Free health care for under 5 year olds increases access to surgical care in Sierra Leone: an analysis of case load and patient characteristics.

BACKGROUND: In April 2010 Sierra Leone launched a nationwide program that provides free health care to all pregnant and lactating women and children under 5 years old. This study evaluates the effect that the free health-care program had on pediatric surgical activities of Connaught Hospital. METHODS: The study period was defined as the 20 months before and after April 27, 2010, the start date of the free health-care program. Data on age, gender, diagnosis, and procedure for patients under 5 years of age and the total number of operations were collected from the Connaught Hospital operating room logbook. RESULTS: The number of operations on children under 5 increased by 500 %, from 42 to 210 cases. This increase was significantly larger than the 17 % increase of 1,393-1,630 seen with operations for patients 5 years and older (p < 0.01). CONCLUSION: The decision by the Sierra Leone President to institute a program of free health care for children under 5 has resulted in an increased number of pediatric surgical cases at Connaught Hospital. Efforts should be undertaken to provide additional supplies and equipment and to develop training programs for surgeons and support staff to care for the children in need of surgical care.

Reductions in inpatient mortality following interventions to improve emergency hospital care in Freetown, Sierra Leone.

BACKGROUND: The demand for high quality hospital care for children in low resource countries is not being met. This paper describes a number of strategies to improve emergency care at a children's hospital and evaluates the impact of these on inpatient mortality. In addition, the cost-effectiveness of improving emergency care is estimated. METHODS AND FINDINGS: A team of local and international staff developed a plan to improve emergency care for children arriving at The Ola During Children's Hospital, Freetown, Sierra Leone. Following focus group discussions, five priority areas were identified to improve emergency care; staff training, hospital layout, staff allocation, medical equipment, and medical record keeping. A team of international volunteers worked with local staff for six months to design and implement improvements in these five priority areas. The improvements were evaluated collectively rather than individually. Before the intervention, the inpatient mortality rate was 12.4%. After the intervention this improved to 5.9%. The relative risk of dying was 47% (95% CI 0.369-0.607) lower after the intervention. The estimated number of lives saved in the first two months after the intervention was 103. The total cost of the intervention was USD 29 714, the estimated cost per death averted was USD 148. There are two main limitation of the study. Firstly, the brevity of the study and secondly, the assumed homogeneity of the clinical cases that presented to the hospital before and after the intervention. CONCLUSIONS: This study demonstarted a signficant reductuion in inpatient mortality rate after an intervention to improve emergency hospital care If the findings of this paper could be reproduced in a larger more rigorous study, improving the quality of care in hospitals would be a very cost effective strategy to save children's lives in low resource settings.

Assessment of pediatric surgery capacity at government hospitals in Sierra Leone.

BACKGROUND: Traditionally, efforts to reduce child mortality in low- and middle-income countries (LMICs) have focused on infectious diseases. However, surgical care is increasingly seen as an important component of primary health care. To understand the baseline surgical capacity in LMICs, a number of studies have recently been published, but none has focused on pediatric surgery. METHODS: The Surgeons OverSeas (SOS) Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) survey was used to collect surgical capacity data from government hospitals in Sierra Leone. The data were analyzed specifically to identify baseline needs for pediatric surgery. RESULTS: Nine hospitals were assessed, and all had a functioning laboratory to test blood and urine and were capable of undertaking resuscitation, suturing, wound débridement, incision and drainage of an abscess, appendectomy, and male circumcision. However, in only 67 % could a pediatric hernia repair be performed, and in none were more complex procedures such as cleft lip and clubfoot repairs performed. Fewer than 50 % of facilities had sufficient gloves, nasogastric tubes, intravenous cannulas, syringes, needles, sutures, urinary catheters, infusion sets, anesthesia machines, or compressed oxygen. CONCLUSIONS: Using the standard PIPES tool, we found severe deficiencies in the pediatric surgical capacity at government hospitals in Sierra Leone. However, a pediatric-specific tool is required to understand more accurately the pediatric surgical situation.

Teaching emergency and essential surgical care in Sierra Leone: a model for low income countries.

BACKGROUND: Surgeons OverSeas (SOS), a New York-based organization with a mission to save lives in developing countries, conducted a surgical needs assessment in Sierra Leone in 2008 which identified a large gap in surgical knowledge. We hypothesized that knowledge transfer could be improved by conducting workshops with significant local faculty participation. DESIGN: Description of emergency and essential surgical care workshops (EESC) workshops and follow-up. SETTING: Freetown and Bo, Sierra Leone. PARTICIPANTS: International and local health providers in Sierra Leone. METHODS: SOS organized EESC workshops in collaboration with significant local surgeons' support. Data on subsequent workshops were recorded. RESULTS: Fifteen instructors were identified and assisted with teaching. Nine of the instructors were specialists from Sierra Leone. Each workshop lasted 3 days. Feedback was gathered after these workshops Subsequent to the SOS workshops, 8 other workshops were undertaken by local surgeons in Sierra Leone, 5 of which were organized and taught solely by local surgeons working for the Sierra Leone Ministry of Health and Sanitation. Three other workshops were organized with external support. CONCLUSIONS: EESC workshops organized with significant local input are useful for knowledge transfer and empower local surgeons to conduct subsequent workshops on their own.

Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care.

HYPOTHESIS: 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. SETTING: Site visits were performed in 2008 at 10 of the 17 government civilian hospitals in Sierra Leone. MAIN OUTCOME MEASURES: The World Health Organization's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was used to assess surgical capacity. RESULTS: 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. CONCLUSION: 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.