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Background Sub-Saharan Africa has one of the highest burdens of surgically treatable conditions in the world and the highest unmet need, especially in rural areas. Zambia is one of the countries in the region taking steps to improve surgical care for its rural populations. Aim To demonstrate changes in surgical capacity in Zambia’s district hospitals over a 3-year period and to provide a baseline from which future interventions in surgical care can be assessed. Methods A cross-sectional assessment of surgical capacity, using a modified WHO questionnaire, was administered in first-level hospitals in nine of Zambia’s ten provinces between November 2012 and February 2013 and again between February and April 2016. The two assessments allowed measurement of changes in surgical workforce, infrastructure, equipment, drugs and consumables; and numbers of major surgical procedures performed over two 12-month periods prior to the assessments. Results There was a significant increase, 2013–2016, in number of theatre staff, from 174 (mean 4.4; SD 1.7) to 235 (mean 6; SD 2.9), P  = 0.02. However, the percentage of hospitals with functioning anaesthetic machines dropped from 64 to 41%. There was also a drop in hospitals reporting availability of instruments, drugs and consumables from 38 to 24 (97–62%) and from 28 to 24 (72–62%), respectively. The median number of caesarean sections in 2012 was 99 [interquartile range (IQR) 42–187] and 100 (IQR 42–126) in 2015 ( P value =0.53). The median number of major surgical procedures in 2012 was 54 (IQR 10–113) and 66 (IQR 18–168) in 2015 ( P  = 0.45). Conclusion An increase in the first-level hospital surgical workforce between 2013 and 2016 was accompanied by reductions in essential equipment and consumables for surgery, and no changes in surgical output. Periodic monitoring of resource availability is needed to address shortages and make safe surgery available to rural populations.

Background Surgical perioperative deaths and major complications are important contributors to preventable morbidity, globally and in sub-Saharan Africa. The surgical safety checklist (SSC) was developed by WHO to reduce surgical deaths and complications, by utilising a team approach and a series of steps to ensure the safe transit of a patient through the surgical operation. This study explored barriers and enablers to the utilisation of the Checklist at the University Teaching Hospital (UTH) in Lusaka, Zambia. Methods A qualitative case study was conducted involving members of surgical teams (doctors, anaesthesia providers, nurses and support staff) from the UTH surgical departments. Purposive sampling was used and 16 in-depth interviews were conducted between December 2018 and March 2019. Data were transcribed, organised and analysed using thematic analysis. Results Analysis revealed variability in implementation of the SSC by surgical teams, which stemmed from lack of senior surgeon ownership of the initiative, when the SSC was introduced at UTH 5 years earlier. Low utilisation was also linked to factors such as: negative attitudes towards it, the hierarchical structure of surgical teams, lack of support for the SSC among senior surgeons and poor teamwork. Further determinants included: lack of training opportunities, lack of leadership and erratic availability of resources. Interviewees proposed the following strategies for improving SSC utilisation: periodic training, refresher courses, monitoring of use, local adaptation, mobilising the support of senior surgeons and improvement in functionality of the surgical teams. Conclusion The SSC has the potential to benefit patients; however, its utilisation at the UTH has been patchy, at best. Its full benefits will only be achieved if senior surgeons are committed and managers allocate resources to its implementation. The study points more broadly to the factors that influence or obstruct the introduction and effective implementation of new quality of care initiatives.

Background Most sub-Saharan African countries struggle to make safe surgery accessible to rural populations due to a shortage of qualified surgeons and the unlikelihood of retaining them in district hospitals. In 2002, Zambia introduced a new cadre of non-physician clinicians (NPCs), medical licentiates (MLs), trained initially to the level of a higher diploma and from 2013 up to a BSc degree. MLs have advanced clinical skills, including training in elective and emergency surgery, designed as a sustainable response to the surgical needs of rural populations. Methods This qualitative study aimed to describe the role, contributions and challenges surgically active MLs have experienced. Based on 43 interviewees, it includes the perspective of MLs, their district hospital colleagues—medical officers (MOs), nurses and managers; and surgeon-supervisors and national stakeholders. Results In Zambia, MLs play a crucial role in delivering surgical services at the district level, providing emergency surgery and often increasing the range of elective surgical cases that would otherwise not be available for rural dwellers. They work hand in hand with MOs, often giving them informal surgical training and reducing the need for hospitals to refer surgical cases. However, MLs often face professional recognition problems and tensions around relationships with MOs that impact their ability to utilise their surgical skills. Conclusions The paper provides new evidence concerning the benefits of ‘task shifting’ and identifies challenges that need to be addressed if MLs are to be a sustainable response to the surgical needs of rural populations in Zambia. Policy lessons for other countries in the region that also use NPCs to deliver essential surgery include the need for career paths and opportunities, professional recognition, and suitable employment options for this important cadre of healthcare professionals.

Zambia has achieved improvements in life expectancy among persons living with HIV (PLHIV) because of high antiretroviral therapy (ART) coverage, which should improve survival due to reductions in AIDS-defining conditions. However, recent estimates of the most common causes of death are not widely available. We utilized mortality surveillance data to report on common causes of death among persons with HIV who died in community settings in Zambia. The Zambian Ministry of Health conducted sentinel mortality surveillance of community deaths in 45 hospitals in 33 of 116 districts from January 2020 through December 2023. Verbal autopsies (VA) were conducted through interviews with relatives or close associates of deceased persons using the 2016 World Health Organization tool. HIV status was reported. A probable cause of death was assigned by a validated computer algorithm (InterVA5). We describe the top assigned causes of death stratified by HIV status. Verbal autopsies were conducted for 67,079 community deaths, of which 11,475 (17.1%) were persons with HIV. The mean age at death was 45 years among persons with HIV and 48 years for persons without HIV (T-test p < 0.001). The most common probable causes of death identified by VA among persons with HIV were HIV/AIDS-related causes (50.4%), cardiac disease (13.1%), pulmonary tuberculosis (7.5%), and digestive neoplasms (3.9%) . Leading probable causes in decedents without HIV were cardiac disease (24.9%), stroke (8.5%), and acute respiratory infection including pneumonia (7.6%). Overall, the percentage of deaths attributed to HIV/AIDS-related causes decreased from 11.2% to 7.5% (trend test p < 0.001) and the percentage of cardiac deaths increased from 18.7% to 25.4% (p < 0.001) from 2020 to 2023. These findings support interventions to strengthen the integrated management of noncommunicable diseases in community settings across Zambia. Among persons with HIV, a high percentage of deaths attributed to HIV/AIDS highlights the need to maintain high ART coverage and retention. Strategies, such as increased use of minimally invasive tissue sampling, may improve characterization of the high proportion of deaths attributed to non-specific HIV/AIDS-related causes through VA surveillance.

BackgroundIn low-income and middle-income countries, an estimated one in three clinical adverse events happens in non-complex situations and 83% are preventable. Poor quality of care also leads to inefficient use of human, material and financial resources for health. Improving outcomes and mitigating the risk of adverse events require effective monitoring and quality control systems.AimTo assess the state of surgical monitoring and quality control systems at district hospitals (DHs) in Malawi, Tanzania and Zambia.MethodsA mixed-methods cross-sectional study of 75 DHs: Malawi (22), Tanzania (30) and Zambia (23). This included a questionnaire, interviews and visual inspection of operating theatre (OT) registers. Data were collected on monitoring and quality systems for surgical activity, processes and outcomes, as well as perceived barriers.Results53% (n=40/75) of DHs use more than one OT register to record surgical operations. With the exception of standardised printed OT registers in Zambia, the register format (often handwritten books) and type of data collected varied between DHs. Monthly reports were seldom analysed by surgical teams. Less than 30% of all surveyed DHs used surgical safety checklists (n=22/75), and <15% (n=11/75) performed surgical audits. 73% (n=22/30) of DHs in Tanzania and less than half of DHs in Malawi (n=11/22) and Zambia (n=10/23) conducted surgical case reviews. Reports of surgical morbidity and mortality were compiled in 65% (n=15/23) of Zambian DHs, and in less than one-third of DHs in Tanzania (n=9/30) and Malawi (n=4/22). Reported barriers to monitoring and quality systems included an absence of formalised guidelines, continuous training opportunities as well as inadequate accountability mechanisms.ConclusionsSurgical monitoring and quality control systems were not standard among sampled DHs. Improvements are needed in standardisation of quality measures used; and in ensuring data completeness, analysis and utilisation for improving patient outcomes.

Supervision by surgical specialists is beneficial because they can impart skills to district hospital-level surgical teams. The SURG-Africa project in Zambia comprises a mentoring trial in selected districts, involving two provincial-level mentoring teams. The aim of this paper is to explore policy options for embedding such surgical mentoring in existing policy structures through a participatory modeling approach. Four group model building workshops were held, two each in district and central hospitals. Participants worked in a variety of institutions and had clinical and/or administrative backgrounds. Two independent reviewers compared the causal loop diagrams (CLDs) that resulted from these workshops in a pairwise fashion to construct an integrated CLD. Graph theory was used to analyze the integrated CLD, and dynamic system behavior was explored using the Method to Analyse Relations between Variables using Enriched Loops (MARVEL) method. The establishment of a provincial mentoring faculty, in collaboration with key stakeholders, would be a necessary step to coordinate and sustain surgical mentoring and to monitor district-level surgical performance. Quarterly surgical mentoring reviews at the provincial level are recommended to evaluate and, if needed, adapt mentoring. District hospital administrators need to closely monitor mentee motivation. Surgical mentoring can play a key role in scaling up district-level surgery but its implementation is complex and requires designated provincial level coordination and regular contact with relevant stakeholders.

Background The global shortage of surgeons disproportionately impacts low- and middle-income countries. To mitigate this, Zambia introduced a ‘task-shifting’ solution and started to train non-physician clinicians (NPCs) called medical licentiates (ML) to perform surgery. The aim of this randomised controlled trial was to assess their contribution to the delivery of surgical care in rural hospitals in Zambia. Methods Sixteen hospitals were randomly assigned to intervention and control arms of the study. Nine MLs were deployed to eight intervention sites. Crude numbers of selected major surgical procedures between intervention and control sites were compared before and after the intervention. Volume and outcomes of surgery were compared within intervention hospitals, between NPCs and surgically active medical doctors (MDs). Results There was a significant increase in the numbers of caesarean sections (CS) in the intervention hospitals (+ 15.2%) and a drop by almost half in the control group (− 47%) ( P  = 0.015), between the two time periods. There were marginal shifts in the numbers of index procedures: a small drop in the intervention group (− 4.9%) and slight increase in the control arm (+ 4.8%) ( P  = 0.505). In all pairs, MLs had higher mean number of CS and other major surgical cases done in the intervention period compared with MDs. There was no significant difference in postoperative wound infection rates for CS ( P  = 0.884) and other major surgical cases ( P  = 0.33) at intervention hospitals between MLs and MDs. Conclusion This study provided evidence that the ML training programme in Zambia is an effective and safe way to bridge the gap in rural hospitals between the demand and the limited availability of surgically trained workforce in the country. Such evidence is greatly needed as more developing countries are developing national surgical plans. Trial registration ISRCTN66099597 Registered: 07/01/2014

The lack of access to quality-assured surgery in rural parts of sub-Saharan Africa, where the numbers of trained health workers are often insufficient, presents challenges for national governments. The case for investing in scaling up surgical systems in low-resource settings is 3-fold: the potential beneficial impact on a large proportion of the global burden of disease; better access for rural populations who have the greatest unmet need; and the economic case. The economic losses from untreated surgical conditions far exceed any expenditure that would be required to scale up surgical care. We identified the resources used in delivering surgery at a rural district-level hospital and an urban based referral hospital in Zambia and calculated their cost through a combination of bottom-up costing and step-down accounting. Surgery performed at the referral hospital is 50 % more expensive compared with the district hospital, mostly because of the higher cost of hospital stay. The low bed occupancy rates at the two hospitals suggest underutilization of the capacity, and/or missing elements of needed capacity, to conduct surgery. Nevertheless, our study confirms that scaling up district-level surgery makes sense, through bringing economies of scale, while acknowledging the need for more comprehensive assessments and costing of capacity constraints. We quantified the economies of scale under different scaling scenarios. If surgery at the district hospital was scaled up by 10, 20 or 50 %, the total cost of surgery would increase proportionately less than that, i.e. by 6, 12 and 30 %, respectively. If this were to lead to less demand for surgery at the referral hospital, say 10 % less surgery, it would result in a reduction of 2.7 % in the total cost. Although the health system as a whole would benefit, the referring hospitals would not derive the full economic benefit, unless Government increased resources for district-level surgery. Le manque d’accès à une chirurgie de bonne qualité dans les zones rurales de l’Afrique subsaharienne, où les agents de santé qualifiés sont souvent en nombre insuffisant, constitue un véritable défi à relever pour les gouvernements de ces pays. La nécessité d’investir dans le renforcement des systèmes chirurgicaux des pays à faibles ressources se fonde sur trois arguments, à savoir: l’éventuelle incidence bénéfique sur une grande partie de la charge de morbidité mondiale; un meilleur accès pour les populations rurales dont les plus grands besoins demeurent insatisfaits; et la rentabilité économique. Les pertes économiques dues à des interventions chirurgicales non effectuées dépassent de loin toutes les dépenses nécessaires pour améliorer les soins chirurgicaux. Nous avons identifié les ressources nécessaires pour effectuer des interventions chirurgicales dans un hôpital de district rural et dans un hôpital de référence en Zambie, et nous en avons calculé le coût en associant une méthode ascendante de calcul des coûts à une comptabilité dégressive. La chirurgie pratiquée à l’hôpital de référence coûte environ 50% plus chère qu’à l’hôpital de district, principalement en raison du coût plus élevé du séjour à l’hôpital. Le faible taux d’occupation des lits dans les deux hôpitaux sous-entend une sous-utilisation de la capacité et / ou l’absence de certains éléments nécessaires pour la mise en œuvre d’une intervention chirurgicale. Néanmoins, notre étude confirme qu’il est logique d’intensifier les interventions chirurgicales au niveau du district afin de réaliser des économies d’échelle, tout en reconnaissant la nécessité de procéder à des évaluations plus complètes et d’analyser le coût des contraintes de capacité. Nous avons quantifié les économies d’échelle suivant les différents scénarios de mise à l’échelle. Si on augmente de 10, 20 ou 50%, le nombre des interventions chirurgicales à l’hôpital de district, l’augmentation du coût total de la chirurgie n’augmenterait proportionnellement que de 6, 12 et 30%, respectivement. Si cela entraîne une réduction de la demande des interventions chirurgicales à l’hôpital de référence, soit environ 10% de moins, le résultat serait une réduction de 2,7% du coût total. S’il est vrai que le système de santé dans son ensemble en bénéficie, les hôpitaux qui font appel à leurs services n’en retireraient pas tous les avantages économiques, à moins que le gouvernement n’augmente les ressources allouées aux interventions chirurgicales au niveau du district. 撒哈拉以南非洲国家的农村地区缺少经过培训的卫生人员, 手 术质量缺乏保障, 可及性差, 给这些国家的政府带来巨大挑 战。因为以下三方面理由, 有必要投入资金扩大资源匮乏地区 的外科体系：有助于减少一大部分全球疾病负担；提高对农 村人口的可及性, 这部分人群未满足的需求最大；同时还有经 济方面的原因。由于外科疾病得不到手术治疗而导致的经济 损失远远超出大规模提供手术所需的支出。我们明确了赞比 亚一家地区级医院和一家市区转诊医院用于手术的资源, 结合 自下而上的成本计算法和逐步会计计算成本。转诊医院的手 术比地区医院贵50%左右, 主要是由于住院成本较高。两家医 院的病床占用率均较低, 提示手术资源利用率低, 和/或缺乏手 术所需的部分要素。但是, 本研究证实了扩大地区外科规模符 合规模经济, 是合理的, 但需要更全面的评估和计算所需条件 的成本。我们量化了不同情境下的规模经济。如果地区医院 的外科扩大10%、20%或50%, 手术成本只分别增加6%、12% 和30%。如果地区医院外科扩大降低了对转诊医院手术的需 求, 假设降低10%, 总成本将减少2.7%。尽管卫生体系总体将 获益, 将患者转诊的医院却不会享受到经济上的获益, 除非政 府为地区外科体系投入更多资源。 La falta de acceso a cirugías de calidad asegurada en las zonas rurales del África sub-Sahariana, donde los números de trabajadores de la salud capacitados son a menudo insuficientes, presenta desafíos para los gobiernos nacionales. Existen tres argumentos para invertir en la ampliación de los sistemas quirúrgicos en entornos de bajos recursos: el impacto beneficioso potencial en una gran proporción de la carga mundial de la enfermedad; mejor acceso para las poblaciones rurales que tienen la mayor necesidad insatisfecha; y el caso económico. Las pérdidas económicas por condiciones quirúrgicas no tratadas superan con creces cualquier gasto que se requiriera para ampliar la atención quirúrgica. Identificamos los recursos usados para administrar la cirugía en un hospital rural a nivel de distrito y en un hospital especializado urbano para pacientes referidos en Zambia. Calculamos su costo a través de una combinación de recolección de costos de manera ascendente y de un proceso de asignación gradual de gastos de estructura. La cirugía realizada en el hospital especializado es aproximadamente un 50% más costosa en comparación con la del hospital del distrito, principalmente debido al mayor costo de hospedar al paciente durante la noche en el hospital. Las bajas tasas de ocupación de camas en los dos hospitales sugieren una subutilización de la capacidad y/o elementos faltantes para la capacidad necesaria para realizar la cirugía. Sin embargo, nuestro estudio confirma que la ampliación de la cirugía a nivel de distrito tiene sentido, al traer economías de escala. Al mismo tiempo reconocemos la necesidad de evaluaciones más completas y el costeo de las limitaciones de capacidad. Cuantificamos las economías de escala en diferentes escenarios de ampliación. Si la cirugía en el hospital del distrito se ampliara en 10, 20 o 50%, el costo total de la cirugía aumentaría proporcionalmente menos que eso, es decir, en 6, 12 y 30%, respectivamente. Si esto diera lugar a una menor demanda de la cirugía en el hospital especializado, por ejemplo, un 10% menos de cirugía, daría como resultado una reducción del 2.7% en el costo total. Aunque el sistema de salud en su conjunto se beneficiaría, los hospitales especializados no obtendrían el beneficio económico completo, a menos que el gobierno aumentara los recursos para la cirugía a nivel de distrito.

Background An estimated nine out of ten persons in sub-Saharan Africa (SSA) are unable to access timely, safe and affordable surgery. District hospitals (DHs) which are strategically located to provide basic (non-specialist) surgical care for rural populations have in many instances been compromised by resource inadequacies, resulting in unduly frequent patient referrals to specialist hospitals. This study aimed to quantify the financial burdens of surgical ambulance referrals on DHs and explore the coping strategies employed by these facilities in navigating the challenges. Methods We employed a multi-methods descriptive case study approach, across a total of 14 purposively selected DHs; seven, three, and four in Tanzania, Malawi and Zambia, respectively. Three recurrent cost elements were identified: fuel, ambulance maintenance and staff allowances. Qualitative data related to coping mechanisms were obtained through in-depth interviews of hospital managers while quantitative data related to costs of surgical referrals were obtained from existing records (such as referral registers, ward registers, annual financial reports, and other administrative records) and expert estimates. Interview notes were analysed by manual thematic coding while referral statistics and finance data were processed and analysed using Microsoft Office Excel 2016. Results At all but one of the hospitals, respondents reported inadequacies in numbers and functional states of the ambulances: four centres indicated employing non-ambulance vehicles to convey patients occassionally. No statistically significant correlation was found between referral trip distances and total annual numbers of referral trips, but hospital managers reported considering costs in referral practices. For instance, ten of the study hospitals reported combining patients to minimize trip frequencies. The total cost of ambulance use for patient transportation ranged from I$2 k to I$58 k per year. Between 34% and 79% of all patient referrals were surgical, with total costs ranging from I$1 k to I$32 k per year. Conclusion Cost considerations strongly influence referral decisions and practices, indicating a need for increases in budgetary allocations for referral services. High volumes of potentially avoidable surgical referrals provide an economic case – besides equitable access to healthcare – for scaling up surgery capacity at the district level as savings from decreased referrals could be reinvested in referral systems strengthening.

Introduction Many countries in sub-Saharan Africa have adopted task shifting of surgical responsibilities to non-physician clinicians (NPCs) as a solution to address workforce shortages. There is resistance to delegating surgical procedures to NPCs due to concerns about their surgical skills and lack of supervision systems to ensure safety and quality of care provided. This study aimed to explore the effects of a new supervision model implemented in Zambia to improve the delivery of health services by surgical NPCs working at district hospitals. Methods Twenty-eight semi-structured interviews were conducted with NPCs and medical doctors at nine district hospitals and with the surgical specialists who provided in-person and remote supervision over an average period of 15 months. Data were analysed using ‘top-down’ and ‘bottom-up’ thematic coding. Results Interviewees reported an improvement in the surgical skills and confidence of NPCs, as well as better teamwork. At the facility level, supervision led to an increase in the volume and range of surgical procedures done and helped to reduce unnecessary surgical referrals. The supervision also improved communication links by facilitating the establishment of a remote consultation network, which enabled specialists to provide real-time support to district NPCs in how to undertake particular surgical procedures and expert guidance on referral decisions. Despite these benefits, shortages of operating theatre support staff, lack of equipment and unreliable power supply impeded maximum utilisation of supervision. Conclusion This supervision model demonstrated the additional role that specialist surgeons can play, bringing their expertise to rural populations, where such surgical competence would otherwise be unobtainable. Further research is needed to establish the cost-effectiveness of the supervision model; the opportunity costs from surgical specialists being away from referral hospitals, providing supervision in districts; and the steps needed for regular district surgical supervision to become part of sustainable national programmes.