1. 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 1

2. 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 2

3. Handbook on Monitoring and Evaluation of Human Resources for Health (WHO, 2009) Working Lifespan Framework 3

4. 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 4

5. Surgical Provider (S, A, O) Density by workforce crisis 5

6. Surgical Provider (S, A, O) Density by World Bank Income Status 6

7. 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 7

8. 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 8

9. 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 9

10. Percent Surgical Workforce trained in LIC working in HIC 10

11. 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 11

12. Possible Workforce Metrics 12

13. 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 13

14. 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 14

15. 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 15

16. Thank You Comments? 16

17. The number of major operations* per surgeon and obstetrician, and per anesthesiologist, by World Bank income category** 17 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)

18. Surgical Workforce Crisis 18