- Derek Alderson, MD, FRCS
- Ruairi Brugha, MD, MSc, FFHMI
- Stuart Fergusson, BSc (Med Sci), MB, ChB, ChM, MRCS, DRCOG, PGCAP, FHEA
- Jakub Gajewski, PhD
- David Galloway, MD, FACS, FRCS, FRCP, FAIS, FAMM, FCSSL, FICP
- John Hyland, FRCSI
- Graham Layer, DM(Oxf), MCh, FACS, FRCSEd, FRCSEng
- Deirdre Mangaoang, MBA
- Eric O’Flynn, MA
- Sean Tierney, FRCSI
The Royal Colleges of Surgeons in the U.K. and Ireland have real concerns about the inequity of care in low- and middle-income countries (LMICs). These organizations also recognize the opportunities that exist to contribute to system strengthening and to develop standards, education, assessment, and advocacy initiatives in order to enhance access to quality surgical care. A particularly important area of this work relates to the contextualized provision of curriculum development and suitable clinical examinations that allow surgeons to benchmark their training and skills against an internationally recognized standard. The Royal Colleges of Surgeons in the U.K. and Ireland work together to contribute to the development and delivery of these activities and provide career-long support for their fellows and members who work to end health care disparities in LMICs.
This article describes contributions from the four surgical Royal Colleges in the U.K. and Ireland. Much of this work is collaborative, especially in relation to advocacy and support for the mission of the World Health Organization (WHO), as well as in curriculum development, quality assurance, and the assessment of young surgeons. These efforts are coordinated activities, and this article summarizes the main areas in which we operate.
RCSI: A partnership approach to global surgery
Since its inception in 1784, the purpose of the Royal College of Surgeons in Ireland (RCSI) has been to educate and train surgeons to meet the needs of patients. Today, its reach is more extensive than its founders could have envisioned, as the RCSI helps develop health care leaders worldwide. In LMICs, the RCSI achieves this goal by partnering with local institutions and unlocking potential at the regional level.1
In 2007, collaborative efforts between the RCSI and the College of Surgeons of East, Central and Southern Africa (COSECSA) began to support the training of surgeons in Africa.2 COSECSA launched in Nairobi in 1999, and one of its aims was to stop the “brain drain” of African surgeons who trained abroad and never returned home. With funding from Irish Aid,3 the Irish government’s official agency for international development, RCSI and COSECSA embarked on a collaborative program to help COSECSA train more surgeons in the region.
Prior to this initiative, COSECSA’s cumulative total of graduates was 17. By December 2016, that number reached 206, which is an average increase of 39 percent in graduating surgeons year-to-year (see Figure 1).
Figure 1. COSECSA graduates 2006–2016
College without walls
COSECSA is a college without walls. It trains surgeons through an expanding network of 99 accredited hospitals and 165 accredited trainers in 12 member countries. All trainees follow the same program of training for the first two years. They then are eligible to sit for COSECSA’s membership exams. In the final three years, trainees choose one of seven specialties and then are eligible to take COSECSA’s fellowship exams.4 The COSECSA training model is shorter than that of many comparable international surgical training institutions and is focused on clinical exposure.
The RCSI has provided support in curriculum development, examinations, and a variety of training and leadership courses. Together, both colleges have designed information technology (IT) resources, such as a mobile-optimized e-logbook and an e-learning portal with content relevant for the region.5 As the number of trainees enrolling in the program has increased, many RCSI departments, including finance, IT, communications, and quality assurance, have supported specific projects managed by COSECSA’s secretariat, a role that oversees the day-to-day administration of COSECSA training and examination processes.
COSECSA is now the largest single contributor to the surgical workforce in the region, and, in fact, the organization has developed an interactive map to document surgeon density.6,7 Significantly, research has shown that surgeons who train locally are increasingly retained in the region.8 More specifically, 85 percent of surgeons practice in the country in which they trained, 88 percent are practicing in East, Central, and Southern Africa, and 93 percent remain in Africa. The brain drain in Africa has become a myth.8
Other positive outcomes from the RCSI’s collaboration offer significant potential for the future financial support of global surgery programs. With real-time data on operations performed by more than 500 surgical trainees in 12 countries, COSECSA is now uniquely positioned to engage in collaborative research on the training of surgeons and practice of surgery in sub-Saharan Africa, and this research could generate vital, translational data for governments and potential funding bodies.
Surgery at the district level: COST- and SURG-Africa
Most countries in the region have a critical need for surgically trained clinicians who are willing to work in district hospitals. Since 2011, RCSI researchers have been leading two European Union-funded projects aiming to generate evidence that a safe surgery model for district hospitals is feasible, effective, and sustainable.
Nonphysician clinicians (NPC) are the backbone of clinical care services for rural communities in many African countries. In Malawi, COST-Africa, also known as Clinical Officer Surgical Training in Africa, accredited and rolled out a national bachelor of science in surgery for clinical officers (COs).9 As a result, the volume of general surgical cases at district hospitals increased by 89 percent. The outcomes of hernia operations done by COs in district hospitals were comparable with those performed in central hospitals.10
COST-Africa also developed a supervision model in Zambia, enabling specialists from central hospitals to travel to district hospitals to deliver on-the-job training, to supervise, and to mentor surgically active district NPCs. This model improves the quality and scope of surgical care at the district level and allows hospitals to save money on referrals. These NPCs help build the surgical skills of general medical officers and provide a potentially sustainable strategy for making surgery available to rural populations.11
In a second European Union-funded study, Scaling up Safe Surgery for District and Rural Populations in Africa (SURG-Africa), NPCs in three countries are being trained in clinical decision making, safe anesthesia, peri- and postoperative monitoring, safe surgery for Ministry of Health (MOH)-approved elective and common emergency conditions, as well as surgical team leadership and management skills.12
RCSI has chosen a point of entry—surgical training and supervision—that best leverages its strengths. Ultimately, it will not be institutions or individuals in high-income countries, but our partners, including governments, that must provide the infrastructure and institutions to train the future surgical providers in Africa.
RCPSG: Training, advocacy, and delivery
The Royal College of Physicians and Surgeons of Glasgow (RCPSG) was founded in 1599 by Maister Peter Lowe, who left his native Scotland for surgical training in France, where he remained for many years. He then returned to improve the medical standards of his local community. More than 400 years later, the RCPSG’s vision remains “the highest possible standards of healthcare.” It pursues this vision through the provision of academic resources, examinations, educational activities, and contributions to medical regulation and public policy. Uniquely for a U.K. Royal College, the Glasgow College membership encompasses surgeons, physicians, dentists, travel medicine specialists, and podiatrists.13
Having demonstrated in the 16th century that health care training and experience gained outside a local community can ultimately serve home populations, as well as build bridges abroad, the RCPSG continues to maintain and promote this perspective today.
With the support of the Scottish government, the RCPSG has recently taken a leading role in reviewing and analyzing the policy background that surrounds global health volunteering work in Scotland. This endeavor resulted in a major report, Global Citizenship in the Scottish Health Service: The Value of International Volunteering, published in May 2017, which challenged the Scottish government to institutionally recognize the mutual benefits of engagement in global health (see Figure 2). The report made eight recommendations to the government, which focused on improved support and coordination of international volunteering efforts by National Health Service workers. Scotland’s Minister for International Development welcomed the report at its launch, and the leaders of this initiative anticipate that the recommendations will be taken forward fully in the coming years.
Figure 2. Mutual benefits for global health volunteering work in Scotland
Source: Royal College of Physicians and Surgeons of Glasgow. Global citizenship in the Scottish Health Service: The Value of International Training. Available at: https://rcpsg.ac.uk/college/influencing-healthcare/policy/global-citizenship. Accessed March 8, 2018.
The RCPSG also has realized its potential to advocate for the prioritization of surgical capacity building in resource-challenged environments. Together with other U.K. surgical colleges, we established a correspondence with Tedros Adhanom Ghebreyesus, PhD, MSc, around the time of his election to WHO director-general, and urged him to place resources behind the World Health Assembly (WHA) landmark 2015 Resolution 68.15 on building capacity in emergency and essential surgical and anesthetic care. Dr. Tedros responded with a letter that demonstrated his commitment to work in consultation with Member States to build national capacity for emergency and surgical care to implement WHA 68.15. “As stated in WHA 68.15, surgical capacity is an essential part of universal health coverage and our political commitment and programs must reflect that,” Dr. Tedros wrote in the letter.14,15 This correspondence was subsequently circulated to multiple nation states at the 2017 WHA to establish his commitment to surgical capacity building, and the RCPSG intends to monitor progress carefully.
Facilitation of medical training
Alongside other Royal Colleges, the RCPSG supports the U.K. Department of Health’s Medical Training Initiative (MTI), which offers a time-limited opportunity for postgraduate medical professionals, primarily from LMICs, to obtain training experience in the U.K. before returning to their country of origin. In addition to sourcing and coordinating placements for a range of applicants on a cost-recovery basis, the RCPSG has instituted its own MTI bursary scheme, the Livingstone Fellowship, which supports some of the start-up costs for Malawian trainee physicians or surgeons coming to the U.K. for targeted training. Physicians who have benefited from this program recently include Wone Banda, MB, BS, MSCS, FCS, and T.K. Itaye, MB, BS, MMed (respectively training in plastic surgery and general and breast surgery), and following a successful year of training in Scotland they have returned to posts in Malawi as consultant specialist surgeons.
Glasgow College fellows and members have a history of supporting underserved communities beyond their home environment. The college has delivered some of its standard educational courses in low-income environments, including the Basic Surgical Skills course, and is scoping future educational opportunities with the Malawian College of Medicine and other institutions. RCPSG fellows and members from around the world can access a variety of travel bursaries, which aim to support the delivery of high-quality clinical input overseas and ensure the effective transfer of learning back into the home environment. Recipients of college support include general surgeons, orthopaedic surgeons, and gastroenterologists. The college has provided resources to provide training and capital equipment for endoscopic services, which is much-needed care in a country with a high incidence of esophageal varices related to schistosomiasis and upper gastrointestinal cancer.
The Glasgow College has restructured to enhance these vital areas of global health involvement and has active projects in sub-Saharan Africa, Sierra Leone, Tamil Nadu, India, Sri Lanka, and Malaysia.
RCSEng: Global surgery research and training
The Royal College of Surgeons of England (RCSEng)16 has developed a broad portfolio of activities in recent years as highlighted in the International Strategy, 2016–2020 (see Figure 3). These efforts are designed to create sustainable surgical services in LMICs. The RCSEng is a member of the G4 Alliance (also known as the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care).17
Figure 3. International Strategy 2016–2020
Source: Royal College of Surgeons of England. Launch of RCS International Strategy 2016–2020. Available at: www.rcseng.ac.uk/news-and-events/news/archive/international-strategy/. Accessed March 8, 2018.
International development project
The RCSEng’s international development project focuses on resource-poor countries to establish basic practices that support continuous quality improvement. At present, the following five projects are under way:
- Core surgical skills training. This project involves working in Gaza at the Al-Shifa Hospital to train local surgeons to become leaders of basic surgical skills courses.
- The safe operating theater. This program involves training a multidisciplinary team to develop best practices in operating theater function and management. This project is taking place in Ethiopia, where a local team will be trained at a large center, enabling these physicians to deliver training to a wider community of health care professionals elsewhere in the country.
- Objective structured clinical examinations development. This project has been initiated in Ethiopia in conjunction with the Ministry of Health and provides examinations for trainee surgeons specifically contextualized for local health problems.
- Surgical capacity building. This project has been developed for northern Sri Lanka and involves week-long workshops in a number of surgical specialties intended to develop skills to manage priority surgical challenges at the local level.
- Development of hub-and-spoke training models. These models are based in Vellore, India, and involve teaching general surgeons in district hospitals how to identify, treat, or refer pediatric surgical conditions.
International surgical training program
As part of the U.K. MTI, surgeons from LMICs are admitted to two-year surgical training placements in the U.K. through the RCSEng. Approximately 40 surgical trainees are successfully placed annually, and the college assists other overseas surgeons with visa (tier 2) procurement and registration with the general medical council, and serves as a source of education, support, and advice.
Global Surgical Frontiers Conference
The RCSEng hosted the sixth annual Global Surgical Frontiers Conference in April 2017. This meeting involves collaboration between the college, international organizations, surgical trainee bodies, and student societies with the goal of introducing young surgeons to the needs and opportunities related to the development of surgery at a global level. The next conference will take place in June, and the theme will be trauma.
Global surgical research
The RCSEng has played a pivotal role in the development of trainee-led clinical research, establishing a trials network in the U.K. that now covers all surgical specialties. In the last two years, this system has been expanded to an international trainee-led research group—GlobalSurg. This group has already undertaken cohort studies, accumulating data on more than 27,000 patients involving more than 1,000 collaborators in more than 100 countries, half of which are LMICs. The group recently initiated the world’s first trainee-led surgical trial centered on LMICs and involving 5,500 patients.18 Oversight committees and policy and implementation committees to support this organization are both provided through RCSEng.
The RCSEng also provides individual support (full salary plus running costs) to enable U.K. trainees to undertake research activities abroad. At present, the college supports three fellows in North America, one in mainland Europe, and one in sub-Saharan Africa. International traveling fellowships also were awarded in 2017 to seven trainees, four of whom are overseas trainees visiting the U.K. from Myanmar, Ethiopia, and India, with three U.K. trainees visiting the Democratic Republic of Congo for trauma, Nepal for pediatric surgery, and Ethiopia for head and neck surgery.
RCSEd: The value of specific partnerships
The Royal College of Surgeons of Edinburgh (RCSEd) has historically been involved in education and assessment on many continents.19,20 It also shares its innovative surgical distance learning masters programs, ESSQ (Edinburgh Surgical Sciences Qualification), in association with the University of Edinburgh since 2007, with 1,750 students enrolled in some 70 countries over 10 years (see Figure 4).21 In 2017–2018, the total number of surgical trainees includes 530 students enrolled for the master of science in surgical sciences and for the ChM (master of surgery) programs in surgical specialties. These programs typify the global impact of the RCSEd on surgical education and training.22
Figure 4. Edinburgh surgery online programs 2007–2017
In an effort to focus on global surgery specifically, this section of this article concentrates on capacity-building initiatives of the RCSEd in two major areas: Malawi and Myanmar, with which the college has had longstanding relationships. The RCSEd has recently developed a partnership with the University of North Carolina (UNC) at Chapel Hill to facilitate the delivery of its surgical training program initiative based in Lilongwe, Malawi.
The RCSEd has bases of operation in Edinburgh and in Birmingham in the U.K., and it has an international office in Kuala Lumpur, Malaysia. It aims to improve the health of our LMIC partners by delivering what they have requested of us, rather than attempting to identify the problems and enforcing change or perhaps providing unwanted resources or systems. Similarly, the RCSEd does not donate large sums of money without restriction, but instead directs its funding to specific projects where there will be a measurable impact and outcome.
Scotland has provided support to Malawi for decades, specifically through the organization’s overseas development fund, as well as via the Scotland Malawi Partnership, the largest community-based international development network in the U.K.23 The RCSEd also has longstanding links with the government of Malawi, and Malawian surgical students are well-represented in the postgraduate surgical distance-learning programs offered jointly with the University of Edinburgh, ESSQ resulting in an MSc (loosely equivalent to membership of the Royal Colleges of Surgeons’ examination) and the ChM in specialty surgery (similar to Fellowship of the Royal Colleges of Surgeons examination standards at the completion of training). Fellows of the RCSEd are involved in the Queen Elizabeth Hospital, Blantyre, and the Malawi College of Medicine; the Edinburgh College was a cofounder of COSECSA, of which Malawi is a member. The RCSEd continues to support COSECSA through an annual traveling fellowship, awards, courses, and assistance with assessments. RCSEd members and fellows also contribute to humanitarian work in Malawi, largely independent efforts that the college does not directly oversee.
The RCSEd’s recent initiative offers a fundamental new direction for surgical training in Malawi, following publication of the LCoGS. The RCSEd provides financial and professional support for the training of Malawian-born surgeons for five years in their own country under COSECSA guidelines. This effort represents true capacity building, and the aspiration is that the total number will rise to five trainees on a rolling cycle as each year’s activity is assessed for successful training outcomes and financial tolerances. The UNC department of surgery has close links with the RCSEd and is facilitating financial support and training on-site with a model that parallels the path of their own students, and as a result, the college will be offering appropriate courses for visiting teams. The first surgical trainee is badged as an RCSEd training fellow with college benefits. She commenced training in March and is expected to visit the college in the U.K. at its expense and for mutual benefit. This model presumably could safely be replicated elsewhere.
Myanmar has been an RCSEd partner for more than four decades. Training and assessments are provided in Yangon (formerly known as Rangoon) and Mandalay, with membership examinations and a biannual diploma ceremony occurring in Yangon.
Collaboration between the RCSEd and surgeons in Myanmar is underpinned by a memorandum of understanding (MoU) with the Department of Medical Science in the Ministry of Health and Sport. The MoU terms reflect the importance of maintaining standards, sustainability, responsibility, and ownership of a health care partnership project. The five-year agreement commenced in 2013 and provides support for surgical training, education, and assessment activities. In addition to specific surgical training resources, topics such as working with multidisciplinary teams, morbidity and mortality conferences, grand rounds, and other topics related to professional practice are embedded in the program.
The RCSEd carried out an early needs assessment for surgical training, with support from a start-up grant from the Tropical Health Education Trust (THET), a charitable funding organization linked to the U.K. government. This assessment led to a successful bid for funding from U.K. Aid, managed by THET, as part of the Trust’s Health Partnership project. This funding has enabled the RCSEd to work closely with the Myanmar Nephro-Urological Society to facilitate capacity building in an underprovided specialty, resulting in 17 trained government urologists for a population of 53 million in 2013.
The two-year pilot program consisted of visits by senior British urologists acting as visiting professors to operate and teach clinical skills, as well as provide general professional training in Yangon and Mandalay. These visits were complemented by short visits of selected Myanmar trainees to specific departments in the U.K. The selected surgeons were accorded observer status with full participation in the host department’s activities, short of direct patient treatment.
This effort has resulted in effective sustainable local delivery of a new surgical training program in urology incorporating workplace-based assessments, a quality improvement program, portfolio development, and an annual appraisal of trainees. Ultimately, these activities will be delivered locally to a high standard, while maintaining a role for the RCSEd in quality assurance and guidance where requested. Again, this model could be readily adopted for other specialties.
Both of these international initiatives are examples of local requests for directed assistance, which the RCSEd, through its examinations and education departments, is able to achieve.
The authors gratefully acknowledge the contributions of the following individuals: David Tolley, MB, FRCSEd, past-president, RCSEd; Mike Lavelle-Jones, MB, ChB, president, RCSEd; and O. James Garden, CBE, BSc, MB, ChB, MD, FRCSEd, FRCPEd, FRSE, regius professor of clinical surgery, dean international, University of Edinburgh.
- Royal College of Surgeons of Ireland. Available at: www.rcsi.com/dublin/. Accessed March 7, 2018.
- College of Surgeons of East, Central and Southern Africa. Available at: www.cosecsa.org/. Accessed March 7, 2018.
- Royal College of Surgeons in Ireland. Department of Foreign Affairs and Trade Irish Aid. Available at: www.rcsi.com/dublin/. Accessed March 7, 2018.
- College of Surgeons of East, Central and Southern Africa. Training and exams. Available at: www.cosecsa.org/training-exams/examination. Accessed March 7, 2018.
- College of Surgeons of East, Central and Southern Africa. E-logbook. Available at: www.cosecsa.org/e-logbook-portal. Accessed March 7, 2018.
- O’Flynn E, Andrew J, Hutch A, et al. The specialist surgeon workforce in East, Central and Southern Africa: A situation analysis. World J Surg. 2016;40(11):2620-2627.
- College of Surgeons of East, Central and Southern Africa. Global surgery map. Available at: www.cosecsa.org/global-surgery-map. Accessed March 7, 2018.
- Hutch A, Bekele A, O’Flynn E, et al. The brain drain myth: Retention of specialist surgical graduates in East, Central and Southern Africa, 1974–2013. World J Surg. 2017;41(12):3046-3053.
- Clinical Officer Surgical Training in Africa (COST-Africa). Clinical Officer Surgical Training in Africa. Available at: www.costafrica.eu/. Accessed March 7, 2018.
- Gajewski J, Conroy R, Bijlmakers L, et al. Quality of surgery in Malawi: Comparison of patient-reported outcomes after hernia surgery between district and central hospitals. World J Surg. Available at: https://rd.springer.com/article/10.1007/s00268-017-4385-9. Accessed March 7, 2018.
- Clinical Officer Surgical Training in Africa (COST-Africa). Data collection. Zambia. Available at: www.costafrica.eu/data-collection.html. Accessed March 27, 2018.
- Royal College of Surgeons in Ireland. Irish-led research to bring safe surgery to rural populations in Africa. Available at: www.rcsi.ie/index.jsp?n=110&p=100&a=10293. Accessed March 7, 2018.
- Royal College of Physicians and Surgeons of Glasgow. Available at: https://rcpsg.ac.uk/. Accessed March 8, 2018.
- World Health Assembly. Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. May 20, 2015. Available at: http://apps.who.int/medicinedocs/documents/s21904en/s21904en.pdf. Accessed March 19, 2018.
- Response letter to the Royal College of Surgeons. Tedros Adhanom Ghebreyesus, Minister, Special Advisor to the Prime Minister of Ethiopia. April 21, 2017. Available at: www.who.int/surgery/DrTedrosLetter.pdf. Accessed March 27, 2018.
- Royal College of Surgeons of England. Available at: www.rcseng.ac.uk/. Accessed March 8, 2018.
- G4 Alliance. Available at: www.theg4alliance.org/. Accessed March 8, 2018.
- Available at: http://globalsurg.org/. Accessed March 8, 2018.
- Royal College of Surgeons of Edinburgh. Available at: www.rcsed.ac.uk/. Accessed March 8, 2018.
- Royal College of Surgeons of Edinburgh. Welcome to the International School of Surgery. Available at: www.iss.rcsed.ac.uk/. Accessed March 8, 2018.
- Royal College of Surgeons of Edinburgh. ESSQ MSc in surgical sciences. Available at: www.essq.rcsed.ac.uk/. Accessed March 8, 2018.
- Royal College of Surgeons of Edinburgh. ChM in general surgery. Available at: www.chm.rcsed.ac.uk/chm-overview/. Accessed March 8, 2018.
- Scotland Malawi Partnership. Available at: www.scotland-malawipartnership.org/. Accessed March 8, 2018.