Substantial strides have been made in recent years to ensure that individuals in underdeveloped countries have access to public health services. However, access to surgical services in these nations remains quite limited. As a result, surgical disease is now recognized as a major contributor to the global health care burden, despite the inroads that volunteer programs have made in bringing surgical care to countless patients around the world.1 This imbalance raises the question of whether the traditional approach to surgical volunteerism could be improved, especially with respect to providing sustainable solutions to visited nations’ surgical problems.
This article examines the magnitude of the global surgical disease crisis, particularly in sub-Saharan Africa, discusses the limitations of volunteerism, and recommends greater use of task shifting to better address this issue.
Magnitude of the problem
Sub-Saharan Africa is one of the most resource-poor areas of the world and accounts for 25 percent of the global disease burden. The region comprises only 3 percent of the world’s health care workers and accounts for less than 1 percent of global health care expenditures.2 Paul Farmer, MD, PhD, medical anthropologist and physician, has referred to surgery in Africa as the neglected stepchild of global health.3
To address this issue, the World Health Organization (WHO) introduced the Global Initiative for Emergency and Essential Surgical Care in 2005.4 In the report prompting the development of this initiative, WHO noted that trauma was a major contributor to the global health care crisis, accounting for one in every 10 deaths worldwide and exceeding all deaths attributed to HIV, malaria, and tuberculosis combined. In contrast, in high-income countries, there were 1.7 deaths for every 10,000 vehicles, and in Africa 50 deaths for every 10,000 vehicles.5
Other deaths that potentially could have been averted if patients had greater access to surgical care include 400,000 maternal deaths, 1 million stillbirths, and 3 million neonatal deaths (primarily during the first 24 hours after delivery).6 One of the conclusions that WHO reached was that surgical care needed to be more accessible to the population in need because long-distance referrals were ineffective and often impossible for patients to complete. In 2009, the Bellagio Essential Surgery Group—an organization committed to raising international awareness for resource-constrained settings in sub-Saharan Africa—also reinforced this concept, emphasizing the need for increased access to surgical services in this region.7 The map of Africa (see Figure 1) emphasizes the large land mass and the magnitude of access over long distances for treatable surgical diseases.
In addition to distance hurdles, many countries in sub-Saharan Africa have an inadequate number of trained physicians, and of the few who have earned medical degrees many of these physicians tend to migrate to urban settings or to countries where they can earn more money—all of which contributes to a “brain drain,” particularly in rural areas. The human resource crisis is most acute for specialists, including surgeons and anesthesiologists. East Africa has 0.25 fully trained surgeons/100,000 persons, compared with 5.69/100,000 in the U.S.8 WHO has prioritized a list of cost-effective interventions for developing countries, including emergency care of trauma, obstetrical complications, and acute abdomens as well as elective hernias, cataracts, and other basic surgical procedures. When these operations were performed, they were carried out at regional and district government hospitals, primarily by nonphysician clinicians (NPCs). (NPCs are addressed in more detail later in this article.)
Inadequate access to timely surgical care not only leads to unnecessary death, but inhibits the ability of survivors to lead productive lives. The X ray of a pediatric patient with an untreated femur fracture (see Figure 2) reinforces the fact that there is a lack of surgical care and the long-term disability that patients such as this must endure.
In 1990, WHO and The World Bank attempted to estimate the global burden of disease. The result was a health measure called the DALY (disability-adjusted life years).1,9 DALY represents the sum of potential years of life lost because of premature mortality added to the years of productive life lost because of disability. Approximately 11 percent of the world’s DALYs stem from conditions that require surgical treatment.
Limitations of volunteerism
Many well-intentioned health care professionals and organizations have sought to improve access to surgical care in limited-resource countries through traditional approaches to volunteerism. On these missions, volunteers perform the necessary surgical procedures and show health care professionals how the operations are done. Unfortunately, this sort of volunteerism frequently yields short-term improvements, in part because the surgeon participants bring with them sophisticated Western interventions that the infrastructure of the visited nations cannot support. Infrastructure issues are particularly acute in the rural reaches of these countries, where most people live. So, whereas volunteerism in rural settings generally improves care transiently, access to that care again disappears when volunteers leave.
Furthermore, the costs of these efforts are quite high, especially when weighed against their long-term impact. Maki and colleagues in 2008 described a list of 543 medical mission organizations that conducted approximately 6,000 annual short-term volunteerism programs originating in the U.S.10 With an average expenditure of $50,000 per mission, a conservative expenditure estimate is $300 million per year. They also noted another significant limitation of these efforts, “lack of standardized evaluation to assess patient safety, quality control and mission impact.”10
A review of the contribution international volunteers make to the workforce in sub-Sahara Africa in 2005 described approximately 1,500 full-time physicians from different organizations with different views and interactions with government officials.11 The leaders of this study concluded that volunteers contribute relatively small numbers to the workforce and are unlikely to do more in the future. Matching U.S. volunteer programs with medical schools and surgical training programs has its place, but only fulfills a small niche in a developing country’s workforce.12
WHO summarized the assessment of interactions between global health initiatives (GHIs) and country health systems in The Lancet in 2009.13 This review generated several general recommendations, including development of agreed indicators for health system strengthening, improved alignment of planning and resource allocations, generation of reliable data for costs and benefits, and increased national and global health financing to support the sustainable and equitable growth of health systems.
To help address their workforce crises, several sub-Saharan countries—Tanzania, Mozambique, and Malawi—have developed the concept of task shifting. Through this process, NPCs replace physicians and provide basic medical services, which may include surgical procedures.14-16 With appropriate training in surgery, the morbidity and mortality rates among NPCs are similar to physicians with acceptable standards as defined by WHO. Several articles have also emphasized that the training costs under this approach are cheaper and of shorter duration and that NPCs are more likely to remain in rural areas.
Task shifting is a relatively novel concept, and several factors limit the success of this approach, including opposition from some physicians who believe it is unethical and that nonphysicians provide substandard care. Also a standardized curriculum for training these individuals has not been created. However, based on my experience, the benefits of this approach can be significant.
A case in point
In 2008, I retired as a pediatric surgeon and general surgery program director at the Maine Medical Center in Portland. I became involved as a surgical educator in a project in Tanzania, sponsored by the World Lung Foundation and the Bloomberg Philanthropies Foundation in New York, NY, and supported by the Tanzania Ministry of Health. The purpose of the program was to expand obstetric surgical education and to develop an infrastructure to meet the needs of a large rural population.
Tanzania has a population of approximately 40 million. Most physicians practice in urban settings and provide extremely limited services to the 80 percent of the population who live in rural areas. Since Tanzania achieved independence from Great Britain in 1961, assistant medical officers (AMOs)—NPCs who have five years of training after graduating from high school—have provided most medical and surgical care to the rural population, including obstetrics, basic general surgery, and anesthesia. A similar cadre of NPCs has also been created in Mozambique and Malawi and has demonstrated comparable results to physicians in terms of morbidity and mortality.
I worked in Kigoma, a town in western Tanzania, at the Maweni Regional Referral Government Hospital. This 150-bed facility, located 1,000 miles from the capital, Dar es Salaam, is the referring hospital for the Kigoma region, which is geographically quite large and has a population of almost 2 million people. One regional, two district, and one mission hospital provide all of the needed surgical care. Three specialty-trained surgeons (one gynecologist and two general surgeons, including the author of this article) serve the entire region.
Physicians in rural Tanzania complete a one-year internship with limited surgical exposure and typically go on to serve primarily as hospital administrators. The district hospitals have the same bed capacity as the regional hospital with no specialty support. The table shows the surgical case distribution at Maweni Hospital. These data are similar to those of other rural hospitals. Cesarean sections (C-sections) account for more than 50 percent of all surgical procedures.
This project examined whether the facilities were providing the met need (percentage of population receiving a medical or surgical intervention) to this population for maternal care. These hospitals were frequently situated too far from the patients in need of care. Lack of transportation and impassable roads during the rainy season further limited access.
Our project was designed to upgrade regional health centers to provide comprehensive emergency obstetrical care (CEmOC), including the ability to perform emergency C-sections and provide blood transfusions. In each center, infrastructure was expanded to include an operating room, a maternity ward, a laboratory with a blood bank, and transport capability. An educational program for fully trained AMOs, supervised by two MD physicians with surgical training, included a three-month course in advanced obstetrical care, as well as surgical concepts applicable to basic surgical care. Nurse midwives also received a three-month course in spinal and general anesthesia. At the completion of their training, each participant completed a one-month supervised internship and then returned to a local health center with a contractual commitment to practice for at least two years.
Two years later, the graduate trainees were performing C-sections and basic general surgical procedures with morbidity and mortality rates comparable to those in the district/regional hospitals. As a result, referrals from distant health care centers have declined, and consequently, the number of maternal complications has decreased and outcomes have improved.
A health care center located in Nguruka was upgraded in April 2009 to permit CEmOC. This center is 150 miles from the regional hospital with approximately 20 miles of paved road and one major river crossing located between both facilities. Before the project intervened, limited deliveries and no C-sections were performed at the center, resulting in frequent referrals and deaths. During the first five months of 2011, 281 deliveries, 24 C-sections, two referrals, and no deaths occurred at the Nguruka center.
The center in Buhingu is a newly upgraded health center facility 75 miles from our hospital on the shore of Lake Tanganyika, with no road access. It serves approximately 80,000 people who must travel a minimum of 12 hours by boat to reach Kigoma, which is where the nearest hospital is located. During this same five-month period last year prior to the introduction of CEmOC, they had 38 deliveries, no C-sections, five referrals, five maternal deaths, and seven perinatal deaths. The project organizers anticipate similar improvement in obstetrical care at the completion of the present course.
The concept spreads
A second region in Tanzania, Morogoro, came on board in the spring of 2010. Three health centers in that area have demonstrated similar improvements in maternal health care access.
This project has assisted the medical and surgical community in these regions in many additional ways. Management of surgical patients, both at the regional and district facilities, has improved in terms of pre- and postoperative surgical management and intraoperative care related to anesthesia, airway management, and fluid requirements. Until 2009, endotracheal intubation for a laparotomy was uncommon at the regional hospital. From March through December 2008 at Maweni Hospital, only 25 patients were intubated and 46 received spinal anesthetics. As a result of our first course, which had an anesthesia-training component, in 2009 those numbers rose to 233 and 191, respectively.
As the surgical educator for the project, I was able to upgrade the AMOs’ surgical technique and patient management skills, including management of complicated obstetrics cases, amputations, laparotomies for perforated viscus, strangulated hernias, and complicated abscesses.
The project also provided the resident and student trainees the opportunity to accompany me to Tanzania, including several third-year surgical residents from our program, for a month rotation, and a fourth-year medical student from Tufts Medical School for six weeks. These individuals attained well-supervised, firsthand experience in delivering both medical and surgical care in a rural area of a developing country.
Model for sustained care
In this unique model in Tanzania, NPCs provide the majority of care in rural settings. A directed educational program and infrastructure development has allowed them to expand their role to meet the population’s surgical needs. Our group would like to see this pilot project adopted by the Tanzania Health Ministry as a model throughout the country.
For the near future, the shifting of responsibilities to NPCs is the only sustainable option to provide surgical care to a large rural population in sub-Saharan Africa. Physicians need to support the presence of NPCs in the health care system and become more involved in their education and professional development.
This article is based on a poster presented at the 92nd Annual Meeting of the New England Surgical Society, September 23–25, 2011.
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