Skip to main content
SpringerLink
Log in

Quality of Surgery in Malawi: Comparison of Patient-Reported Outcomes After Hernia Surgery Between District and Central Hospitals

  • Original Scientific Report
  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Background

District hospitals in Africa could meet the essential surgical needs of rural populations. However, evidence on outcomes is needed to justify investment in this option, given that surgery at district hospitals in some African countries is usually undertaken by non-physician clinicians.

Methods

Baseline and 2–3-month follow-up measurements were undertaken on 98 patients who had undergone hernia repairs at four district and two central hospitals in Malawi, using a modified quality-of-life tool.

Results

There was no significant difference in outcomes between district and central hospital cases, where a good outcome was defined as no more than one severe and three mild symptoms. Outcomes were marginally inferior at district hospitals (OR 0.79, 95% CI 0.63–1.0). However, in the 46 cases that underwent elective surgery at district hospitals, baseline scores for severe symptoms were worse (mean = 3.5) than in the 23 elective central hospital cases (mean = 2.5), p = 0.004. Also, the mean change (improvement) in symptom score was higher in district versus central hospital cases (3.9 vs. 2.3).

Conclusion

The study results support the case for investing in district hospital surgery in sub-Saharan Africa to increase access to essential surgical care for rural populations. This could free up specialists to undertake more complex and referred cases and reduce emergency presentations. It will require investments in training and resources for district hospitals and in supervision from higher levels.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Meara JG, Greenberg SLM (2015) The Lancet Commission on Global Surgery Global surgery 2030: evidence and solutions for achieving health, welfare and economic development. Surgery 157:834–835. https://doi.org/10.1016/j.surg.2015.02.009

    Article  PubMed  Google Scholar 

  2. Ajayi OO, Adebamowo CA (1999) Surgery in Nigeria. Arch Surg 206–211. http://mbbsdost.com/Surgery-Nigeria-Archives-surgery-Chicago-Ill-1960-Ajayi-OO-Adebamowo-OO–1999-Feb/pubmed/12882203

  3. Chokotho L, Jacobsen KH, Burgess D et al (2015) Trauma and orthopaedic capacity of 267 hospitals in east central and southern Africa. Lancet 385:S17. https://doi.org/10.1016/S0140-6736(15)60812-1

    Article  PubMed  Google Scholar 

  4. Grimes CE, Law RSL, Borgstein ES et al (2012) Systematic review of met and unmet need of surgical disease in rural sub-Saharan Africa. World J Surg 36:8–23. https://doi.org/10.1007/s00268-011-1330-1

    Article  PubMed  Google Scholar 

  5. Ozgediz D, Riviello R (2008) The “other” neglected diseases in global public health: surgical conditions in sub-Saharan Africa. PLoS Med 5:e121. https://doi.org/10.1371/journal.pmed.0050121

    Article  PubMed  PubMed Central  Google Scholar 

  6. Mullan F, Frehywot S, Levy J et al (2007) Non-physician clinicians in 47 sub-Saharan African countries. Lancet (London, England) 370:2158–2163. https://doi.org/10.1016/S0140-6736(07)60785-5

    Article  Google Scholar 

  7. Shawar YR, Shiffman J, Spiegel DA (2015) Generation of political priority for global surgery: a qualitative policy analysis. Lancet Glob Health 3:e487–e495. https://doi.org/10.1016/S2214-109X(15)00098-4

    Article  PubMed  Google Scholar 

  8. WHO|The world health report 2003-shaping the future. WHO Published Online First: 2013. http://www.who.int/whr/2003/en/. Accessed 19 June 2017

  9. Groen R, Sesay S, Kushner A et al (2011) Three-stage repair of a giant inguinal hernia in Sierra Leone: a management technique for low-resource settings. J Surg Case Rep 2011:8. https://doi.org/10.1093/jscr/2011.12.8

    Article  PubMed  PubMed Central  Google Scholar 

  10. Shillcutt SD, Clarke MG, Kingsnorth AN (2010) Cost-effectiveness of groin hernia surgery in the western region of Ghana. Arch Surg 145:954. https://doi.org/10.1001/archsurg.2010.208

    Article  PubMed  Google Scholar 

  11. Mabula JB, Chalya PL (2012) Surgical management of inguinal hernias at Bugando Medical Centre in northwestern Tanzania: our experiences in a resource-limited setting. BMC Res Notes 5:585. https://doi.org/10.1186/1756-0500-5-585

    Article  PubMed  PubMed Central  Google Scholar 

  12. Mbah N (2017) Morbidity and mortality associated with inguinal hernia in Northwestern Nigeria. West Afr J Med 26:288–292. http://www.ncbi.nlm.nih.gov/pubmed/18705428. Accessed 19 June 2017

  13. Uribe-Leitz T, Jaramillo J, Maurer L et al (2016) Variability in mortality following caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: a systematic review and analysis of published data. Lancet Glob Health 4:e165–e174. https://doi.org/10.1016/S2214-109X(15)00320-4

    Article  PubMed  Google Scholar 

  14. Jenkins JT, O’Dwyer PJ (2008) Inguinal hernias. BMJ 336:269–272. https://doi.org/10.1136/bmj.39450.428275.AD

    Article  PubMed  PubMed Central  Google Scholar 

  15. Deshpande P, Bl Sudeepthi, Rajan S et al (2011) Patient-reported outcomes: a new era in clinical research. Perspect Clin Res 2:137. https://doi.org/10.4103/2229-3485.86879

    Article  PubMed  PubMed Central  Google Scholar 

  16. Bausewein C, Simon ST, Benalia H et al (2011) Implementing patient reported outcome measures (PROMs) in palliative care-users’ cry for help. Health Qual Life Outcomes 9:27. https://doi.org/10.1186/1477-7525-9-27

    Article  PubMed  PubMed Central  Google Scholar 

  17. Hawn MT, Itani KM, Giobbie-Hurder A et al (2006) Patient-reported outcomes after inguinal herniorrhaphy. Surgery 140:198–205. https://doi.org/10.1016/j.surg.2006.02.003

    Article  PubMed  Google Scholar 

  18. Nelson EC, Eftimovska E, Lind C et al (2015) Patient reported outcome measures in practice. BMJ 350:g7818–g7818. https://doi.org/10.1136/bmj.g7818

    Article  PubMed  Google Scholar 

  19. Albers G, Echteld MA, de Vet HC et al (2010) Evaluation of quality-of-life measures for use in palliative care: a systematic review. Palliat Med 24:17–37. https://doi.org/10.1177/0269216309346593

    Article  PubMed  Google Scholar 

  20. Malawi country data. http://data.worldbank.org/country/malawi. Accessed 19 June 2017

  21. Bailey N, Mandeville KL, Rhodes T et al (2012) Postgraduate career intentions of medical students and recent graduates in Malawi: a qualitative interview study. BMC Med Educ 12:87. https://doi.org/10.1186/1472-6920-12-87

    Article  PubMed  PubMed Central  Google Scholar 

  22. Jiskoot P (2008) On-the-job training of clinical officers in Malawi. Malawi Med J 20:74–7. http://www.ncbi.nlm.nih.gov/pubmed/19537402. Accessed 19 June 2017

  23. Henry JA, Frenkel E, Borgstein E et al (2015) Surgical and anaesthetic capacity of hospitals in Malawi: key insights. Health Policy Plan 30:985–994. https://doi.org/10.1093/heapol/czu102

    Article  PubMed  Google Scholar 

  24. Ahlsén AK, Spong E, Kafumba N et al (2015) Born too small: who survives in the public hospitals in Lilongwe, Malawi? Arch Dis Child Fetal Neonatal Ed 100:F150–F154. https://doi.org/10.1136/archdischild-2013-305877

    Article  PubMed  Google Scholar 

  25. O’Hare B, Phiri A, Lang H-J et al (2015) Task sharing within a managed clinical network to improve child health in Malawi. Hum Resour Health 13:60. https://doi.org/10.1186/s12960-015-0053-z

    Article  PubMed  PubMed Central  Google Scholar 

  26. Global Surgery Map. http://www.cosecsa.org/global-surgery-map. Accessed 19 June 2017

  27. Lavy C, Tindall A, Steinlechner C et al (2007) Surgery in Malawi: a national survey of activity in rural and urban hospitals. Ann R Coll Surg Engl 89:722–724. https://doi.org/10.1308/003588407X209329

    Article  PubMed  PubMed Central  Google Scholar 

  28. Chu K, Rosseel P, Gielis P et al (2009) Surgical task shifting in sub-Saharan Africa. PLoS Med 6:e1000078. https://doi.org/10.1371/journal.pmed.1000078

    Article  PubMed  PubMed Central  Google Scholar 

  29. van Amelsfoort JJC, van Leeuwen PAM, Jiskoot P et al (2010) Surgery in Malawi? The training of clinical officers. Trop Dr 40:74–76. https://doi.org/10.1258/td.2009.090068

    Google Scholar 

  30. Chilopora G, Pereira C, Kamwendo F et al (2007) Postoperative outcome of caesarean sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi. Hum Resour Health 5:17. https://doi.org/10.1186/1478-4491-5-17

    Article  PubMed  PubMed Central  Google Scholar 

  31. Wilson A, Lissauer D, Thangaratinam S, et al (2011) A comparison of clinical officers with medical doctors on outcomes of caesarean section in the developing world: meta-analysis of controlled studies. BMJ 342. http://www.bmj.com/content/342/bmj.d2600. Accessed 19 June 2017

  32. Wilhelm TJ, Thawe IK, Mwatibu B et al (2011) Efficacy of major general surgery performed by non-physician clinicians at a central hospital in Malawi. Trop Dr 41:71–75. https://doi.org/10.1258/td.2010.100272

    Google Scholar 

  33. COST Africa. www.costafrica.eu. Accessed 19 June 2017

  34. Krpata DM, Schmotzer BJ, Flocke S et al (2012) Design and initial implementation of HerQLes: a hernia-related quality-of-life survey to assess abdominal wall function. J Am Coll Surg 215:635–642. https://doi.org/10.1016/j.jamcollsurg.2012.06.412

    Article  PubMed  Google Scholar 

  35. Literacy rates are on the rise but millions remain illiterate (2016). http://www.uis.unesco.org/Library/Documents/fs38-adult-youth-literacy-2016-en.pdf

  36. Blum D, Selman LE, Agupio G et al (2014) Self-report measurement of pain and symptoms in palliative care patients: a comparison of verbal, visual and hand scoring methods in sub-Saharan Africa. Health Qual Life Outcomes 12:118. https://doi.org/10.1186/s12955-014-0118-z

    Article  PubMed  PubMed Central  Google Scholar 

  37. Luboga S, Macfarlane SB, von Schreeb J et al (2009) Increasing access to surgical services in sub-Saharan Africa: priorities for national and international agencies recommended by the Bellagio Essential Surgery Group. PLoS Med 6:e1000200. https://doi.org/10.1371/journal.pmed.1000200

    Article  PubMed  PubMed Central  Google Scholar 

  38. Samuel JC, Tyson AF, Mabedi C et al (2014) Development of a ratio of emergent to total hernia repairs as a surgical capacity metric. Int J Surg 12:906–911. https://doi.org/10.1016/j.ijsu.2014.07.019

    Article  PubMed  PubMed Central  Google Scholar 

  39. Chan KY, Rohaizak M, Sukumar N et al (2004) Inguinal hernia repair by surgical trainees at a Malaysian teaching hospital. Asian J Surg 27:306–312. https://doi.org/10.1016/S1015-9584(09)60057-9

    Article  PubMed  Google Scholar 

  40. Gessessew A, Barnabas GA, Prata N et al (2011) Task shifting and sharing in Tigray, Ethiopia, to achieve comprehensive emergency obstetric care. Int J Gynecol Obstet 113:28–31. https://doi.org/10.1016/j.ijgo.2010.10.023

    Article  Google Scholar 

  41. Eyal N, Cancedda C, Kyamanywa P et al (2015) Non-physician clinicians in sub-Saharan Africa and the evolving role of physicians. Int J Heal policy Manag 5:149–153. https://doi.org/10.15171/ijhpm.2015.215

    Article  Google Scholar 

  42. Gajewski J, Mweemba C, Cheelo M, McCauley T, Kachimba J, Borgstein E, Bijlmakers L, Brugha R (2017) Non-physician clinicians in rural Africa: lessons from the Medical Licentiate programme in Zambia. Hum Resour Health 15(1):53

    Article  PubMed  PubMed Central  Google Scholar 

  43. 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 Int J Obstet Gynaecol 114:1530–1533. https://doi.org/10.1111/j.1471-0528.2007.01489.x

    Article  CAS  Google Scholar 

  44. Mkandawire N, Ngulube C, Lavy C (2008) Orthopaedic clinical officer program in Malawi: a model for providing orthopaedic care. Clin Orthop Relat Res 466:2385–2391. https://doi.org/10.1007/s11999-008-0366-5

    Article  PubMed  PubMed Central  Google Scholar 

  45. Gosselin RA, Thind A, Bellardinelli A (2006) Cost/DALY averted in a small hospital in Sierra Leone: what is the relative contribution of different services? World J Surg 30:505–511. https://doi.org/10.1007/s00268-005-0609-5

    Article  PubMed  Google Scholar 

  46. Hounton SH, Newlands D, Meda N et al (2009) A cost-effectiveness study of caesarean-section deliveries by clinical officers, general practitioners and obstetricians in Burkina Faso. Hum Resour Health 7:34. https://doi.org/10.1186/1478-4491-7-34

    Article  PubMed  PubMed Central  Google Scholar 

  47. Kolstad PR, Burnham G, Kalter HD, et al (1998) Potential implications of the integrated management of childhood illness (IMCI) for hospital referral and pharmaceutical usage in western Uganda. Trop Med Int Health 3:691–9. http://www.ncbi.nlm.nih.gov/pubmed/9754663. Accessed 19 June 2017

  48. Grumbach K, Coffman J (1998) Physicians and nonphysician clinicians: complements or competitors? JAMA 280:825–6. http://www.ncbi.nlm.nih.gov/pubmed/9729998. Accessed 19 June 2017

  49. Group W (1994) Development of the WHOQOL: rationale and current status. Int J Ment Health 23:24–56. https://doi.org/10.2307/41344692

    Article  Google Scholar 

  50. Meltzer ME, Congdon N, Kymes SM et al (2017) Cost and expected visual effect of interventions to improve follow-up after cataract surgery. JAMA Ophthalmol 135:85. https://doi.org/10.1001/jamaophthalmol.2016.4735

    Article  Google Scholar 

Download references

Acknowledgements

Funding was provided by Seventh Framework Programme (Ref. FP7-AFRICA-2010, Grant Agreement No. 266417).

Author information

Authors and Affiliations

  1. Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland

    Jakub Gajewski, Ronan Conroy, Tracey McCauley & Ruairi Brugha

  2. Radboud University Medical Centre Netherlands, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands

    Leon Bijlmakers

  3. College of Medicine, Mahatma Gandhi, Blantyre, Malawi

    Gerald Mwapasa & Eric Borgstein

Authors
  1. Jakub Gajewski
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ronan Conroy
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Leon Bijlmakers
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gerald Mwapasa
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tracey McCauley
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Eric Borgstein
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ruairi Brugha
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jakub Gajewski.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gajewski, J., Conroy, R., Bijlmakers, L. et al. Quality of Surgery in Malawi: Comparison of Patient-Reported Outcomes After Hernia Surgery Between District and Central Hospitals. World J Surg 42, 1610–1616 (2018). https://doi.org/10.1007/s00268-017-4385-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00268-017-4385-9

Search

Navigation