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Shakir M, Shariq SF, Irshad HA, Khowaja AH, Tahir I, Rae AI, Hamzah R, Gupta S, Park KB, Enam SA. Governance Challenges to the Neurosurgical Care of Brain Tumors in Low- and Middle-Income Countries: A Systematic Review. World Neurosurg 2024:S1878-8750(24)01258-0. [PMID: 39038646 DOI: 10.1016/j.wneu.2024.07.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 07/13/2024] [Accepted: 07/15/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Low- and middle-income countries (LMICs) often struggle to provide adequate neurosurgical care due to poor governance and institutional efforts, making access to care difficult. Therefore, our review of literature aims to identify gaps in government, national, and institutional efforts to combat barriers to neurosurgical care of brain tumors in LMICs, to inform future policy and action planning. METHODS A comprehensive literature search was conducted using PubMed, Scopus, Google Scholar, and CINAHL without language restrictions from inception to October 20, 2022. After screening and data extraction, a thematic analysis based on the National Surgical, Obstetric, and Anesthesia Plan (NSOAP) systematically identified and classified notable themes, which were then quantified and presented as percentages. RESULTS A total of 12 studies were included in the final analysis. The review highlighted some of the barriers to providing surgical care of brain tumors in LMICs, including political instability (14%), inadequate national budget for health care (43%), poor government support (14%), lack of support of hospital management (14%), and no coverage under national insurance plans (14%). Strategies that can be implemented to address the barriers include strengthening the local health system (17%), advocating for health ministry support (33%), developing national treatment guidelines (17%), making neurosurgery a part of the national surgical plan (17%), fostering collaborations across various levels of government (17%), changing national insurance policy to include neurosurgical care (17%), and advocating for more resources and changes in global care (33%). CONCLUSIONS Effective governance plays a critical role in addressing challenges as it shapes the availability of resources and policies that affect the quality of care provided. Our study outlines key challenges and strategies reported within literature in an attempt to drive government attention and thereby policy to support the neurosurgical care of brain tumors, particularly in the developing world.
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Affiliation(s)
- Muhammad Shakir
- Section of Neurosurgery, Department Aga Khan University Hospital, Karachi, Pakistan; Centre of Oncological Research in Surgery (COORS), Juma Research Laboratories, Aga Khan University, Karachi, Pakistan
| | | | | | | | - Izza Tahir
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Ali I Rae
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Radzi Hamzah
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Saksham Gupta
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Kee B Park
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Syed Ather Enam
- Centre of Oncological Research in Surgery (COORS), Juma Research Laboratories, Aga Khan University, Karachi, Pakistan.
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Shakir M, Irshad HA, Khowaja AH, Tahir I, Shariq SF, Rae AI, Hamzah R, Gupta S, Park KB, Enam SA. Information Management for the Neurosurgical Care of Brain Tumors: A Scoping Review of Literature from Low- and Middle-Income Countries. World Neurosurg 2024; 190:208-217. [PMID: 39032639 DOI: 10.1016/j.wneu.2024.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 07/03/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Health care in developing countries often lacks adequate bookkeeping and national cancer registries, means of information that have proven to impact disease research and care. The true burden of brain tumors therefore remains unchecked and so does the extent of the problem. Therefore, this study aims to explore the challenges and potential strategies related to information management of brain tumors in low- and middle-income countries (LMICs). METHODS A comprehensive literature search conducted using databases such as PubMed, Scopus, Google Scholar, and Cumulated Index in Nursing and Allied Health Literature, without any language restrictions, from inception to October 20, 2022. Following screening and extraction of data, themes were generated using the information management domain of the National Surgical, Obstetric, and Anesthesia Plan framework. RESULTS The final analysis includes 23 studies that highlighted the challenges to managing information to the surgical care given to brain tumors in LMICs, including lack of proper hospital record system (43%), lack of national brain tumor registry (67%), lack of local management guidelines (10%), and low research output (33%). Some of the proposed strategies in the literature to address these barriers include improving data management systems (45%), developing a population-based brain tumor registry (64%), and formulating local treatment guidelines (9%) for the management of brain tumors. CONCLUSIONS In LMICs, improving patient outcomes and quality of life postneurosurgical intervention for brain tumors requires coordinated efforts to enhance information systems. The support of the government and public health professionals is vital in implementing strategies to achieve this goal.
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Affiliation(s)
- Muhammad Shakir
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | | | | | - Izza Tahir
- Medical College, Aga Khan University, Karachi, Pakistan
| | | | - Ali I Rae
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Radzi Hamzah
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Saksham Gupta
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Kee B Park
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Syed Ather Enam
- Center of Oncological Research in Surgery, Aga Khan University, Karachi, Pakistan.
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Nepogodiev D, Ismail L, Meara JG, Roslani AC, Harrison EM, Bhangu A. Strengthening health systems through surgery. Lancet 2024; 403:2358-2360. [PMID: 38782001 DOI: 10.1016/s0140-6736(24)01031-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Dmitri Nepogodiev
- NIHR Global Health Research Unit on Global Surgery, Institute of Applied Health Research, Institute of Translational Medicine, University of Birmingham, Birmingham B15 2TH, UK.
| | - Lawani Ismail
- Department of Visceral Surgery, University of Abomey-Calavi Faculty of Health Sciences, Cotonou, Benin
| | - John G Meara
- Program in Global Surgery and Social Change and Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - April C Roslani
- Department of Surgery, University Malaya Medical Centre and Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Ewen M Harrison
- Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
| | - Aneel Bhangu
- NIHR Global Health Research Unit on Global Surgery, Institute of Applied Health Research, Institute of Translational Medicine, University of Birmingham, Birmingham B15 2TH, UK
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Baird MD, Madha ES, Arnaouti M, Cahill GL, Hewa Kodikarage SN, Harris RE, Murphy TP, Bartel MC, Rich EL, Pathirana YG, Kim E, Bain PA, Alswaiti GT, Ratnayake AS, Worlton TJ, Joseph MN. Global assessment of military and civilian trauma systems integration: a scoping review. Int J Surg 2024; 110:3617-3632. [PMID: 38935828 PMCID: PMC11175771 DOI: 10.1097/js9.0000000000001265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 02/21/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND The global burden of trauma disproportionately affects low-income countries and middle-income countries (LMIC), with variability in trauma systems between countries. Military and civilian healthcare systems have a shared interest in building trauma capacity for use during peace and war. However, in LMICs it is largely unknown if and how these entities work together. Understanding the successful integration of these systems can inform partnerships that can strengthen trauma care. This scoping review aims to identify examples of military-civilian trauma systems integration and describe the methods, domains, and indicators associated with integration including barriers and facilitators. METHODS A scoping review of all appropriate databases was performed to identify papers with evidence of military and civilian trauma systems integration. After manuscripts were selected for inclusion, relevant data was extracted and coded into methods of integration, domains of integration, and collected information regarding indicators of integration, which were further categorized into facilitators or barriers. RESULTS Seventy-four studies were included with authors from 18 countries describing experiences in 23 countries. There was a predominance of authorship and experiences from High-Income Countries (91.9 and 75.7%, respectively). Five key domains of integration were identified; Academic Integration was the most common (45.9%). Among indicators, the most common facilitator was administrative support and the lack of this was the most common barrier. The most common method of integration was Collaboration (50%). CONCLUSION Current evidence demonstrates the existence of military and civilian trauma systems integration in several countries. High-income country data dominates the literature, and thus a more robust understanding of trauma systems integration, inclusive of all geographic locations and income statuses, is necessary prior to development of a framework to guide integration. Nonetheless, the facilitators identified in this study describe the factors and environment in which integration is feasible and highlight optimal indicators of entry.
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Affiliation(s)
- Michael D. Baird
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center
| | - Emad S. Madha
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of General Surgery, Walter Reed National Military Medical Center
| | - Matthew Arnaouti
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Royal National Orthopaedic Hospital, Stanmore, Middlesex
| | - Gabrielle L. Cahill
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Sadeesh N. Hewa Kodikarage
- Department of Surgery, Army Hospital Colombo
- Postgraduate Institute of Medicine, University of Colombo, Colombo Sri Lanka
| | | | - Timothy P. Murphy
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center
| | - Megan C. Bartel
- Department of General Surgery, Walter Reed National Military Medical Center
| | - Elizabeth L. Rich
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center
| | - Yasar G. Pathirana
- Department of Surgery, Army Hospital Colombo
- Postgraduate Institute of Medicine, University of Colombo, Colombo Sri Lanka
| | - Eungjae Kim
- School of Medicine, Uniformed Services University
| | - Paul A. Bain
- Countway Library, Harvard Medical School, Boston
| | | | | | - Tamara J. Worlton
- Department of General Surgery, Walter Reed National Military Medical Center
- Department of Surgery, Uniformed Services University, Bethesda
| | - Michelle N. Joseph
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of Surgery, Uniformed Services University, Bethesda
- Clinical Trials Unit, University of Warwick, Warwickshire, UK
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Asemu YM, Yigzaw T, Desta FA, Scheele F, van den Akker T. Does higher performance in a national licensing examination predict better quality of care? A longitudinal observational study of Ethiopian anesthetists. BMC Anesthesiol 2024; 24:188. [PMID: 38802780 PMCID: PMC11129401 DOI: 10.1186/s12871-024-02575-w] [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: 09/12/2023] [Accepted: 05/23/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Ethiopia made a national licensing examination (NLE) for associate clinician anesthetists a requirement for entry into the practice workforce. However, there is limited empirical evidence on whether the NLE scores of associate clinicians predict the quality of health care they provide in low-income countries. This study aimed to assess the association between anesthetists' NLE scores and three selected quality of patient care indicators. METHODS A multicenter longitudinal observational study was conducted between January 8 and February 7, 2023, to collect quality of care (QoC) data on surgical patients attended by anesthetists (n = 56) who had taken the Ethiopian anesthetist NLE since 2019. The three QoC indicators were standards for safe anesthesia practice, critical incidents, and patient satisfaction. The medical records of 991 patients were reviewed to determine the standards for safe anesthesia practice and critical incidents. A total of 400 patients responded to the patient satisfaction survey. Multivariable regressions were employed to determine whether the anesthetist NLE score predicted QoC indicators. RESULTS The mean percentage of safe anesthesia practice standards met was 69.14%, and the mean satisfaction score was 85.22%. There were 1,120 critical incidents among 911 patients, with three out of five experiencing at least one. After controlling for patient, anesthetist, facility, and clinical care-related confounding variables, the NLE score predicted the occurrence of critical incidents. For every 1% point increase in the total NLE score, the odds of developing one or more critical incidents decreased by 18% (aOR = 0.82; 95% CI = 0.70 = 0.96; p = 0.016). No statistically significant associations existed between the other two QoC indicators and NLE scores. CONCLUSION The NLE score had an inverse relationship with the occurrence of critical incidents, supporting the validity of the examination in assessing graduates' ability to provide safe and effective care. The lack of an association with the other two QoC indicators requires further investigation. Our findings may help improve education quality and the impact of NLEs in Ethiopia and beyond.
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Affiliation(s)
- Yohannes Molla Asemu
- Health Workforce Improvement Program, Jhpiego, an affiliate of Johns Hopkins University, Ethiopia country office, Addis Ababa, Ethiopia.
- Athena Institute, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Tegbar Yigzaw
- Health Workforce Improvement Program, Jhpiego, an affiliate of Johns Hopkins University, Ethiopia country office, Addis Ababa, Ethiopia
| | - Firew Ayalew Desta
- Health Workforce Improvement Program, Jhpiego, an affiliate of Johns Hopkins University, Ethiopia country office, Addis Ababa, Ethiopia
| | - Fedde Scheele
- Athena Institute, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Obstetrics and Gynecology, OLVG Teaching Hospital, Amsterdam, the Netherlands
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center (AUMC), Amsterdam, the Netherlands
| | - Thomas van den Akker
- Athena Institute, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, the Netherlands
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Henry JA, Madiraju SK, Mwai P, Hung YC, Chaker SC, Slater ED, Waiguru E, Jani P, Nthumba P. Scaling up Surgical Capacity in Kenya: The Kenya Hospital Assessment Tool (K-HAT). J Surg Res 2024; 295:800-810. [PMID: 38159336 DOI: 10.1016/j.jss.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/27/2023] [Accepted: 12/02/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Although substantial progress has been achieved to bring surgical care to the forefront of global health discussions, a number of low-and middle-income countries are still in the process of developing a National Surgical, Obstetric, and Anesthesia Plan (NSOAP). This paper describes the initial step toward the development of the NSOAP through the creation of the Kenya National Hospital Assessment Tool (K-HAT). METHODS A study protocol was developed by a multisectoral collaborative group that represented the pillars of surgical capacity development in Kenya. The K-HAT was adapted from two World Health Organization (WHO) tools: the Service Availability and Readiness Assessment tool and the Situational Analysis Tool. The survey tool was deployed on Open Data Kit, an open-source electronic encrypted database. This new locally adapted tool was pilot tested in three hospitals in Kenya and subsequently deployed in Level 4 facilities. RESULTS Eighty-nine questions representing over 800 data points divided into six WHO Health Systems Strengthening sections comprised the K-HAT which was deployed to over 95% of Level 4 hospitals in Kenya. When compared to the WHO Service Availability and Readiness Assessment tool, the K-HAT collected more detailed information. The pilot test team reported that K-HAT was easy to administer, easily understood by the respondents, and that it took approximately 1 hour to collect data from each facility. CONCLUSIONS The K-HAT collected comprehensive information that can be used to develop Kenya's NSOAP.
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Affiliation(s)
- Jaymie Ang Henry
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas; International Collaboration for Essential Surgery, New York, New York
| | | | - Patrick Mwai
- International Collaboration for Essential Surgery, New York, New York; Department of Urology, University of Toledo Medical Center, Toledo, Ohio
| | - Ya-Ching Hung
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Sara C Chaker
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth D Slater
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Pankaj Jani
- College of Surgeons of East, Central, and Southern Africa, Arusha, Tanzania
| | - Peter Nthumba
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; College of Surgeons of East, Central, and Southern Africa, Arusha, Tanzania
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Qin RX, Zhang G, Lim MX, Waqainabete I, Tudravu J, Turagava J, Patel R, Ulufonua L, Herman J, Teapa D, May YY, Tarere-Lehi M, Leodoro B, Mekoll N, McLeod E, Park KB, Kafoa B, Maoate K, Tangi V. Assessment of essential surgical and anaesthesia care capacity: a cross-sectional study in five Pacific Island Countries. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 39:100830. [PMID: 37484709 PMCID: PMC10362349 DOI: 10.1016/j.lanwpc.2023.100830] [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] [Received: 02/05/2023] [Revised: 05/11/2023] [Accepted: 06/14/2023] [Indexed: 07/25/2023]
Abstract
Background Pacific Island Countries (PICs) face unique challenges in providing surgical care. We assessed the surgical care capacity of five PICs to inform the development of National Surgical, Obstetric and Anaesthesia Plans (NSOAP). Methods We conducted a cross-sectional survey of 26 facilities in Fiji, Tonga, Vanuatu, Cook Islands, and Palau using the World Health Organization - Program in Global Surgery and Social Change Surgical Assessment Tool. Findings Eight referral and 18 first-level hospitals containing 39 functioning operating theatres, 41 post-anaesthesia care beds, and 44 intensive care unit beds served a population of 1,321,000 across the five countries. Most facilities had uninterrupted access to electricity, water, internet, and oxygen. However, CT was only available in 2/8 referral hospitals, MRI in 1/8, and timely blood transfusions in 4/8. The surgical, obstetric, and anaesthetist specialist density per 100,000 people was the highest in Palau (49.7), followed by Cook Islands (22.9), Tonga (9.9), Fiji (7.1), and Vanuatu (5.0). There were four radiologists and 3.5 pathologists across the five countries. Surgical volume per 100,000 people was the lowest in Vanuatu (860), followed by Fiji (2,247), Tonga (2,864), Cook Islands (6,747), and Palau (8,606). The in-hospital peri-operative mortality rate (POMR) was prospectively monitored in Tonga and Cook Islands but retrospectively measured in other countries. POMR was below 1% in all five countries. Interpretation Whilst PICs share common challenges in providing specialised tertiary services, there is substantial diversity between the countries. Strategies to strengthen surgical systems should incorporate both local contextualisation within each PIC and regional collaboration between PICs. Funding None.
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Affiliation(s)
- Rennie X. Qin
- The Program in Global Surgery and Social Change, the Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
- Department of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, The University of Auckland, 22-30 Park Avenue, Auckland 1023, New Zealand
| | - Grace Zhang
- Notre Dame's Kellogg Institute for International Studies: Jenkins Hall, 1130, Notre Dame, IN 46556, USA
| | - Meghan X. Lim
- The Program in Global Surgery and Social Change, the Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
| | - Ifereimi Waqainabete
- Ministry of Health and Medical Services of Fiji, Dinem House, 88 Amy St, Suva, Fiji
| | - Jemesa Tudravu
- Ministry of Health and Medical Services of Fiji, Dinem House, 88 Amy St, Suva, Fiji
| | - Josese Turagava
- Ministry of Health and Medical Services of Fiji, Dinem House, 88 Amy St, Suva, Fiji
| | - Rajeev Patel
- Ministry of Health and Medical Services of Fiji, Dinem House, 88 Amy St, Suva, Fiji
| | | | - Josephine Herman
- Te Marae Ora - Cook Islands Ministry of Health, Rarotonga, Cook Islands
| | - Deacon Teapa
- Te Marae Ora - Cook Islands Ministry of Health, Rarotonga, Cook Islands
| | - Yin Yin May
- Te Marae Ora - Cook Islands Ministry of Health, Rarotonga, Cook Islands
| | | | - Basil Leodoro
- Northern Provincial Hospital, F5RM+CJ3, Luganville, Santo Island, Vanuatu
| | | | - Elizabeth McLeod
- Department of Neonatal and Paediatric Surgery, Royal Children's Hospital, 50 Flemington Rd, Melbourne, VIC 3052, Australia
| | - Kee B. Park
- The Program in Global Surgery and Social Change, the Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
| | - Berlin Kafoa
- Public Health Division, Secretariat of the Pacific Community, Suva, Fiji
| | - Kiki Maoate
- Department of Paediatric Surgery, Christchurch Hospital, University of Otago, 2 Riccarton Avenue, Christchurch 8011, New Zealand
| | - Viliami Tangi
- Ministry of Health, Taufa'ahau Roadd, Nuku'alofa, Tonga
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Guasch E, Ioscovich A, Brogly N, Orbach-Zinger S, Kranke P, Morau E, Gilsanz F. Obstetric anaesthesia manpower and service provision issues (introduction and European perspective). Int J Obstet Anesth 2023; 55:103647. [PMID: 37085390 DOI: 10.1016/j.ijoa.2023.103647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/03/2023] [Accepted: 02/20/2023] [Indexed: 03/02/2023]
Abstract
Global health is an important and far-reaching concept in which health and access to surgical and anaesthetic care is crucial. Universal access to anaesthesia is a challenge in many countries. Manpower shortages are an important cause of difficulties and each European country has found different ways of facing a lack of healthcare professionals. In obstetric anaesthesia, the availability of competent anaesthesiologists has been related to the morbidity and mortality outcomes of patients. In this narrative review, authors from different European countries explain how manpower is managed in obstetric anaesthesia in delivery suites and obstetric operating rooms in different settings. To address manpower difficulties and issues, the goals are to achieve a minimum standard of care and at the same time, to promote clinical excellence through training, delegation to younger or less experienced colleagues, direct or at-a-distance supervision, or other means. The experience of sharing knowledge about the way in which manpower and service provision are organised in other healthcare settings is a significant opportunity to develop strategies for advancing tomorrow's obstetric anaesthesia in the world. While taking into account the level of socio-economic development in different countries, the aim is to standardise practice and workload organisation. Co-operative international projects in training and education in obstetric anaesthesia are ways in which better obstetric patient care can be achieved in the future.
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Affiliation(s)
- E Guasch
- Department of Anaesthesiology and Critical Care, Hospital Universitario La Paz, Madrid, Spain.
| | - A Ioscovich
- Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare Zedek Medical Center, Affiliated with The Hebrew University, Israel
| | - N Brogly
- Department of Anaesthesiology and Critical Care, Hospital Universitario La Paz, Madrid, Spain; Department of Anaesthesiology, Hospital Universitario La Zarzuela, Madrid, Spain
| | - S Orbach-Zinger
- Department of Anaesthesiology, Beilinson Hospital, Petah Tikvah, Affiliated with Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - P Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - E Morau
- Department of Anaesthesia Intensive Care and Perioperative Medicine, CHU Nîmes, Nîmes, France
| | - F Gilsanz
- Anaesthesiology and Intensive Care Medicine, Department of Surgery, Universidad Autónoma de Madrid, Spain
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Awuah WA, Adebusoye FT, Wellington J, Ghosh S, Tenkorang PO, Machai PN, Abdul-Rahman T, Mani S, Salam A, Papadakis M. A reflection of Africa's cardiac surgery capacity to manage congenital heart defects: a perspective. Ann Med Surg (Lond) 2023; 85:4174-4181. [PMID: 37554912 PMCID: PMC10406072 DOI: 10.1097/ms9.0000000000001054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 07/02/2023] [Indexed: 08/10/2023] Open
Abstract
Congenital heart defects (CHDs) are birth abnormalities that may drastically alter the structure and functionality of the heart. For 70% of infants with congenital disorders to survive or maintain a better quality of life, surgery is necessary. Over 500 000 of the 1.5 million CHD cases reported annually, or 1% of all live births, occur in Africa, according to the WHO. A surmounted 90% of these patients are from Africa, and as a consequence, 300 000 infants die annually as a result of poor care or difficulty accessing adequate healthcare. However, the high prevalence of CHDs, precipitated by a plethora of aetiologies worldwide, is particularly pronounced in Africa due to maternal infectious diseases like syphilis and rubella amongst the pregnant populace. In low- and middle-income countries, especially in Africa, where foreign missions and organizations care for the majority of complicated cardiac surgical patients, access to secure and affordable cardiac surgical therapy is a substantial issue. Interventions for CHDs are very expensive in Africa as many of the continent's domiciles possess low expenditures and funding, thereby cannot afford the costs indicated by associated surgical treatments. Access to management and healthcare for CHDs is further hampered by a lack of trained surgical personnel, specialized tools, infrastructure, and diagnostic facilities in Africa.
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Affiliation(s)
| | | | - Jack Wellington
- Cardiff University School of Medicine, Cardiff University, Wales, UK
| | - Shankhaneel Ghosh
- Institute of Medical Sciences and SUM Hospital, Siksha ‘O’ Anusandhan, Bhubaneswar, India
| | | | | | | | | | - Abdus Salam
- Department of Surgery, Khyber Teaching Hospital, Peshawar, Pakistan
| | - Marios Papadakis
- Department of Surgery II, University Hospital Witten-Herdecke, Heusnerstrasse 40, University of Witten-Herdecke, Wuppertal, Germany
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Shetty R, Zadey S, Jindal A, Iyer H, Dubey S, Jesudian G, Smith ER, Staton CA, Fitzgerald TN, Vissoci JRN. Prioritization of surgical, obstetric, trauma, and anesthesia care in India over seven decades: A systematic analysis of policy documents. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002084. [PMID: 37523346 PMCID: PMC10389714 DOI: 10.1371/journal.pgph.0002084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/11/2023] [Indexed: 08/02/2023]
Abstract
Improving access to surgical care in India requires policy-level prioritization of surgical, obstetric, trauma, and anesthesia (SOTA) care. We quantified SOTA care prioritization in the last seven decades by analyzing India's national policy and programmatic documents. Forty documents of national importance over seven decades (1946-2017) were screened for a set of 52 surgical and 6 non-surgical keywords. The number of mentions per keyword was used as a proxy for surgical prioritization. For thematic analysis, surgical mentions were further classified into five domains: Infrastructure, Workforce, Service Delivery, Financing, and Information Management. The total number of mentions was 4681 for the surgical keywords and 2322 for non-surgical. The number of mentions per keyword was 90.02 for surgical keywords and 387 for non-surgical. The older committee reports showed relatively higher SOTA care prioritization compared to the years after 2010. Among the domains, Service Delivery (897) had the maximum number of mentions followed by Infrastructure (545), Workforce (516), Financing (98), and Information Management (40). National Health Policy 2017, the most recent high-level policy, grossly neglected SOTA care. SOTA care is inadequately prioritized in Indian national health policies, especially in the documents after 2010. Concerted efforts are necessary to improve the focus on financing and information management. Prioritization can be improved through a stand-alone national plan for SOTA care along with integration into existing policies.
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Affiliation(s)
- Ritika Shetty
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, India
- Terna Medical College and Hospital, Navi Mumbai, Maharashtra, India
| | - Siddhesh Zadey
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, India
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Duke University, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Dr. D.Y. Patil Medical College, Hospital, and Research Centre, Pune, Maharashtra, India
| | - Anushka Jindal
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, India
- King's College Hospital, Denmark Hill, London, United Kingdom
| | - Himanshu Iyer
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, India
- Department of Surgery, Khurshitji Beharamji Bhabha Municipal General Hospital, Mumbai, Maharashtra, India
| | - Sweta Dubey
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, India
| | - Gnanaraj Jesudian
- Department of EIE, Karunya University, Coimbatore, Tamil Nadu, India
- Association of Rural Surgeons of India/International Federation of Rural Surgeons-Rural Surgery Research and Training Center, Shanthi Bhavan Medical Center, Jharkhand, India
| | - Emily R Smith
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Duke University, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Durham, North Carolina, United States of America
| | - Catherine A Staton
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Duke University, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Durham, North Carolina, United States of America
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Durham, North Carolina, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Duke University, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Durham, North Carolina, United States of America
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11
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Ravelojaona V, Ma X, Samison MF, Rabemalala D, Ayala R, Ramamonjisoa A, Andriamanjato HH, Ravoniaritsoa V, Jumbam DT, Andriamanarivo LM. Incorporating surgical and anesthesia care into universal health care: a national plan for the development of surgery in Madagascar. Can J Anaesth 2023; 70:1131-1154. [PMID: 37378826 DOI: 10.1007/s12630-023-02500-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 09/09/2022] [Accepted: 10/26/2022] [Indexed: 06/29/2023] Open
Abstract
Efforts have been made to strengthen national health systems for safe, affordable, and timely surgical, obstetric, trauma, and anesthesia (SOTA) care since 2015 when the Lancet Commission on Global Surgery (LCoGS) identified critical needs in improving access to essential surgical care for five billion people worldwide. Several governments have developed National Surgical, Obstetric, and Anesthesia Plans (NSOAPs) as a commitment to ensuring safe and accessible surgical care for all of their population. The Ministry of Public Health (MoPH) of Madagascar launched its NSOAP in May 2019, named Le Plan National de Développement de la Chirurgie a Madagascar (PNDCHM). This policy established Madagascar as the first African francophone country to define concrete objectives for the Malagasy health system to meet the targets set by the LCoGS by 2030. The PNDCHM outlined the following priorities and specific action points to be implemented from 2019 to 2023: improving technical capacity, training human resources, developing a health information system, ensuring adequate governance and leadership, offering quality care, creating specific surgical services, and financing and mobilizing resources for implementation. Challenges encountered in the process included complex coordination between different stakeholders, allocating a sufficient budget for its implementation, frequent turnover within the MoPH, and the COVID-19 pandemic. The PNDCHM is a first of its kind in francophone Africa and the many lessons learned can serve as guidance for countries aspiring to build NSOAPs of their own.
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Affiliation(s)
| | - Xiya Ma
- Division of Plastic Surgery, Université de Montréal, Montreal, QC, Canada
| | - Marie-Fidèle Samison
- Department of Standard of Care, Ministry of Public Health, Antananarivo, Madagascar
| | - Dominique Rabemalala
- Technical Direction of University Hospital of Befelatanana Maternity, Antananarivo, Madagascar
| | - Ruben Ayala
- Department of Policy and Advocacy, Operation Smile, Virginia Beach, VA, USA
| | - Anjaramamy Ramamonjisoa
- Department of Policy, Research and Innovation, Operation Smile Madagascar, Antananarivo, Madagascar
| | | | | | - Desmond T Jumbam
- Department of Policy and Advocacy, Operation Smile, Virginia Beach, VA, USA.
- Operation Smile Ghana, Accra, Greater Accra Region, Ghana.
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12
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Rudolfson N, Lantz A, Shrime MG, Johnson W, Smith MD, Hagander L. South Africa and the Surgical Diaspora-A Hub for Surgical Migration and Training. World J Surg 2023; 47:1684-1691. [PMID: 37029798 PMCID: PMC10083063 DOI: 10.1007/s00268-023-06990-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND The shortage of trained surgeons, anesthesiologists, and obstetricians is a major contributor to the unmet need for surgical care in low- and middle-income countries, and the shortage is aggravated by migration to higher-income countries. METHODS We performed a cross-sectional observational study, combining individual-level data of 43,621 physicians from the Health Professions Council of South Africa with data from the registers of 14 high-income countries, and international statistics on surgical workforce, in order to quantify migration to and from South Africa in both absolute and relative terms. RESULTS Of 6670 surgeons, anesthesiologists, and obstetricians in South Africa, a total of 713 (11%) were foreign medical graduates, and 396 (6%) were from a low- or middle-income country. South Africa was an important destination primarily for physicians originating from low-income countries; 2% of all surgeons, anesthesiologists, and obstetricians from low- and middle-income countries were registered in South Africa, and 6% in the other 14 recipient countries. A total of 1295 (16%) South African surgeons, anesthesiologists, and obstetricians worked in any of the 14 studied high-income countries. CONCLUSION South Africa is an important regional hub for surgical migration and training. A notable proportion of surgical specialists in South Africa were medical graduates from other low- or middle-income countries, whereas migration out of South Africa to high-income countries was even larger.
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Affiliation(s)
- Niclas Rudolfson
- Surgery and Public Health, Pediatrics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
- Department of Urology, Kristianstad Central Hospital, Kristianstad, Sweden.
| | - Adam Lantz
- Surgery and Public Health, Pediatrics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Orthopedic Surgery, Helsingborg Hospital, Helsingborg, Sweden
| | - Mark G Shrime
- Mercy Ships, Garden Valley, TX, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Walter Johnson
- Center for Global Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Martin D Smith
- Department of Surgery, University of Witwatersrand, Johannesburg, South Africa
| | - Lars Hagander
- Surgery and Public Health, Pediatrics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Pediatric Surgery, Skane University Hospital, Lund, Sweden
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13
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Improving Surgical Research Capacity in Low- and Middle-Income Countries: Can Episodic Data Collection Reliably Estimate Perioperative Mortality? Ann Surg 2023; 277:e714-e718. [PMID: 34334654 DOI: 10.1097/sla.0000000000005105] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to empirically determine the optimal sample size needed to reliably estimate perioperative mortality (POMR) in different contexts. SUMMARY BACKGROUND DATA POMR is a key metric for measuring the quality and safety of surgical systems and will need to be tracked as surgical care is scaled up globally. Continuous collection of outcomes for all surgical cases is not the standard in high-income countries and may not be necessary in low- and middle-income countries. METHODS We created simulated datasets to determine the sampling frame needed to reach a given precision. We validated our findings using data collected at Mulago National Referral Hospital in Kampala, Uganda. We used these data to create a tool that can be used to determine the optimal sampling frame for a population based on POMR rate and target POMR improvement goal. RESULTS Precision improved as the sampling frame increased. However, as POMR increased, lower sampling percentages were needed to achieve a given precision. A total of 357 eligible cases were identified in the Mulago database with an overall POMR rate of 14%. Precision of ±10% was achieved with 34% sampling, and precision of ±25% was obtained at 9% sampling. Using simulated datasets, a tool was created to determine the minimum sample percentage needed to detect a given mortality improvement goal. CONCLUSIONS Reliably tracking POMR does not require continuous data collection. Data driven sampling strategies can be used to decrease the burden of data collection to track POMR in resource-constrained settings.
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14
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Morriss WW, Enright AC. The Anesthesia Workforce Crisis Revisited. Anesth Analg 2023; 136:227-229. [PMID: 36638506 DOI: 10.1213/ane.0000000000006189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Wayne W Morriss
- From the Department of Anaesthesia, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Angela C Enright
- University of British Columbia, Vancouver, British Columbia, Canada
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15
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Cleft Lip and Palate Research in Low- and Middle-income Countries: A Scientometric Analysis. Plast Reconstr Surg Glob Open 2022; 10:e4122. [PMID: 35186648 PMCID: PMC8846345 DOI: 10.1097/gox.0000000000004122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/14/2021] [Indexed: 11/26/2022]
Abstract
Cleft lip and palate (CLP) comprise over 90% of the world’s congenital anomalies and cause significant disability worldwide, while disproportionally burdening low- and middle-income countries (LMICs). Research can help inform strategies that reduce disparities in accessing CLP care. We performed a scientometric analysis of CLP research in LMICs to identify influential contributors and themes.
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16
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Quene TM, Bust L, Louw J, Mwandri M, Chu KM. Global surgery is an essential component of global health. Surgeon 2022; 20:9-15. [PMID: 34922839 PMCID: PMC8695837 DOI: 10.1016/j.surge.2021.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/26/2021] [Indexed: 02/03/2023]
Abstract
Global surgery as an essential component of global health. Global surgery is the study and practice of improving access to timely, quality, and affordable surgical care. It emphasizes horizontal health systems strengthening through addressing a range of health challenges in surgical care that improve health outcomes, particularly in vulnerable populations. Global surgery specifically contributes to achievement of the Sustainable Development Goals 2030 (SDGs) by addressing the elimination of poverty (SDG 1), ensuring good health and well-being (SDG 3), promoting decent work and economic growth (SDG 8), and reducing inequalities (SDGs 5 and 10). Global surgery issues transcend national boundaries and intersect with other global health issues such as migration and the COVID-19 pandemic. These issues are nested in a highly politicised environment, therefore power and politics should be considered when identifying problems and solutions. Despite evidence of its importance, the global surgery network has not generated substantial attention and resources compared to other global health networks. Global surgery can further increase its effectiveness through linking with health systems strengthening agendas, and identifying unified solutions to improve access to quality surgical care in low- and middle-income countries. Global surgery is indispensable in the achievement of health and well-being for all.
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Affiliation(s)
| | | | | | | | - Kathryn M. Chu
- Corresponding author. Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7507, South Africa
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17
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Development and Implementation of a Longitudinal Global Acute Care and Systems Strengthening Program. Ann Glob Health 2022; 87:125. [PMID: 35036332 PMCID: PMC8698217 DOI: 10.5334/aogh.3385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Increasing access to safe, timely, and affordable acute care in low- and middle-income countries is a worldwide priority. Longitudinal curricula on systems of acute care have not been previously described. Objectives: The authors aimed to develop a novel four-year longitudinal curriculum for medical students addressing systems development across multiple acute care specialties. Methods: The authors followed Kern’s six-step framework for curriculum design. After review of literature, a group of medical students and school of medicine faculty conducted a targeted needs assessment. Foundational goals and objectives were adapted from the 39 interprofessional global health competencies by the Consortium of Universities for Global Health. Educational strategies include didactic sessions, workshops, journal clubs, preceptorships, and community outreach. Clinical years include specialty-specific emphases, guided junior-level discussions, and a capstone project. Yearly SWOT and Kirkpatrick model analyses served as program evaluation. Findings: The Curriculum Council approved the program in July 2019. During the first cycle, the program matriculated 30 students from classes of 2023 (14) and 2022 (16). The first year produced 11 interactive sessions, 6 journal clubs, and 10 seminars led by 31 faculty and guest speakers; 29/30 students completed requirements; 87 evaluations reflected 4.57/5 content satisfaction and 4.73/5 instructor satisfaction. The 2023 cohort reported improved understanding of session objectives (3.13/5 vs. 3.82/5, p = 0.03). Free-text feedback led to implementation of pre-reading standardization and activity outlines. Conclusion: The Program was well-received and successfully implemented. It meets the needs of graduating medical students interested in leading global health work. This novel student-faculty collaborative model could be applied at other institutions seeking to provide students with a foundation in global acute care.
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Velin L, Panayi AC, Lebbe I, Koehl E, Willemse G, Vervoort D. OUP accepted manuscript. BJS Open 2022; 6:6526449. [PMID: 35143626 PMCID: PMC8830757 DOI: 10.1093/bjsopen/zrac001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/02/2021] [Accepted: 01/05/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Lotta Velin
- Correspondence to: Lotta Velin, Centre for Teaching & Research in Disaster Medicine and Traumatology (KMC), Department of Biomedical and Clinical Sciences, Linköping University, Johannes Magnus väg 11, 583 30 Linköping, Sweden (e-mail: )
| | - Adriana C. Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Iris Lebbe
- Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Emmanuelle Koehl
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Gauthier Willemse
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Dominique Vervoort
- Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Juran S, Moren S, Santhirapala V, Roa L, Makasa E, Davies J, Guzman JM, Hagander L, Holmer H, Shrime MG, Weiser TG, Meara JG, Klug SJ, Ljungman D. The Development and Inclusion of Questions on Surgery in the 2018 Zambia Demographic and Health Survey. GLOBAL HEALTH: SCIENCE AND PRACTICE 2021; 9:905-914. [PMID: 34933985 PMCID: PMC8691885 DOI: 10.9745/ghsp-d-20-00619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/14/2021] [Indexed: 11/15/2022]
Abstract
Data from household surveys serve as the backbone to sustainable development planning. For the first time, questions on surgery have been included in a nationwide Demographic and Health Survey, showing that it is feasible to integrate these questions into a large-scale survey. Background: While primary data on the unmet need for surgery in low- and middle-income countries is lacking, household surveys could provide an entry point to collect such data. We describe the first development and inclusion of questions on surgery in a nationally representative Demographic and Health Survey (DHS) in Zambia. Method: Questions regarding surgical conditions were developed through an iterative consultative process and integrated into the rollout of the DHS survey in Zambia in 2018 and administered to a nationwide sample survey of eligible women aged 15–49 years and men aged 15–59 years. Results: In total, 7 questions covering 4 themes of service delivery, diagnosed burden of surgical disease, access to care, and quality of care were added. The questions were administered across 12,831 households (13,683 women aged 15–49 years and 12,132 men aged 15–59 years). Results showed that approximately 5% of women and 2% of men had undergone an operation in the past 5 years. Among women, cesarean delivery was the most common surgery; circumcision was the most common procedure among men. In the past 5 years, an estimated 0.61% of the population had been told by a health care worker that they might need surgery, and of this group, 35% had undergone the relevant procedure. Conclusion: For the first time, questions on surgery have been included in a nationwide DHS. We have shown that it is feasible to integrate these questions into a large-scale survey to provide insight into surgical needs at a national level. Based on the DHS design and implementation mechanisms, a country interested in including a set of questions like the one included in Zambia, could replicate this data collection in other settings, which provides an opportunity for systematic collection of comparable surgical data, a vital role in surgical health care system strengthening.
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Affiliation(s)
- Sabrina Juran
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.
- Epidemiology, Department of Sport and Health Sciences, Technical University Munich, Germany
| | - Sanna Moren
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Surgery, Gothenburg, Sweden
| | | | - Lina Roa
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Canada
| | - Emmanuel Makasa
- Wits Centre of Surgical Care for Primary Health and Sustainable Development, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, United Kingdom
| | | | - Lars Hagander
- WHO Collaborating Centre on Surgery and Public Health, Pediatric Surgery, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund, Sweden
| | - Hampus Holmer
- WHO Collaborating Centre on Surgery and Public Health, Pediatric Surgery, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Mark G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Thomas G Weiser
- Department of Surgery, Stanford University, Stanford, CA, USA
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, United Kingdom
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Stefanie J Klug
- Epidemiology, Department of Sport and Health Sciences, Technical University Munich, Germany
| | - David Ljungman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Surgery, Gothenburg, Sweden
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20
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A Nationwide Enumeration of the Surgical Workforce, its Production and Disparities in Operative Productivity in Liberia. World J Surg 2021; 46:486-496. [PMID: 34839375 PMCID: PMC8803679 DOI: 10.1007/s00268-021-06379-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 12/22/2022]
Abstract
Background Any health care system that strives to deliver good health and well-being to its population relies on a trained workforce. The aim of this study was to enumerate surgical provider density, describe operative productivity and assess the association between key surgical system characteristics and surgical provider productivity in Liberia. Methods A nationwide survey of operation theatre logbooks, available human resources and facility infrastructure was conducted in 2018. Surgical providers were counted, and their productivity was calculated based on operative numbers and full-time equivalent positions. Results A total of 286 surgical providers were counted, of whom 67 were accredited specialists. This translated into a national density of 1.6 specialist providers per 100,000 population. Non-specialist physicians performed 58.3 percent (3607 of 6188) of all operations. Overall, surgical providers performed a median of 1.0 (IQR 0.5–2.7) operation per week, and there were large disparities in operative productivity within the workforce. Most operations (5483 of 6188) were categorized as essential, and each surgical provider performed a median of 2.0 (IQR 1.0–5.0) different types of essential procedures. Surgical providers who performed 7–14 different types of essential procedures were more than eight times as productive as providers who performed 0–1 essential procedure (operative productivity ratio = 8.66, 95% CI 6.27–11.97, P < 0.001). Conclusion The Liberian health care system struggles with an alarming combination of few surgical providers and low provider productivity. Disaggregated data can provide a high-resolution picture of local challenges that can lead to local solutions.
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21
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Ifeanyichi M, Aune E, Shrime M, Gajewski J, Pittalis C, Kachimba J, Borgstein E, Brugha R, Baltussen R, Bijlmakers L. Financing of surgery and anaesthesia in sub-Saharan Africa: a scoping review. BMJ Open 2021; 11:e051617. [PMID: 34667008 PMCID: PMC8527159 DOI: 10.1136/bmjopen-2021-051617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This study aimed to provide an overview of current knowledge and situational analysis of financing of surgery and anaesthesia across sub-Saharan Africa (SSA). SETTING Surgical and anaesthesia services across all levels of care-primary, secondary and tertiary. DESIGN We performed a scoping review of scientific databases (PubMed, EMBASE, Global Health and African Index Medicus), grey literature and websites of development organisations. Screening and data extraction were conducted by two independent reviewers and abstracted data were summarised using thematic narrative synthesis per the financing domains: mobilisation, pooling and purchasing. RESULTS The search resulted in 5533 unique articles among which 149 met the inclusion criteria: 132 were related to mobilisation, 17 to pooling and 5 to purchasing. Neglect of surgery in national health priorities is widespread in SSA, and no report was found on national level surgical expenditures or budgetary allocations. Financial protection mechanisms are weak or non-existent; poor patients often forego care or face financial catastrophes in seeking care, even in the context of universal public financing (free care) initiatives. CONCLUSION Financing of surgical and anaesthesia care in SSA is as poor as it is underinvestigated, calling for increased national prioritisation and tracking of surgical funding. Improving availability, accessibility and affordability of surgical and anaesthesia care require comprehensive and inclusive policy formulations.
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Affiliation(s)
- Martilord Ifeanyichi
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
- EMAI Health Systems and Health Services Consulting, Nijmegen, The Netherlands
| | - Ellis Aune
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Mark Shrime
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Chiara Pittalis
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John Kachimba
- Department of Surgery, University of Zambia University Teaching Hospital, Lusaka, Zambia
| | - Eric Borgstein
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Ruairi Brugha
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Rob Baltussen
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Leon Bijlmakers
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
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22
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Cairo SB, Pu Q, Malemo Kalisya L, Fadhili Bake J, Zaidi R, Poenaru D, Rothstein DH. Geospatial Mapping of Pediatric Surgical Capacity in North Kivu, Democratic Republic of Congo. World J Surg 2021; 44:3620-3628. [PMID: 32651605 DOI: 10.1007/s00268-020-05680-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Despite recent attention to the provision of healthcare in low- and middle-income countries, improvements in access to surgical services have been disproportionately lagging. METHODS This study analyzes the geographic variability in access to pediatric surgical services in the province of North Kivu, Democratic Republic of Congo (DRC). On-site data collection was conducted using the Global Assessment of Pediatric Surgery tool. Spatial distribution of providers was mapped using the Geographical Information System and open-sourced spatial data to determine distances traveled to access surgical care. RESULTS Forty facilities were evaluated across 32 health zones; 68.9% of the provincial population was within 15 km of these facilities. Eleven facilities met a minimum World Health Organization safety score of 8; 48.1% of the population was within 15 km of corresponding facilities. The majority of children were treated by someone with specific pediatric surgery training in only 4 facilities; one facility had a trained pediatric anesthesia provider. Fifty-seven percent of the population was within 15 km of a facility with critical care and emergency medicine (EM) capabilities. There was one pediatric critical care provider and no pediatric EM providers identified within the province. Location-allocation assessment is needed to combine geographic area with potential for greatest impact and facility assessment. CONCLUSIONS Limitations in access to surgical care in the DRC are multifactorial with poor resources, few formally trained surgical providers, and near-absent access to pediatric anesthesiologists. The study highlights the deficits in the capacity for surgical care while demonstrating a reproducible model for assessment and identification of ways to improve access to care.
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Affiliation(s)
- Sarah B Cairo
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, 1001 Main Street, Buffalo, NY, 14203, USA. .,Department of Surgery, Maine Medical Center, Portland, ME, USA.
| | - Qiang Pu
- Department of Geography, University At Buffalo, The State University of New York, Buffalo, NY, USA
| | - Luc Malemo Kalisya
- HEAL Africa Hospital, COSECSA Training Program, Goma, North Kivu Province, Democratic Republic of Congo
| | - Jacques Fadhili Bake
- HEAL Africa Hospital, COSECSA Training Program, Goma, North Kivu Province, Democratic Republic of Congo
| | - Rene Zaidi
- HEAL Africa Hospital, COSECSA Training Program, Goma, North Kivu Province, Democratic Republic of Congo
| | - Dan Poenaru
- Department of Pediatric Surgery, Montreal Children's Hospital, McGill University Health Center, Montreal, QC, Canada
| | - David H Rothstein
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, 1001 Main Street, Buffalo, NY, 14203, USA.,Department of Surgery, University At Buffalo, The State University of New York, Buffalo, NY, USA
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Vervoort D, Swain JD, Pezzella AT, Kpodonu J. Cardiac Surgery in Low- and Middle-Income Countries: A State-of-the-Art Review. Ann Thorac Surg 2021; 111:1394-1400. [DOI: 10.1016/j.athoracsur.2020.05.181] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/10/2020] [Accepted: 05/29/2020] [Indexed: 12/17/2022]
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Cuncannon A, Dosani A, Fast O. Sterile processing in low- and middle-income countries: an integrative review. J Infect Prev 2021; 22:28-38. [PMID: 33841559 PMCID: PMC7841710 DOI: 10.1177/1757177420947468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/14/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Worldwide disparities in surgical capacity are a significant contributor to health inequalities. Safe surgery and infection prevention and control depend on effective sterile processing (SP) of surgical instruments; however, little is known about SP in low- and middle-income countries (LMICs), where surgical site infection is a major cause of postoperative morbidity and mortality. AIM To appraise and synthesise available evidence on SP in LMICs. METHODS An integrative review of research literature was conducted on SP in LMICs published between 2010 and 2020. Studies were appraised and synthesised to identify challenges and opportunities in practice and research. RESULTS Eighteen papers met the inclusion criteria for qualitative analysis. Challenges to advancing SP include limited available evidence, resource constraints and policy-practice gaps. Opportunities for advancing SP include tailored education and mentoring initiatives, emerging partnerships and networks that advance implementation guidelines and promote best practices, identifying innovative approaches to resource constraints, and designing and executing quality assurance and surveillance programmes. DISCUSSION Research investigating safe surgery, including SP, in LMICs is increasing. Further research and evidence are needed to confirm the generalisability of study findings and effectiveness of strategies to improve SP practice in LMICs. This review will help researchers and stakeholders identify opportunities to contribute. The burdens of unsafe surgery transcend geopolitical borders, and the global surgery and research communities are called upon to negotiate historical and present-day inequities to achieve safe surgery for all.
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Affiliation(s)
- Alexander Cuncannon
- School of Nursing and Midwifery, Faculty of Health, Community and Education, Mount Royal University, Calgary, AB, Canada
| | - Aliyah Dosani
- School of Nursing and Midwifery, Faculty of Health, Community and Education, Mount Royal University, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Olive Fast
- School of Nursing and Midwifery, Faculty of Health, Community and Education, Mount Royal University, Calgary, AB, Canada
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25
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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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26
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Exploring the knowledge and attitudes of Cameroonian medical students towards global surgery: A web-based survey. PLoS One 2020; 15:e0232320. [PMID: 32353038 PMCID: PMC7192476 DOI: 10.1371/journal.pone.0232320] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/12/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Global surgery is a growing field studying the determinants of safe and affordable surgical care and advocating to gain the global health community's attention. In Cameroon, little is known about the level of knowledge and attitudes of students. Our survey aimed to describe the knowledge and attitudes of Cameroonian medical students towards global surgery. Materials and methods We performed an anonymous online survey of final-year Cameroonian medical students. Mann-Whitney U test and Spearman correlation analysis were used for bivariate analysis, and the alpha value was set at 0.05. Odds ratios and their 95% confidence intervals were calculated. Results 204 respondents with a mean age of 24.7 years (±2.0) participated in this study. 58.3% were male, 41.6% had previously heard or read about global surgery, 36.3% had taken part in a global surgery study, and 10.8% had attended a global surgery event. Mercy Ships was well known (46.5%), and most students believed that surgical interventions were more costly than medical treatments (75.0%). The mean score of the global surgery evaluation was 47.4% (±29.6%), and being able to recognize more global surgery organizations was correlated with having assumed multiple roles during global surgery studies (p = 0.008) and identifying more global surgery indicators (p = 0.04). Workforce, infrastructure, and funding were highlighted as the top priorities for the development of global surgery in Cameroon. Conclusion Medical students are conscious of the importance of surgical care. They lack the opportunities to nurture their interest and should be taught global surgery concepts and skills.
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Peters AW, Roa L, Rwamasirabo E, Ameh E, Ulisubisya MM, Samad L, Makasa EM, Meara JG. National Surgical, Obstetric, and Anesthesia Plans Supporting the Vision of Universal Health Coverage. GLOBAL HEALTH, SCIENCE AND PRACTICE 2020; 8:1-9. [PMID: 32234839 PMCID: PMC7108944 DOI: 10.9745/ghsp-d-19-00314] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 03/02/2020] [Indexed: 12/11/2022]
Abstract
Developing a national surgical, obstetric, and anesthesia plan is an important first step for countries to strengthen their surgical systems and improve surgical care. Barriers to successful implementation of these plans include data collection, scalability, and financing, yet surgical system strengthening efforts are gaining momentum in achieving universal access to emergency and essential surgical care.
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Affiliation(s)
- Alexander W Peters
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA.
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Lina Roa
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Emmanuel Ameh
- Department of Surgery, National Hospital, Abuja, Nigeria
| | - Mpoki M Ulisubisya
- Ministry of Health Community Development Gender Elderly and Children, Dar es Salaam, Tanzania
| | - Lubna Samad
- Center for Essential Surgical and Acute Care, Indus Health Network, Karachi, Pakistan
| | - Emmanuel M Makasa
- Public Service Management Division Cabinet Office, Office of the President, Lusaka, Zambia
- Wits Centre of Surgical Care for Primary Health & Sustainable Development, School of Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - John G Meara
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
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