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Macharia PM, Wong KLM, Beňová L, Wang J, Makanga PT, Ray N, Banke-Thomas A. Measuring geographic access to emergency obstetric care: a comparison of travel time estimates modelled using Google Maps Directions API and AccessMod in three Nigerian conurbations. GEOSPATIAL HEALTH 2024; 19. [PMID: 38801322 DOI: 10.4081/gh.2024.1266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/01/2024] [Indexed: 05/29/2024]
Abstract
Google Maps Directions Application Programming Interface (the API) and AccessMod tools are increasingly being used to estimate travel time to healthcare. However, no formal comparison of estimates from the tools has been conducted. We modelled and compared median travel time (MTT) to comprehensive emergency obstetric care (CEmOC) using both tools in three Nigerian conurbations (Kano, Port-Harcourt, and Lagos). We compiled spatial layers of CEmOC healthcare facilities, road network, elevation, and land cover and used a least-cost path algorithm within AccessMod to estimate MTT to the nearest CEmOC facility. Comparable MTT estimates were extracted using the API for peak and non-peak travel scenarios. We investigated the relationship between MTT estimates generated by both tools at raster celllevel (0.6 km resolution). We also aggregated the raster cell estimates to generate administratively relevant ward-level MTT. We compared ward-level estimates and identified wards within the same conurbation falling into different 15-minute incremental categories (<15/15-30/30-45/45-60/+60). Of the 189, 101 and 375 wards, 72.0%, 72.3% and 90.1% were categorised in the same 15- minute category in Kano, Port-Harcourt, and Lagos, respectively. Concordance decreased in wards with longer MTT. AccessMod MTT were longer than the API's in areas with ≥45min. At the raster cell-level, MTT had a strong positive correlation (≥0.8) in all conurbations. Adjusted R2 from a linear model (0.624-0.723) was high, increasing marginally in a piecewise linear model (0.677-0.807). In conclusion, at <45-minutes, ward-level estimates from the API and AccessMod are marginally different, however, at longer travel times substantial differences exist, which are amenable to conversion factors.
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Affiliation(s)
- Peter M Macharia
- Population and Health Impact Surveillance Group, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya; Department of Public Health, Institute of Tropical Medicine, Antwerp.
| | - Kerry L M Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London.
| | - Lenka Beňová
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium; Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London.
| | - Jia Wang
- School of Computing and Mathematical Sciences, University of Greenwich, London.
| | - Prestige Tatenda Makanga
- Surveying and Geomatics Department, Midlands State University Faculty of the Built Environment, Gweru, Midlands, Zimbabwe; Climate, Environment and Health Department, Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe; Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool.
| | - Nicolas Ray
- GeoHealth Group, Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland; Institute for Environmental Sciences, University of Geneva, Geneva.
| | - Aduragbemi Banke-Thomas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; School of Human Sciences, University of Greenwich, London, United Kingdom; Maternal and Reproductive Health Research Collective, Surulere, Lagos.
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Kazungu J, Moturi AK, Kuhora S, Ouko J, Quaife M, Nonvignon J, Barasa E. Examining inequalities in spatial access to national health insurance fund contracted facilities in Kenya. Int J Equity Health 2024; 23:78. [PMID: 38637821 PMCID: PMC11027528 DOI: 10.1186/s12939-024-02171-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 04/03/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Kenya aims to achieve universal health coverage (UHC) by 2030 and has selected the National Health Insurance Fund (NHIF) as the 'vehicle' to drive the UHC agenda. While there is some progress in moving the country towards UHC, the availability and accessibility to NHIF-contracted facilities may be a barrier to equitable access to care. We estimated the spatial access to NHIF-contracted facilities in Kenya to provide information to advance the UHC agenda in Kenya. METHODS We merged NHIF-contracted facility data to the geocoded inventory of health facilities in Kenya to assign facility geospatial locations. We combined this database with covariates data including road network, elevation, land use, and travel barriers. We estimated the proportion of the population living within 60- and 120-minute travel time to an NHIF-contracted facility at a 1-x1-kilometer spatial resolution nationally and at county levels using the WHO AccessMod tool. RESULTS We included a total of 3,858 NHIF-contracted facilities. Nationally, 81.4% and 89.6% of the population lived within 60- and 120-minute travel time to an NHIF-contracted facility respectively. At the county level, the proportion of the population living within 1-hour of travel time to an NHIF-contracted facility ranged from as low as 28.1% in Wajir county to 100% in Nyamira and Kisii counties. Overall, only four counties (Kiambu, Kisii, Nairobi and Nyamira) had met the target of having 100% of their population living within 1-hour (60 min) travel time to an NHIF-contracted facility. On average, it takes 209, 210 and 216 min to travel to an NHIF-contracted facility, outpatient and inpatient facilities respectively. At the county level, travel time to an NHIF-contracted facility ranged from 10 min in Vihiga County to 333 min in Garissa. CONCLUSION Our study offers evidence of the spatial access estimates to NHIF-contracted facilities in Kenya that can inform contracting decisions by the social health insurer, especially focussing on marginalised counties where more facilities need to be contracted. Besides, this evidence will be crucial as the country gears towards accelerating progress towards achieving UHC using social health insurance as the strategy to drive the UHC agenda in Kenya.
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Affiliation(s)
- Jacob Kazungu
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya.
| | - Angela K Moturi
- Population & Health Surveillance Group, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Julia Ouko
- National Health Insurance Fund, Nairobi, Kenya
| | - Matthew Quaife
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Justice Nonvignon
- Department of Health Policy, Planning and Management, School of Public Health, University of Ghana, Legon, Accra, Ghana
- Health Economics and Financing Programme, Africa Centres for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Campos LN, Bryce-Alberti M, Hill SK, del Valle DD, Zaigham M, Rábago ADLR, Dey T, Juran S, Uribe-Leitz T. Geospatial mapping of surgical systems for earthquake emergency planning in Guerrero, Mexico: an ecological study. LANCET REGIONAL HEALTH. AMERICAS 2023; 26:100586. [PMID: 37701459 PMCID: PMC10493591 DOI: 10.1016/j.lana.2023.100586] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 09/14/2023]
Abstract
Background Accessibility to surgical services can impact earthquake preparedness and response. We aimed to estimate the population with timely access to surgical care in Guerrero, a Mexican state with high tectonic activity, and identify populations at risk in the event of an earthquake. Methods We conducted an ecological study using open government data. We extracted data from Guerrero municipalities regarding their earthquake risk, social vulnerability, social inequality, marginalisation, and resilience indices. The latest combines municipalities' resistance to unexpected events and capacity to maintain optimal functionality without immediate federal or international support. Geographical coordinates of active public and private surgical facilities in Guerrero were combined with ancillary spatial data on roads and municipalities' population density to estimate population coverage within 30-min and 1-h driving time to surgical facilities in Redivis. We built an ordered beta regression model for each driving time estimate. Findings We identified 25 public and 16 private facilities capable of providing surgical care in Guerrero. The population with access to facilities with surgical capacity within 30 min and 1-h driving times were 48.4% and 69.1%, respectively. We found that municipalities with very high levels of earthquake risk, social vulnerability, social inequality, and marginalisation, and very low levels of resilience had decreased coverage. In the multivariable analysis, the resilience index was statistically significant only for the 30-min model, with an effect size of 0.524 (95% CI 0.082, 1.089). Interpretation Access to surgical care remains unequally distributed in Guerrero municipalities at the highest risk for earthquakes. Municipalities' resilience was the most significant predictor of higher surgical care coverage in 30-min driving time. Our study provides insights on how surgical system strengthening can enhance earthquake emergency disaster planning. Funding No funding.
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Affiliation(s)
- Letícia Nunes Campos
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Faculty of Medical Sciences, Universidade de Pernambuco, Recife, PE, Brazil
| | - Mayte Bryce-Alberti
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Faculty of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Sarah K. Hill
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Diana D. del Valle
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Department of Surgery, National Institute of Medical Sciences and Nutrition “Salvador Zubiran”, Mexico City, Mexico
| | - Mehreen Zaigham
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Obstetrics and Gynecology, Institution of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Alberto de la Rosa Rábago
- Comisión Nacional para la Mejora Continua de la Educación (MEJOREDU), Unidad de Apoyo y Seguimiento a la Mejora Continua e Inonovación Educativa, Ciudad de México, Mexico
| | - Tanujit Dey
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Sabrina Juran
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Tarsicio Uribe-Leitz
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Department of Plastic Surgery, Boston Children’s Hospital, Boston, MA, USA
- Department of Sport and Health Sciences, Technical University Munich, Epidemiology, Munich, Germany
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Omisore AD, Sutton EJ, Akinola RA, Towoju AG, Akhigbe A, Ebubedike UR, Tansley G, Olasehinde O, Goyal A, Akinde AO, Alatise OI, Mango VL, Kingham TP, Knapp GC. Population-Level Access to Breast Cancer Early Detection and Diagnosis in Nigeria. JCO Glob Oncol 2023; 9:e2300093. [PMID: 38096465 PMCID: PMC10730078 DOI: 10.1200/go.23.00093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 09/08/2023] [Accepted: 10/26/2023] [Indexed: 12/18/2023] Open
Abstract
PURPOSE Mammography, breast ultrasound (US), and US-guided breast biopsy are essential services for breast cancer early detection and diagnosis. This study undertook a comprehensive evaluation to determine population-level access to these services for breast cancer early detection and diagnosis in Nigeria using a previously validated geographic information system (GIS) model. METHODS A comprehensive list of public and private facilities offering mammography, breast US, and US-guided breast biopsy was compiled using publicly available facility data and a survey administered nationally to Nigerian radiologists. All facilities were geolocated. A cost-distance model using open-source population density (GeoData Institute) and road network data (OpenStreetMap) was used to estimate population-level travel time to the nearest facility for mammography, breast US, and US-guided biopsy using GIS software (ArcMAP). RESULTS In total, 1,336 facilities in Nigeria provide breast US, of which 47.8% (639 of 1,336) are public facilities, and 218 provide mammography, of which 45.4% (99 of 218) are public facilities. Of the facilities that provide breast US, only 2.5% (33 of 1,336) also provide US-guided breast biopsy. At the national level, 83.1% have access to either US or mammography and 61.7% have access to US-guided breast biopsy within 120 minutes of a continuous one-way travel. There are differences in access to mammography (64.8% v 80.6% with access at 120 minutes) and US-guided breast biopsy (49.0% v 77.1% with access at 120 minutes) between the northern and southern Nigeria and between geopolitical zones. CONCLUSION To our knowledge, this is the first comprehensive evaluation of breast cancer detection and diagnostic services in Nigeria, which demonstrates geospatial inequalities in access to mammography and US-guided biopsy. Targeted investment is needed to improve access to these essential cancer care services in the northern region and the North East geopolitical zone.
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Affiliation(s)
| | - Elizabeth J. Sutton
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Racheal A. Akinola
- Department of Radiology, Lagos State University Teaching Hospital, Lagos, Nigeria
| | | | - Adenike Akhigbe
- Department of Radiology, University of Benin Teaching Hospital, Benin, Nigeria
| | | | - Gavin Tansley
- Department of Surgery, Division of General Surgery, University of British Columbia, Vancouver, BC, Canada
| | | | - Amita Goyal
- Department of Surgery, Division of General Surgery, Dalhousie University, Halifax, NS, Canada
| | | | | | - Victoria Lee Mango
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - T. Peter Kingham
- Department of Surgery, Hepatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gregory C. Knapp
- Department of Surgery, Division of General Surgery, Dalhousie University, Halifax, NS, Canada
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Zadey S, Iyer H, Nayan A, Shetty R, Sonal S, Smith ER, Staton CA, Fitzgerald TN, Nickenig Vissoci JR. Evaluating the status of the Lancet Commission on Global Surgery indicators for India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 13:100178. [PMID: 37383563 PMCID: PMC10306037 DOI: 10.1016/j.lansea.2023.100178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 02/03/2023] [Accepted: 03/02/2023] [Indexed: 06/30/2023]
Abstract
For universal surgical, obstetric, trauma, and anesthesia care by 2030, the Lancet Commission on Global Surgery (LCoGS) suggested tracking six indicators. We reviewed academic and policy literature to investigate the current state of LCoGS indicators in India. There was limited primary data for access to timely essential surgery, risk of impoverishing and catastrophic health expenditures due to surgery, though some modeled estimates are present. Surgical specialist workforce estimates are heterogeneous across different levels of care, urban and rural areas, and diverse health sectors. Surgical volumes differ widely across demographic, socio-economic, and geographic cohorts. Perioperative mortality rates vary across procedures, diagnoses, and follow-up time periods. Available data suggest India falls short of achieving global targets. This review highlights the evidence gap for India's surgical care planning. India needs a systematic subnational mapping of indicators and adaptation of targets as per the country's health needs for equitable and sustainable planning.
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Affiliation(s)
- Siddhesh Zadey
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, 411007, India
- Department of Surgery, Duke University School of Medicine, Durham, NC, 27707, USA
- Global Emergency Medicine Innovation and Implementation Research Center, Duke University, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, 27710, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, 27707, USA
- Dr. D.Y. Patil Medical College, Hospital, and Research Centre, Pune, Maharashtra, 411018, India
| | - Himanshu Iyer
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, 411007, India
| | - Anveshi Nayan
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, 411007, India
- Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, 400012, India
| | - Ritika Shetty
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, 411007, India
- Terna Medical College and Hospital, Navi Mumbai, Maharashtra, 400706, India
| | - Swati Sonal
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, 411007, India
- Division of General and Gastrointestinal Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA
- Department of Surgery, Harvard Medical School, Boston, MA, 02114, USA
| | - Emily R. Smith
- Department of Surgery, Duke University School of Medicine, Durham, NC, 27707, USA
- Global Emergency Medicine Innovation and Implementation Research Center, Duke University, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, 27710, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, 27707, USA
| | - Catherine A. Staton
- Department of Surgery, Duke University School of Medicine, Durham, NC, 27707, USA
- Global Emergency Medicine Innovation and Implementation Research Center, Duke University, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, 27710, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, 27707, USA
| | - Tamara N. Fitzgerald
- Department of Surgery, Duke University School of Medicine, Durham, NC, 27707, USA
- Duke Global Health Institute, Durham, NC, 27710, USA
| | - Joao Ricardo Nickenig Vissoci
- Department of Surgery, Duke University School of Medicine, Durham, NC, 27707, USA
- Global Emergency Medicine Innovation and Implementation Research Center, Duke University, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, 27710, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, 27707, USA
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Hendrix N, Warkaye S, Tesfaye L, Woldekidan MA, Arja A, Sato R, Memirie ST, Mirkuzie AH, Getnet F, Verguet S. Estimated travel time and staffing constraints to accessing the Ethiopian health care system: A two-step floating catchment area analysis. J Glob Health 2023; 13:04008. [PMID: 36701563 PMCID: PMC9880518 DOI: 10.7189/jogh.13.04008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background Despite large investments in the public health care system, disparities in health outcomes persist between lower- and upper-income individuals, as well as rural vs urban dwellers in Ethiopia. Evidence from Ethiopia and other low- and middle-income countries suggests that challenges in health care access may contribute to poverty in these settings. Methods We employed a two-step floating catchment area to estimate variations in spatial access to health care and in staffing levels at health care facilities. We estimated the average travel time from the population centers of administrative areas and adjusted them with provider-to-population ratios. To test hypotheses about the role of travel time vs staffing, we applied Spearman's rank tests to these two variables against the access score to assess the significance of observed variations. Results Among Ethiopia's 11 first-level administrative units, Addis Ababa, Dire Dawa, and Harari had the best access scores. Regions with the lowest access scores were generally poorer and more rural/pastoral. Approximately 18% of the country did not have access to a public health care facility within a two-hour walk. Our results suggest that spatial access and staffing issues both contribute to access challenges. Conclusion Investments both in new health facilities and staffing in existing facilities will be necessary to improve health care access within Ethiopia. Because rural and low-income areas are more likely to have poor access, future strategies for expanding and strengthening the health care system should strongly emphasize equity and the role of improved access in reducing poverty.
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Affiliation(s)
- Nathaniel Hendrix
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Samson Warkaye
- National Data Management Center for Health, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Latera Tesfaye
- National Data Management Center for Health, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Mesfin Agachew Woldekidan
- National Data Management Center for Health, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Asrat Arja
- National Data Management Center for Health, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Ryoko Sato
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Solomon Tessema Memirie
- Addis Center for Ethics and Priority Setting, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alemnesh H Mirkuzie
- National Data Management Center for Health, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Fentabil Getnet
- National Data Management Center for Health, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Adde HA, van Duinen AJ, Andrews BC, Bakker J, Goyah KS, Salvesen Ø, Sheriff S, Utam T, Yaskey C, Weiser TG, Bolkan HA. Mapping population access to essential surgical care in Liberia using equipment, personnel, and bellwether capability standards. Br J Surg 2023; 110:169-176. [PMID: 36469530 PMCID: PMC10364551 DOI: 10.1093/bjs/znac377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 10/02/2022] [Accepted: 10/20/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND Accurate surveillance of population access to essential surgery is key for strategic healthcare planning. This study aimed to estimate population access to surgical facilities meeting standards for safe surgery equipment, specialized surgical personnel, and bellwether capability, cesarean delivery, emergency laparotomy, and long-bone fracture fixation and to evaluate the validity of using these standards to describe the full breadth of essential surgical care needs in Liberia. METHOD An observational study of surgical facilities was conducted in Liberia between 20 September and 8 November 2018. Facility data were combined with geospatial data and analysed in an online visualization platform. RESULTS Data were collected from 51 of 52 surgical facilities. Nationally, 52.9 per cent of the population (2 392 000 of 4 525 000 people) had 2-h access to their closest surgical facility, whereas 41.1 per cent (1 858 000 people) and 48.6 per cent (2 199 000 people) had 2-h access to a facility meeting the personnel and equipment standards respectively. Six facilities performed all bellwether procedures; 38.7 per cent of the population (1 751 000 people) had 2-h access to one of these facilities. Bellwether-capable facilities were more likely to perform other essential surgical procedures (OR 3.13, 95 per cent c.i. 1.28 to 7.65; P = 0.012). These facilities delivered a median of 13.0 (i.q.r. 11.3-16.5) additional essential procedures. CONCLUSION Population access to essential surgery is limited in Liberia; strategies to reduce travel times ought to be part of healthcare policy. Policymakers should also be aware that bellwether capability might not be a valid proxy for the full breadth of essential surgical care in low-income settings.
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Affiliation(s)
- Håvard A Adde
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Alex J van Duinen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.,Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | | | - Juul Bakker
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Kezelebah S Goyah
- Lifebox Foundation, Monrovia, Liberia.,F. J. Grante Memorial Hospital, Greenville, Liberia
| | - Øyvind Salvesen
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Swaliho Sheriff
- Lifebox Foundation, Monrovia, Liberia.,Department of Surgery, Liberia Governmental Hospital, Tubmanburg, Liberia
| | - Terseer Utam
- Lifebox Foundation, Monrovia, Liberia.,Department of Surgery and Traumatology, Redemption Hospital, Monrovia, Liberia
| | | | - Thomas G Weiser
- Department of Surgery, Stanford University, Stanford, California, USA.,Department of Surgery, Stanford-Surgery Policy Improvement Research and Education Center, Stanford University, Palo Alto, California, USA.,Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK.,Lifebox Foundation, London, UK
| | - Håkon A Bolkan
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
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Ross O, Shakya R, Shrestha R, Shah S, Pradhan A, Shrestha R, Bhandari P, Paris B, Shah K, Shrestha A, Zimmerman M, Henrikson H, Tamang S, Rajbhandari R. Pathways to effective surgical coverage in a lower-middle-income country: A multiple methods study of the family physician-led generalist surgical team in rural Nepal. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001510. [PMID: 36963001 PMCID: PMC10021892 DOI: 10.1371/journal.pgph.0001510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 01/24/2023] [Indexed: 03/04/2023]
Abstract
The Lancet Commission on Global Surgery (LCoGS) recommends using specialist surgical workforce density as one of 6 core indicators for monitoring universal access to safe, affordable surgical and anaesthesia care. Using Nepal as a case study, we explored the capacity of a generalist workforce (led by a family physician or MD general practitioner and non-physician anaesthetist) to enable effective surgical delivery through task-shifting. Using a multiple-methods approach, we retrospectively mapped essential surgical care and the enabling environment for surgery in 39 hospitals in 25 remote districts in Nepal and compared it with LCoGS indicators. All 25 districts performed surgery, 21 performed Caesarean section (CS), and 5 met at least 50% of district CS needs. Generalist surgical teams performed CS, the essential major operation at the district level, and very few laparotomies, but no operative orthopaedics. The density of specialist Surgeon/Anaesthesiologist/Obstetrician (SAO) was 0·4/100,000; that of Generalist teams (gSAO) led by a family physician (MD General Practitioners-MDGP) supported by non-physician anaesthetists was eight times higher at 3·1/100,000. gSAO presence was positively associated with a two-fold increase in CS availability. All surgical rates were well below LCoGS targets. 46% of hospitals had adequate enabling environments for surgery, 28% had functioning anaesthesia machines, and 75% had blood transfusion services. Despite very low SAO density, and often inadequate enabling environment, surgery can be done in remote districts. gSAO teams led by family physicians are providing essential surgery, with CS the commonest major operation. gSAO density is eight times higher than specialists and they can undertake more complex operations than just CS alone. These family physician-led functional teams are providing a pathway to effective surgical coverage in remote Nepal.
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Affiliation(s)
- Ollie Ross
- Nick Simons Institute, Lalitpur, Nepal
- University Hospital Southampton, Southampton, United Kingdom
| | | | | | - Shristi Shah
- Galangoor Duwalami Primary Health Care Centre, Maryborough, Australia
| | - Amita Pradhan
- Nick Simons Institute, Lalitpur, Nepal
- KIST Medical College, Lalitpur, Nepal
| | | | | | - Becky Paris
- Hereford County Hospital, Hereford, United Kingdom
| | | | | | | | - Hannah Henrikson
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | | | - Ruma Rajbhandari
- Nick Simons Institute, Lalitpur, Nepal
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
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Daher RP, Gause E, Sterwart BT, Gragnani A. Preparing for a burn disaster in Brazil: Geospatial modelling to inform a coordinated response. Burns 2022:S0305-4179(22)00234-0. [DOI: 10.1016/j.burns.2022.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/22/2022] [Accepted: 08/30/2022] [Indexed: 11/02/2022]
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Meshesha BR, Sibhatu MK, Beshir HM, Zewude WC, Taye DB, Getachew EM, Merga KH, Kumssa TH, Alemayue EA, Ashuro AA, Shagre MB, Gebreegziabher SB. Access to surgical care in Ethiopia: a cross-sectional retrospective data review. BMC Health Serv Res 2022; 22:973. [PMID: 35907955 PMCID: PMC9338639 DOI: 10.1186/s12913-022-08357-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Access to emergency and essential surgical care is still unmet and accessibility is disproportionately inequitable in Ethiopia and other low-and middle-income countries. The aim of this study was to assess surgical care access in terms of capability, capacity, and timeliness of care in different levels of health care in Ethiopia. METHODS A cross-sectional study with retrospective data review was conducted in 172 health facilities from December 30, 2020 to June 10, 2021. Descriptive statistics such as median with interquartile range and proportion were computed using STATA Version 15 statistical software. RESULTS Within a 90-day interval of the study period, 69,717 major and minor surgeries, and 33,052 bellwether procedures were performed, and major surgeries accounted for 58% of the surgeries. About 1.6%, 23.56%, 25.34%, and 32.2% of both major and minor, and 3.1%, 12.8%, 27.6%, and 45.3% of bellwether procedures were performed in health center OR blocks, primary, general, and specialized hospitals, respectively. Private hospitals performed 17.33% of major and minor and 11.2% of bellwether procedures for the period. The average pre-admission waiting time for surgical patients in primary, general, and specialized hospitals was 9.68, 37.6, and 35.9 days, respectively, whereas, in private hospitals, the average pre-admission waiting time was 1.42 days. On average, surgical patients traveled 5 Hrs, 11 Hrs, 28.4 Hrs, and 21.3 Hrs to access surgical services in primary, general, specialized, and private hospitals, respectively. The surgical workforce to the population served ratio was 7.5, 1.15, and 1.31/100.000 population in primary, specialized and general hospitals, respectively. CONCLUSION Most surgical procedures were performed in specialized hospitals, indicating that there is a burden in these health facilities. The pre-admission waiting time for surgical patients was long in higher-level public hospitals. Surgical patients traveled a long distance to access surgical service in higher level hospitals. The ratio of surgical workforce per 100,000 population served was low in all levels of public health facilities in general, and in higher level hospitals in particular. Efforts should therefore be made to strengthen all levels of the health system and improve surgical care access in terms of capacity, capability, and timeliness in the country.
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Affiliation(s)
- Berhane Redae Meshesha
- Ministry of Health of Ethiopia, Addis Ababa, Ethiopia.,Jhpiego Ethiopia, Johns Hopkins University Affiliate, Addis Ababa, Ethiopia.,St. Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia
| | - Manuel Kassaye Sibhatu
- Jhpiego Ethiopia, Johns Hopkins University Affiliate, Addis Ababa, Ethiopia.,College of Medicine and Health Science, Addis Ababa University (AAU), Addis Ababa, Ethiopia
| | | | | | | | | | | | | | | | | | - Mulatu Biru Shagre
- Armauer Hansen Research Institute (AHRI), Addis Ababa, Ethiopia.,Faculty of Medicine, Department of Health Sciences, Child and Family Health, Lund University, Lund, Sweden
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11
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Alayande B, Chu KM, Jumbam DT, Kimto OE, Musa Danladi G, Niyukuri A, Anderson GA, El-Gabri D, Miranda E, Taye M, Tertong N, Yempabe T, Ntirenganya F, Byiringiro JC, Sule AZ, Kobusingye OC, Bekele A, Riviello RR. Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review. CURRENT TRAUMA REPORTS 2022; 8:66-94. [PMID: 35692507 PMCID: PMC9168359 DOI: 10.1007/s40719-022-00229-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 02/02/2023]
Abstract
Purpose of Review Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model. Recent Findings A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager’s four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public–private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda. Summary Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action. Supplementary Information The online version contains supplementary material available at 10.1007/s40719-022-00229-1.
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Affiliation(s)
- Barnabas Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Kathryn M. Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences Stellenbosch University, Cape Town, South Africa
| | | | | | | | - Alliance Niyukuri
- Hope Africa University, Bujumbura, Burundi
- Mercy Surgeons-Burundi, Research Department, Bujumbura, Burundi
- Mercy James Center for Paediatric Surgery and Intensive Care-Blantyre, Blantyre, Malawi
| | - Geoffrey A. Anderson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Deena El-Gabri
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Elizabeth Miranda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Mulat Taye
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ngyal Tertong
- International Fellow, Paediatric Orthopaedic Surgery Department of Orthopaedics, Sheffield Children’s Hospital, Sheffield, UK
| | - Tolgou Yempabe
- Orthopaedic and Trauma Unit, Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana
| | - Faustin Ntirenganya
- University Teaching Hospital of Kigali, Kigali, Rwanda
- Department of Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- NIHR Research Hub On Global Surgery, University of Rwanda, Kigali, Rwanda
| | - Jean Claude Byiringiro
- University Teaching Hospital of Kigali, Kigali, Rwanda
- NIHR Research Hub On Global Surgery, University of Rwanda, Kigali, Rwanda
- School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Olive C. Kobusingye
- Makerere University School of Public Health, Kampala, Uganda
- George Institute for Global Health, Sydney, Australia
| | - Abebe Bekele
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Robert R. Riviello
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
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12
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Use of geospatial analysis for priority setting in surgical system investment in Guatemala. LANCET REGIONAL HEALTH. AMERICAS 2021; 7:100145. [PMID: 36777659 PMCID: PMC9904083 DOI: 10.1016/j.lana.2021.100145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Two-hour and 30 min travel times to a hospital capable of performing emergency general surgery and cesarean section are benchmarks for timely surgical access. This study aimed to estimate the population of Guatemala with timely access to surgical care and identify existing hospitals where the expansion of surgical services would increase access. Methods The World Federation of Societies of Anaesthesiologists (WFSA) Anesthesia Facility Assessment Tool (AFAT) previously identified 37 public Guatemalan hospitals that provide surgical care. Nine additional public non-surgical hospitals were also identified. Geospatial analysis was performed to estimate walking and driving geographic access to all 46 hospitals. We calculated the potential increase in access that would accompany the expansion of surgical services at each of the nine non-surgical hospitals. Findings The percentage of the population with walking access to a surgical hospital within 30 min, 1 h, and 2 h are 5·1%, 12·9%, and 27·3%, respectively. The percentage of people within 30 min, 1 h, and 2 h driving times are 27·3%, 41·1%, and 53·1%, respectively. The median percentage of the population within each of Guatemala's 22 administrative departments with 2 h walking access was 19·0% [IQR 14·1-30·7] and 2 h driving access was 52·4% [IQR 30·5-62·8]. Expansion of surgical care at existing public Guatemalan hospitals in Guatemala would result in a minimal increase in overall geographic access compared to current availability. Interpretation While Guatemala provides universal health coverage, geographic access to surgical care remains inadequate. Geospatial mapping and survey data work synergistically to assess surgical system strength and identify gaps in geographic access to essential surgical care. Funding None.
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13
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Curtis A, Monet JP, Brun M, Bindaoudou IAK, Daoudou I, Schaaf M, Agbigbi Y, Ray N. National optimisation of accessibility to emergency obstetrical and neonatal care in Togo: a geospatial analysis. BMJ Open 2021; 11:e045891. [PMID: 34330852 PMCID: PMC8327815 DOI: 10.1136/bmjopen-2020-045891] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Improving access to emergency obstetrical and neonatal care (EmONC) is a key strategy for reducing maternal and neonatal mortality. Access is shaped by several factors, including service availability and geographical accessibility. In 2013, the Ministry of Health (MoH) of Togo used service availability and other criteria to designate particular facilities as EmONC facilities, facilitating efficient allocation of limited resources. In 2018, the MoH further revised and rationalised this health facility network by applying an innovative methodology using health facility characteristics and geographical accessibility modelling to optimise timely access to EmONC services. This study compares the geographical accessibility of the network established in 2013 and the smaller network developed in 2018. DESIGN We used data regarding travel modes and speeds, geographical barriers and topographical and urban constraints, to estimate travel times to the nearest EmONC facilities. We compared the EmONC network of 109 facilities established in 2013 with the one composed of 73 facilities established in 2018, using three travel scenarios (walking and motorised, motorcycle-taxi and walking-only). RESULTS When walking and motorised travel is considered, the 2013 EmONC network covers 81% and 96.6% of the population at the 1-hour and 2-hour limit, respectively. These figures are slightly higher when motorcycle-taxis are considered (82.8% and 98%), and decreased to 34.7% and 52.3% for the walking-only scenario. The 2018 prioritised EmONC network covers 78.3% (1-hour) and 95.5% (2-hour) of the population for the walking and motorised scenario. CONCLUSIONS By factoring in geographical accessibility modelling to our iterative EmONC prioritisation process, the MoH was able to decrease the designated number of EmONC facilities in Togo by about 30%, while still ensuring that a high proportion of the population has timely access to these services. However, the physical access to EmONC for women unable to afford motorised transport remains inequitable.
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Affiliation(s)
- Andrew Curtis
- GeoHealth Group, Institute of Global Health, University of Geneva, Geneva, Switzerland
- Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland
| | | | - Michel Brun
- Technical Division, UNFPA, New York, New York, USA
| | | | | | | | | | - Nicolas Ray
- GeoHealth Group, Institute of Global Health, University of Geneva, Geneva, Switzerland
- Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland
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14
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Hoh SM, Wahab MYA, Hisham AN, Guest GD, Watters DAK. Mapping timely access to emergency and essential surgical services: The Malaysian experience. ANZ J Surg 2021; 92:223-227. [PMID: 34075677 DOI: 10.1111/ans.16986] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/05/2021] [Accepted: 05/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Surgical conditions form a significant proportion of the global burden of disease. Since the 2015 World Health Assembly resolution A68.15, there is recognition that the provision of essential surgical care is an integral part of universal access to health care. The Lancet Commission on Global Surgery proposed its first surgical indicator to measure a population's access to the Bellwether procedures (laparotomy, caesarean section and treatment of open fracture) within two hours. Bellwether access is a proxy for emergency and essential surgical care. This project aims to map essential surgical access to the Bellwether procedures in Malaysia. METHODS The location and capability of hospitals to perform the Bellwether procedures was obtained from the Ministry of Health (MoH) and MoH hospital specific websites. The Malaysian population data were retrieved from the national department of statistics. Times for patients to travel to hospital were calculated by combining manual contouring and geospatial mapping. RESULTS There were 49 Bellwether-capable MoH hospitals serving a national population of 32.5 million. Overall 94% of Malaysia's population have access to the Bellwethers within two hours. This coverage is universal in West (Peninsular) Malaysia, but there is only 73% coverage in East Malaysia, with 1.8 million residents of Sabah and Sarawak not having timely access. Malaysia's Bellwether capacity compares well with other countries in World Health Organisation's Western Pacific region. CONCLUSION There is good access to essential and emergency surgical services in Malaysia. The incomplete access for 1.8 million people in East Malaysia will inform national surgical planning.
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Affiliation(s)
- Su Mei Hoh
- Department of Surgery, University Hospital Geelong, Deakin University and Barwon Health, Geelong, Victoria, Australia
| | | | | | - Glenn D Guest
- Department of Surgery, University Hospital Geelong, Deakin University and Barwon Health, Geelong, Victoria, Australia
| | - David A K Watters
- Department of Surgery, University Hospital Geelong, Deakin University and Barwon Health, Geelong, Victoria, Australia
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15
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Cossa M, Rose J, Berndtson AE, Noormahomed E, Bickler SW. Assessment of Surgical Care Provided in National Health Services Hospitals in Mozambique: The Importance of Subnational Metrics in Global Surgery. World J Surg 2021; 45:1306-1315. [PMID: 33521876 PMCID: PMC8530447 DOI: 10.1007/s00268-020-05925-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Surgery plays a critical role in sustainable healthcare systems. Validated metrics exist to guide implementation of surgical services, but low-income countries (LIC) struggle to report recommended metrics and this poses a critical barrier to addressing unmet need. We present a comprehensive national sample of surgical encounters from a LIC by assessing the National Health Services of Mozambique. MATERIAL AND METHODS A prospective cohort of all surgical encounters from Mozambique's National Health Service was gathered for all provinces between July and December 2015. Primary outcomes were timely access, provider densities for surgery, anesthesiology, and obstetrics (SAO) per 100,000 population, annualized surgical procedure volume per 100,000, and postoperative mortality (POMR). Secondary outcomes include operating room density and efficiency. RESULTS Fifty-four hospitals had surgical capacity in 11 provinces with 47,189 surgeries. 44.9% of Mozambique's population lives in Districts without access to surgical services. National SAO density was 1.2/100,000, ranging from 0.4/100,000 in Manica Province to 9.8/100,000 in Maputo City. Annualized national surgical case volume was 367 procedures/100,000 population, ranging from 180/100,000 in Zambezia Province to 1,897/100,000 in Maputo City. National POMR was 0.74% and ranged from 0.23% in Maputo Province to 1.78% in Niassa Province. DISCUSSION Surgical delivery in Mozambique falls short of international targets. Subnational deficiencies and variations between provinces pose targets for quality improvement in advancing national surgical plans. This serves as a template for LICs to follow in gathering surgical metrics for the WHO and the World Bank and offers short- and long-term targets for surgery as a component of health systems strengthening.
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Affiliation(s)
- Matchecane Cossa
- Department of Surgery, Maputo Central Hospital, Eduardo Mondlane University, Maputo, Mozambique
| | - John Rose
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
| | - Allison E Berndtson
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, CA, USA
| | - Emilia Noormahomed
- Microbiology Department, Parasitology Laboratory, Department of Medicine, Eduardo Mondlane University, Maputo, Mozambique
- Mozambique Institute of Health Education and Research, Maputo, Mozambique
- Department of Medicine, Division of Infectious Diseases, University of California, San Diego, CA, USA
| | - Stephen W Bickler
- Division of Pediatric Surgery, Rady Children's Hospital, University of California, San Diego, CA, USA
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16
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Stewart BT, Gyedu A, Goodman SK, Boakye G, Scott JW, Donkor P, Mock C. Injured and broke: The impacts of the Ghana National Health Insurance Scheme (NHIS) on service delivery and catastrophic health expenditure among seriously injured children. Afr J Emerg Med 2021; 11:144-151. [PMID: 33680736 PMCID: PMC7910164 DOI: 10.1016/j.afjem.2020.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/28/2020] [Accepted: 09/21/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction Ghana implemented a National Health Insurance Scheme (NHIS) in 2003 as a step toward universal health coverage. We aimed to determine the effect of the NHIS on timeliness of care, mortality, and catastrophic health expenditure (CHE) among children with serious injuries at a trauma center in Ghana. Methods We performed a retrospective cohort study of injured children aged <18 years who required surgery (i.e., proxy for serious injury) at Komfo Anokye Teaching Hospital from 2015 to 2016. Household income data was obtained from the Ghana Statistical Service. CHE was defined as out-of-pocket payments to annual household income ≥10%. Differences in insured and uninsured children were described. Multivariable regression was used to assess the effect of NHIS on time to surgery, length of stay, in-hospital mortality, out-of-pocket expenditure and CHE. Results Of the 263 children who met inclusion criteria, 70% were insured. Mechanism of injury, triage scores and Kampala Trauma Score II were similar in both groups (all p > 0.10). Uninsured children were more likely to have a delay in care for financial reasons (17.3 vs 6.4%, p < 0.001) than insured children, and the families of uninsured children paid a median of 1.7 times more out-of-pocket costs than families with insured children (p < 0.001). Eighty-six percent of families of uninsured children experienced CHE compared to 54% of families of insured children (p < 0.001); however, 64% of all families experienced CHE. Insurance was protective against CHE (aOR 0.21, 95%CI 0.08–0.55). Conclusions NHIS did not improve timeliness of care, length of stay or mortality. Although NHIS did provide some financial risk protection for families, it did not eliminate out-of-pocket payments. The families of most seriously injured children experienced CHE, regardless of insurance status. NHIS and similar financial risk pooling schemes could be strengthened to better provide financial risk protection and promote quality of care for injured children. Despite strides toward universal health coverage with the National Health Insurance Scheme (NHIS) in Ghana, one third of injured children did not have insurance. Families on uninsured injured children pay markedly more out-of-pocket costs than families of insured children. Although families of uninsured children were more likely to experience catastrophic health expenditure (CHE), CHE was commonly experienced regardless of insurance. These findings have useful implications for NHIS, agencies working toward universal health coverage, and trauma systems generally.
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Foote CJ, Tornetta P, Reito A, Al-Hourani K, Schenker M, Bosse M, Coles CP, Bozzo A, Furey A, Leighton R. A Reevaluation of the Risk of Infection Based on Time to Debridement in Open Fractures: Results of the GOLIATH Meta-Analysis of Observational Studies and Limited Trial Data. J Bone Joint Surg Am 2021; 103:265-273. [PMID: 33298796 DOI: 10.2106/jbjs.20.01103] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open fractures are one of the leading causes of disability worldwide. The threshold time to debridement that reduces the infection rate is unclear. METHODS We searched all available databases to identify observational studies and randomized trials related to open fracture care. We then conducted an extensive meta-analysis of the observational studies, using raw and adjusted estimates, to determine if there was an association between the timing of initial debridement and infection. RESULTS We identified 84 studies (18,239 patients) for the primary analysis. In unadjusted analyses comparing various "late" time thresholds for debridement versus "early" thresholds, there was an association between timing of debridement and surgical site infection (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.11 to 1.49, p < 0.001, I2 = 30%, 84 studies, n = 18,239). For debridement performed between 12 and 24 hours versus earlier than 12 hours, the OR was higher in tibial fractures (OR = 1.37, 95% CI = 1.00 to 1.87, p = 0.05, I2 = 19%, 12 studies, n = 2,065), and even more so in Gustilo type-IIIB tibial fractures (OR = 1.46, 95% CI = 1.13 to 1.89, p = 0.004, I2 = 23%, 12 studies, n = 1,255). An analysis of Gustilo type-III fractures showed a progressive increase in the risk of infection with time. Critical time thresholds included 12 hours (OR = 1.51, 95% CI = 1.28 to 1.78, p < 0.001, I2 = 0%, 16 studies, n = 3,502) and 24 hours (OR = 2.17, 95% CI = 1.73 to 2.72, p < 0.001, I2 = 0%, 29 studies, n = 5,214). CONCLUSIONS High-grade open fractures demonstrated an increased risk of infection with progressive delay to debridement. LEVEL OF EVIDENCE Prognostic Level IV. See Instruction for Authors for a complete description of the levels of evidence.
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Affiliation(s)
| | - Paul Tornetta
- Department of Orthopedics, Boston University Medical Center, Boston, Massachusetts
| | - Aleksi Reito
- Tampere University Hospital (TAUH), Tampere, Finland
| | - Khalid Al-Hourani
- Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Mara Schenker
- Orthopedic Trauma Research Unit, Emory University, Atlanta, Georgia
| | - Michael Bosse
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Chad P Coles
- Division of Orthopaedics, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Andrew Furey
- Division of Orthopaedics, Memorial University, St. John's, Newfoundland, Canada
| | - Ross Leighton
- Division of Orthopaedics, Dalhousie University, Halifax, Nova Scotia, Canada
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18
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Rudolfson N, Gruendl M, Nkurunziza T, Kateera F, Sonderman K, Nihiwacu E, Ramadhan B, Riviello R, Hedt-Gauthier B. Validating the Global Surgery Geographical Accessibility Indicator: Differences in Modeled Versus Patient-Reported Travel Times. World J Surg 2021; 44:2123-2130. [PMID: 32274536 PMCID: PMC7266844 DOI: 10.1007/s00268-020-05480-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Since long travel times to reach health facilities are associated with worse outcomes, geographic accessibility is one of the six core global surgery indicators; this corresponds to the second of the “Three Delays Framework,” namely “delay in reaching a health facility.” Most attempts to estimate this indicator have been based on geographical information systems (GIS) algorithms. The aim of our study was to compare GIS derived estimates to self-reported travel times for patients traveling to a district hospital in rural Rwanda for emergency obstetric care. Methods Our study includes 664 women who traveled to undergo a Cesarean delivery in Kirehe, Rwanda. We compared self-reported travel time from home to the hospital (excluding waiting time) with GIS estimated travel times, which were computed using the World Health Organization tool AccessMod, using linear regression. Results The majority of patients used multiple modes of transportation (walking = 48.5%, public transport = 74.2%, private transport = 2.9%, and ambulance 70.6%). Self-reported times were longer than GIS estimates by a factor of 1.49 (95% CI 1.40–1.57). Concordance was higher when the GIS model took into account that all patients in Rwanda are referred via their health center (β = 1.12; 95% CI 1.05–1.18). Conclusions To our knowledge, in this largest to date GIS validation study for geographical access to healthcare in low- and middle-income countries, a standard GIS model was found to significantly underestimate real travel time, which likely is in part because it does not model the actual route patients are travelling. Therefore, previous studies of 2-h access to surgery will need to be interpreted with caution, and future studies should take local travelling conditions into account. Electronic supplementary material The online version of this article (10.1007/s00268-020-05480-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Niclas Rudolfson
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA. .,World Health Organization Collaborating Center for Surgery and Public Health, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
| | - Magdalena Gruendl
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Department of Epidemiology, Technical University Munich, Munich, Germany
| | | | | | - Kristin Sonderman
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA
| | | | | | - Robert Riviello
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA
| | - Bethany Hedt-Gauthier
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
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19
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Nagengast ES, Munabi NCO, Xepoleas M, Auslander A, Magee WP, Chong D. The Local Mission: Improving Access to Surgical Care in Middle-Income Countries. World J Surg 2021; 45:962-969. [PMID: 33388999 PMCID: PMC7921038 DOI: 10.1007/s00268-020-05882-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Billions of people lack access to quality surgical care. Short-term missions are used to supplement the delivery of surgical care in regions with poor access to care. Traditionally known for using international teams, Operation Smile has transitioned to using a local mission model, where surgical service is delivered to areas of need by teams originating within that country. This study investigates the proportion and location of Operation Smile missions that use the local mission model. METHODS A retrospective review was performed of the Operation Smile mission database for fiscal years 2014 to 2019. Missions were classified into local or international missions. Countries were also classified by their income levels as well as their specialist surgical workforce (SAO) density. As no individual patient or provider data was recorded, ethics board approval was not warranted. RESULTS Between 2014 and 2019, Operation Smile held an average of 144.8 (range 135-154) surgical missions per year. Local missions accounted for 97 ± 5.6 (67%) of the missions. Of the 34 program countries, 26 (76%) used local missions. Of the countries that had only international missions, six (75%) were low-income countries and the average SAO density was 1.54 (range 0.19-5.88) providers per 100,000 people. Of the countries with local missions, 24 (92%) were middle-income, and the average SAO density was 30.9 (range 3.4-142.4). CONCLUSION International investments may assist in the creation of local surgical teams. Once teams are established, local missions are a valuable way to provide specialized surgical care within a country's own borders.
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Affiliation(s)
- Eric S Nagengast
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 415, Los Angeles, CA, 90033, USA.
- Division of Plastic and Maxillofacial Surgery, Children's Hospital of Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA.
- Operation Smile Inc., 3641 Faculty Boulevard, Virginia Beach, VA, 23453, USA.
| | - Naikhoba C O Munabi
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 415, Los Angeles, CA, 90033, USA
- Division of Plastic and Maxillofacial Surgery, Children's Hospital of Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
- Operation Smile Inc., 3641 Faculty Boulevard, Virginia Beach, VA, 23453, USA
| | - Meredith Xepoleas
- Division of Plastic and Maxillofacial Surgery, Children's Hospital of Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
- Operation Smile Inc., 3641 Faculty Boulevard, Virginia Beach, VA, 23453, USA
| | - Allyn Auslander
- Division of Plastic and Maxillofacial Surgery, Children's Hospital of Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - William P Magee
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 415, Los Angeles, CA, 90033, USA
- Division of Plastic and Maxillofacial Surgery, Children's Hospital of Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
- Operation Smile Inc., 3641 Faculty Boulevard, Virginia Beach, VA, 23453, USA
- Division of Plastic and Reconstructive Surgery, Shriners Hospital for Children, 909 S Fair Oaks Ave, Pasadena, CA, 91105, USA
| | - David Chong
- Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Flemington Rd, Melbourne, Australia
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Dahir S, Cotache-Condor CF, Concepcion T, Mohamed M, Poenaru D, Adan Ismail E, Leather AJM, Rice HE, Smith ER. Interpreting the Lancet surgical indicators in Somaliland: a cross-sectional study. BMJ Open 2020; 10:e042968. [PMID: 33376180 PMCID: PMC7778782 DOI: 10.1136/bmjopen-2020-042968] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The unmet burden of surgical care is high in low-income and middle-income countries. The Lancet Commission on Global Surgery (LCoGS) proposed six indicators to guide the development of national plans for improving and monitoring access to essential surgical care. This study aimed to characterise the Somaliland surgical health system according to the LCoGS indicators and provide recommendations for next-step interventions. METHODS In this cross-sectional nationwide study, the WHO's Surgical Assessment Tool-Hospital Walkthrough and geographical mapping were used for data collection at 15 surgically capable hospitals. LCoGS indicators for preparedness was defined as access to timely surgery and specialist surgical workforce density (surgeons, anaesthesiologists and obstetricians/SAO), delivery was defined as surgical volume, and impact was defined as protection against impoverishment and catastrophic expenditure. Indicators were compared with the LCoGS goals and were stratified by region. RESULTS The healthcare system in Somaliland does not meet any of the six LCoGS targets for preparedness, delivery or impact. We estimate that only 19% of the population has timely access to essential surgery, less than the LCoGS goal of 80% coverage. The number of specialist SAO providers is 0.8 per 100 000, compared with an LCoGS goal of 20 SAO per 100 000. Surgical volume is 368 procedures per 100 000 people, while the LCoGS goal is 5000 procedures per 100 000. Protection against impoverishing expenditures was only 18% and against catastrophic expenditures 1%, both far below the LCoGS goal of 100% protection. CONCLUSION We found several gaps in the surgical system in Somaliland using the LCoGS indicators and target goals. These metrics provide a broad view of current status and gaps in surgical care, and can be used as benchmarks of progress towards universal health coverage for the provision of safe, affordable, and timely surgical, obstetric and anaesthesia care in Somaliland.
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Affiliation(s)
- Shukri Dahir
- Edna Adan University Hospital, Hargeisa, Somaliland
| | | | - Tessa Concepcion
- Global Health Institute, Duke University, Durham, North Carolina, USA
| | | | - Dan Poenaru
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, McGill University, Montreal, Québec, Canada
| | | | - Andy J M Leather
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - Henry E Rice
- Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Emily R Smith
- Department of Public Health, Baylor University, Waco, Texas, USA
- Global Health Institute, Duke University, Durham, North Carolina, USA
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Knapp GC, Tansley G, Olasehinde O, Wuraola F, Adisa A, Arowolo O, Olawole MO, Romanoff AM, Quan ML, Bouchard-Fortier A, Alatise OI, Kingham TP. Geospatial access predicts cancer stage at presentation and outcomes for patients with breast cancer in southwest Nigeria: A population-based study. Cancer 2020; 127:1432-1438. [PMID: 33370458 DOI: 10.1002/cncr.33394] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/13/2020] [Accepted: 11/17/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The majority of women in Nigeria present with advanced-stage breast cancer. To address the role of geospatial access, we constructed a geographic information-system-based model to evaluate the relationship between modeled travel time, stage at presentation, and overall survival among patients with breast cancer in Nigeria. METHODS Consecutive patients were identified from a single-institution, prospective breast cancer database (May 2009-January 2019). Patients were geographically located, and travel time to the hospital was generated using a cost-distance model that utilized open-source data. The relationships between travel time, stage at presentation, and overall survival were evaluated with logistic regression and survival analyses. Models were adjusted for age, level of education, and socioeconomic status. RESULTS From 635 patients, 609 were successfully geographically located. The median age of the cohort was 49 years (interquartile range [IQR], 40-58 years); 84% presented with ≥stage III disease. Overall, 46.5% underwent surgery; 70.8% received systemic chemotherapy. The median estimated travel time for the cohort was 45 minutes (IQR, 7.9-79.3 minutes). Patients in the highest travel-time quintile had a 2.8-fold increase in the odds of presenting with stage III or IV disease relative to patients in the lowest travel-time quintile (P = .006). Travel time ≥30 minutes was associated with an increased risk of death (HR, 1.65; P = .004). CONCLUSIONS Geospatial access to a tertiary care facility is independently associated with stage at presentation and overall survival among patients with breast cancer in Nigeria. Addressing disparities in access will be essential to ensure the development of an equitable health policy.
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Affiliation(s)
- Gregory C Knapp
- Department of Surgery, Division of General Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Gavin Tansley
- Department of Medicine, Division of Critical Care, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Adewale Adisa
- Department of Surgery, Obafemi Awolowo University, Ile-Ife, Nigeria
| | | | - M O Olawole
- Department of Geography, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Anya M Romanoff
- Breast Surgery, Dubin Breast Center, Icahn School of Medicine at The Mount Sinai Hospital, New York, New York
| | - May Lynn Quan
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | | | | | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Designing, Implementing, and Managing a National Emergency Medical Service in Sierra Leone. Prehosp Disaster Med 2020; 36:115-120. [PMID: 33256859 DOI: 10.1017/s1049023x20001442] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Sierra Leone is one of the least developed low-income countries (LICs), slowly recovering from the effects of a devastating civil war and an Ebola outbreak. The health care system is characterized by chronic shortage of skilled human resources, equipment, and essential medicines. The referral system is weak and vulnerable, with 75% of the country having insufficient access to essential health care. Consequently, Sierra Leone has the highest maternal and child mortality rates in the world. This manuscript describes the implementation of a National Emergency Medical Service (NEMS), a project aiming to create the first prehospital emergency medical system in the country. In 2017, a joint venture of Doctors with Africa (CUAMM), Veneto Region, and Research Center in Emergency and Disaster Medicine (CRIMEDIM) was developed to support the Ministry of Health and Sanitation (MOHS) in designing and managing the NEMS system, one of the very few structured, fully equipped, and free-of-charge prehospital service in the African continent. The NEMS design was the result of an in-depth research phase that included a preliminary assessment, literature review, and consultations with key stakeholders and managers of similar systems in other African countries. From May 27, 2019, after a timeframe of six months in which all the districts have been progressively trained and made operational, the NEMS became operative at national level. By the end of March 2020, the NEMS operation center (OC) and the 81 ambulances dispatched on the ground handled a total number of 36,814 emergency calls, 35,493 missions, and 31,036 referrals.
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Amato SS, Benson JS, Murphy S, Osler TM, Hosmer D, Cook AD, Wolfson DL, Erb A, Malhotra A, An G. Geographic Coverage and Verification of Trauma Centers in a Rural State: Highlighting the Utility of Location Allocationfor Trauma System Planning. J Am Coll Surg 2020; 232:1-7. [PMID: 33022398 DOI: 10.1016/j.jamcollsurg.2020.08.765] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/11/2020] [Accepted: 08/31/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Care at verified trauma centers has improved survival and functional outcomes, yet determining the appropriate location of potential trauma centers is often driven by factors other than optimizing system-level patient care. Given the importance of transport time in trauma, we analyzed trauma transport patterns in a rural state lacking an organized trauma system and implemented a geographic information system to inform potential future trauma center locations. STUDY DESIGN Data were collected on trauma ground transport during a 3-year period (2014 through 2016) from the Statewide Incident Reporting Network database. Geographic information system mapping and location-allocation modeling of the best-fit facility for trauma center verification was computed using trauma transport patterns, population density, road network layout, and 60-minute emergency medical services transport time based on current transport protocols. RESULTS Location-allocation modeling identified 2 regional facilities positioned to become the next verified trauma centers. The proportion of the Vermont population without access to trauma center care within 60 minutes would be reduced from the current 29.68% to 5.81% if the identified facilities become verified centers. CONCLUSIONS Through geospatial mapping and location-allocation modeling, we were able to identify gaps and suggest optimal trauma center locations to maximize population coverage in a rural state lacking a formal, organized trauma system. These findings could inform future decision-making for targeted capacity improvement and system design that emphasizes more equitable access to trauma center care in Vermont.
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Affiliation(s)
| | - Jamie S Benson
- Larner College of Medicine, College of Arts and Sciences, Burlington, VT
| | | | | | - David Hosmer
- Department of Mathematics and Statistics, Burlington, VT
| | - Alan D Cook
- University of Vermont, Burlington, VT; Department of Epidemiology and Biostatistics, University of Texas Health Science Center-Tyler, Tyler, TX
| | | | | | | | - Gary An
- Department of Surgery, Burlington, VT
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James K, Borchem I, Talo R, Aihi S, Baru H, Didilemu F, Moore EM, McLeod E, Watters DA. Universal access to safe, affordable, timely surgical and anaesthetic care in Papua New Guinea: the six global health indicators. ANZ J Surg 2020; 90:1903-1909. [PMID: 33710739 DOI: 10.1111/ans.16148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND The unmet global burden of surgical disease is substantial. The Lancet Commission on Global Surgery (LCoGS) estimated that 5 billion people do not have access to safe, affordable and timely surgical care, with 80% of those without access living in low- and middle-income countries. The Milne Bay Province (pop 331 000) of Papua New Guinea, with an archipelago of islands up to 750 km from its capital, Alotau, has only one hospital capable of performing Caesarean Section, Emergency Laparotomy and managing an open fracture, the three Bellwether procedures. This paper aims to report the six Lancet Commission on Global Surgery metrics for Milne Bay Province. METHODS The study was conducted between January and August 2019. Bellwether access was investigated by a prospective study on 115 patients presenting to hospital. The surgical, anaesthesia and obstetric (SAO) workforce, surgical volume and perioperative mortality rate, were calculated for 2012-2018 from hospital records and operation registers. Financial risk metrics were calculated by surveying 50 patients at discharge from hospital. RESULTS Bellwether access: Only 27.8% (n = 32) of the study population (n = 115) experienced less than 2-hours second delay (journey time to hospital). The average SAO provider density was 1.8 per 100 000 population. There were 606 procedures performed per 100 000 with a mean annual perioperative mortality rate of 0.3%. Catastrophic expenditure is a risk for 29% of the population. CONCLUSION Milne Bay Province can perform surgery safely, but there is limited access to timely surgical care when needed with a significant proportion put at financial risk by requiring it.
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Affiliation(s)
- Kennedy James
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Isaiah Borchem
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Rodney Talo
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Sonia Aihi
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Helai Baru
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Fiona Didilemu
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Eileen M Moore
- Department of Surgery, Deakin University and Barwon Health, Geelong, Victoria, Australia
| | - Elizabeth McLeod
- Paediatric and Neonatal Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia.,Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - David A Watters
- Department of Surgery, Deakin University and Barwon Health, Geelong, Victoria, Australia.,Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
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Anto-Ocrah M, Maxwell N, Cushman J, Acheampong E, Kodam RS, Homan C, Li T. Public knowledge and attitudes towards bystander cardiopulmonary resuscitation (CPR) in Ghana, West Africa. Int J Emerg Med 2020; 13:29. [PMID: 32522144 PMCID: PMC7288511 DOI: 10.1186/s12245-020-00286-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/26/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Early bystander cardiopulmonary resuscitation (CPR) is one of the most important predictors of out-of-hospital cardiac arrests (OHCA) survival. There is a dearth of literature on CPR engagement in countries such as Ghana, where cardiovascular events are increasingly prevalent. In this study, we sought to evaluate Ghanaians' knowledge of and attitudes towards bystander CPR, in the context of the country's nascent emergency medicine network. METHODS Capitalizing on the growing ubiquity and use of social media across the country, we used a novel social media sampling strategy for this study. We created, pre-tested, and distributed an online survey, using the two most utilized social media platforms in Ghana: WhatsApp and Facebook. An airtime data incentive of 5 US dollars, worth between 5 and 10 GB of cellular data based on mobile phone carrier, was provided as incentive. Inclusion criteria were (1) ≥ 18 years of age, (2) living in Ghana. Survey participants were encouraged to distribute the survey within their own networks to expand its reach. We stratified participants' responses by healthcare affiliation, and further grouped healthcare workers into ambulance and non-ambulance personnel. We used chi-square (χ2)/Fisher's Exact tests to compare differences in responses between the groups. Based on the question "have you ever heard of CPR?", an alpha of 0.05 and a 95% confidence interval, we expected to have 80% power to detect a 15% difference in responses between lay and healthcare providers with an estimated sample size of 246 study participants. RESULTS The survey was launched on 8 July 2019 and closed approximately 51 h post-launch. With a 64% completion rate and 479 unique survey completions, the study was overpowered at 96% power, to detect differences in responses between the groups. There was geographic representation across all 10 historic regions of Ghana. Over half (57.8%, n = 277) of the respondents were non-medically affiliated, and 71.9% were women. Healthcare workers were more aware of CPR than lay respondents (96.5% vs 68.1%; p < 0.001). Eighty-five percent of respondents were aware that CPR involves chest compressions, and almost 70% indicated that "mouth to mouth" is a necessary component of CPR. Fewer than 10% were unwilling to administer CPR. Lack of skills (44.9%) and fear of causing harm (25.5%) were barriers noted by respondents for not administering CPR. Notably, a quarter of ambulance workers reported never having received CPR training. If they were to witness a collapse, 62.0% would call an ambulance, and 32.6% would hail a taxi. CONCLUSION The majority of participants are willing to perform CPR. Contextualized training that emphasizes hands-only CPR and builds participants' confidence may increase bystander willingness and engagement.
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Affiliation(s)
- Martina Anto-Ocrah
- Department of Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA. .,Department of Neurology, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA.
| | - Nick Maxwell
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Jeremy Cushman
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Emmanuel Acheampong
- Department of Emergency Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Ruth-Sally Kodam
- Women and Children's Health Advocacy Group-Ghana (https://wachagghana.org/), Accra, Ghana
| | - Christopher Homan
- Department of Computer Sciences, Rochester Institute of Technology, Rochester, NY, USA
| | - Timmy Li
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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Anto-Ocrah M, Cushman J, Sanders M, De Ver Dye T. A woman's worth: an access framework for integrating emergency medicine with maternal health to reduce the burden of maternal mortality in sub-Saharan Africa. BMC Emerg Med 2020; 20:3. [PMID: 31931748 PMCID: PMC6958725 DOI: 10.1186/s12873-020-0300-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 12/31/2019] [Indexed: 12/14/2022] Open
Abstract
Background Within each of the Sustainable Development Goals (SDGs), the World Health Organization (WHO) has identified key emergency care (EC) interventions that, if implemented effectively, could ensure that the SDG targets are met. The proposed EC intervention for reaching the maternal mortality benchmark calls for “timely access to emergency obstetric care.” This intervention, the WHO estimates, can avert up to 98% of maternal deaths across the African region. Access, however, is a complicated notion and is part of a larger framework of care delivery that constitutes the approachability of the proposed service, its acceptability by the target user, the perceived availability and accommodating nature of the service, its affordability, and its overall appropriateness. Without contextualizing each of these aspects of access to healthcare services within communities, utilization and sustainability of any EC intervention-be it ambulances or simple toll-free numbers to dial and activate EMS-will be futile. Main text In this article, we propose an access framework that integrates the Three Delays Model in maternal health, with emergency care interventions. Within each of the three critical time points, we provide reasons why intended interventions should be contextualized to the needs of the community. We also propose measurable benchmarks in each of the phases, to evaluate the successes and failures of the proposed EC interventions within the framework. At the center of the framework is the pregnant woman, whose life hangs in a delicate balance in the hands of personal and health system factors that may or may not be within her control. Conclusions The targeted SDGs for reducing maternal mortality in sub-Saharan Africa are unlikely to be met without a tailored integration of maternal health service delivery with emergency medicine. Our proposed framework integrates the fields of maternal health with emergency medicine by juxtaposing the three critical phases of emergency obstetric care with various aspects of healthcare access. The framework should be adopted in its entirety, with measureable benchmarks set to track the successes and failures of the various EC intervention programs being developed across the African continent.
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Affiliation(s)
- Martina Anto-Ocrah
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA. .,Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, USA.
| | - Jeremy Cushman
- Division of Pre-Hospital Medicine, Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Mechelle Sanders
- Division of Health Services Research and Policy, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Timothy De Ver Dye
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, USA
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Benchmarking Global Trauma Care: Defining the Unmet Need for Trauma Surgery in Ghana. J Surg Res 2019; 247:280-286. [PMID: 31690530 DOI: 10.1016/j.jss.2019.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/01/2019] [Accepted: 10/05/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND The Lancet Commission on Global Surgery recommended 5000 operations/100,000 persons annually, but did not define condition-specific guidelines. New Zealand, Lancet Commission on Global Surgery's benchmark country, documented 1158 trauma operations/100,000 persons, providing a benchmark for trauma surgery needs. We sought to determine Ghana's annual trauma operation rate compared with this benchmark. METHODS Data on all operations performed in Ghana from June 2014 to May 2015 were obtained from representative sample of 48/124 district (first level), 8/11 regional, and 3/5 tertiary hospitals and scaled up for nationwide estimates. Trauma operations were grouped by hospital level and categorized into "essential" (most cost-effective, highest population impact) versus "other" (specialized) as per the World Bank's Disease Control Priorities Project. Ghana's annual trauma operation rate was compared with the New Zealand benchmark to quantify current met needs for trauma surgery. RESULTS About 232,776 operations were performed in Ghana; 35,797 were for trauma. Annual trauma operation rate was 134/100,000 (95% UI: 98-169), only 12% of the New Zealand benchmark. District hospitals performed 62% of all operations in the country, but performed only 38% of trauma operations. Eighty seven percentage of trauma operations were deemed "essential". Among specialized trauma operations, only open reduction and internal fixations had even modest numbers (3483 operations). Most other specialized trauma operations were rare. CONCLUSIONS Ghana has a large unmet need for operative trauma care. The low percentage of trauma operations in district hospitals indicates an even greater unmet need in rural areas. Future global surgery benchmarking should consider benchmarks for trauma and other specialties, as well as for different hospital levels.
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Bagguley D, Fordyce A, Guterres J, Soares A, Valadares E, Guest GD, Watters D. Access delays to essential surgical care using the Three Delays Framework and Bellwether procedures at Timor Leste's national referral hospital. BMJ Open 2019; 9:e029812. [PMID: 31446414 PMCID: PMC6720142 DOI: 10.1136/bmjopen-2019-029812] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Our objectives were to characterise the nature and extent of delay times to essential surgical care in a developing nation by measuring the actual stages of delay for patients receiving Bellwether procedures. SETTING The study was conducted at Timor Leste's national referral hospital in Dili, the country's capital. PARTICIPANTS All patients requiring a Bellwether procedure over a 2-month period were included in the study. Participants whose procedure was undertaken more than 24 hours from initial hospital presentation were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES Data pertaining to the patient journey from onset of symptoms to emergency procedure was collected by interview of patients, their treating surgeons or anaesthetists and the medical records. Timelines were then calculated against the Three Delays Framework. RESULTS Fifty-six patients were entered into the study. Their mean delay from symptom onset to entering the anaesthesia bay for a procedure was 32.3 hours (+/-11.6). The second delay (4.1+/-2.5 hours) was significantly less than the first (20.9+/-11.5 hours; p<0.005) and third delays (7.2+/-1.2 hours; p<0.05). Additionally, patients with acute abdominal pain (of which 18/20 ultimately had open appendicectomy and two emergency laparotomies) had a delay time of 53.3 hours (+/-21.3), significantly more than that for emergency caesarean (22.9+/-18.6 hours; p<0.05) or management of an open long-bone fracture (15.5+/-5.56 hours; p<0.05). CONCLUSIONS Substantial delays were observed for all three stages and each Bellwether procedure. This study methodology could be used to measure access and the three delays to emergency surgical care in low/middle-income countries, although the actual reasons for delay may vary between regions and countries and would require a qualitative study.
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Affiliation(s)
- Dominic Bagguley
- Department of Surgery, Northern Health, Epping, Victoria, Australia
| | - Andrew Fordyce
- Department of Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Jose Guterres
- Department of Surgery, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Alito Soares
- Department of Surgery, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Edgar Valadares
- Department of Surgery, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Glenn Douglas Guest
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - David Watters
- Royal Australasian College of Surgeons, Geelong, Victoria, Australia
- Surgery, Deakin University Faculty of Health, Geelong, Victoria, Australia
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Maina J, Ouma PO, Macharia PM, Alegana VA, Mitto B, Fall IS, Noor AM, Snow RW, Okiro EA. A spatial database of health facilities managed by the public health sector in sub Saharan Africa. Sci Data 2019; 6:134. [PMID: 31346183 PMCID: PMC6658526 DOI: 10.1038/s41597-019-0142-2] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 06/25/2019] [Indexed: 01/08/2023] Open
Abstract
Health facilities form a central component of health systems, providing curative and preventative services and structured to allow referral through a pyramid of increasingly complex service provision. Access to health care is a complex and multidimensional concept, however, in its most narrow sense, it refers to geographic availability. Linking health facilities to populations has been a traditional per capita index of heath care coverage, however, with locations of health facilities and higher resolution population data, Geographic Information Systems allow for a more refined metric of health access, define geographic inequalities in service provision and inform planning. Maximizing the value of spatial heath access requires a complete census of providers and their locations. To-date there has not been a single, geo-referenced and comprehensive public health facility database for sub-Saharan Africa. We have assembled national master health facility lists from a variety of government and non-government sources from 50 countries and islands in sub Saharan Africa and used multiple geocoding methods to provide a comprehensive spatial inventory of 98,745 public health facilities.
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Affiliation(s)
- Joseph Maina
- Population Health Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Paul O Ouma
- Population Health Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Peter M Macharia
- Population Health Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Victor A Alegana
- Population Health Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
- Geography and Environmental Science, University of Southampton, Southampton, UK
- Faculty of Science and Technology, Lancaster University, LA1 4YR, UK
| | - Benard Mitto
- Population Health Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Ibrahima Socé Fall
- World Health Organization, Regional Office for Africa, Brazzaville, Congo
| | - Abdisalan M Noor
- Global Malaria Programme, World Health Organization, Geneva, Switzerland
| | - Robert W Snow
- Population Health Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Emelda A Okiro
- Population Health Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.
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Increased Rwandan Access to Obstetrician–Gynecologists Through a U.S.–Rwanda Academic Training Partnership. Obstet Gynecol 2019; 134:149-156. [DOI: 10.1097/aog.0000000000003317] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tefera A, Lutge E, Sartorius B, Clarke D. The Operative Output of District Hospitals in KwaZulu-Natal Province is Heavily Skewed Toward Obstetrical Care. World J Surg 2019; 43:1653-1660. [DOI: 10.1007/s00268-019-04985-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Stewart BT, Gyedu A, Gaskill C, Boakye G, Quansah R, Donkor P, Volmink J, Mock C. Exploring the Relationship Between Surgical Capacity and Output in Ghana: Current Capacity Assessments May Not Tell the Whole Story. World J Surg 2018; 42:3065-3074. [PMID: 29536141 PMCID: PMC6543845 DOI: 10.1007/s00268-018-4589-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Capacity assessments serve as surrogates for surgical output in low- and middle-income countries where detailed registers do not exist. The relationship between surgical capacity and output was evaluated in Ghana to determine whether a more critical interpretation of capacity assessment data is needed on which to base health systems strengthening initiatives. METHODS A standardized surgical capacity assessment was performed at 37 hospitals nationwide using WHO guidelines; availability of 25 essential resources and capabilities was used to create a composite capacity score that ranged from 0 (no availability of essential resources) to 75 (constant availability) for each hospital. Data regarding the number of essential operations performed over 1 year, surgical specialties available, hospital beds, and functional operating rooms were also collected. The relationship between capacity and output was explored. RESULTS The median surgical capacity score was 37 [interquartile range (IQR) 29-48; range 20-56]. The median number of essential operations per year was 1480 (IQR 736-1932) at first-level hospitals; 1545 operations (IQR 984-2452) at referral hospitals; and 11,757 operations (IQR 3769-21,256) at tertiary hospitals. Surgical capacity and output were not correlated (p > 0.05). CONCLUSIONS Contrary to current understanding, surgical capacity assessments may not accurately reflect surgical output. To improve the validity of surgical capacity assessments and facilitate maximal use of available resources, other factors that influence output should also be considered, including demand-side factors; supply-side factors and process elements; and health administration and management factors.
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Affiliation(s)
- Barclay T Stewart
- Department of Surgery, University of Washington, 1959 NE Pacific St., Suite BB-487, P.O. Box 356410, Seattle, WA, 98195-6410, USA.
- School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
- Department of Interdisciplinary Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Adam Gyedu
- Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Cameron Gaskill
- Department of Surgery, University of Washington, 1959 NE Pacific St., Suite BB-487, P.O. Box 356410, Seattle, WA, 98195-6410, USA
- School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Godfred Boakye
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Robert Quansah
- Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Peter Donkor
- Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Jimmy Volmink
- Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa
- Cochrane Centre, South African Medical Research Council, Parrow, South Africa
| | - Charles Mock
- Department of Surgery, University of Washington, 1959 NE Pacific St., Suite BB-487, P.O. Box 356410, Seattle, WA, 98195-6410, USA
- Harborview Injury Prevention and Research Center, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
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Juran S, Broer PN, Klug SJ, Snow RC, Okiro EA, Ouma PO, Snow RW, Tatem AJ, Meara JG, Alegana VA. Geospatial mapping of access to timely essential surgery in sub-Saharan Africa. BMJ Glob Health 2018; 3:e000875. [PMID: 30147944 PMCID: PMC6104751 DOI: 10.1136/bmjgh-2018-000875] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/04/2018] [Accepted: 07/06/2018] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Despite an estimated one-third of the global burden of disease being surgical, only limited estimates of accessibility to surgical treatment in sub-Saharan Africa exist and these remain spatially undefined. Geographical metrics of access to major hospitals were estimated based on travel time. Estimates were then used to assess need for surgery at country level. METHODS Major district and regional hospitals were assumed to have capability to perform bellwether procedures. Geographical locations of hospitals in relation to the population in the 47 sub-Saharan countries were combined with spatial ancillary data on roads, elevation, land use or land cover to estimate travel-time metrics of 30 min, 1 hour and 2 hours. Hospital catchment was defined as population residing in areas less than 2 hours of travel time to the next major hospital. Travel-time metrics were combined with fine-scale population maps to define burden of surgery at hospital catchment level. RESULTS Overall, the majority of the population (92.5%) in sub-Saharan Africa reside in areas within 2 hours of a major hospital catchment defined based on spatially defined travel times. The burden of surgery in all-age population was 257.8 million to 294.7 million people and was highest in high-population density countries and lowest in sparsely populated or smaller countries. The estimated burden in children <15 years was 115.3 million to 131.8 million and had similar spatial distribution to the all-age pattern. CONCLUSION The study provides an assessment of accessibility and burden of surgical disease in sub-Saharan Africa. Yet given the optimistic assumption of adequare surgical capability of major hospitals, the true burden of surgical disease is expected to be much greater. In-depth health facility assessments are needed to define infrastructure, personnel and medicine supply for delivering timely and safe affordable surgery to further inform the analysis.
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Affiliation(s)
- Sabrina Juran
- United Nations Population Fund, Technical Division, Population and Development Branch, New York City, New York, USA
- Lehrstuhl für Epidemiologie, Technische Universität München, München, Germany
| | - P Niclas Broer
- Klinikum Bogenhausen, Städtisches Klinikum München, Technische Universität München, München, Germany
| | - Stefanie J Klug
- Lehrstuhl für Epidemiologie, Technische Universität München, München, Germany
| | - Rachel C Snow
- United Nations Population Fund, Technical Division, Population and Development Branch, New York City, New York, USA
| | - Emelda A Okiro
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Paul O Ouma
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Robert W Snow
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Andrew J Tatem
- WorldPop, Geography and Environment, University of Southampton, Southampton, UK
- Flowminder Foundation, Stockholm, Sweden
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Victor A Alegana
- WorldPop, Geography and Environment, University of Southampton, Southampton, UK
- Flowminder Foundation, Stockholm, Sweden
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Watters DA, Guest GD, Tangi V, Shrime MG, Meara JG. Global Surgery System Strengthening. Anesth Analg 2018; 126:1329-1339. [DOI: 10.1213/ane.0000000000002771] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ouma PO, Maina J, Thuranira PN, Macharia PM, Alegana VA, English M, Okiro EA, Snow RW. Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded inventory and spatial analysis. Lancet Glob Health 2018; 6:e342-e350. [PMID: 29396220 PMCID: PMC5809715 DOI: 10.1016/s2214-109x(17)30488-6] [Citation(s) in RCA: 213] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 10/18/2017] [Accepted: 12/04/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Timely access to emergency care can substantially reduce mortality. International benchmarks for access to emergency hospital care have been established to guide ambitions for universal health care by 2030. However, no Pan-African database of where hospitals are located exists; therefore, we aimed to complete a geocoded inventory of hospital services in Africa in relation to how populations might access these services in 2015, with focus on women of child bearing age. METHODS We assembled a geocoded inventory of public hospitals across 48 countries and islands of sub-Saharan Africa, including Zanzibar, using data from various sources. We only included public hospitals with emergency services that were managed by governments at national or local levels and faith-based or non-governmental organisations. For hospital listings without geographical coordinates, we geocoded each facility using Microsoft Encarta (version 2009), Google Earth (version 7.3), Geonames, Fallingrain, OpenStreetMap, and other national digital gazetteers. We obtained estimates for total population and women of child bearing age (15-49 years) at a 1 km2 spatial resolution from the WorldPop database for 2015. Additionally, we assembled road network data from Google Map Maker Project and OpenStreetMap using ArcMap (version 10.5). We then combined the road network and the population locations to form a travel impedance surface. Subsequently, we formulated a cost distance algorithm based on the location of public hospitals and the travel impedance surface in AccessMod (version 5) to compute the proportion of populations living within a combined walking and motorised travel time of 2 h to emergency hospital services. FINDINGS We consulted 100 databases from 48 sub-Saharan countries and islands, including Zanzibar, and identified 4908 public hospitals. 2701 hospitals had either full or partial information about their geographical coordinates. We estimated that 287 282 013 (29·0%) people and 64 495 526 (28·2%) women of child bearing age are located more than 2-h travel time from the nearest hospital. Marked differences were observed within and between countries, ranging from less than 25% of the population within 2-h travel time of a public hospital in South Sudan to more than 90% in Nigeria, Kenya, Cape Verde, Swaziland, South Africa, Burundi, Comoros, São Tomé and Príncipe, and Zanzibar. Only 16 countries reached the international benchmark of more than 80% of their populations living within a 2-h travel time of the nearest hospital. INTERPRETATION Physical access to emergency hospital care provided by the public sector in Africa remains poor and varies substantially within and between countries. Innovative targeting of emergency care services is necessary to reduce these inequities. This study provides the first spatial census of public hospital services in Africa. FUNDING Wellcome Trust and the UK Department for International Development.
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Affiliation(s)
- Paul O Ouma
- Population Health Unit, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya.
| | - Joseph Maina
- Population Health Unit, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Pamela N Thuranira
- Population Health Unit, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Peter M Macharia
- Population Health Unit, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Victor A Alegana
- Department of Geography and Environment, University of Southampton, Southampton, UK
| | - Mike English
- Health Services Unit, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Emelda A Okiro
- Population Health Unit, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Robert W Snow
- Population Health Unit, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Ruhumuriza J, Odhiambo J, Riviello R, Lin Y, Nkurunziza T, Shrime M, Maine R, Omondi JM, Mpirimbanyi C, de la Paix Sebakarane J, Hagugimana P, Rusangwa C, Hedt-Gauthier B. Assessing the cost of laparotomy at a rural district hospital in Rwanda using time-driven activity-based costing. BJS Open 2018; 2:25-33. [PMID: 29951626 PMCID: PMC5952380 DOI: 10.1002/bjs5.35] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/09/2017] [Indexed: 01/09/2023] Open
Abstract
Background In low‐ and middle‐income countries, the majority of patients lack access to surgical care due to limited personnel and infrastructure. The Lancet Commission on Global Surgery recommended laparotomy for district hospitals. However, little is known about the cost of laparotomy and associated clinical care in these settings. Methods This costing study included patients with acute abdominal conditions at three rural district hospitals in 2015 in Rwanda, and used a time‐driven activity‐based costing methodology. Capacity cost rates were calculated for personnel, location and hospital indirect costs, and multiplied by time estimates to obtain allocated costs. Costs of medications and supplies were based on purchase prices. Results Of 51 patients with an acute abdominal condition, 19 (37 per cent) had a laparotomy; full costing data were available for 17 of these patients, who were included in the costing analysis. The total cost of an entire care cycle for laparotomy was US$1023·40, which included intraoperative costs of US$427·15 (41·7 per cent) and preoperative and postoperative costs of US$596·25 (58·3 per cent). The cost of medicines was US$358·78 (35·1 per cent), supplies US$342·15 (33·4 per cent), personnel US$150·39 (14·7 per cent), location US$89·20 (8·7 per cent) and hospital indirect cost US$82·88 (8·1 per cent). Conclusion The intraoperative cost of laparotomy was similar to previous estimates, but any plan to scale‐up laparotomy capacity at district hospitals should consider the sizeable preoperative and postoperative costs. Although lack of personnel and limited infrastructure are commonly cited surgical barriers at district hospitals, personnel and location costs were among the lowest cost contributors; similar location‐related expenses at tertiary hospitals might be higher than at district hospitals, providing further support for decentralization of these services.
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Affiliation(s)
- J Ruhumuriza
- Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda
| | - J Odhiambo
- Partners In Health, Harvard Medical School Boston Massachusetts USA
| | - R Riviello
- College of Medicine and Health Sciences University of Rwanda Kigali Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School Boston Massachusetts USA.,Program in Global Surgery and Social Change, Harvard Medical School Boston Massachusetts USA.,Center for Surgery and Public Health, Brigham and Women's Hospital Boston Massachusetts USA
| | - Y Lin
- Department of Global Health and Social Medicine, Harvard Medical School Boston Massachusetts USA.,Department of Surgery University of Colorado Denver Colorado USA
| | - T Nkurunziza
- Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda
| | - M Shrime
- Department of Global Health and Social Medicine, Harvard Medical School Boston Massachusetts USA.,Office of Surgery and Health, Massachusetts Eye and Ear Infirmary Boston Massachusetts USA
| | - R Maine
- Department of Surgery University of Washington Seattle Washington USA
| | - J M Omondi
- Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda.,Ministry of Health, Butaro District Hospital Burera Rwanda
| | - C Mpirimbanyi
- College of Medicine and Health Sciences University of Rwanda Kigali Rwanda
| | | | - P Hagugimana
- Ministry of Health, Butaro District Hospital Burera Rwanda
| | - C Rusangwa
- Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda
| | - B Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School Boston Massachusetts USA
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Shaw BI, Wangara AA, Wambua GM, Kiruja J, Dicker RA, Mweu JM, Juillard C. Geospatial relationship of road traffic crashes and healthcare facilities with trauma surgical capabilities in Nairobi, Kenya: defining gaps in coverage. Trauma Surg Acute Care Open 2017; 2:e000130. [PMID: 29766119 PMCID: PMC5887833 DOI: 10.1136/tsaco-2017-000130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/04/2017] [Accepted: 11/07/2017] [Indexed: 12/13/2022] Open
Abstract
Background Road traffic injuries (RTIs) are a cause of significant morbidity and mortality in low- and middle-income countries. Access to timely emergency services is needed to decrease the morbidity and mortality of RTIs and other traumatic injuries. Our objective was to describe the distribution of roadtrafficcrashes (RTCs) in Nairobi with the relative distance and travel times for victims of RTCs to health facilities with trauma surgical capabilities. Methods RTCs in Nairobi County were recorded by the Ma3route app from May 2015 to October 2015 with latitude and longitude coordinates for each RTC extracted using geocoding. Health facility administrators were interviewed to determine surgical capacity of their facilities. RTCs and health facilities were plotted on maps using ArcGIS. Distances and travel times between RTCs and health facilities were determined using the Google Maps Distance Matrix API. Results 89 percent (25/28) of health facilities meeting inclusion criteria were evaluated. Overall, health facilities were well equipped for trauma surgery with 96% meeting WHO Minimal Safety Criteria. 76 percent of facilities performed greater than 12 of three pre-selected ‘Bellweather Procedures’ shown to correlate with surgical capability. The average travel time and distance from RTCs to the nearest health facilities surveyed were 7 min and 3.4 km, respectively. This increased to 18 min and 9.6 km if all RTC victims were transported to Kenyatta National Hospital (KNH). Conclusion Almost all hospitals surveyed in the present study have the ability to care for trauma patients. Treating patients directly at these facilities would decrease travel time compared with transfer to KNH. Nairobi County could benefit from formally coordinating the triage of trauma patients to more facilities to decrease travel time and potentially improve patient outcomes. Level of evidence III
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Affiliation(s)
- Brian I Shaw
- School of Medicine, University of California, San Francisco, California, USA
| | - Ali Akida Wangara
- Accident and Emergency Department, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Jason Kiruja
- Department of Pediatrics, Kenyatta National Hospital, Nairobi, Kenya
| | - Rochelle A Dicker
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, California, USA
| | | | - Catherine Juillard
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, California, USA
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Orkin AM, Bharmal A, Cram J, Kouyoumdjian FG, Pinto AD, Upshur R. Clinical Population Medicine: Integrating Clinical Medicine and Population Health in Practice. Ann Fam Med 2017; 15:405-409. [PMID: 28893808 PMCID: PMC5593721 DOI: 10.1370/afm.2143] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 01/26/2017] [Indexed: 12/22/2022] Open
Affiliation(s)
- Aaron M Orkin
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
- Department of Family Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Aamir Bharmal
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
- Fraser Health Authority, Surrey, British Columbia
| | - Jenni Cram
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
| | - Fiona G Kouyoumdjian
- Department of Family Medicine, McMaster University, Hamilton, Ontario
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario
| | - Andrew D Pinto
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
- Department of Family Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario
| | - Ross Upshur
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario
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Global surgery: current evidence for improving surgical care. Curr Opin Otolaryngol Head Neck Surg 2017; 25:300-306. [DOI: 10.1097/moo.0000000000000374] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Tansley G, Stewart BT, Gyedu A, Boakye G, Lewis D, Hoogerboord M, Mock C. The Correlation Between Poverty and Access to Essential Surgical Care in Ghana: A Geospatial Analysis. World J Surg 2017; 41:639-643. [PMID: 27766400 PMCID: PMC5558014 DOI: 10.1007/s00268-016-3765-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Surgical disease burden falls disproportionately on individuals in low- and middle-income countries. These populations are also the least likely to have access to surgical care. Understanding the barriers to access in these populations is therefore necessary to meet the global surgical need. METHODS Using geospatial methods, this study explores the district-level variation of two access barriers in Ghana: poverty and spatial access to care. National survey data were used to estimate the average total household expenditure (THE) in each district. Estimates of the spatial access to essential surgical care were generated from a cost-distance model based on a recent surgical capacity assessment. Correlations were analyzed using regression and displayed cartographically. RESULTS Both THE and spatial access to surgical care were found to have statistically significant regional variation in Ghana (p < 0.001). An inverse relationship was identified between THE and spatial access to essential surgical care (β -5.15 USD, p < 0.001). Poverty and poor spatial access to surgical care were found to co-localize in the northwest of the country. CONCLUSIONS Multiple barriers to accessing surgical care can coexist within populations. A careful understanding of all access barriers is necessary to identify and target strategies to address unmet surgical need within a given population.
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Affiliation(s)
- Gavin Tansley
- Department of Surgery, Dalhousie University, Room 8-821, 1276 South Park St, Halifax, NS, B3H2Y9, Canada.
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Department of Interdisciplinary Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Adam Gyedu
- Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Godfred Boakye
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Daniel Lewis
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Marius Hoogerboord
- Department of Surgery, Dalhousie University, Room 8-821, 1276 South Park St, Halifax, NS, B3H2Y9, Canada
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention & Research Centre, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
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