https://globalhealth.duke.edu/sites/default/files/event-attachments/2.18_meara.pdf

Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development

Background

Surgical disease is inadequately addressed globally, and emergency conditions requiring surgery contribute substantially to the global disease burden.



Methods

This was a review of studies that contributed to define the population-based health burden of emergency surgical conditions (excluding trauma and obstetrics) and the status of available capacity to address this burden. Further data were retrieved from the Global Burden of Disease Study 2010 and the University of Washington's Institute for Health Metrics and Evaluation online data.



Results

In the index year of 2010, there were 896 000 deaths, 20 million years of life lost and 25 million disability-adjusted life-years from 11 emergency general surgical conditions reported individually in the Global Burden of Disease Study. The most common cause of death was complicated peptic ulcer disease, followed by aortic aneurysm, bowel obstruction, biliary disease, mesenteric ischaemia, peripheral vascular disease, abscess and soft tissue infections, and appendicitis. The mortality rate was higher in high-income countries (HICs) than in low- and middle-income countries (LMICs) (24·3 versus 10·6 deaths per 100 000 inhabitants respectively), primarily owing to a higher rate of vascular disease in HICs. However, because of the much larger population, 70 per cent of deaths occurred in LMICs. Deaths from vascular disease rose from 15 to 25 per cent of surgical emergency-related deaths in LMICs (from 1990 to 2010). Surgical capacity to address this burden is suboptimal in LMICs, with fewer than one operating theatre per 100 000 inhabitants in many LMICs, whereas some HICs have more than 14 per 100 000 inhabitants.



Conclusion

The global burden of surgical emergencies is described insufficiently. The bare estimates indicate a tremendous health burden. LMICs carry the majority of emergency conditions; in these countries the pattern of surgical disease is changing and capacity to deal with the problem is inadequate. The data presented in this study will be useful for both the surgical and public health communities to plan a more adequate response.

Global disease burden of conditions requiring emergency surgery

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(10)60392-3.pdf

Global operating theatre distribution and pulse oximetry supply: an estimation from reported data

Hypothesis Lack of access to surgical care is a public health crisis in developing countries. There are few data that describe a nation's ability to provide surgical care. This study combines information quantifying the infrastructure, human resources, interventions (ie, procedures), emergency equipment and supplies for resuscitation, and surgical procedures offered at many government hospitals in Sierra Leone. Setting Site visits were performed in 2008 at 10 of the 17 government civilian hospitals in Sierra Leone. Main Outcome Measures The World Health Organization's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was used to assess surgical capacity. Results There was a paucity of electricity, running water, oxygen, and fuel at the government hospitals in Sierra Leone. There were only 10 Sierra Leonean surgeons practicing in the surveyed government hospitals. Many procedures performed at most of the hospitals were cesarean sections, hernia repairs, and appendectomies. There were few supplies at any of the hospitals, forcing patients to provide their own. There was a disparity between conditions at the government hospitals and those at the private and mission hospitals. Conclusion There are severe shortages in all aspects of infrastructure, personnel, and supplies required for delivering surgical care in Sierra Leone. While it will be difficult to improve the infrastructure of government hospitals, training additional personnel to deliver safe surgical care is possible. The situational analysis tool is a valuable mechanism to quantify a nation's surgical capacity. It provides the background data that have been lacking in the discussion of surgery as a public health problem and will assist in gauging the effectiveness of interventions to improve surgical infrastructure and care.

https://www.who.int/surgery/QuantifyingSurgicalCapacity_ArchSurg.pdf

Quantifying Surgical Capacity in Sierra Leone: A Guide for Improving Surgical Care

Introduction
The global surgery workforce is in crisis in many low- and middle-income countries (LMICs). The shortage of surgery, obstetrics, and anesthesia providers is an important cause of the unmet need for surgical care in LMICs. The goal of this paper is to summarize the available literature about surgical physicians in LMICs and to describe ongoing initiatives to supplement the existing surgical workforce data.

Shortage of doctors, shortage of data: a review of the global surgery, obstetrics, and anesthesia workforce literature.

Africa’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. This 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. Uganda 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. The 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.

https://www.globalsurgery.org/documents/WSJsurg.pdf

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

Africa's neglected surgical workforce crisis.

MEPI by OGAC; 
National Institutes of Health (NIH); 
Health Resources and Service Administration (HRSA).

A consortium approach to competency‑based undergraduate medical education in Uganda: Process, opportunities and challenges.

Globally, the role of universities as providers of research education in addition to leading in main - stream research is gaining more importance with demand for evidence based practices. This paper describes the effect of various students and faculty authoring partnerships on the use of the IMRAD style of writing for a university student journal. This was an audit of the Makerere University Students' Journal publications over an 18-year period. Details of the authors' affiliation, year of publication, composition of the authoring teams and use of IMRAD formatting were noted. Data analysis gave results summarised as frequencies and, effect sizes from correlations and the non parametric test. There were 209 articles found with the earliest from 1990 to latest in 2007 of which 48.3% were authored by faculty only teams, 41.1% were authored by student only teams, 6.2% were authored by students and faculty teams, and 4.3% had no contribution from the above mentioned teams. There were significant correlations between the different teams and the years of the publication (r
 s
 = -0.338 p < 0.01 one tailed). Use of the IMRAD formatting was significantly affected by the composition of the teams (Χ2 (2df) = 25.621, p < 0.01) especially when comparing the student only teams to the faculty only teams. (U = 3165 r = - 0.289). There was a significant trend towards student only teams over the years sampled. (z = -4.764, r = -0.34). In the surveyed publications, there was evidence of reduced faculty student authoring teams as evidenced by the trends towards students only authoring teams and reduced use of IMRAD formatting in articles published in the students' journal. Since the university is expected to lead in teaching of research, there is need for increased support for undergraduate research, as a starting point for research education.

/pdf/the-introduction-methods-results-and-discussion-imrad-l11cpb1cup.pdf

The introduction, methods, results and discussion (IMRAD) structure: a Survey of its use in different authoring partnerships in a students' journal

Context and setting Uganda is one of the world’s least developed countries. Makerere Medical School has neither an equipped skills laboratory nor designated trained personnel for teaching clinical skills. Makerere lacks the funds to construct and equip a skills laboratory and train the trainers. Training of clinical skills to medical students has been implemented traditionally during the clinical clerkships in Uganda. In 2003–04 a problem-based learning (PBL), student-centred medical undergraduate curriculum was introduced with the stated goal of early clinical exposure and training of clinical skills. Why the idea was necessary Early introduction of clinical skills was viewed to be beneficial, as these skills may take a significant time to develop. Moreover, early introduction of these skills would probably facilitate the integration of clinical and basic science knowledge. The objectives of the training were to develop competency in communication and history taking, as well as procurement of vital signs. What was done? A clinical skills training curriculum was developed through a number of meetings, and consultation workshops with institutional leaders and faculty. At these forums, consensus was reached regarding the objectives, format and content of the curriculum in order to match and maintain relevance between PBL cases and the skills training curriculum. Initial implementation of the clinical skills training took place during the 2nd semester of 2004. Students in the 1st and 2nd years received 2 clinical skills training sessions of 2 hour each over a period of 15 weeks; 1st-year skills in interpersonal communication and vital signs were taught using mini-lectures, demonstrations and role play, and 2nd-year skills covered interpersonal communication and general history-taking procedures. Teachers demonstrated skills to students, who in turn performed the procedure on their peers. A ratio of 1 teacher to 15 students was maintained. In order to determine the students’ perceptions of the programme, a questionnaire using a 5-point Likert scale was administered to 32 randomly selected 1st-year students from a population of 100. The teachers’ opinion on how to improve the curriculum and their enjoyment of the training were also elicited. Student assessment was not performed in this pilot programme, which was used to obtain data for assessment criteria. Evaluation of the results and impact All students and teachers indicated that they had enjoyed the training sessions. All the students surveyed agreed that the clinical skills programme was tailored to their knowledge level, that session objectives were clear and that teachers demonstrated the skills adequately. Students indicated concern about timely feedback, lack of equipment for learning and time for supervised practice. Faculty recommended improvement of the facilities and recruitment of more faculty to teach the course. This project demonstrated that early training in clinical skills is feasible in resource-limited environments. Moreover, training space may be upgraded as a result of the pilot.

Stephen Kijjambu

Papers

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

Africa's neglected surgical workforce crisis.

A consortium approach to competency‑based undergraduate medical education in Uganda: Process, opportunities and challenges.

The introduction, methods, results and discussion (IMRAD) structure: a Survey of its use in different authoring partnerships in a students' journal

Clinical skills training in a resource constrained medical school.