The Neglect of the Global Surgical Workforce: Experience and Evidence from Uganda

I read the article by Ozgediz et al. entitled ‘‘The Neglect of the Global Surgical Workforce: Experience and Evidence from Uganda’’ [1]. I want to share my experience and contribute my thoughts on this serious problem facing rural populations in sub-Saharan Africa. I had conducted a similar health facility assessment and survey for the government of Cross River State (CRS) in Nigeria in 2000 (unpublished report). I have also worked in Mozambique and witnessed the surgical skill and volume of surgical services rendered by nonphysician surgical technicians called ‘‘tecnicos de cirurgia’’ in Portuguese. I have undergone surgical training as part of my residency training in General Practice/Family Medicine (GP/FM)-original Nigerian Model, and served in peripheral/rural hospitals in Nigeria and Mozambique at the level of Principal Medical Officer/Medical Director for more than 10 years before going into public health medicine. I am therefore not writing as a specialist surgeon but as someone who has served the rural population as a generalist physician with surgical and obstetric training and skills. My review had the same findings as Ozgediz et al. had in Uganda. There were two specialist surgeons for the 18 general hospitals (district hospitals) serving a population of more than 3 million people, 90% living in rural areas. The teaching hospital in the capital city is home to 95% of all the medical doctors in the State (province). This is because most of the doctors at the teaching hospital in the postgraduate residency in various surgical specialties (and other specialties) stay in training an average of 8 years (some stay up to 10 years). In their study in Mozambique Kruk et al. [2] have shown that training more midlevel health workers in surgery is a good investment and a way to respond to the shortage in the surgical workforce. In Nigeria, the surgical and obstetric and gynecologic training component in GP/FM residency (12 months), if maintained as the originally intended, is an equally good investment and way to increase surgical services in rural populations. It is obvious that one way of improving the surgical workforce in Africa is to promote short postgraduate (PG) training programs and intensive rural clerkship at the undergraduate level. A PG training program of 18 months in general surgery, 18 months in OG-GYN, and 18 months in anesthesia, all leading to government and medical council licentiates as specialists and designed for peripheral hospital career development, will go a long way to attract and retain trained specialists in rural and peripheral hospitals. One reason why the Mozambique program has worked is because of the recognition and respect given to these ‘‘tecnicos de cirurgia’’ by the government, medical council, and medical doctors (MD), both generalist physicians and specialists. In fact, the generalist MDs who spend two compulsory years in rural hospitals after graduation in Mozambique refer surgical cases to the ‘‘tecnicos’’ and some of the MDs even get surgical tutoring from the ‘‘tecnicos.’’ Finally, the above proposals of shortening surgical training for MDs or the use of nonphysicians are not substitutes for long surgical training and subspecialist programs. They are intended to produce more hands for basic and life-threatening surgical services until such a time when all the development indices have spread to engulf the rural population. The short training programs will then be adjusted accordingly. The UK recently E. Monjok (&) Institute of Community Health, University of Houston, Texas Medical Center, 1441 Moursund St. Suite 119, Houston, TX 77030, USA e-mail: emonjok@uh.edu