The role of health service delivery networks in achieving universal health coverage in Africa

Most countries in Africa are faced with health system problems that vary from one to the next. Countries with a low Human Development Index (HDI) seem to be more prone to challenges in health service delivery. To mark its 70th anniversary on World Health Day, the World Health Organization (WHO) selected the theme “Universal Health Coverage (UHC): Everyone, Everywhere” and the slogan “Health for All. ”UHC refers to ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship. UHC is a WHO’s priority objective. Most governments have made it their major goal.

This paper provides a perspective on the challenges of achieving UHC in Sub-Saharan Africa (SSA). It also endeavors to spotlight the successful models of Health Service Delivery Networks (HSDNs) that make significant strides in making progress towards achieving UHC. HSDNs propose models that facilitate the attainment of affordability and accessibility while maintaining quality in delivering health services. Additionally, it brings up to speed the challenges associated with setting up HSDNs in health systems in SSA. It then makes propositions of what measures and strategic approaches should be implemented to strengthen HSDNs in SSA. This paper further argues that UHC is not only technically feasible but it is also attainable if countries embrace HSDNs in SSA.

Oxygen delivery systems for adults in Sub-Saharan Africa: A scoping review

Background
Respiratory diseases are the leading cause of death and disability worldwide. Oxygen is an essential medicine used to treat hypoxemia from respiratory diseases. However, the availability and utilization of oxygen delivery systems for adults in sub-Saharan Africa is not well-described. We aim to identify and describe existing data around oxygen availability and provision for adults in sub-Saharan Africa, determine knowledge or research gaps, and make recommendations for future research and capacity building.

Methods
We systematically searched four databases for articles on April 22, 2020, for variations of keywords related to oxygen with a focus on countries in sub-Saharan Africa. Inclusion criteria were studies that included adults and addressed hypoxemia assessment or outcome, oxygen delivery mechanisms, oxygen availability, oxygen provision infrastructure, and oxygen therapy and outcomes.

Results
35 studies representing 22 countries met inclusion criteria. Availability of oxygen delivery systems ranged from 42%-94% between facilities, with wide variability in the consistency of availability. There was also wide reported prevalence of hypoxemia, with most studies focusing on specific populations. In facilities where oxygen is available, health care workers are ill-equipped to identify adult patients with hypoxemia, provide oxygen to those who need it, and titrate or discontinue oxygen appropriately. Oxygen concentrators were shown to be the most cost-effective delivery system in areas where power is readily available.

Conclusions
There is a substantial need for building capacity for oxygen delivery throughout sub-Saharan Africa. Addressing this critical issue will require innovation and a multi-faceted approach of developing infrastructure, better equipping facilities, and health care worker training

Cervical cancer diagnosis and treatment delays in the developing world: Evidence from a hospital-based study in Zambia

Expedited diagnostic processes for all suspected cervical cancer cases remain essential in the effort to improve clinical outcomes of the disease. However, in some developing countries like Zambia, there is paucity of data that assesses factors influencing diagnostic and treatment turnaround time (TAT) and other metrics vital for quality cancer care. We conducted a retrospective hospital-based study at the Cancer Diseases Hospital (CDH) for cervical cancer cases presenting to the facility between January 2014 and December 2018. Descriptive statistics were used to summarize demographic characteristics while a generalized linear model of the negative binomial was used to assess determinants of overall TAT. Our study included 2121 patient case files. The median age was 49 years (IQR: ±17) and most patients (n=634, 31%) were aged between 41–50 years. The International Federation of Gynaecology and Obstetrics (FIGO) Cancer stage II (n =941, 48%) was the most prevalent while stage IV (n=103, 5.2%) was the least. The average diagnostic TAT in public laboratories was 1.48 (95%CI: 1.21–1.81) times longer than in private laboratories. Furthermore, referral delay was 55 days (IQR: 24–152) and the overall TAT (oTAT) was 110 days (IQR: 62–204). The age of the patient, HIV status, stage of cancer and histological subtype did not influence oTAT while marital status influenced oTAT. The observed longer oTAT may increase irreversible adverse health outcomes among cervical cancer patients. There is a need to improve cancer care in Zambia through improved health expenditure especially in public health facilities.

Anaesthesia facility evaluation: a Whatsapp survey of hospitals in Burundi

Background: Data regarding the capacity to provide safe anaesthesia is lacking in many low-income countries. With the increasing popularity of WhatsApp for both personal and professional communication in Africa, we sought to test the feasibility of using this platform to administer a brief survey of anaesthesia equipment availability in Burundi. The aims of the study were to survey a subset of anaesthesia equipment availability in Burundi and to assess the suitability of using a WhatsApp chat group to administer such a survey.

Methods: The survey was distributed via WhatsApp by ATSARPS (Agora des Techniciens Supérieurs Anesthésistes Réanimateurs pour la Promotion de la Santé), an association of anaesthesia providers in Burundi. The questions focused on the presence of five pieces of anaesthesia equipment recommended by the World Health Organization – World Federation of Societies of Anesthesiologists (WHO–WFSA) International Standards for a Safe Practice of Anesthesia, namely a Lifebox pulse oximeter, anaesthesia machine, capnograph, ECG and defibrillator. Questions were sent as free text, and responses were received as a reply or as a personal message to the president of ATSARPS who sent the survey.

Results: Responses received represented data from 55 (85%) of the 65 hospitals that offer anaesthesia care across Burundi. Eightynine per cent of hospitals had a Lifebox pulse oximeter, 91% had an anaesthesia machine, 16% had capnography, 24% had an ECG and 14% had a defibrillator. Among hospitals which responded to our survey, only 60% reported perfoming general endotracheal anaesthesia on a monthly basis.

Conclusion: Data collection in low- and middle-income countries (LMICs) can be challenging; therefore, simple, low-cost methods of data collection need to be developed. We have demonstrated the feasibility of using a WhatsApp chat group among a national society of anaesthesia providers in Burundi to perform an initial abbreviated audit of anaesthesia facilities. We have also identified significant deficits in anaesthesia equipment in Burundi.

The evaluation of a surgical task-sharing program in South Sudan

Background: Five billion people lack timely, affordable, and safe surgical services. Sub-Saharan Africa (SSA) is the region with the scarcest access to surgical care. The surgical workforce is crucial in closing this gap. In SSA, South Sudan has one of the lowest surgical workforce density. Task-sharing being a cost-effective training method, in 2019, the University of British Columbia collaborated with Médecins Sans Frontières to create the Essential Surgical Skills program and launched it in South Sudan. This study aims to evaluate this pilot program. Methods: This is a mixed-method prospective cohort study. Quantitative data include pre- and post-training outputs (number and types of surgeries, complication, re-operation, and mortality) and surgical proficiency of the trainees (quiz, Entrustable Professional Activity (EPA), and logbook data), and online survey for trainers. Semi-structured interviews were performed with trainees at the program completion. Results: Since July 2019, trainees performed 385 operations. The most common procedures were skin graft (14.8%), abscess drainage (9.61%), wound debridement and transverse laparotomy (7.79% each). 172 EPAs have been completed, out of which 136 (79%) showed that the trainee could independently perform the procedure. During the training, the operating room and surgical ward mortality remained similar to the pre-training phase. Furthermore, the surgical morbidity decreased from 25% to less than 5%. The pass rate for all quizzes was 100%. Interviews and survey showed that trainees’ surgical knowledge, interprofessional teamwork, trainers’ global insight on surgical training in Low- and Middle-Income Countries (LMICs), and patient care has improved. Also, the program empowered trainees, developed career path, and local acceptance and retention. The modules were relevant to community needs. Conclusions: This study casts light on the feasibility of training surgeons through a virtual platform in under-resourced regions. The COVID-19 global pandemic highlighted the need to make LMICs independent from fly-in trainers and traditional apprenticeship. Knowledge translation of this training platform’s evaluation will hopefully inform Ministries of Health and their partners to develop their National Surgical, Obstetric and Anesthesia Plans (NSOAPs). Furthermore, thanks to its scalability, both across levels of training and geography, it paves the way for virtual surgical education everywhere in the world.

Cancer care delivery innovations, experiences and challenges during the COVID-19 pandemic: The Rwanda experience

Globally, cancer is the second leading cause of mortality. In 2018, 9.6 million lives were lost to cancer of which over 70% occurred in low and middle-income countries (LMICs) where limited access to cancer care and overwhelming late disease presentations negatively impact cancer related survival and quality of life [1]. Moreover, globally, new cancer cases are expected to increase from 18.1 million in 2018 to 21.4 million by 2030 [2]. In settings of poor health care systems and impoverished communities, the scarcity of and limited access to diagnostic and treatment modalities negatively impacts health outcomes and undermines achievement of the universal health care coverage (UHC) targets.

Over the past 20 years, Rwanda has recorded gains in key health indicators including increased life expectancy (from 48.6 in 2000 to 67.4 in 2015); declines in maternal mortality (from 1071 in 2000 to 210 per 100 000 live births in 2015) [3]. Concurrently, impressive gains were registered in the control of infectious diseases such as HIV, tuberculosis and malaria [3]. However, little gains have been recorded for the management of non-communicable diseases (NCDs) where age-standardized NCD mortality rates slightly decreased from 894.9 to 548.6 deaths per 100 000 people from 2000 to 2016 [4,5]. Anecdotally, plausible hindrances to the prevention and control of NCDs in Rwanda include low community awareness, lack of trained providers, limited access to diagnostic services and treatment capacity for complicated cases

History and Current State of Global Neurosurgery in Sub-Saharan Africa

Archaeological sources reported traces of trepanation in ancient Egypt 3000 years ago, and Papyri of that time already described techniques for the treatment of head trauma (1). The history of modern neurosurgery in Sub-Saharan Africa (SSA) is recent, and there are two significant periods to be considered.

The first period can be called the pre-independence period. This period corresponded to the 1950s, when most African nations were still colonized. During this period, neurosurgical care was delivered by surgeons originally from European countries. For instance, in West Africa, the first neurosurgical operations were carried out in 1957 by a French military medical officer at the Hôpital Principal de Dakar. Later on, in 1972, the first neurosurgical care delivery was organized in “Côte d’Ivoire” under Drs. Courson and Cournil. During the same period, neurosurgery service delivery developed in English-speaking West African countries. In Ghana and Nigeria, the discipline was introduced by local neurosurgeons who had trained in Europe, namely Dr. Mustaffa in 1962 (Ghana) and Dr. Odeku 1969 (Nigeria) (2,3,5). In Southern and Eastern Africa, the specialty was initiated by Dr. P. Cliffort in Kenya and Dr. I. Bailey in Uganda. In Zimbabwe, Dr. Lawrence Levy was the first neurosurgeon to practice the discipline (2, 3).

The second period of Sub-saharan African neurosurgery started after the independence and showed greater involvement of African neurosurgeons. This period began in the 1970s, and among the local neurosurgeons, Drs. Mélaine Kouamé Kangah, Vincent Ba Zézé, and G Dechambenoit contributed significantly to the growth of neurosurgery in Ivory Coast. Similarly, Drs. Mamadou Guèye, Seydou B Badiane, and Y Sakho were pioneers in Senegal. Dr. Kazadi Kalangu did the same in Zimbabwe, while Dr. S Sanoussi and Dr. Wandja pioneered neurosurgery in Niger and Cameroon (2,3). In Burkina Faso, Dr. Abel Kabre, after his training in Dakar in the 80s, has successfully developed its specialty.

Cross-sectional survey of treatments and outcomes among injured adult patients in Kigali, Rwanda

Introduction
Traumatic injuries and their resulting mortality and disability impose a disproportionate burden on sub-Saharan countries like Rwanda. An important facet of addressing injury burdens is to comprehend injury patterns and aetiologies of trauma. This study is a cross-sectional analysis of injuries, treatments and outcomes at the University Teaching Hospital-Kigali (CHUK).

Methods
A random sample of Emergency Centre (EC) injury patients presenting during August 2015 through July 2016 was accrued. Patients were excluded if they had non-traumatic illness. Data included demographics, clinical presentation, injury type(s), mechanism of injury, and EC disposition. Descriptive statics were utilised to explore characteristics of the population.

Results
A random sample of 786 trauma patients met inclusion criteria and were analysed. The median age was 28 (IQR 6–50) years and 69.4% were male. Of all trauma patients 49.4% presented secondary to road traffic injuries (RTIs), 23.9% due to falls, 10.9% due to penetrating trauma. Craniofacial trauma was the most frequent traumatic injury location at 36.3%. Lower limb trauma and upper limb trauma constituted 35.8% and 27.1% of all injuries. Admission was required in 68.2% of cases, 23.3% were admitted to the orthopaedic service with the second highest admission to the surgical service (19.2%). Of those admitted to the hospital, the median LOS was 6 days (IQR 3–14), in the subset of patients requiring operative intervention, the median LOS was also 6 days (IQR 3–16). Death occurred in 5.5% of admitted patients in the hospital.

Conclusion
The traumatic injury burden is borne more proportionally by young males in Kigali, Rwanda. Blunt trauma accounts for a majority of trauma patient presentations; of these RTIs constitute nearly half the injury mechanisms. These findings suggest that this population has substantial injury burdens and prevention and care interventions focused in this demographic group could provide positive impacts in the study setting.

Occurrence of surgical site infection and adherence to chemoprophylaxis protocol in orthopaedics at Univerity Teaching Hospital of Kigali, Rwanda

Background: Surgical Site Infections (SSIs) are among preventable but devastating complications in trauma and orthopaedic surgery. This study was conducted to determine the prevalence of SSIs and assess adherence to antibiotic prophylaxis protocol in the Trauma and Orthopaedic Unit at the University Teaching Hospital of Kigali (CHUK).

Objective: To assess how the orthopaedic practice at University Teaching Hospital of Kigali (CHUK) adheres to the standard protocols of antibiotic prophylaxis and to what extent the orthopaedic SSI occurs at CHUK.

Design: This was a retrospective study.

Methods: Patients who underwent any major trauma or orthopaedic procedure from 1st October 2015 to 31st December 2015 were included. The patient’s clinical records were reviewed to analyze the perioperative antibiotic use and track infectious complications within 90 days post-surgery. Percentages, means and ranges were used to describe the general characteristics and the outcome of interest.

Results: One hundred and thirty two patients with the mean age of 34.9 years were included in the study. Males accounted for 62.8% with a male to female ratio of 1.8/1. Emergencies and elective cases were accounting respectively for 90.1% and 9.8%. SSIs occurred in eight patients accounting for 6.06%. Ceftriaxone was predominantly used at 60.6% of all cases. The recommended chemoprophylaxis administration interval of 60 to 30 minutes prior to skin incision was respected in only 31.7% of cases. A single dose of chemoprophylaxis was given in 89.4% of cases.

Conclusion: The study noted significant deviations from internationally accepted standards of SSI chemoprophylaxis. Therefore, CHUK would be recommended to develop and implement evidencebased protocols for antibiotic prophylaxis in trauma and orthopaedics, to minimize SSI and ensure antibiotic stewardship.

Andersen’s utilization model for cataract surgical rate and empirical evidence from economically-developing areas

Abstract
Background
Un-operated cataract is the leading cause of vision loss worldwide, responsible for 33% of visual impairment, and half of global blindness. The study aimed to build a fast evaluation method utilizing Andersen’s utilization framework and identify predictors of cataract surgical rate in sub-Saharan Africa and China.

Methods
The study was a cross-over ecological epidemiology study with a total of 19 countries in sub-Saharan Africa, and 31 provinces in China. Information was extracted from public data and published studies. Linear regression and structural equation modeling with Bootstrap were used to analyze predictors of CSR and their pathways to impact in sub-Saharan Africa and China separately.

Results
Cataract surgical resources in sub-Saharan Africa were linearly correlated with CSR (β = 0.74, 95% CI: 0.09, 0.91), while GDP/P didn’t impact cataract surgical resources (β = 0.29, 95% CI: − 0.12, 0.75). In China, residents’ average ability to pay was confirmed as the mediator between GDP/P and CSR (p = 0.32, RMSEA = 0.07; βCSR-paying = 0.77, 95% CI: 0.25, 0.90; βpaying-GDP/P = 0.89, 95% CI: 0.82, 0.93).

Conclusions
In sub-Saharan Africa, CSR is determined by health care provision. Local economic development may not directly influence CSR. Therefore, international assistance aimed to providing free cataract surgery directly is crucial. In China, CSR is determined principally by health care demand (ability to pay). To increase CSR in underserved areas of China, ability to pay must be enhanced through social insurance, and reduced surgical fees.