W

hen my wife went into labor in 2006, I was responsible for just two things: calling our obstetrician and making the 20-minute drive to a private maternity hospital in Addis Ababa, the capital of Ethiopia.

Things were much harder for my uncle Mamo and his wife, Adanech, when she went into labor at home in their rural Ethiopian village. After she was in labor for two days with little progress, it was clear that she and the baby were in danger.

She urgently needed surgery — a caesarean section.

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That meant my uncle had to:

  • sell a cow and an ox for cash;
  • buy bus tickets for a trip by gravel road for two hours to the town nearest their farm;
  • arrange for a place to stay overnight;
  • witness his wife’s misery as a hospital nurse examined her, naked, in front of the strangers who were accompanying other women laboring on benches and on the floor of the maternity ward;
  • rush out of the hospital, prescriptions in hand, to buy intravenous fluids and antibiotics at a pharmacy;
  • donate blood because the hospital blood bank was closed;
  • wait for administrative paperwork to clear;
  • and, finally, wait for the doctor to arrive.

It took 24 hours from the time they arrived at the hospital until the “emergency” caesarean was performed.

Despite uncle Mamo’s efforts, my aunt’s determination to have a healthy baby, and the best efforts of local health care workers, my cousin died 10 minutes after she was born.

A huge unmet need

More than 5 billion people — the majority of the world’s people — lack access to safe, affordable, and timely surgical and anesthesia care. It’s a big problem in Ethiopia, where I was born and raised. An average-size hospital serving a population of 100,000 anywhere in the world should have 20 specialists to perform 5,000 lifesaving surgical procedures per year. Ethiopia has fewer than one specialist per 100,000 people.

That ratio hasn’t improved much in the decade since my newborn cousin died. But now my country is in the midst of changing that. I’ve been helping health care workers who aren’t trained as surgeons perform emergency surgery.

Ethiopia is part of an emerging global movement to provide quality basic surgical care to families so women in need of caesarean sections don’t die; kids with compound fractures aren’t crippled; and men aren’t permanently debilitated by hernias. Informed by a 2015 Lancet Commission on Global Surgery report, a group of corporations, institutions of higher learning, and global health advocates have committed themselves to tackling the lack of basic surgical care. Ethiopia was the first country to embrace a radical rethinking of surgery’s conventional doctor-at-the-helm arrangement and earlier this year established a national plan for safe surgery.

In districts where there are no surgeons, we are investing in nonspecialist surgical care providers — health care workers like nurses, clinical officers, general practitioners, and midwives who are already on the job. They aren’t surgeons but can be trained to work as teams to perform certain emergency procedures in their community facilities. This would relieve the burden from the limited number of surgeons who work primarily in larger urban hospitals. The thinking is that teams in the trenches are well positioned to identify medical problems that require surgery and take the lead on delivering uniquely creative solutions.

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In remote hospitals, when nonspecialist surgical care providers gain clinical skills and use checklists — and have the agency to effect change — they can ensure standardized, high-quality surgical care for those who need it.

Checklists are the key. I have to admit, I’m a list guy. Lists are important to me, my profession, and my patients. Use of the World Health Organization’s Safe Surgery Checklist has made surgery safer, globally reducing complications of surgery by 36 percent and deaths by up to 62 percent. Likewise, use of the 2016 WHO guidelines aimed at preventing surgical site infections and curbing the spread of superbugs is also saving lives.

Lists and guidelines are vital for standardizing care and ensuring quality. They can improve safety and timely referrals, preventing the life-threatening complications that result from delays in care.

Because the concept of using nonspecialist surgical care providers to improve access to surgery upends the status quo, this approach is not without skeptics. That’s why we’ve fostered relationships between health workers in rural facilities and specialists in urban hospitals, so surgeons in the latter can see for themselves that if everyone focuses on patient care rather than professional differences, nonspecialist surgical teams can save lives. Lots of them.

A case in point is a senior surgeon who declined, at first, to advise nonspecialists. After visits to two facilities where the initiative is well underway, he agreed to be on call to provide guidance about procedures and help ensure timely referrals. From his office at the Ministry of Health, he’s now the driving force behind Ethiopia’s commitment to deliver surgical care to all who need it.

Firsthand experience convinces me that this reimagined surgical ecosystem works. Emerging evidence shows how the delays and disparities that stymied my uncle and exacted a heavy toll on my aunt and baby cousin may finally begin to end.

Tigistu Adamu Ashengo, M.D., is the associate medical director at Jhpiego, an international, nonprofit health organization affiliated with Johns Hopkins University.

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  • Thank you Tigistu for writing this article. Putting the patients at the center and rethinking how our systems of delivering care might be reorganized would lead the country to deliver a care that is better accessible and of better quality. The article reminded me one procedure myself and a colleague did for a man who had a fall down accident over a hill which resulted in a gangrenous leg with a need for an above knee amputation. He arrived at our hospital days after the accident with severe infections and anemia. We had no surgeon and the family couldn’t accept (for financial reason) our advice of referral for amputation to the nearest hospital where an orthopedist/surgeon might be available. Relying on our little knowledge from our training as a general practitioner and a short training on minor surgical procedures we were able to address the need of the patient and the family of getting care (the amputation) in the hospital. We were lucky enough to get the patient recovered from the infectious process and his life saved. Some task shifting activities will be effective to improve quality of care if supplemented by appropriate coaching and support system to enable the professional provide the intended care. However, task shifting shouldn’t be the ultimate goal by its own. The country should produce adequate number of specialists to be assigned at all levels as per the functional recommendations of facilities in the country and an appropriate facilitation of referral will be key to connect the needy with the service.

  • I agree with you Dr Catherine. Nurses are systematically undervalued and under-utilised – in the sense that they are very often not able to use their training to the full and work to their full potential. In our setting over utilized yet systematically materialistically undervalued by some people who do not have an idea of what type of training a nurse under goes. A nurse has to shout loud to be heard while others whisper to be heard.

  • This article reminded me of a story I heard on NPR about folks in Syria being trained to do surgery with an MD Skyping in as needed from the UK. Some of these people had no prior medical training and yet good results were obtained. In the face of a surgeon shortage we must do what we can with what we have. The previous comment about underutilization of nurses is pertinent, too.

  • I enjoyed reading your article! It is a great approach to alleviate the shortage of specialized healthcare workforce in our country and create sustainable basic surgical care for our people. I personally volunteer with an organization called EthiopiaCardiology, which provides a cardiology fellowship program for internist interested in specializing in Cardiology. I am a Cardiac Sonographer and my part is to teach the Fellows how to perform a Cardiac ultrasound in this program. So far the internists I trained are performing Echocardiogram independently and treating basic Cardiac issues in Jimma University. I am trying to bring one Fellow at a time for a couple of months of clinical training in the institution I am working.
    Hopefully, every Ethiopian who is fortunate enough to be trained in healthcare field, in the U.S or other developed countries, will have the courage to contribute by passing on the knowledge and skill to improve healthcare in Ethiopia.
    Thank you for all you do!

  • In response to the articles referring to the shortage of doctors in some countries and therefore the need to upskill or use other health workers differently, I am writing to update you on the progress of Nursing Now! – a 3 year campaign to raise the profile of nursing globally.

    The ‘Triple Impact’ report on nursing, published in October 2016, concluded that:

    • Nurses are half the health workforce and global goals such as tackling drug resistance and achieving Universal Health Coverage won’t be achieved unless nursing is strengthened;

    • Nurses are systematically undervalued and under-utilised – in the sense that they are very often not able to use their training to the full and work to their full potential. Nurses reported in interviews that they wanted to do much more;

    • Developing nursing will directly contribute to three of the UN’s Sustainable Development Goals – improving health, promoting gender equality, and strengthening economies.

    The report was very well received and led to the Nursing Now! campaign being formed with support from the International Council of Nurses, the Commonwealth Nurses and Midwives Federation, the Royal College of Nursing and others. Dr Tedros Adhanom, Director-General of the World Health Organization, and other global leaders have already pledged support.

    The Nursing Now! campaign will seek to:
    ¥ influence policy and decision makers by demonstrating what nurses can achieve and advocating for specific objectives and goals

    ¥ create a grassroots movement among the global nursing workforce to generate energy, boost morale and encourage recruitment

    The campaign will launch in early 2018 and conclude with a report on progress in 2020 as part of the celebrations of the bicentenary of Florence Nightingale’s birth. Its work will be carried on thereafter at global, national and local levels by the many nursing and other organisations engaged in the campaign.

    The August 2017 ‘Update’ on the Nursing Now! campaign can be found by following the link (cut and paste):
    http://www.appg-globalhealth.org.uk/home/4556655530

    Please do circulate the ‘Update’ widely through your local and global networks and encourage others to register their interest in the campaign by clicking on the link in the ‘Update’ and completing the form.

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