Challenges to fracture service availability and readiness provided by allopathic and traditional health providers: national surveys across The Gambia and Zimbabwe.

Background: Populations in Africa are ageing, hence the number of age-related fragility fractures, including hip fractures, is rising. Hip fractures are an indicator condition for older adult health provision, as they require a multifaceted pathway of care. To enable health service planning, detailed national-level understanding of current fracture service provision is needed.

Methods: The WHO Service Availability & Readiness Assessment survey was modified to evaluate fracture service availability, and readiness. All health care facilities to which a patient with a hip fracture could present in The Gambia and Zimbabwe were invited to participate between October 2021 and January 2023. A further traditional bone-setter (TBS)-specific survey assessed TBS care in The Gambia. Availability of services per 100 000 adults ≥ 18 years, and general, fracture-specific, and hip fracture-specific care readiness were determined.

Results: All invited facilities in Zimbabwe (n = 186), 98% in The Gambia (n = 150), and 35 of 42 (83%) TBS participated in the survey. General availability of hospital facilities was low in both Zimbabwe and The Gambia and many facilities lacked regular electricity, reliable oxygen supplies, and sharp/infectious waste disposal. In The Gambia, 78.6% public hospitals and 53.8% other facility types (e.g. NGO/mission) had no doctors. Fracture care readiness: < 1 orthopaedic surgeon was available for 100 000 adults in both countries. Orthopaedic trained nurses, physiotherapists, and occupational therapists were few. Only 10 (6.7%) facilities in The Gambia and 56 (30.1%) in Zimbabwe had functioning X-ray facilities. Equipment for fracture immobilisation was widely unavailable. No public facility had a dual-energy X-ray absorptiometry scanner; antiresorptive treatment access was limited to < 5% facilities. Hip fracture readiness: only four facilities in The Gambia and 17 in Zimbabwe could offer surgery. Inpatient delays for surgery were long, especially in Zimbabwe. Non-operative management was common in Zimbabwe and in those visiting TBS in The Gambia. Over half TBS (51.4%) reported being able to set a hip fracture, management included traditional medicines (57.1%), splinting (20.0%), manipulation (14.3%) and traction (5.7%). Only 14.3% TBS referred hip fractures to hospital.

Conclusions: Findings highlight multiple important modifiable gaps in care which warrant urgent focus, with recommendations made, given expected increases in fragility fractures and need for universal health coverage.