10.03 Local Impact of General Surgery Task-Sharing in Rural Sierra Leone: A District Hospital Experience.

P. F. Johnston1, S. Jalloh2, A. Samura3, J. A. Bailey1, M. Brittany4, Z. C. Sifri1  1Rutgers New Jersey Medical School,Surgery,Newark, NJ, USA 2College Of Medicine And Allied Health Sciences,Freetown, WESTERN, Sierra Leone 3Kabala Government Hospital,Kabala, KOINADUGU, Sierra Leone 4University Of Maryland – Mercy Medical Center,Baltimore, MD, USA

There exists a disproportionally large burden of surgical disease in low income countries (LICs) but few immediate answers. In Sierra Leone, a handful of trained surgeons serve a country of over 6 million, leaving an excess of surgical burden, particularly in rural regions. This excess burden is borne by non-surgeon physicians and surgically-trained clinical officers (COs). In Sub-Saharan Africa, task-sharing models of CO training have shown some success in the context of caesarian sector. However, limited data exists regarding the contribution of surgical training programs towards tackling the general surgery burden of disease. The aim of this study is to examine the impact of one surgically trained CO on surgical capacity in a district hospital in rural Sierra Leone.


Kabala Government Hospital (KGH) is a 100-bed district hospital in the rural Koinadugu district of Sierra Leone serving a population of approximately 325,000. The surgical team consists of one non-surgeon physician, one nurse anesthetist, and a handful of COs with various levels of training in surgery and anesthesia. One CO has been trained to perform basic, yet essential, surgery by a non-profit organization operating within Sierra Leone.

Case logs from the KGH operating theater over a 14 month period were reviewed to examine this CO’s contribution to hospital’s surgical output. Two-sided Pearson Chi-square test was performed to determine statistical differences between cases with a physician versus a CO as the primary surgeon. 


In total 394 procedures were performed on 375 patients at KGH over the 14 month period examined. The patient population was primarily male (75%) with a mean age 33.9 ± 18.8. The most common procedures performed were inguinal hernia repair (71%), appendectomy (12%), and hydrocelectomy (9%).  Anesthesia was most commonly spinal (50%). The CO was involved in 264 procedures (67%) and primary surgeon for 207 (53%). All cases in the series had a satisfactory immediate surgical outcome as reported in the case logs. No long-term data was available for study.

Physician primaries performed significantly more laparotomies (12% vs. 2%; p = 0.02) than CO primary, but otherwise case types were similar in terms of age, gender, surgery and anesthesia types. 


A surgically-trained CO can significantly enhance the surgical capacity of a district hospital in rural Sierra Leone, performing over half of all operations with satisfactory results. Top down approaches to scaling surgical workforce and infrastructure are costly and will take time, while a large, immediate need exists. Surgical task-sharing programs may be an easily scalable and effective interim solution in areas of excessive burden and limited-resources. Limitations in the complexity of cases performed are expected and likely appropriate.

Long-term and more complete data is needed to ensure quality and safety of surgery performed by graduates of CO training programs.