WEO Newsletter: Travel Report: The Maghreb

WEO have successfully launched training centres throughout Sub-Saharan Africa, mostly in English-speaking countries. In 2023, a visit to Senegal resulted in establishment of our first francophone centre and highlighted the need for training in this region. Regional endoscopy training in Africa has been provided by groups from Egypt and South Africa, providing a model for continent-based training that are both socially and environmentally sustainable. With the aim of investigating both the need for training and the capabilities for provision of training in North Africa, we evaluated current state of endoscopy in the Maghreb: Morocco, Algeria, Tunis.

Morocco is a Mediterranean kingdom in north-west Africa, that gained its independence from the French in 1956. While the political capital is Rabat, the economic capital is the coastal city of Casablanca. The most populated city of Morocco, Casablanca is home to 3.2 million people.

There are several hundred endoscopists in Morocco, who offer standard diagnostic and therapeutic endoscopy, with ERCP available in most public hospitals and EUS in some. To increase health and sciences education and healthcare services in the country, Mohammed VI Foundation for sciences and health was created by the king. It is a non-profit semi-public foundation managing universities in Casablanca, Rabat and Dakhla and multiple healthcare facilities. The Foundation has a strong orientation toward collaboration with African countries.

Bordering Morocco to the east, Algeria is a modern country with an increasingly relaxed border policy that reflects its growing peaceful development. It took a little work to get an entry visa and a couple of hours in immigration to enter the country, but it was worth it. The initial connection came from Dr. Mohammed Omar, Chair of the WEO Middle East Committee who knew Dr. Imad Bougedouma. Just to prove that the world is a tiny place, I discovered over coffee that Imad had spent a week in Oslo for training and is known to Prof Aabakken, President of WEO, who has an Algerian sand painting in his office as proof.

An ex-colony of France, Algeria won its independence after a long and bloody war in 1962, but plunged into a decade-long destructive civil war until 2002. The last twenty-three years of peace has resulted in increasing social development including universal health care, universal education and a rapidly developing middle class.

GI training in Algeria is confined to the public hospital system alone and starts immediately after internship, continuing for four years with the final year focussed on endoscopy. There are three training public hospitals in Algiers, and only a few key hospitals around the country additionally. With the largest land mass of any country in Africa, Algeria has a significant shortage of proceduralists compounded by distance. For new skills acquisition, a shortage of trainers and centres is apparent. The medical system is two-tiered with private and public systems being separate: one cannot be a doctor in both systems simultaneously. Part-time training or part-time work is not possible and this is reflected in the paucity of female practising gastroenterologists, although 55–80% of trainees are women, as childcare responsibilities supersede full-time work.

Dr. Nour from Constantine phoned a friend and put me in contact with Tunisian gastroenterologist, Dr. Sami Boudabbous of Youtube Endoscopy streaming fame, and I now had an “in” to this fascinating and incredibly important key to the Maghreb: it has good diplomatic relations with Morocco and Algeria which includes travel permissions.

Tunisia, with its ancient roots in Hannibal and the empire of Carthage, is more recently recalled as the source of the “Arab spring”. A modern, tolerant and vibrant country, French is widely spoken, Arabic is the official language, and English is increasingly spoken among younger generations, particularly in medical education and academia.

Healthcare in Tunisia is delivered primarily through a public system, which handles most of the national caseload but remains overstretched. In contrast, a rapidly growing private sector offers more modern services though insurance coverage remains limited. There are four medical schools, each associated with a university hospital, offering a 5-year undergraduate medical degree, followed by a 5-year gastroenterology training program. GI trainees must maintain a certified logbook to qualify in both upper and lower endoscopy. On average, each centre hosts about six trainees that must rotate their training around the approved hospitals in the district. Advanced endoscopy training is limited and highly competitive, serving as a stepping stone to private sector practice.

As with Algeria, the public and private systems are deliberately separated to avoid perceptions of conflicts of interest. Public physicians may work privately only after five years of exclusive service in the public sector and are then restricted to two private sessions per week. There is no part-time work policy. This policy has contributed to a skilled workforce in public hospitals, but retention is a growing concern.

Tunisia has plans to launch a National Bowel Cancer Screening Program (NBCSP). An earlier trial had poor outcomes, and with participation rates low at under 17%. It is unclear whether that reflects true screening or symptomatic testing. Concerns have been raised about current workforce capacity and infrastructure to support national screening. Misallocation of endoscopy equipment by the central Ministry of Health further complicates matters, with units sometimes receiving equipment despite lacking trained endoscopists. Rural southern Tunisia has particularly poor access, with rotating physicians from Tunis delivering limited services.

In my travels through the Maghreb, I found an enthusiastic and talented group of gastroenterologists. Endoscopy in the region is systematically taught and is already at a sophisticated level in some regions. Deficits are mainly in developing capacity, quality measures and in advanced endoscopy.

WEO has the opportunity to aid in overcoming political and historical barriers in the regions to re-establish a Maghreb collaboration for training and research connections. At least initially, it is probably best served with Tunisia as a common, accessible centre to foster regional cooperation. Discussions are underway to include these centres into the WEO training centre program and potential co-host a WEO-Maghreb workshop in the next 12 months.