Implementing surgical mentorship in a resource-constrained context: a mixed methods assessment of the experiences of mentees, mentors, and leaders, and lessons learned

Background
A well-qualified workforce is critical to effective functioning of health systems and populations; however, skill gaps present a challenge in low-resource settings. While an emerging body of evidence suggests that mentorship can improve quality, access, and systems in African health settings by building the capacity of health providers, less is known about its implementation in surgery. We studied a novel surgical mentorship intervention as part of a safe surgery intervention (Safe Surgery 2020) in five rural Ethiopian facilities to understand factors affecting implementation of surgical mentorship in resource–constrained settings.

Methods
We designed a convergent mixed-methods study to understand the experiences of mentees, mentors, hospital leaders, and external stakeholders with the mentorship intervention. Quantitative data was collected through a survey (n = 25) and qualitative data through in-depth interviews (n = 26) in 2018 to gather information on (1) intervention characteristics including areas of mentorship, mentee-mentor relationships, and mentor characteristics, (2) organizational context including facilitators and barriers to implementation, (3) perceived impact, and (4) respondent characteristics. We analyzed the quantitative and qualitative data using frequency analysis and the constant comparison method, respectively; we integrated findings to identify themes.

Results
All mentees (100%) experienced the intervention as positive. Participants perceived impact as: safer and more frequent surgical procedures, collegial bonds between mentees and mentors, empowerment among mentees, and a culture of continuous learning. Over 70% of all mentees reported their confidence and job satisfaction increased. Supportive intervention characteristics included a systems focus, psychologically safe mentee-mentor relationships, and mentor characteristics including generosity with time and knowledge, understanding of local context, and interpersonal skills. Supportive organizational context included a receptive implementation climate. Intervention challenges included insufficient clinical training, inadequate mentor support, and inadequate dose. Organizational context challenges included resource constraints and a lack of common understanding of the intervention.

Conclusion
We offer lessons for intervention designers, policy makers, and practitioners about optimizing surgical mentorship interventions in resource-constrained settings. We attribute the intervention’s success to its holistic approach, a receptive climate, and effective mentee-mentor relationships. These qualities, along with policy support and adapting the intervention through user feedback are important for successful implementation.

Development of the anaesthesia workforce and organisation of the speciality in Uganda: a mixed-methods case study

Background: The development of modern anaesthesia practice in many low-income countries has lagged behind that of highincome countries despite early reports. Detailed descriptions of ‘surgery under anaesthesia’ in Uganda are available through Robert W. Felkin’s elaborate accounts of caesarean sections done in the Bunyoro-Kitara Kingdom. However, the earliest documented ‘modern’ surgical and anaesthesia procedures were performed by Sir Albert Cook and his brother Dr Jack Cook in 1897 at Mengo Hospital. Since then, anaesthesia has developed into an independent speciality with workforce development, professional bodies and a recognised practice. This study aimed to describe the development of the anaesthesia workforce and speciality since independence while sharing our experiences to benefit those countries on a similar journey.

Methods: We employed a mixed-methods approach, including surveys among anaesthesia providers, as well as key informant interviews and a workforce database review. Whenever possible, information was corroborated with written literature.

Results: There are three levels of training of anaesthesia providers in Uganda, including a Master of Medicine in anaesthesia for specialist physician providers, a Bachelor of Science in anaesthesia and a Higher Diploma in anaesthesia for non-physician providers. There are two Master of Medicine programmes, two Bachelor of Science in anaesthesia programmes and seven Higher Diploma programmes. The existing workforce consists of 68 specialists and more than 600 non-physician providers. The anaesthesia providers are organised under professional associations, namely the Association of Anesthesiologists of Uganda and the Uganda Anaesthetic Officers Association. International and regional collaborations have been critical in the development of anaesthesia in Uganda.

Conclusion: Uganda still has a low density of anaesthesia providers both in number and distribution but has established critical steps to substantially increase the workforce. These steps include three levels of training with numerous training programmes, professional bodies and partnerships. We present our experiences with different strategies, highlighting those that have failed, and suggest further recommendations on developing anaesthesia in Uganda.

A traveling fellowship to build surgical capacity in Ethiopia: the Jimma University specialized hospital and operation smile partnership

A lack of trained providers is an important contributor to the unmet burden of surgical disease treatment in low- and middle-income countries. The World Health Organization’s Commission on the International Recruitment of Health Personnel lays out guiding principles for addressing this workforce crisis. However, for surgical subspecialties such as plastic surgery, in-country training opportunities remain limited and there is a clear need for effective strategies to retain providers and develop sustainable solutions. We report the design and early implementation of a traveling fellowship in plastic surgery for providers at Jimma University Specialized Hospital in Jimma, Ethiopia. This fellowship is supported by Operation Smile and its network of international surgical volunteers. Since its inception, the program has trained 2 general surgeons with a commitment to helping train a total of 6 surgeons to establish a self-sustaining service. Key innovations include multiple international sites to facilitate broad subspecialty training, commitment of participants to return to Jimma upon completion of the program to establish a local training service, and coordination with national governing bodies to ensure program recognition and support. Ongoing challenges include physical resource limitations and coordination with a wide array of stakeholders. Nongovernmental organizations also have a role to play in supporting the Ministries of Health in scaling up human resources for improved health within their countries. Operation Smile’s traveling fellowship demonstrates a feasible method of addressing the health workforce crisis by providing specialized training and facilitating the development of surgical teaching programs capable of sustainably serving local communities.

Pediatric neurosurgical workforce, access to care, equipment and training needs worldwide.

OBJECTIVE:
The presence and capability of existing pediatric neurosurgical care worldwide is unknown. The objective of this study was to solicit the expertise of specialists to quantify the geographic representation of pediatric neurosurgeons, access to specialist care, and equipment and training needs globally.

METHODS:
A mixed-question survey was sent to surgeon members of several international neurosurgical and general pediatric surgical societies via a web-based platform. Respondents answered questions on 5 categories: surgeon demographics and training, hospital and practice details, surgical workforce and access to neurosurgical care, training and equipment needs, and desire for international collaboration. Responses were anonymized and analyzed using Stata software.

RESULTS:
A total of 459 surgeons from 76 countries responded. Pediatric neurosurgeons in high-income and upper-middle-income countries underwent formal pediatric training at a greater rate than surgeons in low- and lower-middle-income countries (89.5% vs 54.4%). There are an estimated 2297 pediatric neurosurgeons in practice globally, with 85.6% operating in high-income and upper-middle-income countries. In low- and lower-middle-income countries, roughly 330 pediatric neurosurgeons care for a total child population of 1.2 billion. In low-income countries in Africa, the density of pediatric neurosurgeons is roughly 1 per 30 million children. A higher proportion of patients in low- and lower-middle-income countries must travel > 2 hours to seek emergency neurosurgical care, relative to high-income countries (75.6% vs 33.6%, p < 0.001). Vast basic and essential training and equipment needs exist, particularly low- and lower-middle-income countries within Africa, South America, the Eastern Mediterranean, and South-East Asia. Eighty-nine percent of respondents demonstrated an interest in international collaboration for the purposes of pediatric neurosurgical capacity building.

CONCLUSIONS:
Wide disparity in the access to pediatric neurosurgical care exists globally. In low- and lower-middle-income countries, wherein there exists the greatest burden of pediatric neurosurgical disease, there is a grossly insufficient presence of capable providers and equipped facilities. Neurosurgeons across income groups and geographic regions share a desire for collaboration and partnership.