One example of HVO’s dedication to achieving sustainable relationships in the developing world can be illustrated by the Orthopaedics Overseas program in Uganda. During the 1960s Sir Ronald Huckstep, a British-trained orthopaedic surgeon, was instrumental in developing an Orthopaedic Officer’s program at Makerere University. Much of the Ugandan health infrastructure collapsed during the periods of civic unrest that followed (when Idi Amin and Milton Obote ruled), including the departure of a large portion of the health workforce [14
]. Once political stability was reestablished after the overthrow of Obote in 1985, HVO was successful in obtaining a grant from the Patrick J. Leahy War Victims fund in 1989. The focus was on the disabled and victims of civil wars, and the project was entitled the “Uganda Orthopaedics and Physical Therapy for the Disabled Project.” HVO entered a three-year grant agreement with USAID for the Ugandan project to “improve the provision of orthopaedic, prosthetic, orthotic and physical therapy services for Uganda’s thousands of children and adults who have lost upper and lower limbs, been crippled through the paralytic residual of poliomyelitis or otherwise become immobilized, especially those persons whose disabilities resulted from civil strife” [16
The original objectives included the following: (1) teach and train 40 Ugandan medical students, physicians and surgeons in orthopaedic surgery to care for amputees and crippled patients; (2) enhance the efforts of other agencies in Uganda concerned with the training and continuing education of 20 prosthetists, orthotists, and physical therapists; (3) provide one adequately equipped operating room close to the central orthopaedic workshop to permit prompt, reasonable and adequate surgical treatment of patients with crippling injuries and diseases [16
Amendments and extensions to the grant provided for greater objectives which ultimately concluded in 1998. These objectives included: (1) continue to develop a corps of Ugandan orthopaedic surgeons qualified to continue this teaching program by training 150 more medical students, 5 surgeons in-training and 25 physicians in orthopaedic surgery; (2) assist the Ministry of Health in the extension and coordination of orthopaedic services to areas outside of Kampala through an active outreach program; (3) work with the Department of Orthopaedics and various sponsoring agencies to enable qualified personnel from nearby countries to enroll in the Department of Orthopaedics for study, and; (4) provide technical training and assistance to the Department of Orthopaedics and to Mulago Hospital to enhance sustainability and maintenance of donated equipment [16
HVO hired Rodney Belcher, an American orthopaedic surgeon, as Medical Director who soon became Professor and Head of the newly formed Department of Orthopaedics. Under his dedicated and superb stewardship, numerous achievements were realized. HVO continued to supply a steady stream of short-term and long-term volunteers along with considerable management and administrative support. A building was renovated for department offices, clinics, library and seminar/classrooms along with an HVO office. Two operating rooms for “clean surgeries” were built near the orthopaedic ward. A prosthetic workshop was constructed in Mbale Regional Hospital along with a guest house at Mulago Hospital for visitors and volunteers. With regard to teaching and education, the quintessential achievement was the establishment of a Masters in Medicine (Orthopaedics) postgraduate degree at Makerere University and Mulago Hospital. The goal was to sustainably train and supply a corps of qualified surgeons who could continue this program at the finality of the grant. The four-year program began in 1995 with the enrollment of three young Ugandan physicians as the first residents.
In addition, substantial energy was directed towards the training of Operating Room personnel, orthopaedic nursing staff, and the advancement of sterile technique and OR productivity. Further energy was spent in the training of technicians to maintain and service the medical equipment and hospital engineers to attend to the needs of other departments such as radiology, cardiology, anesthesia and respiratory therapy. Many of the staff surgeons were funded for training outside of Uganda to develop other collaborative relationships with successful programs at other academic centers.
Extension of Services (Orthopaedic Outreach Programme) HVO and Dr. Belcher spent considerable effort on the expansion of the delivery of services outside of Kampala at the numerous regional hospitals along with the establishment of an effective referral system from the upcountry regions. HVO volunteers supplemented this Orthopaedic Outreach Programme, and staffed periodic “surgical camps” that increased visibility of available services, identified those in need, and provided education and training for medical officers and surgeons at the peripheral hospitals, thereby strengthening the national referral system [2
]. These successes were documented in a process evaluation in 2004 (see “Does the Orthopaedic Outreach Programme Work for Uganda?”) [3
Further accomplishments include the procurement of educational materials such as books (more than 5000), journals, slide sets, videos, CD-ROMS, computers, and photocopiers. The program also promoted collaboration between orthopaedics and other departments including pathology, radiology, oncology, neurosurgery, and pediatrics. Strengthening capacities within these other departments was another product of the development of a strong orthopaedic program [16
Dr. Belcher was in the process of transition of administrative and management responsibilities to senior Ugandan members of the Department when he was tragically killed in a carjacking on the hospital grounds in 1996. Dr. Ed Naddumba was elected head of the Department and was capably able to sustain an outstanding academic program which continues its vibrancy up to the present [16
Success of the program can also be seen in the number of graduates and contribution to the skilled orthopaedic workforce of Uganda. In the early 1990s there were just six orthopaedic surgeons for the country of approximately 25 million. The residency program has graduated 31, with about half coming from neighboring countries. All but one of the Ugandan graduates are practicing in Uganda. Currently, there are 20 orthopaedic surgeons in Uganda, and 13 graduates of the program remain on staff at Makerere University (T. Beyeza, MD, Chairman, Dept. of Orthopaedics, Makerere University, Kampala, Uganda, personal communication, February 1, 2008).
Through HVO academic volunteers and partnering NGOs, the capacity of the orthopaedic department to further its mission of providing improved musculoskeletal and trauma care to the people of Uganda has increasingly improved. Collaborations with such Northern academic centers as University of British Columbia, as evidenced by the Uganda Clubfoot Project [17
] and University of California, San Francisco with the Institute of Global Orthopedics and Traumatology [8
] have strengthened both programmatic and research capacities and attract global health partners. SIGN [15
], an NGO founded by Lew Zirkle, Orthopaedics Overseas volunteer and former program director, has improved fracture care by introducing (and donating equipment for) intramedullary fixation that may be performed without fluoroscopy, as well as funding for improvement of trauma systems development within the department and hospital [15
]. These efforts have emphasized capacity-building and empowerment of Ugandan physicians to work within their systems, thereby strengthening the infrastructure and long-term sustainability.