Publications

In this Policy Forum, the Bellagio Essential Surgery Group, which was formed to advocate for increased access to surgery in Africa, recommends four priority areas for national and international agencies to target in order to address the surgical burden of disease in sub-Saharan Africa.

Background

Uganda currently has no organized prehospital emergency system. We sought to measure the current burden of injury seen by lay people in Kampala, Uganda and to determine the feasibility of a lay first-responder training program.

Methods

We conducted a cross-sectional survey of current prehospital care providers in Kampala: police officers, minibus taxi drivers, and Local Council officials, and collected data on types and frequencies of emergencies witnessed, barriers to aid provision, history of training, and current availability of first-aid supplies. A context-appropriate course on basic first-aid for trauma was designed and implemented. We measured changes in trainees’ fund of knowledge before and after training.

Results

A total of 309 lay people participated in the study, and during the previous 6 months saw 18 traumatic emergencies each; 39% saw an injury-related death. The most common injury mechanisms were road crashes, assault, and burns. In these cases, 90% of trainees provided some aid, most commonly lifting (82%) or transport (76%). Fifty-two percent of trainees had previous first-aid training, 44% had some access to equipment, and 32% had ever purchased a first-aid kit. Before training, participants answered 45% of test questions correctly (mean %) and this increased to 86% after training (p < 0.0001).

Conclusions

Lay people witness many emergencies and deaths in Kampala, Uganda and provide much needed care but are ill-prepared to do so. A context-appropriate prehospital trauma care course can be developed and improve lay people’s knowledge of basic trauma care. The effectiveness of such a training program needs to be evaluated prospectively.

Background

We previously showed that in the absence of a formal emergency system, lay people face a heavy burden of injuries in Kampala, Uganda, and we demonstrated the feasibility of a basic prehospital trauma course for lay people. This study tests the effectiveness of this course and estimates the costs and cost-effectiveness of scaling up this training.

Methods and findings

For six months, we prospectively followed 307 trainees (police, taxi drivers, and community leaders) who completed a one-day basic prehospital trauma care program in 2008. Cross-sectional surveys and fund of knowledge tests were used to measure their frequency of skill and supply use, reasons for not providing aid, perceived utility of the course and kit, confidence in using skills, and knowledge of first-aid. We then estimated the cost-effectiveness of scaling up the program. At six months, 188 (62%) of the trainees were followed up. Their knowledge retention remained high or increased. The mean correct score on a basic fund of knowledge test was 92%, up from 86% after initial training (n = 146 pairs, p = 0.0016). 97% of participants had used at least one skill from the course: most commonly haemorrhage control, recovery position and lifting/moving and 96% had used at least one first-aid item. Lack of knowledge was less of a barrier and trainees were significantly more confident in providing first-aid. Based on cost estimates from the World Health Organization, local injury data, and modelling from previous studies, the projected cost of scaling up this program was $0.12 per capita or $25-75 per life year saved. Key limitations of the study include small sample size, possible reporter bias, preliminary local validation of study instruments, and an indirect estimate of mortality reduction.

Conclusions

Lay first-responders effectively retained knowledge on prehospital trauma care and confidently used their first-aid skills and supplies for at least six months. The costs of scaling up this intervention to cover Kampala are very modest. This may be a cost-effective first step toward developing formal emergency services in Uganda other resource-constrained settings. Further research is needed in this critical area of trauma care in low-income countries.

A growing body of recent evidence supports the essential role of surgical services in improving population health in low-income countries. Nonetheless, access to surgical services in Uganda, as in many low income countries, is severely limited, largely due to constraints in human resources, infrastructure and supplies. To maximize the impact of surgical services on population health in the context of Uganda’s limited surgical workforce, we propose a ‘recasting’ of the role of the surgeon. Traditionally, the surgeon has played primarily a clinical role in patient care. The demands and isolation of this role have limited the ability of the surgeon to tackle health systems issues related to surgery. Now, the clinical and educational role played by surgeons must be redefined, and the surgeon must also assume a greater role in leadership, management and public health advocacy by documenting the unmet need for surgery and the resources required to improve access to care. Policy and incentives for specialist surgeons to spend amounts of time apportioned to these roles should be developed and supported by health care institutions. Political leadership and commitment will be critical to realizing this ideal. Such a model may be applicable to other countries seeking to maximize the impact of surgical services on population health.

Background

Interest in global health during postgraduate training is increasing across disciplines. There are limited data from surgery residency programs on their attitudes and scope of activities in this area. This study aims to understand how global health education fits into postgraduate surgical training in the US.

Study design

In 2007 to 2008, we conducted a nationwide survey of program directors at all 253 US general surgery residencies using a Web-based questionnaire modified from a previously published survey. The goals of global health activities, type of activity (ie, clinical versus research), and challenges to establishing these programs were analyzed.

Results

Seventy-three programs responded to the survey (29%). Of the respondents, 23 (33%) offered educational activities in global health and 86% (n = 18) of these offered clinical rotations abroad. The primary goals of these activities were to prepare residents for a career in global health and to improve resident recruitment. The greatest barriers to establishing these activities were time constraints for faculty and residents, lack of approval from the Accreditation Council for Graduate Medical Education and Residency Review Committee, and funding concerns. Lack of interest at the institution level was listed by only 5% of program directors. Of the 47 programs not offering such activities, 57% (n = 27) were interested in establishing them.

Conclusions

Few general surgery residency programs currently offer clinical or other educational opportunities in global health. Most residencies that responded to our survey are interested in such activities but face many barriers, including time constraints, Residency Review Committee restrictions, and funding.

Background

Access to surgical services is emerging as a crucial issue in global public health. “Effective coverage” is a health metric used to evaluate essential health services in low- and middle-income countries. It measures the fraction of potential health gained that is actually realized for a given intervention by integrating the concepts of need, use, and quality.

Methods

This study applies the concept of effective coverage to surgical services by considering injuries and obstetric complications as high-priority surgical conditions in low- and middle-income countries.

Results

Effective coverage for both is poor, but it is less well defined for traumatic conditions compared to obstetric conditions owing to a lack of data.

Conclusions

More primary and secondary data are critical to measure effective coverage and to estimate the resources required to improve access to surgical services in low- and middle-income countries.

Hypothesis

Surgical trainees in the United States have a growing interest in both clinical experiences and structured training opportunities in global health. Global health training and exposure can be integrated into a surgical residency program.

Design

The global health activities of surgical residents and faculty in 1 department were evaluated from January 1, 1998, to June 1, 2008, using a survey and personal interviews.

Results

From January 1, 1998, to December 31, 2002, 4 faculty members made more than 20 overseas volunteer medical expeditions, but only 1 resident participated in global health activities. In 2003, a relationship with a surgical training program in a developing country was established. Ten residents and 12 faculty members have made overseas trips during the last 5 years, and 1 international surgeon has visited the United States. During their research block, 4 residents completed 1- to 3-month clinical rotations and contributed to mentored research projects. Three residents completed a university-based Global Health Clinical Scholars Program, and 3 obtained master’s degrees in public health. A joint conference in injury-trauma research was also conducted. A faculty member is based overseas with clinical and research responsibilities, and another is completing a master’s degree in public health.

Conclusions

Global health training and exposure for residents can be effectively integrated into an academic surgical residency program through relationships with training programs in low-income countries. Legitimate academic experiences improve the success of these programs. Reciprocity with collaborative partners must be ensured, and sustained commitment and funding remain a great challenge to such programs. The long-term effect on the development of global health careers is yet to be determined.

Doruk Ozgediz and Robert Riviello discuss the burden of premature death and disability and the economic burden of surgical conditions in Africa.

Background

Africa’s health workforce crisis has recently been emphasized by major international organizations. As a part of this discussion, it has become apparent that the workforce required to deliver surgical services has been significantly neglected.

Methods

This paper reviews some of the reasons for this relative neglect and emphasizes its importance to health systems and public health. We report the first comprehensive analysis of the surgical workforce in Uganda, identify challenges to workforce development, and evaluate current programs addressing these challenges. This was performed through a literature review, analysis of existing policies to improve surgical access, and pilot retrospective studies of surgical output and workforce in nine rural hospitals.

Results

Uganda has a shortage of surgical personnel in comparison to higher income countries, but the precise gap is unknown. The most significant challenges to workforce development include recruitment, training, retention, and infrastructure for service delivery. Curricular innovations, international collaborations, and development of research capacity are some of the initiatives underway to overcome these challenges. Several programs and policies are addressing the maldistribution of the surgical workforce in urban areas. These programs include surgical camps, specialist outreach, and decentralization of surgical services. Each has the advantage of improving access to care, but sustainability has been an issue for all of these programs. Initial results from nine hospitals show that surgical output is similar to previous studies and lags far behind estimates in higher-income countries. Task-shifting to non-physician surgical personnel is one possible future alternative.

Conclusions

The experience of Uganda is representative of other low-income countries and may provide valuable lessons. Greater attention must be paid to this critical aspect of the global crisis in human resources for health.

Hypothesis

A surgical elective in a developing country setting is an essential new component in academic residency training.

Design

A survey of residents and faculty within the Department of Surgery at the University of California-San Francisco, and a collaborative program piloted between the Department of Surgery at the University of California-San Francisco and Makerere University in Kampala, Uganda, including a 6-week clinical elective.

Setting

Mulago and Nsambya hospitals in Kampala, Uganda.

Participants

Two residents and three faculty advisors at the University of California-San Francisco.

Intervention

Development of a 6-week pilot clinical surgical elective.

Main outcome measures

Assessment of the level of interest in international health in an academic surgery program; pathology and case variety, diagnostic methods, and surgical and anesthetic resources and techniques in a pilot developing country.

Results

Forty percent of residents enter residency with prior international health experience whereas 90% express interest in a developing country elective. Twenty-five percent of faculty participate in voluntary international surgical service and research projects. As a result of the survey and the level of interest in our program, two visits to Uganda were made and a residency elective rotation was successfully created. This resulted in exposure of residents to the educational benefits of learning in a resource-constrained setting: a broader scope of surgical conditions and pathology, greater reliance on history-taking and physical examination skills in a low-technology environment, and sociocultural aspects of care provision. Greater questions about global health equity, access to information, and the role of surgery in public health are raised along with potential challenges in international collaboration.

Conclusions

A developing country surgical experience complements the academic mission of service, training, and research, and should be an essential component of surgical training programs. There is interest among residents and faculty in such a program as well as a need for greater commitment to north-south collaborations among academic surgical institutions and societies, as has been successfully implemented abroad. More generally, surgery is an integral part of public health and health systems development worldwide.