The manual has been distributed to many trainers, who through the ‘grandfather clause’ by ISOFS and AFCS are universally accepted as trainers by the fistula surgeons’ community. Many of the initial trainers selected included those who contributed to the manual, throughout Africa and Asia.
Following the publication of the manual, several challenging issues arose. These included how the trainees will be selected, how long it will take to train each trainee, who will provide accreditation and how the programme will be funded.
Selecting the trainee
Guidelines for the selection of trainees for the fistula training programme were determined by members of the FIGO and Partners committee. They believed that all applicants should have completed at least three years of surgical or obstetrics and gynaecology training following graduation from medical school. In essence, trainees would be self-selecting. But retaining the trainees was also an important consideration. One of the major problems, in the past, has been that many trained fistula surgeons often did not stay in their homeland but left to pursue careers elsewhere. This presented a form of ‘brain drain’ of fistula surgeons throughout the developing world. The committee felt that all prospective trainees should be encouraged to offer a minimum term of service determined by their country in providing a fistula surgery service, be it within a dedicated fistula hospital or a general hospital setting. This was felt to be very important, so that each country’s Ministry of Health could maintain autonomy of its own manpower development strategy.
The training period
All trainees need to be accepted by a trainer who must ensure that the appropriate facilities for training are available, for example, adequate patient numbers, good surgical facilities and equipment, computer access and accommodation. Feedback and evaluation are critical to ensure that the programme is fit for purpose.
The training period should be individually tailored following discussion between trainee and trainer. The manual is divided into standard, advanced and expert levels of competency. As the trainees complete each phase of training, they achieve the next level of competency and can be signed off by their trainer. The training programme currently has seven trainees in place, all of them training for the standard level of competency. It is anticipated that most trainees will need a minimum of two months of training in an accredited centre to achieve a standard level of competency. To achieve a higher level of competency will be determined on an individual basis.
Accreditation and certification
The accreditation and certification process for completion of each level of competency is to be shared between FIGO and the professional societies. To date, FIGO is working in tandem with the professional societies to accredit centres and trainers. The accreditation and certification of the trainees is currently in the hands of FIGO. As the numbers of trainees increase, it is planned that each country’s designated professional body along with its academic institutions will provide the competency-based fistula surgery training programme as a specialised form of postgraduate education. They will then become the certification body. This will require negotiation between academic institutions, professional bodies, Ministries of Health and FIGO with their partners.
Funding of the training programme
The funding of trainees on the training programme was surprisingly the easiest of the challenges that arose after completion and publication of the manual. FIGO was integral to this. It negotiated with several non-governmental organisations that were active in the field. These included WAHA International, EngenderHealth, the Fistula Foundation, the United Nations Population Fund and many others. These organisations were able to provide funding for accommodation, expenses and travel, as well as help the hospitals and trainers with improved infrastructure.
In the future, it is anticipated that governments and institutions will take over funding of the training programme, when they become part of the established postgraduate education system.
In the last few years so many positive changes have taken place in the fistula world that it has been overwhelming at times. Raising awareness of obstetric fistulae was the starting point of interest in this field, and has been the reason why we are able to move forward as a community. The tremendous efforts of the surgeons past have brought obstetric fistulae to the forefront of the world’s medical media. This exacting work has meant that more women were being treated, more dedicated units were being developed, more doctors were being trained and most importantly, more lives were being rebuilt. The doctors were not the only ‘heroes’ in this story. Without the continuing support of dedicated nurses, physiotherapists, occupational health therapists, social workers, cured and non-cured patients working as health auxiliaries, non-government organisations and philanthropists, none of their effort would have been fully realised. But it must not be forgotten that this condition is completely preventable. Therefore, the issues which are the basis for it, social and economic development of ‘at risk’ girls/women, must be on the agenda for them to be tackled.
Until there is universal access to emergency obstetric services, antenatal healthcare services, improved transport and socio-economic status, improving medical care for these women will be a challenge. A holistic approach to medical and surgical treatment, rehabilitation and follow-up in the community is a step in the right direction. The publication and implementation of the FIGO and partners competency-based training programme is helping provide a standardised approach to medical and surgical management of this condition. We anticipate that in time it will improve outcomes. However, the training programme has to be part of a wider picture, incorporating integrated social, economic and cultural development programmes. Together they can help prevent the problem. There is no doubt that in the long term, social and economic development will be more cost-effective than medical treatment and highly sustainable. But until then, we must rely on the dedication and delivery of good care by all the professionals working in this field. The FIGO and partners competency-based training programme goes some way in contributing to this laudable objective.
Sohier Elneil, Consultant Urogynaecologist, University College, London
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