Cost-Effectiveness of Two Government District Hospitals in Sub-Saharan Africa.

BACKGROUND: District hospitals in sub-Saharan Africa are in need of investment if countries are going to progress towards universal health coverage, and meet the sustainable development goals and the Lancet Commission on Global Surgery time-bound targets for 2030. Previous studies have suggested that government hospitals are likely to be highly cost-effective and therefore worthy of investment. METHODS: A retrospective analysis of the inpatient logbooks for two government district hospitals in two sub-Saharan African hospitals was performed. Data were extracted and DALYs were calculated based on the diagnosis and procedures undertaken. Estimated costs were obtained based on the patient receiving ideal treatment for their condition rather than actual treatment received. RESULTS: Total cost per DALY averted was 26 (range 17-66) for Thyolo District Hospital in Malawi and 363 (range 187-881) for Bo District Hospital in Sierra Leone. CONCLUSION: This is the first published paper to support the hypothesis that government district hospitals are very cost-effective. The results are within the same range of the US$32.78-223 per DALY averted published for non-governmental hospitals.

Implementation of the WHO Surgical Safety Checklist in an Ethiopian Referral Hospital.

BACKGROUND: The WHO Surgical Safety Checklist has a growing evidence base to support its role in improving perioperative safety, although its impact is likely to be directly related to the effectiveness of its implementation. There remains a paucity of documented experience from low-resource settings on Checklist implementation approaches. We report an implementation strategy in a public referral hospital in Addis Ababa, Ethiopia, based on consultation, local leadership, formal introduction, and supported supervision with subsequent audit and feedback. METHODS: Planning, implementation and assessment took place from December 2011 to December 2012. The planning phase, from December 2011 until April 2012, involved a multidisciplinary consultative approach using local leaders, volunteer clinicians, and staff from non-governmental organisations, to draw up a locally agreed and appropriate Checklist. Implementation in April 2012 involved formal teaching and discussion, simulation sessions and role play, with supportive supervision following implementation. Assessment was performed using completed Checklist analysis and staff satisfaction questionnaires at one month and further Checklist analysis combined with semi-structured interviews in December 2012. RESULTS AND DISCUSSION: Checklist compliance rates were 83% for general anaesthetics at one month after implementation, with an overall compliance rate of 65% at eight months. There was a decrease in Checklist compliance over the period of the study to less than 20% by the end of the study period. The 'Sign out' section was reported as being the most difficult section of the Checklist to complete, and was missed completely in 21% of cases. The most commonly missed single item was the team introduction at the start of each case. However, we report high staff satisfaction with the Checklist and enthusiasm for its continued use. CONCLUSION: We report a detailed implementation strategy for introducing the WHO Surgical Safety Checklist to a low-resource setting. We show that this approach can lead to high completion rates and high staff satisfaction, albeit with a drop in completion rates over time. We argue that maximal benefit of the Surgical Safety Checklist is likely to be when it engenders a conversation around patient safety within a department, and when there is local ownership of this process.

Snapshot of surgical activity in rural Ethiopia: is enough being done?

BACKGROUND: Surgical conditions are responsible for a significant burden of the disease prevalence in sub-Saharan Africa. However, there is a paucity of data surrounding the amount and availability of surgical care. Few surveys exist that document current rates of surgical activity in the low-income setting, and most figures rely on the country estimates. We aim to document accurately the rates of surgery at the district level. METHODS: We performed a retrospective survey of surgical activity in 10 hospitals in the Southern Nation and Nationalities Peoples' Region of Ethiopia using a standardized data collection form. We also performed structured interviews with hospital directors. RESULTS: Surgical output varied across the hospitals from 56 to 421 operations per year per 100,000 catchment population. The most commonly performed operation was cesarean section (29% of major procedures). Emergency surgery accounted for 55% of operations, with the most frequent emergency operation being cesarean section. The overall cesarean section rate was alarmingly low at 0.6%. There are only 76 health workers that are providing a surgical service to this sample population of 12.9 million people. CONCLUSIONS: The rates of surgery found here were very low, consistent with the huge shortage of health workers providing a surgical service. The low cesarean section rate indicates that there is a large unmet surgical disease burden at the population level, and more comprehensive surveys are required to investigate this further. The most important steps to tackle the problem of deficiencies in global surgery are to increase access to surgical care and the surgical workforce capacity.

Transmural eosinophilic gastritis with gastric outlet obstruction: case report and review of the literature.

Eosinophil-associated gastrointestinal disorders (EGIDs) are uncommon conditions whose aetiologies are unclear, but which are characterised by eosinophilic infiltration and inflammation of the gastrointestinal tract in the absence of other causes of eosinophilia. We report the case of a 65-year-old woman with eosinophilic gastritis who underwent a Polya gastrectomy for a suspected gastric tumour with gastric outflow obstruction. Subsequent histological examination showed a non-malignant transmural eosinophilic infiltration of the stomach wall, a rare pathological entity. We present a review of the literature and discuss the management of such cases.