Informal payments in public hospitals in Malawi: the case of Kamuzu Central Hospital

Background Informal payments in public health facilities act as a barrier to accessing quality health services, especially for poor people. This research aimed to investigate informal payments for health care services at Kamuzu Central Hospital (KCH), a public referral hospital in Malawi. Results of this study provide evidence on the prevalence and influencing factors of informal payments for health care so that relevant policies and strategies may be developed to address this problem. Methods This study employed a mixed methods research design. The quantitative study had a sample size of 295 patients and guardians. The qualitative study had 7 key informant interviews (with health workers, health managers and policy makers) and 3 focus group discussions (FGDs) with guardians. Each FGD included 10 participants. Thus, in total, the qualitative sample comprised 52 participants. Quantitative data was analyzed using Excel and STATA. Qualitative data was analyzed using a thematic content analysis approach. Results 80% of patients and guardians had knowledge of informal payments. Approximately 47% of respondents admitted making informal payments to access health services, and 87% of informal payments were made at the request of a health worker. Lack of knowledge, fear and desperation among patients and guardians, low salaries of health workers, and lack of effective disciplinary measures, were reported as key factors influencing informal payments. Regression analysis results showed that occupation and gender were the main determinants of informal payments. Conclusions Informal payments exacerbate inequality in access to free public health services. Particularly, poor people have limited access to health services when informal payments are demanded. This practice is unethical and infringes on people’s rights to universal access to health care. There is a need to strengthen the public health care system by formulating deliberate policies that will deter informal payments in Malawi.

Operative Management and Outcomes of Patients with Sigmoid Volvulus at a Tertiary Public Hospital in Malawi

Background: Sigmoid Volvulus (SV) is a common cause of acute bowel obstruction in Malawi. We aimed to describe the surgical management of SV and its outcomes at Kamuzu Central Hospital, Lilongwe, Malawi. Methods: We retrospectively reviewed records from January 2019 to December 2019 of all SV patients, aged 18 years and above. Data extracted included age, sex, admission date, surgery date, bowel viability at time of surgery, procedure done, suspected anastomotic leakage, length of hospital stay and mortality. The data was analyzed using STATA 14.0. Results: There were more males (n= 59, 81.9 %) than females. The median (IQR) age was 50.5 (38-60) years. A viable sigmoid colon was present in 61 (84.7%) patients. The commonest procedures done were sigmoid resection and primary anastomosis (RPA) (59.7%, n=43) and Hartmann’s procedure (HP) (36.1%, n=26). The median length of hospital stay was 5 days in HP, 7 days in RPA and longest in mesosigmoidopexy (10 days). Suspected anastomotic leakage occurred in 2(4.7%) patients. The overall mortality was 6.9% with all deaths occurring in RPA patients. Conclusion: Mortality is high in SV patients who undergo RPA. We recommend Hartmann’s procedure in cases where the bowel has significant oedema or is gangrenous.

A multidrug-resistant Stenotrophomonas maltophilia clinical isolate from Kamuzu Central Hospital, Malawi

BackgroundStenotrophomonas maltophilia is a significant opportunistic pathogen that is associated with high mortality in immunocompromised individuals. In this study, we describe a multidrug-resistant (MDR) S. maltophilia clinical isolate from Kamuzu Central Hospital (KCH), Lilongwe, Malawi.MethodsA ceftriaxone and meropenem nonsusceptible isolate (Sm-MW08), recovered in December 2017 at KCH, was referred to the National Microbiology Reference Laboratory for identification. In April 2018, we identified the isolate using MALDI Biotyper mass spectrometry and determined its antimicrobial susceptibility profile using microdilution methods. Sm-MW08 was analysed by S1- PFGE, PCR, and Sanger sequencing, in order to ascertain the genotypes that were responsible for the isolate`s multidrug-resistance (MDR) phenotype.ResultsSm-MW08 was identified as S. maltophilia and exhibited resistance to a range of antibiotics, including all β-lactams, aminoglycosides (except arbekacin), chloramphenicol, minocycline, fosfomycin and fluoroquinolones, but remained susceptible to colistin and trimethoprim-sulfamethoxazole. The isolate did not harbour any plasmid but did carry chromosomally-encoded blaL1 metallo-βlactamase and blaL2 β-lactamase genes; this was consistent with the isolate’s resistance profile. No other resistance determinants were detected, suggesting that the MDR phenotype exhibited by Sm-MW08 was innate.ConclusionHerein, we have described an MDR S. maltophilia from KCH in Malawi, that was resistant to almost all locally available antibiotics. We therefore recommend the practice of effective infection prevention measures to curtail spread of this organism.

Informal Payments in Public Hospitals of Malawi - A Case of Kamuzu Central Hospital

Background: Informal payments in public health facilities act as a barrier to accessing quality healthcare services especially for the poor people. There is growing evidence that in most low-income countries, most poor people are unable to access quality health care services due to demands for payments for services that should be accessed for free. This research was aimed at investigating informal payments for health care services at Kamuzu Central Hospital, one of the referral public hospitals in Malawi. Results of this study provide evidence on the magnitude and factors influencing informal payments in Malawi so that relevant policies and strategies may be made to address this problem. Methods: The study employed a mixed methods research design. The quantitative study component had a sample size of 295 patients and guardians at Kamuzu Central Hospital (KCH). The qualitative study included 7 in-depth interviews with key informants (health workers) and 3 focus group discussions with guardians. Each FGD had 10 people. Thus, in total the whole qualitative sample constituted 52 participants. Quantitative data was analyzed using Excel and STATA. Qualitative data was analyzed using thematic content analysis approach. Results: 80% of patients and guardians at KCH had knowledge of informal payments. About 47% of the respondents admitted paying informally to access health care services at KCH and 87% of the informal payments were made at the request of a health worker. The study identifies lack of knowledge, fear and desperation by patients and guardians, low salary for health workers and lack of effective disciplinary measures as some of the key factors influencing informal payments in the public health sector in Malawi. Conclusion: Informal payments exacerbate inequality in the access of health care services that should be provided for free. Specifically, poor people have limited access to quality health care services when informal payments are demanded. This practice is unethical and it infringes on people’s rights to universal access to health care. There is need to strengthen the public health care system in Malawi by formulating deliberate policies that will deter informal payments.

The experiences of adult patients receiving treatment for femoral shaft fractures at Kamuzu Central Hospital, Malawi: a qualitative analysis

Background: There is a growing burden of musculoskeletal trauma in Malawi, and a lack of surgical capacity to manage common, debilitating injuries like femoral shaft fractures (FSFs). Non-operative treatment with skeletal traction remains the standard of care, with surgery available only at central hospitals. Patients experience myriad barriers to care, which can result in delayed treatment and complications. We sought to understand how patients navigate the Malawian health system and the barriers they face while seeking care. Methods: We performed in-depth, semi-structured interviews of 15 adults with closed FSFs during their inpatient hospitalization at Kamuzu Central Hospital (KCH), a public referral hospital in Lilongwe, Malawi. We additionally interviewed one patient who left KCH to seek care at a private hospital. An English-speaking study investigator performed all interviews accompanied by a Chichewa-speaking medical interpreter. Interviews focused on patients’ pathways from injury to present treatment (health system navigation); impressions of the hospital and care received; and the effects of injury/treatment on patients and their families. Interviews were audio-recorded, translated, and transcribed in English. We coded the transcripts and performed a thematic analysis. Results: We identified 6 themes: high variability in health system navigation; frustrations with the biopsychosocial effects of hospitalization; lack of participation in decision-making and uncertainty about treatment course; preference for surgery (vs. traction) based on patients’ own experiences and observations; frustrations with the inequitable provision of surgery ; and patients’ resignation, acceptance, and resilience in the face of hardship. Many patients receiving non-operative treatment described the devastating financial burden imposed upon them and their families by their injury and prolonged hospitalization. They felt they were receiving inferior treatment compared to surgery and suspected that richer patients were receiving more timely care. Conclusion: This qualitative study suggests a need to standardize care for FSF in Malawi, increase availability and timeliness of surgery, and increase transparency and communication between providers and patients. These remedies should focus on improving quality of care and achieving equity in access to care.

Etiology of major limb amputations at a tertiary care centre in Malawi

IntroductionAmputations in low- and middle-income countries (LMICs) represent an important cause of disability and economic hardship. LMIC patients are young and suffer from preventable causes, such as trauma and trauma-related infections. We herein studied the etiology in amputations in a Malawian tertiary care hospital over a 9-year period.Methods Operative and anaesthesia logs at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, were reviewed for 2008–2016. Baseline demographic and clinical variables and type of amputation performed were collected. Only major limb amputations, defined as above or below the knee, above or below the elbow, and above the wrist, were included in this study. Results A total of 610 patients underwent 630 major amputations during the study period. Of these, 170 (27%) patients were female, and the median age of the cohort was 39 (interquartile range [IQR] 25–55). Of these patients, 345 (54.8%) had infection or gangrene recorded among the indications for amputation, 203 (32.2%) had trauma, 94 (14.9%) had cancer and 67 (10.6%) had documented diabetes. Women underwent diabetes-related amputations more often than men (37 out of 67, or 56.1%), and were significantly younger when their amputations were due to diabetes (median age 48 vs 53 years old, P=0.004) or trauma (median age 21 vs 30 years old, P=0.02). The commonest operative procedures were below the knee amputations, at 271 (43%), and above the knee amputations, at 213 (33.8%). ConclusionAmputations in Malawi affect primarily the young, in the most economically productive time of their lives, in contrast to amputees in high-income countries. Preventable causes, such as infection and trauma, lead to the majority of amputations. These etiologies represent an important primary prevention target for public health efforts in LMICs.