Lancet Commission on Global Surgery
Workforce, Training, and Education
Workforce, Training and Education Working Group
Work Plan
April 2014
I.
II.
Important Deadlines
WTE Quantitative Research Projects
III.
C. Surgeon Density
WTE Reporting of Current State
A. Numbers of Surgical Health Care providers
B. Surgeon Mapping (by way of HDM group)
A. Workforce Dynamics
B. Training
IV.
C. Education
WTE Case Vignettes
V.
C. Training of Task Sharing
Tables and Figures
A. RCSI/COSECSA
B. Retention of Health Workers CWI
A. Comparison of training modules (surgeons and task sharers)
B. Minimal Skill Set
C. Access to surgical services
D. Surgical Migration
E. The surgical package (graphic)
F. Surgeon Density (graphic)
VI.
G. Surgeon Density (Urban vs Rural) (graphic)
Papers for the Commission Appendix
VII.
C. Migration of surgeons worldwide.
Work Plan Appendix
A. Surgical training in South Africa
B. National density of surgical health care workers
A. Questions sent to WACS/COSECA/Large organizational bodies
B. WTE Draft Document/Outline
C. Key papers needed to write the WTE section of commission
Lancet Commission on Global Surgery
Workforce, Training, and Education
I. Important Deadlines
Sierra Leone Meeting: June 19-20
 Deliverables
o roughly 1500-word outline
o topics that need to be discussed by commissioners
 eg Task Sharing, university vs college model of training etc
o DEADLINE: June 12, 2014
Initial Draft for Peer Review Due: September 2014
Dubai Meeting: November 2014
Second Peer Review: January 2015
II. WTE Quantitative Research Projects
Situational Analysis
 Number of Surgeons, Anesthetists, OBGYN
o Kathleen O’Neill in Geneva for 3 weeks to work through the WHO situational
analysis data. This includes the Quick Situational Analysis Tool as well as the
more comprehensive SARA tool.
 Person in charge: Johanna to work with Katie to parse out pertinent
data
 Deadline: April 30th (rough draft) May 15th (final draft)
o Lars collecting information from large organizational bodies (eg ISS, FIGO, WFA)
re: numbers
 Person in Charge: Lars
 Deadline: April 30th (rough draft) May 15th (final draft)
o Lund team contacting large number of national colleges to determine surgeon
density
 Person in Charge: Lars
 Deadline: June 15th
o Lars and Co. (Adam, Hampus) collecting numbers on surgical workforce
migration from LICHIC
 Has #surgeons from 40 HIC; proportion of those trained in LIC for about
15 countries – still collecting data
 Person in Charge: Lars
 Deadline: April 30th (rough draft) May 15th (final draft)
o Emmanuel and Nyengo in charge of collecting answers to the questions listed in
appendix from WACS and COSECSA
 Person in Charge: Caris and Emmanuel
 Deadline: April 30th (rough draft) May 15th (final draft)
o Nivaldo collecting numbers in Brazil/Latin America
 Person in Charge: Nivaldo
 Deadline: April 30th (rough draft) May 15th (final draft)
o Eunice Collecting data on number of health workers in Haiti
 Person in Charge: Eunice
 Deadline: April 30th (rough draft) May 15th (final draft)
o Jordan Pyda compiling already published data on workforce numbers
Lancet Commission on Global Surgery
Workforce, Training, and Education
Will pull data from Margo’s published review of Health Workforce,
amongst other publications
 Person in charge: Jordan
 Deadline: April 30th (rough draft) May 15th (final draft)
John Scott compiling data on internal brain drain
 40 articles published on internal brain drain of doctors; 0 on surgeons
 Deadline: April 23 (rough draft) April 30th (final draft)

o
Surgeon Mapping Project conducted by HDM group
 Nakul is in charge of this project – Johanna will help as density of surgeons in rural
areas is a field of interest for WTE group.
 Person in Charge: Primarily Nakul, Johanna as assist
 Deadline: June 15th
Lancet Commission on Global Surgery
Workforce, Training, and Education
III. WTE Reporting of the Current State
Workforce Dynamics
 Determining baseline requirements #’s needed for safe surgical care
o Based in part off of Surgeon Mapping
 What is the current state? What is the ideal state? How do you
get from AB
 Can we use something like Maternal Mortality as a target
outcome?
o Focus on metric of #surgeon/anesthetist per rural population
o Future requirements based on population projections
o Can we estimate number of surgical providers needed per population?
 Deadline: May 30th
 Person in charge: Johanna (in close association with working
group leads)
 Other Workforce Dynamics (see outline below)
o Draft outline
 Deadline: May 30
 Person in charge: Johanna and Caris

Training and Education (see outline below)
o Draft outline
 Deadline: May 30
 Person in charge: Johanna and Caris
Lancet Commission on Global Surgery
Workforce, Training, and Education
IV. WTE Case Vignettes (pop out boxes)
Case Topics
 Case 1: RCSI& COSECSA
o Caris is drafting 500 word document  nearly complete
 Deadline: April 23 (rough draft) April 30th (final draft)
 Case 2: Task shifting in Malawi
o Nyengo is drafting rough draft with Caris
 Deadline: April 23 (rough draft) April 30th (final draft)
 Case 3: University of West Indies
o Jacky collecting information
 Deadline: April 23 (rough draft) April 30th (final draft)
 Case 4: Rwanda HRH
o Robert Riviello/Johanna have written something similar for JGM textbook
o Robert may still be planning to make this a case study therefore would not
be a vignette
 Deadline: April 23 (rough draft) April 30th (final draft)
V. Figures and Tables
Figures & Tables
 Table1 and 2: Comparison of different training modules for 1. Surgeons (3 years vs 5
years for general surgery; paradigms from each continent) and 2. Task Sharers (Masters
degree? Bachelors degree?)
o Johanna +/- new medical student to manage Surgeon Table
o John Scott to manage Task Sharing Table
o Deadline: May 15th
 Table 3: minimal Skill Set required by each provider
o Note: I think it is most important to emphasize that regardless of who does
the procedures, it needs to be done well – which circles back to Quality
Assurance.
o Johanna and Caris in association with other working group leads
o Deadline: May 15th
 Table 4. # of people per country with access to surgical services (Based on Surgeon
Mapping Project)
o Johanna to work closely with Nakul
o Deadline: June 15th
 Table 4: Migration of surgeons from LICHIC
o Lars and Adam
o Deadline: May 15th.
 Figure 1: the surgical package (a graphic image of MOTS)
o Johanna
o Deadline: May 15th
 Figure 2. Surgeon Density.
o Lars
o Deadline: June 15th
Lancet Commission on Global Surgery
Workforce, Training, and Education

Figure 3: Rural vs Urban density of Surgeons (Based on Surgeon Mapping Project. +/Surgeon Density Project)
o Lars, Nakul, Johanna
o Deadline: June 15th
VI. Papers for the Commission Appendix
 National Density of Surgeons, OBGYN, and Anesthetists, World Wide
o Person in charge: Lars
o Deadline: June 15th
 The Migration of surgeons worldwide
o Person in charge: Lars
o Deadline: June 15th
 Training of surgeons in Johannesburg, SA
o Paper to be written by Martin Smith/Martin Vella
o Rowan is in contact with them
o Deadline: May 30th
VII. Appendix to the WTE Workplan
Appendix A: Questions sent to members of WACS and COSECSA (via
spreadsheet for easy answer entry)
Number of trained surgeons in your country
Number of trained anesthetists in your country
Number of trained OBYN in your country
Number of Surgical Nurses (is possible)
Number of Surgical Task Shifters in your country
Number of medical school graduates/year in your country
How many trained surgeons in rural locations in your country
How many trained anesthetists in rural locations in your country
How many trained nurses in rural locations in your country
How many trained OBGYNs in rural locations in your country
How many trained surgical task sharers in rural locations in your country
How many of your institutions participate in morbidity and mortality
conferences?
o Do your surgeons and anesthetists participate in CME
o Comments
o
o
o
o
o
o
o
o
o
o
o
o
Appendix B: WTE Draft Outline
I.
Workforce – current situation
A.
Data is needed on number of
1. Surgeons
Lancet Commission on Global Surgery
Workforce, Training, and Education
II.
2. Obstetricians
3. Anesthetists
4. Nurses
5. Mid-level providers
Definition of surgical and anaesthetic workforce (present situation)
o Health care executives, managers, leaders
 Guidelines for health care managers – see email from Lars
o Surgeons and obstetricians
o Anesthesiologists and non-physician anaesthesetists
o Radiology, pathology
o Nurses and trained theatre staff
o Non physician clinicians
o Technical support staff
o High income country personnel
 Workforce dynamics
o Requirements
 Current requirements (based on estimates of need)
 Likely future requirements (projections of population
growth and likely need)
 Task Sharing – issues, strengths, outcomes,
controversies
 Balance between investing in ex-pat capacity vs local human
resource capacity. My guess is there is 5:1 to 10:1 cost
differential. Would also address where to invest in building
local HR capacity – NGO vs government systems. (David
Bangsberg)
o Recruitment and retention
 Issues – medical schools and graduates – numbers
 Attraction to surgery/anaesthesiology etc as career choices
– potential solutions
 Attraction to rural areas – potential solutions
 Migration – current situation, international policies and
potential solutions
 These are issues that involve ALL elements of surgical
workforce including engineers, radiologists, nurses.
 Internal/external brain drain. See bajinurwe PMID: 23793660
for data saying that many physicians are staying in country to
work for HIV NGO’s causing internal brain drain for other
specialties (David Bangsberg)
 CASE VIGNETTE: University of West Indies
o Partnerships with High Income Countries (HICs)
 Models and which is most desirable
 Support of training and education
 Access to new and innovative methods
Lancet Commission on Global Surgery
Workforce, Training, and Education




Chance to progress/develop local practice
Ongoing support
Partnerships like: http://www.zuhwa.com
Research collaborations
 A means of career advancement without needing to
leave the country

Benefits to HIC personnel
 E.g. Nigel Crisp document on benefits to the NHS
Ministries of Health should be encouraged to own surgical
delivery programs and assume responsibility for their
sustenance. When NGO’s take control they may drain
already weak resources (but MOH is forced to comply)
Planning for the establishment and sustenance of necessary
surgical delivery programs by LMICs is helpful.
NGOs wishing to operate in these countries are free to do so
but should be made to contribute in the training of health
providers.





potential for reverse innovation
Training and education
o Training should reflect the needs of the population
o Emphasize Core Competencies
 Minimal required skill set
o Current models (University Model vs College Model)
 See table re: different models of surgical training by
region/continent
o Task sharing – description, recommendations
 See table re: different models of Task sharing training
o High income country providers and their role in training/edu
o Accreditation
o Retraining of current surgical providers (who may be using out of
date evidence/techniques)
 Eg new guidelines on trauma resuscitation (permissive
hypotension,
 Need to discuss: Is it appropriate to teach principles like
1:1:1 resuscitation with blood products in countries where
only whole blood is available
o Innovative approaches
 Free, online courses (Khan Academy, Coursesa, Harvard
EdX)
 E-learning
 Caris example re: laparoscopy and e-training
o Innovative approaches will require cheap, fast internet
Lancet Commission on Global Surgery
Workforce, Training, and Education
Key Recommendation – increase access to at a minimum
district hospitals and regional hospitals
 Caris knows of Malawi pilot with hotspots, laptops
and dongles.
o Retention – must have trained professionals to teach/train the
professionals of the future – with at least some duplication so that
current professionals can leave if necessary to get further
training/re-training.
o Benefits of training/certifying providers locally as opposed to
sending them elsewhere for training (yet another drain on the
system; increases likelihood that provider might not return?)
o Training for competency in special cases (eg pediatric anesthesia,
high risk anesthesia, pediatric surgery)
o Need to reference recommendations of Training of Health
Professionals Lancet Commission
o CASE VIGNETTES
 Nyengo Mkandawire case vignette on task shifting in Malawi
 RCSI-COSECSA case vignette – Caris to chase
 HRH?
Ensuring performance and quality
o M&E e.g. M&M
 Does this actually happen?
 What are barriers to making it happen
 Do databases/EMR make this easier?
o CME – local and international/partnerships
o Maintenance of certification
 Local
 High income country certification


Appendix C: Key Papers needed to write the WTE section (working list,
in Progress)
1. WHO Working together for health. 2006 World Health Report. Retrieved from
http://www.who.int/whr/2006/en/
2. Chu K, Rosseel P, Gielis P, Ford N. Surgical Task Shifting in Sub-Saharan Africa. Plos Med
2009;6(5):e1000078.
3. Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries. The Lancet
2007;370(9605):2158–63.
4. Hagander LE, Hughes CD, Nash K, et al. Surgeon migration between developing countries and
the United States: train, retain, and gain from brain drain. World J Surg 2013;37(1):14–23.
5. Chen L, Evans T, Anand S, et al. Human resources for health: overcoming the crisis (2004) The
Lancet vol 364(9449) p1984-1990
6. Frenk et al. Health professionals for a new century: transforming education to strengthen health
systems in an interdependent world (2010) The Lancet Vol 376 (9756) p1923-1958
7. Nigel Crisp – benefits to the NHS
Lancet Commission on Global Surgery
Workforce, Training, and Education
8. Crisp NEJM –Distribution of health workers
9. COSECSA 2011 paper
10. Funk, Weiser, Gawande access to surgical care
11. Diallo 2004 Internal Migration
12. Bangsberg Uganda Internal Migration
13. Cochrane Review 2014 Internal Migration.
14. Hoyler M, Finlayson SRG, McClain CD, Meara JG, Hagander L. (2014) Shortage of doctors,
shortage of data: a review of the global surgery, obstetrics, and anesthesia workforce literature.
World Journal of Surgery Vol28 (2) p269-280
15. Improving Health at Home and Abroad: How overseas volunteering from the NHS
benefits the UK and the world http://www.appg-globalhealth.org.uk/reports/4556656050
16. APPG Annual report 2012-2013 http://www.appgglobalhealth.org.uk/reports/4556656050