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Objectives The aim of this study was to characterise the resources and challenges for surgical care and referrals at health centres (HCs) in South Wollo Zone, Ethiopia. Setting Eight primary HCs in South Wollo Zone, Ethiopia. Participants Eight health officers and nurses staffing eight HCs completed a survey. Design The study was a survey-based, cross-sectional assessment of HCs in South Wollo Zone, Ethiopia and data were collected over a 30-day period from November 2014 to January 2015. Primary and secondary outcome measures Survey assessed human and material resources, diagnostic capabilities and challenges and patient-reported barriers to care. Results Eight HCs had an average of 18 providers each, the majority of which were nurses (62.2%) and health officers (20.7%). HCs had intermittent availability of clean water, nasogastric tubes, rectal tubes and suturing materials, none of them had any form of imaging. A total of 168 surgical patients were seen at the 8 HCs; 58% were referred for surgery. Most common diagnoses were trauma/burns (42%) and need for caesarean section (9%). Of those who did not receive surgery, 32 patients reported specific barriers to obtaining care (91.4%). The most common specific barriers were patients not being decision makers to have surgery, lack of family/social support and inability to afford hospital fees. Conclusions HCs in South Wollo Zone, Ethiopia are well-staffed with nurses and health officers, however they face a number of diagnostic and treatment challenges due to lack of material resources. Many patients requiring surgery receive initial diagnosis and care at HCs; sociocultural and financial factors commonly prohibit these patients from receiving surgery. Further study is needed to determine how such delays may impact patient outcomes. Improving material resources at HCs and exploring community and family perceptions of surgery may enable more streamlined access to surgical care and prevent delays.
Ethiopia is a low-income country in Eastern Sub-Saharan Africa with a rapidly growing population. With a population of 102 million in 2016, life expectancy was estimated as 65.5 years.17 Maternal mortality is moderate at 353/100 000 live births, and under age 5 mortality rate is rapidly falling, estimated as 61/100 000 in 2015. Surgical diseases, however, are now a major source of mortality, with non-communicable diseases, particularly cardiovascular disease, malignant neoplasms and digestive diseases, now making up a majority of causes of death. It was reported that only 55% of healthcare facilities could provide basic obstetric care and 52% could provide basic surgical care in 2015. The ratio of healthcare providers and facilities per population is among the lowest in the world, with 149 total hospitals in country, 1343 HCs and 3305 health posts in 2008. This study was conducted in the Amhara region, which, at last regional census, was estimated to have 17.2 million inhabitants in 2007 with 7406 total healthcare providers, 2152 physicians (2.7/100 000 population). In the most recent available provider densities in 2007, an estimated 140 surgeons were practicing in the country, with estimates for 820 by 2015.17 Dessie Referral Hospital is the only referral hospital in South Wollo Zone within the Amhara Region (figure 1) and serves an estimated catchment area of 7 million, with general surgeons, orthopaedic surgeons and obstetricians on staff. While intensive/critical care is limited, and subspecialties such as oncological care are not available, all Bellwether procedures can be performed at this hospital. Amhara region and South Wollo zone map with study site locations. This study was a cross-sectional survey of eight woreda (district) level HCs in the South Wollo Zone of Ethiopia. Survey was designed by the study personnel using review of prior similar studies on barriers to accessing surgery and HC assessment tools.10 18–21 Surveys were distributed to all HCs in the South Wollo Zone for completion. The survey was reviewed by local colleagues at the main study site at Dessie Referral Hospital in South Wollo Zone and feedback incorporated into the final tool. The survey tool was piloted with one HC in Dessie town with a surgeon and HC nurse and all questions were determined to be understandable and possible to answer by the local study personnel. Although Dessie Hospital is considered a ‘referral hospital’ by the Ethiopian healthcare network, according to international standards it meets criteria as a primary hospital, with inpatient and general surgical services available, but lacking subspecialty or intensive care unit services.22 Patients and the public were not involved in the study design or survey tool design; however, local healthcare providers gave input on survey questions during study design. Findings from this study will be made available at the referral hospital for public viewing and dissemination. Surveys were distributed at a regional health bureau meeting. Study participants who completed the survey were nurses or health officers (diploma nurses with additional training) employed at the respective HCs. Orientation and training on survey completion were provided by an Ethiopian nurse who was engaged in the project. This trainer and the principal investigator (PI) were available to answer questions for participants throughout the study period by phone regarding survey completion. The survey was distributed to HC nurses or health officers at all 21 woredas in South Wollo. Participation was voluntary and participants received a small monetary compensation when the survey was returned at the end of the study period. Study participants completed survey questions regarding HC staffing, diagnostic and treatment resources available at their HC, as well as provider comfort level making common surgical diagnoses in their setting. They also recorded data on all patients presenting to their respective HCs with surgical diagnoses as stipulated by the study definitions over a 30-day period. Information about these patients including age, gender, diagnosis, whether or not a referral was made at the clinic visit and barriers expressed or perceived prevented patients from receiving surgical care were recorded. Participants collected patient data over a 30-day period between November 2014 and January 2015; HCs varied in the specific dates of their data collection. Surveys were returned to the study PI in person or via post and compensation was provided on return of completed survey. All participating HCs were in a geographical network making surgical referrals to a single referral hospital in Dessie, Ethiopia. In an effort to avoid selection bias, surveys were distributed to all HCs in the Zone and orientation to the survey was conducted with staff from all HCs. Study population included all HCs in South Wollo Zone which were expected to make referrals to a single hospital in the Zonal capital. Quantitative data such as HC catchment population, staffing, patient age and referral status were analysed with frequencies and SD. Descriptive statistics were used for all variables and no multivariate analysis or associations were calculated. Data were returned via paper forms and entered into RedCap by study personnel. Data were extracted to Microsoft Excel and kept confidential on encrypted computer by study personnel. Descriptive statistics were used to analyse HC providers, resources, diagnostic challenges, patient diagnoses and barriers to care. Data analysis was conducted using Excel and Stata/SE V. 15.1.
