Emergency and essential surgical capacity assessment in Gimbichu district: cross-sectional study : IJS Global Health

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Cross Sectional Study

Emergency and essential surgical capacity assessment in Gimbichu district: cross-sectional study

Gebregzi, Amare H. BSc, MSca,; Meshesha, Berhane R. MD, PhDb; Chekol, Tadesse S. BSc, MScb; Bereded, Eyobed K. BSc, MPHb; Adem, Getachew Y. BSc, MPHb; Beshir, Hassen M. MD, MPHb; Taye, Desalegn B. MD, MPHb; Negash, Fitsum T. BSc, MScc; Andarie, Netsanet B. BSc, MSc

Author Information
International Journal of Surgery: Global Health: September 2022 - Volume 5 - Issue 5 - p e78
doi: 10.1097/GH9.0000000000000078
  • Open

Abstract

Ethiopian government through Federal Ministry of Health second health sector transformation plan (HSTP II, 2020/21–2025) aims to improve the health of population through the realization of accelerating progress toward Universal Health Coverage (UHC), protecting people from emergencies, creating district transformation, and making the health system responsive to people’s needs and expectations. The newly launched HSTP II is the second phase of a 20-year health sector strategy entitled as “Envisioning Ethiopia’s Path to Universal Health Coverage through Strengthening of Primary Health Care”1.

The district transformation agenda aims to improve primary health care access, quality, and equity, while also enhancing community ownership and build a resilient district health system. It also aids in the achievement of HSTP objectives and the advancement of other transformation agendas. As a result, district transformation aspires to develop high-performing districts that support the health sector’s mission and meet the needs of the communities they serve2.

Effectively integrating primary health coverage and surgical and anesthesia care through bottom-up approach to fulfill universal health coverage is a crucial step to avail essential surgical and emergency service in low and middle-income countries2.

The district transformation plan recognizes significant performance gaps between regions, districts, and health facilities, making it challenging to offer equitable and high-quality basic health care to all members of the community. Limited implementation capacity, improper human resource allocation, and a lack of financial resources are some of the key causes of heterogeneity in implementation. Gimbichu district has been selected as one of the model districts for implementing the district transformation plan3. In line with the district transformation agenda, saving life through safe surgery plans to lower essential and emergency surgical service at the district level establishing surgical services at health center level4.

A study done in Tanzania analyzing volume, operations, and financing of surgical service showed that nonphysical inefficiencies in the system needs to be addressed to improve surgical capacity and workflow. They also came to the conclusion that improving physical resources alone would not be enough to improve access to care in this region, or in many other low and middle-income countries5.

A mixed-methods assessment of surgical capacity in Ethiopia’s Amhara and Tigray regions revealed that the average number of surgical cases performed per week is 56, with a limited range of surgeries and inadequate service delivery across facilities. At hospitals, basic facilities such as electricity and running water were claimed to be in low supply. It was common to encounter diagnostic equipment that was either unavailable or broken. The vast majority of surgical and anesthetic services were also performed by nonphysician clinicians6.

A cross-sectional survey done in South Gondar zone of the Amhara region also demonstrated discrepancies in infrastructure, human resources, service provision, and essential equipment and supplies compromising the capacity of hospitals to deliver emergency and essential surgical care (EESC) and effectively address the increasing surgical burden of disease and injury7.

In order to offer equitable and accessible surgical service delivery in Gimbichu district, it is necessary to understand the root causes of the emergency and essential surgical and anesthetic service gaps. The study aims to assess the surgical and anesthesia service delivery capacity of Gimbichu district using WHO’s emergency and essential surgical care situational analysis assessment tool.

Method

Gimbichu is one of the administrative zone in Ethiopia’s Oromia regional state. According to a statistical report released by the Zonal Health Bureau in January 2022, the city has a total population of 133,031 people, with an annual population growth rate of 7.7%, of whom 61,502 men and 60,122 women. Gimbichu district has been chosen as a model district to implement the national district transformation program. In the Gimbichu district, there are 5 regional government-owned health centers and 33 health posts. Six privately owned primary clinics, 2 drug stores, and 1 rural drug vendor are located in the area. These health facilities has a referral linkage with Bishoftu and Mojo hospital.

The study is done after obtaining an approval letter from the Federal Ministry of Health, Health service Quality directorate and exempted for ethical clearance by Oromia regional health bureau ethical review board since. The eligibility criteria for the health facilities included location in rural or semiurban areas, availability of at least 5 beds for inpatient admission of surgical patient, capacity to perform surgical operations, and an informed consent to participate in the study. The study setting for this assessment were the public health facilities providing health service across the Oromia region, East Shao Zone. This includes comprehensive hospital, primary hospital, and health centers. The study is conducted from 1 to 30 of January 2022.

The tool is designed by WHO for situational analysis to assess emergency and essential surgical care, which is part of the WHO integrated management for emergency and essential surgical care (IMEESC) toolkit. The questionnaire consists of the four components; infrastructure, human resources, interventions, and EESC equipment and supplies. It has different categories to assess 8 cadres of surgical workforce, 35 surgical interventions, and 33 different pieces of equipment. Two comprehensive hospitals (Bishoftu and Mojo Hospitals), 5 health facilities (Chef Donsa Health Center, Koka Health Center, Goro Tigri Health Center, Ared Goro Health Center, and Dobi Health Center), and 10 health posts were randomly selected to receive the WHO tool for situational analysis to assess EESC. SPSS version 26 statistical software was used to analyze the data.

A cross-sectional survey design is deployed on selected health facilities to assess the surgical and anesthesia service delivery capacity using WHO’s emergency and essential surgical care situational analysis tool. The study unit for this assessment were comprehensive hospitals, general hospitals, primary hospitals, health centers, health posts, and any other health care delivery system. The target populations are health facilities selected through random sampling techniques. Document review, interview using structured questioner with management team and surgical workforce of the health facility, and direct observation using structured checklist used to collect data.

Result

Infrastructure

More than 1.5 million people are served by 5 health centers and 2 adjacent referral hospitals in Gimbichu district, Oromia regional state. The total amount of surgical procedures performed in a year the health centers and nearby referral hospitals is 2838 (Table 1).

Table 1 - Gimbichu district health facility infrastructure, January 2022.
Parameters Chefe Donsa HC Koka HC Goro Tigri HC Dobi HC Areda Goro HC Bishoftu Hospital Mojo Hospital
Population served by this health care facility 45,042 14,100 21,492 22,894 26,490 12,000,000 361,457
No. beds 4 0 2 2 1 230 78
No. total admissions in 1 y 94 0 8 15 16 7151 NS
No. total outpatients in 1 y 23,983 5450 14,520 9977 17,294 158,546 NS
No. total functioning operating rooms (major and minor) 0 0 0 1 0 5 3
No. patients at this facility requiring major and minor surgical (including obs/gyn) procedures per year 197 0 4 1 0 2338 298
No. children (aged younger than 15 years) at this facility requiring surgical procedures per year 28 1 4 12 0 0 24
No. patients to this facility that you refer for surgical intervention to a higher level facility per year 21 10 30 10 35 0 356
How far (in km) does the average patient travel to get to your health facility for surgical services? 34 12 30 150 13 45 35
If you do not provide surgical services, how far does the average patient travel to access surgical services? 34 51 30 50 68 10 23
NS indicates no service since it is newly opened health facility.

In the district’s health facilities, only 42.86% of WHO-recommended essential health facility infrastructure has always been available (Table 2).

Table 2 - Gimbichu district health facility infrastructure, January 2022.
All the Time Sometime Not Available
Do you have oxygen cylinder or concentrator supply with mask and tubing? 2 2 3
Do you have running water? 4 2 1
Do you have an electricity source/operational power generator? 5 2 0
Do you have a functioning anesthesia machine? 4 3 0
Do you keep medical records? 2 0 5
Do you have an area designated for emergency care? 7 0 0
Do you have an area designated for postoperative care? 7 0 0
Do you have management guidelines available for emergency care? 2 0 5
Do you have management guidelines available for surgery? 1 0 6
Do you have management guidelines available for anesthesia? 0 0 7
Do you have management guidelines available for pain relief? 1 0 6
Do you have a blood bank available at the facility? 1 0 6
Do you have a facility to test hemoglobin and urine? 5 2 0
Do you have a functioning x-ray machine available? 1 0 6
Do you have a functioning pulse oximeter available? 3 0 4

Surgical workforce assessment

There is no surgical workforce (Surgeons, Obstetricians and Anesthetists) found in Gimbichu district health facilities. The nearby health facilities found in Ade’a district, that is, Bishoftu and Mojo Hospitals has a total of 23 surgical workforce serving >1.5 million population in the catchment area.

Surgical interventions/surgical service directory

According to WHO recommended list of surgical and anesthesia interventions to be performed as essential and emergency surgical package, 18.32% of the interventions/procedure are performed by Gimbichu district health facilities. The nearby health facilities where Gimbichu district health facilities linked to refer surgical patients undergoes 56% of procedures listed as emergency and essential surgical services (Fig. 1).

F1
Figure 1:
Gimbichu district health facilities surgical and anesthesia service availability: January 2022.

Equipment and supplies

The recommended equipment and supplies required to establish emergency and essential surgical service are classified in to 3 categories as: capital outlays17, renewable items15, and supplementary equipment for use by skilled health professionals9. The essential equipment and supplies for surgical and anesthetic services are available in 80.67% of capital outlays, 82.85% of renewable items, and 63.77% of supplementary equipments at health institutions in the district (Table 3).

Table 3 - Equipment and supplies availability in Gimbichu district and nearby health facilities: January 2022.
Equipment and Supplies Availability Chefe Donsa HC Koka HC Goro Tigri Dobi HC Areda Goro Bishoftu Hospital Mojo Hospital
Capital outlays Full available 17 17 17 3 8 17 17
Partially available 0 0 0 5 1 0 0
Absent 0 0 0 9 8 0 0
Renewable items Full available 15 15 9 4 15 15 14
Partially available 0 0 3 3 0 0 0
Absent 0 0 3 8 0 0 1
Supplementary equipment Full available 9 9 9 0 3 9 5
Partially available 0 0 0 5 0 0 0
Absent 0 0 0 4 6 0 4

Discussion

There is a national initiative to improve district health system performance by cascading surgical and anesthetic services into district and zonal health facilities by investing in infrastructure and human resource4. This effort has resulted in the construction of 410 surgical centers around the country. The lack of a surgical workforce and a scarcity of surgical materials have been recognized as hurdles to providing surgical services to their community. Thirty-two of the health centers have begun to offer health services in the newly established operation room blocks. The findings of this study also revealed that in Gimbichu district, Chefe Donsa health center, and district-level infrastructures for providing surgical services were met. During data collection, the highlighted gaps were a significant scarcity of surgical workforce and district level commitment to assign sufficient resources for surgical workforce recruitment and retention was a paramount finding4.

The total number of admissions were 133 per year, resulting in a 0.19% hospital admission rate in 9 beds. During the study period, the health facilities referred 282 surgical patients to surrounding health facilities with average distance of 46.6 km to linked health facility with surgical service. These results is far below the prescribed proportion of hospital beds recommendation by WHO global heath observatory, that is, 1 per 1000 population. These findings are similar to study done in St Paul millennium medical college hospital here in Addis Ababa. Main reason for referrals was lack of bed and recommends policy revision to enhance hospitals’ capacity to better absorb surgical patients7.

Basic infrastructures required to undergo emergency and essential surgical service were fulfilled per district based allocation of operation theater building blocks and equipment supplies. There is significant shortage in surgical workforce which is below the standard set for district level surgical service provision. These relates with studies done in sub-Saharan countries having difficulty to fulfill 20 surgical workforce per 100,000 population8.

Minor surgical treatments such as incision and drainage, wound debridement, suturing of lacerations, and superficial lump excisions are not available at all health centers. Herniorrhaphy, appendectomy, and excision biopsies are all referred to surrounding health facilities as intermediate operations. Contrary to the result of this study, aforementioned surgical interventions are provided in rural areas of southeast Nigeria9.

While collaboration and learning between health centers and health posts were excellent, referral linkage between health centers and hospitals in neighboring districts was lacking. The partnership between the health facilities is not governed by any binding agreement and is not dictated by the receiving health institution’s service directory. The poor collaboration and referral linkage is also noticed in study done on surgical ambulance referrals in sub-Saharan Africa in Tanzania, Malawi, and Zambia which increase the economic burden to the community and health facility10.

In Gimbichu district health facilities, an insufficient supply of equipment and supplies was discovered to be the other major cause of surgical referral. The health centers are in desperate need of capital expenditures to fulfill surgical and anesthesia materials and machines, renewable items, and auxiliary equipment for specialized surgical and anesthesia procedures. In most cases, systemic inefficiencies such as inadequate funding, crumbling infrastructure, supply shortages, and manpower shortages compromised district hospital operations in sub-Saharan Africa, resulting in a widespread loss of confidence in district-level health services12–15. Patients frequently bypass lower-level hospitals in favor of higher-level facilities. As a result, referral hospitals are overburdened with noncomplex and nonessential surgery. This is partly due to inadequate awareness of the community on the service provided by district health facilities. This is majorly due to low utilization rate of health facility service directory. In order to limit unnecessary exploitation of national referral hospitals, efforts to reform referral systems in low-income nations require that primary and secondary level hospital services be strengthened and expanded16.

Building community health extension professionals’ competence and utilizing a service directory for surgical patient referral and linkage can dramatically reduce out-of-pocket household expenditures associated with emergency and necessary surgery. The economic costs of untreated surgical diseases considerably outweigh the costs associated with expanding surgical care17. Essential surgery-related out-of-pocket costs are extremely expensive in Malawi, resulting in catastrophic outcomes, particularly for individuals who are already impoverished and at danger of additional impoverishment18.

Conclusion and recommendation

Advocacy session to engage district level cabinet members to prioritize health and surgical service to improve commitments for realization of woreda transformation agenda’s. It is also mandatory to incorporate emergency and essential surgical and anesthesia care as the component of Essential Health Service Package (EHSP). Further improvement areas includes surgical workforce deployment and expanding the surgical capacity of health facilities in Gimbichu district and nearby referral hospitals. Building the capacity of health extension professionals on utilization of health facility service directorate, community level surgical condition assessment, referral and linkage needs to be priority activity to cement responsive primary health system to community surgical demand.

Ethical approval

Ethical approval is not required and waved by Ministry of Health.

Sources of funding

Ministry of Health, Health Service Quality Directorate.

Authors’ contribution

All authors provided critical feedback and helped shape the research, analysis and manuscript.

Conflicts of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)

MT1/1/45/465.

Guarantor

Ministry of Health, Ethiopia.

Acknowledgments

The authors acknowledge the Ministry of Health’s Health Service Quality Directorate for financially funding the research. The study received substantial technical support from USAID’s Health Workforce Improvement program and the Ethiopian Association of Anesthetists.

References

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Keywords:

Emergency and essential surgical and anesthesia care; Primary health care units; Surgical access

Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of IJS Publishing Group Ltd.