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Tools & Skills
Mid term evaluation

To improve the quality of essential and emergency surgical care at district level.

To facilitate repair and replacement of equipment, instruments and materials and train the associated skills required for application and maintenance of these “tools” in the Mission and District Hospitals, targeted at all hospital workers employing them.

At present both expertise and equipment to properly carry out essential and emergency surgical procedures and –management is lacking or at least insufficient at the average hospital in the district. In consequence, this leads to
1. poor results, in terms of outcome (morbidity and mortality)
2. high costs (referral)
3. poor motivation of the staffs concerned.

An extensive survey in 2007 in the Southern Region exposed a wide spread shortage of essential equipment and instruments in all hospitals at district level. As a result, in 2008, a series of instructional workshops in basic surgical skills was embarked upon. The project includes the provision of those instruments and equipment which are essential to carry out the instructed skills.
This project has now been adopted as a CHAM project, which will enhance the scope of the project allowing it to spread out over all parts of the country as well as providing a more secure base for quality assessment and continuity. Also, acquisition of donor funds will be facilitated.
A formal relationship was established with the Kennemer Gasthuis, a large training hospital in Haarlem The Netherlands, to bring technicians and health care workers for maintenance and training purposes to the hospitals in the district.

From January 2008 6 series of workshops have been organized in the District and Mission Hospitals of the Southern region of Malawi.


* bonepinning February 2008
* sutures and suturing May-June 2008
* burns / skingraft November 2008
* POP and bandaging February 2009
* BTLS – Basic Trauma Life Support April-May 2009
* LAS – Local Anesthesia in Surgery October 2009

See separate workshop reports for details


Mission hospitals
01. Palombe, Holy Family Hospital
02. Mlambe Hospital, Lunzu
03. Mulanje Mission Hospital
04. Muona, Trinity Hospital
05. Nguludi, St Joseph's Hospital
06. Malamulo Mission Hospital
07. Montfort Hospital, Nchalo
08. St.Luke's Hospital, Malosa

District hospitals
09. Balaka District Hospital
10. Chikwawa District Hospital
11. Chiradzulu District Hospital
12. Mulanje District Hospital
13. Mwanza District Hospital
14. Mangochi District Hospital
15. Machinga District Hospital, Liwonde
16. Nsanje District Hospital
17. Thyolo District Hospital


In December 2009 and January 2010 all hospitals with the exception of St. Joseph’s Hospital Nguludi have been visited for evaluation by dr. Leonard Banza, orthopedic surgeon, Staff member of Malawi.kom.
Information have been gathered by interviewing clinicians involved (see questionnaire, appendix 1) and consultation theater books / registers.

Evaluation 1¾ year after the workshop BONEPINNING-FRACTURE TREATMENT In all hospitals the donated tools were still available. Only two of the 16 hospitals did not practice skeletal traction as demonstrated in the workshop, because of absence of Orthopedic Clinical Officers. Fracture patients in these hospitals are referred to QECH, Blantyre. In 7 hospitals a refresher course on this topic is still esteemed useful.

Evaluation 1½ year after the workshop SUTURES AND SUTURING In spite of the instruments donated by Malawi.kom, most hospitals signale a shortage of good needle holders and scissors. Two hospitals still use the wrong suture material for abdominal fascia closure (chromic catgut).

Evaluation 1 year after the workshop BURNS / SKINGRAFTING In all hospitals the donated Sober knife for skingrafting which had been demonstrated during the workshop 1 year earlier was available and ready for use. In 1 hospital it is being used regularly. 9 hospitals report having used it a few times. In the other 5 hospitals the Sober knife have not been utilized at all since because of “lack of skills, confidence and willingness”. These findings together with the need for skintransplantations in all these hospitals make repeated refresher courses / demonstrations in the near future advisable.

Evaluation 10 months after the workshop POP AND BANDAGING All donated tools for POP (Plaster Of Paris) treatment are still available and being used. The practice of POP / Bandaging is well known and executed “lege artis” in all hospitals, few complications being signaled. Refresher courses on this topic are not being asked for.

Evaluation 8 months after the workshop BASIC TRAUMA LIFE SUPPORT Bloodpressure machines, neck collars and pulse oximeters are at short distance in all hospitals. The protocols are being followed.

Evaluation 3 months after the workshop LOCAL ANESTHESIA IN SURGERY Tools and drugs are used as demonstrated at the workshop 3 months earlier in all hospitals. Surgery under local anesthesia is taking place. Only 4 hospitals claim to perform hernia repairs under local anesthesia.

Effects on morbidity and mortality cannot be assessed because of absence of reliable registration in the hospitals. Evidently in all hospitals a number of patients have been treated since, who did not receive this treatment before the training, as stated by the interviewed clinicians and indicated by the theaterbooks. Obviously this meant proportionally less referrals and related costs. Concerning the poor motivation previously of involved staffs, the spokesman of all hospitals without exception made it clear that the availability of basic instruments now, and training certain skills in the way it had been done during the workshops had stimulated the enthusiasm and motivation of the clinicians and nurses without any doubt.

For teaching and training Staff members, Clinical Officers and registrars of the Surgical, Orthopedic and Anesthetic department of QECH (Queen Elizabeth Central Hospital, Blantyre) have contributed to all workshops. They are now familiar with the Tools and Skills of the Program and will continue practicing and instructing it.
The Zonal Health Officers of the two areas of the Southern Region, although supporting fully the T & S Project could not take over the follow up of the project, in the way indicated by the Directory Clinical Services of the Ministry of Health, due to shortage of Staff. See letters Dr. Dzowela, DDCS and Dr. Chimbwandira, Zonal Health Officer, appendix 2.
From 2011 District Hospitals in the Southern region will be visited weekly by Staff members of the Surgical Department of QECH (Communication Prof Eric Borgstein), who have been involved in the Tools & Skills Program. Malawi.kom will stimulate continuation of supervising and training the skills by them, so rendering a handover. To this end part of the residual budget (if there will be any) after completion of the Project will be put at the disposal of DOS (Department Of Surgery).