Prioritisation of Surgery in the National Health Strategic Plans of Africa: A Systematic Review

Essential surgery delivery in the Northern Kivu Province of the Democratic Republic of the Congo

INTRODUCTION

Surgical services are an essential part of a functional healthcare system, but the Lancet Commission of Global Surgery (LCoGS) indicators of surgical capacity such as perioperative workforce and surgical volume are unknown in many low- and middle-income countries (LMICs) including the Democratic Republic of Congo (DRC). We aimed to determine the surgical capacity and its associated factors within the DRC.

METHODS

Hospitals were assessed in the North Kivu province of the DRC. Hospital characteristics and surgical rates were determined using the WHO-PGSSC hospital assessment tool and operating room (OR) registries. The primary outcome of interest was the number of Bellwether operations (i.e. Caesarean sections, laparotomies, and external fixation for bone fractures) per 100,000 people. Univariate and multiple linear regressions were performed. Primary predictors were the number of trained surgeons, anaesthesiologists, and obstetricians (SAOs) and the number of perioperative providers (including clinical officers and nurse anaesthetists) per 100,000 people.

RESULTS

Twenty-eight hospitals in North Kivu were assessed over one year in 2021; 24 (86%) were first-level referral health centres while 4 (14%) were second-level referral hospitals. In total, 11,176 Bellwether procedures were performed in the region in one year. Rates per 100,000 people were 1,461 Bellwether surgical interventions, 1.05 SAOs, and 13.1 perioperative providers. In univariate linear regression analysis, each additional SAO added 239 additional cases annually (p = 0.023), while each additional perioperative provider added 110 cases annually (p < 0.001). In our multiple regression analysis adjusting for other hospital services, the association between workforce and Bellwether surgeries was no longer significant.

CONCLUSIONS

The surgical workforce in DRC did not meet the LCoGS benchmark of 20 SAOs per 100,000 people but was not an independent predictor of surgical capacity. Major investment is needed to simultaneously bolster healthcare facilities and increase surgical workforce training.

The Need for Children's Surgical Care Prioritisation in National Surgical Care Policies: A Systematic Review of National Surgical Obstetric and Anaesthetic Plans (NSOAPs) in Sub-Saharan Africa

BACKGROUND

Children born in Sub-Saharan Africa (SSA) have an 85 % risk of requiring surgical care by the age of 15 [1,2]. Yet, children's surgery has been largely neglected by global health policies. National Surgical Obstetric and Anaesthetic Plans' (NSOAPs) reflect countries' strategic health priorities, policies, and targets related to surgical care. This study assessed the prioritisation of children's surgical care in national surgical care policies in SSA.

METHODS

This systematic review of national surgical care policies in SSA conducted in December 2022, analysed NSOAPs developed in SSA electronically for search terms "child∗", "pediatric∗", "paediatric∗" and evaluated manually for children's surgical care in relation to the NSOAP domains, health system building blocks, and surgical care. Policies were evaluated for collaboration.

RESULTS

Eight policies met the inclusion criteria. In the 797 (M = 99.63; SD = 34.83) text-containing pages analysed, there were 258 (15.5; 0-164) mentions of children's surgery search terms. Twenty-five percent (n = 2) of the NSOAPs dedicated sections to children's surgical care, 62.5 % (n = 5) mentioned children's surgery, and 12.5 % (n = 1) did not mention children's surgery. Children's surgery received citations in 25 % (n = 2) of backgrounds, 37.5 % (n = 3) of situational analyses, 87.5 % (n = 7) of strategic frameworks, 37.5 % (n = 3) of monitoring and evaluation, and 25 % (n = 2) of the costing sections. Overall, 62.5 % (n = 5) of countries included a children's surgery stakeholder.

CONCLUSION

NSOAPs are a pragmatic measure of national surgical care priorities. Our findings suggest children's surgery is not widely recognised even where commitments to improving surgical care exist. Greater prioritisation of children's surgery is needed in surgical policy development.

Determinants of Access to Essential Surgery in the Democratic Republic of Congo

INTRODUCTION

In the Democratic Republic of Congo (DRC), the determinants and barriers of essential surgical care are not well described, hindering efforts to improve national surgical programs and access.

METHODS

A cross-sectional study evaluated access to essential surgery in the Butembo and Katwa health zones in the North Kivu province of DRC. A double-clustered random sample of community members was surveyed using questions derived from the Surgeons OverSeas Surgical Needs Assessment Survey, a validated tool to determine the reasons for not seeking, reaching, or receiving a Bellwether surgery (i.e., caesarean delivery, laparotomy, and external fixation of a fracture) when needed.

RESULTS

Overall, 887 households comprising 5944 community members were surveyed from April to August 2022. Six percent (n = 363/5944) of the study population involving 35% (n = 309/887) households needed a Bellwether surgery in the previous year, 30% (n = 108/363) of whom died. Of those who needed surgery, 25% (n = 78) did not go to the hospital to seek care and were more likely to find transportation unaffordable (P = 0.042). The most common reasons for not seeking care were lack of funds for hospitalization, prior poor hospital experience, and fear of hospital care.

CONCLUSIONS

Access and delivery of essential surgery are drastically limited in the North Kivu province of the DRC, such that a quarter of households needing surgery fails to seek surgical care. Poor access was predominantly driven by households' inability to pay for surgery and community distrust of the hospital system.

Prioritization of surgical, obstetric, trauma, and anesthesia care in India over seven decades: A systematic analysis of policy documents

Improving access to surgical care in India requires policy-level prioritization of surgical, obstetric, trauma, and anesthesia (SOTA) care. We quantified SOTA care prioritization in the last seven decades by analyzing India's national policy and programmatic documents. Forty documents of national importance over seven decades (1946-2017) were screened for a set of 52 surgical and 6 non-surgical keywords. The number of mentions per keyword was used as a proxy for surgical prioritization. For thematic analysis, surgical mentions were further classified into five domains: Infrastructure, Workforce, Service Delivery, Financing, and Information Management. The total number of mentions was 4681 for the surgical keywords and 2322 for non-surgical. The number of mentions per keyword was 90.02 for surgical keywords and 387 for non-surgical. The older committee reports showed relatively higher SOTA care prioritization compared to the years after 2010. Among the domains, Service Delivery (897) had the maximum number of mentions followed by Infrastructure (545), Workforce (516), Financing (98), and Information Management (40). National Health Policy 2017, the most recent high-level policy, grossly neglected SOTA care. SOTA care is inadequately prioritized in Indian national health policies, especially in the documents after 2010. Concerted efforts are necessary to improve the focus on financing and information management. Prioritization can be improved through a stand-alone national plan for SOTA care along with integration into existing policies.

An analysis of the inclusion of ear and hearing care in national health policies, strategies and plans

Ear- and hearing-related conditions pose a significant global health burden, yet public health policy surrounding ear and hearing care (EHC) in low- and middle-income countries is poorly understood. The present study aims to characterize the inclusion of EHC in national health policy by analysing national health policies, strategies and plans in English, French, Spanish, Portuguese and Arabic. Three EHC keywords were searched, including ear*, hear* and deaf*. The terms 'human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)', 'tuberculosis' and 'malaria' were included as comparison keywords as these conditions have historically garnered political priority in global health. Of the 194 World Health Organization Member States, there were 100 national policies that met the inclusion criteria of document availability, searchable format, language and absence of an associated national EHC strategy. These documents mentioned EHC keywords significantly less than comparison terms, with mention of hearing in 15 documents, ears in 11 documents and deafness in 3 documents. There was a mention of HIV/AIDS in 92 documents, tuberculosis in 88 documents and malaria in 70 documents. Documents in low- and middle-income countries included significantly fewer mentions of EHC terms than those of high-income countries. We conclude that ear and hearing conditions pose a significant burden of disease but are severely underrepresented in national health policy, especially in low- and middle-income countries.

Ending Neglected Surgical Diseases (NSDs): Definitions, Strategies, and Goals for the Next Decade

While there has been overall progress in addressing the lack of access to surgical care worldwide, untreated surgical conditions in developing countries remain an underprioritized issue. Significant backlogs of advanced surgical disease called neglected surgical diseases (NSDs) result from massive disparities in access to quality surgical care. We aim to discuss a framework for a public health rights-based initiative designed to prevent and eliminate the backlog of NSDs in developing countries. We defined NSDs and set forth six criteria that focused on the applicability and practicality of implementing a program designed to eradicate the backlog of six target NSDs from the list of 44 Disease Control Priorities 3rd edition (DCP3) surgical interventions. The human rights-based approach (HRBA) was used to clarify NSDs role within global health. Literature reviews were conducted to ascertain the global disease burden, estimated global backlog, average cost per treatment, disability-adjusted life-years (DALYs) averted from the treatment, return on investment, and potential gain and economic impact of the NSDs identified. Six index NSDs were identified, including neglected cleft lips and palate, clubfoot, cataracts, hernias and hydroceles, injuries, and obstetric fistula. Global definitions were proposed as a starting point towards the prevention and elimination of the backlog of NSDs. Defining a subset of neglected surgical conditions that illustrates society's role and responsibility in addressing them provides a framework through the HRBA lens for its eventual eradication.

Telesurgery's potential role in improving surgical access in Africa

An estimated five billion people worldwide lack access to surgical care, while LMICs including African nations require an additional 143 million life-saving surgical procedures each year.African hospitals are under-resourced and understaffed, causing global attention to be focused on improving surgical access in the continent. The African continent saw its first telesurgery application when the United States Army Special Operations Forces in Somalia used augmented reality to stabilize lifethreatening injuries.Various studies have been conducted since the first telesurgery implementation in 2001 to further optimize its application.In context of a relative shortage of healthcare resources and personnel telesurgery can considerably improve quality and access to surgical services in Africa.telesurgery can provide remote African regions with access to knowledge and tools that were previously unavailable, driving innovative research and professional growth of surgeons in the region.At the same time, telesurgery allows less trained surgeons in remote areas with lower social determinants of health, such as access, to achieve better health outcomes. However, lack of stable internet access, expensive equipment costs combined with low expenditure on healthcare limits expansive utilization of telesurgery in Africa. Regional and international policies aimed at overcoming these obstacles can improve access, optimize surgical care and thereby reduce disease burden associated with surgical conditions in Africa.

Do health policies address the availability, accessibility, acceptability, and quality of human resources for health? Analysis over three decades of National Health Policy of India

BACKGROUND

Human Resources for Health (HRH) are crucial for improving health services coverage and population health outcomes. The World Health Organisation (WHO) promotes countries to formulate holistic policies that focus on four HRH dimensions-availability, accessibility, acceptability, and quality (AAAQ). The status of these dimensions and their incorporation in the National Health Policies of India (NHPIs) are not well known.

METHODS

We created a multilevel framework of strategies and actions directed to improve AAAQ HRH dimensions. HRH-related recommendations of NHPI-1983, 2002, and 2017 were classified according to targeted dimensions and cadres using the framework. We identified the dimensions and cadres focussed by NHPIs using the number of mentions. Furthermore, we introduce a family of dimensionwise deficit indices formulated to assess situational HRH deficiencies for census years (1981, 2001, and 2011) and over-year trends. Finally, we evaluated whether or not the HRH recommendations in NHPIs addressed the deficient cadres and dimensions of the pre-NHPI census years.

RESULTS

NHPIs focused more on HRH availability and quality compared to accessibility and acceptability. Doctors were prioritized over auxiliary nurses-midwives and pharmacists in terms of total recommendations. AAAQ indices showed deficits in all dimensions for almost all HRH cadres over the years. All deficit indices show a general decreasing trend from 1981 to 2011 except for the accessibility deficit. The recommendations in NHPIs did not correspond to the situational deficits in many instances indicating a policy priority mismatch.

CONCLUSION

India needs to incorporate AAAQ dimensions in its policies and monitor their progress. The framework and indices-based approach can help identify the gaps between targeted and needed dimensions and cadres for effective HRH strengthening. At the global level, the application of framework and indices will allow a comparison of the strengths and weaknesses of HRH-related policies of various nations.

Female breast cancer in sub-Saharan Africa: A PRISMA-S-compliant systematic review of surgery

BACKGROUND

In sub-Saharan countries (SSAs), the advanced stage at diagnosis and the limited surgical interventions of female breast cancer (FBC) lead to poor outcomes. This study assessed current modalities of FBC surgeries.

METHODS

Six literature databases (Medline, Embase, African Journal Online, Google Scholar, Web of Science, Cochrane Library) were searched, plus a manual search, in 2011-2021. We included primary data studies with any setting and presurgeries or postsurgeries treatments, we excluded non-English language studies, editorials, and grey literature.

RESULTS

The search yielded 21 observational studies (16 retrospective, 3 prospective, and 2 case reports). Of the total 6900 patients, 4121 (60%) patients underwent FBC surgical excision only, and 751/2779 (27%) conservative surgery (BCS) or therapy (BCT). All studies reported similar use of mastectomy (>60%), the FBC surgical excision/reconstruction studies displayed more neoadjuvant chemotherapy (536/2779, 19% vs. 215/4121, 5%), and radiotherapy or adjuvant radiotherapy (1461/2779, 52% vs. 411/3921, 4%). Patients' age, histological classification, staging, and follow-up data were often missing.

CONCLUSIONS

The FBC complexity requires structured management by general and plastic surgeons, radiotherapy specialists, and obstetrician-gynecologists through shared guidelines, protocols, and specific programs of public health. In SSAs, FBC surgical strategies should point at decreasing radical mastectomy and increasing BCS/BCT.

Financing of surgery and anaesthesia in sub-Saharan Africa: a scoping review

OBJECTIVE

This study aimed to provide an overview of current knowledge and situational analysis of financing of surgery and anaesthesia across sub-Saharan Africa (SSA).

SETTING

Surgical and anaesthesia services across all levels of care-primary, secondary and tertiary.

DESIGN

We performed a scoping review of scientific databases (PubMed, EMBASE, Global Health and African Index Medicus), grey literature and websites of development organisations. Screening and data extraction were conducted by two independent reviewers and abstracted data were summarised using thematic narrative synthesis per the financing domains: mobilisation, pooling and purchasing.

RESULTS

The search resulted in 5533 unique articles among which 149 met the inclusion criteria: 132 were related to mobilisation, 17 to pooling and 5 to purchasing. Neglect of surgery in national health priorities is widespread in SSA, and no report was found on national level surgical expenditures or budgetary allocations. Financial protection mechanisms are weak or non-existent; poor patients often forego care or face financial catastrophes in seeking care, even in the context of universal public financing (free care) initiatives.

CONCLUSION

Financing of surgical and anaesthesia care in SSA is as poor as it is underinvestigated, calling for increased national prioritisation and tracking of surgical funding. Improving availability, accessibility and affordability of surgical and anaesthesia care require comprehensive and inclusive policy formulations.

Prediction of the Complication Risk in Drug-Resistant Tuberculosis After Surgery: Development and Assessment of a Novel Nomogram

Background: Surgery is increasingly accepted as an adjunctive approach to treat multidrug-resistant tuberculosis (MDR-TB) or extensively drug-resistant tuberculosis (XDR-TB). However, a model that includes all factors to predict the risk of postoperative complications is lacking.

Methods: We developed a prediction model based on 138 patients who had undergone surgery as treatment for drug-resistant tuberculosis (DR-TB) after 24 months. Clinical features on the lesion type (L), treatment history (T), physiologic status of the body (B), and surgical approach (S) were evaluated. Multivariable logistic regression analysis was conducted by clinical features selected in the least absolute shrinkage and selection operator (LASSO) to build a nomogram. The discrimination, calibration, and clinical usefulness of the nomogram were assessed using the C-Index, calibration plots, and decision curves. Internal validation was assessed using bootstrapping.

Results: The nomogram contained the features L, B, T, cavitary, recurrent chest infection (RCI) and MDR-TB/XDR-TB. The model displayed good discrimination with a C-Index of 0.879 (95% CI: 0.799–0.967). A high C-Index of 0.824 was achieved in the interval validation. Decision-curve analysis showed that the nomogram was clinically useful if intervention was decided at the non-adherence possibility threshold of 4%.

Conclusion: Our novel nomogram could be used conveniently to predict postoperative complication risk in DR-TB patients.

Geospatial Mapping of Pediatric Surgical Capacity in North Kivu, Democratic Republic of Congo

BACKGROUND

Despite recent attention to the provision of healthcare in low- and middle-income countries, improvements in access to surgical services have been disproportionately lagging.

METHODS

This study analyzes the geographic variability in access to pediatric surgical services in the province of North Kivu, Democratic Republic of Congo (DRC). On-site data collection was conducted using the Global Assessment of Pediatric Surgery tool. Spatial distribution of providers was mapped using the Geographical Information System and open-sourced spatial data to determine distances traveled to access surgical care.

RESULTS

Forty facilities were evaluated across 32 health zones; 68.9% of the provincial population was within 15 km of these facilities. Eleven facilities met a minimum World Health Organization safety score of 8; 48.1% of the population was within 15 km of corresponding facilities. The majority of children were treated by someone with specific pediatric surgery training in only 4 facilities; one facility had a trained pediatric anesthesia provider. Fifty-seven percent of the population was within 15 km of a facility with critical care and emergency medicine (EM) capabilities. There was one pediatric critical care provider and no pediatric EM providers identified within the province. Location-allocation assessment is needed to combine geographic area with potential for greatest impact and facility assessment.

CONCLUSIONS

Limitations in access to surgical care in the DRC are multifactorial with poor resources, few formally trained surgical providers, and near-absent access to pediatric anesthesiologists. The study highlights the deficits in the capacity for surgical care while demonstrating a reproducible model for assessment and identification of ways to improve access to care.

Day case laparoscopic cholecystectomy at Kilimanjaro Christian Medical Centre, Tanzania

INTRODUCTION

The Lancet Commission on Global Surgery has promoted the case for safe, affordable surgical care in low- and middle-income countries (LMICs). In 2017, Kilimanjaro Christian Medical Centre (KCMC) in Tanzania introduced a day case laparoscopic cholecystectomy (DCLC) service, the first of its kind in Sub-Saharan Africa (SSA). We aimed to evaluate this novel service in terms of safety, feasibility and acceptability by patients and staff.

METHODS

This study used mixed methods and was split into two stages. In stage 1, we reviewed records of all laparoscopic cholecystectomies (LCs) comparing day cases and admissions. These patients were followed up with a telephone questionnaire to investigate complication rates and receive service feedback. Stage 2 consisted of semi-structured interviews with staff exploring the challenges KCMC faced in implementing DCLC.

RESULTS

147 laparoscopic cholecystectomies were completed: 109 were planned for DCLC, 82 (75.2%) of which were successful, whilst 27 (24.8%) patients were admitted. No variables significantly predicted unplanned admission, the commonest causes for which were pain and nausea. In the DCLC group there was 1 readmission. 62 patients answered the follow up questionnaire, 60 (97%) of which were satisfied with the service. Stage 2 interviews suggested staff to be motivated for DCLC but revealed poor organisation of the day case pathway.

CONCLUSION

High rates of DCLC combined with low rates of complications and readmission suggests DCLC is feasible at KCMC. However, staff interviews alluded to administrative problems preventing KCMC from reaching its full DCLC potential. A dedicated day case surgery unit would address most of these problems.

Epidemiology of paediatric injuries in Rwanda using a prospective trauma registry

BACKGROUND

Child survival initiatives historically prioritized efforts to reduce child morbidity and mortality from infectious diseases and maternal conditions. Little attention has been devoted to paediatric injuries in resource-limited settings. This study aimed to evaluate the demographics and outcomes of paediatric injury in a sub-Saharan African country in an effort to improve prevention and treatment.

METHODS

A prospective trauma registry was established at the two university teaching campuses of the University of Rwanda to record systematically patient demographics, prehospital care, initial physiology and patient outcomes from May 2011 to July 2015. Univariable analysis was performed for demographic characteristics, injury mechanisms, geographical location and outcomes. Multivariable analysis was performed for mortality estimates.

RESULTS

Of 11 036 patients in the registry, 3010 (27·3 per cent) were under 18 years of age. Paediatric patients were predominantly boys (69·9 per cent) and the median age was 8 years. The mortality rate was 4·8 per cent. Falls were the most common injury (45·3 per cent), followed by road traffic accidents (30·9 per cent), burns (10·7 per cent) and blunt force/assault (7·5 per cent). Patients treated in the capital city, Kigali, had a higher incidence of head injury (7·6 per cent versus 2·0 per cent in a rural town, P < 0·001; odds ratio (OR) 4·08, 95 per cent c.i. 2·61 to 6·38) and a higher overall injury-related mortality rate (adjusted OR 3·00, 1·50 to 6·01; P = 0·019). Pedestrians had higher overall injury-related mortality compared with other road users (adjusted OR 3·26, 1·37 to 7·73; P = 0·007).

CONCLUSION

Paediatric injury is a significant contributor to morbidity and mortality. Delineating trauma demographics is important when planning resource utilization and capacity-building efforts to address paediatric injury in low-resource settings and identify vulnerable populations.

What is 'global surgery'? Defining the multidisciplinary interface between surgery, anaesthesia and public health

'Global surgery' is the term adopted to describe a rapidly developing multidisciplinary field aiming to provide improved and equitable surgical care across international health systems. Sitting at the interface between numerous clinical and non-clinical specialisms, it encompasses multiple aspects that surround the treatment of surgical disease and its equitable provision across health systems globally. From defining the role of, and need for, optimal surgical care through to identifying barriers and implementing improvement, global surgery has an expansive remit. Advocacy, education, research and clinical components can all involve surgeons, anaesthetists, nurses and allied healthcare professionals working together with non-clinicians, including policy makers, epidemiologists and economists. Long neglected as a topic within the global and public health arenas, an increasing awareness of the extreme disparities internationally has driven greater engagement. Not necessarily restricted to specific diseases, populations or geographical regions, these disparities have led to a particular focus on surgical care in low-income and middle-income countries with the greatest burden and needs. This review considers the major factors defining the interface between surgery, anaesthesia and public health in these settings.

Challenges of Caring for Functionally Single Ventricle Patients in Africa

Surgical palliation has remarkably improved survival of functionally single ventricle (FSV) patients born in developed nations but such outcomes have not occurred in Africa. The poor care coverage for FSV patients in Africa exists within the larger sphere of deficient health care for children born with congenital heart defects (CHDs) in Africa generally. This review takes the position that to improve health-care coverage for CHD patients on the continent, political priority is paramount. This can be attained with cohesive leadership for the CHD agenda, a guiding institution, and the mobilization of civil society to drive advocacy at national and international levels.

Framework for developing a national surgical, obstetric and anaesthesia plan

Background

Emergency and essential surgical, obstetric and anaesthesia (SOA) care are now recognized components of universal health coverage, necessary for a functional health system. To improve surgical care at a national level, strategic planning addressing the six domains of a surgical system is needed. This paper details a process for development of a national surgical, obstetric and anaesthesia plan (NSOAP) based on the experiences of frontline providers, Ministry of Health officials, WHO leaders, and consultants.

Methods

Development of a NSOAP involves eight key steps: Ministry support and ownership; situation analysis and baseline assessments; stakeholder engagement and priority setting; drafting and validation; monitoring and evaluation; costing; governance; and implementation. Drafting a NSOAP involves defining the current gaps in care, synthesizing and prioritizing solutions, and providing an implementation and monitoring plan with a projected cost for the six domains of a surgical system: infrastructure, service delivery, workforce, information management, finance and governance.

Results

To date, four countries have completed NSOAPs and 23 more have committed to development. Lessons learned from these previous NSOAP processes are described in detail.

Conclusion

There is global movement to address the burden of surgical disease, improving quality and access to SOA care. The development of a strategic plan to address gaps across the SOA system systematically is a critical first step to ensuring countrywide scale‐up of surgical system‐strengthening activities.

Healthcare Leaders Develop Strategies for Expanding National Surgical, Obstetric, and Anaesthesia Plans in WHO AFRO and EMRO Regions

BACKGROUND

Worldwide, five billion people lack access to safe, affordable surgical, obstetric, and anaesthesia (SOA) care when needed. In many countries, a growing commitment to SOA care is culminating in the development of national surgical, obstetric, and anaesthesia plans (NSOAPs) that are fully embedded in the National Health Strategic Plan. This manuscript highlights the content and outputs from a World Health Organization (WHO) lead workshop that supported country-led plans for improving SOA care as a component of health system strengthening.

METHODS

In March 2018, a group of 79 high-level global SOA stakeholders from 25 countries in the WHO AFRO and EMRO regions gathered in Dubai to provide technical and strategic guidance for the creation and expansion of NSOAPs.

RESULTS

Drawing on the experience and expertise of represented countries that are at different stages of the NSOAP process, topics covered included (1) the global burden of surgical, obstetric, and anaesthetic conditions; (2) the key principles and components of NSOAP development; (3) the critical evaluation and feasibility of different models of NSOAP implementation; and (4) innovative financing mechanisms to fund NSOAPs.

CONCLUSIONS

Lessons learned include: (1) there is unmet need for the establishment of an NSOAP community in order to provide technical support, expertise, and mentorship at a regional level; (2) data should be used to inform future priorities, for monitoring and evaluation and to showcase advances in care following NSOAP implementation; and (3) SOA health system strengthening must be uniquely prioritized and not hidden within other health strategies.

Surgical leadership in Africa - challenges and opportunities

Surgical care has been described as one of the Cinderellas in the global health development agenda, taking a backseat to public health, child health, and infectious diseases. In the midst of such competing health-care needs, surgical care, often viewed by policy makers as luxurious and the preserve of the rich, gets relegated to the bottom of priority lists. In the meantime, infectious disease, malnutrition, and other ailments, viewed as largely affecting the poor and disadvantaged in society, get embedded in national health plans, receiving substantial funding and public health program development. It is often stated that the main reason for this sad state of affairs in surgical care is the lack of political will to improve matters in the health sector. Indeed, in 2001, the Commission on Macroeconomics and Health concluded that the lack of political will to sufficiently increase spending on health at the sub-national, national, and international levels was perhaps the most critical barrier to improving health in low-income countries. However, at the root of this lack of political will is a lack of political priority for surgical care.

Towards equitable surgical systems: development and outcomes of a national surgical, obstetric and anaesthesia plan in Tanzania

Despite emergency and essential surgery and anaesthesia care being recognised as a part of Universal Health Coverage, 5 billion people worldwide lack access to safe, timely and affordable surgery and anaesthesia care. In Tanzania, 19% of all deaths and 17 % of disability-adjusted life years are attributable to conditions amenable to surgery. It is recommended that countries develop and implement National Surgical, Obstetric and Anesthesia Plans (NSOAPs) to systematically improve quality and access to surgical, obstetric and anaesthesia (SOA) care across six domains of the health system including (1) service delivery, (2) infrastructure, including equipment and supplies, (3) workforce, (4) information management, (5) finance and (6) Governance. This paper describes the NSOAP development, recommendations and lessons learnt from undertaking NSOAP development in Tanzania. The NSOAP development driven by the Ministry of Health Community Development Gender Elderly and Children involved broad consultation with over 200 stakeholders from across government, professional associations, clinicians, ancillary staff, civil society and patient organisations. The NSOAP describes time-bound, costed strategic objectives, outputs, activities and targets to improve each domain of the SOA system. The final NSOAP is ambitious but attainable, reflects on-the-ground priorities, aligns with existing health policy and costs an additional 3% of current healthcare expenditure. Tanzania is the third country to complete such a plan and the first to report on the NSOAP development in such detail. The NSOAP development in Tanzania provides a roadmap for other countries wishing to undertake a similar NSOAP development to strengthen their SOA system.

Surgical Capacity at District Hospitals in Zambia: From 2012 to 2016

BACKGROUND

Sub-Saharan Africa has one of the highest burdens of surgically treatable conditions in the world and the highest unmet need, especially in rural areas. Zambia is one of the countries in the region taking steps to improve surgical care for its rural populations.

AIM

To demonstrate changes in surgical capacity in Zambia's district hospitals over a 3-year period and to provide a baseline from which future interventions in surgical care can be assessed.

METHODS

A cross-sectional assessment of surgical capacity, using a modified WHO questionnaire, was administered in first-level hospitals in nine of Zambia's ten provinces between November 2012 and February 2013 and again between February and April 2016. The two assessments allowed measurement of changes in surgical workforce, infrastructure, equipment, drugs and consumables; and numbers of major surgical procedures performed over two 12-month periods prior to the assessments.

RESULTS

There was a significant increase, 2013-2016, in number of theatre staff, from 174 (mean 4.4; SD 1.7) to 235 (mean 6; SD 2.9), P = 0.02. However, the percentage of hospitals with functioning anaesthetic machines dropped from 64 to 41%. There was also a drop in hospitals reporting availability of instruments, drugs and consumables from 38 to 24 (97-62%) and from 28 to 24 (72-62%), respectively. The median number of caesarean sections in 2012 was 99 [interquartile range (IQR) 42-187] and 100 (IQR 42-126) in 2015 (P value =0.53). The median number of major surgical procedures in 2012 was 54 (IQR 10-113) and 66 (IQR 18-168) in 2015 (P = 0.45).

CONCLUSION

An increase in the first-level hospital surgical workforce between 2013 and 2016 was accompanied by reductions in essential equipment and consumables for surgery, and no changes in surgical output. Periodic monitoring of resource availability is needed to address shortages and make safe surgery available to rural populations.

Assessing the impact of HIV status on injury outcomes: A multicenter study of trauma patients in Rwanda

BACKGROUND

There is conflicting evidence regarding the impact of human immunodeficiency virus serostatus on trauma outcomes in low-resource settings. This study sought to evaluate the impact of human immunodeficiency virus serostatus on mortality outcomes for Rwandan patients presenting after trauma.

METHODS

This retrospective review of the University of Rwanda trauma registry captured all adult trauma patients with known human immunodeficiency virus status presenting between March 2011 and July 2015. Confirmed human immunodeficiency virus-positive cases were matched 1:2 with known human immunodeficiency virus-negative controls using a modified Kampala Trauma Score, sex, and district of residence or primary hospital. All-cause mortality was compared using multivariable logistic regression.

RESULTS

In total, 11,280 patients were recorded prospectively in the registry (169 human immunodeficiency virus positive; 334 human immunodeficiency virus negative matches). There was no difference in delay of hospital presentation or time until operation (P = .50 and P = .57, respectively). Less than 30% of all patients underwent operation during admission (n = 133), and the rate of operative intervention was independent of human immunodeficiency virus serostatus (P = .946). There was no association between development of any complication and human immunodeficiency virus status (P = .837). The overall mortality rate was 8.9% and 3.3% for human immunodeficiency virus-positive and human immunodeficiency virus-negative patients, respectively (P = .010). Human immunodeficiency virus positivity was associated with increased 30-day mortality when controlling for potential confounders (P = .016; odds ratio 3.60, 95% confidence interval: 1.27-10.2, C statistic 0.88).

CONCLUSION

Both human immunodeficiency virus and trauma pose substantial public health threats in sub-Saharan Africa. Known human immunodeficiency virus seropositivity in Rwandan trauma patients is associated with early mortality. Further investigation regarding testing, treatment, and outcomes in human immunodeficiency virus-positive trauma patients is warranted and provides an opportunity for leveraging human immunodeficiency virus global health efforts in trauma outcomes assessment.

Global Surgery - Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa

Surgery has the potential to address one of the largest, neglected burdens of disease in low- and middle-income countries (LMICs), especially in sub-Saharan Africa (SSA). The Lancet Commission on Global Surgery (LCoGS) has provided a blueprint for a systems approach to making safe emergency and elective surgery accessible and affordable and has started to enable African governments to develop national surgical plans. This editorial outlines an important gap, which is the need for surgical systems research, especially at district hospitals which are the first point of surgical care for rural communities, to inform the implementation of country plans. Using the Lancet Commission as a starting point and illustrated by two European Union (EU) funded research projects, we point to the need for implementation research to develop and evaluate contextualised strategies. As illustrated by the case study of Zambia, coordination by global and external stakeholders can enable governments to lead national scale-up of essential surgery, supported by national partners including surgical specialist associations.