SURG Afirica: Mobile Phone Surgical Clinic

Abstract

Since the introduction of a remote consultation network based on modern technologies,
surgical care in Malawi has improved markedly. There is enough evidence of enormous benefits resulting from this simple and almost cost-free intervention, introduced in early 2018 by the SURG-Africa project.

Full text

G E R A L D D A L I T S O M W A P A S A
PHOTO BY RUBÉN BAGÜÉS ON UNSPLASH
Since the introduction of a remote consultation
network based on modern technologies,
surgicalcare in Malawi has improved markedly.
There is enough evidence of enormous benefits
resulting from this simple and almost cost-free
intervention, introduced in early 2018 by the
SURG-Africaproject.
G E R A L D I S T H E  C O U N T R Y C O O R D I N A T O R
A N D R E S E A R C H E R F O R T H E S U R G A F R I C A
P R O J E C T . H E H A S 8 Y E A R S E X P E R I E N C E I N
R U N N I N G S U R G I C A L C A P A C I T Y B U I L D I N G
P R O J E C T S I N M A L A W I A N D H A S W O R K E D I N
M E D I C A L R E S E A R C H , C O O R D I N A T I N G
P R O J E C T S A S W E L L A S M O N I T O R I N G
C L I N I C A L T R I A L S F O R 1 6 Y E A R S . 
S U R G - A F R I C A I S A 4 Y E A R
I M P L E M E N T A T I O N R E S E A R C H P R O J E C T T O
S C A L E U P S A F E A C C E S S I B L E S U R G E R Y
F O R D I S T R I C T A N D R U R A L P O P U L A T I O N S
I N T A N Z A N I A , M A L A W I A N D Z A M B I A .

In Malawi, with 80% of the population living in
villages and small towns, district hospitals are
the primary source of essential surgical care for
rural communities. Surgical services at district
level depend almost entirely on clinical officers,
non-physician clinicians trained to perform
basic surgical procedures along with clinical
services. Until recently clinical officers
practiced unsupervised and did not often have
timely access to surgical specialists for
consultations. This had negative effects on the
functionality of the surgical system and patient
outcomes. District hospital surgical teams used
to refer even simple cases, such as
uncomplicated hernias, when unable to seek
advice. This in turn caused unnecessary
congestion at central level as well as avoidable
risks for patients, due to late surgical
interventions. Unnecessary surgical referrals
increased costs for patients, as in Malawian
culture, family members and relatives follow
patients to provide support during their
journey through the healthcare system; and
care distant from home led to increased
expenses for families, impacting especially on
poorer rural households.
The referral system in Malawi also had several
flaws. Traditionally, patients were referred to
central hospitals without prior discussion with
the receiving surgical teams, carrying only a
referral form that usually missed basic
information about patient history,
investigations performed or reasons for
referral. No feedback was provided to district
surgical teams after after discharge from the
central hospitals, leaving them ignorant
regarding future patient management,
hindering optimal follow up of patients.
The Scaling up Surgery for Rural Population in
Africa (SURG-Africa) project works to improve
surgical care in Malawi, Tanzania and Zambia. This is
done through an innovative model of district level
supervision and mentoring to build capacity of
district hospitals in essential and life-saving surgery.
The capacity building is delivered by teams of
specialists (in surgery, obstetrics, anaesthesia and
nursing) from central hospitals visiting district
facilities on a two-monthly basis.
To fill the gap between visits and to support them
the project developed a clinical network based on
WhatsApp, which is widely used in Malawi and
almost free of charge. The application allows users
(in this case district hospital and central hopsital
clinicians) to share text messages as well as photos,
videos and audio clips in real time, all of which can be
essential to making clinical decisions.
The network was launched in the Southern Region in
March 2018 and is managed by the SURG-Africa
project coordinator. District medical officers from
the ten district hospitals have administrative rights
and control access to the WhatsApp network. Each
officer was requested to add clinicians involved in
surgery. To date, members include about 100
district clinicians and 15 specialists based at Queen
Elizabeth and Zomba central hospitals,
VO I C E S • T H R E E • S U R G E R Y • 1
PHOTO BY CHRISTIAN WIEDIGER ON UNSPLASH

The network facilitates consultations
between district clinicians and experts at
central level, provides education
opportunities and space to exchange the
latest medical knowledge, whilst helping to
streamline surgical referrals from the
district hospitals to central hospitals in
Blantyre and Zomba. The network is
progressively being integrated into
standard practice, particularly in the case
of referrals as it is now compulsory for
district clinicians to post details of each
case in text format, supported by images
where necessary, and wait for specialist
advice, unless urgency dictates immediate
referral, before referring a patient
onwards. At the least, a specialist must
provide their opinion on the clinical
management of the case, but other
clinicians participate as required. The
consultative process continues until a
decision is made on immediate, later orno
referral, with clear reasons for the
decision. After the case has been treated
centrally, feedback is provided to district
teams.
The network has so far been a big success.
During the 4-months April to July 2018, a
total of 95 surgical cases where consulted
on. Over a third of these were managed
locally following advice from the
specialists, avoiding unnecessary referral.
15% of cases received recommendation
for a later referral and 52% resulted in
immediate referral. Response rates were
excellent, with 78% of requests for advice
received a response within 1 hour, and in
68% of cases agreement on clinical
management and referral was reached
within an hour.
VO I C E S • T H R E E • S U R G E R Y •  2
Education is provided during consultation and
referral process.

VO I C E S • T H R E E • S U R G E R Y •  2
Instructions on cases and managing resources in the
district hospitals.

With the scarcity of surgeons and
anaesthetists in districts and rural areas,
the WhatsApp network has proved to be a
feasible way to provide rapid and free
specialist surgical opinion to rural
populations, when needed. Additionally,
advice on the network is usually provided
by more than one expert, as soon as the
message is seen, which is not common
even in normal clinical settings. Another
benefit is that the network allows the
sharing of images and enables specialists
to ask referring clinician more information
about the patient, a great advantage over
the traditional way of referring patient
through a paper-based referral form.
The open discussion of cases on the
network and sharing of feedback after
treatment provide continuing professional
development not only to the clinicians
directly involved but to all clinicians in the
forum. The advice provided on how to
manage a case pre-referral helps in
improving case management and also
streamlines management of referrals at
the central hospital as the patient does not
need to wait for other tests once they
arrive. As evident from the percentage of
referrals avoided or delayed, only
appropriate referrals now happen, with
significant cost savings implications for
patients, their families as well as the wider
health system.
Therefore, using WhatsApp groups can
improve access to safe surgery for remote
population, improve patient care, reduce
expenditure on surgery and is a medium to
teach health personnel on appropriate
management of patients.
VO I C E S • T H R E E • S U R G E R Y •  2
Feedback is provided as routine to district hospitals.