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Report

Teaser, summary, work performed and final results

Periodic Reporting for period 1 - SURG-Africa (Scaling up Safe Surgery for District and Rural Populations in Africa)

Teaser

Summary

Scaling up Safe Surgery for District and Rural Populations in Africa (SURG-Africa) is a 4 year implementation research project to scale up safe accessible surgery for district and rural populations in Tanzania, Malawi and Zambia. There is a huge need to improve surgical services in rural Africa, where an estimated 95% of the population has no access to common general and life saving emergency surgery.

SURG-Africa is testing a supervision model based on findings from an earlier EU FP7 funded study in Zambia and Malawi â€“ COST-Africa 2011-16 (www.costafrica.eu). The model consists of in-service training and support to district hospital surgical teams through (a) periodic visits by surgical specialists to surgically active district hospitals; together with (b) mobile phone and online needs-based support of district surgical clinicians.

The overall aim of SURG-Africa is: to implement surgical systems, that deliver safe, affordable and sustainable essential surgical services to rural populations in LMICs. The specific objectives are:
1. Strengthen national surgical systems to scale to national level, deliver â€“ and monitor through a national surgical information system â€“ emergency and common elective surgery in district hospitals in Tanzania, Malawi, Zambia.
2. Train surgeon specialists to supervise, mentor and provide surgical systems in-service training â€“ comprising clinical, management and systems skills â€“ to district hospital staff.
3. Design and implement research studies, including observational, intervention and community studies, costing studies and economic analyses, to compare processes, outcomes, patient experiences, costs and cost-effectiveness of surgery between district and referral hospitals.
4. Design and implement participatory implementation research studies to identify and explore enablers and obstacles â€“ at all levels, from community to national level â€“ to accessing and delivering essential safe surgery at district hospitals.
5. Disseminate findings to national decision makers and support them in making policy decisions, including assessing budget impacts and appraising options for making safe surgery accessible.
6. Disseminate findings to seven countries in East Central and Southern Africa and support them in designing country-specific interventions for making safe surgery accessible.

In the participating countries, SURG-Africa works under the guidance of the Ministries of Health in consultation with key local stakeholders such as professional associations and other groups supporting delivery of surgical services. A high level of support and engagement by national ministries of health has been achieved in the first 18 months of the study.

Work performed

The work successfully undertaken in the first 18 months has enabled SURG-Africa to become recognised on the global arena of initiatives bringing innovative solutions to sub-Saharan Africa. SURG-Africa has precipitated a remarkably high level of interest and access to senior levels of the Ministry of Health (MoH), including meetings with Permanent Secretaries as well as national programme managers in all countries. In all countries the project fully align with strategic aims of local governments. SURG-Africa was successfully launched at Kilimanjaro Christian Medical Center in March 2017. The event gathered representatives of the Tanzanian Ministry of Health, representatives of the local government, international experts in global surgery as well as all the members of the SURG-Africa consortium. The project was well endorsed by all key stakeholders and the full support for its aims was reconfirmed.

In the initial implementation phase of the project an in-depth situation analysis was done in Zambia, Malawi and Tanzania converting 86 district level health facilities offering surgical care. As part of this research activity qualitative interviews and focus group discussion were held with key stakeholders in each of the countries. Initial mapping of surgical structures was also done by team researchers in each country. The findings of the in-depth situation analysis allowed to gain insight into the current obstacles and enablers to safe surgical care at all levels of care, with a particular focus on the situation at the district level. The findings guided the design of the country-specific, details SURG-Africa intervention. It became apparent that targeted interventions are needed in every country, because the challenges that SURG-Africa aims to address were not homogeneous. The supervision model has been designed taking into account local contexts and needs of individual hospitals participating in the study. Building on the initial concept to include general surgeons and anaesthesiologists in the core supervisory teams, the team has been extended to also include obstetricians and operating theatre nursing specialists. The situation analysis demonstrated a huge need to address gaps in basic maternal health surgical skills as well as in postoperative care of surgical patients.

The final concept of the supervision and an action plan was presented to study participants, both the supervisors and the recipients of the intervention for final changes and approval. Extensive consultations with key stakeholders at all level resulted in adapting the final model of the intervention to the local contexts. Following that, the intervention was ready to kick-off. Starting from January 2018, it is now being tested in 31 district level hospitals in Malawi, Zambia and Tanzania, with another 36 district level facilities monitored in terms of surgical outputs as control sites.

Final results

The project has been introduced to ministry officials in all three countries and received enthusiastic support. The importance of implementing continued supervision at district level has been quickly recognised by local authorities and the proposed model became one of the national priorities in Malawi and Zambia and Tanzania. The SURG-Africa proposed supervision model is perceived as one of the key elements needed in the national health service to allow access to quality-assured surgical services for rural and district populations.

SURG-Africa with the its expertise and experience has contributed to important advances in the National Surgical, Obstetric and Anaesthesia plans in Zambia and Tanzania. The supervision model is included in both plans. These plans envisage a country-wide scale up of the SURG-Africa supervision model beyond the regions where the project operates in the forthcoming years.

SURG-Africa supported the development of the Zambian surgical information system through providing technical expertise and resources to digitalise surgical data collection and implementation of quality control measures.
Studies to estimate the costs of the evaluated supervision models at country level are ongoing and they will provide evidence to inform the budget allocations for scale up of the most cost-effective model. Fully evaluated and costed models will be presented to MsoH, and support will be offered them to roll out an agreed surgical supervision / mentoring model country-wide; and to consider how policy options can be sustained within available national budgets.