ACS, COSECSA Join Forces to Bring Quality Surgical Care to Patients in Sub-Saharan Africa

Each year, surgeons from across Sub-Saharan Africa and the world serve as volunteer examiners in the College of Surgeons of East, Central and Southern Africa (COSECSA) fellowship oral examination—which is equivalent to the American Board of Surgery’s (ABS) oral certifying exam. This past December, I traveled to Windhoek, Namibia, to participate as an examiner and was impressed by the dedication of the trainees, as well as the volunteers who are trying to ensure that quality surgical care becomes available to patients throughout the region.

The largest barrier to surgical care in Sub-Saharan Africa is the lack of adequately trained surgeons. COSECSA was created to meet this need and, together with its collaborative partners, COSECSA has provided quality education and certification across multiple surgical specialties for more than 20 years.

Following is a synopsis of how COSECSA has grown during the past 2 decades due to the dedication and work of its members and partner organizations. I also introduce you to some of the people I met during my experience in Namibia.

History of COSECSA

Originally developed from the Association of Surgeons of East Africa (ASEA), COSECSA was formed with the goal of having a common surgical training program and an exam that would result in an internationally recognized surgical qualification. Other driving factors that led to the founding of this organization included the inadequate number of surgical training positions, variability of training from country to country and hospital to hospital, and decreasing access to training outside of Africa.

COSECSA has been a result of regional and international collaboration since its inception. It emerged out of the ASEA and was inaugurated in December 1999 in Nairobi, Kenya, after endorsement from the ministers of health of the founding countries and the East, Central, and Southern Africa Health Community.

The organization is unique because its training programs are primarily undertaken in a trainee’s country of origin instead of a large central-hub hospital. Education pathways successfully harness existing, but often underused, resources, namely surgeons and hospitals that could be certified as trainers and training centers.

The first annual general meeting was held in Lusaka, Zambia, in 2000, and the first examinations took place in 2003. In 2007, ASEA and COSECSA merged to form one organization. In 2008, the Royal College of Surgeons in Ireland/COSECSA Collaboration Programme began, which resulted in the “school for surgeons” web-based curriculum and is used as the standard academic component.

COSECSA trainees have two levels of qualification available:

• Membership of the College of Surgeons (MCS), which may be obtained after passing an exam following 2 years of postgraduate surgical training
• Fellowship of the College of Surgeons (FCS) in general surgery, orthopaedics, urology, pediatric surgery, otorhinolaryngology, plastic surgery, cardiothoracic surgery, or neurosurgery, which may be obtained after completing at least 5 years of postgraduate training (6 years for neurosurgery) and fulfilling all the requirements of the COSECSA curriculum

Similar to the ABS process, candidates must pass a written exam in order to take the oral exam, which is held immediately before the COSECSA annual general meeting. The FCS designation is recognized in all COSECSA member countries and is similar to being board certified by the ABS or being a fellow of the Royal College of Physicians and Surgeons of Canada.

Currently, COSECSA has 14 member countries: Botswana, Burundi, Ethiopia, Kenya, Malawi, Mozambique, Namibia, Rwanda, South Sudan, Sudan, Tanzania, Uganda, Zambia, and Zimbabwe.

Approximately 140 hospitals have been accredited as training sites by COSECSA, some of which are outside of the member countries. More than 900 trainees have completed the COSECSA certification process, and more than 1,600 surgeons have the FCS designation.

Joint Efforts with the ACS

Both the ACS—as an organization—and ACS Fellows have partnered with COSECSA to further its mission. Some examples include granting access to ACS educational resources and leadership training programs, awarding scholarships, and aiding with the recruitment of surgeon volunteers as external examiners and to participate in direct patient care and onsite teaching at COSECSA training sites.

Perhaps the largest single effort has been the ACS-COSECSA Surgical Training Collaborative. Spearheaded by the ACS Committee on Global Engagement through Operation Giving Back, the goal of the project is to pool the resources of the ACS and multiple US hospital departments of surgery to improve the quality of surgical training at a specific training site, with the aim of increasing the number of surgical trainees.

After several years of planning, in 2018, Hawassa University in Ethiopia, became the first ACS-COSECSA Collaborative site. A consortium of 13 US hospitals currently support the effort, with workgroups focusing on improvements in target areas of education, research, quality, and clinical care. In 2020, a second hub launched at the University Teaching Hospital in Lusaka, Zambia.

The ACS and its members have a long history of collaboration with this relatively young college of surgeons. A number of ACS Fellows who volunteer their time and resources in support of COSECSA were on hand during my visit last year to share their experiences with me.

Dr. Mbaga Walusimbi

The oral portion of the COSECSA fellowship exam took place over 2 days. The general surgery exam was held at Windhoek Central Hospital. My partner examiner on the second day of the test was Mbaga Walusimbi, MD, MS, FACS, a surgeon at Wright State University in Dayton, OH. Originally from Uganda, he has been a surgeon educator in the US for many years. Dr. Walusimbi, who has been participating in the COSECSA exams since 2013, said he finds this very fulfilling.

Some of his friends in Africa were associated with COSECSA and encouraged Dr. Walusimbi to become involved with the program. Dr. Walusimbi travels yearly to wherever the exams are held and volunteers his time and expertise. The breadth of knowledge expected of a general surgeon by COSECSA is impressive, commensurate with the range of surgical problems they will need to treat in practice.

Dr. John Mellinger

John D. Mellinger, MD, FACS, currently is the president of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and vice-president of the ABS. He originally became involved with COSECSA through the Pan-African Academy of Christian Surgeons. He also has been involved in surgery in Africa on behalf of the ABS, teaching a surgeons-as-educators course.

Dr. Mellinger came to Namibia both for the COSECSA exams and on behalf of SAGES to teach their Global Laparoscopic Advancement Program (GLAP) course. SAGES GLAP is a longitudinal program that involves partnerships between the SAGES Go Global Committee and national surgical societies in low- and middle-income settings.

To date, more than 100 practicing surgeons and more than 200 residents have been trained via this program worldwide. The program is designed to teach national surgeons and trainees the fundamentals of laparoscopic surgery-based skills and train-the-trainer skills. This was the first time the course was offered in Africa. A total of 20 Namibian surgeons participated in the event, which was held before the COSECSA exams.

Dr. Sherry Wren

ACS Secretary Sherry M. Wren, MD, FACS, FCS(ECSA), originally became involved with surgery in Africa through Doctors Without Borders. While working at the University of Zimbabwe College of Health Sciences, she learned about COSECSA. Dr. Wren serves on the COSECSA council as its representative for North America and participates in the oral examination and annual general meeting. Dr. Wren explained that one of her main roles is recruiting ACS Fellows to volunteer with COSECSA and work on projects that support surgery in Africa.

Dr. Wren travels to the COSECSA exams and annual general meeting with esteemed colleagues, including ACS Past-President Patricia J. Numann, MD, FACS, former ACS First Vice-President Hilary Sanfey, MD, FACS, and ACS Past-President Barbara Lee Bass, MD, FACS.

This formidable group of surgeon-leaders has a particular interest in supporting women in surgery globally. Dr. Numann gave the inaugural address of Women in Surgery Africa’s (WiSA) first meeting in 2015.

With their support and efforts, two special awards were created: The Association of Women Surgeons (AWS)/WiSA Travel Grants, which sponsors two women consultants/registrars to attend the COSECSA annual general meeting; and the ACS-COSECSA Women Scholars Program for graduating female surgical residents, which covers educational costs and COSECSA fellowship exam expenses.

Dr. Michael Mwachiro

Michael Mwachiro, MBChB, MPH, FCS(ECSA), FACS, a surgical endoscopist at Tenwek Hospital in Kenya, is a COSECSA fellow and Kenyan country representative to the council. He also is an International Fellow of the ACS, a member of the African Organisation for Research and Training in Cancer, and the assistant editor of Annals of African Surgery.

Dr. Mwachiro has firsthand experience with the benefits of collaboration between the ACS and COSECSA. Recently, he was a recipient of the ACS International Guest Scholar Award. This scholarship is offered to young surgeons from countries other than the US or Canada who have demonstrated strong interests in teaching and research.

In 2022, the scholarship provided Dr. Mwachiro with the opportunity to travel to the US, spending time at Loma Linda University in CA, Vanderbilt University in Nashville, TN, and the National Institutes of Health in Bethesda, MD.

When asked about the benefits of ACS membership, Dr. Mwachiro answered without hesitation, “Mentorship, connections, fellowship, and friendship.”

Dr. Rondi Kaufman

Rondi M. Kaufman, MD, MPH, FACS, from Vanderbilt University, also is a COSECSA examiner. Dr. Kaufman is working to support training for Africa’s surgeons in a unique way—by changing the policy for foreign medical trainees.

While a resident, she had the opportunity to do a rotation at a hospital in Kenya, where she discovered the value of such an experience. Unfortunately, African trainees are not able to have a reciprocal experience in the US because, in most cases, short-term training licenses are not available to foreign medical graduates.

Dr. Kaufman believed that a true “resident exchange” would be beneficial for both parties, so she began to investigate. Contacting the Tennessee Board of Medical Examiners, she found that there was no category of license that could be granted to rotating residents from other countries.

Therefore, Dr. Kaufman drafted a bill that would direct the state medical board to grant a training license to foreign medical graduates for 90 days, allowing them to function as surgical residents with the same duties and responsibilities as their American counterparts. She was able to obtain sponsors in the Tennessee House and Senate, and eventually the bill was passed and signed into law.

This process continues with the next step requiring support, persistence, and effort at the federal level to create a short-term visa designation for this category of trainee.

Dr. Abebe Bekele

Abebe Bekele, MD, FACS, directed the COSECSA oral examinations. Dr. Bekele is the secretary general of COSECSA, a thoracic surgeon, and the dean of the School of Medicine at the University of Global Health Equity in Kigali, Rwanda. Dr. Bekele took the COSECSA exams and became a fellow in 2006.

Dr. Bekele has served as the Ethiopia representative to COSECSA for 3 years and chair of the examination committee for 7 years. An International Fellow of the ACS, he is invested in the partnerships between the College and COSECSA.

According to Dr. Bekele, there are several key areas in which partnership with the ACS and its members are of specific benefit to COSECSA and surgery in Africa:

• The ACS/AWS provides sponsorship for 10 women surgeons a year to take COSECSA’s MCS and FCS exams.
• ACS Fellows comprise a significant number of examiners for the MCS and FCS exams: Of 283 examiners in 2022, 95 were overseas examiners, and the majority of those were ACS Fellows.
• The ACS provides connections and access to training sites in the US.
• The ACS currently is collaborating with COSECSA on establishing centers of excellence in surgery in Africa.

Dr. Bekele also offered several practical suggestions on how the ACS and its members can partner with COSECSA to further its mission:

• Individuals, practices, or departments can sponsor a COSECSA trainee, which costs approximately $3,000 per year.
• Volunteer examiners, like the individuals described in this article, are needed for COSECSA’s MCS and FCS exams.
• Digital book donations are useful to trainees.
• Teaching or funding “train-the-trainer” programs, such as the SAGES program, are essential to disseminating skills and knowledge.

In the future—as COSECSA continues its mission to provide access to quality surgery for the people of Africa—Dr. Bekele said that COSECSA hopes to involve more countries in its consortium and increase the number of graduates of COSECSA training programs.

As it continues to grow in reach and depth of training, COSECSA will remain a primary force in training the next generation of surgeons in Sub-Saharan Africa. It is a tremendous opportunity and privilege for the ACS and its Fellows to be a part of this important work.

See related story: ACS-COSECSA Women Scholars Are Announced. 

Dr. Daniel Chase is a rural general surgeon in Hoopeston, IL, and an associate professor of surgery at the Carle Illinois College of Medicine in Urbana. He also is an ACS Governor.