Surgical service monitoring and quality control systems at district hospitals in Malawi, Tanzania and Zambia: a mixed-methods study
===================================================================================================================================

* Morgane Clarke
* Chiara Pittalis
* Eric Borgstein
* Leon Bijlmakers
* Mweene Cheelo
* Martilord Ifeanyichi
* Gerald Mwapasa
* Adinan Juma
* Henk Broekhuizen
* Grace Drury
* Chris Lavy
* John Kachimba
* Nyengo Mkandawire
* Kondo Chilonga
* Ruairí Brugha
* Jakub Gajewski

## Abstract

**Background** In low-income and middle-income countries, an estimated one in three clinical adverse events happens in non-complex situations and 83% are preventable. Poor quality of care also leads to inefficient use of human, material and financial resources for health. Improving outcomes and mitigating the risk of adverse events require effective monitoring and quality control systems.

**Aim** To assess the state of surgical monitoring and quality control systems at district hospitals (DHs) in Malawi, Tanzania and Zambia.

**Methods** A mixed-methods cross-sectional study of 75 DHs: Malawi (22), Tanzania (30) and Zambia (23). This included a questionnaire, interviews and visual inspection of operating theatre (OT) registers. Data were collected on monitoring and quality systems for surgical activity, processes and outcomes, as well as perceived barriers.

**Results** 53% (n=40/75) of DHs use more than one OT register to record surgical operations. With the exception of standardised printed OT registers in Zambia, the register format (often handwritten books) and type of data collected varied between DHs. Monthly reports were seldom analysed by surgical teams. Less than 30% of all surveyed DHs used surgical safety checklists (n=22/75), and <15% (n=11/75) performed surgical audits. 73% (n=22/30) of DHs in Tanzania and less than half of DHs in Malawi (n=11/22) and Zambia (n=10/23) conducted surgical case reviews. Reports of surgical morbidity and mortality were compiled in 65% (n=15/23) of Zambian DHs, and in less than one-third of DHs in Tanzania (n=9/30) and Malawi (n=4/22). Reported barriers to monitoring and quality systems included an absence of formalised guidelines, continuous training opportunities as well as inadequate accountability mechanisms.

**Conclusions** Surgical monitoring and quality control systems were not standard among sampled DHs. Improvements are needed in standardisation of quality measures used; and in ensuring data completeness, analysis and utilisation for improving patient outcomes.

*   health services research
*   surgery
*   quality measurement

## Introduction

There is an urgent need to improve access to surgery to address the unmet global burden of surgical diseases.1 However, as highlighted by the Lancet Global Health Commission on High Quality Health Systems, progress towards universal health coverage cannot be achieved without ensuring that quality of care is at the centre of service delivery,2–4 maintaining the professional standards needed for optimal health outcomes.4 5 In low-income and middle-income countries (LMICs), an estimated one in three clinical adverse events happens in non-complex situations and 83% are preventable.6 Studies indicate that quality improvements could mitigate morbidity and mortality from anaesthesia,7 surgical8–10 and obstetric operative interventions.11 Poor quality of care also leads to inefficient use of human, material and financial resources for health.12 13 Addressing preventable medical mistakes and treatment of hospital-acquired infections accounts for over 10% of hospital expenditure.12 Additional costs include lost productivity and diminished trust in the health system.12

The maintenance of quality standards in surgical care delivery, improving outcomes and mitigating the risk of adverse events, requires effective monitoring systems,14 15 assessing service capacity, volume and outcomes.16 Monitoring surgical activity, outputs and adherence to essential protocols are needed. Quality assurance approaches include surgical safety checklists (SSCs), infection prevention protocols and clinical practice guidelines.4 14 17 Monitoring requires accurate and timely information,4 18 good record-keeping and systematic surveillance of surgical activity, to demonstrate adherence (or lack thereof) to guidelines.16 18 Effective oversight requires that surgical service monitoring is integrated into strong national health information systems capable of ‘*ongoing systematic collection, analysis, evaluation and dissemination of data’*.16 19

The World Health Organization (WHO) SSC is a low-cost method for reducing postoperative complications and mortality through monitoring the process of surgical care delivery, pre-operatively, peri-operatively and post-operatively.20 21 Tracking healthcare outcomes, such as surgical site infections,22 and undertaking morbidity and mortality reviews and audits of adverse events, encourage systematic reflection among surgical providers on the factors determining quality, notably team processes.23 Integration of different surveillance approaches can strengthen overall quality of surgical care,24 25 where measurement is linked to reflection on performance, feedback and identification of areas for improvement26 (figure 1).

![Figure 1](http://qualitysafety.bmj.com/https://qualitysafety.bmj.com/content/qhc/30/12/950/F1.medium.gif)

[Figure 1](http://qualitysafety.bmj.com/content/30/12/950/F1)

Figure 1 
Guidelines for routine surveillance, evaluation and improvement of surgical quality systems (activity, processes, outcomes) at the district hospital. Adapted from WHO.16 17

In practice, health information systems in LMICs are often undermined by inaccurate and incomplete data,27–29 partly due to resource constraints.30 The lack of standardised and reliable hospital data, particularly in sub-Saharan Africa (SSA), impairs assessments of the state of surgical delivery, which often rely instead on expert opinion,31 precluding empirically derived strategies for quality improvement.8 32–34 The implementation of basic quality measures in LMICs, where available, is also highly variable,4 with inconsistent use of SSCs by hospitals,35 36 poor adherence to clinical and practice guidelines4 and substandard execution of clinical audits.37

Periodic assessments of surgical service quality at district hospitals (DHs), which are the entry point into surgical care for rural populations in SSA,1 38 have had singular focuses on: inputs,39 post-operative outcomes,40–42 record keeping,43 44 infection prevention control,45 46 and SSCs.35 47 We know of no studies which provide a comprehensive examination of surgical monitoring and quality control systems at the DH level including surgical activity, processes and outcomes.48 There is also no consensus internationally on a standardised method for measuring surgical service quality in these settings.1 4

This paper aims to provide an empirically based understanding of surgical monitoring and quality control systems at DHs in SSA,1 49 50 to inform context-appropriate standards and solutions for reducing the burden of avoidable surgical morbidity and mortality.1 The mixed-methods cross-sectional study reported here was part of a situation analysis undertaken by the SURG-Africa project to inform an intervention aimed at strengthening district-level surgical care delivery in Malawi, Tanzania and Zambia.51

## Methods

### Sample

Seventy-five surgically active DHs participated in the study: from the Northern Zone, Tanzania (30 of 35 DHs); the Lusaka, Central, Southern, Eastern and Western Provinces, Zambia (23 of 44 DHs) and country-wide in Malawi (22 of 24 government DHs) (see online supplemental file 1 for country breakdown of hospitals, hospital-type and staff included in the study). In Tanzania and Zambia, government and faith-based DHs were included. The study sampling strategy has been outlined in greater detail in a specific protocol publication.51 Participants were purposefully sampled to include staff representatives from surgery, anaesthesia and nursing, with support from District Health Officers (study gatekeepers) at each DH.

### Supplementary data

[[bmjqs-2020-012751supp001.pdf]](pending:yes)

### Data collection

Between July and November 2017, we administered a questionnaire at the 75 DHs. In each hospital, two to three members of the surgical team (see online supplemental file 1 for the breakdown) jointly discussed and provided an agreed response for each question. This consensus approach to the questionnaire was used to maximise validity and reliability of answers and to minimise recall bias. We also conducted semi-structured interviews with members of the surgical team from a subsample of 32 randomly selected DHs. Survey items and interview questions were developed based on a review of relevant literature and this consortium’s previous research experience, detailed elsewhere.51 Data collection tools are presented in online supplemental file 2. Questionnaires and interviews were administered the same day by the research team face-to-face, in English. We then conducted a visual inspection of a cross-section of 1 month’s operating theatre (OT) data from three randomly selected DHs per country.

### Supplementary data

[[bmjqs-2020-012751supp002.pdf]](pending:yes)

### Methodological approach

#### Monitoring and quality systems for surgical activity

The assessment of whether and how surgical activity at DHs was monitored followed the model of Juran *et al*,52 which focuses on three domains: standardisation of data collection, record completeness and utilisation of surgical service records,52 53 as follows:

1.  Standardisation of data collection: number and type of registers at each DHs (*questionnaire*), and data collection practices of the surgical team (*interview*). The *visual inspection* of OT registers examined: register format, number and type of indicators recorded, consistency of indicator terminology used.

2.  Completeness of records: was determined based on percentage of missing data in OT registers (*visual inspection*).

3.  Data utilisation: data analysis and compilation captured through *questionnaire and interview*.

#### Monitoring and quality systems for surgical processes and outcomes

In the absence of comprehensive national guidelines for surgical quality process and outcome measures at district level, we adapted relevant WHO guidelines48 for our study, as described in table 1.

View this table:
[Table 1](http://qualitysafety.bmj.com/content/30/12/950/T1)

Table 1 
Surgical processes and outcomes quality control measures: type and description

The questionnaire assessed whether these five measures were in place and being used at surveyed DHs. The interview questions were developed to triangulate the questionnaire and OT data, so as to delve deeper into information management, surgical quality measures and perceived barriers to surgical quality monitoring.

### Data analysis

#### Quantitative

Data were processed and analysed using SPSS-IBM V.24, generating descriptive statistics on variables of interest. Pearson’s χ2 and Fisher’s exact tests were used to determine any country differences related to: number of OT registers used per hospital; and number of hospitals monitoring surgical quality (for each measure in table 1); as well as differences in monitoring surgical quality between government versus faith-based hospitals. The percentage of missing data in each sampled OT register was calculated as the number of a core set of data points for which no information had been recorded over the total number of those data points, per patient.

#### Qualitative

A hybrid of top-down and bottom-up thematic analysis was performed by the lead researcher, supported by two senior researchers. This followed standard practice54: reading and familiarisation with transcripts; generation of codes to capture emerging themes and analysts’ observations; re-reading of transcripts and initial codes and a second round of coding, applied to all transcripts. Excel (V.16.16.11) was used to catalogue codes and transcript excerpts, which were grouped by emerging themes and subthemes.

#### Analytical integration of phases

The convergent mixed-methods study design was chosen to mitigate any weaknesses associated with qualitative and quantitative approaches, and to triangulate, that is, highlight any expansion or discordance between the results generated from both methods.55 56 The methods were integrated in reporting and discussing the results.57 The presentation of findings follows the Strengthening the Reporting of Observational Studies in Epidemiology reporting guidelines.58

## Results

### Monitoring and quality systems for surgical activity

#### Data collection standardisation

##### Operating theatre registers

Over half of sampled DHs across the three countries used two or three registers to record surgical procedures performed in the major OT (as detailed in online supplemental file 3), typically a general surgical register, anaesthesia register and procedure-specific registers (eg, for obstetric procedures). The proportion of DHs using more than one OT register was largest in Malawi (online supplemental file 3).

### Supplementary data

[[bmjqs-2020-012751supp003.pdf]](pending:yes)

##### Data entry

Most interview participants reported that responsibility for manually entering information about surgical cases into OT registers lay with the lead surgeon, although nurses and anaesthetists sometimes contributed to data entry.

##### Data format

OT register formats were inconsistent across DHs (table 2). In Zambia, the three sampled hospitals used standardised printed registers developed specially for recording surgical OT procedures. In Malawi and Tanzania, most sampled registers were either repurposed from non-surgical registers, or were blank copybooks, where surgical indicators, patient and surgical information were handwritten. Some participants reported that the poor standard of data collection tools was due to lack of attention towards surgical departments.

View this table:
[Table 2](http://qualitysafety.bmj.com/content/30/12/950/T2)

Table 2 
Register format and percentage (%) of missing data from 1 month of operating theatre registers

> If you compare with other programmes like malaria, TB, still they have got all of their data capturing tools well designed, but in surgery you see…they start using a hard cover with a ruler (CO_MW_ 2.1)

##### Indicators

Table 2 presents the number of indicators recorded in each OT register, and table 3 presents categories of information, from basic patient demographics to outcomes of surgery, which were collectively recorded across all OT registers. There was large variability in the number of indicators included (between 9 and 40 indicators) per OT register.

View this table:
[Table 3](http://qualitysafety.bmj.com/content/30/12/950/T3)

Table 3 
Type of information and indicators recorded across all operating theatre registers

In Zambia, the number of indicators was large (40) and consistent. Variability in Tanzania and Malawi indicates lack of standardised data collection across their DHs. There were also inconsistencies in the number of indicators recorded across pages, within the same OT register, where DHs used a ‘*pen and ruler*’ handwritten approach.

Information categories and indicator formats used in DH OT registers differed within and across the three countries. Whereas patient demographics, diagnosis, procedure, surgical team and type of anaesthesia used were commonly recorded in DHs, using similar indicators across countries (table 3), there was variation in recording surgery outcomes. This comprised inconsistent terminology and failure to record outcomes, particularly in Malawi and Tanzania where standardised registers were not used. Printed registers from Zambia included indicators to record post-operative observations of vital signs, such as heart rate, blood pressure, temperature as well as on outcomes (performance and complications) of the surgery. However, some groups of indicators such as category of surgery, patient status and post-operative observations and outcome of surgery were not recorded in all OT registers.

The printed register from Malawi collected data on outcomes (performance, complications and comorbidity) and on post-operative mortality status on transfer to theatre. However, none of the handwritten/re-purposed OT registers from Malawi and Tanzania included indicators to record elective or emergency category of the surgery, or the American Society of Anesthesiologists score (table 3). They lacked substantive data on post-operative observations, and three of these OT registers did not record data on outcomes of surgery.

#### Data completeness

The percentage of missing data for 1 month of OT register records ranged from 0% to 45.5% (see table 2). Tanzania had the lowest proportion of missing data; Zambia had consistent trends of 15%–22% missing data and Malawi DHs had the highest proportion of missing OT data. Percentages of missing data were higher in printed versus handwritten OT registers. However, the former included twice the number, and a greater range of categories than handwritten OT registers from Malawi and Tanzania. Incomplete information in printed registers in Zambia and Malawi were more often for additional categories such as patient status and post-operative observations.

Some participants from Malawi and Zambia confirmed problems with record keeping, notably: incomplete data entries, lost registers, lack of a designated personnel for data entry and failures to enter data into OT registers. Omissions were sometimes due to pressure for the surgical team to quickly prepare for another surgery:

> …We have a challenge whereby surgeons rush, whenever they finish a procedure, rush out of the theatre forgetting recording the cases into the register (Nurse_MW_2.01)

#### Surgical data utilisation

Most interview respondents reported that basic summaries of surgical OT register data (total volume of cases by type of procedure performed) were compiled at regular frequencies for the DH administration, to facilitate budgetary planning, including procurement of supplies and equipment for theatres.

> We send [the data] to the district and it is most useful for them, especially in terms of planning (ML_ZW_1.12)
> 
> “[the administration] are taking for, you know, to see how much we have in our budget (Anaes_TZ_3.3)

Despite sharing data with the DH administration, the reporting surgical departments noted that they were seldom involved in the analysis nor receive feedback. Additionally, <50% of DHs across the sample conducted reviews of monthly surgical reports: 22% of surveyed DHs in Malawi (n=5/22), 48% (n=11/23) in Zambia and 53% (n=16/30) in Tanzania.

Each hospital is also required to integrate their data into the national Health Management Information System (HMIS) to facilitate high-level management and planning of the country’s health system.19 59 But as explained by respondents, the transfer of data from the original files to the electronic HMIS is challenging:

> We don’t have necessary registers, we usually improvise so keeping of data is a problem. And I have noted the theatre data is not entered into the HMIS system at the district hospital (…) The HMIS would not pick from those registers because we use a ruler, draw a line… (CO_MW_2.1)

As is the capacity of data entry clerks and/or administration at the hospital to decipher the information provided by the surgical team:

> [The analysis] is done by non-medical people. So, you find that some data, because they do not know what it is or cannot read what it is, they skip it (Anaes_ZW_1.4)

### Monitoring and quality systems for surgical processes and outcomes

Table 4 reports the number and percentage of DHs within each country that use quality control measures for the purpose of monitoring processes (surgical safety checklists, supervision, case reviews) and outcomes (morbidity and mortality reports, and audits of adverse events) of surgical service delivery.

View this table:
[Table 4](http://qualitysafety.bmj.com/content/30/12/950/T4)

Table 4 
Per cent of district hospitals monitoring surgical quality in Malawi, Tanzania and Zambia

#### Surgical safety checklists

As shown in table 4, <40% of surveyed DHs used SSCs, with least use in Malawi and significantly greater use in faith-based (58%) versus government hospitals (17%): p=0.002. As reported by one participant from Tanzania, the Christian Social Services Commission provided high-level support and guidance on quality control to faith-based health facilities:

> …Those are the people who are really taking care of these faith-based organisation facilities (…) they have given us some information and also we have been attending different meetings about the quality. If you look on our booklet or the consent form of the patient, everything the patient has to be informed on (Surgeon_TZ_3.11)

#### Surgical supervision

External supervision by visiting surgical specialists was not done in Tanzania and in only 9% of DHs in Zambia, compared with 46% in Malawi (see table 4). Internal informal supervision by senior staff was more common, conducted in over 70% of DHs in each country. This comprised overseeing junior colleagues in operations; monitoring their skills in surgery before they were allowed practice unsupervised and orienting staff on relevant surgical protocols (eg, aseptic practice within the OT). Some hospitals established more formal arrangements in an effort to enhance quality of service delivery:

> To improve, three months ago we decided to do any major operation operating with two doctors […] because when you have two doctors you can give each other experience and skills (Anaes_TZ_3.11)

#### Surgical case reviews

As reported in table 4, 73% of DHs in Tanzania conducted surgical case reviews, compared with less than half of DHs in Malawi and Zambia; and were significantly more frequent in faith-based than government hospitals: 88% vs 38%, p=0.0001. Case review frequency varied across hospitals: from daily, weekly to monthly; or were ad hoc, for example, when a difficult case arose. Case reviews were used to reflect on staff surgical performance, for managing difficult inpatient cases or to bring staff together to discuss surgical technique.

> [Case reviews are] a good system where we analyse the cases and discuss how better we can surgically help our patients (CO_MW_2.11)

#### Surgical morbidity and mortality reports, audits of adverse events

As outlined in table 4, surgical morbidity and mortality reports were done in 65% of DHs in Zambia, but less commonly in Tanzania and Malawi (<30%); and were significantly more frequent in faith-based than government hospitals: 63% vs 31%, p=0.02. Audits of surgical adverse events were infrequent, performed in 7%, 9% and 30% of hospitals in Tanzania, Malawi and Zambia, respectively; and were more frequently done for maternal cases.

### District-level teams’ perceptions of obstacles to surgical monitoring and quality systems

The qualitative analysis provided insights into the reasons for inconsistencies in the use of monitoring and quality control measures at DHs. Multiple interview respondents stated there was no formal system for surgical monitoring and quality control at their hospitals:

> We don’t do [quality systems] there. It’s very rare (Nurse_TZ_3.4)

Some respondents reported that selected quality control measures were in use at their facility (as outlined in table 1), but that there was no institutional support nor team approach, reinforced by managerial practices within DHs, to inform the use of such measures.

> We don’t have the standards, so we are used to the way that he or she learned at college. (CO_MW_2.12)

Multiple factors contributed to the absence of a culture for quality control in surgery at the DH.

#### Reliance on individuals

Respondents reported that any surgical monitoring and quality systems approaches used in their hospitals were largely dependent on the abilities and initiative of individuals. The major contributing factor was the lack of formal protocols to guide the work of surgical teams.

> [Quality is] up to an individual, the surgeon and the team involved, they are responsible for that. But we don’t have a system in place. (CO_MW_2.2)

#### Working in isolation

The situation was exacerbated by the absence of relevant training or continuous professional development opportunities available to district surgical teams. Respondents highlighted that such opportunities would help them to become familiar with best practices on surgical monitoring and quality control approaches.

> [Staff] are just working continuously and we don’t receive much external help, like a mentorship from outside…so you find that they are losing out on certain information and training. (Anaes_ZM_1.15)

According to respondents, the consequence of working in isolation and lack of formal supervision at DHs was the inability to compare their practices with others (including external surgical teams), leading to missed opportunities for improvement in quality standards.

> I was thinking if there can be feedback from others, like they see how you are doing it and they tell you ‘no this is not actually how you are supposed to do it, this is how you do it’. Maybe that would be best (MO_ZM_1.3)

#### Lack of accountability

Lastly, a small number of DH staff reported inadequate oversight mechanisms. Some respondents outlined that their hospital had committees or quality assurance teams responsible for hospital-wide standards, but which were not very active and not surgery-specific.

## Discussion

This study provides evidence on current practices and measures used for monitoring and quality control in surgical activity, processes and outcomes in a sample of 75 DHs in Malawi, Zambia and Tanzania. We found lack of standardisation in monitoring and quality control practices across surgically active sampled DHs in all three countries.

Multiple registers sometimes recording the same procedure were consistent findings across hospitals and countries. The use of handwritten registers in Malawi and Tanzania contributed to inconsistencies in the number and range of indicators recorded. As other studies from the region have demonstrated, lack of standardisation contributes to duplication of patient records,60 increased staff workload61 and inaccuracies and inefficiency in reporting into the national HMIS.60 61 Incomplete, damaged and lost hospital records in Malawi and Zambia are consistent with published literature,8 34 44 60 62 although low proportions of missing data in our sample of Tanzanian OT registers contrast with previous studies.63 64 Likely contributory factors for missing data were lack of oversight and direction from higher levels; and because data utilisation, where it happened, focused on its value for informing procurement and budgeting, rather than on analysing and improving the quality of surgical patient care. Less than half of surgical teams in our sample reviewed data on their own performance. This is in line with findings from other studies, which report that neither district healthcare nor administrative staff are adequately trained in data collection and analysis activities.60 61 63 65

Perioperative mortality rate (POMR) is an important indicator of surgical quality.66 The absence of standardised data on outcomes and risk stratifiers of surgery, often because the OT register format does not capture such information, impacts on the extent of retrospective data available to calculate POMR.67 As reported elsewhere, lack of such data and missing data impair capacity to monitor and compare performance within and between countries, so as to improve the delivery of surgical care.66 68 This is also likely to impact negatively on the effectiveness and efficiency of planning processes, resource allocation and performance assessment, both at hospital and health system levels.1

It is difficult to conclude whether the low proportion of DHs using the WHO SSCs were to be expected, as published literature reports checklist implementation in hospitals between 12% and 100%.20 47 69 However, SSC utilisation in our study fell far short of recommended standards for hospitals internationally,16 as well as the target for SSC implementation at all levels of hospitals in Tanzania.50 Barriers to the use of checklists, which were not explored in this study, include: staff turnover, poor work-flow practices, staff resistance and lack of knowledge; and lack of resources, particularly in LMICs,20 47 all of which could be addressed.70 However, the significantly higher proportion of faith-based hospitals (largely from Tanzania in our sample) that use SSCs and undertake surgical case reviews suggests that supportive oversight can achieve improvements.

The higher proportions of DHs in Zambia conducting surgical audits and completing morbidity and mortality reports, compared with DHs in Malawi and Tanzania, may be due to the Zambia Quality Assurance Programme which emphasised the use of outcome data for DH performance monitoring,71 again pointing to the potential of national initiatives. Overall, our results reflect other retrospective studies from the region, including at higher levels of care, which report the absence of surgical audits.8 37 Poor data collection systems and sporadic implementation of other quality measures could be attributed to lack of external supervision in most surveyed hospitals. COST-Africa, a clinical officer surgical training programme in Malawi and Zambia, implemented DH in-service training and supervision, delivered by referral hospital specialist surgeons, from 2013 to 2016, which demonstrated improvements in DH surgical productivity.72 73 External supervision, with the exception of an NGO-financed supervision captured in our survey, had been phased out by 2017 in Malawi. External supervision was not conducted in the surveyed DHs in Tanzania, and was conducted in only two surveyed DHs in Zambia.

The development of standardised country and international surgical information systems is undermined by the lack of consensus on the minimum set of indicators necessary to inform evidence-based monitoring of health service delivery,4 as well as absence of clear guidelines for standardised surgical indicators, data collection methodology and how to integrate such measures into national and international databases.52 Accordingly, the National Surgical, Obstetric and Anaesthesia Plans in Tanzania and Zambia have emphasised the need to strengthen national surgical information systems and quality practices in hospitals at all levels.49 50 74 However, national plans alone will be insufficient. A district perspective is essential, as is regular oversight and engagement with DH surgical teams, strengthening their capacity and understanding of the value of well-collected and analysed patient-related data for improving surgical quality of care.

### Limitations

Several limitations were identified in this study. First, although data reported in this paper have been triangulated using mixed-methods, data were still predominantly self-reported, introducing a potential bias. Second, we did not interview DH information officers. Therefore, reports from participants that hospital administration did not fully understand, or share data with surgical departments, could not be cross-checked. Further research is needed, which was beyond the scope of this study, to investigate how surgical information is used by DH information officers, which would allow assessment of other aspects of data quality such as accuracy, reliability and integration into existing health information systems. Finally, there are limits to the generalisability of results in Zambia and Tanzania because our study only covered a selected geographical area. Also, we focused specifically on district-level surgical care delivery, so further research is needed to compare surgical monitoring and quality control practices across all care levels to draw a more complete picture of the national situation in each country.

## Conclusion

In conclusion, our results indicate potential for improvements in embedding monitoring of the delivery of surgical care and quality control systems’ measures as part of routine delivery of surgical care at district hospitals, which are the entry points to essential surgical services for rural populations in SSA. In particular, improvements are needed in standardisation of data collection practices; and in ensuring data completeness, analysis and utilisation for improving patient outcomes.4 48 The study highlights the need for stronger national oversight of district-level surgical quality of care; resources and capacity strengthening of district surgical teams to analyse and use the surgical data they produce and the incorporation of surgical quality indicators into national health information systems.

## Data availability statement

Data (deidentified participant data) are available on reasonable request from the corresponding author.

## Ethics statements

### Patient consent for publication

Not required.

### Ethics approval

Ethical approval was granted by Research Ethics Committee of the Royal College of Surgeons in Ireland: REC 1417; College of Medicine Research Ethics Committee in Malawi: No. P.05/17/2179; University of Zambia Biomedical Research Ethics Committee: No. 005-05-17; Kilimanjaro Christian Medical College Research Ethics (No. CRERC 2026) and National Institute for Medical Research in Tanzania (No. NIMR/HQ/R.8a/Vol. IX/2600). All Ministries of Health approved the DH data collection. Informed audio-recorded consent was obtained from the study participants.

## Footnotes

*   Twitter @SURGAfrica

*   Contributors MCl: this author helped conceive the original idea and study design; helped with data acquisition, analysis and interpretation and helped review the literature, write the first draft of the manuscript and approve the final manuscript. CP: this author helped conceive the original idea and study design; helped with data acquisition, analysis and interpretation and helped critically appraise and approve the final manuscript. LB, MI, HB: these authors helped with data interpretation and critically appraise and approve the final manuscript. MCh, GM, AJ, GL: these authors helped with data acquisition and critically appraise and approve the final manuscript. EB, CL, JK, NM, KC, RB, JG: these authors helped conceive the original idea and study design and critically appraise and approve the final manuscript.

*   Funding This study was funded by Horizon 2020 Framework Programme (Grant number: 733391).

*   Competing interests None declared.

*   Provenance and peer review Not commissioned; externally peer reviewed.

*   Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

[https://creativecommons.org/licenses/by/4.0/](https://creativecommons.org/licenses/by/4.0/)
This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: [https://creativecommons.org/licenses/by/4.0/](https://creativecommons.org/licenses/by/4.0/).

## References

1.  Meara JG, Leather AJM, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386:569–624.[doi:10.1016/S0140-6736(15)60160-X](http://dx.doi.org/10.1016/S0140-6736(15)60160-X)pmid:http://www.ncbi.nlm.nih.gov/pubmed/25924834
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1016/S0140-6736(15)60160-X&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=25924834&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

2.  Organisation for Economic Cooperation and Development. Ministerial statement: the next generation of health reforms. OECD health Ministerial meeting, Paris, 2017. Available: [https://www.oecd.org/health/ministerial-statement-2017.pdf](https://www.oecd.org/health/ministerial-statement-2017.pdf) [Accessed 16 Nov 2020].
    
    

3.  Kruk ME, Gage AD, Arsenault C, et al. High-Quality health systems in the sustainable development goals era: time for a revolution. Lancet Glob Health 2018;6:e1196–252.[doi:10.1016/S2214-109X(18)30386-3](http://dx.doi.org/10.1016/S2214-109X(18)30386-3)pmid:http://www.ncbi.nlm.nih.gov/pubmed/30196093
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1016/S2214-109X(18)30386-3&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

4.  World Health Organization,OECDInternational Bank for Reconstruction and Development. Delivering quality health services: a global imperative for universal health coverage. Geneva, 2018. Available: [https://apps.who.int/iris/handle/10665/272465](https://apps.who.int/iris/handle/10665/272465) [Accessed 16 Nov 2020].
    
    

5.  Woodward CA. Strategies for assisting health workers to modify and improve skills : developing quality health care : a process of change. Geneva: World Health Organization, 2000.
    
    

6.  Wilson RM, Michel P, Olsen S, et al. Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital. BMJ 2012;344:832. [doi:10.1136/bmj.e832](http://dx.doi.org/10.1136/bmj.e832)pmid:http://www.ncbi.nlm.nih.gov/pubmed/22416061
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

7.  Sobhy S, Zamora J, Dharmarajah K, et al. Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Glob Health 2016;4:e320–7.[doi:10.1016/S2214-109X(16)30003-1](http://dx.doi.org/10.1016/S2214-109X(16)30003-1)pmid:http://www.ncbi.nlm.nih.gov/pubmed/27102195
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

8.  Lillie EMMA, Holmes CJ, O'Donohoe EA, et al. Avoidable perioperative mortality at the University teaching Hospital, Lusaka, Zambia: a retrospective cohort study. Can J Anaesth 2015;62:1259–67.[doi:10.1007/s12630-015-0483-z](http://dx.doi.org/10.1007/s12630-015-0483-z)pmid:http://www.ncbi.nlm.nih.gov/pubmed/26419248
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

9.  Weiser TG, Gawande A. Excess Surgical Mortality: Strategies for Improving Quality of Care. In: Disease control priorities. Third Edition. The World Bank, 2015: 279–305.
    
    

10. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008;372:139–44.[doi:10.1016/S0140-6736(08)60878-8](http://dx.doi.org/10.1016/S0140-6736(08)60878-8)pmid:http://www.ncbi.nlm.nih.gov/pubmed/18582931
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1016/S0140-6736(08)60878-8&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=18582931&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 
    
    [Web of Science](http://qualitysafety.bmj.com/lookup/external-ref?access_num=000257552400028&link_type=ISI) 

11. Sobhy S, Arroyo-Manzano D, Murugesu N, et al. Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis. Lancet 2019;393:1973–82.[doi:10.1016/S0140-6736(18)32386-9](http://dx.doi.org/10.1016/S0140-6736(18)32386-9)pmid:http://www.ncbi.nlm.nih.gov/pubmed/30929893
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

12. Organisation for Economic Cooperation and Development. Tackling Wasteful spending on health. Paris: OECD Publishing, 2017.
    
    

13. Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety: strengthening a value-based approach to reducing patient harm at national level. Paris, 2017. Available: [https://doi.org/10.1787/5a9858cd-en](https://doi.org/10.1787/5a9858cd-en)
    
    

14. Mock CN, Donkor P, Gawande A, et al. Essential surgery: key messages from disease control priorities, 3rd edition. Lancet 2015;385:2209–19.[doi:10.1016/S0140-6736(15)60091-5](http://dx.doi.org/10.1016/S0140-6736(15)60091-5)pmid:http://www.ncbi.nlm.nih.gov/pubmed/25662414
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1016/S0140-6736(15)60091-5&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=25662414&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

15. McQueen KAK. Editorial perspective: global surgery: measuring the impact. World J Surg 2013;37:2505–6.[doi:10.1007/s00268-013-2198-z](http://dx.doi.org/10.1007/s00268-013-2198-z)pmid:http://www.ncbi.nlm.nih.gov/pubmed/23989465
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

16. World Health Organization. Who guidelines for safe surgery: 2009 safe surgery saves lives. Geneva, 2009.
    
    

17. World Health Organization. Surgical care at the district hospital. Geneva, 2003.
    
    

18. Health Metrics Network,World Health Organization. Framework and standards for country health information systems. Geneva, 2012. Available: [http://www.who.int/about/licensing/copyright\_form/en/index.html](http://www.who.int/about/licensing/copyright_form/en/index.html) [Accessed 16 Apr 2020].
    
    

19. AbouZahr C, Boerma T. Health information systems: the foundations of public health. Bull World Health Organ 2005;83:578–83.[doi:/S0042-96862005000800010](http://dx.doi.org//S0042-96862005000800010)pmid:http://www.ncbi.nlm.nih.gov/pubmed/16184276
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=16184276&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 
    
    [Web of Science](http://qualitysafety.bmj.com/lookup/external-ref?access_num=000231343800008&link_type=ISI) 

20. Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf 2014;23:299–318.[doi:10.1136/bmjqs-2012-001797](http://dx.doi.org/10.1136/bmjqs-2012-001797)pmid:http://www.ncbi.nlm.nih.gov/pubmed/23922403
    
    [Abstract/FREE Full Text](http://qualitysafety.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoicWhjIjtzOjU6InJlc2lkIjtzOjg6IjIzLzQvMjk5IjtzOjQ6ImF0b20iO3M6MTk6Ii9xaGMvMzAvMTIvOTUwLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

21. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–9.[doi:10.1056/NEJMsa0810119](http://dx.doi.org/10.1056/NEJMsa0810119)pmid:http://www.ncbi.nlm.nih.gov/pubmed/19144931
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1056/NEJMsa0810119&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=19144931&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 
    
    [Web of Science](http://qualitysafety.bmj.com/lookup/external-ref?access_num=000262812400008&link_type=ISI) 

22. Kao LS, Ghaferi AA, Ko CY, et al. Reliability of superficial surgical site infections as a hospital quality measure. J Am Coll Surg 2011;213:231–5.[doi:10.1016/j.jamcollsurg.2011.04.004](http://dx.doi.org/10.1016/j.jamcollsurg.2011.04.004)pmid:http://www.ncbi.nlm.nih.gov/pubmed/21622011
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1016/j.jamcollsurg.2011.04.004&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=21622011&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

23. Campbell WB. Surgical morbidity and mortality meetings. Ann R Coll Surg Engl 1988;70:363–5.pmid:http://www.ncbi.nlm.nih.gov/pubmed/3207327
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

24. English M, Mwaniki P, Julius T, et al. Hospital Mortality - a neglected but rich source of information supporting the transition to higher quality health systems in low and middle income countries. BMC Med 2018;16:32. [doi:10.1186/s12916-018-1024-8](http://dx.doi.org/10.1186/s12916-018-1024-8)pmid:http://www.ncbi.nlm.nih.gov/pubmed/29495961
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

25. Kongnyuy EJ, Mlava G, van den Broek N. Criteria-based audit to improve a district referral system in Malawi: a pilot study. BMC Health Serv Res 2008;8:190. [doi:10.1186/1472-6963-8-190](http://dx.doi.org/10.1186/1472-6963-8-190)pmid:http://www.ncbi.nlm.nih.gov/pubmed/18808678
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1186/1472-6963-8-190&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=18808678&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

26. van den Akker T, van Rhenen J, Mwagomba B, et al. Reduction of severe acute maternal morbidity and maternal mortality in Thyolo district, Malawi: the impact of obstetric audit. PLoS One 2011;6:e20776. [doi:10.1371/journal.pone.0020776](http://dx.doi.org/10.1371/journal.pone.0020776)pmid:http://www.ncbi.nlm.nih.gov/pubmed/21677788
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=21677788&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

27. Moucheraud C, Schwitters A, Boudreaux C, et al. Sustainability of health information systems: a three-country qualitative study in southern Africa. BMC Health Serv Res 2017;17:23. [doi:10.1186/s12913-016-1971-8](http://dx.doi.org/10.1186/s12913-016-1971-8)pmid:http://www.ncbi.nlm.nih.gov/pubmed/28073361
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

28. Mbondji PE, Kebede D, Soumbey-Alley EW, et al. Health information systems in Africa: descriptive analysis of data sources, information products and health statistics. J R Soc Med 2014;107:34–45.[doi:10.1177/0141076814531750](http://dx.doi.org/10.1177/0141076814531750)pmid:http://www.ncbi.nlm.nih.gov/pubmed/24914127
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1177/0141076813514681&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=24399774&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

29. Beane A, Wagstaff D, Abayadeera A, et al. Surgical surveillance in resource-poor settings. Lancet 2018;391:1571. [doi:10.1016/S0140-6736(18)30498-7](http://dx.doi.org/10.1016/S0140-6736(18)30498-7)pmid:http://www.ncbi.nlm.nih.gov/pubmed/29695338
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

30. Mutale W, Chintu N, Amoroso C, et al. Improving health information systems for decision making across five sub-Saharan African countries: implementation strategies from the African health Initiative. BMC Health Serv Res 2013;13 Suppl 2:S9. [doi:10.1186/1472-6963-13-S2-S9](http://dx.doi.org/10.1186/1472-6963-13-S2-S9)pmid:http://www.ncbi.nlm.nih.gov/pubmed/23819699
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

31. Chan M. From new estimates to better data. Lancet 2012;380:380. [doi:10.1016/S0140-6736(12)62135-7](http://dx.doi.org/10.1016/S0140-6736(12)62135-7)pmid:http://www.ncbi.nlm.nih.gov/pubmed/23245596
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

32. Uribe-Leitz T, Jaramillo J, Maurer L, et al. Variability in mortality following caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: a systematic review and analysis of published data. Lancet Glob Health 2016;4:e165–74.[doi:10.1016/S2214-109X(15)00320-4](http://dx.doi.org/10.1016/S2214-109X(15)00320-4)pmid:http://www.ncbi.nlm.nih.gov/pubmed/26916818
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

33. Bosse G, Abels W, Mtatifikolo F, et al. Perioperative Care and the Importance of Continuous Quality Improvement--A Controlled Intervention Study in Three Tanzanian Hospitals. PLoS One 2015;10:e0136156. [doi:10.1371/journal.pone.0136156](http://dx.doi.org/10.1371/journal.pone.0136156)pmid:http://www.ncbi.nlm.nih.gov/pubmed/26327392
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

34. Raff M, James MFM. An audit of anaesthetic record keeping. Southern African Journal of Anaesthesia and Analgesia 2003;9:7–9.[doi:10.1080/22201173.2003.10873005](http://dx.doi.org/10.1080/22201173.2003.10873005)
    
    

35. Delisle M, Pradarelli JC, Panda N, et al. Variation in global uptake of the surgical safety checklist. Br J Surg 2020;107:e151–60.[doi:10.1002/bjs.11321](http://dx.doi.org/10.1002/bjs.11321)pmid:http://www.ncbi.nlm.nih.gov/pubmed/31903586
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

36. Weiser TG, Haynes AB. Ten years of the surgical safety checklist. Br J Surg 2018;105:927–9.[doi:10.1002/bjs.10907](http://dx.doi.org/10.1002/bjs.10907)pmid:http://www.ncbi.nlm.nih.gov/pubmed/29770959
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1002/bjs.10907&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=29770959&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

37. Pirkle CM, Dumont A, Zunzunegui M-V. Criterion-based clinical audit to assess quality of obstetrical care in low- and middle-income countries: a systematic review. Int J Qual Health Care 2011;23:456–63.[doi:10.1093/intqhc/mzr033](http://dx.doi.org/10.1093/intqhc/mzr033)pmid:http://www.ncbi.nlm.nih.gov/pubmed/21672922
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1093/intqhc/mzr033&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=21672922&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 
    
    [Web of Science](http://qualitysafety.bmj.com/lookup/external-ref?access_num=000292834300013&link_type=ISI) 

38. Rajbhandari R, McMahon DE, Rhatigan JJ, et al. The Neglected Hospital - The District Hospital's Central Role in Global Health Care Delivery. N Engl J Med 2020;382:397–400.[doi:10.1056/NEJMp1911298](http://dx.doi.org/10.1056/NEJMp1911298)pmid:http://www.ncbi.nlm.nih.gov/pubmed/31995684
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

39. Henry JA, Frenkel E, Borgstein E, et al. Surgical and anaesthetic capacity of hospitals in Malawi: key insights. Health Policy Plan 2015;30:985–94.[doi:10.1093/heapol/czu102](http://dx.doi.org/10.1093/heapol/czu102)pmid:http://www.ncbi.nlm.nih.gov/pubmed/25261799
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1093/heapol/czu102&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=25261799&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

40. Gajewski J, Conroy R, Bijlmakers L, et al. Quality of surgery in Malawi: comparison of patient-reported outcomes after hernia surgery between district and central hospitals. World J Surg 2018;42:1610–6.[doi:10.1007/s00268-017-4385-9](http://dx.doi.org/10.1007/s00268-017-4385-9)pmid:http://www.ncbi.nlm.nih.gov/pubmed/29209733
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

41. McCord C, Mbaruku G, Pereira C, et al. The quality of emergency obstetrical surgery by assistant medical officers in Tanzanian district hospitals. Health Aff 2009;28:876–85.[doi:10.1377/hlthaff.28.5.w876](http://dx.doi.org/10.1377/hlthaff.28.5.w876)pmid:http://www.ncbi.nlm.nih.gov/pubmed/19661113
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1377/hlthaff.28.5.w876&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

42. Bosse G, Mtatifikolo F, Abels W, et al. Immediate outcome indicators in perioperative care: a controlled intervention study on quality improvement in hospitals in Tanzania. PLoS One 2013;8:65428. [doi:10.1371/journal.pone.0065428](http://dx.doi.org/10.1371/journal.pone.0065428)pmid:http://www.ncbi.nlm.nih.gov/pubmed/23776482
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

43. Kumwenda B, Jimmy-Gama D, Manyonga V. Factors Affecting Data Quality in the Malawian Health Management Information System. In: Proceedings of the IASTED International Conference health informatics (AfricaHI 2014. Calgary,AB,Canada: ACTAPRESS, 2014: 286–92.
    
    

44. Evaluation M. Improving the Quality of Zambia’s Clinical Care Data - Findings from Expedited Audits of Data Quality in 93 Health Facilities in October. Chapel Hill, 2018.
    
    

45. Fehr J, Hatz C, Soka I, et al. Antimicrobial prophylaxis to prevent surgical site infections in a rural sub-Saharan Hospital. Clin Microbiol Infect 2006;12:1224–7.[doi:10.1111/j.1469-0691.2006.01551.x](http://dx.doi.org/10.1111/j.1469-0691.2006.01551.x)pmid:http://www.ncbi.nlm.nih.gov/pubmed/17121630
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1111/j.1469-0691.2006.01551.x&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=17121630&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 
    
    [Web of Science](http://qualitysafety.bmj.com/lookup/external-ref?access_num=000242790400012&link_type=ISI) 

46. Zulu M, Chalanda M. Investigation of infection prevention and control in selected Malawian hospitals. Africa J Nurs Midwifery 2001.
    
    

47. Vivekanantham S, Ravindran RP, Shanmugarajah K, et al. Surgical safety checklists in developing countries. Int J Surg 2014;12:2–6.[doi:10.1016/j.ijsu.2013.10.016](http://dx.doi.org/10.1016/j.ijsu.2013.10.016)pmid:http://www.ncbi.nlm.nih.gov/pubmed/24239705
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

48. World Health Organisation. Essential surgical care. Aide-Memoire. surgical and emergency obstetrical care at first referral level. Available: [https://www.who.int/surgery/publications/s15985e.pdf?ua=1](https://www.who.int/surgery/publications/s15985e.pdf?ua=1) [Accessed 6 Aug 2020].
    
    

49. Citron I, Jumbam D, Dahm J, et al. Towards equitable surgical systems: development and outcomes of a national surgical, obstetric and anaesthesia plan in Tanzania. BMJ Glob Health 2019;4:e001282.[doi:10.1136/bmjgh-2018-001282](http://dx.doi.org/10.1136/bmjgh-2018-001282)pmid:http://www.ncbi.nlm.nih.gov/pubmed/31139445
    
    [Abstract/FREE Full Text](http://qualitysafety.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiYm1qZ2giO3M6NToicmVzaWQiO3M6MTE6IjQvMi9lMDAxMjgyIjtzOjQ6ImF0b20iO3M6MTk6Ii9xaGMvMzAvMTIvOTUwLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

50. Tanzania Ministry of Health Community Development Gender Elderly and Children. National surgical, obstetric and anaesthesia plan (NSOAP) 2018-2025, 2018. Available: [https://docs.wixstatic.com/ugd/d9a674_4daa353b73064f70ab6a53a96bb84ace.pdf](https://docs.wixstatic.com/ugd/d9a674_4daa353b73064f70ab6a53a96bb84ace.pdf)
    
    

51. Pittalis C, Brugha R, Crispino G, et al. Evaluation of a surgical supervision model in three African countries-protocol for a prospective mixed-methods controlled pilot trial. Pilot Feasibility Stud 2019;5:25.[doi:10.1186/s40814-019-0409-6](http://dx.doi.org/10.1186/s40814-019-0409-6)pmid:http://www.ncbi.nlm.nih.gov/pubmed/30820336
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

52. Juran S, Gruendl M, Marks IH, et al. The need to collect, aggregate, and analyze global anesthesia and surgery data. Can J Anaesth 2019;66:218–29.[doi:10.1007/s12630-018-1261-5](http://dx.doi.org/10.1007/s12630-018-1261-5)pmid:http://www.ncbi.nlm.nih.gov/pubmed/30484168
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1007/s12630-018-1261-5&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

53. WHO, USAID. Health facility & community data. Geneva, 2014. Available: [www.who.int/about/licensing/copyright\_form/en/index.html](http://www.who.int/about/licensing/copyright_form/en/index.html) [Accessed 6 Aug 2020].
    
    

54. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101.[doi:10.1191/1478088706qp063oa](http://dx.doi.org/10.1191/1478088706qp063oa)
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1191/1478088706qp063oa&link_type=DOI) 

55. Pluye P, Hong QN. Combining the power of stories and the power of numbers: mixed methods research and mixed studies reviews. Annu Rev Public Health 2014;35:29–45.[doi:10.1146/annurev-publhealth-032013-182440](http://dx.doi.org/10.1146/annurev-publhealth-032013-182440)pmid:http://www.ncbi.nlm.nih.gov/pubmed/24188053
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1146/annurev-publhealth-032013-182440&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=24188053&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 
    
    [Web of Science](http://qualitysafety.bmj.com/lookup/external-ref?access_num=000336207500004&link_type=ISI) 

56. Creswell JW. A Concise introduction to mixed methods research. SAGE Publications Inc, 2015. [https://us.sagepub.com/en-us/nam/a-concise-introduction-to-mixed-methods-research/book243856](https://us.sagepub.com/en-us/nam/a-concise-introduction-to-mixed-methods-research/book243856)
    
    

57. Fetters MD, Curry LA, Creswell JW. Achieving integration in mixed methods designs-principles and practices. Health Serv Res 2013;48:2134–56.[doi:10.1111/1475-6773.12117](http://dx.doi.org/10.1111/1475-6773.12117)pmid:http://www.ncbi.nlm.nih.gov/pubmed/24279835
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1111/1475-6773.12117&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=24279835&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 
    
    [Web of Science](http://qualitysafety.bmj.com/lookup/external-ref?access_num=000327391900002&link_type=ISI) 

58. von Elm E, Altman DG, Egger M, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. The Lancet 2007;370:1453–7.[doi:10.1016/S0140-6736(07)61602-X](http://dx.doi.org/10.1016/S0140-6736(07)61602-X)pmid:http://www.ncbi.nlm.nih.gov/pubmed/18064739
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1016/s0140-6736(07)61602-x&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

59. World Health Organization. Developing health management information systems: a practical guide for developing countries, 2004.
    
    

60. Kasambara A, Kumwenda S, Kalulu K, et al. Assessment of implementation of the health management information system at the district level in southern Malawi. Malawi Med J 2017;29:240.[doi:10.4314/mmj.v29i3.3](http://dx.doi.org/10.4314/mmj.v29i3.3)pmid:http://www.ncbi.nlm.nih.gov/pubmed/29872514
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

61. Leza D, Phiri J. Challenges of medical records interoperability in developing countries: a case study of the University teaching hospital in Zambia. Ijacsa 2019;10:556–64.[doi:10.14569/IJACSA.2019.0100171](http://dx.doi.org/10.14569/IJACSA.2019.0100171)
    
    

62. Bagheri Nejad S, Allegranzi B, Syed SB, et al. Health-care-associated infection in Africa: a systematic review. Bull World Health Organ 2011;89:757–65.[doi:10.2471/BLT.11.088179](http://dx.doi.org/10.2471/BLT.11.088179)pmid:http://www.ncbi.nlm.nih.gov/pubmed/22084514
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.2471/BLT.11.088179&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=22084514&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 
    
    [Web of Science](http://qualitysafety.bmj.com/lookup/external-ref?access_num=000295707700014&link_type=ISI) 

63. Wilms MC, Mbembela O, Prytherch H, et al. An in-depth, exploratory assessment of the implementation of the National health information system at a district level hospital in Tanzania. BMC Health Serv Res 2014;14:91. [doi:10.1186/1472-6963-14-91](http://dx.doi.org/10.1186/1472-6963-14-91)pmid:http://www.ncbi.nlm.nih.gov/pubmed/24572013
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

64. Lodge W, Menon G, Kuchukhidze S, et al. Assessing completeness of patient medical records of surgical and obstetric patients in northern Tanzania. Glob Health Action 2020;13:1765526. [doi:10.1080/16549716.2020.1765526](http://dx.doi.org/10.1080/16549716.2020.1765526)pmid:http://www.ncbi.nlm.nih.gov/pubmed/32476620
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

65. Conradie A, Duys R, Forget P, et al. Barriers to clinical research in Africa: a quantitative and qualitative survey of clinical researchers in 27 African countries. Br J Anaesth 2018;121:813–21.[doi:10.1016/j.bja.2018.06.013](http://dx.doi.org/10.1016/j.bja.2018.06.013)pmid:http://www.ncbi.nlm.nih.gov/pubmed/30236243
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

66. Watters DA, Hollands MJ, Gruen RL, et al. Perioperative mortality rate (POMR): a global indicator of access to safe surgery and anaesthesia. World J Surg 2015;39:856–64.[doi:10.1007/s00268-014-2638-4](http://dx.doi.org/10.1007/s00268-014-2638-4)pmid:http://www.ncbi.nlm.nih.gov/pubmed/24841805
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1007/s00268-014-2638-4&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=24841805&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

67. Ariyaratnam R, Palmqvist CL, Hider P, et al. Toward a standard approach to measurement and reporting of perioperative mortality rate as a global indicator for surgery. Surgery 2015;158:17–26.[doi:10.1016/j.surg.2015.03.024](http://dx.doi.org/10.1016/j.surg.2015.03.024)pmid:http://www.ncbi.nlm.nih.gov/pubmed/25958067
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

68. Ng-Kamstra JS, Greenberg SLM, Kotagal M, et al. Use and definitions of perioperative mortality rates in low-income and middle-income countries: a systematic review. Lancet. : 2015;385 Suppl 2:S29. [doi:10.1016/S0140-6736(15)60824-8](http://dx.doi.org/10.1016/S0140-6736(15)60824-8)pmid:http://www.ncbi.nlm.nih.gov/pubmed/26313076
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

69. Borchard A, Schwappach DLB, Barbir A, et al. A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery. Ann Surg 2012;256:925–33.[doi:10.1097/SLA.0b013e3182682f27](http://dx.doi.org/10.1097/SLA.0b013e3182682f27)pmid:http://www.ncbi.nlm.nih.gov/pubmed/22968074
    
    [CrossRef](http://qualitysafety.bmj.com/lookup/external-ref?access_num=10.1097/SLA.0b013e3182682f27&link_type=DOI) 
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=22968074&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

70. Panda N, Koritsanszky L, Delisle M, et al. Global survey of perceptions of the surgical safety checklist among medical students, trainees, and early career providers. World J Surg 2020;44:2857–68.[doi:10.1007/s00268-020-05518-x](http://dx.doi.org/10.1007/s00268-020-05518-x)pmid:http://www.ncbi.nlm.nih.gov/pubmed/32307554
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

71. Bouchet B, Francisco M, Øvretveit J. The Zambia quality assurance program: successes and challenges. Int J Qual Health Care 2002;14 Suppl 1:89–95.[doi:10.1093/intqhc/14.suppl\_1.89](http://dx.doi.org/10.1093/intqhc/14.suppl_1.89)pmid:http://www.ncbi.nlm.nih.gov/pubmed/12572792
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

72. Gajewski J, Borgstein E, Bijlmakers L, et al. Evaluation of a surgical training programme for clinical officers in Malawi. Br J Surg 2019;106:e156–65.[doi:10.1002/bjs.11065](http://dx.doi.org/10.1002/bjs.11065)pmid:http://www.ncbi.nlm.nih.gov/pubmed/30620067
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

73. Gajewski J, Cheelo M, Bijlmakers L, et al. The contribution of Non-physician clinicians to the provision of surgery in rural Zambia-a randomised controlled trial. Hum Resour Health 2019;17:60. [doi:10.1186/s12960-019-0398-9](http://dx.doi.org/10.1186/s12960-019-0398-9)pmid:http://www.ncbi.nlm.nih.gov/pubmed/31331348
    
    [PubMed](http://qualitysafety.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fqhc%2F30%2F12%2F950.atom) 

74. Republic of Zambia Ministry of Health. National surgical, obstetric, and anaesthesia strategic plan (NSOAP) year 2017-2021, 2017. Available: [http://www.cosecsa.org/sites/default/files/NSOAP_May 2017.pdf](http://www.cosecsa.org/sites/default/files/NSOAP_May%202017.pdf)
    
    

75. Royal College of Surgeons of England. Safe handover: guidance from the working time directive Working Party. London, 2007.
    
    

76. Royal College of Surgeons. Morbidity and mortality meetings: a guide to good practice. London, 2018.
    
    

77. Royal College of Surgeons in Ireland. Guidelines for clinical audit. Available: [http://www.rcsi.ie/files/surgery/docs/20121109042544\_Approved Audit PDC Oct 2012.pd.pdf](http://www.rcsi.ie/files/surgery/docs/20121109042544_Approved%20Audit%20PDC%20Oct%202012.pd.pdf) [Accessed 6 Aug 2020].