Background: Human resources are essential to the sustainability and scalability of health interventions. A barrier to global cancer efforts has been the scarcity of trained pediatric hematology/oncology (PHO) professionals in low- and middle-income countries (LMIC). Studies highlight this inequity and the need to develop a global PHO workforce through allocation of financial resources, strengthening of healthcare infrastructure, and development of innovative training programs. Ethiopia is the second most populous country in Africa. Because of recent reduction in infant mortality and improved treatment of Malaria and HIV in Ethiopia, non-communicable diseases contribute an increasing proportion of childhood mortality. The annual incidence of pediatric cancer in Ethiopia is estimated to be 6000-8000 cases. Prior to 2013, no dedicated PHO programs existed in Ethiopia, and there was no formal process for training local physicians in PHO. The following intervention aimed to increase local capacity for treating childhood cancer through the creation of a formal two-year PHO fellowship.
Strategy: The PHO fellowship program was created by The Aslan Project, a US non-profit led by a group of experts in PHO, pediatric oncology nursing, and pathology with experience practicing in LMIC, in collaboration with Addis Ababa University (AAU). The goal was to provide a robust educational experience for fellows within the existing resource-constrained clinical environment. Tikur Anbessa Specialized Hospital (TASH) was the initial clinical site (in 2013) for the training program with a second at Jimma University Medical Center (JUMC) in 2016. An Aslan clinical director was present throughout the first year at each location. Visiting faculty from the US and Canada provided clinical supervision, on-site didactics, and professional mentorship. The second year of training included a six-month rotation at a high-functioning cancer institution in India. Fellows were expected to complete a scholarly activity, pass a certification exam, and serve as pediatric hematologist-oncologists in Ethiopia for a minimum of two years following training.
Outcomes: Since 2013, four physicians completed PHO fellowship based in Ethiopia, with extensive support of local healthcare leadership and visiting faculty. One additional fellow left training prior to completion and one fellow currently is in training. Twenty-three faculty members from 18 Universities made 51 trips to Ethiopia for onsite training of fellows from 2013-2019. Each fellow completed a rotation in India in his/her second year (Tata Memorial Hospital, Mumbai, or TMC Kolkata). Fellowship projects included a comprehensive pediatric cancer unit assessment, safe chemotherapy practices, and the role of diagnostic pathology. The four subspecialty-trained physicians have remained local, two at TASH, one at JUMC, and one returned to Gertrude's Children's Hospital in Nairobi, Kenya. JUMC now supports a 22 bed PHO unit running at 90% capacity with over 300 new diagnoses since August 2016. TASH supports a 26 bed inpatient unit and 16 additional inpatient beds at a nearby oncology center, treating over 600 new patients annually. The fellowship structure has succeeded in training subspecialty physicians to establish PHO care in Ethiopia.
Discussion: Developing specialized care in LMIC requires a multifaceted approach, including nursing training, social support, health system buy-in, diagnostic expertise and facility, pharmacy services, and subspecialty physicians. Focusing on physician training for PHO in Ethiopia, we designed a training structure and curriculum to 1) teach resource appropriate medical care, 2) provide sustained clinical mentorship, 3) develop health system leadership skills, and 4) retain physicians to support local pediatric oncology units. Onsite training by visiting faculty was augmented by sending fellows to a mature, middle-income country program and the support of full-time clinical faculty/mentorship for a large portion of the program. Challenges included fellow recruitment, pathologic accuracy, chemotherapy access, nutritional support, and treatment retention. Formal subspecialty PHO training can be implemented in LMIC without established subspecialty physicians, but requires ongoing commitment of administrators, visiting faculty, local universities, and a multidisciplinary team of health professionals.
Alexander: AbbVie: Other: travel funding.