Facilitating access to surgical care through a decentralised case-finding strategy: experience in Madagascar

The delivery and challenges of Pediatric Anesthesia within the humanitarian sector: Médecins Sans Frontières and Mercy Ships

Access to healthcare is inequitable. Poverty, natural disasters and war disproportionally effect those most vulnerable, including children. Non-governmental organizations (NGO) hold a vital role in providing pediatric care in these contexts. Here we describe the delivery and challenges of Pediatric Anesthesia with two such non-governmental organizations; Médecins Sans Frontières (MSF) and Mercy Ships. Descriptions of both are followed by case studies.

Global Surgery and Mercy Ships

Two-thirds of the world population do not have access to safe, affordable and timely surgery. This global surgical crisis largely affects low and middle-income countries, and it will surpass the challenges created by communicable diseases. The barriers of access to surgery range from cost of surgery and patient transportation to availability and quality of surgical infrastructure and providers. Mercy Ships is a Non-Governmental Organisation (NGO) providing free world-class life-saving and life-transforming surgery to the poorest of the poor in West Africa. In order to address barriers to access surgical assessment and care, Mercy Ships switched from centralised patient selection mainly in port cities or capitals to decentralised selection strategy staffed by experienced nursing teams travelling to remote locations nearer to patients' homes. In this way, the under-served rural population is given equal opportunity to access Mercy Ships' free specialised surgical services. In each country served by the Mercy Ships, a 5 year country engagement program is created to focus on improving the quality of life for people living with disease, disfigurement and disability through free direct medical service to reduce the burden of unmet surgical needs. Moreover, our Medical Capacity Building teams concentrate in improving infrastructure and quality control, equipment donation and maintenance. Lastly, Mercy Ships partner with government and policy makers to improve and strengthen their local surgical care delivery system as an indispensable part of the healthcare system. In this vast sea of global surgical crisis, the vision of the Mercy Ships is to eradicate the 'disease of poverty' and effectively do itself out of a job. Mercy Ships' new and the world's largest (37,000 ton) purpose-built hospital ship, the Global Mercy, is joining our current ship, the Africa Mercy (16,500 ton) to save lives and to strengthen local surgical care service. This will more than double our capacity and impact in sub-Saharan Africa following COVID-19 pandemic. Moreover our state-of-art on-board simulation laboratories and traditional practical training of local healthcare providers will further enhance and build their medical capacity. The Global Mercy will become the largest floating and training platform to train next generation African medical and health care professionals so that they can save countless lives by training others in the future. We therefore invite you to partner with us in bringing hope and healing to the forgotten poor in West Africa.

Factors influencing use of essential surgical services in North-East India: a cross-sectional study of obstetric and gynaecological surgery

INTRODUCTION

There continues to be a large gap between need and actual use of surgery in low-resource settings. While policy frequently focuses on expanding the supply of services, demand-side factors are at least as important in determining under utilisation and over utilisation. The aim of this study is to understand how these factors influence the use of selected essential obstetric and gynaecological surgical procedures in the underserved and remote setting of North-East India.

METHODS

The study combines and makes use of data from a variety of surveys and routine systems. Descriptive analysis of variations in caesarean section, hysterectomy and sterilisation and then multivariate logit analysis of demand-side and supply-side factors on access to these services is undertaken.

RESULTS

Surgical rates vary substantially both across and within North-East India, correlated with service capacity and socioeconomic status. Travel times to surgical facilities are associated with rates of caesarean section and hysterectomy but not sterilisation where services are much more deconcentrated. Travel is less important for surgery in private facilities where capacity is much more dispersed but dominated by the non-poor. The presence of non-doctor medical staff is associated with lower levels of surgical activity.

CONCLUSION

In low resource, remote settings policy interventions to improve access to services must recognise that surgical rates in low-resource settings are heavily influenced by demand-side factors. As well as boosting services, mechanisms need to mitigate demand-side barriers particularly distance and influence practice to encourage surgical intervention only where clinically indicated.

Quantifying Inequitable Access to Rapid Burn and Reconstructive Care through Geospatial Mapping

Time-critical pathologies, such as the care of burn-injured patients, rely on accurate travel time data to plan high-quality service provision. Geospatial modeling, using data from the Malaria Atlas Project, together with census data, permits quantification of the huge global discrepancies in temporal access to burn care between high-income and low-resource settings. In this study, focusing on the United Kingdom and Ghana, we found that a 3-fold population difference exists with, respectively, 95.6% and 29.9% of the population that could access specialist burn care within 1-hour travel time. Solutions to such inequalities include upscaling of infrastructure and specialist personnel, but this is aspirational rather than feasible in most low- to middle-income countries. Mixed models of decentralization of care that leverage eHealth strategies, such as telemedicine, may enhance quality of local burns and reconstructive surgical care through skills transfer, capacity building, and expediting of urgent transfers, while empowering local healthcare communities. By extending specialist burn care coverage through eHealth to 8 district hospitals in rural Ghana, we demonstrate the potential to increase specialist population coverage within 1-hour travel time from 29.9% to 45.3%—equivalent to an additional 5.1 million people.

A Household Survey to Evaluate Access to Surgical Care in Vanuatu

INTRODUCTION

Surgical care is an integral part of any healthcare system, yet there is a paucity of data on the burden of surgical disease, surgical capacity and access to surgical services in the Pacific region. This study aimed to evaluate access to surgical care through a pilot household survey in the Vanuatu island of Efate and five of its surrounding islands.

METHODS

The 2009 Vanuatu census' GPS coordinates were used to randomly select 150 rural and 150 urban households from Efate and its surrounding islands. A total of 143 urban households and 142 rural households were available for inclusion in this study. A household questionnaire was developed to evaluate access to surgical care and included information regarding household demographics, socio-economic indicators and perceived and realised barriers to accessing care. The questionnaire was administered by local health workers, and data were collected electronically.

RESULTS

Questionnaires were completed by 285 households. Two hundred and forty-one out of 254 (94.8%) households reported being able to access Port Vila Hospital, if required. The most commonly cited potential barriers to accessing surgical care were financial constraints (42.4%) and transport (26.4%).

CONCLUSION

Our results provide important insights into the geographic, sociocultural and economic barriers to seeking, reaching and receiving surgical care in this region of Vanuatu. Identifying specific areas and communities with poor access to care, alongside the determinants of access, will help in designing both clinical and policy interventions to improve access to surgical care.

Lasting impact: a qualitative study of perspectives on surgery by adult recipients of free mission-based surgical care in Benin

OBJECTIVES

This study aimed to explore how adult patients who received free mission-based elective surgery experienced surgery and its outcomes, in order to provide recommendations for improved service delivery, measurement of impact and future quality initiatives for the humanitarian organisation Mercy Ships and other mission-based surgical platforms.

SETTING

Data were collected in June 2017 in Cotonou, Benin, where the participants had previously received free mission-based elective surgery aboard the Africa Mercy, a non-governmental hospital ship.

PARTICIPANTS

Sixteen patients (seven male, nine female, age range 22-71, mean age 43.25) who had previously received surgical care aboard the Africa Mercy hospital ship between September 2016 and May 2017 participated in the study.

METHODS

Using a qualitative design, 16 individual semistructured interviews were conducted with the assistance of two interpreters. Participants were recruited using purposive sampling from the Mercy Ships patient database. Interview data were coded and organised into themes and subthemes using thematic content analysis in an interpretivist approach.

FINDINGS

Analysis of interview data revealed three main themes: barriers to surgery, experiences with Mercy Ships and changes in perspectives of surgery after their experiences. Key findings included barriers to local surgical provision such as cost, a noteworthy amount of fear and distrust of local surgical teams, exceptional positive experiences with the care at Mercy Ships, and impactful surgery, resulting in high levels of trust in foreign surgical teams.

CONCLUSIONS

While foreign surgical teams are meeting an immediate need for surgical care, the potential enduring legacy is one of trusting only foreigners for surgery. Patients are a critical component to a well-functioning surgical system, and mission-based surgical providers must formulate strategies to mitigate this legacy while strengthening the local surgical system.

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

Background

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

Methods

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

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

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

Results

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

Conclusion

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

Epidemiology of antibiotic-resistant wound infections from six countries in Africa

Introduction

Little is known about the antimicrobial susceptibility of common bacteria responsible for wound infections from many countries in sub-Saharan Africa.

Methods

We performed a retrospective review of microbial isolates collected based on clinical suspicion of wound infection between 2004 and 2016 from Mercy Ships, a non-governmental organisation operating a single mobile surgical unit in Benin, Congo, Liberia, Madagascar, Sierra Leone and Togo. Antimicrobial resistant organisms of interest were defined as methicillin-resistant Staphylococcus aureus (MRSA) or Enterobacteriaceae resistant to third-generation cephalosporins. Generalised mixed-effects models accounting for repeated isolates in a patient, potential clustering by case mix for each field service, age, gender and country were used to test the hypothesis that rates of antimicrobial resistance differed between countries.

Results

3145 isolates from repeated field services in six countries were reviewed. In univariate analyses, the highest proportion of MRSA was found in Benin (34.6%) and Congo (31.9%), while the lowest proportion was found in Togo (14.3%) and Madagascar (14.5%); country remained a significant predictor in multivariate analyses (P=0.002). In univariate analyses, the highest proportion of third-generation cephalosporin-resistant Enterobacteriaceae was found in Benin (35.8%) and lowest in Togo (14.3%) and Madagascar (16.3%). Country remained a significant predictor for antimicrobial-resistant isolates in multivariate analyses (P=0.009).

Conclusion

A significant proportion of isolates from wound cultures were resistant to first-line antimicrobials in each country. Though antimicrobial resistance isolates were not verified in a reference laboratory and these data may not be representative of all regions of the countries studied, differences in the proportion of antimicrobial-resistant isolates and resistance profiles between countries suggest site-specific surveillance should be a priority and local antimicrobial resistance profiles should be used to guide empiric antibiotic selection.