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Development and Validation of the Data Instrument for Surgical Global Outreach. Plast Reconstr Surg 2020; 145:855e-864e. [DOI: 10.1097/prs.0000000000006700] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sriram V, Bennett S. Strengthening medical specialisation policy in low-income and middle-income countries. BMJ Glob Health 2020; 5:e002053. [PMID: 32133192 PMCID: PMC7042575 DOI: 10.1136/bmjgh-2019-002053] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/10/2019] [Accepted: 12/22/2019] [Indexed: 12/13/2022] Open
Abstract
The availability of medical specialists has accelerated in low-income and middle-income countries (LMICs), driven by factors including epidemiological and demographic shifts, doctors' preferences for postgraduate training, income growth and medical tourism. Yet, despite some policy efforts to increase access to specialists in rural health facilities and improve referral systems, many policy questions are still underaddressed or unaddressed in LMIC health sectors, including in the context of universal health coverage. Engaging with issues of specialisation may appear to be of secondary importance, compared with arguably more pressing concerns regarding primary care and the social determinants of health. However, we believe this to be a false choice. Policy at the intersection of essential health services and medical specialties is central to issues of access and equity, and failure to formulate policy in this regard may have adverse ramifications for the entire system. In this article, we describe three critical policy questions on medical specialties and health systems with the aim of provoking further analysis, discussion and policy formulation: (1) What types, and how many specialists to train? (2) How to link specialists' production and deployment to health systems strengthening and population health? (3) How to develop and strengthen institutions to steer specialisation policy? We posit that further analysis, discussion and policy formulation addressing these questions presents an important opportunity to explicitly determine and strengthen the linkages between specialists, health systems and health equity.
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Affiliation(s)
- Veena Sriram
- Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois, USA
| | - Sara Bennett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Global Initiative for Children's Surgery: A Model of Global Collaboration to Advance the Surgical Care of Children. World J Surg 2019; 43:1416-1425. [PMID: 30623232 PMCID: PMC7019676 DOI: 10.1007/s00268-018-04887-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Recommendations by the Lancet Commission on Global Surgery regarding surgical care in low- and middle-income countries (LMICs) require development to address the needs of children. The Global Initiative for Children's Surgery (GICS) was founded in 2016 to identify solutions to problems in children's surgery by utilizing the expertise of practitioners from around the world. This report details this unique process and underlying principles. METHODS Three global meetings convened providers of surgical services for children. Through working group meetings, participants reviewed the status of global children's surgery to develop priorities and identify necessary resources for implementation. Working groups were formed under LMIC leadership to address specific priorities. By creating networking opportunities, GICS has promoted the development of LMIC-LMIC and HIC-LMIC partnerships. RESULTS GICS members identified priorities for children's surgical care within four pillars: infrastructure, service delivery, training and research. Guidelines for provision of care at every healthcare level based on these pillars were created. Seventeen subspecialty, LMIC chaired working groups developed the Optimal Resources for Children's Surgery (OReCS) document. The guidelines are stratified by subspecialty and level of health care: primary health center, first-, second- and third-level hospitals, and the national children's hospital. The OReCS document delineates the personnel, equipment, facilities, procedures, training, research and quality improvement components at all levels of care. CONCLUSION Worldwide collaboration with leadership by providers from LMICs holds the promise of improving children's surgical care. GICS will continue to evolve in order to achieve the vision of safe, affordable, timely surgical care for all children.
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Nasser JS, Chung KC. Economic Analyses of Surgical Trips to the Developing World: Current Concepts and Future Strategies. Hand Clin 2019; 35:381-389. [PMID: 31585597 PMCID: PMC6779176 DOI: 10.1016/j.hcl.2019.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The surgical burden of disease disproportionately affects individuals living in the developing world. In response, the surgical community has increased efforts to provide care to patients in these countries during short-term surgical trips. This article (1) summarizes the current concepts used in the economic evaluation of surgical outreach and (2) presents a conceptual model to describe the ideal approach to performing an economic analysis of surgical interventions in developing countries. This model may ensure that policymakers are provided with information to decrease cost and improve the access to specialty surgery in the developing world.
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Affiliation(s)
- Jacob S. Nasser
- Clinical Research Associate, Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Kevin C. Chung
- Professor of Surgery, Section of Plastic Surgery, Assistant Dean for Faculty Affairs, University of Michigan Medical School, Ann Arbor, MI
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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: 61] [Impact Index Per Article: 12.2] [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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Schucht P, Zubak I, Kuhlen D, Abu-Isa J, Murek M, Raabe A, Soe ZW, Aung K, Soe Myint AT, Thu M. Assisted Education for Specialized Medicine: A Sustainable Development Plan for Neurosurgery in Myanmar. World Neurosurg 2019; 130:e854-e861. [DOI: 10.1016/j.wneu.2019.07.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/29/2019] [Accepted: 07/01/2019] [Indexed: 11/28/2022]
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Evaluating the Economic Impact of Plastic and Reconstructive Surgical Efforts in the Developing World: The ReSurge Experience. Plast Reconstr Surg 2019; 144:485e-493e. [PMID: 31461047 DOI: 10.1097/prs.0000000000005984] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND As the global burden of disease continues to rise, it becomes increasingly important to determine the sustainability of specialty surgery in the developing world. The authors aim to (1) evaluate the cost-effectiveness of plastic and reconstructive surgery in the developing world and (2) quantify the economic benefit. METHODS In this study, the authors performed a retrospective analysis of surgical trips performed by ReSurge International from 2014 to 2017. The organization gathered data on trip information, cost, and clinical characteristics. The authors measured the cost-effectiveness of the interventions using cost per disability-adjusted life-years and defined cost-effectiveness using World Health Organization Choosing Interventions That Are Cost-Effective thresholds. The authors also performed a cost-to-benefit analysis using the human capital approach. RESULTS A total of 22 surgical trips from eight different developing countries were included in this study. The authors analyzed a total of 756 surgical interventions. The cost-effectiveness of the surgical trips ranged from $52 to $11,410 per disability-adjusted life-year averted. The economic benefit for the 22 surgical trips was $9,795,384. According to World Health Organization Choosing Interventions That Are Cost-Effective thresholds, 21 of the surgical trips were considered very cost-effective or cost-effective. CONCLUSIONS Plastic and reconstructive operations performed during short-term surgical trips performed by this organization are economically sustainable. High-volume trips and those treating complex surgical conditions prove to be the most cost-effective. To continue to receive monetary funding, providing fiscally sustainable surgical care to low- and middle-income countries is imperative.
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Denburg AE, Ramirez A, Pavuluri S, McCann E, Shah S, Alcasabas T, Antillon F, Arora R, Fuentes-Alabi S, Renner L, Lam C, Friedrich P, Maser B, Force L, Galindo CR, Atun R. Political priority and pathways to scale-up of childhood cancer care in five nations. PLoS One 2019; 14:e0221292. [PMID: 31425526 PMCID: PMC6699697 DOI: 10.1371/journal.pone.0221292] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 08/02/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Despite increasing global attention to non-communicable diseases (NCDs) and their incorporation into universal health coverage (UHC), the factors that determine whether and how NCDs are prioritized in national health agendas and integrated into health systems remain poorly understood. Childhood cancer is a leading non-communicable cause of death in children aged 0-14 years worldwide. We investigated the political, social, and economic factors that influence health system priority-setting on childhood cancer care in a range of low- and middle-income countries (LMIC). METHODS AND FINDINGS Based on in-depth qualitative case studies, we analyzed the determinants of priority-setting for childhood cancer care in El Salvador, Guatemala, Ghana, India, and the Philippines using a conceptual framework that considers four principal influences on political prioritization: political contexts, actor power, ideas, and issue characteristics. Data for the analysis derived from in-depth interviews (n = 68) with key informants involved in or impacted by childhood cancer policies and programs in participating countries, supplemented by published academic literature and available policy documents. Political priority for childhood cancer varies widely across the countries studied and is most influenced by political context and actor power dynamics. Ghana has placed relatively little national priority on childhood cancer, largely due to competing priorities and a lack of cohesion among stakeholders. In both El Salvador and Guatemala, actor power has played a central role in generating national priority for childhood cancer, where well-organized and -resourced civil society organizations have disrupted legacies of fragmented governance and financing to create priority for childhood cancer care. In India, the role of a uniquely empowered private actor was instrumental in creating political priority and establishing sustained channels of financing for childhood cancer care. In the Philippines, the childhood cancer community has capitalized on a window of opportunity to expand access and reduce disparities in childhood cancer care through the political prioritization of UHC and NCDs in current health system reforms. CONCLUSIONS The importance of key health system actors in determining the relative political priority for childhood cancer in the countries studied points to actor power as a critical enabler of prioritization in other LMIC. Responsiveness to political contexts-in particular, rhetorical and policy priority placed on NCDs and UHC-will be crucial to efforts to place childhood cancer firmly on national health agendas. National governments must be convinced of the potential for foundational health system strengthening through attention to childhood cancer care, and the presence and capability of networked actors primed to amplify public sector investments and catalyze change on the ground.
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Affiliation(s)
- Avram E. Denburg
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Adriana Ramirez
- Harvard School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Suresh Pavuluri
- Harvard School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Erin McCann
- Harvard School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Shivani Shah
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Canada
| | | | - Federico Antillon
- School of Medicine, Universidad Franciso Marroquin, Guatemala City, Guatemala
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | | | | | - Catherine Lam
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Paola Friedrich
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Brandon Maser
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Canada
| | - Lisa Force
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Carlos Rodriguez Galindo
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Rifat Atun
- Harvard School of Public Health, Harvard University, Boston, Massachusetts, United States of America
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Gajewski J, Cheelo M, Bijlmakers L, Kachimba J, Pittalis C, Brugha R. The contribution of non-physician clinicians to the provision of surgery in rural Zambia-a randomised controlled trial. HUMAN RESOURCES FOR HEALTH 2019; 17:60. [PMID: 31331348 PMCID: PMC6647149 DOI: 10.1186/s12960-019-0398-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/11/2019] [Indexed: 05/04/2023]
Abstract
BACKGROUND The global shortage of surgeons disproportionately impacts low- and middle-income countries. To mitigate this, Zambia introduced a 'task-shifting' solution and started to train non-physician clinicians (NPCs) called medical licentiates (ML) to perform surgery. The aim of this randomised controlled trial was to assess their contribution to the delivery of surgical care in rural hospitals in Zambia. METHODS Sixteen hospitals were randomly assigned to intervention and control arms of the study. Nine MLs were deployed to eight intervention sites. Crude numbers of selected major surgical procedures between intervention and control sites were compared before and after the intervention. Volume and outcomes of surgery were compared within intervention hospitals, between NPCs and surgically active medical doctors (MDs). RESULTS There was a significant increase in the numbers of caesarean sections (CS) in the intervention hospitals (+ 15.2%) and a drop by almost half in the control group (- 47%) (P = 0.015), between the two time periods. There were marginal shifts in the numbers of index procedures: a small drop in the intervention group (- 4.9%) and slight increase in the control arm (+ 4.8%) (P = 0.505). In all pairs, MLs had higher mean number of CS and other major surgical cases done in the intervention period compared with MDs. There was no significant difference in postoperative wound infection rates for CS (P = 0.884) and other major surgical cases (P = 0.33) at intervention hospitals between MLs and MDs. CONCLUSION This study provided evidence that the ML training programme in Zambia is an effective and safe way to bridge the gap in rural hospitals between the demand and the limited availability of surgically trained workforce in the country. Such evidence is greatly needed as more developing countries are developing national surgical plans. TRIAL REGISTRATION ISRCTN66099597 Registered: 07/01/2014.
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Affiliation(s)
- Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland.
| | - Mweene Cheelo
- Department of Surgery, Surgical Society of Zambia, University Teaching Hospital, P.O. Box, 50110, Lusaka, Zambia
| | - Leon Bijlmakers
- Radboud University Medical Centre Netherlands, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, Netherlands
| | - John Kachimba
- Department of Surgery, Surgical Society of Zambia, University Teaching Hospital, P.O. Box, 50110, Lusaka, Zambia
| | - Chiara Pittalis
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland
| | - Ruairi Brugha
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland
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Heller O, Somerville C, Suggs LS, Lachat S, Piper J, Aya Pastrana N, Correia JC, Miranda JJ, Beran D. The process of prioritization of non-communicable diseases in the global health policy arena. Health Policy Plan 2019; 34:370-383. [PMID: 31199439 PMCID: PMC6736081 DOI: 10.1093/heapol/czz043] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2019] [Indexed: 12/31/2022] Open
Abstract
Although non-communicable diseases (NCDs) are the leading cause of morbidity and mortality worldwide, the global policy response has not been commensurate with their health, economic and social burden. This study examined factors facilitating and hampering the prioritization of NCDs on the United Nations (UN) health agenda. Shiffman and Smith's (Generation of political priority for global health initiatives: a framework and case study of maternal mortality. The Lancet 370: 1370-9.) political priority framework served as a structure for analysis of a review of NCD policy documents identified through the World Health Organization's (WHO) NCD Global Action Plan 2013-20, and complemented by 11 semi-structured interviews with key informants from different sectors. The results show that a cohesive policy community exists, and leaders are present, however, actor power does not extend beyond the health sector and the role of guiding institutions and civil society have only recently gained momentum. The framing of NCDs as four risk factors and four diseases does not necessarily resonate with experts from the larger policy community, but the economic argument seems to have enabled some traction to be gained. While many policy windows have occurred, their impact has been limited by the institutional constraints of the WHO. Credible indicators and effective interventions exist, but their applicability globally, especially in low- and middle-income countries, is questionable. To be effective, the NCD movement needs to expand beyond global health experts, foster civil society and develop a broader and more inclusive global governance structure. Applying the Shiffman and Smith framework for NCDs enabled different elements of how NCDs were able to get on the UN policy agenda to be disentangled. Much work has been done to frame the challenges and solutions, but implementation processes and their applicability remain challenging globally. NCD responses need to be adapted to local contexts, focus sufficiently on both prevention and management of disease, and have a stronger global governance structure.
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Affiliation(s)
- Olivia Heller
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, Rue Gabrielle-Perret-Gentil 4, Geneva, Switzerland
| | - Claire Somerville
- Gender Centre, Graduate Institute of International and Development Studies, Ch. Eugène-Rigot 2, Geneva, Switzerland
| | - L Suzanne Suggs
- BeCHANGE Research Group, Institute of Public Communication, Università della Svizzera italiana, Via G. Buffi 13, Lugano CH, Switzerland
| | - Sarah Lachat
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, Rue Gabrielle-Perret-Gentil 4, Geneva, Switzerland
| | - Julianne Piper
- Graduate Institute of International and Development Studies, Ch. Eugène-Rigot 2, Geneva, Switzerland
| | - Nathaly Aya Pastrana
- BeCHANGE Research Group, Institute of Public Communication, Università della Svizzera italiana, Via G. Buffi 13, Lugano CH, Switzerland
| | - Jorge C Correia
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, Rue Gabrielle-Perret-Gentil 4, Geneva, Switzerland
| | - J Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Universidad Peruana Cayetano Heredia, Av. Armendariz 445, Miraflores, Lima 18, Peru
- School of Medicine, Universidad Peruana Cayetano Heredia, Av. Armendariz 445, Miraflores, Lima 18, Peru
| | - David Beran
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, Rue Gabrielle-Perret-Gentil 4, Geneva, Switzerland
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Frimpong-Boateng K, Edwin F. Surgical leadership in Africa - challenges and opportunities. Innov Surg Sci 2019; 4:59-64. [PMID: 31579804 PMCID: PMC6754052 DOI: 10.1515/iss-2018-0036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 03/07/2019] [Indexed: 01/06/2023] Open
Abstract
Surgical care has been described as one of the Cinderellas in the global health development agenda, taking a backseat to public health, child health, and infectious diseases. In the midst of such competing health-care needs, surgical care, often viewed by policy makers as luxurious and the preserve of the rich, gets relegated to the bottom of priority lists. In the meantime, infectious disease, malnutrition, and other ailments, viewed as largely affecting the poor and disadvantaged in society, get embedded in national health plans, receiving substantial funding and public health program development. It is often stated that the main reason for this sad state of affairs in surgical care is the lack of political will to improve matters in the health sector. Indeed, in 2001, the Commission on Macroeconomics and Health concluded that the lack of political will to sufficiently increase spending on health at the sub-national, national, and international levels was perhaps the most critical barrier to improving health in low-income countries. However, at the root of this lack of political will is a lack of political priority for surgical care.
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Affiliation(s)
| | - Frank Edwin
- University of Health and Allied Sciences, Ho, Ghana
- Department of Surgery, National Cardiothoracic Centre, Accra, Ghana
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A multicenter observational study on the distribution of orthopaedic fracture types across 17 low- and middle-income countries. OTA Int 2019; 2:e026. [PMID: 33937655 PMCID: PMC7997096 DOI: 10.1097/oi9.0000000000000026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 12/03/2018] [Indexed: 11/29/2022]
Abstract
Objectives: To describe the regional distribution of fractures sustained by women and health care system characteristics across 17 low- and middle-income countries (LMICs). Methods: The INternational ORthopaedic MUlticentre Study in fracture care (INORMUS) is an observational study collecting data on patients in LMICs who sustained a fracture or musculoskeletal injury. As a planned analysis for the INORMUS study, we explored differences in fracture locations and demographics reported among 9878 female patients who sustained a fracture within 17 LMICs in 5 regions (China, Africa, India, Other Asia, and Latin America). Results: Half of our study population (49.6%) was ≥60 years of age. Across all regions, 58.3% of patients possessed health insurance. Latin America possessed the highest proportion (88.8%) of health insurance, while in Africa, patients possessed the lowest (18.0%). Falls from standing were the most prevalent mechanism of injury (51.7%) followed by falls from height (12.8%) and motorcycle-related road traffic injuries (9.7%). The majority of the fractures (65.6%) occurred in patients aged 50 and older. Hip fractures were the most common fracture (26.8%), followed by tibia/fibula (12.6%) and spine fractures (9.7%). Open fractures accounted for 7.6% of fractures and were most commonly tibia/fibula fractures (35.1%). Despite these severe injuries, less than one-third (28.8%) of patients were transported for care after sustaining a fracture by ambulance. Regionally, a majority of female patients in Africa were working age and suffered tibia/fibula (21.6%) and femur fractures (14.0%). Patients in the regional category Other Asia, suffered the highest frequencies of open fractures (9.6% low grade, 7.1% high grade), and disproportionately from motorcycle road traffic injuries (29.9%). Conclusion: Across all regions, the most significant source of fracture burden was in the elderly, and included common fragility fractures, such as hip fractures. Notable regional deviations in fracture distributions were observed within Africa, and Other Asia. Across all studied LMICs, ambulance usage was low, and health insurance coverage was particularly low in Africa and India.
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Sakamoto H, Lee S, Ishizuka A, Hinoshita E, Hori H, Ishibashi N, Komada K, Norizuki M, Katsuma Y, Akashi H, Shibuya K. Challenges and opportunities for eliminating tuberculosis - leveraging political momentum of the UN high-level meeting on tuberculosis. BMC Public Health 2019; 19:76. [PMID: 30651096 PMCID: PMC6335677 DOI: 10.1186/s12889-019-6399-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 01/07/2019] [Indexed: 11/10/2022] Open
Abstract
Background As demonstrated by the United Nations High-Level Meeting on tuberculosis (TB) held in September 2018, the political momentum for TB has been increasing. The aim of this study was to analyze the current challenges and opportunities for global TB control and, with specific focus on policies surrounding TB control, to reveal what kinds of efforts are needed to accelerate global TB control. Methods We organized two expert meetings with the purposes of assessing the current situation and analyzing challenges regarding TB control. By applying Shiffman and Smith’s framework which contains four categories; Actor, Ideas, Political context, and Issue characteristics, we analyzed the challenges and opportunities for global TB control based on the findings from the two expert meetings. Results In the Actor Category, we found that although there has already been active engagement by non-governmental organizations (NGOs), civil society organizations (CSOs) and private sectors, there still remained an area with room for improvement. In particular, the complexities behind varying drug regulatory and procurement systems per country hindered the active participation of the private sector in this area. As for the Ideas category, due to an increasing threat of antimicrobial resistance and growing number of global migrations, TB is now widely recognized as a health security issue rather than a purely health issue. This makes TB an easier target for political attention. As for the Political category, having the UN High-Level Meeting itself is not enough; such meetings must be followed up by actual commitments from heads of states. Lastly the issue characteristic indicates that the amount of funding for R&D for new drugs, vaccines and diagnostics for TB is not at an adequate level, and investment in childhood TB and missing cases are particularly in need. Conclusions This study provides important insight into the current status of global efforts toward end TB epidemic. The outcomes from the UN high-level meeting on TB need to be closely monitored will be crucial for the progress towards this goal.
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Affiliation(s)
- Haruka Sakamoto
- Department of Global Health Policy, Graduate School of Medicine, Medical Building No.3, Hongo Campus, University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, Japan.
| | - Sangnim Lee
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Institute for Global Health Policy Research, Tokyo, Japan
| | - Aya Ishizuka
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Institute for Global Health Policy Research, Tokyo, Japan.,School of Global Studies and Collaboration, Aoyama Gakuin University, Kanagawa, Japan
| | - Eiji Hinoshita
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiroyuki Hori
- Ministry of Health, Labour and Welfare of Japan, Tokyo, Japan
| | - Nanao Ishibashi
- Ministry of Health, Labour and Welfare of Japan, Tokyo, Japan
| | - Kenichi Komada
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masataro Norizuki
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yasushi Katsuma
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Institute for Global Health Policy Research, Tokyo, Japan.,Graduate School of Asia-Pacific Studies, Waseda University, Tokyo, Japan
| | - Hidechika Akashi
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kenji Shibuya
- Department of Global Health Policy, Graduate School of Medicine, Medical Building No.3, Hongo Campus, University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, Japan.,Bureau of International Health Cooperation, National Center for Global Health and Medicine, Institute for Global Health Policy Research, Tokyo, Japan
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Stawicki SP, Nwomeh BC, Peck GL, Sifri ZC, Garg M, Sakran JV, Papadimos TJ, Anderson HL, Firstenberg MS, Gracias VH, Asensio JA. Training and accrediting international surgeons. Br J Surg 2019; 106:e27-e33. [DOI: 10.1002/bjs.11041] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 10/03/2018] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Formal international medical programmes (IMPs) represent an evolution away from traditional medical volunteerism, and are based on the foundation of bidirectional exchange of knowledge, experience and organizational expertise. The intent is to develop multidirectional collaborations and local capacity that is resilient in the face of limited resources. Training and accreditation of surgeons continues to be a challenge to IMPs, including the need for mutual recognition of competencies and professional certification.
Methods
MEDLINE, Embase and Google Scholar™ were searched using the following terms, alone and in combination: ‘credentialing’, ‘education’, ‘global surgery’, ‘international medicine’, ‘international surgery’ and ‘training’. Secondary references cited by original sources were also included. The authors, all members of the American College of Academic International Medicine group, agreed advice on training and accreditation of international surgeons.
Results and conclusion
The following are key elements of training and accrediting international surgeons: basic framework built upon a bidirectional approach; consideration of both high-income and low- and middle-income country perspectives; sourcing funding from current sources based on existing IMPs and networks of IMPs; emphasis on predetermined cultural competencies and a common set of core surgical skills; a decentralized global system for verification and mutual recognition of medical training and certification. The global medical system of the future will require the assurance of high standards for surgical education, training and accreditation.
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Affiliation(s)
- S P Stawicki
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - B C Nwomeh
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - G L Peck
- Department of Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Z C Sifri
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - M Garg
- Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - J V Sakran
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - T J Papadimos
- Department of Anesthesiology, College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio, USA
| | - H L Anderson
- Department of Surgery, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - M S Firstenberg
- Department of Cardiovascular and Thoracic Surgery, Medical Center of Aurora, Aurora, Colorado, USA
| | - V H Gracias
- Department of Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - J A Asensio
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Surgery, Creighton University Medical Center, Omaha, Nebraska, USA
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Effectiveness, cost-effectiveness, and economic impact of a multi-specialty charitable surgical center in Honduras. INTERNATIONAL JOURNAL OF SURGERY OPEN 2019. [DOI: 10.1016/j.ijso.2019.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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66
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Holmer H, Bekele A, Hagander L, Harrison EM, Kamali P, Ng-Kamstra JS, Khan MA, Knowlton L, Leather AJM, Marks IH, Meara JG, Shrime MG, Smith M, Søreide K, Weiser TG, Davies J. Evaluating the collection, comparability and findings of six global surgery indicators. Br J Surg 2018; 106:e138-e150. [PMID: 30570764 PMCID: PMC6790969 DOI: 10.1002/bjs.11061] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 10/01/2018] [Accepted: 10/30/2018] [Indexed: 01/18/2023]
Abstract
Background In 2015, six indicators were proposed to evaluate global progress towards access to safe, affordable and timely surgical and anaesthesia care. Although some have been adopted as core global health indicators, none has been evaluated systematically. The aims of this study were to assess the availability, comparability and utility of the indicators, and to present available data and updated estimates. Methods Nationally representative data were compiled for all World Health Organization (WHO) member states from 2010 to 2016 through contacts with official bodies and review of the published and grey literature, and available databases. Availability, comparability and utility were assessed for each indicator: access to timely essential surgery, specialist surgical workforce density, surgical volume, perioperative mortality, and protection against impoverishing and catastrophic expenditure. Where feasible, imputation models were developed to generate global estimates. Results Of all WHO member states, 19 had data on the proportion of the population within 2h of a surgical facility, 154 had data on workforce density, 72 reported number of procedures, and nine had perioperative mortality data, but none could report data on catastrophic or impoverishing expenditure. Comparability and utility were variable, and largely dependent on different definitions used. There were sufficient data to estimate that worldwide, in 2015, there were 2 038 947 (i.q.r. 1 884 916–2 281 776) surgeons, obstetricians and anaesthetists, and 266·1 (95 per cent c.i. 220·1 to 344·4) million operations performed. Conclusion Surgical and anaesthesia indicators are increasingly being adopted by the global health community, but data availability remains low. Comparability and utility for all indicators require further resolution.
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Affiliation(s)
- H Holmer
- WHO Collaborating Centre for Surgery and Public Health, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden.,Karolinska University Hospital, Solna, Stockholm, Sweden
| | - A Bekele
- Department of Surgery, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia.,University of Global Health Equity, Kigali, Rwanda
| | - L Hagander
- WHO Collaborating Centre for Surgery and Public Health, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Paediatric Surgery, Skåne University Hospital Children's Hospital, Lund, Sweden
| | - E M Harrison
- Department of Clinical Surgery, Royal Infirmary of Edinburgh and Surgical Informatics, Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - P Kamali
- Division of Plastic and Reconstructive Surgery, Medisch Spectrum Twente, Enschede, the Netherlands.,InciSioN, International Student Surgical Network, Leuven, Belgium
| | - J S Ng-Kamstra
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - M A Khan
- InciSioN, International Student Surgical Network, Leuven, Belgium.,CMH Lahore Medical College and Institute of Dentistry, Lahore, Pakistan
| | - L Knowlton
- Department of Surgery, Stanford University, Stanford, California, USA
| | - A J M Leather
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - I H Marks
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK.,InciSioN, International Student Surgical Network, Leuven, Belgium
| | - J G Meara
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, USA
| | - M G Shrime
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Center for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Boston, USA
| | - M Smith
- Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of General Surgery, Chris Hani Baragwaneth Academic Hospital, Johannesburg, South Africa
| | - K Søreide
- Department of Clinical Surgery, Royal Infirmary of Edinburgh and Surgical Informatics, Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK.,Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - T G Weiser
- Department of Clinical Surgery, Royal Infirmary of Edinburgh and Surgical Informatics, Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK.,Department of Surgery, Stanford University, Stanford, California, USA
| | - J Davies
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Institute for Applied Health Research, University of Birmingham, Birmingham, UK.,MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, University of Witwatersrand, Parktown, South Africa
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Sriram V, Hyder AA, Bennett S. The Making of a New Medical Specialty: A Policy Analysis of the Development of Emergency Medicine in India. Int J Health Policy Manag 2018; 7:993-1006. [PMID: 30624873 PMCID: PMC6326640 DOI: 10.15171/ijhpm.2018.55] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 06/10/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Medical specialization is an understudied, yet growing aspect of health systems in low- and middleincome countries (LMICs). In India, medical specialization is incrementally, yet significantly, modifying service delivery, workforce distribution, and financing. However, scarce evidence exists in India and other LMICs regarding how medical specialties evolve and are regulated, and how these processes might impact the health system. The trajectory of emergency medicine appears to encapsulate broader trends in medical specialization in India - international exchange and engagement, the formation of professional associations, and a lengthy regulatory process with the Medical Council of India. Using an analysis of political priority setting, our objective was to explore the emergence and recognition of emergency medicine as a medical specialty in India, from the early 1990s to 2015. METHODS We used a qualitative case study methodology, drawing on the Shiffman and Smith framework. We conducted 87 in-depth interviews, reviewing 122 documents, and observing six meetings and conferences. We used a modified version of the 'Framework' approach in our analysis. RESULTS Momentum around emergency medicine as a viable solution to weak systems of emergency care in India gained traction in the 1990s. Public and private sector stakeholders, often working through transnational professional medical associations, actively pursued recognition from Medical Council of India. Despite fragmentation within the network, stakeholders shared similar beliefs regarding the need for specialty recognition, and were ultimately achieved this objective. However, fragmentation in the network made coalescing around a broader policy agenda for emergency medicine challenging, eventually contributing to an uncertain long-term pathway. Finally, due to the complexities of the regulatory system, stakeholders promoted multiple forms of training programs, expanding the workforce of emergency physicians, but with limited coordination and standardization. CONCLUSION The ideational centrality of postgraduate medical education, a challenging national governance system, and fragmentation within the transnational stakeholder network characterized the development of emergency medicine in India. As medical specialization continues to shape and influence health systems globally, research on the evolution of new medical specialties in LMICs can enhance our understanding of the connections between specialization, health systems, and equity.
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Affiliation(s)
- Veena Sriram
- Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA
| | - Adnan A. Hyder
- Health Systems Program, Department of International Health and International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sara Bennett
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Quality of Surgery in Malawi: Comparison of Patient-Reported Outcomes After Hernia Surgery Between District and Central Hospitals. World J Surg 2018; 42:1610-1616. [PMID: 29209733 DOI: 10.1007/s00268-017-4385-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND District hospitals in Africa could meet the essential surgical needs of rural populations. However, evidence on outcomes is needed to justify investment in this option, given that surgery at district hospitals in some African countries is usually undertaken by non-physician clinicians. METHODS Baseline and 2-3-month follow-up measurements were undertaken on 98 patients who had undergone hernia repairs at four district and two central hospitals in Malawi, using a modified quality-of-life tool. RESULTS There was no significant difference in outcomes between district and central hospital cases, where a good outcome was defined as no more than one severe and three mild symptoms. Outcomes were marginally inferior at district hospitals (OR 0.79, 95% CI 0.63-1.0). However, in the 46 cases that underwent elective surgery at district hospitals, baseline scores for severe symptoms were worse (mean = 3.5) than in the 23 elective central hospital cases (mean = 2.5), p = 0.004. Also, the mean change (improvement) in symptom score was higher in district versus central hospital cases (3.9 vs. 2.3). CONCLUSION The study results support the case for investing in district hospital surgery in sub-Saharan Africa to increase access to essential surgical care for rural populations. This could free up specialists to undertake more complex and referred cases and reduce emergency presentations. It will require investments in training and resources for district hospitals and in supervision from higher levels.
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69
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Shiffman J. Agency, Structure and the Power of Global Health Networks. Int J Health Policy Manag 2018; 7:879-884. [PMID: 30316239 PMCID: PMC6186462 DOI: 10.15171/ijhpm.2018.71] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 07/24/2018] [Indexed: 11/13/2022] Open
Abstract
Global health networks-webs of individuals and organizations linked by a shared concern for a particular condition-have proliferated over the past quarter century. In a recent editorial in this journal, I presented evidence that their effectiveness in addressing four challenges-problem definition, positioning, coalitionbuilding and governance-shapes their ability to influence policy. The editorial prompted five thoughtful commentaries that reflected on these and other challenges. In this follow-up editorial, I build on the commentaries to suggest ways of advancing research on global health networks. I argue that investigators would do well to consider three social theory-influenced global governance debates pertaining to agency-the capacity of individuals and organizations to act autonomously amidst structural constraints. The three debates concern the relationship between agency and structure, the power of ideas vis-à-vis interests and material capabilities, and the level of influence of non-state actors in a global governance system that most scholars identify as state-dominated. Drawing on these debates, I argue that rather than presume global health network influence, we need to find more robust ways to investigate their effects. I argue also that rather than juxtapose agency and structure, ideas and interests and non-state and state power, it would be more productive to consider the ways in which these elements are intertwined.
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Affiliation(s)
- Jeremy Shiffman
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
- Paul H. Nitze School of Advanced International Studies, Washington, DC, USA
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70
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Ljungman D, Vaughan KA, Park KB, Makasa EM, Marten R, Meara JG. World Health Organization: Leading surgical care toward sustainable development in the era of globalization. Surgery 2018; 164:1137-1146. [PMID: 30205897 DOI: 10.1016/j.surg.2018.06.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 06/05/2018] [Indexed: 11/17/2022]
Affiliation(s)
- David Ljungman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Kerry A Vaughan
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA
| | - Kee B Park
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA
| | - Emmanuel M Makasa
- Ministry of Foreign Affairs, Lusaka, Zambia; School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Robert Marten
- London School of Hygiene and Tropical Medicine, London, England
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Plastic & Oral Surgery, Boston Children's Hospital, Boston, MA
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72
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Gajewski J, Bijlmakers L, Brugha R. Global Surgery - Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa. Int J Health Policy Manag 2018; 7:481-484. [PMID: 29935124 PMCID: PMC6015509 DOI: 10.15171/ijhpm.2018.27] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/14/2018] [Indexed: 12/20/2022] Open
Abstract
Surgery has the potential to address one of the largest, neglected burdens of disease in low- and middle-income countries (LMICs), especially in sub-Saharan Africa (SSA). The Lancet Commission on Global Surgery (LCoGS) has provided a blueprint for a systems approach to making safe emergency and elective surgery accessible and affordable and has started to enable African governments to develop national surgical plans. This editorial outlines an important gap, which is the need for surgical systems research, especially at district hospitals which are the first point of surgical care for rural communities, to inform the implementation of country plans. Using the Lancet Commission as a starting point and illustrated by two European Union (EU) funded research projects, we point to the need for implementation research to develop and evaluate contextualised strategies. As illustrated by the case study of Zambia, coordination by global and external stakeholders can enable governments to lead national scale-up of essential surgery, supported by national partners including surgical specialist associations.
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Affiliation(s)
| | - Leon Bijlmakers
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ruairí Brugha
- Royal College of Surgeons in Ireland, Dublin 2, Ireland
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73
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Horton S, Sullivan R, Flanigan J, Fleming KA, Kuti MA, Looi LM, Pai SA, Lawler M. Delivering modern, high-quality, affordable pathology and laboratory medicine to low-income and middle-income countries: a call to action. Lancet 2018; 391:1953-1964. [PMID: 29550030 DOI: 10.1016/s0140-6736(18)30460-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 11/28/2017] [Accepted: 12/08/2017] [Indexed: 11/17/2022]
Abstract
Modern, affordable pathology and laboratory medicine (PALM) systems are essential to achieve the 2030 Sustainable Development Goals for health in low-income and middle-income countries (LMICs). In this last in a Series of three papers about PALM in LMICs, we discuss the policy environment and emphasise three crucial high-level actions that are needed to deliver universal health coverage. First, nations need national strategic laboratory plans; second, these plans require adequate financing for implementation; and last, pathologists themselves need to take on leadership roles to advocate for the centrality of PALM to achieve the Sustainable Development Goals for health. The national strategic laboratory plan should deliver a tiered, networked laboratory system as a central element. Appropriate financing should be provided, at a level of at least 4% of health expenditure. Financing of new technologies such as molecular diagnostics is challenging for LMICs, even though many of these tests are cost-effective. Point-of-care testing can substantially reduce test-reporting time, but this benefit must be balanced with higher costs. Our research analysis highlights a considerable deficiency in advocacy for PALM; pathologists have been invisible in national and international health discourse and leadership. Embedding PALM in LMICs can only be achieved if pathologists advocate for these services, and undertake leadership roles, both nationally and internationally. We articulate eight key recommendations to address the current barriers identified in this Series and issue a call to action for all stakeholders to come together in a global alliance to ensure the effective provision of PALM services in resource-limited settings.
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Affiliation(s)
- Susan Horton
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada.
| | | | - John Flanigan
- Center for Global Health, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kenneth A Fleming
- Center for Global Health, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA; Green Templeton College, University of Oxford, Oxford, UK
| | - Modupe A Kuti
- Department of Chemical Pathology, College of Medicine, University of Ibadan, and University Hospital, Ibadan, Nigeria
| | - Lai Meng Looi
- Department of Pathology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sanjay A Pai
- Columbia Asia Referral Hospital, Bangalore, India
| | - Mark Lawler
- Faculty of Medicine, Health and Life Sciences and Centre for Cancer Research and Cell Biology, Queens University, Belfast, UK
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Efficacy of Facilitated Capacity Building in Providing Cleft Lip and Palate Care in Low- and Middle-Income Countries. J Craniofac Surg 2018; 28:1737-1741. [PMID: 28872505 DOI: 10.1097/scs.0000000000003884] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Providing surgical repair for congenital anomalies such as cleft lip and palate (CLP) can be challenging in low- and middle-income countries. One nonprofit organization seeks to address this need through a partnership model. This model provides long-term aid on multiple levels: surgeon and healthcare provider education, community outreach, and funding. The authors examined the effectiveness of this partnership model in providing CLP care and increasing cleft care capacity over time. This organization maintains data on each partner and procedure and collected data on hospital and patient characteristics through voluntary partner surveys from 2010 to 2014. Effectiveness of care provision outcomes included number of surgeries/partner hospital and patient demographics. Cleft surgical system strengthening was measured by the complexity of repair, waitlist length, and patient follow-up. From 2001 to 2014, the number of procedures/hospital/year grew from 15 to 109, and frequency of alveolar bone grafts increased from 1% to 3.4%. In addition, 97.9% of partners reported that half to most patients come from rural areas. Waitlists decreased, with 9.2% of partners reporting a waitlist of ≥50 in 2011 versus 2.7% in 2014 (P < 0.001). Patient follow-up also improved: 35% of partners in 2011 estimated a follow-up rate of ≥75%, compared with 51% of partners in 2014 (P < 0.001). The increased number of procedures/hospital/year supports the partnership model's effectiveness in providing CLP care. In addition, data supports cleft surgical system strengthening-more repairs use alveolar bone grafts, waitlists decreased, and follow-up improved. These findings demonstrate that the partnership model may be effective in providing cleft care and increasing cleft surgical capacity.
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Cheung M, Healy JM, Hall MR, Ozgediz D. Assessing Interest and Barriers for Resident and Faculty Involvement in Global Surgery. JOURNAL OF SURGICAL EDUCATION 2018; 75:49-57. [PMID: 28729188 DOI: 10.1016/j.jsurg.2017.06.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 06/24/2017] [Accepted: 06/25/2017] [Indexed: 05/05/2023]
Abstract
BACKGROUND Multiple institutions have developed international electives and sustainable global surgery initiatives to facilitate clinical, research, and outreach opportunities with hospitals in resource-poor areas. Despite increasing interest among programs, many institutions have not successfully reached potential involvement. OBJECTIVE This study evaluates the experiences of Yale residents and faculty, measures interest in the development of an international surgical elective, and enumerates barriers to developing or participating in these opportunities. This was performed to develop a formalized elective and assess interest and capacity for surgical global health initiatives, as a seemingly increasing number of trainee applicants and residents were expressing interest in working in resource-poor settings. METHODS Electronic survey of Yale Surgery residents and faculty analyzed using SPSS and Graphpad Prism. RESULTS Among residents, previous global experience correlates with current interest in international opportunities, with 100% remaining interested, and 78% of those without prior experience also expressing interest (p = 0.018). Barriers to pursuing these activities included the use of vacation time, funding, scheduling, family obligations, and concern for personal safety. Among faculty, 28% of respondents have been involved internationally, and most (86%) expressed interest in additional opportunities and all were willing to take residents. Barriers to faculty participation included funding, relative value unit target reduction, protected time, and the desire for institutional support for such activities. CONCLUSIONS A substantial proportion of residents and faculty have experience in global health and motivation to pursue additional opportunities. The main barriers to participation are not a lack of interest, but rather needs for funding support, protected time, and institutional recognition of academic contributions. These findings are being used to develop a global surgery elective and establish long-term partnerships with international colleagues.
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Affiliation(s)
- Maija Cheung
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
| | - James M Healy
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Michael R Hall
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Doruk Ozgediz
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
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76
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Shawar YR, Crane LG. Generating global political priority for urban health: the role of the urban health epistemic community. Health Policy Plan 2017; 32:1161-1173. [PMID: 28582532 PMCID: PMC5886225 DOI: 10.1093/heapol/czx065] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2017] [Indexed: 11/15/2022] Open
Abstract
Over the past decade there has been much discussion of the challenges posed by rapid urbanization in the developing world; yet the health of the urban poor, and especially those residing in low- and middle-income countries, continues to receive little political priority in most developing countries and at the global level. This research applies social science scholarship and a public policy analytical framework to assess the factors that have challenged efforts to make health in urban poor settings a priority. We conducted 19 semi-structured phone interviews with key urban health proponents and experts representing agencies that shape opinions and manage resources in global health. We also conducted a literature review, which included published scholarly literature and reports from organizations involved in urban health provision and advocacy. Utilizing a process-tracing method, we triangulated among these sources of data to create a historical narrative and analyse the factors that shape the global level of attention to and resources for urban health. The urban health agenda continues to be challenged by six factors, three of which concern the political context or characteristics of the issue: long-standing competition with the dominant development agenda that is rural health oriented; limited data and measurement tools that can effectively gauge the extent of the problem; and lack of evidence on how to best to address the issue. The other three factors are directly under the control of the urban health community: the community's ineffective governance; little common understanding among its members of the problem and how to address it; and an unconvincing framing of the issue to the public. The study offers suggestions as to what advocates can do to secure greater attention and resources in order to help address the health needs of the urban poor.
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Affiliation(s)
- Yusra Ribhi Shawar
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA and
| | - Lani G Crane
- Department of Global Health, Save the Children, Washington, DC, USA
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Gajewski J, Mweemba C, Cheelo M, McCauley T, Kachimba J, Borgstein E, Bijlmakers L, Brugha R. Non-physician clinicians in rural Africa: lessons from the Medical Licentiate programme in Zambia. HUMAN RESOURCES FOR HEALTH 2017; 15:53. [PMID: 28830528 PMCID: PMC5568330 DOI: 10.1186/s12960-017-0233-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 08/14/2017] [Indexed: 05/04/2023]
Abstract
BACKGROUND Most sub-Saharan African countries struggle to make safe surgery accessible to rural populations due to a shortage of qualified surgeons and the unlikelihood of retaining them in district hospitals. In 2002, Zambia introduced a new cadre of non-physician clinicians (NPCs), medical licentiates (MLs), trained initially to the level of a higher diploma and from 2013 up to a BSc degree. MLs have advanced clinical skills, including training in elective and emergency surgery, designed as a sustainable response to the surgical needs of rural populations. METHODS This qualitative study aimed to describe the role, contributions and challenges surgically active MLs have experienced. Based on 43 interviewees, it includes the perspective of MLs, their district hospital colleagues-medical officers (MOs), nurses and managers; and surgeon-supervisors and national stakeholders. RESULTS In Zambia, MLs play a crucial role in delivering surgical services at the district level, providing emergency surgery and often increasing the range of elective surgical cases that would otherwise not be available for rural dwellers. They work hand in hand with MOs, often giving them informal surgical training and reducing the need for hospitals to refer surgical cases. However, MLs often face professional recognition problems and tensions around relationships with MOs that impact their ability to utilise their surgical skills. CONCLUSIONS The paper provides new evidence concerning the benefits of 'task shifting' and identifies challenges that need to be addressed if MLs are to be a sustainable response to the surgical needs of rural populations in Zambia. Policy lessons for other countries in the region that also use NPCs to deliver essential surgery include the need for career paths and opportunities, professional recognition, and suitable employment options for this important cadre of healthcare professionals.
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Affiliation(s)
- Jakub Gajewski
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland
| | - Carol Mweemba
- Surgical Society of Zambia, Department of Surgery, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - Mweene Cheelo
- Surgical Society of Zambia, Department of Surgery, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - Tracey McCauley
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland
| | - John Kachimba
- Surgical Society of Zambia, Department of Surgery, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - Eric Borgstein
- College of Medicine, Malawi, Mahatma Gandhi, Blantyre, Malawi
| | - Leon Bijlmakers
- Radboud University Medical Centre Netherlands, Geert Grooteplein Zuid 10, 6525 Nijmegen, GA Netherlands
| | - Ruairi Brugha
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland
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Saluja S, Silverstein A, Mukhopadhyay S, Lin Y, Raykar N, Keshavjee S, Samad L, Meara JG. Using the Consolidated Framework for Implementation Research to implement and evaluate national surgical planning. BMJ Glob Health 2017; 2:e000269. [PMID: 29225930 PMCID: PMC5717928 DOI: 10.1136/bmjgh-2016-000269] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 04/22/2017] [Accepted: 04/24/2017] [Indexed: 11/28/2022] Open
Abstract
The Lancet Commission on Global Surgery defined six surgical indicators and a framework for a national surgical plan that aimed to incorporate surgical care as a part of global public health. Multiple countries have since begun national surgical planning; each faces unique challenges in doing so. Implementation science can be used to more systematically explain this heterogeneous process, guide implementation efforts and ultimately evaluate progress. We describe our intervention using the Consolidated Framework for Implementation Research. This framework requires identifying characteristics of the intervention, the individuals involved, the inner and outer setting of the intervention, and finally describing implementation processes. By hosting a consultative symposium with clinicians and policy makers from around the world, we are able to specify key aspects of each element of this framework. We define our intervention as the incorporation of surgical care into public health planning, identify local champions as the key individuals involved, and describe elements of the inner and outer settings. Ultimately we describe top-down and bottom-up models that are distinct implementation processes. With the Consolidated Framework for Implementation Research, we are able to identify specific strategic models that can be used by implementers in various settings. While the integration of surgical care into public health throughout the world may seem like an insurmountable challenge, this work adds to a growing effort that seeks to find a way forward.
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Affiliation(s)
- Saurabh Saluja
- Department of Surgery, Weill Cornell Medicine, New York, USA.,Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Center for Global Health Delivery - Dubai, Harvard Medical School, Dubai, UAE
| | - Allison Silverstein
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Department of Medical Education, University of Miami, Miami, USA
| | - Swagoto Mukhopadhyay
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Center for Global Health Delivery - Dubai, Harvard Medical School, Dubai, UAE.,Department of Surgery, University of Connecticut, Hartford, USA
| | - Yihan Lin
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Department of Surgery, University of Colorado, Denver, USA
| | - Nakul Raykar
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Department of Surgery, Beth Israel Deaconess Medical Center, Boston, USA
| | - Salmaan Keshavjee
- Center for Global Health Delivery - Dubai, Harvard Medical School, Dubai, UAE
| | - Lubna Samad
- Center for Global Health Delivery - Dubai, Harvard Medical School, Dubai, UAE.,Department of Surgery, Indus Hospital, Karachi, Pakistan
| | - John G Meara
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Center for Global Health Delivery - Dubai, Harvard Medical School, Dubai, UAE.,Department of Plastic Surgery, Boston Children's Hospital, Boston, USA
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80
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Harfouche M, Krowsoski L, Goldberg A, Maher Z. Global surgical electives in residency: The impact on training and future practice. Am J Surg 2017; 215:200-203. [PMID: 28404204 DOI: 10.1016/j.amjsurg.2017.03.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 03/30/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate perceptions regarding the value of global surgical electives (GSEs) and pursuit of a career in global surgery amongst residents and surgeons. METHODS We sent an anonymous questionnaire to all current and former surgical residents of our tertiary-care, university-based institution from the years 2000-2013. Questions addressed the experience and value of practicing surgery in low or middle income countries (LMIC) in residency and as a career. RESULTS Twenty-three (40%) graduates (G) and 36 (84%) surgical residents (R) completed the survey. Thirteen residents (36%) and 13 (52%) graduates had delivered surgical care in a LMIC. Respondents stated that their experience positively impacted patient care (G = 80% vs R = 75%) and learning (G = 75% vs R = 90%). Of the 4 graduates still working in a LMIC, the majority (75%) were providing less than 2 months of care. Logistical reasons and family obligations were the most common barriers (n = 13). CONCLUSION Few graduates are able to incorporate global surgery into their practice despite interest. For enduring participation, logistical and family support is needed.
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Affiliation(s)
| | | | - Amy Goldberg
- Temple University Hospital, Philadelphia, PA, USA.
| | - Zoe Maher
- Temple University Hospital, Philadelphia, PA, USA.
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81
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Shiffman J. Four Challenges That Global Health Networks Face. Int J Health Policy Manag 2017; 6:183-189. [PMID: 28812801 PMCID: PMC5384980 DOI: 10.15171/ijhpm.2017.14] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/28/2017] [Indexed: 11/30/2022] Open
Abstract
Global health networks, webs of individuals and organizations with a shared concern for a particular condition, have proliferated over the past quarter century. They differ in their effectiveness, a factor that may help explain why resource allocations vary across health conditions and do not correspond closely with disease burden. Drawing on findings from recently concluded studies of eight global health networks—addressing alcohol harm, early childhood development (ECD), maternal mortality, neonatal mortality, pneumonia, surgically-treatable conditions, tobacco use, and tuberculosis—I identify four challenges that networks face in generating attention and resources for the conditions that concern them. The first is problem definition: generating consensus on what the problem is and how it should be addressed. The second is positioning: portraying the issue in ways that inspire external audiences to act. The third is coalition-building: forging alliances with these external actors, particularly ones outside the health sector. The fourth is governance: establishing institutions to facilitate collective action. Research indicates that global health networks that effectively tackle these challenges are more likely to garner support to address the conditions that concern them. In addition to the effectiveness of networks, I also consider their legitimacy, identifying reasons both to affirm and to question their right to exert power.
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Affiliation(s)
- Jeremy Shiffman
- Department of Public Administration and Policy, School of Public Affairs, American University, Washington, DC, USA
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82
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Beyond a Moral Obligation: A Legal Framework for Emergency and Essential Surgical Care and Anesthesia. World J Surg 2017; 41:1208-1217. [DOI: 10.1007/s00268-016-3866-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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83
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Lund-Johansen M, Laeke T, Tirsit A, Munie T, Abebe M, Sahlu A, Biluts H, Wester K. An Ethiopian Training Program in Neurosurgery with Norwegian Support. World Neurosurg 2016; 99:403-408. [PMID: 28017754 DOI: 10.1016/j.wneu.2016.12.051] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 12/12/2016] [Accepted: 12/14/2016] [Indexed: 11/26/2022]
Abstract
After a 4-year planning period, a joint Ethiopian/Norwegian training program in neurosurgery was started in June 2006. The collaborating partners were Addis Ababa University; Department of Surgery, Tikur Anbessa Specialized Hospital; University of Bergen; Haukeland University Hospital; and Myungsung Christian Medical Center, a Korean missionary hospital in Addis Ababa, Ethiopia. A memorandum of understanding was signed at dean/chief executive officer levels. Although other initiatives have been involved in supporting neurosurgery in Addis Ababa during the same period, this institutionally founded program has been the main external contributor to neurosurgical capacity building through the education of 21 Ethiopian neurosurgeons, and in supporting a sustainable environment for neurosurgical training within a network of 5 centers in Addis Ababa. This article gives an account of the strategies underlying the program planning, the history of the program, and on the experience gained by it. Finally, ethical problems and challenges encountered in the program are discussed.
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Affiliation(s)
- Morten Lund-Johansen
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
| | - Tsegazeab Laeke
- Addis Ababa University, Department of Surgery, Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia
| | - Abenezer Tirsit
- Addis Ababa University, Department of Surgery, Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia
| | - Tadios Munie
- Addis Ababa University, Department of Surgery, Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia
| | - Mersha Abebe
- Addis Ababa University, Department of Surgery, Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia
| | - Abat Sahlu
- Addis Ababa University, Department of Surgery, Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia
| | - Hagos Biluts
- Addis Ababa University, Department of Surgery, Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia
| | - Knut Wester
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
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84
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Costas-Chavarri A, Meara JG. Need for a standardised procedure classification system in global surgery. BMJ Glob Health 2016; 1:e000034. [PMID: 28588934 PMCID: PMC5321337 DOI: 10.1136/bmjgh-2016-000034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 06/10/2016] [Accepted: 06/13/2016] [Indexed: 12/04/2022] Open
Affiliation(s)
- Ainhoa Costas-Chavarri
- Human Resources for Health Program, Rwanda
- Department of Surgery, Rwanda Military Hospital, Kigali, Rwanda
| | - John G Meara
- Kletjian Professor of Global Surgery, Harvard Medical School, Boston, Massachusetts, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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85
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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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86
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Ng-Kamstra JS, Greenberg SLM, Abdullah F, Amado V, Anderson GA, Cossa M, Costas-Chavarri A, Davies J, Debas HT, Dyer GSM, Erdene S, Farmer PE, Gaumnitz A, Hagander L, Haider A, Leather AJM, Lin Y, Marten R, Marvin JT, McClain CD, Meara JG, Meheš M, Mock C, Mukhopadhyay S, Orgoi S, Prestero T, Price RR, Raykar NP, Riesel JN, Riviello R, Rudy SM, Saluja S, Sullivan R, Tarpley JL, Taylor RH, Telemaque LF, Toma G, Varghese A, Walker M, Yamey G, Shrime MG. Global Surgery 2030: a roadmap for high income country actors. BMJ Glob Health 2016; 1:e000011. [PMID: 28588908 PMCID: PMC5321301 DOI: 10.1136/bmjgh-2015-000011] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/06/2016] [Accepted: 01/19/2016] [Indexed: 12/16/2022] Open
Abstract
The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the world's new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future.
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Affiliation(s)
- Joshua S Ng-Kamstra
- Department of Surgery, University of Toronto, Toronto, Canada
- Program in Global Surgery and Social Change, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
| | - Sarah L M Greenberg
- Program in Global Surgery and Social Change, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Fizan Abdullah
- Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Vanda Amado
- Department of Surgery, Maputo Central Hospital, Maputo, Mozambique
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Geoffrey A Anderson
- Program in Global Surgery and Social Change, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Matchecane Cossa
- National Program of Surgery, Ministry of Health of Mozambique, Maputo, Mozambique
| | - Ainhoa Costas-Chavarri
- Program in Global Surgery and Social Change, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Haile T Debas
- University of California, San Francisco School of Medicine, San Francisco, California, USA
- University of California Global Health Institute, San Francisco, California, USA
| | - George S M Dyer
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sarnai Erdene
- Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Paul E Farmer
- Harvard University, Cambridge, Massachusetts, USA
- Partners In Health, Boston, Massachusetts, USA
| | | | - Lars Hagander
- Pediatric Surgery, Department of Clinical Sciences in Lund, Division of Pediatrics, Lund University, Lund, Sweden
| | - Adil Haider
- Center for Surgery and Public Health, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Andrew J M Leather
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - Yihan Lin
- Program in Global Surgery and Social Change, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Surgery, University of Colorado Faculty of Medicine, Denver, Colorado, USA
| | - Robert Marten
- The Rockefeller Foundation, New York, New York, USA
- Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Craig D McClain
- Department of Anaesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mira Meheš
- The G4 Alliance, New York, New York, USA
| | - Charles Mock
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Global Injury Section, Harborview Injury Prevention and Research Centre, Seattle, Washington, USA
| | - Swagoto Mukhopadhyay
- Program in Global Surgery and Social Change, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
- University of Connecticut School of Medicine Integrated General Surgery Program, Farmington, Connecticut, USA
| | - Sergelen Orgoi
- Department of Surgery, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
- WHO Collaborating Centre for Essential Emergency and Surgical Care (MOG1), Ulaanbaatar, Mongolia
| | | | - Raymond R Price
- Department of Surgery, Center for Global Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Intermountain Surgical Specialists, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Nakul P Raykar
- Program in Global Surgery and Social Change, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Beth Israel Deaconess Medical Centre, Boston, Massachusetts, USA
| | - Johanna N Riesel
- Program in Global Surgery and Social Change, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Plastic Surgery Combined Residency Program, Boston, Massachusetts, USA
| | - Robert Riviello
- Center for Surgery and Public Health, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
- Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Saurabh Saluja
- Program in Global Surgery and Social Change, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Richard Sullivan
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
- Institute of Cancer Policy, King's College London, London, UK
| | - John L Tarpley
- Department of Surgery, Section of Surgical Sciences, Vanderbilt University, Nashville, Tennessee, USA
- Surgical Service, VA Tennessee Valley Health Care System, Nashville, USA
| | - Robert H Taylor
- Department of Surgery, Branch for International Surgical Care, University of British Columbia, Vancouver, Canada
| | - Louis-Franck Telemaque
- Department of Surgery, State Medical School, Port-au-Prince, Haiti
- State University Hospital, Port-au-Prince, Haiti
| | - Gabriel Toma
- Program in Global Surgery and Social Change, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
| | - Asha Varghese
- Developing Health Globally, GE Foundation, Fairfield, Connecticut, USA
| | - Melanie Walker
- President's Delivery Unit, World Bank Group, Washington DC, USA
| | - Gavin Yamey
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Mark G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Otology and Laryngology and Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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87
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Ozgediz D, Langer M, Kisa P, Poenaru D. Pediatric surgery as an essential component of global child health. Semin Pediatr Surg 2016; 25:3-9. [PMID: 26831131 DOI: 10.1053/j.sempedsurg.2015.09.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Recent initiatives in global health have emphasized universal coverage of essential health services. Surgical conditions play a critical role in child health in resource-poor areas. This article discusses (1) the spectrum of pediatric surgical conditions and their treatment; (2) relevance to recent advances in global surgery; (3) challenges to the prioritization of surgical care within child health, and possible solutions; (4) a case example from a resource-poor area (Uganda) illustrating some of these concepts; and (5) important child health initiatives with which surgical services should be integrated. Pediatric surgery providers must lead the effort to prioritize children's surgery in health systems development.
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Affiliation(s)
- Doruk Ozgediz
- Department of Surgery, Yale University, 333 Cedar St, PO Box 208062, New Haven, CT 06520; Advisory Board, Global Partners in Anesthesia and Surgery, Kampala, Uganda.
| | - Monica Langer
- Department of Surgery, Maine Medical Center, Portland Maine, and Tufts University, Boston Massachusetts
| | - Phyllis Kisa
- Department of Surgery, Makerere University, Kampala, Uganda
| | - Dan Poenaru
- McGill University, Consultant Pediatric Surgeon, Montreal Childrens Hospital, Montreal, Quebec, Canada; Bethany Kids at MyungSung Christian Medical Center, Addis Ababa, Ethiopia
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88
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Sullivan R, Alatise OI, Anderson BO, Audisio R, Autier P, Aggarwal A, Balch C, Brennan MF, Dare A, D'Cruz A, Eggermont AMM, Fleming K, Gueye SM, Hagander L, Herrera CA, Holmer H, Ilbawi AM, Jarnheimer A, Ji JF, Kingham TP, Liberman J, Leather AJM, Meara JG, Mukhopadhyay S, Murthy SS, Omar S, Parham GP, Pramesh CS, Riviello R, Rodin D, Santini L, Shrikhande SV, Shrime M, Thomas R, Tsunoda AT, van de Velde C, Veronesi U, Vijaykumar DK, Watters D, Wang S, Wu YL, Zeiton M, Purushotham A. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol 2016; 16:1193-224. [PMID: 26427363 DOI: 10.1016/s1470-2045(15)00223-5] [Citation(s) in RCA: 409] [Impact Index Per Article: 51.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 08/07/2015] [Accepted: 08/07/2015] [Indexed: 12/20/2022]
Abstract
Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US $6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.
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Affiliation(s)
- Richard Sullivan
- Institute of Cancer Policy, King's Health Partners Comprehensive Cancer Centre, London, UK; King's Centre for Global Health, King's Health Partners and King's College London, London, UK.
| | | | - Benjamin O Anderson
- University of Washington School of Medicine, Seattle, WA, USA; Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | - Ajay Aggarwal
- Institute of Cancer Policy, King's Health Partners Comprehensive Cancer Centre, London, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK; London School of Hygiene & Tropical Medicine, London, UK
| | - Charles Balch
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Anna Dare
- Centre for Global Health Research, St Michael's Hospital, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Anil D'Cruz
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | | | - Kenneth Fleming
- Green Templeton College, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Trust, Oxford, UK
| | - Serigne Magueye Gueye
- University Cheikh Anta Diop, Dakar, Senegal; Grand Yoff General Hospital, Dakar, Senegal
| | - Lars Hagander
- Paediatric Surgery and Global Paediatrics, Department of Paediatrics, Lund University, Lund, Sweden
| | - Cristian A Herrera
- Cabinet of the Minister, Ministry of Health, Santiago, Chile; Department of Public Health, School of Medicine, Pontificia Universidad Católica, Santiago, Chile
| | - Hampus Holmer
- Paediatric Surgery and Global Paediatrics, Department of Paediatrics, Lund University, Lund, Sweden
| | - André M Ilbawi
- University of Texas MD Anderson Cancer Centre, Houston, TX, USA; Union for International Cancer Control, Geneva, Switzerland
| | - Anton Jarnheimer
- Paediatric Surgery and Global Paediatrics, Department of Paediatrics, Lund University, Lund, Sweden; Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Jia-Fu Ji
- Peking University Cancer Hospital and Institute, Beijing, China; Chinese Anti-Cancer Association, Tianjin, China
| | | | | | - Andrew J M Leather
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - John G Meara
- Program in Global Surgery and Social Change, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Swagoto Mukhopadhyay
- Program in Global Surgery and Social Change, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shilpa S Murthy
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Public Health, Boston, MA, USA; Department of General Surgery, Indiana University, Bloomington, IN, USA
| | | | - Groesbeck P Parham
- Department of Obstetrics and Gynecology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA; University of Zambia, Lusaka, Zambia
| | - C S Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Robert Riviello
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Public Health, Boston, MA, USA
| | - Danielle Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Luiz Santini
- INCA (Brazilian National Cancer Institute), Rio de Janeiro, Brazil
| | | | - Mark Shrime
- Program in Global Surgery and Social Change, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert Thomas
- Department of Health & Human Services, Melbourne, VIC, Australia
| | - Audrey T Tsunoda
- Gyne-Oncology Department, Barretos Cancer Hospital, Barretos, Brazil
| | - Cornelis van de Velde
- Department of Surgical Oncology, Endocrine and Gastrointestinal Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | | | | | - David Watters
- Deakin University, Geelong, VIC, Australia; Barwon Health, Geelong, VIC, Australia
| | - Shan Wang
- Peking University People's Hospital, Beijing, China; Chinese College of Surgeons, Beijing, China
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong General Hospital, Guangzhou, China; Guangdong Academy of Medical Sciences, Guangzhou, China; Chinese Society of Clinical Oncology, Beijing, China
| | - Moez Zeiton
- Sadeq Institute, Tripoli, Libya; Trauma and Orthopaedic Rotation, North-West Deanery, Manchester, UK
| | - Arnie Purushotham
- Institute of Cancer Policy, King's Health Partners Comprehensive Cancer Centre, London, UK; King's Centre for Global Health, King's Health Partners and King's College London, London, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK
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89
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Brugha R, Bijlmakers L, Borgstein E, Kachimba J. The evidence needed to make surgery a global health priority. LANCET GLOBAL HEALTH 2015; 3:e741. [PMID: 26566746 DOI: 10.1016/s2214-109x(15)00181-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 08/10/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Ruairí Brugha
- Royal College of Surgeons in Ireland, Dublin, Ireland.
| | | | - Eric Borgstein
- Department of Surgery, College of Medicine, University of Malawi, Blantyre, Malawi
| | - John Kachimba
- Surgical Society of Zambia, University of Zambia, Lusaka, Zambia
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90
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Beach D. Global surgical care: directions for further research. LANCET GLOBAL HEALTH 2015; 3:e432. [PMID: 26187482 DOI: 10.1016/s2214-109x(15)00078-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/04/2015] [Accepted: 06/05/2015] [Indexed: 10/23/2022]
Affiliation(s)
- D Beach
- Department of Political Science, University of Aarhus, 8000 Aarhus, Denmark.
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