Providing Surgical Care in Somalia: A Model of Task Shifting

Background:Somalia is one of the most political unstable countries in the world. Ongoing insecurity has forcedan inconsistent medical response by the international community, with little data collection. This paper describesthe “remote” model of surgical care by Medecins Sans Frontieres, in Guri-El, Somalia. The challenges of providingthe necessary prerequisites for safe surgery are discussed as well as the successes and limitations of task shiftingin this resource-limited context.Methods:In January 2006, MSF opened a project in Guri-El located between Mogadishu and Galcayo. Theobjectives were to reduce mortality due to complications of pregnancy and childbirth and from violent and nonviolenttrauma. At the start of the program, expatriate surgeons and anesthesiologists established safe surgicalpractices and performed surgical procedures. After January 2008, expatriates were evacuated due to insecurity andsurgical care has been provided by local Somalian doctors and nurses with periodic supervisory visits fromexpatriate staff.Results:Between October 2006 and December 2009, 2086 operations were performed on 1602 patients. Themajority (1049, 65%) were male and the median age was 22 (interquartile range, 17-30). 1460 (70%) ofinterventions were emergent. Trauma accounted for 76% (1585) of all surgical pathology; gunshot woundsaccounted for 89% (584) of violent injuries. Operative mortality (0.5% of all surgical interventions) was not higherwhen Somalian staff provided care compared to when expatriate surgeons and anesthesiologists.Conclusions:The delivery of surgical care in any conflict-settings is difficult, but in situations where internationalsupport is limited, the challenges are more extreme. In this model, task shifting, or the provision of services by lesstrained cadres, was utilized and peri-operative mortality remained low demonstrating that safe surgical practicescan be accomplished even without the presence of fully trained surgeon and anesthesiologists. If security improvesin Somalia, on-site training by expatriate surgeons and anesthesiologists will be re-established. Until then, the bestway MSF has found to support surgical care in Somalia is continue to support in a “remote” manner.