Outside the Training Paradigm: Challenges and Solutions for Endoscopy Provision in Resource-Limited Settings

Limited-resource settings pose problems for the provision of health services. Experience with the challenges of the provision of endoscopy services and potential solutions are presented by authors who have taught and practiced in such settings in Africa and the Pacific Islands. The concept of limited-resource settings is defined in the context of health services in general. The situation regarding endoscopy provision details and discusses the unique challenges of manpower, endoscopy facilities, endoscope and accessory equipment inventory, and endoscopy reporting. Health services quality is related to wealth and how it is deployed. Simplistically wealth means health, and poverty illness. Low-income and Low middle–income countries have the biggest challenges. One is the health professional workforce. The number of gastroenterologists per 100,000 in South Africa, an upper middle–income country, is 0.33 compared with 3.9 in the United States. Hence, endoscopy provision is by general surgeons and physicians. Upper and lower gastrointestinal endoscopic capacity in East Africa was 106 and 45 procedures per 100,000 persons per year, respectively which is <10% of that reported from high-income countries. Outside major teaching hospitals, most endoscopy is practiced in uncustomized single rooms often in a surgery complex. Endoscope inventory is more expensive than in the United States as is maintenance and repair as they are out of the country resulting in many units being below the minimum requirements to run a sustained service. Electronic reporting systems are few and not standardized. The World Gastroenterology Organisation and the World Endoscopy Organization should be the overarching advocates to support public–private partnerships and develop solutions for sustainable inventory acquisition. Endoscopy must be monitored electronically to assess procedural competency and provide desperately needed information to influence health policy.