Abstract
BackgroundDistrict-level hospitals (DLHs) can play an important role in the delivery of essential surgical services for rural populations in sub-Saharan Africa if adequately prepared and supported. This article describes the protocol for the evaluation of the Scaling up Safe Surgery for District and Rural Populations in Africa (SURG-Africa) project which aims to strengthen the capacity in district-level hospitals (DLHs) in Malawi, Tanzania and Zambia to deliver safe, quality surgery. The intervention comprises a programme of quarterly supervisory visits to surgically active district-level hospitals by specialists from referral hospitals and the establishment of a mobile phone-based consultation network. The overall objective is to test and refine the model with a view to scaling up to national level.MethodsThis mixed-methods controlled pilot trial will test the feasibility of the proposed supervision model in making quality-assured surgery available at DLHs. Firstly, the study will conduct a quantitative assessment of surgical service delivery at district facilities, looking at hospital preparedness, capacity and productivity, and how these are affected by the intervention. Secondly, the study will monitor changes in referral patterns from DLHs to a higher level of care as a result of the intervention. Data on utilisation of the mobile based-support network will also be collected. The analysis will compare changes over time and between intervention and control hospitals. The third element of the study will involve a qualitative assessment to obtain a better understanding of the functionality of DLH surgical systems and how these have been influenced by the intervention. It will also provide further information on feasibility, impact and sustainability of the supervision model.DiscussionWe seek to test a model of district-level capacity building through regular supervision by specialists and mobile phone technology-supported consultations to make safe surgical services more accessible, equitable and sustainable for rural populations in the target countries. The results of this study will provide robust evidence to inform and guide local actors in the national scale-up of the supervision model. Lessons learned will be transferred to the wider region.
Highlights
District-level hospitals (DLHs) can play an important role in the delivery of essential surgical services for rural populations in sub-Saharan Africa if adequately prepared and supported
Since enhanced functionality of DLHs is expected to lead to improve outcomes of surgery, we anticipate that the intervention should, in the longer perspective, make a positive contribution to the overall health of the populations residing in the areas where participating hospitals are located [43]
There is a growing body of research supporting the case for investment in DLHs, building on evidence that essential surgery at DLHs can be delivered safely, cost effectively and is affordable and feasible, even in low resource settings [6, 11]
Summary
District-level hospitals (DLHs) can play an important role in the delivery of essential surgical services for rural populations in sub-Saharan Africa if adequately prepared and supported. A key challenge, is the shortage of qualified staff [13]—surgical clinicians, anaesthetists and nurses—aggravated by labour migration [14], with as few as one surgeon per 2.5 million people in some SSA rural settings [15] This human resource gap is often filled by health professionals with non-specialist training such as medical officers (MOs), non-physician clinicians (NPCs) [16] and general nurses [17]. These cadres have been the backbone of clinical care services at first-level facilities in SSA and experiences from a number of countries demonstrate the benefits of allocating surgical responsibilities (i.e. task-shifting) to non-specialists [18,19,20,21]
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