Workforce Innovations to Expand the Capacity for Surgical Services

Abstract

Surgical interventions are often considered complex procedures to be undertaken by highly trained surgeons, but such specialists are rare in many low-income countries (LICs). However, many common surgical problems in resource-limited settings do not require the intervention of specialized staff. Significant documentation demonstrates that cost-effective surgical interventions can be undertaken in LICs with the innovative use and deployment of trained staff, including emergency care for trauma and obstetrical needs. Despite this documentation, surgical workforce innovations that use nonspecialized cadres often meet with resistance from established surgeons and their professional associations. The most important barrier to the safe provision of preoperative, intraoperative, and postoperative surgical and anesthesia services in LICs is the shortage of trained staff. The well-documented reasons for this scarcity include the following (Chu and others 2009; FAIMER Institute 2008): Low number of medical school graduates. Inadequate initial and ongoing training. Poor salaries and working conditions. Inability to motivate and retain staff in remote and rural areas. Staff attrition due to retirement, death, or resignation, and the consequences of brain drain. The reluctance of governments to invest in human resources compounds the effects of these factors. Current financial constraints, such as those in Tanzania, for example, have forced governments to announce freezes in employing new human resources for health. Sub-Saharan Africa is most affected by the global shortage of human resources for health (Chankova, Muchiri, and Kombe 2009; Mills and others 2008; WHO 2006). Two countries profiled in this chapter, Mozambique and Tanzania, experienced this crisis some years ago (Liese and Dussault 2004; Mills and others 2008; Smith and Henderson-Andrade 2006). In other countries, despite years of interventions to overcome the scarcity of doctors, the shortage has worsened as the result of population growth, presenting a major challenge to the ability of these countries to achieve the health-related Millennium Development Goals (MDGs) (Anand and Barnighausen 2004; Liese and Dussault 2004) (box 17.1). Available doctors tend to concentrate and work in urban areas and in regional or even national hospitals, limiting access for rural populations, who often constitute up to 75 percent of national populations. A major reason for Sub-Saharan Africa’s high maternal mortality is that few infants are born in the presence of skilled attendants. The lack of skilled birth attendants contributes to the 5 million to 6 million maternal deaths, stillbirths, and newborn deaths each year worldwide. In 19 of the 52 Sub-Saharan African countries that reported data, fewer than 50 percent of births were attended by skilled health personnel. The World Health Organization (WHO) estimates that 80 percent of births need to be attended by an adequately equipped and skilled birth attendant to reach the fifth MDG target of reducing maternal mortality by three-quarters (UNECA, African Commission, African Development Bank, and UNDP n.d.). One colleague in Tanzania expressed his frustrations in the following way: The AIDS epidemic in Sub-Saharan Africa may have aggravated this crisis by depriving health systems of a significant proportion of their trained staff (Chen and others 2004). Sub-Saharan Africa has 11 percent of the world’s population and 24 percent of the total estimated global burden of disease; yet it has 3 percent of the global health workforce (Chen and others 2004), only a small percentage of whom are qualified surgeons. Sub-Saharan Africa has less than 1 percent of the number of surgeons that the United States has, despite having a population that is three times as large (Ozgediz, Riviello, and Rogers 2008). Expanding the human workforce is clearly essential to improving the performance of health systems (de Bertodano 2003; Chankova, Muchiri, and Kombe 2009; Liese and Dussault 2004; WHO 2000; World Bank 2004) and improving outcomes, even under difficult circumstances (Chu and others 2009; EQUINET 2007; FAIMER Institute 2008; Mills and others 2008). In Mozambique, the scarcity of human resources for health 30 years ago was alarming; the country had fewer than 5 physicians per 100,000 population. Our research estimated that there are 33 registered nurses and midwives per 100,000 population (Pereira 2010). In Tanzania, the health workforce shortage was disastrous, according to the report of the Joint Learning Initiative (Chen and others 2004). A study by the London School of Hygiene and Tropical Medicine suggests that the number of health care providers would need to increase by more than 58,000 to provide necessary interventions to meet the health-related MDGs for Tanzania (Anyangwe and Mtonga 2007). In most countries in Sub-Saharan Africa, the scarcity of human resources for health existed before independence, as a result of colonial training policies and, in some cases, the massive exodus of colonial professionals after independence (Ministry of Health, Mozambique 2008; Ozgediz and others 2008). In Mozambique, a civil war provoked by neighboring South Africa in the early 1980s worsened the situation. Both Mozambique and Tanzania suffered from the consequences of the brain drain, either externally as health professionals moved to high-income countries (HICs) or internally as they migrated from rural to urban areas (Dodani and LaPorte 2005; McKinsey and Company 2006; Mullan and Frehywot 2007).