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

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.

Anesthesia Capacity of District-Level Hospitals in Malawi, Tanzania, and Zambia: A Mixed-Methods Study.

BACKGROUND: District-level hospitals (DLHs) are the main providers of surgical services for rural populations in Sub-Saharan Africa (SSA). Skilled teams are essential for surgical care, and gaps in anesthesia impact negatively on surgical capacity and outcomes. This study, from a baseline of a project scaling-up access to safe surgical and anesthesia care in Malawi, Tanzania, and Zambia, illustrates the deficit of anesthesia care in DLHs. METHODS: We undertook an in-depth investigation of anesthesia capacity in 76 DLHs across the 3 countries, July to November 2017, using a mixed-methods approach. The quantitative component assessed district-level anesthesia capacity using a standardized scoring system based on an adapted and extended Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) Index. The qualitative component involved semistructured interviews with providers from 33 DLHs, exploring how weaknesses in anesthesia impacted district surgical team practices and quality, volume, and scope of service provision. RESULTS: Anesthesia care at the district level in these countries is provided only by nonphysician anesthetists, some of whom have no formal training. Ketamine anesthesia is widely used in all hospitals, compensating for shortages of other forms of anesthesia. Pediatric size supplies/equipment were frequently missing. Anesthesia PIPES index scores in Malawi (M = 8.0), Zambia (M = 8.3), and Tanzania (M = 8.4) were similar (P = .59), but an analysis of individual PIPES components revealed important cross-country differences. Irregular availability of reliable equipment and supply is a particular priority in Malawi, where only 29% of facilities have uninterrupted access to electricity and 23% have constant access to water, among other challenges. Zambia is mostly affected by staffing shortages, with 30% of surveyed hospitals lacking an anesthesia provider. The challenge that stood out in Tanzania was nonavailability of functioning anesthesia machines among frequent shortages of staff and other equipment. CONCLUSIONS: Tanzania, Malawi, and Zambia are falling far short of ensuring universal access to safe and affordable surgical and anesthesia care for district and rural populations. Mixed-methods situation analyses, undertaken in collaboration with anesthesia specialists-measuring and understanding deficits in district hospital anesthetic staff, equipment, and supplies-are needed to address the critical neglect of anesthesia that is essential to providing surgical responses to the needs of rural populations in SSA.

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

Introduction: Paediatric 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). Methods: Data 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. Results: Similar 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. Conclusions: With 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.

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.

Economic Costs of Providing District- and Regional-Level Surgeries in Tanzania.

BACKGROUND: Access to surgical care is poor in Tanzania. The country is at the implementation stage of its first National Surgical, Obstetric, and Anesthesia Plan (NSOAP; 2018-2025) aiming to scale up surgery. This study aimed to calculate the costs of providing surgical care at the district and regional hospitals. METHODS: Two district hospitals (DHs) and the regional referral hospital (RH) in Arusha region were selected. All the staff, buildings, equipment, and medical and non-medical supplies deployed in running the hospitals over a 12 month period were identified and quantified from interviews and hospital records. Using a combination of step-down costing (SDC) and activity-based costing (ABC), all costs attributed to surgeries were established and then distributed over the individual types of surgeries. These costs were delineated into pre-operative, intra-operative, and post-operative components. RESULTS: The total annual costs of running the clinical cost centres ranged from $567k at Oltrumet DH to $3453k at Mt Meru RH. The total costs of surgeries ranged from $79k to $813k; amounting to 12%-22% of the total costs of running the hospitals. At least 70% of the costs were salaries. Unit costs and relative shares of capital costs were generally higher at the DHs. Two-thirds of all the procedures incurred at least 60% of their costs in the theatre. Open reduction and internal fixation (ORIF) performed at the regional hospital was cheaper ($618) than surgical debridement (plus conservative treatment) due to prolonged post-operative inpatient care associated with the latter ($1177), but was performed infrequently due mostly to unavailability of implants. CONCLUSION: Lower unit costs and shares of capital costs at the RH reflect an advantage of economies of scale and scope at the RH, and a possible underutilization of capacity at the DHs. Greater efficiencies make a case for concentration and scale-up of surgical services at the RHs, but there is a stronger case for scaling up district-level surgeries, not only for equitable access to services, but also to drive down unit costs there, and free up RH resources for more complex cases such as ORIF.

Is lack of health insurance a predictor of worsening of heart failure among adult patients attending referral hospitals in Northwestern Tanzania?

INTRODUCTION: Health insurance coverage is critical for persons living with chronic conditions such as heart failure. Lack of health insurance may affect the ability to access regular healthcare appointments, pay for medication refills which can result in frequent hospitalization that is associated with poor clinical outcomes. In scarce resource locations such as sub-Saharan Africa, where uptake of health insurance is still suboptimal, the effect of health insurance on chronic conditions such as heart failure is poorly understood. The objective of this study was to assess the association of health insurance on the severity of heart failure for patients attending outpatient clinics at tertiary hospitals in Mwanza, Tanzania. METHODS: As part of a larger cohort study, patients with heart failure were recruited from Bugando Medical Center (BMC) and Sekou Toure Regional Hospital (STRH) in Mwanza City, Tanzania. Heart failure was based on Framingham criteria and the severity was determined by New York Heart Association (NYHA) classification. Descriptive analysis and multivariable logistic regression were used to describe the study participants and to assess the association between health insurance status and the severity of heart failure at baseline. RESULTS: 418 patients were enrolled, and majority were female (n = 264, 63%), small scale farmers (n = 278, 66.5%) and were from Mwanza City (n = 299, 71.5%). More than two-thirds of patients did not have health insurance (n = 295, 70.6%) and the majority were in the NYHA I and II classification (n = 267, 64.7%). There was no association between health insurance status and the severity of heart (aOR 0.97; 95% CI 0.84-1.60). Being male, small-scale businessperson and those seen at STRH was associated with higher odds of being in NYHA Class III/IV (aOR = 1.97; 95% CI: 1.21-3.17), (aOR = 2.61; 95% CI: 1.27-5.34) and (aOR 1.91 95% CI: 1.17-3.13) respectively. Having secondary and college education was associated with lower odds of being in Class III/IV (0.42; 95% CI: 0.18-0.98) and (aOR = 0.23 95% CI: 0.06-0.86) respectively. CONCLUSION: In this study, only a third of the patients had health insurance. Health insurance was not associated with the severity of heart failure. Since heart failure is a chronic condition patients who do not have health insurance may incur out of pocket expenses, future research should focus on the effect of out-of-pocket expenditures on clinical outcomes.

Surgical capacity, productivity and efficiency at the district level in Sub-Saharan Africa: A three-country study.

INTRODUCTION: Efficient utilisation of surgical resources is essential when providing surgical care in low-resources settings. Countries are developing plans to scale up surgery, though insufficiently based on empirical evidence. This paper investigates the determinants of hospital efficiency in district hospitals in three African countries. METHODS: Three-month data, comprising surgical capacity indicators and volumes of major surgical procedures collected from 61 district-level hospitals in Malawi, Tanzania, and Zambia, were analysed. Data envelopment analysis was used to calculate average hospital efficiency scores (max. = 1) for each country. Quantile regression analysis was selected to estimate the relationship between surgical volume and production factors. Two-stage bootstrap regression analysis was used to estimate the determinants of hospital efficiency. RESULTS: Average hospital efficiency scores were 0.77 in Tanzania, 0.70 in Malawi and 0.41 in Zambia. Hospitals with high efficiency scores had significantly more surgical staff compared with low efficiency hospitals (DEA score<1). Hospitals that scored high on the most commonly utilised surgical capacity index were not the ones with high surgical volumes or high efficiency. The number of surgical team members, which was lowest in Zambia, was strongly, positively correlated with surgical productivity and efficiency. CONCLUSION: Hospital efficiency, combining capacity measures and surgical outputs, is a better indicator of surgical performance than capacity measures, which could be misleading if used alone for surgical planning. Investment in the surgical workforce, in particular, is critical to improving district hospital surgical productivity and efficiency.

Using Group Model Building to Capture the Complex Dynamics of Scaling Up District-Level Surgery in Arusha Region, Tanzania.

BACKGROUND: Scaling up surgery at district hospitals (DHs) is the critical challenge if the Tanzanian national Surgical, Obstetric, and Anesthesia Plan (NSOAP) objectives are to be achieved. Our study aims to address this challenge by taking a dynamic view of surgical scale-up at the district level using a participatory research approach. METHODS: A group model building (GMB) workshop was held with 18 professionals from three hospitals in the Arusha region. They built a graphical representation of the local system of surgical services delivery through a facilitated discussion that employed the nominal group technique. This resulted in a causal loop diagram (CLD) from which the participants identified the requirements for scaling-up surgery and the stakeholders who could satisfy these. After the GMB sessions, we identified clusters of related variables using inductive thematic analysis and the main feedback loops driving the model. RESULTS: The CLD consists of 57 variables. These include the 48 variables that were obtained through the nominal group technique and those that participants added later. We identified 6 themes: patient benefits, financing of surgery, cost sharing, staff motivation, communication, and effects on referral hospital. There are 5 self-reinforcing feedback loops: training, learning, meeting demand, revenues, and willingness to work in a good hospital. There are four self-correcting feedback loops or 'resistors to change:' recurrent costs, income lost, staff stress, and brain drain. CONCLUSION: This study provides a systems view on the scaling up of surgery from a district level perspective. Its results enable a critical appraisal of the feasibility of implementing the NSOAP. Our results suggest that policy-makers should be wary of 'quick fixes' that have short term gains only. Long term policy that considers the complex dynamics of surgical systems and that allows for periodic evaluation and adaption is needed to scale up surgery in a sustainable manner.

Surgical service monitoring and quality control systems at district hospitals in Malawi, Tanzania and Zambia: a mixed-methods study.

BACKGROUND: In low-income and middle-income countries, an estimated one in three clinical adverse events happens in non-complex situations and 83% are preventable. Poor quality of care also leads to inefficient use of human, material and financial resources for health. Improving outcomes and mitigating the risk of adverse events require effective monitoring and quality control systems. AIM: To assess the state of surgical monitoring and quality control systems at district hospitals (DHs) in Malawi, Tanzania and Zambia. METHODS: A mixed-methods cross-sectional study of 75 DHs: Malawi (22), Tanzania (30) and Zambia (23). This included a questionnaire, interviews and visual inspection of operating theatre (OT) registers. Data were collected on monitoring and quality systems for surgical activity, processes and outcomes, as well as perceived barriers. RESULTS: 53% (n=40/75) of DHs use more than one OT register to record surgical operations. With the exception of standardised printed OT registers in Zambia, the register format (often handwritten books) and type of data collected varied between DHs. Monthly reports were seldom analysed by surgical teams. Less than 30% of all surveyed DHs used surgical safety checklists (n=22/75), and <15% (n=11/75) performed surgical audits. 73% (n=22/30) of DHs in Tanzania and less than half of DHs in Malawi (n=11/22) and Zambia (n=10/23) conducted surgical case reviews. Reports of surgical morbidity and mortality were compiled in 65% (n=15/23) of Zambian DHs, and in less than one-third of DHs in Tanzania (n=9/30) and Malawi (n=4/22). Reported barriers to monitoring and quality systems included an absence of formalised guidelines, continuous training opportunities as well as inadequate accountability mechanisms. CONCLUSIONS: Surgical monitoring and quality control systems were not standard among sampled DHs. Improvements are needed in standardisation of quality measures used; and in ensuring data completeness, analysis and utilisation for improving patient outcomes.

Evaluation of a surgical supervision model in three African countries-protocol for a prospective mixed-methods controlled pilot trial.

BACKGROUND: District-level hospitals (DLHs) can play an important role in the delivery of essential surgical services for rural populations in sub-Saharan Africa if adequately prepared and supported. This article describes the protocol for the evaluation of the Scaling up Safe Surgery for District and Rural Populations in Africa (SURG-Africa) project which aims to strengthen the capacity in district-level hospitals (DLHs) in Malawi, Tanzania and Zambia to deliver safe, quality surgery. The intervention comprises a programme of quarterly supervisory visits to surgically active district-level hospitals by specialists from referral hospitals and the establishment of a mobile phone-based consultation network. The overall objective is to test and refine the model with a view to scaling up to national level. METHODS: This mixed-methods controlled pilot trial will test the feasibility of the proposed supervision model in making quality-assured surgery available at DLHs. Firstly, the study will conduct a quantitative assessment of surgical service delivery at district facilities, looking at hospital preparedness, capacity and productivity, and how these are affected by the intervention. Secondly, the study will monitor changes in referral patterns from DLHs to a higher level of care as a result of the intervention. Data on utilisation of the mobile based-support network will also be collected. The analysis will compare changes over time and between intervention and control hospitals. The third element of the study will involve a qualitative assessment to obtain a better understanding of the functionality of DLH surgical systems and how these have been influenced by the intervention. It will also provide further information on feasibility, impact and sustainability of the supervision model. DISCUSSION: We seek to test a model of district-level capacity building through regular supervision by specialists and mobile phone technology-supported consultations to make safe surgical services more accessible, equitable and sustainable for rural populations in the target countries. The results of this study will provide robust evidence to inform and guide local actors in the national scale-up of the supervision model. Lessons learned will be transferred to the wider region.

Prevalence,awareness and factors associated with hypertension in North West Tanzania.

BACKGROUND: Hypertension is a public health problem, and yet few people are aware of it and even fewer access effective treatment. With the ongoing demographic transition in many parts of Sub-Saharan Africa, people are changing from rural, manual work to urban lifestyles, hence the risk of hypertension increases. OBJECTIVE: This study aimed at determining the prevalence, awareness and risk factors associated with hypertension in North West Tanzania. DESIGN: A community-based cross-sectional study was conducted among adults in Magu District in 2013. Information on socio-demographic, economic and lifestyle characteristics, medical conditions, and risk factors for hypertension were collected according to the WHO Steps survey tool. Measurements of blood pressure, blood sugar, pulse rate, and anthropometry were taken. Multivariate logistic regression was used to estimate the odds ratios (OR) and 95% confidence intervals (95% CI) for factors associated with hypertension (Blood pressure ≥140/90mm/Hg). Frequencies and percentages were used to determine the awareness, and treatment among hypertensive participants. RESULTS: Among 9678 participants, the prevalence of hypertension was 8.0% and pre-hypertension 36.2%. There was a higher prevalence of hypertension at older ages, among females (8.2%) compared to males (7.7%), and among urban dwellers (10.1%) compared to rural residents (6.8%). Overweight, obese, and diabetic individuals had a higher risk of hypertension while HIV positive participants had a lower risk of hypertension (OR = 0.56; 95% CI 0.39 - 0.79). Among participants with hypertension, awareness was less than 10%. CONCLUSION: By integrating blood pressure screening into our long-standing community HIV screening program, we were able to identify many previously undiagnosed cases of hypertension and pre-hypertension. Age, residence, overweight and obesity were the major associated factors for hypertension. Awareness and treatment rates are very low indicating the need for programs to improve awareness, and treatment of hypertension.

The feasibility and acceptability of screening for hypertension in private drug retail outlets: a pilot study in Mwanza region, Tanzania.

BACKGROUND: Hypertension is a major contributor to ill health in sub-Saharan Africa. Developing countries need to increase access for screening. This study assesses the feasibility and acceptability of using private sector drug retail outlets to screen for hypertension in Mwanza region, Tanzania. METHODS: A pilot study took place in eight drug retail outlets from August 2013 to February 2014. Customers ≥18 years were invited for screening. Socio-demographic characteristics, hypertension knowledge, hypertension screening and treatment history were collected. Subjects with systolic blood pressure over 140 mmHg were referred for follow up. Referral slips captured attendance. Mystery client visits and follow up phone calls were conducted to assess service quality. RESULTS: A total of 971 customers were screened, one person refused; 109 (11.2%) had blood pressure over 140/90 mmHg and were referred for ongoing assessment; 85/109 (78.0%) were newly diagnosed. Customers reported that the service was acceptable. Service providers were able to follow the protocol. Only 18/85 (21%) newly diagnosed participants visited the referral clinic within two weeks. CONCLUSIONS: Blood pressure screening was feasible and acceptable to customers of private drug retail outlets. However many who were referred failed to attend at a referral centre and further research is needed in this area.

Risk factors for placental malaria and associated adverse pregnancy outcomes in Rufiji, Tanzania: a hospital based cross sectional study.

BACKGROUND: Prevention and treatment of malaria during pregnancy is crucial for reduction of malaria in pregnancy and its adverse outcomes. The spread of parasite resistance to Sulphadoxine-Pyrimethamine (SP) used for Intermittent Preventive Treatment for malaria in pregnancy (IPTp), particularly in East Africa has raised concerns about the usefulness and the reliability of the IPTp regimen. We aimed to assess the effectiveness of two doses of SP in treating and preventing occurrence of adverse pregnancy outcomes. METHODOLOGY: The study was an analytical cross sectional study which enrolled 350 pregnant women from Kibiti Health Centre, South Eastern Tanzania. Structured questionnaires were used to obtain previous obstetrics and medical history of participants and verified by reviewing antenatal clinic cards. Maternal placental blood samples for microscopic examination of malaria parasites were collected after delivery. Data was analyzed for associations between SP dosage, risk for PM and pregnancy outcome. Sample size was estimated based on precision. RESULTS: Prevalence of placental maternal (PM) was 8% among pregnant women (95%CI, 4.4-13.1%). Factors associated with increased risk of PM were primigravidity (P<0.001) and history of fever during pregnancy (P= 0.02). Use of at least 2 doses of SP for IPTp during pregnancy was insignificantly associated with reducing the risk PM (P=0.08), low birth weight (P=0.73) and maternal anemia (P=0.71) but associated significantly with reducing the risk of preterm birth (P<0.001). CONCLUSION: Two doses of SP for IPTp regime are ineffective in preventing and treating PM and adverse pregnancy outcome. Hence a review to the current IPTp regimen should be considered with possibility of integrating it with other malaria control strategies.