As part of the debate on health systems in West Africa, WATHI met with Professor Serigne Magueye Gueye, President of the West African College of Surgeons (WACS), to discuss the challenges of health systems in Africa. He answers our questions in this interview:
- What can be done to ensure wider and cheaper access to surgical services?
Access to surgical care is an essential component of Universal Health Coverage (UHC). Obviously, I am talking about financial and geographical accessibility to surgical care, which is essential to achieving universal health coverage (UHC). This care should be directed to the community at the lowest possible level.
As regards primary health care, surgical care packages must be offered to help reduce certain cases of morbidity, first and foremost maternal and infant mortality. Nowadays, we know that if emergency obstetric and neonatal care is available at the community level, there is a chance of reducing all pregnancy and childbirth-related complications, but also quite dramatic complications such as obstetric fistulas, which are often talked about.
Guaranteeing universal access to surgical services does not just mean building hospitals or providing them with equipment and human resources. All these things are important, but they also require related services. This can be summed up by addressing the social determinants of health. You can build a hospital, put everything in it, but nobody goes there because people do not have the culture of going to hospitals. Lots of maternity wards are operating empty because they are not attended by the surrounding population. The tradition of giving birth in a hut is still followed, but this practice, often carried out by a matron, must stop.
Guaranteeing universal access to surgical services does not just mean building hospitals or providing them with equipment and human resources (…), it also requires addressing the social determinants of health
One of the social determinants that must be considered, first, is education. That is how people will realize that in certain conditions, it is necessary for them to go to the hospital. Second, hygiene must be instilled. This will prevent people from getting sick and reduce the number of people receiving care. We need to invest more in prevention to eradicate the number of disease cases. Third, we must ban all the harmful factors that may cause diseases, primarily tobacco. Smoking is a disaster that causes not only medical but also surgical complications.
Finally, let us talk about feeding people. Is it possible for a country to cover education and health costs whilst fighting to achieve food self-sufficiency? Even individually, if people spend most of their earnings on food, they may not have money remaining to even immunize their children.
Health financing is also an important dimension in this regard. Still in the same perspective, it is important for people to have a balanced diet. Senegal is a country where rice consumption is very high. By getting people to associate more vegetables and proteins, which are essential for health, with rice, it is possible to reduce this consumption by two-thirds.
- What could be done to change the eating habits of a whole country?
To achieve this, a whole communication and awareness-raising policy needs to be put in place. We must lead by example and be pedagogical in the way we explain the need to change eating habits. TV, radio, etc., can be used for this purpose. People can also be taught the different ways of eating vegetables to vary their diet. By reducing our rice consumption, for example, we can make economies of scale that can be reinvested in education and health, which are the main basic needs of our countries.
- What innovative financing solutions to support health systems in the region?
Financing is a key component in the management of health-related expenditures. The conventional sources of funding for health systems in the region are fragile. Therefore, alternative sources of financing need to be considered. For example, I think that Zakat is an interesting solution in Muslim countries. For Muslims, it is a compulsory legal almsgiving. By organizing a Zakat collection, we would be able to create a structure of trust whereby nationals would donate funds to help care for the poor.
This structure does not necessarily have to be public. Rather, it should be a private non-profit foundation under the authority of the Ministry of the Interior. It could be called the “Zakat Fund for Health and Education.” This foundation could be linked with other Zakat funds from other countries that can support it: in Saudi Arabia, Kuwait, the United Arab Emirates, etc. The money collected by this foundation each year could be used to tackle a particular public health problem: women’s health, surgery for neglected tropical diseases, non-communicable diseases.
Tobacco is a disaster that causes not only medical but also surgical complications
- The lack of human resources in the health sector, associated with brain drain among other factors, is one of the major obstacles to the effectiveness of West African health systems. How can this challenge be addressed?
The brain drain across Africa is dramatic and is often associated with the working environment in African countries. Today, 9 out of 10 Nigerian physicians are said to be willing to leave their country. Senegalese physicians are those who migrate the least. Those who leave usually return to their country because there is an environment that enables them to work.
I came back to Senegal because I knew that in my country, my ethnicity or religion would not be considered before getting a job. Ethnic diversity is normalized and seen as a richness. Unfortunately, this is not the case in all countries.
In many countries, the problem is that all these factors affect people’s daily lives and prevent them from fulfilling their potential. I visited countries where all those working in my field were from the same clan or the same ethnic group. There are countries where this situation occurs in terms of membership of clubs or sects. But that is not the case in Senegal, and it should not happen. As long as this environment is maintained, human resources will stay in this country since their quality of life may be better than in the West.
- What should be done to ensure that quality health workers are available in all geographical areas of our countries?
Senegal has quality health professionals at every level; what matters is their distribution and retention throughout the country. One of the reasons for this is the lack of strong incentive mechanisms dedicated to them. A midwife in a remote rural area cannot be paid the same salary as a midwife in Dakar when the former is not in as comfortable an environment as the latter.
By organizing a Zakat collection, we could be able to create a structure of trust whereby nationals wishing to contribute through their Zakat would donate funds to help care for the poor
The Ministry of Health has attempted to do so through some projects, but this needs to be more structured. For example, Senegal can classify its regions into two or three categories and offer remoteness allowances to health professionals depending on the category they belong to. Incentives should also be considered to ensure that those assigned to the remotest regions feel comfortable where they are on duty. Another disincentive to working in some rural areas is the lack of basic services such as electricity, water, or a nearby bank.
- In addition to incentives, should a mandatory rural service be imposed on a specific category of physicians to decentralize access to quality health professionals across the country?
Physicians cannot be forced to perform compulsory surgery like the army does. You only work best where you thrive. Most of teachers at the Faculties of Medicine in Thiès or Saint-Louis do not live in those regions. So, how are you going to develop medicine in those areas? It is not just a matter of opening faculties and assigning staff who are not willing to stay in these regions. By assigning them to these areas, you should enable them to return to where they are from. Rather than sending them away from home and forgetting them, we must create a reassuring mobility framework based on fair criteria.
Career should not be a constraint from beginning to end. Let us give everyone the ability, as part of their job, to have the flexibility to move back and forth to wherever they wish throughout their career. That said, I think that the training of physicians needs to be reconsidered. This is a fundamental aspect. Indeed, after Madagascar, Senegal has been the second French-speaking African country to start teaching health services. Physicians who were trained before never finished their training without being able to deliver surgical care to the population. Then the medical curriculum was modernized, but did the quality of teaching really improve?
I came back to Senegal because I knew that in my country, my ethnicity or religion would not be considered before getting a job
In our time, physicians were trained over seven years, but now they have eight years of training. So now I really wonder whether eight-year-trained physicians are better than seven-year-trained physicians. The answer actually is no. Then why was this eighth year kept if not to improve the quality of physicians?
I think this eighth year should perhaps be used for additional surgical training to ensure that physicians graduating from medical school have the basic medical skills to serve people wherever they are in the country. That physicians of all specialties can perform basic surgeries no matter where they are located. The great question each and every one of us must ask is, what type of physician do we need for what type of population?
- How can we support the region’s weakest countries in terms of quality human resources?
Guinea-Bissau, Gambia, Liberia, Cape Verde, and Sierra Leone are the countries in the region most in need of support for health human resources. Addressing the shortage of health workers in these countries is one of the objectives of the West African College of Surgeons.
Local training programs should be implemented over two stages. The first stage involves introducing training programs to transfer mid-level skills in all areas of medicine to existing physicians. The second one includes emergency short-term training for practicing physicians to perform essential surgery pending a five-year surgeon training program. Thus, a physician who is assigned to Fongolimbi will be able to provide services like tooth extraction. Long-term training must be mixed with short-term training.
Practicing physicians can be trained in a short period of time to perform essential surgery pending a five-year surgeon training program
Certain responsibilities must also be delegated. Actions or gestures performed only by surgeons can be taught to non-surgical staff who can do something for the population. For instance, if nurses could deliver emergency obstetric and neonatal care such as cesarean sections, maternal mortality would be reduced. That is something I am confident they can do.
- Beyond existing initiatives, what can be done to accelerate regional integration in health? What can the West African Health Organization (WAHO) do in this regard?
WAHO is an extraordinary integration instrument that is exclusive to our region. It does for our region what the World Health Organization (WHO) does at the global level. WAHO has contributed to the harmonization of all specialized training courses in all French-speaking countries. A cardiologist’s training curriculum in Senegal is the same as that in Benin, Niger, etc. Now we are in the final phase of the harmonization process, which also includes the English-speaking countries of West Africa.
WAHO has contributed to the harmonization of all specialized training courses in all French-speaking countries. A cardiologist’s training curriculum in Senegal is the same as that in Benin, Niger, etc
Colleges are being organized under the aegis of WAHO as part of a forum of West African Colleges of Specialized Training. These are the West African College of Physicians, the West African College of Nursing, the West African College of Pharmacists, and the West African College of Surgeons. These colleges are doing outstanding efforts to improve aspects of the West African health systems.
WAHO should be empowered to implement its programs. States should also provide more support for its action at the national level. That is where I think the problem lies. The link between national policies and those defined by WAHO is not very clear.
Crédit photo : seneplus.com