workforce, training, and education emmanuel ameh, lars hagander, caris grimes, nivaldo alonso,...
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Workforce, Training, and Education
Emmanuel Ameh, Lars Hagander, Caris Grimes, Nivaldo Alonso, Eunice Derivoir Merisier, Nyengo Mkandawire, Adam Lantz, Hampus Holmer, Johanna Riesel
The Lancet Commission on Global Surgery
Thursday, June 19, 2014
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Defining the Surgical Workforce
• The health workforce: “All people engaged in actions whose primary intent is to enhance health” (WHO)
• Providing Surgical care is providing a surgical TEAM– Health care executives, managers, leaders– Surgical/Obstetric providers– Anesthetic Providers – perioperative care providers – nurses and trained theater staff– Technical support staff– Radiologists, pathologists– High income country personnel– Community Health Workers
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Handbook on Monitoring and Evaluation of Human
Resources for Health (WHO, 2009)
Working Lifespan Framework
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Workforce: Defining the Current State
• WHO defines health workforce crisis as <2.5 healthworkers/1000 population
• 57 countries in health workforce “crisis”• Little is known about surgical workforce due to
lack of published data• WTE group is collecting data on current state
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Surgical Provider (S, A, O) Density by workforce crisis
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Surgical Provider (S, A, O) Density by World Bank Income Status
HIC
U-M
IC
L-M
IC LIC
HIC
U-M
IC
L-M
IC LIC
HIC
U-M
IC
L-M
IC LIC
HIC
U-M
IC
L-M
IC LIC
Surgeons Anesthesiologists Obstetricians Total surgical work-force
0
10
20
30
40
50
60
70
80
90
100
36.5 35.3
8.9
0.2
13.9 12.6
6.6
0.2
16.6
11.3
0.6 0.2
65.3
60.5
34.1
0.8
Num
ber o
f pro
vide
rs p
er 1
00,0
00 p
opul
ation
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Entry to the Workforce
– Training should reflect the needs of the population– Training curriculum must be updated regularly so
as to match the changing needs of the populations – Emphasize Core Competencies
• Minimal required skill set• Many different ways to train the surgical
provider– Accreditation– Retraining of current surgical providers – Innovative approaches
• Free, online courses • E-learning, e-mentoring, telementoring
– Response to Deficit of Surgical Providers • Task Sharers/Mid-level providers• Visiting surgeons from other
countries/Missionary Surgeons/PAACS
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Task Sharing• Several Countries have adopted the use of “Mid-
Level Providers” or “Non-Physician Clinicians” to address the surgical workforce shortage
• Benefits: shorter training, less expensive, increased workforce numbers in surgery, anesthesia, OBGYN
• Controversy: supervision, quality assurance, difficult decision making, detracting from training of surgeons, appropriate terminology
• Consensus statement to be circulated
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Exit from the Workforce• Migration
– To other countries– Public to Private Sector– Surgical to Nonsurgical Specialties– To Charitable and NGO sector– Rural to urban
• Lack of access to training, infrastructure, remuneration, career opportunities
• International policies to reduce recruitment
• Partnerships with HIC
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Percent Surgical Workforce trained in LIC working in HIC
Switzerland
Slovak republic
Estonia
Austria
Norway
Sweden
Slovenia
Israel
New Zealand
Ireland
Canada
United Kingdom
0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0%
0.5%
0,.%
0.8%
1.0%
1.1%
1.4%
6.5%
7.6%
8.4%
9.5%
13.2%
15.6%
SurgeonsAnesthesiologistsObstetricians
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Performance and Quality• Patients should have access to
basic surgical/anaesthteic/obstetric skills within 2 hours
• Optimum number of surgeons/100,000 population
• M&E e.g. M&M• CME – local and
international/partnerships• Maintenance of certification
• Local • High income country
certification
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Possible Workforce Metrics
Surgical Workforce (SAO) Density (#SAO/100,000 Population)
Distribution of Surgical Workforce (SAO) (#people within 2 hours of surgical care/population)
Proportion of Surgical Workforce (# of SAO/Total National Physician Workforce)
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Primary Research Topics• HIC Benchmarking and Immigration of the Surgical Workforce • The Global workforce project – in 63 countries• MOH survey – sent across the world to report exact number of Surgeons,
Anesthetists, and OBGYN. • Assessing Surgical Workforce Density via the WHO Situational Analysis Tool
in 53 countries• Investigating Training Modules for Surgeons and Anesthetists. • Current requirements (based on estimates of need) to close the gap
between surgical providers and access to basic surgical/anesthetic/obstetric skills within 2 hours
• Likely future requirements (projections of population growth and likely need)
• Teaching Cases: CURE Hydrocephalus, Teaching Laparoscopy in Mongolia
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Key Findings• There is a dearth of data about the true size of the surgical
workforce• Many factors contribute to the current situation of the
surgical workforce• Access to educational Materials and research are limited
in many LMICs• Due to migration factors, current surgical and anesthetic
trainees lack access to available, skilled educators• Developing procedures/treatments based on a
population’s needs is important and may be applicable to other populations around the world
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Recommendations• Overall
– Increased Investment– Improved Training– Better human resources management
• Ministries of Health– Development of Technical capacity to monitor health workforce– Define current situation for their country/gather relevant data– Develop surgical workforce plans to ensure access to basic surgical care within 2
hours – Ensure quality assurance of surgical training, including task sharing– Increased access to fast, affordable internet
• HIC partnerships/NGO’s Charitable Sector– Responsibility not to drain local sector– Train local providers including increased access to eucational and research resources
• Train local providers to be local trainers/educators
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Thank You
Comments?
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The number of major operations* per surgeon and obstetrician, and per anesthesiologist, by World Bank income category**
• Boxes show interquartile range, center point and numeric value shows median value and whiskers indicate maximum and minimum number.• * Data source: Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data.
Lancet. 2008;372:139-44.• ** HIC = High-income (GNI pc $12,616 or more); U-MIC = upper middle income countries ($4,086 - $12,615); L-MIC = lower middle income countries ($1,036
- $4,085); LIC = low income ($1,035 or less)
HIC U-MIC L-MIC LIC0
500
1000
1500
2000
2500
3000
3500
4000
4500
664240
1,017
780
Num
ber o
f maj
or o
pera
tions
per
ane
sthe
siol
ogis
t
HIC U-MIC L-MIC LIC0
100
200
300
400
500
600
700
155
73
236
251
Num
ber o
f maj
or o
pera
itons
per
sur
geon
and
obs
tetr
icia
n
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Surgical Workforce Crisis
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