Reliable access to surgery for the population in rural areas has been a political preoccupation in Niger. Since 1974, mobile surgical teams had been dispatched to provide for surgical needs in these areas, but this arrangement was limited due to its sporadic and temporary nature. Niger is more than four times the size of the UK and consists mainly of desert, where the distances between health structures are significant, and poor road conditions make transfers formidable and difficult. Effective coverage of surgical needs, including that of obstetrical emergencies, requires that surgical capacity be available within the area.
In Niger, the lack of surgeons is largely attributable to the prolonged training (5 years); the current system has only graduated three to five surgeons annually since 2004. Based on this reality, a decision was made to train general practitioners who were going to be working in rural areas in surgical skills during 12 months; In Ethiopia, the length of training consists of 6 months [7]. In Canada and Australia, in certain rural locations, surgical activities are performed by general practitioners, whereas in the United States, many procedures are provided by general surgeons [8–11].
The results of this program in Dosso since the implementation of district surgeons (or general practitioners trained in surgery) are encouraging and promising. The division of 62.1% elective and 37.9% emergent cases can be compared with the results of Humber et al. in British Columbia, Canada, of a respective split of 81 and 19% [11]. The higher percentage of emergent cases in Niger suggests that the needs for these types of programs are even greater in sub-Saharan Africa.
For elective surgeries, we found that the largest needs were in the areas of hernias and hydrocele. In fact, the mobile surgical camps that began in 1974 were specifically developed to address these pathologies in an active population (e.g., cultivators and breeders). In Niger, hernia repair is the most common gastrointestinal surgery, in nearly one of two patients [12]. The findings from a comparative study done in 2003 regarding the management of inguinal hernia at the University Hospital of Niamey and the district hospital of Gaweye showed that the pathology was treated similarly in both institutions with equivalent surgical outcomes and, in fact, the length of stay and cost of treatment was significant less in the district hospital [13]. In emergent surgeries, the obstetric interventions of cesarean and ruptured uterus represented the majority of activities (77.8%) with a mortality rate of 6.25% and minimal morbidity, compared with 5.7% in the regional hospital where fully trained surgeons provided care. This is similar to a Canadian study where results from cesarean surgeries done by generalists was compared with that of specialists; the most surprising observation was the low morbidity rate from these major surgeries was similar for both groups. With 4-month training, on average, the generalists were practicing cesarean sections with a level of acceptable risk and safety [14].
The referrals to the regional hospital were mainly due to orthopedic trauma (66.1%) and abdominal-thoracic trauma (10.4%). Although these generalists are trained in the basic treatment and management of orthopedic fractures, almost half of these cases were referred to the regional hospital simply because of a lack of materials necessary for treatment of these orthopedic trauma cases (e.g., external fixators) and even orthopedic beds for traction. Another contributing factor to the higher referral rate for these injuries was the need for further training in these injuries.
For the management of abdominal trauma requiring splenectomy (0.9%) at the district hospital, the transfers for serious cases required the care of a specialist and possibly further imaging, such as ultrasound. To improve the treatment of abdominal trauma, a budget would need to include the purchase of materials as well as continued education of staff in primary trauma care, as well as an additional training at the University of Niamey. Two district hospitals (Gaya, Doutchi) of the three studied in the region of Dosso are on the route of well-frequented roadways and are the main institutions that receive the patients who are victims from these road traffic injuries. According to the World Health Organization, the burden of mortality and morbidity from these types of trauma are particularly elevated in low- and middle-income countries. In fact, 90% of the burden of road traffic injuries is borne by these countries [15].
Regarding the implications of this type of training program as a method for increasing surgical workforce, the World Health Organization (WHO) has calculated that Africa bears approximately 25% of the burden of the world’s diseases but only 1.3% of the world’s health work force [16]. The lack of surgeons is partly related to the “brain drain” where physicians from developing countries go to more developed regions, such as Europe or the United States. The other factor contributing to the lack of surgeons is the insufficient training mechanisms, which is common across many countries in sub-Saharan Africa and has thus spawned the adoption of different political responses. In Malawi and Mozambique, for example, the health system has trained a cadre of nonphysicians called “assistant medical officers” who can perform common surgical procedures, including laparotomies and cesarean sections [16].
This particular program in Niger of equipping generalists through a dedicated surgical training is based on training physicians who have already been working in district hospitals for 2 years or more and are familiar with life in rural and more isolated areas. The other reason to choose these physicians for this type of training is the reality that all of the physicians in the 34 districts across the country are generalists. This particular training program was of interest to these physicians because this certificate of completion also provides a bonus to their annual salary, in addition to the indemnity they receive as an incentive for working in rural areas. In terms of retention, all physicians trained from this program have remained in their posts, which local officials contribute to the initial selection of trainees for this program (those already working in rural areas who originated from these areas and have settled their families there) as well as the fact that the CDS is not recognized outside of Niger.
The problem of human resources is the common denominator across all developing countries. In Niger, certain operating rooms were not functional because of lack of anesthetists, which raises the question of whether it may be necessary to train generalists in surgery and anesthesia, as in Canada [17]. According to Chen et al. [18], during the last 20 years, economic reforms have diminished public expenditure, freezing any new recruitment and weakening the salaries in the public sector. The authors also measured “health worker density” and demonstrated its correlation with survival rates, calculating that sub-Saharan Africa has only “a tenth of the nurses and doctors for its population” compared with Europe and, even more starkly, “Ethiopia has a fiftieth of the professionals for its population than Italy” [18]. The enormous problems must be resolved with political engagement over the short-term and long-term based on recognition of the reality that these countries face and the importance of the provision of basic life-saving surgical procedures for the population.
In Niger, the engagement of the political leaders to relieve the burden of surgical disease has been led by Ministry of Health, the University of Niamey, and development partners (e.g., the Belgian Technical Cooperation, WHO, World Bank, Italian Cooperation) to establish a short-term emphasis on the creation of the General Practitioner for District Surgery and, in the long-term, for the training of surgical specialists. The goals of these well-targeted efforts address the lack of human resources and materials. Awareness of the human resource issues in district hospitals has encouraged us to plan a strategy that, in additional to financial incentives, could enhance the satisfaction of surgeons in the practice of their profession. Their responsibility would be to follow-up outcomes from those generalists who they have trained and also provide continuous education and supervision during short stays in the district hospitals.