Although interest in Global Surgery is growing, it remains an under-researched area. That makes it difficult to foresee unexpected encounters when implementing research projects in this field. However, these unpredictable outcomes can be part of the beauty of research.
SURG-Africa works to improve the technical skills and professionalism necessary to deliver safe surgery at district-level hospitals in Malawi, Zambia, and Tanzania. Over the past four years, the project has coordinated periodic visits from local mentors to selected district-level hospitals with the aim of training surgical staff. Anaesthetists, surgical nurses, clinical officers, surgeons and doctors have received in-service training designed to boost their proficiency.
During the implementation of this mentorship, some unscripted results appeared. A series of what we have termed ‘collateral benefits’ have enriched the implementation process, shedding light on how to achieve improvements at district level hospitals.
For example, it was not uncommon for mentors to observe poor infrastructure in operating theatres during their visits, including a lack of surgical equipment and insufficient conditions for safe practice. The specialists recorded these needs with the hospital directors, thus acting as a lobbying force. Early evidence from SURG-Africa indicates cases of substantial infrastructural improvements in operating theatres of some hospitals participating in the mentorship visits.
Mark Banda, a theatre nurse at Namwala District Hospital in Zambia, explains: “it used to be very hot. You can imagine someone over the operating table sweating”, referring to the times when there was no air conditioner in the operation theatre. Another issue was the provision of anaesthesia. “Once we intubated the patient, we used to work with a balloon, pumping, giving oxygen”, Mark recalls, describing the manual method used to administer anaesthesia.
SURG-Africa mentors raised these issues with the hospital director every time they visited Namwala District Hospital. Currently, the operating theatre counts new air conditioning and an anaesthesia machine among its equipment.
Moving to Malawi, to Thyolo District Hospital, the SURG-Africa mentoring team used a mobile consultation network - which is indicating positive results in the country - to communicate the lack of functioning bulbs in lamps used for surgical operations. “It’s very dangerous to do laparotomies without working lights”, stated one of the surgeons. This communication channel led to the procurement of new bulbs for lamps.
Before and after. Operation theatre at Thyolo District Hospital, Malawi.
In Tanzania, when the SURG-Africa mentor team started their visits to Usangi Hospital, windows in the operating theatre were merely holes covered with wire mesh, but with no glass. The mentors identified the need to cover the windows completely, to guarantee a safer environment. They raised the matter with the hospital director and currently the operating theatre has windows fully secured by glass.
The SURG-Africa mentoring team also provides training on the safe use of surgical equipment. Sometimes district hospitals have the essential equipment necessary to conduct safe surgery, but staff may lack knowledge about how to use them. This was the case at Mary Mother of the Church, a health facility in Tanzania where there was a brand new anaesthesia machine lying unused in a corner of the operating theatre. “Thanks to SURG-Africa, we are now capable of using the anaesthesia machine safely without any problems”, explained Dr Simon Felix Mbise, General Practitioner. “Now we can conduct ectopic pregnancy, caesarean section, herniorrhaphy, fractures, and excisions of big tumours. And the same occurred with a diathermy machine that now we are able to use to minimize bleeding during operations”.
Anaesthesia machine at Mary Mother of the Church, Tanzania.
There is a misconception that often surrounds district-level hospitals in lower middle-income countries: that because funds are limited it is difficult for them to upgrade their facilities and maintain quality standards. Yes, surgery is often forgotten and treated as the neglected and expensive ‘step-child’ among activities carried out in health facilities. But the reality, as proven by SURG-Africa, is sometimes different.