PAN AFRICAN ASSOCIATION OF SURGEONS (PAAS) INTERNATIONAL CONFERENCE ON IMPLEMENTATION OF GLOBAL SURGERY IN AFRICA, Feb 1st-3rd 2017 at AUC Headquarters, Addis Abeba, Ethiopia
The meeting began on February 1st, 2017 with the opening ceremony. The president of the College of Surgeons of East and Central and Southern Africa (COSECSA), and the chair of the Local Organizing Committee, Dr. Miliard Derbew, started the meeting off with introductions. He noted that over 70% of population in the world has no access to safe surgery and introduced the theme of the conference, implementation of global surgery in Africa. He explained that PAAS is the largest professional society in Africa and welcomed the audience to Ethiopia.
The president of PAAS, Professor KH Yangni-Angate further welcomed the audience. He thanked Dr. Zuma, former chairperson of the AU, for her leadership in advancing medicine in Africa during her tenure and explained the history of PAAS. He noted that African countries will not develop without improvements in healthcare and expressed his hope for a future with sustainable and accessible surgery.
The Representative for HE the Minister of Health of Ethiopia, the Director General of the Ministry of Health, also welcomed the participants to the country. The African Union Commissioner of Social Affairs, HE Dr. Mustafa Kaloko, then spoke. He declared to the audience that despite improvements in global health, there must be more investments and prioritization of global surgery. He encouraged the development of National Surgical Plans as promoted by the Lancet Commission and reiterated the importance of global surgery on the agenda of national governments. His talk officially opened the international conference on global surgery.
The president of PAAS then started the next session, the Solanke Lecture, by sharing his memories of Professor Solanke, the first President of PAAS. This year’s Solanke Lecture was given by the Director General of the Ministry of Health of Ethiopia, Representative for HE the Minister of Health of Ethiopia, who discussed SaLTS (Saving Lives Through Safe Surgery), Ethiopia’s national surgical plan. He introduced the four transformation agendas which lead to the national quality strategy centered around five core areas, clinical and surgical services, maternal health, malnutrition, non-communicable and communicable diseases. He declared surgical care a human right and stated that inefficient use of exiting surgeons is an under-addressed issue, pointing out that 80% of ethiopian surgeons work in big cities, including Addis Ababa and Harar. He lamented the 4 year wait time in Ethiopia for patients who may need life-saving surgery. These concerns have led to the development of SaLTS which addresses leadership and governance, infrastructure and pharmaceuticals, excellence in advocacy and partnership, quality of surgical and anesthesia care. Including use of data for QI, and monitoring and evaluation. SaLTSas he explained it is a roadmap for Ethiopia’s national surgical plan.
After a brief break, the Keynote Address was given by the Representative for the UN-ECA chairperson who advocated for more collaboration between the ministries of health and the ministries of finance in her talk on “Recent social and economic development trends in Africa and implication on health”. She encouraged the audience to advocate for surgery and declared she would do the same.
The meeting continued with a session on the current status of Global Surgery.
Professor John Meara from the US reviewed the Lancet Commission goals. He explained that the future would require a $350B investment. He went the Lancet indicators: Access to care SAO density, surgical volume, peri-operative mortality and finances; he encouraged national surgical plans.
Dr. Emmanuel Makasa presented WHO Resolution WHA68.15, which states the need to strengthen emergency surgical care and anesthesia as a component of universal health care and encouraged the audience to advocate for the implementation of this resolution by forging collaborations at the global, regional and national levels.
Dr. Ken Boffard from the University of Witwartersrand, discussed the importance of trauma in the discussion of access to surgical care across Africa, highlighting the increasing rates of road traffic accidents throughout the world. He discussed cost effective national trauma management courses that teach “what most people need to know to save lives in most situations,” available to participants for as little as $30 per participant.
The AU commission for social affairs then gave an overview of the AU agenda 2063, which lays out a vision for a prosperous, peaceful and integrated Africa that is defined by Africans as opposed to outside narratives. He described a holistic approach to development that includes healthcare. After his talk, members of the audience asked that the AU commit financially to supporting increasing surgical access. The Commissioner encouraged the audience to advocate to the member states, who ultimately make such decisions.
Dr. Gonzalo Barriero, President of the World Federation of the Societies of Anesthesiologists(WFSA), introduced the audience to the structure of the WFSA and explained how the group is working to increase anesthesia coverage around the world. He reiterated that safe anesthesia is necessary for safe surgery and raised concerns about what he sees as a great deal of overlap and duplication of efforts in the global surgery community, which wastes a great deal of money
Lars Hagander from Sweden presented on “Metrics and indicators for surgeryand anesthesia,” highlighting the need for data, but recognizing the difficulty in obtaining it. He explained that good indicators of surgical quality need to be valid, discerning, sensitive to change, on the path to improvement, equitable, integrated, available, collectable and cost-friendly. He then reviewed Global surgery 2030, including the six indicators put forth by the Lancet Commission, four of which have been included in the world bank indicators.
The panel was then followed by a discussion led by moderator Prof Martin Smith, the past- president of PAAS. He asked the panelists what we should be working towards during this meeting.Dr Makasa stated that one objective is to advocate for more involvement from the AU in the implementation of global surgery in the region, because the commission is in the best position to create a platform to further the issue in the region. He explained to the audience that while the WHO works with ministers of health while the AU works with heads of state. The panel reiterated the value of research and encouraged collaboration throughout the region.
The discussion was followed by a welcome cocktail.
The following day, the conference continued with a session on essential surgical care as a part of universal health coverage chaired by the current and past presidents of PAAS as well as the president of the West African College of Surgeons(WACS). Dr. Andualem Beyene opened the day by discussing the implementation of SaLTS in Ethiopia. He explained the advances in training, leadership and management, expansion of the work force as well as the partnerships formed throughout the process. He further explained that there have been challenges, including lack of clear roles.
Mr Yedalay Moctor from AUC discussed telemedicine expansion and implementation in Africa. He argued that if Africa misses the digital revolution, the continent will lag behind as it did during the industrial revolution. He highlighted successful examples of remote surgery as well as the use of cell phones for data collection. He also emphasized the importance of generating and distributing power locally to generate sustainable energy sources. There was discussion after the talk about the feasibility of robotic surgery in Africa as well as the need for reliable energy sources.
Dr. Makasa, standing in for Dr. Walt Johnson, then discussed universal health coverage, explaining that services need to be close to the people, in the form of the district hospital. He stated the importance of not only paying attention to the curative aspects of surgery and that surgeons can play a big role in advocating for preventative policies. He discussed national surgical plans, stating that if you develop national plans, you must have indicators that can be used to track progress towards universal health coverage.
Dr. BisolaOnajin-Omembe discussed anesthesia as part of universal health coverage. She explained the basics and history of anesthesia as a medical practice. She stated that surgical safety check-lists help account for what is happening and encouraged monitoring and safety evaluations. She also addressed the shortage of anesthesiologists throughout Africa, highlighting her own country of Nigeria, which has a density of 0.4 anesthesiologists per 100,000 people.
Prof AO Omigbodum ,President WACS, discussing the health of women and mothers in Universal Healthcare, highlighting that the issue was part of the millennium development goals. He reviewed the indices for assessing maternal health and stated that essential obstetric care is critical for reducing maternal deaths.
Catherine De Vries from the University of Utah discussed primary care, reminding the audience that a large amount of surgery throughout the world is performed by primary care providers. She encouraged a model whereby surgical skills are taught to the people who are performing surgery in the rural areas. She warned that surgical teams need to be available to maintain standards throughout the process.
After a short tea break, the conference continued with a session on appropriate workforce training and education.
HE Dr Martial De-Paul Ikounga,the AU commissioner of science, technology and education discussed the investment of the AU into African you. He stated that innovation is a tool, and surgeons are innovators. He reviewed the commission in Lagos in 1980, which determined that 1% of the GDP of each country should be directed towards Science and Technology. He reminded the audience that surgeons are not only practitioners but also teachers.
Prof. Martin Smith, past president of PAAS, discussed innovation in training and human resource development for global surgery. Access alone is not enough, he stated, but rather it has to be high quality and efficient. He advocated for a paradigm shift from the idea of a “surgeon” ro the idea of “surgery.” He argued that in order to meet shortages, we need to change the education system.
Prof. Eric Borgstein then discussed his experience with task shifting in Malawi. He discussed COST-Africa, which is a successful degree course for clinical officers interest in surgery. He then turned the stage over to Dr. Brugha who discussed the move from COST-Africa to Surg-Africa, which is a funded project to support whomever is doing surgery, whether that be medical officers or surgeons. He stated that to implement any programs, they have to be in response to what a country wants and used Zambia as an example of a place where an already existing clinical officer program was successful.
Prof .Pankaj Jani from Nairobi;President-Elect, COSECSA discussed building the next generation of the surgical workforce. He reviewed the COSECSA model, which has 12 member countries and 18 countries with trainees.
Dr BisolaOnajin-Obembe retook to the stage to discuss building the appropriate anesthesia competencies. She argued for training healthcare practitioners where they are employed to combat brain drain and the continued concentration of doctors in the urban centers.
The conference continued after lunch with a session on global surgery: vital to global health in 2017 and beyond.
Dr Emmanuel Makasa returned to the stage stating that emergency and essential surgical care should be at the district hospital and should be of high quality; he declared that emergency preparedness should not be restricted to infectious diseases and reiterated that health systems are strengthened by surgery.
Dr. Barriero,President WFSA, was also a part of this session. He discussed attempting to find a common denominator between surgeons and anesthesiologists and expressed his concern that the preoccupation with data in the surgical community may prevent those who have no data from moving forward. There was a request from the audience that WFSA aid in strengthening CANECSA, but Dr. Barriero stated that WFSA is “not a bank.”
Dr BisolaOnajin-Obembe returned to the stage and explained that globalization is all about networking together.
Prof AO Omigbodum ,President, WACS agreed that the key to global surgery is collaboration. He stated that WACS is advocating for the government to take training to the district hospitals and smaller communities.
Dr. Miliard Derbew presented the COSESCA organization, highlighting the critical shortage of workforce in the COSECSA region. He reviewed the gender imbalance in the current surgical workforce and stated that there is a global approach for all problems for all problems, especially health.
Michael Klipen from the Association of Surgeons of South Africa stated that you can’t separate healthcare from economics. He reviewed the South African economy and surgical training system, he challenged the audience to learn to speak politics and ask for a budget.
Pr TernaYawe,President-Elect , WACS discussed “building capacity through global surgery” and reviewed the accomplishments of the college, which has trained 6000 specialists in 7 faculties. He talked about the college’s 3 year membership program whereby trainees can leave after three years and begin practice to increase the number of surgical practitioners in the region. He discussed national surgical plans for the region as supported by WACS but modified for each country.
Tommy Wilkinson, an economist from South Africa, gave the final presentation of the panel, “Global Surgery: Vital to Global Health in 2017 and beyond, HTA and Surgery.” He introduced the audience to the concept of health technology assessment which defines “best buys.”
The chair of the panel, Dr. John Meara summarized the panel, highlighting the link between anesthesia and surgery, the different colleges on the continent and the importance of healthcare economics.
The final session of the day focused on PAAS partnerships with international organizations for Global Surgical Care and Anesthesia. Standing in for Dr. Walt Johnson, Dr Emmanuel Makasa once again took the stage, highlighting partnerships for surgical care. He discussed the FENSA document, which allows for an understanding between NGOs and the WHO.
Brendan Allen from the G4 Alliance discussed the pillars of the organization, including advocacy, policy engagement and resource mobilization.
Colin Atkinson from Medtronic then reviewed the organization’s strategies to address healthcare needs, including the fact that if they work with surgeons in high tech settings and then they return to places with little or no technology, they are doing the patient a disservice. He stated that Medtronic wants to know where they can add value and not just be a profit taker.
DrGonzalo Barriero ,President, WFSA returned to the stage and stated that the organization can collaborate through the G4 Alliance and national societies. He explained that though the WFSA does not give a degree, they can give training in specific issues.
Prof Sherry Wren from Stanford University discussed educational and research partnerships. She highlighted deficits in medical education and reviewed some successful education projects, including MEPI, AMPATH and THET. She stated that in the idea state, local needs in curriculum can be addressed with appropriate content and bidirectional relationships which may help to attract and retain surgical workforces. She went through some lessons from the Stanford program, reiterating the need for bidirectional relationships. She reviewed future challenges for such programs, including funding, creating best practices, and the need for sub-Saharan African institutions to feel comfortable saying no.
Erin Berringer from Safe Surgery 2020 gave the final presentation of the day. She reviewed the organization’s work, which is to aid the ministries of health to form national surgical plans, including five day workshops for district hospital teams that give practitioners soft skills to come up with long term goals.
At the end of the session, the PAAS president reiterated that the main role of PAAS is to coordinate partnerships for the advancement of surgery in the region.
The final day of the conference fell on February 3, 2017. The day started with a session on creating and enabling an environment for safe, high quality, affordable surgery and anesthesia when needed in Africa.
Dr Jack Jones Zulu ,the Representative for the Economic Commission for Africa (ECA) offered recommendations for financing global surgery by ECA, African Development Bank. He stated it was time to stop relying on donors and there need innovative ways to raise domestic funds, that we need a healthy labor force to drive development. He noted that the ECA is meeting with WHO next month to discuss health financing in Africa, and PAAS should attend.
Sarah Rayne presented on global surgery research, exploring capacity, accountability and collaboration. She reviewed the barriers to clinical research and presented the success of crowdsourced research.
Dr. Makasa once again presented on strengthening the district hospitals as an essential component of universal coverage. He suggested use of social medial to foster advocacy and to make data easy to visualize and follow.
Prof Tommy Wilkinson presented once again on ensuring quality in implementation: the LCoGS recommendations for Africa and reviewed the goals of the Lancet Commission from an economics perspective, referring once again to the value of HTA.
Prof Martin Veller discussed health information in enabling surgical care development, reiterating the oft-repeated need for data in quality improvement. He declared that biomedical informatics provides sustainable healthcare for the world, but especially for Africa.
The conference participants then broke into four working groups, which sought to make recommendations on each of four topics: expanding access to safe, high quality, affordable surgery and anesthesia, particularly in rural and under-served areas; appropriate workforce training and education; health system strengthening including infrastructure development and financing; and research for essential surgical and anesthesia care. Recommandations and Action-Plan for Global Surgery Implementation in Africa were adopted(Appendix1).
The final session was the scientific session in conjunction with the Surgical Society of Ethiopia, which was holding a parallel conference at the AU throughout the week. The session was chaired by Dr. Henry Ford and Dr. Miliard Derbew.
Dr. Avril Hutch reviewed the partnership with COSECSA and the Royal College of Surgeons in Ireland, highlighting research that shows that 93% of COSECSA-trained surgeons stay in the region.
Dr. Girma Tefera from the American College of Surgeons(ACS) discussed Operation Giving Back, which aims to support the medically underserved domestically and internationally, stating that the ACS board of regents has committed to responding to the workforce crisis in sub-Saharan Africa. He stated that the priorities of the organization are to support women residents, develop online educational resources, train leaders, provide examiners and to aid in research by twinning surgical journals.
Lars Hagander asked the Dr Hutch to what she attributes the incredibly high retention rate in COSECSA.
She responded by saying that surgeons tend to stay where they train. Dr. Derbew further elaborated on that idea, saying that through the time in training, residents and fellows get married, buy property and lay down roots. The President-Elect of COSECSA, Prof. Jani, reminded everyone in the room that as surgeons, they are all possible visiting faculty and should consider joining the program.
In the closing ceremony, PAAS Secretary General Paul Goldberg reviewed the history of PAAS and highlighted targets going forward including Surgical Workforce development, data collection, political influence and finance generation.
The President of PAAS then offered the final communiqué (Appendix2). He reviewed the week and reiterated that PAAS will act for continuous and solid collaboration with the AU commission, the Economic Commission for Africa and the WHO.He emphasized PAAS actions for Global Surgery Implementation in Africa.(Appendix3). He thanked everyone for coming to the conference. He invited all participants to attend the next PAAS international conference at AUC Headquarters next February 2018.
The Representative for the AU commissioner for social affairs declared the conference officially over.