Background Surgery is increasingly recognized as an important driver for health systems strengthening, especially in developing countries. To facilitate quality improvement initiatives, baseline knowledge of capacity for surgical, anaesthetic, emergency and obstetric care is critical. In partnership with the Malawi Ministry of Health, we quantified government hospitals’ surgical capacity through workforce, infrastructure and health service delivery components.Methods From November 2012 to January 2013, we surveyed district and mission hospital administrators and clinical staff onsite using a modified version of the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) tool from Surgeons OverSeas. We calculated percentage of facilities demonstrating adequacy of the assessed components, surgical case rates, operating theatre density and surgical workforce density.Results Twenty-seven government hospitals were surveyed (90% of the district hospitals, all central hospitals). Of the surgical workforce surveyed (n = 370), 92.7% were non-surgeons and 77% were clinical officers (COs). Of the 109 anaesthesia providers, 95.4% were non-physician anaesthetists (anaesthesia COs or ACOs). Non-surgeons and ACOs were the only providers of surgical services and anaesthetic services in 85% and 88.9% of hospitals, respectively. No specialists served the district hospitals. All of the hospitals experienced periods without external electricity. Most did not always have a functioning generator (78.3% district, 25% central) or running water (82.6%, 50%). None of the district hospitals had an Intensive Care Unit (ICU). Cricothyroidotomy, bowel resection and cholecystectomy were not done in over two-thirds of hospitals. Every hospital provided general anaesthesia but some did not always have a functioning anaesthesia machine (52.2%, 50%). Surgical rate, operating theatre density and surgical workforce density per 100 000 population was 289.48–747.38 procedures, 0.98 and 5.41 and 3.68 surgical providers, respectively.Conclusion COs form the backbone of Malawi’s surgical and anaesthetic workforce and should be supported with improvements in infrastructure as well as training and mentorship by specialist surgeons and anaesthetists.

IntroductionFollowing twenty years of economic and social growth, Liberia's fourteen-year civil war destroyed its health system, with most of the health workforce leaving the country. Following the inauguration of the Sirleaf administration in 2006, the Ministry of Health & Social Welfare (MOHSW) has focused on rebuilding, with an emphasis on increasing the size and capacity of its human resources for health (HRH). Given resource constraints and the high maternal and neonatal mortality rates, MOHSW concentrated on its largest cadre of health workers: nurses.Case descriptionBased on results from a post-war rapid assessment of health workers, facilities and community access, MOHSW developed the Emergency Human Resources (HR) Plan for 2007-2011. MOHSW established a central HR Unit and county-level HR officers and prioritized nursing cadres in order to quickly increase workforce numbers, improve equitable distribution of workers and enhance performance. Strategies included increasing and standardizing salaries to attract workers and prevent outflow to the private sector; mobilizing donor funds to improve management capacity and fund incentive packages in order to retain staff in hard to reach areas; reopening training institutions and providing scholarships to increase the pool of available workers.Discussion and evaluationMOHSW has increased the total number of clinical health workers from 1396 in 1998 to 4653 in 2010, 3394 of which are nurses and midwives. From 2006 to 2010, the number of nurses has more than doubled. Certified midwives and nurse aides also increased by 28% and 31% respectively. In 2010, the percentage of the clinical workforce made up by nurses and nurse aides increased to 73%. While the nursing cadre numbers are strong and demonstrate significant improvement since the creation of the Emergency HR Plan, equitable distribution, retention and performance management continue to be challenges.ConclusionThis paper illustrates the process, successes, ongoing challenges and current strategies Liberia has used to increase and improve HRH since 2006, particularly the nursing workforce. The methods used here and lessons learned might be applied in other similar settings.