Surgical Training Program, increasing surgical capacity by training non-physician clinicians to perform surgery in Sierra Leone.
Kirurgi under ebola epidemien og task-sharing i Sierra Leone (SL)
Submitted in 2016: 1. Systematisk review of surgery in SL 2. Admissions and surgery as indicators of hospital functioning in SL during the West-African Ebola outbreak 3. Safety, productivity and predicted contribution of a surgical task-sharing programme in SL. Operational research from the first five years of an innovative new model of training
Systematic review: In order to describe the current knowledge base regarding the health system for surgical care in Sierra Leone, we carried out a systematic review of the published literature on surgery and anaesthesia in the country. We performed searches in PubMed, Embase and African Journals OnLine databases to identify studies pertaining to surgical care. Articles were summarized by means of textual narrative synthesis, using headings that were agreed upon by general consensus by a group of experts before commencing the review process. A total of 232 published studies were identified, and after reviewing titles, abstracts and full text articles, 55 studies remained in the final summary. The current body of literature reveals a high burden of surgical disease, large unmet need for surgery and very limited human resources to address the substantial volume of untreated surgical pathologies in Sierra Leone. Admission and surgery as indicator..: In an attempt to assess the effects of the Ebola viral disease (EVD) on hospital functions in Sierra Leone, the aim of this study was to evaluate changes in provisions of surgery and non-Ebola admissions during the first year of the EVD outbreak. We found a 51% decrease in non-Ebola admissions and 41% fewer surgeries performed compared with the before the outbreak. Governmental hospitals experienced a smaller reduction in non-Ebola admissions (45% versus 60%) and surgeries (31% versus 53%) compared to private non-profit hospitals. Governmental hospitals realized an increased volume of cesarean deliveries by 45% during the EVD outbreak, thereby absorbing the 43% reduction observed in the private non-profit hospitals. Both non-Ebola admissions and surgeries were severely reduced during the EVD outbreak. In addition to responding to the EVD outbreak, governmental hospitals were able to maintain certain core health systems functions. Volume of surgery is a promising indicator of hospital functions that should be further explored. Safety, productivity and...: Surgical task-sharing may be central to expanding the provision of surgical care in low-resource settings. The aims of this paper were to describe the setup of a new surgical task-sharing training programme for associate clinicians and junior doctors in Sierra Leone, assess its productivity and safety and estimate its future role in contributing to surgical volume. This prospective observational study from a consortium of 15 hospitals assess five years’ crude in-hospital mortality and productivity of operations performed during and after completion of a three-year training programme. 48 trainees and nine graduates participated in 27 216 supervised operations between January 2011 and July 2016. During the three-years training, trainees attended a median of 822 operations. Caesarean section, hernia repair and laparotomy were the most common procedures during and after training. Crude in-hospital mortality of caesarean sections and laparotomies performed by trainees was 0·7 per cent (13/1915), 4·3 per cent (7/164) and 0·4 per cent (5/1169), 8·0 per cent (11/137) by graduates. Adjusted for patient sex, surgical procedure, urgency and hospital, mortality was significantly lower for operations performed by trainees and graduates versus those conducted by trainers and supervisors. Graduates of this training programme can rapidly and safely achieve substantial increases in surgical volume in Sierra Leone.
Surgical services in Sierra Leone
Surgery has until a few years back been neglected in global public health, and is referred to as the neglected stepchild in global health (Jim Kim, President of the World Bank, 2009). There are several factors contributing to the poor availability of surgical services. Lack of human resources is paramount among these.
The resolution: Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage were unanimously endorsed by all the World Health Organization’s 194 member states at the annual World Health Assembly this spring (WHA 68.15/2015). It states the important of emergency and essential surgical care and anaesthesia in achieving the health-related Millennium Development Goals and for attending to the unfinished business post-2015, including universal health coverage. Nearly one-third of the burden of human disease worldwide is amenable to surgery (Shrime, Lancet Global Health, 2015). Surgery is a crosscutting intervention, at all ages, involved in every disease category from infections to blindness, from congenital abnormalities to maternal conditions, from the neurological to the cardiac to the neoplastic and relevant for health interventions from prevention to cure. To put this in perspective, HIV, tuberculosis and malaria — currently make up less than one-tenth of the global disease burden, combined (Editorial, The New York Times, 25 September, 2015). More than 90% of the estimated surgical need in Sierra Leone is unmet. In 2012, 24,152 major surgical procedures were performed in the country, equal to a national rate of 400 surgeries per 100,000 inhabitants, with district variations from 32–909 surgeries per 100,000 (Bolkan, Surgery, 2015). This is in great contrast to high income countries that perform on average 11,000 major surgeries/100,000 inhabitants annually (Weiser, Lancet, 2008). Limited data exist on surgical providers and their scope of practice in low-income countries. The Sierra Leonean surgical workforce consisted of 164 full-time positions, equal to 2.7 surgical providers/ 100,000 inhabitants. Non-specialists performed 52.8 % of all surgeries. In rural areas, the densities of specialists and physicians were 26.8 and 6.3 times lower, respectively, compared with urban areas. The average individual productivity was 2.8 surgeries per week, and varied considerably between the cadres of surgical providers and locations (Bolkan, World Journal of Surgery, 2016). Less than half of all of the surgery in Sierra Leone is performed by specialists. Surgical providers were significantly more productive in healthcare facilities with higher volumes of surgery. If all surgical providers were as productive as specialists in the private non-profit sector (5.1 procedures/week), the national volume of surgery would increase by 85 %. There is an obvious need for innovative strategies to address the largely unfulfilled need for surgery in rural parts of low-income countries. Two out of four aims of this project is accomplished: 1. Determine the unmet need for surgery in Sierra Leone (Art. 1 - published) 2. Quantify the the surgical workforce and it's productivity (Art. 2 - published) The remaining two aims are: 3. Volume of surgery as a tracer for hospital performance during an humanitarian crisis (Ebola) (Art. 3). 4. 5 years experience of training middle level health care providers in managing emergency general surgery at district hospitals (Art. 4).
Health system attention in Sierra Leone - from surgery to ebola
The ebola epidemic had a significant effect on many aspects of the health care system in Sierra Leone. As we were in a unique position to document those effects on the healthcare system, we changed the approach for 2014 and documented a 70% decline in hospital admissions for non-related ebola conditions after the onset of the epidemic.
This research project is looking at surgical care in Sierra Leone from a health systems perspective. When the ebola epidemic hit the country in May 2014, it had a significant effect on many aspects of the health care system, and in many ways it was a collapse of ordinary health care. As this research group were in a unique position to document those ebola effects on the healthcare system, we changed the approach for this year and looked at how hospital functioning for non-related ebola conditions changed during the course of the epidemic. The most disturbing indirect ebola effects was that patient stopped using health care facilities for all kinds of conditions as they rightly were afraid of being infected by ebola in the healthcare facilities. Healthcare providers had the same concerns and implemented a practice of “No touch” as a simple mean to protect them against ebola in the absence of adequately available personal protective equipment. As this research group had developed a broad contact network of hospitals in the country prior to the ebola outbreak, it became possible to document the general health system effects of ebola. This was an urgent decision as the results could have significant importance for developing strategies for a recovery of healthcare services under and after the epidemic. The 19 December publication “Ebola and Indirect Effects on Health Service Function in Sierra Leone” was done together with two key directors in the Ministry of Health and published in PLOS Current Outbreak. The results and the publication has been used by the Ministry of Health in Sierra Leone as a basis for developing health system recovery plans and policies. The results are also presented at to World Health Organizations (WHO) lead in the United Mission Emergency Ebola Response (UNMEER) in several meetings; both in Sierra Leone and in Geneva WHO headquarter.
Surgical capacity in Sierra Leone
The research project is describing surgical services in Sierra Leone. A baseline study including 58/60 facilities performing major surgery has been performed. To our knowledge this is the first time a comprehensive nationwide survey of surgical activity has been performed in a low income country.
Over the last decades there has been a rapid shift in the global disease burden away from infectious diseases and towards non-communicable diseases. Conditions in need of surgical care represent a considerable part of the global non-communicable disease burden. Largely, the need for surgical care for this burden in low- and middle-income countries is unmet. Surgery has previously been considered a luxury, but surgical services in low- and middle-income countries has the last decade proved itself highly cost-effective. The huge need, global inequity and cost-effectiveness of surgical interventions has called upon governments, policy makers, and donor agencies to consider surgical healthcare delivery in low- and middle-income countries a priority. To scale up surgical care in LMICs there is a need of baseline data to develop aspirational targets for surgical activity. To date there do not exist population based data on surgical activity from low- and middle-income countries. The first aim of the research project is to establish nationwide population based rates, define the unmet need and coverage of major surgery in a low- and middle-income countries, by conducting a comprehensive mapping of all major surgeries performed in Sierra Leone in 2012.
1. World Health Organization - 5 biannual meeting of the Global Initiative on Essential and Emergency Surgical Care, Trinidad October 2013
2. World Congress of Surgery, Obstetrics, Trauma and Anesthesia, Trinidad October 2013, 2 abstracts presented.
3. Article ready to be submitted.
The second article from this data set is to describe distribution across administrative districts and sectors offering surgical care. Further more surgical activity of the available human resources for surgical care in Sierra Leone will be described. We will be able to explore possible coherence between key district health indicators, such as maternal mortality, under 5 mortality and density of available surgical workforce.
Increasing surgical capacity in Sierra Leone
Surgical and obstetrical emergencies are poorly addressed in Sierra Leone. Lack of human resources is a main contributing factor. There are obvious needs for innovative strategies to cope with the huge unmet need for surgery and obstetric care in rural parts of the country.
Sierra Leone has some of the worst health statistics in the world. In 2008 it was 10 surgeons in the country’s governmental hospital to serve a population of 5,7 millions.
The main aim for the research project is to evaluate a new and innovative surgical training initiative in Sierra Leone, where 30 Associate Clinicians (AC) and medical doctors are trained each for 2 years to handle the majority of acute surgical and obstetrical conditions at the country’s district hospitals. Two students are enrolled every three months, with the first 6 months of basic training followed by 6 months rotations in partner hospitals. After 2 years an exam is obtained followed by six months of houseman ships in governmental hospitals. Curriculum is the WHO Integrated Management of?Emergency and Essential Surgical Care.
Study 1 is a descriptive epidemiological study describing the surgical activity and resources nationwide. This baseline data is essential for the project but also important for national health authorities in their effort to address the problem with unmet needs of surgery.
Study 2 and 3, both prospective observational studies will quantify the resources needed for the new training initiative.
Study 4, a randomized control trial, will evaluate differences in the quality of care between AC trained in the program and national medical doctors.
Challenges are foreseen, as corruption is widespread, infrastructure is underdeveloped. Task shifting of surgery to non-surgeons is still controversial and require more and better data to ensure that quality of care is maintained while coverage of surgery is expanded.
The Surgical Workforce and Surgical Provider Productivity in Sierra Leone: A Countrywide Inventory.
World J Surg 2016 Jun;40(6):1344-51.
PMID: 26822155 - Inngår i doktorgradsavhandlingen
Who is performing surgery in low-income settings: a countrywide inventory of the surgical workforce distribution and scope of practice in Sierra Leone.
Lancet 2015 Apr 27;385 Suppl 2():S44. Epub 2015 apr 26
Rates of caesarean section and total volume of surgery in Sierra Leone: a retrospective survey.
Lancet 2015 Apr 27;385 Suppl 2():S19. Epub 2015 apr 26
Met and unmet needs for surgery in Sierra Leone: A comprehensive, retrospective, countrywide survey from all health care facilities performing operations in 2012.
Surgery 2015 Jun;157(6):992-1001. Epub 2015 apr 28
PMID: 25934081 - Inngår i doktorgradsavhandlingen
Surgical task shifting in Sierra Leone: a controversial attempt to reduce maternal mortality.
BJOG 2015 Jan;122(2):155.
Enhancing access to emergency obstetric care through surgical task shifting in Sierra Leone: confrontation with Ebola during recovery from civil war.
Acta Obstet Gynecol Scand 2015 Jan;94(1):5-7.
Assessing cesarean section and inguinal hernia repair as proxy indicators of the total number of surgeries performed in Sierra Leone in 2012.
Surgery 2015 May;157(5):836-42.
Assessment of caesarean section and inguinal hernia repair as proxy indicators of total number of surgeries.
Lancet 2015 Apr 27;385 Suppl 2():S21. Epub 2015 apr 26
Ebola and Indirect Effects on Health Service Function in Sierra Leone
PLOS Current Outbreak, 2014