Salome Maswime: dynamic leader in global surgery

As Associate Professor and Head of Global Surgery at the University of Cape Town (UCT), South Africa, Salome Maswime is aware of the scale of the job in front of her. “For me the big problem is the disconnect between health systems and clinical care in low and middle income countries, especially concerning surgical care. Outcomes are often poor, there being not enough focus on the quality of surgery, and how it relates to integrated health care and overarching health systems performance”, she explains. Maswime saw such shortcomings first hand in her clinical career in obstetrics and gynaecology, before she took up the new post as Head of Global Surgery at UCT in July, 2019.

Investing in Surgery: A Value Proposition for African Leaders

Globally, poor access to high-quality surgical, obstetric, and anaesthesia care remains a main contributor to global disease burden accounting for about a third of deaths worldwide. The need for strengthening surgical care systems is especially urgent in sub-Saharan Africa, where access is strikingly limited, leading to the highest mortality and morbidity from surgically preventable and treatable conditions in the world. Approximately 93% of the population of sub-Saharan Africa lacks access to safe, affordable, and timely surgical care, compared with less than 10% in high-income countries.2 Despite the immense and growing need for surgical services in sub-Saharan Africa, investments by African public sector leaders to improve surgical systems on the subcontinent have been inadequate. The current COVID-19 pandemic has disrupted health care globally, with an estimation by the CovidSurg Collaborative showing that more than 28 million surgeries will be postponed or cancelled worldwide during the 12 weeks of peak disruption. There is a basic ethical responsibility to provide surgical care as a fundamental human right, in keeping with the principles espoused in the Universal Declaration of Human Rights. Additionally, improved access to high-quality surgical care is an essential component of universal health coverage and will contribute to good health and wellbeing, leading to improved human capital—all of which are vital for poverty reduction and economic growth on the continent.

Priorities for peri‐operative research in Africa

Deaths following surgery are the third largest contributor to deaths globally, and in Africa are twice the global average. There is a need for a peri‐operative research agenda to ensure co‐ordinated, collaborative research efforts across Africa in order to decrease peri‐operative mortality. The objective was to determine the top 10 research priorities for peri‐operative research in Africa. A Delphi technique was used to establish consensus on the top research priorities. The top 10 research priorities identified were (1) Develop training standards for peri‐operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (2) Develop minimum provision of care standards for peri‐operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (3) Early identification and management of mothers at risk from peripartum haemorrhage in the peri‐operative period; (4) The role of communication and teamwork between surgical, anaesthetic, nursing and other teams involved in peri‐operative care; (5) A facility audit/African World Health Organization situational analysis tool audit to assess emergency and essential surgical care, which includes anaesthetic equipment available and level of training and knowledge of peri‐operative healthcare providers (surgeons, anaesthetists and nurses); (6) Establishing evidence‐based practice guidelines for peri‐operative physicians in Africa; (7) Economic analysis of strategies to finance access to surgery in Africa; (8) Establishment of a minimum dataset surgical registry; (9) A quality improvement programme to improve implementation of the surgical safety checklist; and (10) Peri‐operative outcomes associated with emergency surgery. These peri‐operative research priorities provide the structure for an intermediate‐term research agenda to improve peri‐operative outcomes across Africa

Challenges to providing open heart surgery for 186 million Nigerians

Background: Open heart surgery is nonexistent or undeveloped in many African countries due to the prerequisite for specialized multispecialty teams, expensive equipment, and consumables. This review aims to outline strategies for facilitating local skilled workforce training, improve patients’ access, and sustain heart surgery in Africa’s most populous nation. Methods: We reviewed the demographic, socioeconomic, and health metrics published by the United Nations, the World Health Organization (WHO), the World Bank, and other relevant sources for the top three African economies – South Africa, Nigeria, and Egypt. Results: South Africa classified as upper-middle-income nation with gross national income [GNI] $12,475–$4126 spends 8.8% of gross domestic product (GDP), while Egypt and Nigeria both classified as lower-middle-income nations GNI $4125–$1046 spends 5.6% and 3.7% of GDP, respectively, on health care. Egypt performed 45%, South Africa 39%, and Nigeria 0.1% of their WHO projected annual heart surgery volume in 2015. These capacities are consistent with the human development index (HDI), thoracic surgeon-to-population ratio, and health insurance coverage ranking of these countries. Conclusion: Although gross income per capita is comparable, the HDI – a better discriminator of development is higher in Egypt with 0.69 against 0.51 in Nigeria, as evidenced by their respective heart surgery capacities. While the WHO projected 72,000 cases/annum for Nigeria is unattainable with the present workforce, the Pan African Society for Cardiothoracic Surgery (PASCATS) 40/1 million population projection of 7200 cases/annum appears a more realistic goal. However achieving even this modest target will require government political willpower and increased budgetary allocation for expanding insurance coverage. PASCATS advocates three mentorship models: resident senior local consultant, mission teams and senior expatriate consultant, with centralization through regional referral centers as viable pathways to develop cardiac surgery in sub Saharan Africa. Regionalization optimizes the scarce workforce and resources and therefore by combining assets can fast track skill acquisition by trainee surgeons.

Development of Low-Cost Locally Sourced Two-Component Compression Bandages in Western Kenya.

Compression therapy is well-established standard of care for chronic leg ulcers from venous disease and lymphedema. Chronic leg ulcers and lymphedema have a significant impact on quality of life, driven by pain, foul odor, and restricted mobility. Provision of layered compression therapy in resource-limited settings, as in Western Kenya and other regions of sub-Saharan Africa, is a major challenge due to several barriers: availability, affordability, and access to healthcare facilities. When wound care providers from an Academic Model Providing Access to Healthcare (AMPATH) health center in Western Kenya noted that a donated, finite supply of two-component compression bandages was helping to heal chronic leg ulcers, they began to explore the potential of finding a local, sustainable solution. Dermatology and pharmacy teams from AMPATH collaborated with health center providers to address this need.Following a literature review and examination of ingredients in prepackaged brand-name kits, essential components were identified: elastic crepe, gauze, and zinc oxide paste. All of these materials are locally available and routinely used for wound care. Two-component compression bandages were made by applying zinc oxide to dry gauze for the inner layer and using elastic crepe as the outer layer. Feedback from wound clinic providers was utilized to optimize the compression bandages for ease of use.Adjustments to assembly of the paste bandage included use of zinc oxide paste instead of zinc oxide ointment for easier gauze impregnation and cutting the inner layer gauze in half lengthwise to facilitate easier bandaging of the leg, such that there were two rolls of zinc-impregnated gauze each measuring 5 inches × 2 m. Adjustments to use of the compression bandage have included increasing the frequency of bandage changes from 7 to 3 days during the rainy seasons, when it is difficult to keep the bandage dry. Continuous local acquisition of all components led to lower price quotes for bulk materials, driving down the production cost and enabling a cost to the patient of 200 KSh (2 USD) per two-component compression bandage kit. Wound care providers have provided anecdotal reports of healed chronic leg ulcers (from venous stasis, trauma), improved lymphedema, and patient tolerance of compression.Low-cost locally sourced two-component compression bandages have been developed for use in Western Kenya. Their use has been initiated at an AMPATH health center and is poised to meet the need for affordable compression therapy options in Western Kenya. Studies evaluating their efficacy in chronic leg ulcers and Kaposi sarcoma lymphedema are ongoing. Future work should address adaptation of compression bandages for optimal use in Western Kenya and evaluate reproducibility of these bandages in similar settings, as well as consider home- or community-based care delivery models to mitigate transportation costs associated with accessing healthcare facilities.

Barriers to Neurosurgical Training in Sub-Saharan Africa: The Need for a Phased Approach to Global Surgery Efforts to Improve Neurosurgical Care

BACKGROUND: Neurosurgery in low-income countries is faced with multiple challenges. Although the most common challenges include infrastructure and physical resource deficits, an underemphasized barrier relates to the methods and components of surgical training. The role of important aspects, including didactic surgical training, surgical decision-making, workshops, conferences, and assessment methods, has not been duly studied. Knowledge of these issues is a crucial step to move closer to strengthening surgical capacity in low-income countries.
METHODS: We designed an online survey to assess self-perceived and objectively measured barriers to neurosurgical training in various Sub-Saharan African countries. Key outcomes included perception toward adequacy of neurosurgery training and barriers to neurosurgical training at each individual site.
RESULTS: Only 37% of responders felt that their training program adequately prepared them for handling incoming neurosurgical cases. Top perceived limitations of neurosurgery training included lack of physical resources (25% of all responses), lack of practical workshops (22%), lack of program structure (18%), and lack of topic-specific lectures (10%).
CONCLUSIONS: Our results show that most responders believe their training program is inadequate and are interested in improving it through international collaborations. This implies that activities directed at strengthening surgical capacity must address this important necessity. One important strategy is the use of online educational tools. In consideration of the observed limitations in care, resources, and training, we recommend a phased approach to neurosurgical growth in low-income settings.

What is a good result after clubfoot treatment? A Delphi-based consensus on success by regional clubfoot trainers from across Africa.

Congenital talipes equino-varus (CTEV), also known as clubfoot, is one of the most common congenital musculoskeletal malformations. Despite this, considerable variation exists in the measurement of deformity correction and outcome evaluation. This study aims to determine the criteria for successful clubfoot correction using the Ponseti technique in low resource settings through Africa.Using the Delphi method, 18 experienced clubfoot practitioners and trainers from ten countries in Africa ranked the importance of 22 criteria to define an ‘acceptable or good clubfoot correction’ at the end of bracing with the Ponseti technique. A 10cm visual analogue scale was used. They repeated the rating with the results of the mean scores and standard deviation of the first test provided. The consistency among trainers was determined with the intra-class correlation coefficient (ICC). From the original 22 criteria, ten criteria with a mean score >7 and SD 9 and SD<1.5.The consensus definition of a successfully treated clubfoot includes: (1) a plantigrade foot, (2) the ability to wear a normal shoe, (3) no pain, and (4) the parent is satisfied. Participants demonstrated good consistency in rating these final criteria (ICC 0.88; 0.74,0.97).The consistency of Ponseti technique trainers from Africa in rating criteria for a successful outcome of clubfoot management was good. The consensus definition includes basic physical assessment, footwear use, pain and parent satisfaction.

Surgery in Swaziland.

Surgeons working in less developed countries have to manage a wider range of conditions than their colleagues in Britain. It is suggested that such an experience would be a valuable part of the education of a specialist in Britain. A personal series of surgical operations carried out in Swaziland is presented.