WHO - Workforce Conference - Kampala

GPAS participated in the WHO "Global Health Workforce" conference right here in Kampala March 2-6, 2008. It was run by the "Global Health Workforce Alliance" of the WHO and is demonstrative of the increasing emphasis being paid to the health workforce shortage in developing countries—it has definitely been a neglected part of global health. Lots of ministers prominent members of the major international organizations, universities, civil society etc. More than 1000 people attended this conference.





The massive scale-up attempts of the HIV and infectious disease programs have really stressed that "human resources" and "health systems" are the major limiting factors to their success. The first day was highlighted by sessions on leadership, training, and management. I think everyone wanted a bit more animation from the conference.





Indeed it is hard to think of a more pressing issue facing the global surgical community, or the global health community…there is a global shortage of 4.2 million health workers and one million in Africa; and Africa bears 25% of the global burden of disease with only 2% of the world's workforce...for surgery the numbers are also quite extreme but poorly understood due to a lack of research. The problem isn't just shortages of surgeons, but also nurses, anesthetists, and overall neglected health infrastructure.





Nonetheless...several issues predictably came up repeatedly…organizations focusing exclusively on infectious diseases (primarily HIV) pointed out that all the resources for these specific initiatives would improve health systems, while others questioned whether more benefit may be gained by allocating more from these vertical initiatives to health systems…the head of the Global Fund for AIDS TB and malaria indicated that in this next round of the fund for HIV TB and malaria they really want proposals to strengthen health systems. I think for those of us working on other aspects of health systems it would be good to see evidence for the impact of these funds and programs on health systems more broadly—that evidence currently seems lacking. Being biased on the surgical-essential health services sides its hard to appreciate these effects in the hospitals and clinics we have been working in here.





Several of us went to the breakout session on training. A major focus that is relevant to surgery and anesthesia is the role of "task shifting." Its exact definition even, and role are really still being defined...the WHO even now has new policies and programs around this. There was quite a bit of debate about the term "mid-level provider" and "non-physician clinician"...some felt that this term was quite derogatory and pointed to excessive hierarchy when we should all be working as a "team" in health care...others pointed out that plain and simple, some people train longer and have a more specialized set of skills, and that’s the frank reality…





Whatever term you decide you want to use, the "mid-level provider" or "non-physician clinican" is being used quite extensively across sub-Saharan Africa (see Mullan et al Lancet for a review in 47 countries)...one presentation from Malawi echoed their recent publication basically saying that non-physicians are doing C Sections and even more complex obstetric procedures and that their outcomes are similar to physicians. In India there has been a new cadre created to train “rural doctors” in emergency surgery and other essential skills. This presenter stressed that doctors wont work in rural areas and people die as a result.





Others were concerned about quality of care that would be provided by these cadres, and the real need for them. Some argued that in their countries, rather than creating new cadres, what is needed is more effort to appropriate incentives for rural service delivery, and focusing on recruitment and retention...or, in addition, a major problem is that there are many trained personnel who surprisingly are not absorbed into the system—ie they cannot be hired or have "jobs" created for them, so this should be the focus. Surveys in Ethiopia have shown that with salary increases and improved accommodation, a much larger number of doctors would be willing to serve in rural areas.







10 key facts reviewed at the Forum were:





Fact 1 - Health workers work


Health workers are people whose main activities enhance health. They include health care providers and people who manage and support delivery systems. Worldwide, there are 59.8 million health workers. Without them, prevention and treatment of disease and advances in health care would not reach those in need.





Fact 2 - Shortage of health workers


In 2006, WHO stated that a country with less than 2.3 doctors, nurses and midwives per 100,000 people is undergoing a critical health worker shortage. This is the case in 57 countries (36 of which are in sub-Saharan Africa).





Fact 3


One million health workers missing in Africa The global health worker shortfall is over 4.2 million, with 1 million health workers needed for Africa alone.






Fact 4



Sub-Saharan Africa has 25% of the global disease burden Sub-Saharan Africa faces the greatest challenges. It has 11% of the world's population and carries 25% of the global disease burden. Yet the region has only 3% of the global health workforce and accounts for less than 1% of health expenditures worldwide.







Fact 5



Americas have 10% of the global disease burden In comparison, North America and South America, which together have 14% of the world's population but only 10% of the global disease burden, employ 37% of the global health workforce and are responsible for over 50% of the global health expenditure.







Fact 6 - Pandemics



Many factors have led to the health workforce crisis, including growing economic disparities between countries and upsurges in new and old pandemics. Such pandemics pose special challenges to workers; for example, HIV/AIDS is a 'triple threat' to health workers, causing far bigger workloads, psychological stress, and the daily risk of HIV infection.







Fact 7 - Innovative trainings



Training a nurse takes at least three years; training a doctor can take more than six. If action to expand the health workforce is taken now, effects will only begin to be felt years later. Innovative methods (distance learning, task shifting or community health worker programmes) can shorten this delay effect, but there is no "quick fix" to this problem.







Fact 8 - Migration



Health worker migration is increasing due to disparities in working conditions, wages and career opportunities. One in four doctors and one in 20 nurses trained in Africa later migrate to work in more developed countries. In Africa and some Asian countries, a public sector physician's monthly wage can be less than US$ 100; in higher resource countries, monthly salaries can exceed US$ 14 000.







Fact 9 - Funding



WHO estimates that a rapid health workforce scale-up by 2015 would cost US$ 447 million on average per country per year. WHO advocates for 25% of the US$ 12 billion (2004 figure) devoted to international health aid to be spent on the health workforce.







Fact 10



Global Health Workforce Alliance The health workforce issue crosses many sectors - no single entity can successfully address it on its own. The Global Health Workforce Alliance has brought together a coalition of health leaders, civil society and workers to explore solutions to this crisis at the first Global Forum on Human Resources for Health in Kampala, Uganda in March 2008.









At the conclusion of the conference, the "Kampala Declaration" was adopted…it can be viewed at http://www.who.int/workforcealliance/forum/2_declaration_final.pdf







It is good to see more attention paid to the needs of health workers and the workforce worldwide...the goals are very much in line with everything we are trying to do. It was refreshing at the meeting to meet many people who are working on so many other conditions besides the infectious diseases that have been the focus of most international donor efforts---there is such a need for greater coordination, and we are working on that.

Advanced Trauma Care Course

Reflecting on my call nights in the casualty (emergency) department of Mulago over the past four years I can recall countless times I ran through the ABCs of resuscitation or followed through an ATLS algorithm in my head. During most of these occasions I was simultaneously reviewing the approach with Ugandan residents and students and realizing the lack of a more organized trauma training and certification here is a significant but addressable problem.





The residents here at Makerere are the frontlines for trauma care not only at Mulago but in the community as well. As enhancing workforce training is a primary goal of GPAS, we have just completed a pilot course in advanced trauma care here at Mulago.





Injury and trauma contribute to a huge burden of disease here and in other developing countries. The development of trauma systems has been shown to decrease medically preventable deaths in injured patients by as much as 50%. One of the essential elements of trauma systems is the capacity of providers to approach injured patients with the required skills to evaluate and treat these patients.





In collaboration with GPAS, the departments of Surgery, Orthopedics, and Anesthesia here at Makerere University offered an “Advanced Trauma Care” course on February 28 and 29th, 2008. The topics and content were adapted from the similar ATLS course offered by the American College of Surgeons. The faculty here had not previously run a similar course themselves, and it was quite well received by the students, all residents in orthopedics, general surgery, and anesthesia—25 in total. Materials provided by GPAS as well as by www.trauma.org proved to be very helpful in course design and evaluation.





The formal ATLS course includes quite a few algorithms that require technology simply not available here. Therefore the faculty here modified most of the basic ATLS course to fit the context that is readily available in Uganda. The introduction of the ATLS course proper in developing countries has been previously studied—though quite some time ago—and showed a 50% decline in mortality after the introduction of the course (Ali et al. 1993 in Trinidad). A number of modified ATLS courses are available, one that is being used in more rural areas and district hospitals in Africa is the Primary Trauma Care course (see Wilkinson et al. Anesthesia 2006). After discussing with faculty leadership here and reviewing content and materials from all these courses, we came up with the course offered last week for Mulago. In the meantime, in collaboration with GPAS, the surgeons here are planning to formally apply to the ACS Committee on Trauma to support trauma training here through ATLS.





We started very early both days, and went quite late! Lectures were mixed in with practical skills sessions. Presentations were quite animated at times and refreshingly the presenters modified the “accepted doctrine of the west” to tailor to the conditions here, where every form of resource is just more scarce. One of the highlights was having such close collaboration between all the departments of surgery, anesthesia, orthopedics, and obstetrics. Despite resource limitations, the basic approach and principles to identifying and treating life-threatening injuries was stressed.





We are in the process of conducting formal evaluations of the course as well as assessing its impact on patient care. The hospital leadership is making a commitment to ensuring the provision of essential supplies and equipment so that the skills gained by the students can be maximized in patient care.





We hope this course can lay the foundation for other similar courses that can be run here locally—but will need more resources to do so! It cost about $1500 to run, so we will be trying to procure resources to keep it going. Hopefully we can raise independent funding with matching or partial support from the hospital. In the coming weeks we are planning to create an online teaching module containing resources used by GPAS at Mulago as well as resources used by other organizations for similar initiatives worldwide.

Prehospital study kicks off!

GPAS has kicked off plans for a model prehospital trauma care initiative that utilizes current informal systems already in place in Uganda and hopes to build upon previously established recommendations by the WHO and other studies.



Currently there is no public ambulance system in Kampala, so injured patients are most often brought in by police, other local government employees, or bystanders. These first-responders have no medical training and no system exists to provide them with much needed preparation.



The aims of our prehospital initiative include:
-to create an open dialogue between the relevant government and civilian organizations critical for establishing an effective prehospital system

-to provide pilot, first-responder training courses, and distribute cost-effective, practical first aid kits to participants

-to monitor outcomes through emergency admission logs, discharge records, and field surveys

-to tailor the training courses as needed for expansion

-to encourage allocation of resources by local government and to devise novel incentive tools such as certification placards for taxi drivers



On March 11, we helped coordinate a stakeholders meeting between the Injury Center Uganda, the police, the Taxi Drivers Association, Makerere Medical School, Mulago hospital, and representatives from the City Council Health Department in Kampala.



This was the first time these key players had come together to address this issue.



Recognizing the impossibility of creating a de novo prehospital system without a significant if not primary role being played by the local government, everyone was extremely pleased by the attendance and enthusiastic dialog at the stakeholders meeting.



Establishing this open communication and coordination was the first step of our intiative, for which GPAS has received preliminary funding to pursue.



The next phase of the study will be training courses offered in May 2008 that will train ~150 police officers, 50 taxi operators, and 50 local government officials. The pilot course will be offered in select areas of Kampala in order to facilitate timely outcome measurements and monitoring during the study period.



In the coming months we have a lot of preparation to do, but are encouraged not only by the local support here but also by interest expressed by numerous medical/public health professionals around the world.



If you are interested in contributing time or other resources to this GPAS initiative, then please contact us at partners@globalpas.org

Surgical Outreach to Kapchorwa, Uganda

On Feb 18th, 2008, a group of surgeons from UCSF, including Dr. Doruk Ozgediz (Asst. Adjunct Professor of Surgery), Dr. Alexander Ayzengart (PGY4 in General Surgery), and Paul Shen (MS IV), embarked on a surgical outreach visit organized by the African Medical and Research Foundation (AMREF). The initial invitation came courtesy of Dr. Jane Fualal, a consultant faculty general surgeon and endocrine surgery specialist at the Mulago Hospital in Kampala, Uganda. We were to accompany Dr. Fualal to the district hospital of Kapchorwa, located in a small village in the valley of Mt. Elgon on the eastern border of Uganda. Dr Fualal had made multiple prior visits to this remote hospital and had excellent working relationships with the hospital staff.

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At the time of this invitation, our group was actively involved in teaching, patient care, and collaborative research projects with the Department of Surgery at the Mulago Hospital. Due to the gradually strengthening bond between the faculty and residents from our two departments, the degree of our involvement went far beyond mere short medical volunteerism and, over time, has developed into a long-term collaboration. Needless to say, we were happy to contribute to this growing relationship in yet another way.

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On the day of our departure to Kapchorwa, and not knowing what to expect on site, we collected a few boxes of medical and surgical supplies, piled everything into a large mini-van, and headed out to meet Dr. Fualal at the district hospital. After 6 hours of bouncing around on the rural roads of Uganda (imagine potholes sprouting bigger potholes!), we were being greeted by dozens of patients, curious on-lookers, and members of the operating theater staff. However, our meet and greet was short lived, as we were scrubbing on our first case within an hour of arrival. Dr. Fualal, who arrived in Kapchorwa by plane a few hours ahead of us, has been busy evaluating and triaging many patients lining the halls of the hospital, in order to create a manageable operating plan.

Within the span of 2.5 days, we performed close to 25 operations - all under the conditions rivaling the most hardened of any surgical field hospital, where the lack of running water, working surgical lights, and functioning instruments created an additional element of difficulty. Most of the procedures consisted of subtotal and partial thyroidectomies, aimed at providing relief to the patients with gigantic goiters that developed due to widespread iodine deficiency. However, since surgical care has always been hard to come by in many district hospitals of Uganda, and Kapchorwa was no exception to this rule, our operative log covered a multitude of problems that required surgical intervention (anything from large salivary gland tumors to chronic appendicitis).

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True to the surgical etiquette practiced worldwide, we made it a point to see all of our patients after each operative day. Despite all of the challenges mentioned above, most operations went as smoothly as expected, with all patients doing well on their 1st postoperative day. Just imagine stepping into a large room full of people that are gingerly nursing their neck dressings and actively sharing their experiences and worries with any neighbor willing to listen! This was one of the many cultural differences that stirred and shocked our senses on the daily basis while in Uganda.

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So, was it all work and no fun, all the time? Of course not! At the end of our stay in Kapchorwa, we found a little free time to visit the valley of Mt. Elgon and to track on foot to the top of Sipi falls. It is difficult to do justice to the beauty of Uganda's countryside in mere words... let me direct you to our photo section, so you can judge for yourself!

Take care, Alex Ayzengart.