Strengthening surgical and anaesthetic services at district level in the African region: issues, challenges and proposed actions

Ndihokubwayo, Jean-Bosco; Coulibaly, Salia; Cherian, Meena; Ekeke, M.M.; Nabyonga, Juliet; Musango, Laurent; Nkurunziza, Theoneste; King, Caroline A.; Premaratne, Ishani D.; Johnson, Wayne D.

doi:10.4314/ecajs.v22i1.3

Cited by 20 publications

(27 citation statements)

References 9 publications

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“…We created composite indicators for measuring the health system’s capacity to provide basic and comprehensive post-abortion care based on the signal functions described earlier (figure 1). We also constructed two less-restrictive composite indicators for basic and comprehensive provision of post-abortion care on the basis of evidence from other studies that appropriate referral in obstetric care, 15–17 sufficient trained health staff, 16 and provision of post-abortion family planning counselling remains a challenge for facilities 8,10 in many low-income countries. For the first less-restrictive composite indicator of basic post-abortion care, the signal function of staff availability was excluded.…”

Section: Methodsmentioning

confidence: 99%

Health systems' capacity to provide post-abortion care: a multicountry analysis using signal functions

Owolabi

Biddlecom

Whitehead

2019

The Lancet Global Health

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Summary Background Abortion-related mortality is one of the main causes of maternal mortality worldwide. Laws often restrict the provision of safe abortion care, yet post-abortion care is a service that all countries have committed to provide to manage abortion complications. There is minimal evidence on the capacity of national health systems to provide post-abortion care. Methods We did a multicountry analysis of data from nationally representative Service Provision Assessment surveys done between 2007 to 2017 in ten countries across three regions (Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda). Data were available for all ten countries from 2007 to 2015. We included facilities offering childbirth delivery services and classified facilities as primary or referral level. We measured signal functions for post-abortion care (the availability of key equipment and ability to perform services) to assess the proportion of primary-level and referral-level facilities in each country with the capacity to provide basic and comprehensive post-abortion care, respectively. We calculated the proportion of facilities providing each post-abortion care signal function to examine specific gaps in service provision. Findings There are critical gaps in the provision of post-abortion care at all facilities that offer delivery services. In seven (70%) of ten countries, less than 10% of primary-level facilities could provide basic post-abortion care, and in eight (80%) of ten countries less than 40% of referral-level facilities could provide comprehensive post-abortion care. In no country could all referral facilities provide all the essential services that need to be included in basic post-abortion care. Interpretation The capacity of primary-level and referral-level health facilities to provide basic and comprehensive post-abortion care, respectively, is low. The results highlight the gap between political commitments to address the consequences of unsafe abortion and the capacity of health systems to provide post-abortion care. Increasing the provision of good-quality post-abortion care is essential to reduce the level of abortion-related morbidity and mortality.

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Section: Methodsmentioning

confidence: 99%

Health systems' capacity to provide post-abortion care: a multicountry analysis using signal functions

Owolabi

Biddlecom

Whitehead

2019

The Lancet Global Health

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“…This results in poor health outcomes [8] and substantial economic losses [5]. A key strategy for meeting the unmet need for surgery lies in the strengthening of district health systems [9,10]. Most health systems in SSA have a pyramidal structure, with numerous community providers (health centres, dispensaries, health posts, and sometimes outreach clinics offered by mobile teams) at the base.…”

Section: Introductionmentioning

confidence: 99%

“…They therefore ensure that only complex cases are managed in the high cost environment of specialist hospitals. In reality however, DH functions in SSA have in most cases been compromised by systemic inefficiencies such as inadequate funding [9,10,12], poor infrastructure, shortages of supplies, and deficiencies in manpower [13,14], resulting in a general loss of confidence in district-level health services. Patients often go straight to higherlevel hospitals, bypassing the DHs close to them.…”

Section: Introductionmentioning

confidence: 99%

Surgical ambulance referrals in sub-Saharan Africa – financial costs and coping strategies at district hospitals in Tanzania, Malawi and Zambia

Ifeanyichi¹,

Broekhuizen²,

Cheelo

et al. 2021

BMC Health Serv Res

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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.

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“…Passive surveillance systems to monitor bacterial infections and associated resistance patterns are not common practice [4], and there are few robust estimates of the burden of bacteremia in children in resource-limited settings [5] due to limited access to microbiology facilities and molecular diagnostic tools [6]. In addition, uncontrolled (prehospital) use of antibiotics in SSA [7] limits reliable identification of bacteria via traditional blood culture. This results in a paucity of reliable data on the prevalence and sensitivity pattern of commonly isolated pathogens over time [2, 8, 9].…”

mentioning

confidence: 99%

Bacteremia in Childhood Life-Threatening Infections in Urban Gambia: EUCLIDS in West Africa

Secka

Herberg

Sarr

et al. 2019

Open Forum Infectious Diseases

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BackgroundThe limited availability of microbiology services in sub-Saharan Africa impedes accurate diagnosis of bacterial pathogens and understanding of trends in prevalence and antibiotic sensitivities. We aimed to characterize bacteremia among hospitalized children in The Gambia and to identify factors associated with bacteremia and mortality.MethodsWe prospectively studied children presenting with suspected severe infection to 2 urban hospitals in The Gambia, between January 2013 and September 2015. Demographic and anthropometric data, clinical features, management, and blood culture results were documented. Urine screens for antibiotic activity were performed in a subset of participants.ResultsOf 411 children enrolled (median age, 29 months; interquartile range, 11–82), 79.5% (325 of 409) reported prehospital antibiotic use. Antimicrobial activity by urinary screen for antibiotic activity was detected in 70.8% (n = 80 of 113). Sixty-six bacterial pathogens were identified in 65 (15.8%) participants and Staphylococcus aureus predominated. Gram-positive organisms were more commonly identified than Gram-negative (P < .01). Antibiotic resistance against first-line antimicrobials (ampicillin and gentamicin) was common among Gram-negative bacteria (39%; range, 25%–100%). Factors significantly associated with bacteremia included the following: gender, hydration status, musculoskeletal examination findings, admission to the Medical Research Council The Gambia at London School of Hygiene & Tropical Medicine hospital, and meeting sepsis criteria. Those associated with increased mortality were presence of a comorbidity, clinical pallor, tachypnea, and altered consciousness. Tachycardia was associated with reduced mortality.ConclusionsThe bacteremia rate in children with suspected childhood life-threatening infectious diseases in The Gambia is high. The pattern of pathogen prevalence and antimicrobial resistance has changed over time compared with previous studies illustrating the importance of robust bacterial surveillance programs in resource-limited settings.

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Strengthening surgical and anaesthetic services at district level in the African region: issues, challenges and proposed actions

Cited by 20 publications

References 9 publications

Health systems' capacity to provide post-abortion care: a multicountry analysis using signal functions

Health systems' capacity to provide post-abortion care: a multicountry analysis using signal functions

Surgical ambulance referrals in sub-Saharan Africa – financial costs and coping strategies at district hospitals in Tanzania, Malawi and Zambia

Bacteremia in Childhood Life-Threatening Infections in Urban Gambia: EUCLIDS in West Africa

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