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BRT 2016 Dalhousie

Building Collaborative Teams to Strengthen Global Surgery

The role of global surgery and anesthesia projects in the training of surgical teams in LMICs

Prof. Patrick Kyamanywa Mmed, MPH, FCS Deputy Vice Chancellor

Kampala International University - Uganda

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AG Context…

• Growing global health challenges; high surgical disease burden in LMICs

• shortage of clinicians and training programs

• weak healthcare infrastructure and inadequate supplies

• Low funding for surgery and anaesthesia research/innovations/projects...still ‘the neglected stepchild of global public health’

• WHO: shortage of surgery and anesthesia human resources is a fundamental challenge to improving global surgical capacity

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Objectives

The objective of my lecture is to stimulate critical thought about the role of global surgery and anesthesia projects in the training of surgical teams in LMICs

• Seeking answers to questions such as – What needs to be done differently?

– what the key skills set should be: global surgical disease burden

– what kind of curriculum should be developed? … issues of accreditation vs pragmatism

– how can the shortage of trainers, trainees and need for sub-specialization be addressed?

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AG …more issues

– Addressing sustainability and true capacity transfer: • human resources- training, deployment, retention (including

biomedical engineers);

• supply chain management – drugs, equipment and consumables; training resources,

• continuous access to refresher training ;

• research support;

• lobbying and advocacy for policy shifts;

• program leadership and institutional systems

– How can we get more funding to surgery and anesthesia? Support for increased Enrolment, research etc

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AG Skills set

• Local challenges, gaps and priorities?

• Future trends?

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AG Curriculum

• Context e.g – Health infrastructure and funding

– Ethical considerations

– Future trends – professional and disease burden

• Capacity to deliver

• E-approaches: teleconferencing, access to recorded sessions

• Accreditation: locally, regionally e.g COSECSA, WACS and internationally

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AG Participatory process

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An international team discussing surgical training in Rwanda

AG Trainers and trainees

• Presence and recruitment

– Mentors

– Supervisors

– twinning

• Professional development: bi-directional

• Retention challenges and strategies

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AG Enrolment …

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AG Equipment and on-site training

Technology & skills transfer

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AG Funding

• Advocacy

• Grants and Research

• Enrolment

• Systems

• Innovations

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AG Sustainability

• Leadership

• Communication and equity

• Systems and capacity building

• Formalization of collaborations

• Training resources

• Translation of research into local practice

• Monitoring and evaluation of agreed milestones

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AG Engage the leadership…

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AG Who’s our voice at the table?

adapted from WHO/WB 2002

AG Some models of projects

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Partnership Model Duration Specialty

CNIS – EAC region short courses especially GPs, some surgical materials

5-10days Surg/Ob-Gyn

CASIEF-Rwanda Short-long; supplies, residence training and CMEs

- 4 weeks (for 10 months a year): Canadian - Residents from Rwanda-6mo in Canada

Anesthesia

HRH –Rwanda long presence, full program engagement, supplies

3 -9 months per year All specialties

Vanderbilt-Kijabe, Kenya

Long presence, , full program engagement , supplies

3-9months per year Surgery and anesthesia

St. Joseph’s Hamilton ; UBC– Uganda

Long presence (reverse movement), supplies

Residents to Canada for 6-1yr months, Fellowships

All specialties

AG Rwanda’s HRH program

AG GPAS in Uganda

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• GPAS: Global Partners in Anesthesia and Surgery -UCSF (http://www.globalsurgery.org/projects/)

– first conference 2010 by UCSF, then UBC 2011, Ontario 2012 and Uganda 2015

• agenda includes:

– knowing who else is in the field,

– harmonization of approaches,

– “Sowing the mustard seeds” in different sub-specialization areas

– advocacy for policy change to mainstream surgery and anesthesia

AG CASIEF - Rwanda

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Framework for global institutional partnerships

Sewankambo N, Tumwine JK, Tomson G, Obua C, Bwanga F, et al. (2015) Enabling Dynamic Partnerships through Joint Degrees between Low- and High-Income Countries for Capacity Development in Global Health Research: Experience from the Karolinska Institutet/Makerere University Partnership. PLoS Med 12(2): e1001784. doi:10.1371/journal.pmed.1001784 http://127.0.0.1:8081/plosmedicine/article?id=info:doi/10.1371/journal.pmed.1001784

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The Paris Declaration on Aid Effectiveness (2005) and Accra Agenda for Action (2008)

1. Ownership: Developing countries set their own strategies for

poverty reduction, improve their institutions and tackle corruption.

(Stronger leadership on aid coordination and use of country

systems in delivery) – academic leadership

2. Alignment: Donor countries align behind these objectives and use

local systems.

3. Harmonization: Donor countries coordinate, simplify procedures

and share information to avoid duplication.

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4. Results: Developing countries and donors shift focus to development results

and results get measured. (Regular Impact Assessment; capacity

development for sustainability and ability to manage future development)

5. Mutual accountability: Donors and partners are accountable for

development results.

http://www.oecd.org/dac/effectiveness/parisdeclarationandaccraagendafora

ction.htm#Paris Inclusiveness of all partners

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The Paris Declaration on Aid Effectiveness (2005) and Accra Agenda for Action

(2008)…contd

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Take home message…

Commitment to continuity

Ownership by all key players

National priorities, systems and landscape

Transfer of knowledge, skills and technology

Ethical principles

Xchange: Bidirectional & mutual benefit

Talk about it and evaluate often

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AG Thank you!

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AG Bibliography

• Alkire, B. C., Raykar, N. P., Shrime, M. G., Weiser, T. G., Bickler, S. W., Rose, J. A., … Farmer, P. E. (2015). Global access to surgical care: a modelling study. The Lancet. Global Health, 3(6), e316–e323. doi:10.1016/S2214-109X(15)70115-4

• Meara, J. G., Hagander, L., & Leather, A. J. M. (2015). Surgery and global health: a Lancet Commission. The Lancet, 383(9911), 12–13. doi:10.1016/S0140-6736(13)62345-4

• Binagwaho, A., Kyamanywa, P., Farmer, P.E.,et al. (2013). The human resources for health program in Rwanda - A new partnership . New England Journal of Medicine 369 (21);2054 – 2059

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• Goecke M.E, Kanashiro J, Kyamanywa P, Hollar G (2008) An international surgery elective in Mbarara, Uganda: An enriching experience for developing Can Meds competencies. Canadian Journal of Surgery, 51(4), August 2008 289-295

• Robin T Petroze, Gita N Mody, Edmond Ntaganda, J Forrest Calland, Robert Riviello, Emile Rwamasirabo, Georges Ntakiyiruta, Patrick Kyamanywa, Emmanuel Kayibanda (2012) Collaboration in Surgical Capacity Development: A Report of the Inaugural Meeting of the Strengthening Rwanda Surgery Initiative. World Journal of Surgery, 09/2012; DOI:10.1007/s00268-012-1769-8

• Robin T Petroze, Reinou S Groen, Francine Niyonkuru, Melissa Mallory, Edmond Ntaganda, Shahrzad Joharifard, Thomas M Guterbock, Adam L Kushner, Patrick Kyamanywa, J Forrest Calland (2012); Estimating operative disease prevalence in a low-income country: Results of a nationwide population survey in Rwanda. Surgery, PMID 23253378

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Robert Riviello, Doruk Ozgediz, Renee Y. Hsia, Georges Azzie, Mark Newton, John Tarpley (2010). Role of Collaborative Academic Partnerships in Surgical Training, Education, and Provision. World J Surg (2010) 34:459–465

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