World Journal of Surgery

, Volume 42, Issue 6, pp 1610–1616 | Cite as

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

  • Jakub Gajewski
  • Ronan Conroy
  • Leon Bijlmakers
  • Gerald Mwapasa
  • Tracey McCauley
  • Eric Borgstein
  • Ruairi Brugha
Original Scientific Report



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.


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.


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).


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.



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

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.


  1. 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. CrossRefPubMedGoogle Scholar
  2. 2.
  3. 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. CrossRefPubMedGoogle Scholar
  4. 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. CrossRefPubMedGoogle Scholar
  5. 5.
    Ozgediz D, Riviello R (2008) The “other” neglected diseases in global public health: surgical conditions in sub-Saharan Africa. PLoS Med 5:e121. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 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. CrossRefGoogle Scholar
  7. 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. CrossRefPubMedGoogle Scholar
  8. 8.
    WHO|The world health report 2003-shaping the future. WHO Published Online First: 2013. Accessed 19 June 2017
  9. 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. CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Shillcutt SD, Clarke MG, Kingsnorth AN (2010) Cost-effectiveness of groin hernia surgery in the western region of Ghana. Arch Surg 145:954. CrossRefPubMedGoogle Scholar
  11. 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. CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Mbah N (2017) Morbidity and mortality associated with inguinal hernia in Northwestern Nigeria. West Afr J Med 26:288–292. Accessed 19 June 2017
  13. 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. CrossRefPubMedGoogle Scholar
  14. 14.
    Jenkins JT, O’Dwyer PJ (2008) Inguinal hernias. BMJ 336:269–272. CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Deshpande P, Bl Sudeepthi, Rajan S et al (2011) Patient-reported outcomes: a new era in clinical research. Perspect Clin Res 2:137. CrossRefPubMedPubMedCentralGoogle Scholar
  16. 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. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Hawn MT, Itani KM, Giobbie-Hurder A et al (2006) Patient-reported outcomes after inguinal herniorrhaphy. Surgery 140:198–205. CrossRefPubMedGoogle Scholar
  18. 18.
    Nelson EC, Eftimovska E, Lind C et al (2015) Patient reported outcome measures in practice. BMJ 350:g7818–g7818. CrossRefPubMedGoogle Scholar
  19. 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. CrossRefPubMedGoogle Scholar
  20. 20.
    Malawi country data. Accessed 19 June 2017
  21. 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. CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Jiskoot P (2008) On-the-job training of clinical officers in Malawi. Malawi Med J 20:74–7. Accessed 19 June 2017
  23. 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. CrossRefPubMedGoogle Scholar
  24. 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. CrossRefPubMedGoogle Scholar
  25. 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. CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Global Surgery Map. Accessed 19 June 2017
  27. 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. CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Chu K, Rosseel P, Gielis P et al (2009) Surgical task shifting in sub-Saharan Africa. PLoS Med 6:e1000078. CrossRefPubMedPubMedCentralGoogle Scholar
  29. 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. Google Scholar
  30. 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. CrossRefPubMedPubMedCentralGoogle Scholar
  31. 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. Accessed 19 June 2017
  32. 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. Google Scholar
  33. 33.
    COST Africa. Accessed 19 June 2017
  34. 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. CrossRefPubMedGoogle Scholar
  35. 35.
    Literacy rates are on the rise but millions remain illiterate (2016).
  36. 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. CrossRefPubMedPubMedCentralGoogle Scholar
  37. 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. CrossRefPubMedPubMedCentralGoogle Scholar
  38. 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. CrossRefPubMedPubMedCentralGoogle Scholar
  39. 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. CrossRefPubMedGoogle Scholar
  40. 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. CrossRefGoogle Scholar
  41. 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. CrossRefGoogle Scholar
  42. 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):53CrossRefPubMedPubMedCentralGoogle Scholar
  43. 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. CrossRefGoogle Scholar
  44. 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. CrossRefPubMedPubMedCentralGoogle Scholar
  45. 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. CrossRefPubMedGoogle Scholar
  46. 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. CrossRefPubMedPubMedCentralGoogle Scholar
  47. 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. Accessed 19 June 2017
  48. 48.
    Grumbach K, Coffman J (1998) Physicians and nonphysician clinicians: complements or competitors? JAMA 280:825–6. Accessed 19 June 2017
  49. 49.
    Group W (1994) Development of the WHOQOL: rationale and current status. Int J Ment Health 23:24–56. CrossRefGoogle Scholar
  50. 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. CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2017

Authors and Affiliations

  1. 1.Royal College of Surgeons in IrelandDublin 2Ireland
  2. 2.Radboud University Medical Centre NetherlandsNijmegenThe Netherlands
  3. 3.College of MedicineBlantyreMalawi

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