Ann R Coll Surg Engl 2007; 89: 722-724 722Malawi is a small, but densely populated, country in subSaharan Africa. The population is approximately 12 million. 1 The average income is less than one UK pound a day and it is currently ranked as one of the poorest and least developed countries in the world -55% of the population is below the international poverty line of one US dollar per day. 2It has a network of 21 district hospitals, one in each rural health district, and four central hospitals in the four major urban areas. Together, these government hospitals cover approximately 60% of the country's health needs. In addition, there are several mission and independent hospitals which together cover the other 40%. There has been recent interest in district hospital surgery in Africa with the publication of the new World Health Organization book Surgery at the District Hospital 3 encouraging surgery to be done at a district level where it is needed rather than being transferred to tertiary centres. There has also been investment in district surgery in Malawi recently with the completion of two European Union funded district hospitals in the south of the country. Both of these have several operating theatres. There are only 15 trained surgeons of any specialty in Malawi and there are no surgeons stationed at any of the district hospitals. Most district hospitals have one doctor, the district health officer, who is recruited straight from internship and is busy with running the hospital and health district as well as overseeing the clinical work. The district health officer is helped by a number of clinical officers who are paramedic clinicians with 4 years' practically orientated training. Surgeons from central hospitals also periodically visit the districts to run clinics and sometimes to operate. We decided to investigate exactly what surgery was being done in the country as a whole. We have already reported a limited survey of district activity. 4 This study examines surgical activity over a 1-year period in both district and central hospitals. Patients and MethodsTwo of the authors visited every district and central hospital in Malawi over the course of 2004 as part of routine clinical support visits. They met with the district health officer or clinical officers i nvolved with surgery and reviewed the operating theatre log book. All operations done in the operating theatres in 2003 were recorded. In many hospitals, procedures such as drainage of abscesses were done in the out-patient departments and were not recorded. Eye operations were often done by visiting teams who kept separate records. These were not recorded. Operations were classified into the categories outlined in the

BackgroundEpidemiological data on childhood disability are lacking in Low and Middle Income countries (LMICs) such as Malawi, hampering effective service planning and advocacy. The Key Informant Method (KIM) is an innovative, cost-effective method for generating population data on the prevalence and causes of impairment in children. The aim of this study was to use the Key Informant Method to estimate the prevalence of moderate/severe, hearing, vision and physical impairments, intellectual impairments and epilepsy in children in two districts in Malawi and to estimate the associated need for rehabilitation and other services.MethodsFive hundred key informants (KIs) were trained to identify children in their communities who may have the impairment types included in this study. Identified children were invited to attend a screening camp where they underwent assessment by medical professionals for moderate/severe hearing, vision and physical impairments, intellectual impairments and epilepsy.ResultsApproximately 15,000 children were identified by KIs as potentially having an impairment of whom 7220 (48%) attended a screening camp. The estimated prevalence of impairments/epilepsy was 17.3/1000 children (95% CI: 16.9–17.7). Physical impairment (39%) was the commonest impairment type followed by hearing impairment (27%), intellectual impairment (26%), epilepsy (22%) and vision impairment (4%). Approximately 2100 children per million population could benefit from physiotherapy and occupational therapy and 300 per million are in need of a wheelchair. An estimated 1800 children per million population have hearing impairment caused by conditions that could be prevented or treated through basic primary ear care. Corneal opacity was the leading cause of vision impairment. Only 50% of children with suspected epilepsy were receiving medication. The majority (73%) of children were attending school, but attendance varied by impairment type and was lowest among children with multiple impairments (38%).ConclusionUsing the KIM this study identified more than 2500 children with impairments in two districts of Malawi. As well as providing data on child disability, rehabilitation and referral service needs which can be used to plan and advocate for appropriate services and interventions, this method study also has an important capacity building and disability awareness raising component.

Trauma management training of health-workers plays a pivotal role in tackling the ever-growing trauma burden in Africa. Our study suggests cascading PTC courses may be an effective model in delivering trauma training in low-resource settings, however further studies are required to determine its efficacy in improving clinical competence and retention of knowledge and skills in the long term.