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Scaling up Safe Surgery for District and Rural Populations in Africa

Periodic Reporting for period 3 - SURG-Africa (Scaling up Safe Surgery for District and Rural Populations in Africa)

Reporting period: 2020-01-01 to 2021-06-30

Scaling up Safe Surgery for District and Rural Populations in Africa (SURG-Africa) was 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 was testing a supervision model based on findings from an earlier EU FP7 funded study in Zambia and Malawi – COST-Africa 2011-16 ( 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 was: to implement surgical systems, that deliver safe, affordable and sustainable essential surgical services to rural populations in LMICs. The specific objectives were:
1. Strengthen national surgical systems to scale to the national level, deliver – and monitor through a national surgical information system – 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 – comprising clinical, management and systems skills – 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 – at all levels, from community to national level – 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 worked under the guidance of the Ministries of Health in consultation with key local stakeholders such as professional associations and other groups supporting the 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.
The work successfully undertaken in over four years (2017-2021) has enabled SURG-Africa to become recognized in the global arena of initiatives bringing innovative solutions to rural hospitals in 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 was fully aligned with strategic aims of local governments.

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 groups 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, detailed SURG-Africa intervention. It became apparent that targeted interventions are needed in every country because the challenges that SURG-Africa aimed 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 the postoperative care of surgical patients.

SURG-Africa intervention was completed in 2020 after the initial COVID-19 restrictions were lifted in all participant countries. The results show immediate improvements in the way surgical care is provided in the participating facilities. Of importance are improved teamwork of the district surgical teams, infrastructural changes following visiting surgeon's recommendations and reported improved surgical confidence of individual surgical providers. Regular interactions with study participants through series of participatory action research meetings confirmed the positive impact that the project has had.

All studies have been completed and so far the team has published over 30 peer-reviewed papers, with several more in preparation.

Work of SURG-Africa has been presented at numerous conferences including the World Congress of Surgery in Krakow, Poland, where the team had 7 oral presentations and the annual scientific conferences of COSECSA in Maputo (2017), Kigali (2018) and Kampala (2019).
The project has been adopted by ministries and became one of the national priorities in Malawi and Zambia and Tanzania. The SURG-Africa proposed supervision model was 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 have been presented to MsoH, together with budgetary options to continue the intervention beyond the lifetime of the project.

The Managed Clinical Network implemented in all three countries has been particularly successful in Malawi. Two media articles have been published to document the success and one video was produced (available on the project website). The network led to a significant reduction of surgical referrals, improved communication between district and central hospitals, as well as provided a platform for knowledge sharing between surgical specialist and non-specialist providers.
SURG-Africa trainers and district level clinicians after successful operation in Chongwe District H
SURG-Africa designed a surgical logbook which is used in all government hospitals in Malawi and Tanz
SURG-Africa supervision in a district hospital in Zambia
SURG-Africa supervisors providing training to local clinicians in Namwala,Zambia
SURG-Africa team at the project launch, 31 March 2017 Moshi, Tanzania
Surgical patient walking to the OT room in Mangochi, Malawi
SURG-Africa supervisors assisting local team in Mwanza, Malawi
SURG-Africa Train the Trainer workshop participants. Arusha, Tanzania