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Trapani D, Murthy SS, Hammad N, Casolino R, Moreira DC, Roitberg F, Blay JY, Curigliano G, Ilbawi AM. Policy strategies for capacity building and scale up of the workforce for comprehensive cancer care: a systematic review. ESMO Open 2024; 9:102946. [PMID: 38507895 PMCID: PMC10966170 DOI: 10.1016/j.esmoop.2024.102946] [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: 09/23/2023] [Revised: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Patients with cancer in low- and middle-income countries experience worse outcomes as a result of the limited capacity of health systems to deliver comprehensive cancer care. The health workforce is a key component of health systems; however, deep gaps exist in the availability and accessibility of cancer care providers. MATERIALS AND METHODS We carried out a systematic review of the literature evaluating the strategies for capacity building of the cancer workforce. We studied how the policy strategies addressed the availability, accessibility, acceptability, and quality (AAAQ) of the workforce. We used a strategic planning framework (SWOT: strengths, weaknesses, opportunities, threats) to identify actionable areas of capacity building. We contextualized our findings based on the WHO 2030 Global Strategy on Human Resources for Health, evaluating how they can ultimately be framed in a labour market approach and inform strategies to improve the capacity of the workforce (PROSPERO: CRD42020109377). RESULTS The systematic review of the literature yielded 9617 records, and we selected 45 eligible papers for data extraction. The workforce interventions identified were delivered mostly in the African and American Regions, and in two-thirds of cases, in high-income countries. Many strategies have been shown to increase the number of competent oncology providers. Optimization of the existing workforce through role delegation and digital health interventions was reported as a short- to mid-term solution to optimize cancer care, through quality-oriented, efficiency-improving, and acceptability-enforcing workforce strategies. The increased workload alone was potentially detrimental. The literature on retaining the workforce and reducing brain drain or attrition in underserved areas was commonly limited. CONCLUSIONS Workforce capacity building is not only a quantitative problem but can also be addressed through quality-oriented, organizational, and managerial solutions of human resources. The delivery of comprehensive, acceptable, and impact-oriented cancer care requires an available, accessible, and competent workforce for comprehensive cancer care. Efficiency-improving strategies may be instrumental for capacity building in resource-constrained settings.
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Affiliation(s)
- D Trapani
- Department of Oncology and Hemato-Oncology, University of Milano, Milano; European Institute of Oncology, IRCCS, Milan, Italy.
| | - S S Murthy
- Global Cancer Disparities Initiative, Division of Surgical Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - N Hammad
- Michael's Hospital, University of Toronto, Toronto, Canada
| | - R Casolino
- Department of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland
| | - D C Moreira
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, USA
| | - F Roitberg
- Hospital Sírio-Libanês, São Paulo, Brazil
| | - J-Y Blay
- Department of Medical Oncology, Centre Leon Berard, Lyon, France
| | - G Curigliano
- Department of Oncology and Hemato-Oncology, University of Milano, Milano; European Institute of Oncology, IRCCS, Milan, Italy
| | - A M Ilbawi
- Department of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland
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Taliente F, Kisekka PK, Ssembuusi J, Kagolo M, Katantazi A, Iacobelli V, Giuliante F. Enhancing surgical oncology in Sub-Saharan Africa through international cooperation. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:918-920. [PMID: 36690532 DOI: 10.1016/j.ejso.2023.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/11/2023] [Accepted: 01/14/2023] [Indexed: 01/17/2023]
Abstract
Cancer burden is rising in sub- Saharan Africa. Surgery is the best option for the treatment of solid tumors, both for oncologic results and cost-effectiveness. A surgical system to deliver safe, quick and affordable treatment options is not available. High income countries models for cancer care are not applicable in SSA especially in rural settings. Afro-centric models are needed, and the Surgical oncologist should be the heart of this system. Local surgeons must be trained in surgical oncology to develop a tailored surgical system for the setting they are operating in. Education and Training should be supported by international collaborations with high income countries.
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Affiliation(s)
- Francesco Taliente
- CUAMM Medical Doctors with Africa, Kampala, Uganda; Hepatobiliary Surgery Unit, Foundation ''Policlinico Universitario A. Gemelli'', IRCCS, Catholic University, Rome, Italy.
| | - Paul Kasalirwe Kisekka
- CUAMM Medical Doctors with Africa, Kampala, Uganda; Matany Saint Kizito Hospital, Moroto, Uganda
| | | | | | | | - Valentina Iacobelli
- CUAMM Medical Doctors with Africa, Kampala, Uganda; Department of Women and Children's Health, Gynecologic Oncology Unit, Catholic University of the Sacred Heart, Rome, Italy
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Foundation ''Policlinico Universitario A. Gemelli'', IRCCS, Catholic University, Rome, Italy
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Abstract
Background: Remarkable gains have been made in global health with respect to provision of essential and emergency surgical and anesthesia care. At the same time, little has been written about the state of surgical care, or the potential strategies for scale-up of surgical services in sub-Saharan Africa, southeast Nigeria inclusive. Objective: The aim was to document the state of surgical care at district hospitals in southeast Nigeria. Methods: We surveyed 13 district hospitals using the World Health Organization (WHO) tool for situational analysis developed by the “Lancet Commission on Global Surgery” initiative to assess surgical care in rural Southeast Nigeria. A systematic literature review of scientific literatures and policy documents was performed. Extraction was performed for all articles relating to the five National Surgical, Obstetric and Anesthesia Plans (NSOAPs) domains: infrastructure, service delivery, workforce, information management and financing. Findings: Of the 13 facilities investigated, there were six private, four mission and three public hospitals. Though all the facilities were connected to the national power grid, all equally suffered electricity interruption ranging from 10–22 hours daily. Only 15.4% and 38.5% of the 13 hospitals had running water and blood bank services, respectively. Only two general surgeon and two orthopedic surgeons covered all the facilities. Though most of the general surgical procedures were performed in private and mission hospitals, the majority of the public hospitals had limited ability to do the same. Orthopedic procedures were practically non-existent in public hospitals. None of the facilities offered inhalational anesthetic technique. There was no designated record unit in 53.8% of facilities and 69.2% had no trained health record officer. Conclusion: Important deficits were observed in infrastructure, service delivery, workforce and information management. There were indirect indices of gross inadequacies in financing as well.
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Schroeder AD, Tubre DJ, Voigt C, Filipi CJ. The State of Surgical Task Sharing for Inguinal Hernia Repair in Limited-Resource Countries. World J Surg 2021; 44:1719-1726. [PMID: 32144469 DOI: 10.1007/s00268-020-05390-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND In limited-resource countries, the morbidity and mortality related to inguinal hernias is unacceptably high. This review addresses the issue by identifying capacity-building education of non-surgeons performing inguinal hernia repairs in developing countries and analyzing the outcomes. METHODS PubMed was searched and included are studies that reported on task sharing and surgical outcomes for inguinal hernia surgery. Educational methods with quantitative and qualitative effects of the capacity-building methods have been recorded. Excluded were papers without records of outcome data. RESULTS Seven studies from African countries reported 14,108 elective inguinal hernia repairs performed by 230 non-surgeons with a mortality rate of 0.36%. Complications were reported in 4 of the 7 studies with a morbidity rate of 14.2%. Two studies reported on follow-up: one with no recurrences in 408 patients at 7.4 months and the other one with 0.9% recurrences in 119 patients at 12 months. Direct comparison of outcomes from trained non-surgeons to surgeons or surgically trained medical doctors is limited but suggests no difference in outcomes. Quantitative capacity-building effects include increase in surgical workforce, case volume, elective procedures, mesh utilization, and decreased referrals to higher level of care institutions. Qualitative capacity-building effects include feasibility of prospective research in limited-resource settings, improved access to surgical care, and change in practice pattern of local physicians after training for mesh repair. CONCLUSION Systematic training of non-surgeons in inguinal hernia repair is potentially a high-impact capacity-building strategy. High-risk patients should be referred to a fully trained surgeon whenever possible. Randomized study designs and long-term outcomes beyond 1 year are needed.
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Affiliation(s)
- Alexander D Schroeder
- Creighton University School of Medicine, 2500 California Plaza, Omaha, NE, 68178, USA
| | - Dustin J Tubre
- Creighton University School of Medicine, 2500 California Plaza, Omaha, NE, 68178, USA
| | - Charles Voigt
- Creighton University School of Medicine, 2500 California Plaza, Omaha, NE, 68178, USA
| | - Charles J Filipi
- Creighton University School of Medicine, 2500 California Plaza, Omaha, NE, 68178, USA.
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Blears EE, Pham NK, Bauer VP. A systematic review and meta-analysis of valued obstetric and gynecologic (OB/GYN) procedures in resource-poor areas. Surg Open Sci 2020; 2:127-135. [PMID: 32754717 PMCID: PMC7391913 DOI: 10.1016/j.sopen.2020.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/15/2020] [Accepted: 03/25/2020] [Indexed: 11/24/2022] Open
Abstract
Background Obstetric and gynecologic procedures are valuable in rural settings. Data identifying common procedures may better prepare surgeons to meet patient needs in remote settings. Materials and methods A literature review using key MeSH terms was performed according to methods described by the Cochrane Collaboration and PRISMA on studies that described obstetric and gynecologic surgery in rural high-income countries or any setting in middle- to low-income countries. Meta-analysis was performed using random effects modeling for odds ratios of cesarean delivery and hysterectomy as proportions of total surgical volume. Results A total of 195 studies were included for qualitative synthesis and 22 for quantitative analysis. Obstetric and gynecologic procedures made up a 19% of all surgical cases. As compared to other obstetric and gynecologic surgical procedures, cesarean delivery was the most common procedure with odds ratio of 2.39 (95% confidence interval 1.48–3.86), and hysterectomy was the second most common procedure with odds ratio of 1.60 (1.57–1.64). However, heterogeneity between the studies was extremely high and risk of bias was high, limiting quality of findings. Conclusion Greater provision of surgical care can be enhanced by defining which procedures are most needed, which include many obstetric and gynecologic procedures, most commonly cesarean delivery and hysterectomy.
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Affiliation(s)
| | - Nguyen K Pham
- University of Texas-Medical Branch, 815 Market St, Galveston, TX, 77555
| | - Valerie P Bauer
- Steward Medical Group, Scenic Mountain Medical Center, 1601 W 11th Pl, Big Spring, TX 79720
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Gajewski J, Borgstein E, Bijlmakers L, Mwapasa G, Aljohani Z, Pittalis C, McCauley T, Brugha R. Evaluation of a surgical training programme for clinical officers in Malawi. Br J Surg 2019; 106:e156-e165. [PMID: 30620067 DOI: 10.1002/bjs.11065] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/28/2018] [Accepted: 10/30/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Shortages of specialist surgeons in African countries mean that the needs of rural populations go unmet. Task-shifting from surgical specialists to other cadres of clinicians occurs in some countries, but without widespread acceptance. Clinical Officer Surgical Training in Africa (COST-Africa) developed and implemented BSc surgical training for clinical officers in Malawi. METHODS Trainees participated in the COST-Africa BSc training programme between 2013 and 2016. This prospective study done in 16 hospitals compared crude numbers of selected numbers of major surgical procedures between intervention and control sites before and after the intervention. Volume and outcomes of surgery were compared within intervention hospitals between the COST-Africa trainees and other surgically active cadres. RESULTS Seventeen trainees participated in the COST-Africa BSc training. The volume of surgical procedures undertaken at intervention hospitals almost doubled between 2013 and 2015 (+74 per cent), and there was a slight reduction in the number of procedures done in the control hospitals (-4 per cent) (P = 0·059). In the intervention hospitals, general surgery procedures were more often undertaken by COST-Africa trainees (61·2 per cent) than other clinical officers (31·3 per cent) and medical doctors (7·4 per cent). There was no significant difference in postoperative wound infection rates for hernia procedures at intervention hospitals between trainees and medical doctors (P = 0·065). CONCLUSION The COST-Africa study demonstrated that in-service training of practising clinical officers can improve the surgical productivity of district-level hospitals.
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Affiliation(s)
- J Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - E Borgstein
- Department of Surgery, College of Medicine, Blantyre, Malawi
| | - L Bijlmakers
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - G Mwapasa
- Department of Surgery, College of Medicine, Blantyre, Malawi
| | - Z Aljohani
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - C Pittalis
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - T McCauley
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - R Brugha
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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Favero G, Carvalho LF, Barbosa TS, Valente C, Macerox N, Barbosa P, Pfiffer T, Kho R, Baracat EC, Project BC, Abrão MS. The Responsible Use of Minimally Invasive Surgery in Remote Areas of Brazil: Feasibility and Safety of a Temporary Gynecologic Operative Expedition. J Gynecol Surg 2015. [DOI: 10.1089/gyn.2014.0141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Giovanni Favero
- Department of Gynecology and Obstetrics, University of São Paulo Medical School, São Paulo, Brazil
| | - Luiz Fernando Carvalho
- Department of Gynecology and Obstetrics, University of São Paulo Medical School, São Paulo, Brazil
| | | | | | | | | | - Tatiana Pfiffer
- Department of Gynecology and Obstetrics, University of São Paulo Medical School, São Paulo, Brazil
| | - Rosanne Kho
- Department of Gynecology, Mayo Clinic, Phoenix, AZ
| | - Edmund Chada Baracat
- Department of Gynecology and Obstetrics, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Maurício Simões Abrão
- Department of Gynecology and Obstetrics, University of São Paulo Medical School, São Paulo, Brazil
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Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J, Mérisier ED, El-Halabi S, Farmer PE, Gawande A, Gillies R, Greenberg SLM, Grimes CE, Gruen RL, Ismail EA, Kamara TB, Lavy C, Lundeg G, Mkandawire NC, Raykar NP, Riesel JN, Rodas E, Rose J, Roy N, Shrime MG, Sullivan R, Verguet S, Watters D, Weiser TG, Wilson IH, Yamey G, Yip W. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015; 386:569-624. [PMID: 25924834 DOI: 10.1016/s0140-6736(15)60160-x] [Citation(s) in RCA: 2122] [Impact Index Per Article: 235.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- John G Meara
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA; Boston Children's Hospital, Boston, MA, USA.
| | - Andrew J M Leather
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - Lars Hagander
- Pediatric Surgery and Global Pediatrics, Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Blake C Alkire
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Nivaldo Alonso
- Plastic Surgery Department, University of São Paulo, São Paulo, Brazil
| | - Emmanuel A Ameh
- Department of Surgery, Division of Peadiatric Surgery, National Hospital, Abuja, Nigeria
| | - Stephen W Bickler
- Rady Children's Hospital, University of California, San Diego, San Diego, CA, USA
| | - Lesong Conteh
- School of Public Health, Imperial College London, London, UK
| | - Anna J Dare
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | | | | | | | - Paul E Farmer
- Department of Global Health and Social Medicine, Division of Global Health Equity, Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA; Partners in Health, Boston, MA, USA
| | - Atul Gawande
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Ariadne Labs Boston, MA, USA
| | - Rowan Gillies
- Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Sarah L M Greenberg
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA; Boston Children's Hospital, Boston, MA, USA; Medical College of Wisconsin, Milwaukee, WI, USA
| | - Caris E Grimes
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - Russell L Gruen
- The Alfred Hospital and Monash University, Melbourne, VIC, Australia; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | | - Thaim Buya Kamara
- Connaught Hospital, Freetown, Sierra Leone; Department of Surgery, University of Sierra Leone, Freetown, Sierra Leone
| | - Chris Lavy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ganbold Lundeg
- Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Nyengo C Mkandawire
- Department of Surgery, College of Medicine, University of Malawi, Blantyre, Malawi; School of Medicine, Flinders University, Adelaide, SA, Australia
| | - Nakul P Raykar
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA; Boston Children's Hospital, Boston, MA, USA; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Johanna N Riesel
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Edgar Rodas
- The Cinterandes Foundation, Universidad del Cuenca, and Universidad del Azuay, Cuenca, Ecuador; Universidad del Azuay, Cuenca, Ecuador
| | - John Rose
- Department of Surgery, University of California, San Diego, CA, USA
| | | | - Mark G Shrime
- Department of Otology and Laryngology, Harvard Medical School, Boston, USA; Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA; Harvard Interfaculty Initiative in Health Policy, Cambridge, MA, USA
| | - Richard Sullivan
- Institute of Cancer Policy, Kings Health Partners Integrated Cancer Centre, King's Centre for Global Health, King's College London, London, UK
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - David Watters
- Royal Australasian College of Surgeons, East Melbourne, and Deakin University, Melbourne, VIC, Australia
| | - Thomas G Weiser
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Iain H Wilson
- Department of Anaesthesia, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Gavin Yamey
- Evidence to Policy Initiative, Global Health Group, University of California, San Francisco, CA, USA
| | - Winnie Yip
- Blavatnik School of Government, University of Oxford, Oxford, UK
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Henry JA, Bem C, Grimes C, Borgstein E, Mkandawire N, Thomas WEG, Gunn SWA, Lane RHS, Cotton MH. Essential Surgery: The Way Forward. World J Surg 2015; 39:822-32. [DOI: 10.1007/s00268-014-2937-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Remick KN, Wong EG, Chuot Chep C, Morton RT, Monsour A, Fisher D, Oh JS, Wilson R, Malone DL, Branas C, Elster E, Gross KR, Kushner AL. Development of a novel Global Trauma System Evaluation Tool and initial results of implementation in the Republic of South Sudan. Injury 2014; 45:1731-5. [PMID: 25192865 DOI: 10.1016/j.injury.2014.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/01/2014] [Accepted: 08/03/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Trauma remains a leading cause of death and disability in the world, and trauma systems decrease mortality from trauma. We developed the Global Trauma System Evaluation Tool (G-TSET) specifically for use in low- and middle-income countries (LMICs). The Sudan People's Liberation Army (SPLA) in the Republic of South Sudan (RSS) desires a military trauma system (MTS) which allowed us to pilot the G-TSET. METHODS The G-TSET was developed by modifying key components of a trauma system applicable to LMICs. We partnered with the SPLA Medical Corps using clinical collaboration, direct observation, and discussion groups. Benchmarks and indicators were scored with 5 indicating "full capability" and 1 meaning "not present" and were used to develop a SPLA MTS plan. RESULTS The overall MTS score was 1.15 indicating an urgent need for system development. The assessment highlighted the need for SPLA Command support. Battlefield care, transport to a trauma facility, and inter-facility communication were identified for improvement. After essential battlefield care, consisting primarily of bandaging and splinting, transport times for injured SPLA soldiers were 12h to 3 days by truck. Based on our findings, we collaborated with SPLA medical leadership to develop a plan to develop a formal MTS. CONCLUSION We piloted a novel trauma system assessment tool for the MTS in the RSS. Qualitatively, we identified gaps in the MTS and provided the medical leadership with a plan for improvement. We anticipate a short-term follow-up to quantify improvement, and we seek to validate this tool for use in other countries.
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Affiliation(s)
- Kyle N Remick
- Trauma and Acute Care Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, United States; Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
| | - Evan G Wong
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, United States.
| | - Chep Chuot Chep
- SPLA Medical Corps, SPLA Military Hospital, Juba, South Sudan.
| | | | | | - Dane Fisher
- Uniformed Services University of the Health Sciences School of Medicine, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
| | - John S Oh
- Trauma and Acute Care Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, United States; Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
| | - Ramey Wilson
- Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
| | - Debra L Malone
- Trauma and Acute Care Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, United States; Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
| | - Charles Branas
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 8th Floor, Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States.
| | - Eric Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
| | - Kirby R Gross
- Joint Trauma System, US Army Institute of Surgical Research, 3698 Chambers Pass Ste B, JBSA Ft Sam Houston, TX 78234, United States.
| | - Adam L Kushner
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, United States; Surgeons OverSeas (SOS), 504 E. 5th Street, Suite 3E, New York, NY 10009, United States; Columbia University, Department of Surgery, New York, NY, United States.
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Abstract
Short-term medical service trips (MSTs) aim to address unmet health care needs of low- and middle-income countries. The lack of critically reviewed empirical evidence of activities and outcomes is a concern. Developing evidence-based recommendations for health care delivery requires systematic research review. I focused on MST publications with empirical results. Searches in May 2013 identified 67 studies published since 1993, only 6% of the published articles on the topic in the past 20 years. Nearly 80% reported on surgical trips. Although the MST field is growing, its medical literature lags behind, with nearly all of the scholarly publications lacking significant data collection. By incorporating data collection into service trips, groups can validate practices and provide information about areas needing improvement.
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Affiliation(s)
- Kevin J Sykes
- Kevin J. Sykes is with the Department of Health Policy and Management in the School of Medicine at the University of Kansas Medical Center, Kansas City
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Abstract
Neonates are the most vulnerable age group in terms of anesthetic risk and perioperative mortality, especially in the developing world. Prematurity, malnutrition, delays in presentation, and sepsis contribute to this risk. Lack of healthcare workers, poorly maintained equipment, limited drug supplies, absence of postoperative intensive care, unreliable water supplies, or electricity are further contributory factors. Trained anesthesiologists with the skills required for pediatric and neonatal anesthesia as well as basic monitoring equipment such as pulse oximetry will go a long way to improve the unacceptably high anesthetic mortality.
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Affiliation(s)
- Adrian T Bösenberg
- Department Anesthesiology and Pain Management, Faculty Health Sciences, University Washington, Seattle, WA, USA
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13
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Akenroye OO, Adebona OT, Akenroye AT. Surgical Care in the Developing World-Strategies and Framework for Improvement. J Public Health Afr 2013; 4:e20. [PMID: 28299109 PMCID: PMC5345438 DOI: 10.4081/jphia.2013.e20] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 10/21/2013] [Indexed: 12/22/2022] Open
Abstract
The purpose of this study was to identify the various problems with surgical care in the developing world and enumerate identified strategies or propose solutions. We also sought to rank these strategies in order of potential impact. The MEDLINE database was sought. Studies published in English, reporting currently employed solutions to identified barriers or problems to surgical care in developing countries or potential solution(s) and published between 2000 and 2012 were eligible for inclusion. 2156 articles were identified for possible inclusion. MeSH terms include surgery, general surgery, developing countries, health services accessibility and quality improvement. Forty-nine full articles with a primary focus on the solutions to the challenges to surgical care in the developing world were included in the final review. Many articles identified problems with infrastructure, workforce shortage, inadequate or inappropriate policies, and poor financing as major problems with healthcare in the developing world. Solutions addressing these problems are multifactorial and would require active participation of local authorities and collaboration with providers from the developed world. The burden of surgical care is increasing. There is poor access to surgical services in the developing world. If and when surgical care is received, the quality could be less than the standard in developed nations. Solutions exist to tackle these problems but require a multidimensional approach to be successful.
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Affiliation(s)
- Olusola O. Akenroye
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA 02115, USA. E-mail:
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14
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Stewart B, Khanduri P, McCord C, Ohene-Yeboah M, Uranues S, Vega Rivera F, Mock C. Global disease burden of conditions requiring emergency surgery. Br J Surg 2013; 101:e9-22. [PMID: 24272924 DOI: 10.1002/bjs.9329] [Citation(s) in RCA: 295] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND Surgical disease is inadequately addressed globally, and emergency conditions requiring surgery contribute substantially to the global disease burden. METHODS This was a review of studies that contributed to define the population-based health burden of emergency surgical conditions (excluding trauma and obstetrics) and the status of available capacity to address this burden. Further data were retrieved from the Global Burden of Disease Study 2010 and the University of Washington's Institute for Health Metrics and Evaluation online data. RESULTS In the index year of 2010, there were 896,000 deaths, 20 million years of life lost and 25 million disability-adjusted life-years from 11 emergency general surgical conditions reported individually in the Global Burden of Disease Study. The most common cause of death was complicated peptic ulcer disease, followed by aortic aneurysm, bowel obstruction, biliary disease, mesenteric ischaemia, peripheral vascular disease, abscess and soft tissue infections, and appendicitis. The mortality rate was higher in high-income countries (HICs) than in low- and middle-income countries (LMICs) (24.3 versus 10.6 deaths per 100,000 inhabitants respectively), primarily owing to a higher rate of vascular disease in HICs. However, because of the much larger population, 70 per cent of deaths occurred in LMICs. Deaths from vascular disease rose from 15 to 25 per cent of surgical emergency-related deaths in LMICs (from 1990 to 2010). Surgical capacity to address this burden is suboptimal in LMICs, with fewer than one operating theatre per 100,000 inhabitants in many LMICs, whereas some HICs have more than 14 per 100,000 inhabitants. CONCLUSION The global burden of surgical emergencies is described insufficiently. The bare estimates indicate a tremendous health burden. LMICs carry the majority of emergency conditions; in these countries the pattern of surgical disease is changing and capacity to deal with the problem is inadequate. The data presented in this study will be useful for both the surgical and public health communities to plan a more adequate response.
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Affiliation(s)
- B Stewart
- Department of Surgery, University of Washington, Seattle, Washington, USA
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Abstract
BACKGROUND We report through a retrospective analysis our experience of providing surgical care and on-the-job training through mobile surgical missions in southern Sudan during the post conflict period between 2005 and 2009. METHODS Three surgical teams conducted 23 missions in 5 primary health care centers sited in remote areas of southern Sudan. King's analytical framework for surgical care in developing countries is adopted to evaluate the appropriateness of services rendered. Exact logistic regression was performed to investigate differences in mortality depending on the level of training of the operators and anesthetists. RESULTS A total of 1,543 patients were operated on during a 5 year period, of which 9 (0.58%) died. The majority of operations were elective surgery cases (which may help contextualize the exceptionally low mortality rate). Several adaptations to surgical techniques adopted and preoperative and postoperative care were required. There were no statistically significant differences in mortality between operations performed by expatriate specialists and local midlevel providers with lower level training. CONCLUSIONS This experience in southern Sudan demonstrates that surgical services can be established utilizing simple facilities and equipment and employing local personnel selected and trained on-the-job by teams composed of a consultant surgeon, anesthetist, and scrub nurse. Delegation of tasks relating to anesthesia and surgery to midlevel health providers is an appropriate approach in developing countries facing shortage and maldistribution of more qualified health workers.
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Mgbakor AC, Adou BE. Plea for greater use of spinal anaesthesia in developing countries. Trop Doct 2011; 42:49-51. [PMID: 22037518 DOI: 10.1258/td.2011.100305] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
When it is indicated for surgical procedures below the umbilicus in our low-resource countries, spinal anaesthesia has many advantages: it is simple, cheap, safe and easy to learn and carry out. It reduces nursing load and the risk of aspiration pneumonitis as well as overall postoperative mortality and morbidity. We prospectively carried out a study of 419 patients operated under spinal anaesthesia during our normal surgical activities. Despite the materials and conditions that were not always those recommended in the published literature, we had very satisfactory results with: (1) a high patient acceptance rate (93.9%); (2) relatively rare adverse effects - the most frequent being hypotension and vomiting each observed in seven (1.67%) patients. We had two cases (0.48%) of the rare cauda equina syndrome. In poor-resource countries, the culture of spinal anaesthesia should be better developed and encouraged by the training institutions.
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Iddriss A, Shivute N, Bickler S, Cole-Ceesay R, Jargo B, Abdullah F, Cherian M. Emergency, anaesthetic and essential surgical capacity in the Gambia. Bull World Health Organ 2011; 89:565-72. [PMID: 21836755 DOI: 10.2471/blt.11.086892] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 04/04/2011] [Accepted: 04/10/2011] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To assess the resources for essential and emergency surgical care in the Gambia. METHODS The World Health Organization's Tool for Situation Analysis to Assess Emergency and Essential Surgical Care was distributed to health-care managers in facilities throughout the country. The survey was completed by 65 health facilities - one tertiary referral hospital, 7 district/general hospitals, 46 health centres and 11 private health facilities - and included 110 questions divided into four sections: (i) infrastructure, type of facility, population served and material resources; (ii) human resources; (iii) management of emergency and other surgical interventions; (iv) emergency equipment and supplies for resuscitation. Questionnaire data were complemented by interviews with health facility staff, Ministry of Health officials and representatives of nongovernmental organizations. FINDINGS Important deficits were identified in infrastructure, human resources, availability of essential supplies and ability to perform trauma, obstetric and general surgical procedures. Of the 18 facilities expected to perform surgical procedures, 50.0% had interruptions in water supply and 55.6% in electricity. Only 38.9% of facilities had a surgeon and only 16.7% had a physician anaesthetist. All facilities had limited ability to perform basic trauma and general surgical procedures. Of public facilities, 54.5% could not perform laparotomy and 58.3% could not repair a hernia. Only 25.0% of them could manage an open fracture and 41.7% could perform an emergency procedure for an obstructed airway. CONCLUSION The present survey of health-care facilities in the Gambia suggests that major gaps exist in the physical and human resources needed to carry out basic life-saving surgical interventions.
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Affiliation(s)
- Adam Iddriss
- Department of Surgery, Johns Hopkins University School of Medicine, Harvey 319, 600 Wolfe Street, Baltimore, MD 21205, United States of America.
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Cotton MH. The academic discipline of tropical surgery. World J Surg 2010; 34:2269-71. [PMID: 20607256 DOI: 10.1007/s00268-010-0701-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Atiyeh BS, Gunn SWA, Hayek SN. Provision of essential surgery in remote and rural areas of developed as well as low and middle income countries. Int J Surg 2010; 8:581-5. [DOI: 10.1016/j.ijsu.2010.07.291] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2009] [Revised: 06/21/2010] [Accepted: 07/21/2010] [Indexed: 10/19/2022]
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Morris C, Perris A, Klein J, Mahoney P. Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent? Anaesthesia 2009; 64:532-9. [PMID: 19413824 DOI: 10.1111/j.1365-2044.2008.05835.x] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In rapid sequence induction of anaesthesia in the emergency setting in shocked or hypotensive patients (e.g. ruptured abdominal aortic aneurysm, polytrauma or septic shock), prior resuscitation is often suboptimal and comorbidities (particularly cardiovascular) may be extensive. The induction agents with the most favourable pharmacological properties conferring haemodynamic stability appear to be ketamine and etomidate. However, etomidate has been withdrawn from use in some countries and impairs steroidogenesis. Ketamine has been traditionally contra-indicated in the presence of brain injury, but we argue in this review that any adverse effects of the drug on intracranial pressure or cerebral blood flow are in fact attenuated or reversed by controlled ventilation, subsequent anaesthesia and the greater general haemodynamic stability conferred by the drug. Ketamine represents a very rational choice for rapid sequence induction in haemodynamically compromised patients.
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Affiliation(s)
- C Morris
- Derby Hospitals Foundation Trust Derby, UK.
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Abstract
PURPOSE OF REVIEW To highlight the problems faced in developing countries where healthcare resources are limited, with particular emphasis on pediatric anesthesia. RECENT FINDINGS The fact that very few publications address pediatric anesthesia in the developing world is not surprising given that most anesthetics are provided by nonphysicians, nurses or unqualified personnel. In compiling this article information is drawn from pediatric surgical, anesthetic and related texts. In a recent survey more than 80% of anesthesia providers in a poor country acknowledged that with the limited resources available they could not provide basic anesthesia for children less than 5 years. Although many publications could be regarded as anecdotal, the similarities to this survey suggest that the lack of facilities is more generalized than we would like to believe. SUMMARY The real risk of anesthesia in comparison to other major health risks such as human immunodeficiency virus, malaria, tuberculosis and trauma remains undetermined. The critical shortage of manpower remains a barrier to progress. Despite erratic electrical supplies, inconsistent oxygen delivery, paucity of drugs or equipment and on occasion even lack of running water, many provide life-saving anesthesia. Perioperative morbidity and mortality is, however, understandably high by developed world standards.
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Affiliation(s)
- Adrian T Bösenberg
- Department of Anesthesia, Faculty of Health Sciences, University Cape Town, Observatory, South Africa.
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Meo G. Reply. World J Surg 2007. [DOI: 10.1007/s00268-006-0655-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Contini S, Gosselin RA. Rural surgery in southern Sudan. World J Surg 2007; 31:613; author reply 614. [PMID: 17219283 DOI: 10.1007/s00268-006-0306-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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