Mapping Training in Fistula Management: An Overview of Capacities and Needs Obstetric Fistula Working Group Meeting on Training Niamey, Niger – 19 to 20 April, 2005

Overview of Mapping Process Objective: To provide an overview of current treatment and training capacities and needs Method:  Questionnaire distributed to Working Group Members and to countries via UNFPA country offices (completed by gov’t ministries, NGOs, treatment facilities, and UNFPA) –Questionnaires received from 13 countries: Bangladesh, Benin, Burkina Faso, DRC, Eritrea, Kenya 1, Mauritania, Niger, Senegal, Sierra Leone, Sudan, Tanzania 2, Uganda 2  Review of available needs assessments and other sources for other countries 1 2 received (UNFPA/AMREF), 2 Covers only AMREF supported facilities

Limitations:  Lacks data from countries not already active in the Campaign  Lack of universal definitions made comparability between countries difficult  Data not available or routinely collected in many countries

Incidence and Cases Treated by Country CountryEstimated annual incidence Cases treated annually Benin60*44 Burkina Faso131*49 DRC Ethiopia Kenya Mali Niger Nigeria20,0004,146 Sierra Leone Sudan Tanzania20001,000 Uganda  Over 8,000 treated  Range of ~7% to ~73% repaired (not really comparable)  Data collection noted as difficult *reported cases

# of Facilities Providing Treatment by Country  Range from 0 to >30  4 facilities known to have more than 300 cases annually (Addis Ababa, Katsina, Kano, Goma)  2 known to have approximately 250 (Bugando, Bamako) CountryNumber of facilities Bangladesh12 Benin3 Burkina Faso3 Chad4 DRC14 Eritrea3 Ethiopia1 + outreach centres Kenya7 Mali3 Mauritania0 Niger3 Nigeria> 30? Senegal6 Sierra Leone4 Sudan8 Tanzania11 Uganda6

# Nat’l Doctors Skilled in Fistula Repair  Masks varying levels of skill and activity  May include those trained who do not actively repair and some active although not fully trained  Includes varying disciplines, ob/gyns, urologists and general surgeons CountryNumber of Doctors Bangladesh20 Benin2 Burkina Faso6 Chad6 DRC7 Eritrea3 Ethiopia6 + 5 (many trained) Kenya7+ Mali8 + 3 in training Mauritania0 (4 attempt) Niger6 Nigeria? (many trained) Senegal15 Sierra Leone2 Sudan9 Tanzania16 Uganda5

Characteristics of Repair Surgeons  Many countries have few to no national surgeons that can perform complicated repairs.  The following countries mentioned: –Kenya (5), Tanzania (5), Uganda (1), Chad (1-2), Senegal (2), Mali (4?), Benin (2), DRC (4), Sudan (7), Niger (4), Bangladesh (12), Nigeria (~15)  Number of repairs performed often not listed, perhaps not available

Types of training received  Training at a fistula treatment centre (mostly reported at Addis Ababa Fistula Hospital, Babbar Ruga Hospital, Katsina, Dr. Abbo Centre, Khartoum, Dhaka Medical College)  Workshops (noted in Bangladesh, Kenya, Uganda and Tanzania)  On-the-job training by experts (expatriate & national)  Self-trained through practice  Post-graduate studies (urology/gynaecology)

Trainers The majority of the countries had at least one trainer (8 of 13) Some countries still lack national capacity and rely on expatriate expertise

# of OT and Ward Nurses skilled in fistula care  For many countries, none trained or information unavailable CountryOTWard Bangladesh16 Eritrea920 Kenya10 Niger108 Nigeria Senegal88 Sierra Leone57 Tanzania3020 Uganda10

Social workers and Others Only 4 countries noted social workers trained in fistula: Bangladesh (6), Niger (6), Senegal (1), Kenya (# unknown), known that Nigeria and Mali have several NGOs working in this area Other types of professionals noted (not specified in questionnaire): –Physiotherapists, 15 in 3 countries (all AMREF facilities)

National Plans and Standards Countries with national or sub-national plans: Bangladesh, Burkina Faso, Eritrea, Kenya, TZ, Uganda Countries with national plans for training: Bangladesh, Eritrea, Kenya, TZ, Uganda Countries with national training standards: Bangladesh, Senegal, Kenya, Uganda

National Curricula Countries with national training curricula for treatment: Bangladesh, Sudan, Kenya (ongoing), Uganda Countries with national training curricula for counseling: Bangladesh, Sudan, Kenya (ongoing, part of above effort)

Fistula in Medical Curricula Countries with fistula in the national medical curricula: Bangladesh, Burkina Faso (not sufficient), Sudan, Senegal, Mozambique, TZ Countries with fistula in post-graduate medical curricula: Bangladesh, Kenya, Sudan, Senegal, TZ

Types of Training Underway Surgeons and nurses learn on the job. Theoretical and practical workshops in national/regional centres. Medical student rotations. Training workshops led by visiting specialists. Training workshops led by international universities, i.e. Stanford in Eritrea. Workshops led by international/regional NGOs, i.e. AMREF MOH funding a fistula centre for on the job training.

Training Needs Doctors –from 4 to 100 Surgical nurses – from 4 to 200 Ward nurses – from 15 to 60 Social workers – from 40 to 300 Others – physiotherapists; anaesthetists

Training Gaps In some cases, no official training underway. Only urology training includes fistula. NGOs bring experts but don’t train local doctors. Critical shortage of health workers. Only theoretical aspects taught. Lack of space at regional training centres – Addis, Katsina, etc.

Discussion Questions What are our realistic training goals? to train as many as possible or a few motivated surgeons? How many repairs can a surgeon reasonably do in a year? How many per prevalence or incidence are needed? How many trainers are needed to meet this need? Do we have enough already? Nurses, physiotherapists, social workers, anaesthetists?? Pre-service curricula – how much should it include?