BackgroundMost 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.MethodsThis 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.ResultsIn 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.ConclusionsThe 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.

Background District-level hospitals (DLHs) can play an important role in the delivery of essential surgical services for rural populations in sub-Saharan Africa if adequately prepared and supported. This article describes the protocol for the evaluation of the Scaling up Safe Surgery for District and Rural Populations in Africa (SURG-Africa) project which aims to strengthen the capacity in district-level hospitals (DLHs) in Malawi, Tanzania and Zambia to deliver safe, quality surgery. The intervention comprises a programme of quarterly supervisory visits to surgically active district-level hospitals by specialists from referral hospitals and the establishment of a mobile phone-based consultation network. The overall objective is to test and refine the model with a view to scaling up to national level. Methods This mixed-methods controlled pilot trial will test the feasibility of the proposed supervision model in making quality-assured surgery available at DLHs. Firstly, the study will conduct a quantitative assessment of surgical service delivery at district facilities, looking at hospital preparedness, capacity and productivity, and how these are affected by the intervention. Secondly, the study will monitor changes in referral patterns from DLHs to a higher level of care as a result of the intervention. Data on utilisation of the mobile based-support network will also be collected. The analysis will compare changes over time and between intervention and control hospitals. The third element of the study will involve a qualitative assessment to obtain a better understanding of the functionality of DLH surgical systems and how these have been influenced by the intervention. It will also provide further information on feasibility, impact and sustainability of the supervision model. Discussion We seek to test a model of district-level capacity building through regular supervision by specialists and mobile phone technology-supported consultations to make safe surgical services more accessible, equitable and sustainable for rural populations in the target countries. The results of this study will provide robust evidence to inform and guide local actors in the national scale-up of the supervision model. Lessons learned will be transferred to the wider region.

Background:Cancer of the bladder is the ninth leading cause of cancer in developed countries. It is the second most common urological malignancy. Transitional cell carcinoma (TCC) is the most common histological subtype in developed countries. In most of Africa, the most common type is squamous cell carcinoma (SCC). Cancer of bladder guidelines produced by the European Urological Association and the American Urological Association, including the tumor, node, and metastasis staging is focused on TCC of the bladder.Objectives:The purpose of the study is to review the pathogenesis, pathology, presentation, and management of cancer of the bladder in Africa and to use this information to propose a practical staging system for SCC.Methods:The study used the meta-analysis guideline provided by PRISMA using bladder cancer in Africa as the key search word. The study collected articles available on PubMed as of July 2017, Africa Online and Africa Index Medicus. PRISMA guidelines were used to screen for full-length hospital-based articles on cancer of the bladder in Africa. These articles were analyzed under four subcategories which were pathogenesis, pathology, clinical presentation, and management. The information extracted was pooled and used to propose a practical staging system for use in African settings.Results:The result of evaluation of 821 articles yielded 23 full-length papers on hospital-based studies of cancer of the bladder in Africa. Cancer of the bladder in most of Africa is still predominantly SCC (53%–69%). There has been a notable increase in TCC in Africa (9%–41%). The pathogenesis is mostly schistosoma-related SCC presents late with painful hematuria and necroturia (20%). SCC responds poorly to chemotherapy or radiotherapy. The main management of SCC is open surgery. This review allowed for a practical organ-based stage of SCC of the bladder that can be used in Africa.Conclusion:Bladder cancer in Africa presents differently from that in developed countries. Guidelines on cancer of the bladder may need to take account of this to improve bladder cancer management in Africa.

The Ministry of Health, Community Development, Gender, Elderly and Children is charged with improving the health and welfare of all Tanzanian citizens. In considering the high burden of disease due to surgically treatable conditions in the country, the MOHCDGEC in collaboration with partners has developed the first National Surgical, Obstetric and Anaesthesia Plan (NSOAP) 2018-2025, to address challenges in access to high quality surgical, obstetrics and anaesthesia (SOA) services in Tanzania. Access to safe, timely and affordable SOA care is limited for a significant proportion of Tanzanians especially those in rural areas. This lack of access is in large part due to human resources challenges. At present, of the recommended 20 physician surgeons, obstetricians and anaesthesiologists per 100,000 population, there are only a total of 0.46 per 1000,000 Tanzanians in the country making widespread access impossible. Additionally, there are factors such as limited access to surgical and anaesthesia equipment, supplies, medicines, blood and blood products and essential utilities like clean water, oxygen and electricity which exacerbate this situation. Strengthening the Tanzanian SOA system is imperative to reducing surgically preventable mortality and morbidity. Currently about 19.3% of deaths and 17 % of Disability-Adjusted Life Years (DALY) in Tanzania are attributable to diseases amenable to surgery. Surgical, Obstetric, and Anaesthesia services are critical in reducing the unacceptably high levels of maternal mortality, one of the key sustainable development goals, by making Caesarian sections, post-partum hemorrhage, uterine rupture, ectopic pregnancy and retained products of conception amongst other conditions safer for mothers. Surgery and anaesthesia is also essential in preventing deaths resulting from road traffic accidents, also one of the key sustainable development goals. Additionally, as outlined in the LCoGS, the economic benefits from preventing lives lost and averting disabilities from surgically treatable conditions will be substantial and promote economic development of our Country. The high costs of seeking and receiving surgical care often places patients at the risk of being impoverished as a result of seeking or receiving surgical care. Currently, about 66% of Tanzanians risk catastrophic expenditure and 86% risk impoverishing expenditure from seeking surgical care. Addressing all components of SOA access, including risk of impoverishment, is crucial to achieving Tanzania Vision 2025, the Global Sustainable Development Goals (SDGs) and Universal Health Coverage. This NSOAP lays out the necessary steps to improve each of the 6 major domains of the surgery, anaesthesia and obstetric health system: (a) service delivery, (b) infrastructure, (c) workforce, (d) information management and technology, (e) finance and (f) governance. It will be key to act synergistically across all of these health system building blocks to guarantee an impact. This NSOAP is designed to align with and complement existing ...

Women of reproductive (16-45 years) mainly undergoing Caesarean sections and children aged 0-15 years who accounted for two-thirds of trauma cases are the main patient populations undergoing surgery at district hospitals in Zambia and Malawi. Verification and analysis of routine hospital data, across 10-30% of districts countrywide, demonstrated the need to prioritise quality assurance in surgery and anaesthesia, and preventive interventions in children.