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

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.

Perceptions of the risk for Ebola and health facility use among health workers and pregnant and lactating women--Kenema District, Sierra Leone, September 2014

With an estimated maternal mortality ratio of 1,100 per 100,000 live births and a neonatal mortality rate of 49 per 1,000 live births, Sierra Leone has the highest maternal mortality ratio and the fourth highest neonatal mortality rate in the world, accounting for 2,400 maternal and 11,200 newborn deaths annually. By straining the fragile health care infrastructure, the Ebola virus disease (Ebola) epidemic might put pregnant women and their newborns at even greater risk for adverse outcomes.

Thermal stability of turnip yellow mosaic virus RNA: effect of pH and multivalent cations on RNA deaggregation and degradation

Light scattering studies of RNA isolated from turnip yellow mosaic virus (TYMV) revealed a molar mass of 1.9.10(6) g mol-1, which is close to the value of 2.0.10(6) g mol-1 published for intact genomic TYMV RNA (2M RNA). However, gel electrophoresis under denaturing conditions demonstrated that only 30-40% of this native RNA was 2M RNA. Sucrose gradient centrifugation revealed the occurrence of a series of smaller RNA size classes, the mass ratios of which were greatly influenced by the pH of the solution and the presence of EDTA. These results suggest that native TYMV RNA preparations originally contain a mixture of intact RNA particles and of aggregates of RNA fragments with the same molar mass of about 2.10(6) g mol-1, and that the size classes are intermediates in the deaggregation process of the degraded genomic TYMV RNA. The native RNA displayed pH-dependent deaggregation and degradation. The degradation process of 2M RNA followed (pseudo) first-order kinetics. Lower degradation rates were observed for RNA depleted of divalent cations and polyamines. For depleted 2M RNA an enthalpy of activation of about 100 kJ mol-1 and an almost zero entropy of activation was calculated. Similar values were also found for depleted E. coli ribosomal RNAs and depleted MS2 RNA, demonstrating that all RNAs are equally vulnerable to degradation. In the presence of multivalent cations the activation enthalpy for 2M TYMV RNA degradation increased to 150 kJ mol-1 and the entropy of activation to 150 J K-1 mol-1, indicative for a different degradation mechanism.

A hydrodynamic study with quasielastic light scattering and sedimentation of bacterial elongation factor EF-Tu.guanosine-5'-diphosphate complex under nonassociating conditions

The hydrodynamics of the bacterial elongation factor EF-Tu have been studied in the presence of its ligand guanosine-5'-diphosphate (GDP) by sedimentation in the ultracentrifuge and quasielastic light scattering. Sedimentation studies have made it possible to establish experimental conditions under which only negligible aggregation of the protein occurs (neutral pH, concentration less than 3 mg/mL). Analysis of the light intensity autocorrelation functions under these conditions revealed two independent scattering species with diffusion coefficients of 0.71 X 10(-6) and 0.04 X 10(-6) cm2 s-1. The material with the lower diffusion coefficient, i.e., the aggregates, represented less than 1% of the total number of EF-Tu particles. The other 99% diffused as monomeric molecules with a molar mass corresponding to the value calculated from the known primary structure of the protein. The hydrodynamic parameters derived from the experimental data suggest that EF-Tu.GDP in solution is close to a spherical particle.

Mutant species of EF-Tu, altered at position 375, exhibit a reduced affinity for aminoacylated transfer-RNAs

The interaction between EF-Tu X GTP and aminoacyl-tRNA is shown to be influenced by mutations at site 375 of this three-domain protein. Site 375 is located in domain II near the interface with domain I [(1984) EMBO J. 3, 113-120]. Replacement of the alanine at this site by a threonine or valine residue results in lower binding constants with Phe-tRNA and Tyr-tRNA, as was evaluated by the hydrolysis protection technique. The data are discussed in the light of what is known about the three-dimensional structure of the protein and its interaction sites with aminoacyl-tRNA.