Limited sterile processing capabilities for safe surgery in low-income and middle-income countries: experience in the Republic of Congo, Madagascar and Benin

It is highly difficult to perform safe surgery without sterile instruments, yet the capacity to adequately clean, disinfect and sterilise surgical instruments in low-income and middle-income countries is largely unknown. Sterile Processing Education Charitable Trust developed an assessment tool and, in partnership with Mercy Ships, evaluated the sterile processing capacity in 59 facilities in Madagascar, Benin and the Republic of Congo. This data-driven analysis paper illustrates how lack of sterile processing capacity acts as a barrier to safe surgical care. Our tool identified widespread lack of knowledge of techniques and resources needed for sterile processing. Only 12% of workers in Republic of Congo and Benin had sterile processing training and none in Madagascar. None of the hospitals surveyed met basic standards for cleaning, disinfection and sterilisation as defined by the WHO/Pan American Health Organization. Examples of poor practice included lack of cleaning supplies (basic brushes and detergents), incorrect drying and storage of surgical instruments, and inattention to workflow causing cross-contamination. Bleach (sodium hypochlorite) solutions, damaging to instruments, were used universally. In our experience, using an assessment tool allowed identification of specific gaps in sterile processing capacity. Many of the gaps are amenable to simple solutions requiring minimal resources and achievable by most hospitals. We recommend that stakeholders seeking to strengthen surgical health systems in low-resource settings incorporate sterile processing capacity assessments and training into their programmes.