Research Article: Increasing Access to Surgical Services in Sub-Saharan Africa: Priorities for National and International Agencies Recommended by the Bellagio Essential Surgery Group

Date Published: December 22, 2009

Publisher: Public Library of Science

Author(s): Sam Luboga, Sarah B. Macfarlane, Johan von Schreeb, Margaret E. Kruk, Meena N. Cherian, Staffan Bergström, Paul B. M. Bossyns, Ernest Denerville, Delanyo Dovlo, Moses Galukande, Renee Y. Hsia, Sudha P. Jayaraman, Lindsey A. Lubbock, Charles Mock, Doruk Ozgediz, Patrick Sekimpi, Andreas Wladis, Ahmed Zakariah, Naméoua Babadi Dade, Peter Donkor, Jane Kabutu Gatumbu, Patrick Hoekman, Carel B. IJsselmuiden, Dean T. Jamison, Nasreen Jessani, Peter Jiskoot, Ignatius Kakande, Jacqueline R. Mabweijano, Naboth Mbembati, Colin McCord, Cephas Mijumbi, Helder de Miranda, Charles A. Mkony, Pascoal Mocumbi, Jean Bosco Ndihokubwayo, Pierre Ngueumachi, Gebreamlak Ogbaselassie, Evariste Lodi Okitombahe, Cheikh Tidiane Toure, Fernando Vaz, Charlotte M. Zikusooka, Haile T. Debas

Abstract: In this Policy Forum, the Bellagio Essential Surgery Group, which was formed to advocate for increased access to surgery in Africa, recommends four priority areas for national and international agencies to target in order to address the surgical burden of disease in sub-Saharan Africa.

Partial Text: In sub-Saharan Africa, only 46% of births are attended by skilled personnel, compared to 96% in Europe (according to data for the African Region of the World Health Organization [WHO] from 2000 to 2008 [1]). In 2005, slightly over one quarter of a million women died from complications of childbirth [1]; most of these deaths could have been avoided by providing women with access to basic obstetric care and obstetric surgical care. On average, across sub-Saharan Africa, a population of 10,000 is served by two doctors and 11 nursing and midwifery personnel, compared to 32 and 79 respectively serving the same number of people in Europe (WHO data 2000–2007 [1]). A child born in sub-Saharan Africa in 2007 could expect to live only 52 years, which is 22 years less than its European counterpart [1]. Such starkly contrasting figures drive national and international efforts to build health system capacity to save lives and increase life expectancies in Africa. We argue that these efforts should include surgical capacity, a neglected component of a functioning health system.

Surgical care is usually concentrated in overloaded specialist referral hospitals that are inaccessible to patients who are unable or unwilling to travel. Those patients who do reach a health facility often arrive at a relatively advanced state of disease when the curative window may have passed. For example, 77% of patients with breast cancer evaluated in a tertiary Ugandan health facility presented in advanced stage compared with a much smaller fraction in high-income countries [8].

Injury, including road traffic injuries, accounts for nearly 10% of all DALYs lost in sub-Saharan Africa [2], and it is predicted that injury will contribute 20% of the global burden of disease by 2020 [10]. Experience in high-income countries has shown that improving the organization and planning for trauma care can consistently decrease deaths among all treated trauma patients by 15%–20%, and trauma systems have decreased 50% of medically preventable deaths [11]. Yet there is little support for African countries to improve their trauma care systems.

There are not enough health workers trained to provide adequate surgical services in specialist or district hospitals. This situation reflects both the critical shortage of health workers throughout sub-Saharan Africa [13],[14] and a lack of surgical specialists. Although some surgical procedures require highly skilled staff, a specialist surgeon is not required to perform many of the procedures described by Debas et al. [2]. An audit of eight district hospitals in Zambia, for example, concluded that nonsurgeons could have been trained to provide 86% of all operations performed [15]. The reality, in any case, is that the operations are not being performed by surgeons; in Uganda, Ozgediz recorded 3,621 operations (53% obstetric) at four district hospitals in a year, but noted that there was only one obstetric surgeon in one of the hospitals and no surgeons at the other three [16].

There is little evidence to answer basic questions about the prevalence and incidence of surgical conditions and the provision of surgical interventions in sub-Saharan Africa. For example, the global burden of surgical disease as estimated by Debas et al. is, at best, a rough estimate. Weiser et al., in calculating the global volume of surgery, found data on surgical volume for only 20% of African countries compared to 54% of European countries [19].

The BESG was formed in order to stimulate national and international efforts to improve access to surgical services in sub-Saharan Africa. Our recommendations are consistent with other recent calls to include surgery in the global health agenda [5],[16],[21],[22]. We are not proposing a new vertical initiative; rather, we advocate for the integration of surgical care into ongoing programs. Surgical services can be mainstreamed into health systems through ongoing international and national initiatives.



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