Strengthening the global surgical workforce: Aspects of access, migration and quality

Background. Over five billion people worldwide lack access to safe and affordable surgery and anesthesia care when required. There is a critical unmet need for surgical care, especially in low-income and middle-income countries (LMICs). The shortage of surgical providers is one of the most influential barriers to receiving surgical care, and the maldistribution is aggravated by doctors emigrating to more affluent regions, where many physicians also nurture an interest in working abroad.Aims. The aims of this thesis were: I. To quantify the global supply and distribution of surgeons, anesthesiologists and obstetricians by country and to build a World Health Organization (WHO) surgical workforce database. II. To calculate high-income countries’ (HICs) dependency on recruiting surgeons, anesthesiologists and obstetricians from LMICs. III. To measure the proportion of surgeons, anesthesiologists and obstetricians from LMICs now working in an HIC. IV. To quantify and analyze the surgical workforce in South Africa who were educated in another LMIC, and South African surgical specialists who had emigrated to an HIC. V. To investigate how LMICs perceive short-term visits from surgeons, anesthesiologists and obstetricians from an HIC. VI. To investigate Swedish orthopedic surgeons’, anesthesiologists’ and obstetricians’ experience of, interest in, barriers to, and perceived value of international clinical work, and to assess whether there were any differences based on gender, specialty and seniority.Methods. To address these aims we: I. Collected existing and new data on the number and the distribution of surgical specialists globally. II. Collected details of the number of surgical specialists and data on their country of initial medical qualification who were now working in an HIC. III. Combined data on the number and the distribution of surgical specialists globally with the number of surgical specialists and their country of initial medical qualification now working in an HIC. IV. Collected data on the number of surgical specialists in South Africa and their country of initial medical qualification. V. Analyzed studies involving visiting surgical teams from HICs working in LMICs. VI. Surveyed all Swedish orthopedic surgeons, anesthesiologists and obstetricians. Results. There were two million specialist surgeons, anesthesiologists and obstetricians worldwide. Low-income countries had 0.7 such providers per 100,000 population (interquartile range [IQR]: 0.5–1.9), compared with 56.9 (IQR: 32.0–85.3) in HICs. HICs’ dependency on surgeons, anesthesiologists and obstetricians with a medical degree from an LMIC was 12%. Half of all surgeons, anesthesiologists, and obstetricians who had emigrated from an LMIC to an HIC came from a country in workforce crisis. In low-income countries and lower-middle income countries, the proportion of surgical specialists abroad was 6.0% and 11.0%, respectively, compared with 1.2% and 3.0% in upper-middle income countries and HICs, respectively. Of all surgical specialists currently working in South Africa, 6% were educated in another LMIC. At least 16% of South African surgical specialists had emigrated to work in an HIC. Surgical short-term visits from doctors who underwent their training in an HIC are insufficiently described from the perspective of stakeholders in LMICs. Swedish doctors have a broad experience of, and interest in, operating abroad, with differences based on gender, specialty, and seniority. Multiple personal and institutional benefits of working abroad were reported, with significant differences found between doctors from LMICs compared to those from HICs. Participation is limited primarily by family commitments at home, followed by difficulties in finding the right contacts, medico-legal challenges, and fear of not having the right competence.Significance. Most of the world’s surgical patients are either served by non-physicians or non-specialists, or else they are not treated at all. This research has provided data on the global surgical workforce with respect to access, migration and quality. Surgical workforce density has been acknowledged as a standard national health system indicator by the WHO, the World Bank, and The Lancet Commission on Global Surgery. It is currently used to track Sustainable Development Goal 3.8.1