1 Introduction

Studying surgical services and the workforce in sub-Saharan Africa is crucial for enhancing access to quality surgical care in the region. The limited available literature primarily focuses on basic obstetric and trauma care [1]. Surgical conditions, particularly abdominal emergencies, are considered by some authors to be “other neglected tropical diseases”. Conditions such as appendicitis, peritonitis, bowel obstruction, and strangulated hernias seem to be overlooked components of surgical efforts compared to trauma and obstetric care [2]. Despite numerous recommendations advocating for the production of evidence based on reliable data on this subject to guide policymakers, there is only one out of five countries in the Sub-Saharan African region that produces data on surgical volume [3, 4]. This knowledge gap underscores the urgent need for concerted efforts to address abdominal emergencies in particular and surgical care in general in the region.

Senegal, with a population of ~ 18 million people, experiences an unequal distribution of medical practitioners across its regions [5, 6]. Over one-third of healthcare professionals are based in the Dakar Region, the nation's capital [7]. This imbalance may affect the availability of specialized health practitioners. Furthermore, challenges related to human resources and financial barriers contribute to limited access to healthcare services in Senegal as well as in many low- and middle-income countries [8]. Several individual research studies conducted in Senegal have focused on abdominal emergencies, primarily examining patient profiles and prognostic factors [9,10,11].

The World Health Organization (WHO) has set a goal of achieving universal access to safe and affordable surgical care for all countries [12]. In Senegal, the first step toward achieving this goal is to obtain reliable data about abdominal surgical emergencies. Therefore, it is imperative to address this information gap to inform health policies and enhance the quality of healthcare in sub-Saharan Africa. This nationwide survey aimed to study the organization of abdominal emergency surgical care across healthcare services in Senegal.

2 Methodology

2.1 Design

This was a cross-sectional nationwide survey. The study period was between October 1st, 2023, and January 20th, 2024.

2.2 Population and sampling

The target population included all registered healthcare facilities in Senegal that supply emergency surgical services. Only surgical services for handling abdominal surgical emergencies were included, and private facilities were excluded.

We excluded private facilities due to logistical constraints and data accessibility issues in private healthcare facilities. Additionally, public hospitals are often the primary providers of emergency services, especially for lower-income populations who may not have access to private healthcare.

The sampling frame for these services was derived from the list of health structures and services provided by the Directorate of Public Health Facilities of the Ministry of Health and Social Action of Senegal.

2.3 Study setting

The study was performed in 14 regions of Senegal, which is a West African country that have a population of 18,032,473 people in 2023, resulting in a density of 92 inhabitants per square kilometer. The population exhibits a male predominance of 50.6% [5]. The majority of the population is concentrated in urban areas, with Dakar being the most populated city, accounting for 21.6% of the total population [13]. The gross domestic product per capita is $1,446 combined with a poverty line of 34% [13]. The Senegalese health system is a pyramid structure with three levels: central, intermediate, and peripheral. The public health facilities, or hospitals, serve as referral centers at the central level, followed by health centers at the intermediate level and health posts at the peripheral level. Similarly, public health facilities are classified into three levels (Level 1, 2 and 3) based on the specialized care available, with Level 3 being the most advanced.

The healthcare system in Senegal is based on 56 district units. Public and private services are provided in hospitals, health centers, health posts, and clinics [6]. According to the National Statistics and Demography Agency in 2019, there were 40 public health facilities [7]. The distribution of healthcare personnel across regions shows that the Dakar region accounts for more than one-third (36%) of healthcare professionals [7]. Figure 1 shows the public health facility with abdominal surgical emergency activity using GPS data from the published “master facility list” of Senegal (database of all healthcare establishments within a country) [14].

Fig. 1
figure 1

Senegal map showing the public health facility (blue dots: GPS localization) with abdominal surgical emergency activity (created with Google Maps) [14]

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2.4 Survey tool and studied parameters

A structured questionnaire was designed to gather data on organizational characteristics. The questionnaire underwent pretesting for clarity and relevance.

The questionnaire survey was designed to be brief and easily completed. The 15 questions were divided into 3 sections.

  • Section I addressed the following infrastructure-related data: the type of health-care facility (level 1, 2 and 3), working hours, availability and type of surgical coverage, presence of dedicated operating rooms for abdominal emergency surgery, availability of appropriate equipment in operating rooms, number of beds in the department, and existence and number of beds specifically designated for patients requiring special monitoring.

  • Section II focused on surgical activities, including the number of scheduled surgeries, the number of emergency surgeries, the existence of  morbidity and mortality meetings and their frequencies, collaboration with other departments in the hospitals, and the presence of mechanisms to collect and assess patient satisfaction.

  • Section III centered on human resources: the existence of continuing professional development programs, the number of surgeons, the evaluation of the adequacy of human resources, and strategies employed to address shortages in human resources.

2.5 Data collection

In each hospital, the surgeon or designated staff members responsible for surgical services were contacted by phone to complete the online questionnaire (supplementary file). The data were collected using a self-administered online survey form via the ONA data kit. No sampling was conducted, and all hospitals were included in the survey.

2.6 Definition of terms

  • Abdominal Surgical Emergency: Any condition requiring emergency laparotomy, typically of digestive origin, excluding vascular, urological, and gynecological-obstetric causes. Examples include intestinal obstruction, generalized acute peritonitis, acute appendicitis, and abdominal trauma.

  • General Surgeon: A physician who specializes in general surgery, holds a Doctor of Medicine degree and a specialized degree in general surgery and is responsible for managing abdominal surgical emergencies.

  • Residents: medical doctors who have completed their initial medical training and are currently undergoing specialized training in surgery.

  • Trainees doctors: medical students who are in the final stages of their initial training and who are undertaking internships in various departments, including surgical services.

  • Nurses: Paramedical healthcare professionals who provide direct patient care under the supervision of physicians and surgeons.

  • Nurses trainees: Paramedical healthcare professionals in the final stages of their initial training who provide direct patient care under the supervision of seniors nurses.

  • Temporary workers: Medical or paramedical practitioners without a permanent contract who provide services in hospitals.

  • Surgical coverage: medical team available to respond to emergencies or provide necessary surgical care outside regular working hours.

2.7 Data analysis

Categorical variables in the descriptive study were described in terms of frequency and proportion, while quantitative variables were presented as the means with their extremes or standard deviations. Charts, plots, and maps were generated via Microsoft Excel and Google Maps.

3 Results

All 33 identified healthcare facilities responded to the survey (100%). Table 1 shows the city, name and type of surveyed health care facility. Table 2 describes the characteristics of the health-care facilities surveyed.

Table 1 City, name and type of surveyed health-care facility (n = 33)
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Table 2 Characteristics of the health-care facilities surveyed (n = 33)
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3.1 Infrastructure

The health-care facility levels varied, with 51.6% at level 2, 30.3% at level 1, and 18.1% at level 3. The emergency abdominal surgery department was available for 96.7% of the surveyed structures. The team primarily consisted of surgeons and residents (45.2%) or surgeons and medical trainees (48.8%). The average bed capacity of the services was 21.9, with a standard deviation of 13.9. The absence of a dedicated hospitalization section for patients requiring special monitoring was found in 69.6% of facilities. However, those equipped with such beds typically had two (12.1%) or three (15.0%) beds. Dedicated operating rooms for abdominal emergency surgery were present in more than half (54.6%) of the departments. The availability of appropriate equipment within operating rooms was reported by 57.5% of facilities.

3.2 Surgical activities

On average, the services performed 17.6 scheduled surgical interventions with a standard deviation of 11.5 and 29.7 emergency surgical interventions with a standard deviation of 16.8 per month. Morbidity and mortality conferences were not routinely held in the majority of departments (only 27.3%). Among those conducting such meetings, the most common frequency was monthly (14.1%). Nearly all departments (96.9%) reported collaboration with other departments, primarily through phone calls (84.8%) and visits (45.4%). Multidisciplinary meetings were less common (6.6%).

3.3 Human resources

Professional development programmes were present only in 24.2% of departments. The most common types of programs offered were masterclasses or staff meetings (12.1% each). A total of 70 surgeons were identified, resulting in a national ratio of 0.39 general surgeons per 100,000 inhabitants, as described in Table 3. Figure 2 illustrates the density of general surgeons per 100,000 inhabitants, while Fig. 3 depicts the number of health care facilities handling abdominal surgical emergencies per region.

Table 3 General surgeon density across different Senegalese regions
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Fig. 2
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Senegal map showing the general surgeon density per 100,000 habitants (created with Microsoft Excel) [5, 7]

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Fig. 3
figure 3

Senegal map showing the number of health care facilities handling abdominal surgical emergencies per region (created with Microsoft Excel) [5, 7]

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Service heads reported a shortage of an adequate number of surgeons. Most of the departments did not have adequate human resources (69.6%). The strategies employed to address staff shortages included additional working hours by staff (54.5%), temporary workers (30.3%) or the use of trainee doctors or nurses (12.1%).

4 Discussion

The World Health Organization considers surgery a fundamental component of universal health coverage that plays a crucial role in achieving equitable advancements in global health and well-being [15].

This cross-sectional nationwide survey aimed to comprehensively assess the organizational aspects of abdominal emergency surgical care across healthcare services in Senegal. By systematically examining organizational characteristics, this research seeks to provide valuable insights that can contribute to improving resource allocation, enhancing the coordination of surgical activities, and ultimately increasing the access to and quality of emergency abdominal surgery across all levels of healthcare provision in Senegal [16].

We found an inadequate number of beds and human resources available in the operating room, indicating a need for prioritized resource allocation. This suggests a need for targeted resource allocation based on facility level and patient needs. Higher-level facilities should be equipped with dedicated beds for critically ill patients and additional operating rooms to handle the greater surgical burden. In fact, the number of hospital beds, particularly for surgical patients requiring specific surveillance, is an important indicator of the efficacy and fluidity of surgical care [17,18,19].

In addition, team composition should be strengthened. Most medical teams are composed of surgeons and less qualified staff. Promoting multidisciplinary teams and a sufficient number of healthcare practitioners by improving the quality of training could enhance patient care and outcomes [20, 21]. Similarly, only 24.2% of the participants reported continuing professional development programs. Continuing to invest in comprehensive and targeted professional development programs for the surgical workforce is essential for maintaining and enhancing skills, adapting to new technologies, and addressing specific departmental needs [21]. Professional development for surgical staff is crucial, particularly in settings where resources and access to training are limited. A previous study in East, Central, and Southern Africa demonstrated the feasibility of online training to enhance continuing surgical education and improve learning outcomes [22]. This strategy could help Senegalese health systems to have sufficient specialist surgeons at different levels of care [23].

Moreover, enhancing surgical capacity can improve patient outcomes. For example, a study from Malawi showed an increase in the mortality rate of patients transferred from district hospitals due to the inadequacy of these facilities to manage these patients [24]. Similarly, Parker et al. (2020) demonstrated that curative surgery significantly improves survival rates for colorectal cancer in rural settings, underscoring the need for increased surgical capacity to improve outcomes [25]. This suggests that enhancing surgical capacity, particularly for emergency abdominal surgeries, could lead to better health outcomes in the Senegalese context.

Morbidity and mortality conferences were not routinely held (only 27.3%). Implementing regular morbidity and mortality conferences across all departments can facilitate knowledge sharing, improve case management, and potentially reduce adverse outcomes. This would be an overall effort to expand collaboration with other departments to optimize resource utilization and patient flow [26, 27]. These meetings could help identify specific solutions to reduce complications. An example of implementing such solutions is the establishment of a surgical critical care service. A study in Kenya demonstrated that this approach led to a reduction in failure-to-rescue rates in emergency abdominal surgery [28].

4.1 Limitations

The cross-sectional design of this study provides information only at a single point in time, limiting the ability to assess changes over time. In addition, the self-reported nature of the data by department introduces the potential for bias and inaccuracies. The study did not investigate patient outcomes, restraining the understanding of the relationship between infrastructure, practices, and clinical effectiveness. Besides, the study focused only on public healthcare facilities, which may introduce bias by not providing an overall view of emergency abdominal surgery availability in Senegal. Consequently, the generalisability of the results may be limited. In fact, previous reports suggest that nearly 40% of healthcare services in the African region, including Senegal, are provided by the private sector [29]. Future studies should include private healthcare facilities to provide a more comprehensive assessment.

4.2 Strengths and perspectives

To the best of our knowledge, this study is the first of its kind to explore abdominal emergency surgical care across senegalese healthcare services. This study's importance lies not only in potentially informing healthcare policymakers but also in guiding healthcare practitioners toward aligning their efforts with best practices in emergency surgical care. This study provides insight for policy makers and future directions for research and practice. Future studies could expand the knowledge in this field by using the World Health Organization (WHO) tool for situational analysis to assess emergency and essential surgical care [30]. The use of qualitative methods, such as interviews and observations, can help researchers explore more deeply the reasons behind reported practices and identify potential barriers to improvement. Outcome-based studies could also help in investigating the associations among specific infrastructure characteristics, collaborative practices, and patient outcomes in terms of morbidity, mortality, and length of stay .

5 Conclusion

This research indicates that significant deficiencies are present in the essential physical and human resources required to conduct fundamental life-saving surgical procedures. It provides a snapshot of the infrastructure and surgical activities of abdominal emergency surgery departments in Senegal. It highlights variations in facility levels, team composition, and resource availability. While most departments have readily available surgical teams, dedicated beds for critically ill patients and operating rooms for emergency surgery are not ubiquitous. Furthermore, routine morbidity and mortality conferences are lacking in many departments. These findings suggest potential areas for improvement in the delivery of emergency surgical care in the region.