Publications

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.