Improving quality of surgical and anaesthesia care at hospital level in Sub-Saharan Africa: a systematic review protocol of health system strengthening interventions. PROSPERO Registration number: CRD42019125570

Introduction: Over 5 billion people in the world do not have access to safe, affordable surgical and anaesthesia care when needed. In order to improve health outcomes in patients with surgical conditions, both access to care and the quality of care needs to be improved. A recent commission on high quality health highlighted that poor-quality care is now a bigger barrier than non-utilisation of the health system for reducing mortality.
Aim: To carry out a systematic review to provide an evidence-based summary of hospital-based interventions associated with improved quality of surgical and anaesthesia care in Sub-Saharan African countries (SSACs).
Methods and Analysis: Three search strings: 1) surgery and anaesthesia, 2) quality improvement hospital-based interventions, 3) SSACs will be combined.
The following databases: EMBASE, Global Health, MEDLINE, CINAHL, Web of Science and Scopus will be searched. Further relevant studies will be identified from national and international health organisations and publications and reference lists of all selected full text articles.
The review will include all type of original articles in English. Article screening, data extraction and assessment of methodological quality will be done by two reviewers independently and any disputes will be resolved by a third reviewer or team consensus. Three types of outcomes will be collected including clinical, process and implementation outcomes. The primary outcome will be mortality. Secondary outcomes will include other clinical outcomes (major and minor complications), as well as process and implementation outcomes. Descriptive statistics and outcomes will be summarised and discussed. For the primary outcome the methodological rigour will be assessed.
Ethics and Dissemination: The results will be published in a peer reviewed open access journal and presented at national and international conferences. As this is a review of secondary data no formal ethical approval is required.
Conclusion: The results will inform development of Quality Improvement Intervention (QII) in surgical and anaesthetic care in the hospital setting in SSACs.
Protocol PROSPERO registration number CRD42019125570

Strengths and Limitations of this study
• A comprehensive search strategy for original articles and grey literature both published and unpublished was created and included.
• The inclusion of all fields of surgery in the search strategy will ensure that no health system strengthening interventions (HSSI) implemented within Sub-Saharan Africa (SSA) region are missed.
• It is possible that the included studies (and reported data) will be too few to address the objectives of this study.
• There is the potential that the data retrieved from different studies may not be applicable to every SSA country context due to differences in the healthcare system and therefore will need to be carefully adapted to the context of another country.
• Although every effort will be made to address the publication bias we acknowledge that unsuccessful quality improvement efforts and unwanted side-effects are rarely published. Therefore, this review may not reflect the real current experience of failed attempts in the field of quality improvement of surgical care.