Geneva Health Forum Archive

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Training African Doctors in Surgery for HIV Prevention: The ‘Operation AB’ Model and its Successful Pilot Testing in Swaziland

Author(s): I. I. Schenker*1, E. Gross2, D. P. Simelane3
Affiliation(s): 1International Department, Jerusalem AIDS Project, 2Pediatric Surgery, Hadassah Medical Organization, Jerusalem, Israel, 3ED, Family Life Association of Swaziland, Manzini, Swaziland
Keywords: Male circumcision, HIV prevention, global health, technology transfer, international collaboration, training

Male Circumcision (MC) is a proven HIV prevention intervention. Three controlled trials provided evidence that MC reduces the probability of transmission from infected women to men by up to 60%. Countries most affected by HIV/AIDS need now to develop evidence-based policies, programmes and training; and be guided by the international community how to scale-up or role-out MC services. Swaziland has pioneered in pilot testing a technology transfer and training model in which Israeli and Swazi physicians trained together in scaling up MC for HIV prevention at a community based clinic.


‘Operation AB’ -launched in October 2007- is an international partnership aimed at significantly scaling up MC in Swaziland through capacity building and training. The project brings together The Jerusalem AIDS Project, a veteran non-profit NGO, based in Israel, The Hadassah Medical Organization, The Government of Swaziland and FLAS. The project brought to Swaziland a unique experience in massive MC gained in Israel for a decade.


The pilot project entailed three delegations of two Israeli surgeons and one health educator. Each team visited Mbabane two weeks. During each period the JAIP-Hadassah experts provided training in MC, clinical and public health guidance and supported service delivery at community-based clinics and government hospitals. Several hundred procedures were performed and 10 local doctors trained in adult MC. Scaling up of MC services resulted in a dramatic increase of procedure per day (maximum = 15)and halving the turnover time between patients.

Lessons learned:

Israeli surgeons gained a unique experience providing adult MC services for migrating from Eastern Europe and Ethiopia ages 96Y to 6M. 80,000 adult MCs were performed from 1989 to 2007 in Israel, an unprecedented experience in the field. Developing and implementing an international collaboration in surgical training for MC and the technology transfer to Swaziland, where HIV prevalence is close to 40% and MC prevalence is less than 15% - is doable, rewarding to both trainers and trainees and could be replicated to other countries.

Noma: Niger-Switzerland Collaboration for an Aetiological Research Project


D. Baratti-Mayer*1, I. Bolivar2, B. Stadelmann2, A. Mombelli3, J. Schrenzel4, B. Pittet5, D. Montandon5, S. Hugonnet6, J. Bornand7, A. Gervaix8, A. Jaquinet9, D. Pittet6

Affiliation(s): 1GESNOMA-Plastic and Reconstructive Surgery, University Hospitals of Geneva, 2Institut für Angewandte Immunologie, IAI, Zuchwil, 3Periodontology and Oral Pathophysiology, School of Dental Medicine, 4Genomic Research Laboratory, 5Plastic and Reconstructive Surgery, 6Infection Control Programme, 7Central Laboratory of Virology, 8Paediatry, 9Maxillo-facial Surgery, University Hospitals of Geneva, Switzerland
Keywords: Noma, oral bacteria, Niger, phylogeny
Background: Noma is a gangrenous disease which leads to severe disfigurement with high mortality and morbidity, affecting almost exclusively young children in the poorest populations. Even if noma has been known since Antiquity, its cause remains unknown. A bacteriological aetiology has long been hypothesized. Some bacteria have been identified in samples taken from noma cases: Prevotella melaninogenica, Corynebacterium pyogenes, Fusobacterium nucleatum, Bacteroides fragilis, Bacillus cereus, Prevotella intermedia and Fusobacterium necrophorum. However, due to the rapidity of the disease progression and the remote areas where the children live, only 10% attend an adequate centre during the acute phase. For these reasons, some of the investigated lesions were not acute and might have been most probably colonized by non-pathogenic bacteria or infected or superinfected by organisms of questionable pathogenicity. In addition, only culture techniques which failed to identify some fragile bacteria and difficult to grow were available in the field. Finally, control children were never included.

Microbiological studies conducted on the aetiology of noma have failed to identify a putative pathogen, mainly because of field and technical difficulties. To obtain a description of the oral flora of noma and control children, it was indispensable to have: a local team able to recognize the diseased population, provide explanations to parents, and include rapidly every acute case; and a state-of-the art and up to date laboratory able to apply molecular methods to frozen samples.  GESNOMA (Geneva Study group on Noma) is a group of two teams of healthcare workers, one located in Zinder (Niger) and the other in Geneva. The Niger team has been taught sampling techniques and collected samples, frozen in Zinder, were analysed in Geneva. The Geneva multidisciplinary team includes experts in paediatrics, dentistry, periodontology, plastic and maxillofacial surgery, epidemiology, infectious diseases, virology, biology and genomics. The project started in September 2001; its main part is designed as a case-control study including acute cases of noma in children less than 12 years old. For each case, four control children from the same village and the same age were included. We also included children presenting an acute necrotising gingivitis (ANG), a lesion which often precedes the development of noma. Every child underwent general, facial and oral examination. Samples of gingival fluid, blood and mucosal swabs were collected. For noma cases, diseased and healthy sites were sampled. The first objective of the study was to document and compare bacterial flora in oral samples of children with or without, noma or ANG.


A preliminary bacteriological analysis has been conducted on the first included cases: 23 acute noma and 9 children with ANG. For each child, the closest age-matched control of the same sex was selected. The total 78 samples were pooled in seven libraries according to child and site status and analysed for bacterial composition by molecular methods (PCR, cloning, sequencing). The observed diversity represented 339 bacterial species. Analysis showed that Prevotella intermedia and members of the Peptostreptococcus genus are associated with the disease, without distinction between noma and ANG.

Lessons learned:

This study, suggesting that noma can be considered as a progression of an ANG, is an example of a research project of a disease affecting the poorest populations. In the same way as noma requires complex surgery not always possible under field conditions, the study of its aetiology needs sophisticated microbiological techniques usually not available in the local country. But do these local difficulties mean that we have to stop any aetiological investigation of this terrible scourge affecting African children?

Duration of Post Vesico Vaginal Fistula Surgery Urethral Catheter: How Short is Long Enough?

Author(s): S. J. Lengmang1
Affiliation(s): 1Evangel Vesico Vaginal Fistula Centre, Jos, Nigeria
Keywords: Vesico vaginal fistula, urethral catheter, duration, quality of care

It is estimated that there are about two million women with genital fistula globally, mostly in Sub-Saharan Africa and Asia. There are about 800,000 cases in Nigeria (mostly Northern Nigeria). Over 95% are due to prolonged obstructed labour. It affects the poorest of the poor and women in conflict and war zones. There are limited centres competent in taking care of the backlog of cases and the centres are often limited in resources including physical structure. The practice globally is to keep urethral catheter between one to four weeks after surgery. Shorter days with urethral catheter could increase rate of repair and quality of care within limited resources and decrease the problems of prolonged urethral catheters. Our centre is not aware of any report of urethral catheter post vesico vaginal fistula surgery shorter than one week.


To investigate the minimum number of days a urethral catheter was used with cure after simple vesico vaginal fistula surgery and its effect on women’s urinary and sexual system.


A twenty year-old woman who had vesico vaginal fistula from prolonged obstructed labour for six years, but looked otherwise healthy was treated with surgery through vaginal route. The fistula measured 4x5 cm and was located near the cervix. There was little tissue loss and minimum fibrosis and her packed cell volume was 32 %. The bladder was closed with a simple interrupted closure with 2/0 vicryl, while the vaginal epithelium was closed with 2/0 chromic catgut suture. A size 18 Foley’s urethral catheter and vaseline gauze vaginal pack for two days. The woman remained cured with only two - day post surgery urethral catheter after six months follow up with no residual urinary or sexual problem. Women reported greater preference and satisfaction for a two day post vesico vaginal fistula surgery urethral catheter.

Lessons learned:

Two-day urethral catheter after a simple vesico vaginal fistula repair is long enough in cases with the characteristics listed here: First repair; fistula not involving the sphincter mechanism; moderate or no fibrosis; little or no bladder tissue loss; tension-free repair; no co-morbid condition.

ICT and International Hospital Cooperation

Author(s): P. de Lorme1
Affiliation(s): 1International Affairs Department, Rouen University Hospital, France

ICT (Information Communication Technology), medical and nursing staff training, proximity health access, transfer of competences, public health, cultural dialogue, migrant’s health


Experience in international cooperation in health fields, Asia, Africa, Middle-East, Latin America, East European countries, European Union.


As regard to quick evolution of health systems and problems arisen from difficulties to insure equal access to healthcare and supplies for populations, which is a real challenge for health managers and politics everywhere, ICT may represent an interesting tool for improving health access and country planning, regulation and competences maintaining. Rouen University Hospital is implementing regularly ICT connexions: 2 examples: with our partner Belo Horizonte University Hospital (Hospital das Clinicas) in Brasil (Minais Gerais state) are performed medical and nursing staffs in different health fields and specialities like, radiology, surgery, paediatric, pneumology. Some of them are streamed to ‘favellas’ which are equipped and also to isolated surroundings. In nursing staffs, training meetings versed to operation rooms start in 2007, dealing with different topics as nursing competences, good practices, patient’s flow regulation, emergency medical system, standards applied, organization references, quality process, certification. IP standards connexions are used, timing is between 2 and 3 hours. Each meeting requires from both part preconditions of preparation. First of all, are discussed by internet, objectives and main contents, planning, one pre-connexion test is always performed taking into account time-lag, 1 technician online in case of communication-breakdown. Reciprocally, our partner in Brazil is performing ICT connexions with peripheral isolated primary health centres areas. Applications are focused to emergency diagnosis (cardiology tests), prevention programmes. Must be outlined a significant decreasing of patient’s transfers to upper health level. These experiences are very interesting for us in Europe too as regard to equivalent problems we have to face up linked to lack of health professionals, doctors and nurses badly distributed within certain areas which lead to unequal distribution and access to health deliveries. One main challenge is to answer to new health needs and demand (ageing) and to propose capacity of proximity healthcare supply. A second example is concerning the cultural dialogue. It has been realised through multipoint Visio conference with 3 African countries a debate following a movie projection dealing with IHV theme within its medico-psychological aspects as regard to orphan children suffering of this pathology. A workshop has been realised recently also in the same way versed to migrant’s health we meet in our hospitals, meeting attended between specialists in Rouen and Dakar (Senegal). Important point to be retained: ICT tools may represent a parameter of social cohesion for populations because, breaks isolation, allows dialogue between any health professionals and their recognition and more able afterwards to imply them in different public health programmes, maintains continue training and access to updated information, favours health access diagnosis and treatments which may introduce a better comfort for patients as well.


Patient’s transfers avoided, proximity health access favoured, better observance follow up, health comfort and social cohesion improved.

A Surgeon’s Experience in Haiti

Author(s): M. Assal1
Affiliation(s): 1Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Switzerland
Background: On January 12, 2010, at 16.50, a devastating earthquake of high magnitude (7.0) struck the island of Haiti. Two hundred thousand lives were lost in the first few seconds. Those who survived the initial overwhelming event were left with severe physical and psychological injuries. There were a very large number of crush injuries to the extremities with or without associated fractures, multiple extremity fractures and more rarely axial (pelvic or spinal) fractures, open contaminated wounds, compartment syndromes, and traumatic amputations. The immediate psychological injuries comprised mostly of posttraumatic stress disorders.
The Swiss Humanitarian Aid Unit was rapidly deployed in Port au Price. The first medical team reached Port-au-Prince General Hospital on the 5th day after the earthquake and quickly began surgical activities after just 3 hours on site. The team consisted of one team leader, one orthopaedic surgeon, one general surgeon, two anesthesiologists, two pediatricians, one obstetrician/gynecologist, one anesthesia nurse and three polyvalent nurses. Medical equipment brought to the scene consisted of light equipment (surgical tools, dressing and casting material, some medication), in addition to some material already present in the Port-au-Prince General Hospital (operating tables, some medication, etc.). The team focused on providing medical and surgical care to children and traumatized pregnant women. Orthopaedic surgeons were on the frontline in providing acute care, with fracture stabilization using plaster of Paris, traction, or external fixation. Adequate débridement and delayed primary closure of wounds, fasciotomies, and amputations were also among the major orthopaedic procedures. In addition, all the routine medical and surgical emergencies of daily life needed to be addressed by the specialists of the same team. This was a substantial additional burden placed on our team.

Health Care Provision and Health Systems in the Immediate Phase of Mass Population Migration: Field Experience in Sri lanka

Author(s): l. dassanayake*1, A. Karunarathne2
Affiliation(s): 1Department of Orthopaedic Surgery Teaching Hospital Anuradhapura and Disaster prepairedness and resp, MInistry of Health, Colombo, 2Department of Neurosurgery, Teaching Hospital Anuradhapura, Anuradhapura, Sri Lanka
Keywords: Mass population migration, disaster, health

Provision of an optimum health care services determine the survival during disasters. Especially when the community had being on migration for a considerable time ,poor quality water, poor sanitation reduced food supplies and overcrowding may aggravate the health issues and demands for the health system to function on it’s full stretch. Scenario discussed will be the ground level experience of establishment of the health care system and provision of primary health care during the initial disaster phase in zone 4 of Menik farm relief villages with the sudden influx of 44,000 internally displaced population on the days of 15th and 16th of May 2009. This population had being on migration for months.


Identification and predicting the health issues of the community, assessing the capacity of the existing health facilities, prioritizing the services carried out before and on arrival of the IDP’s. First 24 hours spent on preventing the mortality among IDP’s by treating the life threatening conditions and launching the existing heath facility to its fullest extent. With the progress of the time services were expanded and consolidated. Special attentions were paid to health education,early detection and prevention of infectious outbreaks and strengthening the primary health care.Mobile health clinics were used to access the population in the peripheries of the zone until the proper primary health care centers are established. A Close coordination was established between the ground level and the central level to facilitate the smooth flow of logistics,human resources and enabling ground level to contribute efficiently in decision making.


A. Identification of the nature of health issue: On migration for a long period of time; Large number of unattended medical and surgical problems; Dehydration; Sub-optimal antenatal care compared to other areas; Came with epidemics of Hepatitis A, diarrhea and Chicken pox.
B. Identification of Main Issues in managing the health: A population with a very high morbidity; Limited man power; limited amount of logistics; Minimal infrastructure; Language barrier; Extreme stress in all levels of the staff; No emergency or disaster medicine physicians.
C. Prioritizing the Health services for the first day: Prevent deaths during the initial phase; Only life threatening conditions treated in first 24 hours; ORT to all patients with diarrhea under direct observation; Provision of bottled water with ORT to patients; Majority of the selected patients forresuscitation and treatments within first 24 hours were having diarrhea or severe chest infections; Provision of Water and food as a secondary objective.
D. Second Day: Started treating the other cases; Started collection of the vital demographic data; Finding volunteers from the community; Starting the antenatal clinics with mid wives; Starting nutritional center, feeding center, children’s clinic and health education programs.
E. By first week: Initiation of the EPI program; Start maintaining the health records; Acquisition of Mobile lab; Negotiating with NGO’s to expedite the construction of Primary Health Care Centers. Coordination of the resources and planning to provide a much comprehensive primary health care was started by the end of the first week.

Health Sector Support as a Bridge to Peace in the Northern Caucasus

Author(s): K. Dzgoev*1, V. Besolov2, S. Parizheva3, A. Avtorkhanova4, N. Lorenz5
Affiliation(s): 1Department of Surgery, State Medical Academy, Vladikavkaz, 2Republican Centre of Medical Prophylaxis, Ministry of Health of the Republic North Ossetia-Alania, Vladikavkaz, 3Republican Center of Medical Prophylactics, Ministry of Health of Republic of Ingushetia, Nazran, 4Republican Center of Medical Prophylactics, Ministry of Health of the Chechen Republic, Grozny, Russian Federation, 5Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
Keywords: Health threats and access to health at times of crisis, Health systems during conflict and recovery, peace building

The legacy of more than a decade of instability in the Northern Caucasus combined with the consequences of the disintegration of the Soviet state has left the region impoverished and burdened with health problems such as infectious diseases (TB, HIV/AIDS and Sexually Transmitted Infections), and life-style related health problems. In the aftermath of the hostilities there has been very little to no interaction between health professionals in the area of continuous medical education, or in exchanging on medical problems. This paper presents efforts to achieve concrete health outputs and promote trust and collaboration among health professionals in a post-conflict region, while addressing at the same time health problems and achieving project-specific outputs.


In 2001, the Swiss Agency for Development and Cooperation/Swiss Humanitarian Aid, in collaboration with the health authorities of the three republics, began a medical programme which has provided support to laboratory (TB, HIV/AIDS) and health promotion services. Equipment and technical support were provided. Continuous training of health professionals in priority areas received particular attention. In a second phase activities were streamlined, and the promotion of collaboration and interaction between health professionals from the three republics became an explicit objective of the programme.


Independent national and international quality control has shown that TB and HIV diagnostics have improved in North Ossetia, Ingushetia and Chechnya since the inception of the programme. HIV/AIDS prevention has led to some improvements in the attitude of the sexually active population regarding preventative/protective behaviour particularly reflected in an, albeit modest, increase in the use of condoms. Equally important is that the health departments of the three republics collaborate regularly, for example, in sharing health education tools. More than 150 health professionals from the three republics were jointly trained in the State Medical Academy of North Ossetia and obtained recognized post graduate training certificates. In addition more than 400 professionals from North Ossetia, Ingushetia and Chechnya participated in a medical conference on current health issues in the Northern Caucasus. A high level steering committee with representatives from the three republics provides oversight on the programme. The efforts outlined above not only contribute to a better quality and harmonization of the regional health services, but they also promote peace and understanding in the region. As demonstrated in other regional settings (1) critical factors for success have been the involvement of a trusted third party. In this case, SDC provided “on the ground” activities, committed, well connected and competent professionals, a clear focus on significant clinical and public health concerns and a comparatively long term commitment of external support combined with an academic grounding. This case study from the Northern Caucasus confirms once more that the WHO’s (2) “Health as a Bridge for Peace” is a valid approach, which should be used more actively. (1) Skinner H, Abdeen Z, Abdeen H, et al: Promoting Arab and Israeli Cooperation: A Model for PeaceBuilding Through Health Initiatives. Lancet 2005, 365:1274-77.   (2) “Health as a Bridge for Peace” was formally accepted by the 51st World Health Assembly in May 1998 as a feature of the ‘Health for All in the 21st Century’ strategy.

Tackling the Forgotten Elephant of Global Health Equity: Disparities in Injury Mortality in Uganda and the United States

Author(s): S. Jayaraman*1, D. Ozgediz2, J. Miyamoto3, N. Caldwell3, M. Lipnick4, C. Mijumbi5, J. Mabweijano6, R. Hsia7, R. Dicker1
Affiliation(s): 1Dept of Surgery, Univ of California San Francisco, San Francisco, United States, 2Dept of Surgery, Univ of Toronto, Toronto, Canada, 3School of Medicine, Univ of California San Francisco, San Francisco, 4Dept of Medicine, Brigham and Women’s Hospital, Boston, United States, 5Dept of Anesthesia, 6Dept of Surgery, Mulago Hospital and Makerere University, Kampala, Uganda, 7Dept of Emergency Medicine, Univ of California San Francisco, San Francisco, United States
Keywords: Injury, disparity, road traffic crash

Worldwide more than five million people die from injury every year. Low and middle income countries bear a disparate burden of injury: 90% of all deaths from road traffic injuries occur in these settings. This disparity is only projected to increase. The Global Burden of Disease Project predicts that the burden of injury will increase by 28% between 2004 and 2030, whereas rates of TB, malaria and HIV/AIDS will decline during the same time. Despite this, there is little data available on the burden of injury from low and middle income countries. We hypothesized that injury mortality is high in Kampala, Uganda and that it is higher than the rates seen in high-income countries.


We developed a comprehensive injury mortality database by compiling all deaths recorded from 7/07 to 12/07 in Kampala by the Mulago Hospital Mortuary, the Kampala City Council Mortuary, and the Uganda Ministry of Health Post-Mortem Reports. We defined the time frame based on feasibility and data availability. We analyzed this database descriptively and compared the results to data from the US Centers for Disease Control and San Francisco County.


This is the first study to describe injury mortality in Kampala using a new, comprehensive death statistics database and it shows that urban injury mortality is significantly higher in Kampala than in the United States and San Francisco. Rates are highest in young adults suggesting that Uganda faces an enormous economic burden from injury. Differences in injury epidemiology (table 1) and outcomes (figure 1) are shown. In Kampala, road traffic crashes (46%) is the most common mechanism compared to assault (38%) in San Francisco.
Our findings raise three important issues in Kampala: the high degree of injury burden, the lack of appropriate prevention measures and immediate trauma care, and the need for organized data collection. The high prevalence of injury, death from road traffic crashes and injury to the head and neck in Kampala must be explored further. Second, there is no formal emergency medical system in Kampala. Immediate prehospital care by trained first-responders has been shown to save lives and be cost-effective in other settings and engaging in such capacity building interventions for trauma and emergency surgical services could broadly strengthen the health system and improve emergency medical services in general. Third, there is an urgent need for accurate injury-related vital statistics. It is unclear how many injury deaths in Kampala are avertable today and an organized prospective vital statistics database could help define this further.

Baseline Compliance of a Cohort of Healthcare Workers with Universal Precautions

Author(s): L. dassanayake*1, A. Karunarathne2, D. Munidasa1, S. Thenuwara1
Affiliation(s): 1Department of Orthopaedic Surgery, 2Department of Neurosurgery, Teaching Hospital Anuradhapura, Anuradhapura, Sri Lanka
Keywords: Health Care worker, Compliance, Universal precautions, Globalization

Globalization, mass population migration war are considered to be the main causative factors for the spread of infections like HIV and Hepatitis B in previously disease free regions. Health care workers in emergency surgical units (ESHCW) are considered as a high risk category of acquiring these infections by infectious blood and body fluids. This is becoming a challenge to most health authorities and hospitals. Universal precautions (UP) are recommended to minimize this risk. Objective of this study was to understand the current compliance level of ESHCW with UP and identify factors affect the compliance.


First 15 minute management of the first victim in 29 consecutive casualty incidents brought to Teaching Hospital Anuradhapura in 2009 was observed.


Total encounters between ESHCW and patients were 359. UP were breached in 1033 occasions with average 2.87 per encounter. Average break rate was 2.91 in doctors. It is 2.78 and 2.93 among nurses and orderlies respectively. The lowest break rate seen in senior residents and highest in interns. There is a significant reduction in breaking UP with increasing severity of incident (Pearson correlation -0.797, P-0.203) Wearing gloves were seen in 12.81%. Usage of aprons seen in 4.45%. 22.84% of ESHCW remained at bedside without an apparent role. 82.17% attended other victims without hand washing or changing gloves. Compliance of the EHCW with UP remain low in the study population. Increasing the severity of incident reduce the non compliance significantly which is opposite of the general belief. Wearing apron is significantly lower than wearing gloves. Approximately 1/5 of the EHCW remain at bed side unnecessarily. Every 4/5 EHCWs attend other patients without hand washing or changing the gloves which can be a mode of transmitting infections between trauma victims. This denotes base line compliance of health care workers with universal precautions remain low. It is becoming a new challenge to health authorities in a phase of increasing risk of infections due to infectious blood and body fluids.

Emergency Evacuation of a Selected Multistoried Hospital Building

Author(s): A. S. Karunarathne*1, L. Dassanayake2, P. Gunasena1
Affiliation(s): 1Neurosurgery, 2Orthopaedic surgery, Teaching Hospital Anuradhapura, Anuradhapura, Sri Lanka
Keywords: Emergency evacuation, Hospital buildings

Hospitals play a very important role in external disaster situations, providing essential care for the affected. But relatively a less attention is paid towards internal disasters involving hospitals, necessitating immediate evacuation of patients and the staff. A special attention should be paid on this aspect since the potential of survival and safe evacuation is less in patients the main inhabitants of most hospital buildings, than in normal population. The objectives of this study were to assess the knowledge of the patients and the staff members residing in the SMB building, regarding the existing emergency exit path of the building and to assess the safety and the physical status of the evacuation pathway.


A cross sectional study was carried out at SBM building which is the most recently constructed and the tallest building of Teaching Hospital Anuradhapura. An internal emergency to the building was hypothesized on the 24/10/2007 at 21.00hrs and all the staff members and eighty patients who were physically present in building were interviewed and the emergency exit path was inspected.


None of the patients and majority of the staff members was aware of the availability of an emergency exit. Emergency exit path was not properly maintained in a way to facilitate safe efficient evacuation. Thus a mechanism to educate patients and staff on emergency exit usage needs to be formulated. Maintaining the effective width of the evacuation pathways is of prime importance. Emphasis should be given to designing the emergency evacuation infrastructure and strategies at the level of hospital building planning.