In many countries with limited resources, inadequate pathology services are an obstacle to proper cancer care and effective use of scant available resources. For many diseases, such as breast cancer, the lack of adequate pathology service means the lack of a definitive pathology diagnosis. The 2005 Breast Health Global Initiative (BHGI) Summit brought together experts from different countries to produce consensus guidelines on breast healthcare in low-resource and middle-resource countries (LMCs). These guidelines indicate that a pathologic diagnosis must be available before initiation of treatment.1 Barriers to adequate pathology services can include lack of recognition of pathology as an integral part of the multidisciplinary healthcare team2 and limited professional resources.3 To reduce barriers to adequate health care in LMCs, collaborative projects with high-resource countries are being encouraged by international health organizations such as the World Health Organization (WHO) and the BHGI.4 This article reviews 2 collaborative efforts by a medical center in Ghana and addresses the following question. What are the barriers encountered and the key elements of a successful collaboration between LMCs and high-resource countries?
At Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, a breakdown of technical equipment and lack of pathologists resulted in closure of the surgical pathology laboratory in 2004. At an international meeting in January 2005, 1 USA and 1 Norwegian pathologist were asked if their departments could help with the pathology problem at KATH. This article describes the proposals, the barriers encountered, and the key elements of the final successful collaboration between a low-resource and a high-resource country. The proposal to the USA hospital focused on receiving specimens for diagnosis. A detailed proposal was not developed, as several key operational barriers were identified early on, including legal issues, technical capacity issues, and staff capacity issues. The proposal to the University Hospital of North Norway (UNN) resulted in development of a 5-year plan to reestablish surgical pathology at KATH. Two KATH technicians came to UNN and trained in the histopathology laboratory for 3 months. On their return, they started producing slides at KATH. Since April 2006, weekly shipments of hematoxylin and eosin (H & E) stained slides have been sent to UNN by courier service. When needed, paraffin blocks are sent on request. In March 2006, 2 young Ghanaian physicians were received as trainees at the UNN to do full resident work and training with the aim of being approved as specialists in pathology in Ghana by 2010. Full surgical pathology service and training of new pathologists on site are expected to be reestablished at KATH by 2010. Cancer 2008;113(8 suppl):2338–46. © 2008 American Cancer Society.
In Ghana, with a population of around 22 million, there are 9 pathologists (6 consultants and 3 specialist pathologists), of which only 6 were active in surgical pathology in 2007. The Ghana College of Physicians and Surgeons (Programmes in Laboratory Medicine) estimates that minimal patient care would require at least 117 anatomic pathologists. Komfo Anokye Teaching Hospital (KATH) in Kumasi is associated with Kwame Nkrumah University of Science and Technology and is the main teaching hospital for its medical school (1 of 3 medical schools in Ghana). The 1000-bed hospital opened a new oncology department in 2004 and is 1 of 2 national cancer centers, covering the northern sector of Ghana, which has a population of 10 million. However, the surgical pathology laboratory was closed in 2004 because of a combination of factors such as equipment failure (breakdown of the department's only microtome), budgeting and management issues (a shift in priorities), competing pathology needs (a heavy load of forensic autopsies), and capacity issues (teaching responsibilities for the only pathologist). Some specimens were sent to private laboratories in Accra, from which it would take 6 weeks to 6 months to receive a pathology report. Without a surgical pathology unit, KATH lost the approval to train pathologists, and the medical school was threatened with closure due to a lack of pathology teachers.
The head of the newly created KATH oncology department was invited to attend the January 2005 BHGI Summit, where he had an opportunity to explain the pathology resource problem in Ghana and to explore collaborative opportunities with other participants, including a pathologist from the USA and a pathologist from Norway. This article describes a proposal presented to a USA community-based hospital that was unsuccessful, and 1 presented to a university hospital in North Norway that was accepted and brought into action.
Proposal to a Community-based Hospital in the USA
Two ideas were presented to a not-for-profit community hospital in Southern California, shipping slides from Ghana to the USA for interpretation and generation of a pathology report, and alternatively, shipping tissue from Ghana to the USA to be processed, to have slides interpreted, and to have reports generated. A detailed proposal was not developed as several operational barriers were identified early on in the discussions, including legal issues (medical liability and international regulations regarding transporting tissue across international borders), technical capability issues, and staffing capacity issues.
The legal department in the community hospital was reluctant to authorize the project. They believed that the use of hospital equipment (microscopes for slide reading and computers for generating reports) for an international project would put the organization at risk for legal action, should a suit be filed by patients or physicians in Ghana. Although medical malpractice suits are uncommon in developing countries, the potential risk was identified as a limiting barrier. The legal department did not object to volunteer activities of the sponsoring staff pathologist if these activities were performed outside the hospital facility. However, establishing a separate facility to accommodate volunteer activities was not economically feasible.
Mailing human tissue across international borders was not considered feasible because of international regulations. At the same time, the technical capability to process tissue in a timely manner, prepare paraffin blocks, and cut and stain slides was not available at KATH.
The community hospital could not support the projected additional work load. Although the pathology department at the hospital philosophically supported providing assistance to Ghana in interpretation of slides, the additional case burden added to an already overcommitted pathology staff was not feasible. However, the pathology group did not object to sponsoring pathologists spending nonhospital time on the project. All of these factors together made the project proposal unsuccessful.
Proposal to a University Hospital of North Norway
Extensive discussions took place between KATH and the University Hospital of North Norway (UNN) to develop a long-term plan for sustainable development at KATH, with the support of both UNN hospital management and pathology department staff. In June 2005, the sponsoring Norwegian pathologist went to Kumasi and met with KATH management, the KATH pathology department staff, and other leading medical staff to further discuss a 5-year sustainable project (Table 1).
|Phase 1 3 mo||• Two KATH technicians are received at UNN for training in histotechnology.|
|• Pieces of formalin-fixed tissue selected by KATH house physicians for microscopy are sent to UNN for processing, slide production, interpretation and reporting.|
|Phase 2 4 y||• Technicians return to KATH and take over tissue processing and slide production.|
|• More technicians are trained in histotechnology at KATH.|
|• Slides ready for microscopy are sent to UNN for interpretation and reporting.|
|• One or 2 KATH physicians are received at UNN for 4 years of training for the specialty of pathology.|
|• One or 2 technicians are received at UNN for training in cytology screening for the last 2 years of the phase.|
|Phase 3 undetermined duration||• Physicians return to KATH, are recognized as specialists/consultants in pathology by Ghanaian authorities, and take over diagnostic interpretation and reporting.|
|• Problem cases are sent to UNN for consultation.|
|• More pathologists are trained at KATH.|
|• Cytology is established at KATH, assisted by cytotechnologists returning from UNN.|
|• Immunohistochemistry and frozen section service are established at KATH with support from UNN if economically feasible.|
In agreement with the request from KATH, the plan included training of technicians in histopathology, sending specimens to UNN for diagnosis, and training of physicians for the pathology specialty, with gradual transfer of functions from UNN to KATH as capabilities were developed. The program goal was sustainable development: A nucleus of persons competent in pathology would be established at KATH, from which pathology competency in the country could grow and spread to serve the population of Ghana, adding to the development of pathology originating from the Korle Bu Teaching Hospital in Accra, the capital.
Training of technicians
Two KATH technicians (who had bachelor degrees in medical technology but no experience running histopathology laboratories) actively took part in the daily routine of the UNN Pathology Department, rotating through all of its main procedures in histopathology, such as tissue processing, embedding, cutting, and staining. They also spent a few days in neuropathology, immunohistochemistry, cytology, and other specialty laboratories. The UNN onsite training included nonsalary compensation of room, board, and local transportation, which had the advantage of requiring only a tourist visa, all of which helped to expedite the project start date.
Sending wet specimens
The sending of wet, formalin-fixed, but unprocessed, tissue specimens to UNN was never realized. The airlines either did not accept wet specimens or the cost of transportation, if accepted, was too high. Thus, no specimens were sent until the tissues could be processed at KATH, which allowed the specimens to be sent as glass slides.
Restarting slide production at KATH
KATH management recognized the need for new equipment and purchased 2 microtomes, 2 tissue processors, and 2 embedding stations that were in place when the technicians returned to KATH. Two months later, 1 consultant and 2 technicians from UNN visited KATH for 10 days to support the establishment of routine slide production (Fig. 1). The visit also included the reporting of old cases received before the closure of the laboratory in 2004 and basic instruction of young house doctors on gross examination of surgical specimens. Staining is largely limited to hematoxylin and eosin (H&E), although some special stains are available.
Sending specimens to UNN
Several methods of sending slides from KATH to UNN were tested by using 5-slide, plastic, transport boxes provided by UNN. Sending specimens by ordinary postal service took about 2 weeks, and many slides were broken on arrival. Different shipping companies were tested. DHL proved to be more timely and had less broken slides than other companies and has been used successfully for weekly shipments since May 2006. Due to limited capacity at UNN, an upper limit of 16 cases per week has been set. The slides are temporarily stored at UNN.
Service request form
A typed service request form for each specimen is sent with the slides. The request includes a KATH accession number, patient name and age, clinical information, description of gross examination and block selection. The request form is scanned to create an electronic file and sent along with the pathology report to KATH.
The pathology reports are sent by facsimile transmission twice a week, with a copy sent by ordinary mail once a week. On average, the reports are received about 10 days after the slides have been sent. When immunohistochemistry is needed, a preliminary diagnosis is given, and paraffin blocks are requested.
KATH management selected 2 young physicians from the pathology department for training at UNN. A detailed list of plans and premises, Table 2, was made available to both hospitals' representatives and the trainees. Although the list was never formally signed, it has served as a mutual agreement on what is expected from each participant.
|Training Program Plan|
|The physicians will have status as trainees and are not expected to apply for Norwegian medical license or for recognition as specialists in Norway.|
|For the recognition as specialist in pathology in Norway, 5 years of training is required.6 Of these, 4 years must be in anatomic pathology, whereas the 5th year can be in either pathology or other relevant medical practice. This 5th year requirement can be fulfilled at KATH.|
|The aim of the program for the trainees is that their 4-year training at UNN together with 1-year practice at KATH will give the necessary basis for their recognition as specialists in pathology in Ghana.|
|They will work under supervision and have no direct contact with patients or their relatives. Their reports will be cosigned by a responsible pathologist.|
|They will follow the work schedule and training program of the department's residents, with some modifications suited to their needs.|
|The main emphasis will be on surgical pathology and cytology for which they, by the end of the 4th year of training, will be expected to fulfill the numbers and types of examined specimens required for recognition as specialists in pathology in Norway.|
|The requirements for autopsies (200 autopsies including microscopic examination) should be fulfilled largely or fully by their work in Ghana.|
|As for all employments at UNN, the first 6 months will be a period of probation, with continued employment dependent on a proper adaptation to the job situation.|
|After the completion of the 4-year training period, the trainees are expected to return to Ghana, and they should have an obligation to do so for a minimum length of time determined by KATH.|
|KATH will pay GBP 8000 to UNN for each of the 4 years of the training period.|
|Each of the trainees will be paid NOK 200,000 per year from UNN in equal monthly rates minus income tax deduction and contribution to national insurance, which includes health insurance.|
|The trainees will each receive an offer to rent a hospital-owned, 1-room, furnished apartment.|
|The trainees will be expected to attend an evening Norwegian language course and 2 Norwegian postgraduate pathology courses per year. The costs will be covered by UNN.|
|UNN will cover one economy fare round-trip travel Tromsø-Kumasi per year for each trainee.|
|No more than 2 weeks before arrival in Tromsø, they should be tested for MRSA (methicillin-resistant staphylococcus aureus) and shown to be negative.|
On their arrival in Tromso, on a cold winter day, the 2 young doctors were given some warm cloths and taken to their apartments. In the department of pathology, each was assigned an office space with a microscope, a computer, and a personal copy of Rosai and Ackerman's Surgical Pathology.5
Their participation in the routine work of the department was started on the second day after their arrival. Close supervision of cutting, microscopy, and sign-out procedures was provided during the first 3 months, largely by 1 consultant pathologist. As the clinical information on the request forms would be in the Norwegian language, getting acquainted with the language was an important issue during this period, as was basic introduction to surgical pathology. The trainees were allowed to use English in their gross and microscopic descriptions, which soon made it possible for them to make a substantial contribution to the routine labor. The gross descriptions were dictated to a tape recorder at the cutting table and later transcribed to the data system by the trainees. (UNN transcription staff were not trained in English dictation.) At the end of the first 3 months, the trainees were fully integrated into the UNN pathology residents' rotation and were following the specialist training program of the Norwegian Medical Association.6
As an important preparation for their future work, trainees perform the primary examination of all cases received from KATH, and they are also responsible for contacting the hospital when extra clinical information or extra blocks are needed. Further close contact with KATH is maintained through their autopsy training, which is done at KATH during a 4-week period each year under the supervision of a visiting UNN consultant. The primary reasons for this arrangement was the limited number of autopsies being performed at UNN and the high number of autopsies performed at KATH. This has also opened the door for an exchange in autopsy training between KATH and UNN, and in January 2007, 1 of the UNN residents was invited to Ghana for a 4-week autopsy training.
To strengthen their application for recognition as pathology specialists in Ghana, the trainees have taken the initiative to take the British Part I specialty exam, of which they successfully passed the theory part in 2007. To further strengthen their qualifications to be approved as consultants and to obtain accreditation to train pathologists, they are involved in 2 research projects, both of which compare pathology of the breast in Ghanaian and Norwegian women.
Infrastructure and Equipment Upgrades at KATH
Communication and transfer of specimens and reports between the 2 hospitals have not encountered significant problems since a reliable system was established. E-mail, mobile and stationary phone, telefax, and DHL courier service have all been generally reliable and efficient.
In addition to the new equipment necessary to restart the histology laboratory and acquired by the KATH management during 2005, the pathology department had a few old, and some new, relatively simple microscopes. To improve working conditions for pathologists and to prepare for specialist training, 2 high-quality double-headed microscopes, 1 refurbished, and 1 new one were provided by UNN in 2007. A third double-headed microscope and other new equipment have been acquired by KATH for the laboratories of their new facility.
The old pathology building has offices, histopathology laboratories, an autopsy room, and morgue storage facility for 136 bodies. A new pathology building (Fig. 2) was completed in 2007 and is a well equipped forensic pathology unit that includes the following facilities, 204-body capacity morgue with 2 histopathology laboratories, autopsy room with 3tables, cutting room, offices, records unit, lecture room, anatomy museum, rest rooms, kitchenette, and library. The old and new pathology buildings are physically connected by a road and a walkway and are networked to the hospital information system.
Funding for project planning is always difficult and often relies on ancillary opportunities. For the initial planning visit of a UNN pathologist to Kumasi, an application was submitted to the Norwegian Peace Corps, but it was rejected on the grounds that Ghana is not on the United Nations' list of the 49 least developed countries, to which most of the governmental Norwegian developmental support is directed. In the end, UNN paid the air ticket, and KATH provided local transport, board, and lodging.
KATH paid for travel expenses, and UNN provided board and lodging, local transportation, and a small sum of pocket money for the 3-month training of the 2 KATH technicians.
Sending of slides and diagnostic work at UNN
The shipment of slides to UNN is paid for by KATH, and the handling and reporting of the cases at UNN are done free of charge.
The physician trainees receive a UNN salary sufficient for a modest living (NOK 250,000), plus expenses for language courses and for 2 postgraduate pathology courses per year. These expenses are covered in part (about 25%) by a grant from KATH/Ghanaian Ministry of Health (8000 GBP per year) and in part by UNN from means made available by keeping vacant 1 resident position at the department of pathology.
Visits to KATH, equipment, and new facility
The KATH management has paid for upgraded facilities and equipment. The Norwegian governmental agency, NORAD (Norwegian Agency for Development Cooperation), has paid for the travel to Kumasi for a consultant and 2 technicians in 2006, and for a consultant, resident, and the 2 trainees to Kumasi in 2007 and 2008, as well as a new double-headed microscope. UNN has donated a refurbished double-headed microscope and some smaller utility articles (slide transportation boxes, small instruments, and other autopsy articles).
UNN has granted paid leave for their employees during their visits to KATH. No extra pay is given to the UNN staff for their contributions to supervision and training or for the reporting of KATH cases.
Three years after the initial contact between KATH and UNN, the process of reestablishing surgical pathology at the KATH Department of Pathology is well on its way, and a surgical pathology service is running, although with a capacity that is insufficient to fully meet the demand. New and better facilities, doubling the department space, opened in February 2008. House physicians perform gross examination and cutting, and histological slides ready to be studied under the microscope are produced from all cases as they come in. New technicians are trained locally. Slides from a fixed quota of 16 cases are sent to UNN every week, and the reports are received about 10 days after the slides have been sent. By the end of October 2007, 1102 cases from KATH had been reported from UNN, including a broad spectrum of organs and 303 cases of cancer, with cancer of the cervix and breast as the most frequent malignancies (Table 3). The functioning histology laboratory has made it possible to invite pathologists from other institutions for shorter periods. Two Ghanaian doctors are at the end of their second year of training for the specialty of pathology at UNN with good progress and are expected to apply for approval as specialists in Ghana in 2010. A third physician, who is training for the specialty in Germany, is expected to join the department at about the same time. The addition of 2 double-headed microscopes provided by UNN, and a third provided by KATH, prepare the groundwork for training of more pathologists at KATH.
|Organ or Site||Total||Malignant Neoplasms||Benign Neoplasms||Non-neoplastic Lesions|
|Skin and subcutis||133||22||44||67|
|Salivary glands, jaws andoral cavity||77||30||13||34|
|Esophagus and stomach||44||15||0||29|
|Ovaries and tubes||39||9||13||17|
|Airways and lungs||28||12||6||10|
|Kidney and urinary passages||24||10||1||13|
|Bone (except jaws) and joints||22||6||7||9|
|Eye and orbit||20||12||1||7|
|Central nervous system||5||3||1||1|
Concerns about potential malpractice suits were a major cause for the refusal to provide diagnostic service by the Californian hospital. However, on the condition that the service is based on the same ethical and quality assurance standards as for the department's ordinary service, the risk of legal action is presumably much lower in serving a low-resource country.
Slide quality is generally acceptable, but fixation is often less than optimal, probably because of the use of nonbuffered formalin and often long timeframe for storage before cutting. Gross descriptions and block selection have been improved by means of feedback from UNN, but these skills need to be developed further.
Capacity issues at UNN
The capacity at UNN made it necessary to set a limit on the number of cases that could be received. Concerns that arose among staff concerning the perceived extra workload of hosting physician trainees for 4 years were mitigated by the sponsoring pathologist who agreed to be the sole supervisor for the trainees for the first 3 to 6 months, with the understanding that after the first few months, the contribution of the trainees to the department's workforce would outweigh the burden of their supervision, which, indeed, turned out to be true. The initial plan to train 1 or 2 KATH technicians in cytology screening in 2007 or 2008 was postponed because capacity problems at the UNN cytology section, and KATH needs to find another solution, probably with a stronger focus on training pathologists in fine-needle aspiration cytology.
Capacity issues at KATH
As the new service has become known at KATH, the number of specimens submitted to its department of pathology has grown to 3 times the UNN limit, and a backlog of several hundred cases had been accumulated by the end of 2007. Most of this was cleared during January 2008 by visiting UNN pathologists. At the same time, by another initiative from KATH, a relay of visiting USA pathologists from Utah was started and is expected to last for at least 1 year.
A basic knowledge of the Norwegian language was necessary for the trainees to understand clinical information, to follow departmental seminars and discussions, and to attend postgraduate courses required for the specialty. It was soon realized, however, that pressing too hard for language acquisition would seriously delay their acquisition of pathology skills. Allowing the trainees to type their gross and microscopic descriptions in English enabled them to contribute to the daily work from the very beginning of their training, and a mixed use of English and Norwegian provides good oral communication.
Brain drain and medical license restrictions
The emigration of well-educated medical personnel is a major problem for Ghana,7, 8 and this was raised as a concern by UNN. This concern, together with the desire to expedite the start of the training process, were the reasons for not asking the trainees to apply for Norwegian medical licenses and specialty approval, although their training is designed to be equivalent to a pathology residency program. UNN staff, therefore, take full responsibility for the trainees' work product and cosign all diagnostic reports. The fact that the trainees were selected for training and, in part, paid for by KATH gives them a moral obligation to return and contribute to the service and to the further development of pathology in Ghana, for which they are preparing themselves and appear eager to do.
Whereas the sending of wet tissues over international borders met with both logistic and legal problems, the transport of slides and paraffin blocks by courier service goes smoothly.
Key Elements of Success
Several key elements have contributed to the progress of the project. Similar collaborations between other institutions may be confronted with other barriers and find other solutions. However, we believe most of the success can be attributed to direct person-to-person contact and commitment to the project from both sides, sustainable development, a comprehensive program, and detailed clarification of premises for training.
Direct person-to-person contact and commitment to the project from both sides
This project would not have been started without recognition of the importance of pathology and the initiative by KATH to actively seek assistance. Doing this by direct person-to-person contact helped to create a commitment to the project. International organizations and meetings focusing on health care in developing countries, such as the BHGI Summit, can provide direct person-to-person networking opportunities. The ability and willingness of the new KATH management to provide basic material resources and to contribute part of the expenses for training of technicians and physicians have been essential for complete funding. The willingness of UNN management and the pathology department staff to help without full compensation for the cost has been a necessary condition of success and for obtaining NORAD support.
Although the application for support from the Peace Corps was unsuccessful, it was fruitful as it required planning for long-term sustainable development, which has been a key concept in Norwegian governmental development cooperation. In this case, that implied a time-limited maximum effort with a long-term effect, leading to the reestablishment of an activity that is expected to have the capacity to continue and further develop on its own, although continued support at a lower level will be beneficial.
Rather than seeking the relief of a single element of the crisis, the focus of the program has been on what is needed to reestablish a self-supported surgical pathology service with a capacity for further development. The training of technicians and reestablishment of the histology laboratory was a prerequisite for the provision of a diagnostic service. Receiving KATH specimens for diagnosis at UNN provides excellent material for preparing the trainees for their future positions as KATH pathologists. Training of pathology specialists implies that the diagnostic service provided by UNN is time-limited and, thus, more easily absorbed.
Detailed clarification of premises for training
The detailed list of premises for the training of physicians for the specialty has been helpful in making it clear from the start what was expected from the institutions and from the trainees themselves, securing a smooth adaptation to the program from all parts.
The newly established collaboration with a USA pathologist in Utah, in combination with continued diagnostic service from UNN, will hopefully make it possible to keep pace with an increased influx of specimens to the KATH Pathology Department. The trainees are expected to be recognized as specialists in Ghana and to take over the service in 2010. Efforts will be made to promote them to consultants for them to train more specialists locally. UNN will continue to be available for consultation with problem cases. A cryostat is already in place in the new facility, and plans are underway for the introduction of a frozen-section service, immunohistochemistry, and fine-needle aspiration cytology.
Funding for the BHGI, 2007 Global Summit on International Breast Health-Implementation and Guidelines for International Breast Health and Cancer Control–Implementation publication came from partnering organizations who share a commitment to medically underserved women. We thank and gratefully acknowledge these organizations and agencies for grants and conference support: Fred Hutchinson Cancer Research Center; Susan G. Komen for the Cure; American Society of Clinical Oncology (ASCO); US National Cancer Institute, Office of International Affairs (OIA); American Cancer Society; Lance Armstrong Foundation; US Agency for Healthcare Research and Quality (*Grant 1 R13 HS017218-01); US Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion; American Society of Breast Disease; Oncology Nursing Society; US. National Cancer Institute, Office of Women's Health (OWH); and US. National Institutes of Health, Office of Research on Women's Health (ORWH).
*Funding for the 2007 Global Summit on International Breast Health–Implementation was made possible (in part) by Grant No. One R13 HS017218-01 from the Agency for Healthcare Research and Quality (AHRQ). The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations suggest endorsement by the US government.
We thank and gratefully acknowledge the generous support of our corporate partners through unrestricted educational grants: Pfizer Inc; AstraZeneca; Bristol-Myers Squibb Company; Ethicon Endo Surgery, Inc; GE Healthcare; F. Hoffmann-La Roche AG; and Novartis Oncology.
BHGI is a global health alliance of organizations and individuals. We are grateful to our collaborators throughout the world who share the BHGI mission and vision. Thank you for your important contributions to this endeavor for medically underserved women.