Access to care solutions in healthcare for obstetric care in Africa: A systematic review

Background
Emergency Medical Services (EMS) systems exist to reduce death and disability from life-threatening medical emergencies. Less than 9% of the African population is serviced by an emergency medical services transportation system, and nearly two-thirds of African countries do not have any known EMS system in place. One of the leading reasons for EMS utilization in Africa is for obstetric emergencies. The purpose of this systematic review is to provide a qualitative description and summation of previously described interventions to improve access to care for patients with maternal obstetric emergencies in Africa with the intent of identifying interventions that can innovatively be translated to a broader emergency context.

Methods
The protocol was registered in the PROSPERO database (International Prospective Register of Systematic Reviews) under the number CRD42018105371. We searched the following electronic databases for all abstracts up to 10/19/2020 in accordance to PRISMA guidelines: PubMed/MEDLINE, Embase, CINAHL, Scopus and African Index Medicus. Articles were included if they were focused on a specific mode of transportation or an access-to-care solution for hospital or outpatient clinic care in Africa for maternal or traumatic emergency conditions. Exclusion criteria included in-hospital solutions intended to address a lack of access. Reference and citation analyses were performed, and a data quality assessment was conducted. Data analysis was performed using a qualitative metasynthesis approach.

Findings
A total of 6,457 references were imported for screening and 1,757 duplicates were removed. Of the 4,700 studies that were screened against title and abstract, 4,485 studies were excluded. Finally, 215 studies were assessed for full-text eligibility and 152 studies were excluded. A final count of 63 studies were included in the systematic review. In the 63 studies that were included, there was representation from 20 countries in Africa. The three most common interventions included specific transportation solutions (n = 39), community engagement (n = 28) and education or training initiatives (n = 27). Over half of the studies included more than one category of intervention.

Interpretation
Emergency care systems across Africa are understudied and interventions to improve access to care for obstetric emergencies provides important insight into existing solutions for other types of emergency conditions. Physical access to means of transportation, efforts to increase layperson knowledge and recognition of emergent conditions, and community engagement hold the most promise for future efforts at improving emergency access to care.

Views from Multidisciplinary Oncology Clinicians on Strengthening Cancer Care Delivery Systems in Tanzania

Background
In response to the increasing burden of cancer in Tanzania, the Ministry of Health Community Development, Gender, Elderly and Children launched National Cancer Treatment Guidelines (TNCTG) in February 2020. The guidelines aimed to improve and standardize oncology care in the country. At Ocean Road Cancer Institute (ORCI), we developed a theory-informed implementation strategy to promote guideline-concordant care. As part of the situation analysis for implementation strategy development, we conducted focus group discussions to evaluate clinical systems and contextual factors that influence guideline-based practice prior to launching of TNCTG.

Methods
In June 2019, three focus group discussions were conducted with a total of 21 oncology clinicians at ORCI, stratified by profession. A discussion guide was used to stimulate dialogue about facilitators and barriers to delivery of guideline concordant care. Discussions were audio recorded, transcribed, translated, and analyzed using thematic framework analysis.

Results
Participants identified factors both within the inner context of ORCI clinical systems and outside of ORCI. Themes within the clinical systems included: capacity and infrastructure, information technology, communication, efficiency and quality of services provided. Contextual factors external to ORCI included: inter-institutional coordination, oncology capacity in peripheral hospitals, public awareness and beliefs, and financial barriers. Participants provided pragmatic suggestions for strengthening cancer care delivery in Tanzania.

Conclusion
Our results highlight several barriers and facilitators within and outside of the clinical systems at ORCI that may affect uptake of the TNCTG. Our findings were used to inform a broader guideline implementation strategy, in effort to improve uptake of the TNCTGs at ORCI.

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.

Increasing Antimicrobial Resistance in Surgical Wards at Mulago National Referral Hospital, Uganda, from 2014 to 2018—Cause for Concern?

Antimicrobial Resistance (AMR) and Healthcare Associated Infections (HAIs) are major global public health challenges in our time. This study provides a broader and updated overview of AMR trends in surgical wards of Mulago National Referral Hospital (MNRH) between 2014 and 2018. Laboratory data on the antimicrobial susceptibility profiles of bacterial isolates from 428 patient samples were available. The most common samples were as follows: tracheal aspirates (36.5%), pus swabs (28.0%), and blood (20.6%). Klebsiella (21.7%), Acinetobacter (17.5%), and Staphylococcus species (12.4%) were the most common isolates. The resistance patterns for different antimicrobials were: penicillins (40–100%), cephalosporins (30–100%), β-lactamase inhibitor combinations (70–100%), carbapenems (10–100%), polymyxin E (0–7%), aminoglycosides (50–100%), sulphonamides (80–100%), fluoroquinolones (40–70%), macrolides (40–100%), lincosamides (10–45%), phenicols (40–70%), nitrofurans (0–25%), and glycopeptide (0–20%). This study demonstrated a sustained increase in resistance among the most commonly used antibiotics in Uganda over the five-year study period. It implies ongoing hospital-based monitoring and surveillance of AMR patterns are needed to inform antibiotic prescribing, and to contribute to national and global AMR profiles. It also suggests continued emphasis on infection prevention and control practices (IPC), including antibiotic stewardship. Ultimately, laboratory capacity for timely bacteriological culture and sensitivity testing will provide a rational choice of antibiotics for HAI.

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

Surgical management and outcomes of late-presenting acute limb ischaemia at 2 referral hospitals in Addis Ababa, Ethiopia: A 1-year prospective study

Objective: The study was performed to show the overall perspective of surgical management for acute limb ischemia specific to Ethiopian population.
Methods: A prospective planned cohort study was conducted to analyze the socio-demography, clinical presentation, causes of limb ischemia, and outcomes of surgical intervention, and variables associated with complications of acute limb ischemia.
Results:A total of 102 patients were operated upon. The male to female ratio was 2:1; the mean age of presentation was 54±17 years. Patients presented after an average of 9±4.8 days of symptom onset. The type of procedures performed were, thrombectomy 51(47.2%), primary amputation 24(22.2%), bypass or interposition vascular grafts 10(9.2%), embolectomy 10(9.2%), primary vascular repair 7(6.4%), and femoro-femoral graft 6(5.5%). Local and systemic complications occurred in 35.3% and 17.6% respectively. Amputation after re-vascularization surgery was seen in 32.4%. A 30-day total amputation & mortality rate was 52.9% and 9.8% respectively. Clinical variables found to have a statistical significant association (P<0.05) with complications were age ≥ 60 years, late presentation (≥ 9days), patients with hypertensive disease and previous myocardial infarction.
Conclusions: Optimizing co-morbidities, timely detection and treating immediately on arrival could potentially play a key role in improving surgical outcomes of acute limb ischemia.

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.

The role of Mitrofanoff appendicovesicostomy in the management of a pelvic fracture distraction defect in a 24- year-old man after multiple failed reconstruction attempts

Failed Pelvic Fracture Distraction Defect repairs present a considerable challenge for management. Re-do urethroplasties for failed repairs are associated with higher recurrence and morbidity rates. The case presented describes a male patient with a pelvic fracture urethral distraction defect (PFUDD) who had undergone multiple failed repairs. The Mitrofanoff appendicovesicostomy was successfully carried out and the patient remains continent to date. The Mitrofanoff appendicovesicostomy is not commonly employed in the management of adult urethral stricture disease. We present our experience with managing a pelvic fracture urethral disruption defect (PFUDD) after multiple failed urethroplasties using a continent catheterisable urinary diversion techniqu

Invasive breast Cancer treatment in Tanzania: landscape assessment to prepare for implementation of standardized treatment guidelines

Background
Incidence of breast cancer continues to rise in low- and middle-income countries, with data from the East African country of Tanzania predicting an 82% increase in breast cancer from 2017 to 2030. We aimed to characterize treatment pathways, receipt of therapies, and identify high-value interventions to increase concordance with international guidelines and avert unnecessary breast cancer deaths.

Methods
Primary data were extracted from medical charts of patients presenting to Bugando Medical Center, Tanzania, with breast concerns and suspected to have breast cancer. Clinicopathologic features were summarized with descriptive statistics. A Poisson model was utilized to estimate prevalence ratios for variables predicted to affect receipt of life-saving adjuvant therapies and completion of therapies. International and Tanzanian guidelines were compared to current care patterns in the domains of lymph node evaluation, metastases evaluation, histopathological diagnosis, and receptor testing to yield concordance scores and suggest future areas of focus.

Results
We identified 164 patients treated for suspected breast cancer from April 2015–January 2019. Women were predominantly post-menopausal (43%) and without documented insurance (70%). Those with a confirmed histopathology diagnosis (69%) were 3 times more likely to receive adjuvant therapy (PrR [95% CI]: 3.0 [1.7–5.4]) and those documented to have insurance were 1.8 times more likely to complete adjuvant therapy (1.8 [1.0–3.2]). Out of 164 patients, 4% (n = 7) received concordant care based on the four evaluated management domains. The first most common reason for non-concordance was lack of hormone receptor testing as 91% (n = 144) of cases did not undergo this testing. The next reason was lack of lymph node evaluation (44% without axillary staging) followed by absence of abdominopelvic imaging in those with symptoms (35%) and lack of histopathological confirmation (31%).

Conclusions
Patient-specific clinical data from Tanzania show limitations of current breast cancer management including axillary staging, receipt of formal diagnosis, lack of predictive biomarker testing, and low rates of adjuvant therapy completion. These findings highlight the need to adapt and adopt interventions to increase concordance with guidelines including improving capacity for pathology, developing complete staging pathways, and ensuring completion of prescribed adjuvant therapies.

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.