Mark Newton, MD Kijabe Hospital (Kenya)

Vanderbilt University

Task Shifting: Stretching the

Anesthesia Coverage in East Africa

Why is task shifting necessary?

●Surgical Burden●Anesthesia and

Surgical workforce

●Urban: Rural Balance

●Mortality:anesthesia

●Solution Models●Expansion

●234 million global surgical volume in 2004

●75% of the operations were in the richest 30% of the world’s population

●25% of the operations occurred in 75% of the population which had less income

●Poorest 34.8% of the population received only 3.5% of all surgery undertaken

●Estimates translate to 1 operation for every 25 human beings

●234 million almost doubles the number of annual births at 130 million

●This number is 7 times the number ( 33.2 million) of people infected with HIV

●Globally, at 3% perioperative adverse events and 0.5% mortality almost 7 million have major complications and 1 million die.

●Uganda: 2.5 general surgeons/1 million population vs. USA 55 gen surgeons/1 million ( 22 X difference)

●Surgical subspecialists: not good data but estimates demonstrate examples of no neurosurgeons for 50 million population; 39 pediatric surgeons for Sub-Saharan Africa (800 million)

●Pediatric Surgeons: USA 1/500,000 population vs. SSA 1/20 million (40 X difference)

Comparison of Economic and Health Status in UK and Uganda

●Child mortality rates are 1.4 times higher in rural vs. urban

●Births attended by skilled health personnel: urban sector has 2X more

●90-95% of the physicians live in the urban setting in Africa but over 50% of the surgical need is rural

Fewer Providers=higher mortality

Problem: “Anaesthesia in developing countries- a risk for patients”

●Anesthesia Mortality○Malawi 1/504

○Zimbabwe 1/482

(obstetrical operative mortality 1/293)

○Togo 1/133

○Nigeria 1/387

* Lancet Vol 371 March 2008 IA Walker, IH Wilson

Anesthesia Mortality: Multifactorial

●“Anaesthesia services in developing countries: defining the problem” (Anaesthesia, 2007, 62 S Hodges, IA Walker, IH Wilson)

○23% have facilities and supplies for safe anesthesia in adult

○13% have facilities for a child○6% have safe facilities for a C/section

●“ Anaesthesia is one of the top four causes of death in the operative maternal patient which is primarily in the rural hospital and 90% are avoidable” (S Africa Inquiry)

Solution: Task Shifting

● Historical:○ `French 19th Century

deployed health officers for rural service

○ 1918-1920 Uganda and Kenya trained basic surgical/medical skills to health workers

○ WHO, 2006 World Health Report: “systematic delegation of tasks to less-specialized cadres”

“ Non-Physician clinicians (NPC) in 47 sub-Saharan African countries”

●NPC is 25 of 47 sub-Saharan African countries with various roles and in 9 countries, NPC were equal or greater in number than physicians

●Many NPC were trained in less urban, closer to home institutions, and tended to remain in the rural sector.

●English speaking Africa with more NPC than West Africa and French speaking Africa in comparison to numbers of physicians.

F Mullen, S Frehywot Lancet 2007, 307:2158-63

Mozambique, Malawi, Tanzania Review of NPC

●90% of C-section, ruptured ectopic, and hysterectomies performed by non-physician surgical care providers

●After 7 years of the review, 90% are still practicing in the rural sector although 0% of the physicians are still in the rural areas

“Human resources necessary for emergency medical surgery” S Bergstrom IJGO 107S2 (2009)

Anaesthesia Task Shifting: Kijabe Hospital (Kenya) Model

●In 1995, assessment determined, RN training for rural Kenya needed

●Academic focus: Chair, U of Oregon

●Curriculum development: GOK, national academic establishment early

Ministry of Health

Nursing Council of Kenya

University of Nairobi Department of Surgery (Anaesthesiology)

Kenya Society of Anesthesiology

Point of Service Competency Based●Quality trainee and not quantity

(2/theatre)●Rural based trainee chosen by

community●Power point lectures, notes, clinical

case presentation, research, ICU, PACU

●Anesthesia infrastructure at appropriate levels for rural Africa

●Tools for success: Computer training and personal library (books)

TROP ical Anesthesia Focus

●Trauma●Regional●Obstetrics●Pediatrics

Life time risk of dying during Pregnancy is 1/6 in some sub-Saharan African countries

Task Shifting Training Priorities

●Trauma○ LMIC account for 85% of all RTA and Africa has

the highest number of deaths/10,000 vehicles

●Regional○ Less expensive and safe, when appropriately

trained

●Obstetrics○ C-section most common surgery and Obstetrical

hemorrhage and preeclampsia very common

●Pediatrics○ 50% population<18 yo and estimated that 85% will

have surgery before reaching 15 yo

Advanced Anesthesia Task Shifting

Paediatrics

Pain: Chronic

Regional: nerveblock

Advanced Airway Skills

KRNA Clinical Research (2009)

●Spinal narcotics for labor●Pediatric Spinal Fusion●Ondansetron (oral) as anti-emetic●Halothane and pediatric

neurosurgical●Left uterine displacement●Case reports

Customized model of anesthesia task shifting

Primary school:S Sudan

Medical Student: Somaliland Registered Nurse

Clinical Officer

RURALKenya NGO Referral

Hospital System50-250 bed hospitals x

4

URBANUniversity of Nairobi

(registrars)

MOHGovernment of Kenya

Ministry of Health (Provincial, District

Level RN’s Sponsored)

InternationalMedical StudentsResidents and fellows

● Southern Sudan● Somalia● Pediatric

Anesthesia Fellowship Sept 2010

East Africa

KIJABE HOSPITAL

Kenya

Building the Future Wave….

Vanderbilt InternationalAnesthesia (VIA)

Kijabe 2007: 67812008: 80702009: 9152

CURE 2007: 21512008: 22702009: 2340

Tenwek2007: 61172008: 57282009: 6300

Litein 2007: 12542008: 14172009: 1512

Kapsowar 2007: 1027 2008: 12002009: 1334

Total Surgeries

2007: 17,3302008: 18,685

2009: 20,698

Ten year growth in Kijabe Hospital

Task Shifting Success●National and regional acceptance●Standardized curriculum, course length,

licensing/CME requirements, oversight●Physician fear of financial loss removed●Rural trainees trained in rural centers●Train quality not quantity●Partnership with academic institutions

“in-country” and external academic groups utilizing rural appropriate technology

Advancement Steps●Outcome studies for the various task

shifting cadres and rural (NPA) vs. urban (physician) care

●Anesthesia management parameter development for non- physician anesthesia providers in LIC

●Shift focus of training on TROP (trauma, regional, obstetrics, and pediatrics) based upon studies to determine case distribution for non-physician anesthesia

In Conclusion,

Where there is no Anesthesiologist!

Task Shifting is the only option!