Module 4: Surgical Workforce

The lack of human resources in developing countries often is the greatest challenge to providing surgical care.  Thus, simply funding and providing equipment will not completely address the surgical disparities that exist between low and high income countries.  Low- and lower-middle-income countries comprise approximately 48% of the global population and have 20% of the surgical workforce, or 19% of all surgeons, 15% of anesthesiologists, and 29% of obstetricians. (1) “The shortage of physicians and nurses in Africa has been well-documented: Africa bears nearly 25% of the global burden of disease with only 2% of the global health workforce.” (2) For example, in Sierra Leone, there are fewer than 10 fully trained surgeons, and only one is younger than 50. “There is no next generation of surgeons in the country.” (3) In Uganda, there are only 75 fully-trained general surgeons for a population of 30 million people. In all of East Africa, there are only 400 fully trained surgeons for a population of more than 200 million people.(4) Tanzania has only two physicians for every 100,000 people, as compared with 256 for every 100,000 people in the United States.(5) Malawi has 21 district hospitals, but none has a permanent surgeon.(6) There is also a chronic shortage of qualified pediatric surgeons in many developing countries. In West Africa, there are only 10 surgeons with pediatric training, while an additional 29 practice in East and Southern Africa. (7) There is also a great shortage of health care workers trained to provide obstetrical care. In Senegal, there are only 15 Medical Officers with the skills to perform cesarean sections for approximately 11 million people. (8) Mozambique has 435 physicians and only 26 obstetricians for a population of nearly 20 million. “This dearth of physicians and other providers skilled in emergency obstetric care is echoed throughout Africa.” (9) In addition to the absolute shortage of health care providers for surgical and anesthetic care, there is an imbalance in the distribution of those who can provide surgical care. Most physicians and surgeons choose to practice in urban areas, creating extraordinary access challenges for rural populations who are in the greatest need of receiving surgical care.(10)

The paucity of surgeons in developing countries is largely due to the length of the training required, its cost, and the fact that surgeons can earn more money in higher-income countries, which results in brain drain. Ghana has been one of many countries to experience this brain drain. “Ghana has been unable to provide an adequate supply of physicians for the country in part because more than two-thirds of Ghanaian-trained medical school graduates left the country between 1993 and 2000.”(11) Brain drain can also occur within a country. Many countries have difficulty retaining trained personnel to work in government hospitals because nongovernmental organizations pay much more than the government. This draws valuable health workers away from needy government hospitals. In addition, “many physicians, particularly specialists, choose to practice in the capital or in other large cities to maximize their professional and personal opportunities, leaving rural areas severely understaffed.” (12)

Footnotes

(1) Holmer, H., Lantz, A., Kunjumen, T., Finlayson, S., Hoyler, M., Siyam, A., ... & Hagander, L. (2015). Global distribution of surgeons, anaesthesiologists, and obstetricians. The Lancet Global Health, 3, S9-S11.

(2) Ozgediz, D., and Riviello, R. “The ‘Other’ Neglected Diseases in Global Public Health: Surgical Conditions in Sub-Saharan Africa.” PLoS Med. 5.6 (2008).

(3) Kushner, A. “Addressing the Millennium Development Goals From a Surgical Perspective. Essential Surgery and Anesthesia in 8 Low- and Middle- Income Countries.” Archives of Surgery. 145.2 (2010): 154-159.

(4) Abdullah, F., et. al. “Assessment of Surgical and Obstetrical Care at 10 District Hospitals in Ghana Using On-Site Interviews.” Journal of Surgical Research. (2010).

(5) Casey, K. “The Global Impact of Surgical Volunteerism.” Surgical Clinics of North America. 87 (2007):949-960.

(6) Lavy, C., et. al. “Surgery in Malawi- a national survey of activity in rural and urban hospitals.” Ann R Coll Surg Engl. 89.7 (2007); 722-4.

(7) Bickler, S., and Rode, H. “Surgical Services for Children in Developing Countries.” Bulletin of the World Health Organization. 80.10 (2002).

(8) Abdullah, F., et. al. “Assessment of Surgical and Obstetrical Care at 10 District Hospitals in Ghana Using On-Site Interviews.” Journal of Surgical Research. (2010).

(9) Kruk, M., et. al. “Economic evaluation of surgically trained assistant medical officers in performing major obstetric surgery in Mozambique.” BJOG. 114 (2007): 1253-1260.

(10) Ozgediz, D., et. al. “The Neglect of the Global Surgical Workforce: Experience and Evidence from Uganda.” World J Surg. 32. (2008): 1208-1215.

(11) Abdullah, F., et. al. “Assessment of Surgical and Obstetrical Care at 10 District Hospitals in Ghana Using On-Site Interviews.” Journal of Surgical Research. (2010).

(12) Kruk, M., et. al. “Economic evaluation of surgically trained assistant medical officers in performing major obstetric surgery in Mozambique.” BJOG. 114 (2007): 1253-1260.