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Lule H, Mugerwa M, SSebuufu R, Kyamanywa P, Posti JP, Wilson ML. Rural trauma team development training amongst medical trainees and traffic law enforcement professionals in a low-income country: a protocol for a prospective multicenter interrupted time series. Int J Surg Protoc 2024; 28:12-19. [PMID: 38433864 PMCID: PMC10905493 DOI: 10.1097/sp9.0000000000000013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 09/28/2023] [Indexed: 03/05/2024] Open
Abstract
Background Road traffic injuries and their resulting mortality disproportionately affect rural communities in low-middle-income countries (LMICs) due to limited human and infrastructural resources for postcrash care. Evidence from high-income countries show that trauma team development training could improve the efficiency, care, and outcome of injuries. A paucity of studies have evaluated the feasibility and applicability of this concept in resource constrained settings. The aim of this study protocol is to establish the feasibility of rural trauma team development and training in a cohort of medical trainees and traffic law enforcement professionals in Uganda. Methods Muticenter interrupted time series of prospective interventional trainings, using the rural trauma team development course (RTTDC) model of the American College of Surgeons. A team of surgeon consultants will execute the training. A prospective cohort of participants will complete a before and after training validated trauma related multiple choice questionnaire during September 2019-November 2023. The difference in mean prepost training percentage multiple choice questionnaire scores will be compared using ANOVA-test at 95% CI. Time series regression models will be used to test for autocorrelations in performance. Acceptability and relevance of the training will be assessed using 3 and 5-point-Likert scales. All analyses will be performed using Stata 15.0. Ethical approval was obtained from Research and Ethics Committee of Mbarara University of Science and Technology (Ref: MUREC 1/7, 05/05-19) and Uganda National Council for Science and Technology (Ref: SS 5082). Retrospective registration was accomplished with Research Registry (UIN: researchregistry9490).
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Affiliation(s)
- Herman Lule
- Department of Surgery, Kiryandongo Regional Referral Hospital, Kigumba, Uganda
- Department of Clinical Neurosciences, Injury Epidemiology and Prevention (IEP) Research Group, Turku Brain Injury Centre
| | - Michael Mugerwa
- Department of Clinical Neurosciences, Injury Epidemiology and Prevention (IEP) Research Group, Turku Brain Injury Centre
| | | | - Patrick Kyamanywa
- Mother Kevin Postgraduate Medical School, Uganda Martyr’s University, Nkozi, Uganda
| | - Jussi P. Posti
- Department of Neurosurgery and Turku Brain Injury Centre, Neurocentre, Turku University Hospital and University of Turku, Turku, Finland
| | - Michael L. Wilson
- Heidelberg Institute of Global Health (HIGH), University Hospital and University of Heidelberg, Heidelberg, Germany
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Omondi MP, Mwangi JC, Sitati FC, Onga’ngo H. Patterns of facility and patient related factors to the orthopedic and trauma admissions at the Kenyatta National Hospital: A qualitative assessment. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002323. [PMID: 38271345 PMCID: PMC10810445 DOI: 10.1371/journal.pgph.0002323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 01/05/2024] [Indexed: 01/27/2024]
Abstract
Inappropriate utilization of higher-level health facilities and ineffective management of the referral processes in resource-limited settings is increasingly becoming a concern in health care management in developing countries. This is characterized by self-referrals and frequent bypassing of nearest health facilities coupled with low formal referral mechanisms. This scenario lends itself to a situation where uncomplicated medical conditions are unnecessarily managed in a high-cost health facility. This situation compromises the ability and capacity of Kenyatta National Hospital (KNH) to function as a tertiary referral health facility as envisioned by Kenya Health Sector Referral Implementation Guidelines of 2014, Kenya 201 constitution and KNH legal statue of 1987. The study objective was to assess the patterns of facility and patient related factors to the orthopaedic and trauma admissions at the KNH. This was a descriptive qualitative study design. The study was conducted amongst the orthopaedic and trauma admission caseload for 2021. Data collection was done through a) data abstraction from 905 patients charts admitted during February to December 2021 and b) 10 (ten) semi-structured interviews with 10 major health facilities that refer to KNH to understand the reasons for referral to KNH. Quantitative data was analysed using Statistical Package for Social Science version 21.0 to calculate the frequency distribution. Qualitative data from the data abstraction and transcripts from the KIIs were analysed using NVivo version 12. The major facility and patient related factors to the orthopaedic and trauma admissions at KNH were inadequate human resource capacity and availability (42.7%), financial constraints (23.3%), inadequate Orthopaedic equipment's and implants availability (20.0%) and inadequate health facility infrastructure (6.3%) while the major patient related factor was patient's preference (23.4%). In conclusion, to decongest KNH requires that the lower-level health facilities need to be better equipped and resourced to handle essential orthopaedic and trauma care.
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Affiliation(s)
- Maxwell Philip Omondi
- Department of Surgery, Thematic Unit–Orthopedic Surgery, University of Nairobi, Nairobi, Kenya
| | - Joseph Chege Mwangi
- Department of Surgery, Thematic Unit–Orthopedic Surgery, University of Nairobi, Nairobi, Kenya
| | - Fred Chuma Sitati
- Department of Surgery, Thematic Unit–Orthopedic Surgery, University of Nairobi, Nairobi, Kenya
| | - Herbert Onga’ngo
- Department of Orthopedics, Kenyatta National Hospital, Nairobi, Kenya
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Keshri VR, Parveen S, Abimbola S, Mishra B, Khurram MF, Peden M, Norton R, Jagnoor J. The health workforce conundrum for burn care in Uttar Pradesh, India: a qualitative exploration. Glob Public Health 2024; 19:2345370. [PMID: 38686925 DOI: 10.1080/17441692.2024.2345370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 04/15/2024] [Indexed: 05/02/2024]
Abstract
Delivering specialised care for major burns requires a multidisciplinary health workforce. While health systems 'hardware' issues, such as shortages of the healthcare workforce and training gaps in burn care are widely acknowledged, there is limited evidence around the systems 'software' aspects, such as interest, power dynamics, and relationships that impact the healthcare workforce performance. This study explored challenges faced by the health workforce in burn care to identify issues affecting their performance. Qualitative in-depth interviews were conducted with a purposively selected sample (n = 31, 18 women and 13 men) of various cadres of the burn care health workforce in Uttar Pradesh, India. Inductive coding and thematic analysis identified three major themes. First, the dynamics within the multidisciplinary team where complex relations, power and normative hierarchy hampered performance. Second, the dynamics between health workers and patients due to the clinical and emotional challenges of dealing with burn injuries and multitasking. Third, dynamics between specialised burn units and broader health systems are narrated in challenges due to inadequate first response and delayed referral from primary care facilities. These findings indicate that burn care health workers in India face multiple challenges that need systemic intervention with a multipronged human resource for health framework.
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Affiliation(s)
- Vikash Ranjan Keshri
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, New Delhi, India
| | - Samina Parveen
- The George Institute for Global Health, New Delhi, India
- Ipas Development Foundation, New Delhi, India
| | - Seye Abimbola
- School of Public Health, University of Sydney, Sydney, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Brijesh Mishra
- Department of Plastic Surgery, King George's Medical University, Lucknow, India
| | - Mohammed Fahad Khurram
- Department of Plastic Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
| | - Margie Peden
- The George Institute for Global Health, New Delhi, India
- The George Institute for Global Health UK, Imperial College London, London, UK
| | - Robyn Norton
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health UK, Imperial College London, London, UK
| | - Jagnoor Jagnoor
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, New Delhi, India
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Ryan I, Shah KV, Barrero CE, Uamunovandu T, Ilbawi A, Swanson J. Task Shifting and Task Sharing to Strengthen the Surgical Workforce in Sub-Saharan Africa: A Systematic Review of the Existing Literature. World J Surg 2023; 47:3070-3080. [PMID: 37831136 DOI: 10.1007/s00268-023-07197-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND A major constraint to surgical care delivery in low-resource settings is inadequate workforce availability. Surgical task shifting (TShifting) and task sharing (TSharing), in which non-surgeon clinicians (NSCs) are trained to perform select surgical procedures, have been proposed as one solution. However, patterns of safety and efficacy of surgical TShifting/TSharing are not well-established. This study aims to summarize the current literature and assess clinical outcomes and impact of surgical TShifting/TSharing in sub-Saharan Africa. METHODS A two-tiered systematic, PRISMA-adherent literature review of surgical TShifting/TSharing in sub-Saharan Africa was conducted. Collected data included healthcare settings; types of surgeries performed; attitudes toward NSCs; and categories, training, capacity, clinical outcomes, safety, retention, cost-effectiveness, and supervision of NSCs. A random effects meta-analysis of morbidity and mortality rates between NSCs and surgeons was conducted. RESULTS Among the 659 abstracts screened, 31 studies met inclusion criteria and were integrated in the final analysis. Eighteen studies (58%) report on the capacity and aptitude of NSCs, 16 (52%) on clinical outcomes and safety, and seven (23%) on attitudes. NSCs performed 1999 (61%) of 3304 total surgical cases studied. The most common operations reported were hernia repair (n = 12, 57%), acute abdominal (n = 12, 57%), and orthopedic procedures (n = 6, 29%). No differences were found between NSC and surgeon case morbidity [315 (16%) vs. 224 (17%); p > 0.05] and mortality [44 (2.2%) vs. 33 (2.5%); p > 0.05] rates. CONCLUSION NSCs are increasingly performing surgical tasks in regions of sub-Saharan Africa deficient in trained surgeons and appear to have non-inferior safety outcomes in select programs.
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Affiliation(s)
- Isabel Ryan
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Keshav V Shah
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Carlos E Barrero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Andre Ilbawi
- Department of Universal Health Coverage, WHO, Geneva, Switzerland
| | - Jordan Swanson
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Kakembo N, Grabski DF, Situma M, Ajiko M, Kayima P, Nyeko D, Shikanda A, Okello I, Tumukunde J, Nabukenya M, Ogwang M, Kisa P, Muzira A, Ruzgar N, Fitzgerald TN, Sekabira J, Ozgediz D. Met and Unmet Need for Pediatric Surgical Access in Uganda: A Country-Wide Prospective Analysis. J Surg Res 2023; 286:23-34. [PMID: 36738566 DOI: 10.1016/j.jss.2022.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 12/05/2022] [Accepted: 12/24/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Children's surgical access in low and low-middle income countries is severely limited. Investigations detailing met and unmet surgical access are necessary to inform appropriate resource allocation. MATERIALS AND METHODS Surgical volume, outcomes, and distribution of pediatric general surgical procedures were analyzed using prospective pediatric surgical databases from four separate regional hospitals in Uganda. The current averted burden of surgical disease through pediatric surgical delivery in Uganda and the unmet surgical need based on estimates from high-income country data was calculated. RESULTS A total of 8514 patients were treated at the four hospitals over a 6-year period corresponding to 1350 pediatric surgical cases per year in Uganda or six surgical cases per 100,000 children per year. The majority of complex congenital anomalies and surgical oncology cases were performed at Mulago and Mbarara Hospitals, which have dedicated pediatric surgical teams (P < 0.0001). The averted burden of pediatric surgical disease was 27,000 disability adjusted life years per year, which resulted in an economic benefit of approximately 23 million USD per year. However, the average case volume performed at the four regional hospitals currently represents 1% of the total projected pediatric surgical need. CONCLUSIONS This investigation is one of the first to demonstrate the distribution of pediatric surgical procedures at a country level through the use of a prospective locally created database. Significant disease burden was averted by local pediatric and adult surgical teams, demonstrating the economic benefit of pediatric surgical care delivery. These findings support several ongoing strategies to increase pediatric surgical access in Uganda.
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Affiliation(s)
- Nasser Kakembo
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - David F Grabski
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia.
| | - Martin Situma
- Department of Surgery, Mbarara University of Science and Technology, Mbarara Hospital, Mbarara, Uganda
| | - Margaret Ajiko
- Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda
| | - Peter Kayima
- Department of Surgery, St. Mary's Lacor Regional Referral Hospital, Lacor, Uganda
| | - David Nyeko
- Department of Surgery, St. Mary's Lacor Regional Referral Hospital, Lacor, Uganda
| | - Anne Shikanda
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Innocent Okello
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Janat Tumukunde
- Department of Anesthesiology, Makerere University School of Medicine, Kampala, Uganda
| | - Mary Nabukenya
- Department of Anesthesiology, Makerere University School of Medicine, Kampala, Uganda
| | - Martin Ogwang
- Department of Surgery, St. Mary's Lacor Regional Referral Hospital, Lacor, Uganda
| | - Phyllis Kisa
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Arlene Muzira
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Nensi Ruzgar
- Yale University School of Medicine, New Haven, Connecticut
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - John Sekabira
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Doruk Ozgediz
- Department of Surgery, University of California, San Francisco, California
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Ifeanyichi M, Broekhuizen H, Juma A, Chilonga K, Kataika E, Gajewski J, Brugha R, Bijlmakers L. Economic Costs of Providing District- and Regional-Level Surgeries in Tanzania. Int J Health Policy Manag 2022; 11:1120-1131. [PMID: 33673732 PMCID: PMC9808166 DOI: 10.34172/ijhpm.2021.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 01/31/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Access to surgical care is poor in Tanzania. The country is at the implementation stage of its first National Surgical, Obstetric, and Anesthesia Plan (NSOAP; 2018-2025) aiming to scale up surgery. This study aimed to calculate the costs of providing surgical care at the district and regional hospitals. METHODS Two district hospitals (DHs) and the regional referral hospital (RH) in Arusha region were selected. All the staff, buildings, equipment, and medical and non-medical supplies deployed in running the hospitals over a 12 month period were identified and quantified from interviews and hospital records. Using a combination of step-down costing (SDC) and activity-based costing (ABC), all costs attributed to surgeries were established and then distributed over the individual types of surgeries. These costs were delineated into pre-operative, intra-operative, and post-operative components. RESULTS The total annual costs of running the clinical cost centres ranged from $567k at Oltrumet DH to $3453k at Mt Meru RH. The total costs of surgeries ranged from $79k to $813k; amounting to 12%-22% of the total costs of running the hospitals. At least 70% of the costs were salaries. Unit costs and relative shares of capital costs were generally higher at the DHs. Two-thirds of all the procedures incurred at least 60% of their costs in the theatre. Open reduction and internal fixation (ORIF) performed at the regional hospital was cheaper ($618) than surgical debridement (plus conservative treatment) due to prolonged post-operative inpatient care associated with the latter ($1177), but was performed infrequently due mostly to unavailability of implants. CONCLUSION Lower unit costs and shares of capital costs at the RH reflect an advantage of economies of scale and scope at the RH, and a possible underutilization of capacity at the DHs. Greater efficiencies make a case for concentration and scale-up of surgical services at the RHs, but there is a stronger case for scaling up district-level surgeries, not only for equitable access to services, but also to drive down unit costs there, and free up RH resources for more complex cases such as ORIF.
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Affiliation(s)
- Martilord Ifeanyichi
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Henk Broekhuizen
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Adinan Juma
- East, Central and Southern Africa Health Community, Arusha, Tanzania
| | - Kondo Chilonga
- Department of Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Edward Kataika
- East, Central and Southern Africa Health Community, Arusha, Tanzania
| | - Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruairi Brugha
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leon Bijlmakers
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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Velin L, Lantz A, Ameh EA, Roy N, Jumbam DT, Williams O, Elobu A, Seyi-Olajide J, Hagander L. Systematic review of low-income and middle-income country perceptions of visiting surgical teams from high-income countries. BMJ Glob Health 2022; 7:e008791. [PMID: 35483711 PMCID: PMC9052057 DOI: 10.1136/bmjgh-2022-008791] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/05/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The shortage of surgeons, anaesthesiologists and obstetricians in low-income and middle-income countries (LMICs) is occasionally bridged by foreign surgical teams from high-income countries on short-term visits. To advise on ethical guidelines for such activities, the aim of this study was to present LMIC stakeholders' perceptions of visiting surgical teams from high-income countries. METHOD We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in November 2021, using standardised search terms in PubMed/Medline (National Library of Medicine), EMBASE (Elsevier), Global Health Database (EBSCO) and Global Index Medicus, and complementary hand searches in African Journals Online and Google Scholar. Included studies were analysed thematically using a meta-ethnographic approach. RESULTS Out of 3867 identified studies, 30 articles from 15 countries were included for analysis. Advantages of visiting surgical teams included alleviating clinical care needs, skills improvement, system-level strengthening, academic and career benefits and broader collaboration opportunities. Disadvantages of visiting surgical teams involved poor quality of care and lack of follow-up, insufficient knowledge transfers, dilemmas of ethics and equity, competition, administrative and financial issues and language barriers. CONCLUSION Surgical short-term visits from high-income countries are insufficiently described from the perspective of stakeholders in LMICs, yet such perspectives are essential for quality of care, ethics and equity, skills and knowledge transfer and sustainable health system strengthening. More in-depth studies, particularly of LMIC perceptions, are required to inform further development of ethical guidelines for global surgery and support ethical and sustainable strengthening of LMIC surgical systems.
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Affiliation(s)
- Lotta Velin
- Department of Biomedical and Clinical Sciences, Linköping University, Centre for Teaching and Research in Disaster Medicine and Traumatology, Linkoping, Sweden
| | - Adam Lantz
- Department of Clinical Sciences in Lund, Orthopedic Surgery, Helsingborg Hospital, Faculty of Medicine, Lund University, Lund, Sweden
| | - Emmanuel A Ameh
- Department of Surgery, National Hospital Abuja, Abuja, Federal Capital Territory, Nigeria
| | - Nobhojit Roy
- WHO Collaborating Centre for Research on Surgical Care Delivery in LMICs, Mumbai, India
- The George Institute for Global Health, New Delhi, India
| | - Desmond T Jumbam
- Department of Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
| | - Omolara Williams
- Department of Surgery, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
| | - Alex Elobu
- Gastrointestinal Surgery, Mulago Hospital, Kampala, Uganda
- Institute of Digestive Diseases, Kampala, Uganda
| | - Justina Seyi-Olajide
- Paediatric Surgery Unit, Department of Surgery, Lagos University Teaching Hospital, Surulere, Lagos, Nigeria
| | - Lars Hagander
- Department of Clinical Sciences in Lund, Pediatric Surgery, Skåne University Hospital in Lund, Faculty of Medicine, Lund University, Lund, Sweden
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Wilson S, Bah MM, George P, Caulker A, Holmer H, Leather AJ, Kamara TB. Challenges and solutions to providing surgery in Sierra Leone hospitals: a qualitative analysis of surgical provider perspectives. BMJ Open 2022; 12:e052972. [PMID: 35105579 PMCID: PMC8808401 DOI: 10.1136/bmjopen-2021-052972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE This study aimed to use qualitative interviews with surgical providers to explore challenges and solutions to providing surgical and anaesthesia care in Sierra Leone's hospitals. DESIGN Data were collected through anonymous, semistructured interviews. We used a qualitative framework approach to analyse interview data and determine themes relating to challenges that were reported. SETTING A purposive sample of 12 hospitals was selected throughout Sierra Leone to include district and referral hospitals of varying ownership (private, non-governmental organisation and government). PARTICIPANTS The most senior surgical provider available during each hospital site visit participated in a semistructured interview. A total of 12 interviews were conducted. RESULTS Providers described both challenges and solutions relating to the following categories: equipment and supplies, access to services, human resources, infrastructure, management and patient factors. These challenges were found to affect surgical care in hospitals by delaying surgical care, decreasing operative capacity and decreasing quality of care. Providers identified not only the root causes of these challenges, but also the varied workarounds and solutions they employ to overcome them. CONCLUSION Surgical providers can offer important insights into challenges affecting surgical services in hospitals. Despite working in challenging environments with limited resources, providers have developed innovative solutions to improve surgical and anaesthesia care in hospitals in Sierra Leone. Qualitative research has an important role to play in improving understanding of the challenges facing surgeons in low-income countries.
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Affiliation(s)
- Spencer Wilson
- General Surgery, Boston Medical Center, Boston, Massachusetts, USA
| | - Mohamed M Bah
- Department of Surgery, Connaught Hospital, Freetown, Sierra Leone
| | - Peter George
- Department of Surgery, Connaught Hospital, Freetown, Sierra Leone
| | - Augustus Caulker
- Department of Surgery, Connaught Hospital, Freetown, Sierra Leone
| | - Hampus Holmer
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Andrew Jm Leather
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, King's College London, London, UK
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Shanthakumar D, Payne A, Leitch T, Alfa-Wali M. Trauma Care in Low- and Middle-Income Countries. Surg J (N Y) 2021; 7:e281-e285. [PMID: 34703885 PMCID: PMC8536645 DOI: 10.1055/s-0041-1732351] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 05/21/2021] [Indexed: 11/13/2022] Open
Abstract
Background
Trauma-related injury causes higher mortality than a combination of prevalent infectious diseases. Mortality secondary to trauma is higher in low- and middle-income countries (LMICs) than high-income countries. This review outlines common issues, and potential solutions for those issues, identified in trauma care in LMICs that contribute to poorer outcomes.
Methods
A literature search was performed on PubMed and Google Scholar using the search terms “trauma,” “injuries,” and “developing countries.” Articles conducted in a trauma setting in low-income countries (according to the World Bank classification) that discussed problems with management of trauma or consolidated treatment and educational solutions regarding trauma care were included.
Results
Forty-five studies were included. The problem areas broadly identified with trauma care in LMICs were infrastructure, education, and operational measures. We provided some solutions to these areas including algorithm-driven patient management and use of technology that can be adopted in LMICs.
Conclusion
Sustainable methods for the provision of trauma care are essential in LMICs. Improvements in infrastructure and education and training would produce a more robust health care system and likely a reduction in mortality in trauma-related injuries.
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Affiliation(s)
| | - Anna Payne
- Department of Surgery, Royal London Hospital, London, United Kingdom
| | - Trish Leitch
- Department of Surgery, St George's Hospital, London, United Kingdom
| | - Maryam Alfa-Wali
- Department of Surgery, Royal London Hospital, London, United Kingdom
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10
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Ifeanyichi M, Aune E, Shrime M, Gajewski J, Pittalis C, Kachimba J, Borgstein E, Brugha R, Baltussen R, Bijlmakers L. Financing of surgery and anaesthesia in sub-Saharan Africa: a scoping review. BMJ Open 2021; 11:e051617. [PMID: 34667008 PMCID: PMC8527159 DOI: 10.1136/bmjopen-2021-051617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This study aimed to provide an overview of current knowledge and situational analysis of financing of surgery and anaesthesia across sub-Saharan Africa (SSA). SETTING Surgical and anaesthesia services across all levels of care-primary, secondary and tertiary. DESIGN We performed a scoping review of scientific databases (PubMed, EMBASE, Global Health and African Index Medicus), grey literature and websites of development organisations. Screening and data extraction were conducted by two independent reviewers and abstracted data were summarised using thematic narrative synthesis per the financing domains: mobilisation, pooling and purchasing. RESULTS The search resulted in 5533 unique articles among which 149 met the inclusion criteria: 132 were related to mobilisation, 17 to pooling and 5 to purchasing. Neglect of surgery in national health priorities is widespread in SSA, and no report was found on national level surgical expenditures or budgetary allocations. Financial protection mechanisms are weak or non-existent; poor patients often forego care or face financial catastrophes in seeking care, even in the context of universal public financing (free care) initiatives. CONCLUSION Financing of surgical and anaesthesia care in SSA is as poor as it is underinvestigated, calling for increased national prioritisation and tracking of surgical funding. Improving availability, accessibility and affordability of surgical and anaesthesia care require comprehensive and inclusive policy formulations.
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Affiliation(s)
- Martilord Ifeanyichi
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
- EMAI Health Systems and Health Services Consulting, Nijmegen, The Netherlands
| | - Ellis Aune
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Mark Shrime
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Chiara Pittalis
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John Kachimba
- Department of Surgery, University of Zambia University Teaching Hospital, Lusaka, Zambia
| | - Eric Borgstein
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Ruairi Brugha
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Rob Baltussen
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Leon Bijlmakers
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
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Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals. Surgery 2021; 170:1397-1404. [PMID: 34130809 DOI: 10.1016/j.surg.2021.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 04/27/2021] [Accepted: 05/04/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children's surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity. METHODS Two years of a prospective clinical database of children's surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered. RESULTS From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society. CONCLUSION This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers.
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Drevin G, Albutt K, Baluku M, Tuhumwiire C, Deng H, Musinguzi N, Modest V, Ngonzi J, Ttendo S, Firth P. Outcome Measurement at a Ugandan Referral Hospital: Validation of the Mbarara Surgical Services Quality Assurance Database. World J Surg 2021; 44:2550-2556. [PMID: 32333160 DOI: 10.1007/s00268-020-05537-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Five billion people lack access to surgery. Accurate and complete data have been identified as essential to the global scale-up of perioperative care. This study retrospectively validates the Mbarara Surgical Services Quality Assurance Database (SQUAD), an electronic outcomes database at a Ugandan secondary referral hospital. METHODS SQUAD data were compared to paper records from August 2013 to January 2017. To assess data entry accuracy, two researchers independently extracted 24 patient variables from 170 charts. To assess completeness of patient capture, SQUAD entries were compared to a sample of charts returned to the Medical Records Department, and to a sample of entries in ward and operating room logbooks. Two-tailed binomial proportions with 95% CI were calculated from the comparative results of patient observations, against a predefined accuracy of 0.85-0.95. RESULTS Agreement between completed validation observations from charts and SQUAD data was 91.5% (n = 3734/4080 data points). Binomial tests indicated that 15 variables had higher than 95% accuracy. A total 19 of 24 variables had ≥ 85% accuracy. The completeness of SQUAD patient capture was 98.2% (n = 167/170) of charts returned to the Medical Records Department, 97.5% (n = 198/203) of operating logbook entries, and 100% (n = 111/111) of ward logbook entries, respectively. CONCLUSION SQUAD closely reflects the primary surgical and anaesthetic data at a Ugandan secondary hospital. Data accuracy of key variables and completeness of population capture were comparable to those of databases in high-income countries and outperformed those of other low- and middle-income countries.
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Affiliation(s)
- Gustaf Drevin
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Department for Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Katherine Albutt
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Department of General Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Moris Baluku
- Department of Anaesthesia and Critical Care, Mbarara Regional Referral Hospital, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Caleb Tuhumwiire
- Department of Surgery, Mbarara Regional Referral Hospital, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Hao Deng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Nicholas Musinguzi
- Harvard-Mbarara University of Science and Technology Collaborative, Mbarara, Uganda
| | - Vicki Modest
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Joseph Ngonzi
- Department of Obstetrics and Gynaecology, Mbarara Regional Referral Hospital, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Stephen Ttendo
- Department of Anaesthesia and Critical Care, Mbarara Regional Referral Hospital, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Paul Firth
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA.
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13
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Bentounsi Z, Lavy C, Pittalis C, Clarke M, Rizk J, Le G, Brugha R, Borgstein E, Gajewski J. Which Surgical Operations Should be Performed in District Hospitals in East, Central and Southern Africa? Results of a Survey of Regional Clinicians. World J Surg 2021; 45:369-377. [PMID: 33000309 PMCID: PMC7773610 DOI: 10.1007/s00268-020-05793-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND In East, Central and Southern Africa (ECSA), district hospitals (DH) are the main source of surgical care for 80% of the population. DHs in Africa must provide basic life-saving procedures, but the extent to which they can offer other general and emergency surgery is debated. Our paper contributes to this debate through analysis and discussion of regional surgical care providers' perspectives. METHODS We conducted a survey at the College of Surgeons of East, Central and Southern Africa Conference in Kigali in December 2018. The survey presented the participants with 59 surgical and anaesthesia procedures and asked them if they thought the procedure should be done in a district level hospital in their region. We then measured the level of positive agreement (LPA) for each procedure and conducted sub-analysis by cadre and level of experience. RESULTS We had 100 respondents of which 94 were from ECSA. Eighteen procedures had an LPA of 80% or above, among which appendicectomy (98%), caesarean section (97%) and spinal anaesthesia (97%). Twenty-one procedures had an LPA between 31 and 79%. The surgical procedures that fell in this category were a mix of obstetrics, general surgery and orthopaedics. Twenty procedures had an LPA below 30% among which paediatric anaesthesia and surgery. CONCLUSION Our study offers the perspectives of almost 100 surgical care providers from ECSA on which surgical and anaesthesia procedures should be provided in district hospitals. This might help in planning surgical care training and delivery in these hospitals.
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Affiliation(s)
- Zineb Bentounsi
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Old Road, Oxford, OX3 7LD UK
| | - Chris Lavy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Old Road, Oxford, OX3 7LD UK
| | - Chiara Pittalis
- Royal College of Surgeons in Ireland, Beaux Lane House, Dublin, 2 Ireland
| | - Morgane Clarke
- Royal College of Surgeons in Ireland, Beaux Lane House, Dublin, 2 Ireland
| | - Jean Rizk
- Royal College of Surgeons in Ireland, Beaux Lane House, Dublin, 2 Ireland
| | - Grace Le
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Old Road, Oxford, OX3 7LD UK
| | - Ruairi Brugha
- Royal College of Surgeons in Ireland, Beaux Lane House, Dublin, 2 Ireland
| | - Eric Borgstein
- Department of Surgery, Queen Elizabeth Central Hospital, Chipatala Avenue, PO Box 95, Blantyre, Malawi
| | - Jakub Gajewski
- Royal College of Surgeons in Ireland, Beaux Lane House, Dublin, 2 Ireland
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14
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Beard JH, Ohene-Yeboah M, Löfgren J. International Consensus and External Validity in Global Surgery Research and Task Shifting-Reply. JAMA Surg 2020; 155:171-172. [PMID: 31642883 DOI: 10.1001/jamasurg.2019.4088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jessica H Beard
- Lewis Katz School of Medicine, Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Temple University, Philadelphia, Pennsylvania
| | - Michael Ohene-Yeboah
- School of Medicine and Dentistry, Department of Surgery, University of Ghana, Accra, Ghana
| | - Jenny Löfgren
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden
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15
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Lantz A, Holmer H, Finlayson SRG, Ricketts TC, Watters DA, Gruen RL, Johnson WD, Hagander L. Measuring the migration of surgical specialists. Surgery 2020; 168:550-557. [PMID: 32620304 DOI: 10.1016/j.surg.2020.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/30/2020] [Accepted: 04/04/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The lack of access to essential surgical care in low-income countries is aggravated by emigration of locally-trained surgical specialists to more affluent regions. Yet, the global diaspora of surgeons, obstetricians, and anesthesiologists from low-income and middle-income countries has never been fully described and compared with those who have remained in their country of origin. It is also unclear whether the surgical workforce is more affected by international migration than other medical specialists. In this study, we aimed to quantify the proportion of surgical specialists originating from low-income and middle-income countries that currently work in high-income countries. METHODS We retrieved surgical workforce data from 48 high-income countries and 102 low-income and middle-income countries using the database of the World Health Organization Global Surgical Workforce. We then compared this domestic workforce with more granular data on the country of initial medical qualification of all surgeons, anesthesiologists, and obstetricians made available for 14 selected high-income countries to calculate the proportion of surgical specialists working abroad. RESULTS We identified 1,118,804 specialist surgeons, anesthesiologists, or obstetricians from 102 low-income and middle-income countries, of whom 33,021 (3.0%) worked in the 14 included high-income countries. The proportion of surgical specialists abroad was greatest for the African and South East Asian regions (12.8% and 12.1%). The proportion of specialists abroad was not greater for surgeons, anesthesiologists, or obstetricians than for physicians and other medical specialists (P = .465). Overall, the countries with the lowest remaining density of surgical specialists were also the countries from which the largest proportion of graduates were now working in high-income countries (P = .011). CONCLUSION A substantial proportion of all surgeons, anesthesiologists, and obstetricians from low-income and middle-income countries currently work in high-income countries. In addition to decreasing migration from areas of surgical need, innovative strategies to retain and strengthen the surgical workforce could involve engaging this large international pool of surgical specialists and instructors.
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Affiliation(s)
- Adam Lantz
- Department of Orthopedic Surgery, Helsingborg Hospital, Lund University, Sweden; WHO Collaborating Centre for Surgery and Public Health, Department of Clinical Sciences, Lund, Faculty of Medicine, Lund University, Sweden.
| | - Hampus Holmer
- WHO Collaborating Centre for Surgery and Public Health, Department of Clinical Sciences, Lund, Faculty of Medicine, Lund University, Sweden; Department of Global Public Health, Karolinska Institutet, Solna, Sweden
| | | | - Thomas C Ricketts
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina, Chapel Hill, NC
| | - David A Watters
- Department of Surgery, Deakin University and Barwon Health, University Hospital Geelong, Australia
| | - Russell L Gruen
- College of Health and Medicine, Australian National University, Canberra, Australia
| | | | - Lars Hagander
- WHO Collaborating Centre for Surgery and Public Health, Department of Clinical Sciences, Lund, Faculty of Medicine, Lund University, Sweden; Department of Pediatric Surgery, Skane University Hospital, Lund, Sweden
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16
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Isolated Jejunal Perforation and Mesentery Injury following a Kick on the Abdomen of a College Student: A Case Report from a District Hospital in Northern Ghana. Case Rep Crit Care 2020. [DOI: 10.1155/2020/3063472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction. Isolated jejunal perforation from blunt abdominal trauma is an extremely rare intra-abdominal injury that poses a huge diagnostic challenge. Delay in diagnosis and initiation of treatment often leads to significant morbidity and mortality. Diagnosis particularly in resource-poor settings may be extremely challenging and often relies on a high index of suspicion. This is due to lack of adequate diagnostic facilities and human resource to deal with the condition with resulting high occurrence of adverse outcomes. Case Presentation. We report a case of isolated jejunal perforation with associated mesentery injury in a young college student who sustained a kick to his abdomen while playing soccer. This is an unusual presentation since most reported cases often resulted from motor vehicular accidents, bicycle handlebar, and fall from a height. We emphasized the role of critical level of suspicion with a good history and physical examination as the major source of diagnosis since diagnostic procedures, such as abdominal ultrasonography and computed tomography, are largely unavailable in most resource-constraint settings. Early surgical intervention following diagnosis leads to good recovery and reduced mortality. Conclusion. Sufficient vigilance and suspicions of small bowel perforation should always be considered after blunt trauma even when symptoms and physical findings are minimal and when diagnostic capacity is limited.
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17
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Burden of emergency pediatric surgical procedures on surgical capacity in Uganda: a new metric for health system performance. Surgery 2020; 167:668-674. [DOI: 10.1016/j.surg.2019.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 11/17/2019] [Accepted: 12/04/2019] [Indexed: 11/24/2022]
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Straube S, Chang-Bullick J, Nicholaus P, Mfinanga J, Rose C, Nichols T, Hackner D, Murphy S, Sawe H, Tenner A. Novel educational adjuncts for the World Health Organization Basic Emergency Care Course: A prospective cohort study. Afr J Emerg Med 2020; 10:30-34. [PMID: 32161709 PMCID: PMC7058880 DOI: 10.1016/j.afjem.2019.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/22/2019] [Accepted: 11/24/2019] [Indexed: 12/02/2022] Open
Abstract
Introduction The World Health Organization's (WHO) Basic Emergency Care Course (BEC) is a five day, in-person course covering basic assessment and life-saving interventions. We developed two novel adjuncts for the WHO BEC: a suite of clinical cases (BEC-Cases) to simulate patient care and a mobile phone application (BEC-App) for reference. The purpose was to determine whether the use of these educational adjuncts in a flipped classroom approach improves knowledge acquisition and retention among healthcare workers in a low-resource setting. Methods We conducted a prospective, cohort study from October 2017 through February 2018 at two district hospitals in the Pwani Region of Tanzania. Descriptive statistics, Fisher's exact t-tests, and Wilcoxon ranked-sum tests were used to examine whether the use of these adjuncts resulted in improved learner knowledge. Participants were enrolled based on location into two arms; Arm 1 received the BEC course and Arm 2 received the BEC-Cases and BEC-App in addition to the BEC course. Both Arms were tested before and after the BEC course, as well as a 7-month follow-up exam. All participants were invited to focus groups on the course and adjuncts. Results A total of 24 participants were included, 12 (50%) of whom were followed to completion. Mean pre-test scores in Arm 1 (50%) were similar to Arm 2 (53%) (p=0.52). Both arms had improved test scores after the BEC Course Arm 1 (74%) and Arm 2 (87%), (p=0.03). At 7-month follow-up, though with significant participant loss to follow up, Arm 1 had a mean follow-up exam score of 66%, and Arm 2, 74%. Discussion Implementation of flipped classroom educational adjuncts for the WHO BEC course is feasible and may improve healthcare worker learning in low resource settings. Our focus- group feedback suggest that the course and adjuncts are user friendly and culturally appropriate.
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Bath M, Bashford T, Fitzgerald JE. What is 'global surgery'? Defining the multidisciplinary interface between surgery, anaesthesia and public health. BMJ Glob Health 2019; 4:e001808. [PMID: 31749997 PMCID: PMC6830053 DOI: 10.1136/bmjgh-2019-001808] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/20/2019] [Accepted: 09/28/2019] [Indexed: 12/11/2022] Open
Abstract
'Global surgery' is the term adopted to describe a rapidly developing multidisciplinary field aiming to provide improved and equitable surgical care across international health systems. Sitting at the interface between numerous clinical and non-clinical specialisms, it encompasses multiple aspects that surround the treatment of surgical disease and its equitable provision across health systems globally. From defining the role of, and need for, optimal surgical care through to identifying barriers and implementing improvement, global surgery has an expansive remit. Advocacy, education, research and clinical components can all involve surgeons, anaesthetists, nurses and allied healthcare professionals working together with non-clinicians, including policy makers, epidemiologists and economists. Long neglected as a topic within the global and public health arenas, an increasing awareness of the extreme disparities internationally has driven greater engagement. Not necessarily restricted to specific diseases, populations or geographical regions, these disparities have led to a particular focus on surgical care in low-income and middle-income countries with the greatest burden and needs. This review considers the major factors defining the interface between surgery, anaesthesia and public health in these settings.
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Affiliation(s)
- Michael Bath
- Centre for Neuroscience, Surgery, and Trauma, Queen Mary University of London, London, UK
| | - Tom Bashford
- NIHR Global Health Research Group on Neurotrauma, Division of Anaesthesia, University of Cambridge, Cambridge, UK
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20
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Passman J, Oresanya LB, Akoko L, Mwanga A, Mkony CA, O'Sullivan P, Dicker RA, Löfgren J, Beard JH. Survey of surgical training and experience of associate clinicians compared with medical officers to understand task-shifting in a low-income country. BJS Open 2019; 3:704-712. [PMID: 31592089 PMCID: PMC6773640 DOI: 10.1002/bjs5.50184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 04/23/2019] [Indexed: 11/07/2022] Open
Abstract
Background A workforce crisis exists in global surgery. One solution is task-shifting, the delegation of surgical tasks to non-physician clinicians or associate clinicians (ACs). Although several studies have shown that ACs have similar postoperative outcomes compared with physicians, little is known about their surgical training. This study aimed to characterize the surgical training and experience of ACs compared with medical officers (MOs) in Tanzania. Methods All surgical care providers in Pwani Region, Tanzania, were surveyed. Participants reported demographic data, years of training, and procedures assisted and performed during training. They answered open-ended questions about training and post-training surgical experience. The median number of training cases for commonly performed procedures was compared by cadre using Wilcoxon rank sum and Student's t tests. The researchers performed modified content analysis of participants' answers to open-ended questions on training needs and experiences. Results A total of 21 ACs and 12 MOs participated. ACs reported higher exposure than MOs to similar procedures before their first independent operation (median 40 versus 17 cases respectively; P = 0·031). There was no difference between ACs and MOs in total training surgical volume across common procedures (median 150 versus 171 cases; P = 0·995). Both groups reflected similarly upon their training. Each cadre relied on the other for support and teaching, but noted insufficient specialist supervision during training and independent practice. Conclusions ACs report similar training and operative experience compared with their physician colleagues in Tanzania.
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Affiliation(s)
- J. Passman
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - L. B. Oresanya
- Department of SurgeryLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
| | - L. Akoko
- Department of SurgeryMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - A. Mwanga
- Department of SurgeryMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - C. A. Mkony
- Department of SurgeryMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - P. O'Sullivan
- Department of SurgeryUniversity of California, San Francisco School of MedicineSan FranciscoUSA
| | - R. A. Dicker
- Department of SurgeryUniversity of California, Los Angeles David Geffen School of MedicineLos AngelesCaliforniaUSA
| | - J. Löfgren
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - J. H. Beard
- Department of SurgeryLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
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21
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Pittalis C, Brugha R, Gajewski J. Surgical referral systems in low- and middle-income countries: A review of the evidence. PLoS One 2019; 14:e0223328. [PMID: 31560716 PMCID: PMC6764741 DOI: 10.1371/journal.pone.0223328] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/18/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Referral networks are critical in the timely delivery of surgical care, particularly for populations residing in rural areas who have limited access to specialist services. However, in low- and middle-income countries (LMICs) referral networks are often undermined by systemic inefficiencies. If equitable access to essential surgical services is to be achieved, sound evidence is needed to ensure efficient patient care pathways. The aim of this scoping review was to investigate current knowledge regarding inter-hospital surgical referral systems in LMICs to identify the main obstacles to their functioning and to critically assess proposed solutions. METHODS MEDLINE, EMBASE and Global Health databases and grey literature were systematically searched to identify relevant studies. The search generated 2261 unique records, of which 14 studies were selected for inclusion in the review. The narrative synthesis of retrieved data is based on a conceptual framework developed though a thematic analysis approach. RESULTS Multiple shortages in surgical infrastructure, equipment and personnel, as well as gaps in surgical and decision-making skills of clinicians at sending hospitals, act as obstacles to safe and appropriate referrals. Comprehensive protocols for surgical referrals are lacking in most LMICs and established patient pathways, when in place, are not correctly followed. Interventions to improve coordination and communication between different level facilities may enhance efficiency of referral pathways. Strengthening capacity of referring hospitals to manage more surgical conditions locally could improve outcomes, decrease the need for referral and reduce the burden on tertiary facilities. DISCUSSION The field of surgical referrals is still an uncharted territory and the limited empirical evidence available is of low quality. Developing strategies for assessing functionality and effectiveness of referral systems in surgery is essential to improve access, coverage and quality of services in resource-limited settings, as well as overall health systems performance.
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Affiliation(s)
- Chiara Pittalis
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- * E-mail:
| | - Ruairi Brugha
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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22
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Law TJ, Bulamba F, Ochieng JP, Edgcombe H, Thwaites V, Hewitt-Smith A, Zoumenou E, Lilaonitkul M, Gelb AW, Workneh RS, Banguti PM, Bould D, Rod P, Rowles J, Lobo F, Lipnick MS. Anesthesia Provider Training and Practice Models: A Survey of Africa. Anesth Analg 2019; 129:839-846. [PMID: 31425228 DOI: 10.1213/ane.0000000000004302] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In Africa, most countries have fewer than 1 physician anesthesiologist (PA) per 100,000 population. Nonphysician anesthesia providers (NPAPs) play a large role in the workforce of many low- and middle-income countries (LMICs), but little information has been systematically collected to describe existing human resources for anesthesia care models. An understanding of existing PA and NPAP training pathways and roles is needed to inform anesthesia workforce planning, especially for critically underresourced countries. METHODS Between 2016 and 2018, we conducted electronic, phone, and in-person surveys of anesthesia providers in Africa. The surveys focused on the presence of anesthesia training programs, training program characteristics, and clinical scope of practice after graduation. RESULTS One hundred thirty-one respondents completed surveys representing data for 51 of 55 countries in Africa. Most countries had both PA and NPAP training programs (57%; mean, 1.6 pathways per country). Thirty distinct training pathways to become an anesthesia provider could be discriminated on the basis of entry qualification, duration, and qualification gained. Of these 30 distinct pathways, 22 (73%) were for NPAPs. Physician and NPAP program durations were a median of 48 and 24 months (ranges: 36-72, 9-48), respectively. Sixty percent of NPAP pathways required a nursing background for entry, and 60% conferred a technical (eg, diploma/license) qualification after training. Physicians and NPAPs were trained to perform most anesthesia tasks independently, though few had subspecialty training (such as regional or cardiac anesthesia). CONCLUSIONS Despite profound anesthesia provider shortages throughout Africa, most countries have both NPAP and PA training programs. NPAP training pathways, in particular, show significant heterogeneity despite relatively similar scopes of clinical practice for NPAPs after graduation. Such heterogeneity may reflect the varied needs and resources for different settings, though may also suggest lack of consensus on how to train the anesthesia workforce. Lack of consistent terminology to describe the anesthesia workforce is a significant challenge that must be addressed to accelerate workforce research and planning efforts.
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Affiliation(s)
- Tyler J Law
- From the Division of Global Health Equity, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Fred Bulamba
- Department of Anesthesia, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - John Paul Ochieng
- Department of Anesthesia, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Hilary Edgcombe
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Victoria Thwaites
- Department of Anesthesia, Inverclyde Royal Hospital, Glasgow, United Kingdom
| | - Adam Hewitt-Smith
- Department of Anesthesia, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | | | - Maytinee Lilaonitkul
- From the Division of Global Health Equity, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Adrian W Gelb
- From the Division of Global Health Equity, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Rediet S Workneh
- Department of Anesthesiology, Addis Ababa University, College of Health Sciences, Addis Ababa, Ethiopia
| | - Paulin M Banguti
- Department of Anesthesia, Critical Care and Emergency Medicine, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Dylan Bould
- Department of Anesthesia and Pain Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | - Pascal Rod
- International Federation of Nurse Anesthetists, Mantes la Jolie, France
| | - Jackie Rowles
- School of Nurse Anesthesia, Texas Christian University, Fort Worth, Texas
| | - Francisco Lobo
- Anesthesiology Department, Centro Hospitalar do Porto, Porto, Portugal
- Department of Anesthesiology, Intensive Care and Perioperative Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Michael S Lipnick
- From the Division of Global Health Equity, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
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23
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Prinja S, Sharma Y, Dixit J, Thingnam SKS, Kumar R. Cost of Treatment of Valvular Heart Disease at a Tertiary Hospital in North India: Policy Implications. PHARMACOECONOMICS - OPEN 2019; 3:391-402. [PMID: 30783991 PMCID: PMC6710307 DOI: 10.1007/s41669-019-0123-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND Lack of data on the cost of cardiac care is an impediment to evidence-based planning, especially for determining provider payment rates under publically financed health insurance schemes. OBJECTIVE This study estimates the unit costs of outpatient consultation, hospitalization, intensive care, selected surgical procedures and diagnostics for providing cardiac care for valvular heart disease at a tertiary hospital in India. METHODS We undertook an economic costing of cardiac care using both patient and health system perspectives. For the health system costs, a bottom-up costing methodology was used. Data on all resources (capital and recurrent) utilized for the delivery of cardiac care services for valvular heart disease for 1 year were collected. Data on out-of-pocket expenditures was collected from 100 cardiac patients who underwent valve replacement and balloon valvotomy procedures. All estimated costs represent the year 2016-2017. RESULTS The health system cost of an outpatient cardiac consultation was estimated as 182.4 Indian rupees (INR) (US$2.8) and INR334.8 (US$5.2) in the cardiology, and cardio-thoracic and vascular surgery (CTVS) departments, respectively. The cost of hospitalization per bed-day in cardiology, CTVS and the intensive care unit (ICU) was INR1040 (US$16), INR3853 (US$60) and INR12,635 (US$197), respectively. The median out-of-pocket expenditure for valve replacement surgery using mechanical and bio-prosthetic valves was estimated to be INR107,800 (US$1684) and INR154,000 (US$2406), respectively, and for balloon valvotomy was estimated to be INR14,456 (US$367). Overall package cost per mechanical and bio-prosthetic single valve replacement surgery and balloon valvotomy procedure was estimated as INR127,919 (US$1999), INR148,919 (US$2372) and INR14,456 (US$226), respectively. CONCLUSION Our findings are useful for planning expansion of public sector cardiac care services, developing package rates for publically financed insurance schemes in India and for undertaking research on cost effectiveness of various models of cardiac care.
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Affiliation(s)
- Shankar Prinja
- School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Yashpaul Sharma
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jyoti Dixit
- School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shyam Kumar Singh Thingnam
- Department of Cardiothoracic and Vascular Surgery (CTVS), Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Kumar
- School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
BACKGROUND Abdominal operations account for a majority of surgical volume in low-income countries, yet population-level prevalence data on surgically treatable abdominal conditions are scarce. OBJECTIVE In this study, our objective was to quantify the burden of surgically treatable abdominal conditions in Uganda. METHODS In 2014, we administered a two-stage cluster-randomized Surgeons OverSeas Assessment of Surgical Need survey to 4,248 individuals in 105 randomly selected clusters (representing the national population of Uganda). FINDINGS Of the 4,248 respondents, 185 reported at least one surgically treatable abdominal condition in their lifetime, giving an estimated lifetime prevalence of 3.7% (95% CI: 3.0 to 4.6%). Of those 185 respondents, 76 reported an untreated condition, giving an untreated prevalence of 1.7% (95% CI: 1.3 to 2.3%). Obstructed labor (52.9%) accounted for most of the 238 abdominal conditions reported and was untreated in only 5.6% of reported conditions. In contrast, 73.3% of reported abdominal masses were untreated. CONCLUSIONS Individuals in Uganda with nonobstetric abdominal surgical conditions are disproportionately undertreated. Major health system investments in obstetric surgical capacity have been beneficial, but our data suggest that further investments should aim at matching overall surgical care capacity with surgical need, rather than focusing on a single operation for obstructed labor.
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Tran TM, Fuller AT, Butler EK, Muhumuza C, Ssennono VF, Vissoci JR, Makumbi F, Chipman JG, Galukande M, Haglund MM, Luboga S. Surgical need among the ageing population of Uganda. Afr Health Sci 2019; 19:1778-1788. [PMID: 31149008 PMCID: PMC6531960 DOI: 10.4314/ahs.v19i1.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Uganda's ageing population (age 50 years and older) will nearly double from 2015 to 2050. HIV/AIDS, diabetes, stroke among other disease processes have been studied in the elderly population. However, the burden of disease from surgically-treatable conditions is unknown. OBJECTIVES To determine the proportion of adults above 50 years with unmet surgical need and deaths attributable to probable surgically-treatable conditions. METHODS A cluster randomized sample representing the national population of Uganda was enumerated. The previously validated Surgeons Overseas assessment of surgical need instrument, a head-to-toe verbal interview, was used to determine any surgically-treatable conditions in two randomly-selected living household members. Deaths were detailed by heads of households. Weighted metrics are calculated taking sampling design into consideration and Taylor series linearization was used for sampling error estimation. RESULTS The study enumerated 425 individuals above age 50 years. The prevalence proportion of unmet surgical need was 27.8% (95%CI, 22.1-34.3). This extrapolates to 694,722 (95%CI, 552,279-857,157) individuals living with one or more surgically treatable conditions. The North sub-region was observed to have the highest prevalence proportion. Nearly two out of five household deaths (37.9%) were attributed to probable surgically treatable causes. CONCLUSION There is disproportionately high need for surgical care among the ageing population of Uganda with approximately 700,000 consultations needed.
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Affiliation(s)
- Tu M Tran
- Duke University Division of Global Neurosurgery and Neuroscience
| | - Anthony T Fuller
- Duke University Division of Global Neurosurgery and Neuroscience
- Duke University School of Medicine
| | - Elissa K Butler
- University of Washington Department of Surgery 1959 NE Pacific Street Box 356410 Seattle, WA 98195 USA
| | | | - Vincent F Ssennono
- Uganda Bureau of Statistics, Kampala, Uganda; Statistics House, Plot 9 Colville Street Box 7186 Kampala, Uganda
| | | | | | - Jeffrey G Chipman
- University of Minnesota Department of Surgery, Minneapolis, MN, USA; 420 Delaware Street SE Mayo Mail Code 195 Minneapolis, MN 55455 USA
| | - Moses Galukande
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Michael M Haglund
- Duke University Division of Global Neurosurgery and Neuroscience
- Duke University School of Medicine
- Duke University Department of Neurosurgery, Durham, NC, USA Durham, NC, USA 310 Trent Drive, Room 301 Durham, NC 27710 USA
| | - Samuel Luboga
- Makerere University College of Health Sciences, Department of Anatomy, Kampala, Uganda P. O. Box 7072, New Mulago Hospital Complex Kampala, Uganda
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Norris AJ, Norris CE. Factors influencing non-attendance to scheduled eye surgery in rural Swaziland. AFRICAN VISION AND EYE HEALTH 2019. [DOI: 10.4102/aveh.v78i1.490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Abstract
Background Improvement in the surgical system requires intersectoral coordination. To achieve this, the development of National Surgical, Obstetric, and Anaesthesia Plans (NSOAPS) has been recommended. One of the first steps of NSOAP development is situational analysis. On the ground situational analyses can be resource intensive and often duplicative. In 2016, the Ministry of Health of Tanzania issued a directive for the creation of an NSOAP. This systematic review aimed to assess if a comprehensive situational analysis could be achieved with existing data. These data would be used for evidence-based priority setting for NSOAP development and streamline any additional data collection needed. Methods A systematic literature review of scientific literature, grey literature, and policy documents was performed as per PRISMA. Extraction was performed for all articles relating to the five NSOAPS domains: infrastructure, service delivery, workforce, information management, and financing. Results 1819 unique articles were generated. Full-text screening produced 135 eligible articles; 46 were relevant to surgical infrastructure, 53 to workforce, 81 to service delivery, 11 to finance, and 15 to information management. Rich qualitative and quantitative data were available for each domain. Conclusions Despite little systematic data collection around SOA, a thorough literature review provides significant evidence which often have a broader scope, longer timeline and better coverage than can be achieved through snapshot-stratified samples of directed on the ground assessments. Evidence from the review was used during stakeholder discussion to directly inform the NSOAP priorities in Tanzania.
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Fatima I, Humayun A, Anwar MI, Shafiq M. Evaluating quality standards' adherence in surgical care: a case study from Pakistan. Int J Qual Health Care 2018; 30:138-144. [PMID: 29300889 DOI: 10.1093/intqhc/mzx179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 12/12/2017] [Indexed: 11/13/2022] Open
Abstract
Objective To explore the extent of adherence to surgical quality standards and areas of improvement. Design Multi-method case study was done. Assessment of observed/actual and self-reported adherence to quality standards in surgical care was done on WHO's safe-surgery checklist. Client satisfaction through exit interviews assessed of all operated during 1 month. Semi-structured interviews of key informants were conducted to identify areas of improvements in surgical care in this hospital. Setting Conducted in a tertiary care teaching hospital in Lahore, Pakistan. Participants Out of all 154 patients during 1 month were admitted with indications for surgery and 35.71% patients gave consent and participated in the study. Outcome measure Actual and reported adherence data were categorized in excellent, good, satisfactory and poor adherence to standards. For in-depth interviews, themes were identified from textual data. Results Overall activities in surgical department were performed well, patients were satisfied and hospital surgical mortality rate was zero but infection control measures needs attention and these practices were found poor with high re-operation and re-admissionrate (P-value < 0.001). Adherence to standards of surgical quality was inadequate in pre-operative, operative and post-op steps as assessed on the checklist but actual adherence was different from reported adherence by surgical care providers. Conclusion This case study shows a complete picture of surgical care quality in a hospital of Pakistan. Discrepancy between perceived/reported adherence and actual practice was found. Patients' satisfaction is not a reliable outcome measure of surgical care quality.
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Affiliation(s)
- Iram Fatima
- Institute of Quality and Technology Management, University of the Punjab at Khayaban-e-Jamia Punjab, Lahore, Pakistan
| | - Ayesha Humayun
- Department of Public Health and Community Medicine, Federal Postgraduate Medical Institute & Shaikh Khalifa Bin Zayed Al-Nahyan Medical College, Shaikh Zayed Medical Complex, Khayaban-e-Jamia Punjab, Lahore, Pakistan
| | - Muhammad Imran Anwar
- Department of Surgery, Federal Postgraduate Medical Institute & Shaikh Khalifa Bin Zayed Al-Nahyan Medical College, Shaikh Zayed Medical Complex, Khayaban-e-Jamia Punjab, Lahore, Pakistan
| | - Muhammad Shafiq
- Institute of Quality and Technology Management, University of the Punjab at Khayaban-e-Jamia Punjab, Lahore, Pakistan
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Current Challenges of Plastic Surgical Care in Sub-Saharan Africa (Maputo, Mozambique). PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1893. [PMID: 30324071 PMCID: PMC6181493 DOI: 10.1097/gox.0000000000001893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/13/2018] [Indexed: 11/26/2022]
Abstract
Background: Limited data exist on plastic surgery practices in Sub-Saharan Africa. The aim of this study was to characterize the spectrum of disease and operative procedures at a teaching hospital in Maputo, Mozambique to help understand the challenges of providing care for the local providers and to provide contextual relevance for training through partnerships. Methods: A mixed-methods approach was utilized to perform an ongoing needs assessment. A retrospective review was performed of plastic surgery operative records, ward admissions records, and death records in a tertiary-care hospital in Maputo, Mozambique for the period January 2015 to December 2015. Results: Limited resources (equipment, block-time, personnel, and perioperative services) were observed. The most common diagnoses for the 455 patients evaluated were burns (44%) and neoplasms (17%). Congenital abnormalities accounted for only 1% of the patient diagnoses. Of the 408 procedures performed, the majority were skin grafts (43%) and skin excisions (31%). Sepsis from burns accounted for 70% of documented deaths (14/20). The mean number of days to skin grafting for inpatients was 53 days. Conclusion: We observed a large burden of burns and skin graft procedures at a public referral teaching hospital in Mozambique. Our findings provide contextual relevance to help focus public health efforts and improve plastic surgery training and practices.
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Varela C, Young S, Groen R, Banza L, Mkandawire NC, Viste A. Untreated surgical conditions in Malawi: A randomised cross-sectional nationwide household survey. Malawi Med J 2018; 29:231-236. [PMID: 29872512 PMCID: PMC5811994 DOI: 10.4314/mmj.v29i3.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Noncommunicable diseases, such as surgical conditions have received little attention from public health planners in low income countries (LIC) like Malawi. Though increasingly recognised as a growing global health problem, the burden of surgical pathologies and access to surgical care has not been adequately identified in many LIC. Information on the spectrum and burden of surgical disease in Malawi is important to uncover the unmet need for surgery and for planning of the National Health Service. Methods This was a multistage random cluster sampling national survey. Households were selected from clusters using probability proportional to size method. 1448 households and 2909 interviewees were analysed. The Surgeons Overseas Assessment of Surgical need (SOSAS) tool was used to collect data. This electronic tablet based questionnaire tool included general information and a dual personalised head to toe inquiry on surgical conditions. The general information included number of household members, and inquired on any death within the past twelve months, and if any of the deaths in the family had a suspected surgical condition leading to that death. Data was collected by specially trained third year medical students. Results Out of 1480 selected households, 1448 (98%) agreed to participate, with 2909 interviewed individuals included in the study. The median household size was 6 individuals (range 1 – 47). Median age of interviewed persons was 35 years (range 0.25 – 104 years). 1027 out of 2909 (35%) of the interviewed people reported to be living with a condition requiring surgical consultation or intervention, whereas 146 of 616 (24%) of the total deaths reported to have occurred in the preceding 12 months were reported to have died from a surgically related condition. Most individuals did not seek health care due to lack of funds for transportation to the health facility. Only 3.1% of those that reported a surgical condition had surgical intervention. Conclusions There is a large unmet need for surgical care in Malawi. A third of the population is living with a condition needing surgical consultation or intervention, and a quarter of all deaths are potentially avoidable with surgery. Urgent scale up of surgical services and training are needed to reduce this huge gap in public health planning in the country.
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Affiliation(s)
- Carlos Varela
- Kamuzu Central Hospital, Lilongwe, Malawi.,Lilongwe Campus, College of Medicine, University of Malawi, Lilongwe, Malawi.,Institute of Clinical Sciences (K1 and Centre for International Health, University of Bergen, Bergen, Norway
| | - Sven Young
- Kamuzu Central Hospital, Lilongwe, Malawi.,Lilongwe Campus, College of Medicine, University of Malawi, Lilongwe, Malawi.,Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Reinou Groen
- Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Department of Obstetrics and Gynaecology, Alaska Native Medical Center, Anchorage, Alaska, USA
| | - Leonard Banza
- Kamuzu Central Hospital, Lilongwe, Malawi.,Lilongwe Campus, College of Medicine, University of Malawi, Lilongwe, Malawi.,Institute of Clinical Sciences (K1 and Centre for International Health, University of Bergen, Bergen, Norway
| | | | - Asgaut Viste
- Institute of Clinical Sciences (K1 and Centre for International Health, University of Bergen, Bergen, Norway.,Department of Acute and Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
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Kibwana S, Yigzaw M, Molla Y, van Roosmalen J, Stekelenburg J. Job satisfaction among anesthetists in Ethiopia-a national cross-sectional study. Int J Health Plann Manage 2018; 33:e960-e970. [PMID: 30033611 DOI: 10.1002/hpm.2573] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ethiopia has substantially increased production of associate clinician anesthetists. This study aimed to determine the level of and factors that predict job satisfaction among a national sample of anesthetists. METHODS A cross-sectional study conducted in 2014 sampled 252 anesthetists. Respondents rated 37 items related to job satisfaction and working and living conditions using a Likert scale, which ranged from 1 (strongly disagree) to 5 (strongly agree). Univariate and multivariable logistic regressions were used to determine factors associated with the main outcome variable, level of job satisfaction. Adjusted odds ratios and 95% confidence intervals were calculated to show the magnitude of associations. RESULTS Less than half (n = 107, 42.5%) of anesthetists were satisfied with their job. Work environment (aOR = 1.87, 95% CI = 1.06, 3.31) and more than 10 years of experience working in the public health system (aOR = 4.96, 95% CI = 1.11, 22.13) were predictors of job satisfaction in the multivariable model. CONCLUSION Ethiopian anesthetists have low levels of job satisfaction, with work environment and years of experience being factors that predict their satisfaction positively. Motivation and retention of this cadre will require emphasis on creating a safe and conducive work environment, and interventions designed to motivate junior anesthetists.
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Affiliation(s)
| | | | | | | | - Jelle Stekelenburg
- Department of Obstetrics & Gynecology, Leeuwarden Medical Centre, Leeuwarden, The Netherlands.,Department of Health Sciences, Global Health, University Medical Centre Groningen/University of Groningen, Groningen, The Netherlands
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Couper I, Ray S, Blaauw D, Ng'wena G, Muchiri L, Oyungu E, Omigbodun A, Morhason-Bello I, Ibingira C, Tumwine J, Conco D, Fonn S. Curriculum and training needs of mid-level health workers in Africa: a situational review from Kenya, Nigeria, South Africa and Uganda. BMC Health Serv Res 2018; 18:553. [PMID: 30012128 PMCID: PMC6048766 DOI: 10.1186/s12913-018-3362-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 07/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Africa's health systems rely on services provided by mid-level health workers (MLWs). Investment in their training is worthwhile since they are more likely to be retained in underserved areas, require shorter training courses and are less dependent on technology and investigations in their clinical practice than physicians. Their training programs and curricula need up-dating to be relevant to their practice and to reflect advances in health professional education. This study was conducted to review the training and curricula of MLWs in Kenya, Nigeria, South Africa and Uganda, to ascertain areas for improvement. METHODS Key informants from professional associations, regulatory bodies, training institutions, labour organisations and government ministries were interviewed in each country. Policy documents and training curricula were reviewed for relevant content. Feedback was provided through stakeholder and participant meetings and comments recorded. 421 District managers and 975 MLWs from urban and rural government district health facilities completed self-administered questionnaires regarding MLW training and performance. RESULTS Qualitative data indicated commonalities in scope of practice and in training programs across the four countries, with a focus on basic diagnosis and medical treatment. Older programs tended to be more didactic in their training approach and were often lacking in resources. Significant concerns regarding skills gaps and quality of training were raised. Nevertheless, quantitative data showed that most MLWs felt their basic training was adequate for the work they do. MLWs and district managers indicated that training methods needed updating with additional skills offered. MLWs wanted their training to include more problem-solving approaches and practical procedures that could be life-saving. CONCLUSIONS MLWs are essential frontline workers in health services, not just a stop-gap. In Kenya, Nigeria and Uganda, their important role is appreciated by health service managers. At the same time, significant deficiencies in training program content and educational methodologies exist in these countries, whereas programs in South Africa appear to have benefited from their more recent origin. Improvements to training and curricula, based on international educational developments as well as the local burden of disease, will enable them to function with greater effectiveness and contribute to better quality care and outcomes.
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Affiliation(s)
- Ian Couper
- Ukwanda Centre for Rural Health, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa. .,Centre for Rural Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Sunanda Ray
- Department of Community Medicine, College of Health Sciences, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Duane Blaauw
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Private Bag 3, Johannesburg, 2050, South Africa
| | - Gideon Ng'wena
- Maseno University School of Medicine, PO Box 333, Maseno, Kenya
| | - Lucy Muchiri
- Department of Human Pathology, School of Medicine, College of Health Sciences, University of Nairobi, P.O. Box 19676, Nairobi, 00202, Kenya
| | - Eren Oyungu
- School of Medicine, Moi University, PO Box 4606, Eldoret, 030100, Kenya
| | - Akinyinka Omigbodun
- College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria
| | - Imran Morhason-Bello
- Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Charles Ibingira
- College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda
| | - James Tumwine
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Daphney Conco
- School of Public Health, University of the Witwatersrand, Wits Education Campus, 27 Saint Andrews Road, Parktown, Johannesburg, 2193, South Africa
| | - Sharon Fonn
- School of Public Health, University of the Witwatersrand, Wits Education Campus, 27 Saint Andrews Road, Parktown, Johannesburg, 2193, South Africa
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Hung YC, Bababekov YJ, Stapleton SM, Mukhopadhyay S, Huang SL, Briggs SM, Chang DC. Reducing road traffic deaths: where should we focus global health initiatives? J Surg Res 2018; 229:337-344. [PMID: 29937011 DOI: 10.1016/j.jss.2018.04.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/26/2018] [Accepted: 04/17/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Current global surgery initiatives focus on increasing surgical workforce; however, it is unclear whether this approach would be helpful globally, as patients in low-resource countries may not be able to reach hospitals in a timely fashion without formal Emergency Medical Services (EMS). We hypothesize that increased surgical workforce correlates with decreased road traffic deaths (RTDs) only in countries with EMS. METHODS Estimated RTDs were obtained from the Global Status Report on Road Safety 2013, which estimated the RTD rate in 2010 (RTD 2010). The classification of EMS was defined by the Global Status Report on Road Safety 2009. The density of surgeons, anesthesiologists, and obstetricians (SAO density) and 2010 income classification were accessed from the World Bank. Multivariable regression analysis was performed adjusting for different countries, income levels, and trauma system characteristics. Sensitivity analysis was performed. RESULTS One-fourth of the countries reported not having formal EMS (n = 41, 23.4%). On adjusted analysis, SAO density was not associated with changes in RTD 2010 in countries without EMS (n = 25, P = 0.50). However, in countries with EMS, each increase in SAO density per 100,000 population decreased RTDs by 0.079 per 100,000 population (n = 97, P <0.001). Income was the only other factor resulting in reduced mortality rates (P = 0.004). Sensitivity analysis confirmed these findings. CONCLUSIONS Increases in surgical workforce reduce RTDs only when EMS exist. Surgical workforce and EMS must be seen as part of the same system and developed together to maximize their effect in reducing RTDs. Global health initiatives should be tailored to individual country need. LEVEL OF EVIDENCE Level II (Ecological study).
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Affiliation(s)
- Ya-Ching Hung
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts; Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts; National Yang Ming University, School of Public Health, Taipei, Taiwan.
| | - Yanik J Bababekov
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Sahael M Stapleton
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Swagoto Mukhopadhyay
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts; University of Connecticut Health Center, Farmington, Connecticut
| | - Song-Lih Huang
- National Yang Ming University, School of Public Health, Taipei, Taiwan
| | - Susan M Briggs
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
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Ruhumuriza J, Odhiambo J, Riviello R, Lin Y, Nkurunziza T, Shrime M, Maine R, Omondi JM, Mpirimbanyi C, de la Paix Sebakarane J, Hagugimana P, Rusangwa C, Hedt-Gauthier B. Assessing the cost of laparotomy at a rural district hospital in Rwanda using time-driven activity-based costing. BJS Open 2018; 2:25-33. [PMID: 29951626 PMCID: PMC5952380 DOI: 10.1002/bjs5.35] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/09/2017] [Indexed: 01/09/2023] Open
Abstract
Background In low‐ and middle‐income countries, the majority of patients lack access to surgical care due to limited personnel and infrastructure. The Lancet Commission on Global Surgery recommended laparotomy for district hospitals. However, little is known about the cost of laparotomy and associated clinical care in these settings. Methods This costing study included patients with acute abdominal conditions at three rural district hospitals in 2015 in Rwanda, and used a time‐driven activity‐based costing methodology. Capacity cost rates were calculated for personnel, location and hospital indirect costs, and multiplied by time estimates to obtain allocated costs. Costs of medications and supplies were based on purchase prices. Results Of 51 patients with an acute abdominal condition, 19 (37 per cent) had a laparotomy; full costing data were available for 17 of these patients, who were included in the costing analysis. The total cost of an entire care cycle for laparotomy was US$1023·40, which included intraoperative costs of US$427·15 (41·7 per cent) and preoperative and postoperative costs of US$596·25 (58·3 per cent). The cost of medicines was US$358·78 (35·1 per cent), supplies US$342·15 (33·4 per cent), personnel US$150·39 (14·7 per cent), location US$89·20 (8·7 per cent) and hospital indirect cost US$82·88 (8·1 per cent). Conclusion The intraoperative cost of laparotomy was similar to previous estimates, but any plan to scale‐up laparotomy capacity at district hospitals should consider the sizeable preoperative and postoperative costs. Although lack of personnel and limited infrastructure are commonly cited surgical barriers at district hospitals, personnel and location costs were among the lowest cost contributors; similar location‐related expenses at tertiary hospitals might be higher than at district hospitals, providing further support for decentralization of these services.
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Affiliation(s)
- J Ruhumuriza
- Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda
| | - J Odhiambo
- Partners In Health, Harvard Medical School Boston Massachusetts USA
| | - R Riviello
- College of Medicine and Health Sciences University of Rwanda Kigali Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School Boston Massachusetts USA.,Program in Global Surgery and Social Change, Harvard Medical School Boston Massachusetts USA.,Center for Surgery and Public Health, Brigham and Women's Hospital Boston Massachusetts USA
| | - Y Lin
- Department of Global Health and Social Medicine, Harvard Medical School Boston Massachusetts USA.,Department of Surgery University of Colorado Denver Colorado USA
| | - T Nkurunziza
- Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda
| | - M Shrime
- Department of Global Health and Social Medicine, Harvard Medical School Boston Massachusetts USA.,Office of Surgery and Health, Massachusetts Eye and Ear Infirmary Boston Massachusetts USA
| | - R Maine
- Department of Surgery University of Washington Seattle Washington USA
| | - J M Omondi
- Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda.,Ministry of Health, Butaro District Hospital Burera Rwanda
| | - C Mpirimbanyi
- College of Medicine and Health Sciences University of Rwanda Kigali Rwanda
| | | | - P Hagugimana
- Ministry of Health, Butaro District Hospital Burera Rwanda
| | - C Rusangwa
- Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda
| | - B Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School Boston Massachusetts USA
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Beyond Infrastructure: Understanding Why Patients Decline Surgery in the Developing World: An Observational Study in Cameroon. Ann Surg 2017; 266:975-980. [PMID: 27849672 DOI: 10.1097/sla.0000000000002002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to quantify and describe a population of patients in rural Cameroon who present with a surgically treatable illness but ultimately decline surgery, and to understand the patient decision-making process and identify key socioeconomic factors that result in barriers to care. BACKGROUND An estimated 5 billion people lack access to safe, affordable surgical care and anesthesia when needed, and this unmet need resides disproportionally in low-income countries (LICs). An understanding of the socioeconomic factors underlying decision-making is key to future efforts to expand surgical care delivery in this population. We assessed patient decision-making in a LIC with a cash-based health care economy. METHODS Standardized interviews were conducted of a random sample of adult patients with treatable surgical conditions over a 7-week period in a tertiary referral hospital in rural Cameroon. Main outcome measures included participant's decision to accept or decline surgery, source of funding, and the relative importance of various factors in the decision-making process. RESULTS Thirty-four of 175 participants (19.4%) declined surgery recommended by their physician. Twenty-six of 34 participants declining surgery (76.4%) cited procedure cost, which on average equaled 6.4 months' income, as their primary decision factor. Multivariate analysis revealed female gender [odds ratio (OR) 3.35, 95% confidence interval (95% CI) 2.14-5.25], monthly earnings (OR 0.83, 95% CI, 0.77-0.89), supporting children in school (OR 1.22, 95% CI 1.13-1.31), and inability to borrow funds from family or the community (OR 6.49, 95% CI 4.10-10.28) as factors associated with declining surgery. CONCLUSION Nearly one-fifth of patients presenting to a surgical clinic with a treatable condition did not ultimately receive needed surgery. Both financial and sociocultural factors contribute to the decision to decline care.
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Chichom-Mefire A, Mbome Njie V, Verla V, Atashili J. A Retrospective One-Year Estimation of the Volume and Nature of Surgical and Anaesthetic Services Delivered to the Populations of the Fako Division of the South-West Region of Cameroon: An Urgent Call for Action. World J Surg 2017; 41:660-671. [PMID: 27778076 DOI: 10.1007/s00268-016-3775-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Surgery-related conditions account for the majority of admissions in primary referral hospitals in Sub-Saharan Africa. The role of surgery in the reduction of global disease burden is well recognized, but there is a great qualitative and quantitative disparity in the delivery of surgical and anaesthetic services between countries. This study aims at estimating the nature and volume of surgery delivered in an entire administrative division of Cameroon. METHODS In this retrospective survey conducted during the year 2013, we used a standard tool to analyse the infrastructure and human resources involved in the delivery of surgical and anaesthetic services in the Fako division in the south-west region of Cameroon. We also estimated the nature and volume of surgical services as a rate per catchment population. RESULTS Public, private and mission hospital contributed equally to the delivery of surgical services in the Fako. For every 100,000 people, there were <5 operative rooms. A total of 2460 surgical interventions were performed by 2.2 surgeons, 1.1 gynaecologists and 0.3 anaesthetists. These surgical interventions consisted mostly of minor and emergency procedures. Neurosurgery, paediatric, thoracic and endocrine surgery were almost non-existent. CONCLUSIONS The volume of surgery delivered in the Fako is far below the minimum rates required to meet up with the most basic requirements of the populations. It is likely that most of these surgical needs are left unattended. A community-based assessment of unmet surgical needs is necessary to accurately estimate the magnitude of the problem and guide surgical capacity improvements.
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Affiliation(s)
- Alain Chichom-Mefire
- Faculty of Health Sciences, University of Buea, Buea, Cameroon. .,Department of Surgery and Obstetrics/Gynaecology, Regional Hospital Limbe, Limbe, Cameroon.
| | - Victor Mbome Njie
- Faculty of Health Sciences, University of Buea, Buea, Cameroon.,Regional Delegation of Public Health, Buea, Cameroon
| | - Vincent Verla
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Julius Atashili
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
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Muhirwa E, Habiyakare C, Hedt-Gauthier BL, Odhiambo J, Maine R, Gupta N, Toma G, Nkurunziza T, Mpunga T, Mukankusi J, Riviello R. Non-Obstetric Surgical Care at Three Rural District Hospitals in Rwanda: More Human Capacity and Surgical Equipment May Increase Operative Care. World J Surg 2017; 40:2109-16. [PMID: 27098541 PMCID: PMC4982876 DOI: 10.1007/s00268-016-3515-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background Most mortality attributable to surgical emergencies occurs in low- and middle-income countries. District hospitals, which serve as the first-level surgical facility in rural sub-Saharan Africa, are often challenged with limited surgical capacity. This study describes the presentation, management, and outcomes of non-obstetric surgical patients at district hospitals in Rwanda. Methods This study included patients seeking non-obstetric surgical care at three district hospitals in rural Rwanda in 2013. Demographics, surgical conditions, patient care, and outcomes are described; operative and non-operative management were stratified by hospitals and differences assessed using Fisher’s exact test. Results Of the 2660 patients who sought surgical care at the three hospitals, most were males (60.7 %). Many (42.6 %) were injured and 34.7 % of injuries were through road traffic crashes. Of presenting patients, 25.3 % had an operation, with patients presenting to Butaro District Hospital significantly more likely to receive surgery (57.0 %, p < 0.001). General practitioners performed nearly all operations at Kirehe and Rwinkwavu District Hospitals (98.0 and 100.0 %, respectively), but surgeons performed 90.6 % of the operations at Butaro District Hospital. For outcomes, 39.5 % of all patients were discharged without an operation, 21.1 % received surgery and were discharged, and 21.1 % were referred to tertiary facilities for surgical care. Conclusion Significantly more patients in Butaro, the only site with a surgeon on staff and stronger surgical infrastructure, received surgery. Availing more surgeons who can address the most common surgical needs and improving supplies and equipment may improve outcomes at other districts. Surgical task sharing is recommended as a temporary solution.
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Affiliation(s)
| | | | - Bethany L Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Rebecca Maine
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Surgery, University of California, San Francisco, CA, USA
| | - Neil Gupta
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Gabriel Toma
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Robert Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.,University Teaching Hospital, Kigali, Rwanda
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Sangwan A, Prinja S, Aggarwal S, Jagnoor J, Bahuguna P, Ivers R. Cost of Trauma Care in Secondary- and Tertiary-Care Public Sector Hospitals in North India. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:681-692. [PMID: 28409489 DOI: 10.1007/s40258-017-0329-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Several initiatives to provide trauma care, including ambulance services, creation of a network of trauma hospitals and insurance schemes for cashless treatment, are currently being implemented in India. However, lack of information on the cost of trauma care is an impediment to the evidence-based planning for such initiatives. In this study, we aim to bridge this gap in evidence by estimating the unit cost of an outpatient consultation, inpatient bed-day of hospitalization, surgical procedure and diagnostics for providing trauma care through secondary- and tertiary-level hospitals in India. METHODS We undertook an economic costing of trauma care in a secondary-care district hospital and a tertiary-level teaching and research hospital in North India. Cost analysis was undertaken using a health system perspective, employing a bottom-up costing methodology. Data on all resources-capital or recurrent-on delivery of trauma care during the period of April 2014 to March 2015 were collected. Standardized unit costs were estimated after adjusting for bed occupancy rates. Sensitivity analysis was performed to account for the uncertainties due to differences in prices and other assumptions. RESULTS The cost of trauma care in the tertiary care hospital was INR 9585 (US$147.4) per day-care consultation; INR 2470 (US$37.7) per bed-day hospitalization (excluding ICU), INR 12,905 (US$198.5) per bed day in ICU and INR 21,499 (US$330.8) per surgery. Similarly, in the secondary-care hospital, the cost of trauma care was INR 482 (US$7.4) per outpatient consultation, INR 791 (US$12.2) per bed day of hospitalization, INR 186 (US$2.9) per minor surgery and INR 6505 (US$100.1) per major surgery. CONCLUSION The estimates generated can be used for planning and managing trauma care services in India. The findings may also be used for undertaking future research in estimating the cost effectiveness of trauma care services or models of care.
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Affiliation(s)
- Ankur Sangwan
- Health Economics, School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India
| | - Shankar Prinja
- Health Economics, School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India.
| | - Sameer Aggarwal
- Department of Orthopedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jagnoor Jagnoor
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Pankaj Bahuguna
- Health Economics, School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India
| | - Rebecca Ivers
- The George Institute for Global Health, University of Sydney, Sydney, Australia
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Epiu I, Tindimwebwa JVB, Mijumbi C, Chokwe TM, Lugazia E, Ndarugirire F, Twagirumugabe T, Dubowitz G. Challenges of Anesthesia in Low- and Middle-Income Countries: A Cross-Sectional Survey of Access to Safe Obstetric Anesthesia in East Africa. Anesth Analg 2017; 124:290-299. [PMID: 27918334 DOI: 10.1213/ane.0000000000001690] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The United Nations 2015 Millennium Development Goals targeted a 75% reduction in maternal mortality. However, in spite of this goal, the number of maternal deaths per 100,000 live births remains unacceptably high across Sub-Saharan Africa. Because many of these deaths could likely be averted with access to safe surgery, including cesarean delivery, we set out to assess the capacity to provide safe anesthetic care for mothers in the main referral hospitals in East Africa. METHODS A cross-sectional survey was conducted at 5 main referral hospitals in East Africa: Uganda, Kenya, Tanzania, Rwanda, and Burundi. Using a questionnaire based on the World Federation of the Societies of Anesthesiologists (WFSA) international guidelines for safe anesthesia, we interviewed anesthetists in these hospitals, key informants from the Ministry of Health and National Anesthesia Society of each country (Supplemental Digital Content, http://links.lww.com/AA/B561). RESULTS Using the WFSA checklist as a guide, none of respondents had all the necessary requirements available to provide safe obstetric anesthesia, and only 7% reported adequate anesthesia staffing. Availability of monitors was limited, and those that were available were often nonfunctional. The paucity of local protocols, and lack of intensive care unit services, also contributed significantly to poor maternal outcomes. For a population of 142.9 million in the East African community, there were only 237 anesthesiologists, with a workforce density of 0.08 in Uganda, 0.39 in Kenya, 0.05 in Tanzania, 0.13 in Rwanda, and 0.02 anesthesiologists in Burundi per 100,000 population in each country. CONCLUSIONS We identified significant shortages of both the personnel and equipment needed to provide safe anesthetic care for obstetric surgical cases across East Africa. There is a need to increase the number of physician anesthetists, to improve the training of nonphysician anesthesia providers, and to develop management protocols for obstetric patients requiring anesthesia. This will strengthen health systems and improve surgical outcomes in developing countries. More funding is required for training physician anesthetists if developing countries are to reach the targeted specialist workforce density of the Lancet Commission on Global Surgery of 20 surgical, anesthetic, and obstetric physicians per 100,000 population by 2030.
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Affiliation(s)
- Isabella Epiu
- From the *Department of Anaesthesia, University of California Global Health Institute - Makerere University College of Health Sciences, Kampala, Uganda; †Department of Anaesthesia, Mulago Hospital, Kampala, Uganda; ‡Department of Anaesthesia, University of Nairobi, Nairobi, Kenya; §Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; ‖Centre Hospitalo-Universitaire de Kamenge, Bujumbura, Burundi; ¶University of Rwanda, Kigali, Rwanda; and #Department of Anaesthesia and Perioperative Care, University of California, San Francisco
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Baxter LS, Ravelojaona VA, Rakotoarison HN, Herbert A, Bruno E, Close KL, Andean V, Andriamanjato HH, Shrime MG, White MC. An Observational Assessment of Anesthesia Capacity in Madagascar as a Prerequisite to the Development of a National Surgical Plan. Anesth Analg 2017; 124:2001-2007. [DOI: 10.1213/ane.0000000000002049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Spiegel DA, Droti B, Relan P, Hobson S, Cherian MN, O'Neill K. Retrospective review of Surgical Availability and Readiness in 8 African countries. BMJ Open 2017; 7:e014496. [PMID: 28264832 PMCID: PMC5353330 DOI: 10.1136/bmjopen-2016-014496] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The purpose of this study was to assess surgical availability and readiness in 8 African countries using the WHO's Service Availability and Readiness Assessment (SARA) tool. SETTING We analysed data for surgical services, including basic and comprehensive surgery, comprehensive obstetric care, blood transfusion, and infection prevention, obtained from the WHO's SARA surveys in Sierra Leone, Uganda, Mauritania, Benin, Zambia, Burkina Faso, Democratic Republic of Congo and Togo. PRIMARY AND SECONDARY OUTCOME MEASURES Among the facilities that were expected to offer surgical services (N=3492), there were wide disparities between the countries in the number of facilities per 100 000 population that reported offering basic surgery (1.0-12.1), comprehensive surgery (0.1-0.8), comprehensive obstetric care (0.1-0.8) and blood transfusion (0.1-0.8). Only 0.1-0.3 facilities per 100 000 population had all three bellwether procedures available, namely laparotomy, open fracture management and caesarean section. In all the countries, the facilities that reported offering surgical services generally had a shortage of the necessary items for offering the services and this varied greatly between the countries, with the facilities having on average 27-53% of the items necessary for offering basic surgery, 56-83% for comprehensive surgery, 49-72% for comprehensive obstetric care and 54-80% for blood transfusion. Furthermore, few facilities had all the necessary items present. However, facilities that reported offering surgical services had on average most of the necessary items for the prevention of infection. CONCLUSIONS There are important gaps in the surgical services in the 8 African countries surveyed. Efforts are therefore urgently needed to address deficiencies in the availability and readiness to deliver surgical services in these nations, and this will require commitment from multiple stakeholders. SARA may be used to monitor availability and readiness at regular intervals, which will enable stakeholders to evaluate progress and identify gaps and areas for improvement.
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Affiliation(s)
- D A Spiegel
- Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - B Droti
- World Health Organization, Geneva, Switzerland
| | - P Relan
- North Shore University Hospital, Manhasset, New York, USA
| | - S Hobson
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - M N Cherian
- World Health Organization, Geneva, Switzerland
| | - K O'Neill
- World Health Organization, Geneva, Switzerland
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Bendix P, Havens JM. The Global Burden of Surgical Disease. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0070-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Uribe-Leitz T, Jaramillo J, Maurer L, Fu R, Esquivel MM, Gawande AA, Haynes AB, Weiser TG. Variability in mortality following caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: a systematic review and analysis of published data. LANCET GLOBAL HEALTH 2017; 4:e165-74. [PMID: 26916818 DOI: 10.1016/s2214-109x(15)00320-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 11/25/2015] [Accepted: 12/08/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that high quality accompanies increased global access to surgical care. We aimed to assess surgical mortality following three common surgical procedures--caesarean delivery, appendectomy, and groin (inguinal and femoral) hernia repair--to quantify the potential risks of expanding access without simultaneously addressing issues of quality and safety. METHODS We collected demographic, health, and economic data for 113 countries classified as low income or lower-middle income by the World Bank in 2005. We did a systematic review of Ovid, MEDLINE, PubMed, and Scopus from Jan 1, 2000, to Jan 15, 2015, to identify studies in these countries reporting all-cause mortality following the three commonly undertaken operations. Reports from governmental and other agencies were also identified and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We first used a fully conditional specification (FCS) multiple imputation method to establish complete datasets for all missing variables that we considered potentially predictive of surgical mortality. We then used regression-based predictive mean matching imputation methods, specified within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confidence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates. FINDINGS From an initial 1302 articles and reports identified, 247 full-text articles met our inclusion criteria, and 124 provided data for surgical mortality for at least one of the three selected operations. We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality was 7·9 per 1000 operations for caesarean delivery (IQR 2·8-19·9), 2·2 per 1000 operations for appendectomy (0·0-17·2), and 4·9 per 1000 operations for groin hernia (0·0-11·7). Perioperative mortality estimates by subregion ranged from 2·8 (South Asia) to 50·2 (East Asia) per 1000 caesarean deliveries, 2·4 (South Asia) to 54·0 (Central sub-Saharan Africa) per 1000 appendectomies, and 0·3 (Andean Latin America) to 25·5 (Southern sub-Saharan Africa) per 1000 hernia repairs. INTERPRETATION All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care. FUNDING None.
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Affiliation(s)
| | | | - Lydia Maurer
- Stanford University School of Medicine, Stanford, CA, USA
| | - Rui Fu
- Management Science and Engineering, Stanford University, Stanford, CA, USA
| | | | - Atul A Gawande
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Alex B Haynes
- Ariadne Labs: a Joint Center for Health System Innovation, Boston, MA, USA; Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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Cherewick ML, Cherewick SD, Kushner AL. Operative needs in HIV+ populations: An estimation for sub-Saharan Africa. Surgery 2016; 161:1436-1443. [PMID: 28043694 DOI: 10.1016/j.surg.2016.11.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 11/18/2016] [Accepted: 11/22/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND In 2015, it was estimated that approximately 36.7 million people were living with HIV globally and approximately 25.5 million of those people were living in sub-Saharan Africa. Limitations in the availability and access to adequate operative care require policy and planning to enhance operative capacity. METHODS Data estimating the total number of persons living with HIV by country, sex, and age group were obtained from the Joint United Nations Programme on HIV/AIDS (UNAIDS) in 2015. Using minimum proposed surgical rates per 100,000 for 4, defined, sub-Saharan regions of Africa, country-specific and regional estimates were calculated. The total need and unmet need for operative procedures were estimated. RESULTS A minimum of 1,539,138 operative procedures were needed in 2015 for the 25.5 million persons living with HIV in sub-Saharan Africa. In 2015, there was an unmet need of 908,513 operative cases in sub-Saharan Africa with the greatest unmet need in eastern sub-Saharan Africa (427,820) and western sub-Saharan Africa (325,026). Approximately 55.6% of the total need for operative cases is adult women, 38.4% are adult men, and 6.0% are among children under the age of 15. CONCLUSION A minimum of 1.5 million operative procedures annually are required to meet the needs of persons living with HIV in sub-Saharan Africa. The unmet need for operative care is greatest in eastern and western sub-Saharan Africa and will require investments in personnel, infrastructure, facilities, supplies, and equipment. We highlight the need for global planning and investment in resources to meet targets of operative capacity.
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Affiliation(s)
- Megan L Cherewick
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | | | - Adam L Kushner
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Surgery, Columbia University, New York, NY
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Schuster RC, de Sousa O, Rivera J, Olson R, Pinault D, Young SL. Performance-based incentives may be appropriate to address challenges to delivery of prevention of vertical transmission of HIV services in rural Mozambique: a qualitative investigation. HUMAN RESOURCES FOR HEALTH 2016; 14:60. [PMID: 27717388 PMCID: PMC5054578 DOI: 10.1186/s12960-016-0157-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 09/27/2016] [Indexed: 06/01/2023]
Abstract
BACKGROUND Performance-based incentives (PBIs) have garnered global attention as a promising strategy to improve healthcare delivery to vulnerable populations. However, literature gaps in the context in which an intervention is implemented and how the PBIs were developed exist. Therefore, we (1) characterized the barriers and promoters to prevention of vertical transmission of HIV (PVT) service delivery in rural Mozambique, where the vertical transmission rate is 12 %, and (2) assessed the appropriateness for a PBI's intervention and application to PVT. METHODS We conducted 24 semi-structured interviews with nurses, volunteers, community health workers, and traditional birth attendants about the barriers and promoters they experienced delivering PVT services. We then explored emergent themes in subsequent focus group discussions (n = 7, total participants N = 92) and elicited participant perspectives on PBIs. The ecological motivation-opportunity-ability framework guided our iterative data collection and thematic analysis processes. RESULTS The interviews revealed that while all health worker cadres were motivated intrinsically and by social recognition, they were dissatisfied with low and late remuneration. Facility-based staff were challenged by factors across the rest of the ecological levels, primarily in the opportunity domain, including the following: poor referral and record systems (work mandate), high workload, stock-outs, poor infrastructure (facility environment), and delays in obtaining patient results and donor payment discrepancies (administrative). Community-based cadres' opportunity challenges included lack of supplies, distance (work environment), lack of incorporation into the health system (administration), and ability challenges of incorrect knowledge (health worker). PBIs based on social recognition and that enable action on intrinsic motivation through training, supervision, and collaboration were thought to have the most potential for targeting improvements in record and referral systems and better integrating community-based health workers into the health system. Concerns about the implementation of incentives included neglect of non-incentivized tasks and distorted motivation among colleagues. CONCLUSIONS We found that highly motivated health workers encountered severe opportunity challenges in their PVT mandate. PBIs have the potential to address key barriers that facility- and community-based health workers encounter when delivering PVT services, specifically by building upon existing intrinsic motivation and leveraging highly valued social recognition. We recommend a controlled intervention to monitor incentives' effects on worker motivation and non-incentivized tasks to generate insights about the feasibility of PBIs to improve the delivery of PVT services.
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Affiliation(s)
- Roseanne C. Schuster
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853 United States of America
- School of Human Evolution and Social Change, Arizona State University, Tempe, AZ 85287-2402 United States of America
| | | | - Jacqueline Rivera
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853 United States of America
| | - Rebecca Olson
- Humphrey School of Public Affairs, University of Minnesota, 310 19th Street S, Minneapolis, MN 55455 United States of America
| | - Delphine Pinault
- CARE Uganda, CARE Mozambique, 596 Av. Mártires de Mueda, Maputo, Mozambique
| | - Sera L. Young
- Program in International Nutrition, Department of Population Medicine and Diagnostic Sciences, Cornell University, Ithaca, NY 14853 United States of America
- Department of Anthropology, Northwestern University, 515 Clark Street, 60208 Evanston, IL United States of America
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Squires A, Uyei SJ, Beltrán-Sánchez H, Jones SA. Examining the influence of country-level and health system factors on nursing and physician personnel production. HUMAN RESOURCES FOR HEALTH 2016; 14:48. [PMID: 27523185 PMCID: PMC4983794 DOI: 10.1186/s12960-016-0145-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 07/28/2016] [Indexed: 05/04/2023]
Abstract
BACKGROUND A key component to achieving good patient outcomes is having the right type and number of healthcare professionals with the right resources. Lack of investment in infrastructure required for producing and retaining adequate numbers of health professionals is one reason, and contextual factors related to socioeconomic development may further explain the trend. Therefore, this study sought to explore the relationships between country-level contextual factors and healthcare human resource production (defined as worker-to-population ratio) across 184 countries. METHODS This exploratory observational study is grounded in complexity theory as a guiding framework. Variables were selected through a process that attempted to choose macro-level indicators identified by the interdisciplinary literature as known or likely to affect the number of healthcare workers in a country. The combination of these variables attempts to account for the gender- and class-sensitive identities of physicians and nurses. The analysis consisted of 1 year of publicly available data, using the most recently available year for each country where multiple regressions assessed how context may influence health worker production. Missing data were imputed using the ICE technique in STATA and the analyses rerun in R as an additional validity and rigor check. RESULTS The models explained 63 % of the nurse/midwife-to-population ratio (pseudo R (2) = 0.627, p = 0.0000) and 73 % of the physician-to-population ratio (pseudo R (2) = 0.729, p = 0.0000). Average years of school in a country's population, emigration rates, beds-per-1000 population, and low-income country statuses were consistently statistically significant predictors of production, with percentage of public and private sector financing of healthcare showing mixed effects. CONCLUSIONS Our study demonstrates that the strength of political, social, and economic institutions does impact human resources for health production and lays a foundation for studying how macro-level contextual factors influence physician and nurse workforce supply. In particular, the results suggest that public and private investments in the education sector would provide the greatest rate of return to countries. The study offers a foundation from which longitudinal analyses can be conducted and identifies additional data that may help enhance the robustness of the models.
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Affiliation(s)
- Allison Squires
- Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010 United States of America
- Research on Medical Education Outcomes (ROMEO) Division, School of Medicine, New York University, 433 First Avenue, New York, NY 10010 United States of America
| | - S. Jennifer Uyei
- Division of Comparative Effectiveness and Decision Science, New York University School of Medicine, 227 East 30th Street, New York, NY 10016 United States of America
| | - Hiram Beltrán-Sánchez
- Department of Community Health Sciences, California Center for Population Research, University of California, Los Angeles, 650 Charles E. Young Drive South, Room 41-257 CHS, Los Angeles, CA 53706-1393 United States of America
| | - Simon A. Jones
- Population Health, New York University School of Medicine, 227 East 30th Street, New York, NY 10016 United States of America
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Dare AJ, Lee KC, Bleicher J, Elobu AE, Kamara TB, Liko O, Luboga S, Danlop A, Kune G, Hagander L, Leather AJM, Yamey G. Prioritizing Surgical Care on National Health Agendas: A Qualitative Case Study of Papua New Guinea, Uganda, and Sierra Leone. PLoS Med 2016; 13:e1002023. [PMID: 27186645 PMCID: PMC4871553 DOI: 10.1371/journal.pmed.1002023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 04/07/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Little is known about the social and political factors that influence priority setting for different health services in low- and middle-income countries (LMICs), yet these factors are integral to understanding how national health agendas are established. We investigated factors that facilitate or prevent surgical care from being prioritized in LMICs. METHODS AND FINDINGS We undertook country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. We conducted 74 semi-structured interviews with stakeholders involved in health agenda setting and surgical care in these countries. Interviews were triangulated with published academic literature, country reports, national health plans, and policies. Data were analyzed using a conceptual framework based on four components (actor power, ideas, political contexts, issue characteristics) to assess national factors influencing priority for surgery. Political priority for surgical care in the three countries varies. Priority was highest in Papua New Guinea, where surgical care is firmly embedded within national health plans and receives significant domestic and international resources, and much lower in Uganda and Sierra Leone. Factors influencing whether surgical care was prioritized were the degree of sustained and effective domestic advocacy by the local surgical community, the national political and economic environment in which health policy setting occurs, and the influence of international actors, particularly donors, on national agenda setting. The results from Papua New Guinea show that a strong surgical community can generate priority from the ground up, even where other factors are unfavorable. CONCLUSIONS National health agenda setting is a complex social and political process. To embed surgical care within national health policy, sustained advocacy efforts, effective framing of the problem and solutions, and country-specific data are required. Political, technical, and financial support from regional and international partners is also important.
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Affiliation(s)
- Anna J. Dare
- King’s Centre for Global Health, King’s College London and King’s Health Partners, London, United Kingdom
| | - Katherine C. Lee
- Global Health Group, Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Josh Bleicher
- Global Health Group, Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Alex E. Elobu
- Department of Surgery, Mulago Hospital, Kampala, Uganda
| | - Thaim B. Kamara
- Department of Surgery, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Osborne Liko
- Department of Surgery, Port Moresby General Hospital, Port Moresby, Papua New Guinea
| | - Samuel Luboga
- Department of Anatomy, Makerere University College of Health Sciences, Kampala, Uganda
| | - Akule Danlop
- Department of Surgery, Port Moresby General Hospital, Port Moresby, Papua New Guinea
| | - Gabriel Kune
- Department of Surgery, Port Moresby General Hospital, Port Moresby, Papua New Guinea
| | - Lars Hagander
- Department of Clinical Sciences–Lund, Lund University, Lund, Sweden
| | - Andrew J. M. Leather
- King’s Centre for Global Health, King’s College London and King’s Health Partners, London, United Kingdom
| | - Gavin Yamey
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- * E-mail:
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48
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Cavallaro FL, Cresswell JA, Ronsmans C. Obstetricians' Opinions of the Optimal Caesarean Rate: A Global Survey. PLoS One 2016; 11:e0152779. [PMID: 27031516 PMCID: PMC4816518 DOI: 10.1371/journal.pone.0152779] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/19/2016] [Indexed: 11/19/2022] Open
Abstract
Background The debate surrounding the optimal caesarean rate has been ongoing for several decades, with the WHO recommending an “acceptable” rate of 5–15% since 1997, despite a weak evidence base. Global expert opinion from obstetric care providers on the optimal caesarean rate has not been documented. The objective of this study was to examine providers’ opinions of the optimal caesarean rate worldwide, among all deliveries and within specific sub-groups of deliveries. Methods A global online survey of medical doctors who had performed at least one caesarean in the last five years was conducted between August 2013 and January 2014. Respondents were asked to report their opinion of the optimal caesarean rate—defined as the caesarean rate that would minimise poor maternal and perinatal outcomes—at the population level and within specific sub-groups of deliveries (including women with demographic and clinical risk factors for caesareans). Median reported optimal rates and corresponding inter-quartile ranges (IQRs) were calculated for the sample, and stratified according to national caesarean rate, institutional caesarean rate, facility level, and respondent characteristics. Results Responses were collected from 1,057 medical doctors from 96 countries. The median reported optimal caesarean rate was 20% (IQR: 15–30%) for all deliveries. Providers in private for-profit facilities and in facilities with high institutional rates reported optimal rates of 30% or above, while those in Europe, in public facilities and in facilities with low institutional rates reported rates of 15% or less. Reported optimal rates were lowest among low-risk deliveries and highest for Absolute Maternal Indications (AMIs), with wide IQRs observed for most categories other than AMIs. Conclusions Three-quarters of respondents reported an optimal caesarean rate above the WHO 15% upper threshold. There was substantial variation in responses, highlighting a lack of consensus around which women are in need of a caesarean among obstetric care providers worldwide.
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Affiliation(s)
- Francesca L. Cavallaro
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Jenny A. Cresswell
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Carine Ronsmans
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
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49
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Davies JF, Lenglet A, van Wijhe M, Ariti C. Perioperative mortality: Analysis of 3 years of operative data across 7 general surgical projects of Médecins Sans Frontières in Democratic Republic of Congo, Central African Republic, and South Sudan. Surgery 2016; 159:1269-78. [PMID: 26883163 DOI: 10.1016/j.surg.2015.12.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 11/16/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The African continent has the greatest burden of surgical disability-adjusted life years, yet the least is known about operative care here. This analysis describes the surgical patients admitted to 7 hospitals supported by the Médécins Sans Frontières (MSF) over 3 years in 3 conflict-affected countries-Eastern Democratic Republic of Congo, Central African Republic, and South Sudan. METHODS A standardized operative data collection tool was used for routine collection of operative inpatient data between 2011 and 2013 at 7 MSF surgical facilities. Surgical records of 14,482 patients were analyzed to describe surgical epidemiology, major procedures, and perioperative mortality. The perioperative mortality rate (POMR) was calculated within 2 days of admission (POMR2) and within 30 days from admission (POMR30). The POMR is used as a marker of quality of operative care. RESULTS Caesarean delivery was the most common major procedure performed and had a POMR30 of 5.28 per 1,000 admissions. The overall inpatient mortality was 19.67 per 1,000 admissions. Children had greater POMR than adults for the same procedure types (47.97 vs 15.89 deaths per 1,000 admissions, P < .001); 85.1% of all major procedures were emergency procedures and between 3 and 30% of admissions were related to violence. After adjustment, perioperative death was associated with emergency surgery, violence, and age younger than 15 years. CONCLUSION POMRs varied by age group and type of major procedure performed. Collecting surgical data is achievable and can inform future planning and support for national surgical programs. More information is needed on operative outcomes in adults and children in low-resource settings to improve quality and access to care.
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Affiliation(s)
- Jessica F Davies
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Annick Lenglet
- Médecins Sans Frontières - Operational Centre Amsterdam, Amsterdam, Netherlands.
| | - Marten van Wijhe
- Médecins Sans Frontières - Operational Centre Amsterdam, Amsterdam, Netherlands
| | - Cono Ariti
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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50
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Linden AF, Maine RG, Hedt-Gauthier BL, Kamanzi E, Gauvey-Kern K, Mody G, Ntakiyiruta G, Kansayisa G, Ntaganda E, Niyonkuru F, Mubiligi J, Mpunga T, Meara JG, Riviello R. Validation of a community-based survey assessing nonobstetric surgical conditions in Burera District, Rwanda. Surgery 2016; 159:1217-26. [PMID: 26775073 DOI: 10.1016/j.surg.2015.10.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 10/02/2015] [Accepted: 10/03/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Validated, community-based surveillance methods to monitor epidemiologic progress in surgery have not yet been employed for surgical capacity building. The goal of this study was to create and assess the validity of a community-based questionnaire collecting data on untreated surgically correctable disease throughout Burera District, Rwanda, to accurately plan for surgical services at a district hospital. METHODS A structured interview to assess for 10 index surgically treatable conditions was created and underwent local focus group and pilot testing. Using a 2-stage cluster sampling design, Rwandan data collectors conducted the structured interview in 30 villages throughout the Burera District. Rwandan physicians revisited the surveyed households to perform physical examinations on all household members, used as the gold standard to validate the structured interview. RESULTS A total of 2,990 individuals were surveyed and 2,094 (70%) were available for physical examination. The calculated sensitivity and specificity of the survey tool were 44.5% (95% CI, 38.9-50.2%) and 97.7% (95% CI, 96.9-98.3%), respectively. The conditions with the highest sensitivity and specificity were hydrocephalus, clubfoot, and injuries/infections. Injuries/infections and hernias/hydroceles were the conditions most frequently found on examination that were not reported during the interview. CONCLUSION This study provides the first attempt to validate a community-based surgical surveillance tool. The finding of low sensitivity was likely related to limited access to care and poor health literacy. Accurate community-based surveys are critical to planning integrated health systems that include surgical care as a core component.
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Affiliation(s)
- Allison F Linden
- Department of Surgery, Georgetown University Hospital, Washington, DC; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA.
| | - Rebecca G Maine
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Bethany L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | | | - Gita Mody
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Georges Ntakiyiruta
- Department of Surgery, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | | | - Edmond Ntaganda
- Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda
| | | | - Joel Mubiligi
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | - John G Meara
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA
| | - Robert Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
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