When looking at pathology scarcity in sub-Saharan Africa one may ask, “Where do we start?” There are so many elements which need improvement: advocacy for pathologists and pathology as a practice, quality assurance in laboratories, and proper reporting to cancer registries to name a few. So again we ask, “Where do we start?”
Task sharing and shifting - an innovative strategy that takes existing medical personnel, trains them to train other medical personnel on pathology practices who then go on to “share” the tasks of pathologists. Task sharing and shifting has proven effective as demonstrated in a study at University of Nairobi (UoN) and Aga Khan University Hospital, Nairobi (AKUHN) in Kenya.1
In Kenya, diagnostic procedures for cancer, such as fine-needle aspiration biopsy (FNAB) cytology and bone marrow aspiration and trephine (BMAT) biopsy, have been performed almost exclusively by pathologists at county hospitals, which are tertiary health facilities. The scarcity of pathologists limits the number of biopsies which can be performed. Broader access to FNABs and BMAT biopsies, which do not need to be performed solely by pathologists, is thus limited, largely because there are few well-trained personnel to perform these diagnostic techniques.2 UoN and AKUHN sought to change that.
The overall aim of the study was to provide diagnostic support for cancer care, using a two-step approach: first, a training-of-trainers workshop trained pathology residents from the UoN and AKUHN and practicing pathologists from five participating hospitals to become trainers in FNAB and BMAT biopsy techniques; and second, these new trainers trained additional pathologists, medical officers (MO), and clinical officers (CO) to perform quality FNAB and BMAT biopsy procedures. In parallel, laboratory technologists were trained in the handling and processing of FNAB and BMAT biopsy samples by experienced laboratory technologists. In total, 74 medical personnel were trained in FNAB and BMAT biopsy techniques.
Initially, all FNABs were performed by a pathologist, and by the end of the study, the medical and clinical officers were performing 60% to 100% of the FNAB and BMAT biopsy procedures. This allows the pathologists to prepare and evaluate more biopsy samples, provide diagnoses for patients and may even reduce turnaround time. When compared to the year prior to the study, the number of FNABs performed showed an overall increase of 41% across all facilities. There was an even more marked increase in the number of BMAT biopsies at the training sites, from a total of 38 procedures to 140 procedures over the same period, an increase of 268%. Furthermore, trephine biopsies were performed for the first time in two of the facilities. With broader access to these procedures, this is hopeful news for patients in need of biopsies.
In broader settings, task sharing and shifting has been demonstrated previously to be useful for training laboratory technologists to process tumor specimens3 and in the delivery of HIV care.4 Training non-pathologist medical and paramedical staff to perform procedures such as the FNAB and BMAT biopsy may overcome some of the challenges associated with the scarcity of pathologists in resource-limited countries.5 At the very least, it will open the opportunity for pathologists to spend more time managing existing labs, innovating work-arounds for the existing laboratory resources, or setting up new labs entirely. While it won’t solve all of the problems related to pathology scarcity, it’s a start.
In part four, we’ll introduce you to additional solutions including implementation of telepathology as already demonstrated in Rwanda and the impact pathologists from around the globe can make on pathology in resource-limited countries.
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1 Sayed S, Field A, Rajab J, et al. Task Sharing and Shifting to Provide Pathology Diagnostic Services: The Kenya Fine-Needle Aspiration Biopsy Cytology and Bone Marrow Aspiration and Trephine Biopsy Training Program. J Glob Oncol. 2018;4:1–11.
2 Field AS. Cytopathology in low medical infrastructure countries: Why and how to integrate to capacitate health care. Clin Lab Med. 2018;38:175–182.
3 Mpunga T, Hedt-Gauthier BL, Tapela N, et al. Implementation and validation of telepathology triage at cancer referral center in rural Rwanda. J Glob Oncol. 2016;2:76–82.
4 Mwai GW, Mburu G, Torpey K, et al. Role and outcomes of community health workers in HIV care in sub-Saharan Africa: A systematic review. J Int AIDS Soc. 2013;16:18586.
5 Sayed S, Lukande R, Fleming KA. Providing pathology support in low-income countries. J Glob Oncol. 2015;1:3–6.