BackgroundReferral networks are critical in the timely delivery of surgical care, particularly for populations residing in rural areas who have limited access to specialist services. However, in low- and middle-income countries (LMICs) referral networks are often undermined by systemic inefficiencies. If equitable access to essential surgical services is to be achieved, sound evidence is needed to ensure efficient patient care pathways. The aim of this scoping review was to investigate current knowledge regarding inter-hospital surgical referral systems in LMICs to identify the main obstacles to their functioning and to critically assess proposed solutions.MethodsMEDLINE, EMBASE and Global Health databases and grey literature were systematically searched to identify relevant studies. The search generated 2261 unique records, of which 14 studies were selected for inclusion in the review. The narrative synthesis of retrieved data is based on a conceptual framework developed though a thematic analysis approach.ResultsMultiple shortages in surgical infrastructure, equipment and personnel, as well as gaps in surgical and decision-making skills of clinicians at sending hospitals, act as obstacles to safe and appropriate referrals. Comprehensive protocols for surgical referrals are lacking in most LMICs and established patient pathways, when in place, are not correctly followed. Interventions to improve coordination and communication between different level facilities may enhance efficiency of referral pathways. Strengthening capacity of referring hospitals to manage more surgical conditions locally could improve outcomes, decrease the need for referral and reduce the burden on tertiary facilities.DiscussionThe field of surgical referrals is still an uncharted territory and the limited empirical evidence available is of low quality. Developing strategies for assessing functionality and effectiveness of referral systems in surgery is essential to improve access, coverage and quality of services in resource-limited settings, as well as overall health systems performance.

Background District-level hospitals (DLHs) can play an important role in the delivery of essential surgical services for rural populations in sub-Saharan Africa if adequately prepared and supported. This article describes the protocol for the evaluation of the Scaling up Safe Surgery for District and Rural Populations in Africa (SURG-Africa) project which aims to strengthen the capacity in district-level hospitals (DLHs) in Malawi, Tanzania and Zambia to deliver safe, quality surgery. The intervention comprises a programme of quarterly supervisory visits to surgically active district-level hospitals by specialists from referral hospitals and the establishment of a mobile phone-based consultation network. The overall objective is to test and refine the model with a view to scaling up to national level. Methods This mixed-methods controlled pilot trial will test the feasibility of the proposed supervision model in making quality-assured surgery available at DLHs. Firstly, the study will conduct a quantitative assessment of surgical service delivery at district facilities, looking at hospital preparedness, capacity and productivity, and how these are affected by the intervention. Secondly, the study will monitor changes in referral patterns from DLHs to a higher level of care as a result of the intervention. Data on utilisation of the mobile based-support network will also be collected. The analysis will compare changes over time and between intervention and control hospitals. The third element of the study will involve a qualitative assessment to obtain a better understanding of the functionality of DLH surgical systems and how these have been influenced by the intervention. It will also provide further information on feasibility, impact and sustainability of the supervision model. Discussion We seek to test a model of district-level capacity building through regular supervision by specialists and mobile phone technology-supported consultations to make safe surgical services more accessible, equitable and sustainable for rural populations in the target countries. The results of this study will provide robust evidence to inform and guide local actors in the national scale-up of the supervision model. Lessons learned will be transferred to the wider region.

Background Shortages of specialist surgeons in African countries mean that the needs of rural populations go unmet. Task‐shifting from surgical specialists to other cadres of clinicians occurs in some countries, but without widespread acceptance. Clinical Officer Surgical Training in Africa (COST‐Africa) developed and implemented BSc surgical training for clinical officers in Malawi. Methods Trainees participated in the COST‐Africa BSc training programme between 2013 and 2016. This prospective study done in 16 hospitals compared crude numbers of selected numbers of major surgical procedures between intervention and control sites before and after the intervention. Volume and outcomes of surgery were compared within intervention hospitals between the COST‐Africa trainees and other surgically active cadres. Results Seventeen trainees participated in the COST‐Africa BSc training. The volume of surgical procedures undertaken at intervention hospitals almost doubled between 2013 and 2015 (+74 per cent), and there was a slight reduction in the number of procedures done in the control hospitals (–4 per cent) (P = 0·059). In the intervention hospitals, general surgery procedures were more often undertaken by COST‐Africa trainees (61·2 per cent) than other clinical officers (31·3 per cent) and medical doctors (7·4 per cent). There was no significant difference in postoperative wound infection rates for hernia procedures at intervention hospitals between trainees and medical doctors (P = 0·065). Conclusion The COST‐Africa study demonstrated that in‐service training of practising clinical officers can improve the surgical productivity of district‐level hospitals.

The Ministry of Health, Community Development, Gender, Elderly and Children is charged with improving the health and welfare of all Tanzanian citizens. In considering the high burden of disease due to surgically treatable conditions in the country, the MOHCDGEC in collaboration with partners has developed the first National Surgical, Obstetric and Anaesthesia Plan (NSOAP) 2018-2025, to address challenges in access to high quality surgical, obstetrics and anaesthesia (SOA) services in Tanzania. Access to safe, timely and affordable SOA care is limited for a significant proportion of Tanzanians especially those in rural areas. This lack of access is in large part due to human resources challenges. At present, of the recommended 20 physician surgeons, obstetricians and anaesthesiologists per 100,000 population, there are only a total of 0.46 per 1000,000 Tanzanians in the country making widespread access impossible. Additionally, there are factors such as limited access to surgical and anaesthesia equipment, supplies, medicines, blood and blood products and essential utilities like clean water, oxygen and electricity which exacerbate this situation. Strengthening the Tanzanian SOA system is imperative to reducing surgically preventable mortality and morbidity. Currently about 19.3% of deaths and 17 % of Disability-Adjusted Life Years (DALY) in Tanzania are attributable to diseases amenable to surgery. Surgical, Obstetric, and Anaesthesia services are critical in reducing the unacceptably high levels of maternal mortality, one of the key sustainable development goals, by making Caesarian sections, post-partum hemorrhage, uterine rupture, ectopic pregnancy and retained products of conception amongst other conditions safer for mothers. Surgery and anaesthesia is also essential in preventing deaths resulting from road traffic accidents, also one of the key sustainable development goals. Additionally, as outlined in the LCoGS, the economic benefits from preventing lives lost and averting disabilities from surgically treatable conditions will be substantial and promote economic development of our Country. The high costs of seeking and receiving surgical care often places patients at the risk of being impoverished as a result of seeking or receiving surgical care. Currently, about 66% of Tanzanians risk catastrophic expenditure and 86% risk impoverishing expenditure from seeking surgical care. Addressing all components of SOA access, including risk of impoverishment, is crucial to achieving Tanzania Vision 2025, the Global Sustainable Development Goals (SDGs) and Universal Health Coverage. This NSOAP lays out the necessary steps to improve each of the 6 major domains of the surgery, anaesthesia and obstetric health system: (a) service delivery, (b) infrastructure, (c) workforce, (d) information management and technology, (e) finance and (f) governance. It will be key to act synergistically across all of these health system building blocks to guarantee an impact. This NSOAP is designed to align with and complement existing ...

ObjectivesReliable referral systems are essential to the functionality and efficiency of the wider health care system in low‐ and middle‐income countries (LMICs), particularly in surgery as the disease burden is growing while resources remain constrained and unevenly distributed. Yet, this is a critically under‐researched area. This study aimed to provide a comprehensive assessment of surgical referral systems in a LMIC, Malawi, with a view to shedding light on this important aspect of public health and share lessons learned.MethodsWe conducted a prospective analysis of all inter‐hospital referrals received at Queen Elizabeth Central Hospital (QECH) in 2014–2015. A subsample of 255 referrals was assessed by three independent surgical experts against necessity and quality of the transfer to identify any inefficiencies in the referral process.Results1317 patients were referred to QECH during the study period (average 53/month), 80% sent by government district hospitals. One in 3 cases were referred unnecessarily, many of which could have been managed locally. In 82% of cases, there was no communication with QECH prior to referral, 41% had incorrect/incomplete diagnosis by the referring clinicians and 39% of referrals were not timely.ConclusionsOur findings provide the first evidence on the state of the surgical referral system in Malawi and contribute to building the body of knowledge necessary to inform system improvements. Responses should include reducing inappropriate use of specialist care and ensuring better care pathways for surgical patients, especially in rural areas, where access to specialist expertise is not available at present.