Surgical Care and Health Systems

Hepato-pancreato-biliary surgery in West Africa: a timely capacity assessment

BACKGROUND

West Africa has among the highest rates of hepato-pancreato-biliary (HPB) malignancies in the world. Although surgery is critical for treatment, the availability of HPB surgery in Africa is unknown. This cross-sectional study investigated the current HPB surgical capacity of West African hospitals.

METHOD

The Surgeons OverSeas Personnel, Infrastructure, Procedure, Equipment, and Supplies (PIPES) survey was modified to include HPB-specific parameters and quantify capacity. The survey was completed by consultant surgeons from West Africa. A PIPES index was calculated, and a higher score corresponded to greater HPB surgical capacity.

RESULTS

The HPB PIPES survey was completed by 35 institutions from The Gambia, Ghana, Ivory Coast, and Nigeria. Most institutions (94.2%) were tertiary referral centres; five had an HPB-trained surgeon. The most commonly available procedure was an open cholecystectomy (91.4%), followed by gastric bypass (88.6%). Major hepatic resections (14.3%) and the Whipple procedure (17.1%) were rare. ICU capabilities were present at 88.6% of facilities while interventional radiology was present in 25.7%.

CONCLUSIONS

This is the first HPB capacity assessment in Africa. This study showed the limited availability of HPB surgery in West Africa. These results can be used for regional quality improvement initiatives and as a baseline for future capacity assessments.

Global Surgery: The Challenges and Strategies to Win a War That Must Be Won

Background

Modern science has conquered seas, land, and space. Although great strides have been made in technology and infectious diseases, global surgery, which was reborn in 2015, has not made much progress. The burden of surgical disease in low- and middle-income countries remains seemingly unconquerable, and its growth unstoppable. The myriad challenges in meeting the surgical needs of 5 billion people has intrigued the author.

Methods

The author collected the views of plastic surgeons on sources and impediments to the scale-up of plastic surgery in low- and middle-income countries, as well as potential strategies for overcoming these obstacles. The author then performed a literature search reviewing the topics that arose from those discussions. The author proposes a strategy using plastic surgery as a model surgical discipline.

Results

A root-cause analysis suggests that the Alma Ata Declaration, with its focus on primary healthcare, is the probable genesis of global surgery (GS) woes. The absence of a clear GS community leader and the fragmented nature of GS advocates who operate in multiple silos, without a clear unified goal, are the primary reasons GS advocates have achieved so little on the ground.

Conclusions

Global surgery requires a business model to sustainably meet the surgical needs of the 5 billion people globally. The proposed and implemented strategies must meet rigorous criteria to ensure sustainability, as quick-fix solutions are counterproductive. The development of centers of excellence offers a viable solution to problems that must be addressed successfully.

Building towards equitable access to safe surgery for every child

Kids Operating Room (KidsOR) is a global health charity focused entirely on helping transform surgical care for children around the world. KidsOR corroborates and puts into practice the argument of the Lancet Commission on Global Surgery that surgical care is a valuable investment and should be incorporated as an essential component of a functioning health care system. Moreover, by investing in local capacities, we distance ourselves from the status quo of international health aid, more specifically short-term medical missions and specific disease interventions. Our focus is to integrate the capabilities inherent to the country in the development of human resources that fosters greater local empowerment. As a result, despite the challenges of the time, we have shipped a pristine Operating Room to a partner hospital on average once every 12 days. Our strategy also includes a funding programme that supports the development and training of local surgeons and anaesthetists. By 2030 we have committed to open 120 new Operating Rooms in Africa, and we expect to achieve 1.2 million years averted of Disability Adjusted Life Years (DALYs) for every year of full activity in our Operating Rooms as well as to strengthen the economies across sub-Saharan Africa economies by a combined total of 2.5 billion US dollars a year. We also look to the future and advocate for a new aid model for the 21st century in consonance with the principles encouraged by the 1978 Alma Ata Declaration and aiming to make health for all more than a slogan. LEVEL OF EVIDENCE: : IV.

National surgical, obstetric, anaesthesia and nursing plan, Nigeria

Recent evidence suggests that strengthening surgical care within existing health systems will strengthen the overall health-care system. However, Nigeria's national strategic health development plan 2018-2022 placed little emphasis on surgical care. To address the gap, we worked with professional societies and other partners to develop the national surgical, obstetric, anaesthesia and nursing plan 2019-2023. The aim was to foster actions to prioritize surgical care for the achievement of universal health coverage. In addition to creating a costed strategy to strengthen surgical care, the plan included children's surgery and nursing: two key aspects that have been neglected in other national surgical plans. Pilot implementation of the plan began in 2020, supported by a nongovernmental organization with experience in surgical care in the region. We have created specific entry points to facilitate the pilot implementation. In the pilot, an electronic surgery registry has been created; personnel are being trained in life support; nurses are being trained in safe perioperative care; biomedical technicians and sterile supplies nurses are being trained in surgical instrument repair and maintenance; and research capacity is being strengthened. In addition, the mainstream media are being mobilized to improve awareness about the plan among policy-makers and the general population. Another development partner is interested in providing support for paediatric surgery, and a children's hospital is being planned. As funding is a key challenge to full implementation, we need innovative domestic funding strategies to support and sustain implementation.

A longitudinal surgical systems strengthening research program for medical students: the exploration of a model for global health education

BACKGROUND

In response to the staggering global burden of conditions requiring emergency and essential surgery, the development of international surgical system strengthening (SSS) is fundamental to achieving universal, timely, quality, and affordable surgical care. Opportunity exists in identifying optimal collaborative processes that both promote global surgery research and SSS, and include medical students. This study explores an education model to engage students in academic global surgery and SSS via institutional support for longitudinal research.

OBJECTIVES

We set out to design a program to align global health education and longitudinal health systems research by creating an education model to engage medical students in academic global surgery and SSS.

PROGRAM DESIGN AND IMPLEMENTATION

In 2015, medical schools in the United States and Colombia initiated a collaborative partnership for academic global surgery research and SSS. This included development of two longitudinal academic tracks in global health medical education and academic global surgery, which we differentiated by level of institutional resourcing. Herein is a retrospective evaluation of the first two years of this program by using commonly recognized academic output metrics.

MAIN ACHIEVEMENTS

In the first two years of the program, there were 76 total applicants to the two longitudinal tracks. Six of the 16 (37.5%) accepted students selected global surgery faculty as mentors (Acute Care Surgery faculty participating in SSS with Colombia). These global surgery students subsequently spent 24 total working weeks abroad over the two-year period participating in culminating research experiences in SSS. As a quantitative measure of the program's success, the students collectively produced a total of twenty scholarly pieces in the form of accepted posters, abstracts, podium presentations, and manuscripts in partnership with Colombian research mentors.

POLICY IMPLICATIONS

The establishment of scholarly global health education and research tracks has afforded our medical students an active role in international SSS through participation in academic global surgery research. We propose that these complementary programs can serve as a model for disseminated education and training of the future global systems-aware surgeon workforce with bidirectional growth in south and north regions with traditionally under-resourced SSS training programs.

Top 10 Resources in Global Surgery

This resource list could serve to orient those interested in global surgery and could be supplemented with resources advocating for global surgery from clinical, population health, or policy perspectives.

Development of an emergency medical system model for resource-constrained settings

OBJECTIVES

An emergency care system is an important aspect for healthcare organisations in low- and middle-income countries (LMICs) with a growing burden from emergency disease conditions. Evaluations of emergency care systems in LMICs in broader contexts are lacking. Thus, this study aimed to develop a comprehensive emergency medical system model appropriate for resource-constrained settings, based on expert opinions.

METHODS

We used the Delphi method, in which questionnaire surveys were administered three times to an expert panel (both emergency medical care providers and healthcare service researchers), from which opinions on the model's components were compiled. The panel members were mostly from Asian countries. In the first round, the questionnaire drew a list of model components developed through a literature review; the panel members then proposed new components to create a more comprehensive list. In the second and third rounds, the panel members rated the listed components to achieve consensus, as well as to remove components with low ratings. Finally, we rearranged the list to improve its usability.

RESULTS

In total, 32 experts from 12 countries participated. The final model totalled 177 components, categorised into 8 domains (leadership, community-based actions, emergency medical services, upward referral, definitive care, rehabilitation, downward referral, and evaluation and research). No components needed removal.

CONCLUSIONS

We developed a comprehensive emergency care system model, which could provide a basis to evaluate emergency care systems in resource-constrained LMICs; however, field-testing and validation of this system model remain to be done.

Identifying Information Gaps in a Surgical Capacity Assessment Tool for Developing Countries: A Methodological Triangulation Approach

BACKGROUND

Surgical capacity assessment in low- and middle-income countries (LMICs) is challenging. The Surgeon OverSeas' Personnel Infrastructure Procedure Equipment and Supplies (PIPES) survey tool has been proposed to address this challenge. There is a need to examine the gaps in veracity and context appropriateness of the information obtained using the PIPES tool.

METHODS

We performed a methodological triangulation by comparing and contrasting information obtained using the PIPES tool with information obtained simultaneously via three other methods: time and motion study (T&M); provider focus group discussions (FGDs); and a retrospective review of hospital records.

RESULTS

In its native state, the PIPES survey does not capture the role of non-physician clinicians who contribute immensely to surgical care delivery in LMICs. The surgical workforce was more accurately captured by the FGDs and T&M. It may also not reflect the improvisations (e.g., patients sharing beds, partitioning the operating theater, and using preoperative rooms for surgery, etc.) that occur to expand surgical capacity to overcome the limited infrastructure and equipment.

CONCLUSIONS

The PIPES tool captures vital surgical capacity information but has gaps that can be filled by modifying the tool and/or using ancillary methodologies. The interests of the researcher and the local stakeholders' perspectives should inform such modifications.

Access to controlled medicines for anesthesia and surgical care in low-income countries: a narrative review of international drug control systems and policies

PURPOSE

This article describes the functioning of the international drug control system, its integration into national legislation and policy, and the collective impact on access to medicines.

SOURCE

We conducted a review of the three international drug control conventions, peer-reviewed articles, and grey literature known to the authors that describes national and international drug control systems and their impact on access to controlled medicines. This review was supplemented with literature derived from a structured search of MEDLINE^® for articles relating to medical uses of ketamine in low- and middle-income countries conducted to strengthen an advocacy campaign. We illustrate the impact of the drug control system on access to medicines through an analysis of current levels of availability of opioids in many countries as well as through a description of the ongoing advocacy work to ensure the availability of ketamine for medical care in low-income countries.

PRINCIPAL FINDINGS

The complexity of the international drug control system, along with health providers' lack of knowledge regarding key provisions, presents a barrier to improving access to safe anesthesia care in low- and middle-income countries. Fifteen of the 46 essential medicines of potential relevance to perioperative care are listed under one or more of the schedules of the three international drug control conventions and, subsequently, are required to be under national controls, potentially decreasing their availability for medical use.

CONCLUSION

Improving the capacity and quality of anesthesia care in low- and middle-income countries requires attention to improving access to controlled medicines. Anesthesiologists and others involved in global health work should collaborate with policymakers and others to improve national and international drug control legislation to ensure that attempts to thwart illicit drug trafficking and use do not compromise availability of controlled medicines.

Improving surgical systems in low- and middle-income countries: an inclusive framework for monitoring and evaluation

High disease burden and inadequate resources have formed the basis for advocacy to improve surgical care in low- and middle-income countries (LMICs). Current measures are heavily focused on availability of resources rather than impact and fail to fully describe how surgery can be more integrated into health systems. We propose a new monitoring and evaluation framework of surgical care in LMICs to integrate surgical diseases into broader health system considerations and track efforts toward improved population health. Although more discussion is required, we seek to broaden the dialogue of how to improve surgical care in LMICs through this comprehensive framework.