Emergency, Anaesthetic and Essential Surgical Capacity in the Gambia

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Bull World Health Organ2011;89:565572 | doi:10.2471/BLT.11.086892

Research

565

Emergency, anaesthetic and essential surgical capacity in the

GambiaAdam Iddriss,a Nestor Shivute,b Stephen Bickler,c Ramou Cole-Ceesay,d Bakary Jargo,e Fizan Abdullaha &Meena Cherian

Introduction

Rates o death and disability rom treatable surgical conditionscontinue to be unacceptably high in low- and middle-incomecountries.1 Conditions such as injuries (road trac accidents,

burns and alls), inections (osteomyelitis and septic arthritis),pregnancy-related complications and a variety o abdominalemergencies aect primarily young adults and impose a sig-nicant burden on society. Surgical conditions account or upto 11% o the worlds disability-adjusted lie years.1 Barriers tothe delivery o sae, timely and eective surgical care includea lack o inrastructure as well as a shortage o physical andhuman resources.

Te Gambia is a low-income country located in western sub-Saharan Arica whose health prole resembles that o many otherdeveloping countries o the region (able 1). With a populationo more than 1.66 million, o which 55% lives in urban areas,the Gambia is one o the most densely populated countries in

Arica. More than 80% o the Gambian population lives on lessthan 2 United States dollars a day. Te leading causes o inpatientmortality are malaria, anaemia, maternal deaths, cerebrovascularaccidents and trauma.

Te objective o the present study was to assess the currentcapacity or essential surgical and anaesthesia care in the Gam-bia or the purpose o providing a benchmark or critical areasneeding improvement.

Methods

Assessment of surgical resources

In June 2008, a team rom the Global Initiative or Emergency

and Essential Surgical Care (GIEESC) o the World HealthOrganization (WHO) visited 11 health acilities in the Gambiato assess potential sites or implementation o the WHO Emer-gency and Essential Surgical Care programme. Te selected siteswere organized in collaboration with the Gambias Ministry oHealth and WHO country oce to provide broad geographicalcoverage o the country. Te WHO ool or Situation Analysisto Assess Emergency and Essential Surgical Care survey wassubsequently distributed to health-care management ocials atacilities throughout the country.4 Data were collected duringApril 2009 and surveys were completed by 65 o 76 health acili-ties (85.5% response rate) in the Gambia, including one tertiaryreerral hospital (1.5%), 7 (10.8%) district/general hospitals, 46

(70.8%) health centres and 11 (16.9%) private health acilities.Te survey included 110 questions divided into our

sections. Section I consisted o 23 questions concerning inra-structure and type o health-care acility, the characteristics othe surgical population served, and the availability o oxygen,running water and electricity. Section II included 8 questionson human resources, including the number o specialist surgeonsand anaesthesiologists, physicians, nurses and non-physician

Abstracts in ,,Franais,Pand Espaol at the end of each article.

Objective To assess the resources or essential and emergency surgical care in the Gambia.Methods The World Health Organizations Tool or Situation Analysis to Assess Emergency and Essential Surgical Care was distributedto health-care managers in acilities throughout the country. The survey was completed by 65 health acilities one tertiary reerralhospital, 7 district/general hospitals, 46 health centres and 11 private health acilities and included 110 questions divided into oursections: (i) inrastructure, type o acility, population served and material resources; (ii) human resources; (iii) management o emergencyand other surgical interventions; (iv) emergency equipment and supplies or resuscitation. Questionnaire data were complemented byinterviews with health acility sta, Ministry o Health ofcials and representatives o nongovernmental organizations.Findings Important defcits were identifed in inrastructure, human resources, availability o essential supplies and ability to perormtrauma, obstetric and general surgical procedures. O the 18 acilities expected to perorm surgical procedures, 50.0% had interruptionsin water supply and 55.6% in electricity. Only 38.9% o acilities had a surgeon and only 16.7% had a physician anaesthetist. Allacilities had limited ability to perorm basic trauma and general surgical procedures. O public acilities, 54.5% could not perormlaparotomy and 58.3% could not repair a hernia. Only 25.0% o them could manage an open racture and 41.7% could perorm anemergency procedure or an obstructed airway.Conclusion The present survey o health-care acilities in the Gambia suggests that major gaps exist in the physical and humanresources needed to carry out basic lie-saving surgical interventions.

a Department o Surgery, Johns Hopkins University School o Medicine, Harvey 319, 600 Wole Street, Baltimore, MD, 21205, United States o America (USA).b Country Ofce, World Health Organization, Kaniang, Gambia.c Department o Surgery, University o Caliornia at San Diego, San Diego, USA.d Ministry o Health, Banjul, Gambia.e Royal Victoria Teaching Hospital, Banjul, Gambia. Department o Essential Health Technologies, World Health Organization, Geneva, Switzerland.Correspondence to Adam Iddriss (e-mail: [email protected]).(Submitted: 16 February 2011 Revised version received: 4 April 2011 Accepted: 10 April 2011 Published online: 6 May 2011)
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Adam Iddriss et al.Surgery, anaesthesia and trauma care capacity in the GambiaResearch

proess ionals who were providing sur-gery or anaesthesia services. Section IIIincluded 10 questions to assess emer-gency interventions such as resuscitation,suturing, cricothyroidotomy and burn

management, as well as other surgicalinterventions such as caesarean section,ractures, hernia and laparotomy. Sec-tion IV consisted o 69 questions on theavailability o emergency equipmentand supplies or resuscitation, includ-ing capital outlays, renewable items andsupplementary equipment.

Data rom the questionnaires wascomplemented by interviews with healthacility sta, government ocials in theMinistry o Health and representativeso nongovernmental organizations

(NGOs) responsible or health acili-ties. Te additional content covered thestate o health care in the Gambia andthe challenges o administering surgicaland anaesthesia services in a resource-constrained setting.

We used Stata version 10.0 (Stata-Corp. LP, College Station, United Stateso America) to perorm the statisticalanalysis. We employed descriptive sta-tistical methods to compare individualelements o the survey between publichealth acilities (i.e. the Royal Victoriaeaching Hospital [RVH], generalhospitals and health centres) and privatehospitals. We perormed bivariate analy-sis using Fishers exact test to compare

the results or public health acilitiesand private hospitals, with signicanceset at P< 0.05.

Results

Health facility characteristics

O the 65 acilities that responded tothe survey, 18 (27.7%) were consideredreerral hospitals capable o deliver-ing surgical services. Data analysis wasthereore ocused on these 18 acilities,which included the countrys tertiary re-erral hospital (5.6%), 5 (27.8%) generalhospitals, 6 (33.3%) health centres and6 (33.3%) private hospitals. Te popula-tions served by each acility ranged rom25 600 to 400 900.

Health infrastructure

able 2 depicts the key inrastructural el-ements available in the health acilities as-sessed. Consistent sources o oxygen sup-ply, running water and electricity wereavailable at 14 (77.8%), 9 (50.0%) and 8(44.4%) o acilities, respectively. Func-tioning power generators and anaesthesiamachines were available at 9 (52.9%) and12 (70.6%) acilities, respectively, and 4(23.5%) health acilities reported havingno unctioning anaesthesia machines. A

comparison o public health acilitieswith private hospitals showed that asignicantly higher raction o private

acilities had running water consistentlyavailable (P= 0.009), unctioning powergenerators (P= 0.009) and an uninter-rupted supply o electricity (P= 0.002).

All 18 o the health acilities studied

had at least one unctioning operatingroom. Te RVH had our; two unc-tioning operating rooms existed in twoo the ve (45.5%) remaining public a-cilities and in two (33.3%) o the privateacilities. Te RVH had 576 beds; thenumber o beds ranged rom 51 to 300in other general hospitals, rom 3 to 100in health centres and rom 11 to 50 inprivate hospitals.

Human resources

able 3 shows health acility surgical

and anaesthesia sta. Only 7 (38.9%)acilities had a surgeon, including theRVH, which had 8; 3 (16.7%) acilitieshad a general doctor perorming surgery.Only 3 (16.7%) acilities reported rely-ing on paramedical sta such as surgicaltechnicians to perorm basic surgicalprocedures. Anaesthesia was delivered byanaesthesiologists in 4 (22.2%) acilities,general doctors in 1 (5.6%) acility andnon-physicians in the rest. Only one ob-stetrician/gynaecologist was available in8 (44.4%) o the acilities assessed. Most

acilities (83.3%) had several paramed-ics and midwives who perormed minorsurgical interventions.

Table 1. Selected health indicators for the Gambia, the World Health Organization (WHO) African Regiona and the United States ofAmerica (USA)

Characteristic Gambia WHO African

Region

USA

Total population (in thousands) 1663 792 378 305 826

Human Development Index Rank (2009)2 168 NA 13GDP per capita (PPP$; 2007) 1225 NA 47 988Total annual expenditure on health as % o GDP (2006) 4.3 5.5 15.3Government expenditure on health care, as % o total expenditure (2006) 8.7 8.7 19.3Private expenditure on health, as % o total health expenditure (2006) 41.7 53 54.2Physician density per 100 000 inhabitants (2003; 2007; 2003)b 1 2 26Nurses per 1000 inhabitants (2000) 1.21 1.1 940Hospital beds per 10 000 inhabitants (2005) 8 10 31Lie expectancy at birth (years) (2007) 59 45 78Inant mortality per 1000 inhabitants (2007) 84 88 6Maternal mortality ratio per 100 000 live births (2005) 690 900 11Under-fve mortality rate (per 1000 live births) (2007) 114 145 8

HIV prevalence among adults per 100 000 inhabitants (2007) 2091 4735 452Tuberculosis prevalence per 100 000 inhabitants (2007) 423 475 3Tuberculosis incidence per 100 000 inhabitants (2007) 257 363 4

GDP, gross domestic product; HIV, human immunodefciency virus; NA, not available; PPP$, purchasing power parity dollar; USA, United States o America.a All WHO Member States in the Arican continent except Egypt, the Libyan Arab Jamahirya, Morocco, Somalia, Sudan and Tunisia.b The three dates in parentheses correspond to the data in this row in each o the three columns.Source: World Health Organization Global Health Observatory.3
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Bull World Health Organ2011;89:565572 | doi:10.2471/BLT.11.086892 567

Adam Iddriss et al. Surgery, anaesthesia and trauma care capacity in the GambiaResearch

General and trauma surgery

Te ability o each health acility toprovide several basic surgical procedureswas assessed (able 4). All general hos-pitals reported perorming at least 100surgeries annually; 4 (66.7%) o them

perormed more than 500 per year.Health centres reported rom 11 to 300annual surgical admissions, while generalhospitals reported rom 100 to morethan 5000. Surgical admissions to privatehospitals ranged rom 11 to 200 a year.

All acilities were able to perormincision and drainage o abscesses andmale circumcision. Laparotomies wereperormed in 56.3% o acilities. Com-pared with public acilities, a signicantlygreater percentage o private acilitiesperormed appendectomies, caesareansections and hernia repairs (P= 0.044).Only 5 (29.4%) acilities repaired ob-stetric stulas. Management guidelinesor surgical care were available in only 10(55.6%) acilities.

Regarding trauma procedures, 93.8%o acilities removed oreign bodies and82.4% managed burns. Cricothyroid-otomy/tracheostomy and chest tubeinsertion were perormed in only 41.2%and 33.3% acilities, respectively. Manage-ment guidelines or emergency care were

available in only 8 (44.4%) acilities. Pa-tients needing procedures not perormedin health acilities and hospitals because oa lack o skilled personnel, equipment orsupplies were reerred to tertiary acilities.

O the health acilities without o-cial operating rooms, several managedto carry out basic lie-saving proceduresincluding burn management (72.7%),incision and drainage o abscesses (81.8%)and oreign body removal (66.7%). Moretechnically dicult or equipment-inten-sive procedures such as appendectomy

(2.3%), laparotomy (4.8%) and openracture repair (2.5%) were less requentlyavailable.

Anaesthesia

Te availability o the resources neededto provide anaesthesia services was as-sessed (able 4). Te most common typeso anaesthesia provided were ketamineintravenous anaesthesia (82.4%) andregional anaesthesia (76.5%), while spinal(72.2%) and general inhalational (72.2%)

anaesthesia were also available. Manage-ment guidelines or anaesthesia and painmanagement were available in 10 (58.8%)and 5 (27.8%) acilities, respectively.

Table 2. Percentage availability of infrastructure and health resources in the Gambia,2009

Resource Total Public Private P

(n= 17) (n= 11) (n= 6)

Medical records 88.9 91.7 83.3 1Laboratory 77.8 75.0 83.3 1Oxygen 77.8 66.7 100 0.245Functioning anaesthesia machine 70.6 63.6 83.3 0.6Operational power generator 52.9 25.0 100 0.009Running water 50.0 25.0 100 0.009Postoperative care area 50.0 33.3 83.3 0.131Blood bank 47.1 50.0 40.0 1Electricity 44.4 16.7 100 0.002X-ray machine 38.9 41.7 33.3 1Emergency care area 33.3 16.7 66.7 0.107

Table 3. Human resources for surgery and anaesthesia in the Gambia, 2009

Staff Total Public Private

(n= 18) (n= 12) (n= 6)

Surgeon physician 14 12 2Anaesthesiologist physician 4 4 0Obstetrician/gynaecologist 8 5 3General doctors providing surgery 3 1 2General doctors providing anaesthesia 1 0 1Non-physician anaesthetists 14 12 2Surgical technician 7 0 7Paramedics/midwives 88 61 27

Table 4. Percentage availability of general surgery, trauma and anaesthesiaprocedures in the Gambia, 2009

Procedure Total Public Private P

(n= 18) (n= 12) (n= 6)

General surgery and trauma

Abscess incision and drainage 100.0 100.0 100.0 1Male circumcision 100.0 100.0 100.0 1Foreign body 93.8 100.0 80.0 0.313Acute burns 82.4 91.7 60.0 0.191

Appendectomy 58.8 41.7 100.0 0.044Caesarean section 58.8 41.7 100.0 0.044Hernia repair 58.8 41.7 100.0 0.044Laparotomy 56.3 45.5 80.0 0.308Amputation 44.4 33.3 66.7 0.321Cricothyroidotomy/tracheostomy 41.2 41.7 40.0 1Closed racture 41.2 41.7 40.0 1Skin grating 38.9 27.3 66.7 0.141Chest tube insertion 33.3 27.3 60.0 0.299Open racture 29.4 25.0 50.0 0.344Obstetric fstula 29.4 16.7 60.0 0.117

Anaesthesia

Ketamine 82.4 75.0 100.0 0.515Regional 76.5 75.0 80.0 1Spinal 72.2 58.3 100.0 0.114General inhalational 72.2 66.7 83.3 0.615
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Emergency and sterilizationequipment and supplies

Te availability o emergency equipmentand supplies was assessed in each o thehealth acilities (able 5). Resuscitator

bags were available in 10 (58.8%) acili-ties, while 12 (66.7%) acilities reportedhaving intravenous inusion sets. Naso-gastric tubes were available in 7 (38.9%)acilities, and examination gloves andsterile gloves were available in 12 (66.7%)and 10 (55.6%) acilities, respectively.Sterilizers were consistently available in9 (52.9%) acilities, while other steriliza-tion methods, including cold sterilizationand boiling, were used in the remainder.Only 3 (18.8%) acilities reported havingadequate eye protection or health sta

and 6 (35.3%) reported having enoughprotective aprons.

Discussion

Although surgery is a cost-eective ele-ment o preventive health care,1 accessto essential surgery is limited in mostresource-constrained settings.510 Tis isthe rst survey to assess the status o es-sential and emergency surgical care ando anaesthesia services in the Gambia.Te most striking nding was the absenceo any acilities equipped with all o thephysical resources nee ded to provideemergency and essential surgical care. Ma-jor gaps in the physical resources neededto carry out basic surgical and anaestheticcare in the Gambia were identied. Teseincluded decits in the availability owater, electricity, oxygen, and emergencyand anaesthesia equipment.

Te WHO ool or Situation Analy-sis to Assess Emergency and EssentialSurgical Care was used to assess surgicalcapacity in several countries. In Aghani-

stan, 30% o acilities had limited oxygendelivery mechanisms, 40% had unreliablesources o running water and only 34%had uninterrupted electrical power.9

Comparatively, in the Gambia reliablesources o oxygen, running water andelectricity were available in 77.8%, 50.0%and 44.4% o acilities. In Sierra Leone,only 20% o acilities had unctioning an-aesthesia machines8 compared with 75.0%

in the Gambia. In Ghana, a shortage oadequately trained human resources wasidentied as the major barrier to the de-livery o surgical and anaesthetic services;88% o acilities could perorm caesareansections and 94% could perorm appen-dectomies.10 Human resource shortageswere also identied as an obstacle in theGambia, where only 58.8% o acilitieswere perorming caesarean sections andappendectomies. Tus, surgical and an-aesthesia services in the Gambia are at anintermediate level when compared withthose o neighbouring countries.

Access to care

In the Gambia, inequitable access tosurgical services is propitiated to someextent by the concentration o health a-cilities and sta in urban areas such as theWestern Division.11 As a result o poorlydeveloped reerral systems and a lack ophysicians in secondary health acilities,many patients are reerred to distanthealth acilities or basic procedures that

should be perormed at the primary andsecondary levels. Health centres andprivate hospitals will rst reer cases todistrict hospitals beore reerring themto the RVH. Unortunately, the RVHis already overstretched and aces humanand physical resource challenges similarto those aced by the institutions assessedin this project. Moreover, the GambianRiver, which divides the country, urtherhinders access to basic surgery acilitiesby limiting transportation rom distantrural areas to Banjul. Although improved

transportation to more distant acilitieswith better equipment may temporarilyhelp reduce these inequities, it is not asustainable solution or patients requir-

ing urgent assessment and management.Policies in support o resource allocationor improving district-level access tosurgical care that can save lives and pre-vent disability are needed to relieve theburden on tertiary-level health acilities

such as the RVH.

Human resources

Te shortage o health personnel at theprimary level is also a major obstacle tothe provision o surgical and anaesthesiaservices in the Gambia (able 3). Al-though several health services have beenexpanded, stang does not meet theneeds o the institutions or their catch-ment areas. Te Gambia has less than0.5 physicians per 10 000 inhabitants,compared with 2.4 per 10 000 in the

WHO Arican Region.3 Moreover, most(80%) o the practicing physicians are noto Gambian nationality.11 Te brain drainis pervasive because many health workersleave the public health system to work inthe private sector, in NGOs or in othercountries.1214 o compensate or the lacko trained personnel, health acilities haveincreasingly relied on paramedical sta tomeet their surgical and anaesthesia needs.Despite the noticeable lack o surgeonsin many o the acilities assessed in thisstudy, every acility had ample nursing

and health-care sta.

General surgery and trauma

Access to essential surgery and emergencyservices is a key determinant o health,15yet many bas ic procedures, includingamputation, racture repair and chest tubeinsertion, were not provided in many othe acilities assessed in our study. Manyalso lacked management guidelines oremergency, anaesthesia and surgical care.16Tus, implementing the aorementionedguidelines in all health acilities could bea cost-eective intervention or prevent-ing surgical complications and reducingmorbidity and mortality.

Te widespread availability o malecircumcision is encouraging, given therole o this procedure in HIV preven-tion eorts (able 1 and able 4).17 Agreater percentage o private hospitalsthan public ones perormed herniarepair, appendectomy and caesareansection. Other studies have documenteddisparities in inrastructure, supplies and

equipment between public and privatehealth-care acilities in the developingworld.18,19 Our ndings indicate thatin the Gambia private acilities may

Table 5. Percentage availability of essential supplies in private and public hospitals inthe Gambia, 2009

Item Total Public Private P

(n= 18) (n= 12) (n= 6)

Examination gloves 66.7 75.0 50.0 0.344Intravenous inusion set 66.7 75.0 50.0 0.344Resuscitator bag 58.8 58.3 60.0 1Sterilizer 52.9 54.5 50.0 1Nasogastric tubes 38.9 33.3 50.0 0.627Eye protection 18.8 18.2 20.0 1
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be better equipped to perorm certainprocedures than public ones. In addi-tion, private acilities reported greaterreliance on surgical technicians andparamedical sta or providing healthservices (able 3), perhaps a refection

o the countrys historical reliance onnurses and other paramedical sta orprocedure s such as catara ct and lensextraction.20 Non-physicians in countriessuch as the Democratic Republic o theCongo, Kenya, Malawi and Mozambiquehave perormed basic surgical proceduresor years with outcomes equivalent tothose observed when specialists perormthem.2124 Strengthening the trainingo mid-level health-care providers inthe Gambia in emergency, surgical andanaesthesia procedures at the district

level would certainly help to attenuatethe human resource crisis and ull parto the unmet need or basic surgical care.

Although surgery is a specializedactivity that cannot be made availablein every acility, certain emergencyproced ure s and te chni ques , such asburn management, should be morewidely availa ble . Despi te the lac k oan operating room, several acilitiesnot included in the statistical analysisperormed several basic emergency andessential surgical procedures. Increasing

the capacity o these centres to provideessential surgical care may also help toreduce the burden o conditions requir-ing surgery in the Gambia.

Te Gambian government, havingrecognized the enormous decits thatexist within the health-care system, hastried to provide citizens with improvedaccess to better surgical and anaestheticcare. Te nations only medical school,established in 2000, has integrated sur-gery into the medical school curriculumto encourage students to pursue surgical

careers. Te Ministry o Health has es-tablished a successul collaboration withthe World Health Organization and twointernational organizations to advancethe state o maternal and child healththrough improved delivery o emergencyand obstetric services at one site in theGambia.25Similar collaborations wouldalso help to overcome the lack o othernecessary surgical procedures in theGambia. More system-wide changes areneeded to create a sustainable mecha-nism or procuring and maintaining the

supplies and technical skills required toperorm surger y saely.

Anaesthesia

A global anaesthesia workorce crisis isemerging.26,27 Our work highlights theshortage o trained anaesthesia providersand services in the Gambia, where an-aesthesia in reerral hospitals is delivered

primarily by nurses and clinical ocers.Tus, it is thus extremely important toensure appropriate training in the coun-try and to motivate health-care workersto pursue careers in anaesthesiology.Te WHO Integrated Management orEmergency and Essential Surgical Caretoolkit provides management guidelinesthat should be incorporated in the train-ing when building surgical capacity innon-surgical programmes in district- andsub-district-level health acilities thathave no surgery specialists.

As in other resource-limited healthsettings, in the Gambia ketamine-basedanaesthesia (82.4%) was the type mostcommonly available in the health acili-ties assessed.28 Tis may refect a shortageo the skills and equipment needed toprovide spinal and general anaesthesia.

Challenges with partnerships

Increased mortality has been correlatedwith decits in health inrastructure,29medical technology30 and integration oresources to provide surgical services.31

Te capacity o health acilities to providebasic lie-saving interventions must bestrengthened. Multidisciplinary partner-ships, such as between governments andNGOs, oer welcome opportunities toimprove health care in countries suchas the Gambia and to develop solutionsthat can generate important changes.Te Global Initiative or Emergency andEssential Surgical Care (GIEESC) wasestablished by WHO in 2005 to reducedeath and disability associated withsurgical conditions.32 Trough technicalassistance, needs assessments and educa-tion and training, the GIEESC strength-ens resource-limited countries capacityto deliver sae and eective emergencysurgical care. Our study suggests that theGIEESC can play an important role inbringing together stakeholders interestedin building surgical capacity in primaryhealth-care acilities and in ensuring theavailability o material resources and oproperly trained human resources.

Our study has limitations. First, the

sample was taken only rom acilities o-ering surgery and anaesthesia services.

Second, some o the assessed acilitiesmay have undergone signicant inra-structural improvements since the timeo the survey, although this is unlikely.Despite these limitations, the data pre-sented accurately refect the Gambias

current capacity to provide surgery andanaesthesia services.Te WHO tool has been validated

or assessing the capacity o health acili-ties in the developing world.33 Althoughgood test-retest reliability has beendocumented or the sections coveringphysical inrastructure, equipment andhuman resources, those parts that per-tain to the process o delivering healthcare can benet rom supplemental data.Overall, the WHO tool makes it possibleto quickly assess health acilities capacity

or delivering essential surgical and anaes-thetic services and to compare data acrossdeveloping countries.

Conclusion

In conclusion, the Gambia aces manyobstacles to the delivery o surgical andanaesthesia services, including a shortageo human resources, equipment, suppliesand inrastructure. Future studies areneeded to help determine precisely howthe shortage in each area aects surgicaloutcomes. o eectively reduce death

and disability rom surgical conditions,eorts to improve surgical capacitywithin the Gambian health-care systemmust ocus on the district level. rainingmid-level health practitioners in surgeryand developing partnerships betweenthe government and NGOs may be im-portant steps towards improving surgicaland anaesthetic services in the Gambia.

Acknowledgements

We are grateul or the support o thehealth acility visit team, including Agnes

Kuye, Alpha Jallow and Tomas Sukwa(World Health Organization CountryOce, the Gambia), Momodou Baro(Royal Victoria eaching Hospital, Ban-jul, the Gambia) and Yankuba Kassama(Ministry o Health, the Gambia).

Funding: Tis work was supported by theJohns Hopkins Center or Global Health(grant number 5R25W007506) romthe Fogarty International Center at theNational Institutes o Health.

Competing interests: None declared.
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65 . 46 7 110 11 )1 : )3 )2 )4 .

.

18 . 50.0% . 55.6% 38.9% . 16.7% . 54.5% 25% . 58.3% 41.7%

.

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65(1,7/,4611),110,:(1);(2);(3);(4)

18,50.0%,55.6%38.9%,16.7%,54.5%,58.3%25.0%,41.7%

,

Rsum

Capacit en termes durgence, danesthsie et de chirurgie essentielle en GambieObjectif valuer les ressources en soins chirurgicaux essentiels etdurgence en Gambie.MthodesLoutil danalyse de situation pour valuer les soins chirurgicauxdurgence et essentiels de lOrganisation mondiale de la Sant a tdistribu aux gestionnaires de soins de sant dans les tablissementsde tout le pays. Lenqute a t remplie par 65 tablissements

de sant - un hpital de rrence tertiaire, 7 hpitaux de district/gnraux, 46 centres de sant et 11 tablissements de sant privs - etcomptait 110 questions, rparties en quatre sections: (i) inrastructures,type dtablissement, population traite et ressources matrielles;(ii) ressources humaines; (iii) gestion des urgences et autres interventionschirurgicales; (iv) quipements durgence et de ranimation. Les donnesdu questionnaire ont t compltes par des entretiens avec le personneldes tablissements de sant, des onctionnaires du ministre de la Santet des reprsentants dorganisations non gouvernementales.Rsultats Des lacunes importantes ont t identifes en termesdinrastructures, de ressources humaines, de disponibilit dquipements

essentiels et de capacit eectuer des interventions de traumatologie,dobsttrique et de chirurgie gnrale. Sur les 18 tablissementssupposs eectuer des interventions chirurgicales, 50.0% rencontraientdes interruptions dapprovisionnement en eau et 55,6% en lectricit.Seuls 38,9% des tablissements disposaient dun chirurgien et 16,7%dun mdecin anesthsiste. Tous les tablissements avaient une capacit

limite pour eectuer des interventions traumatologiques de base et dechirurgie gnrale. Ce sont 54,5% des tablissements publics qui nepouvaient pas eectuer de laparotomie et 58,3% ne pouvaient pas gurirune hernie. Seuls 25.0% dentre eux pouvaient traiter une racture ouverteet 41,7% pouvaient eectuer une intervention durgence pour dgagerdes voies respiratoires obstrues.Conclusion La prsente tude sur les tablissements de soins de santen Gambie suggre dimportantes lacunes en termes de ressourceshumaines et physiques ncessaires pour eectuer des interventionschirurgicales de base, permettant de sauver des vies.


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Resumen

Capacidad de asistencia de emergencias, asistencia anestsica y asistencia de traumatismos en GambiaObjetivo Evaluar los recursos existentes de la asistencia esencial y deciruga de emergencia en Gambia.Mtodos Se distribuy la herramienta de Anlisis de la situacin de laOrganizacin Mundial de la Salud para evaluar la asistencia quirrgicaesencial y de emergencia entre gerentes de asistencia sanitaria deinstituciones de todo el pas. El estudio se llev a cabo en 65 institucionessanitarias (un hospital de asistencia sanitaria especializada, 7 hospitalesde distrito/generales, 46 centros de salud y 11 centros sanitariosprivados) y se incluyeron 110 preguntas divididas en cuatro secciones:(a) inraestructura, tipo de centro, poblacin atendida y recursosmateriales; (b) recursos humanos; (c) gestin de las urgencias y otrasintervenciones quirrgicas; (d) equipamiento de urgencias y suministrospara reanimacin. Los datos del cuestionario se complementaroncon entrevistas mantenidas con el personal del centro sanitario, losuncionarios del Ministerio de Sanidad y los representantes de lasorganizaciones no gubernamentales.Resultados Se identifcaron defciencias importantes en lasinraestructuras, los recursos humanos, la disponibilidad de suministros

esenciales y la habilidad para realizar intervenciones quirrgicas detraumatologa, obstetricia y ciruga general. De los 18 centros en los que seesperaba que se realizaran procedimientos quirrgicos, el 50,0% surieroninterrupciones en el suministro de agua y el 55,6% en el suministro deelectricidad. Solo el 38,9% de los centros contaba con un cirujano y solo el16,7% contaba con un mdico anestesista. Todos los centros presentaronlimitaciones a la hora de llevar a cabo los procedimientos quirrgicosbsicos de traumatologa y ciruga general. De los centros pblicos, el54,5% no pudo realizar laparotomas y el 58,3% no pudo reparar unahernia. Solo el 25,0% de los centros pudo gestionar una ractura abiertay el 41,7% pudo llevar a cabo un procedimiento de urgencia por vasrespiratorias obstruidas.Conclusin El presente estudio de centros de asistencia sanitaria enGambia sugiere que las mayores lagunas se encuentran en los recursossicos y humanos necesarios para llevar a cabo intervenciones quirrgicasbsicas para salvar vidas.

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Emergency, Anaesthetic and Essential Surgical Capacity in the Gambia

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