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