Background
The expansion of local training programmes is crucial to address the shortages of specialist paediatric surgeons across Sub-Saharan Africa. This study assesses whether the current training ...programme for paediatric surgery at the College of Surgeons of East, Central and Southern Africa (COSECSA) is exposing trainees to adequate numbers and types of surgical procedures, as defined by local and international guidelines.
Methods
Using data from the COSECSA web-based logbook, we retrospectively analysed numbers and types of operations carried out by paediatric surgical trainees at each stage of training between 2015 and 2019, comparing results with indicative case numbers from regional (COSECSA) and international (Joint Commission on Surgical Training) guidelines.
Results
A total of 7,616 paediatric surgical operations were recorded by 15 trainees, at different stages of training, working across five countries in Sub-Saharan Africa. Each trainee recorded a median number of 456 operations (range 56–1111), with operative experience increasing between the first and final year of training. The most commonly recorded operation was inguinal hernia (
n
= 1051, 13.8%). Trainees performed the majority (
n
= 5607, 73.6%) of operations recorded in the eLogbook themselves, assisting in the remainder. Trainees exceeded both local and international recommended case numbers for general surgical procedures, with little exposure to sub-specialities.
Conclusions
Trainees obtain a wide experience in common and general paediatric surgical procedures, the number of which increases during training. Post-certification may be required for those who wish to sub-specialise. The data from the logbook are useful in identifying individuals who may require additional experience and centres which should be offering increased levels of supervised surgical exposure.
Background
In East, Central and Southern Africa (ECSA), district hospitals (DH) are the main source of surgical care for 80% of the population. DHs in Africa must provide basic life-saving ...procedures, but the extent to which they can offer other general and emergency surgery is debated. Our paper contributes to this debate through analysis and discussion of regional surgical care providers' perspectives.
Methods
We conducted a survey at the College of Surgeons of East, Central and Southern Africa Conference in Kigali in December 2018. The survey presented the participants with 59 surgical and anaesthesia procedures and asked them if they thought the procedure should be done in a district level hospital in their region. We then measured the level of positive agreement (LPA) for each procedure and conducted sub-analysis by cadre and level of experience.
Results
We had 100 respondents of which 94 were from ECSA. Eighteen procedures had an LPA of 80% or above, among which appendicectomy (98%), caesarean section (97%) and spinal anaesthesia (97%). Twenty-one procedures had an LPA between 31 and 79%. The surgical procedures that fell in this category were a mix of obstetrics, general surgery and orthopaedics. Twenty procedures had an LPA below 30% among which paediatric anaesthesia and surgery.
Conclusion
Our study offers the perspectives of almost 100 surgical care providers from ECSA on which surgical and anaesthesia procedures should be provided in district hospitals. This might help in planning surgical care training and delivery in these hospitals.
Background
Countries in Sub-Saharan Africa lack adequate surgical workforces to achieve safe and affordable care for their populations. The Global Surgery movement highlights the urgent need to ...address this situation. Interventions include not only financial, material and infrastructural support, but also collaborative information flow to support surgical training. In 2015, an electronic logbook was launched for surgical trainees across Sub-Saharan Africa.
Objectives
To assess the integration and context sustainability of surgical e-logbooks in Sub-Saharan Africa.
Methods
In January 2019, a survey analysis of surgical trainees was employed using quantitative and qualitative methods. Participants (active trainees and recent fellows) completed an anonymous internet-based questionnaire evaluating end-user feedback, perceptions and self-reported compliance. Multi-point Likert Scale measures and free-text thematic analysis were used.
Results
358 (68.19%) eligible individuals across 21 Sub-Saharan countries and seven surgical specialties voluntarily participated. The e-resource demonstrated integration into local curricula with the majority of users maintaining activity and reporting moderate-high compliance. Context appropriateness measures were high with 203 (69.76%) deeming it convenient to use. The principle obstacle to compliance was internet connectivity (74, 25.96%), while behavioural factors including supervisor engagement were implicated. The e-logbook demonstrated future sustainability with the majority (243, 78.14%) of participants intent on maintaining usage beyond completion of surgical training.
Conclusions
We describe the successful integration and sustainability of electronic surgical logbooks for trainees across Sub-Saharan Africa. However context-appropriate resources are essential for Low- and Middle-Income Countries. Internet connectivity may hinder the achievement of several Global Surgery objectives in Sub-Saharan Africa.
Background
Access to surgery is a challenge for low-income countries like Malawi due to shortages of specialists, especially in rural areas. District hospitals (DH) cater for the immediate surgical ...needs of rural patients, sending difficult cases to central hospitals (CH), usually with no prior communication.
Methods
In 2018, a secure surgical managed consultation network (MCN) was established to improve communication between specialist surgeons and anaesthetists at Queen Elizabeth and Zomba Central Hospitals, and surgical providers from nine DHs referring to these facilities.
Results
From May to December 2018, DHs requested specialist advice on 249 surgical cases through the MCN, including anonymised images (52% of cases). Ninety six percent of cases received advice, with a median of two specialists answering. For 74% of cases, a first response was received within an hour, and in 68% of the cases, a decision was taken within an hour from posting the case on MCN. In 60% of the cases, the advice was to refer immediately, in 26% not to refer and 11% to possibly refer at a later stage.
Conclusion
The MCN facilitated quick access to consultations with specialists on how to manage surgical patients in remote rural areas. It also helped to prevent unnecessary referrals, saving costs for patients, their guardians, referring hospitals and the health system as a whole. With time, the network has had spillover benefits, allowing the Ministry of Health closer monitoring of surgical activities in the districts and to respond faster to shortages of essential surgical resources.
Efficient utilisation of surgical resources is essential when providing surgical care in low-resources settings. Countries are developing plans to scale up surgery, though insufficiently based on ...empirical evidence. This paper investigates the determinants of hospital efficiency in district hospitals in three African countries.
Three-month data, comprising surgical capacity indicators and volumes of major surgical procedures collected from 61 district-level hospitals in Malawi, Tanzania, and Zambia, were analysed. Data envelopment analysis was used to calculate average hospital efficiency scores (max. = 1) for each country. Quantile regression analysis was selected to estimate the relationship between surgical volume and production factors. Two-stage bootstrap regression analysis was used to estimate the determinants of hospital efficiency.
Average hospital efficiency scores were 0.77 in Tanzania, 0.70 in Malawi and 0.41 in Zambia. Hospitals with high efficiency scores had significantly more surgical staff compared with low efficiency hospitals (DEA score<1). Hospitals that scored high on the most commonly utilised surgical capacity index were not the ones with high surgical volumes or high efficiency. The number of surgical team members, which was lowest in Zambia, was strongly, positively correlated with surgical productivity and efficiency.
Hospital efficiency, combining capacity measures and surgical outputs, is a better indicator of surgical performance than capacity measures, which could be misleading if used alone for surgical planning. Investment in the surgical workforce, in particular, is critical to improving district hospital surgical productivity and efficiency.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
ObjectiveThis study aimed to provide an overview of current knowledge and situational analysis of financing of surgery and anaesthesia across sub-Saharan Africa (SSA).SettingSurgical and anaesthesia ...services across all levels of care—primary, secondary and tertiary.DesignWe performed a scoping review of scientific databases (PubMed, EMBASE, Global Health and African Index Medicus), grey literature and websites of development organisations. Screening and data extraction were conducted by two independent reviewers and abstracted data were summarised using thematic narrative synthesis per the financing domains: mobilisation, pooling and purchasing.ResultsThe search resulted in 5533 unique articles among which 149 met the inclusion criteria: 132 were related to mobilisation, 17 to pooling and 5 to purchasing. Neglect of surgery in national health priorities is widespread in SSA, and no report was found on national level surgical expenditures or budgetary allocations. Financial protection mechanisms are weak or non-existent; poor patients often forego care or face financial catastrophes in seeking care, even in the context of universal public financing (free care) initiatives.ConclusionFinancing of surgical and anaesthesia care in SSA is as poor as it is underinvestigated, calling for increased national prioritisation and tracking of surgical funding. Improving availability, accessibility and affordability of surgical and anaesthesia care require comprehensive and inclusive policy formulations.
Abstract
Background
An estimated nine out of ten persons in sub-Saharan Africa (SSA) are unable to access timely, safe and affordable surgery. District hospitals (DHs) which are strategically located ...to provide basic (non-specialist) surgical care for rural populations have in many instances been compromised by resource inadequacies, resulting in unduly frequent patient referrals to specialist hospitals. This study aimed to quantify the financial burdens of surgical ambulance referrals on DHs and explore the coping strategies employed by these facilities in navigating the challenges.
Methods
We employed a multi-methods descriptive case study approach, across a total of 14 purposively selected DHs; seven, three, and four in Tanzania, Malawi and Zambia, respectively. Three recurrent cost elements were identified: fuel, ambulance maintenance and staff allowances. Qualitative data related to coping mechanisms were obtained through in-depth interviews of hospital managers while quantitative data related to costs of surgical referrals were obtained from existing records (such as referral registers, ward registers, annual financial reports, and other administrative records) and expert estimates. Interview notes were analysed by manual thematic coding while referral statistics and finance data were processed and analysed using Microsoft Office Excel 2016.
Results
At all but one of the hospitals, respondents reported inadequacies in numbers and functional states of the ambulances: four centres indicated employing non-ambulance vehicles to convey patients occassionally. No statistically significant correlation was found between referral trip distances and total annual numbers of referral trips, but hospital managers reported considering costs in referral practices. For instance, ten of the study hospitals reported combining patients to minimize trip frequencies. The total cost of ambulance use for patient transportation ranged from I$2 k to I$58 k per year. Between 34% and 79% of all patient referrals were surgical, with total costs ranging from I$1 k to I$32 k per year.
Conclusion
Cost considerations strongly influence referral decisions and practices, indicating a need for increases in budgetary allocations for referral services. High volumes of potentially avoidable surgical referrals provide an economic case – besides equitable access to healthcare – for scaling up surgery capacity at the district level as savings from decreased referrals could be reinvested in referral systems strengthening.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Low- and middle-income countries (LMICs) are the worst affected by a lack of safe and affordable access to safe surgery. The significant unmet surgical need can be in part attributed to surgical ...workforce shortages that disproportionately affect rural areas of these countries. To combat this, Malawi has introduced a cadre of non-physician clinicians (NPCs) called clinical officers (COs), trained to the level of a Bachelor of Science (BSc) in Surgery. This study explored the barriers and enablers to their retention in rural district hospitals (DHs), as perceived by the first cohort of COs trained to BSc in Surgery level in Malawi.
A longitudinal qualitative research approach was used based on interviews with 16 COs, practicing at DHs, during their BSc training (2015); and again with 15 of them after their graduation (2019). Data from both time points were analysed and compared using a top-down thematic analysis approach.
Of the 16 COs interviewed in 2015, 11 intended to take up a post at a DH following graduation; however, only 6 subsequently did so. The major barriers to remaining in a DH post as perceived by these COs were lack of promotion, a more attractive salary elsewhere; and unclear, stagnant career progression within surgery. For those who remained working in DH posts, the main enablers are a willingness to accept a low salary, to generate greater opportunities to engage in additional earning opportunities; the hope of promotional opportunities within the government system; and greater responsibility and recognition of their surgical knowledge and skills as a BSc-holder at the district level.
The sustainability of surgically trained NPCs in Malawi is not assured and further work is required to develop and implement successful retention strategies, which will require a multi-sector approach. This paper provides insights into barriers and enablers to retention of this newly-introduced cadre and has important lessons for policy-makers in Malawi and other countries employing NPCs to deliver essential surgery.
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