Disease Control Priorities: Essential Surgical Services in Africa

Disease Control Priorities: Essential Surgical Services in Africa

 

By Haile T. Debas, M.D., Executive Director, Global Health Sciences, University of California, San Francisco; and Colin McCord, M.D., Columbia University

 

Neglect of Surgery in Public Health

The second edition of Disease Control Priorities in Developing Countries (DCP2) has brought focus on the potential role of surgery as a public health strategy. It showed that surgical services provided in low-cost district hospitals in resource-constrained countries are highly cost-effective. We describe here some important developments in essential general and obstetrical surgery as a result of, or accompanying, the publication of DCP2.

Obstetrical Surgery by Assistant Medical Officers:

Faced with critical shortages of physicians trained to do surgery plus a concentration of those with this training in big cities, three African countries—Mozambique, Tanzania and Malawi—chose to give surgical training to assistant medical officers (AMOs), health personnel without the medical degree. These programs began 40 years ago in Tanzania, 23 years ago in Mozambique, and more recently in Malawi. In all three countries, they were independent initiatives with no outside assistance specific to the program. The AMOs provide most of the clinical health care outside of cities and a significant fraction of the surgical services within the cities. All have had two or three years of special training to equip them for the job and to provide them with surgical experience under supervision. The supervision has been provided through formal programs in Mozambique. But in Tanzania and Malawi, supervision occurred informally through on-the-job training.

An evaluation of the AMO surgical training program was conducted from 2004 to 2006 by a team of surgeons and obstetricians from the three African countries, Karolinska Institute, and Columbia University’s Program to Avert Maternal Death and Disability through a Bill & Melinda Gates Foundation grant.

The evaluation concentrated on emergency obstetrical surgery not only because of the magnitude of the problem of maternal mortality, but also because so many lives in these small hospitals are saved by relatively uncomplicated obstetrical procedures. Another reason to look closely at obstetrical surgery is to estimate the extent to which this service is reaching the population served by “met need” and “case fatality” indicators. [Met need is the number of complicated deliveries treated in all hospitals in a region, divided by the need, estimated at 15 percent of total deliveries. Case fatality is the number of maternal deaths from direct obstetric causes, divided by the number of complicated cases treated in a region’s hospitals.] Using these two United Nations (UN) Indicators, it is possible to estimate the impact of obstetrical surgery on maternal mortality in a region.

The Tanzanian part of the assistant medical officers surgery review used “met need” and “case fatality” to estimate the contribution of AMOs to the reduction on maternal mortality. All 16 hospitals in two regions (Kigoma and Mwanza), with a combined population of 5 million, were visited in two phases:

• Phase 1 reviewed operating room and delivery room records to determine the amount of work done by AMOs and overall case fatality. There were 39,000 obstetrical admissions, with 7,000 complicated cases. Overall, 75 percent of the operations were done by AMOs. Case fatality was 1.2 percent in one region and 2.2 percent in the other (the UN target for countries like Tanzania is 1 percent). The region with the lower mortality had only one surgical specialist for a population of 1.6 million. Although the second region has a university hospital with six obstetrical specialists and a residency training program, the case fatality rate did not improve.

In both regions, the study showed that the “met need” was only 30 percent overall. Despite a considerable number of hospitals capable of performing obstetrical surgery, two out of three women in need of such surgery never reached a hospital. The main reason for this seems to be the cost of transport over long distances to widely scattered hospitals.

• Phase 2 looked prospectively at the complicated deliveries in the same hospitals, in order to compare AMO and medical officer (MO) maternal and fetal death outcomes and selected indicators of quality of care and maternal/fetal risk. In the review of 1,134 complicated cases, no differences were found.

Two major programmatic and policy conclusions can be made from this study: (1) an urgent need exists to expand the number of health facilities with the ability to provide access and services to emergency obstetrical surgery; and (2) AMOs can provide these services safely and effectively.

In Tanzania, with more than 1,200 AMOs available, as well as an existing infrastructure of three to four health centers per district, this expansion could take place in just a few years. The critical requirement is funding to upgrade the basic surgical capacity of health centers and to provide decent living conditions for staff.

Further Research and Scaling-up

To build a body of evidence on the cost-effectiveness of essential surgery as described in DCP2 and to develop effective training programs, two pilot projects with support from the Disease Control Priorities Project have been undertaken in Uganda:

1) Cost-effectiveness analysis of surgical services in a 100-bed district hospital. The conclusions from this small study were:

• Surgical services provided in a Ugandan district hospital are cost-effective but not to the same extent as found in Bangladesh and Sierra Leone studies.¹

• Inadequate funding for health services in general, and for surgical services in particular, has a negative impact on the cost-effectiveness of interventions. Most importantly, lack of funding severely limits the capacity of hospitals to provide basic health services that could reduce disease burden. The lower cost-effectiveness results reported in this study are mainly due to inadequate funding for health services and the infrastructure needed to support surgery as opposed to the cost-effectiveness of the surgical services themselves.

• The differences in the results in the 3 studies (Uganda, Bangladesh, and Sierra Leone) suggest that more robust and comprehensive cost-effectiveness research should be undertaken, preferably in more than one country and at different levels of care, using similar methodologies that would allow for comparisons between different study sites.

2) Initial planning is underway to examine how surgical training modules in essential general surgery, as well as obstetrical surgery, may be provided to non-surgeons to develop a regional surgical workforce. The concept is to train doctors, nurses, and medical officers to acquire appropriate surgical skills to provide essential surgical care in district hospitals. The effort would represent a partnership among the Ministry of Education, the departments of surgery and anesthesia at Makerere University, and institutions from developed countries. Lack of funds curtailed progress beyond the early planning period, but the groundwork already done would allow the rapid start of a program should funds become available.

The University of California, San Francisco (UCSF) and Makerere University have begun to collaborate in support of surgical education and trauma care. Several faculty members and residents from the University of California, San Francisco, have spent time at Makerere University over the past two years. The Head of Makerere University’s Trauma Service, which is the only Trauma Service in Kampala, is now at UCSF for a three-month sabbatical to study Trauma Care Systems with the hope of establishing a trauma care system in Uganda.

Bellagio Conference on “Increasing Access to Surgical Services in Resource-Constrained Settings in Sub-Sahara Africa” (June 4-8, 2007).

The primary goal of this Bellagio Conference was to examine implementation of the findings in the DCP2 chapter on surgery. It was jointly hosted by UCSF Global Health Sciences and the Karolinska Institute and brought together African leaders in surgery, administration, health systems experts, a minister of health, and representatives from the World Bank, the World Health Organization, and the Bill & Melinda Gates Foundation.

The goals of the meeting were:

1. To take stock of what is known about the need to improve access to surgical services in sub-Saharan Africa, the cost-effectiveness of specific interventions, and existing national and international efforts to support the delivery of these interventions;

2. To assess health system and human resource constraints to integrating surgical services at the district level within health systems in sub-Saharan Africa, and identify training programs, resource reallocation and policies required to tackle these challenges; and

3. To prepare a roadmap of activities to improve access to surgical services in sub-Saharan Africa and to engage national and international stakeholders to advocate for and implement this roadmap.

There is great expectation that out of this Bellagio Conference will emerge a road-map for creating rural surgical service capacity, and that fundable models in several sub-Saharan African countries will be developed.

A summary of the findings and recommendations of the Bellagio Conference will appear on this website (www.dcp2.org). We are optimistic that, out of the Bellagio Conference, specific projects will be identified that, with appropriate funding, will lead to the implementation of the findings of the DCP2 chapter on surgery.

Key Lessons Learned:

• Eleven percent of all DALYs are from conditions that are very likely to require surgery.²

• Surgical care is cost-effective when provided in low-cost district hospitals, with estimated cost per surgical DALY at $38, and $33 in South Asia and Sub-Saharan Africa, respectively.

• Surgery has a major role to play in public health in the prevention of death and disability—including injuries, obstetrical emergencies, and a wide-range of emergency abdominal and non-abdominal conditions, plus elective conditions that improve quality of life and productivity, such as cataracts, hernias, and clubfoot.

• Lack of a surgical workforce and basic surgical capacity at rural health centers pose the most important constraints requiring urgent solutions.

• Assistant medical officers can be trained to provide emergency obstetrical care safely and effectively.

• The focus by DCPP on the cost-effectiveness of surgical care in rural hospitals in developing countries has resulted in the Rockefeller Foundation’s hosting an International Conference on “Increasing Access to Surgical Services in Resource-Constrained Settings in Sub-Saharan Africa.” The Bellagio Conference is expected to recommend practical projects that, with funding, can be implemented.

 

¹ McCord, C., and Q. Chowdhury. 2003. “A Cost-Effective Small Hospital in Bangladesh: What It Can Mean for Emergency Obstetric Care.” International Journal of Gynaecology and Obstetrics 81 (1): 83–92.

² Calculating DALYs: A year lived in complete health counts as 1.0 DALY. A death, on the other hand, is worth 0.0 DALY. A year spent in less than total health counts as some portion of a DALY. The exact amount is determined by the severity of the incapacity that affected individuals typically suffer and represents a judgment based on an expert estimate. The calculation also considers the length of time the disease or condition generally lasts, ranging from a stretch of acute illness lasting only days or weeks to a lifetime of disability. To account for differences in the age when a disease, disability, or death may occur, as well as for the unreliability of predicting people’s future survival, years of life remaining are discounted at a rate of 3 percent. The DALY values for various diseases and conditions used in DCP2 come from calculations based on world-wide research results.