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Building Surgical Research Capacity in Mozambique

Bickler, Stephen W. MD; Funzamo, Carlos MD, MPH; Rose, John MD, MPH; Assane, Americo MD; Cassocera, Paulino NPT; Vaz, Fernando MD; Assis, Antonio MD; Noormahomed, Emilia Virginia MD, PhD

doi: 10.1097/ACM.0000000000000339
Reports in Brief

Author affiliations:S. Bickler, Rady Children’s Hospital and University of California, San Diego; C. Funzamo, Ministry of Health, Maputo, Mozambique; J. Rose, University of California, San Diego; A. Assane, F. Vaz, A. Assis, E.V. Noormahomed, Universidade Eduardo Mondlane, Maputo, Mozambique; P. Cassocera, Instituto Superior de Ciencias de Saúde, Maputo, Mozambique

Funding/Support: This research was supported by grant number R24TW008910 from the Fogarty International Center, National Institutes of Health (NIH). The NIH Common Fund supports the award.

Other disclosures: None reported.

Ethical approval: Ethical approval for the study was obtained from the National Bioethics Committee in Mozambique and the human research protections program at the University of California, San Diego.

Disclaimers: The content is solely the responsibility of the authors and does not represent the official views of the Fogarty International Center or the NIH.

Previous presentations: These results have been presented and published in various venues including Academic Surgical Congress (New Orleans, 2013), World Congress of Surgery, Trauma, and Anesthesia (Trinidad and Tobago, 2013), and the World Journal of Surgery.

Correspondence should be addressed to Dr. Bickler, University of California, San Diego, Department of Surgery, 9500 Gillman Dr. #0739, La Jolla, CA; e-mail: sbickler@ucsd.edu.

Background: Surgically treatable conditions are increasingly recognized as important public health problems in low- and middle-income countries.1–3 In Mozambique, the majority of surgery in rural areas is performed by “técnicos de cirurgia”—nonphysician surgeons trained locally. To better define rural surgical needs in Mozambique and to improve surgical care, the Universidade Eduardo Mondlane (UEM) formed a research partnership with the University of California, San Diego (UCSD) in 2010. Funded by a Medical Education Partnership Initiative linked award, the specific aims of the of the project are to identify the best strategies for building emergency and essential surgical capacity in rural areas of Mozambique and to increase capacity for surgical research at UEM and its allied institutions.

Intervention: During the first 36 months of the UEM-UCSD surgical partnership, a number of research projects have been initiated. These have focused on defining the unmet need for surgical care in rural communities surrounding hospitals; types of surgical procedures performed by the nonphysician surgeons; clinical epidemiology of pediatric trauma as one of the unmet surgical needs; and risk-adjusted outcomes of surgical patients. These projects have been used as the platform to increase capacity for surgical research among local personnel.

Outcomes: A community-based survey of 6,104 people living near three primary referral hospitals in rural Mozambique, conducted June 2012 to June 2013, showed that 36% of the respondents had current or historical surgical disease. Review of inpatient records revealed that about 60% of hospital admissions were for treatment of surgical conditions. Compared with patients admitted for nonsurgical problems, surgical patients had longer hospital stays and a greater number of total hospital days. In the rural hospitals studied, nonphysician surgeons performed more than 95% of the surgical procedures and 52 different types of operations, of which 73% were surgical emergencies. The three most common procedures were cesarean section (62%), herniorrhaphy (9%), and exploratory laparotomy (4%). Ten procedures accounted for 80% of the surgical volume. Seventy percent of the pediatric surgical admissions were for injuries, with falls (44%), burns (23%), and road traffic accidents (18%) being the most common. Calculation of risk-adjusted operative outcomes is currently under way.

Comment: Our preliminary findings suggest that surgical conditions, especially injuries and obstetrical problems, are common in rural areas of Mozambique and place a significant burden on the health system. While typical of the surgical epidemiology observed in other low- and middle income countries, it emphasizes the important role surgical care has in treating maternal and child health problems. Given the high prevalence of untreated surgical conditions identified in our community-based survey, there is a critical need to better understand which factors limit delivery of surgical care and how surgery fits into the larger health system. Some of the greatest challenges exist in the supply, training, and distribution of human resources for surgical care. Educating and training surgeons is time consuming and expensive, and once qualified, many are reluctant to serve in rural first-level hospitals where the needs are often the greatest. The técnicos de cirurgia model used in Mozambique can provide important information on how best to address the critical need for surgeons in other countries in Sub-Saharan Africa.

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References

1. Bickler SW, Spiegel DA. Global surgery—defining a research agenda. Lancet. 2008;372:90–92
2. Spiegel DA, Abdullah F, Price RR, Gosselin RA, Bickler SW. World Health Organization Global Initiative for Emergency and Essential Surgical Care: 2011 and beyond. World J Surg. 2013;37:1462–1469
3. Bickler SW, Weiser TG, Kassebaum NDebas H, Mock C, Kruk M, Gwande Aet al. . Global burden of surgical conditions. Volume 9: Essential Surgery, Disease Control Priorities in Developing Countries.3rd ed Washington, DC: World Bank.
© 2014 by the Association of American Medical Colleges