Doruk Ozgediz

The burden of surgical conditions and access to surgical care in low- and middle-income countries

Surgery is an essential component of health systems but has generally been neglected within global public health. This is despite growing evidence documenting the cost-effectiveness of essential surgical care in low- and middle-income countries (LMICs).1 The overall burden of disease that may be cured, palliated or treated with surgical intervention is large and (probably) rapidly growing, and this concept must therefore be revisited. n nThere are major gaps in knowledge related to surgery in LMICs. What exactly is the burden and distribution of surgical conditions in LMICs? What is the unmet surgical need? What resources (human, financial, physical) are required to improve access to surgical care? What impact would this have on global health disparities, and how does this compare with other interventions? How can essential surgical services be integrated into health systems’ surveillance and evaluation? This paper outlines a research agenda and argues that enough is already known to justify accelerated action.

The neglect of the global surgical workforce: experience and evidence from Uganda.

BackgroundAfrica’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.MethodsThis 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.ResultsUganda 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.ConclusionsThe 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.

Evaluating international global health collaborations: Perspectives from surgery and anesthesia trainees in Uganda

BACKGROUNDnThe number of international academic partnerships and global health programs is expanding rapidly worldwide. Although the benefits of such programs to visiting international partners have been well documented, the perceived impacts on host institutions in resource-limited settings have not been assessed adequately. We sought to describe the perspectives of postgraduate, Ugandan trainees toward international collaborations and to discuss how these perceptions can be used to increase the positive impact of international collaborations for the host institution.nnnMETHODSnWe conducted a descriptive, cross-sectional survey among anesthesia and surgery trainees at Makerere College of Health Sciences (Kampala, Uganda) using a pretested, self-administered questionnaire. Data were summarized as means or medians where applicable; otherwise, descriptive statistical analyses were performed.nnnRESULTSnOf 43 eligible trainees, 77% completed the questionnaire. The majority (75%) agreed that visiting groups improve their training, mostly through skills workshops and specialist camps. A substantial portion of trainees reported that international groups had a neutral or negative impact on patient care (40%). Only 15% agreed that research projects conducted by international groups are in priority areas for Uganda. Among those surveyed, 28% reported participation in these projects, but none has published as a coauthor. Nearly one-third of trainees (31%) reported discomfort with the ethics of some clinical decisions made by visiting faculty.nnnCONCLUSIONnThe current perspective from the surgery and anesthesia trainees of Makerere College of Health Sciences demonstrates rich ground for leveraging international collaborations to improve training, primarily through skills workshops, specialist camps, and more visiting faculty involvement. This survey also identified potential challenges in collaborative research and ethical dilemmas that warrant further examination.

Medical student teaching: a peer-to-peer toolbox for time-constrained resident educators.

tion s pro ents that d endi resi have r dent t es. ges i those c isco ( r duri port atest c was r % in 2 entl rred e to t ntrod iorit s been i t even t time c by r nstitut gical r has m utyh and m the e e i s g l f t is not yet dawn as you, the senior surgical resident, t the intensive care unit for morning rounds. Despite arly hour, your mind is already consumed with anticip esponsibilities of the day ahead: “Why is Mr. Smith’s white count rising?” “Will the new intern make it out under 30 hours this morning?” “When will I find time to prepare for conference tomorrow?” “How will this morning’s lap splenectomy go? The attending is ery particular and it’s my first.” “We have to fly through rounds to meet the first OR patient in reop!” In the intensive care unit, you are met with the shy bu tares of the 3 new third-year medical students joining the ou heard they were starting their month-long rotation to ut you had forgotten about it. They stand stiffly, energet nsure what to say or do to start the day. “Welcome to the service,” you say with a smile. In the bac our mind, another ball enters your juggling act, and you er how you will manage to integrate them in the team an ime to teach.

The Care of Injured Patients Admitted to Mulago National Referral Hospital in Kampala, Uganda

Background: Injury represents a growing global health crisis. Uganda, like much of Sub-Saharan Africa, faces little pre-hospital and medical infrastructure, severe shortages of healthcare workers and a large and growing disease burden from injury. This study aimed to describe the epidemiology of injured patients admitted to Mulago National Referral Hospital in Kampala, Uganda and determine their use of surgical resources. nMethods: We used data from a cross-sectional study in 2007-08 involving 1833 patients admitted to Mulago Hospital with ICD 10-based injury diagnoses to analyze inpatient injury care based on demographics, mechanism of injury, diagnosis, operative care, hospital length of stay, and outcomes. nResults: The median age was 25y, 76% were men. Injuries from road traffic crashes (61%) or assault (25%) resulted orthopedic (37%) or head injuries (28%). 30% of patients (n=542) underwent operation, mostly orthopedic (n=312, 58%). Needing operations and needing orthopedic procedures had longer hospital stays (6d vs. 1, p<0.0001) and (11d p<0.0001), respectively. Only four cases of intracranial drainage and 58 deaths were noted (3%). nConclusions: Orthopedic and head injuries are main causes for injury-related admission to Mulago Hospital. Patients requiring orthopedic procedures have long stays. Tracking injury morbidity and mortality is a worthwhile priority in this setting, but require greatly improved medical record systems and public health surveillance.

Research in surgery and anesthesia: challenges for post-graduate trainees in Uganda.

Background: Research is critical to the training and practice of surgery and anesthesia in all settings, regardless of available resources. Unfortunately, the output of surgical and perioperative research from Africa is low. Makerere University College of Health Sciences′ (MakCHS) surgical and anesthesia trainees are required to conduct research, though few publish findings or go on to pursue careers that incorporate research. We believe that early career experiences with research may greatly influence physicians′ future conduct and utilization of research. We therefore sought to analyze trainee experiences and perceptions of research to identify interventions that could increase production of high-quality, locally led, surgical disease research in our resource-constrained setting. Methods: Following ethical approval, a descriptive, cross-sectional survey was conducted among anesthesia and surgery trainees using a pretested, self-administered questionnaire. Data were tabulated and frequency tables generated. Results: Of the 43 eligible trainees, 33 (77%) responded. Ninety-four percent identify research as important to career development, and 85% intend to publish their dissertations. The research dissertation is considered a financial burden by 64%. Also, 49% reported that their departments place low value on their research, and few of the findings are utilized. Trainees report that lack of protected research time, difficulty in finding research topics, and inadequate mentorship are the main challenges to conducting research projects. Discussion: Our anesthesia and surgery trainees spend considerable resources on research endeavors. Most have significant interest in incorporating research into their careers, and most intend to publish their work in peer-reviewed journals. Here we identify several challenges facing trainees including research project development, financing and mentorship. We hope to use these results to improve support in these areas for our trainees and those in other resource-limited areas.