Workforce, Training and Education Working Group

Lancet Commission on Global Surgery
Workforce, Training, and Education

Workforce, Training and Education Working Group

Work Plan

April 2014

I.Important Deadlines

II.WTE Quantitative Research Projects

A.Numbers of Surgical Health Care providers

B.Surgeon Mapping (by way of HDM group)

C. Surgeon Density

III.WTE Reporting of Current State

A.Workforce Dynamics

B.Training

C. Education

IV.WTE Case Vignettes

A.RCSI/COSECSA

B.Retention of Health Workers CWI

C. Training of Task Sharing

V.Tables and Figures

A.Comparison of training modules (surgeons and task sharers)

B.Minimal Skill Set

C.Access to surgical services

D. Surgical Migration

E.The surgical package (graphic)

F.Surgeon Density (graphic)

G. Surgeon Density (Urban vs Rural) (graphic)

VI.Papers for the Commission Appendix

A.Surgical training in South Africa

B.National density of surgical health care workers

C. Migration of surgeons worldwide.

VII.Work Plan Appendix

A.Questions sent to WACS/COSECA/Large organizational bodies

B.WTE Draft Document/Outline

C. Key papers needed to write the WTE section of commission

I. Important Deadlines

Sierra Leone Meeting: June 19-20

Deliverables
roughly 1500-word outline
topics that need to be discussed by commissioners
eg Task Sharing, university vs college model of training etc

DEADLINE: June 12, 2014

Initial Draft for Peer Review Due: September 2014

Dubai Meeting: November 2014

Second Peer Review: January 2015

II. WTE Quantitative Research Projects

Situational Analysis

Number of Surgeons, Anesthetists, OBGYN
Kathleen O’Neill in Geneva for 3 weeks to work through the WHO situational analysis data. This includes the Quick Situational Analysis Tool as well as the more comprehensive SARA tool.
Person in charge: Johanna to work with Katie to parse out pertinent data
Deadline: April 30th (rough draft) May 15th (final draft)
Lars collecting information from large organizational bodies (egISS, FIGO, WFA) re: numbers
Person in Charge: Lars
Deadline: April 30th (rough draft) May 15th (final draft)
Lund team contacting large number of national colleges to determine surgeon density
Person in Charge: Lars
Deadline: June 15th
Lars and Co. (Adam, Hampus) collecting numbers on surgical workforce migration from LICHIC
Has #surgeons from 40 HIC; proportion of those trained in LIC for about 15 countries – still collecting data
Person in Charge: Lars
Deadline:April 30th (rough draft) May 15th (final draft)
Emmanuel and Nyengo in charge of collecting answers to the questions listed in appendix from WACS and COSECSA
Person in Charge: Caris and Emmanuel
Deadline: April 30th (rough draft) May 15th (final draft)
Nivaldo collecting numbers in Brazil/Latin America
Person in Charge: Nivaldo
Deadline: April 30th (rough draft) May 15th (final draft)
Eunice Collecting data on number of health workers in Haiti
Person in Charge: Eunice
Deadline: April 30th (rough draft) May 15th (final draft)
Jordan Pyda compiling already published data on workforce numbers
Will pull data from Margo’s published review of Health Workforce, amongst other publications
Person in charge: Jordan
Deadline:April 30th (rough draft) May 15th (final draft)
John Scott compiling data on internal brain drain
40 articles published on internal brain drain of doctors; 0 on surgeons
Deadline: April 23 (rough draft) April 30th (final draft)

Surgeon Mapping Project conducted by HDM group

Nakul is in charge of this project – Johanna will help as density of surgeons in rural areas is a field of interest for WTE group.
Person in Charge: Primarily Nakul, Johanna as assist
Deadline: June 15th

III. WTE Reporting of the Current State

Workforce Dynamics

Determining baseline requirements #’s needed for safe surgical care
Based in part off of Surgeon Mapping
What is the current state? What is the ideal state? How do you get from AB
Can we use something like Maternal Mortality as a target outcome?
Focus on metric of #surgeon/anesthetist per rural population
Future requirements based on population projections
Can we estimate number of surgical providers needed per population?
Deadline: May 30th
Person in charge: Johanna (in close association with working group leads)
Other Workforce Dynamics (see outline below)
Draft outline
Deadline: May 30
Person in charge: Johanna and Caris

Training and Education (see outline below)
Draft outline
Deadline: May 30
Person in charge: Johanna and Caris

IV. WTE Case Vignettes (pop out boxes)

Case Topics

Case 1: RCSI& COSECSA
Caris is drafting 500 word document nearly complete
Deadline: April 23 (rough draft) April 30th (final draft)
Case 2: Task shifting in Malawi
Nyengo is drafting rough draft with Caris
Deadline: April 23 (rough draft) April 30th (final draft)
Case 3: University of West Indies
Jacky collecting information
Deadline: April 23 (rough draft) April 30th (final draft)
Case 4: Rwanda HRH
Robert Riviello/Johanna have written something similar for JGM textbook
Robert may still be planning to make this a case study therefore would not be a vignette
Deadline: April 23 (rough draft) April 30th (final draft)

V. Figures and Tables

Figures & Tables

Table1 and 2: Comparison of different training modules for 1. Surgeons (3 years vs 5 years for general surgery; paradigms from each continent) and 2. Task Sharers (Masters degree? Bachelors degree?)
Johanna +/- new medical student to manage Surgeon Table
John Scott to manage Task Sharing Table
Deadline: May 15th
Table 3: minimal Skill Set required by each provider
Note: I think it is most important to emphasize that regardless of who does the procedures, it needs to be done well – which circles back to Quality Assurance.
Johanna and Caris in association with other working group leads
Deadline: May 15th
Table 4. # of people per country with access to surgical services (Based on Surgeon Mapping Project)
Johanna to work closely with Nakul
Deadline: June 15th
Table 4: Migration of surgeons from LICHIC
Lars and Adam
Deadline: May 15th.
Figure 1: the surgical package(a graphic image of MOTS)
Johanna
Deadline: May 15th
Figure 2. Surgeon Density.
Lars
Deadline: June 15th
Figure 3: Rural vs Urban density of Surgeons (Based on Surgeon Mapping Project. +/- Surgeon Density Project)
Lars, Nakul, Johanna
Deadline: June 15th

VI. Papers for the Commission Appendix

National Density of Surgeons, OBGYN, and Anesthetists, World Wide
Person in charge: Lars
Deadline: June 15th
The Migration of surgeons worldwide
Person in charge: Lars
Deadline: June 15th
Training of surgeons in Johannesburg, SA
Paper to be written by Martin Smith/Martin Vella
Rowan is in contact with them
Deadline: May 30th

VII. Appendix to the WTE Workplan

Appendix A: Questions sent to members of WACS and COSECSA (via spreadsheet for easy answer entry)

Number of trained surgeons in your country
Number of trained anesthetists in your country
Number of trained OBYN in your country
Number of Surgical Nurses (is possible)
Number of Surgical Task Shifters in your country
Number of medical school graduates/year in your country
How many trained surgeons in rural locations in your country
How many trained anesthetists in rural locations in your country
How many trained nurses in rural locations in your country
How many trained OBGYNs in rural locations in your country
How many trained surgical task sharers in rural locations in your country
How many of your institutions participate in morbidity and mortality conferences?
Do your surgeons and anesthetists participate in CME
Comments

AppendixB: WTE Draft Outline

Workforce – current situation
Data is needed on number of
Surgeons
Obstetricians
Anesthetists
Nurses
Mid-level providers
Definition of surgical and anaesthetic workforce (present situation)
Health care executives, managers, leaders
Guidelines for health care managers – see email from Lars
Surgeons and obstetricians
Anesthesiologists and non-physician anaesthesetists
Radiology, pathology
Nurses and trained theatre staff
Non physician clinicians
Technical support staff
High income country personnel

Workforce dynamics
Requirements
Current requirements (based on estimates of need)
Likely future requirements (projections of population growth and likely need)
Task Sharing – issues, strengths, outcomes, controversies
Balance between investing in ex-pat capacity vs local human resource capacity. My guess is there is 5:1 to 10:1 cost differential. Would also address where to invest in building local HR capacity – NGO vs government systems. (David Bangsberg)
Recruitment and retention
Issues – medical schools and graduates – numbers
Attraction to surgery/anaesthesiologyetc as career choices – potential solutions
Attraction to rural areas – potential solutions
Migration – current situation, international policies and potential solutions
These are issues that involve ALL elements of surgical workforce including engineers, radiologists, nurses.
Internal/external brain drain. See bajinurwePMID: 23793660 for data saying that many physicians are staying in country to work for HIV NGO’s causing internal brain drain for other specialties (David Bangsberg)
CASE VIGNETTE: University of West Indies
Partnerships with High Income Countries (HICs)
Models and which is most desirable
Support of training and education
Access to new and innovative methods
Chance to progress/develop local practice
Ongoing support
Partnerships like:
Research collaborations
A means of career advancement without needing to leave the country
potential for reverse innovation
Benefits to HIC personnel
E.g. Nigel Crisp document on benefits to the NHS
Ministries of Health should be encouraged to own surgical delivery programs and assume responsibility for their sustenance. When NGO’s take control they may drain already weak resources (but MOH is forced to comply)
Planning for the establishment and sustenance of necessary surgical delivery programs by LMICs is helpful.
NGOs wishing to operate in these countries are free to do so but should be made to contribute in the training of health providers.

Training and education
Training should reflect the needs of the population
Emphasize Core Competencies
Minimal required skill set
Current models (University Model vs College Model)
See table re: different models of surgical training by region/continent
Task sharing – description, recommendations
See table re: different models of Task sharing training
High income country providers and their role in training/edu
Accreditation
Retraining of current surgical providers (who may be using out of date evidence/techniques)
Eg new guidelines on trauma resuscitation (permissive hypotension,
Need to discuss: Is it appropriate to teach principles like 1:1:1 resuscitation with blood products in countries where only whole blood is available
Innovative approaches
Free, online courses (Khan Academy, Coursesa, Harvard EdX)
E-learning
Carisexample re: laparoscopy and e-training
Innovative approaches will require cheap, fast internet
Key Recommendation – increase access to at a minimum district hospitals and regional hospitals
Caris knows of Malawi pilot with hotspots, laptops and dongles.
Retention – must have trained professionals to teach/train the professionals of the future – with at least some duplication so that current professionals can leave if necessary to get further training/re-training.

Benefits of training/certifying providers locally as opposed to sending them elsewhere for training (yet another drain on the system; increases likelihood that provider might not return?)
Training for competency in special cases (eg pediatric anesthesia, high risk anesthesia, pediatric surgery)
Need to reference recommendations of Training of Health Professionals Lancet Commission
CASE VIGNETTES
NyengoMkandawire case vignette on task shifting in Malawi
RCSI-COSECSA case vignette – Caris to chase
HRH?

Ensuring performance and quality
M&E e.g. M&M
Does this actually happen?
What are barriers to making it happen
Do databases/EMR make this easier?
CME – local and international/partnerships
Maintenance of certification
Local
High income country certification

Appendix C: Key Papers needed to write the WTE section (working list,in Progress)

1. WHO Working together for health. 2006 World Health Report. Retrieved from

2. Chu K, Rosseel P, Gielis P, Ford N. Surgical Task Shifting in Sub-Saharan Africa. Plos Med 2009;6(5):e1000078.

3. Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries. The Lancet 2007;370(9605):2158–63.

4. Hagander LE, Hughes CD, Nash K, et al. Surgeon migration between developing countries and the United States: train, retain, and gain from brain drain. World J Surg 2013;37(1):14–23.

5. Chen L, Evans T, Anand S, et al. Human resources for health: overcoming the crisis (2004) The Lancet vol 364(9449) p1984-1990

6. Frenk et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world (2010) The Lancet Vol 376 (9756) p1923-1958

7. Nigel Crisp – benefits to the NHS

8. Crisp NEJM –Distribution of health workers

9. COSECSA 2011 paper

10. Funk, Weiser, Gawande access to surgical care

11. Diallo 2004 Internal Migration

12. Bangsberg Uganda Internal Migration

13. Cochrane Review 2014 Internal Migration.

14. Hoyler M, Finlayson SRG, McClain CD, Meara JG, Hagander L. (2014) Shortage of doctors, shortage of data: a review of the global surgery, obstetrics, and anesthesia workforce literature. World Journal of Surgery Vol28 (2) p269-280

15. Improving Health at Home and Abroad: How overseas volunteering from the NHS benefits the UK and the world

16. APPG Annual report 2012-2013