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Developing Sustainable Orthopaedic Care in Northern Tanzania: An International Collaboration

Sheth, Neil P. MD*; Hardaker, W. Mack MS; Zakielarz, Kevin S. MSPA; Rudolph, Michele BS§; Massawe, Honest MD; Levin, L. Scott MD, FACS; Premkumar, Ajay MD, MPH**

Author Information
Journal of Orthopaedic Trauma: October 2018 - Volume 32 - Issue - p S25-S28
doi: 10.1097/BOT.0000000000001296

Abstract

BACKGROUND

There is a severe lack of access to surgical care, including orthopaedic surgery, in low- and middle-income countries (LMICs).1–4 A shortage of orthopaedic surgical care in LMICs is further complicated by increased demand because of high and growing rates of road traffic accidents and other causes of injury, which often require operative intervention.5–8

Tanzania, an East African country with a gross domestic product per capita that falls in the bottom 15% of nations worldwide, is no exception to these trends; road traffic accidents were the fourth leading cause of death in Tanzanians aged 14–49 years.9,10 There are a total of 237 hospitals in Tanzania, with a majority concentrated in populous cities such as Dar es Salaam, on the nation's east coast. In the northern part of the country, there are approximately 12 million inhabitants and a high volume of foreign travelers; an adequate tertiary facility to deliver musculoskeletal care in northern Tanzania is essential.

Kilimanjaro Christian Medical Center (KCMC), a 700-bed teaching facility in Moshi, Tanzania, is the only existing tertiary referral hospital serving the 5 distinct Northern Tanzanian regions: Arusha, Kilimanjaro, Singida, Tanga and Manyara. Fig. 1. KCMC sees 110,000 patients annually in the outpatient clinic and admits nearly 25,000 patients for treatment.11 The associated university is the largest educational institute in Tanzania with 1200 medical students and an additional 800 students throughout 16 different allied health schools.

FIGURE 1.
FIGURE 1.:
Map of the Northern Corridor of Tanzania depicting the catchment area of Kilimanjaro Christian Medical Center.

SEVERE RESOURCE SHORTAGE

For Tanzania's population of approximately 50 million people, there are roughly 45 practicing orthopaedic surgeons; there is 1 orthopaedic surgeon for every 1.7 million Tanzanians compared with 1 orthopaedic surgeon for every 11 thousand Americans in the United States.12,13 Given the severe shortage of trained orthopaedic surgeons, most surgeons in Tanzania are inundated with acute trauma care and musculoskeletal infections; elective procedures are infrequently performed and the burden of neglected care continues to rise.

As the largest hospital in Northern Tanzania, KCMC receives most of the acute surgical trauma and all transfers from regional hospitals for definitive orthopaedic care. However, the orthopaedic ward can only house 59 patients, which is not adequate to handle the daily/weekly burden. Facing a similar burden of disease as that of a busy Level 1 trauma center in the United States, the vast majority of patients at KCMC do not receive clinically indicated surgical treatment because of patients' financial constraints, material resource deficits, and systems limitations. After waiting on average greater than 10 days, at best, 50% of patients receive any type of surgical care, despite the fact that more than 95% of admitted patients have injuries that would be indicated for operative treatment.11 Those with lower extremity long bone fractures who do not receive definitive surgical treatment are commonly admitted for 6 weeks of skeletal traction. This treatment modality renders patients immobile and carries a high rate of venous-thromboembolism, skin breakdown, as well as nonunion, malunion, and severe long-term disability, which can have devastating effects on income and employment status.14

HISTORICAL SOLUTIONS

The current systems of care in LMICs are generally insufficient and incapable of handling the existing and growing burden of musculoskeletal disease. This has led to increased enthusiasm in the developed world for providing surgical services in these austere environments. From this enthusiasm, the mission trip concept has evolved to provide medical and surgical care during periodic short trips–the “surgical teaching” trip. Such trips are becoming more frequent, with an estimated 6000 trips sponsored by US organizations accounting for approximately 200,000 surgical cases and $250 million annually.15,16 However, such trips may be poor at promoting sustained local capacity.

In addition to concerns over whether visiting teams may use culturally insensitive practices or undermine the local population's perception of the local provider's ability to deliver care, questions remain over how much local providers are able to replicate what they have learned during surgical mission trips because of the system constraints that persist after the visiting team departs.

Given several known concerns regarding surgical mission trips, a series of questions arise when considering the efficacy and bioethics of such trips as a solution to address the enormous demand for orthopaedic surgical services in LMICs17 (Table 1).

TABLE 1.
TABLE 1.:
Bioethical Questions of Surgical Mission Trips17

Evaluation of historical solutions suggests that we need a better answer. It is important to determine what is needed locally in a country such as Tanzania to increase surgical capacity, ensure surgical safety, improve reproducibility, deliver affordable care, and provide adequate patient follow-up for the diagnosis and treatment of postoperative complications.

DETAILS OF OUR GLOBAL PARTNERSHIP

We present a novel, sustainable global collaborative solution to the problem outlined above by building an Orthopaedic Center of Excellence in Moshi, Tanzania, to be populated year-round by international advisors. This initiative is a public–private partnership between the University of Pennsylvania, KCMC, the Tanzanian Health Ministry, and various third-party partners. The focus of this initiative is to ultimately transition care to a new workforce of local surgeons and clinical staff, trained at this center, within 5 years.

With the University of Pennsylvania at the helm, this collaboration has been formulated to include 26 major academic institutions to collectively provide year-round coverage of the center for the initial 4–5 years. Each team will consist of approximately 20 members with a focus on orthopaedic trauma, adult reconstruction, pediatric orthopaedics, and plastic/hand surgery (Table 2). To support consistency of care across teams throughout the entire year, clinical guidelines for the most common orthopaedic conditions will be created and incorporate the latest available evidence. Although each team will be responsible for airfare costs, food and lodging will be provided in a secure gated campus adjacent to the hospital.

TABLE 2.
TABLE 2.:
Visiting Team Constituents and Overall Team Focus

In conjunction with our multidisciplinary team, which includes members from the Wharton School of Business and the Leonard Davis Institute of Health Economics, we have been fortunate to form strategic alliances with implant manufacturers and with GE Healthcare Africa, which have been crucial in developing an informed approach for working in the region, as well as a reliable source of implants at a reduced cost, hospital supplies, imaging equipment, and access to equipment maintenance and training. In return for these services, we have agreed to exclusively use GE equipment, when available. As KCMC is partly funded by the Tanzanian government, we have been bolstered by government support through donations of land with adequate access to water, sanitation, and power and negotiated a reduced import tax rate on implants used at this new center. These alliances mark a large shift from the current reliance on a donation system from charities and developed nations for implants and equipment, often bypassing the device and equipment manufacturers and even improperly avoiding associated import taxes, a system which is inherently unreliable and unsustainable, and may lead to poorly functioning equipment and ultimately, suboptimal care.

KCMC is already home to one of the largest orthopaedic surgery residencies in East Africa and draws residents from several surrounding countries. As such, resident surgical education will be at the core of this global partnership, with the specific aim of creating the next generation of African surgeons trained in the latest surgical techniques with the most current surgical equipment and resources. Although we anticipate KCMC residents to form the core surgical workforce at this center after transitioning care from international teams, we also acknowledge that many of KCMC's current non-Tanzanian residents often return to their country of origin, and we hope to better equip them to care for their communities while also furthering the dissemination of modern orthopaedics in this region.

In most developing nations, state-of-the art health care is available only to those at the top of the wealth pyramid, who can afford these services locally or travel internationally for care; minimal or no access to modern surgical care is available for the vast majority of the population, the pyramid's foundation. To make the institute financially viable, a tiered payment system is being designed based on specific package designations and local expectations. Nonsurgical components of care such as number of beds per room, number of meals provided, and group versus individual therapy sessions will all differ between packages. Costs for those without means will be in part covered by those who are able to pay. Regardless of the patient's ability to pay, the quality of surgical care delivered will be equal.

We acknowledge several barriers to our model, including but not limited to recruiting adequate international teams, training and retaining a local administrative workforce, ensuring appropriate transitions between international care teams, creating a culture of respect to support bidirectional knowledge transfer between local and international providers, avoiding potential disruptions in implant and equipment supply, and attracting those in the local population with means to help offset the cost to those without the ability to pay. To address these barriers, we have developed protocols for surgical treatment and postoperative care to guide team recruitment and transitions. We have consulted with several hospital management companies with experience in the region and created a thorough organizational chart which clearly defines the roles and responsibilities of all partners in this collaboration, which has been agreed to by all parties. Every surgical team will undergo training on cultural awareness and orientations with local staff, which will promote the ethical principles of distributive justice, beneficence, solidarity, informed consent, and patient autonomy. A surgical educational curriculum for local physicians will incorporate bidirectional knowledge transfer with visiting teams. In-depth financial modeling has guided assumptions on financial viability and profitability within a 5-year time horizon before transitioning care to local providers. Marketing and outreach initiatives have begun to identify and ultimately retain high-earning potential patients in the region to access orthopaedic care at this center.

CONCLUSIONS AND NEXT STEPS

Our vision is to channel the conviction at the heart of all surgical mission trips into a collaborative solution to build long-term orthopaedic surgical capacity in Northern Tanzania and more broadly, East Africa, through an Orthopaedic Center of Excellence in Moshi, Tanzania. In addition to providing culturally sensitive, affordable orthopaedic care, resident education is at the center of our mission to build the local surgical workforce, and over several years, reduce the influence of foreign surgical teams (see Figure, Supplemental Digital Content 1, https://links.lww.com/JOT/A464). Our group is currently securing additional local partners and further engaging in outreach with existing orthopaedists and traditional bone healers in the region. We hope to open the doors and begin patient care in this Center of Excellence by 2021.

REFERENCES

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Keywords:

Africa; Tanzania; sustainable workforce; surgical training

Supplemental Digital Content

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