Mapping Training in Fistula Management: An Overview of Capacities and Needs

1. 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

2. 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, Kenya1, Mauritania, Niger, Senegal, Sierra Leone, Sudan, Tanzania2, Uganda2 • Review of available needs assessments and other sources for other countries 1 2 received (UNFPA/AMREF), 2 Covers only AMREF supported facilities

3. 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

4. Incidence and Cases Treated by Country • Over 8,000 treated • Range of ~7% to ~73% repaired (not really comparable) • Data collection noted as difficult *reported cases

5. # 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)

6. # 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

7. 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

8. 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)

9. 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

10. # of OT and Ward Nurses skilled in fistula care • For many countries, none trained or information unavailable

11. 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)

12. 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

13. 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)

14. 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

15. 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.

16. 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

17. 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.

18. 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?