Health System Strengthening in Sub-Saharan Africa


Surgical Care

Safe, accessible/affordable surgical care is a neglected Global Health priority, with an estimated 36 million cases of unmet surgical need in western and eastern SSA alone. Globally, 17m deaths and 77m DALYs might be averted each year with basic surgical care. We focus on Ethiopia and Sierra Leone. In both countries research has identified resource limitations, inefficiencies, access difficulties, inequities, and implementation problems. The main issues identified are; the low level of operative procedures, and the low productivity of surgical units; the limited human resources, of which two-thirds of surgeons and nearly all anaesthetists are non-specialists; the inequitable resource distribution, with rural districts grossly disadvantaged; concerns regarding the quality of care, particularly anaesthetic procedures, mainly linked to resource limitations – all leading to considerable unmet need for surgical care. Low access is strongly linked to inability to pay, and traditional beliefs. We found very little research into surgical care system/service innovations to address these problems. Rural areas are generally disadvantaged with respect to coverage and access. By developing\ and implementing district surgical care plans, we aim to promote access, increase surgical volume/ productivity, and reduce deaths and complications. 

Previous surgical care research in Sierra Leone, conducted by teams from Norway (Trondheim and Lund), USA (Harvard, Columbia, John’s Hopkins) and KCL indicates

a) 24,152 operative procedures were performed in 2012, (400/100,000 inhabitants). Hernia repair accounted for 22% and caesarean section for 21% of the total.  Private, nonprofit facilities performed 54% of the operations, compared with 40% by governmental and 6% by private for-profit facilities.

a) limited human resources – only 164 active surgeons of which one-third are specialists, and one half non-specialist physicians. Most anaesthetics are provided by nurse anaesthetists, whose numbers were boosted by a 2008 UNFPA Training Program in 2008.

b) inefficient resource utilisation with few procedures per surgeon, particularly non-specialists and those in rural areas.

d) inequitable resource distribution – while 70% of Sierra Leoneans live within 2 hours of a surgical centre, surgeon-to-population ratios were 1:45 058 in urban zones and 1:467 929 in rural zones. The density of consultant and medical doctors were 27 and six times higher in urban areas compared with rural areas, respectively. There is a 30-fold range between districts in procedures per inhabitant

e) concerns regarding the quality of care, particularly anaesthetic procedures, mainly linked to resource limitations; functioning anaesthetic machines, oxygen supplies, and monitoring devices

f) considerable unmet need – 90% of the estimated operative need in Sierra Leone was unmet in 2012. Population surveys indicate that two-thirds of fractures and three-quarters of inguinal hernias (a prevalence of 7% among adult males) were untreated. Most of those requiring surgery are younger adults. Failure to provide surgical care accounts for a significant proportion of avoidable deaths, and through chronic disability, long-term adverse effects on both individual and national wealth.

g) low access to services is strongly linked to unwillingness/ inability to pay, although one study also identified common fears as: becoming half human after surgery; complications from procedures; stigma from having a scar; and concern about the quality of the care available in Sierra Leone. In one study 12% of surgical patients left hospital after a diagnosis, but before the planned procedure took place.

h) Surgical care is given a low health priority in Sierra Leone. Resource constraints and competing health priorities, particularly ITD prevent surgery from receiving attention. There is currently no national policy or plan. Effective political and surgical leadership, access to country-specific surgical disease indicators, and higher domestic health expenditures are facilitating factors that promote surgical care on national health agendas.

i) There are only 10 dentists, 4 dental nurses and one technician in the whole country, all based in Freetown. KCL Dental School has developed a 5 year strategic plan to develop a non-specialist workforce of ‘dental therapists’, conduct a paediatric dental care needs assessment survey, and initiate a school-based dental hygiene education program.

A scoping review of surgical care research in Ethiopia reveals quite extensive research quantifying the need, describing the human and facility resource limitations, access difficulties and inequities, and implementation problems. However, we could find no evaluations of innovations in surgical care systems or services to address these problems. With respect to surgical care, Sodo has a new primary hospital (staffed by general doctors) and Butajira (in Meskan) has a general hospital. There is also a surgical unit attached to an NGO run hospital in Meskan (Project Mercy). There are around 18 health centres across the three districts. While some surgical procedures may be feasible at district level, for other procedures referral to regional or zonal level hospitals may be necessary. The research plan would be to develop, implement and evaluate a comprehensive district level surgical care plan operating at three levels; district level management and governance, facility strengthening and quality improvement, and community involvement (increasing demand for treatment and reduce barriers and delays in accessing surgical care). There may also be a need, as part of this process, to quantify the unmet needs through representative surveys in the DSS. There is very strong Federal MoH support for task-sharing surgical care to improve access. Relevant policy initiatives include a flagship programme (Saving Lives through Safe Surgery), and attention to care quality through the Ethiopian Hospital Alliance for Quality (EHAQ).

Maternal care

ASSET will focus on maternal care services in Ethiopia and South Africa and on Emergency Obstetric and Neonatal Care in Sierra Leone (lined to the surgical care platform in that country). In Ethiopia and Sierra Leone much progress remains to be made towards achieving the MDG targets for maternal and neonatal mortality. Attendance at ANC is patchy, and a high proportion of women lack skilled birth attendants, and give birth outside of formal facilities. Antenatal care attendance, access to skilled birth attendants and facility deliveries are low. Pre-eclampsia, haemorrhage and sepsis are chief causes of maternal death. Distance and cost are barriers to emergency care. Much research to date has focused on describing these problems, and looking at their determinants (poverty, low education, geography, and paucity of services). Very little if any research has evaluated interventions or innovations in care that might address these issues. In Ethiopia, some evidence supports effectiveness of ‘birth preparedness’ and risk stratification as strategies to increase ANC use and facility birth for high risk pregnancies. There is also an interesting strand of research on making maternity services more ‘compassionate and respectful’ and ‘respectful’ and on assessing the satisfaction of service recipients. The use of mhealth (tablets and smart phones) to develop HMIS for maternal care has been piloted . We aim to show impact of health system strengthening on relevant process and outcome indicators. In South Africa, maternal deaths are coming under control, but, as in Ethiopia violence against pregnant women, and depression are common, under-detected and managed, and linked to worse mother and child outcomes. We aim to improve mental health, and adherence to antenatal care pathways. 

Integrated primary health care

PHC morbidity data from South Africa shows that chronic non-communicable diseases (NCDs) are the leading cause of consultation, with high levels of comorbidity between hypertension, diabetes, COPD and depression. Depression is particularly unlikely to be detected and treated. Similar data are not yet available from Ethiopia, where rates of NCDs are certainly lower, but prevalence of depression is similar, with negligible detection. PACK, already being rolled out in South Africa, is to be adopted by Ethiopia as their standard of care (the Ethiopia Primary Health Care Guidelines; PHCG). PACK aims to integrate care for chronic diseases into a single platform, servicing all chronic care patients collaboratively, at one service point, with explicit evidence-based care pathways for the identification and management of multiple chronic diseases, by nurses, with ongoing mentoring and support. We will focus on the comorbidity between depression and other sentinel chronic diseases and illness episodes, which are burdensome, undermanaged and tractable to evidence-based intervention. In Ethiopia, subject to a PHC morbidity survey, this may be hypertension and COPD. In South Africa we will focus upon TB (often multiply drug-resistant and comorbid with HIV), and upon chronic progressive and life-limiting conditions (e.g. congestive heart failure, COPD, and frail dependent older adults) amenable to a palliative care approach.

The integrated PHC program in Ethiopia would be based around an implementation and evaluation of the contextualised Practical Approach to Care (PACK) clinical guidelines (Ethiopia PHCG). The four pillars of the PACK programme are designed to be tailored to local policy and health system priorities, with a ‘localisation package’ comprising an adaptation toolkit and mentorship support for the localiser. Support from MoH, and significant investment in the implementation process have been critical factors. The Ethiopia Federal Ministry of Health is committed to adopt and scale up the Ethiopia PHCG as a national program for continuing care in PHC (the Primary Health Care Clinical Guideline - PHCCG) . We have secured their support for a pilot implementation accompanied by robust research evaluations in three SNPPR districts, as a contribution to this national program.