**4. Equipment**

*Minimum equipment required for gastrointestinal endoscopy includes:* 


Challenges of Gastrointestinal Endoscopy in Resource-Poor Countries 7

and endoscopic ultrasonography are yet to be available in most developing countries

In Nigeria, doctor to population ratio is 3 per 10,000 compared to US which stands at 26 per 10,000. The gap is even much wider when one considers the gastroenterologist to population ratio. Nigeria has only about 60 gastroenterologists (registered with the Society for Gastroenterology and Hepatology in Nigeria, SOGHIN). Out of this number, there are some who do not practice gastrointestinal endoscopy because they work in centres that do not have facilities for it. This number is grossly inadequate for a population of over 140 million. The anatomical pathologist plays an essential role in the diagnosis of numerous digestive disorders. The number of pathologists in Nigeria is equally abysmally low for the population and only very few of them are trained specially for gastrointestinal diseases. Some high-income countries such as Austrialia, Canada, Saudi Arabia, the USA and the United Arab Emirates and the UK have sustained their relatively high physician – to population ratio by recruiting medical graduates from developing regions, including countries in sub-Saharan Africa (Labonte et al 2006, Mullan 2006, Pond et al 2006). In contrast, over half of the countries in sub-Saharan Africa do not meet the minimum acceptable physician to population ratio of one per 5000 (WHO 2007). Several recent reviews of health workers employed in Austrialia, Canada, the UK and the USA have shown the extent of brain drain. An estimated 13272 physicians trained in sub-Saharan Africa are practising in Australia, Canada, the UK and the USA (Mullan 2006). Around a third of medical graduates from Nigerian medical schools migrate within 10 years of graduation to Canada, the UK and the USA (Ihekweazu 2005). Nurses, who commonly bear the brunt of health-care delivery in sub-Saharan Africa are also not left out in the brain drain (Labonte 2006, Mandeville 2009)

Staffing requirements for the performance of GI endoscopy should be based on what is needed to ensure safe and proficient performance of the individual procedure. Currently, staffing may vary as determined by local practice requirements, patient characteristics, and the type of endoscopic procedure being performed. While the physician is performing endoscopic procedure, the endoscopy suite staff will concentrate on patient monitoring, documentation and technical assistance. The level of education and training of the staff can vary, including qualified nurses with training in endoscopy and qualified nurses trainable

Because objective evidence pertaining to the relationship between endoscopy unit staffing levels and patient outcomes is lacking, it is difficult to make concrete recommendations to the developing countries where there is an acute shortage of medical staff including trained

The World Gastroenterology Organization (WGO), a Federation of 110 National Societies and 4 regional associations of gastroenterology representing over 50,000 individual members worldwide focuses on the improvement of standards in gastroenterology training and education on a global scale. It has been christened the "global guardian of digestive

including Nigeria.

**5. Staff requirements** 

**5.1 Global distribution of medical personnel** 

**5.2 Minimum staffing requirements** 

endoscopists and support staff.

on the job.

**5.3 Staff training** 


#### *Ancillary equipment*


*Permanently sited in the endoscopy facility will be the following items:* 


#### *Rapid access (within 1-2minutes) to the following equipment is also mandatory.*


These minimum requirements are not even available in some of the surgical theatres and intensive care units of hospitals in the developing countries and therefore it will be unrealistic to expect endoscopy facilities to have them. Some teaching hospitals in resourcepoor countries do not offer gastrointestinal endoscopy. In centres where the service is available, there may be only one functional gastroscope and/or one functional colonoscope. Often a lot of accessories are improvised. Again, using Nigeria as example, therapeutic endoscopy is still at its infancy. Majority of the teaching hospitals in the country have no facility for therapeutic endoscopy. One or 2 centres may be able to do band ligation of esophageal varices albeit in an unsustainable fashion. In one of the centres the doctors modified the normal variceal banding technique by cutting size 14 Folley's urethral catheters to size and reloading them on previously used caps, all in an attempt to reduce cost (Ladep et al 2008). Infection control remains a challenge in such ingenuity. It is also common to find non-immersible endoscopes in developing countries with obvious implication for cross-infection. The newer techniques in endoscopy like capsule endoscopy and endoscopic ultrasonography are yet to be available in most developing countries including Nigeria.
