Medical efforts to reduce surgery-related deaths

Research shows that patients in Ugandan health facilities are twice as likely to die following surgery compared to the global average for surgical-related deaths, with children facing even greater risks. 
A study across Uganda and 13 other African countries reveals that children undergoing surgery in these regions are more than ten times more likely to die than children in high income countries.
“Outcomes following anaesthesia and surgery for children in Africa are poor,” states a report published in The Lancet in April.

“Complication and mortality rates are fourfold and elevenfold higher, respectively, than in high-income countries.” Dr Mary Theresa Nabukenya, a paediatric anesthesiologist and critical care specialist at Mulago National Referral Hospital, attributes the poor surgical outcomes to an inadequate workforce, limited training for medical personnel, deficiencies in the ambulance system, and the government’s failure to ensure a consistent supply of medicines and surgical materials.

Dr Moses Galukande, the president-elect of the Association of Surgeons of Uganda (ASOU), underscores the challenges in accessing safe surgical services, noting in a separate study that only two out of 10 Ugandans who need surgical care can access it.

Joyce Letiru, a nurse, shares her struggles in accessing necessary surgical care. After experiencing knee issues for eight years, she was advised to undergo knee replacement surgery to relieve the severe pain she endured, yet the high cost (approximately Shs9m) for the knee implant was beyond her means.

“I told the doctor I did not have the money, so I returned to work, continuing to experience severe pain due to the nature of my job, which requires long hours of standing,”Letiru recalls.
In July 2022, however, Letiru received free implants and knee replacement surgery at Mulago Hospital, thanks to a donation from American partners led by Dr Jerry Cooper. Many Ugandans, face similar barriers, leading to preventable deaths or permanent disabilities because they cannot afford the cost of surgery or essential materials.

Children most affected
Two researchers, Piero Alberti from the University of Oxford and Phyllis Kisa from Makerere University Medical School, investigated mortality rates at Mulago and Mbarara hospitals, where many children with complications are referred.
Their report from 2012 to 2017 shows an overall mortality rate of 36 percent for admitted neonates who underwent surgery.
The highest mortality rate, at 86 percent, was observed in cases of gastroschisis (a birth defect where there is a hole in the abdominal (belly) wall beside the belly button). While this represents an improvement from the previous national rate of 98 percent, it starkly contrasts with the four percent mortality rate seen in high-income countries.
In their May 2024 analysis, the researchers noted that Uganda’s health facilities struggle to meet the substantial demand for paediatric surgical services. They observed that hospitals face shortages of staff, medications, surgical equipment, and basic amenities.
Additional studies indicate that common causes of surgery-related deaths include uncontrolled bleeding, limited availability of blood for transfusions, inadequate administration of anaesthesia (including overdoses), improper placement of breathing aids, and infections such as surgical wound infections and sepsis.Other contributing factors are heart failure, respiratory complications, and delayed presentations
at health facilities.

The report highlights that surgical treatment is often delayed due to factors such as financial constraints, gender inequality, and reliance on community healers. Long distances to healthcare facilities and overcrowded wards further complicate access to necessary resources.
Although Mulago is a tertiary centre handling a larger proportion of neonatal emergencies, the researchers stressed that many of these deaths could be prevented. They attribute the high mortality rate to a lack of perioperative support resources at both Mulago and Mbarara hospitals, including limited access to ventilation, total parenteral nutrition (nutrients administered directly into the bloodstream), and critical care medications.
While Mulago has a paediatric and neonatal intensive care unit (ICU) supported by one paediatric anaesthetist, its limited capacity of eight beds and lack of specialised ICU staff mean that most post-operative patients are managed on general wards.
Studies at Mbale Hospital revealed a two percent post-operative death rate, indicating that many patients were cared for by individuals without surgical specialisation, including non-physician anaesthetists. Nearly 60 percent of postoperative deaths at Mbale occurred more than 24 hours after surgery.

The researchers noted that poor patient outcomes often result from delays in recognising and addressing deteriorating conditions on the wards.
They suggested that the failure to promptly rescue patients following complications may be a critical indicator of the quality of perioperative care in healthcare facilities.
The report also indicated that no patients survived following cardiac arrest, a trend consistent with findings at other healthcare facilities in the country. However, they referenced the International Surgical Outcomes Study, which reported that in highand middle-income countries, 40 percent of cardiac arrest patients survived.

Anaesthesia-related death

In a 2016 meta-analysis conducted by Soha Sobhy and colleagues, researchers examined 44 studies involving 632,556 pregnancies across lowand middle-income countries, including Uganda. They found significant risks associated with anaesthesia use during childbirth.
Published in The Lancet, the report indicates that anaesthesia was responsible for 2.8 percent of all maternal deaths, 3.5 percent of direct maternal deaths (those resulting from obstetric complications), and 13.8 percent of deaths following cesarean sections.
The researchers recommended that the international focus on strengthening health systems should also address risk factors related to anaesthesia use, particularly in rural areas, to improve maternal anaesthetic care. The most common causes of anaesthesia-related deaths,according to scientists, include circulatory failure due to hypovolemia (a decrease in blood volume) combined with anaesthetic overdose, or complications from regional anaesthesia. Other causes involve decreased oxygen levels, undetected intubation issues, difficult intubations, technical failures in anaesthetic equipment, and aspiration of stomach contents.

Intubation is a procedure in which a healthcare provider inserts a tube through a patient's mouth or nose and down into the trachea (windpipe) to maintain an open airway, allowing air to pass through. This tube can be connected to a machine that supplies oxygen, ensuring proper breathing.

Progress
Prof Frank Asiimwe, former president of the Association of Surgeons of Uganda (ASOU), notes that Uganda's healthcare system is embracing new technologies to make surgery safer and more accessible.
“The adoption of technologies for diagnostic interventions is paving way for minimally invasive surgery and interventional radiology,” says Prof Asiimwe.
Prof Asiimwe was part of a team of Ugandan medical experts who, in collaboration with peers from India, successfully performed Uganda’s first kidney transplant at Mulago Hospital.
Dr John Sekabira, a paediatric surgeon and acting deputy director of Mulago Hospital, highlights the addition of capnography, an advanced monitoring technology that enhances anaesthesia safety.

Minimally invasive surgery

Mulago Hospital,in collaboration with several partners, has introduced safer surgical procedures, notably through advancements in laparoscopic surgery.
This minimally invasive technique uses a high-resolution camera inserted into the body through small incisions, typically around one centimetre in size, often called "keyhole" surgery.
Dr Sekabira explains, “Patients who undergo this new method recover quickly due to the smaller incisions. It is also cosmetic, leaving minimal scarring, and patients spend less time in the hos pital recovering.”

In addition, with support from the Korea International Cooperation Agency (KOICA), Mulago Hospital has established a training centre to educate its staff and other health professionals in laparoscopic techniques. The hospital also performs arthroscopic surgery, another minimally invasive procedure that involves small incisions to repair damaged ligaments; fibrous tissues that connect bones.

Dr Alexander Bagirana, assistant clinical head of the accident and emergency department at Mulago Hospital, notes that during a surgical camp in July 2023, two patients with sports-related injuries successfully underwent knee ligament replacement surgeries.
One of these patients, Musa Matovu from Proline Football Club, shares his experience,“I tore my ligament last season but could not afford surgery at the time. When I heard about the medical camp, my club helped me register. I had my surgery this week, and I am already seeing improvement.”

New plan
Dr Rony Bahatungire, acting commissioner of clinical services at the Ministry of Health, says as the government works to address the gaps in surgical care, health workers must make every
effort to save patients. He stresses the importance of teamwork and collaboration with the Ministry of Health to develop practical solutions.
"Many of the necessary changes to enhance our work environment are budget-neutral. We need dedication to our work, and this commitment will lead to improvements in our intervention outcomes. As we see positive results, we will find more satisfaction in our work,”he says.

Private hospitals advancing 

Dr Peter Kibuuka, the chief executive officer of Kampala Hospital, highlights how private facilities have invested heavily in talent and cutting-edge equipment to ensure safe surgical procedures.

“For example, we now use laser surgery for prostate removal rather than traditional surgery. This approach dissolves the prostate tissue without requiring extensive incisions,allowing patients to go home within a day. Keyhole surgery, which involves minimal cutting, saves both time and money, enabling patients to return to work shortly after,”he added.
Dr Kibuuka says with advancements in laser surgery, laparoscopic techniques, and critical care, the country can "enhance the safety of surgery."

IMPROVING ACCESS
Dr Moses Galukande from ASOU says surgical camps have been established across various regions to help those who cannot access life-saving surgeries.
“Last year, more than 2,000 people attended, and approximately 1,400 surgeries were performed within one week. This service is provided free of charge,” he says, adding that resources for these surgeries come from partnerships and organisational support.

“Although these services are free, resources are still needed, including surgeons, anesthesiologists, nurses, lab technicians, and imaging specialists all volunteer their time and skills without charging fees. Supplies such as sutures, IV fluids, and medications are also required, which we often source through extensive collaboration with the Ministry of Health and other organisations,” he adds.
Dr Mary Theresa Nabukenya, a paediatric anesthesiologist and critical care specialist at Mulago National Referral Hospital, underscores the urgent need for the government to take decisive action to address challenges in anaesthesia and surgical care.