Access to Orthopaedic Surgical Care in Northern Tanzania: A Modelling Study

Measurements of Impoverishing and Catastrophic Surgical Health Expenditures in Low- and Middle-Income Countries and Reduction Interventions in the Last 30 Years: A Systematic Review

INTRODUCTION

Approximately 33 million people suffer catastrophic health expenditure (CHE) from surgery and/or anesthesia costs. The aim of this systematic review is to evaluate catastrophic and impoverishing expenditure associated with surgery and anesthesia in low- and middle-income countries (LMICs).

METHODS

We performed a systematic review of all studies from 1990 to 2021 that reported CHE in LMICs for treatment of a condition requiring surgical intervention, including cesarean section, trauma care, and other surgery.

RESULTS

77 studies met inclusion criteria. Tertiary facilities (23.4%) were the most frequently studied facility type. Only 11.7% of studies were conducted in exclusively rural health-care settings. Almost 60% of studies were retrospective in nature. The cost of procedures ranged widely, from $26 USD for a cesarean section in Mauritania in 2020 to $74,420 for a pancreaticoduodenectomy in India in 2018. GDP per capita had a narrower range from $315 USD in Malawi in 2019 to $9955 USD in Malaysia in 2015 (Median = $1605.50, interquartile range = $1208.74). 35 studies discussed interventions to reduce cost and catastrophic expenditure. Four of those studies stated that their intervention was not successful, 18 had an unknown or equivocal effect on cost and CHE, and 13 concluded that their intervention did help reduce cost and CHE.

CONCLUSIONS

CHE from surgery is a worldwide problem that most acutely affects vulnerable patients in LMICs. Existing efforts are insufficient to meet the true need for affordable surgical care unless assistance for ancillary costs is given to patients and families most at risk from CHE.

Orthopaedic and trauma research in Tanzania: A scoping review

Tanzania is disproportionately burdened by musculoskeletal injuries as it faces unique challenges when dealing with trauma care. This scoping review aims to summarize and assess the current state of orthopaedic and trauma research in Tanzania. By identifying key themes, trends, and gaps in the literature, this review seeks to guide future research initiatives catered specifically to the needs of Tanzania's healthcare system. Utilizing the PRISMA-ScR protocol, OVID Medline, PubMed, and CINAHL databases were searched from inception to June 17, 2023, using keywords such as "Orthopaedics" "Trauma" and "Tanzania". One hundred and ninety-two eligible studies were included and the Arksey and O'Malley framework for scoping studies was followed. There was a notable growth of relevant publications from 2015 onward, with peaks in growth in the years 2019, 2021, and 2020. The studies employed diverse research methodologies, with cross-sectional (n = 41, 21%) and prospective studies (n = 39, 20%) being the most prevalent, and randomized-controlled trials being the least prevalent methodology, making up eight studies (4.2%). The most common study themes were trauma (n = 101, 52.6%), lower extremity (n = 31, 16%), and spine-related issues (n = 27, 14%). Only three studies looked at work-related injuries (1.6%). Road traffic injuries (RTIs) were the most common mechanism of trauma in 77.0% of the trauma focused studies. Fifty-three percent of the studies were conducted by a majority of Tanzanian authors. This scoping review highlights various trends in orthopaedic and trauma research in Tanzania, with a particular emphasis on road traffic-related injuries. Various gaps are explored, including a lack of research on work-related injuries and a paucity of experimental research. Our findings underline areas where future research is warranted. The future of orthopaedic and trauma care in Tanzania depends on the efforts and collaboration of both local and international stakeholders.

Systems issues limiting acute fracture care delivery at a tertiary care hospital in Northern Tanzania

Introduction

sub-Saharan Africa experiences a significant musculoskeletal trauma burden. Among patients who receive surgical treatment, there have been no reports as to how often surgical care is determined to be "adequate" or, if "inadequate", then what hospital and orthopaedic specialty-specific systems limitations might be prohibitive.

Methods

data from patients presenting to the orthopaedic trauma service at a tertiary care center in sub-Saharan Africa were prospectively collected over a 6-week period and then retrospectively reviewed to determine whether the surgical treatment was "adequate" (or otherwise, "inadequate") according to the principle of restoring length, alignment, and rotation. Exclusion criteria included insufficient clinical information; isolated spinal injury; infection; cases involving only removal of hardware; soft-tissue procedures; tumor cases; and medical (non-surgical) conditions.

Results

112 cases were included for analysis. Surgery was indicated in 106 of 112 cases (94.6%), and of those, surgery was performed in 62 cases (58.4%). Among patients who underwent surgery with available post-operative imaging (n=56), surgical treatment was "inadequate" in 24 cases (42.9%). The most common reasons treatment was deemed "inadequate" included unavailability of appropriate implants (n=16), unavailability of intraoperative fluoroscopy (n=10) and incomplete intraoperative evaluation of injury (n=5).

Conclusion

several systems limitations prevent the delivery of adequate surgical treatment in patients with acute orthopaedic traumatic injuries, including lack of intraoperative fluoroscopy and lack of implant availability. This study will serve as a useful baseline for ongoing efforts seeking to improve orthopaedic specialty resource availability and facilitate more effective fracture care in this region.

Barriers and Motivations for Health Insurance Subscription Among Health-Care Users in Cameroon

INTRODUCTION

Surgical care is a significant component of the overall health expenditure in low- and middle-income countries. In Cameroon, out-of-pocket payments for surgical service are very high with many patients declining potentially curative surgical procedures. Less than 2% of the population is enrolled in a health insurance scheme leading to a propensity for catastrophic health expenses when accessing care. To assess the perceived barriers and motivations for health insurance subscription among health-care users in Cameroon.

METHODS

This was a cross-sectional community-based qualitative study conducted in the Center Region of Cameroon. A total of 37 health-care users (health insurance subscribers and nonsubscribers) were purposively identified. Four focused group discussions and thirteen in-depth interviews were conducted. All anonymized transcripts were analyzed using a thematic analysis approach.

RESULTS

The six major themes identified as barriers to health insurance subscription were lack of trust in the existing health insurance schemes, inadequate knowledge on how health insurance works, premiums believed to be too expensive, the complexity of the claims processing system, minimal usage of health-care services and practice of self-medication. Motivational factors included the knowledge of having access to quality health services even without money in the event of an unforeseen illness and having a large family/household size. The importance of mass sensitization on the benefits of health insurance was noted.

CONCLUSION

Health insurance is still very underutilized in Cameroon. This results in significant out-of-pocket payment for health services by Cameroonians with catastrophic consequences to households. With most Cameroonians in the informal sector and underemployed, it is imperative to put in place a national strategic plan to overcome existing barriers and increase health insurance coverage especially among the poor. This has the potential to significantly increase access to safe, quality, timely and affordable surgical care.

Evaluating the Social Impact of a Proposed Orthopedic Center of Excellence in Northern Tanzania: A Novel Use of the Impact Multiple of Money Methodology

BACKGROUND

Musculoskeletal injuries-often a result of Road Traffic Accidents (RTAs)-represent a significant burden in sub-Saharan Africa. RTA victims are faced with lifelong disability and diminished employment. Northern Tanzania in particular lacks the orthopedic surgical capacity needed to provide patients with definitive surgical fixation. While there is great potential in establishing an Orthopedic Center of Excellence (OCE), the precise social impact of such an initiative is currently unknown.

METHODS

To demonstrate the social value of an orthopedic OCE in Northern Tanzania, this paper proposes a methodology for calculating social impact. This methodology draws upon RTA-related Disability Adjusted Life Years (DALYs), current and projected surgical complication rates, anticipated changes in surgical volume, and average per capita income to quantify how much social value can be gained by mitigating the impact of RTAs. These parameters can be utilized to calculate an impact multiplier of money (IMM), stating the social returns on each dollar invested.

RESULTS

Modeling exercises demonstrate that improvements in the complication rate and surgical volume over the current baseline results in significant social impact. In the best-case scenario, the COE is expected to yield over $131 million over 10 years, with an IMM of 13.19.

CONCLUSIONS

Investments in orthopedic care will yield significant dividends, as demonstrated by our novel methodology. The cost-effectiveness of the OCE is comparable to, if not greater, than many other global health initiatives. More broadly, the IMM methodology can be used to quantify the impact of other projects aimed at reducing long-term injury.

Barriers to accessing follow up care in post-hospitalized trauma patients in Moshi, Tanzania: A mixed methods study

Disproportionately high injury rates in Sub-Saharan Africa combined with limited access to care in both the acute injury phase and for injury patients requiring continued care after hospital discharge remains a challenge. We aimed to characterize barriers to transportation and access to care in a cohort of post-hospitalized injury patients in Moshi, Tanzania. This was a mixed-methods study of a prospective cohort of trauma registry patients presenting to Kilimanjaro Christian Medical Center between August 2018 and January 2020. We conducted standardized patient/family surveys and in-depth interviews at a 2-week follow up visit after hospital discharge, and focus groups with healthcare providers. Quantitative results were analyzed using descriptive statistics and multivariable logistic regression using R statistical software. Qualitative results were analyzed using thematic analysis through an iterative process using NVivo software. A total of 1,365 patients were enrolled in the trauma registry, with 169 patients followed up at 2 weeks. Over half of patients at follow-up, 101 (59.8%), reported challenges in traveling. The majority of patients were male (80.3%). Difficulty in traveling since injury was associated with female gender (aOR 5.85 [95% CI 1.20-33.59]) and a need for non-family members escorts for travel (aOR 7.10 [95% CI 1.43-41.66]). Those who reported assault or fall as the mechanism of injury as compared to road traffic injury and had health insurance were less likely to report challenges in traveling (aOR 0.19 [95% CI 0.03-0.90]), 0.11 [95% CI 0.01-0.61], 0.14 [95% 0.02-0.80]). Transportation barriers that emerged from qualitative data included inability to use regular means of transportation, financial challenges, physical barriers, rigid compliance to physician orders, access to healthcare, and social support barriers. Our findings demonstrate several areas to address transportation barriers for post-injury patients in Tanzania. Educational interventions such as clarification of doctors' orders of strict bedrest, provision of vouchers to support financial challenges and alternate means of transportation given physical barriers and reliance on social support may address some of these barriers.

Definitive surgical femur fracture fixation in Northern Tanzania: implications of cost, payment method and payment status

Introduction

Kilimanjaro Christian Medical Centre (KCMC) covers major orthopaedic trauma for a catchment population of 12.5 million people in northern Tanzania. Femur fractures, the most common traumatic orthopaedic injury at KCMC (39%), require open reduction and internal fixation (ORIF) for definitive treatment. It is unclear whether payment affects care. This study sought to explore associations of payment method with episodes of care for femur fracture ORIFs at KCMC.

Methods

we performed a retrospective review of orthopaedic records between February 2018 and July 2018. Patients with femur fracture ORIF were eligible; patients without charts were excluded. Ethical clearance was obtained from the KCMC ethics committee. Statistical analysis utilized descriptive statistics, Chi-squared and Fisher’s exact Tests, and Student´s t-tests where appropriate.

Results

of 76 included patients, 17% (n=13) were insured, 83% (n=63) paid out-of-pocket, 11% (n=8) had unpaid balance, and 89% (n=68) fully paid. Average patient charge ($417) was 42% of per capita GDP ($998). Uninsured patients had higher bills ($429 vs $356; p=0.27) and were significantly more likely to pay an advance payment (95.2% vs 7.7%; p<0.001). Inpatient care was equivalent regardless of payment. Unpaid patients were less likely to receive follow-up (76.5% vs. 25%; p=0.006) and waited longer from injury to admission (31.5 vs 13.3 days; p<0.001), from admission to surgery (30.1 vs 11.1 days; p<0.001), and from surgery to discharge (18.4 vs 7.1 days; p<0.001).

Conclusion

equal standard of care is provided to all patients. However, future efforts may decrease disparities in advance payment, timeliness, and follow-up.

Limb Salvage for Musculoskeletal Tumors in the Austere Environment: Review of the Literature With Illustrative Cases Regarding Considerations and Pitfalls

Although there is literature discussing the treatment of acute and chronic trauma in austere environments, no literature or guidelines for the treatment of musculoskeletal tumors exist. This series discusses case examples with considerations and pitfalls of performing limb-salvage surgery in an underserved location. Cases of limb-salvage surgery performed by the same orthopaedic oncologist in Haiti and the Dominican Republic are discussed with a review of the literature on limb salvage for musculoskeletal tumors in developing nations. All patients successfully underwent limb-salvage surgery after considering multiple factors including tumor type and location. Patients with metastatic disease, likelihood of substantial blood loss, and poor health were not candidates for limb-salvage surgery. Medical missions and the development of partnerships with established training programs make limb salvage a greater possibility. Knowledge of the facility, anesthesia support, and instrumentation available is vital. Advanced imaging, blood products, and allograft are likely unavailable or difficult to obtain. Established continuity of care is necessary, and training of the local surgeon should be provided. Surgery should only be considered if it is safe and provides more of a benefit to the patient than an amputation.

Sterility of 3D-Printed Orthopedic Implants Using Fused Deposition Modeling

The use of 3-dimensional (3D) printing in orthopedics is developing rapidly and impacting the areas of preoperative planning, surgical guides, and simulation. As this technology continues to improve, the greatest impact of 3D printing may be in low- and middle-income countries where surgical items are in short supply. This study investigated sterility of 3D-printed ankle fracture fixation plates and cortical screws. The hypothesis was that the process of heated extrusion in fused deposition modeling printing would create sterile prints in a timely fashion that would not require postproduction sterilization. A free computer-assisted design program was used to design the implant models. One control group and 8 study groups were printed. Print construct, orientation, size, and postproduction sterilization differed among the groups. Sterility was assessed using thioglycollate broth cultures at 24 hours, 48 hours, and 7 days. Positive growth was speciated for aerobic and anaerobic bacteria. Print time and failed prints were recorded. Control samples were 100% positive for bacterial growth. All test samples remained sterile at all time points (100%). Speciation of control samples was obtained, and Staphylococcus was the most common species. Print times varied; however, no print time exceeded 6.75 minutes. Eighteen prints (17%) failed in the printing process. These findings demonstrate an intrinsic sterilization process associated with fused deposition modeling 3D printing and indicate the feasibility of 3D-printed surgical implants and equipment for orthopedic applications. With future research, 3D-printed implants may be a treatment modality to assist orthopedic surgeons in low- and middle-income countries. [Orthopedics. 2020; 43(1): 46-51.].

Three-dimensional Printing Technology in Orthopaedics

Three-dimensional (3-D) printing technology is affecting how orthopaedic surgeries are planned and executed. Like many innovations, 3-D printers are becoming smaller, more affordable, and more accessible. Free access to open-source 3-D imaging software has also made clinical implementation of this technology widely feasible. Within the last decade, 3-D printing advancements have improved the way orthopaedic surgeons can approach both common and complex cases. Advanced imaging studies can be used to create musculoskeletal models, which can then be used to create custom orthopaedic guides and instruments. Similarly, 3-D printing is being applied to improve the field of biologic therapies in orthopaedics. Application of 3-D printing technology has been associated with important improvements in education, preoperative planning, surgical care, and patient-specific devices and treatments. Improvements in cost-effectiveness, access, and usability of 3-D printing technology have made it possible for orthopaedic surgeons to use this powerful tool using desktop 3-D printers in their clinic or office. The types of printers and materials available to print are constantly expanding, but many of the basic 3-D printing principles persist throughout these advances in the field. A clear understanding of this technology is important to the clinical implementation of 3-D printing for current and future practice of orthopaedic care.

Understanding surgical care delivery in Sub-Saharan Africa: a cross-sectional analysis of surgical volume, operations, and financing at a tertiary referral hospital in rural Tanzania

Background

Access to surgical care in Low- and Middle-Income Countries (LMICs) such as Tanzania is extremely limited. Northern Tanzania is served by a single tertiary referral hospital, Kilimanjaro Christian Medical Centre (KCMC). The surgical volumes, workflow, and payment mechanisms in this region have not been characterized. Understanding these factors is critical in expanding access to healthcare. The authors sought to evaluate the operations and financing of the main operating theaters at KCMC in Sub-Saharan Africa.

Methods

The 2018 case volume and specialty distribution (general, orthopaedic, and gynecology) in the main operating theaters at KCMC was retrieved through retrospective review of operating report books. Detailed workflow (i.e. planned and cancelled cases, lengths of procedures, lengths of operating days) and financing data (patient payment methods) from the five KCMC operating theater logs were retrospectively reviewed for the available five-month period of March 2018 to July 2018. Descriptive statistics and statistical analysis were performed.

Results

In 2018, the main operating theaters at KCMC performed 3817 total procedures, with elective procedures (2385) outnumbering emergency procedures (1432). General surgery (1927) was the most operated specialty, followed by orthopaedics (1371) and gynecology (519). In the five-month subset analysis period, just 54.6% of planned operating days were fully completed. There were 238 cancellations (20.8% of planned operations). Time constraints (31.1%, 74 cases) was the largest reason; lack of patient payment accounted for as many cancellations as unavailable equipment (6.3%, 15 cases each). Financing for elective theater cases included insurance 45.5% (418 patients), and cash 48.4% (445 patients).

Conclusion

While surgical volume is high, there are non-physical inefficiencies in the system that can be addressed to reduce cancellations and improve capacity. Improving physical resources is not enough to improve access to care in this region, and likely in many LMIC settings. Patient financing and workflow will be critical considerations to truly improve access to surgical care.

TRANSPORTATION BARRIERS TO ACCESS HEALTH CARE FOR SURGICAL CONDITIONS IN MALAWI a cross sectional nationwide household survey

Background

It is estimated that nearly five billion people worldwide do not have access to safe surgery. This access gap disproportionately affects low-and middle-income countries (LMICs). One of the barriers to healthcare in LMICs is access to transport to a healthcare facility. Both availability and affordability of transport can be issues delaying access to health care. This study aimed to describe the main transportation factors affecting access and delay in reaching a facility for health care in Malawi.

Methods

This was a multi-stage, clustered, probability sampling with systematic sampling of households for transportation access to general health and surgical care. Malawi has an estimated population of nearly 18 million people, with a total of 48,233 registered settlements spread over 28 administrative districts. 55 settlements per district were randomly selected for data collection, and 2–4 households were selected, depending on the size. Two persons per household were interviewed.

The Surgeons Overseas Assessment of Surgical need (SOSAS) tool was used by trained personnel to collect data during the months of July and August 2016.

Analysis of data from 1479 households and 2958 interviewees was by univariate and multivariate methods.

Results

Analysis showed that 90.1% were rural inhabitants, and 40% were farmers. No formal employment was reported for 24.9% persons. Animal drawn carts prevailed as the most common mode of transport from home to the primary health facility - normally a health centre. Travel to secondary and tertiary level health facilities was mostly by public transport, 31.5 and 43.4% respectively. Median travel time from home to a health centre was 1 h, and 2.5 h to a central hospital. Thirty nine percent of male and 59% of female head of households reported lack financial resources to go to a hospital.

Conclusion

In Malawi, lack of suitable transport, finances and prolonged travel time to a health care centre, all pose barriers to timely access of health care. Improving the availability of transport between rural health centres and district hospitals, and between the district and central hospitals, could help overcome the transportation barriers to health care.

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.

Developing Sustainable Orthopaedic Care in Northern Tanzania: An International Collaboration

There is a devastating lack of access to surgical care, including orthopaedic surgery, in low- and middle-income countries. Similar to other low- and middle-income countries, Tanzania has a severe shortage of trained orthopaedic surgeons. The surgeons available are inundated with acute trauma care and musculoskeletal infections; elective procedures are infrequently performed and the burden of neglected care continues to rise annually. Over the past several years, our interdisciplinary team of both American and Tanzanian members has worked to understand the current local cultural and economic barriers to increasing surgical capacity, ensuring surgical safety, delivering affordable care, providing adequate patient follow-up, and improving surgical education. We propose a new paradigm for the delivery of musculoskeletal care and creation of sustained surgical capacity in this setting by building an Orthopaedic Center of Excellence in Moshi, Tanzania, augmented by international partner institutions year-round. This initiative is a public-private partnership led by the University of Pennsylvania in conjunction with Kilimanjaro Christian Medical Center. A growing number of contributors, including the Tanzanian Health Ministry, several universities, and industry partners, including general electric (GE) Health Care Africa, are currently helping to advance this concept into reality. Through our model, we aim to increase surgical capacity and quality, as well as enhance local surgical education, with the ultimate objective of training the next generation of African surgeons in the latest surgical techniques and equipment.