In 2015, the World Health Organization (WHO) recognized surgical and anesthesia care as essential components of universal health coverage.1 That same year, The Lancet Commission on Global Surgery estimated that five billion people in the world lack access to safe, affordable, and timely surgical and anesthesia care, contributing to 18 million deaths annually, and that surgically treatable conditions account for up to one third of the global burden of disease.2

Many populations with limited access to surgery and anesthesia care live in low and middle-income countries, but populations within high-income countries (HICs) also experience inequitable access to surgical and anesthesia services.3 In countries such as the USA, Canada, and Australia, shortages of surgical, anesthesia, and obstetric providers in rural communities limit access to timely care and place undue burden on patients.4,5 Rural counties in the USA face a shortage of perioperative providers, with over 60% having no general surgeon, over 80% having no anesthesiologist, and over 50% having no anesthesia provider, making 24/7 access to obstetric and emergency surgical services challenging.6 In locations where services do exist, disparities in perioperative outcomes are common with African American children having 3.4 times the odds of dying within 30 days of surgery compared with White children. Additionally, Black and Hispanic women in labour are less likely to receive epidural analgesia than non-Hispanic White women and Indigenous peoples in Canada have a 30% higher mortality and higher complication rates than non-Indigenous patients.7,8,9,10

To address these workforce shortages and health disparities, academic institutions in HICs should rethink how they train physicians and collaborate with underserved communities.

The HEAL Initiative model

The Health, Equity, Action, and Leadership (HEAL) Initiative fellowship based at the University of California San Francisco (UCSF) is one model for training and transforming future health care leaders. The HEAL Initiative is a two-year multidisciplinary fellowship founded on principles of equity, humility, solidarity, and community. The HEAL Initiative recognizes that health is deeply influenced by economic, racial, and power inequities that exist within society and that understanding this structural violence requires witnessing it first-hand without looking away.11,12

Each year, HEAL recruits an interprofessional cohort of 20–30 fellows from around the world to immerse themselves in domestic and international resource-denied communities. The HEAL Initiative collaborates with a network of partner hospitals and nongovernmental organizations who have spent decades serving patients in their communities. Fellows come from diverse professional backgrounds including physicians, nurses, program managers, pharmacists, and community health workers. Among physicians, HEAL recruits across medical specialties including surgery, anesthesiology, and obstetrics and gynecology (OB/GYN). The HEAL Initiative is designed to be bidirectional, with half of each cohort representing underserved, resource-denied communities in the USA and abroad. As “site fellows,” these professionals are often employed by hospitals and organizations at HEAL partner sites. Site fellows possess deep experience with the historical structures challenging their communities and impacting care.

The other half of each cohort is composed of “rotating fellows,” who spend one year at a domestic HEAL partner site and the second year at an international partner site. Most rotating fellows are physicians and recent residency graduates. Domestically, their primary focus is providing clinical care as attending physicians while internationally the focus is on program implementation, clinical care, and community engagement. Over the course of two years, HEAL fellows collaborate and challenge one another through regular training, journal clubs, and narrative assignments focused on the program’s pillars of structural competency, power and privilege, leadership, and advocacy. Structural competency can be defined as, “the capacity for health professionals to recognize and respond to health and illness as the downstream effects of broad social, political, and economic structures.”13

The HEAL Initiative’s funding model centres on the fact that high cost, short term, locums providers are commonly used to fill the large vacancies in health care jobs in rural and Indigenous communities in the USA.14 The HEAL Initiative instead fills a single open position in a workforce shortage area with two post-residency trained physicians who split one full-time equivalent (FTE) over the course of two years. While one fellow works internationally, the other works in Navajo Nation, and vice versa. The fellows are compensated at the equivalent of a postgraduate year-5 salary and the remainder of their FTE supports a Navajo health worker and an international health worker to join the fellowship from HEAL’s partner sites. One FTE funds four health workers creating a redistributive justice model that builds local capacity and fills open positions in high-need areas with trained specialists.

Every HEAL fellow is provided support for professional development including funding for higher education (e.g., master’s degree) or further training (e.g., point-of-care ultrasound). HEAL draws upon its alumni base to help teach, develop curricula, and provide mentorship to fellows and alumni. Through its affiliation with UCSF, the program offers access to a large network of physicians and resources for clinical support, continuing medical education, and research collaboration.

The HEAL Initiative has developed partnerships with domestic sites including Natividad Medical Center in Salinas, CA and multiple facilities on Navajo Nation, the largest Native American reservation in the USA. International partner sites exist in Mexico, Haiti, Mali, Liberia, Rwanda, Malawi, Uganda, India, and Nepal, spanning organizations including Partners in Health, Jan Swasthya Sahyog, Muso, and Last Mile Health (Figure). All current HEAL rotating fellows in surgery, anesthesia, and OB/GYN are based in Navajo Nation and Uganda as part of a collaboration between the UCSF Center for Health Equity in Surgery and Anesthesia and Busitema University.

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figure 1

Map of HEAL partner sites (used with permission of the HEAL Initiative)11

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Impact

The HEAL Initiative began in 2015 and has graduated five cohorts of fellows with two additional cohorts currently in training. To date, HEAL has trained 164 fellows and alumni. As of 2019, approximately 47% of HEAL fellows were from the USA outside of Navajo Nation, 24% from Navajo Nation, 11% from South Asia, 11% from sub-Saharan Africa and 7% from Mexico and Haiti. About 65% of HEAL trainees have been physicians with the remainder being other allied health professionals. The HEAL Initiative has strong alumni retention with 11 former rotating fellows continuing to work at Navajo Nation facilities.

With respect to perioperative care, HEAL has graduated two surgeons, two anesthesiologists, and four OB/GYNs. Additionally, there are two surgeons and five OB/GYNs currently enrolled. Of the two surgeon alumni, one is a staff physician at a Navajo Nation facility and the other continues to work in rural India. Of the two anesthesiologist alumni, one is completing a pediatric anesthesiology fellowship and the other continues to work in India. Of the four OB/GYN alumni, three are staff physicians at Navajo Nation facilities, and one works for a federally qualified health centre in the USA.

The HEAL Initiative has helped impact perioperative care in Neno, Malawi through implementation of routine use of the WHO Surgical Safety Checklist and initiation of a gynecology clinic for cervical cancer screening in Mbale, Uganda through resumption of endoscopy services and expansion of surgical training opportunities for Ugandan resident physicians, and across Navajo Nation with resource provision, clinical decision support, and physician and nursing workforce support throughout the COVID-19 pandemic.

Challenges

Since the inception of the HEAL Initiative, one or fewer anesthesia providers and one or fewer surgeons have applied to be fellows each year. Given that HEAL is in its early years, this may be the result of limited awareness of the existence of the program, especially among perioperative providers. Additionally, recruitment of perioperative providers to be rotating fellows has been challenging because of limited exposure to rural and resource-denied settings in training, the financial opportunity costs that result from the time commitment of the program, and the concern for potential atrophy of technical skills. Challenges to recruitment of perioperative providers to be site fellows include a limited pool of perioperative providers working at HEAL’s current partner sites, small numbers of perioperative providers currently working on Navajo Nation who identify as Navajo or Indigenous, and family and job requirements that make substantial time away difficult.

Call to action

Over the last seven years, the HEAL Initiative has grown from an idea into a network of nearly 200 fellows and alumni committed to serving, supporting, and advocating for resource-denied communities around the world. This community is HEAL’s greatest strength serving as a forum to share diverse experiences and perspectives on health care as it is and develop ideas on health care as it could be. Despite this success, only a small proportion of HEAL fellows have been recruited from perioperative specialties. More surgeons, anesthesiologists, and OB/GYNs are urgently needed to fill access and quality gaps in underserved areas and academic centres should be obligated to meet this need. The HEAL Initiative serves as a model for how academic centres, who historically have approached surgery and anesthetic care from a unidirectional, mission-based focus, can stand in solidarity with underserved populations by creating inclusive training opportunities that improve clinical care, provide community support, and augment health worker recruitment to rural and resource-denied communities both domestically and internationally.

The HEAL Initiative has had particular success in recruiting permanent providers to Navajo Nation, a rural and resource-constrained setting with high provider vacancy rates.13 While a considerable provider shortage remains in surgery and anesthesia across Navajo Nation, HEAL has shown strong retention in primary care and OB/GYN such that the program is looking to expand to other sites. The HEAL Initiative has had a large impact as one organization at one academic institution highlighting the potential of what could be accomplished if other institutions replicate HEAL’s model to create programs that are not just directed toward, but inclusive of rural and underserved communities. From conception to design, from implementation to evaluation, from administration to the frontlines, the community hoping to be served must always be centred. Adopting and incorporating a bidirectional, long-term, partnership-based model like the HEAL Initiative is a necessary first step in perioperative health equity work to align the interests of academic institutions with the needs of vulnerable patients wherever they may live.