World Journal of Surgery

, Volume 37, Issue 4, pp 721–729 | Cite as

Liberian Surgical and Anesthesia Infrastructure: A Survey of County Hospitals

  • Lisa Marie Knowlton
  • Smita Chackungal
  • Bernice Dahn
  • Drake LeBrun
  • Jason Nickerson
  • Kelly McQueen



There is a significant burden of disease in low-income countries that can benefit from surgical intervention. The goal of this survey was to evaluate the current ability of the Liberian health care system to provide safe surgical care and to identify unmet needs in regard to trained personnel, equipment, infrastructure, and outcomes measurement.


A comprehensive survey tool was developed to assess physical infrastructure of operative facilities, education and training for surgical and anesthesia providers, equipment and medications, and the capacity of the surgical system to collect and evaluate surgical outcomes at district-level hospitals in Africa. This tool was implemented in a sampling of 11 county hospitals in Liberia (January 2011). Data were obtained from the Ministry of Health and by direct government-affiliated hospital site visits.


The total catchment area of the 11 hospitals surveyed was 2,313,429—equivalent to roughly 67 % of the population of Liberia (3,476,608). There were 13 major operating rooms and 34 (1.5 per 100,000 population) physicians delivering surgical, obstetric, or anesthesia care including 2 (0.1 per 100,000 population) who had completed formal postgraduate training programs in these specialty areas. The total number of surgical cases for 2010 was 7,654, with approximately 43 % of them being elective procedures. Among the facilities that tracked outcomes in 2010, a total of 11 intraoperative deaths (145 per 100,000 operative cases) were recorded for 2009. The 30-day postoperative mortality at hospitals providing data was 44 (1,359 per 100,000 operative cases). Metrics were also used to evaluate surgical output, safety of anesthesia, and the burden of obstetric disease.


A significant volume of surgical care is being delivered at county hospitals throughout Liberia. The density and quality of appropriately trained personnel and infrastructure remain critically low. There is strong evidence for continued development of emergency and essential surgical services, as well as improved surgical outcomes tracking, at county hospitals in Liberia. These results serve to inform the international community and donors of the ongoing global surgical and anesthesia crisis.


Pulse Oximetry County Hospital Anesthesia Care Anesthesia Provider Heavily Indebted Poor Country 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors thank the Republic of Liberia Ministry of Health and Social Welfare as well as William E. Martin for their support and assistance in providing countrywide data.


  1. 1.
    Debas HT, Gosselin R, McCord C et al (2006) Surgery. In: Jamison DT, Breman JG, Measham AR et al (eds) Disease control priorities in developing countries. Oxford University Press, New York, pp 1245–1260Google Scholar
  2. 2.
    Farmer PE, Kim JY (2008) Surgery and global health: a view from beyond the OR. World J Surg 32:533–536. doi: 10.1007/s00268-008-9525-9 PubMedCrossRefGoogle Scholar
  3. 3.
    Gosselin R, Maldonado A, Elder G (2010) Comparative cost-effectiveness analysis of two MSF surgical trauma centers. World J Surg 34:415–419. doi: 10.1007/s00268-009-0230-0 PubMedCrossRefGoogle Scholar
  4. 4.
    Gosselin RA, Heitto M (2008) Cost-effectiveness of a district trauma hospital in Battambang, Cambodia. World J Surg 32:2450–2453. doi: 10.1007/s00268-008-9708-4 PubMedCrossRefGoogle Scholar
  5. 5.
    Shillcutt SD, Clarke MG, Kingsnorth AN (2010) Cost-effectiveness of groin hernia surgery in the western region of Ghana. Arch Surg 145:954–961PubMedCrossRefGoogle Scholar
  6. 6.
    Gosselin R, Gialamas G, Atkin D (2011) Comparing the cost-effectiveness of short orthopedic missions in elective and relief situations in developing countries. World J Surg 35:951–955. doi: 10.1007/s00268-010-0947-9 PubMedCrossRefGoogle Scholar
  7. 7.
    Freudenberg S, Sano D, Ouangré E et al (2006) Commercial mesh versus nylon mosquito net for hernia repair: a randomized double-blind study in Burkina Faso. World J Surg 30:1784–1789. doi: 10.1007/s00268-006-0108-3 PubMedCrossRefGoogle Scholar
  8. 8.
    Chu K, Trelles M, Ford N (2011) Quality of care in humanitarian surgery. World J Surg 35:1169–1172. doi: 10.1007/s00268-011-1084-9 PubMedCrossRefGoogle Scholar
  9. 9.
    Ozgediz D, Jamison D, Cherian M et al (2008) The burden of surgical conditions and access to surgical care in low- and middle-income countries. Bull World Health Organ 86:646–647PubMedCrossRefGoogle Scholar
  10. 10.
    Sherman L, Clement PT, Cherian MN et al (2011) Implementing Liberia’s poverty reduction strategy: an assessment of emergency and essential surgical care. Arch Surg 146:35–39PubMedCrossRefGoogle Scholar
  11. 11.
    Notrica M, Evans F, Knowlton L et al (2011) Rwandan surgical and anesthesia infrastructure: a survey of district hospitals. World J Surg 35:1770–1780. doi: 10.1007/s00268-011-1125-4 PubMedCrossRefGoogle Scholar
  12. 12.
    Linden A, Sekidde F, Galukande M et al (2012) Challenges of surgery in developing countries: a survey of surgical and anesthesia capacity in Uganda’s public hospitals. World J Surg 36:1056–1065. doi: 10.1007/s00268-012-1482-7 PubMedCrossRefGoogle Scholar
  13. 13.
    Central Intelligence Agency (2012) The World FactbookGoogle Scholar
  14. 14.
    Liberia Institute of Statistics and Geo-Information Services (2009) 2008 National population and housing census final results. Monrovia, LiberiaGoogle Scholar
  15. 15.
    Republic of Liberia Ministry of Planning and Economic Affairs (2006) United Nations Development Program National Human Development report 2006Google Scholar
  16. 16.
    Challoner K, Forget N (2011) Effect of civil war on medical education in Liberia. Int J Emerg Med 4:6PubMedCrossRefGoogle Scholar
  17. 17.
    United Nations Development Program (2010) The real wealth of nations: pathways to human development. Palgrave MacMillan, New YorkGoogle Scholar
  18. 18.
    Republic of Liberia Ministry of Planning and Economic Affairs (2010) Millennium Development Goals 2010 reportGoogle Scholar
  19. 19.
    Liberia Institute of Statistics and Geo-Information Services (2008) Liberia demographic and health survey 2007. Monrovia, LiberiaGoogle Scholar
  20. 20.
    World Health Organization (2009) WHO country cooperation strategy 2008–2011. WHO Regional Office for Africa, BrazzavilleGoogle Scholar
  21. 21.
    Liberia Institute of Statistics and Geo-Information Services (2010) The national census of health workers in Liberia 2009. Monrovia, LiberiaGoogle Scholar
  22. 22.
    Enarson P, La Vincente S, Gie R et al (2008) Implementation of an oxygen concentrator system in district hospital paediatric wards throughout Malawi. Bull World Health Organ 86:344–348PubMedCrossRefGoogle Scholar
  23. 23.
    Peel D, Howie SRC (2009) Oxygen concentrators for use in tropical countries: a survey. J Clin Eng 34:205–209Google Scholar
  24. 24.
    Funk LM, Weiser TG, Berry WR et al (2010) Global operating theater distribution and pulse oximetry supply: an estimation from reported data. Lancet 376:1055–1061PubMedCrossRefGoogle Scholar
  25. 25.
    Howie SR, Hill SE, Peel D et al (2008) Beyond good intentions: lessons on equipment donation from an African hospital. Bull World Health Organ 86:52–56PubMedCrossRefGoogle Scholar
  26. 26.
    Groen RS, Samai M, Kamara TB et al (2012) The unmet surgical disease burden in the developing world. Lancet 379:616PubMedCrossRefGoogle Scholar
  27. 27.
    Groen R, Samai M, Petroze R et al (2012) Pilot testing of a population-based surgical survey tool in Sierra Leone. World J Surg 36:771–774. doi: 10.1007/s00268-012-1448-9 PubMedCrossRefGoogle Scholar
  28. 28.
    Chu KM, Ford N, Trelles M (2010) Operative mortality in resource-limited settings: the experience of Medecins Sans Frontiers in 13 countries. Arch Surg 145:721–725PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2013

Authors and Affiliations

  • Lisa Marie Knowlton
    • 1
    • 2
  • Smita Chackungal
    • 1
  • Bernice Dahn
    • 3
  • Drake LeBrun
    • 4
  • Jason Nickerson
    • 5
  • Kelly McQueen
    • 6
  1. 1.Harvard School of Public HealthHarvard UniversityBostonUSA
  2. 2.Department of General SurgeryUniversity of British ColumbiaVancouverCanada
  3. 3.Ministry of Health and Social WelfareMonroviaLiberia
  4. 4.Thomas J. Watson FoundationNew YorkUSA
  5. 5.Centre of Global HealthInstitute of Population Health, University of OttawaOttawaCanada
  6. 6.Harvard Humanitarian InitiativeHarvard UniversityBostonUSA

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