Dataset Information

Barriers to increase surgical productivity in Sierra Leone: a qualitative study.

ABSTRACT:

Objective

To explore factors influencing surgical provider productivity and identify barriers against and opportunities to increase individual surgical productivity in Sierra Leone, in order to explain the observed increase in unmet surgical need from 92.2% to 92.7% and the decrease in surgical productivity to 1.7 surgical procedures per provider per week between 2012 and 2017.

Design and methods

This explanatory qualitative study consisted of in-depth interviews about factors influencing surgical productivity in Sierra Leone. Interviews were analysed with a thematic network analysis and used to develop a conceptual framework.

Participants and setting

21 surgical providers and hospital managers working in 12 public and private non-profit hospitals in all regions in Sierra Leone.

Results

Surgical providers in Sierra Leone experience a broad range of factors within and outside the health system that influence their productivity. The main barriers involve both patient and facility financial constraints, lack of equipment and supplies, weak regulation of providers and facilities and a small surgical workforce, which experiences a lack of recognition. Initiation of a Free Health Care Initiative for obstetric and paediatric care, collaborations with partners or non-governmental organisations, and increased training opportunities for highly motivated surgical providers are identified as opportunities to increase productivity.

Discussion

Broader nationwide health system strengthening is required to facilitate an increase in surgical productivity and meet surgical needs in Sierra Leone. Development of a national strategy for surgery, obstetrics and anaesthesia, including methods to reduce financial barriers for patients, improve supply-mechanisms and expand training opportunities for new and established surgical providers can increase surgical capacity. Establishment of legal frameworks and appropriate remuneration are crucial for sustainability and retention of surgical health workers.

SUBMITTER: Bakker J

PROVIDER: S-EPMC8693091 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:BackgroundLittle is known about the social and political factors that influence priority setting for different health services in low- and middle-income countries (LMICs), yet these factors are integral to understanding how national health agendas are established. We investigated factors that facilitate or prevent surgical care from being prioritized in LMICs.Methods and findingsWe undertook country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. We conducted 74 semi-structured interviews with stakeholders involved in health agenda setting and surgical care in these countries. Interviews were triangulated with published academic literature, country reports, national health plans, and policies. Data were analyzed using a conceptual framework based on four components (actor power, ideas, political contexts, issue characteristics) to assess national factors influencing priority for surgery. Political priority for surgical care in the three countries varies. Priority was highest in Papua New Guinea, where surgical care is firmly embedded within national health plans and receives significant domestic and international resources, and much lower in Uganda and Sierra Leone. Factors influencing whether surgical care was prioritized were the degree of sustained and effective domestic advocacy by the local surgical community, the national political and economic environment in which health policy setting occurs, and the influence of international actors, particularly donors, on national agenda setting. The results from Papua New Guinea show that a strong surgical community can generate priority from the ground up, even where other factors are unfavorable.ConclusionsNational health agenda setting is a complex social and political process. To embed surgical care within national health policy, sustained advocacy efforts, effective framing of the problem and solutions, and country-specific data are required. Political, technical, and financial support from regional and international partners is also important.

Project description:BackgroundSierra Leone, a low-income and post-conflict country, has an extreme shortage of qualified medical doctors. Given the complex challenges facing medical education in this country and the need for context-specific knowledge, the aim of this paper is to explore the undergraduate medical education experience in Sierra Leone through qualitative interviews with recent graduates.MethodsIn-depth interviews were conducted with purposively sampled junior doctors (n = 15) who had graduated from the only medical school in Sierra Leone. Additionally, semi-structured interviews were held with senior teaching staff at the School (n = 7). Interviews were conducted in October 2013. Results were thematically analysed.ResultsThe analytical framework consisted of four themes. Medical school experiences (Theme 1) were described as 'stressful and tedious' but also 'interesting and enjoyable'. Various constraints were experienced linked to the Medical school capacity (Theme 2), including human (limited number of teachers, teaching skills), organisational (departmental differences, curriculum related challenges), physical (lacking teaching facilities on campus, transportation problems) and financial capacity (inadequate remunerations for teachers, most students receive scholarships). Medical school culture (Theme 3) was by some participants perceived as fearful and unfair. Findings suggest various coping strategies (Theme 4) were used at school ('creatively' hire extra teaching staff, teaching schedule upon availability of staff), staff (juggle multiple roles, teach flexibly), and student levels (comply with 'hidden' rules, negotiate teaching support from less qualified health personnel).ConclusionsThis study has provided an insight into the student perspective on medical education in Sierra Leone. Numerous capacity related concerns were identified; which are unsurprising for an educational institution in a low-income and conflict affected country. While the School, staff and students have found creative ways to deal with these constraints, participants' accounts of stress imply more is needed. For example, findings suggest that: students could be better supported in their self-directed learning, more effort is required to ensure basic needs of students are met (like shelter and food), and the power imbalance between staff and students could be addressed. Also better alignment amongst learning objectives and assessment methods will likely diminish student distress and may, consequently, reduce exam failure and possibly drop-out.

Project description:IntroductionSurgical access is central to universalising health coverage, yet 5 billion people lack timely access to safe surgical services. Surgical need is particularly acute in post conflict settings like Sierra Leone. There is limited understanding of the barriers and opportunities at the service delivery and community levels. Focusing on fractures and wound care which constitute an enormous disease burden in Sierra Leone as a proxy for general surgical need, we examine provider and patient perceived factors impeding or facilitating surgical care in the post-Ebola context of a weakened health system.MethodsAcross Western Area Urban (Freetown), Bo and Tonkolili districts, 60 participants were involved in 38 semistructured interviews and 22 participants in 5 focus group discussions. Respondents included surgical providers, district-level policy-makers, traditional healers and patients. Data were thematically analysed, combining deductive and inductive techniques to generate codes.ResultsInteracting demand-side and supply-side issues affected user access to surgical services. On the demand side, high cost of care at medical facilities combined with the affordability and convenient mode of payment to the traditional health practitioners hindered access to the medical facilities. On the supply side, capacity shortages and staff motivation were challenges at facilities. Problems were compounded by patients' delaying care mainly spurred by sociocultural beliefs in traditional practice and economic factors, thereby impeding early intervention for patients with surgical need. In the absence of formal support services, the onus of first aid and frontline trauma care is borne by lay citizens.ConclusionWithin a resource-constrained context, supply-side strengthening need accompanying by demand-side measures involving community and traditional actors. On the supply side, non-specialists could be effectively utilised in surgical delivery. Existing human resource capacity can be enhanced through better incentives for non-physicians. Traditional provider networks can be deployed for community outreach. Developing a lay responder system for first-aid and front-line support could be a useful mechanism for prompt clinical intervention.

Project description:Strong leadership capabilities are essential for effective health services, yet definitions of leadership remain contested. Despite the acknowledged contextual specificity of leadership styles, most leadership theories draw heavily from Western conceptualizations. This cultural bias may attenuate the effectiveness of programmes intended to transform healthcare practice in Sub-Saharan Africa, where few empirical studies on health leadership have been conducted. This paper examines how effective leadership by doctors was perceived by stakeholders in one particular context, Sierra Leone. Drawing together extensive experience of in-country healthcare provision with a series of in-depth interviews with 27 Sierra Leonean doctors, we extended a grounded-theory approach to come to grips with the reach and relevance of contemporary leadership models in capturing the local experiences and relevance of leadership. We found that participants conceptualized leadership according to established leadership models, such as transformational and relational theories. However, participants also pointed to distinctive challenges attendant to healthcare provision in Sierra Leone that required specific leadership capabilities. Context-specific factors included health system breakdown, politicization in the health sector and lack of accountability, placing importance on skills such as persistence, role modelling and taking initiative. Participants also described pressure to behave in ways they deemed antithetical to their personal and professional values and also necessary in order to continue a career in the public sector. The challenge of navigating such ethical dilemmas was a defining feature of leadership in Sierra Leone. Our research demonstrates that while international leadership models were relevant in this context, there is strong emphasis on contingent or situational leadership theories. We further contribute to policy and practice by informing design of leadership development programmes and the establishment of a more enabling environment for medical leadership by governments and international donors.

Project description:BackgroundSierra Leone is pursuing multiple initiatives to establish in-country postgraduate medical education (PGME), as part of national efforts to strengthen the health workforce. This paper explored the career preferences of junior doctors in Sierra Leone; and the potential benefits and challenges with regards to the development of PGME locally.MethodsJunior doctors (n = 15) who had graduated from the only medical school in Sierra Leone were purposively sampled based on maximum variation (e.g. men/women, years of graduation). In-depth interviews were conducted in October 2013, and digital diaries and two follow-up interviews were used to explore their evolving career aspirations until November 2016. Additionally, 16 semi-structured interviews with key informants were held to gather perspectives on the development of PGME locally. Results were thematically analysed.ResultsAll junior doctors interviewed intended to pursue PGME with the majority wanting primarily a clinical career. Half were interested in also gaining a public health qualification. Major factors influencing career preferences included: prior exposure, practical (anticipated job content), personal considerations (individual interests), financial provision, and contextual (aspirations to help address certain health needs). Majority of doctors considered West Africa but East and South Africa were also location options for clinical PGME. Several preferred to leave the African continent to pursue PGME. Factors influencing decision-making on location were: financial (scholarships), practical (availability of preferred specialty), reputation (positive and negative), and social (children). Key informants viewed the potential benefits of expanding PGME in Sierra Leone as: cost-effectiveness (compared to overseas specialist training), maintaining service delivery during training years, decreasing loss of doctors (some decide not to return after gaining their specialist degree abroad), and enhancing quality control and academic culture of the local medical school. Major perceived challenges were capacity constraints, especially the dearth of specialists required to achieve training programme accreditation.ConclusionsThis study has provided an insight into the career preferences of junior doctors in Sierra Leone. It is timely as there is increasing political and professional momentum to expand PGME locally. Findings may guide those involved in this PGME expansion in terms of how possibly to influence junior doctors in their career decision-making.