Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hospitals using a WHO assessment tool

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1 Tropical Medicine and International Health doi: /j x volume 15 no 9 pp september 2010 Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hospitals using a WHO assessment tool Shelly Choo 1, Henry Perry 2, Afua A. J. Hesse 3, Francis Abantanga 4, Elias Sory 5, Hayley Osen 1, Charles Fleischer-Djoleto 6, Rachel Moresky 7, Colin W. McCord 8, Meena Cherian 9 and Fizan Abdullah 1 1 Department of Surgery, Johns Hopkins University, Baltimore MD, USA 2 Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA 3 Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana 4 Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana 5 Director-General, Ghana Health Services, Accra, Ghana 6 World Health Organization Country Office, Accra, Ghana 7 Department of Medicine, Columbia University Medical Center, New York, NY, USA 8 Department of Surgery, Columbia University Medical Center, New York, NY, USA 9 Emergency and Essential Surgical Care Program, Department of Essential Health Technologies, Health Systems and Services, World Health Organization Headquarters, Geneva, Switzerland Summary 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. keywords Ghana, surgery, anaesthesia, obstetrics, Africa Introduction 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 middleincome 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 live births. Ghana has only 1.5 physicians per 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 ª 2010 Blackwell Publishing Ltd 1109

2 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 people. District hospitals serve people and typically have 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. Methods In 2009, WHO collected information with the Ministry of Health Ghana on 17 health facilities. A questionnaire called the WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was used. It was developed by WHO Global Initiative Emergency and Essential Surgical Care (GIEESC) members in 2007 ( EESCsurvey.pdf, WHO 2010). The assessment tool addresses four elements of surgical services: infrastructure, human resources, types of surgical interventions and equipment. All data were entered into the WHO database. The average number of kilometres patients travelled to the facility or to a referral facility was calculated by taking the average of the midpoints of the range of kilometres the patients travelled as reported by the hospitals. The percentage of hospitals performing procedures or referring for a particular procedure was calculated by dividing the number of hospitals reporting they performed the procedures or referring for a particular procedure by the total number of hospitals. To determine the overall availability of general patient care supplies, intra-operative equipment and supplies, anaesthesia equipment and supplies for adults, and anaesthesia equipment and supplies for children, the percentage of supply items the hospitals had available all the time under the type of category was noted. Then, the averages of the percentages were determined for each category. A detailed list of the equipment and supplies surveyed is found in Appendix 1. Results 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 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 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. 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). A total of 82% of the hospitals reported having at least one general medical officer available full-time to provide Table 1 Hospital facility characteristics and resources Characteristics 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) 1110 ª 2010 Blackwell Publishing Ltd

3 Table 2 Surgical, obstetrical and anaesthesia care providers Healthcare provider Surgeons (fully qualified) 3* Anaesthesiologists (fully qualified) 0 Obstetrician Gynaecologists 3 (fully qualified) General doctors performing 9 surgical, obstetrical and gynaecological procedures General doctors providing anaesthesia 0 Anaesthesia non-physician providers 11 Surgical non-physician providers 1 Paramedics Midwives 73 total surgical, obstetric and anaesthesia care workforce (%) *This includes foreign fully qualified surgeons who are practicing at district hospitals in Ghana. 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 Table 3 Availability of hospital supplies and equipment Equipment and supplies* General patient care supplies 86 Intra-operative equipment 78 and supplies Anaesthesia equipment 54 and supplies (adult-sized) Anaesthesia equipment 40 and supplies (paediatric-sized) Overall average percentage of items in the category available at all times (%) *Overall average percentage of items in the category available at all times was calculated by first determining the percentage of supplies the hospitals had available all the time under the type of category (i.e. general patient care supplies, intra-operative equipment and supplies, etc.). Then, the averages of the percentages were taken for all the hospitals for each category. List of supplies can be found in Appendix 1. 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 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. 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. Discussion 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. ª 2010 Blackwell Publishing Ltd 1111

4 Table 4 Overview of procedures and referral patterns Procedure perform (%) sometimes refer (%) Procedure perform (%) sometimes refer (%) Burn management procedures Paediatric surgery procedures* Acute burn management Urology procedures Contracture release, skin grafting Male circumcision 88 0 Ear, nose and throat procedures Hydrocele repair Removal of foreign body Cystostomy Cricothyroidotomy, tracheostomy Urethral stricture repair General surgery procedures Other Herniorrhaphy Incision and drainage of abscess Appendectomy Suturing Laparotomyà Wound debridement Obstetrical gynaecology procedures Resuscitation Dilatation and curettage 94 6 Biopsy Caesarean section Chest tube insertion Tubal ligation 82 6 Anaesthesia Ophthalmology procedures Ketamine anaesthesia 82 6 Cataract removal General anaesthesia Orthopaedic procedures Spinal anaesthesia Fracture (closed treatment) Regional anaesthesia Joint dislocation Amputation Fracture (open treatment) Drainage of osteomyelitis or septic arthritis *Congenital hernia repair, club-foot treatment, neonatal surgery, cleft lip repair. For wound closure, episiotomy, cervical and vaginal lacerations. àfor the treatment of acute abdomen, intestinal obstruction, perforation, injuries, uterine rupture, ectopic pregnancy. For airway and venous access (including peripheral venous cut down). For the removal of lymph node or other superficial mass 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) ª 2010 Blackwell Publishing Ltd

5 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 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 population) (Derbew et al. 2006). In contrast, the United States has 7.5 general surgeons per 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 , has only 8 (Hodges et al. 2007). In comparison, there are 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. Acknowledgements This work was supported by the Bloomberg Philanthropies, the World Lung Foundation, and the Doris Duke Charitable Foundation. References Chen L, Evans T, Anand S et al. (2004) Human resources for health: overcoming the crisis. Lancet 364, De Brouwere V, Dieng T, Diadhiou M et al. (2009) Task shifting for emergency obstetric surgery in district hospitals in Senegal. Reproductive Health Matters 17, Debas HT, Gosselin R, McCord C & Thind A (2006) Surgery. In: Disease Control Priorities in Developing Countries, 2nd edn. ª 2010 Blackwell Publishing Ltd 1113

6 (eds D Jamison, JG Breman, A Meashem, et al.) Oxford University Press, New York, pp Derbew M, Beveridge M, Howard A et al. (2006) Building surgical research capacity in Africa: the Ptolemy project. PLoS Medicine 3, e305. Desai S (2006) Expanding emergency obstetric care: innovative role by federation of obstetric and gynecological societies of India, Delhi. Evans CL, Maine D, McCloskey L et al. (2009) Where there is no obstetrician increasing capacity for emergency obstetric care in rural India: an evaluation of a pilot program to train general doctors. International Journal of Gynaecology and Obstetrics 107, Ghana Health Service (2009) Ghana Health Services, Ed. Ghana Ministry of Health (MOH) (2007) Human Resources for Health Development. Publications/HRH%20ANNUAL%20REPORT% pdf Hodges SC, Mijumbi C, Okello M et al. (2007) Anaesthesia services in developing countries: defining the problems. Anaesthesia 62, Kingham TP, Kamara TB, Cherian MN et al. (2009) Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care. Archives of Surgery 144, discussion 128. Kwakwa F & Jonasson O (1997) The general surgery workforce. American Journal of Surgery 173, discussion Laxminarayan R, Mills AJ, Breman JG et al. (2006) Advancement of global health: key messages from the disease control priorities project. Lancet 367, McCord C, Mbaruku G, Pereira C, Nzabuhakwa C & Bergstrom S (2009) The quality of emergency obstetrical surgery by assistant medical officers in Tanzanian district hospitals. Health Affairs (Millwood) 28, w Ozgediz D, Jamison D, Cherian M et al. (2008a) The burden of surgical conditions and access to surgical care in low- and middle-income countries. Bulletin of the World Health Organization 86, Ozgediz D, Kijjambu S, Galukande M et al. (2008b) Africa s neglected surgical workforce crisis. Lancet 371, Ozgediz D, Galukande M, Mabweijano J et al. (2008c) The neglect of the global surgical workforce: experience and evidence from Uganda. World Journal of Surgery 32, Pereira C, Cumbi A, Malalane R et al. (2007) Meeting the need for emergency obstetric care in Mozambique: Work performance and histories of medical doctors and assistant medical officers trained for surgery. BJOG 114, Reich MR & Takemi K (2009) G8 and strengthening of health systems: follow-up to the Toyako Aummit. Lancet 373, Taira BR, Cherian MN, Yakandawala H et al. (2009) Survey of emergency and surgical capacity in the conflict-affected regions of Sri Lanka. World Journal of Surgery 34, Unite for Children: UNICEF (2009) At a Glace: Ghana, Ed. Walker I, Wilson I & Bogod D (2007) Anaesthesia in developing countries. Anaesthesia 62, 2 3. Weiser TG, Regenbogen SE, Thompson KD et al. (2008) An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 372, World Health Organization Emergency and Essential Surgical Care. WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC). Corresponding Author Fizan Abdullah, Department of Surgery, Johns Hopkins University, Harvey 319, 600 Wolfe St. Baltimore, MD 21205, USA. Tel.: ; fa@jhmi.edu Appendix 1 List of equipment and supplies General patient care supplies Absorbent cotton wool, adhesive tape, apron (plastic reusable), bandages (sterile), batteries for flashlight, blood pressuremeasuring equipment, capped bottle, disposable needles (size #25, 21 19), examination table, gloves for examination (small, medium and large), intravenous fluid infusion set, IV cannula (sizes 18, 22, 24), light source (lamp & flash light), nasogastric tube, scalp vein infusion set, sharps disposal container, sheeting (plastic) for examination table, soap, sterile gauze dressing, splints for extremity injuries, syringes (2, 10 ml), towel cloth, tourniquet, urinary catheter, wash basin, waste disposal container, stethoscope, thermometer, tongue depressor, vaginal speculum. Intra-operative equipment and supplies Capped bottle for alcohol-based solutions, chest tube insertion equipment, cricothyroidotomy set, eye protection for intraoperative use, face masks, forceps Kocher (no teeth), forceps artery, gloves (sterile), kidney dishes, nail brush (for surgical scrubbing), needle holder, needles, cutting and round-bodied (for suturing), retractor, scalpel handle with a blade, scissors, sterilizer, suture (synthetic, absorbable) ª 2010 Blackwell Publishing Ltd

7 Anaesthesia equipment and supplies (adults) Batteries for Laryngoscope, endotracheal tubes (cuffed, adult sizes), laryngoscope handle, laryngoscope blades (adult), oxygen cylinder concentrator, Magill forceps (adult), mask and tubing to connect to oxygen supply, oropharyngeal airway (adult size), spare bulbs, suction pump. Anaesthesia equipment and supplies (paediatrics) Endotracheal tubes, laryngoscope blade, Magill forceps, oropharyngeal airway. ª 2010 Blackwell Publishing Ltd 1115