Healthcare Leaders Develop Strategies for Expanding National Surgical, Obstetric, and Anaesthesia Plans in WHO AFRO and EMRO Regions.

BACKGROUND: Worldwide, five billion people lack access to safe, affordable surgical, obstetric, and anaesthesia (SOA) care when needed. In many countries, a growing commitment to SOA care is culminating in the development of national surgical, obstetric, and anaesthesia plans (NSOAPs) that are fully embedded in the National Health Strategic Plan. This manuscript highlights the content and outputs from a World Health Organization (WHO) lead workshop that supported country-led plans for improving SOA care as a component of health system strengthening. METHODS: In March 2018, a group of 79 high-level global SOA stakeholders from 25 countries in the WHO AFRO and EMRO regions gathered in Dubai to provide technical and strategic guidance for the creation and expansion of NSOAPs. RESULTS: Drawing on the experience and expertise of represented countries that are at different stages of the NSOAP process, topics covered included (1) the global burden of surgical, obstetric, and anaesthetic conditions; (2) the key principles and components of NSOAP development; (3) the critical evaluation and feasibility of different models of NSOAP implementation; and (4) innovative financing mechanisms to fund NSOAPs. CONCLUSIONS: Lessons learned include: (1) there is unmet need for the establishment of an NSOAP community in order to provide technical support, expertise, and mentorship at a regional level; (2) data should be used to inform future priorities, for monitoring and evaluation and to showcase advances in care following NSOAP implementation; and (3) SOA health system strengthening must be uniquely prioritized and not hidden within other health strategies.

The cost of providing and scaling up surgery: a comparison of a district hospital and a referral hospital in Zambia.

The lack of access to quality-assured surgery in rural parts of sub-Saharan Africa, where the numbers of trained health workers are often insufficient, presents challenges for national governments. The case for investing in scaling up surgical systems in low-resource settings is 3-fold: the potential beneficial impact on a large proportion of the global burden of disease; better access for rural populations who have the greatest unmet need; and the economic case. The economic losses from untreated surgical conditions far exceed any expenditure that would be required to scale up surgical care. We identified the resources used in delivering surgery at a rural district-level hospital and an urban based referral hospital in Zambia and calculated their cost through a combination of bottom-up costing and step-down accounting. Surgery performed at the referral hospital is ∼50% more expensive compared with the district hospital, mostly because of the higher cost of hospital stay. The low bed occupancy rates at the two hospitals suggest underutilization of the capacity, and/or missing elements of needed capacity, to conduct surgery. Nevertheless, our study confirms that scaling up district-level surgery makes sense, through bringing economies of scale, while acknowledging the need for more comprehensive assessments and costing of capacity constraints. We quantified the economies of scale under different scaling scenarios. If surgery at the district hospital was scaled up by 10, 20 or 50%, the total cost of surgery would increase proportionately less than that, i.e. by 6, 12 and 30%, respectively. If this were to lead to less demand for surgery at the referral hospital, say 10% less surgery, it would result in a reduction of 2.7% in the total cost. Although the health system as a whole would benefit, the referring hospitals would not derive the full economic benefit, unless Government increased resources for district-level surgery.

Evaluation of trauma and critical care training courses on the knowledge and confidence of participants in Kenya and Zambia.

BACKGROUND: Trained health-care personnel are essential for improved outcomes for injured and critically ill patients. The highest injury-related mortality is seen in sub-Saharan Africa, where there is a paucity of skilled personnel. Therefore, the College of Surgeons of East, Central, and Southern Africa (COSECSA) along with Emory University provided an acute trauma care (ATC) and fundamental critical care support course (FCCS). This study evaluates the impact of American-derived courses on the knowledge and confidence of participants from resource-limited countries. METHODS: Courses were held in Lusaka, Zambia, and Nakuru, Kenya. Participants were COSECSA trainees and personnel from local institutions. The evaluation used a pre-/postcourse multiple-choice exam for knowledge acquisition and a pre-/postcourse questionnaire for confidence assessment. Confidence was measured using a 5-point Likert score, with 5 being the highest level of confidence. Confidence or self-reported efficacy is correlated with increased performance of new skills. RESULTS: There were 75 participants (median age = 31 years, 67% male). Three-quarters of the participants reported no prior specific training in either trauma or critical care. Knowledge increased from an average of 51 to 63.3% (p = 0.002) overall, with a 21.7% gain for those who scored in the lowest quartile. Confidence increased from pre- to postcourse on all measures tested: 22 clinical situations (10 trauma, 9 critical care, 3 either) and 15 procedures (p < 0.001 for all measures both individually and aggregated, Wilcoxon rank sum test). The strongest absolute increase in confidence, as well as the largest number of participants who reported any increase, were all in the procedures of cricothyroidotomy [median: pre = 3 (IQR: 2-3) to post = 5 (IQR: 4-5)], DPL [median: pre = 3 (IQR: 2-4) to post = 5 (IQR: 4-5)], and needle decompression [median: pre = 3 (IQR: 3-4) to post = 5 (IQR: 5-5)]. CONCLUSIONS: Participants from resource-limited countries benefit from ATC/FCCS courses as demonstrated by increased knowledge and confidence across all topics presented. However, the strongest increase in confidence was in performing life-saving procedures. Therefore, future courses should emphasize essential procedures, reduce didactics, and link knowledge acquisition to skill-based teaching.