Search

This study explored the extent to which health promotion techniques and activities are incorporated into public health and clinical care at a District Hospital in the Greater Accra Region of Ghana, as well as the challenges that this process faces. Information was obtained at the hospital facility through direct observation, interviews and open-ended questionnaires. Findings showed that the process of incorporating health promotion activities into public health and clinical care at the hospital was underdeveloped. The challenges this process faces based on the research findings include structural challenges, inadequate logistics, increased workload, insufficient human resource capacity, lack of motivation for staff, lack of cooperation, teamwork and consultation, inadequate management and enforcement support, prolonged hospital hours for healthcare workers and patients, and inadequate knowledge of health promotion and training. To address these challenges, suggested measures include promoting teamwork and collaboration among healthcare professionals, training and continuous education, government involvement and enforcement of health promotion integration at the hospital, hospital management involvement, media sensitization and advocacy, provision of financial, material and human resources, motivation and encouragement of the process of health promotion integration, and patient involvement. Further research is also recommended to broaden the scope of this study by involving other health practitioner categories and health promotion stakeholders. [ABSTRACT FROM AUTHOR]

Background “Kayakalp” is a National initiative to give awards to those public health facilities that demonstrate high level of cleanliness, hygiene, and infection control. It encourages every public health facility in the country to work toward standards of excellence to help the facilities to maintain cleanliness and hygiene. Objective The objective of the study was to find out baseline data, assess different key areas, and to compare the performance of different parameters mentioned in the Kayakalp program. Materials and Methods An observational cross-sectional study was conducted in two hospitals (one medical college and one district hospital) of West Bengal during 2020–2021. The study population consisted of staffs and admitted patients. Direct observation, record review, staff interview, and patient interview were done using the Kayakalp assessment checklist, relevant hospital records, etc. Assessment of performance was based on seven key parameter-hospital upkeep, sanitation and hygiene, hospital support service, waste management, infection control, hygiene promotion, and feedback mechanism. Collected data were entered in Microsoft Office Excel data sheet and analyzed there. The presentation of data was done using the principles of descriptive statistics in tabular form and bar diagrams. Results The studied district hospital scored much higher (total score 371) than the medical college (total score 237) in almost all key areas. Different component-wise following scores were noted among those two hospitals: hospital upkeep (55.4% vs. 37.7%), sanitation and hygiene (59.3% vs. 26%), hospital support service (57.5% vs. 47.5%), waste management (60% vs. 43.3%), infection control measures (61% vs. 59%), and hygiene promotion (51.3% vs. 35%). There was no system for feedback mechanism from the public on cleanliness in the studied medical college care hospital. Conclusion All health institutions should be under the Kayakalp program for improvement in the quality of patient care-related services.

As study after study has pointed out, the health care systems in Africa pay little attention to the critical interface between education and good health, especially when it comes to the education of women and mothers, who are the primary line of defense against child diseases, and perform simultaneously most domestic chores and critical agricultural activities. While many medical educational institutions on the continent tend to perpetuate, at times, skewed and irrelevant Eurocentric health training, the national pyramidal health structure, weakened at the village level, and disproportionately favoring the provincial and national hospitals, gives the illusion that rural areas are well-served, when in actuality they are not. This chapter endorses the restrengthening of an uncompromised health care system to make it effective and efficient for both rural and urban areas; one that finds ways of trimming financial and human resource waste; revamps the institutions that train health care and service providers to make the system responsive to the real health needs of the people and not just the wealthy; one that compensates physicians just as civil servants; and aligns the educational system with targeted and ex- pected measurable health outcomes. [ABSTRACT FROM AUTHOR]

Background/Aims Paediatric surgical care is a critical component of child health and basic universal health coverage and therefore should be included in comprehensive evaluations of surgical capacity. This study adapted and validated the Children’s Surgical Assessment Tool (CSAT), a tool developed for district and tertiary hospitals in Nigeria to evaluate hospital infrastructure, workforce, service delivery, financing, and training capacity for paediatric surgery, for use in district hospitals in Rwanda. Methods We used a three-round modified Delphi process to adapt the CSAT to the Rwandan context. An expert panel of surgeons, anaesthesiologists, paediatricians, and health systems strengthening experts were invited to participate based on their experience with paediatric surgical or anaesthetic care at district hospitals or with health systems strengthening in the Rwandan context. We used the Content Validity Index to validate the final tool. Results The adapted tool had a final score of 0.84 on the Content Validity Index, indicating a high level of agreement among the expert panel. The final tool comprised 171 items across five domains: facility characteristics, service delivery, workforce, financing, and training/research. Conclusion The adapted CSAT is appropriate for use in district hospitals in Rwanda to evaluate the capacity for paediatric surgery. This study provides a framework for adapting and validating a comprehensive paediatric surgical assessment tool to local contexts in LMICs and used in similar settings in sub-Saharan Africa.

Background Circumcision is one of the most common surgical procedures in boys in Indonesia. In cases patient with hemophilia (PWH), doctors tend to avoid this procedure due to increased bleeding tendency. In 2007, we developed a protocol for clotting factor concentrate (CFC) administration for circumcision in SWH, namely, the “Yogyakarta Method.” Objective To evaluate the outcomes of the Yogyakarta Method for circumcising PWH. Methods This descriptive study was based on medical records of PWH who underwent circumcision at Dr. Sardjito Hospital (DSH), Yogyakarta and 3 surrounding hospitals under DSH supervision from 2008-2017 and 2018-2022. Diagnoses of hemophilia were based on clinical findings and factor assays. Subjects with hemophilia A received factor VIII (25 IU/kg/dose) and those with hemophilia B received factor IX (50 IU/kg/dose) before, during and after the procedure. In addition, patients received tranexamic acid (15 mg/kg/dose). Circumcision was performed by a pediatric surgeon or urologist. Results From 2008-2017, 28 PWH underwent circumcision, 14/28 of whom were in DSH. Twenty-six patients had hemophilia A and 2 had hemophilia B. Their severities were mild (12 subjects), moderate (10), and severe (6). Subjects’ median age was 10.5 (5-19) years and their median CFC use was 8 (range 7-10) doses in hemophilia A and 4 (range 4-5) doses in hemophilia B patients. Three of 28 PWH had bleeding episodes after the procedure. Following the encouraging results from the initial 2008-2017 study period, most of PWH circumcised in 2018-2022 underwent the procedure in the same 3 district hospitals rather than at DSH (21/28 subjects), and had similar CFC consumption. Only 1 bleeding episode occurred after the procedure during the second study period. Conclusion The Yogyakarta method is safe and sufficient to control bleeding in circumcision of PWH. This method is also suitable in a district hospital setting.

Background Circumcision is one of the most common surgical procedures in boys in Indonesia. In cases patient with hemophilia (PWH), doctors tend to avoid this procedure due to increased bleeding tendency. In 2007, we developed a protocol for clotting factor concentrate (CFC) administration for circumcision in PWH, namely, the "Yogyakarta Method." Objective To evaluate the outcomes of the Yogyakarta Method for circumcising PWH. Methods This descriptive study was based on medical records of PWH who underwent circumcision at Dr. Sardjito Hospital (DSH), Yogyakarta and 3 surrounding hospitals under DSH supervision from 2008-2017 and 2018-2022. Diagnoses of hemophilia were based on clinical findings and factor assays. Subjects with hemophilia A received factor VIII (25 IU/kg/dose) and those with hemophilia B received factor IX (50 IU/kg/dose) before, during and after the procedure. In addition, patients received tranexamic acid (15 mg/kg/dose). Circumcision was performed by a pediatric surgeon or urologist. Results From 2008-2017, 28 PWH underwent circumcision, 14/28 of whom were in DSH. Twenty-six patients had hemophilia A and 2 had hemophilia B. Their severities were mild (12 subjects), moderate (10 subjects), and severe (6 subjects). Subjects' median age was 10.5 (5-19) years and their median CFC use was 8 (range 7-10) doses in hemophilia A and 4 (range 4-5) doses in hemophilia B patients. Three of 28 PWH had bleeding episodes after the procedure. Following the encouraging results from the initial 2008-2017 study period, most of PWH circumcised in 2018-2022 underwent the procedure in the same 3 district hospitals rather than at DSH (21/28 subjects), and had similar CFC consumption. Only 1 bleeding episode occurred after the procedure during the second study period. Conclusion The Yogyakarta method is safe and sufficient to control bleeding in circumcision of PWH. This method is also suitable in a district hospital setting. [ABSTRACT FROM AUTHOR]

Background: Stillbirths are a global public health challenge, predominantly affecting low- and middle-income countries. The causes of most stillbirths are preventable. Objectives: this study reviewed perinatal clinical audit data from Kgapane Hospital over a 4-year period with a special focus on the factors associated with stillbirths. Methods: File audits were done for all stillbirths occurring at Kgapane Hospital and its catchment area from 2018 to 2021. The data from these audits were analysed to identify factors associated with stillbirths. Results: A total of 392 stillbirths occurred during the study period at Kgapane Hospital and its surrounding clinics, resulting in a stillborn rate of 19.06/1000 births. Of the 392 stillbirths recorded, audits were conducted on 354 of the maternal case records. The five most common causes of stillbirths identified were: hypertensive disorders in pregnancy (HDP) (29.7%), intrauterine growth restriction without HDP (11.6%), birth asphyxia (7.1%), premature labour (< 1000 g) (6.5%) and maternal infections (5.9%) including HIV with unsuppressed VL, intrauterine infection, coronavirus disease (COVID) and syphilis. Modifiable factors that can form the basis of improvement strategies should include training, timeous referral, plus improved resources and staffing. Conclusion: Understanding the causes of stillbirths can guide improvement strategies to reduce this heart-breaking complication of pregnancy. Contribution: Family physicians working in rural hospitals are also responsible for perinatal care. Understanding the factors associated with stillbirths will guide them to develop improvement strategies to reduce these preventable deaths. [ABSTRACT FROM AUTHOR]

Background: A robust knowledge on the pattern of use of emergency care resources not only serves as an indicator of universal access to care but also provides a basis for quality improvement within the health system. This study was undertaken to describe the pattern of emergency room visits at Brits District Hospital (BDH) in North West province, South Africa. The objectives of this study were to determine the sociodemographic characteristics of emergency department (ED) users and other patterns of ED use. Methods: This was a cross-sectional descriptive study that was conducted at a district hospital. All patients who reported for emergency care in the ED in 2016 were eligible for the study. Data were extracted and analysed from a systematic sample of 355 clinical notes and hospital administrative records. Results: The age group that visited the ED most frequently (25.3%) was 25-34 years old. A high proportion of the ED users (60%) were self-referred, and only 38% were transported by the emergency medical response services (EMRS). Few (5.6%) presentations were of a non-urgent nature. Trauma-related conditions accounted for the most frequent presentation at the ED (36.5%). Conclusion: Although most ED users were self-referred, their clinical presentations were appropriate and underscore the need for policy strategies to reduce the burden of trauma in the catchment population Contribution: The study findings may have an impact on future health policies by providing decision-makers with baseline information on the pattern of use of ED resources, ensuring better resource deployment and greater access to care. [ABSTRACT FROM AUTHOR]

BackgroundThe Taiwanese government adopted the National Health Insurance (NHI) system in March 1995. This study aimed to understand the difference in medication costs before (year 2019) and during the COVID-19 pandemic (2020–2021) among different hospitals for treating their patients.MethodsThe NHI claims database consisting of claims of prescription drugs for inpatients (IPD) and outpatients (OPD) in Taiwan was used to determine drug expenditure in different hospitals, particularly the top 10 prescription Anatomical Therapeutic Chemical (ATC) categories.ResultsIn medical centers, L01X (other antineoplastic agents) showed the highest drug expenditure, followed by L04A (immunosuppressants) and J05A (direct-acting antivirals). The drug expenditure pattern in regional hospitals was similar to that in medical centers, with L01X (other antineoplastic agents) showing the highest drug expenditure. L01X (other antineoplastic agents) also showed the highest drug expenditure in district hospitals, followed by N05A (antipsychotics) and A10B (blood glucose-lowering drugs, excluding insulin). In clinics, A10B (blood glucose-lowering drugs, excluding insulin) showed the highest drug expenditure. The total medication costs in 2021 were lower or similar to those in 2019. The use of systemic use anti-infectives decreased over time in OPDs among all hospita1 levels but increased in IPDs in medical centers and district hospitals. Furthermore, our analysis revealed that the trend in drug expenditure closely mirrored the trend in drug prescription volume for the highest annual sum cost item among the top 10 drug subgroups across different hospital levels.ConclusionOur analysis found that annual drug expenditures in 2021 were lower or similar to those in 2019, suggesting that the COVID-19 pandemic has contributed to this reduction in drug expenditure.

Background: We sought to determine the achievement of key performance indicators (KPIs) of initial trauma care at district (first‐level) and regional (second‐level) hospitals in Ghana and to assess the effectiveness of a standardized trauma intake form (TIF) to improve care. Methods: A stepped‐wedge cluster randomized trial was performed with direct observations of trauma management before and after introducing the TIF at emergency units of eight hospitals for 17.5 months. Differences in KPIs were assessed using multivariable logistic regression and generalized linear mixed regression. Results: Management of 4077 patients was observed; 30% at regional and 70% at district hospitals. Eight of 20 KPIs were performed significantly more often at regional hospitals. TIF improved care at both levels. Fourteen KPIs improved significantly at district and eight KPIs improved significantly at regional hospitals. After TIF, regional hospitals still performed better with 18 KPIs being performed significantly more often than district hospitals. After TIF, all KPIs were performed in >90% of patients at regional hospitals. Examples of KPIs for which regional performed better than district hospitals after TIF included: assessment for oxygen saturation (83% vs. 98%) and evaluation for intra‐abdominal bleeding (82% vs. 99%, all p < 0.001). Mortality decreased among seriously injured patients (injury severity score ≥9) at both district (15% before vs. 8% after, p = 0.04) and regional (23% vs. 7%, p = 0.004) hospitals. Conclusions: TIF improved care and lowered mortality at both hospital levels, but KPIs remained lower at district hospitals. Further measures are needed to improve initial trauma care at this level. Clinical trials registration: Clinicaltrials.gov (NCT04547192). [ABSTRACT FROM AUTHOR]

Introduction/Background: Safe and quality surgery is crucial for child health. In Rwanda, district hospitals serve as primary entry points for pediatric patients needing surgical care. This paper reports on the organizational readiness and facility capacity to provide pediatric surgery in three district hospitals in rural Rwanda. Methods: We administered the Children's Surgical Assessment Tool, adapted for a Rwandan district hospital, to assess facility readiness across 5 domains (infrastructure, workforce, service delivery, financing, and training) at three Partners in Health supported district hospitals (Kirehe, Rwinkwavu, and Butaro District Hospitals). We used the Safe Surgery Organizational Readiness Tool (SSORT) to measure perceived individual and team readiness to implement surgical quality improvement interventions across 14 domains. Results: None of the facilities had a dedicated pediatric surgeon, and the most common barriers to pediatric surgery were lack of surgeon (68%), lack of physician anesthesiologists (19%), and inadequate infrastructure (17%). There were gaps in operating and recovery room infrastructure and information management for pediatric outpatients and referrals. In SSORT interviews (n = 47), the highest barriers to increasing pediatric surgery capacity were facility capacity (mean score = 2.6 out of 5), psychological safety (median score = 3.0 out of 5), and resistance to change (mean score = 1.5 out of 5 with 5 = no resistance). Conclusions: This study highlights challenges in providing safe and high‐quality surgical care to pediatric patients in three rural district hospitals in Rwanda. It underscores the need for targeted interventions to address facility and organizational barriers prior to implementing interventions to expand pediatric surgical capacity. [ABSTRACT FROM AUTHOR]

Background: Computed tomography (CT) has become an invaluable aid in medical diagnostic workup, and its global usage has been shown to be consistently increasing across all departments. While typically located in regional or central hospitals in South Africa, its recent introduction at the district level has many foreseeable benefits. We evaluated its utility at one of the first district hospitals in the Western Cape to obtain a CT suite. Objectives: This study aimed to describe the type of CT scans ordered, the clinical indications, the prevalence of significant abnormal findings and the agreement between the clinical opinion and radiological diagnosis. Methods: A descriptive cross-sectional study was conducted over a 1-year period at Khayelitsha Hospital, an entry-level hospital just outside of Cape Town. Results: A total of 3242 CT scans were analysed. The mean age of patients was 46 years; 51.4% were males. A mean of 13 scans were performed per working day. The head and neck area were the most scanned region (n = 1841, 52.3%). Predominantly requested by the Emergency Centre (n = 1382, 42.6%), indications were mainly for general medical conditions workup (n = 2151, 66.4%). Most scans showed abnormalities (n = 2710, 83.6%), with 2115 (65.2%) considered relevant (‘positive yield’). Clinical and CT diagnoses agreed in 1610 (49.7%) cases. Conclusion: Computed tomography usage at the district level demonstrated positive yield rates comparable to that of tertiary centres. This implies an appropriate utilisation of the service with a potential decrease in the burden on the referral centre. Contribution: Computed tomography scanners at district-level facilities are appropriately utilised and can provide greater access to care while potentially decreasing the burden on referral centres.

Training of medical interns at the Middelburg district hospital has been introduced as part of the mandatory 6 months’ rotation in Family Medicine department since 2021. This report provides an overview of what has been attained in 2021 and 2022. It covers various aspects of the activities medical interns have been exposed to in the Middelburg hospital and the surrounding primary health care clinics. Contribution: Sharing experiences of family medicine training for medical interns in district hospitals is essential because the 6 months’ rotation is new for most family physician trainers, especially those in small hospitals and primary health care clinics. Taking into account the paucity of evidence on the topic, the report brings current information that supports that training medical interns in district hospitals and primary health care clinics prepares them to be comfortable and competent clinicians for the generalist work during the community service year ahead.

Introduction: Burundi, like many African nations, faces challenges in providing accessible emergency care. The aim of this study was to assess the type of staff training, accessibility to imaging, and availability of essential equipment in the district hospitals of Burundi in order to inform strategic planning for healthcare delivery. Methods: In June 2022 an online survey was sent to each district hospital of the country. Complete responses were analysed and, where appropriate, significance determined by chi-square analysis, with p

Background: A robust knowledge on the pattern of use of emergency care resources not only serves as an indicator of universal access to care but also provides a basis for quality improvement within the health system. This study was undertaken to describe the pattern of emergency room visits at Brits District Hospital (BDH) in North West province, South Africa. The objectives of this study were to determine the sociodemographic characteristics of emergency department (ED) users and other patterns of ED use. Methods: This was a cross-sectional descriptive study that was conducted at a district hospital. All patients who reported for emergency care in the ED in 2016 were eligible for the study. Data were extracted and analysed from a systematic sample of 355 clinical notes and hospital administrative records. Results: The age group that visited the ED most frequently (25.3%) was 25–34 years old. A high proportion of the ED users (60%) were self-referred, and only 38% were transported by the emergency medical response services (EMRS). Few (5.6%) presentations were of a non-urgent nature. Trauma-related conditions accounted for the most frequent presentation at the ED (36.5%). Conclusion: Although most ED users were self-referred, their clinical presentations were appropriate and underscore the need for policy strategies to reduce the burden of trauma in the catchment population Contribution: The study findings may have an impact on future health policies by providing decision-makers with baseline information on the pattern of use of ED resources, ensuring better resource deployment and greater access to care.

Burundi, like many African nations, faces challenges in providing accessible emergency care. The aim of this study was to assess the type of staff training, accessibility to imaging, and availability of essential equipment in the district hospitals of Burundi in order to inform strategic planning for healthcare delivery. In June 2022 an online survey was sent to each district hospital of the country. Complete responses were analysed and, where appropriate, significance determined by chi-square analysis, with p <0.05 considered significant. Forty of 45 district hospitals completed the survey, of which 35 were rural (matching national demographics). The majority of district hospitals (21/40) had ready access to ≥4/5 critical drugs while few (5/40) were equipped with ≥4/5 key material. One quarter had 24/7 physician coverage and X-ray available. Only 3 had continuous access to ultrasound studies despite most district hospitals having ultrasound machines. Trained emergency room staff were almost totally absent from the field, with only 6 nurses, 4 generalists, and 1 specialist reported across 9 sites. Even a single EM-trained staff member was significantly correlated with being better equipped for emergencies (p <0.01). Burundi needs a strategic investment in emergency preparedness and care. Policy initiatives and technology purchases have demonstrated reasonable penetration down to the district hospital level, however, trained personnel are essential to develop sustainable emergency capacity. [ABSTRACT FROM AUTHOR]

An 'audit' is defined as 'the review and the evaluation of the health care procedures and documentation for the purpose of comparing the quality of care which is provided, with the accepted standards'. Studying the prescription audit is that part of the audit which seeks to monitor, evaluate and if necessary, suggest modifications in the prescribing practices of medical practitioners. In this study, we aimed to study the prescription pattern and assess the quality of prescription, with the standard prescription norms in Out Patient department of various specialities of the District Hospital, Bandipora. This observational study was conducted on the patients receiving medication during treatment in the outpatient departments of various specialities of the District Hospital, Bandipora, over a period of one month and the calculated sample size was 95 (according to the guidelines of prescription audit by MoHFW). An additional sample of 5 was included in the study, making the total sample size 100. A total of 20 parameters were assessed using a checklist. It was found that out of 100 study participants, brief history was mentioned in 51% prescriptions; dosage, duration and frequency was mentioned in 72% prescriptions, sign and stamp of the treating doctor was present on 37% prescriptions; medications were written in capital letters in 70% prescriptions, but were written in generic form in only 17% prescriptions. 78% of the medication orders were clear and readable; route of administration was not mentioned in 65% prescriptions. Vitamins, tonics or enzymes were prescribed in only 10% prescriptions, while antibiotics were prescribed in 44% prescriptions. [ABSTRACT FROM AUTHOR]

Background and Aims: Dengue is endemic in Thailand and imposes a high burden on the health system and society. We conducted a prospective cohort study in Umphang District, Tak Province, Thailand, to investigate the share of dengue cases with long symptoms and their duration. Here we present the results of the enrollment process during the COVID‐19 pandemic with implications and challenges for research and policy. Methods: In a prospective cohort study conducted in Umphang District, Thailand, we examined the prevalence of persistent symptoms in dengue cases. Clinically diagnosed cases were offered free laboratory testing, We enrolled ambulatory dengue patients regardless of age who were confirmed through a highly sensitive laboratory strategy (positive NS1 and/or IgM), agreed to follow‐up visits, and gave informed consent. We used multivariate logistic regressions to assess the probability of clinical dengue being laboratory confirmed. To determine the factors associated with study enrollment, we analyzed the relationship of patient characteristics and month of screening to the likelihood of participation. To identify underrepresented groups, we compared the enrolled cohort to external data sources. Results: The 150 clinical cases ranged from 1 to 85 years old. Most clinical cases (78%) were confirmed by a positive laboratory test, but only 19% of those confirmed enrolled in the cohort study. Women, who were half as likely to enroll as men, were underrepresented in the cohort. Conclusions: The Thai physicians' clinical diagnoses at this rural district hospital had good agreement with laboratory diagnoses. By identifying underrepresented groups and disparities, future studies can ensure the creation of statistically representative cohorts to maximize their scientific value. This involves recruiting and retaining underrepresented groups in health research, such as women in this study. Promising strategies for meaningful inclusion include multi‐site enrollment, offering in‐home or virtual services, and providing in‐kind benefits like childcare for underrepresented groups. Key points: Cohort studies are a powerful tool for examining correlates of major diseases, such as dengueThe validity of the resulting data, however, depends on the representativeness of the underlying cohortDuring the COVID‐19 pandemic, only a small share of eligible patients were willing to join the cohort study in Thailand's Tak ProvinceComparisons with external data showed that adult women were particularly underrepresented in the cohort due to their household and childcare responsibilitiesThe analyses showed how cohort studies could be improved by identifying underrepresented groups, offering targeted support services and performing statistical weighting [ABSTRACT FROM AUTHOR]

Abstract Background Papua New Guinea (PNG) is one of the 14 countries categorised as having a triple burden of tuberculosis (TB), multidrug-resistant TB (MDR TB), and TB-human immunodeficiency virus (HIV) co-infections. TB infection prevention and control (TB-IPC) guidelines were introduced in 2011 by the National Health Department of PNG. This study assesses the implementation of this policy in a sample of district hospitals in two regions of PNG. Methods The implementation of TB-IPC policy was assessed using a survey method based on the World Health Organization (WHO) IPC assessment framework (IPCAF) to implement the WHO’s IPC core components. The study included facility assessment at ten district hospitals and validation observations of TB-IPC practices. Results Overall, implementation of IPC and TB-IPC guidelines was inadequate in participating facilities. Though 80% of facilities had an IPC program, many needed more clearly defined IPC objectives, budget allocation, and yearly work plans. In addition, they did not include senior facility managers in the IPC committee. 80% (n = 8 of 10) of hospitals had no IPC training and education; 90% had no IPC committee to support the IPC team; 70% had no surveillance protocols to monitor infections, and only 20% used multimodal strategies for IPC activities. Similarly, 70% of facilities had a TB-IPC program without a proper budget and did not include facility managers in the TB-IPC team; 80% indicated that patient flow poses a risk of TB transmission; 70% had poor ventilation systems; 90% had inadequate isolation rooms; and though 80% have personal protective equipment available, frequent shortages were reported. Conclusions The WHO-recommended TB-IPC policy is not effectively implemented in most of the participating district hospitals. Improvements in implementing and disseminating TB-IPC guidelines, monitoring TB-IPC practices, and systematic healthcare worker training are essential to improve TB-IPC guidelines’ operationalisation in health settings to reduce TB prevalence in PNG.

Abstract Background and Aims Dengue is endemic in Thailand and imposes a high burden on the health system and society. We conducted a prospective cohort study in Umphang District, Tak Province, Thailand, to investigate the share of dengue cases with long symptoms and their duration. Here we present the results of the enrollment process during the COVID‐19 pandemic with implications and challenges for research and policy. Methods In a prospective cohort study conducted in Umphang District, Thailand, we examined the prevalence of persistent symptoms in dengue cases. Clinically diagnosed cases were offered free laboratory testing, We enrolled ambulatory dengue patients regardless of age who were confirmed through a highly sensitive laboratory strategy (positive NS1 and/or IgM), agreed to follow‐up visits, and gave informed consent. We used multivariate logistic regressions to assess the probability of clinical dengue being laboratory confirmed. To determine the factors associated with study enrollment, we analyzed the relationship of patient characteristics and month of screening to the likelihood of participation. To identify underrepresented groups, we compared the enrolled cohort to external data sources. Results The 150 clinical cases ranged from 1 to 85 years old. Most clinical cases (78%) were confirmed by a positive laboratory test, but only 19% of those confirmed enrolled in the cohort study. Women, who were half as likely to enroll as men, were underrepresented in the cohort. Conclusions The Thai physicians' clinical diagnoses at this rural district hospital had good agreement with laboratory diagnoses. By identifying underrepresented groups and disparities, future studies can ensure the creation of statistically representative cohorts to maximize their scientific value. This involves recruiting and retaining underrepresented groups in health research, such as women in this study. Promising strategies for meaningful inclusion include multi‐site enrollment, offering in‐home or virtual services, and providing in‐kind benefits like childcare for underrepresented groups.

Objective: To explore Rwandan women's experiences, priorities, and preferences in accessing health care for non‐pregnancy‐related conditions and inform development of healthcare services related to these conditions among women of reproductive age at district hospitals and health centers in Rwanda. Methods: We used a mixed‐methods, exploratory sequential design. Semi‐structured qualitative interviews were conducted with Rwandan women and coded thematically. A cross‐sectional quantitative survey based on the qualitative data was administered to women attending health centers. Results: Seventeen interviews and 150 surveys were conducted. Women identified conditions including back pain, gynecologic cancers, and abnormal vaginal bleeding as concerns. They generally reported positive experiences while accessing health care and knowledge of accessing health care. Barriers to care were identified, including transportation costs and inability to miss work. Women expressed a desire for more control over their care and the importance of maintaining their dignity while accessing health care. Conclusion: These findings provide useful insights to inform development of non‐pregnancy‐related healthcare services for women in Rwanda according to their priorities and preferences. The reported end‐user health concerns, barriers to care, and diminished control over their care point to a need to evolve health systems around user‐tailored needs and design interventions optimizing access whilst promoting dignified care. Synopsis: This mixed‐methods study explores priorities, preferences, and experiences in the care of women in rural Rwanda. It identifies key health concerns, barriers to care, and the importance of dignified care. [ABSTRACT FROM AUTHOR]

Background: Globally, diabetes mellitus (DM) remains one of the leading causes of mortality, with approximately 2 million deaths in 2019, the condition also contributes significantly to adverse health conditions and costs. The study aimed to describe the quality of care (QOC) rendered to patients with type 2 DM (T2DM) seeking care at Wentworth Hospital (WWH), a district hospital in KwaZulu-Natal province, South Africa. Methods: A descriptive cross-sectional design was used, and all patients living with T2DM on treatment who had accessed care for at least 1 year were included. Data were collected through structured exit interviews, and their clinical data were extracted from their medical records. Their knowledge, attitudes and practices were assessed using a 5-point Likert scale. Results: The mean age (standard deviation [s.d.]) was 59 (13.0) years and most (65.3%) were female, of African (30.0%) and Indian (38.6%) descent, with two-thirds (69.4%) obtaining a secondary school education. Their mean glycated haemoglobin (HbA1c) (s.d.) was 8.6 (2.4%). Over 82% had one or more comorbidity, while 30% had at least one DM-related complication. Generally, participants were pleased with the care received, but their knowledge and practices related to their T2DM was suboptimal. Conclusion: This study indicates that the QOC was suboptimal due to poor efficacy indicators, poor knowledge and lack of adequate lifestyle measures, despite the frequency of medical practitioner reviews. Contributions: This study identified gaps in QOC and will aid South African public sector policy-makers in devising quality improvement initiatives. [ABSTRACT FROM AUTHOR]

Abstract Background The coronavirus disease 2019 (COVID-19) pandemic continues to evolve. Globally, COVID-19 continues to strain even the most resilient healthcare systems, with Omicron being the latest variant. We made a thorough search for literature describing the effects of the COVID-19 in a high human immunodeficiency virus (HIV)/tuberculosis (TB) burden district-level hospital setting. We found scanty literature. Methods A retrospective observational study was conducted at Khayelitsha District Hospital in Cape Town, South Africa (SA) over the period March 2020–December 2021. We included confirmed COVID-19 cases with HIV infection aged from 18 years and above. Analysis was performed to identify predictors of mortality or hospital discharge among people living with HIV (PLWH). Predictors investigated include CD4 count, antiretroviral therapy (ART), TB, non-communicable diseases, haematological, and biochemical parameters. Findings This cohort of PLWH with SARS-CoV-2 infection had a median (IQR) age of 46 (37–54) years, male sex distribution of 29.1%, and a median (IQR) CD4 count of 267 (141–457) cells/mm3. Of 255 patients, 195 (76%) patients were discharged, 60 (24%) patients died. One hundred and sixty-nine patients (88%) were on ART with 73(28%) patients having acquired immunodeficiency syndrome (AIDS). After multivariable analysis, smoking (risk ratio [RR]: 2.86 (1.75–4.69)), neutrophilia [RR]: 1.024 (1.01–1.03), and glycated haemoglobin A1 (HbA1c) [RR]: 1.01 (1.007–1.01) were associated with mortality. Conclusion The district hospital had a high COVID-19 mortality rate among PLWH. Easy-to-access biomarkers such as CRP, neutrophilia, and HbA1c may play a significant role in informing clinical management to prevent high mortality due to COVID-19 in PLWH at the district-level hospitals.

Strengthening surgical capacity of district hospitals (DHs) in low- and middle-income countries (LMICs) has been recognised globally as key to improving equitable access to surgical care. This commentary considers the benefits and challenges of surgical mentoring in South Africa and applies the lessons learned to other low-resource settings. Surgical team mentoring programmes require consideration of all stakeholders involved, with strong relationships between mentors and mentees, and the possible establishment of roaming district surgical teams. Other components of a surgical ecosystem must also be strengthened including defining a DH surgical package of care, ensuring strong referral systems through a hub and spoke model, and routine monitoring and evaluation. These recommendations have the potential to strengthen surgical capacity in DHs in low-resource settings which is critical to achieving health for all.

Background: Papua New Guinea (PNG) is one of the 14 countries categorised as having a triple burden of tuberculosis (TB), multidrug-resistant TB (MDR TB), and TB-human immunodeficiency virus (HIV) co-infections. TB infection prevention and control (TB-IPC) guidelines were introduced in 2011 by the National Health Department of PNG. This study assesses the implementation of this policy in a sample of district hospitals in two regions of PNG. Methods: The implementation of TB-IPC policy was assessed using a survey method based on the World Health Organization (WHO) IPC assessment framework (IPCAF) to implement the WHO's IPC core components. The study included facility assessment at ten district hospitals and validation observations of TB-IPC practices. Results: Overall, implementation of IPC and TB-IPC guidelines was inadequate in participating facilities. Though 80% of facilities had an IPC program, many needed more clearly defined IPC objectives, budget allocation, and yearly work plans. In addition, they did not include senior facility managers in the IPC committee. 80% (n = 8 of 10) of hospitals had no IPC training and education; 90% had no IPC committee to support the IPC team; 70% had no surveillance protocols to monitor infections, and only 20% used multimodal strategies for IPC activities. Similarly, 70% of facilities had a TB-IPC program without a proper budget and did not include facility managers in the TB-IPC team; 80% indicated that patient flow poses a risk of TB transmission; 70% had poor ventilation systems; 90% had inadequate isolation rooms; and though 80% have personal protective equipment available, frequent shortages were reported. Conclusions: The WHO-recommended TB-IPC policy is not effectively implemented in most of the participating district hospitals. Improvements in implementing and disseminating TB-IPC guidelines, monitoring TB-IPC practices, and systematic healthcare worker training are essential to improve TB-IPC guidelines' operationalisation in health settings to reduce TB prevalence in PNG. [ABSTRACT FROM AUTHOR]

Background: Neck pain is one of the most common and prevalent health problems which may interrupt an individual’s well-being and productivity, making it a serious public health issue even if the consequences aren’t severe. It is a topic of keen interest among health professionals/practitioners, executives and policy makers in the health sector. Methodology: A was cross sectional survey was conducted over a time period of six months for determining the commonly used treatment approaches by the physical therapists of KP for neck pain For data collection census was performed, giving us the total sample of 120 which included all the physical therapists practicing in tertiary care and DHQ hospitals of KP. For data collection, a self-administered questionnaire from a previously published study was utilized. Frequency distribution was demonstrated with the help of percentages and counts while for comparing categorical variables, Chi-square test was utilized. To indicate Statistical significance, P value of

Background Access to surgical care is poor in Tanzania. The country is at the implementation stage of its first National Surgical, Obstetric, and Anesthesia Plan (NSOAP; 2018-2025) aiming to scale up surgery. This study aimed to calculate the costs of providing surgical care at the district and regional hospitals.Methods Two district hospitals (DHs) and the regional referral hospital (RH) in Arusha region were selected. All the staff, buildings, equipment, and medical and non-medical supplies deployed in running the hospitals over a 12 month period were identified and quantified from interviews and hospital records. Using a combination of step-down costing (SDC) and activity-based costing (ABC), all costs attributed to surgeries were established and then distributed over the individual types of surgeries. These costs were delineated into pre-operative, intra-operative, and post-operative components. ResultsThe total annual costs of running the clinical cost centres ranged from $567k at Oltrumet DH to $3453k at Mt Meru RH. The total costs of surgeries ranged from $79k to $813k; amounting to 12%-22% of the total costs of running the hospitals. At least 70% of the costs were salaries. Unit costs and relative shares of capital costs were generally higher at the DHs. Two-thirds of all the procedures incurred at least 60% of their costs in the theatre. Open reduction and internal fixation (ORIF) performed at the regional hospital was cheaper ($618) than surgical debridement (plus conservative treatment) due to prolonged post-operative inpatient care associated with the latter ($1177), but was performed infrequently due mostly to unavailability of implants.Conclusion Lower unit costs and shares of capital costs at the RH reflect an advantage of economies of scale and scope at the RH, and a possible underutilization of capacity at the DHs. Greater efficiencies make a case for concentration and scale-up of surgical services at the RHs, but there is a stronger case for scaling up district-level surgeries, not only for equitable access to services, but also to drive down unit costs there, and free up RH resources for more complex cases such as ORIF.

BackgroundScaling up surgery at district hospitals (DHs) is the critical challenge if the Tanzanian national Surgical, Obstetric, and Anesthesia Plan (NSOAP) objectives are to be achieved. Our study aims to address this challenge by taking a dynamic view of surgical scale-up at the district level using a participatory research approach. MethodsA group model building (GMB) workshop was held with 18 professionals from three hospitals in the Arusha region. They built a graphical representation of the local system of surgical services delivery through a facilitated discussion that employed the nominal group technique. This resulted in a causal loop diagram (CLD) from which the participants identified the requirements for scaling-up surgery and the stakeholders who could satisfy these. After the GMB sessions, we identified clusters of related variables using inductive thematic analysis and the main feedback loops driving the model. ResultsThe CLD consists of 57 variables. These include the 48 variables that were obtained through the nominal group technique and those that participants added later. We identified 6 themes: patient benefits, financing of surgery, cost sharing, staff motivation, communication, and effects on referral hospital. There are 5 self-reinforcing feedback loops: training, learning, meeting demand, revenues, and willingness to work in a good hospital. There are four self-correcting feedback loops or ‘resistors to change:’ recurrent costs, income lost, staff stress, and brain drain. ConclusionThis study provides a systems view on the scaling up of surgery from a district level perspective. Its results enable a critical appraisal of the feasibility of implementing the NSOAP. Our results suggest that policy-makers should be wary of ‘quick fixes’ that have short term gains only. Long term policy that considers the complex dynamics of surgical systems and that allows for periodic evaluation and adaption is needed to scale up surgery in a sustainable manner.

Background: Globally, diabetes mellitus (DM) remains one of the leading causes of mortality, with approximately 2 million deaths in 2019, the condition also contributes significantly to adverse health conditions and costs. The study aimed to describe the quality of care (QOC) rendered to patients with type 2 DM (T2DM) seeking care at Wentworth Hospital (WWH), a district hospital in KwaZulu-Natal province, South Africa. Methods: A descriptive cross-sectional design was used, and all patients living with T2DM on treatment who had accessed care for at least 1 year were included. Data were collected through structured exit interviews, and their clinical data were extracted from their medical records. Their knowledge, attitudes and practices were assessed using a 5-point Likert scale. Results: The mean age (standard deviation [s.d.]) was 59 (13.0) years and most (65.3%) were female, of African (30.0%) and Indian (38.6%) descent, with two-thirds (69.4%) obtaining a secondary school education. Their mean glycated haemoglobin (HbA1c) (s.d.) was 8.6 (2.4%). Over 82% had one or more comorbidity, while 30% had at least one DM-related complication. Generally, participants were pleased with the care received, but their knowledge and practices related to their T2DM was suboptimal. Conclusion: This study indicates that the QOC was suboptimal due to poor efficacy indicators, poor knowledge and lack of adequate lifestyle measures, despite the frequency of medical practitioner reviews. Contributions: This study identified gaps in QOC and will aid South African public sector policy-makers in devising quality improvement initiatives.

Background: South Africa experienced high mortality during the COVID-19 pandemic. Resources were limited, particularly at the district hospital (DH) level. Overwhelmed healthcare facilities and a lack of research at a primary care level made the management of patients with COVID-19 challenging. The objective of this study was to describe the in-hospital mortality trends among individuals with COVID-19 at a DH in South Africa. Methods: Retrospective observational analysis of all adults who demised in hospital from COVID-19 between 01 March 2020 and 31 August 2021 at a DH in South Africa. Variables analysed included: background history, clinical presentation, investigations and management. Results: Of the 328 participants who demised in hospital, 60.1% were female, 66.5% were older than 60 and 59.6% were of black African descent. Hypertension and diabetes mellitus were the most common comorbidities (61.3% and 47.6%, respectively). The most common symptoms were dyspnoea (83.8%) and cough (70.1%). ‘Ground-glass’ features on admission chest X-rays were visible in 90.0% of participants, and 82.8% had arterial oxygen saturations less than 95% on admission. Renal impairment was the most common complication present on admission (63.7%). The median duration of admission before death was four days (interquartile range [IQR]: 1.5–8). The overall crude fatality rate was 15.3%, with the highest crude fatality rate found in wave two (33.0%). Conclusion: Older participants with uncontrolled comorbidities were most likely to demise from COVID-19. Wave two (characterised by the ‘Beta’ variant) had the highest mortality rate. Contribution: This study provides insight into the risk factors associated with death in a resource-constrained environment.

IntroductionPaediatric surgical care is a significant challenge in Sub-Saharan Africa (SSA), where 42% of the population are children. Building paediatric surgical capacity to meet SSA country needs is a priority. This study aimed to assess district hospital paediatric surgical capacity in three countries: Malawi, Tanzania and Zambia (MTZ).MethodsData from 67 district-level hospitals in MTZ were collected using a PediPIPES survey tool. Its five components are procedures, personnel, infrastructure, equipment, and supplies. A PediPIPES Index was calculated for each country, and a two-tailed analysis of variance test was used to explore cross-country comparisons.ResultsSimilar paediatric surgical capacity index scores and shortages were observed across countries, greater in Malawi and less in Tanzania. Almost all hospitals reported the capacity to perform common minor surgical procedures and less complex resuscitation interventions. Capacity to undertake common abdominal, orthopaedic and urogenital procedures varied—more often reported in Malawi and less often in Tanzania. There were no paediatric or general surgeons or anaesthesiologists at district hospitals. General medical officers with some training to do surgery on children were present (more often in Zambia). Paediatric surgical equipment and supplies were poor in all three countries. Malawi district hospitals had the poorest supply of electricity and water.ConclusionsWith no specialists in district hospitals in MTZ, access to safe paediatric surgery is compromised, aggravated by shortages of infrastructure, equipment and supplies. Significant investments are required to address these shortfalls. SSA countries need to define what procedures are appropriate to national, referral and district hospital levels and ensure that an appropriate paediatric surgical workforce is in place at district hospitals, trained and supervised to undertake these essential surgical procedures so as to meet population needs.

Background: The coronavirus disease 2019 (COVID-19) pandemic continues to evolve. Globally, COVID-19 continues to strain even the most resilient healthcare systems, with Omicron being the latest variant. We made a thorough search for literature describing the effects of the COVID-19 in a high human immunodeficiency virus (HIV)/tuberculosis (TB) burden district-level hospital setting. We found scanty literature. Methods: A retrospective observational study was conducted at Khayelitsha District Hospital in Cape Town, South Africa (SA) over the period March 2020–December 2021. We included confirmed COVID-19 cases with HIV infection aged from 18 years and above. Analysis was performed to identify predictors of mortality or hospital discharge among people living with HIV (PLWH). Predictors investigated include CD4 count, antiretroviral therapy (ART), TB, non-communicable diseases, haematological, and biochemical parameters. Findings: This cohort of PLWH with SARS-CoV-2 infection had a median (IQR) age of 46 (37–54) years, male sex distribution of 29.1%, and a median (IQR) CD4 count of 267 (141–457) cells/mm3. Of 255 patients, 195 (76%) patients were discharged, 60 (24%) patients died. One hundred and sixty-nine patients (88%) were on ART with 73(28%) patients having acquired immunodeficiency syndrome (AIDS). After multivariable analysis, smoking (risk ratio [RR]: 2.86 (1.75–4.69)), neutrophilia [RR]: 1.024 (1.01–1.03), and glycated haemoglobin A1 (HbA1c) [RR]: 1.01 (1.007–1.01) were associated with mortality. Conclusion: The district hospital had a high COVID-19 mortality rate among PLWH. Easy-to-access biomarkers such as CRP, neutrophilia, and HbA1c may play a significant role in informing clinical management to prevent high mortality due to COVID-19 in PLWH at the district-level hospitals. [ABSTRACT FROM AUTHOR]

Background: A major disparity exists in access to specialised healthcare between rural and urban areas. Specialist outreach programmes are one of the ways in which rural specialist healthcare inequality is being addressed. A number of rural district hospitals (RDH) employ local, private specialists (LPS) to supplement public specialist outreach. Limited research exists on private specialist outreach and support (PSOS) in sub-Saharan Africa or South Africa. Methods: This was a descriptive, exploratory, qualitative study using thematic analysis of semi-structured interviews. Non-probability, purposive sampling was used to obtain a sample size of 16 participants. The audio recordings were transcribed verbatim and analysed with the framework method and ATLAS.ti version 8© software. Results: Four major themes emerged, namely roles of LPS, effects, sustainability and feasibility of PSOS. Overall PSOS was considered sustainable, feasible and had positive effects in and beyond the sub-districts. The value of PSOS was supported by improved access and timeliness of services, improved competency of RDH medical practitioners, improved coordination, comprehensiveness and continuity of care. Private specialist outreach and support was, however, associated with increased burden on the RDH resources and required a basic level of RDH infrastructure to function effectively. Conclusion: The perceived contribution of private specialist outreach services was positive overall. Implementation in RDHs is feasible, but should involve consideration of factors in the hospital, town, sub-district and district prior to implementation. Contribution: This paper provides evidence that private specialist outreach and support services are feasible in the state health sector, provided that certain considerations are taken into account.

Impressive progress has been made in global surgery in the past 10 years, and now serious and evidence-based national strategies are being developed for scaling-up surgical services in sub-Saharan Africa. Key to achieving this goal requires developing a realistic country-based estimate of burden of surgical disease, developing an accurate estimate of existing need, developing methods, rigorously planning and implementing the plan, and scaling-up essential surgical services at the national level.

Background: Coronavirus disease 2019 (COVID-19) is associated with an increased prevalence and mortality from diabetic ketoacidosis (DKA) globally. With limited access to specialised care, most patients with DKA in South Africa are managed at district hospital level. This study describes the profile of patients admitted to a district hospital in South Africa with DKA and COVID-19 and examines associated risk factors encountered. Methods: This was a case series of all patients presenting to a district hospital with DKA and COVID-19 infection between July 2020 and July 2021. Data extracted included patients' demographic profiles, biochemical results, comorbidities and clinical outcomes. Results: The median age of the 10 patients admitted during the study period was 39 years old (±12), six of whom were male. The hemoglobin A1c (HbA1c) values on admission ranged from 9.7 to 13.8. Five of the patients had pre-existing type 2 diabetes mellitus (DM). Four of the known DM patients were on metformin only, and one was on biphasic insulin. Three patients had other pre- existing comorbidities, two patients with hypertension and one with human immunodeficiency virus (HIV). Three patients demised, two of whom were hypoxic on admission. Conclusion: Diabetic ketoacidosis appears more commonly in COVID-19 infected patients with type 2 DM and at a young age. Suboptimal glycaemic control was associated with DKA, and hypoxia was a strong predictor for mortality. Treatment inertia was evident in the known DM group, who were on monotherapy despite persistent hyperglycaemia. Greater vigilance is required to detect ketosis in type 2 DM and intensify therapy to improve glycaemic control. [ABSTRACT FROM AUTHOR]

The most recent big reform of the Polish health system took place in 2017 and introduced a basic hospital service provision system. Hospitals were able to be included in the network and receive flat-rate financing from the National Health Fund. The current paper aims to assess how the relative situation of hospitals changed between 2015 and 2018. This study is based on multicriteria rankings which take into account the values of profit/loss on sales, the contract with the NHF, the income from health services outside the NHF, the income from rental and lease, the employment of doctors, the employment of nurses, liabilities, operating costs, and interns and residents per hospital bed. The similarity of rankings constructed using different methods is shown. Based on the results of the Chi-squared test, it can be concluded that the inclusion in the network does not affect whether the relative situation of a hospital between 2015 and 2018 improved or not. In the regression analysis, the dummy variable for level 1 hospital was negatively related to the median rank; however, this impact was not statistically significant. [ABSTRACT FROM AUTHOR]

Strengthening surgical capacity of district hospitals (DHs) in low- and middle-income countries (LMICs) has been recognised globally as key to improving equitable access to surgical care. This commentary considers the benefits and challenges of surgical mentoring in South Africa and applies the lessons learned to other low-resource settings. Surgical team mentoring programmes require consideration of all stakeholders involved, with strong relationships between mentors and mentees, and the possible establishment of roaming district surgical teams. Other components of a surgical ecosystem must also be strengthened including defining a DH surgical package of care, ensuring strong referral systems through a hub and spoke model, and routine monitoring and evaluation. These recommendations have the potential to strengthen surgical capacity in DHs in low-resource settings which is critical to achieving health for all. [ABSTRACT FROM AUTHOR]

Background/aims: Paediatric surgical care is a critical component of child health and basic universal health coverage and therefore should be included in comprehensive evaluations of surgical capacity. This study adapted and validated the Children's Surgical Assessment Tool (CSAT), a tool developed for district and tertiary hospitals in Nigeria to evaluate hospital infrastructure, workforce, service delivery, financing, and training capacity for paediatric surgery, for use in district hospitals in Rwanda., Methods: We used a three-round modified Delphi process to adapt the CSAT to the Rwandan context. An expert panel of surgeons, anaesthesiologists, paediatricians, and health systems strengthening experts were invited to participate based on their experience with paediatric surgical or anaesthetic care at district hospitals or with health systems strengthening in the Rwandan context. We used the Content Validity Index to validate the final tool., Results: The adapted tool had a final score of 0.84 on the Content Validity Index, indicating a high level of agreement among the expert panel. The final tool comprised 171 items across five domains: facility characteristics, service delivery, workforce, financing, and training/research., Conclusion: The adapted CSAT is appropriate for use in district hospitals in Rwanda to evaluate the capacity for paediatric surgery. This study provides a framework for adapting and validating a comprehensive paediatric surgical assessment tool to local contexts in LMICs and used in similar settings in sub-Saharan Africa.

Aim: This study aimed to understand themedication usage among different hospitals in Taiwan. Materials & methods: The NHI claims database consisting of claims prescription drugs in Taiwan was used to determine drug prescriptions in different hospitals. Results: In the medical center, L01X showed the highest drug expenditure and the drug prescription pattern in regional hospitals was similar to that in the medical center. The highest drug expenditure in the district hospital and clinics was A10B. Conclusion: Our analysis suggests that the annual pharmaceutical expenditures from 2016 to 2018 were increasing over time in all hospitals. The generic drug usage in medical centers/regional hospitals was lower than district hospitals/clinics.

Objectives: To investigate patient satisfaction regarding healthcare services at a district hospital. The research question was: what is the level of patient satisfaction regarding service delivery? Design: An observational cross-sectional descriptive study conducted in September 2019. Settings: A district hospital in Botswana serving a population of 90 000. Outpatients from the Eye clinic, Casualty and Outpatient Department, Sexual Reproductive Health clinic and Infectious Diseases Control Centre were selected for the study Participants: 240 stable outpatients over 17 years selected through consecutive sampling participated voluntarily after giving informed consent. Main outcome measures: The level of satisfaction was measured using 19 questions on five-point Likert scales ranging from strongly disagree 1, disagree 2, unsure 3, agree 4 to strongly agree 5. A binary outcome was created into satisfied and unsatisfied using the mean score as the cut-off point. Age, gender, employment, education and departments were independent variables. Results: 65% (95% CI: 58-71%) were satisfied but unsatisfied with: doctor's politeness (66.9%; 95% CI: 60-73%), explaining (67.8%; 95% CI: 61-73%), privacy (65.6%; 95% CI: 59-72%), skills (67.4%; 95% CI: 61-73%), confidence (67.4% 95% CI: 61-73%), compassion (66.5%; 95% CI: 60-72%) and waiting time (49.2%; 95% CI: 42-57%). Department visited predicted satisfaction (p=0.002); those from the Eye clinic and Sexual Reproductive Health clinic were satisfied compared to others. Conclusion: Satisfaction was generally high but lower regarding specified services and departments visited. There is a need for targeted interventions. Studies are needed to explore reasons for lower satisfaction in Casualty, Outpatient Department and Infectious Diseases Control Centre. [ABSTRACT FROM AUTHOR]

Background: Since access to essential surgical care (ESC) in rural Sarawak, Malaysia, remains subpar, this study aimed to identify pitfalls in its ESC delivery and possible solutions to improve it. Methods: This cross‐sectional study was undertaken in the Sarawak General Hospital between January 2019 and December 2019. It assessed the caseload of five essential surgical procedures referred from nearby district hospitals. It analysed the number of patients stranded in the accident and emergency department, their waiting time for ward transfer and the duration between admission day and timing of surgery for patients with appendicitis. Results: There were 259 referrals for one of the five essential surgical procedures. The baseline characteristics between the referred and the local cohorts of patients for the designated procedures were comparable in terms of gender (P = 0.486), body mass index (P = 0.598) and ASA score (P = 0.284), with the exceptions being that the referred cohorts were older (43.2 vs. 39.7, P = 0.008) and with different racial composition (p < 0.001). The mean number of patients stranded in emergency department was 34.2 ± 4.9 per day and the mean bed waiting time was 21.4 ± 6.3 h. For patients who required appendicectomy, 70.8% of patients had surgery performed within 24 h of admission. Conclusion: The delivery of ESC in Sarawak's district hospitals demands urgent attention for improvement. The action framework proposed outlined six priorities: infrastructure development, service delivery, surgical training, finance, information management and governance. [ABSTRACT FROM AUTHOR]

Background: Acute myocardial infarction (AMI) following ischaemic heart disease (IHD) is associated with increased morbidity and mortality. The condition remains a management challenge in resource-constrained environments. This study analysed the management and outcomes of patients presenting with AMI at a district hospital in KwaZulu-Natal. Methods: A descriptive study that assessed hospital records of all patients diagnosed with AMI over a 2-year period (01 August 2016 to 31 July 2018). Data extracted recorded patient demographics, risk factors, timing of care, therapeutic interventions, follow up with cardiology and mortality of patients. Results: Of the 140 patients who were admitted with AMI, 96 hospital records were analysed. The mean (standard deviation [s.d.]) age of patients was 55.8 (±12.7) years. Smoking (73.5%) and hypertension (63.3%) were the most prevalent risk factors for patients with ST elevation myocardial infarction (STEMI) in contrast to dyslipidaemia (70.2%) and hypertension (68.1%) in patients with non-ST elevation myocardial infarction (NSTEMI). Almost 49.5% of patients arrived at hospital more than 6 h after symptom onset. Three (12.5%) patients received thrombolytic therapy within the recommended 30-min time frame. The mean triage-to-needle time was 183 min -- range (3; 550). Median time to cardiology appointment was 93 days. The in-hospital mortality of 12 deaths considering 140 admissions was 8.6%. Conclusion: In a resource-constrained environment with multiple systemic challenges, in-hospital mortality is comparable to that in private sector conditions in South Africa. This entrenches the role of the family physician. There is need for more coordinated systems of care for AMI between district hospitals and tertiary referral centres. [ABSTRACT FROM AUTHOR]

Background: Previous studies have found that indications for lumbar punctures (LPs) are managed differently, which raises the question of whether all LPs performed are clinically necessary. This study aimed to determine whether unnecessary (clinically not indicated) LPs were being performed at a district hospital in the Free State, South Africa. Method: This was a retrospective descriptive study. A list from the National Health Laboratory Service (NHLS) was used to identify all patients on whom an LP was performed in the adult emergency department of National District Hospital (NDH) in Bloemfontein, from 1 January 2018 to 30 June 2018. Data were captured on a data sheet and included demographic information, clinical signs and symptoms the patients presented with and the cerebrospinal fluid results. Results: A total of 364 patients fit the inclusion criteria. Of these patients, 97 files (26.6%) could not be found, patient gender and LP results could be retrieved from the NHLS barcodes. After reviewing the presenting symptoms and signs captured on the 267 files, the primary researcher considered 150 (56.4%) of the LPs performed to have been carried out unnecessarily. From the total population of 364 patients, 246 (67.6%) of the LP results were normal. Only 118 (32.4%) of the LPs performed showed some form of central nervous system pathology. Of the 150 LPs assessed to have been unnecessarily performed, 124 (84.0%) were normal. Conclusion: This retrospective review indicates that a high percentage of LPs that were clinically not indicated were performed at NDH during the study period. [ABSTRACT FROM AUTHOR]

Background: Access to surgical care is poor in Tanzania. The country is at the implementation stage of its first National Surgical, Obstetric, and Anesthesia Plan (NSOAP; 2018-2025) aiming to scale up surgery. This study aimed to calculate the costs of providing surgical care at the district and regional hospitals. Methods: Two district hospitals (DHs) and the regional referral hospital (RH) in Arusha region were selected. All the staff, buildings, equipment, and medical and non-medical supplies deployed in running the hospitals over a 12 month period were identified and quantified from interviews and hospital records. Using a combination of step-down costing (SDC) and activity-based costing (ABC), all costs attributed to surgeries were established and then distributed over the individual types of surgeries. These costs were delineated into pre-operative, intra-operative, and post-operative components. Results: The total annual costs of running the clinical cost centres ranged from $567k at Oltrumet DH to $3453k at Mt Meru RH. The total costs of surgeries ranged from $79k to $813k; amounting to 12%-22% of the total costs of running the hospitals. At least 70% of the costs were salaries. Unit costs and relative shares of capital costs were generally higher at the DHs. Two-thirds of all the procedures incurred at least 60% of their costs in the theatre. Open reduction and internal fixation (ORIF) performed at the regional hospital was cheaper ($618) than surgical debridement (plus conservative treatment) due to prolonged post-operative inpatient care associated with the latter ($1177), but was performed infrequently due mostly to unavailability of implants. Conclusion: Lower unit costs and shares of capital costs at the RH reflect an advantage of economies of scale and scope at the RH, and a possible underutilization of capacity at the DHs. Greater efficiencies make a case for concentration and scale-up of surgical services at the RHs, but there is a stronger case for scaling up district-level surgeries, not only for equitable access to services, but also to drive down unit costs there, and free up RH resources for more complex cases such as ORIF. [ABSTRACT FROM AUTHOR]

Background: Scaling up surgery at district hospitals (DHs) is the critical challenge if the Tanzanian national Surgical, Obstetric, and Anesthesia Plan (NSOAP) objectives are to be achieved. Our study aims to address this challenge by taking a dynamic view of surgical scale-up at the district level using a participatory research approach. Methods: A group model building (GMB) workshop was held with 18 professionals from three hospitals in the Arusha region. They built a graphical representation of the local system of surgical services delivery through a facilitated discussion that employed the nominal group technique. This resulted in a causal loop diagram (CLD) from which the participants identified the requirements for scaling-up surgery and the stakeholders who could satisfy these. After the GMB sessions, we identified clusters of related variables using inductive thematic analysis and the main feedback loops driving the model. Results: The CLD consists of 57 variables. These include the 48 variables that were obtained through the nominal group technique and those that participants added later. We identified 6 themes: patient benefits, financing of surgery, cost sharing, staff motivation, communication, and effects on referral hospital. There are 5 self-reinforcing feedback loops: training, learning, meeting demand, revenues, and willingness to work in a good hospital. There are four self-correcting feedback loops or ‘resistors to change:’ recurrent costs, income lost, staff stress, and brain drain. Conclusion: This study provides a systems view on the scaling up of surgery from a district level perspective. Its results enable a critical appraisal of the feasibility of implementing the NSOAP. Our results suggest that policy-makers should be wary of ‘quick fixes’ that have short term gains only. Long term policy that considers the complex dynamics of surgical systems and that allows for periodic evaluation and adaption is needed to scale up surgery in a sustainable manner. [ABSTRACT FROM AUTHOR]

Abstract Background An estimated nine out of ten persons in sub-Saharan Africa (SSA) are unable to access timely, safe and affordable surgery. District hospitals (DHs) which are strategically located to provide basic (non-specialist) surgical care for rural populations have in many instances been compromised by resource inadequacies, resulting in unduly frequent patient referrals to specialist hospitals. This study aimed to quantify the financial burdens of surgical ambulance referrals on DHs and explore the coping strategies employed by these facilities in navigating the challenges. Methods We employed a multi-methods descriptive case study approach, across a total of 14 purposively selected DHs; seven, three, and four in Tanzania, Malawi and Zambia, respectively. Three recurrent cost elements were identified: fuel, ambulance maintenance and staff allowances. Qualitative data related to coping mechanisms were obtained through in-depth interviews of hospital managers while quantitative data related to costs of surgical referrals were obtained from existing records (such as referral registers, ward registers, annual financial reports, and other administrative records) and expert estimates. Interview notes were analysed by manual thematic coding while referral statistics and finance data were processed and analysed using Microsoft Office Excel 2016. Results At all but one of the hospitals, respondents reported inadequacies in numbers and functional states of the ambulances: four centres indicated employing non-ambulance vehicles to convey patients occassionally. No statistically significant correlation was found between referral trip distances and total annual numbers of referral trips, but hospital managers reported considering costs in referral practices. For instance, ten of the study hospitals reported combining patients to minimize trip frequencies. The total cost of ambulance use for patient transportation ranged from I$2 k to I$58 k per year. Between 34% and 79% of all patient referrals were surgical, with total costs ranging from I$1 k to I$32 k per year. Conclusion Cost considerations strongly influence referral decisions and practices, indicating a need for increases in budgetary allocations for referral services. High volumes of potentially avoidable surgical referrals provide an economic case – besides equitable access to healthcare – for scaling up surgery capacity at the district level as savings from decreased referrals could be reinvested in referral systems strengthening.

Background: Coronavirus disease 2019 (COVID-19) is associated with an increased prevalence and mortality from diabetic ketoacidosis (DKA) globally. With limited access to specialised care, most patients with DKA in South Africa are managed at district hospital level. This study describes the profile of patients admitted to a district hospital in South Africa with DKA and COVID-19 and examines associated risk factors encountered. Methods: This was a case series of all patients presenting to a district hospital with DKA and COVID-19 infection between July 2020 and July 2021. Data extracted included patients’ demographic profiles, biochemical results, comorbidities and clinical outcomes. Results: The median age of the 10 patients admitted during the study period was 39 years old (±12), six of whom were male. The hemoglobin A1c (HbA1c) values on admission ranged from 9.7 to 13.8. Five of the patients had pre-existing type 2 diabetes mellitus (DM). Four of the known DM patients were on metformin only, and one was on biphasic insulin. Three patients had other pre-existing comorbidities, two patients with hypertension and one with human immunodeficiency virus (HIV). Three patients demised, two of whom were hypoxic on admission. Conclusion: Diabetic ketoacidosis appears more commonly in COVID-19 infected patients with type 2 DM and at a young age. Suboptimal glycaemic control was associated with DKA, and hypoxia was a strong predictor for mortality. Treatment inertia was evident in the known DM group, who were on monotherapy despite persistent hyperglycaemia. Greater vigilance is required to detect ketosis in type 2 DM and intensify therapy to improve glycaemic control.

Background: Previous studies have found that indications for lumbar punctures (LPs) are managed differently, which raises the question of whether all LPs performed are clinically necessary. This study aimed to determine whether unnecessary (clinically not indicated) LPs were being performed at a district hospital in the Free State, South Africa. Method: This was a retrospective descriptive study. A list from the National Health Laboratory Service (NHLS) was used to identify all patients on whom an LP was performed in the adult emergency department of National District Hospital (NDH) in Bloemfontein, from 1 January 2018 to 30 June 2018. Data were captured on a data sheet and included demographic information, clinical signs and symptoms the patients presented with and the cerebrospinal fluid results. Results: A total of 364 patients fit the inclusion criteria. Of these patients, 97 files (26.6%) could not be found, patient gender and LP results could be retrieved from the NHLS barcodes. After reviewing the presenting symptoms and signs captured on the 267 files, the primary researcher considered 150 (56.4%) of the LPs performed to have been carried out unnecessarily. From the total population of 364 patients, 246 (67.6%) of the LP results were normal. Only 118 (32.4%) of the LPs performed showed some form of central nervous system pathology. Of the 150 LPs assessed to have been unnecessarily performed, 124 (84.0%) were normal. Conclusion: This retrospective review indicates that a high percentage of LPs that were clinically not indicated were performed at NDH during the study period.

Abstract Background Appendicitis is the most common cause of acute abdomen. Although emergency surgery used to be the standard treatment for both simple and complex appendicitis, there are now options for interval surgery, laparoscopic surgery, and even non-surgical treatment. In this study, we aimed to establish better treatment strategies for pediatric acute appendicitis and to find out whether minimally invasive treatment is superior to the traditional open approach. We retrospectively reviewed the cases of acute appendicitis treated in our hospital during the period from 2013 to 2018. The patients who underwent appendectomy were divided into four groups. Group 1 underwent early appendectomy with open approach, group2 underwent interval appendectomy with open approach, group 3 underwent early appendectomy with laparoscopic approach, and group 4 underwent interval appendectomy with laparoscopic approach. In addition to the above groups, the non-surgical treatment group was also studied. Clinical presentation, laboratory findings, imaging results, operative time, morbidity, and length of hospital stay were reviewed. Results One hundred six children’s records were reviewed. Thirty-five of them were selected for non-surgery as they were cases with no fecal stone and first onset appendicitis, and 15 of these 35 patients (42.9%) relapsed after antibiotic treatment. As for the appendix diameter, the relapse group was significantly larger than the non-relapse group (p=0.007). In cases of surgery, group 4 had significantly less intraoperative blood loss than group 1 (p

Aim: Trauma is a leading cause of morbidity and mortality in the first four decades of life. Thoracoabdominal gunshot wounds carry a significant risk of mortality. This risk of death is reduced if patients are managed in dedicated units. This study examines the outcome of these patients managed in a district level hospital. Method: In this retrospective review, patients with thoracoabdominal gunshot wounds were identified from operating room registry for the period of January 2015 to December 2018. Data was collected retrospectively from folders and analysed for the primary outcome of mortality. Results: Sixty-eight thoracoabdominal gunshot wounds were managed operatively over the period described. Only six patients were female. The median age was 29.5 years. Fourteen patients required postoperative transfer to a level 1 trauma unit. Thirteen patients died, nine at the district hospital and four at the level 1 unit. Significant differences in organ injuries were noted in the patients that died compared to the survivors. Discussion: The in-hospital mortality rate of patients managed at the district hospital was 13.2% which is comparable to international rates of 12–18%. However, the subset of patients that required postoperative transfer to a level 1 trauma unit had a high mortality rate of 28.6%. The DH is committed to managing unstable and unresponsive patients once they present. Improved mortality rates will only occur with better prehospital transport policies and by equipping the DH to manage these patients postoperatively. Conclusion: Management of these patients can be successful at a district hospital. However, significant obstacles exist to their optimal care, as demonstrated by the high mortality patients requiring postoperative transfer.