SAMSS Newsletter, August 31, 2010
The Sub-Saharan African Medical Schools Study (SAMSS) tracks innovations in medical education in Sub-Saharan Africa. This Newsletter and the website http://samss.org are designed to raise awareness about issues related to medical education in Sub-Saharan Africa. Using this information, policymakers, donors and medical educators can make informed decisions that will strengthen their health systems.
In this issue the SAMSS newsletter will focus on surgical and anesthesia services in Sub-Saharan Africa.
There is a critical shortage of specialist surgeons and anesthetists in Sub-Saharan Africa with first referral level (district or rural) health facilities most affected. The World Health Organization (WHO) recognized these deficiencies in the capacity to deliver basic surgical services in Low and Middle Income Countries (LMICs) and established the Emergency and Essential Surgical Care (EESC) project in 2004. EESC designed country level training workshops aimed to strengthen the delivery of emergency, surgical and anesthetic services in district level health facilities. Training materials include the Integrated Management of Emergency and Essential Surgical Care toolkit, supplemented by the manual “Surgical Care at the District Hospital”. These training materials can be adopted to local needs and integrated into existing training initiatives at universities and medical colleges. The Global Initiative for Emergency and Essential Surgery Care (GIEESC) was established in 2005 to support the EESC program by promoting collaborations among organizations, agencies and institutions. The third GIEESC meeting held on June 5, 2009 in Ulaanbaatar, Mongolia reported on global, regional, and country progress toward implementation of the EESC project. The meeting consisted of updates from sixteen countries including eight African countries; Ethiopia, Gambia, Liberia, Malawi, Sierra Leone, Tanzania, Uganda and Zambia. Working groups were developed to discuss how surgery can be integrated into health systems and what the barriers are to surgical care at district level healthcare facilities, in addition to resource mobilization and partnerships.
In “Addressing the Millennium Development goals from a surgical perspective”, Kushner et al explored surgical and anesthetic capacity in 132 district-level health facilities in eight countries. The study found critical shortfalls of resources to provide basic surgical care in these facilities. For example, only in 44% of these district-level health facilities were cesarean sections performed. The authors argued that strengthening surgical and anesthetic services will reduce morbidity and mortality and help achieve three of the health-related Millennium Development goals: 4. reduction of child mortality, 5. improvement of maternal health, and 6. the combat of HIV/AIDS.
A cross-sectional survey by Kruk et al explored the providers of and expenditures for surgical care in eight district hospitals in Mozambique, Tanzania and Uganda. The survey found that there were no specialist surgeons or anesthetists in any of the hospitals and that most surgical and anesthesia services were provided by generalist physicians, Non-Physician Clinicians (NPCs), and nurses. Due to the shortage of generalist doctors at district hospitals, most surgical care is provided by NPCs, including roughly 36% of major surgeries. The study indicated that until Sub-Saharan Africa trains enough surgeons and anesthetists to serve its populations, the use of NPCs and nurses will be instrumental to improving access to essential surgery in the region. In a similar study, a pilot internet-based survey was conducted by Dubowitz et al to estimate per-capita anesthesia providers in LMICs. Uganda has about 14 physician-anesthesiologists for a population of 30 million people and a similar ratio is observed in neighboring country Kenya. Uganda and Kenya have recognized this workforce challenge and are utilizing “anesthetic officers” (also known as “nurse anesthetists”) to fill the need. The study recognizes the role of anesthetic officers but also calls for recruiting more medical students into specialist training positions.
In “Building and retaining the neglected anesthesia health workforce: is it crucial for health systems strengthening through primary health care?”, Cherian et al discuss the importance of trained anesthesia health workforce at first referral level facilities in reducing mortality and morbidity. In addition to long term strategies such as training more physician anesthetists, the authors recommend the use of task shifting or trained non-physician anesthetists at the first referral level to increase the capacity of these facilities to provide anesthesia services. Awareness building on the contribution of anesthesia services in reducing mortality and morbidity will be an important step toward securing political commitment and investments in education, training and retention of the anesthesia health workforce.
In “Role of Collaborative Academic Partnerships in Surgical Training, Education, and Provision”, Riviello et al examined the experiences of six partnerships between North American academic medical centers (AMCs) and hospitals in Sub-Saharan Africa: (1) University of California San Francisco (UCSF) with the Bellagio Essential Surgery Group; (2) USCF with Makerere University, Uganda; (3) Vanderbilt with Baptist Medical Center, Ogbomoso, Nigeria; (4) Vanderbilt with Kijabe Hospital, Kenya; (5) University of Toronto, Hospital for Sick Children with the Ministry of Health in Botswana; and (6) Harvard (Brigham and Women’s Hospital and Children’s Hospital Boston) with Partners in Health in Haiti and Rwanda. The collection of reflections from these partnerships included advice on adapting the collaboration mission to the local needs and the importance of relationships and mutual learning. In a similar study, Mark Newton of the Department of Anesthesiology, Vanderbilt University (USA) and Peter Bird of the Department of Surgery, Kijabe Hospital (Kenya), explored the impact of parallel anesthesia and surgical provider training in Sub-Saharan Africa. The authors presented a ten year review of rural hospitals in East Africa which developed the parallel training program. The training program ranged from 15-16 months and focused on regional, pediatric, obstetrical and trauma care, reflecting the local needs. The authors further highlighted the importance of partnerships between resource-rich and resource-poor countries to address the surgical and anesthesia needs in Sub-Saharan Africa.
Finally, the Bellagio Essential Surgery Group (BESG) proposed the following four recommendations for national and international agencies in order to address the surgical burden of disease in Sub-Saharan Africa: 1. Strengthen surgical services at district hospitals, 2. Improve systems for delivery of trauma care, 3. Expand the supply and quality of health workers with surgical skills, and 4. Build evidence to inform interventions to improve access to surgery in the region.
Francis Omaswa, MBCHB, MMed, FRCS, FCS
Executive Director, African Centre for Global Health and Social Transformation
Co-Chair, SAMSS Advisory Committee
Fitzhugh Mullan, MD
The George Washington University
Principal Investigator, SAMSS
Seble Frehywot, MD, MHSA
The George Washington University
Co-Principal Investigator, SAMSS
On behalf of the SAMSS Advisory Committee
OBGYN bed at a maternity ward in Jimma, Ethiopia
SAMSS Advisory Committee
Magdalena Awases PhD, MA, HMPP, RN
Charles Boelen MD, MPH, MSc
Mohenou Isidore Jean-Marie Diomande MD
Dela Dovlo MB Ch.B, MPH, MWACP
Diaa Eldin Elgaili Abubakr MD
Josefo João Ferro MD
Abraham Haileamlak MD
Jehu Iputo MBChB, PhD
Marian Jacobs MBChB
Abdel Karim Koumaré MD, MPH
Mwapatsa Mipando MSc, PhD
Gottlieb Monekosso MD, DSc, FRCP, FWACP, DTMEH
Emiola Oluwabunmi Olapade-Olaopa MD,. FRCS, FWACS
Francis Omaswa MBCHB, MMed, FRCS, FCS
Paschalis Rugarabamu DDS, MDent
Nelson K. Sewankambo MBChB, M.Sc, M.Med, FRCP
SAMSS site visit team at Jimma University School of Medicine, Ethiopia