- Email: [email protected]
Improving Access to Surgery in a Developing Country: Experience from a Surgical Collaboration in Sierra Leone
REFLECTIONS
Improving Access to Surgery in a Developing Country: Experience from a Surgical Collaboration in Sierra Leone Adam L. Kushner, MD,*† Thaim B. Kamara, MD,‡§ Reinou S. Groen, MD,* Betsy D. Fadlu-Deen, RN,‡ Kisito S. Doah, MD,§ and T. Peter Kingham, MD*储 *Surgeons Overseas (SOS), New York, New York; †Department of Surgery, Columbia University, New York, New York; ‡Department of Surgery, Connaught Hospital, Freetown, Republic of Sierra Leone; §Sierra Leone Ministry of Health and Sanitation, Freetown, Republic of Sierra Leone; and 储Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York BACKGROUND: Although surgery is increasingly recognized as an essential component of primary health care, there has been little documentation of surgical programs in low- and middle-income countries. Surgeons OverSeas (SOS) is a New York-based organization with a mission to save lives in developing countries by improving surgical care. This article highlights the surgical program in Sierra Leone as a possible model to improve access to surgery. METHODS: An SOS team conducted a needs assessment of
surgical capacity in Sierra Leone in February 2008. Interventions were then developed and programs were implemented. A follow-up assessment was conducted in December 2009, which included interviews of key Sierra Leone hospital personnel and a review of operating room log books. RESULTS: Based on an initial needs assessment, a program was developed that included training, salary support, and the provision of surgical supplies and equipment. Two 3-day workshops were conducted for a total of 44 health workers, salary support given to over 100 staff, and 2 containers of supplies and equipment were donated. Access to surgery, as measured by the number of major operations at Connaught Hospital, increased from 460 cases in 2007 to 768 cases in 2009. CONCLUSIONS: The SOS program in Sierra Leone highlights a method for improving access to surgery that incorporates an initial needs assessment with minimal external support and local staff collaboration. The program functions as a catalyst by providing training, salary support, and supplies. The beneficial results of the program can then be used to advocate for additional resources for surgery from policy makers. This model could be beneficial in other resource-poor countries in Correspondence: Inquiries to Adam L. Kushner, MD, Department of Surgery, Surgeons OverSeas (SOS), Box 854, Alpine, NJ 07620; fax: ⫹1-201-768-7517; e-mail: [email protected]
270
which improved access to surgery is desired. (J Surg 67: 270-273. © 2010 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
INTRODUCTION Surgery is recognized increasingly as a neglected but important component of global health care.1,2 Although examples exist of specialty groups or academic institutions in high-income countries collaborating with counterparts in low- and middleincome countries (LMICs),3-5 few publications in the world literature describe programs that improve access to surgery. Many surgical projects in LMICs consist of “surgical blitzes,”6 which are well-intentioned programs that often lack sufficient local involvement or fail to provide for long-term sustainability. With growing interest in undertaking surgical missions among surgical residents7 and interest from academic institutions8,9 the need to encourage collaborative and sustainable programs is imperative. Surgeons OverSeas (SOS) is a nonprofit organization based in New York, New York with a mission of saving lives in developing countries by improving surgical care. It was founded in 2007 by surgeons interested in promoting global surgery and strengthening surgical health care systems in resource-limited environments. This article describes initial experiences and results from the SOS surgical program in Sierra Leone.
METHODS In February 2008, a survey of surgical capacity in the West African country of Sierra Leone was conducted by an SOS team (T.B.K. and T.P.K.) using the World Health Organization, Tool for the Situational Analysis of Emergency and Essential Surgical Care.10 The results of that survey were published subsequently.11 In addressing the deficiencies identified during the
Journal of Surgical Education • © 2010 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
1931-7204/$30.00 doi:10.1016/j.jsurg.2010.05.004
survey, a 3-part program was developed in conjunction with Sierra Leone surgeons and the Sierra Leone Ministry of Health and Sanitation. The program included training, supplies and equipment, and salary support. All input from SOS team members were discussed continuously and verified with the Head of Surgery at Connaught Hospital (T.B.K.) and with the Ministry of Health and Sanitation. A brief evaluation of the program was conducted in December 2009 (A.L.K. and R.S.G.) by interviewing Connaught Hospital staff and by documenting the number of operations per year recorded in the operating room log book.
Salary Support After identifying the problem of losing surgical staff to better funded public health and private sector initiatives, SOS planned initially to provide salary support to the local surgeons. These surgeons, however, suggested distributing the funds among the operating room nurses and support staff. Additional funds were also distributed to the staff of the surgical wards and emergency room. This intervention began in July 2008 with $800 dispersed monthly and divided among approximately 100 staff. Connaught Hospital Operative Cases
RESULTS Training The initial implementation of the SOS program began in July 2008 when a 2-person team (A.L.K. and R.S.G.) spent 6 weeks in the Department of Surgery at Connaught Hospital, which is Sierra Leone’s tertiary care referral center in the capital, Freetown. The major emphasis was on strengthening clinical teaching by assisting with ward rounds, conducting lectures, and relieving local surgeons by covering emergency surgical duty. During this mission, two 3-day emergency and essential surgical care workshops based on the World Health Organization’s Surgical Care at the District Hospital12 were also conducted in Freetown and in Bo, the second largest city. Ten Sierra Leone surgical specialists assisted with workshop logistics, gave presentations, and taught practical skills sessions that included airway maintenance, bowel anastomosis, chest tube insertion, and tendon repair. Forty-four students participated in the workshops (21 in Freetown and 23 in Bo). After these initial workshops, Connaught Hospital surgeons have undertaken additional surgery training courses on their own. Other SOS teams returned for limited periods: 1 general surgeon for 1 week in October 2008; and in 2009, 1 general surgeon returned for 6 weeks in January to March, 1 orthopedic surgeon for 2 weeks in February, 1 general surgeon for 6 weeks in May and June, 2 general surgeons for 1 week in July, and 1 general surgeon and 1 tropical doctor for 2 weeks in December. The emphasis of these missions was on training with minimal provision of direct patient care. Supplies and Equipment Two containers of supplies and equipment were delivered to Connaught Hospital; 1 was delivered in October 2008 and 1 in December 2009, and each shipment contained consumable supplies such as gauze, bandages, sutures, and chest tubes, as well as equipment such as hospital beds, IV poles, an X-ray machine, and stretchers. The equipment was dispersed throughout the hospital, and the consumables were kept in a secure storage room in the operating room suite. The supplies were used for patients too poor to purchase the needed materials themselves.
A review of the operating room log book at Connaught Hospital showed an increase in the number of major operations performed from January 2007 to December 2009. In 2007, 460 operations were performed; in 2008, this number rose to 695, and in 2009, 768 operations were preformed (Table 1). Connaught Hospital Management stated that the salary support was the main reason for the increase in caseload which led to decreased operating room staff absenteeism and increased morale.
DISCUSSION As the need to improve surgery in many LMICs is recognized increasingly,1,2,13 few programs exist that provide long-term assistance and training. The SOS surgical program in Sierra Leone was developed as a model to improve surgical care in resource-poor countries in which the local Ministry of Health views a need for improvement. The cornerstones of the SOS program are to identify local surgeons with whom to work and then, in collaboration with the Ministry of Health and using World Health Organization assessment tools, to identify the deficiencies in surgical capacity. In Sierra Leone, which is 1 of the poorest countries in the world and consistently ranked near the bottom of the United Nations development index,14 this approach was implemented with an initial degree of success. By working with Sierra Leone surgeons and the Sierra Leone Ministry of Health and Sanitation a survey of surgical capacity was conducted and published.11 The survey results led to identifying training and surgical supplies and equipment as essential to improve patient care and salary support to improve personnel motivation. Surgical training in high-income countries has been organized and regulated for many years, which is lacking in many
TABLE 1. Yearly Major Surgical Procedures at Connaught Hospital, Freetown, Sierra Leone
Journal of Surgical Education • Volume 67/Number 4 • July/August 2010
Year
Number of Operations
2007 2008 2009
460 695 768 271
LMICs like Sierra Leone. Recently, however, Sierra Leone was awarded partial accreditation for a surgical residency by the West African College of Surgeons. Short-term surgical programs often include some educational opportunities for local surgical trainees, but it is difficult to have surgical trainees as their priority when often the goal is to perform many cases in a short time period.6,15 The SOS program emphasizes teaching on ward rounds, in conferences, and by giving lectures rather than by providing direct patient care. The SOS approach is to support the local surgeons and attempt to improve access to surgery as measured by an increase in the number of procedures that are accomplished locally. The initial needs assessment emphasized that for more surgical cases to be performed locally, more consumable supplies, such as gauze and sutures, and better equipment, such as operating room tables and surgical instruments, were needed. Without private funds or insurance, patients often cannot pay for the care they need. Although certainly not sustainable in the long run, the provision of these containers allowed many more patients to receive much needed care. Additionally, unlike many other programs, the material was consigned directly to the Minister of Health and Sanitation with delivery directly to the staff of Connaught Hospital. The Ministry of Health and Sanitation has subsequently recognized the necessity of such supplies and equipment and efforts are now underway to procure such material directly. According to Connaught Hospital Management, the provision of salary support to surgical nurses and support staff led to a decrease in absenteeism and an increase in productivity and morale. Numerous reports document the health care workforce deficiencies in Africa and the problem of brain drain.16-18 The SOS program focused on paying health care workers more, treating them with respect, and providing them with a comfortable and safe work environment. Although not sustainable in the long term, plans are underway for the Ministry of Health and Sanitation to increase the salaries of Sierra Leone health care workers. In addition to the salary support, SOS provided protective items such as boots, aprons, gloves, and goggles for the operating room staff. These items are part of a Surgery and HIV Awareness and Response Program that includes providing HIV protective gear and education about universal precautions and postexposure prophylaxis. The SOS sponsored emergency and essential surgical care workshops were also unique; surgical skills workshops had been given in Sierra Leone previously, but this was the first program in which most of the work was conducted by Sierra Leone surgeons. SOS’ primary role was providing funding and assisting with some of the logistics. The local faculty attended a facilitators meeting hosted by World Health Organization before the workshop, received copies of the Surgical Care at the District Hospital manual, and Integrated Management of Emergency and Essential Surgical Care tool kit, developed presentations, presented with a high degree of sophistication, and took time away from their own private practices to travel to the 272
courses. Encouraging local surgeons to take training courses seems to be an efficient use of resources, and afterward the surgeons in Sierra Leone were empowered to conduct additional sessions on their own. Overall, this model succeeded because of the efforts of the Sierra Leone surgeons who took on the role of surgical leaders and trainers. SOS functioned mainly as a catalyst, by bringing people and ideas together. Although the provision by SOS of containers of materials and salary support is not sustainable in the long term, it was determined that these efforts would be essential in improving immediate access to surgery. Additionally, the impressive results have caused policy makers within the Ministry of Health and Sanitation to devote additional resources to surgery, which will include direct purchasing of needed supplies and increases in health care worker salaries. It is important to note that the absolute effect of providing training, supplies, and salary support cannot be determined fully by this study and that additional metrics need to be considered and measured to evaluate the program. However, at a minimum, the initial results of the SOS program seem to have assisted with increasing access to surgery. The SOS program is not the only approach to improve surgery in LMICs; however, the combination of a needs assessment, program planning, provision of supplies, training, and salary support, all in collaboration with local surgeons and the local Ministry of Health, is a model that should be studied more. A valuable resource for surgeons wishing to volunteer in the developing world can be found by visiting the American College of Surgeons Operation Giving Back website at http://www. operationgivingback.org. Information on Surgeons OverSeas can be found at http://www.humanitariansurgery.org.
REFERENCES 1. Debas H, Gosselin R, McCord C, Thind A. Surgery. In:
Jamison D, ed. Disease Control Priorities in Developing Countries in Developing Countries. 2nd ed. Washington, DC: World Bank; 2006. 2. Farmer PE, Kim JY. Surgery and global health: a view
from beyond the OR. World J Surg. 2008;32:537-542. 3. Abenavoli FM. Operation Smile humanitarian missions.
Plast Reconstr Surg. 2005;115:356-357. 4. Chu K, Rosseel P, Trelles M, Gielis P. Surgeons without
Borders: a brief history of surgery at Medecins sans Frontieres. World J Surg. 20100;34:411-414. 5. Alpers MP. Hospital twinning between Australia and
Papua New Guinea. P N G Med J. 2003;46:81-86. 6. Nthumba PM. “Blitz surgery”: redefining surgical needs,
training, and practice in sub-Saharan Africa. World J Surg. 2010;34:433-437.
Journal of Surgical Education • Volume 67/Number 4 • July/August 2010
7. Powell AC, Mueller C, Kingham P, et al. International
13. Weiser TG, Regengogen SE, Thompson KD, et al. An
experience, electives, and volunteerism in surgical training: a survey of resident interest. J Am Coll Surg. 2007; 205:162-168.
estimation of the global volume of surgery: a modeling strategy based on available data. Lancet. 2008;372:139144.
8. Ozgediz D, Wang J, Jayaraman S, et al. Surgical training
14. Human Development Report, United Nations Devel-
and global health: initial results of a 5-year partnership with a surgical training program in a low-income country. Arch Surg. 2008;143:860-865; Discussion: 865. 9. Klaristenfeld DD, Chupp M, Cioffi WG, White RE. An
opment Program. Available at: http://hdr.undp.org/en/ statistics/. Accessed January 22, 2010. 15. Maki J, Qualls M, White B, Kleefield S, Crone R. Health
impact assessment and short-term medical missions: a methods study to evaluate quality of care. BMC Health Surv Res. 2008;8:121.
international volunteer program for general surgery residents at Brown Medical School: the Tenwek Hospital Africa experience. J Am Coll Surg. 2008;207:125-128. 10. World Health Organization. Tool for Situational Anal-
ysis to Assess Emergency and Essential Surgical Care. Available at: http://www.who.int/surgery/publications/ QuickSitAnalysisEESCsurvey.pdf. Accessed January 22, 2010.
16. Anyangwe SC, Mtonga C. Inequities in the global health
tk;4workforce: the greatest impediment to health in subSaharan Africa. Int J Environ Res Public Health. 2007;4: 93-100. 17. Stilwell B, Diallo K, Zurn P, et al. Migration of health-
ing surgical capacity in Sierra Leone: a guide for improving surgical care. Arch Surg. 2009;144:122-127.
care workers from developing countries: strategic approaches to its management. Bull World Health. 2004;82: 595-600.
12. World Health Organization. Surgical Care at the Dis-
18. McCoy D, Bennett S, Witter S, et al. Salaries and incomes
trict Hospital. Available at: http://www.who.int/surgery/ publications/en/SCDH.pdf. Accessed January 22, 2010.
of health workers in sub-Saharan Africa. Lancet. 2008; 371:675-681.
11. Kingham TP, Kamara TB, Cherian MN, et al. Quantify-
Journal of Surgical Education • Volume 67/Number 4 • July/August 2010
273
Improving Access to Surgery in a Developing Country: Experience from a Surgical Collaboration in Sierra Leone Adam L. Kushner, MD,*† Thaim B. Kamara, MD,‡§ Reinou S. Groen, MD,* Betsy D. Fadlu-Deen, RN,‡ Kisito S. Doah, MD,§ and T. Peter Kingham, MD*储 *Surgeons Overseas (SOS), New York, New York; †Department of Surgery, Columbia University, New York, New York; ‡Department of Surgery, Connaught Hospital, Freetown, Republic of Sierra Leone; §Sierra Leone Ministry of Health and Sanitation, Freetown, Republic of Sierra Leone; and 储Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York BACKGROUND: Although surgery is increasingly recognized as an essential component of primary health care, there has been little documentation of surgical programs in low- and middle-income countries. Surgeons OverSeas (SOS) is a New York-based organization with a mission to save lives in developing countries by improving surgical care. This article highlights the surgical program in Sierra Leone as a possible model to improve access to surgery. METHODS: An SOS team conducted a needs assessment of
surgical capacity in Sierra Leone in February 2008. Interventions were then developed and programs were implemented. A follow-up assessment was conducted in December 2009, which included interviews of key Sierra Leone hospital personnel and a review of operating room log books. RESULTS: Based on an initial needs assessment, a program was developed that included training, salary support, and the provision of surgical supplies and equipment. Two 3-day workshops were conducted for a total of 44 health workers, salary support given to over 100 staff, and 2 containers of supplies and equipment were donated. Access to surgery, as measured by the number of major operations at Connaught Hospital, increased from 460 cases in 2007 to 768 cases in 2009. CONCLUSIONS: The SOS program in Sierra Leone highlights a method for improving access to surgery that incorporates an initial needs assessment with minimal external support and local staff collaboration. The program functions as a catalyst by providing training, salary support, and supplies. The beneficial results of the program can then be used to advocate for additional resources for surgery from policy makers. This model could be beneficial in other resource-poor countries in Correspondence: Inquiries to Adam L. Kushner, MD, Department of Surgery, Surgeons OverSeas (SOS), Box 854, Alpine, NJ 07620; fax: ⫹1-201-768-7517; e-mail: [email protected]
270
which improved access to surgery is desired. (J Surg 67: 270-273. © 2010 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
INTRODUCTION Surgery is recognized increasingly as a neglected but important component of global health care.1,2 Although examples exist of specialty groups or academic institutions in high-income countries collaborating with counterparts in low- and middleincome countries (LMICs),3-5 few publications in the world literature describe programs that improve access to surgery. Many surgical projects in LMICs consist of “surgical blitzes,”6 which are well-intentioned programs that often lack sufficient local involvement or fail to provide for long-term sustainability. With growing interest in undertaking surgical missions among surgical residents7 and interest from academic institutions8,9 the need to encourage collaborative and sustainable programs is imperative. Surgeons OverSeas (SOS) is a nonprofit organization based in New York, New York with a mission of saving lives in developing countries by improving surgical care. It was founded in 2007 by surgeons interested in promoting global surgery and strengthening surgical health care systems in resource-limited environments. This article describes initial experiences and results from the SOS surgical program in Sierra Leone.
METHODS In February 2008, a survey of surgical capacity in the West African country of Sierra Leone was conducted by an SOS team (T.B.K. and T.P.K.) using the World Health Organization, Tool for the Situational Analysis of Emergency and Essential Surgical Care.10 The results of that survey were published subsequently.11 In addressing the deficiencies identified during the
Journal of Surgical Education • © 2010 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
1931-7204/$30.00 doi:10.1016/j.jsurg.2010.05.004
survey, a 3-part program was developed in conjunction with Sierra Leone surgeons and the Sierra Leone Ministry of Health and Sanitation. The program included training, supplies and equipment, and salary support. All input from SOS team members were discussed continuously and verified with the Head of Surgery at Connaught Hospital (T.B.K.) and with the Ministry of Health and Sanitation. A brief evaluation of the program was conducted in December 2009 (A.L.K. and R.S.G.) by interviewing Connaught Hospital staff and by documenting the number of operations per year recorded in the operating room log book.
Salary Support After identifying the problem of losing surgical staff to better funded public health and private sector initiatives, SOS planned initially to provide salary support to the local surgeons. These surgeons, however, suggested distributing the funds among the operating room nurses and support staff. Additional funds were also distributed to the staff of the surgical wards and emergency room. This intervention began in July 2008 with $800 dispersed monthly and divided among approximately 100 staff. Connaught Hospital Operative Cases
RESULTS Training The initial implementation of the SOS program began in July 2008 when a 2-person team (A.L.K. and R.S.G.) spent 6 weeks in the Department of Surgery at Connaught Hospital, which is Sierra Leone’s tertiary care referral center in the capital, Freetown. The major emphasis was on strengthening clinical teaching by assisting with ward rounds, conducting lectures, and relieving local surgeons by covering emergency surgical duty. During this mission, two 3-day emergency and essential surgical care workshops based on the World Health Organization’s Surgical Care at the District Hospital12 were also conducted in Freetown and in Bo, the second largest city. Ten Sierra Leone surgical specialists assisted with workshop logistics, gave presentations, and taught practical skills sessions that included airway maintenance, bowel anastomosis, chest tube insertion, and tendon repair. Forty-four students participated in the workshops (21 in Freetown and 23 in Bo). After these initial workshops, Connaught Hospital surgeons have undertaken additional surgery training courses on their own. Other SOS teams returned for limited periods: 1 general surgeon for 1 week in October 2008; and in 2009, 1 general surgeon returned for 6 weeks in January to March, 1 orthopedic surgeon for 2 weeks in February, 1 general surgeon for 6 weeks in May and June, 2 general surgeons for 1 week in July, and 1 general surgeon and 1 tropical doctor for 2 weeks in December. The emphasis of these missions was on training with minimal provision of direct patient care. Supplies and Equipment Two containers of supplies and equipment were delivered to Connaught Hospital; 1 was delivered in October 2008 and 1 in December 2009, and each shipment contained consumable supplies such as gauze, bandages, sutures, and chest tubes, as well as equipment such as hospital beds, IV poles, an X-ray machine, and stretchers. The equipment was dispersed throughout the hospital, and the consumables were kept in a secure storage room in the operating room suite. The supplies were used for patients too poor to purchase the needed materials themselves.
A review of the operating room log book at Connaught Hospital showed an increase in the number of major operations performed from January 2007 to December 2009. In 2007, 460 operations were performed; in 2008, this number rose to 695, and in 2009, 768 operations were preformed (Table 1). Connaught Hospital Management stated that the salary support was the main reason for the increase in caseload which led to decreased operating room staff absenteeism and increased morale.
DISCUSSION As the need to improve surgery in many LMICs is recognized increasingly,1,2,13 few programs exist that provide long-term assistance and training. The SOS surgical program in Sierra Leone was developed as a model to improve surgical care in resource-poor countries in which the local Ministry of Health views a need for improvement. The cornerstones of the SOS program are to identify local surgeons with whom to work and then, in collaboration with the Ministry of Health and using World Health Organization assessment tools, to identify the deficiencies in surgical capacity. In Sierra Leone, which is 1 of the poorest countries in the world and consistently ranked near the bottom of the United Nations development index,14 this approach was implemented with an initial degree of success. By working with Sierra Leone surgeons and the Sierra Leone Ministry of Health and Sanitation a survey of surgical capacity was conducted and published.11 The survey results led to identifying training and surgical supplies and equipment as essential to improve patient care and salary support to improve personnel motivation. Surgical training in high-income countries has been organized and regulated for many years, which is lacking in many
TABLE 1. Yearly Major Surgical Procedures at Connaught Hospital, Freetown, Sierra Leone
Journal of Surgical Education • Volume 67/Number 4 • July/August 2010
Year
Number of Operations
2007 2008 2009
460 695 768 271
LMICs like Sierra Leone. Recently, however, Sierra Leone was awarded partial accreditation for a surgical residency by the West African College of Surgeons. Short-term surgical programs often include some educational opportunities for local surgical trainees, but it is difficult to have surgical trainees as their priority when often the goal is to perform many cases in a short time period.6,15 The SOS program emphasizes teaching on ward rounds, in conferences, and by giving lectures rather than by providing direct patient care. The SOS approach is to support the local surgeons and attempt to improve access to surgery as measured by an increase in the number of procedures that are accomplished locally. The initial needs assessment emphasized that for more surgical cases to be performed locally, more consumable supplies, such as gauze and sutures, and better equipment, such as operating room tables and surgical instruments, were needed. Without private funds or insurance, patients often cannot pay for the care they need. Although certainly not sustainable in the long run, the provision of these containers allowed many more patients to receive much needed care. Additionally, unlike many other programs, the material was consigned directly to the Minister of Health and Sanitation with delivery directly to the staff of Connaught Hospital. The Ministry of Health and Sanitation has subsequently recognized the necessity of such supplies and equipment and efforts are now underway to procure such material directly. According to Connaught Hospital Management, the provision of salary support to surgical nurses and support staff led to a decrease in absenteeism and an increase in productivity and morale. Numerous reports document the health care workforce deficiencies in Africa and the problem of brain drain.16-18 The SOS program focused on paying health care workers more, treating them with respect, and providing them with a comfortable and safe work environment. Although not sustainable in the long term, plans are underway for the Ministry of Health and Sanitation to increase the salaries of Sierra Leone health care workers. In addition to the salary support, SOS provided protective items such as boots, aprons, gloves, and goggles for the operating room staff. These items are part of a Surgery and HIV Awareness and Response Program that includes providing HIV protective gear and education about universal precautions and postexposure prophylaxis. The SOS sponsored emergency and essential surgical care workshops were also unique; surgical skills workshops had been given in Sierra Leone previously, but this was the first program in which most of the work was conducted by Sierra Leone surgeons. SOS’ primary role was providing funding and assisting with some of the logistics. The local faculty attended a facilitators meeting hosted by World Health Organization before the workshop, received copies of the Surgical Care at the District Hospital manual, and Integrated Management of Emergency and Essential Surgical Care tool kit, developed presentations, presented with a high degree of sophistication, and took time away from their own private practices to travel to the 272
courses. Encouraging local surgeons to take training courses seems to be an efficient use of resources, and afterward the surgeons in Sierra Leone were empowered to conduct additional sessions on their own. Overall, this model succeeded because of the efforts of the Sierra Leone surgeons who took on the role of surgical leaders and trainers. SOS functioned mainly as a catalyst, by bringing people and ideas together. Although the provision by SOS of containers of materials and salary support is not sustainable in the long term, it was determined that these efforts would be essential in improving immediate access to surgery. Additionally, the impressive results have caused policy makers within the Ministry of Health and Sanitation to devote additional resources to surgery, which will include direct purchasing of needed supplies and increases in health care worker salaries. It is important to note that the absolute effect of providing training, supplies, and salary support cannot be determined fully by this study and that additional metrics need to be considered and measured to evaluate the program. However, at a minimum, the initial results of the SOS program seem to have assisted with increasing access to surgery. The SOS program is not the only approach to improve surgery in LMICs; however, the combination of a needs assessment, program planning, provision of supplies, training, and salary support, all in collaboration with local surgeons and the local Ministry of Health, is a model that should be studied more. A valuable resource for surgeons wishing to volunteer in the developing world can be found by visiting the American College of Surgeons Operation Giving Back website at http://www. operationgivingback.org. Information on Surgeons OverSeas can be found at http://www.humanitariansurgery.org.
REFERENCES 1. Debas H, Gosselin R, McCord C, Thind A. Surgery. In:
Jamison D, ed. Disease Control Priorities in Developing Countries in Developing Countries. 2nd ed. Washington, DC: World Bank; 2006. 2. Farmer PE, Kim JY. Surgery and global health: a view
from beyond the OR. World J Surg. 2008;32:537-542. 3. Abenavoli FM. Operation Smile humanitarian missions.
Plast Reconstr Surg. 2005;115:356-357. 4. Chu K, Rosseel P, Trelles M, Gielis P. Surgeons without
Borders: a brief history of surgery at Medecins sans Frontieres. World J Surg. 20100;34:411-414. 5. Alpers MP. Hospital twinning between Australia and
Papua New Guinea. P N G Med J. 2003;46:81-86. 6. Nthumba PM. “Blitz surgery”: redefining surgical needs,
training, and practice in sub-Saharan Africa. World J Surg. 2010;34:433-437.
Journal of Surgical Education • Volume 67/Number 4 • July/August 2010
7. Powell AC, Mueller C, Kingham P, et al. International
13. Weiser TG, Regengogen SE, Thompson KD, et al. An
experience, electives, and volunteerism in surgical training: a survey of resident interest. J Am Coll Surg. 2007; 205:162-168.
estimation of the global volume of surgery: a modeling strategy based on available data. Lancet. 2008;372:139144.
8. Ozgediz D, Wang J, Jayaraman S, et al. Surgical training
14. Human Development Report, United Nations Devel-
and global health: initial results of a 5-year partnership with a surgical training program in a low-income country. Arch Surg. 2008;143:860-865; Discussion: 865. 9. Klaristenfeld DD, Chupp M, Cioffi WG, White RE. An
opment Program. Available at: http://hdr.undp.org/en/ statistics/. Accessed January 22, 2010. 15. Maki J, Qualls M, White B, Kleefield S, Crone R. Health
impact assessment and short-term medical missions: a methods study to evaluate quality of care. BMC Health Surv Res. 2008;8:121.
international volunteer program for general surgery residents at Brown Medical School: the Tenwek Hospital Africa experience. J Am Coll Surg. 2008;207:125-128. 10. World Health Organization. Tool for Situational Anal-
ysis to Assess Emergency and Essential Surgical Care. Available at: http://www.who.int/surgery/publications/ QuickSitAnalysisEESCsurvey.pdf. Accessed January 22, 2010.
16. Anyangwe SC, Mtonga C. Inequities in the global health
tk;4workforce: the greatest impediment to health in subSaharan Africa. Int J Environ Res Public Health. 2007;4: 93-100. 17. Stilwell B, Diallo K, Zurn P, et al. Migration of health-
ing surgical capacity in Sierra Leone: a guide for improving surgical care. Arch Surg. 2009;144:122-127.
care workers from developing countries: strategic approaches to its management. Bull World Health. 2004;82: 595-600.
12. World Health Organization. Surgical Care at the Dis-
18. McCoy D, Bennett S, Witter S, et al. Salaries and incomes
trict Hospital. Available at: http://www.who.int/surgery/ publications/en/SCDH.pdf. Accessed January 22, 2010.
of health workers in sub-Saharan Africa. Lancet. 2008; 371:675-681.
11. Kingham TP, Kamara TB, Cherian MN, et al. Quantify-
Journal of Surgical Education • Volume 67/Number 4 • July/August 2010
273