title: Surgical and anaesthetic capacity of hospitals in Malawi: key insights.
abstract: BACKGROUND
  Surgery is increasingly recognized as an important driver for health systems strengthening, especially in developing countries. To facilitate quality improvement initiatives, baseline knowledge of capacity for surgical, anaesthetic, emergency and obstetric care is critical. In partnership with the Malawi Ministry of Health, we quantified government hospitals' surgical capacity through workforce, infrastructure and health service delivery components.
  
  
  METHODS
  From November 2012 to January 2013, we surveyed district and mission hospital administrators and clinical staff onsite using a modified version of the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) tool from Surgeons OverSeas. We calculated percentage of facilities demonstrating adequacy of the assessed components, surgical case rates, operating theatre density and surgical workforce density.
  
  
  RESULTS
  Twenty-seven government hospitals were surveyed (90% of the district hospitals, all central hospitals). Of the surgical workforce surveyed (n = 370), 92.7% were non-surgeons and 77% were clinical officers (COs). Of the 109 anaesthesia providers, 95.4% were non-physician anaesthetists (anaesthesia COs or ACOs). Non-surgeons and ACOs were the only providers of surgical services and anaesthetic services in 85% and 88.9% of hospitals, respectively. No specialists served the district hospitals. All of the hospitals experienced periods without external electricity. Most did not always have a functioning generator (78.3% district, 25% central) or running water (82.6%, 50%). None of the district hospitals had an Intensive Care Unit (ICU). Cricothyroidotomy, bowel resection and cholecystectomy were not done in over two-thirds of hospitals. Every hospital provided general anaesthesia but some did not always have a functioning anaesthesia machine (52.2%, 50%). Surgical rate, operating theatre density and surgical workforce density per 100 000 population was 289.48-747.38 procedures, 0.98 and 5.41 and 3.68 surgical providers, respectively.
  
  
  CONCLUSIONS
  COs form the backbone of Malawi's surgical and anaesthetic workforce and should be supported with improvements in infrastructure as well as training and mentorship by specialist surgeons and anaesthetists.
authors.affiliation: International Collaboration for Essential Surgery (ICES), New York, NY, USA, University of California, Berkeley School of Public Health, Berkeley, CA, USA, Gradian Health Systems, New York, NY, USA, Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi, Faculty of Medicine, Flinders University, Adelaide, Australia and School of Anaesthesia, Queen Elizabeth Central Hospital, Blantyre, Malawi International Collaboration for Essential Surgery (ICES), New York, NY, USA, University of California, Berkeley School of Public Health, Berkeley, CA, USA, Gradian Health Systems, New York, NY, USA, Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi, Faculty of Medicine, Flinders University, Adelaide, Australia and School of Anaesthesia, Queen Elizabeth Central Hospital, Blantyre, Malawi jaymie.henry@gmail.com.
authors.forename: Jaymie Ang
authors.initials: JA
authors.lastname: Henry
authors.affiliation: International Collaboration for Essential Surgery (ICES), New York, NY, USA, University of California, Berkeley School of Public Health, Berkeley, CA, USA, Gradian Health Systems, New York, NY, USA, Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi, Faculty of Medicine, Flinders University, Adelaide, Australia and School of Anaesthesia, Queen Elizabeth Central Hospital, Blantyre, Malawi.
authors.forename: Erica
authors.initials: E
authors.lastname: Frenkel
authors.affiliation: International Collaboration for Essential Surgery (ICES), New York, NY, USA, University of California, Berkeley School of Public Health, Berkeley, CA, USA, Gradian Health Systems, New York, NY, USA, Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi, Faculty of Medicine, Flinders University, Adelaide, Australia and School of Anaesthesia, Queen Elizabeth Central Hospital, Blantyre, Malawi International Collaboration for Essential Surgery (ICES), New York, NY, USA, University of California, Berkeley School of Public Health, Berkeley, CA, USA, Gradian Health Systems, New York, NY, USA, Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi, Faculty of Medicine, Flinders University, Adelaide, Australia and School of Anaesthesia, Queen Elizabeth Central Hospital, Blantyre, Malawi.
authors.forename: Eric
authors.initials: E
authors.lastname: Borgstein
authors.affiliation: International Collaboration for Essential Surgery (ICES), New York, NY, USA, University of California, Berkeley School of Public Health, Berkeley, CA, USA, Gradian Health Systems, New York, NY, USA, Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi, Faculty of Medicine, Flinders University, Adelaide, Australia and School of Anaesthesia, Queen Elizabeth Central Hospital, Blantyre, Malawi International Collaboration for Essential Surgery (ICES), New York, NY, USA, University of California, Berkeley School of Public Health, Berkeley, CA, USA, Gradian Health Systems, New York, NY, USA, Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi, Faculty of Medicine, Flinders University, Adelaide, Australia and School of Anaesthesia, Queen Elizabeth Central Hospital, Blantyre, Malawi International Collaboration for Essential Surgery (ICES), New York, NY, USA, University of California, Berkeley School of Public Health, Berkeley, CA, USA, Gradian Health Systems, New York, NY, USA, Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi, Faculty of Medicine, Flinders University, Adelaide, Australia and School of Anaesthesia, Queen Elizabeth Central Hospital, Blantyre, Malawi.
authors.forename: Nyengo
authors.initials: N
authors.lastname: Mkandawire
authors.affiliation: International Collaboration for Essential Surgery (ICES), New York, NY, USA, University of California, Berkeley School of Public Health, Berkeley, CA, USA, Gradian Health Systems, New York, NY, USA, Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi, Faculty of Medicine, Flinders University, Adelaide, Australia and School of Anaesthesia, Queen Elizabeth Central Hospital, Blantyre, Malawi.
authors.forename: Cyril
authors.initials: C
authors.lastname: Goddia
mesh_terms: D000777:Anesthetics / Q000600:supply & distribution*; D003695:Delivery of Health Care / Q000706:statistics & numerical data; D006295:Health Resources / Q000600:supply & distribution*; D006761:Hospitals / Q000706:statistics & numerical data*; D008295:Malawi; D066231:Surgeons / Q000600:supply & distribution*
chemical_list: D000777:Anesthetics
keywords: Anaesthesia; Malawi; clinical officers; global health; global surgery; surgery; surgical burden; surgical capacity; surgical care