The Role of a Clinical Advisor in a Humanitarian Organisation
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Judith Kendell, FRRHH member, discusses her role as an advisor in Anaesthesia with Médecins Sans Frontières (MSF), a humanitarian organisation providing medical care in conflict, disaster, remote and rural healthcare settings. The advisor's responsibilities include clinical work, teaching, and managerial tasks, while collaborating with other organisations to develop standards and guidelines for low-resource contexts. In this article, Judith shares the importance of training, patient safety, and data collection to ensure quality of care in diverse and challenging humanitarian settings. The role is described as varied, challenging, and rewarding for clinicians interested in humanitarian medicine.
Clinical work in humanitarian settings presents new challenges and fosters new skills and expertise. Having completed eight missions with Médecins sans Frontières (MSF), I felt I still had much to learn when I applied for the role of Advisor (MSF uses the term ‘Referent’) in Anaesthesia. This was a full-time position, based at MSF’s Operational Centre in Brussels (OCB), which I held for five years between 2017-2022. It is a role that combines clinical work and teaching in the field with a managerial, advisory and clinical governance role at Headquarters. It was an excellent opportunity to broaden my experience of humanitarian medicine, while contributing to the delivery of perioperative care in the field.
MSF is an international organisation that provides humanitarian assistance and medical care to people affected by conflict, epidemics, disasters or exclusion from healthcare. It currently has clinical programmes in more than 70 countries worldwide, which are managed by one of six Operational Centres (OCs) based in Europe and West Africa.
Each OC has a large medical department, employing advisors in all the major clinical specialties and allied clinical disciplines. Specialist working groups are organised to facilitate close collaboration between advisors and their peers in other OCs and organisations, to develop clinical standards, guidelines and training materials for low-resource and humanitarian contexts.
Proposals for intervention in a humanitarian context are developed by teams on the ground, with detailed knowledge of the relevant geography, politics and healthcare demographics. These teams and their Operational Managers then work with the relevant advisors to define an intervention that meets clinical priorities and is appropriate to the local context and resources available.
Interventions that include surgery and preoperative care are increasing.
Francois Dumont. Laparotomy in 15 years old patient with complex bullet injuries in the abdomen. MSF field trauma clinic, Hammam al-Alil, Mosul, Iraq. 2017.
Seydou Camara. Caesarean section in Centre de Réference, Douentza, Mali, which is supported by MSF through the provision of staff and equipment.
They vary greatly, from field hospitals providing life and limb-saving surgery in the context of war or sudden onset disasters, to the targeted support of public hospitals to improve surgical capacity and quality of care in the face of overwhelming needs. Smaller numbers of projects focus on specialist surgery, such as ortho-plastic reconstruction.
MSF recruits 90% of clinical staff locally, with small numbers of expatriates providing clinical support and supervision. Therefore, the level of care that can be provided and the complexity of clinical techniques and equipment used must be appropriate to local levels of training and expertise.
The medical devices and pharmaceuticals used in MSF projects are procured centrally and shipped from one of three supply centres in Europe.
Julien Dewarichet. Part of the first cargo of emergency kits being sent from the MSF Supply warehouse in Brussels to Ukraine. 2022.
This ensures that only the essential drugs and equipment approved for use in MSF projects can be ordered and that these comply with defined, technical requirements, and international standards. Catalogues of all approved items are kept under review by the relevant advisors and working groups, and updated as clinical practice evolves. It is also the responsibility of the advisor to determine the equipment and drugs used in individual projects, according to local infrastructure and the level of care provided.
Training and capacity-building are a major part of the advisor’s role and essential to ensure quality of care. Advisors guide the recruitment of local staff from a distance and determine the level of expatriate supervision required, but an early field visit is desirable to support team-building and identify training needs.
Informal, clinical supervision and teaching is a routine part of all field work. However, advisors also work in collaboration with other organisations to identify short, clinical courses suitable for delivery in the field, and they contribute as instructors for courses such as BASIC DHS and Primary Trauma Care.
Acquiring the skills needed for anaesthesia and surgery in humanitarian contexts is a challenge for both local and expatriate clinicians. MSF and its advisors support short courses in the UK and Belgium and provide an annual surgical workshop in Dusseldorf, which will also soon be taught in Abidjan, Ivory Coast. However, the limitations of short courses for developing clinical skills are well recognised and MSF is exploring the possibility of establishing a training programme in the field. Security constraints and visa requirements make most surgical projects unsuitable for use as an international training centre, but MSF has an interim arrangement with Stellenbosch University, South Africa, to provide clinical training for MSF staff at Tygerberg Hospital.
Clinical governance is central to the advisor’s role, with particular emphasis on patient safety and clinical effectiveness. While in Brussels, I introduced a centralised registration form and database for patient safety incidents and supported projects to manage, investigate and learn from serious incidents in the field. Blame-free reporting and learning can be novel concepts for many clinicians and managers, but engagement, supported by online teaching and webinars, is gradually increasing.
Specialist working groups aim to ensure consistent and effective clinical practice across widely varying contexts and levels of care through the development of policies, guidelines and clinical tools for use in the field. This work is often in collaboration with other organisations, particularly the International Committee of the Red Cross (ICRC) and World Health Organisation (WHO), to produce documents for resource-limited and humanitarian settings based on a broad consensus of available expertise. Read more on the WHO Interagency Integrated Triage Tool.
Interagency Integrated Triage Tool (Adult) for Low-Resource Settings. Developed by WHO in collaboration with ICRC and MSF.
All projects collect standardised data on clinical activity and outcomes, which are reported centrally and provide crude measures of quality of care. Advisors also use audit cycles in individual projects to assess and improve more specific aspects of care.
In summary, the role of an advisor in a humanitarian organisation is enormously varied, challenging and rewarding. It was a privilege to work at the centre of a large and truly multi-national organisation that has developed significant expertise in humanitarian healthcare. I would recommend it to any clinician motivated to make humanitarian medicine a significant part of their career.
