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

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

Introduction
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.

Methods
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.

Results
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).

Conclusion
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

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

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

Methods
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.

Results
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.

Conclusion
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.

The spectrum and burden of in-patient paediatric musculoskeletal diseases in Northern Tanzania

Background
Musculoskeletal diseases (MSD) are a major contributor to the global burden of disease and disability, and disproportionally affect low- and middle-income countries; however, there is a dearth of epidemiological data. Affected children often face increased morbidity, social isolation and economic hardship.

Aim
To assess the spectrum and burden of paediatric MSD in children aged 5–18 years admitted to a major referral hospital in Tanzania.

Methods
This was a retrospective cohort study of children aged 5–18 years admitted to Kilimanjaro Christian Medical Centre (KCMC) whose initial diagnosis was recognised as a musculoskeletal condition by the International Classification of Diseases-10 between 1 January and 31 December 2017.

Results
During 2017, 163 cases of confirmed paediatric MSD were admitted to KCMC, representing 21.2% of all admissions of children aged 5–18 years (n = 769). Bone disease was the most common diagnosis. They comprised 106 (65.0%) traumatic fractures, 31 (19.0%) osteo-articular infections, 9 (5.5%) malunions and 3 (1.8%) pathological fractures. Congenital defects and rheumatic disease were relatively uncommon, accounting for only 6 (3.7%) and 4 (2.5%) MSD admissions, respectively.

Conclusion
The majority of cases of MSD were related to fractures, followed by osteo-articular infections, while recognised cases of rheumatic disease were rare. The study, although small, identified the sizeable burden and spectrum of paediatric MSD admitted to a hospital in Tanzania over a 12-month period and highlights the need for larger studies to inform the optimal allocation of health resources.

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

Objectives
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.

Setting
Urban referral center in resource-limited setting.

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

Results
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).

Conclusion
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.

Pre-course online cases for the world health organization’s basic emergency care course in Uganda: A mixed methods analysis

Introduction
The Ministry of Health – Uganda implemented the World Health Organization’s Basic Emergency Care course (BEC1) to improve formal emergency care training and address its high burden of acute illness and injury. The BEC is an open-access, in-person, short course that provides comprehensive basic emergency training in low-resource settings. A free, open-access series of pre-course online cases available as downloadable offline files were developed to improve knowledge acquisition and retention. We evaluated BEC participants’ knowledge and self-efficacy in emergency care provision with and without these cases and their perceptions of the cases.

Methods
Multiple Choice Questions (MCQs2) and Likert-scale surveys assessed 137 providers’ knowledge and self-efficacy in emergency care provision, respectively, and focus group discussions explored 74 providers’ perceptions of the BEC course with cases in Kampala in this prospective, controlled study. Data was collected pre-BEC, post-BEC and six-months post-BEC. We used liability analysis and Cronbach alpha coefficients to establish intercorrelation between categorised Likert-scale items. We used mixed model analysis of variance to interpret Likert-scale and MCQ data and thematic content analysis to explore focus group discussions.

Results
Participants gained and maintained significant increases in MCQ averages (15%) and Likert-scale scores over time (p 0.05). Nurses experienced more significant initial gains and long-term decays in MCQ and self-efficacy than doctors (p = 0.009, p < 0.05). Providers found the cases most useful pre-BEC to preview course content but did not revisit them post-course. Technological difficulties and internet costs limited case usage. Conclusion Basic emergency care courses for low-resource settings can increase frontline providers’ long-term knowledge and self-efficacy in emergency care. Nurses experienced greater initial gains and long-term losses in knowledge than doctors. Online adjuncts may enhance health professional education in low-to-middle income countries.

The role of telepathology in diagnosis of pre-malignant and malignant cervical lesions: Implementation at a tertiary hospital in Northern Tanzania

Introduction
Adequate and timely access to pathology services is a key to scale up cancer control, however, there is an extremely shortage of pathologists in Tanzania. Telepathology (scanned images microscopy) has the potential to increase access to pathology services and it is increasingly being employed for primary diagnosis and consultation services. However, the experience with the use of telepathology in Tanzania is limited. We aimed to investigate the feasibility of using scanned images for primary diagnosis of pre-malignant and malignant cervical lesions by assessing its equivalency to conventional (glass slide) microscopy in Tanzania.

Methods
In this laboratory-based study, assessment of hematoxylin and eosin stained glass slides of 175 cervical biopsies were initially performed conventionally by three pathologists independently. The slides were scanned at x 40 and one to three months later, the scanned images were reviewed by the pathologists in blinded fashion. The agreement between initial and review diagnoses across participating pathologists was described and measured using Cohen’s kappa coefficient (κ).

Results
The overall concordance of diagnoses established on conventional microscopy compared to scanned images across three pathologists was 87.7%; κ = 0.54; CI (0.49–0.57).The overall agreement of diagnoses established by local pathologist on conventional microscopy compared to scanned images was 87.4%; κ = 0.73; CI (0.65–0.79). The concordance of diagnoses established by senior pathologist compared to local pathologist on conventional microscopy and scanned images was 96% and 97.7% respectively. The inter-observer agreement (κ) value were 0.93, CI (0.87–1.00) and 0.94, CI (0.88–1.00) for conventional microscopy and scanned images respectively.

Conclusions
All κ coefficients expressed good intra- and inter-observer agreement, suggesting that telepathology is sufficiently accurate for primary diagnosis in surgical pathology. The discrepancies in interpretation of pre-malignant lesions highlights the importance of p16 immunohistochemistry in definitive diagnosis in these lesions. Sustainability factors including hardware and internet connectivity are essential components to be considered before telepathology may be deemed suitable for widely use in Tanzania.

A Journey Undertaken by Families to Access General Surgical Care for their Children at Muhimbili National Hospital, Tanzania; Prospective Observational Cohort Study

Background
A majority of the 2 billion children lacking access to safe, timely and affordable surgical care reside in low-and middle-income countries. A barrier to tackling this issue is the paucity of information regarding children’s journey to surgical care. We aimed to explore children’s journeys and its implications on accessing general paediatric surgical care at Muhimbili National Hospital (MNH), a tertiary centre in Tanzania.

Methods
A prospective observational cohort study was undertaken at MNH, recruiting patients undergoing elective and emergency surgeries. Data on socio-demographic, clinical, symptoms onset and 30-days post-operative were collected. Descriptive statistics and Mann–Whitney, Kruskal–Wallis and Fisher’s exact tests were used for data analysis.

Result
We recruited 154 children with a median age of 36 months. The majority were referred from regional hospitals due to a lack of paediatric surgery expertise. The time taken to seeking care was significantly greater in those who self-referred (p = 0.0186). Of these participants, 68.4 and 31.1% were able to reach a referring health facility and MNH, respectively, within 2 h of deciding to seek care. Overall insurance coverage was 75.32%. The median out of pocket expenditure for receiving care was $69.00. The incidence of surgical site infection was 10.2%, and only 2 patients died.

Conclusion
Although there have been significant efforts to improve access to safe, timely and affordable surgical care, there is still a need to strengthen children’s surgical care system. Investing in regional hospitals may be an effective approach to improve access to children surgical 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 …

Phenotypic Bacterial Isolates, Antimicrobial Susceptibility Pattern and Associated Factors among Septicemia Suspected Patients at a hospital, in Northwest Ethiopia. Prospective cross- sectional study

Background
Septicemia is a life-threatening infection when pathogenic bacteria infiltrate the bloodstream, leading morbidity and mortality in Ethiopian hospital patients. Multidrug resistance is a therapeutic challenge among this patient and has a paucity of data in the hospitals. Therefore, this study aimed to assess the bacterial isolates, antimicrobial susceptibility pattern, and associated factors among septicemia suspected patients.

Methods
Prospective cross-sectional study was conducted among 214 septicemia suspected patients from February to June 2021 a hospital in northwest, Ethiopia. Blood samples were collected aseptically and processed to identify bacterial isolates by using different standard microbiological procedures. Antimicrobial susceptibility pattern was performed using the modified Kirby Bauer disc diffusion on Mueller Hinton agar. Epi-data V4.2 was used to enter data and SPSS V25 for analysis. The variables were assessed using a bivariate logistic regression model with a 95% confidence interval, and declared statistically significant; P-value was < 0.05.

Results
The overall bacterial isolates was found 45/214 (21%) in this study. Gram-negative and positive bacteria were 25/45(55.6%), 20/45(44.4%) respectively. The most common bacterial isolates were Staphylococcus aureus12/45 (26.7%), Klebsiella pneumonia8/45(17.8%), Escherichia coli 6/45 (13.3%). Gram-negative bacteria showed susceptible to amikacin (88%), meropenem, imipenem (76%), but resistance to (92%) ampicillin, (85.7%) amoxicillin-clavulanic acid. S.aureus (91.7%) resistance to Penicillin, (58.3%) cefoxitin and (75%) susceptible to ciprofloxacillin. S.pyogenes and S.agalactia were (100%) susceptible to Vancomacin. Multidrug resistance was found in 27/45(60%) of the bacterial isolates. The main predictors related to patients suspected of septicemia were prolonged hospitalization (AOR = 2.29, 95% CI: 1.18, 7.22), fever (AOR = 0.39, 95%CI: 0.18, 0.85) and length of hospital stay (AOR = 0.13, 95%CI: 0.02, 0.82).

Conclusions
Bacterial isolates among septicemia suspected patients were high. The majority of the bacterial isolates were multidrug-resistant. To prevent antimicrobial resistance, specific antibiotic utilization strategy should be applied.