The impact of the increasing burden of trauma in Malawi on orthopedic trauma service priorities at Kamuzu Central Hospital

Abstract

Background and purpose - The burden of road traffic injuries globally is rising rapidly, and has a huge effect on health systems and development in low- and middle-income countries. Malawi is a small low-income country in southeastern Africa with a population of 16.7 million and a gross national income per capita of only 250 USD. The impact of the rising burden of trauma is very apparent to healthcare workers on the ground, but there are very few data showing this development. Patients and methods - The annual number of femoral fracture patients admitted to Kamuzu Central Hospital (KCH) in the Capital of Malawi, Lilongwe, from 2009 to 2014 was retrieved from the KCH trauma database. Linear regression curve estimation was used to project the growth in the burden of femoral fractures and the number of operations performed for femoral fractures over the same time period. Results - 992 patients with femoral fractures (26% of all admissions for fractures) presented at KCH from 2009 through 2014. In this period, there was a 132% increase in the annual number of femoral fractures admitted to KCH. In the same time period, the total number of operations more than doubled, but there was no increase in the number of operations performed for femoral fractures. Overall, there was a 7% mortality rate for patients with femoral fractures. Interpretation - The burden of femoral fractures in Malawi is rising rapidly, and the surgical resources available cannot keep up with this development. Limited funds for orthopedic trauma care in Malawi should be invested in central training hospitals, to develop a sustainable number of orthopedic surgeons and improve current infrastructure and equipment. The centralization of orthopedic surgical care delivery at the central training hospitals will lead to better access to surgical care and early return of patients to local district hospitals for rehabilitation, thus increasing surgical throughput and efficiency in a more cost-effective manner, with the goal of expanding the future orthopedic surgical workforce to meet the national need.

Figure 1.

Malawi is a densely populated, landlocked country in southern Africa. About twothirds of the length of the country lies along the western shore of Lake Malawi, the third largest lake in Africa after Lake Victoria and Lake Tanganyika. Courtesy of d-maps.com (http://www.dmaps.com).

Figure 2.

Observed annual number of adult femoral fractures admitted to KCH (top, blue), and the annual number of femoral IM nails performed at KCH (bottom, green). The straight lines in red are the regression-line estimations with projections for the coming years. An increasing gap is apparent between femoral trauma burden and delivery of service.

Figure 3.

The annual number of orthopedic operations performed at KCH from 2008 through 2014 (black) shows a rapid increase in surgical activity after international support for the KCH surgery training program started in 2008, but this appears to have reached a plateau from 2011 onwards due to the availability of only 1 theater. The regression-line estimation (red) shows a statistically signifi cant increase in surgical activity over the whole period (p = 0.009).