Exploring the Relationship Between Surgical Capacity and Output in Ghana: Current Capacity Assessments May Not Tell the Whole Story

Assessment of essential surgical and anaesthesia care capacity: a cross-sectional study in five Pacific Island Countries

Background

Pacific Island Countries (PICs) face unique challenges in providing surgical care. We assessed the surgical care capacity of five PICs to inform the development of National Surgical, Obstetric and Anaesthesia Plans (NSOAP).

Methods

We conducted a cross-sectional survey of 26 facilities in Fiji, Tonga, Vanuatu, Cook Islands, and Palau using the World Health Organization - Program in Global Surgery and Social Change Surgical Assessment Tool.

Findings

Eight referral and 18 first-level hospitals containing 39 functioning operating theatres, 41 post-anaesthesia care beds, and 44 intensive care unit beds served a population of 1,321,000 across the five countries. Most facilities had uninterrupted access to electricity, water, internet, and oxygen. However, CT was only available in 2/8 referral hospitals, MRI in 1/8, and timely blood transfusions in 4/8. The surgical, obstetric, and anaesthetist specialist density per 100,000 people was the highest in Palau (49.7), followed by Cook Islands (22.9), Tonga (9.9), Fiji (7.1), and Vanuatu (5.0). There were four radiologists and 3.5 pathologists across the five countries. Surgical volume per 100,000 people was the lowest in Vanuatu (860), followed by Fiji (2,247), Tonga (2,864), Cook Islands (6,747), and Palau (8,606). The in-hospital peri-operative mortality rate (POMR) was prospectively monitored in Tonga and Cook Islands but retrospectively measured in other countries. POMR was below 1% in all five countries.

Interpretation

Whilst PICs share common challenges in providing specialised tertiary services, there is substantial diversity between the countries. Strategies to strengthen surgical systems should incorporate both local contextualisation within each PIC and regional collaboration between PICs.

Funding

None.

Nationwide enumeration of emergency operations performed in Ghana

PURPOSE

To determine the population-based rate of emergency surgery performed in Ghana, categorized by hospital level.

METHODS

Data on operations performed from June 2014 to May 2015 were obtained from a nationally representative sample of hospitals and scaled up to nationwide estimates. Operations were categorized as to: "emergency" or "elective" and as to "essential" (most cost-effective, highest population impact) or "other" according to the World Bank's Disease Control Priorities project.

RESULTS

Of 232,776 (95% UI 178,004-287,549) total operations performed nationally, 48% were emergencies. 112,036 emergency operations (95% UI 92,105-131,967) were performed and the annual national rate was 416 per 100,000 population (95% UI 342-489). Most emergency operations (87%) were in the essential category. Of essential emergency procedures, 47% were obstetric and gynecologic, 22% were general surgery, and 31% were trauma. District (first-level) hospitals performed 54%, regional hospitals 10%, and tertiary hospitals 36% of all emergency operations. About half (54%) of district hospitals did not have a fully trained surgeon, however, these hospitals performed 36% of district hospital emergency operations and 20% of all emergency operations.

CONCLUSIONS

Emergency operations make up nearly half of all operations performed in Ghana. Most are performed at district hospitals, many of which do not have fully trained surgeons. Obstetric procedures make up a large portion of emergency operations, indicating a need for improved provision of non-obstetric emergency surgical care. These data are useful for future benchmarking efforts to improve availability of emergency surgical care in Ghana and other low- and middle-income countries.

Incidence of childhood burn injuries and modifiable household risk factors in rural Ghana: A cluster-randomized, population-based, household survey

BACKGROUND

We aimed to determine the incidence of childhood burn injuries in rural Ghana and describe modifiable household risk factors to inform prevention initiatives.

METHODS

We performed a cluster-randomized, population-based survey of caregivers of children in a rural district in Ghana, representing 2713 households and 14,032 children. Caregivers were interviewed regarding childhood burn injuries within the past 6 months and household risk factors.

RESULTS

357 households were sampled. Most used an open fire with biomass fuel for cooking (85.8%). Households rarely cooked in a separate kitchen (10%). Stove height was commonly within reach of children under five years (<1 m; 96.0%). The weighted annualized incidence of CBI was 63 per 1000 child-years (6.4% of children per year); reported mean age was 4.4 years (SD 4.0). The most common etiology was flame burn. Older age (OR 0.89, 95% CI 0.8-1.0) and households with an older sibling ≥12 years (OR 0.58, 95% CI 0.3-1.3) seemed to be associated with lower odds of CBI.

CONCLUSIONS

Childhood burn injury is common in rural Ghana. Opportunities exist to reduce the risk of childhood burn injury childhood burns in rural settings by supporting the transition to safer cooking arrangements, child barrier apparatuses in homes without older children, and/or development of formal childcare programs.

Impact of surgical infrastructure and personnel on volume and availability of essential surgical procedures in Liberia

BACKGROUND

Essential surgical procedures rank among the most cost-effective of all healthcare interventions. The aim of this study was to enumerate surgical volumes in Liberia, quantify surgical infrastructure, personnel and availability of essential surgical procedures, describe surgical facilities, and assess the influence of human resources and infrastructure on surgical volumes.

METHODS

An observational countrywide survey was done in Liberia between 20 September and 8 November 2018. All healthcare facilities performing surgical procedures requiring general, regional or local anaesthesia in an operating theatre between September 2017 and August 2018 were eligible for inclusion. Information on facility infrastructure and human resources was collected by interviewing key personnel. Data on surgical volumes were extracted from operating theatre log books.

RESULTS

Of 70 healthcare facilities initially identified as possible surgical facilities, 52 confirmed operative capacity and were eligible for inclusion; all but one shared surgical data. A national surgical volume of 462 operations per 100 000 population was estimated. The median hospital offered nine of 26 essential surgical procedures. Unequal distributions of surgical infrastructure, personnel, and essential surgical procedures were identified between facilities. In multivariable regression analysis, surgical human resources (β = 0·60, 95 per cent c.i. 0·34 to 0·87; P < 0·001) and infrastructure (β = 0·03, 0·02 to 0·04; P < 0·001) were found to be strongly associated with operative volumes.

CONCLUSION

The availability of essential surgical procedures in Liberia is extremely low. Descriptive tools can quantify inequalities, guide resource allocation, and highlight rational investment areas.

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.

Mixed-methods assessment of surgical capacity in two regions in Ethiopia

Background

Surgery is among the most neglected parts of healthcare systems in low- and middle-income countries. Ethiopia has launched a national strategic plan to address challenges in the surgical system. This study aimed to assess surgical capacity in two Ethiopian regions to inform priority areas for improvement.

Methods

A mixed-methods study was conducted using two tools adapted from the Lancet Commission's Surgical Assessment Tools: a quantitative Hospital Assessment Tool and a qualitative semistructured interview tool. Fifteen hospitals selected by the Federal Ministry of Health were surveyed in the Tigray and Amhara regions to assess the surgical system across five domains: service delivery, infrastructure, workforce, information management and financing.

Results

Service delivery was low across hospitals with a mean(s.d.) of 5(6) surgical cases per week and a narrow range of procedures performed. Hospitals reported varying availability of basic infrastructure, including constant availability of electricity (9 of 15) and running water (5 of 15). Unavailable or broken diagnostic equipment was also common. The majority of surgical and anaesthesia services were provided by non-physician clinicians, with little continuing education available. All hospitals tracked patient-level data regularly and eight of 15 hospitals reported surgical volume data during the assessment, but research activities were limited. Hospital financing specified for surgery was rare and the majority of patients must pay out of pocket for care.

Conclusion

Results from this study will inform programmes to simultaneously improve each of the health system domains in Ethiopia; this is required if better access to and quality of surgery, anaesthesia and obstetric services are to be achieved.