[Show abstract][Hide abstract] ABSTRACT: Background: The shortage and mal-distribution of surgical specialists in sub-Saharan African countries is born out of shortage of individuals choosing a surgical career, limited training capacity, inadequate remuneration, and reluctance on the part of professionals to work in rural and remote areas, among other reasons. This study set out to assess the views of clinicians and managers on the use of task shifting as an effective way of alleviating shortages of skilled personnel at a facility level. Methods: 37 in-depth interviews with key informants and 24 focus group discussions were held to collect qualitative data, with a total of 80 healthcare managers and frontline health workers at 24 sites in 15 districts. Quantitative and descriptive facility data were also collected, including operating room log sheets to identify the most commonly conducted operations. Results: Most health facility managers and health workers supported surgical task shifting and some health workers practiced it. The practice is primarily driven by a shortage of human resources for health. Personnel expressed reluctance to engage in surgical task shifting in the absence of a regulatory mechanism or guiding policy. Those in favor of surgical task shifting regarded it as a potential solution to the lack of skilled personnel. Those who opposed it saw it as an approach that could reduce the quality of care and weaken the health system in the long term by opening it to unregulated practice and abuse of privilege. There were enough patient numbers and basic infrastructure to support training across all facilities for surgical task shifting. Conclusion: Whereas surgical task shifting was viewed as a short-term measure alongside efforts to train and retain adequate numbers of surgical specialists, efforts to upscale its use were widely encouraged.
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: Of more than the 2,323 recognized and operating medical schools in 177 countries (world wide) not all are subjected to external evaluation and accreditation procedures. Quality Assurance in medical education is part of a medical school's ethical responsibility and social accountability. Pushing this agenda in the midst of resource limitation, numerous competing interests and an already overwhelmed workforce were some of the challenges faced but it is a critical element of our medical profession's social contract. This analysis paper highlights the process of standard defining for Medical Education in a typically low resourced sub Saharan medial school environment. METHODS: The World Federation for Medical Education template was used as an operating point to define standards. A wide range of stakeholders participated and meaningfully contributed in several consensus meetings. Effective participatory techniques were used for the information gathering process and analysis. RESULTS: Standards with a clear intent to enhance education were set through consensus. A cyclic process of continually measuring, judging and improving all standards was agreed and defined. Examples of the domains tackled are stated. CONCLUSION: Our efforts are good for our patients, our communities and for the future of health care in Uganda and the East African region.
BMC Medical Education 05/2013; 13(1):73. · 1.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The shortage and mal-distribution of surgical specialists in sub-Saharan African countries is born out of shortage of individuals choosing a surgical career, limited training capacity, inadequate remuneration, and reluctance on the part of professionals to work in rural and remote areas, among other reasons. This study set out to assess the views of clinicians and managers on the use of task shifting as an effective way of alleviating shortages of skilled personnel at a facility level.
37 in-depth interviews with key informants and 24 focus group discussions were held to collect qualitative data, with a total of 80 healthcare managers and frontline health workers at 24 sites in 15 districts. Quantitative and descriptive facility data were also collected, including operating room log sheets to identify the most commonly conducted operations.
Most health facility managers and health workers supported surgical task shifting and some health workers practiced it. The practice is primarily driven by a shortage of human resources for health. Personnel expressed reluctance to engage in surgical task shifting in the absence of a regulatory mechanism or guiding policy. Those in favor of surgical task shifting regarded it as a potential solution to the lack of skilled personnel. Those who opposed it saw it as an approach that could reduce the quality of care and weaken the health system in the long term by opening it to unregulated practice and abuse of privilege. There were enough patient numbers and basic infrastructure to support training across all facilities for surgical task shifting.
Whereas surgical task shifting was viewed as a short-term measure alongside efforts to train and retain adequate numbers of surgical specialists, efforts to upscale its use were widely encouraged.
BMC Health Services Research 01/2013; 13:292. · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Uganda faces a colossal shortages of human resources for health. Previous literature has largely focused on those who leave. This paper reports on a study of physicians working in 18 public and private facilities in Uganda as part of a larger study of more than 641 hospital-based health workers in Uganda. We report what could entice physicians to stay longer, satisfaction with current positions, and future career intentions.
This study took place in 18 Ugandan hospitals. We describe the 49 physicians who participated in 11 focus groups and the 63 physicians who completed questionnaires, out of a larger sample of 641 health workers overall.
Only 37% of physicians said they were satisfied with their jobs, and 46% reported they were at risk of leaving the health sector or the country. After compensation, the largest contributors to dissatisfaction among physicians were quality of management, availability of equipment and supplies (including drugs), quality of facility infrastructure, staffing and workload, political influence, community location, and professional development.
Physicians in our study were highly dissatisfied, with almost half the sample reporting a risk to leave the sector or the country. The established link in literature between physician dissatisfaction and departure from the health system suggests national and regional policy makers should consider interventions that address the contributors to dissatisfaction identified in our study.
International Journal of Health Planning and Management 01/2011; 26(1):2-17. · 0.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Recently, surgical services have been gaining greater attention as an integral part of public health in low-income countries due to the significant volume and burden of surgical conditions, growing evidence of the cost-effectiveness of surgical intervention, and global disparities in surgical care. Nonetheless, there has been limited discussion of the key aspects of health policy related to surgical services in low-income countries. Uganda, like other low-income sub-Saharan African countries, bears a heavy burden of surgical conditions with low surgical output in health facilities and significant unmet need for surgical care. To address this lack of adequate surgical services in Uganda, a diverse group of local stakeholders met in Kampala, Uganda, in May 2008 to develop a roadmap of key policy actions that would improve surgical services at the national level. The group identified a list of health policy priorities to improve surgical services in Uganda. The priorities were classified into three areas: (1) human resources, (2) health systems, and (3) research and advocacy. This article is a critical discussion of these health policy priorities with references to recent literature. This was the first such multidisciplinary meeting in Uganda with a focus on surgical services and its output may have relevance to health policy development in other low-income countries planning to improve delivery of surgical services.
World Journal of Surgery 11/2010; 34(11):2511-7. · 2.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Surgical conditions contribute significantly to the disease burden in sub-Saharan Africa. Yet there is an apparent neglect of surgical care as a public health intervention to counter this burden. There is increasing enthusiasm to reverse this trend, by promoting essential surgical services at the district hospital, the first point of contact for critical conditions for rural populations. This study investigated the scope of surgery conducted at district hospitals in three sub-Saharan African countries.
In a retrospective descriptive study, field data were collected from eight district hospitals in Uganda, Tanzania, and Mozambique using a standardized form and interviews with key informants. Overall, the scope of surgical procedures performed was narrow and included mainly essential and life-saving emergency procedures. Surgical output varied across hospitals from five to 45 major procedures/10,000 people. Obstetric operations were most common and included cesarean sections and uterine evacuations. Hernia repair and wound care accounted for 65% of general surgical procedures. The number of beds in the studied hospitals ranged from 0.2 to 1.0 per 1,000 population.
The findings of this study clearly indicate low levels of surgical care provision at the district level for the hospitals studied. The extent to which this translates into unmet need remains unknown although the very low proportions of live births in the catchment areas of these eight hospitals that are born by cesarean section suggest that there is a substantial unmet need for surgical services. The district hospital in the current health system in sub-Saharan Africa lends itself to feasible integration of essential surgery into the spectrum of comprehensive primary care services. It is therefore critical that the surgical capacity of the district hospital is significantly expanded; this will result in sustainable preventable morbidity and mortality. Please see later in the article for the Editors' Summary.
PLoS Medicine 01/2010; 7(3):e1000243. · 15.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is a growing recognition that the provision of surgical services in low-income countries is inadequate to the need. While constrained health budgets and health worker shortages have been blamed for the low rates of surgery, there has been little empirical data on the providers of surgery and cost of surgical services in Africa. This study described the range of providers of surgical care and anesthesia and estimated the resources dedicated to surgery at district hospitals in three African countries.
We conducted a retrospective cross-sectional survey of data from eight district hospitals in Mozambique, Tanzania, and Uganda. There were no specialist surgeons or anesthetists in any of the hospitals. Most of the health workers were nurses (77.5%), followed by mid-level providers (MLPs) not trained to provide surgical care (7.8%), and MLPs trained to perform surgical procedures (3.8%). There were one to six medical doctors per hospital (4.2% of clinical staff). Most major surgical procedures were performed by doctors (54.6%), however over one-third (35.9%) were done by MLPs. Anesthesia was mainly provided by nurses (39.4%). Most of the hospital expenditure was related to staffing. Of the total operating costs, only 7% to 14% was allocated to surgical care, the majority of which was for obstetric surgery. These costs represent a per capita expenditure on surgery ranging from US$0.05 to US$0.14 between the eight hospitals.
African countries have adopted different policies to ensure the provision of surgical care in their respective district hospitals. Overall, the surgical output per capita was very low, reflecting low staffing ratios and limited expenditures for surgery. We found that most surgical and anesthesia services in the three countries in the study were provided by generalist doctors, MLPs, and nurses. Although more information is needed to estimate unmet need for surgery, increasing the funds allocated to surgery, and, in the absence of trained doctors and surgeons, formalizing the training of MLPs appears to be a pragmatic and cost-effective way to make basic surgical services available in underserved areas. Please see later in the article for the Editors' Summary.
PLoS Medicine 01/2010; 7(3):e1000242. · 15.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In this Policy Forum, the Bellagio Essential Surgery Group, which was formed to advocate for increased access to surgery in Africa, recommends four priority areas for national and international agencies to target in order to address the surgical burden of disease in sub-Saharan Africa.
PLoS Medicine 12/2009; 6(12):e1000200. · 15.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is significant concern about the worldwide migration of nursing professionals from low-income countries to rich ones, as nurses are lured to fill the large number of vacancies in upper-income countries. This study explores the views of nursing students in Uganda to assess their views on practice options and their intentions to migrate.
Anonymous questionnaires were distributed to nursing students at the Makerere Nursing School and Aga Khan University Nursing School in Kampala, Uganda, during July 2006, using convenience sampling methods, with 139 participants. Two focus groups were also conducted at one university.
Most (70%) of the participants would like to work outside Uganda, and said it was likely that within five years they would be working in the U.S. (59%) or the U.K. (49%). About a fourth (27%) said they could be working in another African country. Only eight percent of all students reported an unlikelihood to migrate within five years of training completion. Survey respondents were more dissatisfied with financial remuneration than with any other factor pushing them towards emigration. Those wanting to work in the settings of urban, private, or U.K./U.S. practices were less likely to express a sense of professional obligation and/or loyalty to country. Those who have lived in rural areas were less likely to report wanting to emigrate. Students with a desire to work in urban areas or private practice were more likely to report an intent to emigrate for financial reasons or in pursuit of country stability, while students wanting to work in rural areas or public practice were less likely to want to emigrate overall.
Improving remuneration for nurses is the top priority policy change sought by nursing students in our study. Nursing schools may want to recruit students desiring work in rural areas or public practice to lead to a more stable workforce in Uganda.
Human Resources for Health 03/2008; 6:5. · 1.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: The Makerere University Faculty of Medicine started the implementation of the Problem Based Learning/Community Based Education and Service curriculum for incoming students in the academic year 2003/2004. It undertook an intense preparatory period of 2 years before implementation, which included sensitizing, and training tutors to take their new role. Objectives: To evaluate student and tutor perception of the New PBL Curriculum at the Faculty of Medicine and to evaluate tutors perception of how well the students were doing. Methods: The study was at the end of the first semester, after seventeen weeks of the new curricula implementation. A 19-item questionnaire was self-administered by the students. An open discussion led by one of the investigators followed that questionnaire filling session. A 5-point likert scale was used to rate the different aspects. A different questionnaire was administered to the 35 academic staff that had tutored the twenty tutorial groups of eight to ten students each. The data collected from the two questionnaires was analyzed using SSPS software. The Faculty Research Committee approved the study. Results: Out of 180 students, 135 students filled in the questionnaire. In addition 25 tutors out of 35 filled in their questionnaire. The tutors’ facilitation of the tutorials was rated highly by the students. Students’ rated their (students’) participation in the tutorial process as excellent. The students rated access to learning resources as inadequate and they were anxious as to whether they were learning enough. On the other hand the tutors were satisfied with the depth and scope of the discussions by the students. The majority of the tutors thought it was the right move to introduce PBL. They were however concerned about sustainability of the novel educational reform (PBL). Conclusion: The students perceived the new method as acceptable. They expressed anxiety and uncertainly as to whether they were learning enough. And whereas the students were not sure they were learning enough, the tutors were satisfied with the depth of knowledge exhibited by the students. To sustain the reform tutors’ concerns and fears ought to be addressed.
East and Central African Journal of Surgery (ISSN: 1024-297X) Vol 13 Num 1. 01/2008;
[Show abstract][Hide abstract] ABSTRACT: CONTEXT: The maldistribution of physicians in sub-Saharan Africa is having serious impacts on population health. Understanding the effect requires investigation from both donor and recipient countries. However, investigation from the perspective of donor countries has been lacking. METHODS: This brief communication describes a model process for the design of a research project that addresses medical migration issues from the perspective of eight African medical schools. During an international meeting, the participants designed an initial "ideal" study, and then rapidly tested its feasibility through a brief survey, and group discussion through a listserv, teleconferences and one face-to-face meeting. FINDINGS AND PRACTICAL IMPLICATIONS: Innovative research ideas can be followed-up with surveys to test the feasibility of an "ideal" research design, modifying the design accordingly. This is currently occurring with our medical migration survey study.
Education for Health Change in Learning & Practice 06/2007; 20(1):27.
[Show abstract][Hide abstract] ABSTRACT: The faculty of Medicine, (FOM) Makerere University Kampala was started in 1924 and has been running a traditional curriculum for 79 years. A few years back it embarked on changing its curriculum from traditional to Problem Based Learning (PBL) and Community Based Education and Service (COBES) as well as early clinical exposure. This curriculum has been implemented since the academic year 2003/2004. The study was done to describe the steps taken to change and implement the curriculum at the Faculty of Medicine, Makerere University Kampala.
To describe the steps taken to change and implement the new curriculum at the Faculty of Medicine.
The stages taken during the process were described and analysed.
The following stages were recognized characterization of Uganda's health status, analysis of government policy, analysis of old curriculum, needs assessment, adoption of new model (SPICES), workshop/retreats for faculty sensitization, incremental development of programs by faculty, implementation of new curriculum.
The FOM has successfully embarked on curriculum change. This has not been without challenges. However, challenges have been taken on and handled as they arose and this has led to the implementation of new curriculum. Problem based learning can be adopted even in a low resourced country like Uganda.
[Show abstract][Hide abstract] ABSTRACT: Mixed dentition analysis forms an essential part of an orthodontic assessment. Moyer's method which is commonly used for this analysis is based on data derived from a Caucasian population. The applicability of tables derived from the data Moyer used to other ethnic groups has been doubted. However no meta-analyses have been done to statistically prove this.
To assess the applicability of Moyer's method in different ethnic groups.
A meta-analysis of studies done on other populations using Moyer's method.
The seven articles included in this study were identified by a literature search of Medline (1966-June 2003) using predetermined key words, inclusion and exclusion criteria. 195 articles were reviewed and meta-analyzed.
Overall the correlation coefficients were found to be borderline in variation with a p-value of 0.05. Separation of the articles into Caucasian and Asian groups also gave borderline p-values of 0.05.
Variation in the correlation coefficients of different populations using Moyer's method may fall either side. This implies that Moyer's method of prediction may have population variations. For one to be sure of the accuracy while using Moyer's method it may be safer to develop prediction tables for specific populations. Thus Moyer's method cannot universally be applied without question.
[Show abstract][Hide abstract] ABSTRACT: Background: Makerere University introduced a new policy1 on the minimum qualification for appointment to a lecturer teaching position and eligibility for subsequent promotions. The highlight of the policy is a requirement for a PhD or equivalent as the minimum qualification necessary for appointment to a lecturer position and above. As a result of this policy fewer and fewer members have shown interest or indeed joined the Faculty of Medicine teaching staff roll. Objectives: This study set out to investigate the perception of the faculty and the impact of the policy on staffing. Methods: Literature review, oral and a questionnaire interviews were used to gather data. Participants included current members of teaching staff (of biomedical sciences and clinical disciplines) postgraduate students and visiting overseas academic staff and adjunct staff employed by the Ministry of Health at teaching hospitals. Data collected was analyzed and summarized in tabular form. Results: A PhD or equivalent is required as a minimum qualification to join academic positions at lecturer level and above at Faculty of Medicine and subsequent promotion to higher positions. There was a significant lag in promotions and recruitment in the Faculty of Medicine compared to counterparts employed by the Uganda Ministry of Health at the teaching hospitals. Participants expressed strong views that a PhD or equivalent should not be a minimum requirement nor should it be a prerequisite for promotions though it should be encouraged. Policy documents from other universities did not require a PhD or equivalent qualifications as a minimum requirement for appointment to the academic ranks of those institutions. Conclusion: Whereas it is desirable for the academic staff to acquire a PhD, it should not be a mandatory requirement. The policy was not in the best interest of the Faculty of Medicine and may not be for other medical schools to impose that requirement for appointment or promotion. University policy makers should consider schools of medicine as an exception to the policy requiring a PhD or equivalent as minimum requirement for teaching at a Medical School.
East and Central African Journal of Surgery (ISSN: 1024-297X) Vol 9 Num 2.
[Show abstract][Hide abstract] ABSTRACT: Background: The surgical work output in Uganda is qualitatively and quantitatively inadequate. The number of surgeons is estimated at 100 for a population of over 26 million Ugandans. This paper reports on how to improve recruitment of surgical trainees and training of surgeons in Uganda, focusing on perceptions of potential trainees, trainers, and medical administrators. Methods: This was cross sectional, descriptive study sampled at least 50% of each of the relevant category of interviewees. Self-administered questionnaire and focus group discussions were used to collect data, which was analyzed manually using a master sheet. It was approved by the Ethics and Research Committee. Results: Paediatrics and Public Health were rated as the disciplines of choice for postgraduate training in Uganda. The reasons why potential trainees would shy away from specialized surgical training were excessive workload, risk of catching HIV/AIDS, low financial returns and a poor learning environment. The major bottlenecks in surgical training, which were cited, included inadequate number of scholarships, inadequate supervision by trainers, inadequate facilities and poor work conditions for trainers. Conclusion: The remedies to this complex problem revolve round providing more resources, (human, materials, money), improving supervision by the trainers, advocacy for an evidence based curriculum content and availing more funding into the Medical Education sector to improve Human Resource for Health development.
East and Central African Journal of Surgery (ISSN: 1024-297X) Vol 11 Num 1.
[Show abstract][Hide abstract] ABSTRACT: Background
While PEPFAR investments were associated with HIV-related survival, it has been less clear what the effects of this investment in HIV care have been for health-care use generally, especially in maternal care. Understanding of these effects could have implications for how to organise future global health initiatives for major health problems. Maternal mortality in Uganda remains high (310 per 100 000 livebirths in 2010) and could be reduced by increasing deliveries at health facilities.Methods
We visited all of Uganda's 56 districts to collect maternity care data from Health Management Information System records, between the years 2005 and 2010, including monthly reports from all public and most private facilities. Our unit of analysis was district-month. We fitted a negative binomial mixed effects model, with number of infants delivered in health facilities per district-month as outcome, and three categories (tertiles) of population-adjusted annual number of PEPFAR-supported patients on antiretroviral therapy (ART) as input. We adjusted for regional HIV prevalence and proportion of elementary school-aged children attending school. To adjust for secular and seasonal effects, we included control variables for year and month. Random effects for district and an offset for district population were included in the model.FindingsPeople on ART per district-month per 1000 population grew from 1079 in 2005, to 6485 in 2010. Facility deliveries averaged 709 per district-month, growing from 561 in 2005 to 830 in 2010. The average rate of health facility deliveries increased by 4% (incidence rate ratio [IRR] 1·04, 95% CI 1·008–1·068, p=0·012) in districts with medium-level PEPFAR investment in ART care, compared with lowest PEPFAR investment districts. In higher-level investment districts, deliveries increased by 8% (IRR 1·08, 95% CI 1·037–1·126, p=0·0001), relative to low-investment districts.InterpretationPEPFAR investments in ART scale-up in Uganda appear to be associated with small increases in health facility deliveries.FundingThis research was funded by the US Centers for Disease Control, Division of Public Health Systems and Workforce Development through a cooperative agreement with the University of Washington and through subcontracts with Makerere University and the Uganda Ministry of Health.