Quantifying Surgical Capacity in Sierra Leone

Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
Archives of surgery (Chicago, Ill.: 1960) (Impact Factor: 4.93). 03/2009; 144(2):122-7; discussion 128. DOI: 10.1001/archsurg.2008.540
Source: PubMed


Lack of access to surgical care is a public health crisis in developing countries. There are few data that describe a nation's ability to provide surgical care. This study combines information quantifying the infrastructure, human resources, interventions (ie, procedures), emergency equipment and supplies for resuscitation, and surgical procedures offered at many government hospitals in Sierra Leone.
Site visits were performed in 2008 at 10 of the 17 government civilian hospitals in Sierra Leone.
The World Health Organization's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was used to assess surgical capacity.
There was a paucity of electricity, running water, oxygen, and fuel at the government hospitals in Sierra Leone. There were only 10 Sierra Leonean surgeons practicing in the surveyed government hospitals. Many procedures performed at most of the hospitals were cesarean sections, hernia repairs, and appendectomies. There were few supplies at any of the hospitals, forcing patients to provide their own. There was a disparity between conditions at the government hospitals and those at the private and mission hospitals.
There are severe shortages in all aspects of infrastructure, personnel, and supplies required for delivering surgical care in Sierra Leone. While it will be difficult to improve the infrastructure of government hospitals, training additional personnel to deliver safe surgical care is possible. The situational analysis tool is a valuable mechanism to quantify a nation's surgical capacity. It provides the background data that have been lacking in the discussion of surgery as a public health problem and will assist in gauging the effectiveness of interventions to improve surgical infrastructure and care.

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Available from: Thaim B Kamara, Feb 20, 2015
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    • "Besides antibiotics to treat pneumonia and neonatal sepsis, WHO recommends that children with very severe pneumonia and neonatal conditions that result in hypoxaemia be given oxygen therapy.7–9 Because of transport difficulties, oxygen is often unavailable in remote district hospitals.10–13 "
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    ABSTRACT: Background In developing countries such as Papua New Guinea (PNG), district hospitals play a vital role in clinical care, training health-care workers, implementing immunization and other public health programmes and providing necessary data on disease burdens and outcomes. Pneumonia and neonatal conditions are a major cause of child admission and death in hospitals throughout PNG. Oxygen therapy is an essential component of the management of pneumonia and neonatal conditions, but facilities for oxygen and care of the sick newborn are often inadequate, especially in district hospitals. Improving this area may be a vehicle for improving overall quality of care. Method A qualitative study of five rural district hospitals in the highlands provinces of Papua New Guinea was undertaken. A structured survey instrument was used by a paediatrician and a biomedical technician to assess the quality of paediatric care, the case-mix and outcomes, resources for delivery of good-quality care for children with pneumonia and neonatal illnesses, existing oxygen systems and equipment, drugs and consumables, infection-control facilities and the reliability of the electricity supply to each hospital. A floor plan was drawn up for the installation of the oxygen concentrators and a plan for improving care of sick neonates, and a process of addressing other priorities was begun. Results In remote parts of PNG, many district hospitals are run by under-resourced non-government organizations. Most hospitals had general wards in which both adults and children were managed together. Paediatric case-loads ranged between 232 and 840 patients per year with overall case-fatality rates (CFR) of 3–6% and up to 15% among sick neonates. Pneumonia accounts for 28–37% of admissions with a CFR of up to 8%. There were no supervisory visits by paediatricians, and little or no continuing professional development of staff. Essential drugs were mostly available, but basic equipment for the care of sick neonates was often absent or incomplete. Infection control measures were inadequate in most hospitals. Cylinders were the major source of oxygen for the district hospitals, and logistical problems and large indirect costs meant that oxygen was under-utilized. There were multiple electricity interruptions, but hospitals had back-up generators to enable the use of oxygen concentrators. After 6 months in each of the five hospitals, high-dependency care areas were planned, oxygen concentrators installed, staff trained in their use, and a plan was set out for improving neonatal care. Interpretation If MGD-4 targets for child health are to be met, reducing neonatal mortality and deaths from pneumonia will have to include better quality services in district hospitals. Establishing better oxygen supplies with a systems approach can be a vehicle for addressing other areas of quality and safety in district hospitals.
    Full-text · Article · Dec 2013 · Paediatrics and international child health
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    • "An estimated 11% of the global burden of disease can be treated with surgery (Debas et al. 2012) and recent studies from Sierra Leone and Rwanda document a high prevalence of surgically treatable conditions and deaths that could possibly have been averted with timely access to surgical care (Groen et al. 2012; Petroze et al. 2013). Although data exist on the lack of surgical capacity in numerous LMICs (Kingham et al. 2009; Choo et al. 2010; Kushner et al. 2010; Iddriss et al. 2011; Sherman et al. 2011), few studies have evaluated access to surgical care, and those that did are quantitative (Mock et al. 1997; Hang & Byass 2009; Grimes et al. 2011). "
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    ABSTRACT: To determine themes and beliefs that influence health-seeking behaviour and barriers to accessing surgical care. In January 2012 in Western Area Province of Sierra Leone, six Focus Group Discussions (FGDs) were conducted. The FDGs consisted of three male only and three female only groups in an urban, a slum and a rural setting. Researchers investigated a wide range of topics including definitions of surgery, types of surgical procedures, trust, quality of care, human resources, post-operative care, permission-seeking and traditional beliefs. Although many individual beliefs were expressed, common fears were as follows: becoming half human after surgery; complications from procedures; stigma from having a scar; and financial burdens resulting from the cost of care. Participants also expressed concern about the quality of the care available in Sierra Leone. The concept of being half human after surgery, previously not documented in the literature, is noteworthy and should be explored more fully. Qualitative research in other parts of Sierra Leone and other LMICs into beliefs of the local population could improve programmes for access and delivery of surgical care.
    Full-text · Article · Nov 2013 · Tropical Medicine & International Health
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    • "The movement to incorporate surgery into broader global health initiatives has produced quantitative assessments of surgical and anesthetic capacity in a growing number of countries [5e17], including a recent national survey of 18 hospitals in Bolivia [18]. At 7.8 per 100,000 population, the number of trained surgeons per capita is more than 10 times higher in Santa Cruz than in many sub-Saharan African and central Asian nations [8] [11] [25] for which data have been published. In fact, the US has only 5.7 general surgeons per 100,000 population, although this number does not include obstetricians and specialists [26]. "
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    ABSTRACT: Objectives: This investigation aimed to document surgical capacity at public medical centers in a middle-income Latin American country using the Surgeons OverSeas (SOS) Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) survey tool. Materials and methods: We applied the PIPES tool at six urban and 25 rural facilities in Santa Cruz, Bolivia. Outcome measures included the availability of items in five domains (Personnel, Infrastructure, Procedures, Equipment, and Supplies) and the PIPES index. PIPES indices were calculated by summing scores from each domain, dividing by the total number of survey items, and multiplying by 10. Results: Thirty-one of the 32 public facilities that provide surgical care in Santa Cruz were assessed. Santa Cruz had at least 7.8 surgeons and 2.8 anesthesiologists per 100,000 population. However, these providers were unequally distributed, such that nine rural sites had no anesthesiologist. Few rural facilities had blood banking (4/25), anesthesia machines (11/25), postoperative care (11/25), or intensive care units (1/25). PIPES indices ranged from 5.7-13.2, and were significantly higher in urban (median 12.6) than rural (median 7.8) areas (P < 0.01). Conclusions: This investigation is novel in its application of a Spanish-language version of the PIPES tool in a middle-income Latin American country. These data document substantially greater surgical capacity in Santa Cruz than has been reported for Sierra Leone or Rwanda, consistent with Bolivia's development status. Unfortunately, surgeons are limited in rural areas by deficits in anesthesia and perioperative services. These results are currently being used to target local quality improvement initiatives.
    Full-text · Article · Jun 2013 · Journal of Surgical Research
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