Electricity and generator availability in LMIC hospitals: improving access to safe surgery

Barriers to Neurosurgical Care of Brain Tumors in Low- and Middle-Income Countries: A Systematic Review of the Service Delivery Challenges

INTRODUCTION

Brain tumors pose a major challenge in low- and middle-income countries (LMICs) due to limited resources and high costs, resulting in hampered service delivery of neurosurgical care and significant disparities in patient outcomes compared to high-income nations. Therefore, our systematic review aims to identify barriers to service delivery in providing adequate surgical care for the management of brain tumors in LMICs.

METHODS

We searched Scopus, PubMed, Google Scholar, and CINAHL, from inception to October 20, 2022. The data from the eligible studies were extracted and analyzed qualitatively.

RESULTS

The final analysis included 35 articles, which highlighted significant challenges in providing adequate surgical care for brain tumors in LMICs. Among the cited studies, 10% reported lack of multidisciplinary team structures, 61% noted delayed patient presentation, 16% highlighted delays in neuroimaging, 10% reported delays in scheduling surgery, lack of training for specialized surgery (3%), lack of intra-operative facilities (19%), power supply interruption (6%), and lack of advanced diagnostic and specialized surgery facilities (19%). Strategies for addressing these challenges include cross-border collaboration (7%), public education, and awareness (13%), establishing multidisciplinary teams (20%), utilizing alternative surgical techniques (13%), 7% intraoperative ultrasound, 13% intraoperative cytology smear), and establishing satellite hospitals for low-risk care (7%), standard operating procedure and infection control (13%).

CONCLUSION

Targeted interventions considering economic constraints are essential to improve the availability, affordability, and quality of neuro-oncologic services in developing countries. International collaborations and building capacity are vital for improving patient outcomes and service delivery, as well as forming multidisciplinary teams and utilizing resource-saving, innovative methods.

Enhancing Cranio-Maxillofacial Fracture Care in Low- and Middle-Income Countries: A Systematic Review

Background: Cranio-maxillofacial (CMF) injuries represent a significant challenge in low- and middle-income countries (LMICs), exacerbated by inadequate infrastructure, resources, and training. This systematic review aims to evaluate the current strategies and solutions proposed in the literature to improve CMF fracture care in LMICs, focusing on education, patient transfer, and off-label solutions. Methods: A comprehensive literature search was conducted using PubMed/Medline from January 2000 to June 2023. Studies were selected based on the Preferred Reporting Items for Systematic Review and Meta-analysis Statement (PRISMA). Solutions were categorized into three main areas: education (digital and on-site teaching, fellowships abroad), patient transfer to specialized clinics, and off-label/non-operative solutions. Results: Twenty-three articles were included in the review, revealing a consensus on the necessity for enhanced education and training for local surgeons as the cornerstone for sustainable improvements in CMF care in LMICs. Digital platforms and on-site teaching were identified as key methods for delivering educational content. Furthermore, patient transfer to specialized national clinics and innovative off-label techniques were discussed as immediate solutions to provide quality care despite resource constraints. Conclusions: Effective CMF fracture care in LMICs requires a multifaceted approach, prioritizing the education and training of local healthcare professionals, facilitated patient transfer to specialized centers, and the adoption of off-label solutions to leverage available resources. Collaborative efforts between international organizations, local healthcare providers, and educational institutions are essential to implement these solutions effectively and improve patient outcomes in LMICs.

A Community-Based, Mobile Electronic Medical Record System App for High-Quality, Integrated Antiretroviral Therapy in Lilongwe, Malawi: Design Process and Pilot Implementation

BACKGROUND

Differentiated service delivery (DSD) increases antiretroviral therapy (ART) access in sub-Saharan Africa by moving clients out of congested ART clinics to communities for care. However, DSD settings challenge provider adherence to complex, chronic care treatment guidelines and have burdensome systems for client monitoring and evaluation (M&E), reducing data for decision-making. Electronic medical record systems (EMRS) improve client outcomes and reduce M&E workload. Traditional EMRS cannot operate in most DSD settings with unreliable power and poor connectivity.

OBJECTIVE

This study aims to detail the human-centered design (HCD) process of developing a mobile EMRS for community-based DSD services in Lilongwe, Malawi.

METHODS

Lighthouse Trust (LT) operates 2 Ministry of Health (MoH) clinics in Lilongwe, Malawi, with a combined total of >35,000 ART clients. LT's real-time, point-of-care EMRS collects complex client M&E data and provides decision-making support, ensuring adherence to integrated HIV and tuberculosis guidelines that optimize client and program outcomes. LT's EMRS scaled to all large MoH ART clinics. LT also implements a nurse-led community-based ART program (NCAP), a DSD model to provide ART and rapid assessment for 2400 stable LT clients in the community. LT, alongside collaborators, from the University of Washington's International Training and Education Center for Health and technology partner, Medic, used the open-source Community Health Toolkit (CHT) and HCD to develop an open-source, offline-first, mobile EMRS-like app, "community-based ART retention and suppression" (CARES). CARES aims to bring EMRS-like provider benefits to NCAP's DSD clients.

RESULTS

CARES design took approximately 12 months and used an iterative process of highly participatory feedback sessions with provider, data manager, and M&E team inputs to ensure CARES optimization for the NCAP and LT settings. The CARES mobile EMRS prototype supports NCAP providers with embedded prompts and alerts to ensure adherence to integrated MoH ART guidelines, aiming to improve the quality of client care. CARES facilitates improved data quality and flow for NCAP M&E, aiming to reduce data gaps between community and clinic settings. The CARES pilot demonstrates the potential of a mobile, point-of-care EMRS-like app that could benefit NCAP clients, providers, and program teams with integrated client care and complete M&E data for decision-making. CARES challenges include app speed, search features to align longitudinal records, and CARES to EMRS integration that supports timely care alerts.

CONCLUSIONS

Leveraging the CHT and HCD processes facilitated the design of a locally specified and optimized mobile app with the promise to bring EMRS-like benefits to DSD settings. Moving from the CARES prototype to routine NCAP implementation should result in improved client care and strengthened M&E while reducing workload. Our transparent and descriptive process shares the progress and pitfalls of the CARES design and development, helping others in this digital innovation area to learn from our experiences at this stage.

Vascular Surgery in Low-Income and Middle-Income Countries: A State-of-the-Art Review

BACKGROUND

Cardiovascular disease (CVD) represents 32% of all global deaths. Studies have shown an increase in CVD prevalence and mortality with the most substantial increase in low-income and middle-income countries (LMICs). Within LMICs, we sought to 1) measure the burden of CVD with respect to aortic aneurysm (AA), ischemic stroke (IS), and peripheral arterial disease (PAD); 2) quantify surgical access to vascular surgery services; and 3) identify challenges and solutions to addressing disparities.

METHODS

The Institute for Health Metrics and Evaluation Global Burden of Disease Results Tool was used to assess the global burden of CVD (AA, PAD, IS). Population data were extracted from the World Bank & Workforce data. A literature review was completed through PubMed.

RESULTS

The number of deaths attributable to AA, PAD, and IS in LMICs increased by up to 102% between 1990 and 2019. Disability-adjusted life-years (DALYs) lost to AA, PAD, and IS in LMICs also increased by up to 67%. High-income countries (HIC) had a less considerable increase in deaths and DALYs during this time period. There are 101 and 72.7 vascular surgeons per 10 million people in the United States and United Kingdom, respectively. LMICs, such as Morocco, Iran, and South Africa have 10 times less this number. Ethiopia has 0.25 vascular surgeons per 10 million people, 400 times less than the United States. Interventions addressing these global disparities should address infrastructure and financing, data collection and sharing, patient knowledge and beliefs, and workforce development.

CONCLUSIONS

Extreme regional discrepancies are evidence at a global scale. Identifying mechanisms to expand the vascular surgical workforce to meet the increasing need for vascular surgical access is imminent.

The state of surgery, obstetrics, trauma, and anaesthesia care in Ghana: a narrative review

Background

Conditions amenable to surgical, obstetric, trauma, and anaesthesia (SOTA) care are a major contributor to death and disability in Ghana. SOTA care is an essential component of a well-functioning health system, and better understanding of the state of SOTA care in Ghana is necessary to design policies to address gaps in SOTA care delivery.

Objective

The aim of this study is to assess the current situation of SOTA care in Ghana.

Methods

A situation analysis was conducted as a narrative review of published scientific literature. Information was extracted from studies according to five health system domains related to SOTA care: service delivery, workforce, infrastructure, finance, and information management.

Results

Ghanaians face numerous barriers to accessing quality SOTA care, primarily due to health system inadequacies. Over 77% of surgical operations performed in Ghana are essential procedures, most of which are performed at district-level hospitals that do not have consistent access to imaging and operative room fundamentals. Tertiary facilities have consistent access to these modalities but lack consistent access to oxygen and/or oxygen concentrators on-site as well as surgical supplies and anaesthetic medicines. Ghanaian patients cover up to 91% of direct SOTA costs out-of-pocket, while health insurance only covers up to 14% of the costs. The Ghanaian surgical system also faces severe workforce inadequacies especially in district-level facilities. Most specialty surgeons are concentrated in urban areas. Ghana’s health system lacks a solid information management foundation as it does not have centralized SOTA databases, leading to incomplete, poorly coded, and illegible patient information.

Conclusion

This review establishes that surgical services provided in Ghana are focused primarily on district-level facilities that lack adequate infrastructure and face workforce shortages, among other challenges. A comprehensive scale-up of Ghana’s surgical infrastructure, workforce, national insurance plan, and information systems is warranted to improve Ghana’s surgical system.

Artificial intelligence for strengthening healthcare systems in low- and middle-income countries: a systematic scoping review

In low- and middle-income countries (LMICs), AI has been promoted as a potential means of strengthening healthcare systems by a growing number of publications. We aimed to evaluate the scope and nature of AI technologies in the specific context of LMICs. In this systematic scoping review, we used a broad variety of AI and healthcare search terms. Our literature search included records published between 1st January 2009 and 30th September 2021 from the Scopus, EMBASE, MEDLINE, Global Health and APA PsycInfo databases, and grey literature from a Google Scholar search. We included studies that reported a quantitative and/or qualitative evaluation of a real-world application of AI in an LMIC health context. A total of 10 references evaluating the application of AI in an LMIC were included. Applications varied widely, including: clinical decision support systems, treatment planning and triage assistants and health chatbots. Only half of the papers reported which algorithms and datasets were used in order to train the AI. A number of challenges of using AI tools were reported, including issues with reliability, mixed impacts on workflows, poor user friendliness and lack of adeptness with local contexts. Many barriers exists that prevent the successful development and adoption of well-performing, context-specific AI tools, such as limited data availability, trust and evidence of cost-effectiveness in LMICs. Additional evaluations of the use of AI in healthcare in LMICs are needed in order to identify their effectiveness and reliability in real-world settings and to generate understanding for best practices for future implementations.

Climate change and emergency care in Africa: A scoping review

Introduction

Climate change is a global public health emergency with implications for access to care and emergency care service disruptions. The African continent is particularly vulnerable to climate-related extreme weather events due to an already overburdened health system, lack of early warning signs, poverty, inadequate infrastructure, and variable adaptive capacity. Emergency care services are not only utilized during these events but also threatened by these hazards. Considering that the effects of climate change are expected to increase in intensity and prevalence, it is increasingly important for emergency care to prepare to respond to the changes in presentation and demand. The aim of this study was to perform a scoping review of the available literature on the relationship between climate change and emergency care on the African continent.

Methods

A scoping review was completed using five databases: Pubmed, Web of Science, GreenFILE, Africa Wide Information, and Google Scholar. A 'grey' literature search was done to identify key reports and references from included articles. Two independent reviewers screened articles and a third reviewer decided conflicts. A total of 1,382 individual articles were initially screened with 17 meeting full text review. A total of six articles were included in the final analysis. Data from four countries were represented including Uganda, Ghana, Tanzania, and Nigeria.

Results

Analysis of the six articles yielded three key themes that were identified: climate-related health impacts that contribute to surges in demand and resource utilization, opportunities for health sector engagement, and solutions to improve emergency preparedness. Authors used the outcomes of the review to propose 10 recommendations for decision-makers and leaders.

DXDiscussion

Incorporating these key recommendations at the local and national level could help improve preparedness and adaptation measures in highly vulnerable, populated areas on the African continent.

3D-printed activated charcoal inlet filters for oxygen concentrators: A circular economy approach

As of May 2021, the current COVID-19 pandemic is still plaguing the world, challenging all the countries and their health systems, globally. In this context, conditions typical of low-resource settings surfaced also in high-resource ones (e.g., the lack of essential medical equipment, of resources etc.), while exacerbating in the already resource-scarce settings, because of COVID-19. This is the case of oxygen concentrators that are one of the first-line medical devices for treating COVID-19 patients. Since the beginning of 2020, their demand has been rapidly growing worldwide, aggravating the situation for low-resource settings, where the availability of devices providing oxygen-enriched air was already scarce. In fact, due to their delicacy, the lack of spare parts and of an appropriate health technology management system, oxygen concentrators can often be found broken or not working properly in these settings. The underlying problems have deep roots. The current regulatory frameworks and standards, which are set by high-income countries, are too stringent, and do not take into account the limited resources of poorer settings. Thus, they are often inapplicable in such settings. One of the main issues affecting the oxygen concentrators, is that related to the filters, which are designed to filter out dust, particles, bacteria, and to be used in medical locations complying with international standards (e.g., the air filtration level in a surgical theatre in Italy is at 99.97%). When used in low-resource settings, which do not comply with these standards and face several challenges (e.g., dust), these filters have a much-reduced lifespan. For these reasons, this paper aims to present the redesign of the inlet filter of an oxygen concentrator, which is used to prevent gross particles to enter the device. The redesign is based on a reverse engineering approach, and on the use of 3D-printing along with activated charcoal. After testing the filtration efficiency with a particle counter, the filter design has been refined through several iterations. The final prototype performs particularly well when filtering particles above 1 μm (with a filtration efficiency of 64.2%), and still has a satisfactory performance with any particle size over 0.3 μm (with a filtration efficiency of 38.8%). Following the United Nations Sustainable Development Goals, this project aims to empower local communities, and start a positive trend of self-sustained supply chain of simple spare parts for medical devices, leveraging on frugal engineering, 3D-printing, locally produced activated charcoal, and circular economy.

Changes in surgical volume, workforce, and productivity in Sierra Leone between 2012 and 2017

BACKGROUND

The Lancet Commission on Global Surgery recommends a minimum of 20 surgical specialists and 5,000 annual operations per 100,000 population by 2030. In 2012, Sierra Leone was far from reaching these targets. This study aimed to assess the changes in surgical activity, surgical workforce, and surgical productivity between 2012 and 2017.

METHODS

A nationwide, retrospective mapping of surgical activity and workforce in 2012 was repeated in 2017. All 60 facilities performing comprehensive surgery in Sierra Leone in 2017 were identified and data was obtained from surgical records and through structured interviews with facility directors. Annual estimates were calculated and compared with 2012.

RESULTS

The surgical workforce increased from 164.5 to 312.8 full-time positions. The annual volume of surgeries was enhanced by 15.6% (95% CI: 7.8-23.4%) from 24,152 to 27,928 (26,048-29,808) operations. With simultaneous population growth, this led to a decrease in surgical volume from 400 to 372 procedures per 100,000 population and an unmet operative need of 92.7%. The mean productivity of surgical providers went from 2.8 to 1.7 surgeries per week per full-time position. An increasing number of caesarean deliveries were performed in public institutions, by associate clinicians.

CONCLUSION

The unmet need for surgery in Sierra Leone remains very high, despite an increase in the surgical workforce, subsidizing maternal healthcare, and initiation of a surgical task-sharing program. The decline in surgical productivity with simultaneous increases in the surgical workforce calls for further exploration of the barriers to access and delivery of surgical care in Sierra Leone.

Pragmatic Recommendations for the Prevention and Treatment of Acute Kidney Injury in Patients with COVID-19 in Low- and Middle-Income Countries

Current recommendations for the management of patients with COVID-19 and acute kidney injury (AKI) are largely based on evidence from resource-rich settings, mostly located in high-income countries. It is often unpractical to apply these recommendations to resource-restricted settings. We report on a set of pragmatic recommendations for the prevention, diagnosis, and management of patients with COVID-19 and AKI in low- and middle-income countries (LMICs). For the prevention of AKI among patients with COVID-19 in LMICs, we recommend using isotonic crystalloid solutions for expansion of intravascular volume, avoiding nephrotoxic medications, and using a conservative fluid management strategy in patients with respiratory failure. For the diagnosis of AKI, we suggest that any patient with COVID-19 presenting with an elevated serum creatinine level without available historical values be considered as having AKI. If serum creatinine testing is not available, we suggest that patients with proteinuria should be considered to have possible AKI. We suggest expansion of the use of point-of-care serum creatinine and salivary urea nitrogen testing in community health settings, as funding and availability allow. For the management of patients with AKI and COVID-19 in LMICS, we recommend judicious use of intravenous fluid resuscitation. For patients requiring dialysis who do not have acute respiratory distress syndrome (ARDS), we suggest using peritoneal dialysis (PD) as first choice, where available and feasible. For patients requiring dialysis who do have ARDS, we suggest using hemodialysis, where available and feasible, to optimize fluid removal. We suggest using locally produced PD solutions when commercially produced solutions are unavailable or unaffordable.

Power Outages and Community Health: a Narrative Review

PURPOSE OF REVIEW

Power outages, a common and underappreciated consequence of natural disasters, are increasing in number and severity due to climate change and aging electricity grids. This narrative review synthesizes the literature on power outages and health in communities.

RECENT FINDINGS

We searched Google Scholar and PubMed for English language studies with titles or abstracts containing "power outage" or "blackout." We limited papers to those that explicitly mentioned power outages or blackouts as the exposure of interest for health outcomes among individuals living in the community. We also used the reference list of these studies to identify additional studies. The final sample included 50 articles published between 2004 and 2020, with 17 (34%) appearing between 2016 and 2020. Exposure assessment remains basic and inconsistent, with 43 (86%) of studies evaluating single, large-scale power outages. Few studies used spatial and temporal control groups to assess changes in health outcomes attributable to power outages. Recent research linked data from electricity providers on power outages in space and time and included factors such as number of customers affected and duration to estimate exposure. The existing literature suggests that power outages have important health consequences ranging from carbon monoxide poisoning, temperature-related illness, gastrointestinal illness, and mortality to all-cause, cardiovascular, respiratory, and renal disease hospitalizations, especially for individuals relying on electricity-dependent medical equipment. Nonetheless the studies are limited, and more work is needed to better define and capture the relevant exposures and outcomes. Studies should consider modifying factors such as socioeconomic and other vulnerabilities as well as how community resiliency can minimize the adverse impacts of widespread major power outages.

Health care during electricity failure: The hidden costs

Background

Surgery risks increase when electricity is accessible but unreliable. During unreliable electricity events and without data on increased risk to patients, medical professionals base their decisions on anecdotal experience. Decisions should be made based on a cost-benefit analysis, but no methodology exists to quantify these risks, the associated hidden costs, nor risk charts to compare alternatives.

Methods

Two methodologies were created to quantify these hidden costs. In the first methodology through research literature and/or measurements, the authors obtained and analyzed a year’s worth of hour-by-hour energy failures for four energy healthcare system (EHS) types in four regions (SolarPV in Iraq, Hydroelectric in Ghana, SolarPV+Wind in Bangladesh, and Grid+Diesel in Uganda). In the second methodology, additional patient risks were calculated according to time and duration of electricity failure and medical procedure impact type. Combining these methodologies, the cost from the Value of Statistical Lives lost divided by Energy shortage ($/kWh) is calculated for EHS type and region specifically. The authors define hidden costs due to electricity failure as VSL/E ($/kWh) and compare this to traditional electricity costs (always defined in $/kWh units), including Levelized Cost of Electricity (LCOE also in $/kWh). This is quantified into a fundamentally new energy healthcare system risk chart (EHS-Risk Chart) based on severity of event (probability of deaths) and likelihood of event (probability of electricity failure).

Results

VSL/E costs were found to be 10 to 10,000 times traditional electricity costs (electric utility or LCOE based). The single power source EHS types have higher risks than hybridized EHS types (especially as power loads increase over time), but all EHS types have additional risks to patients due to electricity failure (between 3 to 105 deaths per 1,000 patients).

Conclusions

These electricity failure risks and hidden healthcare costs can now be calculated and charted to make medical decisions based on a risk chart instead of anecdotal experience. This risk chart connects public health and electricity failure using this adaptable, scalable, and verifiable model.

Rapid in-country sequencing of whole virus genomes to inform rabies elimination programmes

Genomic surveillance is an important aspect of contemporary disease management but has yet to be used routinely to monitor endemic disease transmission and control in low- and middle-income countries. Rabies is an almost invariably fatal viral disease that causes a large public health and economic burden in Asia and Africa, despite being entirely vaccine preventable. With policy efforts now directed towards achieving a global goal of zero dog-mediated human rabies deaths by 2030, establishing effective surveillance tools is critical. Genomic data can provide important and unique insights into rabies spread and persistence that can direct control efforts. However, capacity for genomic research in low- and middle-income countries is held back by limited laboratory infrastructure, cost, supply chains and other logistical challenges. Here we present and validate an end-to-end workflow to facilitate affordable whole genome sequencing for rabies surveillance utilising nanopore technology. We used this workflow in Kenya, Tanzania and the Philippines to generate rabies virus genomes in two to three days, reducing costs to approximately £60 per genome. This is over half the cost of metagenomic sequencing previously conducted for Tanzanian samples, which involved exporting samples to the UK and a three- to six-month lag time. Ongoing optimization of workflows are likely to reduce these costs further. We also present tools to support routine whole genome sequencing and interpretation for genomic surveillance. Moreover, combined with training workshops to empower scientists in-country, we show that local sequencing capacity can be readily established and sustainable, negating the common misperception that cutting-edge genomic research can only be conducted in high resource laboratories. More generally, we argue that the capacity to harness genomic data is a game-changer for endemic disease surveillance and should precipitate a new wave of researchers from low- and middle-income countries.

A Context-Specific Design of an Electrosurgical Unit and Monopolar Handheld to Enhance Global Access to Surgical Care: A Design Approach Based on Contextual Factors

To comply with the large global need for surgery, surgical equipment that fits the challenging environment in low- and middle-income countries (LMICs) should be designed. The aim of this study is to present a context-specific design of an electrosurgical unit (ESU) and a monopolar handheld to improve global access to surgery. This paper presents both a detailed description of electrosurgery in clinical practice in LMICs and the design of an ESU generator and monopolar handheld for this specific setting. Extensive fieldwork (by means of surveys, interviews, observations, and collection of maintenance records) was done by authors RO, KO, and LH. Feedback from users working in Kenya on the first demonstrator designs was obtained, after which the designs were adapted into conceptual prototypes. These were further evaluated by surveying respondents who attended the annual meeting of the College of Surgeons of East, Central, and Southern Africa (COSECSA) in Kigali, Rwanda in December 2018. Conceptual prototypes were developed for (a) an affordable ESU that is compact and battery powered and (b) a robust reusable monopolar handheld that can be cleaned in the autoclave and by chemicals (e.g., glutaraldehyde solution). The conceptual prototypes were positively received by the 51 respondents of the survey. The findings from the field work and the feedback from users during the design phase have led to a clear understanding of the specific needs and potential solutions. The presented conceptual prototypes need to be further developed into functional prototypes, which could be implemented in Kenya and other settings for further evaluation.

Rapid in-country sequencing of whole virus genomes to inform rabies elimination programmes

Genomic surveillance is an important aspect of contemporary disease management but has yet to be used routinely to monitor endemic disease transmission and control in low- and middle-income countries. Rabies is an almost invariably fatal viral disease that causes a large public health and economic burden in Asia and Africa, despite being entirely vaccine preventable. With policy efforts now directed towards achieving a global goal of zero dog-mediated human rabies deaths by 2030, establishing effective surveillance tools is critical. Genomic data can provide important and unique insights into rabies spread and persistence that can direct control efforts. However, capacity for genomic research in low- and middle-income countries is held back by limited laboratory infrastructure, cost, supply chains and other logistical challenges. Here we present and validate an end-to-end workflow to facilitate affordable whole genome sequencing for rabies surveillance utilising nanopore technology. We used this workflow in Kenya, Tanzania and the Philippines to generate rabies virus genomes in two to three days, reducing costs to approximately £60 per genome. This is over half the cost of metagenomic sequencing previously conducted for Tanzanian samples, which involved exporting samples to the UK and a three- to six-month lag time. Ongoing optimization of workflows are likely to reduce these costs further. We also present tools to support routine whole genome sequencing and interpretation for genomic surveillance. Moreover, combined with training workshops to empower scientists in-country, we show that local sequencing capacity can be readily established and sustainable, negating the common misperception that cutting-edge genomic research can only be conducted in high resource laboratories. More generally, we argue that the capacity to harness genomic data is a game-changer for endemic disease surveillance and should precipitate a new wave of researchers from low- and middle-income countries.

Addressing Supply Chain Management Issues in Cost-effective Maternal and Pediatric Global Surgery: A Call to Action

Persistent global disparities in maternal and neonatal outcomes exist, in part, due to a lack of access to safe surgery. This commentary examines the relative need for increased focus on access to safe maternal and pediatric surgery globally, starting with a focus on cost-effective surgeries. There is a need to understand context-specific surgeries for regions, including understanding regional versus tertiary development. Most important is a need to understand the crucial role of supply chain management (SCM) in developing better access to maternal and pediatric surgery in limited resource settings. We evaluate the role of SCM in global surgery and global health, and the current landscape of inefficiency. We outline specific findings and takeaways from recent solutions developed in pediatric and maternal surgery to address SCM inefficiencies. We then examine the applicability to other settings and look at the future. Our goal is to summarize the challenges that exist today in a global setting to provide better access to maternal and pediatric surgery and outline solutions relying on structural, SCM-related framework.

Cardiac Arrhythmias in Africa: Epidemiology, Management Challenges, and Perspectives

Africa is experiencing an increasing burden of cardiac arrhythmias. Unfortunately, the expanding need for appropriate care remains largely unmet because of inadequate funding, shortage of essential medical expertise, and the high cost of diagnostic equipment and treatment modalities. Thus, patients receive suboptimal care. A total of 5 of 34 countries (15%) in Sub-Saharan Africa (SSA) lack a single trained cardiologist to provide basic cardiac care. One-third of the SSA countries do not have a single pacemaker center, and more than one-half do not have a coronary catheterization laboratory. Only South Africa and several North African countries provide complete services for cardiac arrhythmias, leaving more than hundreds of millions of people in SSA without access to arrhythmia care considered standard in other parts of the world. Key strategies to improve arrhythmia care in Africa include greater government health care funding, increased emphasis on personnel training through fellowship programs, and greater focus on preventive care.

Medical equipment donation in low-resource settings: a review of the literature and guidelines for surgery and anaesthesia in low-income and middle-income countries

BACKGROUND

Medical equipment donation to low-resource settings is a frequently used strategy to address existing disparities, but there is a paucity of reported experience and evaluation. Challenges such as infrastructure gaps, lack of technological and maintenance capabilities, and non-prioritisation of essential supplies have previously been highlighted. This pragmatic review summarises existing guidelines and literature relevant to surgical and anaesthesia equipment, with recommendations for future initiatives and research.

METHODS

Retrospective literature review including both academic and grey literature from 1980 to 2018. We conducted a narrative synthesis to identify key factors that were condensed thematically.

RESULTS

Thirty-three biomedical equipment donation guidelines were identified from governments, WHO, World Bank, academic colleges and non-governmental organisations, and 36 relevant studies in peer-reviewed literature. These highlighted the need to consider all stages of the donation process, including planning, sourcing, transporting, training, maintaining and evaluating equipment donation. Donors were advised to consult national guidelines to ensure equipment was appropriate, desirable and non-costly to both parties. User training and access to biomechanical engineers were suggested as necessary for long-term sustainability. Finally, equitable partnerships between donors and recipients were integral to reducing inappropriate donations and to improve follow-up and evaluation.

CONCLUSION

There is a paucity of evidence on the causes of success or failure in medical equipment donation, despite its domination of equipment sourcing across many low-resource settings. Equitable partnerships, consultation of policies and guidelines, and careful planning may improve equipment usability and life span. A concerted effort is required to increase awareness of guidelines among health professionals worldwide.

Surgical Instrument Reprocessing in Resource-Constrained Countries: A Scoping Review of Existing Methods, Policies, and Barriers

BACKGROUND

Surgical infections are a major cause of morbidity and mortality in low- and middle-income countries (LMICs). Inadequately reprocessed surgical instruments can be a vector for pathogens. Little has been published on the current state of surgical instrument reprocessing in LMICs.

METHODS

We performed a scoping review of English-language articles in PubMed, Web of Science, and Google Scholar databases describing current methods, policies, and barriers to surgical instrument reprocessing in LMICs. We conducted qualitative analysis of all studies to categorize existing practices and barriers to successful surgical instrument reprocessing. Barriers were non-exclusively categorized by theme: training/education, resource availability, environment, and policies/procedures. Studies associating surgical infections with existing practices were separately evaluated to assess this relationship.

RESULTS

Nine hundred seventy-two abstracts were identified. Forty studies met criteria for qualitative analysis and three studies associated patient outcomes with surgical instrument reprocessing. Most studies (n = 28, 70%) discussed institution-specific policies/procedures; half discussed shortcomings in staff training. Sterilization (n = 38, 95%), verification of sterilization (n = 19, 48%), and instrument cleaning and decontamination (n = 16, 40%) were the most common instrument reprocessing practices examined. Poor resource availability and the lack of effective education/training and appropriate policies/procedures were cited as the common barriers. Of the case series investigating surgical instrument reprocessing with patient outcomes, improperly cleaned and sterilized neurosurgical instruments and contaminated rinse water were linked to Pseudomonas aeruginosa ventriculitis and Mycobacterium port site infections, respectively.

CONCLUSIONS

Large gaps exist between instrument reprocessing practices in LMICs and recommended policies/procedures. Identified areas for improvement include instrument cleaning and decontamination, sterilization aspects of instrument reprocessing, and verification of sterilization. Education and training of staff responsible for reprocessing instruments and realistic, defined policies and procedures are critical, and lend themselves to improvement interventions.