Scaling up Access to Emergency Surgery in Uganda: Meeting the Human Resource Gap
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Transcript of Scaling up Access to Emergency Surgery in Uganda: Meeting the Human Resource Gap
Scaling up Access to Scaling up Access to Emergency Surgery in Emergency Surgery in Uganda: Meeting the Uganda: Meeting the
Human Resource GapHuman Resource Gap
Doruk Ozgediz, MD MScDoruk Ozgediz, MD MSc11, Olga Bornemisza MSc, Olga Bornemisza MSc22, , Charles Hongoro PhDCharles Hongoro PhD22, Jackson Amone MD MSc, Jackson Amone MD MSc33, ,
Diana Farmer MDDiana Farmer MD33, Haile Debas MD, Haile Debas MD33
11 Global Health Sciences and the Department of Surgery, UCSF Global Health Sciences and the Department of Surgery, UCSF22 Health Policy Unit, London School of Hygiene and Tropical Medicine Health Policy Unit, London School of Hygiene and Tropical Medicine33 Department of Clinical Services, Ministry of Health, Republic of Uganda Department of Clinical Services, Ministry of Health, Republic of Uganda
Surgery in Developing CountriesSurgery in Developing Countries
90% of global surgical need90% of global surgical need• Poor access to carePoor access to care
50% of Global Burden of Disease50% of Global Burden of Disease
Cost-effectivenessCost-effectiveness• Emergency Obstetric CareEmergency Obstetric Care• TraumaTrauma• CataractsCataracts
Uganda: Health CareUganda: Health Care
25 million population25 million population 80-90% rural, hard to reach areas80-90% rural, hard to reach areas Total Health expenditure/capita $18Total Health expenditure/capita $18
• WHO $34/capitaWHO $34/capita• USA $5000/capitaUSA $5000/capita
Declining HIV prevalenceDeclining HIV prevalence Conflict in the north: 2 million IDP’sConflict in the north: 2 million IDP’s
Health Systems/Services Research:Health Systems/Services Research:An Economic ModelAn Economic Model
SupplySupply• Human ResourcesHuman Resources• InfrastructureInfrastructure
DemandDemand• Transport costTransport cost• GenderGender• Cultural beliefsCultural beliefs
New Policy: Emergency Surgery in New Policy: Emergency Surgery in Ugandan Subdistricts Ugandan Subdistricts
DecentralizationDecentralization• National Health Policy (1999)National Health Policy (1999)
214 Health Subdistricts214 Health Subdistricts• 139 (65%) HC4’s required upgrading139 (65%) HC4’s required upgrading
Equity: “Services closer to the people”Equity: “Services closer to the people”• Emergency Obstetric Care and MDG’sEmergency Obstetric Care and MDG’s• TraumaTrauma
Cost-effective?Cost-effective?
Uganda Health Infrastructure
Health UnitHealth Unit LocationLocation PopulationPopulation
HC IHC I VillageVillage 10001000
HC IIHC II ParishParish 50005000
HC IIIHC III Sub-CountySub-County 20,00020,000
HC4HC4 CountyCounty 100,000100,000
District HospitalDistrict Hospital DistrictDistrict 100,000 to 1 million100,000 to 1 million
Regional Referral Regional Referral HospitalHospital
Region (3-5 Districts)Region (3-5 Districts) 1-2 million1-2 million
National Referral National Referral HospitalHospital
NationalNational Over 20 millionOver 20 million
HypothesisHypothesis
There are significant human resource There are significant human resource constraints to scaling up surgery at constraints to scaling up surgery at the subdistrict level in Ugandathe subdistrict level in Uganda
MethodsMethods
Literature reviewLiterature review
Semi-structured in-depth interviewsSemi-structured in-depth interviews• Thematic analysisThematic analysis
Site visitsSite visits
Results: SurgicalResults: SurgicalWorkforce ConstraintsWorkforce Constraints
StaffingStaffing• ProductionProduction• MigrationMigration
SkillsSkills• ClinicalClinical• ManagementManagement
SolutionsSolutions
Staffing: ProductionStaffing: Production
150 physicians/year150 physicians/year
MD:population ratio 1: 12-25,000MD:population ratio 1: 12-25,000
100 general surgeons/total; 20 100 general surgeons/total; 20 orthopedicorthopedic
26% of HC4 no medical officer26% of HC4 no medical officer• Solution: Surgical paramedicsSolution: Surgical paramedics
Staffing: MigrationStaffing: Migration
Brain drain: 30% of new doctors Brain drain: 30% of new doctors migrate abroadmigrate abroad
• Solution: Improved paySolution: Improved pay
• Solution: Develop research/training Solution: Develop research/training capacitycapacity
Clinical SkillsClinical Skills
Young physicians out of internshipYoung physicians out of internship• Solution: Senior staffSolution: Senior staff
Not enough training or regularity of Not enough training or regularity of practicepractice• Solution: Surgical campsSolution: Surgical camps• Solution: Integrating ES curriculum or Solution: Integrating ES curriculum or
rural surgery curriculum into trainingrural surgery curriculum into training
Management SkillsManagement Skills
Budgets, Admin, SupervisionBudgets, Admin, Supervision• Solution: separate cadreSolution: separate cadre
Overwhelm clinical responsibilitiesOverwhelm clinical responsibilities• Solution: second medical officerSolution: second medical officer• Solution: shifting personnel from Solution: shifting personnel from
hospitalshospitals
Conclusions and Areas ofConclusions and Areas ofFurther ResearchFurther Research
Multi-level HR constraintsMulti-level HR constraints• Evidence base of strategiesEvidence base of strategies
Training, Distribution of ManpowerTraining, Distribution of Manpower Decentralization with limited resourcesDecentralization with limited resources
• Cost-effectiveness vs. equityCost-effectiveness vs. equity
Consider integration of trauma Consider integration of trauma training with emergency surgerytraining with emergency surgery
Surgery/Trauma care as an essential Surgery/Trauma care as an essential population-based interventionpopulation-based intervention
Thank YouThank You