Quality of health care services and performance in public hospitals in Africa: A protocol for systematic review

Background: The delivery of high-quality health care services and performance is the main aim of all health care systems globally. This review objective is to determine the quality of health care services and performance in public hospitals in Africa through a systematic review and meta-analysis of existing studies.

Methods: The search will be conducted in pre-determined databases (e.g., PubMed), for eligible studies between 2000 and 2020, to identify studies published in English, which applied the service quality gap (SERVIQUAL) model to determine the quality of health care services and performance in public hospitals in Africa. The search will also include a review of reference lists of included studies for other eligible studies. Eligible studies will include experimental and observational studies. Two authors will independently screen the search output, select studies and extract data, resolve discrepancies by consensus and discussions. Two authors will use Cochrane risk of bias tools for experimental studies, and Hoy for observational studies. The review will also assess study quality and risk of bias using standardized tools. The review aims to provide comprehensive information on the quality of health care services and performance in public hospitals in Africa.

Discussion: Understanding patients’ or clients’ expectations and perceptions on the quality of health care services provided in the health care systems are very crucial in the improvement of the health status of the general population. The SERVIQUAL model is a standardized tool used to assess the quality gap of patients/clients perspectives on health care services in hospitals globally. The findings from this review will provide information on the quality gap of health care provided in public hospitals in SSA. Also, we anticipate that the findings will inform policymakers in health care systems on how to improve and maintain the quality of health care services in public hospitals in different African settings.

Systematic review registration number: PROSPERO CRD 420212264100 dated 25/07/2021

Equitable access to quality trauma systems in Low and Middle Income Countries

Injuries in low-income and middle-income countries are prevalent and their number is expected to increase. Death and disability after injury can be reduced if people reach healthcare facilities in a timely manner. Knowledge of barriers to access to quality injury care is necessary to intervene to improve outcomes. We combined a four-delay framework with WHO Building Blocks and Institution of Medicine Quality Outcomes Frameworks to describe barriers to trauma care in three countries in sub-Saharan Africa: Ghana, South Africa and Rwanda. We used a parallel convergent mixed-methods research design, integrating the results to enable a holistic analysis of the barriers to access to quality injury care. Data were collected using surveys of patient experiences of injury care, interviews and focus group discussions with patients and community leaders, and a survey of policy-makers and healthcare leaders on the governance context for injury care. We identified 121 barriers across all three countries. Of these, 31 (25.6%) were shared across countries. More than half (18/31, 58%) were predominantly related to delay 3 (‘Delays to receiving quality care’). The majority of the barriers were captured using just one of the multiple methods, emphasising the need to use multiple methods to identify all barriers. Given there are many barriers to access to quality care for peoplewho have been injured in Rwanda, Ghana and South Africa, but few of these are shared across countries, solutions to overcome these barriers may also be contextually dependent. This suggests the need for rigorous assessments of contexts using multiple data collection methods before developing interventions to improve access to quality car

The true costs of cesarean delivery for patients in rural Rwanda: Accounting for post-discharge expenses in estimated health expenditures

While it is recognized that there are costs associated with postoperative patient follow-up, risk assessments of catastrophic health expenditures (CHEs) due to surgery in sub-Saharan Africa rarely include expenses after discharge. We describe patient-level costs for cesarean section (c-section) and follow-up care up to postoperative day (POD) 30 and evaluate the contribution of follow-up to CHEs in rural Rwanda.

We interviewed women who delivered via c-section at Kirehe District Hospital between September 2019 and February 2020. Expenditure details were captured on an adapted surgical indicator financial survey tool and extracted from the hospital billing system. CHE was defined as health expenditure of ≥ 10% of annual household expenditure. We report the cost of c-section up to 30 days after discharge, the rate of CHE among c-section patients stratified by in-hospital costs and post-discharge follow-up costs, and the main contributors to c-section follow-up costs. We performed a multivariate logistic regression using a backward stepwise process to determine independent predictors of CHE at POD30 at α ≤ 0.05.

Of the 479 participants in this study, 90% were classified as impoverished before surgery and an additional 6.4% were impoverished by the c-section. The median out-of-pocket costs up to POD30 was US$122.16 (IQR: $102.94, $148.11); 63% of these expenditures were attributed to post-discharge expenses or lost opportunity costs (US$77.50; IQR: $67.70, $95.60). To afford c-section care, 64.4% borrowed money and 18.4% sold possessions. The CHE rate was 27% when only considering direct and indirect costs up to the time of discharge and 77% when including the reported expenses up to POD30. Transportation and lost household wages were the largest contributors to post-discharge costs. Further, CHE at POD30 was independently predicted by membership in community-based health insurance (aOR = 3.40, 95% CI: 1.21,9.60), being a farmer (aOR = 2.25, 95% CI:1.00,3.03), primary school education (aOR = 2.35, 95% CI:1.91,4.66), and small household sizes had 0.22 lower odds of experiencing CHE compared to large households (aOR = 0.78, 95% CI:0.66,0.91).

Costs associated with surgical follow-up are often neglected in financial risk calculations but contribute significantly to the risk of CHE in rural Rwanda. Insurance coverage for direct medical costs is insufficient to protect against CHE. Innovative follow-up solutions to reduce costs of patient transport and compensate for household lost wages need to be considered.

Burden and trend of colorectal cancer in 54 countries of Africa 2010–2019: a systematic examination for Global Burden of Disease

Colorectal cancer plays significant role in morbidity, mortality and economic cost in Africa.

To investigate the burden and trends of incidence, mortality, and disability-adjusted life-years (DALYs) of colorectal cancer in Africa from 2010 to 2019.

This study was conducted according to Global Burden of Disease (GBD) 2019 analytic and modeling strategies. The recent GBD 2019 study provided the most updated and compressive epidemiological evidence of cancer incidence, mortality, years lived with disability (YLDs), years of life lost (YLLs), and DALYs.

In 2019, there were 58,000 (95% UI: 52,000–65,000), 49,000 (95% UI: 43,000–54,000), and 1.3 million (95% UI: 1.14–1.46) incident cases, deaths and DALYs counts of colorectal cancer respectively in Africa. Between 2010 and 2019, incidence cases, death, and DALY counts of CRC were significantly increased by 48% (95% UI: 34–62%), 41% (95% UI: 28–55%), and 41% (95% UI: 27–56%) respectively. Change of age-standardised rates of incidence, death and DALYs were increased by 11% (95% UI: 1–21%), 6% (95% UI: − 3 to 16%), and 6% (95% UI: − 5 to 16%) respectively from 2010 to 2019. There were marked variations of burden of colorectal cancer at national level from 2010 to 2019 in Africa.

Increased age-standardised death rate and DALYs of colorectal cancer indicates low progress in CRC standard care-diagnosis and treatment, primary prevention of modifiable risk factors and implementation of secondary prevention modality. This serious effect would be due to poor cancer infrastructure and policy, low workforce capacity, cancer center for diagnosis and treatment, low finical security and low of universal health coverage in Africa.

Effect of Delay of Care for Patients with Craniomaxillofacial Trauma in Rwanda

Craniomaxillofacial (CMF) trauma represents a significant proportion of global surgical disease burden, disproportionally affecting low- and middle-income countries where care is often delayed. We investigated risk factors for delays to care for patients with CMF trauma presenting to the highest-volume trauma hospital in Rwanda and the impact on complication rates.

Study Design
This prospective cohort study comprised all patients with CMF trauma presenting to the University Teaching Hospital of Kigali, Rwanda, between June 1 and October 1, 2020.

Urban referral center in resource-limited setting.

Epidemiologic data were collected, and logistic regression analysis was undertaken to explore risk factors for delays in care and complications.

Fifty-four patients (94.4% men) met criteria for inclusion. The mean age was 30 years. A majority of patients presented from a rural setting (n = 34, 63%); the most common cause of trauma was motor vehicle accident (n = 18, 33%); and the most common injury was mandibular fracture (n = 28, 35%). An overall 78% of patients had delayed treatment of the fracture after arrival to the hospital, and 81% of these patients experienced a complication (n = 34, P = .03). Delay in treatment was associated with 4-times greater likelihood of complication (odds ratio, 4.25 [95% CI, 1.08-16.70]; P = .038).

Delay in treatment of CMF traumatic injuries correlates with higher rates of complications. Delays most commonly resulted from a lack of surgeon and/or operating room availability or were related to transfers from rural districts. Expansion of the CMF trauma surgical workforce, increased operative capacity, and coordinated transfer care efforts may improve trauma care.

Artificial intelligence and machine learning for early detection and diagnosis of colorectal cancer in sub-Saharan Africa

Colorectal cancer (CRC) was once considered a rare disease in sub-Saharan Africa (SSA), but decades of globalisation has changed this narrative. Currently, CRC is the fifth most common cancer in SSA, and while CRC incidence and mortality are decreasing in some high-income countries, rates in SSA are on the rise.1 Because CRC develops from a benign precursor polyp over several years, early detection is critical to either prevent malignancy or detect it at an early stage when it is highly curable. Moreover, curative surgery has been shown to improve survival in a SSA setting.2 Unfortunately, more than 60% of patients in SSA present with stage 4 CRC with a <1% 5 year survival rate.3–5 In contrast, almost 40% of patients in the USA present with stage 1 CRC, resulting in a 5-year survival rate of 90%.6 7 Widespread population-based CRC screening programmes and tools (eg, faecal immunochemical test (FIT), colonoscopy) have improved early detection in high-income countries, but SSA-specific data, tools and screening programmes are currently lacking. There is an urgent need to develop more efficient approaches to CRC screening and early detection that do not rely heavily on trained healthcare personnel or specialised resources (eg, endoscopy, pathology), which are often scarce in low- and middle-income countries (LMICs).

Recent technological advances and developments in artificial intelligence (AI) and machine learning (ML) methods have the potential to transform global health, particularly for early detection and diagnosis of CRC in SSA. Researchers are collecting enormous volumes of data, and while data science applications are largely underdeveloped in Africa, many enabling factors are already in place. Developments in cloud computing, substantial investments in digitising health information, and robust mobile phone penetration have poised many places in SSA with the necessary basics to initiate meaningful AI/ML applications.8 Businesses in SSA …

Evaluating the impact of neurosurgical rotation experience in Africa on the interest and perception of medical students towards a career in neurosurgery: a protocol for a continental, cross-sectional study

Africa has the second highest neurosurgical workforce deficit globally. Despite the many recent advancements in increasing neurosurgical access in Africa, published reports have shown that the vast majority of undergraduate students have little or no exposure to neurosurgery. The lack of exposure may pose a challenge in reducing the neurosurgical workforce deficit, which is one of the long-term strategies of tackling the unmet burden of disease. Students may also miss the opportunity to appreciate the specialty and its demands as well as nurture their interest in the field. This study aims to assess the impact of a neurosurgical rotation during medical school in shaping the perception and interest of students towards a career in neurosurgery.

The cross-sectional study will be conducted through the dissemination of a self-administered e-survey hosted on Google Forms from 21st February 2021 to 20th March 2021. The survey will contain five-point Likert scale, multiple-choice and free-text questions. The structured questionnaire will have four sections with 27 items: (i) socio-demographic background, (ii) neurosurgical experience, (iii) perception towards a neurosurgical career and (iv) interest in a neurosurgical career. All consenting medical students in African medical schools who are in their clinical years (defined as fourth to sixth years or higher years of study) will be eligible. Odds ratios and their 95% confidence intervals, Wilcoxon rank-sum test, Welch t-test and adjusted logistic regression models will be used to test for associations between independent and dependent variables. Statistical significance will be accepted at P < 0.05.

Public awareness, knowledge of availability, and willingness to use neurosurgical care services in Sub-Saharan Africa: A cross-sectional study

Low- and middle-income countries bear the majority of neurosurgical disease burden and patients face significant barriers to seeking, reaching, and receiving care. We aimed to understand barriers to seeking care among adult Africans by evaluating the public perception, knowledge of availability, and readiness to use neurosurgical care services.

An e-survey was distributed among African adults who are not in the health sector or pursuing a health-related degree. Chi-square test and ANOVA were used for bivariate analysis and the alpha value was set at 0.05. Odds ratios and their 95% confidence intervals were calculated.

Six hundred and sixty-two adults from 16 African countries aged 25.4 (95% CI: 25.0, 25.9) responded. The majority lived in urban settings (90.6%) and were English-speaking (76.4%) men (54.8%). Most respondents (76.3%) could define neurosurgery adequately. The most popular neurosurgical diseases were traumatic brain injury (76.3%), congenital brain and spine diseases (67.7%), and stroke (60.4%). Unwillingness to use or recommend in-country neurosurgical services was associated with rural dwelling (β = -0.69, SE = 0.31, P = 0.03), lack of awareness about the availability of neurosurgeons in-country (β = 1.02, SE = 0.20, P<0.001), and believing neurosurgery is expensive (β = -1.49, SE = 0.36, P<0.001).

Knowledge levels about neurosurgery are satisfactory; however, healthcare-seeking is negatively impacted by multiple factors.

Development and Implementation of an Antimicrobial Stewardship Checklist in Sub-saharan Africa: a Co-creation Consensus Approach


Antimicrobial stewardship (AMS) initiatives promote the responsible use of antimicrobials in healthcare settings as a key measure to curb the global threat of antimicrobial resistance (AMR). Defining the core elements of AMS is essential for developing and evaluating comprehensive AMS programmes. This project used co-creation and Delphi-consensus procedures to adapt and extend the existing published international AMS checklist. The overall objective was to arrive at a contextualised checklist of core AMS elements and key behaviours for use within healthcare settings in Sub-Saharan Africa as well as to implement the checklist in health institutions in four African countries.


The AMS checklist tool was developed using a modified Delphi approach to achieve local, expert consensus on items to be included on the checklist. Fourteen healthcare/public health professionals from Tanzania, Zambia, Uganda, and Ghana were invited to review, score and comment on items from a published, global AMS checklist. Following their feedback, eight items were re-phrased and 25 new items added to the checklist. The final AMS checklist tool was deployed across 19 healthcare sites and used to assess AMS programmes before and after an AMS intervention in 14 of the 19 sites.


The final tool comprised 54 items. Across the 14 sites, the checklist consistently showed improvements for all AMS components following the intervention. The greatest improvements observed were the presence of formal multidisciplinary AMS structures (79%) and the execution of a point-prevalence survey (72%). Elements with the least improvement were access to laboratory/imaging services (7%) and the presence of adequate financial support for AMS (14%). In addition to capturing quantitative and qualitative changes associated with the AMS intervention, project evaluation suggested that administering the AMS checklist made unique contributions to ongoing AMS activities. Furthermore, 29 additional AMS activities were reported as a direct result of the prompting checklist questions.


Contextualised, co-created AMS tools are necessary for managing antimicrobial use across healthcare settings and increasing local AMS ownership and commitment. This study led to the development of a new AMS checklist which proved successful in capturing AMS improvements in Tanzania, Zambia, Uganda, and Ghana. The tool also made unique contributions to furthering local AMS efforts. The study extends existing AMS materials for low and middle-income countries and provides empirical evidence for successful use in practice.

Effect of unmanned aerial vehicle (drone) delivery on blood product delivery time and wastage in Rwanda: a retrospective, cross-sectional study and time series analysis

The accessibility of blood and blood products remains challenging in many countries because of the complex supply chain of short lifetime products, timely access, and demand fluctuation at the hospital level. In an effort to improve availability and delivery times, Rwanda launched the use of drones to deliver blood products to remote health facilities. We evaluated the effect of this intervention on blood product delivery times and wastage.

We studied data from 20 health facilities between Jan 1, 2015, and Dec 31, 2019, in Rwanda. First, we did a cross-sectional comparison of data on emergency delivery times from the drone operator collected between March 17, 2017, and Dec 31, 2019, with two sources of estimated driving times (Regional Centre for Blood Transfusion estimates and Google Maps). Second, we used interrupted time series analysis and monthly administrative data to assess changes in blood product expirations after the commencement of drone deliveries.

Between March 17, 2017, and Dec 31, 2019, 12 733 blood product orders were delivered by drones. 5517 (43%) of 12 733 were emergency orders. The mean drone delivery time was 49·6 min (95% CI 49·1 to 50·2), which was 79 min faster than existing road delivery methods based on estimated driving times (p<0·0001) and 98 min faster based on Google Maps estimates (p<0·0001). The decrease in mean delivery time ranged from 3 min to 211 min depending on the distance to the facility and road quality. We also found a decrease of 7·1 blood unit expirations per month after the start of drone delivery (95% CI −11·8 to −2·4), which translated to a 67% reduction at 12 months.

We found that drone delivery led to faster delivery times and less blood component wastage in health facilities. Future studies should investigate if these improvements are cost-effective, and whether drone delivery might be effective for other pharmaceutical and health supplies that cannot be easily stored at remote facilities.

Canadian Institutes for Health Research.