Mapping population access to essential surgical care in Liberia using equipment, personnel, and bellwether capability standards

Analysis of implementation science strategies to train laparoscopic surgical skills among Liberian surgeons using ALL-SAFE

BACKGROUND

Significant disparities exist in laparoscopic training opportunities for surgeons in low- and middle-income countries (LMICs). ALL-SAFE is an innovative, low-cost training system for LMIC surgeons' laparoscopic development. However, strategies to implement and scale ALL-SAFE are unstudied. We aimed to assess the impact of implementation science strategies on ALL-SAFE uptake in Liberia, a novel and low-resource context.

METHODS

This study used implementation science approaches to evaluate ALL-SAFE uptake in three Liberian hospitals: John F. Kennedy Medical Center, Phebe, and ELWA. Five validated implementation strategies of program orientation, local champions, network weaving, feedback mechanisms, and practical supervision were piloted. All five strategies were implemented at two hospitals, while four strategies, excluding clinician supervision, were implemented at the final site as a pseudo-control, to evaluate the impact of resource-intensive supervision. Participants included surgical consultants, residents, and medical students. Engagement was assessed with mixed methods including participant number, practice hours, module completion rates, and strategy feasibility through end-user interviews.

RESULTS

Across three hospitals, 33 participants used ALL-SAFE for 87.8 total training hours (5,268 min). Participant numbers varied across sites (NJFK = 20, 80%; NPhebe = 7, 88%; NELWA = 6, 86%), as did practice times (TotalJFK = 3,060 min, Median time/ParticipantJFK = 103 min; TotalPhebe = 1,434 min, Median time/ParticipantPhebe = 126 min; TotalELWA = 774 min, Median time/ParticipantELWA = 100 min). Sites with practical supervision demonstrated higher engagement than those without (P = 0.042). Interviews (n = 8) revealed positive perceptions toward program orientation, practical supervision, and network weaving. Participants recommended thirteen additional strategies for sustainability including translating ALL-SAFE skills to patient care.

CONCLUSION

Our study is one of the first to evaluate implementation science strategies for laparoscopic training in sub-Saharan Africa. The implementation bundles of five validated strategies were considered feasible by Liberian surgeons in both urban and rural hospitals. Mixed methods suggested a positive association between engagement and the resource-intensive practical supervision strategy. Future studies should focus on quantifying individual strategy contributions with rigorous implementation designs and assessing sustainability strategies.

The economic burden associated with unmet surgical needs in Liberia: a retrospective macroeconomic analysis based on a nationwide enumeration of surgical procedures

OBJECTIVES

The economic consequences of untreated surgical disease are potentially large. The aim of this study was to estimate the economic burden associated with unmet surgical needs in Liberia.

DESIGN

A nationwide enumeration of surgical procedures and providers was conducted in Liberia in 2018. We estimated the number of disability-adjusted life years (DALYs) saved by operative activities and converted these into economic losses averted using gross national income per capita and value of a statistical life (VSL) approaches. The total, the met and the unmet needs for surgery were determined, and economic losses caused by unmet surgical needs were estimated. Finally, we valued the economic losses avoided by various surgical provider groups.

RESULTS

A total of 55 890 DALYs were averted by surgical activities in 2018; these activities prevented an economic loss of between US$35 and US$141 million. About half of these values were generated by the non-specialist physician workforce. Furthermore, a non-specialist physician working a full-time position for 1 year prevented an economic loss of US$717 069 using the VSL approach, while a specialist resident and a certified specialist saved US$726 606 and US$698 877, respectively. The burden of unmet surgical need was associated with productivity losses of between US$388 million and US$1.6 billion; these losses equate to 11% and 46% of the annual gross domestic product for Liberia.

CONCLUSION

The economic burden of untreated surgical disease is large in Liberia. There is a need to strengthen the surgical system to reduce ongoing economic losses; a framework where specialist and non-specialist physicians collaborate may result in better economic return than a narrower focus on training specialists alone.