The MMR on perioperative care challenges involved a quantitative survey and semi-structured interviews with 20 perioperative clinicians. The data were presented in five domains: infrastructure, service delivery, workforce, information management, and financing. Each domain’s qualitative findings were connected to the quantitative survey findings, and three additional subthemes emerged from the inductive analysis of interview data: sociopolitical landscape, leadership and governance, and global events (such as COVID-19 and market volatility).

Infrastructure

The three teaching hospitals, DUGH, HUSH, and WUSH, serve about 23 million people. About 26,272 surgical admissions (approximately 115 surgeries per 100,000 population) were recorded over 1 year (January 01 to December 25, 2022). Obstetric and gynecologic surgical procedures comprised approximately 74.58% (19,593/26,272) of the total surgical admissions, while the rest were from other surgical departments, including orthopedics. The hospitals’ infrastructure was not readily available during the hospital walkthrough survey. Table 1 displays the mean frequency of the availability of perioperative infrastructure over the 5-month study period.

Table 1 Mean availability of perioperative infrastructure in three teaching hospitals of southern Ethiopia, Sept. 1, 2022, to Jan 30, 2023

Two themes were generated from the interview data: scarcity and system breakdown (inadequate equipment and supplies, and malfunctioning infrastructure) and cascading impact on frontline workflow, with shortages of anesthetic drugs and inadequate laboratory and radiological services being the most recurring concerns. Clinicians reported these issues hindering patient care, causing surgery cancelations, delays, errors, and an increased risk of complications. A participant commented,

“…when it comes to materials and equipment, for example, cautery machines, autoclaves, and suction machines are not enough or some of them are not functioning well. … there has been cancellation of surgical cases due to shortage of anesthetic medications.” (Participant 1).

Talking about perioperative efficiency and workflow, a clinician said:

“The workflow in the operating room is inefficient, and there is a lack of space and the number of OR tables are not adequate.” (Participant 2).

The MMR found that blood shortages are a significant challenge in hospitals, with availability only 26–50% of the time. The mean time to get in-stock and out-of-stock blood after placing an order is 0.42 (0.14) and 13.67 (9.61) h, respectively. Perioperative clinicians acknowledged that these shortages resulted surgery cancelations, treatment delays, and even death. Factors contributing to these shortages include declining blood donations, increased demand, and issues with blood collection and storage. The excerpt below highlights the many challenges that hospitals face when blood supply is short.

“Another major barrier to the cancellation of the cases is blood shortages…, and it is usually difficult to get type-specific blood; and there are more cases of blood shortage related cancellations than for other reasons; and there is also a problem with blood collection in blood banks and a policy problem at a national level. In the past for example, hospitals used to collect from volunteering patient attendants or family—it was a practical alternative to replacing hands-on blood.” (Participant 3).

Participants’ account revealed that problems span from poor blood collection practices in blood banks to the national policy issues hindering effective blood management. It suggests that a multifaceted approach is needed to address blood collection practices, storage policies, and potential policy changes to ensure a reliable blood supply for surgical procedures.

Overall, the study revealed perioperative challenges due to a shortage of essential equipment and supplies, including anesthetic drugs, blood products, laboratory services, and operating room supplies, with a cascading effect to frontline care delivery.

Service delivery: surgical volume, quality, and safety

Of the total surgical admissions over a year, Bellwether procedures comprised about 41.38% (10,872/26,272). Cesarean deliveries contributed the highest (9027/10,872, 83.03%) among the Bellwether procedures followed by open fracture repair including fixation (1049/10,872, 9.65%) and laparotomy (796/10,872, 7.32%). Further analysis of the survey data revealed that the WHO surgical safety checklist and perioperative monitoring standards were used 76–100% of the time, whereas there was poor compliance to the use of perioperative protocols or guidelines (1–25% usage rate). Table 2 shows the summary statistics for mean frequency of usage of quality and safety assurance mechanisms.

Table 2 Mean usage rate of quality and safety assurance mechanisms in three teaching hospitals of southern Ethiopia, Sept. 1, 2022, to Jan 30, 2023

Three themes were constructed from the qualitative interviews of clinicians related to service delivery: poor patient safety culture (PSC) such as poor compliance to and incomplete use of safety checklists, protocols, and guidelines, top-down approach quality improvement (QI), and fragmented perioperative communication.

Most interviewees stated that there is incomplete documentation of perioperative care and they do not always use the WHO safety checklist. They also noted the lack of existing perioperative PSC and poor compliance to the utilization of protocols and guidelines. For example, a clinician expressed the issue as follows:

“… there is a WHO checklist and that is good at least we have started it, but it is only filled the ‘time out’ section most of the time; I mean, we don’t fill in a ‘sign in’ and ‘sign out’—and it often differs from one professional to another; and sometimes they forget attaching it with a patient chart.” (Participant 5).

Another said:

“There have been many instances of implementation training and team meetings to improve our documentation problems and to fill existing gaps, but there is no tangible change.” (Participant 15).

Furthermore, clinicians believe that there is inadequate interprofessional communication, collaboration, and team-based care among hospital departments, leading to delays in care, errors, and patient harm. For example, a clinician said:

“We sometimes take part in quality meetings but not often.” (Participant 13).

Another described it as follows: “The surgeon may not be aware of the patient’s medical history, or the nurse may not be aware of the surgeon’s instructions.” (Participant 12).

The interviews also revealed that perioperative QI initiatives are not sustainable and challenging to improve care over time. For instance, one interviewee explained the issue as

“there are some quality improvement projects, like SaLTS [saving lives through safe surgery], that are conducted to increase OR efficiency and quality of surgical and anesthesia care. The problem, however, is that projects often begin, but we do not see a sustainable change. The baseline problem usually recurs in the middle of the projects or after completion.” (Participant 8).

Taken together, the qualitative themes focused on the pervasive weaknesses in the perioperative safety culture and the ineffectiveness of current improvement efforts. The excerpts suggest a sense of frustration and powerlessness among the clinicians, with a pessimistic overall tone regarding the current state of perioperative practices. While they acknowledge their participation in some practices like safety checklists, they also express a lack of tangible change despite repeated training and meetings. This suggests that they may not feel fully empowered to implement or enforce stricter protocols. The lack of sustainable improvement suggests a need for a more comprehensive approach to addressing the root causes of the quality and safety issues.

Surgical workforce

Combining all the surgical, obstetric, and anesthesia (SOA) specialist workforce together, there were only 0.58 practitioners per 100,000 population at the participating teaching hospitals. There were 62 OR nursing practitioners (mean (SD), 13.3 (4.9) per hospital). Table 3 illustrates the surgical workforce volume at the surveyed hospitals during data collection period.

Table 3 Perioperative workforce density in three teaching hospitals of southern Ethiopia, Sept. 1, 2022, to Jan 30, 2023

The interview data analysis produces two major themes related to the workforce, which are job dissatisfaction and uncertainties about workforce volume. Concerns regarding lack of job satisfaction were more widespread among healthcare professionals. They raised several factors, including unfair pay, lack of recognition, lack of health insurance, high workload, and poor workplace conditions. For example, one clinician said,

“I don’t think the country’s salary for health professionals goes with standard of living, especially from the current inflation.” (Participant 6).

Perioperative clinicians’ workforce volume is a topic of debate, with some arguing a shortage, others criticize the quality of health professional education and subspeciality care. For example, a participant put it as follows:

“There is still a shortage of human power per the capacity this hospital can deliver. If I tell you the OR nursing standard for example, there should be minimum of three nurses per table, I mean scrub, circulator, and runner; but it has not been possible until now in this hospital.” (Participant 1).

Another said:

“…the number of professionals is increasing now; on top of that, the shortage of human power has decreased because of the increase in residents [Surgical fellow students] intake capacity. … We cannot say that there is a shortage of human power per the capacity this hospital can deliver. However, there are still no subspecialist surgeons; for example, there are many patients who are referred to another institution for neuro, thoracic and pediatric surgery.” (Participant 9).

In general, the findings revealed that hospitals were understaffed, with the SOA specialist workforce below 1 per 100,000 population per cadre. Also, providers reported that there is job dissatisfaction among clinicians which might have an indirect effect on the quality of perioperative care they deliver.

Budget and financing

A survey of participating hospitals revealed that less than 10% of patients had health insurance coverage for perioperative care. The out-of-pocket costs of surgical care were unknown. However, the hospitals covered the cost of maternity care, including cesarean delivery, for free. Analysis of interview data showed that costly perioperative care, insufficient or nonexistent health insurance, insufficient hospital funding for surgical care, and treating patients who lacked insurance or financial resources raised ethical and moral concerns among clinicians.

Providers recognize that financial barriers to surgical care impact patient care-seeking behavior, leading to delays. They occasionally offer free care, particularly for emergency cases. For example, one clinician said,

“Most of the patients come to government medical facilities with the assumption of getting medical care with minimal payment or for free; and many say, ‘we don’t have the money’ after the procedure is done—it is the biggest challenge.” (Participant 5).

Another said,

“Sometimes a patient who can’t pay comes for surgery, especially for emergency surgery, and we use OR reserve supplies, to provide the service—you can’t deny an emergency care; and sometimes we, professionals, even spend money ourselves and buy important supplies for patients; but there’s no other way to provide care for such patients.” (Participant 20).

Providers also reported that government health insurance does not cover all surgical procedures, and many patients lack coverage. Commenting on this issue, one interviewee said,

“There are a small number of patients with health insurance; what’s the problem? most of the supplies are not found in hospitals, including anesthetic agents; it means that patients buying from a private pharmacy will be covering the expense by their-selves, and you know it is unintended.” (Participant 18).

Moreover, clinicians argue that the government lacks sufficient funding for surgical care, resulting in shortages of essential supplies and equipment. The availability of anesthetic drugs and other surgical supplies is often limited. They suggest a need for upscale surgical care financing. Explaining this matter, one clinician said,

“The biggest problem is that availability of the hospital’s supply of anesthetic drugs and other surgical supplies, such as gloves, catheters, stiches, and so on, and it runs out quickly and often. There is a need to upscale surgical care financing. I don’t believe that the authorities well consider the surgical service.” (Participant 8).

A lack of clarity exists regarding providing care to patients who cannot afford or lack insurance. Providers acknowledge delays in care, cancelations of procedures, and complications due to delayed care. A participant put it as follows:

“The worst thing is when a patient who can’t pay comes to us. It is extremely hard, especially in emergency situations, because every minute and hour count on the patient’s outcome. It’s clear that the outcome will be poor as such patients wait more time to get the service, but we can’t do anything as professionals—we have no option.” (Participant 14).

Clinicians often face ethical and moral dilemmas when patients cannot afford surgical care. They must decide whether to provide care to those who cannot pay or turn the patient away. For example, a provider stated,

“sometimes you may get leftover OR supplies from other patients; so, we, the surgical team, let emergency patients get the surgical services for free, but it is not always possible. It is a moral burden as a clinician to decide on such issues. I believe hospitals should have a mechanism for such patients, like a social service or something else.” (Participant 19).

Overall, the MMR reveals inadequate hospital financing and high perioperative cost. Qualitative themes focused on the ethical and moral burdens and frustration faced by clinicians due to the excessive cost of perioperative care, insufficient financial resources, and lack of a clear policy on providing care to those who cannot afford it. While clinicians acknowledge some resourcefulness, like using leftover supplies, they primarily view themselves as bystanders in a situation beyond their control. The overall tone is pessimistic as clinicians are caught between providing necessary care and the limitations imposed by the financial system. They emphasize the need for improved financing and clear guidelines to address these ethical dilemmas.

Information management

Two out of the three surveyed teaching hospitals had electronic HMIS at admission, but all the perioperative data recording was paper based. Further survey analysis revealed that perioperative patient outcome data, such as postoperative mortality and complications, anesthesia-related adverse events, and nursing care adverse events, were collected only sometimes (26–50% of the time). In contrast, two themes emerged from the interview transcript: fragmented and inconsistent health data recording and poor support system for research and quality improvement (QI) projects.

The clinicians reported that the information management system at their hospital is not adequate. This includes problems with accessing patient information, lost records, and a lack of coordination between different departments. For example, an interviewee said,

“For new patients coming to our hospital, their information is now computerized; but once they are triaged to each ward, they get a paper-based medical card; some medical charts may be lost; and sometimes we have difficulty obtaining a prior medical history.” (Participant 9).

Another said:

“Sometimes the card number of patients can be lost; sometimes, if it’s soon enough, some clinicians who have given the medical care may remember the patients’ past situation, and they’re issued a new medical card number. But it is not good practice, I believe.” (Participant 18).

Interviewees acknowledged that the challenges related to health information management make it difficult to track a patient’s progress and to provide continuity of care or may even have a medicolegal concern. Explaining this issue, a clinician said:

“There were also times when we met a medicolegal issue, and we lost a patient’s medical record. We need to improve the way we manage patient health data and the hospital information system in general.” (Participant 11).

The providers also reported that there is difficulty accessing perioperative data for research purposes and that lack of funding for perioperative QI projects. This makes it difficult to track patient outcomes and identify areas for improvement. A clinician commenting on this theme said:

“the experts who access the patient charts do not easily cooperate, … I’m not sure but I haven’t ever heard a hospital budget that is specifically funded for QI projects or clinical audit purpose; We need a system in place to collect data and track patient outcomes. We also need funding to support research projects.” (Participant 6).

In summary, this study found that most of the health data recording was paper-based; that there was no a clear mechanism to track perioperative outcome data prospectively over time; that there was poor health data management system, such as poor documentation, difficulty in accessing prior patient information, and a lack of coordination between different department; and that there was poor support system for research and QI projects.

Sociopolitical landscape, leadership and governance, and global events

The clinicians reported that the sociopolitical unrest in Ethiopia has also had a significant impact on the hospital’s ability to provide safe and quality perioperative care. This includes violence and instability in the region, which has made it difficult to get perioperative supplies due to disruptions to supply chains; a decrease in government funding for healthcare, which has led to cuts in services; and a decrease in public trust in the healthcare system. For example, a provider explained the issue as follows:

“… the price of medications and other supplies is being increased from time to time; it’s often hard to find the materials we want; it’s hard to say that we’re providing standardized healthcare service; and I think all this problem is related to the social unrest in the country. And you know we have been in political turmoil, even we had a civil war [occurred in northern Ethiopia]. These are big issues for all these shortages of the basic needs in healthcare.” (Participant 2).

Another said:

“domestic civil and political unrest and global market instability have a significant impact on our medical delivery; it’s hard to give quality surgical care. The community already has financial hardship, it’s become harder and harder to pay for medical expenses.” (Participant 12).

While some clinicians acknowledge the disruptive effects of COVID-19 on the global market and healthcare delivery, they generally view it as an exacerbating factor rather than the root cause of problems. They argue that sociopolitical instability creates a more significant challenge, making it difficult to respond effectively to the pandemic. For example, one participant put it as follows:

“COVID-19 has disrupted the global market; I understand that, but it is affecting all not only us; if we were stable inside, its impact would have been negligible, because you can see many countries, including those in Africa, have already recovered from it. So, our internal unrest takes the lion’s share; and COVID is a complement.” (Participant 3).

Another said:

“… COVID has shown us how our healthcare system is poor; … there is an improvement in IPC [infection prevention and control]—our facemask use is improved; for example, there were professionals who entered the OR without wearing a mask. However, much has changed since the coronavirus—the overall healthcare system has been disrupted since then; surgical supplies and medications have been expensive.” (Participant 10).

Finally, perioperative providers have identified a lack of good leadership and governance at both local and national levels as a significant challenge in the healthcare system. They have reported corrupt and unskilled healthcare leaders and a lack of prioritization among authorities. For example, one clinician expressed the issue as follows:

“What worries me most is, the authorities do not seem to be ready to change the problems of the healthcare system; some of them are corrupted and others are politically delegated without any healthcare leadership training or lack the necessity experience. Overall, I believe the administrative perspective towards healthcare, particularly for surgery, must be improved, I mean, here at hospital or the university and at national level.” (Participant 7).

Together, participants’ narratives highlighted the detrimental impact of external factors, such as weak national governance, sociopolitical instability, resource constraints, and global market volatility on the hospital’s ability to deliver safe and quality perioperative care. The overall tone is pessimistic regarding the ability to provide optimal care under these circumstances. Therefore, the findings suggest that clinicians feel impacted by these external factors, rather than being a direct cause of the problems.

Putting all findings together, this MMR revealed persisting major gaps in Ethiopian perioperative care. A joint display table linking the key survey findings of perioperative hospital capacity to quotes of contextual challenges perceived by clinicians is shown as an additional.pdf file. In this table, meta-inferences are shown with colored arrows, indicating convergence (agreement), complementarity (different but non-contradictory interpretations), or expansion (allowing for overlap and further interpretation) between the findings. There was no divergence (conflicting interpretations) during the linking activity (Additional file 1). In addition, the schematic concept map in Fig. 2 visually depicts the intricate interplay among the key qualitative themes and survey results. This visualization displays how these interconnected challenges disrupt the quality and safety of perioperative care within the system.

Fig. 2

A concept map of interconnected perioperative care challenges and associated quality and safety disruption, 2023. Note: Red text boxes imply illustrative quantitative data points for each domain. Abbreviation: HIMS, health information management system; SOA, surgical, obstetrics, and anesthesia