Surgery is increasingly being recognized as an integral component of global health efforts. The recent Lancet Commission report “Global Surgery 2030” estimated that 5 billion people worldwide lack access to safe surgical care1. As much as 30% of the total global burden of disease could be treated with surgery, but currently only 6% of the 313 million surgical procedures performed each year take place in low- and middle-income countries (LMICs) where the burden is highest1. For example, in eastern sub-Saharan Africa, where an estimated 21.5 million procedures would be necessary to meet the current surgical burden, only 4.3 million are performed2. This is in stark contrast to the surgical abundance in high-income areas of North America, where 15.8 million procedures are medically needed and 63.4 million performed3. One of the main causes of this geographic maldistribution of surgical care is a dramatic shortage of surgical providers that persists in LMICs. The World Health Organization (WHO) has determined that there is a “health workforce crisis” in 57 LMICs, calling current global surgical capacity “critically inadequate and grossly inequitably distributed”4.
With the global surgical burden of disease constantly increasing, it is estimated that more than one million new surgical providers will be needed to address the treatment needs of these patients5. Clearly, scaling up human resources for health is essential, but how best to do this remains unclear. The 2010 WHO “Global Code of Practice on the International Recruitment of Health Personnel” sets out guiding principles for addressing the shortage of health personnel. In section 5.2, the code states that international organizations are encouraged to provide “effective and appropriate technical assistance, support for health personnel retention … and access to specialized training, technology and skills transfers” in countries with a limited capacity to expand their own workforce6. A number of organizations have answered this call to action and various initiatives have been proposed specifically with regards to surgery. Nevertheless, effective strategies to increase the surgical workforce and increase local retention of surgeons in LMICs continue to pose a challenge.
With a presence in more than 60 countries, Operation Smile is an international organization that provides free cleft lip and palate surgical and related services. In its early years, the organization followed a short-term humanitarian mission model but has since expanded its service offering to encompass permanent comprehensive cleft care centers in 29 countries, as well as provide for a diverse set of educational and sustainability initiatives7. The organization has also extended beyond utilizing volunteers from high-income countries to include a large, international network of providers, including surgeons, pediatricians, anesthesiologists and nurses7. We present here a novel educational program that seeks to address the workforce crisis in Ethiopia through a traveling plastic surgical fellowship for Ethiopian surgeons, utilizing Operation Smile’s large network of international volunteer plastic surgeons to build local workforce capacity, encourage in-country provider retention, and build sustainability through the promotion of future training programs.
Surgical need in Ethiopia
At last estimate, there were 185 hospitals serving a population of 102.4 million people in Ethiopia, with 80% of the population estimated to be living in rural areas8. Ethiopia’s per capita gross national income is US$660, with 30% of the population living below the international poverty line of US$1.25/d8. Further, only 4.9% of the gross domestic product is allocated to public spending on health, classifying this nation as one of the poorest countries in the world in terms of health care9. Before 1985, all surgical training was conducted internationally, and until 2004, there remained only one surgical training program in the country10. Since 2004 that number has expanded to 8 training programs10, and while these gains are encouraging, the increase in number of providers is far outpaced by the increase in surgical need. The College of Surgeons of East, Central and Southern Africa (COSECSA), an independent surgical governing body for 10 countries in sub-Saharan Africa, maintains a registry of providers and documented only 392 surgeons working in Ethiopia in 2015 (0.41 surgeons per 100,000 patients)11. This number falls far short of the targeted 20 surgical, anesthetic, and obstetric providers per 100,000 members of the population recommended by the Lancet Commission1.
Within Ethiopia, concerning trends also exist in terms of provider distribution. A 2008 survey by Berhan12 on the physician workforce shortage in Ethiopia found that 73% of physicians left the public sector to work in private hospitals or to live abroad. A more recent survey specifically of surgical graduates by Chao et al13 in 2012 had more promising findings; of 225 graduates from Ethiopian surgical training programs, 75% were still practicing in Ethiopia, with 80% of those practicing in the public sector. However, the study also found that 48% of graduates were practicing in the capital city of Addis Ababa, despite the fact that only 3.7% of the country’s population is concentrated there13. In the Jimma region of Ethiopia there are only 11 documented surgeons, or 0.44 per 100,000 members of the population, compared with the 6.34 surgeons per 100,000 members of the population in Addis Ababa11.
Plastic surgery in Ethiopia
While overall surgical capacity in Ethiopia is limited, for those seeking specialty services, such as plastic surgery, the lack of access is even more pronounced. In comparison to the 8 general surgery programs in the country, there is only one accredited plastic surgery training program11. This lack of training opportunity translates to a paucity of specialty providers and an increased backlog of patients. Using a projection model based on paved roads, gross domestic product per capita, and cesarean section rates, Carlson et al14 estimates the backlog of cleft lip and palate cases in Ethiopia to be 13,384. Beyond the treatment of congenital conditions, plastic surgery encompasses traumatic reconstruction, hand surgery, neoplastic reconstruction, and burn care, all common and debilitating conditions in Ethiopia. The broad nature of the subspecialty, in turn, reinforces the immense potential found in training new plastic surgeons to have a far reaching impact in addressing Ethiopia’s surgical burden of disease.
The Operation Smile-Jimma University specialized hospital partnership
In addition to providing comprehensive cleft lip and palate care, Operation Smile is committed to increasing surgical capacity and building local infrastructure in LMICs. The organization has significantly moved towards models of local sustainability. At the organization’s inception in 1982, patients received care from teams comprised entirely of international volunteers, but by 2012, more than two-thirds of volunteers were from LMICs15. This transition to programming led by in-country teams is dependent on available human resources for health. With only one Ethiopian plastic surgeon volunteer within Operation Smile, Ethiopian patients continue to depend heavily on care provided by international teams.
Over the 12 years Operation Smile has worked in Ethiopia, the organization has established a trusted relationship with Jimma University Specialized Hospital (JUSH). JUSH is one of the few specialized hospitals in Ethiopia and serves an estimated population of >15 million people15. Currently, it is the only referral hospital in the southwestern part of the country, providing services for ~15,000 in-patients and 160,000 out-patients each year15. In addition, the facility trains undergraduate and postgraduate medical students, as well as students in other health-related disciplines.
After several years of collaboration with Operation Smile, JUSH expressed a desire to increase surgical capacity and create its own plastic surgery service through the formal specialty training and credentialing of several Ethiopian general surgeons. Operation Smile saw an opportunity to meet this need through a novel, travelling fellowship program, leveraging the organization’s large international network of surgeons to maximize training opportunities. The fellowship program was jointly developed by Operation Smile and JUSH, and approved by COSECSA and the Ethiopian Ministry of Health, with the intent to generate additional plastic surgery providers and encourage them to practice in areas of highest need in Ethiopia. This is facilitated by a commitment from the trainees to deliver surgical care at JUSH for a minimum of 5 years after completion of the program and to participate in ongoing program efforts to train future plastic surgeons and strengthen local training programs. It is the long-term vision that these individuals will ultimately be able to comprise a COSECSA-certified plastic surgery educational service at JUSH.
Selection of the trainees was undertaken through a collaborative process based on trainee interest and input from Operation Smile senior volunteer surgeons, JUSH administration, and the Ethiopian Ministry of Health. Involvement of trainees in the fellowship is staggered in waves of one to 2 surgeons each to minimize disruption of the hospital’s workforce. The program involves rotations in both Addis Ababa and abroad and consists of 3 terms over a total of 3 years, a timeframe consistent with COSECSA standards for plastic surgery fellowships10. All travel and living costs for program participants are covered by philanthropic donations through Operation Smile.
Beginning in January 2015, the first wave of 2 general surgeons began their training. Both trainees spent the initial 6 months learning basic plastic and reconstructive surgery at Addis Ababa University. The second term lasted 18 months and took place at Eda Hospital in Taiwan. In the third term the 2 initial trainees diverged, one beginning a 12-month fellowship in cleft care at Chang Gung Hospital in Taiwan and the other beginning 12 months of training at a series of locations with established relationships with Operation Smile. Figure 1 illustrates the timeline and location of rotations, and Table 1 demonstrates the required training topics for completion. A full curriculum can be found in Supplemental Digital Content 1 (http://links.lww.com/IJSGH/A2). Assessment of the trainees is ongoing and a formal review is expected in early 2018. Real-time feedback from participants and faculty indicate that the trainees are favorably performing at a level similar to other plastic surgery residents in their host programs.
Upon completion of the program, the trainees return to Jimma, where they will apply their skills and develop the plastic surgery service at JUSH. Each subsequent wave of trainees will follow a similar, but not identical path, receiving training from a number of experienced Operation Smile surgeons around the world. After a sufficient number of trained surgeons have returned to Jimma, rotations will transition locally with the establishment of a formal plastic surgery fellowship at JUSH.
With the increasing surgical burden of disease and the geographic maldistribution of providers in LMICs, educational opportunities are now more necessary than ever. Numerous organizations have responded to this need through a variety of educational initiatives, each with its own strengths and limitations. Some of these initiatives have included task sharing or shifting16,17, tele-education through online learning modules18–20, and partnership-based models with volunteer faculty from high-income countries traveling to partner institutions in LMICs21–23. It is beyond the scope of the current manuscript to address each model, but given the enormity of the workforce crisis, additional methods of training are needed to continue to keep pace with growing demands.
Educational exchanges represent one such innovative approach to address the shortage of health personnel. The WHO “Global Code of Practice on the International Recruitment of Health Personnel” article 5.3 remarks on these educational exchanges that “member states should recognize the value both to their health systems and to health personnel themselves of professional exchanges between countries and … opportunities to work and train abroad”6. The Operation Smile-JUSH partnership for a traveling fellowship exemplifies these guiding principles in several unique characteristics. By leveraging an extensive international network of surgeons, Operation Smile is able to provide specialty training not otherwise readily available in-country, and additionally does so without requiring significant volunteer time or travel from international surgical faculty. By establishing a commitment from trainees to returning and serving at JUSH, the program ensures that surgeons are retained in areas of greatest need. With the formation of a new teaching service, the program provides an element of sustainability and ultimately of self-governance. Finally, by ensuring strong cooperation with the hospital administration, the government, national, and regional surgical governing bodies, the program ensures that graduates are nationally credentialed and supported in their continuing practice in Ethiopia.
Despite its potential, there are several important limitations to this fellowship program. While the delivery of surgical education will be a critical component of scaling up human resources for health, surgical systems’ limitations within the surgeon’s environment must also be addressed. Notably, these include infrastructure requirements and the availability of critical equipment and supplies. Operation Smile’s long-term engagement with JUSH necessarily extends beyond delivery of training and includes deployment of critical resources to continue physical capacity building. Such commitment to the improvement of physical infrastructure will be necessary for scaling the program as shortages of electricity, water, central oxygen supply, and blood banks remain a major challenge at many hospitals around the country12. In addition, international partnerships require significant logistical coordination and communication, which can be difficult, particularly when the project involves a diverse group of stakeholders and integration of trainees into existing programs. Funding is also a potential obstacle to overcome. Operation Smile has been fortunate to have sustained commitment from diverse funding sources, but ultimately self-sustaining funding will be necessary for the program’s longevity. It is the long-term goal that future training will ultimately be transitioned to JUSH, with the creation of an accredited plastic surgery training program. With this transition from an international rotating fellowship to locally based training, the aim is for financial support for the program to be transitioned to the Ministry of Health. Until that time, Operation Smile will continue support the infrastructure, training, and human capacity of this fellowship as the program becomes regionally self-driven and self-supported.
Numerous initiatives have shown that nongovernmental organizations (NGOs) have a role to play in supporting Ministries of Health in their efforts to scale up human resources for health within their countries. NGO partnerships with hospitals and training institutions in LMICs represent a way to address critical shortages in surgery providers, as well as to provide specialty training. The Operation Smile travelling fellowship demonstrates the ability to provide training opportunities not otherwise available in-country by leveraging a broad network of international surgeon volunteers. It is the goal of any educational initiative to be translated into further capacity building. Accordingly, by establishing a commitment of program participants to create a local plastic surgery training program upon completion of the fellowship, the Operation Smile-JUSH partnership will continue to grow the plastic surgery capacity of the region. Given the vast burden of surgical disease in LMICs and the paucity of trained providers, innovation and novel approaches are needed to build the workforce. The Operation Smile partnership with JUSH offers one such opportunity to address the human resource crisis and provide the foundation for a stronger surgical system.
Sources of funding
All authors were involved with the study conception and design, literature review, manuscript drafting, critical revision, editing, and approval of the final version of this manuscript.
Conflict of interest disclosures
The authors declare that they have no financial conflict of interest with regard to the content of this report.
Research registration unique identifying number (UIN)
The authors would like to thank Dr William Magee Jr, DDS, MD and Kathy Magee for helping us partner with Operation Smile International and supporting surgical research and education in lower- and middle-income countries.
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