1. Scaling up Access to Emergency Surgery in Uganda: Meeting the Human Resource Gap Doruk Ozgediz, MD MSc 1, Olga Bornemisza MSc 2, Charles Hongoro PhD 2, Jackson Amone MD MSc 3, Diana Farmer MD 3, Haile Debas MD 3 1 Global Health Sciences and the Department of Surgery, UCSF 2 Health Policy Unit, London School of Hygiene and Tropical Medicine 3 Department of Clinical Services, Ministry of Health, Republic of Uganda

2. Surgery in Developing Countries 90% of global surgical need 90% of global surgical need Poor access to carePoor access to care 50% of Global Burden of Disease 50% of Global Burden of Disease Cost-effectiveness Cost-effectiveness Emergency Obstetric CareEmergency Obstetric Care TraumaTrauma CataractsCataracts

3. Uganda: Health Care 25 million population 25 million population 80-90% rural, hard to reach areas 80-90% rural, hard to reach areas Total Health expenditure/capita $18 Total Health expenditure/capita $18 WHO $34/capitaWHO $34/capita USA $5000/capitaUSA $5000/capita Declining HIV prevalence Declining HIV prevalence Conflict in the north: 2 million IDP’s Conflict in the north: 2 million IDP’s

4. Health Systems/Services Research: An Economic Model Supply Supply Human ResourcesHuman Resources InfrastructureInfrastructure Demand Demand Transport costTransport cost GenderGender Cultural beliefsCultural beliefs

5. New Policy: Emergency Surgery in Ugandan Subdistricts Decentralization Decentralization National Health Policy (1999)National Health Policy (1999) 214 Health Subdistricts 214 Health Subdistricts 139 (65%) HC4’s required upgrading139 (65%) HC4’s required upgrading Equity: “Services closer to the people” Equity: “Services closer to the people” Emergency Obstetric Care and MDG’sEmergency Obstetric Care and MDG’s TraumaTrauma Cost-effective? Cost-effective?

6. Uganda Health Infrastructure Health Unit LocationPopulation HC I Village1000 HC II Parish5000 HC III Sub-County20,000 HC4County100,000 District Hospital District 100,000 to 1 million Regional Referral Hospital Region (3-5 Districts) 1-2 million National Referral Hospital National Over 20 million

7. Hypothesis There are significant human resource constraints to scaling up surgery at the subdistrict level in Uganda There are significant human resource constraints to scaling up surgery at the subdistrict level in Uganda

8. Methods Literature review Literature review Semi-structured in-depth interviews Semi-structured in-depth interviews Thematic analysisThematic analysis Site visits Site visits

13. Results: Surgical Workforce Constraints Staffing Staffing ProductionProduction MigrationMigration Skills Skills ClinicalClinical ManagementManagement Solutions Solutions

14. Staffing: Production 150 physicians/year 150 physicians/year MD:population ratio 1: 12-25,000 MD:population ratio 1: 12-25,000 100 general surgeons/total; 20 orthopedic 100 general surgeons/total; 20 orthopedic 26% of HC4 no medical officer 26% of HC4 no medical officer Solution: Surgical paramedicsSolution: Surgical paramedics

15. Staffing: Migration Brain drain: 30% of new doctors migrate abroad Brain drain: 30% of new doctors migrate abroad Solution: Improved paySolution: Improved pay Solution: Develop research/training capacitySolution: Develop research/training capacity

17. Clinical Skills Young physicians out of internship Young physicians out of internship Solution: Senior staffSolution: Senior staff Not enough training or regularity of practice Not enough training or regularity of practice Solution: Surgical campsSolution: Surgical camps Solution: Integrating ES curriculum or rural surgery curriculum into trainingSolution: Integrating ES curriculum or rural surgery curriculum into training

18. Management Skills Budgets, Admin, Supervision Budgets, Admin, Supervision Solution: separate cadreSolution: separate cadre Overwhelm clinical responsibilities Overwhelm clinical responsibilities Solution: second medical officerSolution: second medical officer Solution: shifting personnel from hospitalsSolution: shifting personnel from hospitals

19. Conclusions and Areas of Further Research Multi-level HR constraints Multi-level HR constraints Evidence base of strategiesEvidence base of strategies Training, Distribution of Manpower Training, Distribution of Manpower Decentralization with limited resources Decentralization with limited resources Cost-effectiveness vs. equityCost-effectiveness vs. equity Consider integration of trauma training with emergency surgery Consider integration of trauma training with emergency surgery Surgery/Trauma care as an essential population-based intervention Surgery/Trauma care as an essential population-based intervention

20. Thank You