of catheter placement attempts, intraprocedural complications, EVD infections, catheter dislodgement, need for repositioning and replacement and duration of EVD catheter.
Gajewski et al., 2019a. Malawi (sub-Saharan Africa) Low-income economy.	Prospective, cross-sectional comparison study.	Multi-centre study. 18 Government district hospitals with the capacity to deliver major surgery.	Surgical task-shifting. Hernia repairs, performed on 559 patients. Major surgery; elective and emergency procedures.	COs: non-physicians. COs performed 523 hernia repairs. MDs: non-specialist physicians. MDs performed 36 hernia repairs.	Background training: Diploma in Clinical Medicine and 2-year (minimum) work experience providing clinical and surgical care in district hospitals/rural healthcare facilities. Study training: COST-Africa training programme, leading to the accreditation of a B.Sc. in General Surgery by the University of Malawi College of Medicine. The programme included 4 months of theoretical training; a 24-month surgical placement in district hospitals; 8-month further training in advanced surgical skills.	Perioperative mortality and wound infection rates (in-hospital).	No surgical deaths occurred during the study period.	No differences between COs and MDs in wound infection rates.
Gajewski et al., 2019b. Zambia (sub-Saharan Africa) Low-income economy.	Prospective, cross-sectional comparison study. The length of the intervention varied across hospitals between 8 and 24 months, with an average of 17-month duration.	Multi-centre study. 8 (public or mission) district hospitals with a functioning operating theatre and capacity to scale up surgery.	Surgical task-shifting. Caesarean sections and index general surgery procedures (comprising hysterectomy, salpingectomy, laparotomy, hernia and hydrocele repair). Major surgery.	Medical licentiates (MLs): non-physicians. MLs performed 725 procedures: 544 caesarean sections and 181 other index procedures. MDs: non-specialist physicians. They were the highest qualified cadre operating in the study hospitals. MDs performed 1002 operations: 770 caesarean sections and 232 other index procedures.	Background training: 2-year Advanced Diploma course that comprised a theoretical and a practical component (rotations in internal medicine, paediatrics, surgery and obstetrics and gynaecology) + 1-year internship. Study training: COST-Africa training programme. This included a 3-month course in surgery and a placement in district hospitals. Level of supervision: MLs who were deployed to the intervention district hospitals received quarterly supervision by specialist surgeons.	Mortality and wound infection rates for caesarean sections and index general surgery procedures.	1 surgical death following an exploratory laparotomy performed by an MD. No deaths were registered following caesarean sections.	Equivalent wound infection rates between MLs and MDs for caesarean sections and index general surgery procedures.
Gerber et al., 2019. Texas (USA). High-income economy.	Retrospective patient chart review. Data were collected between 2012 and 2016.	Single-centre study. Texas Children’s Hospital, Houston.	Surgical task-shifting. 551 newborn circumcisions using the Gomco clamp. Minor surgical procedure.	APPs: non-physicians. APPs included physician assistants and NPs. APPs performed 314 circumcisions. Attending paediatric urologists: specialist physicians. Paediatric urologists performed 237 circumcisions.	Training and supervision: APPs underwent training led by attending urologists. Initially, they observed 10 newborn circumcisions; then, they first assisted the urologist on 10 procedures and they performed 10 circumcisions under direct supervision. Upon completion of the training, APPs were qualified to perform newborn circumcisions autonomously, with only indirect supervision from the attending surgeon.	Complications, 30-day return to the operating room, revision of circumcision, circumcision-related penile surgery and intraoperative bleeding.		No difference in complications, 30-day return to the operating room, revision of circumcision, circumcision-related penile surgery and intraoperative bleeding.
Gessessew et al., 2011. Ethiopia (sub-Saharan Africa). Low-income economy.	Retrospective cohort study. Data were collected between January 2006 and December 2008.	Multi-centre study. 11 district hospitals and 2 health centres with CEmOC status.	Surgical task-shifting. Caesarean sections. Major, emergency and elective operations.	Health officers: non-physicians. Health officers performed 1574 caesarean sections, including 55.9% of emergency operations. Obstetricians: specialist physicians. Obstetricians performed 1261 caesarean sections, including 63.9% of elective operations.	Training and supervision: 3 years of training in public health and clinical medicine and 6–9 months of experience in CEmOC services (including obstetric surgery). Health officers operated independently.	Maternal and foetal deaths; hospital length of stay.	No difference in maternal and foetal death rates.	Equivalent duration of postoperative hospital length of stay.
Giramonti and Kogan, 2018. New York (USA). High-income economy.	Prospective study. Data were collected over 14 months.	Single-centre study. Albany Medical Center, Division of Urology.	Surgical task-shifting. 150 paediatric sleeve circumcisions using surgical loupes. Minor surgery; elective procedure.	NP: non-physician. The NP performed 100 operations. Urologist: specialist physician. The urologist performed 50 operations.	Background training: The NP had 15 years of experience in urology and over 5 years of observation of circumcision, hypospadias repair and hernia repair. She had performed over 60 office circumcisions for newborns using the Gomco clamp. Study training and supervision: The NP was first trained as an assistant to the attending surgeon in the operating room. Once sufficient knowledge was established, the NP performed 10 operations under direct supervision and 14 operations under indirect supervision. She then operated independently.	Operative time.		Equivalent operative time between the NP and the urologist.
Harrell et al., 2020. Tennessee (USA). High-income economy.	Retrospective records review. Data were collected between January 2014 and January 2019.	Single-centre study. Hospital-based aeromedical service affiliated with a Level 1 trauma centre.	Surgical task-shifting. Tube thoracostomies. Major emergency procedures.	Aeromedical personnel (registered nurses and flight paramedics): non-physicians. They performed 49 prehospital tube thoracostomies (PTT). Physicians performed 98 hospital tube thoracostomies (HTT).	Training and supervision: Didactic training sessions to develop clinical reasoning, simulations using a manikin and in-hospital clinical experience assisting the trauma team performing the tube thoracostomy. Biannual competency checks in chest tube insertion. Qualified aeromedical personnel operated independently.	Mortality and complications (malposition, organ injury, dislodgement of chest tube and empyema and pneumonia). Time to chest tube placement, needle decompression, unilateral placement, initial drainage, small bore chest tube and chest tube days. Hospital length of stay, intensive care unit length of stay, ventilator days, emergency department disposition (ward floor, intensive care unit and operating theatre) and hospital disposition (home, rehabilitation and skilled nursing facility).	There were no differences in mortality rates between aeromedical personnel in the PTT and physicians in the HTT.	Time to chest tube placement: 21.92 minutes (PTT) vs 157.04 minutes (HTT), P < 0.001. Needle decompression: 41.7% (PTT) vs 4.1% (HTT), P < 0.001. Small bore chest tube: 0% (PTT) vs 9.2% (HTT), P = 0.056. Disposition to intensive care unit: 67.3% (PTT) and 34% (HTT), P = 0.006. Intensive care unit length of stay: 10.35 days (PTT) and 6.70 days (HTT), P = 0.034.
Homan et al., 2013. New England (USA). High-income economy.	Retrospective chart review. Data were collected for the most recent 125 caesarean section deliveries at each hospital.	Multi-centre study. Two rural hospitals: one family medicine hospital (FMH) was staffed with family doctors performing caesarean sections ; in the second obstetric hospital (OBH), obstetricians performed caesarean sections.	Surgical task-shifting. 250 caesarean sections. Major surgical operations. Both elective and emergency operations.	Family physicians operating at the FMH: non-specialist physicians. They performed 125 caesarean sections over a period of 60 months. Obstetricians operating at the OBH: specialist physicians. They performed 125 caesarean sections over a period of 30 months.	Background training: one family physician was trained in caesarean deliveries during residency; one family physician completed a rural obstetrics fellowship programme; the third family physician was trained whilst employed in the National Health Service Corps in Alaska. All family physicians had performed 37–50 primary caesarean deliveries and assisted on 75–110 caesarean sections before being credentialed at the FMH. Level of supervision: family physicians were the primary providers of caesarean sections at the FMH during the study period.	Maternal outcomes: mortality, intraoperative complications, infectious complications, postoperative complications and maternal hospital length of stay. Neonatal outcomes: foetal death, gestational age, Apgar score, transfer to neonatal intensive care unit, readmission and hospital length of stay. Quality indicators: decision to incision time, total surgical time and surgery scheduled at ≥39 weeks.	No maternal deaths occurred during the study period. One foetal death at 38 weeks occurred at the FMH because of amniotic band syndrome with a cord accident (P = 1.0).	Total postoperative complications (mean): 0.03 (FMH) vs 0.12 (OBH), P = 0.03). Maternal hospital length of stay: 3.0 days (FMH) vs 2.6 days (OBH), P < 0.01). Total surgical time: 55.2 minutes vs 42.5 minutes, P < 0.01. No differences between FMH and OBH for maternal intraoperative complications and infectious complications. Neonatal outcomes: No differences between FMH and OBH. No differences between FMH and OBH in decision to incision time and surgery scheduled at ≥39 weeks.
Hounton et al., 2009. Burkina Faso (sub-Saharan Africa). Low-income economy.	Retrospective, cross-sectional, facility-based survey. Data were collected for 2004 and 2005.	Multi-centre study. 22 public-sector facilities providing caesarean sections in 6 regions of Burkina Faso. These included national, regional and district hospitals. District hospitals comprised both rural and urban hospitals.	Surgical task-shifting. 2305 caesarean sections. Major surgical procedures; emergency operations.	COs: non-physicians. COs performed 733 caesarean sections. General doctors trained in essential surgery: non-specialist physicians. They performed 552 caesarean sections. Obstetricians: specialist physicians. They performed 1020 caesarean sections.	Background training of COs: COs were registered nurses with 2 additional years of training in surgery. Background training of general doctors: 6-month training programme in essential surgery.	Maternal death, perinatal death, postoperative complications (wound infection, wound dehiscence and haemorrhage), duration of caesarean sections and postoperative hospital length of stay.	Newborn case fatality rates: 198/1000 (COs) vs 125/1000 (general doctors) vs 99/1000 (obstetricians) (significant). No differences between provider types in maternal mortality rates.	Hospital length of stay: 9 days (COs) vs 9 days (general doctors) vs 6 days (obstetricians) (significant). Operative duration: 53 minutes (COs) vs 57 minutes (general doctors) vs 46 minutes (obstetricians) (significant). No differences between COs, general doctors and obstetricians in postoperative complications.
Matinhure et al., 2018. Tanzania (sub-Saharan Africa). Lower-middle-income economy.	Retrospective, cross-sectional, documentary review. Data were collected between January 2014 and December 2015.	Multi-centre study. 3 primary health facilities (health centres) and 3 secondary health facilities (district hospitals).	Surgical task-shifting. 4302 caesarean sections. Major, elective and emergency operations.	AMOs: non-physicians. In total, AMOs performed 3544 caesarean sections. 88% were emergency caesarean sections and 12% were elective. MDs. In total, MDs performed 758 caesarean sections. 95% were emergency caesarean sections and 5% were elective.	Background training: AMOs were qualified COs with >3 years of experience. They had undergone a further 2 years of training (Advanced Diploma in Clinical Medicine), including rotations in obstetrics and gynaecology, surgery, child health and community medicine.	Early maternal outcomes (48 hours post-surgery): maternal death rate and complications. Neonatal outcomes (24 hours post-surgery): neonatal death rate and neonatal complications.	No significant differences between AMOs and MDs in maternal and neonatal mortality rates.	No significant differences between AMOs and MDs in maternal and neonatal complications.
Matumaini et al., 2021. Uganda (sub-Saharan Africa). Low-income economy.	Prospective, observational study. Data were collected between September 2013 and February 2014.	Multi-centre study. 2 private, not-for-profit hospitals and 1 government public health facility.	Surgical task-shifting. 274 voluntary medical male circumcisions (VMMCs). Outpatient procedures, offered on a walk-in basis.	COs and nurses: non-physicians. In total, they performed 221 (80.7%) VMMCs. Physicians. In total, they performed 53 (19.3%) VMMCs.	Training: the background training of non-physicians was not described. Level of supervision: non-physicians operated independently.	Adverse events: any, post-surgical bleeding (2 hours post-surgery), excessive skin removal, fever post-surgery, pus discharge post-surgery and urethral injury (recorded 2 hours, 24 hours, 3 days and 7 days post-surgery). Operative time for circumcision.		Operative time: 15.45 minutes (non-physicians) vs 32.72 minutes (doctors), P < 0.001. No significant difference in the occurrence of adverse events between non-physicians and doctors.
McCord et al., 2009. Tanzania (sub-Saharan Africa). Lower-middle-income economy.	Retrospective cohort study. Data were collected between January and May 2006.	Multi-centre study. 9 government district hospitals and 5 mission hospitals.	Surgical task-shifting. 1088 emergency major obstetrical surgeries. 778 operations were performed in government hospitals; 309 operations were performed in mission hospitals.	AMOs: non-physicians. AMOs operated on 945 patients. MOs: non-specialist physicians who were licenced to practise medicine and surgery. MOs worked independently or alongside an AMO (task-sharing). MOs operated on 143 patients and task-sharing occurred in 21 cases.	Training: AMOs were COs (3 years of medical training) who had received a further 2 years of clinical training, including a 3-month rotation in surgery and a 3-month rotation in obstetrics. Following qualification, AMOs were officially licenced to practise medicine and surgery, including performing caesarean sections. Level of supervision: AMOs in the intervention group operated independently.	Fatal outcomes, including maternal deaths and perinatal deaths and major postoperative complications. ‘Quality indicators’ included ‘lack of absolute maternal or foetal indication’, ‘urgent blood need, but no transfusion’ and ‘over 3 hours to urgently indicated operation’.	No difference between AMOs and MOs in maternal mortality and perinatal mortality rates.	Equivalence between AMOs and MOs for all major postoperative complications. No difference in ‘quality indicators’.
Mpirimbanyi et al., 2017. Rwanda (sub-Saharan Africa). Low-income economy.	Retrospective, cross-sectional study. Data were collected between January 2015 and December 2015.	Multi-centre study. 3 district hospitals, run by the Rwandan Ministry of Health and by a USA-based NGO.	Surgical task-shifting. Patients underwent general surgery to treat the following emergency conditions: acute abdominal conditions (14.3%), complicated hernias (7.9%), soft tissue infections (71.6%), urological emergencies (5.3%) and thoracic emergencies (0.9%).	GPs: non-specialist physicians. GPs operated on 74/122 (60.7%) patients. General surgeon: specialist physician, who operated in Butaro District Hospital. The general surgeon operated on 48/122 (39.3%) patients.	The background training of GPs was not described. No training received as part of this study. Level of supervision: in Kirehe and Rwinkwavu District Hospitals, the GPs operated independently, as they were the only operators available. In Butaro District Hospital, GPs were supported by the general surgeon.	Clinical outcomes (patient dead, discharged or recommended for transfer). In-hospital postoperative complications (any, surgical site infection, unplanned reoperation, wound dehiscence and cardiac arrest) and length of hospital stay.	There were no differences in mortality rates between patients treated by GPs or by the general surgeon.	There were no differences in presence of postoperative complications, types of postoperative complications, clinical outcomes and length of hospital stay between the GPs and the general surgeon.
Ngcobo et al., 2018. South Africa (sub-Saharan Africa). Upper-middle-income economy.	Retrospective review of patient files. Data were collected over 16 months, commencing in January 2014.	Multi-centre study. All clinics and hospitals in Tshwane District providing free VMMC. All centres were supported by the Centre for HIV/AIDS Prevention Studies (CHAPS).	Surgical task-shifting. 4849 patients underwent surgical VMMC.	Clinical associates (CAs): non-physicians. CAs performed 4300 procedures (88.7%). Doctors: non-specialist physicians. Doctors undertook training to perform VMMCs delivered through CHAPs. Doctors performed 549 (11.3%) procedures.	Background training: CAs undertook a training programme delivered by CHAPs to perform VMMC. Training covered theoretical and practical aspects of VMMC procedures. Level of supervision: CAs operated independently.	Intraoperative adverse events and postoperative adverse events, including swelling, pain, bleeding, infection and wound destruction (within 2 days of the VMMC procedure). Operative duration of VMMC procedures was recorded.		Operative duration was significantly shorter for CAs than for doctors (t = −7, 46 minutes; P< 0.001). Equivalence between ACs and doctors for intraoperative and postoperative adverse events.
Ouédraogo et al., 2015. Burkina Faso (sub-Saharan Africa). Low-income economy.	Prospective, descriptive and analytical study. Data were collected between February and October 2013.	Single-centre study. 1 district hospital, serving both rural and urban catchment areas.	Surgical task-shifting. 541 women underwent caesarean sections, 46 (7.7%) women underwent laparotomies and 14 (2.3%) women underwent repair of traumatic lesions. Major surgery; emergency operations.	Surgical nurses: non-physicians. Surgical nurses performed 34.8% of major obstetric procedures. Obstetricians: specialist physicians. Obstetricians performed 65.2% of major obstetric procedures.	Background training: Surgical nurses received surgical training to manage obstetric complications, including caesarean sections, emergent laparotomy for extra-uterine pregnancy or uterine rupture and sutures of traumatic lesions. Level of supervision: the level of supervision received by surgical nurses was not specified in the study.	Maternal mortality and morbidity, neonatal mortality and operative duration for caesarean section and laparotomy.	Caesarean sections. Neonatal mortality: 2.6% (surgical nurses) vs 6.6% (obstetricians), P = 0.043. No difference in maternal mortality between surgical nurses and obstetricians. Laparotomies. No differences in maternal or neonatal mortality rates between surgical nurses and obstetricians.	Caesarean sections and laparotomies. Median operative duration: 31.2 minutes (surgical nurses) vs 28.1 minutes (obstetricians), P = 0.001. Equivalent morbidity outcomes between surgical nurses and obstetricians.
Ramdas et al., 2018. The Netherlands. High-income economy.	Retrospective cross-sectional study. Data were collected between 2008 and 2014.	Multi-centre study. Primary and secondary healthcare settings.	Surgical task-shifting. 2986 basal cell carcinoma excisions. Minor surgical procedures.	231 GPs: non-specialist physicians. GPs performed 931 basal cell carcinoma excisions. 22 plastic surgeons: specialist physicians. Plastic surgeons performed 1040 basal cell carcinoma excisions. 22 dermatologists: specialist physicians. Dermatologists performed 1015 basal cell carcinoma excisions.	Training and supervision: GPs were generalist doctors, with no medical or surgical specialization. They operated independently.	Number of completely excised basal cell carcinomas and risk of incomplete basal cell carcinoma excision.Comparisons between GPs and dermatologists.		Rate of complete excisions: 70% (GP) vs 93% (dermatologist): (P < 0.001). Risk of incomplete excision (GP vs dermatologist): OR 6.2 (4.6–8.4), P < 0.0001.
Rech et al., 2014. The study was conducted in Kenya, South Africa, Tanzania and Zimbabwe (sub-Saharan Africa). Lower-middle- and upper-middle-income economies. Task-shifting was only practised in Tanzania.	Prospective, cross-sectional study. Data were collected in 2011 and 2012.	Multi-centre study. In Tanzania, 14 healthcare sites in 2011 and 29 sites in 2012 were visited. These included fixed, outreach and mobile healthcare sites.	Surgical task-shifting. VMMCs. In Tanzania, 128 VMMCs were performed in 2011 and 251 in 2012.	NPCs, including nurses, COs or AMOs. In Tanzania, NPCs performed 116 VMMCs (91%) in 2011 and 239 VMMCs in 2012 (95%). MDs: non-specialist or specialist physicians. In Tanzania, physicians performed 12 VMMCs (9%) in 2011 and 12 VMMCs in 2012 (5%).	Training: the background training of NPCs was not described in detail. Level of supervision: the majority of NPCs in Tanzania operated independently. They completed all suturing in 84% of cases in 2011 and in 97% of cases in 2012.	Surgical efficiency was measured in relation to two outcome variables: ‘primary provider time with client’ and ‘total elapsed operating time’.		No association between provider type and surgical efficiency outcomes.
Tariku et al., 2019. Ethiopia (sub-Saharan Africa). Low-income economy.	Retrospective cohort study. Data were collected between July 2015 and June 2016.	Multi-centre study. 1 general hospital and 1 district hospital. Both hospitals satisfied Comprehensive Emergency Obstetric and Newborn Care (EmONC) standards.	Surgical task-shifting. 474 caesarean sections. Major surgical procedures; mostly emergency surgeries (92%).	Non-physician surgeons (NPSs): non-physicians. NPSs performed 388 procedures. Physicians: non-specialist and specialist physicians. They comprised 8 GPs and 78 obstetricians. Physicians performed 85 procedures.	Background training: NPSs were BSc health officers or BSc nurses who had undertaken 4 years of training on integrated emergency surgery and obstetrics. Level of supervision: the level of supervision received by NPSs was not specified.	Immediate newborn outcomes (composite measure): death or live birth with distress.	No significant differences between NPSs and physicians.	No significant differences between NPSs and physicians.
Thevi et al., 2017. Malaysia (East Asia and Pacific). Upper-middle-income economy.	Retrospective analysis of patient charts. Data were collected between 2007 and 2014.	Single-centre study. Melaka Hospital, a government-funded, specialist referral hospital in Malacca.	Surgical task-shifting. 12 992 cataract surgeries. Minor surgery.	MOs: non-specialist physicians. They performed 1498 cataract surgeries. Gazetting specialists: physicians specialized in ophthalmology who had to work under the supervision of senior specialists. They performed 759 cataract surgeries. Specialists: opthalmologists who were authorized to operate independently. They performed 10 720 cataract surgeries.	Training: MOs had completed medical school, but they had not undertaken any further specialization. Level of supervision: MOs had to be supervised by a specialist surgeon during surgery.	Intraoperative complications: including posterior capsular rupture (PCR) without vitreous loss, PCR with vitreous loss, central corneal oedema, zonular dehiscence, dropped nucleus and suprachoroidal haemorrhage. Visual outcomes: best-corrected visual acuity, measured 6 weeks postoperatively. Visual acuity was classified as good, impaired or poor vision.		Intraoperative complications: 11.7% of patients operated on by MOs experienced intraoperative complications as opposed to 5.1% of patients treated by specialist ophthalmologists (P < 0.001). Poor or impaired visual outcomes: 18.8% (MOs and gazetting specialists) vs 15.7% (specialists) (OR 1.25, 1.09–1.42, P < 0.001).
Tobome et al., 2021. Benin (sub-Saharan Africa). Lower-middle-income economy.	Observational, retrospective and descriptive study. Data were collected between March 2018 and November 2019.	Single-centre study. Referral and general hospital, which lacks an intensive care unit, a computed tomography scan and a microbiological laboratory.	Surgical task-shifting. Laparotomy for acute generalized peritonitis (AGP). Major, emergency general surgery. The main causes of AGP were ileal perforation (63.5%), gastric-duodenal ulcer perforation (14.3%), appendicular (7.9%) and cryptogenetic (7.9%).	GP: non-specialist physician. The GP performed 46 laparotomies (73%). General surgeons: specialist physicians. General surgeons performed 17 laparotomies (27%).	Background training: the GP had completed medical school and had 3 years of work experience. He had acquired surgical skills by working in other African and European hospitals. Level of supervision: the GP operated independently.	Mortality, morbidity and postoperative hospital length of stay.	No difference in mortality rates between the GP and the general surgeons.	Equivalent morbidity and hospital length of stay between the GP and the general surgeons.
Tyson et al., 2014. Malawi (sub-Saharan Africa) Low-income economy.	Retrospective case–control study. Data were collected between January and December 2012.	Single-centre study. A tertiary referral hospital in the central region of Malawi.	Surgical task-shifting. 1004 paediatric patients underwent 1186 paediatric surgical procedures (excluding orthopaedic surgery). Minor surgical operations (31%) and major surgical operations (57%). Elective (66%) and emergency (32%) operations. The most common operative cases included congenital surgery (23%), trauma and burns (14%), ear, nose, throat (13%), general surgery (13%) and soft tissue (12%).	COs: non-physicians. COs performed 475 (40%) paediatric surgical operations. MDs: specialist physicians, comprising surgical residents and consultant surgeons. MDs performed 566 (48%) paediatric surgical operations.	Training: COs had completed the Diploma in Clinical Medicine (3 years of didactic education and a 1-year clinical internship at a central or district hospital). Upon completion, COs were licenced to practise independently. Level of supervision: COs operated independently or with the support of a specialist.	Mortality, complications, reoperation rates and hospital length of stay.	No difference in mortality rates between COs and MDs.	No difference in complication rates between COs and MDs, even when stratified by case complexity (minor or major surgery). Reoperation rate: 17% (COs) vs 7.1% (MDs), P < 0.001. Hospital length of stay: 24 days (COs) vs 10 days (MDs), P < 0.001. The authors noted that reoperation rates and hospital length of stay did not differ significantly after controlling for burn cases.
Wamalwa et al., 2015. Kenya (sub-Saharan Africa). Lower-middle-income economy.	Prospective (cohort) study. Data were collected over an 18-month period.	Single-centre study. General surgical unit at Garissa Provincial General Hospital.	Surgical task-shifting. Inguinal hernia repair, utilizing the Shouldice or the Lichtenstein surgical techniques. Major general surgery; elective procedures.	MO: non-specialist physician. The MO operated on 25 patients. General surgeon: specialist physician. The general surgeon operated on 20 patients.	Background training: the MO was a generalist doctor with no postgraduate specialization. Study training: the MO was trained to perform hernia repair using the Shouldice and the Litchenstein techniques in a standard manner. Level of supervision: the MO operated independently.	Operative time (minutes), number of technically difficult operations and postoperative complications (at 24 hours and 2 weeks post-surgery).		No difference in outcomes between the MO and the general surgeon.
Wilhelm et al., 2011. Malawi (sub-Saharan Africa). Low-income economy.	Retrospective review of theatre books. Data were collected between January 2003 and December 2007.	Single-centre study. Zomba Central Hospital, Department of Surgery and Orthopaedics. Teaching hospital that serves as the district hospital for the Zomba District and as the referral hospital for the south-eastern zone. It serves a catchment population of ∼2.6 million people.	Surgical task-shifting. Transvesical prostatectomy for benign prostate hyperplasia, ventriculoperitoneal shunting for hydrocephalus and hernia repair with bowel resection and anastomosis for strangulated hernia were selected for outcome analysis.	COs: non-physicians. In total, COs performed 61 VP shuntings, 113 trasvesical prostatectomies and 21 hernia repairs. General surgeons: specialist physicians. ‘Surgeon present’ operations included 51 VP shuntings, 101 transvesical prostatectomies and 32 hernia repairs.	Background training of COs: 3-year pre-service training followed by a 1-year internship. The internship included a 3-month rotation in general surgery and obstetrics and gynaecology. Surgical skills were further developed through on-the-job instruction by supervisors. Level of supervision: COs in the study intervention group operated independently.	VP-shunting: mortality (perioperative), wound infection, postoperative hospital length of stay, shunt revision and shunt explant. Transvesical prostatectomy: mortality (perioperative), wound infection, bladder leakage, postoperative hospital length of stay, postoperative blood transfusion and reoperation. Hernia repair: mortality (perioperative), wound infection, postoperative hospital length of stay, reoperation and anastomotic leakage.	VP-shunting. No difference in mortality rates between COs and general surgeons. Transvesical prostatectomy. No difference in mortality rates between COs and general surgeons. Hernia repair. No difference in mortality rates between COs and general surgeons.	VP-shunting. Hospital length of stay: 10 days (4–15) (COs) vs 8 days (3–35) (surgeons), P = 0.03. No significant differences for other morbidity measures. Transvesical prostatectomy. Hospital length of stay: 16 days (9–74) (COs) vs 15 days (7–38) (surgeons), P = 0.05. Postoperative blood transfusion: 19.5% (COs) vs 9.9% (surgeons), P = 0.06. No differences between COs and surgeons in other morbidity measures. Hernia repair. No significant differences between COs and surgeons for morbidity outcomes.
Wilhelm et al., 2017. Malawi (sub-Saharan Africa). Low-income economy.	Retrospective comparative study. Data were collected between January 2006 and December 2010.	Single-centre study. Zomba Central Hospital, Department of Surgery and Orthopaedics. Teaching hospital that serves as the district hospital for the Zomba District and as the referral hospital for the south-eastern zone. It serves a catchment population of ∼2.6 million people.	Surgical task-shifting. Major amputations (108 procedures) and open reductions and plating of fractured long bones (155 procedures). Major orthopaedic surgeries.	Orthopaedic clinical officers (OCOs): non-physicians. OCOs performed 71.3% of major amputations and 38.7% of internal fixations of long bones with plates. International surgeons: specialist physicians. All surgeons were general surgeons; one had also trained in orthopaedic surgery. They performed 28.7% of major amputations and 61.3% of internal fixations of long bones with plates.	Training: OCOs had ∼4 years of work experience as medical assistants and had completed the Diploma in Clinical Orthopaedics, an 18-month training course from the Malawi College of Health Sciences. Before being licenced to work independently, OCOs had operated under close supervision for several years. Level of supervision: OCOs in the intervention group operated independently.	Major amputations. Perioperative mortality, postoperative blood transfusion, postoperative infection, reoperation rates and postoperative hospital length of stay. Open reduction and internal fixations with plates. Postoperative infection, reoperation rates, other complications and postoperative hospital length of stay.	Major amputations. There were no differences in mortality rates between OCOs and surgeons. Open reduction and internal fixations with plates.	Major amputations. Equivalent postoperative blood transfusion, postoperative infection, reoperation rates and hospital length of stay. Open reduction and internal fixations with plates. Equivalent postoperative infection, reoperation rates, other complications and hospital length of stay.
Van Duinen et al., 2019. Sierra Leone (sub-Saharan Africa). Low-income economy.	Prospective, observational, multi-centre, non-inferiority study.	Multi-centre study. 9 public and private hospitals across Sierra Leone: 4 were public district hospitals, 1 was a public regional hospital, 1 was a public tertiary hospital and 3 were private non-profit hospitals. Data were collected between October 2016 and May 2017.	Surgical task-shifting. 1282 caesarean sections, including laparotomy for uterine rupture. Major operations. Prevalent indications: obstructed and prolonged labour (ACs 55.5%, MDs 54.6%), previous caesarean section (ACs 15.1%; MDs 11.7%), antepartum haemorrhage (ACs 10.8%; MDs 12.3%) Emergency caesarean sections: 81.3% of caesarean sections performed by ACs; 88.9% of caesarean sections performed by MDs.	ACs: non-physicians. 11/12 ACs were trained in Sierra Leone. ACs performed 444 caesarean sections. Of these, 443 caesarean sections were analysed. MDs: specialist and non-specialist physicians. 25/50 MDs were trained in Sierra Leone.	Background and study training: CHOs with 2 years of work experience could undertake a task-sharing/shifting training programme to qualify as ACs. A 2-year training programme to manage basic emergency surgical and obstetrical conditions. 4 ACs (33%) had <1 year of previous work experience; 7 (58%) ACs had 1–5 years of previous work experience. Solely 1 AC (8%) had over 5 years of previous work experience. Level of supervision: ACs were the primary surgical providers for ‘intervention group’ patients.	Primary outcomes: perioperative maternal mortality (intraoperative or within 30 days of the operation). Secondary outcomes: perinatal outcomes and maternal morbidity parameters; operative time and duration of hospital length of stay. Perinatal outcomes included macerated and fresh stillbirths and neonatal deaths and perinatal deaths (the sum of fresh stillbirths and early neonatal deaths). Maternal morbidity parameters included blood loss exceeding 600 ml, reoperation, readmission, wound infection and persistent postoperative abdominal pain.	Maternal mortality: 0.2% (ACs) vs 1.8% (MDs), adjusted OR 0.11, 0.01–0.63. Neonatal stillbirth: 12.7% (ACs) vs 16.6% (MDs), adjusted OR 0.74 95% confidence interval 0.56–0.98. There were no other significant differences in (early and late) neonatal deaths and perinatal deaths.	Readmission rates: 3.7% (ACs) vs 1.7% (MDs), adjusted OR 2.17, 1.08–4.42). Operative time: 31.9 minutes (ACs) vs 38.9 minutes (MDs), P < 0.001. There were no significant differences in blood loss exceeding 600 ml, reoperation, wound infection, persistent postoperative abdominal pain or duration of hospital stay.
Young and Bowling, 2012. Michigan (USA). High-income economy.	Retrospective, non-inferiority trial with a 5% point difference. Data were collected between June 2005 and March 2010.	Single-centre study. Urban, Level I trauma centre.	Surgical task-shifting. Placement of intracranial pressure (ICP) monitors as a result of traumatic brain injury. Emergency, major surgical procedure.	MLPs: non-physicians. MLPs performed 70 ICP monitor placements. Neurosurgeons: specialist physicians. They performed 22 ICP monitor placements.	Training and level of supervision: MLPs began by first assisting in the operating room and managing patients in the general surgery ward, before treating patients with trauma in the emergency department and in the critical care unit. After 4/5 years of experience, above-average MLPs were eligible for neurosurgical training. MLPs were directly supervised by a senior MLP with neurosurgical experience and by attending neurosurgeons and they had to correctly place five ICP monitors under supervision before operating independently. The decision to place ICP monitors remained the responsibility of the neurosurgeons.	Mortality and expected ratio of survivors, major complications (infection, haemorrhage and leak) and minor complications (malfunction and malposition). Time to monitor placement, duration of monitoring (days) and good Glasgow Outcome Score (score 4 or 5).	No difference in mortality rates between MLPs and neurosurgeons.	Major complications: 1.4% (MLPs) vs 0% (neurosurgeons), P = 0.0128 (significantly <5%). Minor complications: 5.7% vs 0%, P = 0.80. Duration of monitor placement: 5 days vs 7.5 days, P = 0.018. No difference in good Glasgow Outcome Score between provider groups.