Module 3: Surgery in Resource-Poor Settings

Surgical Infrastructure

In order for hospitals to be able to provide safe, effective surgery, they first must have an operating room with electricity, running water, and oxygen. However, “having an operation room is only the first of several steps; all hospitals with surgical programs need postoperative care and blood-banking. In fact, even a small district hospital needs at least two operating theaters (one for emergencies, usually obstetric, and another for elective cases), a blood bank on site, a laboratory, anesthesia machines and staff who know how to use and repair them, and an uninterrupted source of electricity.” (1) Unfortunately, in resource-poor settings these requirements are scarcely met. A study on 10 out of the 17 government civilian hospitals in Sierra Leone revealed that “there is a paucity of electricity, running water, oxygen, and fuel.” (2) In these hospitals, basic supplies such as oxygen and anesthesia were severely limited. 60% of the hospitals had an interrupted supply of oxygen, while 40% had no oxygen. Only 20% had a functioning anesthesia machine.(3) Therefore, “owing to the scarcity and cost of fuel, patients’ families were sometimes required to provide the necessary fuel to power generators during surgical procedures. Even when electricity was available, lighting was a problem, given there were approximately 6 individual light bulbs that worked in all of the dome lights through Sierra Leone.” (4) A study which assessed 132 facilities in 8 low-middle income countries (Sri Lanka, Mongolia, Tanzania, Afghanistan, Sierra Leone, Liberia, Gambia and São Tomé and Principe) found that no country had 100% of its facilities reporting continuous supply of uninterrupted water, electricity, and oxygen. “The results clearly demonstrate massive shortfalls in the infrastructure and physical resources required to provide the most basic surgical care to save lives and prevent long-term disability.” (5) In addition, there is often a shortage of basic materials in resource poor settings.  Survey results from Sierra Leone showed that only 50% of hospitals had equipment sterilizers, 30% had adequate supplies of suction pumps, and 20% had regular supplies of sterile gloves. (6) A survey of hospitals in sub-Saharan Africa found that there was a lack of materials such as extension tubings, three way stop-cocks and large syringes, as well as stock-outs of linens and anesthetic agents. (7)

In resource-poor settings, there is also a shortage of anesthesia and pulse-oximetry equipment.  “Equipment for carrying out anesthesia and surgery is often deficient, and facilities for sophisticated postoperative care are frequently minimal and dependent on the individual initiative of the surgeons concerned.” (8) Though pulse oximetry is an essential monitoring device for safe surgery and anesthesia monitoring, it was absent more than half of the time in low-income regions. (9) A study that obtained profiles of operating theatres from 769 hospitals in 92 countries found that the %age of operating theatres in Africa without pulse oximetry was between 51-70%, while for North American and Western Europe it was less than 1%.(10) Though pulse oximetry is underutilized in developing countries, it is still recognized as a very important component of surgical care: “All countries with anesthesia standards regard pulse oximetry as mandatory for surgery. Most anesthetists in developed settings do not give anesthesia without pulse oximetry.” (11) The absence of pulse oximetry in many operating theatres is not only a safety concern for patients, but it also increases doubt about the availability of other essential equipment such as sutures, surgical instruments, drugs, and autoclaves.

In addition to the absence of monitoring devices and access to basic supplies such as oxygen and electricity, there is also a lack of physical spaces equipped for surgery in developing countries. The estimated number of operating theatres in west sub-Saharan Africa is estimated at 1 per 100,000 people, while in Eastern Europe it is 25 per 100,000 people. High income regions averaged more than 14 operating rooms per 100,000 people.(12) In developing countries, there are also fewer specialized centers. For example, in the U.S. there is 1 cardiac center per 120,000 people, while in Africa there is 1 per 33,000,000 people, and in Asia there is 1 per 16,000,000 people.(13)

There are also many other infrastructural problems that prevent people from accessing surgical care in developing countries. For example, poor road conditions make even short trips difficult, costly and time consuming for the average patient. (14) Other barriers include the lack of information and education regarding surgical procedures, poor referral systems, as well as social barriers related to maternal health where women are limited by cultural norms to not seek care outside of the home. (15) See Clinic Challenges in Resource-Poor Settings Course for more in-depth explanations of these barriers.

Surgical Outcomes

Though surgery can prevent loss of life, it is also associated with a significant risk of complications and death. Studies in industrialized countries have shown a perioperative rate of death from inpatient surgery from 0.4 to 0.8% and a rate of major complications of 3 to 17%. These rates are likely to be higher in developing countries.(16) Some studies suggest that in developing countries, there is a death rate of 5-10% for major surgery, and that approximately 7 million patients undergoing surgery each year have major complications, including 1 million that die during or immediately after surgery every year. (17) High anesthesia-related mortality rates have also been reported in a number of resource-limited settings. For example, in a central hospital in Malawi, 1 in 504 deaths were anesthesia-related, while 1 in 133 deaths in a teaching hospital in Togo were anesthesia-related. (18)  A study on rural surgery in southern Sudan found that the most common postoperative complications were due to urine retention in men after hernia repair (7%), wound infection (1.8%), and headaches after spinal anesthesia (1%).(19) However, Doctors Without Borders recently conducted a study on 20,000 surgeries in resource-limited areas from 2001 to 2008. The death rate was only 0.2%.(20) This “study shows that surgery can be safely performed in areas with minimal resources and little or no sophisticated technology.” (21) Similarly, a study on surgical care in Sudan found that out of the 1642 patients served, there were only 14 fatal complications (0.79%) demonstrating that “it is feasible to establish surgical services in rural areas of developing countries by utilizing simple facilities, providing them with basic equipment, and employing local personnel.” (22)

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(1) Farmer, P., and Kim, J. “Surgery and Global Health: A View from Beyond the OR.” World J Surgery. 32. (2008): 533-536. Accessed on 2 November 2010.

(2) Kingham, T., et. al. “Quantifying Surgical Capacity in Sierra Leone A Guide For Improving Surgical Care.” Arch Surg. 144.2 (2009); 122-127. Accessed on 4 November 2010.

(3) Ibid.

(4) Ibid.

(5) Kushner, A. “Addressing the Millennium Development Goals From a Surgical Perspective. Essential Surgery and Anesthesia in 8 Low- and Middle- Income Countries.” Archives of Surgery. 145.2 (2010): 154-159. Accessed on 29 October 2010.

(6) Funk, L., et. al. “Global operating theatre distribution and pulse oximetry supply: an estimation from reported data.” The Lancet. 376. 9746. (2010): 1055-1061. Accessed on 4 November 2010.

(7) Lokossou, T. “Anesthesia in French-speaking Sub-Saharan Africa: an overview.” Acta Anaesth. Belg. 58. (2007):197-209. Accessed on 9 November 2010.

(8) Bickler, S., and Rode, H. “Surgical Services for Children in Developing Countries.” Bulletin of the World Health Organization. 80.10 (2002). Accessed on 2 November 2010.

(9) Funk, L., et. al. “Global operating theatre distribution and pulse oximetry supply: an estimation from reported data.” The Lancet. 376. 9746. (2010): 1055-1061. Accessed on 4 November 2010.

(10) Ibid.

(11) Ibid.

(12) Ibid.

(13) Nyawawa, E., et. al. “Cardiac Surgery: One Year Experience of Cardiac Surgery at Muhimbili National Hosptial, Dar es Salaam, Tanzania.” East and Central African Journal of Surgery. 15.1 (2010): 111-118. Accessed on 4 November 2010.

(14) Kingham, T., et. al. “Quantifying Surgical Capacity in Sierra Leone A Guide For Improving Surgical Care.” Arch Surg. 144.2 (2009); 122-127. Accessed on 4 November 2010.

(15) McQueen et. al. “Essential Surgery: Integral to the Right to Health.” Health and Human Rights in Practice. 12.1 (2010): 137-152. Accessed on 13 September 2010.

(16) Haynes, A. “A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population.” The New England Journal of Medicine. 360.5 (2009): 491-499. Accessed on 1 November 2010.

(17) Weiser, T., et. al. “An Estimation of the Global Volume of Surgery: A Modelling Strategy Based on Available Data.” Lancet. 372. (2008): 139-44. Accessed on 1 November 2010.

(18) Chu, K. “Operative Mortality in Resource-Limited Settings.” Arch Surg. 145.8 (2010): 721-725. Accessed on 4 November 2010.

(19) Meo, G., et. al. “Rural Surgery in Southern Sudan.” World Journal of Surgery. 30 (2006): 495-504. Accessed on 4 November 2010.

(20) “Surgery in dire conditions can be safe.” The Los Angeles Times. Accessed on 4 November 2010.

(21) Ibid.

(22) Meo, G., et. al. “Rural Surgery in Southern Sudan.” World Journal of Surgery. 30 (2006): 495-504. Accessed on 4 November 2010.