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Objectives To survey infrastructure characteristics, personnel, equipment and procedures of surgical, obstetric and anaesthesia care in 17 hospitals in Ghana.
Methods The assessment was completed by WHO country offices using the World Health Organization Tool for Situational Analysis to Assess Emergency and Essential Surgical Care, which surveyed infrastructure, human resources, types of surgical interventions and equipment in each facility.
Results Overall, hospitals were well equipped with general patient care and surgical supplies. The majority of hospitals had a basic laboratory (100%), running water (94%) and electricity (82%). More than 75% had the basic supplies needed for general patient care and basic intra-operative care, including sterilization. Almost all hospitals were able to perform major surgical procedures such as caesarean sections (88%), herniorrhaphy (100%) and appendectomy (94%), but formal training of providers was limited: a few hospitals had a fully qualified surgeon (29%) or obstetrician (36%) available.
Conclusions The greatest barrier to improving surgical care at district hospitals in Ghana is the shortage of adequately trained medical personnel for emergency and essential surgical procedures. Important future steps include strengthening their number and qualifications.
Évaluation de la capacité pour la chirurgie, l’obstétrique et l’anesthésie dans 17 hôpitaux du Ghana en utilisant un outil d’évaluation de l’OMS
Objectifs: Surveiller les caractéristiques de l’infrastructure, du personnel, des équipements et procédures pour les soins de chirurgie, d’obstétrique et d’anesthésie dans 17 hôpitaux au Ghana.
Méthodes: L’évaluation a été réalisée par les bureaux nationaux de l’OMS à l’aide de ‘l’outil d’analyse de situation de l’OMS pour l’évaluation des soins chirurgicaux d’urgence et essentiels’, portant sur l’infrastructure, les ressources humaines, les types d’interventions chirurgicales et l’équipement dans chaque service.
Résultats: Globalement, les hôpitaux étaient bien équipés avec des fournitures pour les soins généraux aux patients et chirurgicaux. La majorité des hôpitaux avait un laboratoire de base (100%), de l’eau courante (94%) et de l’électricité (82%). Plus de 75% avaient des fournitures de base nécessaires pour les soins généraux aux patients et de base pour des soins intra-opératoires, y compris la stérilisation. Presque tous les hôpitaux étaient en mesure d’effectuer des interventions chirurgicales majeures telles que la césarienne (88%), l’herniorraphie (100%) et l’appendicectomie (94%), mais la formation officielle des prestataires était limitée: peu d’hôpitaux disposaient d’un chirurgien entièrement qualifié (29%) ou un obstétricien (36%).
Conclusions: Le plus grand obstacle à l’amélioration des soins chirurgicaux dans les hôpitaux de district au Ghana est le manque de formation appropriée du personnel médical d’urgence et pour les interventions chirurgicales essentielles. Les prochaines étapes importantes comprennent le renforcement de leur nombre et leurs qualifications.
Evaluación, mediante el uso de la herramienta de la OMS, de la capacidad de cirugía, obstetricia y anestesia en 17 hospitales de Ghana
Objetivos: Evaluar las características de la infraestructura, el personal, los equipos y procedimientos de cuidados quirúrgicos, obstétricos y anestesia de 17 hospitales de Ghana.
Métodos: La evaluación se completó en las oficinas locales de la OMS utilizando la herramienta de la OMS para el análisis situacional para la evaluación de los cuidados esenciales de emergencia y cirugía, la cual evalúa la infraestructura, los recursos humanos, los tipos de intervención quirúrgica y los equipos de cada centro.
Resultados: En general, los hospitales estaban bien equipados con suministros quirúrgicos y de cuidados generales del paciente. La mayoría de los hospitales tenían un laboratorio básico (100%), agua corriente (94%), y electricidad (82%). Más del 75% tenían los suministros básicos requeridos para realizar cuidados generales de pacientes y cuidados básicos intra-operativos, incluyendo esterilización. Casi todos los hospitales eran capaces de realizar procedimientos quirúrgicos mayores tales como cesáreas (88%), herniorrafía (100%) y apendisectomía (94%), pero el entrenamiento formal para proveedores era limitado: pocos hospitales tenían un cirujano cualificado (29%) o un obstetra (36%) disponible.
Conclusiones: La mayor barrera para mejorar los cuidados quirúrgicos en hospitales distritales de Ghana es la falta de personal médico adecuadamente entrenado para procedimientos esenciales de emergencia y quirúrgicos. Pasos futuros importantes incluyen el aumentar su número y mejorar sus cualificaciones.
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An emerging priority in health systems strengthening in developing countries is emergency and essential surgical care at district hospitals (Ozgediz et al. 2008b; Reich & Takemi 2009). District hospitals in developing countries play an important role as the first level of referral for patients who are presenting with surgical and obstetric conditions (i.e. fractures, obstructed labour, appendicitis and other intra-abdominal emergencies).
It is estimated that surgical and obstetrical conditions account for 11% of the world’s disability-adjusted life years (DALYs) lost each year, with low- and middle-income countries (LMICs) carrying most of this burden (Debas et al.). However, one-third of the population, which is located in the poorest countries, receives only 3.5% of the world’s surgical procedures (Weiser et al. 2008). In Ghana, 30% of 22 million people live on less than US$1.25 per day (UNICEF 2009). A total of 11% of Ghana’s children die before reaching age 5, and the maternal mortality ratio is 540 maternal deaths per 100 000 live births. Ghana has only 1.5 physicians per 10 000 population (UNICEF 2009).
Improving surgical, obstetrical and anaesthesia care capacities in district hospitals within low-income countries is an essential component of health care system delivery and also has the potential for being a cost-effective investment (Laxminarayan et al. 2006). However, data assessing the number and types of surgical workers, equipment and procedures available at district-level facilities in developing countries are rare. Ghana was chosen for the study because of the interest within the Ghana Health Service and among academic surgeons to improve surgical care delivery and access. Particular emphasis was placed on documenting and examining evidence relating to the capacity of first referral hospitals to provide surgical services. Governmental health services (a.k.a. Ghana Health Service) operate at three levels – the sub-district, the district and the region. At the sub-district level, health centres, health posts and their community outreach workers provide basic preventive and curative services for a population of approximately 20 000 people. District hospitals serve 100 000–200 000 people and typically have 50–200 beds. There are over 120 district hospitals in Ghana (Ghana Health Service 2009). At the regional level and above, each of Ghana’s 10 regions has a regional referral hospital, and there are also three teaching hospitals in the country, all of which provide higher level referral care.
Our objectives were to document the surgical, obstetrical and anaesthetic capacity, particularly infrastructure characteristics, personnel, equipment and procedures performed in 17 facilities in Ghana.
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All hospitals were first level referral centres. A total of 82% (n = 14) were district hospitals, and 18% (n = 3) were private, non-governmental or mission hospitals (Table 1). The average number of beds at each facility was 182 (data not shown). All the hospitals surveyed had at least one operating room, with 59% reporting at least two. The average size of each hospital’s catchment area was 148 115 people, and, on average, 1136 patients underwent a surgical procedure (both major and minor) during the previous year, of which 9% were paediatric patients under 15 . On average, the selected hospitals were 311 km (range 79–847 km) away from the country’s capital, Accra. The average distance patients had to travel for services offered by the hospital was 74 km, and the average distance patients had to travel to reach a higher level referral centre was 98 km.
Table 1. Hospital facility characteristics and resources
| Classification of hospital|
| District hospital||82% (14/17)|
| Private/NGO/Mission hospital||18% (3/17)|
|Infrastructure and resources|
| Laboratory (haemoglobin, urinalysis)||100% (17/17)|
| Operating room||100% (17/17)|
| Running water||94% (16/17)|
| Electricity||82% (14/17)|
| Operational power generator||82% (14/17)|
| Dedicated area for post-operative care||64% (11/17)|
| Dedicated area for emergency care||59% (10/17)|
| Blood bank||53% (9/17)|
The majority of hospitals reported having basic laboratory services, running water and electricity (Table 1). Twelve of the 17 hospitals had a blood bank at least some of the time. Eleven hospitals reported no formal designated area for post-operative care or for emergency care (Table 1).
In total, there were 232 full-time surgical, obstetrical and anaesthetic providers in the 17 facilities (Table 2). Midwives who perform minor obstetrical surgical procedures comprised most (73%) of the surgical, obstetrical and anaesthesia workforce. Surgeons who had completed a formal residency in general surgery comprised only 3%, as did obstetricians/gynaecologists. General medical officers providing surgical care comprised 9% of the workforce (Table 2).
Table 2. Surgical, obstetrical and anaesthesia care providers
|Healthcare provider||Percentage of total surgical, obstetric and anaesthesia care workforce (%)|
|Surgeons (fully qualified)||3*|
|Anaesthesiologists (fully qualified)||0|
|Obstetrician/Gynaecologists (fully qualified)||3|
|General doctors performing surgical, obstetrical and gynaecological procedures||9|
|General doctors providing anaesthesia||0|
|Anaesthesia non-physician providers||11|
|Surgical non-physician providers||1|
A total of 82% of the hospitals reported having at least one general medical officer available full-time to provide surgical care (Table 2). Less than 30% of the surveyed facilities reported having a fully qualified surgeon, and less than 40% reported having a qualified obstetrician/gynaecologist available to perform surgical or obstetrical procedures (Table 2). All but two hospitals reported having a midwife or paramedic who also performed minor surgical procedures.
All facilities reported having some basic supplies for general patient care (Table 3). More than 90% of the hospitals had the following were readily available: stethoscopes, examination tables, blood pressure cuffs, adhesive tape, sterile gauze dressings, sterile bandages and soap. Foley catheters, batteries for flashlights, suction pumps, thermometers and light sources were available in more than 70% of the facilities. The least common general patient supply item available in these 17 facilities was intravenous infusor bags (present in 56% of the facilities) and splints for extremities (present in 35% of the facilities). All hospitals had at least one basic intra-operative item needed for basic surgical care (Table 3). More than 80% reported that the following were readily available: scalpels, retractors, sutures, scissors, forceps, sterile gloves and sterilizer.
Table 3. Availability of hospital supplies and equipment
|Equipment and supplies*||Overall average percentage of items in the category available at all times (%)|
|General patient care supplies||86|
|Intra-operative equipment and supplies||78|
|Anaesthesia equipment and supplies (adult-sized)||54|
|Anaesthesia equipment and supplies (paediatric-sized)||40|
Table 4 provides an overview of the types of procedures performed at the surveyed hospitals. Almost all hospitals reported being able to perform major surgical procedures such as hernia repair (strangulated or elective), appendectomy and laparotomy. More than 80% had the capability to perform caesarean sections, dilatation and curettage and tubal ligations. At times, however, 6–18% of the hospitals had to refer patients requiring these procedures. A total of 59% offered cataract removal, usually on an intermittent basis. Many reported that rotating ophthalmologists came to the hospital periodically.
Table 4. Overview of procedures and referral patterns
|Procedure||Percentage of facilities who perform (%)||Percentage of facilities who sometimes refer (%)||Procedure||Percentage of facilities who perform (%)||Percentage of facilities who sometimes refer (%)|
|Burn management procedures||Paediatric surgery procedures*||28||57|
| Acute burn management||100||35||Urology procedures|
| Contracture release, skin grafting||35||71|| Male circumcision||88||0|
|Ear, nose and throat procedures|| Hydrocele repair||76||12|
| Removal of foreign body||94||35|| Cystostomy||65||29|
| Cricothyroidotomy, tracheostomy||12||76|| Urethral stricture repair||35||47|
|General surgery procedures||Other|
| Herniorrhaphy||100||12|| Incision and drainage of abscess||100||0|
| Appendectomy||94||12|| Suturing†||100||0|
| Laparotomy‡||82||35|| Wound debridement||100||12|
|Obstetrical/gynaecology procedures|| Resuscitation§||100||12|
| Dilatation and curettage||94||6|| Biopsy¶||65||24|
| Caesarean section||88||18|| Chest tube insertion||41||53|
| Tubal ligation||82||6||Anaesthesia|
|Ophthalmology procedures|| Ketamine anaesthesia||82||6|
| Cataract removal||59||29|| General anaesthesia||71||29|
|Orthopaedic procedures|| Spinal anaesthesia||76||12|
| Fracture (closed treatment)||76||35|| Regional anaesthesia||65||24|
| Joint dislocation||64||29|| || || |
| Amputation||59||53|| || || |
| Fracture (open treatment)||12||76|| || || |
| Drainage of osteomyelitis or septic arthritis||41||59|| || || |
Most district hospitals did not have the capacity to manage airway emergencies. Open reduction and internal fixation of fractures were rarely performed, as was any type of paediatric surgery other than paediatric herniorrhaphy (herniotomy). An average of 29% of the facilities reported referring patients requiring one of the procedures to a regional hospital. The most common overall reason that the hospital referred patients for one of these procedures was attributable to lack of surgical skills among the physician staff (27%). The second most common reason was non-functional equipment (16%), followed by lack of supplies and drugs (13%).
More than 80% of hospitals reported having nurse anaesthetists to provide anaesthesia care (Table 3). While 76% of the hospitals reported having a functional anaesthesia machine, only 18% reported having basic anaesthesia equipment required for endotracheal intubation (and for emergency cricothyroidotomy) (Table 4). The majority of hospitals did report, however, being able to perform general anaesthesia, spinal anaesthesia, ketamine anaesthesia and regional anaesthesia. There were no physician anaesthesiologists in any of the facilities.
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This study aimed to assess the surgical, obstetrical and anaesthesia capacity in terms of infrastructure characteristics, personnel, procedures and referrals as well as equipment at 17 health facilities throughout Ghana utilizing the WHO Tool for Situational Analysis. Although the health facilities were generally well equipped to provide obstetrical and general surgical care, formal training of those providing surgical and anaesthesia care was limited. There were only six fully trained surgeons working in these 17 hospitals (as defined by completing formal residency training). Unsurprisingly, the most common reason for referral of a patient in need of a particular procedure was the lack of adequately skilled medical personnel to perform the procedure.
Several studies that describe the availability of surgical and anaesthesia equipment at district hospitals in developing countries used the same WHO tool. In Sierra Leone, 40% of surveyed hospitals had no oxygen supply and only 20% had a functioning anaesthesia machine (Kingham et al. 2009). Comparatively in Ghana, 77% had oxygen supply and 76% had a functioning anaesthesia machine. In Sri Lanka, lack of equipment and supplies was commonly cited as a limiting factor in providing adequate surgical care (Taira et al. 2009). Only 59% of the facilities in Sri Lanka had examination gloves and 54% had sterile gloves (Taira et al. 2009), while in our study, 94% of the hospitals reported that sterile gloves were readily available. In Uganda, safe anaesthesia as delineated by the International Standards of the World Federation of Societies of Anesthesiologists was available in only 23%, 13% and 6% of facilities for adults, children and women undergoing caesarean section, respectively (Hodges et al. 2007). These facilities lacked the minimal equipment needed to provide anaesthesia. Thus, Ghana’s facilities are somewhat better equipped than those in its neighbouring countries.
Ghana had 2026 medical officers in 2006 (Ghana MOH 2007). The Ministry of Health estimates a shortage of at least 1706 Medical Officers, which represents an 84% increase in the number of Medical Officers in the country and a seemingly insurmountable shortage in the near term. The exact extent of the shortage of fully qualified general surgeons is not known, but as only 7–10 fully qualified surgeons graduate each year, it must be considerable (A.A.J. Hesse, F. Abantanga, personal communication).
Ghana shares with other African nations the plight of shortages of appropriately trained healthcare providers, particularly in rural areas and for basic and essential surgical services (Chen et al. 2004; Ozgediz et al. 2008c). In Uganda, for instance, there are only 75 fully trained general surgeons for a population of nearly 30 million people (0.25 surgeons/100 000 population), and there is only one post-graduate training programme that graduates 3–5 trainees each year (Ozgediz et al. 2008a,b,c). In total in East Africa, there are only 400 surgeons responsible for providing surgical care to more than 200 million people (0.2 surgeons/100 000 population) (Derbew et al. 2006). In contrast, the United States has 7.5 general surgeons per 100 000 population (Kwakwa & Jonasson 1997). Approaches to addressing this human resource shortage have included short-term surgical training for medical officers or non-physician surgical providers who provide medical care at rural or district hospitals (Evans et al. 2009). However, widespread success and implementation of this approach has not been achieved (McCord et al. 2009; Pereira et al. 2007). Medical Officers in rural hospitals in developing countries commonly abandon their posts because of a lack of support services available in the hospital and because they have more lucrative opportunities in urban areas (Evans et al. 2009). Often, positions for physicians capable of providing surgical care in rural areas offer few opportunities for professional development, and the salaries are usually much lower than these physicians could earn in more urban areas.
For obstetrical care, there were only seven fully qualified obstetricians/gynaecologists who had completed a formal residency in obstetrics/gynaecology reported in our study to perform caesarean sections and other major gynaecological/obstetrical procedures. Many other countries in Africa face a similar situation. In Senegal, there are only 15 Medical Officers skilled enough to perform caesarean sections for approximately 11 million people (De Brouwere et al. 2009). India has 771 public sector obstetricians/gynaecologists but needs 6000 for its 2000 first referral units in rural areas (Desai 2006; Evans et al. 2009). The country has attempted to address this issue through pilot training programmes of medical officers to provide comprehensive obstetrical care (i.e. caesarean sections, neonatal resuscitation and blood transfusions) with some success, although 8 of the 16 Medical Officers who were trained were unable to perform any caesarean sections partly attributable to the lack of facility capacity (Evans et al. 2009).
There were no physicians who provided anaesthesia at the district hospitals included in our study, although there were 25 formally trained nurse anaesthetists (with advanced diplomas in anaesthesia). In other developing countries, the number of physician anaesthesiologists is also small. In Afghanistan, with a population of 32 million people, there are only nine anaesthesiologists, and Bhutan, with a population of 672 425, has only 8 (Hodges et al. 2007). In comparison, there are 12 000 anaesthesiologists for a population of 64 million in the United Kingdom (Walker et al. 2007).
One of the limitations of our study is that only 17 of the more than 120 district hospitals in Ghana were included in the study. Therefore, we cannot determine the degree to which these findings are representative of all hospitals or even of all district hospitals. Another limitation is that the time to be travelled per catchment area was not collected. We were also not able to completely characterize and determine the number and types of surgical procedures performed annually to determine the burden of surgical conditions in Ghana. This information would be helpful in prioritizing procedures that are regularly performed in health facilities. Nevertheless, our study does provide the best available data thus far regarding the adequacy of district hospitals in Ghana to provide surgical care.
In conclusion, the purpose of this study was to assess the surgical, obstetrical and anaesthesia capacity in the surveyed hospitals in Ghana. The greatest barrier to improving surgical care at district hospitals in Ghana is the limited training received by medical personnel currently performing emergency and essential surgical and obstetric procedures. The hospitals in our survey are relatively well equipped. Our study shows that the lack of adequate emergency and essential surgical care is mostly attributable to the shortage of skilled surgical providers and not necessarily attributable to unavailable equipment or facilities. Important future steps include increasing the number and improving the formal training of providers of emergency and essential surgical services at first level referral facilities.