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Liu RH, Manana W, Tollefson TT, Ntirenganya F, Shaye DA. Perspectives on the state of cleft lip and cleft palate patient care in Africa. Curr Opin Otolaryngol Head Neck Surg 2024; 32:202-208. [PMID: 38695446 DOI: 10.1097/moo.0000000000000979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
PURPOSE OF REVIEW Patients with cleft lip -palate (CLP) experience morbidity and social stigma, particularly in low-income and middle-income countries (LMICs) such as those of sub-Saharan Africa (SSA). Delays in treatment secondary either to lack of awareness, skills, equipment and consumables; poor health infrastructure, limited resources or a combination of them, has led to SSA having the highest rates of death and second highest rates of disability-adjusted life years in patients with CLP globally. Here we review current perspectives on the state of comprehensive cleft lip and palate repair in Africa. RECENT FINDINGS To bridge gaps in government health services, nongovernmental organizations (NGOs) have emerged to provide care through short-term surgical interventions (STSIs). These groups can effect change through direct provision of care, whereas others strengthen internal system. However, sustainability is lacking as there continue to be barriers to achieving comprehensive and longitudinal cleft care in SSA, including a lack of awareness of CLP as a treatable condition, prohibitive costs, poor follow-up, and insufficient surgical infrastructure. With dedicated local champions, a comprehensive approach, and reliable partners, establishing sustainable CLP services is possible in countries with limited resources. SUMMARY The replacement of CLP 'missions' with locally initiated, internationally supported capacity building initiatives, integrated into local healthcare systems will prove sustainable in the long-term.
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Affiliation(s)
- Rui Han Liu
- Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Wayne Manana
- Division of Oral and Maxillofacial Surgery, Department of Dentistry, College of Health Science, University of Zimbabwe, Harare, Zimbabwe
| | - Travis T Tollefson
- Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, USA
| | - Faustin Ntirenganya
- Department of Surgery, University Teaching Hospital Kigali
- School of Medicine and Pharmacy, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
| | - David A Shaye
- Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, University Teaching Hospital Kigali
- School of Medicine and Pharmacy, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
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Mac Quene T, Smith L, Odland ML, Levine S, D'Ambruoso L, Davies J, Chu K. Prioritising and mapping barriers to achieve equitable surgical care in South Africa: a multi-disciplinary stakeholder workshop. Glob Health Action 2022; 15:2067395. [PMID: 35730572 PMCID: PMC9225684 DOI: 10.1080/16549716.2022.2067395] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Surgical healthcare in South Africa is inequitable with a considerable lack of resources in the public health sector. Identifying barriers to care and creating research priorities to mitigate these barriers can contribute to strategic interventions to improve equitable access to quality surgical care. OBJECTIVE To use the Four Delays Framework to map barriers to surgical care and identify priorities to achieve equitable and timely access to quality surgical care in South Africa. METHODS A multi-disciplinary stakeholder workshop was held in Cape Town, South Africa in January 2020. A Four Delays Framework (delays in seeking care, reaching care, receiving care, and remaining in care) was used to identify barriers that occur at each delay and the top 10 priorities for intervention. Barriers were categorised into overarching themes and schematically mapped. RESULTS Thirty-four stakeholders including health service users, health service providers, and community members participated in this exercise. In total, 34 barriers were identified with 73 connections to various delays. Specifically, 14 barriers were related to delays in seeking care, 11 were related to delays in reaching care, 20 were related to delays in receiving care, and 28 were related to delays in remaining in care. The highest priority barriers across the delays were Lack of service provider's knowledge, training and experience, and Limited surgical outreach. The barrier Lack of decentralised services was related to all four delays. Barriers were interconnected and potentially reinforcing. CONCLUSIONS This workshop is the first of its kind to generate evidence on the delays to surgical care in South Africa. Mapping crucial interconnected, potentially reinforcing barriers, and priority interventions demonstrated how a multifaceted approach may be required to address delays to access. Further research focused on the identified priorities will contribute to efforts to promote equitable access to quality surgical care in South Africa.
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Affiliation(s)
- Tamlyn Mac Quene
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Luné Smith
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Maria Lisa Odland
- Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Susan Levine
- Department of Anthropology, Humanities Faculty, University of Cape Town, Cape Town, South Africa
| | - Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland, UK
| | - Justine Davies
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Institute for Applied Health Research, University of Birmingham, Birmingham, UK.,Faculty of Health Sciences, Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - Kathryn Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Nezerwa Y, Miranda E, Velin L, Shyaka I, Mukagaju F, Busomoke F, Nsanzimana JDD, Mukeshimana M, Mushimiyimana D, Mukambasabire B, Uwimana L, Ntirenganya F, Furaha C, Riviello R, Pompermaier L. Referral of Burn Patients in the Absence of Guidelines: A Rwandan Study. J Surg Res 2022; 278:216-222. [DOI: 10.1016/j.jss.2022.04.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 04/11/2022] [Accepted: 04/22/2022] [Indexed: 11/29/2022]
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Alayande B, Chu KM, Jumbam DT, Kimto OE, Musa Danladi G, Niyukuri A, Anderson GA, El-Gabri D, Miranda E, Taye M, Tertong N, Yempabe T, Ntirenganya F, Byiringiro JC, Sule AZ, Kobusingye OC, Bekele A, Riviello RR. Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review. CURRENT TRAUMA REPORTS 2022; 8:66-94. [PMID: 35692507 PMCID: PMC9168359 DOI: 10.1007/s40719-022-00229-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 02/02/2023]
Abstract
Purpose of Review Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model. Recent Findings A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager’s four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public–private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda. Summary Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action. Supplementary Information The online version contains supplementary material available at 10.1007/s40719-022-00229-1.
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Affiliation(s)
- Barnabas Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Kathryn M. Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences Stellenbosch University, Cape Town, South Africa
| | | | | | | | - Alliance Niyukuri
- Hope Africa University, Bujumbura, Burundi
- Mercy Surgeons-Burundi, Research Department, Bujumbura, Burundi
- Mercy James Center for Paediatric Surgery and Intensive Care-Blantyre, Blantyre, Malawi
| | - Geoffrey A. Anderson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Deena El-Gabri
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Elizabeth Miranda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Mulat Taye
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ngyal Tertong
- International Fellow, Paediatric Orthopaedic Surgery Department of Orthopaedics, Sheffield Children’s Hospital, Sheffield, UK
| | - Tolgou Yempabe
- Orthopaedic and Trauma Unit, Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana
| | - Faustin Ntirenganya
- University Teaching Hospital of Kigali, Kigali, Rwanda
- Department of Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- NIHR Research Hub On Global Surgery, University of Rwanda, Kigali, Rwanda
| | - Jean Claude Byiringiro
- University Teaching Hospital of Kigali, Kigali, Rwanda
- NIHR Research Hub On Global Surgery, University of Rwanda, Kigali, Rwanda
- School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Olive C. Kobusingye
- Makerere University School of Public Health, Kampala, Uganda
- George Institute for Global Health, Sydney, Australia
| | - Abebe Bekele
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Robert R. Riviello
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
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Twahirwa I, Niyonshuti N, Uwase C, Rickard J. Comparison of Outcomes of Emergency Laparotomies Performed During Daytime Versus Nights and Weekends in Rwandan University Teaching Hospitals. World J Surg 2021; 46:61-68. [PMID: 34581844 DOI: 10.1007/s00268-021-06327-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency laparotomy is a common procedure with high morbidity and mortality. The aim of this study was to assess if the time of surgery (day versus night and weekend) affects the morbidity and mortality in a low-resource setting. METHODS A retrospective study was conducted in 2 university teaching hospitals in Rwanda. Patient characteristics, time of laparotomy, operative details and postoperative outcomes were recorded. Chi-square and Wilcoxon rank sum tests were used to determine factors and outcomes associated with time of surgery. Logistic regression was used to determine factors associated with mortality. RESULTS In 309 patients, who underwent emergency laparotomy, 147 (48%) patients were operated during the daytime, 123 (40%) patients were operated during the night shift and 39 (12%) patients were operated on the weekend. Common diagnoses were intestinal obstruction (n = 141, 46%), peritonitis (n = 101, 33%) and abdominal trauma (n = 40, 13%). The overall mortality rate was 16% with 14% in patients operated during day and 17% in patients operated during night and weekends (p = 0.564). Overall, the morbidity rate was 30% with 27% in patients operated during the day compared with 32% in patients operated during night/weekends (p = 0.348). After controlling for confounding factors, there was no association between time of operation and mortality or morbidity. CONCLUSION Morbidity and mortality associated with emergency laparotomy are high but the time of day for emergency laparotomy did not affect outcome in Rwandan referral hospitals.
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Affiliation(s)
- Isaie Twahirwa
- University of Rwanda, Kigali, Rwanda
- University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Norbert Niyonshuti
- University of Rwanda, Kigali, Rwanda
- University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Clement Uwase
- University of Rwanda, Kigali, Rwanda
- University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Jennifer Rickard
- University of Rwanda, Kigali, Rwanda.
- University Teaching Hospital of Kigali, Kigali, Rwanda.
- University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA.
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Gallaher J, Kayange L, Purcell LN, Reid T, Charles A. Are Surgeons Enough? The Relationship between Increasing Surgical Demand and Access to Surgery in a Resource-Limited Environment. J Surg Res 2021; 267:569-576. [PMID: 34265600 DOI: 10.1016/j.jss.2021.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/25/2021] [Accepted: 06/09/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The relationship between increasing surgical demand and access to operative intervention remains unclear in delivering general surgical care in resource-limited settings, where demand often exceeds capacity. We sought to characterize the association between general surgery patient volume and operative intervention at a tertiary hospital in Malawi, which has an adequate surgical workforce. METHODS We analyzed patients admitted to Kamuzu Central Hospital Lilongwe, Malawi, with a general surgery complaint from 2018-2020. We examined the relationship between the census at the time of admission, the use of operative intervention, and the time to operative intervention. The patient census was defined as low (≤30 patients), medium (31-49 patients), and high (≥50 patients), based on historical patterns. RESULTS 2,701 patients were included. The mean daily census was 46 patients (SD 10). For the medium and high census, the adjusted risk ratio of undergoing surgery was 0.86 (95% CI 0.78, 0.95) and 0.81 (95% CI 0.73, 0.90), respectively, adjusted for admission diagnosis. For patients requiring urgent abdominal exploration, at a census of 25, the adjusted mean time to operation was 0.8 days (95% CI 0.1, 1.5) compared to 2.8 days (95% CI 2.1, 3.5) at a census of 65 patients. CONCLUSIONS Despite an adequate surgical workforce, an increasing mean daily census significantly reduced the use of operative intervention and increased time to operation for patients who needed urgent abdominal exploration. Additional improvements in the surgical ecosystem beyond surgeons are necessary to improve surgical access.
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Affiliation(s)
- Jared Gallaher
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
| | - Linda Kayange
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Laura N Purcell
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Trista Reid
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA; Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
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