Empowering The Rural Surgeons, The Way Forward For Meeting The Surgical Needs Of Rural Areas

Globally, 60% of the surgical procedures are carried out for 15% of the world population in developed countries. On the other hand, 34% of the poor who live in developing countries get only 3% of the world’s surgeries [1]. While the World Health Organization (WHO) recommends that there should be at least 20 surgeons per 100,000 populations, countries like Rwanda have only 0.4 surgeons per 100,000 populations [2]. The Lancet commission on Global surgery estimates that a population of 100000 would ideally require 5000 surgical procedures every year. Although the Indian national average is about 800 in most of the rural areas and in the North-eastern states it varies from 30 to 300 [3].

The problems related to providing the surgical care for rural patients are many [4-5]. It starts with not knowing how many of them need surgery [6]. Most of the problems are related to accessibility, availability, and affordability for the patients. For the surgeons, the major problems are the lack of equipment, training, and the qualified support staff. There also the legal problems like the Government regulations limiting the use of ultrasound in rural areas and transfusion of unbanked blood. The corporate hospitals try to prevent the rural areas from performing surgical procedures so that they have patients for surgery. They do this by advertisement and enticing the rural surgeons to move to urban areas. We look at the various models and options available for empowering the surgeons in the rural areas.

We looked at the various models of empowering the rural surgeons working in rural and remote areas. Some were from historic data from publications like the Short- and Long-Term Missions. The data from the hospitals where, the author organized the Surgical Camps both before and after the Surgical Camps were analyzed to assess the benefit of the intervention. The tool used for comparison was the rate of surgical coverage calculated by surgical procedures for every 100000 population in the target areas every year.

THE SHORT-TERM MEDICAL MISSIONS

Caring for the sick has long been considered a hallmark of Christianity. Christian health care workers cite biblical references of the call to medical missions as an example of God’s unconditional love (Matthew 10:8; Luke 10:8-9, 25-34). Although Christians have been involved in medical missions throughout history, participation in short-term medical missions (STMMs) has grown dramatically in the past few years [7]. The most cost-effective, feasible, and replicable methods to implement the complex systems needed to provide surgery are still debated [8]. The short-term surgical missions can be structured in a way high quality sustainable care could be provided as shown by Operation Smile, Himalayan Cataract project, Team Hear and Partners in Health, etc. [8]. Common criticisms include unsafe practices, lack of consideration for cultural differences, and lack of coordination with the host country. But the positive impact of STMM teams in providing much needed services to resource- limited countries calls for continued efforts to sustain this ministry [9].

THE LONG-TERM MEDICAL MISSIONS

Pioneering work in remote areas often attract young surgeons and they can help take surgeries to remote rural areas [10]. There are several factors that discourage young doctors to work in remote and rural areas [11]. Figure 1 summarizes these factors [11]. Studies have also shown that although many doctors do go to rural areas for a variety of reasons many do not stay on in rural areas [12]. A study by the Public Health Foundation of India and the National Rural Health Mission of the Government of India in Chhattisgarh [13] found that practitioners’ initial decisions to join service in rural and remote areas were widely influenced by geographical affinities and familial associations. Once in service, the practitioners confronted complex adverse conditions and circumstances, including poor working and living arrangements, long estrangements from families, and threats to personal security. Once they left the rural areas for whatever reason hardly anyone came back. The reasons that were given were the following.

1. Toiling in obscurity
2. Constraints in working conditions.
3. Erosion of Professional Skills
4. Lack of good schools
5. Lack of need specific training.

Figure 1:  shows the Motivating and demotivating factors

Another important reason that attracts surgeons to work in rural areas is training [14]. The Pan African Academy of Christian Surgeons [PAACS] offers rural based general surgery program that has a retention rate of over 50% in short term and 35% long term. Opportunities for learning and upgrading skills through contact with the parent missions abroad helped many of the surgeons stay on in rural areas working with the mission hospitals [15].

THE DIAGNOSTIC CAMP / SURGICAL CAMP MODEL

Empowering the rural hospital to do procedures that are new and not available at other places help in retaining surgeons in rural areas. The Burrows Memorial Christian Hospital in the year 2002 started the Diagnostic Camps – Surgical Camp model [16]. This helped the hospital increase the number of surgeries from 92 per year to 3685 a year [17]. Most of the diagnostic facilities available at the hospital was taken to the remote rural areas where the surgical diagnosis was made. The patients then came to the hospital for surgical treatment. There was no external funding and patients paid for the treatment.

THE NUMBERS

The density of specialist surgeons, anaesthetists, and obstetricians (SAO number) per 100 000 population, correlates with specific health outcomes. The WHO recommends 20-40 SAO / 100,000 population. In India, the SAO number is 6.8 with the rural number being an abysmal 2/100,000 which is the same as sub-Saharan Africa [18].

EMPOWERING

MENTOR SHIP BY SENIOR SURGEONS

Mentorship or teaching new skills by mentors who visit the rural surgeons to train them is wonderful way of empowering the rural surgeons. For example, while one of the authors trained at Christian Medical College [CMC], Vellore the college had not started Laparoscopic surgeries. Faculty from CMC Vellore stayed for two weeks with the author to train in laparoscopic surgeries. Similarly, overseas visiting surgeons can teach new skills that empower the rural surgeons [19]. This type of training is possible when the mentors know the trainees well and understand their capabilities. Empowering the rural surgeons was felt as a great need during the Karad Consensus meeting organized by Lancet commission on Global Surgery [20].

In this model the trainers’ salaries and often the travel was paid by the parent institutions, or the project and the trainees took care of the local hospitality of the trainers.

1. LEARNING DURING SURGICAL CAMPS

From the year 2003 to 2013 the team from the organization SEESHA [21] organized 116 surgical camps at 29 different rural hospitals. During this period about 23 junior surgeons either accompanied the team or were at the local hospital to learn. The surgical camps were typically for 3 to 4 days at a place and most of the time was combined with another place [22].

The following table 1 gives the results of the training that they received and what they did after the training related to laparoscopic surgeries. It shows that half of them had training at only one surgical camp and this was not sufficient for them to continue laparoscopic surgeries thus highlighting the importance of regular Proctorship

The results also show that those who continued to do laparoscopic surgeries when they went back to their places or at the place where they received training needed a minimum of 3 such surgical camps and some required as many as 12 surgical camps for sufficient training.

Table 2 gives the list of Laparoscopic Surgeries carried out during these surgical camps [14]. Although the exact numbers are not available after doing a few themselves the Proctors helped the local surgeons do these surgeries.

Table 2: Number of Laparoscopic Surgeries carried out during Surgical Camps

Table 3 shows the number of surgeries performed in some of these places during the next few years. These include only the major surgical procedures but just with these calculations show that the surgical coverage increased from 235 to 628 per 40000 population which translates roughly to an improvement of one and a half times the surgical coverage of the target population [from 600 per 100000 to 1500 per 100000 populations]

2. LEARNING THROUGH FORMAL TRAINING PROGRAM

The University of Leeds through their NIHR – GHRG project [23] started the Project GILLS for the rural surgeons primarily in Northeast India. The project developed a formal training program in Gas Insufflation Less Laparoscopic Surgeries [GILLS] and organized the Target training program [24].

During the year 2019 the Project GILLS worked with rural surgeons from Tukrajhar in Assam near Bhutan border, Medzhiphema in Nagaland, Aizawl in Mizoram, Biru in Jharkhand, Satoli in Uttarakhand, Ambilikai, ICC Hospital, Sitilingi and Gudalur in Tamil Nadu and Bhalukpong in Arunachal Pradesh.

Table 4 shows the number of days spent at the various hospitals training and empowering the rural surgeons.

The travel cost to the project during the year 2019 was INR 2017409 [21696 Pounds or 1808 Pounds a month]. The project team stays in South India and the travel was to Northeast India (Assam, Mizoram, Nagaland, Arunachal Prades), Uttarakhand, Jharkhand and South India covering about 8000 to 10000 kilometres a month. In addition, the cost covers one training program for the 6 trainees and the cost of the faculty or trainers for the contact training program and two formal Proctor –ship programs and few other visits of the faculty to the rural hospitals.

The cost works out to about INR 2756 (30 Pounds) per surgery carried out during the surgical camp.

The approximate target population served by these hospitals derived from the last census data is as follows [Table 5]

Many of these places before the rural surgeons started the work there had no surgical work going on at the hospitals. The examples are the Crofts Memorial Hospital, the Government CHC Medzhiphema and Jalukie and Aarohi. Some places like the Family Health Clinic and Tribal Health Initiative had few emergency surgeries like LSCS going on but not on a regular basis. Others like SBMC and Bethesda Hospital had less than 50 surgical procedures a year few years ago. All the rural hospitals listed started training with the project team before 2019 except Shanthi Bhavan Medical Center that started working with the team only during the latter half.

During the year 2019 a total of 732 major surgical procedures were carried out at the surgical camps. This includes 97 Gas Insufflation Less Laparoscopic Surgeries. There were 277 surgeries for urinary tract stones. The local surgeons learnt Gas Insufflation Less Laparoscopic Surgeries and Urology surgeries. The other surgeries were for patients whom they collected for surgical camps. The cost of these surgical procedures if carried out elsewhere would start from INR 60000 [645 Pounds] to the patients and often are much higher. If the costs of travel of the patient and relatives to the city for surgical procedures this cost could be well over 1500 Pounds per surgical procedure. The cost to the project including the salaries works out to about 60 pounds per surgical procedure carried out.

Table 6 shows the Surgical procedures carried out during the Surgical Camps

The total number of surgeries carried out at some of these places is given below in Table 7. The total numbers at these places in the calendar year 2018 and 219 are given and these include the surgeries carried out at the Surgical Camps.

The surgical camps alone added 317 surgical procedures per 100000 populations a year for the immediate target areas of the population. The immediate target population for the rural hospitals where most of the surgical procedures were carried out was 82180 and the number of surgical procedures there was 697. Hence for these hospitals alone if the contribution of the surgical camps were calculated it is 848 per 100000 populations a year.

In 2019 the Surgical Coverage in the immediate target population of the rural areas where these empowered rural surgeons were working was 3739 per 1000000 populations. This figure was 2880. for the year 2018 and if the trend continues in two or three years the Lancet recommended figure of 5000 per 100000 populations a year could be achieved in these areas.

Another thing to note is that the patients come from the extended target area for the surgical procedures and hence the actual coverage at the local target population would be less than the estimate indicates.

The impact of the project could be summarized as follows.

COSTS FOR SURGICAL PROCEDURES CARRIED OUT

The cost to the Project per surgical procedure carried out is about INR 5500 or 60 Pounds (including staff salaries, training programs, etc.) and to the patient about INR 9500 paid at the local facility. The cost saving per patient if these were carried out elsewhere would be about INR 120000 or about 1290 pounds per surgical procedure carried out.

In other words, the impact of the project was a saving of about 944280 Pounds or a saving of about 87.8 million rupees for the patients in 2019.

SURGICAL COVERAGE IMPROVEMENT

Few years ago, in the project area the Surgical Coverage would have been less than 30 per 100000 populations per year [as surveyed in 2017 from the Government data]. The presence of rural surgeons at these facilities improved the surgical coverage significantly. Although the exact figures are not available from the registers the approximate figures indicate surgical care coverage of 1287 per 100000 populations a year.

This increased to 2880 per 100000 populations a year when the rural surgeons started learning new procedures during the surgical camps and advanced surgical procedures were available during the surgical camps

In the year 2019 with the rural surgeons being empowered to do the new surgical procedures that they had learnt during the surgical camps the coverage increased to 3739 per 100000 populations a year.

RURAL SURGEONS STAYING ON IN RURAL AREAS

During the project period that started in 2018 more rural surgeons started training with the model of onsite training with Surgical Camps. However, at one of the places it was not feasible to continue the Surgical Camps and the rural surgeons stopped the surgical camps and is considering moving out of the rural area. Two of the current rural surgeons had seriously considered leaving the place where they are working now. One of the significant considerations for them to stay on was the empowerment through the training.

Empowering Rural Surgeons is a cost – effective sustainable long-term solution for improving the surgical care in rural areas. Scaling up of the training could be enhanced by funding the salaries and travel of the Trainers for these Proctorship programs.