Simple, affordable and potentially sustainable: improving paediatric surgical care in Malawi

In Sub-Saharan Africa, where children below 15 years old account for more than half of the total population, 94% of people do not have access to safe and affordable surgery. It is estimated that 85% of children in Africa will require surgical treatment by the age of 15. There are insufficient resources at all levels of care, with no paediatric surgical expertise in rural areas. The lack of paediatric surgical care in this region results in unnecessary disability and mortality from potentially curable conditions. 

In partnership with global medical technology company BD (Becton, Dickinson and Company) the RCSI Institute of Global Surgery has developed a new model aimed at improving access to surgical care for children in Malawi, which is Africa’s most rural country.

KidSURG, launched in 2021, benefits from RCSI’s 15 years of experience in surgical training, education and research in Africa. Since 2011, RCSI researchers have been working with European and African partners to establish sustainable solutions to enable access to safe surgery in district hospitals. These efforts have allowed the team to develop and test a unique approach to surgical capacity building in rural areas.

A critical shortage of surgeons

There are 2.4 million children in Malawi living with a surgically correctable condition. Treatment options are limited because of critical shortages of paediatric surgeons – there are just six available country-wide and they are all located in urban areas – as well as a lack of adequate infrastructure to cater for the surgical needs of children. These shortcomings have resulted in a large unmet need for paediatric surgery in Malawi, inevitably contributing to avoidable mortality and morbidity.

In Malawi district hospitals are the primary point of access for health services and almost all are staffed with non-physician clinician (non-doctor) healthcare providers. These frontline providers are generalists with limited surgical knowledge and skills. They are often, however, the only accessible source and means for rural populations to receive essential surgical care.

In its first year, the KIDSURG model has delivered health-enhancing and life-saving surgical care to rural children across Southern Malawi. It has done this by linking specialists at referral hospitals with surgical teams at district hospitals.

Visiting paediatric surgical specialists from central city hospitals regularly visit four rural hospitals in the country. They train the best available non-doctors on how to stabilise children with life-threatening surgical conditions; and they train them to make clinical decisions that give the children the best chance of survival and recovery. 39 district clinicians have been trained so far and the target is to train 100 by the end of the second year.

To ensure continued support in-between the visits, the KidSURG team has developed a Managed Clinical Network based on mobile phone technology. This allows clinicians participating in the programme to consult on cases via text messages, accompanied by photographs, videos and audio clips.

This approach has expanded the frontline capacity for diagnosis, decision-making and the provision of basic surgical treatment at the district hospital level.

District hospital surgical care has also been integrated with specialist services at a central hospital through streamlined referrals to enable safe and timely transfers of patients that require advanced surgical care.

A sea-change for children in Malawi

The enabling of rapid and evidence-based decision-making at the clinical coalface – where specialist surgeons advise local clinicians in real-time on whether to stabilise and observe, to operate or to refer the child for higher level surgical care – is producing a sea-change in the surgical care of children in Africa’s most rural, and one of its poorest, countries.

Characteristic of the few ground-breaking initiatives in resource-poor countries, the model is simple, affordable, effective and potentially sustainable.

What is truly remarkable is how well this project is being implemented on the ground and the incredibly high level of take-up by rural hospitals. Between June 2021 and April 2022, 388 paediatric surgical cases were referred to a specialist paediatric hospital in Malawi. Virtually all (387) of these cases benefited from a mobile phone consultation before referral. Patient histories were provided for 98% of the cases discussed, and the results of the physical examination were provided for 81%.

96% of referred patients were alive after arrival and treatment at the specialist hospital. Given that some emergency cases, such as a perforated abdominal organ or ruptured uterus, often deteriorate rapidly, the evidence shows the potential positive impact of this novel model.

All photography courtesy of kidSURG/Antonio Jaén Osuna