Using participatory action research to empower district hospital staff to deliver quality-assured essential surgery to rural populations in Malawi, Zambia and Tanzania

Background: In 2017 the SURG-Africa project set out to institute a surgical, obstetric, trauma and anesthesia (SOTA) care capacity-building intervention focused on non-specialist providers at district hospitals in Zambia, Malawi and Tanzania. The aim was to scale up quality-assured SOTA care for rural populations. This paper reports the process of developing the intervention and our experience of initial implementation, using a participatory approach. Methods: Participatory Action Research workshops were held in the 3 countries in July–October 2017 and in October 2018–July 2019, involving representatives of key local stakeholder groups: district hospital (DH) surgical teams and administrators, referral hospital SOTA specialists, professional associations and local authorities. Through semi-structured discussions, qualitative data were collected on participants’ perceptions and experiences of barriers to the provision of SOTA care at district level, and on the training and supervision needs of district surgical teams. Data were compared for themes across countries and across surgical team cadres. Results: All groups reported a lack of in-service training to develop essential skills to manage common SOTA cases; use and care of equipment; essential anesthesia care including resuscitation skills; and infection prevention and control. Very few district surgical teams had access to supervision. SOTA providers at DHs reported a demand for more feedback on referrals. Participants prioritized training needs that could be addressed through regular in-service training and supervision visits from referral hospital specialists to DHs. These data were used by participants in an action-planning cycle to develop site-specific training plans for each research site. Conclusion: The inclusive, participatory approach to stakeholder involvement in SOTA system strengthening employed by this study supported the design of a locally relevant and contextualized intervention. This study provides lessons on how to rebalance power dynamics in Global Surgery, through giving a voice to district surgical teams

Critical shortage of capacity to deliver safe paediatric surgery in sub-Saharan Africa: evidence from 67 hospitals in Malawi, Zambia, and Tanzania

IntroductionPaediatric surgical care is a significant challenge in Sub-Saharan Africa (SSA), where 42% of the population are children. Building paediatric surgical capacity to meet SSA country needs is a priority. This study aimed to assess district hospital paediatric surgical capacity in three countries: Malawi, Tanzania and Zambia (MTZ).MethodsData from 67 district-level hospitals in MTZ were collected using a PediPIPES survey tool. Its five components are procedures, personnel, infrastructure, equipment, and supplies. A PediPIPES Index was calculated for each country, and a two-tailed analysis of variance test was used to explore cross-country comparisons.ResultsSimilar paediatric surgical capacity index scores and shortages were observed across countries, greater in Malawi and less in Tanzania. Almost all hospitals reported the capacity to perform common minor surgical procedures and less complex resuscitation interventions. Capacity to undertake common abdominal, orthopaedic and urogenital procedures varied—more often reported in Malawi and less often in Tanzania. There were no paediatric or general surgeons or anaesthesiologists at district hospitals. General medical officers with some training to do surgery on children were present (more often in Zambia). Paediatric surgical equipment and supplies were poor in all three countries. Malawi district hospitals had the poorest supply of electricity and water.ConclusionsWith no specialists in district hospitals in MTZ, access to safe paediatric surgery is compromised, aggravated by shortages of infrastructure, equipment and supplies. Significant investments are required to address these shortfalls. SSA countries need to define what procedures are appropriate to national, referral and district hospital levels and ensure that an appropriate paediatric surgical workforce is in place at district hospitals, trained and supervised to undertake these essential surgical procedures so as to meet population needs

The status of pediatric surgery in Malawi: a narrative mini-review

IntroductionPediatric surgery is essential to a well-functioning health system. Unmet surgical needs contribute to 6.7% of pediatric deaths in Malawi. Understanding the current state of pediatric surgical care in Malawi is necessary to recognize gaps and opportunities in service delivery and to develop evidence-based national planning and solutions.MethodsThis narrative mini review synthesized the literature on the state of pediatric surgery in Malawi through the pillars of the World Health Organization's Health System Building Blocks. A search of PubMed, Embase, and Scopus databases was executed to identify relevant studies and a thematic analysis was performed. Further, to ensure contextual accuracy, pediatric surgeons from Malawi were consulted and involved in this review.ResultsTwenty-six papers were identified. In Malawi's central hospitals, there are six specialist pediatric surgeons for a pediatric population of more than 8 million. There is limited pediatric surgical capacity at the district hospitals. There is little to no written evidence of the national governing and finance structures in place for pediatric surgical services.DiscussionIn countries like Malawi, where a significant portion of the population comprises children, it is crucial to recognize that pediatric services are currently inadequate and fall short of the required standards. It is crucial to prioritize the enhancement of services specifically designed for this age group. This review aims to shed light on the existing gaps within pediatric surgical services in Malawi, providing valuable insights that can inform the development of comprehensive national surgical planning strategies

Using participatory action research to empower district hospital staff to deliver quality-assured essential surgery to rural populations in Malawi, Zambia, and Tanzania

BackgroundIn 2017 the SURG-Africa project set out to institute a surgical, obstetric, trauma and anesthesia (SOTA) care capacity-building intervention focused on non-specialist providers at district hospitals in Zambia, Malawi and Tanzania. The aim was to scale up quality-assured SOTA care for rural populations. This paper reports the process of developing the intervention and our experience of initial implementation, using a participatory approach.MethodsParticipatory Action Research workshops were held in the 3 countries in July–October 2017 and in October 2018–July 2019, involving representatives of key local stakeholder groups: district hospital (DH) surgical teams and administrators, referral hospital SOTA specialists, professional associations and local authorities. Through semi-structured discussions, qualitative data were collected on participants’ perceptions and experiences of barriers to the provision of SOTA care at district level, and on the training and supervision needs of district surgical teams. Data were compared for themes across countries and across surgical team cadres.ResultsAll groups reported a lack of in-service training to develop essential skills to manage common SOTA cases; use and care of equipment; essential anesthesia care including resuscitation skills; and infection prevention and control. Very few district surgical teams had access to supervision. SOTA providers at DHs reported a demand for more feedback on referrals. Participants prioritized training needs that could be addressed through regular in-service training and supervision visits from referral hospital specialists to DHs. These data were used by participants in an action-planning cycle to develop site-specific training plans for each research site.ConclusionThe inclusive, participatory approach to stakeholder involvement in SOTA system strengthening employed by this study supported the design of a locally relevant and contextualized intervention. This study provides lessons on how to rebalance power dynamics in Global Surgery, through giving a voice to district surgical teams

Breast and cervical cancer screening services in Malawi: a systematic review

Background: To identify and to assess factors enhancing or hindering the delivery of breast and cervical cancer screening services in Malawi with regard to accessibility, uptake, acceptability and effectiveness. Methods: Systematic review of published scientific evidence. A search of six bibliographic databases and grey literature was executed to identify relevant studies conducted in Malawi in the English language, with no time or study design restrictions. Data extraction was conducted in Excel and evidence synthesis followed a thematic analysis approach to identify and compare emerging themes. Results: One hundred and one unique records were retrieved and 6 studies were selected for final inclusion in the review. Multiple factors affect breast and cervical cancer service delivery in Malawi, operating at three interlinked levels. At the patient level, lack of knowledge and awareness of the disease, location, poor screening environment and perceived quality of care may act as deterrent to participation in screening; at the health facility level, services are affected by the availability of resources and delivery modalities; and at the healthcare system level, inadequate funding and staffing (distribution, supervision, retention), and lack of appropriate monitoring and guidelines may have a negative impact on services. Convenience of screening, in terms of accessibility (location, opening times) and integration with other health services (e.g. reproductive or HIV services), was found to have a positive effect on service uptake. Building awareness of cancer and related services, and offering quality screening (dedicated room, privacy, staff professionalism etc.) are significant determinants of patient satisfaction. Conclusions: Capitalising on these lessons is essential to strengthen breast and cervical cancer service delivery in Malawi, to increase early detection and to improve survival of women affected by the disease.</p

Surgical informed consent practices and influencing factors in sub-Saharan Africa: a scoping review of the literature

Introduction: Current international standards in consent to surgery practices are usually derived from health systems in Western countries, while little attention has been given to other contexts such as sub-Saharan Africa (SSA), despite this region facing the highest burdens of disease amenable to surgery globally. The aim of this study was to examine how the concept of informed consent for surgery is interpreted and applied in the context of SSA, and factors affecting current practices. Methods: A systematic search of Medline, Embase and African Journal OnLine databases as well as grey sources was executed in May 2023 to retrieve relevant literature published since 2010 in English language against a set of given criteria. The socioecological framework for health was used for organising and summarising the identified evidence. Results: A total of 27 papers were included in the review. Findings revealed that consent to surgery practices is generally substandard across SSA and the process is not adequate. Patients' understanding of informed consent is limited, likewise awareness of their rights to decision-making. A range of factors at the individual, interpersonal, institutional and system/societal levels affect the informed consent process. Conclusion: There is a need to find more culturally acceptable and ethical ways to include the participation of patients in the decision-making process for surgical treatment in the SSA and define standards more closely aligned with the local context.</p

Improving Access to Surgery Through Surgical Team Mentoring – Policy Lessons From Group Model Building With Local Stakeholders in Malawi

Background There is much scope to empower district hospital (DH) surgical teams in low- and middle- income countries to undertake a wider range and a larger number of surgical procedures so as to make surgery more accessible to rural populations and decrease the number of unnecessary referrals to central hospitals (CHs). For surgical team mentoring in the form of field visits to be undertaken as a routine activity, it needs to be embedded in the local context. This paper explores the complex dimensions of implementing surgical team mentoring in Malawi by identifying stakeholder-sourced scenarios that fit with, among others, national policy and regulations, incentives to perform surgery, career opportunities, competing priorities, alternatives for performing surgery locally and the proximity and role of referral hospitals.Methods A mixed methods approach was used which combined stakeholder input – obtained through two group model building (GMB) workshops and further consultations with local stakeholders and SURG-Africa project staff – and dynamic modeling to explore policy options for sustaining and rolling out surgical team mentoring. Sensitivity analyses were also performed.Results Each of the two GMB workshops resulted in a causal loop diagram (CLD) with an array of factors and feedback loops describing the complexity of surgical team mentoring. Six implementation scenarios were defined to perform such mentoring. For each the resource requirements were identified for the institutions involved – notably DHs, CHs and the party that would finance the required mentoring trips – along with the potential for scaling up surgery at DHs under severe financial constraints. Conclusion To sustain surgical mentoring, it is important that an approach of continued communication, monitoring, and (re-)evaluation is taken. In addition, an output- or performance-based financing scheme for DHs is required to incentivize them to scale up surgery

Supervision as a tool for building surgical capacity of district hospitals: the case of Zambia

Introduction: Many countries in sub-Saharan Africa have adopted task shifting of surgical responsibilities to non-physician clinicians (NPCs) as a solution to address workforce shortages. There is resistance to delegating surgical procedures to NPCs due to concerns about their surgical skills and lack of supervision systems to ensure safety and quality of care provided. This study aimed to explore the effects of a new supervision model implemented in Zambia to improve the delivery of health services by surgical NPCs working at district hospitals. Methods: Twenty-eight semi-structured interviews were conducted with NPCs and medical doctors at nine district hospitals and with the surgical specialists who provided in-person and remote supervision over an average period of 15 months. Data were analysed using 'top-down' and 'bottom-up' thematic coding. Results: Interviewees reported an improvement in the surgical skills and confidence of NPCs, as well as better teamwork. At the facility level, supervision led to an increase in the volume and range of surgical procedures done and helped to reduce unnecessary surgical referrals. The supervision also improved communication links by facilitating the establishment of a remote consultation network, which enabled specialists to provide real-time support to district NPCs in how to undertake particular surgical procedures and expert guidance on referral decisions. Despite these benefits, shortages of operating theatre support staff, lack of equipment and unreliable power supply impeded maximum utilisation of supervision. Conclusion: This supervision model demonstrated the additional role that specialist surgeons can play, bringing their expertise to rural populations, where such surgical competence would otherwise be unobtainable. Further research is needed to establish the cost-effectiveness of the supervision model; the opportunity costs from surgical specialists being away from referral hospitals, providing supervision in districts; and the steps needed for regular district surgical supervision to become part of sustainable national programmes.</p