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Klazura G, Wong LY, Ribeiro LLPA, Kojo Anyomih TT, Ooi RYK, Berhane Fissha A, Alam SF, Daudu D, Nyalundja AD, Beltrano J, Patil PP, Wafford QE, Rapolti DI, Sullivan GA, Graf A, Veras P, Nico E, Sheth M, Shing SR, Mathur P, Langer M. 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. J Surg Res 2024; 299:163-171. [PMID: 38759332 DOI: 10.1016/j.jss.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/14/2024] [Accepted: 04/18/2024] [Indexed: 05/19/2024]
Abstract
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.
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Affiliation(s)
- Greg Klazura
- University of Illinois at Chicago, Chicago, Illinois
| | - Lye-Yeng Wong
- Department of Cardiothoracic Surgery, Stanford Hospital, Stanford, California.
| | | | | | | | - Aemon Berhane Fissha
- Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
| | - Syeda Fatema Alam
- Department of Public Health, North South University, Dhaka, Bangladesh
| | - Davina Daudu
- Faculty of Surgery, University of Western Australia, Nedlands, Western Australia, Australia
| | - Arsene Daniel Nyalundja
- Faculty of Medicine, Université Catholique de Bukavu, Bukavu, South Kivu, Democratic Republic of Congo
| | | | - Poorvaprabha P Patil
- Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | | | | | - Gwyneth A Sullivan
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Akua Graf
- University of Illinois at Chicago, Chicago, Illinois
| | - Perry Veras
- Loyola Stritch School of Medicine, Maywood, Illinois
| | - Elsa Nico
- University of Illinois at Chicago, Chicago, Illinois
| | - Monica Sheth
- Loyola Stritch School of Medicine, Oak Park, Illinois
| | - Samuel R Shing
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Priyanka Mathur
- Northwestern University Feinberg School of Medicine, Chicago Illinois
| | - Monica Langer
- Lurie Children's Hospital of Chicago, Chicago, Illinois
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Cassidy BP, Yeramosu T, Mbomuwa FJ, Chidothi P, Wu HH, Martin C, Harrison WJ, Chokotho L, Agarwal-Harding KJ. Epidemiology and Management of Pediatric Fractures in Malawi. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202407000-00013. [PMID: 39042502 PMCID: PMC11254115 DOI: 10.5435/jaaosglobal-d-24-00026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 05/29/2024] [Accepted: 06/07/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Pediatric fractures are common in Malawi, and surgical care, when needed, remains inaccessible to many. Understanding which children in Malawi receive surgery or nonsurgical treatment would help set priorities for trauma system development. METHODS We used multivariate logistic regression to evaluate associations between surgical treatment and age, sex, school enrollment, injury mechanism, fracture type, open fracture, referral status, hospital of presentation, delayed presentation (≥2 days), healthcare provider, and inpatient vs outpatient treatment. RESULTS From 2016 to 2020, 10,400 pediatric fractures were recorded in the Malawi Fracture Registry. Fractures were most commonly of the wrist (26%), forearm (17%), and elbow (14%). Surgical fixation was performed on 4.0% of patients, and 24 (13.0%) open fractures were treated nonsurgically, without débridement or fixation. Fractures of the proximal and diaphyseal humerus (odds ratio [OR], 3.72; 95% confidence interval [CI], 2.36 to 5.87), knee (OR, 3.16; 95% CI, 1.68 to 5.95), and ankle (OR, 2.63; 95% CI, 1.49 to 4.63) had highest odds of surgery. Odds of surgical treatment were lower for children referred from another facility (OR, 0.62; 95% CI, 0.49 to 0.77). CONCLUSIONS Most Malawian children with fractures are treated nonsurgically, including many who may benefit from surgery. There is a need to increase surgical capacity, optimize referral patterns, and standardize fracture management in Malawi.
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Affiliation(s)
- Benjamin P. Cassidy
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - Teja Yeramosu
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - Foster J. Mbomuwa
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - Paul Chidothi
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - Hao-Hua Wu
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - Claude Martin
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - William James Harrison
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - Linda Chokotho
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - Kiran J. Agarwal-Harding
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
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Whitaker J, Edem I, Togun E, Amoah AS, Dube A, Chirwa L, Munthali B, Brunelli G, Van Boeckel T, Rickard R, Leather AJM, Davies J. Health system assessment for access to care after injury in low- or middle-income countries: A mixed methods study from Northern Malawi. PLoS Med 2024; 21:e1004344. [PMID: 38252654 PMCID: PMC10843098 DOI: 10.1371/journal.pmed.1004344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/05/2024] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Injuries represent a vast and relatively neglected burden of disease affecting low- and middle-income countries (LMICs). While many health systems underperform in treating injured patients, most assessments have not considered the whole system. We integrated findings from 9 methods using a 3 delays approach (delays in seeking, reaching, or receiving care) to prioritise important trauma care health system barriers in Karonga, Northern Malawi, and exemplify a holistic health system assessment approach applicable in comparable settings. METHODS AND FINDINGS To provide multiple perspectives on each conceptual delay and include data from community-based and facility-based sources, we used 9 methods to examine the injury care health system. The methods were (1) household survey; (2) verbal autopsy analysis; (3) community focus group discussions (FGDs); (4) community photovoice; (5) facility care-pathway process mapping and elucidation of barriers following injury; (6) facility healthcare worker survey; (7) facility assessment survey; (8) clinical vignettes for care process quality assessment of facility-based healthcare workers; and (9) geographic information system (GIS) analysis. Empirical data collection took place in Karonga, Northern Malawi, between July 2019 and February 2020. We used a convergent parallel study design concurrently conducting all data collection before subsequently integrating results for interpretation. For each delay, a matrix was created to juxtapose method-specific data relevant to each barrier identified as driving delays to injury care. Using a consensus approach, we graded the evidence from each method as to whether an identified barrier was important within the health system. We identified 26 barriers to access timely quality injury care evidenced by at least 3 of the 9 study methods. There were 10 barriers at delay 1, 6 at delay 2, and 10 at delay 3. We found that the barriers "cost," "transport," and "physical resources" had the most methods providing strong evidence they were important health system barriers within delays 1 (seeking care), 2 (reaching care), and 3 (receiving care), respectively. Facility process mapping provided evidence for the greatest number of barriers-25 of 26 within the integrated analysis. There were some barriers with notable divergent findings between the community- and facility-based methods, as well as among different community- and facility-based methods, which are discussed. The main limitation of our study is that the framework for grading evidence strength for important health system barriers across the 9 studies was done by author-derived consensus; other researchers might have created a different framework. CONCLUSIONS By integrating 9 different methods, including qualitative, quantitative, community-, patient-, and healthcare worker-derived data sources, we gained a rich insight into the functioning of this health system's ability to provide injury care. This approach allowed more holistic appraisal of this health system's issues by establishing convergence of evidence across the diverse methods used that the barriers of cost, transport, and physical resources were the most important health system barriers driving delays to seeking, reaching, and receiving injury care, respectively. This offers direction and confidence, over and above that derived from single methodology studies, for prioritising barriers to address through health service development and policy.
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Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Idara Edem
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Insight Institute of Neurosurgery & Neuroscience, Flint, Michigan, United States of America
- Michigan State University, East Lansing, Michigan, United States of America
| | - Ella Togun
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Abena S. Amoah
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Albert Dube
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
| | - Lindani Chirwa
- Karonga District Hospital, Karonga District Health Office, Karonga, Malawi
- School of Medicine & Oral Health, Department of Pathology, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi
| | - Boston Munthali
- Mzuzu Central Hospital, Department of Orthopaedic Surgery, Mzuzu, Malawi
- Lilongwe Institute of Orthopaedic and Neurosurgery, Lilongwe, Malawi
| | - Giulia Brunelli
- Health Geography and Policy Group, ETH Zurich, Zurich, Switzerland
| | - Thomas Van Boeckel
- Health Geography and Policy Group, ETH Zurich, Zurich, Switzerland
- Center for Disease Dynamics Economics and Policy, Washington, DC, United States of America
| | - Rory Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Andrew JM Leather
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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Maheta B, Yesantharao PS, Thawanyarat K, Akhter MF, Rowley M, Nazerali RS. Timing of autologous fat grafting in implant-based breast reconstruction: Best practices based on systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2023; 86:273-279. [PMID: 37797375 DOI: 10.1016/j.bjps.2023.09.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/14/2023] [Accepted: 09/08/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Fat grafting is commonly undertaken as a third-stage procedure in patients with staged implant-based breast reconstruction (IBR). However, fat grafting performed during second-stage expander/implant exchange provides faster results without an additional procedure and associated risks (Patel et al., 2020). We previously demonstrated that fat grafting during second-stage expander/implant exchange did not increase clinical complications (Patel et al., 2020). As a corollary, this study investigates patients' satisfaction with second- versus third-stage fat grafting to help establish a set of best practices for the timing of fat grafting in such patients. METHODS A review of PubMed/MEDLINE databases (2010-2022) was performed to identify articles investigating the quality of life in patients undergoing second- or third-stage fat grafting after IBR. BREAST-Q scores were pooled using random-effects modeling and the DerSimonian-Laird method. Post-hoc sensitivity analyses were completed using the Hartung-Knapp-Sidik-Jonkman method. The Haldane-Anscombe correction was used for outcomes with low counts. All study analyses adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Six studies (216 patients) were included. Pooled random-effects modeling demonstrated no significant changes in BREAST-Q satisfaction with outcome scores when comparing patients who received second- versus third-stage fat grafting (p = 0.178) with results robust to sensitivity analyses. In addition, pooled analyses of the available data demonstrated that second-stage fat grafting did not increase downstream revision surgery needs compared to third-stage fat grafting. CONCLUSIONS In combination with our prior work, this meta-analysis suggests that second-stage fat grafting provides not only equivalent but improved clinical and quality of life outcomes with fewer procedures in patients undergoing expander/IBR.
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Affiliation(s)
- Bhagvat Maheta
- California Northstate University College of Medicine, Elk Grove, CA, USA
| | - Pooja S Yesantharao
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Kometh Thawanyarat
- Medical College of Georgia at Augusta University, AU/UGA Medical Partnership, Athens, GA, USA
| | - Maheen F Akhter
- Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Mallory Rowley
- State University of New York, Upstate Medical University, Syracuse, NY, USA
| | - Rahim S Nazerali
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA.
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Flocks Monaghan C, Pittalis C, Byrne E, Hussein I, Chilunjika T, Nandi B, Borgstein E, Gajewski J. The status of pediatric surgery in Malawi: a narrative mini-review. Front Pediatr 2023; 11:1195691. [PMID: 37484773 PMCID: PMC10357470 DOI: 10.3389/fped.2023.1195691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction Pediatric surgery is essential to a well-functioning health system. Unmet surgical needs contribute to 6.7% of pediatric deaths in Malawi. Understanding the current state of pediatric surgical care in Malawi is necessary to recognize gaps and opportunities in service delivery and to develop evidence-based national planning and solutions. Methods This narrative mini review synthesized the literature on the state of pediatric surgery in Malawi through the pillars of the World Health Organization's Health System Building Blocks. A search of PubMed, Embase, and Scopus databases was executed to identify relevant studies and a thematic analysis was performed. Further, to ensure contextual accuracy, pediatric surgeons from Malawi were consulted and involved in this review. Results Twenty-six papers were identified. In Malawi's central hospitals, there are six specialist pediatric surgeons for a pediatric population of more than 8 million. There is limited pediatric surgical capacity at the district hospitals. There is little to no written evidence of the national governing and finance structures in place for pediatric surgical services. Discussion In countries like Malawi, where a significant portion of the population comprises children, it is crucial to recognize that pediatric services are currently inadequate and fall short of the required standards. It is crucial to prioritize the enhancement of services specifically designed for this age group. This review aims to shed light on the existing gaps within pediatric surgical services in Malawi, providing valuable insights that can inform the development of comprehensive national surgical planning strategies.
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Affiliation(s)
- Celina Flocks Monaghan
- Institute of Global Surgery, School of Population Health, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Chiara Pittalis
- Institute of Global Surgery, School of Population Health, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Elaine Byrne
- Centre for Positive Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Israa Hussein
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tiyamike Chilunjika
- Department of Surgery, University of Malawi College of Medicine, Zomba, Malawi
| | - Bip Nandi
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
- Michael E. Debakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Eric Borgstein
- Department of Surgery, University of Malawi College of Medicine, Zomba, Malawi
| | - Jakub Gajewski
- Institute of Global Surgery, School of Population Health, Royal College of Surgeons in Ireland, Dublin, Ireland
- Centre for Global Surgery, University of Stellenbosch, Cape Town, South Africa
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Chinkhumba J, Mpinganjira S, Kumitawa A, Malopa M, Longwe D, Phiri VS, Nyirenda TS, Mwapasa V. Household costs and care seeking patterns associated with COVID-19 in Blantyre, Malawi. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002003. [PMID: 37363908 PMCID: PMC10292703 DOI: 10.1371/journal.pgph.0002003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 05/10/2023] [Indexed: 06/28/2023]
Abstract
Economic consequences of COVID-19 illness and healthcare use for households in low income countries are not well known. We estimated costs associated with COVID-19 care-seeking and treatment from a household perspective and assessed determinants of treatment costs. A cross-sectional household survey was conducted between December 2020 and November 2021 in urban and peri-urban areas of Blantyre district. Adults (age ≥18 years) with confirmed COVID-19 were asked to report the symptoms they experienced or prompted them to seek COVID-19 tests as well as healthcare seeking behaviors preceding and following COVID-19 diagnosis. For individuals who sought healthcare, information on out-of-pocket expenditures incurred while seeking and receiving care including on transport, food etc. by both the patients and their guardians was collected. Finally, data on time use seeking, receiving care and during convalesces was recorded. Multivariate Generalized Linear Models were used to evaluate association between household COVID-19 costs and their determinants. Of 171 individuals who took part in the study, the average age was 40.7 years, standard deviation (SD) 15.0, and 50.8% were females. Most participants (85.3%) were symptomatic. Of these, 67.8% sought care at health facilities and the majority (91.7%) were treated as outpatients. The average total household cost associated with COVID-19 seeking, receiving care and convalescence was $62.81 (SD $126.02). Average costs for outpatient and inpatient cases were $52.96 (SD $54.35) and $172.39 (SD $407.08), respectively. Average out-of-pocket household expenditures were $42.62 (SD $123.10), accounting for 62% of total household costs. Being a male COVID-19 patient and engagement in formal employment were significantly associated with high COVID-19 household costs. Households face high economic burden related to COVID-19 sickness and healthcare use. Social policies that support households cope with both the direct and indirect COVID-19 cost are needed to ensure access to healthcare and protect households from COVID-19 related shocks.
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Affiliation(s)
- Jobiba Chinkhumba
- Department of Health Systems and Policy, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Health Economics and Policy Unit, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Samuel Mpinganjira
- Department of Epidemiology and Biostatistics, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Andrew Kumitawa
- Department of Epidemiology and Biostatistics, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Mercy Malopa
- Department of Epidemiology and Biostatistics, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Dalitso Longwe
- Department of Epidemiology and Biostatistics, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Vincent Samuel Phiri
- Department of Epidemiology and Biostatistics, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Tonney S. Nyirenda
- Department of Pathology, School of Medicine and Oral Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Victor Mwapasa
- Department of Epidemiology and Biostatistics, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
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Whitaker J, Amoah AS, Dube A, Chirwa L, Munthali B, Rickard RF, Leather AJM, Davies J. Novel application of multi-facility process map analysis for rapid injury care health system assessment in Northern Malawi. BMJ Open 2023; 13:e070900. [PMID: 37263691 DOI: 10.1136/bmjopen-2022-070900] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVES We used the process mapping method and Three Delays framework, to identify and visually represent the relationship between critical actions, decisions and barriers to access to care following injury in the Karonga health system, Northern Malawi. DESIGN Facilitated group process mapping workshops with summary process mapping synthesis. SETTING Process mapping workshops took place in 11 identified health system facilities (one per facility) providing injury care for a population in Karonga, Northern Malawi. PARTICIPANTS Fifty-four healthcare workers from various cadres took part. RESULTS An overall injury health system summary map was created using those categories of action, decision and barrier that were sometimes or frequently reported. This provided a visual summary of the process following injury within the health system. For Delay 1 (seeking care) four barriers were most commonly described (by 8 of 11 facilities) these were 'cultural norms', 'healthcare literacy', 'traditional healers' and 'police processes'. For Delay 2 (reaching care) the barrier most frequently described was 'transport'-a lack of timely affordable emergency transport (formal or informal) described by all 11 facilities. For Delay 3 (receiving quality care) the most commonly reported barrier was that of 'physical resources' (9 of 11 facilities). CONCLUSIONS We found our novel approach combining several process mapping exercises to produce a summary map to be highly suited to rapid health system assessment identifying barriers to injury care, within a Three Delays framework. We commend the approach to others wishing to conduct rapid health system assessments in similar contexts.
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Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Abena S Amoah
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
- Department of Parasitology, Leiden University Center for Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Albert Dube
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
| | - Lindani Chirwa
- Karonga District Health Office, Karonga, Malawi
- Department of Pathology, School of Medicine & Oral Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Boston Munthali
- Lilongwe Institute of Orthopaedic and Neurosurgery, Lilongwe, Malawi
- Department of Orthopaedic Surgery, Mzuzu Central Hospital, Mzuzu, Malawi
| | - Rory F Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Andrew J M Leather
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand Johannesburg Faculty of Health Sciences, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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8
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Genetu A, Gezahegn D, Getachew H, Deneke A, Bekele A. Financial risk of emergency abdominal surgery: a cross sectional study from Ethiopia. BMC Health Serv Res 2022; 22:1090. [PMID: 36028811 PMCID: PMC9413941 DOI: 10.1186/s12913-022-08480-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/23/2022] [Indexed: 11/23/2022] Open
Abstract
Background The Lancet Commission on Global Surgery suggested six indicators every country should use to measure their surgical systems. One of these indicators, catastrophic expenditure (CE), is defined as money paid for service which amounts to more than 10% of the patient’s total annual expenditure, or more than 40% of annual non-food household expenditure. Ethiopian Ministry of Health has set a target of 100% protection from CE by 2030. However, so far there is lack of studies that assess financial risk of surgery. Methods Using a cross sectional study design, financial risk assessment was carried out on 142 patients from Yekatit 12 and Zewditu Memorial hospitals in Addis Ababa, Ethiopia from May 15 to September 15, 2021. Results Appendectomy (69.0%), emergency laparotomy (26.1%) and cholecystectomy (4.9%) resulted in mean direct medical expenditures of 111.7USD, 200.70USD and 224.60USD, respectively. Medications and imaging accounted for 60.8 and 13.9% of total treatment cost. By applying the two definitions of catastrophic expenditure, 67.6 and 62.7% of patients sustained CE, respectively Overall rates of CE across procedures were 67.3 and 59.1% for appendectomy, 70.2 and 70.2% for laparotomy, 57.0 and 71.2% for cholecystectomy. Thirty-five (24.6%) patients had some form of insurance, with Community Based Health Insurance being the most common form (57%). Insured patients were less likely to sustain CE with both definitions (AOR 0.09, p = 0.002 and AOR 0.10, p = 0.006 respectively). Conclusion and recommendations Substantial proportion of patients undergoing emergency abdominal surgery sustain CE in Addis Ababa. Medications and imaging take major share of total cost mainly because patients have to acquire them from private set ups. Policy makers should work on availing medications and imaging in public hospitals as well as expand insurance and other forms of surgical care financing to protect patients from CE.
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Affiliation(s)
- Abraham Genetu
- College of Health Sciences, Addis Ababa University, Zambia Street, P.O.Box 8977, Addis Ababa, Ethiopia.
| | - Demmelash Gezahegn
- College of Health Sciences, Addis Ababa University, Zambia Street, P.O.Box 8977, Addis Ababa, Ethiopia
| | - Hana Getachew
- St Paul's Millennium Medical College, Addis Ababa, Ethiopia
| | - Andualem Deneke
- College of Health Sciences, Addis Ababa University, Zambia Street, P.O.Box 8977, Addis Ababa, Ethiopia
| | - Abebe Bekele
- College of Health Sciences, Addis Ababa University, Zambia Street, P.O.Box 8977, Addis Ababa, Ethiopia.,University of Global Health Equity, Kigali, Rwanda
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9
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Ifeanyichi M, Broekhuizen H, Juma A, Chilonga K, Kataika E, Gajewski J, Brugha R, Bijlmakers L. Economic Costs of Providing District- and Regional-Level Surgeries in Tanzania. Int J Health Policy Manag 2022; 11:1120-1131. [PMID: 33673732 PMCID: PMC9808166 DOI: 10.34172/ijhpm.2021.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 01/31/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Access to surgical care is poor in Tanzania. The country is at the implementation stage of its first National Surgical, Obstetric, and Anesthesia Plan (NSOAP; 2018-2025) aiming to scale up surgery. This study aimed to calculate the costs of providing surgical care at the district and regional hospitals. METHODS Two district hospitals (DHs) and the regional referral hospital (RH) in Arusha region were selected. All the staff, buildings, equipment, and medical and non-medical supplies deployed in running the hospitals over a 12 month period were identified and quantified from interviews and hospital records. Using a combination of step-down costing (SDC) and activity-based costing (ABC), all costs attributed to surgeries were established and then distributed over the individual types of surgeries. These costs were delineated into pre-operative, intra-operative, and post-operative components. RESULTS The total annual costs of running the clinical cost centres ranged from $567k at Oltrumet DH to $3453k at Mt Meru RH. The total costs of surgeries ranged from $79k to $813k; amounting to 12%-22% of the total costs of running the hospitals. At least 70% of the costs were salaries. Unit costs and relative shares of capital costs were generally higher at the DHs. Two-thirds of all the procedures incurred at least 60% of their costs in the theatre. Open reduction and internal fixation (ORIF) performed at the regional hospital was cheaper ($618) than surgical debridement (plus conservative treatment) due to prolonged post-operative inpatient care associated with the latter ($1177), but was performed infrequently due mostly to unavailability of implants. CONCLUSION Lower unit costs and shares of capital costs at the RH reflect an advantage of economies of scale and scope at the RH, and a possible underutilization of capacity at the DHs. Greater efficiencies make a case for concentration and scale-up of surgical services at the RHs, but there is a stronger case for scaling up district-level surgeries, not only for equitable access to services, but also to drive down unit costs there, and free up RH resources for more complex cases such as ORIF.
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Affiliation(s)
- Martilord Ifeanyichi
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Henk Broekhuizen
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Adinan Juma
- East, Central and Southern Africa Health Community, Arusha, Tanzania
| | - Kondo Chilonga
- Department of Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Edward Kataika
- East, Central and Southern Africa Health Community, Arusha, Tanzania
| | - Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruairi Brugha
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leon Bijlmakers
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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Koch R, Nkurunziza T, Rudolfson N, Nkurunziza J, Bakorimana L, Irasubiza H, Sonderman K, Riviello R, Hedt-Gauthier BL, Shrime M, Kateera F. Does community-based health insurance protect women from financial catastrophe after cesarean section? A prospective study from a rural hospital in Rwanda. BMC Health Serv Res 2022; 22:717. [PMID: 35642031 PMCID: PMC9153099 DOI: 10.1186/s12913-022-08101-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 05/18/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The implementation of community-based health insurance in (CBHI) in Rwanda has reduced out of pocket (OOP) spending for the > 79% of citizens who enroll in it but the effect for surgical patients is not well described. For all but the poorest citizens who are completely subsidized, the OOP (out of pocket) payment at time of service is 10%. However, 55.5% of the population is below the international poverty line meaning that even this copay can have a significant impact on a family's financial health. The aim of this study was to estimate the burden of OOP payments for cesarean sections in the context of CBHI and determine if having it reduces catastrophic health expenditure (CHE). METHODS This study is nested in a larger randomized controlled trial of women undergoing cesarean section at a district hospital in Rwanda. Eligible patients were surveyed at discharge to quantify household income and routine monthly expenditures and direct and indirect spending related to the hospitalization. This was used in conjunction with hospital billing records to calculate the rate of catastrophic expenditure by insurance group. RESULTS About 94% of the 340 women met the World Bank definition of extreme poverty. Of the 330 (97.1%) with any type of health insurance, the majority (n = 310, 91.2%) have CBHI. The average OOP expenditure for a cesarean section and hospitalization was $9.36. The average cost adding transportation to the hospital was $19.29. 164 (48.2%) had to borrow money and 43 (12.7%) had to sell possessions. The hospital bill alone was a CHE for 5.3% of patients. However, when including transportation costs, 15.4% incurred a CHE and including lost wages, 22.6%. CONCLUSION To ensure universal health coverage (UHC), essential surgical care must be affordable. Despite enrollment in universal health insurance, cesarean section still impoverishes households in rural Rwanda, the majority of whom already lie below the poverty line. Although CBHI protects against CHE from the cost of healthcare, when adding in the cost of transportation, lost wages and caregivers, cesarean section is still often a catastrophic financial event. Further innovation in financial risk protection is needed to provide equitable UHC.
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Affiliation(s)
- Rachel Koch
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.
- University of Utah, Salt Lake City, USA.
| | - Theoneste Nkurunziza
- Department for Sport and Health Sciences, Epidemiology, Technical University of Munich, Munich, Germany
| | - Niclas Rudolfson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- WHO Collaborating Centre for Surgery and Public Health, Lund University, Lund, Sweden
| | | | | | | | - Kristin Sonderman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
| | - Robert Riviello
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Bethany L Hedt-Gauthier
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Mark Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Center for Global Surgery Evaluation, Boston, USA
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11
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Padovany MM, Patterson RH, Bowder AN, O'Brien E, Alkire BC, Katz AM, Mitnick CD, Lu C. Impact of out-of-pocket expenses for surgical care on households in rural Haiti: a mixed-methods study. BMJ Open 2022; 12:e061731. [PMID: 35613787 PMCID: PMC9125749 DOI: 10.1136/bmjopen-2022-061731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/06/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES This study aimed to report household catastrophic spending on surgery and the experiences of patients and families seeking surgical care in rural Haiti. DESIGN The study used an explanatory, sequential mixed-methods approach. We collected both quantitative and qualitative data from the participants through interviews. SETTING A rural tertiary hospital (St. Boniface Hospital) in southern Haiti. PARTICIPANTS There were 200 adult Haitian surgical patients who entered the study. Of these, 41 were excluded due to missing variables or health expenditure outliers. The final sample included 159 participants. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcomes were (1) direct and indirect payments for surgical care; (2) the rate of catastrophic health expenditure (CHE) (as defined by the Sustainable Development Goals (10% of total household expenditure) and WHO (10%, 20%, 30% and 40% of household capacity to pay)) due to surgical care; and (3) common themes across the lived experiences of households of surgical patients seeking care. RESULTS The median household expenditure on surgery-related expenses was US$385.6, slightly more than half of per capita gross domestic product in Haiti (US$729.3). Up to 86% of households experienced CHE, as defined by the Sustainable Development Goals, due to receiving surgical care. Patients commonly paid for surgical costs through loans and donations (69.8%). The qualitative analysis revealed prominent themes related to barriers to care including the burden of initiating care-seeking, care-seeking journeys and social suffering. CONCLUSIONS CHE is common for Haitian surgical patients, and the associated care-seeking experiences are often arduous. These findings suggest that low, flat fees in non-profit hospital settings may not be sufficient to mitigate the costs of surgical care or the resulting challenges that patients experience.
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Affiliation(s)
| | - Rolvix H Patterson
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alexis N Bowder
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Eva O'Brien
- University of Miami Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Blake C Alkire
- Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Arlene M Katz
- Department of Global Health & Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Carole D Mitnick
- Department of Global Health & Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Chunling Lu
- Department of Global Health & Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, MA, USA
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12
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Naidu P, Ataguba JE, Shrime M, Alkire BC, Chu KM. Surgical Catastrophic Health Expenditure and Risk Factors for Out-of-Pocket Expenditure at a South African Public Sector Hospital. World J Surg 2022; 46:769-775. [DOI: 10.1007/s00268-022-06472-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2022] [Indexed: 10/19/2022]
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13
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Ifeanyichi M, Aune E, Shrime M, Gajewski J, Pittalis C, Kachimba J, Borgstein E, Brugha R, Baltussen R, Bijlmakers L. Financing of surgery and anaesthesia in sub-Saharan Africa: a scoping review. BMJ Open 2021; 11:e051617. [PMID: 34667008 PMCID: PMC8527159 DOI: 10.1136/bmjopen-2021-051617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Martilord Ifeanyichi
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
- EMAI Health Systems and Health Services Consulting, Nijmegen, The Netherlands
| | - Ellis Aune
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Mark Shrime
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Chiara Pittalis
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John Kachimba
- Department of Surgery, University of Zambia University Teaching Hospital, Lusaka, Zambia
| | - Eric Borgstein
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Ruairi Brugha
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Rob Baltussen
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Leon Bijlmakers
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
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14
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Ifeanyichi M, Broekhuizen H, Cheelo M, Juma A, Mwapasa G, Borgstein E, Kachimba J, Gajewski J, Brugha R, Pittalis C, Bijlmakers L. Surgical ambulance referrals in sub-Saharan Africa - financial costs and coping strategies at district hospitals in Tanzania, Malawi and Zambia. BMC Health Serv Res 2021; 21:728. [PMID: 34301242 PMCID: PMC8299644 DOI: 10.1186/s12913-021-06709-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 06/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An estimated nine out of ten persons in sub-Saharan Africa (SSA) are unable to access timely, safe and affordable surgery. District hospitals (DHs) which are strategically located to provide basic (non-specialist) surgical care for rural populations have in many instances been compromised by resource inadequacies, resulting in unduly frequent patient referrals to specialist hospitals. This study aimed to quantify the financial burdens of surgical ambulance referrals on DHs and explore the coping strategies employed by these facilities in navigating the challenges. METHODS We employed a multi-methods descriptive case study approach, across a total of 14 purposively selected DHs; seven, three, and four in Tanzania, Malawi and Zambia, respectively. Three recurrent cost elements were identified: fuel, ambulance maintenance and staff allowances. Qualitative data related to coping mechanisms were obtained through in-depth interviews of hospital managers while quantitative data related to costs of surgical referrals were obtained from existing records (such as referral registers, ward registers, annual financial reports, and other administrative records) and expert estimates. Interview notes were analysed by manual thematic coding while referral statistics and finance data were processed and analysed using Microsoft Office Excel 2016. RESULTS At all but one of the hospitals, respondents reported inadequacies in numbers and functional states of the ambulances: four centres indicated employing non-ambulance vehicles to convey patients occassionally. No statistically significant correlation was found between referral trip distances and total annual numbers of referral trips, but hospital managers reported considering costs in referral practices. For instance, ten of the study hospitals reported combining patients to minimize trip frequencies. The total cost of ambulance use for patient transportation ranged from I$2 k to I$58 k per year. Between 34% and 79% of all patient referrals were surgical, with total costs ranging from I$1 k to I$32 k per year. CONCLUSION Cost considerations strongly influence referral decisions and practices, indicating a need for increases in budgetary allocations for referral services. High volumes of potentially avoidable surgical referrals provide an economic case - besides equitable access to healthcare - for scaling up surgery capacity at the district level as savings from decreased referrals could be reinvested in referral systems strengthening.
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Affiliation(s)
- Martilord Ifeanyichi
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands. .,EMAI Health Systems and Health Services Consulting, Nijmegen, The Netherlands.
| | - Henk Broekhuizen
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Mweene Cheelo
- Surgical Society of Zambia, Department of Surgery, University Teaching Hospital, Lusaka, Zambia
| | - Adinan Juma
- East, Central and Southern Africa Health Community, Arusha, Tanzania
| | - Gerald Mwapasa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Eric Borgstein
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - John Kachimba
- Surgical Society of Zambia, Department of Surgery, University Teaching Hospital, Lusaka, Zambia
| | - Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruairi Brugha
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Chiara Pittalis
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leon Bijlmakers
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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15
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Zhang Y, Guan Y, Hu D, Vanneste J, Zhu D. The Basic vs. Ability-to-Pay Approach: Evidence From China's Critical Illness Insurance on Whether Different Measurements of Catastrophic Health Expenditure Matter. Front Public Health 2021; 9:646810. [PMID: 33869132 PMCID: PMC8044960 DOI: 10.3389/fpubh.2021.646810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/28/2021] [Indexed: 11/13/2022] Open
Abstract
Alleviating catastrophic health expenditure (CHE) is one of the vital objectives of health systems, as defined by the World Health Organization. However, no consensus has yet been reached on the measurement of CHE. With the aim of further relieving the adverse effects of CHE and alleviating the problem of illness-caused poverty, the Critical Illness Insurance (CII) program has been operational in China since 2012. In order to verify whether the different measurements of CHE matter under China's CII program, we compare the two-layer CII models built by using the basic approach and the ability-to-pay (ATP) approach at a range of thresholds. Exploiting the latest China family panel studies dataset, we demonstrate that the basic approach is more effective in relieving CHE for all insured households, while the ATP approach works better in reducing the severity of CHE in households facing it. These findings have meaningful implications for policymaking. The CII program should be promoted widely as a supplement to the current Social Basic Medical Insurance system. To improve the CII program's effectiveness, it should be based on the basic approach, and the threshold used to measure CHE should be determined by the goal pursued by the program.
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Affiliation(s)
- Ying Zhang
- School of Economics and Management, Southeast University, Nanjing, China
| | - Yongmei Guan
- School of Economics and Management, Southeast University, Nanjing, China
| | - Ding Hu
- Business School, Nanjing University, Nanjing, China
| | - Jacques Vanneste
- Faculty of Business and Economics, University of Antwerp, Antwerp, Belgium
| | - Dongmei Zhu
- School of Economics and Management, Southeast University, Nanjing, China
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Phull M, Grimes CE, Kamara TB, Wurie H, Leather AJM, Davies J. What is the financial burden to patients of accessing surgical care in Sierra Leone? A cross-sectional survey of catastrophic and impoverishing expenditure. BMJ Open 2021; 11:e039049. [PMID: 34006018 PMCID: PMC7942261 DOI: 10.1136/bmjopen-2020-039049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To measure the financial burden associated with accessing surgical care in Sierra Leone. DESIGN A cross-sectional survey conducted with patients at the time of discharge from tertiary-level care. This captured demographics, yearly household expenditure, direct medical, direct non-medical and indirect costs for surgical care, and summary household assets. Missing data were imputed. SETTING The main tertiary-level hospital in Freetown, Sierra Leone. PARTICIPANTS 335 surgical patients under the care of the hospital surgical team receiving operative or non-operative surgical care on the surgical wards. OUTCOME MEASURES Rates of catastrophic expenditure (a cost >10% of annual expenditure), impoverishment (being pushed into, or further into, poverty as a result of surgical care costs), amount of out-of-pocket (OOP) costs and means used to meet these costs were derived. RESULTS Of 335 patients interviewed, 39% were female and 80% were urban dwellers. Median yearly household expenditure was US$3569. Mean OOP costs were US$243, of which a mean of US$24 (10%) was spent prehospital. Of costs incurred during the hospital admission, direct medical costs were US$138 (63%) and US$34 (16%) were direct non-medical costs. US$46 (21%) were indirect costs. Catastrophic expenditure affected 18% of those interviewed. Concerning impoverishment, 45% of patients were already below the national poverty line prior to admission, and 9% of those who were not were pushed below the poverty line following payment for surgical care. 84% of patients used household savings to meet OOP costs. Only 2% (six patients) had health insurance. CONCLUSION Obtaining surgical care has substantial economic impacts on households that pushes them into poverty or further into poverty. The much-needed scaling up of surgical care needs to be accompanied by financial risk protection.
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Affiliation(s)
- Manraj Phull
- Department of Surgery, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | - Caris E Grimes
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Surgery, Medway NHS Foundation Trust, Gillingham, UK
| | - Thaim B Kamara
- Department of Surgery, University of Sierra Leone College of Medicine and Allied Health Sciences, Freetown, Sierra Leone
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Andy J M Leather
- King's Centre for Global Health, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Justine Davies
- Centre of Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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17
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Okoroh JS, Riviello R. Challenges in healthcare financing for surgery in sub-Saharan Africa. Pan Afr Med J 2021; 38:198. [PMID: 33995804 PMCID: PMC8106793 DOI: 10.11604/pamj.2021.38.198.27115] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/05/2021] [Indexed: 01/14/2023] Open
Abstract
One-third of the global burden of disease is attributed to surgical conditions yet, 5 billion people globally, lack access to surgery. The Lancet Commission on Global Surgery, Obstetrics, and Anesthesia (LCOGS) published guidelines for improving access by reducing catastrophic health expenditures (CHEs) by 2030. This is especially important in sub-Saharan Africa (SSA) where 90% of the extreme poor reside. In this paper, we provide a narrative review of four studies on CHEs for surgical care in SSA published since 2015. We discuss healthcare financing in the countries and summarize the authors’ key findings of out-of-pocket payments (OOP) and CHEs. Briefly, the studies enrolled 130 to 300 patients and collected direct OOPs via chart review of health costs or patient interviews. Indirect costs were calculated from lost wages and transportation costs. CHEs were defined as health costs exceeding 10% of the GDP per capita or the household income. Despite healthcare being reported as free in all studies, 60%-90% of surgical patients had CHEs with all costs considered. OOPs persists for medicines and anesthesia that should be covered under any health insurance scheme. In some cases, indirect costs associated with transportation and wages were major drivers of CHEs for surgery. Without addressing these gaps in coverage, more people will risk impoverishment in seeking surgical care in SSA.
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Affiliation(s)
- Juliet Siena Okoroh
- University of Alabama, Department of Surgery, Birmingham, Alabama, United States of America
| | - Robert Riviello
- Brigham and Women´s Hospital, Division of Trauma, Burn, Surgical Critical Care, Boston, Massachusetts, United States of America
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18
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Dunne JA, Cappuyns L, Kumiponjera D. Re: Regional incidence of and reconstructive management patterns in melanoma and nonmelanoma skin cancer of the head and neck: A 3-year analysis in the inpatient setting. J Plast Reconstr Aesthet Surg 2020; 73:2239-2260. [PMID: 32826181 DOI: 10.1016/j.bjps.2020.05.102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/09/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Jonathan A Dunne
- Imperial College Healthcare NHS Trust, London, UK; Queen Elizabeth Central Hospital, Blantyre, Malawi.
| | - Laura Cappuyns
- Queen Elizabeth Central Hospital, Blantyre, Malawi; Nottingham University Hospitals NHS Trust, Nottingham, UK
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19
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Seyi-Olajide JO, Anderson J, Enivwaene AO, Ibrahim SH, Farmer D, Ameh EA. Catastrophic Healthcare Expenditure from Typhoid Perforation in Children in Nigeria. Surg Infect (Larchmt) 2020; 21:586-591. [PMID: 32423308 DOI: 10.1089/sur.2020.134] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background: Out-of-pocket payments and catastrophic healthcare expenditures (CHE) are important barriers to achieving equity and access to emergency and essential surgical care in low- and middle-income countries (LMICs), with important implications for universal health coverage (UHC). However, data on CHE for surgical care in these settings are limited, especially with regard to infections. Methods: We performed a retrospective review of 32 children receiving laparotomy for typhoid intestinal perforation in a four-year period. Data on medical costs were reviewed. Because of the lack of reliable data on household incomes and average national incomes for Nigeria, gross domestic product per capita was used to calculate CHE. The GDP per capita for the country during the study period was $2,028.182. Expenditure >10% GDP per capita (or > $202.82) was considered CHE. Results: There were 15 boys and 17 girls aged 2-15 years (mean 7.72 years). Seventeen patients (53%) were referred from district/general hospitals or mission hospitals. After surgical treatment, 16 patients (50%) developed complications (intra-abdominal abscesses and incision complications), and nine (28.1%) required re-operation. Seven patients (21.9%) required intensive care (ICU) treatment and three (9.4%) died from overwhelming infection. The hospital stay was 3-93 days (mean 23 days). The average total medical cost was $452 (range $236-$1,700). The total medical costs exceeded 10% of GDP ($202.82) for all patients. Total expenditure for four patients requiring intensive care exceeded $202.82 for the ICU care alone. Conclusion: Surgical treatment of typhoid intestinal perforation in children is associated with a high rate of CHE if care is provided at tertiary hospitals. Investments in prevention and control of this and other surgical infections as well as scale up of capacity at district hospitals to provide such care are important in preventing CHE.
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Affiliation(s)
- Justina O Seyi-Olajide
- Paediatric Surgery Unit, Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Jamie Anderson
- Department of Surgery, University of California, Davis Medical Center, Sacramento, California, USA
| | - Augustine O Enivwaene
- Division of Paediatric Surgery, Department of Surgery, National Hospital, Abuja, Nigeria
| | - Salamatu Halid Ibrahim
- Division of Paediatric Surgery, Department of Surgery, National Hospital, Abuja, Nigeria
| | - Diana Farmer
- Department of Surgery, University of California, Davis Medical Center, Sacramento, California, USA
| | - Emmanuel A Ameh
- Division of Paediatric Surgery, Department of Surgery, National Hospital, Abuja, Nigeria
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Pittalis C, Brugha R, Bijlmakers L, Mwapasa G, Borgstein E, Gajewski J. Patterns, quality and appropriateness of surgical referrals in Malawi. Trop Med Int Health 2020; 25:824-833. [PMID: 32324928 DOI: 10.1111/tmi.13406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Reliable referral systems are essential to the functionality and efficiency of the wider health care system in low- and middle-income countries (LMICs), particularly in surgery as the disease burden is growing while resources remain constrained and unevenly distributed. Yet, this is a critically under-researched area. This study aimed to provide a comprehensive assessment of surgical referral systems in a LMIC, Malawi, with a view to shedding light on this important aspect of public health and share lessons learned. METHODS We conducted a prospective analysis of all inter-hospital referrals received at Queen Elizabeth Central Hospital (QECH) in 2014-2015. A subsample of 255 referrals was assessed by three independent surgical experts against necessity and quality of the transfer to identify any inefficiencies in the referral process. RESULTS 1317 patients were referred to QECH during the study period (average 53/month), 80% sent by government district hospitals. One in 3 cases were referred unnecessarily, many of which could have been managed locally. In 82% of cases, there was no communication with QECH prior to referral, 41% had incorrect/incomplete diagnosis by the referring clinicians and 39% of referrals were not timely. CONCLUSIONS Our findings provide the first evidence on the state of the surgical referral system in Malawi and contribute to building the body of knowledge necessary to inform system improvements. Responses should include reducing inappropriate use of specialist care and ensuring better care pathways for surgical patients, especially in rural areas, where access to specialist expertise is not available at present.
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Affiliation(s)
- Chiara Pittalis
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruairi Brugha
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leon Bijlmakers
- Nijmegen International Centre for Health Systems Research and Education, Radboud University, Nijmegen, The Netherlands
| | - Gerald Mwapasa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Eric Borgstein
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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