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Innovation and clinical specialities: surgery
example the closed management of fractures and dislocations,
skeletal traction for fractures, irrigation and debridement for open
fractures and infections (osteomyelitis, septic arthritis),
amputations, and manipulation and casting for clubfoot. The
challenge lies in teaching safe and reliable methods that have often
been displaced by higher cost technologies, while maintaining
similar outcomes. Another consideration is whether some of these
technological advances may be adapted through low cost
production and dissemination in LMICs 26-40 . The “SIGN”
intramedullary nailing system for femur and tibia fractures is one
example, although the implants are currently exported free of
charge to low income countries, rather than being produced
locally 41 . However, surgical complications from nailing fractures
that were before successfully treated conservatively by traction or
other means will need to be monitored. Another example of a low
cost, transferable technology is the Ponseti method for clubfoot
care, which relies upon serial casting followed by a minor surgical
procedure (heelcord release) and then a long-term splinting 42-45 .
While the method was developed in a high-income country (USA),
excellent results have been achieved in several LMICs, even in
patients up to 6 years of age 42 . The treatment may be delivered by
nonmedical personnel, for example by orthopaedic clinical officers
in Malawi or physiotherapists in Nepal 42-44 .
Establishing and maintaining adequate capacity at the facilities
level must begin with a situational analysis of all district level health
facilities, to obtain a baseline and inform health planners as to
which improvements are required. Furthermore, a mechanism for
monitoring of capacity would be invaluable to ministries of health,
and would contribute to strengthening each health information
system. An example is the Service Availability Mapping (SAM)
technology developed by the World Health Organization
(WHO) 46,48 . Both district level and facilities based questionnaires are
utilized, and health workers enter information into personal digital
assistants (PDAs), and also record the location with a global
positioning system device (GPS). The data is then processed
(digital maps, graphs, etc.) and can be disseminated to help
inform decision making and the development of health care
policies. Mapping has been carried out in Tanzania 48 , Uganda,
Albania, Rwanda, Kenya, and Zambia. Recently, a surgical
questionnaire has been incorporated into this methodology, and a
pilot project has been initiated in Mongolia in collaboration with the
WHO and the ministry of health. Monitoring the capacity to deliver
facilities based health services such as surgery will enhance the
delivery of services. There is also the need to define the unmet
need for surgical services at the population level, which will require
community based surveys. This additional information will help
prioritize services, and guide local allocation of resources.
Once the capacity to provide basic orthopaedic and surgical
services is available, trained health workers must be available to
deliver the services. While only 10% of the world’s burden of
disease is found in the Americas, this region has 37% of the global
health work force and accounts for 50% of the world’s health
spending 49 . In stark contrast, Sub Saharan Africa must utilize 3%
of the world’s health work force to tackle 24% of the global
disease burden, and accounts for less than 1% of the world’s
health spending 49 . Brain drain has been an enormous problem,
with workers migrating both between and within (rural to urban)
countries 49-57 . There is a critical shortage of health workers in 57
countries worldwide (36 in Africa) 49 . Common problems impacting
health worker satisfaction include a lack of materials, inadequate
salary, inadequate training or lack of supportive supervision, poor
working conditions, inadequate living conditions, and inadequate
professional recognition 50 . Other factors may include better
opportunities in the private sector, with non-governmental
organizations, and in other countries. A nationwide survey in
Uganda demonstrated that less than 50% of health workers were
satisfied, and more than 50% of physicians would prefer to
emmigrate 51 . A mixture of both financial and non-financial
incentives must be provided in order to retain health workers.
There will never be enough surgeons to staff even the tertiary
facilities in LMICs, let alone primary health care facilities, for
decades to come. A recent report from Sierra Leone documented
only 10 trained surgeons for a population of 5.3 million 25 . Any
approach to human resources must strongly consider task shifting
as a means to provide the necessary number of surgical
caregivers, at least over the short term 58-75 . While there remains
some controversy regarding the use of non-physician clinicians,
especially for surgery, these health workers may be found in at
least 25 of 47 Sub Saharan African countries 58 . While the training
is shorter and less costly than for physicians (and is based on the
local disease burden), the curriculum and scope of practice have
not been standardized. Non-physician caregivers perform
selected surgical services in Ethiopia, Angola, Ghana, Kenya,
Mozambique, Tanzania, Malawi, and Uganda. Several reports
have suggested that alternate cadres of health worker can safely
and successfully perform caesarian section, as evidenced in
Mozambique, Malawi and Tanzania 61-64 . Orthopaedic services have
been shiften to non-surgeons effectively in Uganda and Malawi 65-
67
. Malawi has nine orthopaedic surgeons for a population of
approximately 27 million, and Orthopaedic Clinical Officers (OCO)
provide all of the district hospital level orthopaedic services for the
country, under remote supervision from the few orthopaedic
surgeons 65,66 . A diploma is offered after eighteen months of
training, and core competencies include the treatment of
musculoskeletal infections, burns, clubfoot, fractures and
dislocations, and amputations 66 . Of 117 caregivers trained in this
programme, only 11% have retired or relocated 66 . Uganda also
utilizes 200 orthopaedic officers, as only 23 orthopaedic surgeons
are available for a population of 28 million 67 . Another approach is
the training of a “rural surgeon”; a pilot project has been initiated
in India, and medical school graduates enroll in a 3 year training
programme which focuses on competency in a finite number of
common surgical procedures drawn from all of the surgical
subspecialties, adapted to the local disease burden 74,75 . These
individuals are typically recruited from a rural environment, and
plan to practice in a rural environment. Further study will be
required to evaluate the utility of this approach.
Integration of surgical services in primary healthcare
reforms
The most recent World Health Report 23 focuses on how primary
health care reforms may strengthen health systems and provide
universal access to quality health services. Within this scheme, the
primary care team serves to coordinate the delivery of health
services, directly interfacing with communities and individuals.
Despite the emphasis on primary care and preventive medicine,
and the suggestion that hospital based services should be
reduced, surgical care is recognized as an important component
Hospital and Healthcare Innovation Book 2009/2010 113