SURG-Africa has been looking at how to scale up access to safe surgery for rural populations in Malawi, Tanzania and Zambia, through strengthening surgical care provided by district hospitals. This has centred on regular in-service training for the surgical teams at district hospitals. Specialists from referral hospitals have visited district hospitals quarterly or bi-monthly for two years to provide mentoring, training and supervision to the local teams.

At our initial action-planning workshops, the visiting specialists and district hospital teams worked together to compose site-specific training visit plans for each hospital and agree the priority areas for skills training and mentoring. These were also informed by detailed analyses undertaken by the SURG-Africa teams on the surgical activity at each district hospital and focus group discussions at baseline participatory action research workshops in each country.

During this process, we realised there was in most cases a lack of set local or national guidance about the scope of surgical care that district hospitals should provide, i.e. which surgical cases should be done at district-level hospitals, and which should be referred to a higher-level hospital. It is really important to advance understanding on the level of surgical care that district-level hospitals are expected to provide, as this influences how to plan staff training and development, guidance to give on making appropriate referrals to higher-level hospitals, and advocacy for necessary resources, infrastructure and personnel for district hospitals.

We had the opportunity to ask regional surgeons and anaesthetists attending a conference of the College of Surgeons of East, Central and Southern Africa (COSECSA) their opinions on this subject in December 2018. We have reported our results in our paper ‘Which Surgical Operations Should be Performed in District Hospitals in East, Central and Southern Africa? Results of a Survey of Regional Clinicians’

It was very interesting to discover that there were clear areas of consensus amongst respondents across 15 countries about the types of operation that should and should not be done at district level, but there was a group of operations including bowel resection and anastomosis where there was quite a mixed response and difference of opinion about where these should be done and who should undertake these cases.

As well as considering the opinions of experienced surgical providers in the region, we are interested in what surgery is already happening in district hospitals. Our SURG-Africa colleagues have collected data on the surgical activity of the intervention and control district hospitals in our research sites (published here, and more publications to follow). While this is really useful data on district hospitals in Malawi, Tanzania and Zambia, we are also interested in what surgery is currently done in district hospitals across Africa.  We wanted to get a general overview of the reported current surgical capacity and delivery to help us understand district hospital surgical activity better and suggest targets for further development and research in the region.

We undertook a scoping review on surgery in district hospitals to find out, according to published literature:

• In district hospitals in sub-Saharan Africa, what types of surgical procedures are provided?
• How many surgical procedures are performed per year?
• Are there any measures of quality, safety or outcomes of surgery?
• Who provides anaesthesia and/or surgery?
• What type of anaesthesia is delivered?

 
We searched PubMed and Ovid EMBASE for publications from January 2000 to December 2019. We included studies if they contained information about types of surgical procedures performed, number of operations per year, types of anaesthesia delivered, cadres of surgical/anaesthesia providers and/or patients' outcomes.

Our results showed what we suspected, that there was a paucity of published data about what was happening in district hospitals.  This is perhaps not surprising as most district level hospitals would be unlikely to submit articles to peer reviewed journals.  However we did find 52 relevant publications which provided information about 16 countries.

These demonstrated that district hospitals were a group of diverse institutions ranging from 21 to 371 beds. The three most frequently reported procedures were caesarean section, laparotomy and hernia repair, but a wide range of orthopaedics, plastic surgery and neurosurgery procedures were also mentioned. The number of operations performed per year per district hospital ranged from 239 to 5233. The most mentioned anaesthesia providers were non-physician clinicians trained in anaesthesia. They deliver mainly general and spinal anaesthesia. Depending on countries, articles referred to different surgical care providers: specialist surgeons, medical officers and non-physician clinicians. 15 articles reported perioperative complications among which surgical site infection was the most frequent. Fifteen articles reported perioperative deaths of which the leading causes were sepsis, haemorrhage and anaesthesia complications.

We concluded that district hospitals play a significant role in sub-Saharan Africa, providing both emergency and elective surgeries. Most procedures are done under general or spinal anaesthesia, often administered by non-physician clinicians. Depending on countries, surgical care may be provided by medical officers, specialist surgeons and/or non-physician clinicians. Research on safety, quality and volume of surgical and anaesthesia care in this setting is scarce, and more attention to these questions is required.
 
Our full findings are published here in ‘Surgical care in district hospitals in sub-Saharan Africa: a scoping review’.



Professor Chris Lavy and Grace Drury, NDORMS, University of Oxford.

In the SURG-Africa project, multiple sources of data are collected on different aspects of surgical service delivery in the three partner countries: Malawi, Tanzania and Zambia. The data we collect range from volumes and types of surgeries, patient outcomes, self-confidence of surgical teams to patient level studies and qualitative evidence exploring deeper behind the numbers. These datasets provide an overview of the current situation, which is helpful to the authorities in the decision-making process, such as the allocation of health resources, the strategic plan of pilot intervention, and in priority-setting for the next phase of work. For example, our data from Tanzania were used to help develop the National Surgical Obstetric and Anaesthesia Plan for the country. There are also other ways in which data can be used. After the hospitals’ data were collected and cleaned, a regional map can be made using these data to show the hospitals’ performance in terms of volume of surgical procedures undertaken. ​

At the local level, the health data help district hospitals monitor their performance and their goals. For instance, this table compares the relative ranking between indicators and hospitals displayed in colour codes. The darker green indicates that a hospital’s performance is better than the average level (green), while the light green indicates that the hospital’s performance is below the average level. Then each row shows the rank of a hospital in each dimension. For Hospital 1, the scores in the Indicator 2 and 4 are better than the average. However, the scores of Indicator 6 to 8 are low, which may be the goal of the next round. In addition, the vertical comparison presents the selection of priorities. As for the Indicator 2, the performance of four hospitals is better than the average. Only three hospitals need to strengthen relevant work in this area. These quantitative data may be complemented by the use of qualitative methods in those four hospitals to investigate reasons behind their performance and the experiences gained from the process, which may help to promote the policy nationwide.

For policy makers, data visualisation helps to make better use of information. The table of performance comparison is an example. It is hard to read large amounts of data in a spreadsheet and make comparisons. Data visualisation techniques offer more user-friendly options. As in the example presented here, all information is transformed into an easy to read table. The vertical comparison shows the relative ranking of each hospital in a specific area. This facilitates to identify which hospitals perform well and which hospitals need further improvement. The horizontal comparison shows the performance of a hospital in different domains, highlighting strengths and weaknesses. These data visualization techniques are helpful in supporting monitoring and planning efforts, which provide policy makers and central authorities with an overview of the situation on the ground. As to the SURG-Africa project, the economic analysis of the routine data collected in district hospitals can be used to estimate the intervention impact whether it imposes significant influence on local surgical works.

How did we learn all these lessons, and how did we collect the data? SURG-Africa brought in resources to address data collection challenges in rural areas. And the challenges are severe. The findings by our colleague (Clarke et al. 2021) shows that some hospitals perform well in collecting surgical records, while in other hospitals the share of missing data is over 20%. 
​
If countries were prioritising data collection, the information we presented here could be captured by locally funded data collection systems. There is no reason for countries not to start prioritising collecting quality and reliable data, as data help to make the right decisions. But, over all, data helps to build stronger health systems and, consequently, to save lives.    
 

Reference
1. World Health Organization. Urban HEART: urban health equity assessment and response tool. 2010.
2. Clarke M, Pittalis C, Borgstein E, et al Surgical service monitoring and quality control systems at district hospitals in Malawi, Tanzania and Zambia: a mixed-methods study BMJ Quality & Safety Published Online First: 16 March 2021. doi: 10.1136/bmjqs-2020-012751.

A 2009 study conducted by researchers at Harvard Medical School and Cambridge Health Alliance found that 45,000 USA citizens had died every year, up to that date, as a direct result of not having any health insurance coverage. Three years later, the New England Journal of Medicine published a study stating that death rates are reduced considerably when Medicaid (free health insurance provided for the USA Government) is expanded. ​

Last week, at the market, my Mum fell and broke her arm. After calling the emergency services, she had to wait for 30 minutes, lying on the ground. People immediately gathered around her, shouting instructions: “she needs to stand up”, someone called out. “She can’t be moved, the emergency services advised”, explained the woman who had phoned, starting a public debate on how good or bad the health system in the country was.

I phoned my Mum the following day to check how she was. After showing me a huge and rather ugly bruise, she complained about the length of time she had needed to wait until the ambulance appeared, and the hours she had spent at the accident and emergency room once she was taken to the hospital.
—They checked thoroughly, in case they had to operate, but I was lucky and the fracture didn’t need an operation —she said with relief.
—I guess these are the advantages of having a health system in which surgery is always available for patients who need it —I pointed out.
—Is not that the norm?
—It might be in Europe, but not in the countries we work with. That is why places like Zambia or Tanzania are currently implementing this thing called a National Surgical Obstetric and Anaesthesia Plan (NSOAP).
—And, what is that? —my mum asked curiously.
—It is a plan developed by the Ministry of Health that coordinates the delivery of all health services for surgical, obstetric and anaesthesia care across the country. Zambia is actually the first country in the world to put the NSOAP into action and SURG-Africa is supporting the Government to implement some elements of it and to carry out a mid-term evaluation of the plan.  
—I understand, but is access to surgery such a big issue there? 
—Most people in sub-Saharan Africa don’t have access to safe surgical services. For example, they might need surgery for complications during childbirth, for trauma from accidents, or for treating cancer. If someone there falls and breaks an arm, they wouldn’t really have easy access to surgery and might suffer the consequences of it for life.
My mum grimaced with pain.
—And what’s the N…, what did you say?
—NSOAP
—With the NSOAP,  what will change?
—Well, that is the idea. It aims to change things by putting in place a structure that considers the full picture of surgical needs, anticipates what is needed in the health system to meet these needs, and channels money to gather the necessary resources for surgical care. And to do this fully, countries need to include rural hospitals as well, not just those in cities. In Malawi, for example, most of the population lives in rural areas. Imagine what happens to people when they need surgery and their nearest hospital can’t provide them with it? They have to travel to a larger hospital further away. But there might not be an ambulance available to get them there. In emergency situations, such as a problem in childbirth, or a bad traffic accident, this gets  really serious. See Mum, for your emergency, an ambulance came, collected you and drove you to the hospital. When they discharged you, the ambulance took you back home. This just doesn’t happen in many places around the world.    
—Will it happen with the NSOAP? Will people have access to all they need through this plan?
—Well, as a first step, it makes surgery a priority nationwide and that is already a good start. Then, these countries need to implement it with all relevant people. Countries make commitments to invest resources in surgery, identifying areas of need through their data systems. In the end, the aim is to positively impact on the population’s ability to get the surgical care they need.
​My mum looked at her arm, thoughtfully, for a few seconds. Finally, she asked:
—And, how do you say it is called again? Soap what?…
—NSOAP, Mum.
—It certainly sounds like it is a good plan to have in every country. But I really hope it is easier to turn it into a real change, than to remember the name.


Mairéad Finn is a health systems researcher at the Institute of Global Surgery, RCSI, and Adjunct Assistant Professor at the Centre for Global Health, Trinity College.

Antonio Jaén is our Communication Specialist. Learn more about him here. 

​​Throughout this Covid-19 pandemic, we have again realized that everything is related and connected. Yet, everything is dysfunctional. We have also observed, painfully, that any solution to a complex problem, surrounded by uncertainty, requires a holistic and systemic approach, with both multidisciplinary and interdisciplinary cooperation.

When challenged by the ongoing crisis, surgeons and other healthcare professionals have responded by actively engaging and connecting through digital media to share knowledge and solve problems. Actually, as highlighted by bestselling author Yuval Noah Harari, fear, gossip and fantasy have been the key elements that have united the members of our species in complex social groups to confront risk and reshape reality. For surgeons, #GlobalSurgery has become more important than ever before. 
 
The British physician Sir Muir Gray identified a series of major issues, shared by all healthcare systems, concerning quality, equity and the use of resources, among others.  Responding to these, in my opinion, should be a priority for #GlobalSurgery. 
 
Healthcare models must be transformed to focus on generating value –not just on promoting the industrialized production of surgical procedures and services–. And value is different for different stakeholders: from allocation of resources, to technical, personalised and population value.
 
Fortunately, the initiatives launched by surgeons, anaesthesiologists, and other healthcare professionals to move #GlobalSurgery forward are an example of collaboration, even more so during the Covid-19 pandemic. In this new context, social media and other videoconferencing technology platforms are instrumental to bringing change.
 
Social media, since its introduction in the first decade of the 21st century, has made it possible to connect students, residents and surgeons in different stages of training, regardless of distance, borders or differences in time, language, or culture. By eliminating the hierarchy, the communication flows have been enriched. In fact, surgical knowledge is ubiquitous. It is truly shared and distributed globally at present.
 
There are many examples of actions and activities that are contributing to the new #GlobalSurgery culture: communities of practice on social networks such as Facebook, videos on surgical technique on Youtube and other video platforms (AIS Channel, WebSurg, etc.), mobile applications for cognitive training (TouchSurgery), transmission of surgery congresses on digital platforms (American College of Surgeons Clinical Congress, National Congress of Surgery of Spain, Congress of the Colombian Association of Surgery, etc) or the conversation # SoMe4Surgery on Twitter.
 
Communication among surgeons, other healthcare professionals and patients through social media can have many advantages, but also some disadvantages. The objective of improving surgical practice and making it safer can be achieved through the creation of knowledge-based networks that respond quickly and flexibly to local societal conditions and to the quick changes faced by professionals and practitioners in healthcare services. 

​When she was eight, Hawa tripped on her way to school. A few weeks later, part of her face fell off.
 
No scraped knee should ever turn into a hole in a little girl’s face.

But Hawa lives in Sierra Leone, where her stumble set off a cascade. First, the scratch evolved into a deep-space infection in her leg. However, because she lived with nine siblings, and because her family survived on an intermittent income, a doctor’s visit would have been a luxury. 
 
Then the flesh around her upper lip turned red. Then purple. Then black. Then her mother took her to the hospital, where she was given oral antibiotics. They didn’t work.
 
Hawa stayed in the hospital for months, only leaving after her family’s money ran out. During that time, the normal commensal bacteria in her mouth and nose destroyed her nose, her upper lip, her hard palate, and the sight in her right eye. She would spend the next fourteen years covering the hole where her nose used to be with a scarf. 
 
Hawa’s disease—called noma or cancrum oris—does not exist in high-income countries. The last time it was seen with any regularity was in the Nazi concentration camps of World War II. That’s because, fundamentally, it is a disease of malnutrition, of poor oral hygiene, of poverty—and of inequity.
 
But commensal bacteria don’t have to destroy a little girl’s face. There’s nothing special about the bugs in Hawa’s mouth. We’ve all got them. Even with her chronic malnutrition, if Hawa had been placed on intravenous antibiotics and given good oral hygiene within the first 48 hours of the onset of her facial infection, the whole cascade could have been arrested. 
 
In her case, economics, distance, transportation, and family pressures delayed her presentation long enough that, by the time she got to the hospital, the antibiotics could do nothing to halt the advancing necrosis. All they could do was impoverish her family.
 
In his book, In the Company of the Poor, Paul Farmer writes, “Poverty is not some accident of nature but the result of historically given and economically driven forces.” In Hawa’s case, those forces look like being born a girl into a rural village in a previously colonised country not two years after the end of a decade-long civil war that claimed 50,000 lives.
 
And Hawa isn’t unique. Thirty percent of the world’s disease requires surgery, but 5 billion people can’t access surgery when they need it. And a quarter of people who get surgical care every year are driven into financial catastrophe by its costs.
 
The historically given and economically driven forces behind Hawa’s face—they’re everywhere. And they are the challenge—and the opportunity—of surgery. 
 
In the end, repairing Hawa’s face isn’t complex. It simply entails moving the right types of normal tissue from the right places to re-create a nose and a lip and a hard palate. The techniques to do this have been around since before the destruction of Babylon. 
 
The hardest part of Hawa’s story isn’t what happens within operating theatre walls. The hardest part is getting her there. 
 
Hawa’s face tells more than just the story of an infectious disease run riot. It tells the story of forces she never bargained for. Of systemic inequities—a lack of knowledge that treatment exists, distance to the nearest hospital, economic stressors on her family, a lack of surgical providers, and a dearth of surgical infrastructure—she had no part in creating. It tells the story of a girl who lost the birth lottery.
 
For far too long, the global health community has treated surgery as a luxury, a problem to be addressed once more “important” global health issues are resolved. Absent from national health plans or international resolutions, surgical disease has been relegated to the purview of two-week mission trips and surgical safaris. 
 
In other words, it’s been relegated to the perpetuation of colonial structures, doomed to suffer under historically given dynamics. “We” send “our” surgeons to “their” countries to fix noses and lips, while leaving deeper, systemic inequities that underpin them unchanged. 
 
It’ll never work. Surgical disease like Hawa’s is enmeshed. It’s entangled in complex historical and structural forces. 
 
To address it well, we must take off our colonial glasses. We must look beyond the operating theatre’s walls. We must see surgical disease not as an accident of nature—and we must see surgery as the starting point for reversing Farmer’s forces.
 
We’ve known how to make Hawa’s face better for a thousand years. We must make her life better too.

​Based at Radboud University Medical Centre in Nijmegen, the Netherlands, I have carried responsibility for the health economics arm of SURG-Africa, and of its predecessor COST-Africa. A large chunk of our research was dedicated to establishing the cost of providing and scaling up district-level surgery in Malawi, Zambia and Tanzania. In our studies we looked at the financial costs of all types of resources used in providing surgery, irrespective of whether or not patients pay a fee. ​

Examples of resources included are: staff salaries and other emoluments of surgery providers; medicines, surgical and non-surgical supplies used in theatre or in the ward for post-operative care; surgical patient transport by ambulance; depreciation of infrastructure such as buildings and equipment; maintenance of medical and non-medical equipment used in surgery; utilities (electricity, water, telephone communication); administration and other overhead. We also considered the economic costs (i.e., including depreciation and opportunity costs). This allowed a full costing of the provision of surgery, from the very first clinic consultation to the last follow-up visit. It proved an eye-opener for many of the hospital staff that we worked with: surgery turned out to be much more resource intensive and costly than they had thought. 

More recently we calculated the cost of surgical referrals by ambulance in the three countries and conducted an analysis of the strategies that district hospitals employ to cope with the high financial burden involved. We found that hospital management teams have already taken various measures to contain the cost of running their ambulances, for instance by transporting two or more patients in a single ambulance trip. And although in some places there may be still some room for efficiency gains, the manoeuvring space for the hospital management teams is limited, which further undermines the fragile financial positions of the hospitals.

It is also worth mentioning that several years back (under COST-Africa) we conducted a study in Malawi to establish the direct and indirect costs that patients and their families incur to access essential surgery. Unsurprisingly, we found that out-of-pocket household expenditure was high and in many instances catastrophic, putting households, especially those who are already poor, at risk of further impoverishment. This underlined that scaling-up surgical services in rural areas needs to be accompanied by health insurance or some other form of financial risk protection. 

As part of our more recent research work we conducted a series of group model building workshops in each of the three countries. The purpose of the workshops was to examine the complexity of scaling-up district-level surgery (in Tanzania) and of surgical team mentoring in support of such scaling-up (in Malawi and Zambia), which forms the core of the SURG-Africa project. The workshop participants represented various parties that have a role in providing surgical services. Through a participatory approach, and supported by our team from Radboud UMC, they developed causal loop diagrams that describe the complexities and cause-and-effect relationships at hand. This provided the basis for a set of very practical policy options to increase access to surgery for rural populations. We shared our summary findings with the workshop participants for their feedback, after which we developed and submitted three articles to scientific journals. We hope the articles will be accepted and published soon, so they reach a wider audience.

It has been a privilege and a joy to work with professionals ‘on the ground’ – hospital managers, clinicians, theatre staff, pharmacy, radiology and laboratory staff, medical records clerks, procurement officers, financial administrators, social welfare staff, transport officers, drivers – sometimes in quite remote places. We appreciate their dedication to work in circumstances that are often far from easy. I say that on behalf of my colleague Martilord Ifeanyichi and my former colleagues Henk Broekhuizen (under SURG-Africa) and Dennis Cornelissen (under COST-Africa), who each spent considerable time in the field conducting interviews and collecting data, which were not always easy to obtain. We have enjoyed the work, the friendly relations, and the nsima/nshima/ugali with chambo/nyama/kuku and tasty relish/soup! We would like to thank the local research coordinators (Mweene Cheelo, Gerald Mwapasa, Adinan Juma) for their support in organising our field trips and in the data collection itself.

We look forward to continued interactions with provincial/regional-level health programme officers and national-level policy makers about options and future strategies to scale-up surgery for rural populations in Malawi, Tanzania and Zambia. 
 

​To access journal articles published on the topic so far, click here.

More on Dr Leon Bijlmakers here. 

Marisa Wallace is a medical student at Queen's University Belfast and MSc Global Health graduate. ​