Surgical Care Deficiencies and Workarounds

This blog post, focused on essential surgical inputs, is the first in a series looking at innovative solutions to fundamental challenges in the provision of safe surgical care in low-resource settings.

At the G4 Alliance, our mission is to advocate for the neglected surgical patient. While the patient's plight to gain access to safe, affordable surgical care remains at the forefront of our objective, it’s crucial to heighten awareness of local facility needs to provide that care. In order for a hospital to provide quality care, it must have certain fundamental essentials such as running water, reliable electricity, and oxygen. While that may sound obvious, the vast majority of Low- and Middle-Income Countries (LMICs) are underwhelmingly replete of these needs.

A recent survey conducted at 430 hospitals in 19 LMICs found that approximately 1/3 of participating hospitals did not have access to running water. In Liberia, as many as 80% of surveyed hospitals did not have continuous running water. A lack of essential resources not only complicates patient care but also drastically limits the efficiency of the health system.

Electricity is another essential resource to support health care delivery and well-functioning hospital systems.  Yet a 2013 WHO study found that as little as 34% of hospitals surveyed in 13 sub-Saharan African countries were found to have consistent and reliable access to electricity. Of the countries polled, only Uganda and Tanzania had 50% of their health-care facilities with access to electricity. The Gambia reported that 0% of their health-care facilities had access to electricity. These statistics point out the unfortunate truth that LMICs are far from obtaining a complete surgical ecosystem.

Fig. 1 Access to Electricity at Hospitals in Sub-Saharan Africa

Source: Powering Healthcare: The State of Play in Health Facility Electrification (Webinar), July 19, 2016; Compiled from Adair-Rohani et al. 2013 for sub-Saharan Africa, data from Guyana and Egypt is from the Service Provision Assessment (SPA) of USAID’s Measure Health Initiative (United States Agency for International Development, 2013).

Source: Powering Healthcare: The State of Play in Health Facility Electrification (Webinar), July 19, 2016; Compiled from Adair-Rohani et al. 2013 for sub-Saharan Africa, data from Guyana and Egypt is from the Service Provision Assessment (SPA) of USAID’s Measure Health Initiative (United States Agency for International Development, 2013).


In a similar study conducted by the WHO in 2008, hospitals in Liberia were found to be severely lacking in fundamental supplies and infrastructure. The results are eye-opening; with only about 31% of hospitals having access to oxygen, 18% to water, and 25% having access to electricity.  

Efficient hospitals operate like an ecosystem, with inputs, outputs, and essential processes supporting the proper functioning of the health system. When a fundamental input such as oxygen, water or electricity is lacking, the entire system suffers, impacting the ability of hospitals to deliver basic health services ranging from primary health care to emergency and essential surgery, obstetrics, trauma and anaesthesia care.

Fig 2. The Surgical Ecosystem

Source: Dr. Catherine deVries, University of Utah & G4 Alliance, 2015

Source: Dr. Catherine deVries, University of Utah & G4 Alliance, 2015

Fortunately,  a variety of innovative solutions have been developed to alleviate some of these limitations. This is where workarounds come into play. While not an end-all be-all, workarounds provide some wiggle room when dealing with fundamental problems that can’t be fixed immediately. Furthermore, there is no guarantee of the water’s cleanliness, making it difficult for surgeons to effectively clean their hands or instruments.

In addition to running water, the lack of oxygen and electricity available for anaesthesia, in particular, is a huge concern. Without a steady source of electricity, it is  nearly impossible to run an oxygen machine full-time. This is where companies like Gradian Health Systems and Diamedica play an integral role, providing alternative solutions to fundamental problems. Gradian developed a Universal Anaesthesia Machine that can operate in places where “unreliable electricity and shortages of compressed medical gases preclude the use of conventional machines.” Similarly, Diamedica’s Glostavent anesthesia machine has the ability to operate without electricity or the need for compressed gases, which better adapts to the limited resources in LMICs. Both of these innovations  offer long-term solutions in creating a more complete surgical ecosystem.

Another key component in the surgical ecosystem are cleanly instruments. When thinking about cleaning instruments, disinfection is not the answer. Surgical instruments need to be sterilized before they are used. Unlike sterilization, disinfection fails to eliminate bacterial spores which can create an unsafe environment. With a lack of access to clean water and electricity, hospitals must seek out safe alternatives to combat poor work conditions.

This is where devices like the Portable Sterilizer by Eniware comes into play. According to Eniware, the Portable Sterilizer is “environmentally friendly, easy to use, safe, and effective...the unit requires no external energy sources, including electricity or fuel.” This innovative breakthrough is another brilliant example of progress being made for sustainable equipment. With electricity being overwhelmingly deplete in most LMIC hospitals, Eniware has allowed these facilities to continue their surgical care without the fear of spreading infection or causing disease.

While these and other steps are being taken in order to alleviate the shortage of essential inputs for surgery on a fundamental level, we are far from reaching that goal. Access to basic necessities is the tip of the iceberg in the complex surgical ecosystem. Innovative solutions to provide these necessities are a great start. We must keep innovating in order to advance progress, otherwise the neglected surgical patient we advocate for is left waiting for help. Running water, electricity, and oxygen pave the groundwork for a comprehensive surgical ecosystem.

Global development and government leaders are also taking notice of the urgent need to strengthen hospital systems infrastructure to strengthen health care delivery. In a recent webinar hosted by the Clean Energy Solutions Center and the United Nations Foundation’s Energy Access Practitioner Network, a group of distinguished panelists highlighted “the role energy plays in strengthening health systems, particularly the functionality of health facilities and the services provided in them.”  

Advocacy will also play a critical role in transforming the reality of these troubling statistics. The G4 Alliance and our members remain committed to raising awareness for the importance of a well-balanced health ecosystem and the role of investment and innovation in bridging the gap between available resources and current needs.

We’re on the right track towards strengthening health care in LMICs, but there is still much work to be done. An integrated ecosystem approach will be vital to understanding what strategies will lead to the best outcomes from hospitals and the health system overall.

"The need for improved hospital care in parts of the world where there is little or none of it is hotly contested, in large part because these places also lack the staff, stuff, and systems to deliver primary and preventive care,” states by Dr. Paul Farmer, co-founder of Partners In Health and Chair of the Department of Global Health and Social Medicine at Harvard Medical School. “Development economists and public-health specialists may argue that hospitals are a bad investment, but politicians know that cutting off funding to public hospitals is politically and socially unsustainable. The debate is too rarely informed by a consideration of what it might or should cost to link hospital care to better primary care. Everyone, everywhere, is likely to need both at some point between birth and death."


Adair-Rohani, Heather, Karen Zukor, Sophie Bonjour, Susan Wilburn, Annette C. Kuesel Ryan Hebert, and Elaine R. Fletcher. "Limited Electricity Access in Health Facilities of Sub-Saharan Africa: A Systematic Review of Data on Electricity Access, Sources, and Reliability." Global Health: Science and Practice. N.p., 14 Aug. 2013. Web. 28 July 2016.

Chawla, Sagar S., Shailvi Gupta, Frankline M. Onchiri, Elizabeth B. Habermann, Adam L. Kushner, and Barclay T. Stewart. "Water Availability at Hospitals Low- and Middle-income Countries: Implications for Improving Access to Safe Surgical Care." Journal of Surgical Research. Elsevier Inc., 17 June 2016. Web. 28 July 2016. 

Sherman, Lawrence, Peter T. Clement, Meena N. Cherian, Nestor Ndayimirije, WR-Liberia, Luc Noel, Bernice Dahn, Walter T. Gwenigale, and Adam L. Kushner. "Economic Growth and Poverty Reduction Strategy." Encyclopedia of World Poverty 146 (2011): 35-39. World Heath Organization. American Medical Association, 13 Feb. 2012. Web. 28 July 2016.