GPAS Blog Posts now on the Global Health Hub

GPAS blog posts are now found at www.globalhealthhub.org

2nd Annual Conference on Surgery and Anesthesia

VANCOUVER, Canada - This past weekend the University of British Columbia's Branch for International Surgery in collaboration with GPAS and several other partners hosted the Second Annual Conference on Surgery and Anesthesia in Uganda.

This years conference picked up right where last years left off... there has been lots of great progress and brainstorming on collaboration it the mean time. A big thanks to the folks at UBC for hosting and everyone who participated.

Speakers and attendees this year included Dr. Sam Kaggwa (Head of Department of Surgery - Mulago Hospital), Dr. Angela Enright (President, World Federation of Societies of Anaesthesiologists), Dr. Sam Zaramba (Former Director of Health Services, Ministry of Health, Uganda), Dr. Tito Beyeza (Head of Makerere Department of Orthopedics), and Dr. Norgrove Penny (CBM International) among many others.

The goal of this meeting (of predominantly academic surgery and anesthesia groups) is to promote greater collaboration among those active in Uganda and to create a forum to explore and harmonize strategies for improving capacity to provide surgical services in resource-poor settings.

The four primary topics - training/research, Economics of developing a strong health system, Scalability, and Enduring partnerships - sparked lively debate and discussions throughout the day.

While a concrete set of resolutions has not yet been reached, several strategies for moving forward were suggested including:

• Creation of coordination desk in Uganda for collaborators
• Greater coordination of teaching/training visits
• Improved research training opportunities and mentorship for Ugandan faculty and trainees
• Curriculum redesign and supplementation
• Creation of a surgical disease burden / disability task force within the MOH
• Consensus guidelines for donations to Mulago surgery, anesthesia, and casualty departments
• Identifying and organizing discrete joint teaching workshops that augment current curriculum
• Lobbying MOH for MMed tuition waivers for priority positions
• Lobbying MOH for increased staff positions for postgraduates
• Identification of one rural health center as a remote teaching, training site
• Using policy and activities to discourage brain drain (ie poaching foreign medical graduates for North America)

---

Links:

• Complete conference video
  
• Online conference discussion forum
  
• Select conference presentations slides
  • Enduring Partnerships - Norgrove Penny CM, MD, FRCS
  • Task Shifting - by Shafique Pirani

---

UNAMS – GPAS Conference

By: Justin Miyamoto

The 5^th Annual UNAMS Conference, “Solutions for Healthcare in Uganda,” convened physicians, research scientists, public health officials, and representatives of several non-governmental organizations at the University of California at San Francisco, on April 24^th, 2010, to examine practical steps towards meeting the goal of increased harmonization of efforts to improve healthcare in Uganda. Conference participants and panelists dialogued on the roles of medical missions and academic collaborations, innovations to alleviate workforce shortages, and strategies collaborative healthcare initiatives.

Participants from: Ugandan North American Medical Association (UNAMS), Global Partners in Anesthesia and Surgery (GPAS), Ugandan Sustainable Trauma Orthopaedic Program (USTOP), Institute for Global Orthopaedics & Traumatology (iGOT), UCSF, University of British Columbia, MakerereMulago Hospital (Kampala, Uganda), Duke University, Association of Anaesthetists of Great Britain and Ireland (AAGBI), Brigham and Women’s Hospital, Johns Hopkins University, International Injury Research Unit (IIRU). University, Ugandan Ministry of Health,

Discussion Highlights:
Participants agreed on the importance of making harmonization and transparency a higher international priority. The challenges of improving healthcare in Uganda cannot be met without multilateral and coordinated actions.

Participants acknowledged multiple causes of the health workforce shortage. Some believed strengthening the infrastructure and financial incentives to retain physicians may be required. Others disagreed with this potential approach.

Emphasis on developing systems to accept and organize donations is an essential step to guide appropriate, cost-effective donations.

Difficulties encountered while encouraging policy change surrounding pre-hospital care were acknowledged. Lessons from other fields of medicine highlighted experience in policy change sprouting from, and advocated by Ugandan citizens/researchers.

1. How have groups looked at the utility of direct donations vs. monetary donations to seed in-country purchase of goods/services?

Some panelists highlighted experiences with unlawful confiscation of donated goods, which was felt to be a government responsibility to address. Towards issues of donation which may be addressed by internationals: Currently, there is no system to accept donations at Mulago Hospital, Uganda’s national referral hospital. As many essential medical supplies may already be in storage, there is a need to organize and catalogue what materials are already on site and which are thus, most in need. Further transparency to guide useful donations (based on power sources, cost-effective replaceable parts, and accessible user manuals) is needed. US researchers have assisted with this type of work in the past, but increased financial capital to retain already trained Ugandan biomedical engineers as suggested one long-term solution to this pressing issue.

2. What percentage of medical students who train at Makerere stay in the region after graduation? Do externally trained Ugandans return to practice?

Participants acknowledged that the official statistics state 1/3 of medical students leave Uganda after graduation. Post-residency options for surgery are less well defined than in the US, and many graduates must volunteer until the university or government comes around to providing a job. In the meantime, graduates moonlight as general practitioners or eventually, migrate for better job opportunities or compensation to Southern Sudan, Rwanda or South Africa. Panelists noted that at the district hospital level (one level below the national referral hospital), physician positions remain unfilled. Without affiliated schools or reliable utilities (electricity), it’s difficult to keep physicians on site. Some questioned if training medical assistants to do the same job could fill that gap.

3. We’ve heard that they’re aren’t enough establishment physicians in the Ugandan healthcare system. What next steps can be taken to address this, and the greater health workforce crisis in Uganda?

Experience by research groups in communicable disease, and specifically those focusing on malaria in Uganda, recognized research as a vehicle to 1) uncover data that identifies health and health workforce disparities and 2) infuse the local healthcare workforce with financial capital. Participants acknowledged that the continuous presence of their research group in Uganda engendered trust, long-term collaboration, and skills transfer on a health workforce level, and legitimacy on a national level with ministries of health. Panelists researching in pre-hospital care noted that published data on the scalability of training lay first responders do exist – at a cost of 12 cents per capita – but it has not been successful in changing pre-hospital care. Experience of the malaria group noted that effective policy change was advocated for from within, by Ugandan citizens and scientists who lead and disseminate the research themselves.

4. It seems that with some communicable diseases like TB/Malaria, the intervention is a pill. We can track that and look at outcomes. What does the data to show your “bang for the buck” with trauma care?

Trauma is a very diverse disease which makes it more difficult to measure. Although providing 1 unit of trauma care can’t be measured the same [as in communicable diseases], the 12 cents per capita estimate for the pre-hospital lay first responder program was based on how much it would cost to scale up for the city, how much running the program would cost, and how much it costs in comparable cities. Efforts to track this intervention’s effect on morbidity and mortality have proven formidable, but the group continues to think about ways to improve this data collection system.

Panelists: Cephas Mjumbi, Isabeau Walker, Kayvan Roayaie, Rick Coughlin, Piotr Blachut, Hamed Umedaly, Abdulgafoor M. Bachani, Felicia Lester, Mike Lipnick, Doruk Ozgediz, Grant Dorsey, Keita Ikeda, Adithya Cattamanchi, Fred Okuku, Paul Bollinger

Unanswered Questions…

1. How does one design academic collaborations that don't burden the resource constrained partner institution?

2. How does one promote harmonization among the various participating parties?

3. Can outside pressures force development of a healthcare system faster than a country's economy is ready to support?

4. How much data are enough data to convince the global health community to prioritize the surgical disease burden?

Post written by Justin Miyamoto:

Justin Miyamoto is a rising medical student at the University of California at San Francisco. He has a BA in Biochemistry & Labor and Workplace studies from the University of California at Los Angeles and is currently a research fellow of Global Partners in Anesthesia and Surgery (GPAS).

"Uganda: Pay Doctors Well to Stem Brain Drain"

The Ugandan Health Minister recently announced that 14 senior surgeons left Uganda last year to work in Rwanda, where salaries are reportedly several times higher, according to an editorial on allafrica.com.

Already, Uganda has a severe shortage of surgeons and cannot afford to lose more to other countries. According to the news article, fresh graduates from Uganda's medical schools can expect to earn roughly $270 a month.

While Uganda and many African countries have an immense need for additional health professionals from all backgrounds and sufficient incentives to prevent brain drain, surgery and perioperative services have been particularly neglected. There is no UNAIDS of PEPFAR for trauma care, yet injuries alone accounts for 16% of the global burden of disease. The result is a crisis in health workforce and infrastructure that needs immediate attention.

Story link:
http://allafrica.com/stories/201004070499.html

Online Global Surgery & Anesthesia Forum

"Harmonization" is the degree to which public health research or clinical activities share information and coordinate with each other to avoid duplication of efforts and maximize efficacy.

Lack of harmonization among researchers, health care workers, donors etc... poses a significant obstacle to optimizing the utilization of limited resources available for improving public health in low-income countries.

This is just as true in surgery and anesthesia as it is for other areas of global health.
The Paris Declaration (PD) (2005) and Accra Agenda for Action (AAA) (2008) outlined the critical need for higher levels of collaboration, transparency and coordination between research efforts, both at a national and international level.

There is great need for mechanisms to facilitate harmonization.

GPAS has recently began pursuing several projects in this area... more to come on those soon.

One project not created by GPAS but already out there is the ghdonline.org. You can read about the mission at www.ghdonline.org, but in essence this moderated discussion group/forum is an interesting tool that has potential to facilitate communication and collaboration among others interested in this are of global health.
The "Surgical and Anesthesia" discussion group was just launched in recent weeks. I encourage all those interested to join, contribute, and provide feedback on ways to improve the forum.

Anyone who knows of other "surgery and anesthesia" forums, other tools or even new ideas to promote harmonization, please post!