Abstract

There is much scope to empower district hospital (DH) surgical teams in low- and middle-income countries to undertake a wider range and a larger number of surgical procedures so as to make surgery more accessible to rural populations and decrease the number of unnecessary referrals to central hospitals (CHs). For surgical team mentoring in the form of field visits to be undertaken as a routine activity, it needs to be embedded in the local context. This paper explores the complex dimensions of implementing surgical team mentoring in Malawi by identifying stakeholder-sourced scenarios that fit with, among others, national policy and regulations, incentives to perform surgery, career opportunities, competing priorities, alternatives for performing surgery locally and the proximity and role of referral hospitals. A mixed methods approach was used which combined stakeholder input - obtained through two group model building (GMB) workshops and further consultations with local stakeholders and SURG-Africa project staff - and dynamic modeling to explore policy options for sustaining and rolling out surgical team mentoring. Sensitivity analyses were also performed. Each of the two GMB workshops resulted in a causal loop diagram (CLD) with an array of factors and feedback loops describing the complexity of surgical team mentoring. Six implementation scenarios were defined to perform such mentoring. For each the resource requirements were identified for the institutions involved - notably DHs, CHs and the party that would finance the required mentoring trips - along with the potential for scaling up surgery at DHs under severe financial constraints. To sustain surgical mentoring, it is important that an approach of continued communication, monitoring, and (re-)evaluation is taken. In addition, an output- or performance-based financing scheme for DHs is required to incentivize them to scale up surgery.

Highlights

  • IntroductionMillions of people lack access to safe surgery.[1]. A large percentage of these live in low- and middle-income countries in sub-Saharan Africa

  • Worldwide, millions of people lack access to safe surgery.[1]

  • Implications for the public Scaling up surgery at district hospitals (DHs) in order to make safe surgery more accessible for rural populations requires mentoring of DH surgical teams through periodic field visits by teams of senior surgical staff who are usually based at central hospitals (CHs)

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Summary

Introduction

Millions of people lack access to safe surgery.[1]. A large percentage of these live in low- and middle-income countries in sub-Saharan Africa. Most (surgical) care at Malawian DHs is provided by a cadre of non-physician clinicians, called clinical officers in Malawi.[5] The European Unionfunded SURG-Africa project was designed to demonstrate an effective way to improve district surgical capacity using locally available resources It has implemented and evaluated surgical mentoring and supervision between 2018 and 2020.6 This intervention consisted of two complementary parts: periodic mentoring trips of DH surgical teams by specialists from CHs; and a managed remote surgical consultation network based on WhatsApp.[7] The rationale behind the intervention was that surgical teams at DHs would be empowered in terms of professional knowledge, skills and confidence to undertake a wider range and a larger number of surgical procedures. Through this two-pronged intervention it was expected that surgery would become more accessible to rural populations and that the number of unnecessary referrals to CHs would decrease

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