World Health Organization Global Initiative for Emergency and Essential Surgical Care: 2011 and beyond

Examining nonmilitary and nongovernmental humanitarian surgical capacity and response in armed conflicts: A scoping review of the recent literature

BACKGROUND

Armed conflicts pose a burden on health care services. We sought to assess the surgical capacity and responses of nonmilitary and nongovernmental humanitarian responders in armed conflicts through proxy indicators to identify strategies to address surgical needs.

METHODS

We searched 6 databases for articles/studies from January 1, 2013, to March 10, 2023. We included articles detailing the surgical capacity of nonmilitary, nongovernmental organizations operating in armed conflicts. We defined surgical capacity through indicators including the type and number of surgical procedures; number of operating rooms, surgical beds, surgeons, anesthesiologists, and surgical equipment; and type of anesthesia employed.

RESULTS

We screened 2,187 abstracts and 279 full texts and included 30 articles/studies. Our sample covered 23 countries and 17 surgical specialties. Most publications focused on surgical capacity assessment (63.3%, 19/30) and surgical and clinical outcomes (63.3%, 19/30). Most articles/studies reported surgical capacity indicators at the hospital (56.7%, 17/30) and multinational (26.7%, 8/30) levels. The number (86.7%, 26/30) and type (76.7%, 23/30) of surgical procedures performed were the most commonly reported. More than one half of the articles (53.3%, 16/30) described strategies to meet surgical needs in armed conflicts. Most strategies addressed information management (68.8%, 11/16), health workforce (62.5%, 10/16), and service delivery (62.5%, 10/16).

CONCLUSION

This review collated common approaches for strengthening health care services in armed conflicts. Several articles emphasized strategies for improving information management, service delivery, and workforce capacity. Hence, we call for standardization of response protocols and multilevel collaborations to maintain or even scale up surgical capacity in armed conflicts.

Surgical outreach for the Americas: a self-sustainable model for partnership and education

INTRODUCTION

It is estimated that up to 28% of global disease burden is surgical with hernias representing a unique challenge as the only definitive treatment is surgery. Surgical Outreach for the Americas (SOfA) is a nongovernmental organization focused primarily on alleviating the disease burden of inguinal and umbilical hernias in Central America. We present the experience of SOfA, a model focused on partnership and education.

METHODS

SOfA was established in 2009 to help individuals recover from ailments that are obstacles to working and independent living. Over the past 15 years, SOfA has partnered with local healthcare providers in the Dominican Republic, El Salvador, Honduras, and Belize. The SOfA team consists of surgeons, surgery residents, triage physicians, an anesthesiologist, anesthetists, operating room nurses, recovery nurses, a pediatric critical care physician, sterile processing technicians, interpreters, and a team coordinator. Critical partnerships required include the CMO, internal medicine, general surgery, nursing, rural health coordinators and surgical training programs at public hospitals.

RESULTS

SOfA has completed 24 trips, performing 2074 procedures on 1792 patients. 71.4% of procedures were hernia repairs. To enhance sustainability of healthcare delivery, SOfA has partnered with the local facilities through capital improvements to include OR tables, OR lights, anesthesia machines, monitors, hospital beds, stretchers, sterilizers, air conditioning units, and electrosurgical generators. A lecture series and curriculum on perioperative care, anesthesia, anatomy, and operative technique is delivered. Local surgery residents and medical students participated in patient care, learning alongside SOfA teammates. Recently, SOfA has partnered with SAGES Global Affairs Committee to implement a virtual Global Laparoscopic Advancement Program, a simulation-based laparoscopic training curriculum for surgeons in El Salvador.

CONCLUSION

A sustainable partnership to facilitate surgical care in low resource settings requires longitudinal, collaborative relationships, and investments in capital improvements, education, and partnership with local healthcare providers, institutions, and training programs.

Sustainable equipment donation in otolaryngology in low-resource settings

PURPOSE OF REVIEW

The purpose of this review is to examine current practices in surgical equipment donation to lower- and middle-income countries (LMICs) with a particular focus on otolaryngology-head and neck surgery (OHNS). This is designed as a pragmatic review to guide potential donor communities to implement sustainable OHNS equipment donation in LMICs.

RECENT FINDINGS

LMICs are increasingly reliant on international equipment donation. In terms of OHNS services, global OHNS have compiled a list of essential equipment for baseline care in LMICs. Especially in terms of audiology, OHNS equipment donation has the potential to have a significant impact on populational health. However, there is a scarcity of research on donated equipment in OHNS. A suggested blueprint for sustainable equipment donation follows these steps: establish partnerships, assess needs, source equipment, and follow-up and evaluate the intervention. Key further considerations for sustainability include remanufacturing and repurposing methods, maintenance, and contextual understanding.

SUMMARY

Sustainable equipment donation in otolaryngology is an important part of global health equity and healthcare delivery in low-resource settings. Despite the good intentions behind medical equipment donations, there are many challenges; donors and recipients should engage in collaborative, needs-based planning processes that result in long-term sustainability, local capacity building, and community participation.

Rethinking referral systems in rural chiapas: A mixed methods study

Background

Despite the assurance of universal health coverage, large disparities exist in access to surgery in the state of Chiapas. The purpose of this study was to determine the effectiveness of the surgical referral system at hospitals operated by the Ministry of Health in Chiapas.

Methods

13 variables were extracted from surgical referrals data from three public hospitals in Chiapas over a three-year period. Interviews were performed of health care workers involved in the referral system and surgical patients. The quantitative and qualitative data was analyzed convergently and reported using a narrative approach.

Findings

In total, only 47.4% of referred patients requiring surgery received an operation. Requiring an elective, gynecological, or orthopedic surgery and each additional surgery cancellation were significantly associated with lower rates of receiving surgery. The impact of gender and surgical specialty, economic fragility of farmers, dependence upon economic resources to access care, pain leading people to seek care, and futility leading patients to abandon the public system were identified as main themes from the mixed methods analysis.

Interpretation

Surgical referral patients in Chiapas struggle to navigate an inefficient and expensive system, leading to delayed care and forcing many patients to turn to the private health system. These mixed methods findings provide a detailed view of often overlooked limitations to universal health coverage in Chiapas. Moving forward, this knowledge must be applied to improve referral system coordination and provide hospitals with the necessary workforce, equipment, and protocols to ensure access to guaranteed care.

Funding

Harvard University and the Abundance Fund provided funding for this project. Funding sources had no role in the writing of the manuscript or decision to submit it for publication.

Safety and Sustainability: Optimizing Outcomes and Changing Paradigms in Global Health Endeavors

Background

The need to address inequities in global surgical care has garnered increased attention since 2015, after the Lancet Commission on Global Surgery underscored the importance of ensuring safe, accessible, affordable, and timely surgical and anesthetic care. The vast unmet global plastic surgery needs make plastic surgery care essential in reducing the global burden of disease. In the past, many nonprofit organizations undertook humanitarian activities within low- and middle-income countries that were primarily service-provision oriented. The Lancet Commission on Global Surgery report prompted a shift in focus from direct patient care models to sustainable global surgical models. The realization that 33% of deaths worldwide were due to unmet surgical needs led to a global shift of strategy toward the development of local systems, surgical capacity, and a focus on patient safety and quality of care within international global surgery partnerships.

Methods

In this report, the authors explore some of the primary components of sustainable international global surgical partnerships discussed in a recent panel at the American Society of Plastic Surgeons Plastic Surgery The Meeting 2022, titled "Safety and Sustainability Overseas: Optimizing Outcomes and Changing Paradigms in Global Health Endeavors." A literature review elaborating the topics discussed was performed.

Results

This report focuses on cultural competence and humility, international collaboration, and the use of technology and innovation, all of which are needed to promote sustainability and patient safety, within global surgery efforts.

Conclusions

The adoption of these components into international surgical collaborations will lead to greatly enhancing the development and sustainability of mutually beneficial relationships.

Essential equipment and services for otolaryngology care: a proposal by the Global Otolaryngology-Head and Neck Surgery Initiative

PURPOSE OF REVIEW

To highlight the need for comprehensive resource lists to provide baseline care of otolaryngologic conditions; to present a proposed list of essential equipment and services that may be applied toward surgical systems research, policymaking, and charitable efforts in global otolaryngology-head and neck surgery.

RECENT FINDINGS

To provide effective and high-quality surgical care across care settings, there must be a global standard for equipment and ancillary services necessary to provide baseline care. Though there have been efforts to devise resource standards via equipment lists and appraisal tools, these have been limited in scope to general surgery, emergency care, and a few other subspecialty surgical contexts. Recent efforts have brought attention to the significant burden imposed by otolaryngologic conditions such as hearing loss, otitis media, head and neck cancer, head and neck trauma, and upper airway foreign bodies. Yet, there has not been a comprehensive list of resources necessary to provide baseline care for common otolaryngologic conditions.

SUMMARY

Through an internal survey of its members, the Global Otolaryngology-Head and Neck Surgery Initiative has compiled a list of essential equipment and services to provide baseline care of otolaryngologic conditions. Our efforts aimed to address common otolaryngologic conditions that have been previously identified as high-priority with respect to prevalence and burden of disease. This expert-driven list of essential resources functions as an initial framework to be adapted for internal quality assessment, implementation research, health policy development, and economic priority-setting.

Surgical Capacity in Public and Private Health Facilities After a Five-Year Strategic Plan Implementation in Ethiopia: A Cross Sectional Study

Background

Surgical capacity is critical for ensuring optimum access to safe, affordable, and timely emergency and essential surgical care (EESC) in low- and middle-income countries (LMICs) like Ethiopia. A five-year strategic plan has been implemented during 2016-2020 in Ethiopia to improve surgical capacity.

Objectives

This study aims to evaluate the impact of the five-year strategy in surgical capacity in the country.

Methods

A cross sectional survey was conducted in 172 health care facilities in Ethiopia from December 30, 2020, to June 10, 2021. Descriptive statistical analysis was done using STATA statistical software Version 15.

Findings

A total of 2,312 surgical workforces were available and, the surgical workforce to population ratio ranged from 1.13:100,000 for public specialized hospitals to 10.8:100,000 for health centre operation room (OR) blocks. Surgical bed to population ratio was 0.03:1000 population, and the average numbers of OR tables per facility were 34. Nearly 25% and 10% of OR tables were not functional in public primary hospitals and private hospitals, respectively. The average surgical volume to population ratio was 189:100,000.

Conclusions

Following the implementation of surgical care strategy, the surgical workforce density has increased. However, the study revealed that there is still a huge unmet gap in surgical capacity. The improvement in surgical volume is very low compared to the increment in the surgical workforce density. In addition to the investment being made to build surgical capacity, emphasis needs to be put on surgical system design and strengthening surgical system efficiency.

Cost-effectiveness of gasless laparoscopy as a means to increase provision of minimally invasive surgery for abdominal conditions in rural North-East India

Laparoscopic surgery, a minimally invasive technique to treat abdominal conditions, has been shown to produce equivalent safety and efficacy with quicker return to normal function compared to open surgery. As such, it is widely accepted as a cost-effective alternative to open surgery for many abdominal conditions. However, access to laparoscopic surgery in rural North-East India is limited, in part due to limited equipment, unreliable supplies of CO₂ gas, lack of surgical expertise and a shortage of anaesthetists. We evaluate the cost-effectiveness of gasless laparoscopy as a means to increase provision of minimally invasive surgery (MIS) for abdominal conditions in rural North-East India. A decision tree model was developed to compare costs, evaluated from a patient perspective, and health outcomes, disability adjusted life years (DALYs), associated with gasless laparoscopy, conventional laparoscopy or open abdominal surgery in rural North-East India. Results indicate that MIS (performed by conventional or gasless laparoscopy) is less costly and produces better outcomes, fewer DALYs, than open surgery. These results were consistent even when gasless laparoscopy was analysed using least favourable data from the literature. Scaling up provision of MIS through increased access to gasless laparoscopy would reduce the cost burden to patients and increase DALYs averted. Based on a sample of 12 facilities in the North-East region, if scale up was achieved so that all essential surgeries amenable to laparoscopic surgery were performed as such (using conventional or gasless laparoscopy), 64% of DALYS related to these surgeries could be averted, equating to an additional 454.8 DALYs averted in these facilities alone. The results indicate that gasless laparoscopy is likely to be a cost-effective alternative to open surgery for abdominal conditions in rural North-East India and provides a possible bridge to the adoption of full laparoscopic services.

Access to surgical care in Ethiopia: a cross-sectional retrospective data review

BACKGROUND

Access to emergency and essential surgical care is still unmet and accessibility is disproportionately inequitable in Ethiopia and other low-and middle-income countries. The aim of this study was to assess surgical care access in terms of capability, capacity, and timeliness of care in different levels of health care in Ethiopia.

METHODS

A cross-sectional study with retrospective data review was conducted in 172 health facilities from December 30, 2020 to June 10, 2021. Descriptive statistics such as median with interquartile range and proportion were computed using STATA Version 15 statistical software.

RESULTS

Within a 90-day interval of the study period, 69,717 major and minor surgeries, and 33,052 bellwether procedures were performed, and major surgeries accounted for 58% of the surgeries. About 1.6%, 23.56%, 25.34%, and 32.2% of both major and minor, and 3.1%, 12.8%, 27.6%, and 45.3% of bellwether procedures were performed in health center OR blocks, primary, general, and specialized hospitals, respectively. Private hospitals performed 17.33% of major and minor and 11.2% of bellwether procedures for the period. The average pre-admission waiting time for surgical patients in primary, general, and specialized hospitals was 9.68, 37.6, and 35.9 days, respectively, whereas, in private hospitals, the average pre-admission waiting time was 1.42 days. On average, surgical patients traveled 5 Hrs, 11 Hrs, 28.4 Hrs, and 21.3 Hrs to access surgical services in primary, general, specialized, and private hospitals, respectively. The surgical workforce to the population served ratio was 7.5, 1.15, and 1.31/100.000 population in primary, specialized and general hospitals, respectively.

CONCLUSION

Most surgical procedures were performed in specialized hospitals, indicating that there is a burden in these health facilities. The pre-admission waiting time for surgical patients was long in higher-level public hospitals. Surgical patients traveled a long distance to access surgical service in higher level hospitals. The ratio of surgical workforce per 100,000 population served was low in all levels of public health facilities in general, and in higher level hospitals in particular. Efforts should therefore be made to strengthen all levels of the health system and improve surgical care access in terms of capacity, capability, and timeliness in the country.

Open source surgical fracture table for digitally distributed manufacturing

Roughly a third of the surgical procedures the World Bank is prioritizing as essential and cost-effective are orthopedic procedures. Yet in much of the developing world, prohibitive costs are a substantial barrier to universal access. One area where this is clear is surgical fracture tables, which generally cost >US$200,000 new. With the advent of 3-D printing, a new way to reduce medical equipment costs is to use open source hardware licensed designs to fabricate digitally-distributed manufactured medical hardware. That approach is applied here to make surgical tables more accessible. This study describes the design and manufacture of an open source surgical fracture table that uses materials that are widely available worldwide with specialty components being 3-D printed. The bill of materials and assembly instructions are detailed and the fracture table is validated to perform mechanically to specifications. Using an open source desktop RepRap-class 3-D printer, the components can be printed in a little over a week of continuous printing. Including the 3-D printed parts, the open source fracture table can be constructed for under US$3,000 in material costs, representing a 98.5% savings for commercial systems, radically increasing accessibility. The open source table can be adjusted 90–116 cm in height, tilted from +/-15 degrees, the leg height ranges from 31 to 117 cm, the arm supports and foot holder both have a 180-degree range, the foot position has a 54 cm range, and the legs can be adjusted from 55 to 120 degrees. It is mechanically adjusted so does not require electricity, however, surgical staff need to be trained on how to perform needed adjustments during surgery. The open source surgical table has verified performance for mechanical loading over 130 kg, geometric flexibility to allow for wide array of common surgeries, is radiolucent in surgical zones, and is modular and upgradeable.

The impact of novel coronavirus disease (COVID-19) on emergency and essential surgical care in Gedeo and Sidama zone hospitals: An institutional-based multicenter cross-sectional study

Background

COVID-19 was initially detected in China's Wuhan, the capital of Hubei Province, in December 2019, and has since spread throughout the world, including Ethiopia. Long-term epidemics will overwhelm the capacity of hospitals and the health system as a whole, with dire consequences for the developing world's damaged health systems. Focusing on COVID-19-related activities while continuing to provide essential services such as emergency and essential surgical care is critical not only to maintaining public trust in the health system but also to reducing morbidity and mortality from other illnesses. The goal of this study was to see how COVID-19 affected essential and emergency surgical care in Gedeo and Sidama zone hospitals.

Method

ology: A cross-sectional study was carried out in ten (10) hospitals in the Gedeo and Sidama zone. The information was gathered with the help of the world health organization (WHO) situational analysis tool for determining emergency and essential surgical care (EESC) capability. Infrastructure, human resources, interventions, and EESC equipment and supplies were used to assess the hospitals' capacity.

Result

54.3% of the 35 fundamental therapies indicated in the instrument were available before COVID-19 at all sites, while 25.2 percent were available after the COVID-19 pandemic. During the COVID-19 pandemic, there was a sharing of resources for treatment centers, such as a scarcity of oxygen and anesthesia machines, and emergency surgery was postponed. Before admission, the average distance traveled was 58 km.

Conclusion

The COVID-19 pandemic, as well as existing disparities in infrastructure, human resources, service provision, and essential equipment and supplies, reveal significant gaps in hospitals' capacity to provide emergency and essential surgical services and effectively address the growing surgical burden of disease and injury in Gedeo and Sidama zone primary, general, and referral hospitals.

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54.3% of basic interventions were available before COVID-19 at all facilities reduced to 25.2%.

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COVID-19 pandemic high effect on emergency and essential surgical cervices.

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Discrepancies in infrastructure, human resources, and other services also affect EESC.

Interpersonal challenges in surgical care provision in rural Mexico: A qualitative study

Background

Chiapas is among the states with the lowest access to health care in Mexico. A better understanding of the role of interpersonal relationships in referral systems could improve access to care in the region. The purpose of this study was to analyze the underlying barriers and facilitators to accessing surgical care at public hospitals run by the Ministry of Health in Chiapas.

Methods

In this qualitative interview study, we performed semi-structured interviews with 19 surgical patients and 18 healthcare workers at three public hospitals in the Fraylesca Region of Chiapas to explore barriers and facilitators to successfully accessing surgical treatment. Transcripts were coded and analyzed using an inductive, thematic approach to data analysis.

Findings

The five major themes identified as barriers to surgical care were dehumanization of patients, the toll of rehumanizing patients, animosity in the system, the refraction of violence onto patients, and poor resource coordination. Three themes identified as facilitators to receiving care were teamwork, social capital, and accompaniment.

Interpretation

Health care workers described a culture of demoralization and mistrust within the health system worsened by a scarcity of resources. As a result, patient care is hampered by conflict, miscommunication, and feelings of dehumanization. Efforts to improve access to surgical care in the region should consider strategies to improve teamwork and expand patient accompaniment.

Funding

Harvard University and the Abundance Fund provided funding for this project. Funding sources had no role in the writing of the manuscript or decision to submit it for publication.Resumen.

Antecedentes

Chiapas es uno de los estados en Mexico con el menor acceso a la atención médica, y a los servicios quirúrgicos. Una mejor comprensión del papel de las relaciones interpersonales en los sistemas de referencias podría mejorar el acceso a la atención medica en la región. El objetivo del estudio es analizar las barreras y facilitadores para acceder a la atención quirúrgica en los hospitales públicos pertenecientes a la Secretaria de Salud del estado de Chiapas.

Método

En este estudio cualitativo, realizamos entrevistas semiestructuradas con 19 pacientes quirúrgicos y 18 trabajadores de la salud en tres hospitales públicos en la región de la Frailesca de Chiapas para explorar barreras y facilitadores para acceder al tratamiento quirúrgico. Las transcripciones se codificaron y analizaron utilizando un enfoque temático.

Resultados

Las cinco barreras principales identificadas fueron la deshumanización de los pacientes, el costo a re humanizar pacientes, la animosidad en el sistema, la refracción de la violencia sobre los pacientes y la mala coordinación de recursos. Tres facilitadores para recibir cirugía fueron el trabajo en equipo, el capital social, y el acompañamiento.

Interpretaciones

Los trabajadores de la salud describieron una cultura de desmoralización y desconfianza en el sistema de salud que se agrava con la escasez de recursos. Como resultado se obtiene, conflicto, falta de comunicación, y sentimientos de deshumanización que empeoran la atención al paciente. Recomendaciones para mejorar el acceso a los servicios quirúrgicos en la región incluyen estrategias para mejorar el trabajo en equipo y ampliar el acompañamiento de los pacientes.

Financiamiento

La Universidad de Harvard y the Abundance Fund proporcionaron fondos para este proyecto. Las fuentes de financiamiento no influyen en la redacción ni en la publicación del manuscrito.

Resources and Geographic Access to Care for Severe Pediatric Pneumonia in Four Resource-limited Settings

Rationale: Pneumonia is the leading cause of death in children worldwide. Identifying and appropriately managing severe pneumonia in a timely manner improves outcomes. Little is known about the readiness of healthcare facilities to manage severe pediatric pneumonia in low-resource settings. Objectives: As part of the HAPIN (Household Air Pollution Intervention Network) trial, we sought to identify healthcare facilities that were adequately resourced to manage severe pediatric pneumonia in Jalapa, Guatemala (J-GUA); Puno, Peru (P-PER); Kayonza, Rwanda (K-RWA); and Tamil Nadu, India (T-IND). We conducted a facility-based survey of available infrastructure, staff, equipment, and medical consumables. Facilities were georeferenced, and a road network analysis was performed. Measurements and Main Results: Of the 350 healthcare facilities surveyed, 13% had adequate resources to manage severe pneumonia, 37% had pulse oximeters, and 44% had supplemental oxygen. Mean (±SD) travel time to an adequately resourced facility was 41 ± 19 minutes in J-GUA, 99 ± 64 minutes in P-PER, 40 ± 19 minutes in K-RWA, and 31 ± 19 minutes in T-IND. Expanding pulse oximetry coverage to all facilities reduced travel time by 44% in J-GUA, 29% in P-PER, 29% in K-RWA, and 11% in T-IND (all P < 0.001). Conclusions: Most healthcare facilities in low-resource settings of the HAPIN study area were inadequately resourced to care for severe pediatric pneumonia. Early identification of cases and timely referral is paramount. The provision of pulse oximeters to all health facilities may be an effective approach to identify cases earlier and refer them for care and in a timely manner.

The need for craniofacial trauma and oncologic reconstruction in global surgery

The global burden of surgical disease is concentrated in low- and middle-income countries and primarily consists of injuries and malignancies. While global reconstructive surgery has a long and well-established history, efforts thus far have been focused on addressing congenital anomalies. Craniofacial trauma and oncologic reconstruction are comparatively neglected despite their higher prevalence. This review explores the burden, management, and treatment gaps of craniofacial trauma and head and neck cancer reconstruction in low-resource settings. We also highlight successful alternative treatments used in low-resource settings and pearls that can be learned from these areas.

Virtual Connections: Improving Global Neurosurgery Through Immersive Technologies

The field of neurosurgery has always been propelled by the adoption of novel technologies to improve practice. Although advancements have occurred in the diagnosis, treatment, and long-term outcomes of patients, these have not translated to global patient benefit. Up to five million people each year do not have access to safe and affordable neurosurgical interventions, and those in low- and middle-income countries (LMICs) are disproportionately affected. Current approaches to increase neurosurgical capacity are unlikely to meet the UN Sustainable Development Goals target by 2030, and many of the most successful programs have been disrupted by the travel restrictions of the COVID-19 pandemic. There is therefore a pressing need for creative virtual solutions. An area of growing relevance is the use of immersive technologies: virtual reality (VR) and augmented reality (AR). AR allows additional information to be superimposed onto the surgeon's visual field, thus enhancing intra-operative visualization. This can be used for remote tele-proctoring, whereby an experienced surgeon can virtually assist with a procedure regardless of geographical location. Expert guidance can therefore be given to both neurosurgical trainees and non-neurosurgical practitioners, further facilitating the growing practice of neurosurgical task-shifting in LMICs. VR simulation is another useful tool in remote neurosurgical training, with the potential to reduce the learning curve of complex procedures whilst conserving supplies in low-resource settings. The adoption of immersive technologies into practice is therefore a promising approach for achieving global neurosurgical equity, whilst adapting to the long-term disruptions of the pandemic.

Epidemiology of injured patients in rural Uganda: A prospective trauma registry's first 1000 days

Trauma is a leading cause of morbidity and mortality worldwide. Data characterizing the burden of injury in rural Uganda is limited. Hospital-based trauma registries are a critical tool in illustrating injury patterns and clinical outcomes. This study aims to characterize the traumatic injuries presenting to Soroti Regional Referral Hospital (SRRH) in order to identify opportunities for quality improvement and policy development. From October 2016 to July 2019, we prospectively captured data on injured patients using a locally designed, context-relevant trauma registry instrument. Information regarding patient demographics, injury characteristics, clinical information, and treatment outcomes were recorded. Descriptive, bivariate, and multivariate statistical analyses were conducted. A total of 4109 injured patients were treated during the study period. Median age was 26 years and 63% were male. Students (33%) and peasant farmers (31%) were the most affected occupations. Falls (36%) and road traffic injuries (RTIs, 35%) were the leading causes of injury. Nearly two-thirds of RTIs were motorcycle-related and only 16% involved a pedestrian. Over half (53%) of all patients had a fracture or a sprain. Suffering a burn or a head injury were significant predictors of mortality. The number of trauma patients enrolled in the study declined by five-fold when comparing the final six months and initial six months of the study. Implementation of a context-appropriate trauma registry in a resource-constrained setting is feasible. In rural Uganda, there is a significant need for injury prevention efforts to protect vulnerable populations such as children and women from trauma on roads and in the home. Orthopedic and neurosurgical care are important targets for the strengthening of health systems. The comprehensive data provided by a trauma registry will continue to inform such efforts and provide a way to monitor their progress moving forward.

Global Health and Surgical Infection: From Neglect to Emerging Frontier

Background: In past decades, surgical site infections (SSIs) were neglected and not given much global attention in low- and middle-income countries (LMICs). The risk and incidence of SSIs in LMICs continue to increase. Methods: We reviewed the limited quality data on SSIs and complicated intra-abdominal infections in these settings that have hampered advocacy and infection prevention and control efforts. Results: This review identifies the rising profile of global surgery that has resulted in efforts to scale up access to surgical care as well as increase surgical volumes to address unmet needs. The fallout of these efforts would be increasing SSI rates and a rising volume of laparotomies for intra-abdominal infections. Conclusion: Surgical infections are an emerging frontier in global health and surgery. There is an urgent need for global advocacy and investments in their prevention and control.

The Burden of Pediatric Musculoskeletal Diseases Worldwide

Global burden of disease (GBD) refers to the economic and human costs resulting from poor health. The disability-adjusted life year is a measure of life lost from premature death and life not lived at 100% health. Surgery has long been neglected in the distribution of resources for global health. Because of years of life lived with a disability and the large proportion of children in a population, pediatric musculoskeletal conditions early in life can contribute to the GBD. Fortunately, the World Health Organization has recently promoted essential surgical services through its Emergency and Essential Surgical Care Project and Global Initiative.

Residency perception survey among neurosurgery residents in lower-middle-income countries: grassroots evaluation of neurosurgery education

OBJECTIVE

The evolution of the neurosurgical specialty in lower-middle-income countries is uniformly a narrative of continuous struggle for recognition and resource allocation. Therefore, it is not surprising that neurosurgical education and residency training in these countries is relatively nascent. Dr. Harvey Cushing in 1901 declared that he would specialize in neurosurgery and gave his greatest contribution to the advancement of neurosurgical education by laying the foundations of a structured residency training program. Similar efforts in lower-middle-income countries have been impeded by economic instability and the lack of well-established medical education paradigms. The authors sought to evaluate the residency programs in these nations by conducting a survey among the biggest stakeholders in these educational programs: the neurosurgical residents.

METHODS

A questionnaire addressing various aspects of the residency program from a resident’s perspective was prepared with Google Forms and circulated among neurosurgery residents through social media and email groups. Where applicable, a 5-point Likert scale was used to grade the responses to the questions. Responses were collected from May to October 2019 and analyzed using descriptive statistics. Complete anonymity of the respondents was ensured to keep the responses unbiased.

RESULTS

A total of 195 responses were received, with 189 of them from lower-middle-income countries (LMICs). The majority of these were from India (75%), followed by Brazil and Pakistan. An abiding concern among residents was lack of work hour regulations, inadequate exposure to emerging subspecialties, and the need for better hands-on training (> 60% each). Of the training institutions represented, 89% were offering more than 500 major neurosurgical surgeries per year, and 40% of the respondents never got exposure to any subspecialty. The popularity of electronic learning resources was discernible and most residents seemed to be satisfied with the existent system of evaluation. Significant differences (p < 0.05) among responses from India compared with those from other countries were found in terms of work hour regulations and subspecialty exposure.

CONCLUSIONS

It is prudent that concerned authorities in LMICs recognize and address the deficiencies perceived by neurosurgery residents in their training programs. A determined effort in this direction would be endorsed and assisted by a host of international neurosurgical societies when it is felt that domestic resources may not be adequate. Quality control and close scrutiny of training programs should ensure that the interests of neurosurgical trainees are best served.

Sustainable Orthopaedic Surgery Residency Training in East Africa: A 10-Year Experience in Kenya

Low- and middle-income countries (LMICs) have continued to lag behind high-income countries in all measurable outcomes of health care. As concluded by the World Health Organization during the 2013 Global Forum on Human Resources for Health, an adequate healthcare workforce is mandatory to provide universal health coverage. Despite efforts to increase the numbers of healthcare workers, an extreme deficit in highly trained surgeons remains. Several options exist to provide training for surgeons in LMICs, including local training by local surgeons, sending local surgeons abroad for training, or local training by short-term or long-term visiting surgeons from high-income countries. This article further discusses the benefits and challenges of each option and reviews the 10-year outcomes of the Orthopaedic Surgery Residency Program at the CURE Kenya Hospital in Kijabe, Kenya. The program has graduated nine orthopaedic surgeons who are all practicing in Africa, five of which are full-time attending consultants in residency training programs. An additional eight residents are currently in the program. Sustainable orthopaedic training can be accomplished in LMICs as demonstrated by the ongoing success of the CURE Kenya Orthopaedic Surgery Residency Program. Additional efforts to expand and replicate this model may assist in providing improved access to high-quality universal healthcare in LMICs.

The Economic Burden of Non-fatal Musculoskeletal Injuries in Northeastern Tanzania

Background:

Although musculoskeletal injuries have increased in sub-Saharan Africa, data on the economic burden of non-fatal musculoskeletal injuries in this region are scarce.

Objective:

Socioeconomic costs of orthopedic injuries were estimated by examining both the direct hospital cost of orthopedic care as well as indirect costs of orthopedic trauma using disability days and loss of work as proxies.

Methods:

This study surveyed 200 patients seen in the outpatient orthopedic ward of the Kilimanjaro Christian Medical Center, a tertiary hospital in Northeastern Tanzania, during the month of July 2016.

Findings:

Of the patients surveyed, 88.8% earn a monthly income of less than $250 and the majority of patients (73.7%) reported that the healthcare costs of their musculoskeletal injuries were a catastrophic burden to them and their family with 75.0% of patients reporting their medical costs exceeded their monthly income. The majority (75.3%) of patients lost more than 30 days of activities of daily living due to their injury, with a median (IQR) functional day loss of 90 (30). Post-injury disability led to 40.6% of patients losing their job and 86.7% of disabled patients reported a wage decrease post-injury. There were significant associations between disability and post-injury unemployment (p < .0001) as well as lower post-injury wages (p = .022).

Conclusion:

This exploratory study demonstrates that in this region of the world, access to definitive treatment post-musculoskeletal injury is limited and patients often suffer prolonged disabilities resulting in decreased employment and income.

Where There Is No Trauma System: A Successful Patient Evacuation in the Republic of Kiribati

Research is lacking around how best to approach trauma care in resource poor settings, particularly in remote areas such as the islands of the South Pacific. Without examples of successful treatment of high-risk cases in these settings, countries are unable to move forward with developing policies and standardized procedures for emergency care.The Republic of Kiribati is a Pacific Island nation composed of 33 islands spanning over 2,000 miles in the central Pacific Ocean. With the only hospital located on Kiritimati Island and inadequate boat transportation, the government recently committed to providing an aircraft for patients to receive appropriate medical care. In 2016, a 20-year-old female, primigravida, on a neighboring island, failed to progress in labor for 24 hours and needed an emergency cesarean section. A radio call was made to Kiritimati, and a team consisting of a general surgeon, nurse, and a laboratory technician was dispatched. The patient was brought to the local clinic and flown to Kiritimati where a team was prepared to perform the cesarean section.The successful patient evacuation emphasizes the importance of a dedicated health care team, government commitment, and the constant quality communication when approaching feasibility of trauma and emergency care. (Disaster Med Public Health Preparedness. 2019;13:774-776).

Disseminating technology in global surgery

Background

Effective dissemination of technology in global surgery is vital to realize universal health coverage by 2030. Challenges include a lack of human resource, infrastructure and finance. Understanding these challenges, and exploring opportunities and solutions to overcome them, are essential to improve global surgical care.

Methods

This review focuses on technologies and medical devices aimed at improving surgical care and training in low- and middle-income countries. The key considerations in the development of new technologies are described, along with strategies for evaluation and wider dissemination. Notable examples of where the dissemination of a new surgical technology has achieved impact are included.

Results

Employing the principles of frugal and responsible innovation, and aligning evaluation and development to high scientific standards help overcome some of the challenges in disseminating technology in global surgery. Exemplars of effective dissemination include low-cost laparoscopes, gasless laparoscopic techniques and innovative training programmes for laparoscopic surgery; low-cost and versatile external fixation devices for fractures; the LifeBox pulse oximeter project; and the use of immersive technologies in simulation, training and surgical care delivery.

Conclusion

Core strategies to facilitate technology dissemination in global surgery include leveraging international funding, interdisciplinary collaboration involving all key stakeholders, and frugal scientific design, development and evaluation.

Consortium of Orthopaedic Academic Traumatologists: A Model for Collaboration in Orthopaedic Surgery

In March 2016, North American academic leaders with an interest in and commitment to the field of global orthopaedics met in Orlando, Florida, to gauge each institution's clinical, research, and educational programs in developing countries, establish the main limitations to participating in global health efforts, and assess areas of need for both the participating institutions and their international partners. After this inaugural meeting, a needs assessment survey was distributed to the group to better understand how to organize and unify the individual institutional global efforts. The results revealed that surgeons believed there was a vital need for improved communication, mentorship, and infrastructural support between North American universities. To this end, the Consortium of Orthopaedic Academic Traumatologists (COACT) was founded. The COACT seeks to promote a novel framework geared toward improving trauma care capacity by building collaborative partnerships among leading academic centers across the United States and Canada. The consortium represents a comprehensive partnership that promotes communication, collaboration, and advocacy through a central network to facilitate investigative, educational, and clinical services. Academic partners share best practices, resources, and opportunities in their international outreach projects in low- and middle-income countries in the field of orthopaedic trauma. Over the course of the past 2 years, the COACT has grown to more than 80 faculty, fellow, resident, and student members, representing over 20 orthopaedic institutions across North America.

Challenges for the surgical capacity building of township hospitals among the Central China: a retrospective study

BACKGROUND

China's rapid transition in healthcare service system has posed considerable challenges for the primary care system. Little is known regarding the capacity of township hospitals (THs) to deliver surgical care in rural China with over 600 million lives. We aimed to ascertain its current performance, barriers, and summary lessons for its re-building in central China.

METHODS

This study was conducted in four counties from two provinces in central China. The New Rural Cooperative Medical System (NRCMS) claim data from two counties in Hubei province was analyzed to describe the current situation of surgical care provision. Based on previous studies, self-administered questionnaire was established to collect key indicators from 60 THs from 2011 to 2015, and social and economic statuses of the sampling townships were collected from the local statistical yearbook. Semi-structured interviews were conducted among seven key administrators in the THs that did not provide appendectomy care in 2015. Determinants of appendectomy care provision were examined using a negative binominal regression model.

RESULTS

First, with the rapid increase in inpatient services provided by the THs, their proportion of surgical service provision has been nibbled by out-of-county facilities. Second, although DY achieved a stable performance, the total amount of appendectomy provided by the 60 THs decreased to 589 in 2015 from 1389 in 2011. Moreover, their proportion reduced to 26.77% in 2015 from 41.84% in 2012. Third, an increasing number of THs did not provide appendectomy in 2015, with the shortage of anesthesiologists and equipment as the most mentioned reasons (46.43%). Estimation results from the negative binomial model indicated that the annual average per capita disposable income and tightly integrated delivery networks (IDNs) negatively affected the amount of appendectomy provided by THs. By contrast, the probability of appendectomy provision by THs was increased by performance-related payment (PRP). Out-of-pocket (OOP) cost gap of appendectomy services between the two different levels of facilities, payment method, and the size of THs presented no observable improvement to the likelihood of appendectomy care in THs.

CONCLUSION

The county-level health system did not effectively respond to the continuously increasing surgical care need. The surgical capacity of THs declined with the surgical patterns' simplistic and quantity reduction. Deficits and critical challenges for surgical capacity building in central China were identified, including shortage of human resources and medical equipment and increasing income. Moreover, tight IDNs do not temporarily achieve capacity building. Therefore, the reimbursement rate should be further ranged, and physicians should be incentivized appropriately. The administrators, policy makers, and medical staff of THs should be aware of these findings owing to the potential benefits for the capacity building of the rural healthcare system.

Anaesthesia in austere environments: literature review and considerations for future space exploration missions

Future space exploration missions will take humans far beyond low Earth orbit and require complete crew autonomy. The ability to provide anaesthesia will be important given the expected risk of severe medical events requiring surgery. Knowledge and experience of such procedures during space missions is currently extremely limited. Austere and isolated environments (such as polar bases or submarines) have been used extensively as test beds for spaceflight to probe hazards, train crews, develop clinical protocols and countermeasures for prospective space missions. We have conducted a literature review on anaesthesia in austere environments relevant to distant space missions. In each setting, we assessed how the problems related to the provision of anaesthesia (e.g., medical kit and skills) are dealt with or prepared for. We analysed how these factors could be applied to the unique environment of a space exploration mission. The delivery of anaesthesia will be complicated by many factors including space-induced physiological changes and limitations in skills and equipment. The basic principles of a safe anaesthesia in an austere environment (appropriate training, presence of minimal safety and monitoring equipment, etc.) can be extended to the context of a space exploration mission. Skills redundancy is an important safety factor, and basic competency in anaesthesia should be part of the skillset of several crewmembers. The literature suggests that safe and effective anaesthesia could be achieved by a physician during future space exploration missions. In a life-or-limb situation, non-physicians may be able to conduct anaesthetic procedures, including simplified general anaesthesia.

Assessment of communication technology and post-operative telephone surveillance during global urology mission

Objective

Compliance with post-operative follow-up in the context of international surgical trips is often poor. The etiology of this problem is multifactorial and includes lack of local physician involvement, transportation costs, and work responsibilities. We aimed to better understand availability of communication technologies within Belize and use this information to improve follow-up after visiting surgical trips to a public hospital in Belize City. Accordingly, a 6-item questionnaire assessing access to communication technologies was completed by all patients undergoing evaluation by a visiting surgical team in 2014. Based on this data, a pilot program for patients undergoing surgery was instituted for subsequent missions (2015–2016) that included a 6-week post-operative telephone interview with a visiting physician located in the United States.

Results

Fifty-four (n = 54) patients were assessed via survey with 89% responding that they had a mobile phone. Patients reported less access to home internet (59%), local internet (52%), and email (48%). Of 35 surgical patients undergoing surgery during 2 subsequent surgical trips, 18 (51%) were compliant with telephone interview at 6-week follow-up. Issues were identified in 3 (17%) patients that allowed for physician assistance. The cost per patient interview was $10 USD.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3256-2) contains supplementary material, which is available to authorized users.

Partnerships for Global Child Health

Child mortality remains a global health challenge and has resulted in demand for expanding the global child health (GCH) workforce over the last 3 decades. Institutional partnerships are the cornerstone of sustainable education, research, clinical service, and advocacy for GCH. When successful, partnerships can become self-sustaining and support development of much-needed training programs in resource-constrained settings. Conversely, poorly conceptualized, constructed, or maintained partnerships may inadvertently contribute to the deterioration of health systems. In this comprehensive, literature-based, expert consensus review we present a definition of partnerships for GCH, review their genesis, evolution, and scope, describe participating organizations, and highlight benefits and challenges associated with GCH partnerships. Additionally, we suggest a framework for applying sound ethical and public health principles for GCH that includes 7 guiding principles and 4 core practices along with a structure for evaluating GCH partnerships. Finally, we highlight current knowledge gaps to stimulate further work in these areas. With awareness of the potential benefits and challenges of GCH partnerships, as well as shared dedication to guiding principles and core practices, GCH partnerships hold vast potential to positively impact child health.

Is TAVR Ready for the Global Aging Population?

The emergence of the global pandemic of chronic diseases necessitates critical assessment of interventions that can be targeted at both the individual and population levels. Among cardiovascular diseases, the increasing prevalence of valvular heart diseases such as aortic stenosis parallels the rising burden of atherosclerotic cardiovascular diseases. As an alternative to surgical aortic valve replacement, technological innovation has allowed development of minimally invasive transcatheter aortic valve replacement (TAVR). This review examines whether TAVR can be applicable in low-resource regions across the world. Although revolutionary, TAVR is currently complex and requires a "Heart Team" approach for optimized patient care. We propose the emergence of telemedicine networks, newer valve designs that allow implementation of minimal approaches, and the use of minimal numbers of specialists for adapting TAVR to settings where surgical backup is not available. With efforts to reduce resource utilization, these alternate strategies have the potential to affect implementation of TAVR globally.

The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

Operating Room Personnel Viewpoints About Certified Registered Nurse Anesthetists

The purpose of this project was to explore what attitudes physicians, nurses, and operating room technicians had about working with Certified Registered Nurse Anesthetists (CRNAs) to better understand practice barriers and facilitators. This Q methodology study used a purposive sample of operating room personnel from four institutions in the Midwestern United States. Participants completed a -4 to +4 rank-ordering of their level of agreement with 34 attitude statements representing a wide range of beliefs about nurse anesthetists. Centroid factor analysis with varimax rotation was used to analyze 24 returned Q sorts. Three distinct viewpoints emerged that explained 66% of the variance: favoring unrestricted practice, favoring anesthesiologist supervision, and favoring anesthesiologist practice. Research is needed on how to develop workplace attitudes that support autonomous nurse anesthetist practice and to understand preferences for restricted practice in team members other than physicians.

The 2016 AANS Presidential Address: Leading the way

This AANS presidential address focuses on enduring values of the neurosurgical profession that transcend the current political climate. The address was delivered by Dr. Batjer during a US presidential election year, but the authors have intentionally avoided discussing the current chaos of the American health care system in the knowledge that many pressing issues will change depending on the outcome of the 2016 elections. Instead, they have chosen to focus on clarifying what neurosurgeons, and the American Association of Neurological Surgeons, in particular, stand for; identifying important challenges to these fundamental principles and values; and proposing specific actions to address these challenges. The authors cite "de-professionalism" and commoditization of medicine as foremost among the threats that confront medicine and surgery today and suggest concrete action that can be taken to reverse these trends as well as steps that can be taken to address other significant challenges. They emphasize the importance of embracing exceptionalism and never compromising the standards that have characterized the profession of neurosurgery since its inception.

Understanding and Addressing the Global Need for Orthopaedic Trauma Care

➤The burden of musculoskeletal trauma is high worldwide, disproportionately affecting the poor, who have the least access to quality orthopaedic trauma care.➤Orthopaedic trauma care is essential, and must be a priority in the horizontal development of global health systems.➤The education of surgeons, nonphysician clinicians, and ancillary staff in low and middle income countries is central to improving access to and quality of care.➤Volunteer surgical missions from rich countries can sustainably expand and strengthen orthopaedic trauma care only when they serve a local need and build local capacity.➤Innovative business models may help to pay for care of the poor. Examples include reducing costs through process improvements and cross-subsidizing from profitable high-volume activities.➤Resource-poor settings may foster innovations in devices or systems with universal applicability in orthopaedics.

Challenges in Prevention and Care Delivery for Women with Cervical Cancer in Sub-Saharan Africa

Virtually all cases of invasive cervical cancer are associated with infection by high-risk strains of human papilloma virus. Effective primary and secondary prevention programs, as well as effective treatment for early-stage invasive cancer have dramatically reduced the burden of cervical cancer in high-income countries; 85% of the mortality from cervical cancer now occurs in low- and middle-income countries. This article provides an overview of challenges to cervical cancer care in sub-Saharan Africa (SSA) and identifies areas for programmatic development to meet the global development goal to reduce cancer-related mortality. Advanced stage at presentation and gaps in prevention, screening, diagnostic, and treatment capacities contribute to reduced cervical cancer survival. Cost-effective cervical cancer screening strategies implemented in low resource settings can reduce cervical cancer mortality. Patient- and system-based barriers need to be addressed as part of any cervical cancer control program. Limited human capacity and infrastructure in SSA are major barriers to comprehensive cervical cancer care. Management of early-stage, locally advanced or metastatic cervical cancer involves multispecialty care, including gynecology oncology, medical oncology, radiology, pathology, radiation oncology, and palliative care. Investment in cervical cancer care programs in low- and middle-income countries will need to include effective recruitment programs to engage women in the community to access cancer screening and diagnosis services. Though cervical cancer is a preventable and treatable cancer, the challenges to cervical control in SSA are great and will require a broadly integrated and sustained effort by multiple stakeholders before meaningful progress can be achieved.

Addressing the Global Disparities in the Delivery of Pediatric Orthopaedic Services: Opportunities for COUR and POSNA

The burden of musculoskeletal conditions, especially injuries, is increasing in low-income and middle-income countries. Road traffic injuries have become epidemic. There are multiple barriers to accessing surgical services at both the individual (utilization) and the health system (availability) levels, and deficiencies in education and training of health providers. Specialty societies such as the Pediatric Orthopaedic Society of North America (POSNA) have an opportunity to play an important role through teaching and training. The POSNA Children's Orthopedics in Underserved Regions (COUR) committee has supported the Visiting Scholars Program, which invites surgeons from the developing world to attend a scientific meeting and facilitates the scholar's visit to North American pediatric orthopaedic centers. POSNA members have held global educational courses that support an educational exchange between lecturers and attendees. The COUR web site allows for submission of trip reports that document successes and obstacles experienced by members performing overseas clinical care and teaching. The web site also provides educational resources relevant to providing care in these environments. POSNA collaborates with other societies, such as the American Academy of Orthopaedic Surgeons and the Society of Military Orthopaedic Surgeons, to provide education in disaster management. In addition to increasing member involvement, specialty societies have the opportunity for continued data collection from overseas care, application of US registry data to disease processes in the developing world, and further collaboration with one another.

Deficiencies in the availability of essential musculoskeletal surgical services at 883 health facilities in 24 low- and lower-middle-income countries

BACKGROUND

The sequelae of acute musculoskeletal conditions, especially injuries and infections, are responsible for significant disability in low- and middle-income countries. This study characterizes the availability of selected musculoskeletal surgical services at different tiers of the health system in a convenience sample of 883 health facilities from 24 low- and lower-middle-income countries.

METHODS

Selected data points from the World Health Organization's (WHO) tool of situational analysis of surgical availability were extracted from the WHO's database in December, 2013. These included infrastructure, physical resources and supplies, interventions, and human resources. For a descriptive analysis, facilities were divided into two groups based on number of beds (<100, 100-300, and >300) and level of facility (primary referral, secondary/tertiary, and Private/NGO/Mission). Statistical comparison was made between public and Private/NGO/Mission facilities based on number of beds (≤100, 100-300, and >300) using a Chi-Square analysis, with statistical significance at p < 0.05.

FINDINGS

Significant deficiencies were noted in infrastructure, physical resources and supplies, and human resources for the provision of essential orthopedic surgical services at all tiers of the health system. Availability was significantly lower in public versus Private/NGO/Mission facilities for nearly all categories in facilities with ≤100 beds, and in a subset of measures in facilities with between 100 and 300 beds.

INTERPRETATION

Deficiencies in the availability of orthopedic surgical services were observed at all levels of health facility and were most pronounced at facilities with ≤100 beds in the public sector. Strengthening the delivery of essential surgical services, including orthopedics, at the primary referral level must be prioritized if we are to reduce the burden of death and disability from a variety of emergent health conditions.

FUNDING

There were no sources of funding.

Innovation in income-poor environments

Background

At the core of surgical development in any economic environment lies innovation. Innovation in high-income countries (HICs) often derives from research, whereas innovation in low- and middle-income countries (LMICs) may be spontaneous owing to a desperate drive to meet a local need. The local needs are substantial because of the unequal access to healthcare in LMICs.

Methods

The experience of the author in working in LMICs through Operation Hernia, a medical charity, provides a backdrop for this review. Other published innovative devices and models are discussed.

Results

Innovation in income-poor countries has provided cost-effective but efficient solutions to local health needs. Some innovations have been enhanced and adopted worldwide.

Conclusion

HICs can learn more from innovative strategies adopted in LMICs.

Assessment of cesarean delivery availability in 26 low- and middle-income countries: a cross-sectional study

OBJECTIVE

We sought to assess the capacity to provide cesarean delivery (CD) in health facilities in low- and middle-income countries.

STUDY DESIGN

We conducted secondary analysis of 719 health facilities, in 26 countries in Africa, the Pacific, Asia, and the Mediterranean, using facility-based cross-sectional data from the World Health Organization Situational Analysis Tool to Assess Emergency and Essential Surgical Care.

RESULTS

A total of 531 (73.8%) facilities reported performing CD. In all, 126 (17.5%) facilities did not perform but referred CD; the most common reasons for doing so were lack of skills (53.2%) and nonfunctioning equipment (42.9%). All health facilities surveyed had at least 1 operating room. Of the facilities performing CD, 47.3% did not report the presence of any type of anesthesia provider and 17.9% did not report the presence of any type of obstetric/gynecological or surgical care provider. In facilities reporting a lack of functioning equipment, 26.4% had no access to an oxygen supply, 60.8% had no access to an anesthesia machine, and 65.9% had no access to a blood bank.

CONCLUSION

Provision of CD in facilities in low- and middle-income countries is hindered by a lack of an adequate anesthetic and surgical workforce and availability of oxygen, anesthesia, and blood banks.

Inter-facility transfer of surgical emergencies in a developing country: effects on management and surgical outcomes

OBJECTIVES

Outcomes of surgical emergencies are associated with promptness of the appropriate surgical intervention. However, delayed presentation of surgical patients is common in most developing countries. Delays commonly occur due to transfer of patients between facilities. The aim of the present study was to assess the effect of delays in treatment caused by inter-facility transfers of patients presenting with surgical emergencies as measured by objective and subjective parameters.

METHODS

We prospectively collected data on all patients presenting with an acute surgical emergency at Aga Khan University Hospital (AKUH). Information regarding demographics, social class, reason and number of transfers, and distance traveled were collected. Patients were categorized into two groups, those transferred to AKUH from another facility (transferred) and direct arrivals (non-transfers). Differences between presenting physiological parameters, vital statistics, and management were tested between the two groups by the chi square and t tests.

RESULTS

Ninety-nine patients were included, 49 (49.5 %) patients having been transferred from another facility. The most common reason for transfer was "lack of satisfactory surgical care." There were significant differences in presenting pulse, oxygen saturation, respiratory rate, fluid for resuscitation, glasgow coma scale, and revised trauma score (all p values <0.001) between transferred and non-transferred patients. In 56 patients there was a further delay in admission, and the most common reason was bed availability, followed by financial constraints. Three patients were shifted out of the hospital due to lack of ventilator, and 14 patients left against medical advice due to financial limitations. One patient died.

CONCLUSIONS

Inter-facility transfer of patients with surgical emergencies is common. These patients arrive with deranged physiology which requires complex and prolonged hospital care. Patients who cannot afford treatment are most vulnerable to transfers and delays.

Framework for advancing otolaryngology: head and neck surgery in Ethiopia

The American Academy of Otolaryngology--Head and Neck Surgery and its members have shown continuing commitment to improving global otolaryngology care through humanitarian and international outreach programs. These efforts, based on a surgical mission model, have produced only modest improvements in otolaryngologic care in Ethiopia. In cooperation with the Ethiopian Ministry of Health and 2 Ethiopian medical schools, we present a framework for otolaryngology education for the next decade. It recognizes the limitations of the current didactic paradigm and aims to use available domestic and international resources to improve the quality and availability of head and neck surgical and medical services.

Surgical care in low and middle-income countries: burden and barriers

Surgically correctable pathology accounts for a sizeable proportion of the overall global burden of disease. Over the last decade the role of surgery in the public health agenda has increased in prominence and attempts to quantify surgical capacity suggest that it is a significant public health issue, with a great disparity between high-income, and low- and middle-income countries (LMICs). Although barriers such as accessibility, availability, affordability and acceptability of surgical care hinder improvements in LMICs, evidence suggests that interventions to improve surgical care in these settings can be cost-effective. Currently, efforts to improve surgical care are mainly coordinated by academia and intuitions with strong surgical and global health interests. However, with the involvement of various international organisations, policy makers, healthcare managers and other stakeholders, a collaborative approach can be achieved in order to accelerate progress towards improved and sustainable surgical care. In this article, we discuss the current burden of global surgical disease and explore some of the barriers that may be encountered in improving surgical capacity in LMICs. We go on to consider the role that international organisations can have in improving surgical care globally. We conclude by discussing surgery as a global health priority and possible solutions to improving surgical care globally.

The World Health Organization's action plan on the road traffic injury pandemic: is there any action for orthopaedic trauma surgeons?

Road traffic crash-related death, injury, and chronic disability continue to be a major worldwide burden to drivers, pedestrians, and users of mass transit, especially in low- and middle-income countries (LMIC). Projections predict worsening of this burden, and while motorization of LMIC increases exponentially, a corresponding improvement in prehospital and acute in-hospital trauma care has not been seen. The WHO now has 2 programs that address different elements of this challenge, namely, the Violence and Injury Prevention department (prevention) and the Emergency and Essential Surgical Care project (treatment). Activities of Violence and Injury Prevention have included developing guidelines for prehospital and essential trauma care, whereas activities of the Emergency and Essential Surgical Care have included developing the Integrated Management of Emergency and Essential Surgical Care toolkit and a textbook, "Surgical Care at the District Hospital." Organized surgical institutions in high-income countries-trauma associations, university departments, surgical nongovernmental organizations, etc.-can benefit from the infrastructure and tools the WHO has developed to better address the deficits in surgical services to improve the equitable distribution of surgical care services and resources to LMIC.

The role of surgery in global health: analysis of United States inpatient procedure frequency by condition using the Global Burden of Disease 2010 framework

Background

The role of surgical care in promoting global health is the subject of much debate. The Global Burden of Disease 2010 study (GBD 2010) offers a new opportunity to consider where surgery fits amongst global health priorities. The GBD 2010 reinforces the DALY as the preferred methodology for determining the relative contribution of disease categories to overall global burden of disease without reference to the likelihood of each category requiring surgery. As such, we hypothesize that the GBD framework underestimates the role of surgery in addressing the global burden of disease.

Methods and Findings

We compiled International Classification of Diseases, Version 9, codes from the United States Nationwide Inpatient Sample from 2010. Using the primary diagnosis code for each hospital admission, we aggregated admissions into GBD 2010 disease sub-categories. We queried each hospitalization for a major operation to determine the frequency of admitted patients whose care required surgery. Major operation was defined according to the Agency for Healthcare Research and Quality (AHRQ). In 2010, 10 million major inpatient operations were performed in the United States, associated with 28.6% of all admissions. Major operations were performed in every GBD disease subcategory (range 0.2%–84.0%). The highest frequencies of operation were in the subcategories of Musculoskeletal (84.0%), Neoplasm (61.4%), and Transport Injuries (43.2%). There was no disease subcategory that always required an operation; nor was there any disease subcategory that never required an operation.

Conclusions

Surgical care cuts across the entire spectrum of GBD disease categories, challenging dichotomous traditional classifications of ‘surgical’ versus ‘nonsurgical’ diseases. Current methods of measuring global burden of disease do not reflect the fundamental role operative intervention plays in the delivery of healthcare services. Novel methodologies should be aimed at understanding the integration of surgical services into health systems to address the global burden of disease.