**7. Sedation**

8 Gastrointestinal Endoscopy

health". In 2007 it published a document about the basic standards of a gastroenterology training program (WGO 2007). In drawing up the standards of training the WGO took into consideration the existing training programs in various countries. It is noteworthy that Egypt and Sudan were the only African countries that provided information about their existing training programs to the WGO Committee. The other countries in Africa, including

The WGO has training centres in the developing countries but these are very few and countries in the catchment areas of the centres have not taken adequate advantage of the institutions to develop their local digestive endoscopists. Prospective trainees usually find it

The WGO proposes a minimum number of each procedure that must be completed by the trainees in the training centres. The body differentiates between level 1 and level 2 endoscopists with a remark that level 1 might be sufficient for some developing countries. A level 1 endoscopist is expected to be proficient in esophagogastroduodenoscopy, treatment of non-variceal bleeding, treatment of variceal bleeding, esophageal dilatation, flexible sigmoidoscopy, colonoscopy, polypectomy, placement of percutaneous endoscopic gastrostomy, liver biopsy, abdominal puncture and foreign body removal. It is a sad truth that most endoscopy centres in developing countries such as Nigeria do not carry out any form of therapeutic endoscopy. It therefore follows that trainees in these centres will not acquire the competences required of a level 1 endoscopist. Training of endoscopists takes place in the teaching hospitals that are grossly ill-equiped to perform the function. There are 2 postgraduate medical colleges in Nigeria: The West African College of Physicians or Surgeons and the National Postgraduate Medical College of Nigeria. These colleges supervise the training of residents and eventually certify them after passing the requisite examinations. The current practice does not ensure adequate exposure for the trainees who hardly complete the minimum number of procedures before they present themselves for examination. Furthermore, the method of evaluation is such that one can pass without having completed the prescribed procedures. Sometimes incessant industrial actions make it practically impossible for trainees to complete the procedures during the training period. The evaluation has no practical endoscopy component. In the developed countries, methods used in the evaluation of trainee competence vary from place to place and may include observation during procedure, formal assessment of clinical skills, using a patient-based examination, formal in-practice examination, use of log books, annual assessments, final assessment and feedback from trainees. These evaluation methods are largely absent in the developing countries. Where they exist, the regulations are often not applied strictly for economic, social and political reasons. The regulatory authorities are sometimes faced with a situation where they have to decide between closing a health facility because it lacks basic equipment and staff; and allowing it to continue to function at a substandard level because

Over the course of endoscopic examination, the external surface and internal channels of flexible endoscopes and accessory equipment are exposed to body fluids and contaminants. Disinfection of these reusable instruments poses special problems. Given their relatively

Nigeria did not respond to the enquiry.

**5.4 Minimum training standards** 

of political interests.

**6. Infection control** 

difficult to secure funding from their countries.

The provision of sedation and analgesia has been an important component of performing endoscopic procedure on the gastrointestinal tract. The different procedures can create pain and discomfort and are associated with anxiety for the patient. It is for this reason that sedation has become an essential component of endoscopy.

For routine diagnostic endoscopic procedures sedation is almost always used in North America and Australia. However in Europe, Asia and some African countries, the sedation

Challenges of Gastrointestinal Endoscopy in Resource-Poor Countries 11

the training institutions (Teaching Hospitals, Specialist Hospitals, Federal Medical Centres and some private hospitals). Because of funding constraints, these visits are not as regular as they should be. The Federal Government of Nigeria can make the regulatory colleges more efficient by improving the funding of their activities so that they do not depend on the hospitals being accredited for any financial assistance, a situation that may introduce

There are inherent difficulties of measuring quality in gastrointestinal endoscopic procedures. This is particularly so because complications are rare. Because mortality is negligible, rates do not vary greatly among physicians. Also there is a lack of surrogate measurable outcome measures in GI endoscopy. Measuring the process is the alternative

Quality measurement is even more problematic in developing countries because of a general lack of baseline. There are no guidelines in place that reflect the peculiar economic realities

The cost of endoscopic procedures in developing countries is often out of the reach of many patients. Poverty is a major problem that militates against access to health care. Poverty exacerbates poor health while poor health makes it harder to get out of poverty. In Nigeria, most patients have to make out – of – pocket payments at the point of service and this has adversely affected service delivery. The Federal Government of Nigeria recently introduced the National Health Insurance Scheme but the coverage is still very low and does not cover all medical procedures and treatments. Catastrophic expenditure is more frequent when

The problems that face the teaching and practice of gastrointestinal endoscopy in developing countries are protean and generally reflect the low level of human and

• There is an acute shortage of trained endoscopists, gastrointestinal pathologists, nurses and other support staff. This situation is daily compounded by the continuing brain-drain. • Inadequate budgetary allocation to health and poor implementation of health programs

• Lack of modern gastrointestinal endoscopic equipment and consumables for effective

• Health service delivery is characterized by a high rate of out-of-pocket payments and a low rate of prepayment schemes, a situation that deprives many families of needed care

The health care system in the developing countries needs a radical reorganization. The budgetary allocation to health and the implementation of policies related to health need

but, again, there has not been any significant progress in process measurement.

health care has to be paid for out – of – pocket at the point of service.

• Lack of guidelines for the practice and teaching of gastroenterology.

conflict of interest.

in these countries.

and budgets.

radical improvement.

**9. Cost of endoscopic procedures** 

**10. Conclusions and recommendations** 

infrastructural development in these countries:

• Inadequate and unsteady power supply.

service delivery and training.

because they cannot afford it.

**8.2 Quality measurement** 

rate varies among countries and even among centres of the same country. The use of sedation improves the tolerance and acceptance of gastrointestinal endoscopy (Bell 2004) but increases the cost of the procedure and is responsible for about 50% of the GI endoscopy complication rates (Lazzaroni et al 2005).

Sedation for gastrointestinal endoscopy may induce central respiratory depression and/or airway obstruction. Early diagnosis and treatment of these complications is mandatory and this can only be accomplished by patient monitoring.
