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A Cross-Sectional Survey of Essential Surgical Capacity in Somalia

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A Cross-Sectional Survey of Essential Surgical Capacity in Somalia Downloaded from bmjopen.bmj.com on July 31, 2014 - Published by group.bmj.com Open Access Research A cross-sectional survey of essential surgical capacity in Somalia Natalie Elkheir,1 Akshay Sharma,2 Meena Cherian,3 Omar Abdelrahman Saleh,4 Marthe Everard,4 Ghulam Rabani Popal,4 Abdi Awad Ibrahim5 To cite: Elkheir N, Sharma A, ABSTRACT et al Strengths and limitations of this study Cherian M, . A cross- Objective: To assess life-saving and disability- sectional survey of essential preventing surgical services (including emergency, ▪ surgical capacity in Somalia. Provides insight into the surgical capacity of trauma, obstetrics, anaesthesia) of health facilities in BMJ Open 2014;4:e004360. Somalia. doi:10.1136/bmjopen-2013- Somalia and to assist in the planning of strategies for ▪ Identifies significant gaps and areas for improve- 004360 strengthening surgical care systems. ment towards evidence-based planning to improve Design: Cross-sectional survey. surgical infrastructure, skills training and equipment ▸ Prepublication history for Setting: Health facilities in all 3 administrative zones of and supplies. this paper is available online. Somalia; northwest Somalia (NWS), known as ▪ Does not capture data from every first-referral To view these files please Somaliland; northeast Somalia (NES), known as health facility of the country. visit the journal online Puntland; and south/central Somalia (SCS). ▪ In some cases, measures captured are estimates. (http://dx.doi.org/10.1136/ Participants: 14 health facilities. bmjopen-2013-004360). Measures: The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was Received 29 October 2013 ’ estimating the global volume of surgery at 234 Revised 29 January 2014 employed to capture a health facility s capacity to deliver Accepted 31 January 2014 surgical and anaesthesia services by investigating four million surgical procedures annually and sig- categories of data: infrastructure, human resources, nificant disparities between procedures per- interventions available and equipment. formed in high-income and low-income Results: The 14 facilities surveyed in Somalia represent countries, global public health initiatives have 10 of the 18 districts throughout the country. The traditionally neglected the necessity for the facilities serve an average patient population of 331 250 provision of surgical services.2 Poor access to people, and 12 of the 14 identify as hospitals. While surgical services, particularly at rural facilities, major surgical procedures were provided at many results in excess morbidity and mortality from facilities (caesarean section, laparotomy, a broad range of treatable surgical conditions appendicectomy, etc), only 22% had fully available oxygen access, 50% fully available electricity and less including injuries, complications of pregnancy, than 30% had any management guidelines for sequelae of infectious diseases, acute abdom- emergency and surgical care. Furthermore, only 36% inal conditions and congenital abnormalities. were able to provide general anaesthesia inhalation due Improving access to surgical services in low- to lack of skills, supplies and equipment. Basic supplies income countries requires addressing gaps in for airway management and the prevention of infection infrastructure, training and skills of personnel, transmission were severely lacking in most facilities. appropriate equipment and medications. Conclusions: According to the results of the WHO 1St George’s Hospital, Tool for Situational Analysis to Assess Emergency and London, UK Essential Surgical Care survey, there exist significant Background 2 Harvard College, Harvard gaps in the capacity of emergency and essential surgical Somalia’s 21 years of war, armed conflict and University, Cambridge, services in Somalia including inadequacies in essential Massachusetts, USA insecurity have had a devastating effect on the equipment, service provision and infrastructure. The 3Emergency & Essential health sector. The current situation is at its Surgical Care Programme, information provided by the WHO tool can serve as a worst since the beginning of the civil war in Health Systems and basis for evidence-based decisions on country-level 1991, with unprecedented levels of child mal- policy regarding the allocation of resources and Innovation, World Health nutrition and internal displacement, as well as Organization—HQ, Geneva, provision of emergency and essential surgical services. fl Switzerland con ict and insecurity rife in parts of the 4 3 fl World Health Organization country. Continuing con ict has left 90% of Somalia, Nairobi, Kenya health infrastructure looted, damaged or 5Ministry of Health Somalia, destroyed.4 Thelowhealthworkforceratios Mogadishu, Somalia INTRODUCTION before the war have depreciated through high Correspondence to Conditions that can be treated with surgery levels of healthcare worker emigration, leaving Akshay Sharma; account for 11% of the world’s disability- an estimated 3 physicians per 100 000 popula- [email protected] adjusted life years.1 Despite recent data tion (total 253 physicians), 11 nurses per Elkheir N, Sharma A, Cherian M, et al. BMJ Open 2014;4:e004360. doi:10.1136/bmjopen-2013-004360 1 Downloaded from bmjopen.bmj.com on July 31, 2014 - Published by group.bmj.com Open Access 100 000 population (861 nurses) and 2 midwives per METHODS 100 000 population (116 midwives) serving the whole The WHO Tool for Situational Analysis to Assess country.5 Emergency and Essential Surgical Care (EESC) was Rates of death and disability from treatable surgical employed to capture a health facility’s capacity to perform conditions continue to be unacceptably high. Somalia’s basic surgical (including obstetrics and trauma) and anaes- maternal mortality rate is estimated to be 1044 per thesia interventions by investigating four categories of 100 000 live-births, one of the highest in the region.6 data: infrastructure, human resources, interventions pro- This corresponds to a lifetime risk of one maternal vided and equipment availability. The tool queries the death for every 10 women. The leading causes of mater- availability of eight types of care providers, 35 surgical nal death (antepartum and postpartum haemorrhage, interventions and 67 items of equipment.7 The answer obstructed labour and eclampsia) can all be addressed ‘available’ was defined as ‘fully available for all patients all with appropriate emergency obstetric care, which often of the time’,while‘sometimes’ was defined as ‘available require surgical and anaesthetic interventions. Trauma, with frequent shortages or difficulties’ (WHO EESC as a consequence of road traffic accidents, armed fight- Situational Analysis Tool, 2012, http://www.who.int/ ing and landmine explosions, is also common. In 2010 surgery/publications/WHO_EESC_SituationAnalysisTool. and 2011, WHO reported more than 7500 war-wounded pdf). civilians who were admitted to the three main hospitals Facilities were also asked the size of the ‘population in Mogadishu, one in five being children and one in served’, intending to quantify the population living in three women (WHO. Emergency and Essential Surgical the catchment area. This value represents the number Care. 2013. http://www.who.int/surgery/en/). of residents who might use the facility as their first- The health sector faces overwhelming challenges in a referral health facility, not the number of patients seen. country where two decades of lawlessness have resulted The WHO Tool for Situational Analysis to Assess EESC in the collapse of central government and three almost was distributed by the Ministry of Health and WHO autonomously ruled zones: northwest Somalia (NWS), Somalia to 20 first-referral level health facilities around known as Somaliland; northeast Somalia (NES), known the country and was completed at 14 health facilities as Puntland; and south/central Somalia (SCS). representing 10 of the 18 regions of Somalia and all Somalia’s public health system is tiered, comprising three administrative zones. The survey was extended to regional referral hospitals, district hospitals, maternal regional medical officers and facility administrators. and child health centres and health posts. However, hos- Participation in the survey and reporting to the WHO pitals and health facilities are limited in number, inad- was voluntary. The physical surveys were then obtained equately distributed, operate using vastly different either by post directly to the WHO Somalia office standards and often cannot provide a minimum package (Nairobi, Kenya) or by site visits from the Somalia of primary healthcare (PHC) services. As funders and Ministry of Health (MoH), the WHO country office and public health experts adopt the expansion of primary members of the Global Initiative for EESC (GIEESC) healthcare services, the inclusion of surgical services at between September 2011 and April 2012. the first-referral level is critical. The purpose of this Despite efforts to standardise the reporting and collec- survey was to collect knowledge gained from compre- tion of much of the data by site visits performed by hensive quantitative assessments of surgical capacity in agents affiliated to the authors, it must be noted that an Somalia in order to assist in planning strategies for uni- inherent reporting bias may be present in the data, versal access to life-saving and disability-preventing surgi- given that survey data were compiled by different agents cal services (WHO. Emergency and Essential Surgical at each site.
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