Emergency, anaesthetic and essential surgical capacity in the Gambia
Adam Iddriss a, Nestor Shivute b, Stephen Bickler c, Ramou Cole-Ceesay d, Bakary Jargo e, Fizan Abdullah a & Meena Cherian f
a. Department of Surgery, Johns Hopkins University School of Medicine, Harvey 319, 600 Wolfe Street, Baltimore, MD, 21205, United States of America (USA).
b. Country Office, World Health Organization, Kanifang, Gambia.
c. Department of Surgery, University of California at San Diego, San Diego, USA.
d. Ministry of Health, Banjul, Gambia.
e. Royal Victoria Teaching Hospital, Banjul, Gambia.
f. Department of Essential Health Technologies, World Health Organization, Geneva, Switzerland.
Correspondence to Adam Iddriss (e-mail: email@example.com).
(Submitted: 16 February 2011 – Revised version received: 04 April 2011 – Accepted: 10 April 2011 – Published online: 06 May 2011.)
Bulletin of the World Health Organization 2011;89:565-572. doi: 10.2471/BLT.11.086892
Rates of death and disability from treatable surgical conditions continue to be unacceptably high in low- and middle-income countries.1 Conditions such as injuries (road traffic accidents, burns and falls), infections (osteomyelitis and septic arthritis), pregnancy-related complications and a variety of abdominal emergencies affect primarily young adults and impose a significant burden on society. Surgical conditions account for up to 11% of the world’s disability-adjusted life years.1 Barriers to the delivery of safe, timely and effective surgical care include a lack of infrastructure as well as a shortage of physical and human resources.
The Gambia is a low-income country located in western sub-Saharan Africa whose health profile resembles that of many other developing countries of the region (Table 1). With a population of more than 1.66 million, of which 55% lives in urban areas, the Gambia is one of the most densely populated countries in Africa. More than 80% of the Gambian population lives on less than 2 United States dollars a day. The leading causes of inpatient mortality are malaria, anaemia, maternal deaths, cerebrovascular accidents and trauma.
Table 1. Selected health indicators for the Gambia, the World Health Organization (WHO) African Regiona and the United States of America (USA)
The objective of the present study was to assess the current capacity for essential surgical and anaesthesia care in the Gambia for the purpose of providing a benchmark for critical areas needing improvement.
Assessment of surgical resources
In June 2008, a team from the Global Initiative for Emergency and Essential Surgical Care (GIEESC) of the World Health Organization (WHO) visited 11 health facilities in the Gambia to assess potential sites for implementation of the WHO Emergency and Essential Surgical Care programme. The selected sites were organized in collaboration with the Gambia's Ministry of Health and WHO country office to provide broad geographical coverage of the country. The WHO Tool for Situation Analysis to Assess Emergency and Essential Surgical Care survey was subsequently distributed to health-care management officials at facilities throughout the country.4 Data were collected during April 2009 and surveys were completed by 65 of 76 health facilities (85.5% response rate) in the Gambia, including one tertiary referral hospital (1.5%), 7 (10.8%) district/general hospitals, 46 (70.8%) health centres and 11 (16.9%) private health facilities.
The survey included 110 questions divided into four sections. Section I consisted of 23 questions concerning infrastructure and type of health-care facility, the characteristics of the surgical population served, and the availability of oxygen, running water and electricity. Section II included 8 questions on human resources, including the number of specialist surgeons and anaesthesiologists, physicians, nurses and non-physician professionals who were providing surgery or anaesthesia services. Section III included 10 questions to assess emergency interventions such as resuscitation, suturing, cricothyroidotomy and burn management, as well as other surgical interventions such as caesarean section, fractures, hernia and laparotomy. Section IV consisted of 69 questions on the availability of emergency equipment and supplies for resuscitation, including capital outlays, renewable items and supplementary equipment.
Data from the questionnaires was complemented by interviews with health facility staff, government officials in the Ministry of Health and representatives of nongovernmental organizations (NGOs) responsible for health facilities. The additional content covered the state of health care in the Gambia and the challenges of administering surgical and anaesthesia services in a resource-constrained setting.
We used Stata version 10.0 (StataCorp. LP, College Station, United States of America) to perform the statistical analysis. We employed descriptive statistical methods to compare individual elements of the survey between public health facilities (i.e. the Royal Victoria Teaching Hospital [RVTH], general hospitals and health centres) and private hospitals. We performed bivariate analysis using Fisher’s exact test to compare the results for public health facilities and private hospitals, with significance set at P < 0.05.
Health facility characteristics
Of the 65 facilities that responded to the survey, 18 (27.7%) were considered referral hospitals capable of delivering surgical services. Data analysis was therefore focused on these 18 facilities, which included the country’s tertiary referral hospital (5.6%), 5 (27.8%) general hospitals, 6 (33.3%) health centres and 6 (33.3%) private hospitals. The populations served by each facility ranged from 25 600 to 400 900.
Table 2 depicts the key infrastructural elements available in the health facilities assessed. Consistent sources of oxygen supply, running water and electricity were available at 14 (77.8%), 9 (50.0%) and 8 (44.4%) of facilities, respectively. Functioning power generators and anaesthesia machines were available at 9 (52.9%) and 12 (70.6%) facilities, respectively, and 4 (23.5%) health facilities reported having no functioning anaesthesia machines. A comparison of public health facilities with private hospitals showed that a significantly higher fraction of private facilities had running water consistently available (P = 0.009), functioning power generators (P = 0.009) and an uninterrupted supply of electricity (P = 0.002).
All 18 of the health facilities studied had at least one functioning operating room. The RVTH had four; two functioning operating rooms existed in two of the five (45.5%) remaining public facilities and in two (33.3%) of the private facilities. The RVTH had 576 beds; the number of beds ranged from 51 to 300 in other general hospitals, from 3 to 100 in health centres and from 11 to 50 in private hospitals.
Table 3 shows health facility surgical and anaesthesia staff. Only 7 (38.9%) facilities had a surgeon, including the RVTH, which had 8; 3 (16.7%) facilities had a general doctor performing surgery. Only 3 (16.7%) facilities reported relying on paramedical staff such as surgical technicians to perform basic surgical procedures. Anaesthesia was delivered by anaesthesiologists in 4 (22.2%) facilities, general doctors in 1 (5.6%) facility and non-physicians in the rest. Only one obstetrician/gynaecologist was available in 8 (44.4%) of the facilities assessed. Most facilities (83.3%) had several paramedics and midwives who performed minor surgical interventions.
General and trauma surgery
The ability of each health facility to provide several basic surgical procedures was assessed (Table 4). All general hospitals reported performing at least 100 surgeries annually; 4 (66.7%) of them performed more than 500 per year. Health centres reported from 11 to 300 annual surgical admissions, while general hospitals reported from 100 to more than 5000. Surgical admissions to private hospitals ranged from 11 to 200 a year.
Table 4. Percentage availability of general surgery, trauma and anaesthesia procedures in the Gambia, 2009
All facilities were able to perform incision and drainage of abscesses and male circumcision. Laparotomies were performed in 56.3% of facilities. Compared with public facilities, a significantly greater percentage of private facilities performed appendectomies, caesarean sections and hernia repairs (P = 0.044). Only 5 (29.4%) facilities repaired obstetric fistulas. Management guidelines for surgical care were available in only 10 (55.6%) facilities.
Regarding trauma procedures, 93.8% of facilities removed foreign bodies and 82.4% managed burns. Cricothyroidotomy/tracheostomy and chest tube insertion were performed in only 41.2% and 33.3% facilities, respectively. Management guidelines for emergency care were available in only 8 (44.4%) facilities. Patients needing procedures not performed in health facilities and hospitals because of a lack of skilled personnel, equipment or supplies were referred to tertiary facilities.
Of the health facilities without official operating rooms, several managed to carry out basic life-saving procedures including burn management (72.7%), incision and drainage of abscesses (81.8%) and foreign body removal (66.7%). More technically difficult or equipment-intensive procedures such as appendectomy (2.3%), laparotomy (4.8%) and open fracture repair (2.5%) were less frequently available.
The availability of the resources needed to provide anaesthesia services was assessed (Table 4). The most common types of anaesthesia provided were ketamine intravenous anaesthesia (82.4%) and regional anaesthesia (76.5%), while spinal (72.2%) and general inhalational (72.2%) anaesthesia were also available. Management guidelines for anaesthesia and pain management were available in 10 (58.8%) and 5 (27.8%) facilities, respectively.
Emergency and sterilization equipment and supplies
The availability of emergency equipment and supplies was assessed in each of the health facilities (Table 5). Resuscitator bags were available in 10 (58.8%) facilities, while 12 (66.7%) facilities reported having intravenous infusion sets. Nasogastric tubes were available in 7 (38.9%) facilities, and examination gloves and sterile gloves were available in 12 (66.7%) and 10 (55.6%) facilities, respectively. Sterilizers were consistently available in 9 (52.9%) facilities, while other sterilization methods, including cold sterilization and boiling, were used in the remainder. Only 3 (18.8%) facilities reported having adequate eye protection for health staff and 6 (35.3%) reported having enough protective aprons.
Table 5. Percentage availability of essential supplies in private and public hospitals in the Gambia, 2009
Although surgery is a cost-effective element of preventive health care,1 access to essential surgery is limited in most resource-constrained settings.5–10 This is the first survey to assess the status of essential and emergency surgical care and of anaesthesia services in the Gambia. The most striking finding was the absence of any facilities equipped with all of the physical resources needed to provide emergency and essential surgical care. Major gaps in the physical resources needed to carry out basic surgical and anaesthetic care in the Gambia were identified. These included deficits in the availability of water, electricity, oxygen, and emergency and anaesthesia equipment.
The WHO Tool for Situation Analysis to Assess Emergency and Essential Surgical Care was used to assess surgical capacity in several countries. In Afghanistan, 30% of facilities had limited oxygen delivery mechanisms, 40% had unreliable sources of running water and only 34% had uninterrupted electrical power.9 Comparatively, in the Gambia reliable sources of oxygen, running water and electricity were available in 77.8%, 50.0% and 44.4% of facilities. In Sierra Leone, only 20% of facilities had functioning anaesthesia machines8 compared with 75.0% in the Gambia. In Ghana, a shortage of adequately trained human resources was identified as the major barrier to the delivery of surgical and anaesthetic services; 88% of facilities could perform caesarean sections and 94% could perform appendectomies.10 Human resource shortages were also identified as an obstacle in the Gambia, where only 58.8% of facilities were performing caesarean sections and appendectomies. Thus, surgical and anaesthesia services in the Gambia are at an intermediate level when compared with those of neighbouring countries.
Access to care
In the Gambia, inequitable access to surgical services is propitiated to some extent by the concentration of health facilities and staff in urban areas such as the Western Division.11 As a result of poorly developed referral systems and a lack of physicians in secondary health facilities, many patients are referred to distant health facilities for basic procedures that should be performed at the primary and secondary levels. Health centres and private hospitals will first refer cases to district hospitals before referring them to the RVTH. Unfortunately, the RVTH is already overstretched and faces human and physical resource challenges similar to those faced by the institutions assessed in this project. Moreover, the Gambian River, which divides the country, further hinders access to basic surgery facilities by limiting transportation from distant rural areas to Banjul. Although improved transportation to more distant facilities with better equipment may temporarily help reduce these inequities, it is not a sustainable solution for patients requiring urgent assessment and management. Policies in support of resource allocation for improving district-level access to surgical care that can save lives and prevent disability are needed to relieve the burden on tertiary-level health facilities such as the RVTH.
The shortage of health personnel at the primary level is also a major obstacle to the provision of surgical and anaesthesia services in the Gambia (Table 3). Although several health services have been expanded, staffing does not meet the needs of the institutions or their catchment areas. The Gambia has less than 0.5 physicians per 10 000 inhabitants, compared with 2.4 per 10 000 in the WHO African Region.3 Moreover, most (80%) of the practicing physicians are not of Gambian nationality.11 The brain drain is pervasive because many health workers leave the public health system to work in the private sector, in NGOs or in other countries.12–14 To compensate for the lack of trained personnel, health facilities have increasingly relied on paramedical staff to meet their surgical and anaesthesia needs. Despite the noticeable lack of surgeons in many of the facilities assessed in this study, every facility had ample nursing and health-care staff.
General surgery and trauma
Access to essential surgery and emergency services is a key determinant of health,15 yet many basic procedures, including amputation, fracture repair and chest tube insertion, were not provided in many of the facilities assessed in our study. Many also lacked management guidelines for emergency, anaesthesia and surgical care.16 Thus, implementing the aforementioned guidelines in all health facilities could be a cost-effective intervention for preventing surgical complications and reducing morbidity and mortality.
The widespread availability of male circumcision is encouraging, given the role of this procedure in HIV prevention efforts (Table 1 and Table 4).17 A greater percentage of private hospitals than public ones performed hernia repair, appendectomy and caesarean section. Other studies have documented disparities in infrastructure, supplies and equipment between public and private health-care facilities in the developing world.18,19 Our findings indicate that in the Gambia private facilities may be better equipped to perform certain procedures than public ones. In addition, private facilities reported greater reliance on surgical technicians and paramedical staff for providing health services (Table 3), perhaps a reflection of the country’s historical reliance on nurses and other paramedical staff for procedures such as cataract and lens extraction.20 Non-physicians in countries such as the Democratic Republic of the Congo, Kenya, Malawi and Mozambique have performed basic surgical procedures for years with outcomes equivalent to those observed when specialists perform them.21–24 Strengthening the training of mid-level health-care providers in the Gambia in emergency, surgical and anaesthesia procedures at the district level would certainly help to attenuate the human resource crisis and fulfil part of the unmet need for basic surgical care.
Although surgery is a specialized activity that cannot be made available in every facility, certain emergency procedures and techniques, such as burn management, should be more widely available. Despite the lack of an operating room, several facilities not included in the statistical analysis performed several basic emergency and essential surgical procedures. Increasing the capacity of these centres to provide essential surgical care may also help to reduce the burden of conditions requiring surgery in the Gambia.
The Gambian government, having recognized the enormous deficits that exist within the health-care system, has tried to provide citizens with improved access to better surgical and anaesthetic care. The nation’s only medical school, established in 2000, has integrated surgery into the medical school curriculum to encourage students to pursue surgical careers. The Ministry of Health has established a successful collaboration with the World Health Organization and two international organizations to advance the state of maternal and child health through improved delivery of emergency and obstetric services at one site in the Gambia.25 Similar collaborations would also help to overcome the lack of other necessary surgical procedures in the Gambia. More system-wide changes are needed to create a sustainable mechanism for procuring and maintaining the supplies and technical skills required to perform surgery safely.
A global anaesthesia workforce crisis is emerging.26,27 Our work highlights the shortage of trained anaesthesia providers and services in the Gambia, where anaesthesia in referral hospitals is delivered primarily by nurses and clinical officers. Thus, it is thus extremely important to ensure appropriate training in the country and to motivate health-care workers to pursue careers in anaesthesiology. The WHO Integrated Management for Emergency and Essential Surgical Care toolkit provides management guidelines that should be incorporated in the training when building surgical capacity in non-surgical programmes in district- and sub-district-level health facilities that have no surgery specialists.
As in other resource-limited health settings, in the Gambia ketamine-based anaesthesia (82.4%) was the type most commonly available in the health facilities assessed.28 This may reflect a shortage of the skills and equipment needed to provide spinal and general anaesthesia.
Challenges with partnerships
Increased mortality has been correlated with deficits in health infrastructure,29 medical technology30 and integration of resources to provide surgical services.31 The capacity of health facilities to provide basic life-saving interventions must be strengthened. Multidisciplinary partnerships, such as between governments and NGOs, offer welcome opportunities to improve health care in countries such as the Gambia and to develop solutions that can generate important changes. The Global Initiative for Emergency and Essential Surgical Care (GIEESC) was established by WHO in 2005 to reduce death and disability associated with surgical conditions.32 Through technical assistance, needs assessments and education and training, the GIEESC strengthens resource-limited countries’ capacity to deliver safe and effective emergency surgical care. Our study suggests that the GIEESC can play an important role in bringing together stakeholders interested in building surgical capacity in primary health-care facilities and in ensuring the availability of material resources and of properly trained human resources.
Our study has limitations. First, the sample was taken only from facilities offering surgery and anaesthesia services. Second, some of the assessed facilities may have undergone significant infrastructural improvements since the time of the survey, although this is unlikely. Despite these limitations, the data presented accurately reflect the Gambia’s current capacity to provide surgery and anaesthesia services.
The WHO tool has been validated for assessing the capacity of health facilities in the developing world.33 Although good test-retest reliability has been documented for the sections covering physical infrastructure, equipment and human resources, those parts that pertain to the process of delivering health care can benefit from supplemental data. Overall, the WHO tool makes it possible to quickly assess health facilities’ capacity for delivering essential surgical and anaesthetic services and to compare data across developing countries.
In conclusion, the Gambia faces many obstacles to the delivery of surgical and anaesthesia services, including a shortage of human resources, equipment, supplies and infrastructure. Future studies are needed to help determine precisely how the shortage in each area affects surgical outcomes. To effectively reduce death and disability from surgical conditions, efforts to improve surgical capacity within the Gambian health-care system must focus on the district level. Training mid-level health practitioners in surgery and developing partnerships between the government and NGOs may be important steps towards improving surgical and anaesthetic services in the Gambia.
We are grateful for the support of the health facility visit team, including Agnes Kuye, Alpha Jallow and Thomas Sukwa (World Health Organization Country Office, the Gambia), Momodou Baro (Royal Victoria Teaching Hospital, Banjul, the Gambia) and Yankuba Kassama (Ministry of Health, the Gambia).
This work was supported by the Johns Hopkins Center for Global Health (grant number 5R25TW007506) from the Fogarty International Center at the National Institutes of Health.
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