BUILDING THE NEXT GENERATION OF THE SURGICAL WORK FORCE TO MEET THE EMERGING SURGICAL CONDITIONS

Professor Pankaj G. Jani. M.Med. FRCS, FCS(ECSA)Department of Surgery, University of Nairobi. Kenyatta National HospitalChair Senate, ECSA - CHSVice President, COSECSAVice Chair Board , G4 Alliance

DJCC, Arusha 10th April. 2017

WHY SURGERY

The Next Decade should be devoted to surgery

KEY MESSAGE 1 5 Billion people lack access to:

--safe,

-- affordable surgical and

-- anesthesia care when needed (out of the 7 billion people)

KEY MESSAGE 2

143 million additional surgical procedures are needed each year

-- to save lives and prevent disability

KEY MESSAGE 3

33 million households experience catastrophic health expenditure

Paying for surgery and anaesthesia each year

KEY MESSAGE 4

Investing in surgical and anaesthesia services is affordable, saves lives and promotes economic growth

KEY MESSAGE 5

Surgery is an indivisible, indispensable part of health care

THE NEGLECTED SURGICAL PATIENT

Surgery has an image problem--- It is seen as expensive and complex

Surgery comprises multiple treatment modalities for many different diseases -- this makes it difficult to define as a cause around which people can easily uniteSurgery is perceived as peripheral to essential health care by many – members of Public to Policy makers, founders and govts.

SURGERY IMPROVES HEALTH CARE DELIVERY IN ALL ASPECTS

Surgery is an interdisciplinary speciality involving :-- Trauma - Fractures-- Obstetrics - Obst. labour-- Ophthalmology - Cataracts-- Cong. Conditions - Club foot, Cleft Lip-- Cancer - Breast and cervical Ca.-- Appendicitis and Hernias

EMERGING CONDITIONS-TRAUMA (AND C/S)

TRAUMAAccounts for more deaths that HIV, TB and Malaria combined

TRAUMA accounts for approx. 10 deaths every minute (5M/YR)

C/S accounts for approx. 1 death per Hr.

GLOBAL HEALTHRemarkable gains made in Global Health in past 25 yrs. BUT:-- Progress has not been uniform

Mortality and Morbidity from common conditions requiring Surgery have grown in LIC’s and LMIC’sDevelopment has stagnated or regressed

High level info. on benefits to the Global Economy of investing in surgical services

INVESTING IN SURGERY

• SURGERY REQUIRES A STRONG HEALTH SYSTEM TO BE DELIVERED SAFELY AND EFFECIENTLY

(A Hospital that can provide good surgical services can generally provide good other services as well)

Developing a Global Surgery Advocacy Plan

GLOBAL 4 ALLIANCE (G4A)

Global SURGERY,OBS., TRAUMA & ANAES Alliance

• Advocacy

• Policy

• Fundraising

• Implementation

THE G4 GLOBAL CONSULTATIVE PROCESS

15

Overview of the G4 Global Consultative Process

16

G4 Developing a Platform to Collect Surgical Care Data

Prof. Pankaj Jani, MBChB, MMEDVice-President COSECSA,Chair, Senate ECSA - CHSVice Chair, G4 Alliance

Why an Operative Data Platform?

VISIONARIES 0F COSECSA HAD REALISED THIS IN 1996

MILESTONES OF COSECSA

• Resolution to establish COSECA in 1999• First Council of COSECSA elected Lusaka 2002

• COSECSA integrated in ECSA-HC in 2003• First Examinations in Kampala, Uganda in 2003 at MCS level

• First Surgeons graduated in Harare in 2004• COSECSA and ASEA Merged 2007

COSECSA12 Member countries6 Satellite training countries

COSECSA COUNTRIES

12 member countries>500M Pop

SATELITE COUNTRIES – NIGER, CAMEROON, GABON, LESOTHO, SOMALILAND, DRC.

MISSION OF COSECSA

The Mission ofCOSECSA is:To promote access to and excellence in Surgical Care, Training and Research.

ORIGINS OF COSECSA

• The Fellows of Association of Surgeons of East Africa (ASEA) whose long-term commitment was to:

• Promote surgical access, excellence• Provide training• Support surgical care givers through Fellowship

• The Ministers of Health in ECSA-HC for the Vision of the Need for a College of Medicine in the Region

HOW HAVE THESE ACHIEVEMENTS BEEN MADE?

• COSECSA is a “College without Walls”• We use national resources to train:

• Established training institutions• Health care delivery institutions• Practitioners and employed educators deliver training• Trainees are employees engaged by health delivery systems

• The whole country is a training ground• Students do not need to be translocated in order to train

WHAT QUALIFICATIONS DOES COSECSA OFFER?

• Membership of the College• MCS• Not a registrable professional qualification• 2 years of training after internship

• Fellowship• FCS in a speciality• 3 years training

RELATIONSHIP WITH COUNTRY SURGICAL SOCIETIES

•COSECSA works through the Country Chapters

•Each surgical society is the Country Chapter• Therefore the Country Chapters are the face of COSECSA in

each country.

•The two country representatives on Council are the link between COSECSA and the Country surgical society

MCS

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016MCS 7 8 9 10 7 11 11 12 16 19 35 29 38 43

7 8 9 107

11 11 1216

19

35

29

38

43

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5

10

15

20

25

30

35

40

45

50

MCS Expon. (MCS) Expon. (MCS)

FCS (2004 – 4; 2016 – 47)

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2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

NUMBER OF SURGEONS IN ECSA COUNTRIESCountry Population (m) Surgeon per

20000 population

Present

Kenya 45 2250 515(23%) 25Uganda 36 1800 235(13) 15Tanzania 50 2500 165(6.6%) 7Zambia 15 750 75(10%) 10Zimbabwe 14 700 131(19%) 20Malawi 17 850 32(3.7%) 5Ethiopia 97 4850 315(6.5%) 7Mozambique 25 1250 60(4.8%) 5Rwanda 12 600 57(9.5%) 10RWANDA 11 500 27 (4.1%)5Burundi 10 500 19(4%) 5

DISTRIBUTION OF SURGEONS IN THE ECSA REGION

85 % of the Surgeons serve 15% of the urban population

SURGICAL WORKFORCE NUMBERS – 10 COUNTRIES

• Total number of surgeons and trainees in ECSA Region approx. – 2400

• Total number of surgeons trained by COSECSA (206) and trainees (400) in COSECSA – 600--Today approx. 25% of the Surgical force in the ECSA region is from

COSECSA

• 50% of ALL Surgical trainees in the ECSA region are COSECSA Trainees

PROGRESS

• E-Registration

• E-Learning

• E-Log Book

• E-CPD (in –progress)

E-LOGBOOK

• Launched Feb 2015• Developed collaboratively by

COSECSA and RCSI• Mobile optimised• Easy to use• Nearly 50,000 operations

logged• Generates consolidation

sheets, print outs

Abou

THE EMERGING SURGICAL CONDITIONS

MOST COMMON OPERATIONS -OVERALL

Data

1 Wound - debridement / haematoma / delayed closure 1719

2 Hernia inguinal - adult 1468

3 Appendicectomy 1236

4 Laparotomy (no other procedure) 1037

5 Diaphyseal femur fracture intramedullary nailing 989

6 Excision of skin lesion, closure 868

7 Drainage of superficial abscess 844

8 Breast lump - excision 597

9 Hernia abdominal wall 563

10 Caesarian section 538

EXTRACT FROM MCS CONSOLIDATION SHEET

Data

SKILLS LAB

E-LEARNING

WHAT IS NEEDED (IS SURGEONS TO PROVIDE EM. AND ESS. SX)

3 SURGEONS per DISTRICT HOSPITAL (Em. & Ess. Care)

WHAT IS THE GAP IN NUMBER OF SURGEONS.

• Kenya – 257 D.H. – Needed approx. 771 Surgeons

• Zambia – 85 D.H. – Needed approx. 255 Surgeons

• Malawi - 28 D.H. – Needed approx. 84 Surgeons

(Existing surgeons are and will mainly work in Urban areas)

COSECSA SCALE UP OF TRAININGCOUNTRY POP. (M) NO. OF

DISTRICT HOSPITALS

HOSPITALS REQUIRED IF SERVING 200,000 POP.

TOTAL NO. OF SURGs. REQUIRED IN 10 YRS (3/DH)

SURGs. REQUIRED PER YEAR

TRAINING HOSPITALS REQUIRED (4 SURGs./ YEAR)

HOSPITALS THAT CAN TRAIN

NO. OF DR.’S GRADUATING

NO. OF DR.’S GRADUATING TO DO SURGERY

GENERAL SURGEONS PRESENT

1. KENYA 45 257 225 771 77 19 24 750 10% 515

2. ZAMBIA 14 85 70 255 26 7 13 200 15% 75

3. RWANDA 12 35 60** 105 11 3 4 80 15% 57

• Population: 45 M• Area: 582,000 km2

• 257 district hospitals

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Operations per 100,000 population in Kenya

KENYA - HOSPITALS THAT CAN TRAIN (NEEDS GOVT. SUPPORT TO SCALE UP)

• Level 5: Hosps: KNH. MTRH + 7 Prov. Hosps. = 9• Level 5 (other): Machakos, Kisii, Meru and Thika = 4• Mission : Tenwek, Kijabe, Mater, Kikuyu = 4• Private : Nairobi Hosp.; AKH, Nbi., Msa and Kisumu;

Msa. Hosp. and Pandya Hosp. Msa., M.P.Shah, Nbi. = 7

• Total = 24 Hospitals • 24 X 4 = 96 per year X 10 yrs. = 960

ACS COLLABORATION PARTNERSHIP

AM. COLL. OF SURGS. AND OGBEducational Resources and Support: We understand that there is an urgent need to scale up training of the surgical workforce and to develop a retention plan. We applaud your innovative approach to scale up training of the surgical workforce by developing a special curriculum for hospital-based surgical training. We will continue to promote volunteerism opportunities for ACS Fellows to visit some of these training sites. We are happy to share some of our on-line educational resources to assist you in your efforts. Although a few of these materials are available on-line for free, more educational materials can be made available at no cost to those surgeons who elect to become ACS Fellows. For more info about membership please visit https://www.facs.org/member-services/join

MOU: CAGS AND COSECSA

ASSA COLLABORATION PROGRAM

KENYA DIASPORA

COSECSA SCALE UP OF TRAINING

COUNTRY POP. (M)NO. OF DISTRICT HOSPITALS

HOSPITALS REQUIRED IF SERVING 200,000 POP.

TOTAL NO. OF MCS REQUIRED IN 10 YRS

MCS’S REQUIRED PER YEAR

TRAINING HOSPITALS REQUIRED (4 MCS PER YEAR)

HOSPITALS THAT CAN TRAIN

NO. OF DR.’S GRADUATING

NO. OF DR.’S GRADUATING TO DO SURGERY

GENERAL SURGEONS PRESENT

4. UGANDA 38 139 190** 105 10 14 14 200 10% 240

5. TANZANIA 48 152 250** 456 49 13 20 760 10% 165

6. ZIMBABWE 14 95 70 285 28 9 8 200 20% 131

COSECSA SCALE UP OF TRAINING

COUNTRY POP. (M)NO. OF DISTRICT HOSPITALS

HOSPITALS REQUIRED IF SERVING 200,000 POP.

TOTAL NO. OF MCS REQUIRED IN 10 YRS

MCS’S REQUIRED PER YEAR

TRAINING HOSPITALS REQUIRED (4 MCS PER YEAR)

HOSPITALS THAT CAN TRAIN

NO. OF DR.’S GRADUATING

NO. OF DR.’S GRADUATING TO DO SURGERY

GENERAL SURGEONS PRESENT

7. MALAWI 17 28 85* 84 8 4 4 80 10% 32

8. ETHIOPIA 90 215 450* 375 37 13 15 3000 2.5% 450

9. MOZAMBIQUE 24 128 120 385 38 12 3 200* 25% 60

KENYA - REALITY ON GROUND (COSECSA)Hospital Based training

• KNH -- Training 2 Per Year• MTRH -- Training 4 Per Year• Coast Gen. --- Training 4 Per Year• Kikuyu – Training 2 Per Year• Tenwek --- Training 4 Per year• Kijabe --- Training 4 Per year • Mater --- Training 2 Per year13 other hospitals awaiting accreditation

CONCLUSION• COSECSA is a unique and an incomparable regional surgical

accrediting and training college which aims to improve global outcomes through safer surgery especially in the much needed rural locations of Africa.

• Significance: The prime aim of COSECSA is to provide safer surgery mainly in the rural locations across East Central and Southern Africa and globally.

• This aim has been achieved through accreditation of training institutions, trainers and examiners together with organizing various courses, seminars, workshops, E-learning programs and examinations.

PROBLEMS TO IMPLEMENT SCALE UP

• Govts. And Med. Boards -- To realise/appreciate and assist Scale up

• Improve surgeons’ welfare so more MO’s train in surgery

• TRAINING : Int. and local Surgical Community -- READY to Assist with training thro Visiting faculty

• Skills Labs, E – Learning Programs, Etc to augment training

ASANTE SANA