1. Malamulo Adventist Hospital, PB2, Makwasa, Malawi
Starting a PAACS Surgery Residency Transformed Malamulo Adventist Hospital
Hayton RA, Kamwiyo M, Mabuku S, Steffes BC
Malamulo Adventist Hospital, PB2, Makwasa, Malawi
Objective: To determine the effect of starting a general surgery residency at a rural mission hospital in a Low- and Middle-Income Country (LMIC) low-resource setting.
Setting: A rural church-run hospital in a LMIC, low-resource, Malawi, Africa.
Participants: Malamulo Adventist Hospital, Pan-African Academy of Christian Surgeons, Loma Linda University Health, Seventh-day Adventist Church, Adventist Health International.
Results: The creation and development of surgical residency training at a rural mission hospital transformed the whole hospital and produced progress in patient care and finances throughout the hospital.
Conclusion: Starting and maintaining a surgery residency in a low-resource mission hospital is a benefit, not a drain, to the LMIC rural hospital.
Key Words: global surgery, surgical education, Low- and Middle-Income Countries, mission hospital, sustainability.
Results
Discussion
Malamulo Adventist Hospital experienced rapid and sustained growth and improvement in care through the four years, 2014 – With the enhanced services at the hospital, quality of care improved as shown through decreased length of stays and a drop in inpatient mortality. This is largely due to starting a general surgery residency at the rural mission hospital.   Not all of the improvements can be attributed to, nor directly linked to, the Malamulo-PAACS general surgery residency, but it is the main change in the last 10 years. There was an increase in the numbers of private patients and referrals to the rural mission hospital as the added services and improved outcomes began to raise the name and reputation of the institution. This increase was not seen in the areas of the hospital that are not affected by the surgical department. Due to the increased paying patients, the hospital finances turned a corner and became increasingly stable. The church organization decided to make Malamulo Adventist Hospital’s surgical training program an example and based goals and objectives around supporting the hospital and the program [6]. “The church organization, its operations, and mission will support the PAACS program and open two additional sites in the quinqueneum and expand the specialty training program in Malamulo” [7]. The amount of financial donations to the rural mission hospital increased significantly after the residency program was started. The hospital finances improved dramatically after The growth was pronounced in areas of the hospital that are directly affected by the growing surgical services, while areas of the hospital that are not at all effected by the surgical training program, were stagnant or decreased during the same time period. The financial stability and sustainability of Malamulo was enriched.
Improved patient care is evident with a trend of decreasing hospital mortality rate, maternal mortality rate, and patient length of stay. The arrow shows the beginning of PAACS. Many factors have caused this trend.: attempts to comply with accreditation requirements the PAACS program has driven the improvement of the ICU, nursing to patient ratios laboratory tests available, radiology capabilities and the establishment of Morbidity and Mortality conferences and quality improvement initiatives. The trend is also a result of the increased number of doctors at the hospital with PAACS residents and specialists as well as improved academic rigor in patient care.
Introduction
According to the World Health Organization, there are more deaths due to lack of access to safe surgery than HIV, TB, and Malaria combined [1]. Ninety-three percent of the people in Sub-Saharan Africa do not have access to safe, affordable surgical and anesthesia care [1]. In Sub-Saharan Africa, 87% of the surgical specialists provide care in urban settings where 15% of the population lives, and this is one of the reasons why the Pan-African Academy of Christian Surgeons (PAACS) encourages their graduate surgeons to continue providing surgery to the underserved populations in rural Africa [2]. There is a need for comprehensive and sustainable solutions that include capacity building, the development of local training programs for surgical specialists and better retention of trainees in rural areas [3]. In a response to the need for surgeons in Africa, PAACS has been training African physicians as surgeons to care for the poor and sick since 1997 [4]. PAACS has run residencies to train surgeons in 13 rural mission hospitals throughout the African continent with the intention to develop compassionate and competent surgeons for Africa. This model of 5-year residencies has been successful in training surgeons at rural mission hospital locations [4]. PAACS training has shown a successful and high retention rate of developing African certified surgeon graduates to provide surgical care in Africa both in cities and in rural locations. [5].
We hypothesize that the creation of a general surgery residency at a rural mission hospital in a LMIC is not only feasible and sustainable, it is desirable and beneficial for the hospital as a whole.
There as been a definite increase in the number of surgeries done at Malamulo, as graphed quarterly since This increase in volume of surgery has been directly due to the PAACS program. The other departments of the hospital that are affected by the increased surgical care have all seen marked increase since With PAACS elevating the reputation of the hospital as a center of education and specialty care, many areas of the hospital have been improved as a result.
Conclusion
The creation of a PAACS general surgery residency at Malamulo Adventist Hospital, a rural mission hospital in a LMIC, is not only feasible and sustainable, it is desirable and beneficial for the hospital as a whole. It has been shown that starting the certified post-graduate surgery training did not financially hurt the hospital but rather led it directly and indirectly to sustained growth, improved care, and progresses. The institution benefited in function and finances by training surgeons for LMIC.
The finances of the whole hospital have improved significantly in the end-of-year reports. Although the Liabilities did not increase, the Assets and Working Capital with Net Liquidity and the ratio of Liquid Assets to Commitments all had significant improvements. These changes are concurrent with the beginning of the PAACS program at Malamulo Adventist Hospital.
References
[1] Meara JG, Greenberg SL. “The Lancet Commission: Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.” Surgery. 2015; 157(5):
[2] O’Flynn E, Mkandawire N, Erzingatsian K, “The Specialist Surgeon Workforce in East, Central and Southern Africa: A Situation Analysis.” World J Surg (2016) 40:
[3] Gosselin RA, Gyamfi YA, Contini S (2011) Challenges of meeting surgical needs in the developed world. World J Surg 35:258–261.
[4] Pollock JD, Haisch C. “Is it possible to train surgeons for rural Africa? A report of a successful international program,” World J. Surg. 35 (2011) 493–499.
[5] Van Essen C, Tarpley MJ. “Increasing and Retaining African Surgeons Working in Rural Hospitals: An Analysis of PAACS Surgeons with Twenty-Year Program Follow-Up.” World J Surg 2018 Sept 3.
[6] Seventh-day Adventist Church. Accessed 19 Mar
[7] Seventh-day Adventist Southern Africa – Indian Ocean Division Health Ministries. “Health Ministries Department Strategy : Every Member Sharing
Wholeness and Serving All” 2016 Reach the World.
Contact: Ryan Hayton, MD FACS:
In the departments that are used by and affected by the increase in surgical care, finances were enhanced significantly. There was a greater increase in Gross Income as compared to Expenses which lead to improved Net Income in those departments which are used by and related to surgical patients. These included the Theatre, Private Outpatient Clinic, Clinical Department, Lab, Radiology, Room & Board, Pharmacy. The departments of the hospital which are not utilized directly by surgical patients, like outlying clinics and dental, did not see an improvement over this same period of time.
Methods
In August 2014, Malamulo Adventist Hospital, which has been providing healthcare since 1915 in rural Southern Malawi, started a PAACS general surgery residency. Malamulo started collecting data for the hospital in 2009 with an ever increasingly robust set of statistics. At the end of each year, Malamulo prepares an audited financial statement in accordance with the Seventh-day Adventist church standards. We analyzed the Malamulo Adventist Hospital clinical statistics and year-end financial statements. Graphs were
created using Windows Excel and second-degree
polynomial trendlines were added by Excel.