Those of us who took the initiative to launch CapaCare (8) had previous experience of emergency aid through large organisations such as the Red Cross and Médecins Sans Frontières. These organisations function well during emergencies and crises, and they also try to help achieve a lasting improvement in the supply of health services in the recipient country. We saw a need for starting a programme that should primarily seek to enhance local capacities for treatment. Sierra Leone in 2008 seemed an appropriate location for such a programme. The country had endured a brutal civil war that had ended in 2002. The population was among the world’s poorest, but motivated to avoid further wars and willing to attempt to escape from poverty, corruption and a dysfunctional social order. Crime was at a manageable level, and the government was in favour of reform (9).
We established cooperation with a Danish organisation, Friends of Masanga, which operated the Masanga hospital in the rainforest in the interior of the country. This was an old leprosy hospital, which had been founded by Scandinavian and English Adventists and was located far from the population centres. This isolation provided us with a certain amount of control of the security situation. The programme was also based on some further facts: In 2007, Sierra Leone had ten licensed surgeons. Over a five-month period in the same year, a total of 724 surgical and birth-related interventions were recorded in the ten largest public hospitals (10). Life expectancy remains below 50 years, child mortality (under the age of five) is 20 % and maternal mortality is 970 per 100 000 (11).
In 2012, a total of 32 doctors graduated in Sierra Leone, which is the highest figure in recent history. Many of them leave the country. Now in 2013, only four of the surgeons in the public sector hail from Sierra Leone, whereof one is younger than fifty (Dr. Bash-Taqi, Director of Postgraduate Training, Ministry of Health and Sanitation, Sierra Leone, personal communication). To specialise they have to go abroad, most commonly to Ghana or Nigeria. Training a sufficient number of doctors to cover the country’s needs will take many years. In the country, there is a group of health workers referred to as Community Health Workers (CHO). These practitioners receive three years of training qualifying them for primary practice in outlying areas, but they are not permitted to undertake surgery. A similar group of health workers in East Africa have undertaken surgery for many years, with acceptable results (12). In the short term it appeared that training the Community Health Officers to perform surgery would be the only available option.
We wished to formalise this training and give it an established position in the country’s health services. We encountered a fair amount of opposition from doctors, but with the support of the Ministry of Health we succeeded in obtaining permission for Community Health Officers to practice surgery. On this basis we have initiated a two-year training programme into which eight students are enrolled annually. The programme is funded by the Kavli Foundation, Lion’s Club district 104B and other privately raised funds. From its outset in January 2011 up to April 2013, a total of 17 students have participated in 5 511 surgical operations. The project has a preliminary timeframe to 2017.
The activity is mainly based at the Masanga Hospital, in cooperation with eight other hospitals operated by international aid organisations and staffed with European surgeons or gynaecologists. The establishment of this network enables us to make use of the surgical and obstetric competence available in the country for systematic teaching, by sending the candidates on a six-month rotation schedule to our partners. The theoretical training is provided by doctors and nurses from Europe, preferably surgeons, gynaecologists, anaesthesiologists and radiologists. These lecturers arrive on short-term stays lasting 3 – 6 weeks to teach the candidates at the Masanga Hospital. The curriculum is based on WHO’s Integrated Management for Emergency and Essential Surgical Care (IMEESC) toolkit (13). In addition, we arrange an annual course in surgery where pigs are used as models, supervised by Herman Lonnee, who works as an anaesthesiologist at St. Olavs Hospital. Furthermore, we arrange annual courses in ultrasound diagnostics, which are open to young doctors from the public sector as well.