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Shakir M, Tahir I, Shariq SF, Khowaja AH, Irshad HA, Rae AI, Hamzah R, Gupta S, Park KB, Enam SA. Follow-Up Care for Brain Tumors in Low- and Middle-Income Countries: A Systematic Review of Existing Challenges and Strategies for the Future. Neurosurgery 2024:00006123-990000000-01270. [PMID: 38967439 DOI: 10.1227/neu.0000000000003082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/16/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Brain tumors have a poor prognosis and a high death rate. Sufficient aftercare is necessary to enhance patient results. But follow-up care provision is fraught with difficulties in low- and middle-income countries (LMICs), where a variety of variables can impede access to care. Therefore, our systematic review aimed to identify challenges to follow-up care for brain tumors and possible solutions in LMICs. METHODS A thorough search of the literature was performed from the beginning until October 20, 2022, using Google Scholar, PubMed, Scopus, and CINAHL. Studies focusing on the aftercare of brain tumors in LMICs met the inclusion criteria. Two reviewers used the National Surgical, Obstetric, and Anesthesia Plan categories to identify themes, extract relevant data, and evaluate individual articles. After being discovered, these themes were arranged in Microsoft Excel to make reporting and comprehension simpler. RESULTS A total of 27 studies were included in the review. Among the studies included, the most frequently cited barriers to follow-up care were financial constraints (54%), long-distance travel (42%), and a lack of awareness about the importance of follow-up care (25%). Other challenges included preference for traditional or alternative medications (4%) and high treatment costs (8%). Proposed strategies included implementing mobile clinics (20%), establishing a documentation system (13%), and educating patients about the importance of follow-up care (7%). CONCLUSION In LMICs, several issues pertaining to personnel, infrastructure, service delivery, financing, information management, and governance impede the provision of follow-up treatment for patients with brain tumors. As established by the suggested techniques found in the literature, addressing these issues will necessitate concurrent action by stakeholders, legislators, health ministries, and government agencies.
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Affiliation(s)
- Muhammad Shakir
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Izza Tahir
- Medical College, Aga Khan University, Karachi, Pakistan
| | | | | | | | - Ali I Rae
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Radzi Hamzah
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Saksham Gupta
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Kee B Park
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Syed Ather Enam
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
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2
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Alidina S, Hayirli TC, Amiri A, Barash D, Chwa C, Hellar A, Kengia JT, Kissima I, Mayengo CD, Meara JG, Mwita WC, Staffa SJ, Tibyehabwa L, Wurdeman T, Kapologwe NA. Organizational learning in surgery in Tanzania's health system: a descriptive cross-sectional study. Int J Qual Health Care 2024; 36:mzae048. [PMID: 38814661 DOI: 10.1093/intqhc/mzae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/05/2024] [Accepted: 05/30/2024] [Indexed: 05/31/2024] Open
Abstract
Organizational learning is critical for delivering safe, high-quality surgical care, especially in low- and middle-income countries (LMICs) where perioperative outcomes remain poor. While current investments in LMICs prioritize physical infrastructure, equipment, and staffing, investments in organizational learning are equally important to support innovation, creativity, and continuous improvement of surgical quality. This study aims to assess the extent to which health facilities in Tanzania's Lake Zone perform as learning organizations from the perspectives of surgical providers. The insights gained from this study can motivate future quality improvement initiatives and investments to improve surgical outcomes. We conducted a cross-sectional analysis using data from an adapted survey to explore the key components of organizational learning, including a supportive learning environment, effective learning processes, and encouraging leadership. Our sample included surgical team members and leaders at 20 facilities (health centers, district hospitals, and regional hospitals). We calculated the average of the responses at individual facilities. Responses that were 5+ on a 7-point scale or 4+ on a 5-point scale were considered positive. We examined the variation in responses by facility characteristics using a one-way ANOVA or Student's t-test. We used univariate and multiple regression to assess relationships between facility characteristics and perceptions of organizational learning. Ninety-eight surgical providers and leaders participated in the survey. The mean facility positive response rate was 95.1% (SD 6.1%). Time for reflection was the least favorable domain with a score of 62.5% (SD 35.8%). There was variation by facility characteristics including differences in time for reflection when comparing by level of care (P = .02) and location (P = .01), and differences in trying new approaches (P = .008), capacity building (P = .008), and information transfer (P = .01) when comparing public versus faith-based facilities. In multivariable analysis, suburban centers had less time for reflection than urban facilities (adjusted difference = -0.48; 95% CI: -0.95, -0.01; P = .046). Surgical team members reported more positive responses compared to surgical team leaders. We found a high overall positive response rate in characterizing organizational learning in surgery in 20 health facilities in Tanzania's Lake Zone. Our findings identify areas for improvement and provide a baseline for assessing the effectiveness of change initiatives. Future research should focus on validating the adapted survey and exploring the impact of strong learning environments on surgical outcomes in LMICs. Organizational learning is crucial in surgery and further research, funding, and policy work should be dedicated to improving learning cultures in health facilities.
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Affiliation(s)
- Shehnaz Alidina
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
| | - Tuna Cem Hayirli
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
| | - Adam Amiri
- W.P. Carey School of Business, Arizona State University, 1151 S Forest Ave Tempe, AZ 85281 USA
| | - David Barash
- GE Foundation, 41 Farnsworth St, Boston, MA 02210 USA
| | - Cindy Chwa
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
| | | | - James T Kengia
- Department of Health, Social Welfare and Nutrition Services, President's Office Regional Administration and Local Government, P.O. Box 1923, Dodoma 00255, Tanzania
| | | | | | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue Boston, MA 02115, USA
| | - Winfrida C Mwita
- Kilimanjaro Clinical Research Institute, P. O. Box 2236, Moshi 25116, Tanzania
- Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, P. O. Box 2240, Moshi 25116, Tanzania
| | - Steven J Staffa
- Department of Anesthesiology and Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Leopold Tibyehabwa
- Programs, Pathfinder International, P.O.BOX 77991, Dar es Salaam, Tanzania
| | - Taylor Wurdeman
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
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Ifeanyichi M, Dim C, Bognini M, Kebede M, Singh D, Onwujekwe O, Hargest R, Friebel R. Can sugar taxes be used for financing surgical systems in Nigeria? A mixed-methods political economy analysis. Health Policy Plan 2024; 39:509-518. [PMID: 38668636 PMCID: PMC11095260 DOI: 10.1093/heapol/czae021] [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: 04/11/2023] [Revised: 01/11/2024] [Accepted: 03/26/2024] [Indexed: 05/16/2024] Open
Abstract
This study determined the feasibility of investing revenues raised through Nigeria's sugar-sweetened beverage (SSB) tax of 10 Naira/l to support the implementation of the National, Surgical, Obstetrics, Anaesthesia and Nursing Plan, which aims to strengthen access to surgical care in the country. We conducted a mixed-methods political economy analysis. This included a modelling exercise to predict the revenues from Nigeria's SSB tax based on its current tax rate over a period of 5 years, and for several scenarios such as a 20% ad valorem tax recommended by the World Health Organization. We performed a gap analysis to explore the differences between fiscal space provided by the tax and the implementation cost of the surgical plan. We conducted qualitative interviews with key stakeholders and performed thematic analyses to identify opportunities and barriers for financing surgery through tax revenues. At its current rate, the SSB tax policy has the potential to generate 35 914 111 USD in year 1, and 189 992 739 USD over 5 years. Compared with the 5-year adjusted surgical plan cost of 20 billion USD, the tax accounts for ∼1% of the investment required. There is a substantial scope for further increases in the tax rate in Nigeria, yielding potential revenues of up to 107 663 315 USD, annually. Despite an existing momentum to improve surgical care, there is no impetus to earmark sugar tax revenues for surgery. Primary healthcare and the prevention and treatment of non-communicable diseases present as the most favoured investment areas. Consensus within the medical community on importance of primary healthcare, along the recent government transition in Nigeria, offers a policy window for promoting a higher SSB tax rate and an adoption of other sin taxes to generate earmarked funds for the healthcare system. Evidence-based advocacy is necessary to promote the benefits from investing into surgery.
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Affiliation(s)
- Martilord Ifeanyichi
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, Cowdray House 1.12, Houghton Street, London WC2A 2AE, United Kingdom
- Health Policy Research Group, Department of Pharmacology and Therapeutics, University of Nigeria Enugu Campus (UNEC), Enugu, Nigeria
| | - Cyril Dim
- Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria
| | - Maeve Bognini
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, Cowdray House 1.12, Houghton Street, London WC2A 2AE, United Kingdom
| | - Meskerem Kebede
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, Cowdray House 1.12, Houghton Street, London WC2A 2AE, United Kingdom
| | - Darshita Singh
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, Cowdray House 1.12, Houghton Street, London WC2A 2AE, United Kingdom
| | - Obinna Onwujekwe
- Health Policy Research Group, Department of Pharmacology and Therapeutics, University of Nigeria Enugu Campus (UNEC), Enugu, Nigeria
| | - Rachel Hargest
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, Cowdray House 1.12, Houghton Street, London WC2A 2AE, United Kingdom
- School of Medicine, University Hospital of Wales, Cardiff CF14 4XN, United Kingdom
- Royal College of Surgeons of England, London, United Kingdom
| | - Rocco Friebel
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, Cowdray House 1.12, Houghton Street, London WC2A 2AE, United Kingdom
- Center for Global Development Europe, London SW1P 3SE, United Kingdom
- Department of Health Policy, London School of Economics and Political Science, London WC2A 2AE, United Kindom
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Remmers CA, Conroy MM, Korom BM, Malloy ME, Sieracki R, Fairbanks SL, Nelson DA. Anesthesiologists and Community Engagement: A Scoping Review of the Literature. Anesth Analg 2024; 138:794-803. [PMID: 38009932 DOI: 10.1213/ane.0000000000006740] [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: 11/29/2023]
Abstract
Millions of individuals require anesthesia services each year. Although anesthesia-associated mortality rates have declined, anesthetic-related morbidity remains high, particularly among vulnerable populations. Disparities in perioperative screening, optimization, surveillance, and follow-up contribute to worse outcomes in these populations. Community-engaged collaborations may be the essential ingredient needed for anesthesiologists to improve disparities in anesthetic outcomes and prioritize the needs of patients and communities. This scoping review seeks to examine the available literature on community engagement among anesthesiologists to identify gaps and seek opportunities for future work. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). OVID MEDLINE, Scopus, and Web of Science Core Collection were searched to identify sources that used or recognized community-engaged strategies and involved the work of anesthesiologists. Sources were selected based on inclusion criteria and consistent data were extracted from each paper for compilation in a data chart. The initial search generated 1230 articles of which 16 met criteria for inclusion in the review. An updated search of the literature and reference scan of included sources resulted in 7 additional articles being included. The sources were grouped according to overarching themes and methods used and ultimately categorized according to the spectrum of public participation developed by the International Association for Public Participation (IAP2). This spectrum includes 5 levels: inform, consult, involve, collaborate, and empower. This review identified 5 sources at the inform level, 8 studies in consult, 0 in involve, 7 in collaborate, and 3 in empower. Results indicate that most initiatives representing deeper levels of community engagement, at the collaborate or empower level, occur internationally. Efforts that occur in the United States tend to emphasize engagement of individual patients rather than communities. There is a need to pursue deeper, more meaningful community-engaged efforts within the field of anesthesiology at a local and national level.
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Affiliation(s)
| | | | | | | | - Rita Sieracki
- From the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Stacy L Fairbanks
- Department of Obstetric Anesthesia, Advocate Aurora Sinai Hospital, Milwaukee, Wisconsin
| | - David A Nelson
- Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Takoutsing BD, Endalle G, Senyuy WP, Celestin BM, Kwasseu GK, Tanyi PB, Jumbam DT, Kanmounye US. Identifying opportunities for global surgery in Cameroon: an analysis of existing health policies and events. Pan Afr Med J 2024; 47:143. [PMID: 38933430 PMCID: PMC11204985 DOI: 10.11604/pamj.2024.47.143.38399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 02/18/2024] [Indexed: 06/28/2024] Open
Abstract
Introduction the burden of diseases amenable to surgery, obstetrics, trauma, and anesthesia (SOTA) care is increasing globally but low- and middle-income countries are disproportionately affected. The Lancet Commission on Global Surgery proposed National Surgical, Obstetrics, and Anesthesia Plans as national policies to reduce the global SOTA burden. These plans are dependent on comprehensive stakeholder engagement and health policy analysis. Objective: in this study, we analyzed existing national health policies and events in Cameroon to identify opportunities for SOTA policies. Methods we searched the Cameroonian Ministry of Health´s health policy database to identify past and current policies. Next, the policies were retrieved and screened for mentions of SOTA-related interventions using relevant keywords in French and English, and analyzed using the 'eight-fold path´ framework for public policy analysis. Results we identified 136 policies and events and excluded 16 duplicates. The health policies and events included were implemented between 1967 and 2021. Fifty-nine policies and events (49.2%) mentioned SOTA care: governance (n=25), infrastructure (n=21), service delivery (n=11), workforce (n=11), information management (n=10), and funding (n=8). Most policies and events focused on maternal and neonatal health, followed by anesthesia, ophthalmologic surgery, and trauma. National, multinational civil society organizations and private stakeholders supported these policies and events, and the Cameroonian Ministry of Public Health was the largest funder. Conclusion most Cameroonian SOTA-related policies and events focus on maternal and neonatal care, and health financing is the health system component with the least policies and events. Future SOTA policies should build on existing strengths while improving neglected areas, thus attaining shared global and national goals by 2030.
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Affiliation(s)
- Berjo Dongmo Takoutsing
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Geneviève Endalle
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Wah Praise Senyuy
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Bilong Mbangtang Celestin
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | | | | | - Desmond Tanko Jumbam
- Department of Policy and Advocacy, Operation Smile Ghana, Accra, Greater Accra, Ghana
| | - Ulrick Sidney Kanmounye
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
- Department of Policy and Advocacy, Operation Smile Ghana, Accra, Greater Accra, Ghana
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6
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Bekele A, Alayande BT, Powell BL, Obi N, Seyi-Olajide JO, Riviello RR, Ntirenganya F, Ameh EA, Makasa EM. National Surgical Healthcare Policy Development and Implementation: Where do We Stand in Africa? World J Surg 2023; 47:3020-3029. [PMID: 37550548 DOI: 10.1007/s00268-023-07131-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND National surgical policies have been increasingly adopted by African countries over the past decade. This report is intended to provide an overview of the current state of adoption of national surgical healthcare policies in Africa, and to draw a variety of lessons from representative surgical plans in order to support transnational learning. METHODS Through a desk review of available African national surgical healthcare plans and written contributions from a committee comprising six African surgical policy development experts, a few key lessons from five healthcare plans were outlined and iteratively reviewed. RESULTS The current state of national surgical healthcare policies across Africa was visually mapped, and lessons from a few compelling examples are highlighted. These include the power of initiative from Senegal; regional leadership from Zambia; contextualization, and renewal of commitment from Ethiopia; multidisciplinary focus and creation of multiple implementation entry points from Nigeria; partnerships and involvement of multiple stakeholders from Rwanda; and the challenge of surgical policy financing from Tanzania. The availability of global expertise, the power of global partnerships, and the critical role of health ministries and Ministers of Health in planning and implementation have also been highlighted. CONCLUSIONS Strategic planning for surgical healthcare improvement is at various stages across the continent, with potential for countries to learn from one another. Convenings of stakeholders and Ministers of Health from countries at various stages of strategic surgical plan development, execution, and evaluation can enhance African surgical policy development through the exchange of ideas, lessons, and experiences.
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Affiliation(s)
- Abebe Bekele
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali Heights, Plot 772, KG 7 Ave., 5Th Floor, PO Box 6955, Kigali, Rwanda
| | - Barnabas Tobi Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali Heights, Plot 772, KG 7 Ave., 5Th Floor, PO Box 6955, Kigali, Rwanda.
- Harvard TH Chan School of Public Health, Boston, MA, USA.
| | - Britany L Powell
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali Heights, Plot 772, KG 7 Ave., 5Th Floor, PO Box 6955, Kigali, Rwanda
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Robert R Riviello
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali Heights, Plot 772, KG 7 Ave., 5Th Floor, PO Box 6955, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | | | - Emmanuel A Ameh
- Department of Surgery, National Hospital, Central Business District, Abuja, Nigeria
| | - Emmanuel M Makasa
- Wits Centre of Surgical Care for Primary Health and Sustainable Development, University of the Witwatersrand, Johannesburg, South Africa
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Bishop D, van Dyk D, Dyer R. Safe obstetric anaesthesia in low- and middle-income countries-a perspective from Africa. BJA Educ 2023; 23:432-439. [PMID: 37876763 PMCID: PMC10591126 DOI: 10.1016/j.bjae.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 10/26/2023] Open
Affiliation(s)
- D. Bishop
- University of Kwazulu-Natal, Durban, South Africa
| | - D. van Dyk
- University of Cape Town, Cape Town, South Africa
| | - R.A. Dyer
- University of Cape Town, Cape Town, South Africa
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Ravelojaona V, Ma X, Samison MF, Rabemalala D, Ayala R, Ramamonjisoa A, Andriamanjato HH, Ravoniaritsoa V, Jumbam DT, Andriamanarivo LM. Incorporating surgical and anesthesia care into universal health care: a national plan for the development of surgery in Madagascar. Can J Anaesth 2023; 70:1131-1154. [PMID: 37378826 DOI: 10.1007/s12630-023-02500-8] [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: 05/27/2022] [Revised: 09/09/2022] [Accepted: 10/26/2022] [Indexed: 06/29/2023] Open
Abstract
Efforts have been made to strengthen national health systems for safe, affordable, and timely surgical, obstetric, trauma, and anesthesia (SOTA) care since 2015 when the Lancet Commission on Global Surgery (LCoGS) identified critical needs in improving access to essential surgical care for five billion people worldwide. Several governments have developed National Surgical, Obstetric, and Anesthesia Plans (NSOAPs) as a commitment to ensuring safe and accessible surgical care for all of their population. The Ministry of Public Health (MoPH) of Madagascar launched its NSOAP in May 2019, named Le Plan National de Développement de la Chirurgie a Madagascar (PNDCHM). This policy established Madagascar as the first African francophone country to define concrete objectives for the Malagasy health system to meet the targets set by the LCoGS by 2030. The PNDCHM outlined the following priorities and specific action points to be implemented from 2019 to 2023: improving technical capacity, training human resources, developing a health information system, ensuring adequate governance and leadership, offering quality care, creating specific surgical services, and financing and mobilizing resources for implementation. Challenges encountered in the process included complex coordination between different stakeholders, allocating a sufficient budget for its implementation, frequent turnover within the MoPH, and the COVID-19 pandemic. The PNDCHM is a first of its kind in francophone Africa and the many lessons learned can serve as guidance for countries aspiring to build NSOAPs of their own.
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Affiliation(s)
| | - Xiya Ma
- Division of Plastic Surgery, Université de Montréal, Montreal, QC, Canada
| | - Marie-Fidèle Samison
- Department of Standard of Care, Ministry of Public Health, Antananarivo, Madagascar
| | - Dominique Rabemalala
- Technical Direction of University Hospital of Befelatanana Maternity, Antananarivo, Madagascar
| | - Ruben Ayala
- Department of Policy and Advocacy, Operation Smile, Virginia Beach, VA, USA
| | - Anjaramamy Ramamonjisoa
- Department of Policy, Research and Innovation, Operation Smile Madagascar, Antananarivo, Madagascar
| | | | | | - Desmond T Jumbam
- Department of Policy and Advocacy, Operation Smile, Virginia Beach, VA, USA.
- Operation Smile Ghana, Accra, Greater Accra Region, Ghana.
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9
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Jumbam DT, Reddy CL, Meara JG, Makasa EM, Atun R. A Financing Strategy to Expand Surgical Health Care. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2100295. [PMID: 37348937 DOI: 10.9745/ghsp-d-21-00295] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 03/28/2023] [Indexed: 06/24/2023]
Abstract
Despite an evolving need to provide surgical health care globally, few health systems, particularly in low-income and middle-income countries (LMICs), can sufficiently provide such care. The vast majority of the world's people-an estimated 5 billion-are unable to access safe and affordable surgical health care when they need it. This is a significant concern for global public health because the demand for these services is rising with the epidemiological and demographic transitions occurring worldwide. A principal driver of weak surgical health care services is a lack of adequate health system financing for surgical health care. This article examines the financing of surgical health care by analyzing global trends in health system financing, approaches to expand fiscal space for health, and empirical perspectives on the design, introduction, and scale-up of policies to improve surgical systems. We describe a surgical health care financing strategy, together with broader political and economic considerations, to provide policy recommendations to fund the expansion of surgical health care and an essential surgical package as part of universal health coverage in LMICs.
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Affiliation(s)
- Desmond T Jumbam
- Department of Policy and Advocacy, Operation Smile, Virginia Beach, VA, USA
| | - Che L Reddy
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
- Health Systems Innovation Lab, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Emmanuel M Makasa
- Wits Centre of Surgical Care for Primary Health and Sustainable Development, School of Clinical Medicine, University of Witwatersrand, Johannesburg, South Africa
| | - Rifat Atun
- Health Systems Innovation Lab, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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10
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Jumbam DT, Bustamante A, Alayande BT, Ayala R, Kouam JC, Dzirasa I, Segura C, Kum FV, Muhumuza A, Riviello R, Rata M, Foretia DA, Bekele A. To advance global surgery and anaesthesia, train more advocates. BMJ Glob Health 2023; 8:bmjgh-2023-012848. [PMID: 37270175 DOI: 10.1136/bmjgh-2023-012848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/22/2023] [Indexed: 06/05/2023] Open
Affiliation(s)
- Desmond T Jumbam
- Department of Health Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
| | - Atenas Bustamante
- Department of Health Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
| | | | - Ruben Ayala
- Department of Health Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
| | - Jean Cedric Kouam
- Nkafu Policy Institute, Denis & Lenora Foretia Foundation, Yaounde, Cameroon
| | - Irene Dzirasa
- Department of Health Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
- Operation Smile Ghana, Accra, Ghana
| | - Carolina Segura
- Department of Health Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
| | - Fuein Vera Kum
- Nkafu Policy Institute, Denis & Lenora Foretia Foundation, Yaounde, Cameroon
| | - Arsen Muhumuza
- Department of Health Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
| | - Robert 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, Massachusetts, USA
| | - Mikyla Rata
- Department of Health Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
| | - Denis A Foretia
- Nkafu Policy Institute, Denis & Lenora Foretia Foundation, Yaounde, Cameroon
- Global Surgery Institute, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Abebe Bekele
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
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Morriss WW, Enright AC. The Anesthesia Workforce Crisis Revisited. Anesth Analg 2023; 136:227-229. [PMID: 36638506 DOI: 10.1213/ane.0000000000006189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Wayne W Morriss
- From the Department of Anaesthesia, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Angela C Enright
- University of British Columbia, Vancouver, British Columbia, Canada
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12
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Jumbam DT, Amoako E, Blankson PK, Xepoleas M, Said S, Nyavor E, Gyedu A, Ampomah OW, Kanmounye US. The state of surgery, obstetrics, trauma, and anaesthesia care in Ghana: a narrative review. Glob Health Action 2022; 15:2104301. [PMID: 35960190 PMCID: PMC9586599 DOI: 10.1080/16549716.2022.2104301] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Desmond T Jumbam
- Department of Policy and Advocacy, Operation Smile Ghana, Accra, Ghana.,Department of Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
| | - Emmanuella Amoako
- Department of Paediatrics and Child Health, Cape Coast Teaching Hospital, Cape Coast, Ghana.,Department of Paediatrics and Child Health, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Paa-Kwesi Blankson
- Oral and Maxillofacial Surgery Unit, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Meredith Xepoleas
- Department of Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
| | - Shady Said
- Department of Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
| | - Elikem Nyavor
- Department of Policy and Advocacy, Operation Smile Ghana, Accra, Ghana
| | - Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.,Department of Surgery, University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Opoku W Ampomah
- Department of Policy and Advocacy, Operation Smile Ghana, Accra, Ghana.,Plastics and Reconstructive Surgery Unit, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Ulrick Sidney Kanmounye
- Department of Policy and Advocacy, Operation Smile Ghana, Accra, Ghana.,Department of Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
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13
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Jumbam DT, Kanmounye US, Citron I, Kamalo P. Evidence-Driven Policies for Sustainably Scaling Up Surgical Task-Sharing in Malawi Comment on "Improving Access to Surgery Through Surgical Team Mentoring - Policy Lessons From Group Model Building With Local Stakeholders in Malawi". Int J Health Policy Manag 2022; 11:2752-2754. [PMID: 35418010 PMCID: PMC9818105 DOI: 10.34172/ijhpm.2022.6979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/28/2022] [Indexed: 01/21/2023] Open
Abstract
This commentary discusses an article by Broekhuizen et al which assesses policy options for scaling up the SURG-Africa surgical team mentoring program in Malawi to increase access to surgical care. In modeling these scenarios, the authors assess the cost of scaling up surgical teams mentoring and the impacts of scaling the program on district hospitals (DHs) and central hospitals (CHs). The additional costs borne by DHs when increasing surgical volume remains a significant issue identified by the authors and could ultimately determine the success of the program. The piece indirectly advocates for an increased role for task-shifting. The Ministry of Health of Malawi will have to ensure the appropriate governance and regulatory processes are in place to maintain quality and accountability.
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Affiliation(s)
- Desmond T. Jumbam
- Department of Policy and Advocacy, Operation Smile, Virginia Beach, VA, USA
- Operation Smile Ghana, Accra, Ghana
| | - Ulrick Sidney Kanmounye
- Department of Policy and Advocacy, Operation Smile, Virginia Beach, VA, USA
- Operation Smile DR Congo, Kinshasa, Democratic Republic of Congo
| | | | - Patrick Kamalo
- Department of Neurosurgery, Queen Elizabeth Central Hospital, Blantyre, Malawi
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14
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Dohlman LE, Thakkar N, Jivanelli B, Pakala S, Brouillette MA. Regional anesthesia global health collaborations- a scoping review of current intervention methods. Curr Opin Anaesthesiol 2022; 35:647-653. [PMID: 35942724 DOI: 10.1097/aco.0000000000001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Perioperative anesthesia-related mortality is significantly higher in low-resource compared to high-resource countries. Regional anesthesia techniques can provide safety, cost, and access benefits when compared to general anesthesia in these settings but is underutilized primarily due to a lack of experienced educators and training opportunities. Academic institutions and international organizations are attempting to fill this educational gap through collaborations, but these efforts need examination for best practices going forward. RECENT FINDINGS Most collaborative anesthesia interactions between high and low resource areas have occurred between North America or Europe, and Africa or Asia and a majority have involved an educational intervention. Only 7% of the studies used a recognized framework to evaluate the intervention used in their research, such as the Kirkpatrick, REAIM or CFIR method. All recent studies reviewed reported a positive impact from educational collaborations. Only 7% of interventions have had a primary focus on regional anesthesia and most were reported between 2016 and 2022. SUMMARY Robust reports on international collaborations providing capacity enhancing educational interventions in regional anesthesia have increased in recent years but are still rare and should be encouraged going forward. Short courses supported by high-resource countries can be effective in low-resource areas when partnerships produce curricula that are well designed.
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Affiliation(s)
- Lena E Dohlman
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Niharika Thakkar
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery
| | - Bridget Jivanelli
- Kim Barrett Memorial Library, HSS Education Institute, Hospital for Special Surgery
| | - Swetha Pakala
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery.,Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Mark A Brouillette
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery.,Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
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15
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Mediratta S, Lepard JR, Barthélemy EJ, Corley J, Park KB. Barriers to neurotrauma care in low- to middle-income countries: an international survey of neurotrauma providers. J Neurosurg 2022; 137:789-798. [PMID: 34952519 DOI: 10.3171/2021.9.jns21916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 09/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Delays along the neurosurgical care continuum are associated with poor outcomes and are significantly greater in low- to middle-income countries (LMICs), with timely access to neurotrauma care remaining one of the most significant unmet neurosurgical needs worldwide. Using Lancet Global Surgery metrics and the Three Delays framework, the authors of this study aimed to identify and characterize the most significant barriers to the delivery of neurotrauma care in LMICs from the perspective of local neurotrauma providers. METHODS The authors conducted a cross-sectional study through the dissemination of a web-based survey to neurotrauma providers across all World Health Organization geographic regions. Responses were analyzed with descriptive statistics and Kruskal-Wallis testing, using World Bank data to provide estimates of populations at risk. RESULTS Eighty-two (36.9%) of 222 neurosurgeons representing 47 countries participated in the survey. It was estimated that 3.9 billion people lack access to neurotrauma care within 2 hours. Nearly 3.4 billion were estimated to be at risk for impoverishing expenditure and 2.9 billion were at risk of catastrophic expenditure as a result of paying for care for neurotrauma injuries. Delays in seeking care were rated as slightly common (p < 0.001), those in reaching care were very common (p < 0.001), and those in receiving care were slightly common (p < 0.05). The most significant causes for delays were associated with reaching care, including geographic distance from a facility, lack of ambulance service, and lack of finances for travel. All three delays were correlated to income classification and geographic region. CONCLUSIONS While expanding the global neurosurgical workforce is of the utmost importance, the study data suggested that it may not be entirely sufficient in gaining access to care for the emergent neurosurgical patient. Significant income and region-specific variability exists with regard to barriers to accessing neurotrauma care. Highlighting these barriers and quantifying worldwide access to neurotrauma care using metrics from the Lancet Commission on Global Surgery provides essential insight for future initiatives aiming to strengthen global neurotrauma systems.
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Affiliation(s)
- Saniya Mediratta
- 1Faculty of Medicine, Imperial College London, South Kensington Campus, London
- 2NIHR Global Health Research Group on Neurotrauma, University of Cambridge, United Kingdom
| | - Jacob R Lepard
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama
- 4Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Ernest J Barthélemy
- 4Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- 5Department of Neurosurgery, Mount Sinai Health System, New York, New York; and
| | - Jacquelyn Corley
- 4Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- 6Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Kee B Park
- 4Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
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Broekhuizen H, Lansu M, Gajewski J, Pittalis C, Ifeanyichi M, Juma A, Marealle P, Kataika E, Chilonga K, Rouwette E, Brugha R, Bijlmakers L. Using Group Model Building to Capture the Complex Dynamics of Scaling Up District-Level Surgery in Arusha Region, Tanzania. Int J Health Policy Manag 2022; 11:981-989. [PMID: 33590734 PMCID: PMC9808173 DOI: 10.34172/ijhpm.2020.249] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 12/01/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Scaling up surgery at district hospitals (DHs) is the critical challenge if the Tanzanian national Surgical, Obstetric, and Anesthesia Plan (NSOAP) objectives are to be achieved. Our study aims to address this challenge by taking a dynamic view of surgical scale-up at the district level using a participatory research approach. METHODS A group model building (GMB) workshop was held with 18 professionals from three hospitals in the Arusha region. They built a graphical representation of the local system of surgical services delivery through a facilitated discussion that employed the nominal group technique. This resulted in a causal loop diagram (CLD) from which the participants identified the requirements for scaling-up surgery and the stakeholders who could satisfy these. After the GMB sessions, we identified clusters of related variables using inductive thematic analysis and the main feedback loops driving the model. RESULTS The CLD consists of 57 variables. These include the 48 variables that were obtained through the nominal group technique and those that participants added later. We identified 6 themes: patient benefits, financing of surgery, cost sharing, staff motivation, communication, and effects on referral hospital. There are 5 self-reinforcing feedback loops: training, learning, meeting demand, revenues, and willingness to work in a good hospital. There are four self-correcting feedback loops or 'resistors to change:' recurrent costs, income lost, staff stress, and brain drain. CONCLUSION This study provides a systems view on the scaling up of surgery from a district level perspective. Its results enable a critical appraisal of the feasibility of implementing the NSOAP. Our results suggest that policy-makers should be wary of 'quick fixes' that have short term gains only. Long term policy that considers the complex dynamics of surgical systems and that allows for periodic evaluation and adaption is needed to scale up surgery in a sustainable manner.
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Affiliation(s)
- Henk Broekhuizen
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Monic Lansu
- Department of Business Administration, Institute for Management Research, Radboud University, Nijmegen, The Netherlands
| | - Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons Ireland, Dublin 2, Ireland
| | - Chiara Pittalis
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Martilord Ifeanyichi
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Adinan Juma
- East Central and Southern Africa Health Community, Arusha, Tanzania
| | - Paul Marealle
- Tanzania Surgical Association, Dar Es Salaam, Tanzania
| | - Edward Kataika
- East Central and Southern Africa Health Community, Arusha, Tanzania
| | | | - Etiënne Rouwette
- Department of Business Administration, Institute for Management Research, Radboud University, Nijmegen, The Netherlands
| | - Ruairi Brugha
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Leon Bijlmakers
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
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17
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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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18
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Siow SL, Wahab MYA, Chuah JS, Mahendran HA. Access to essential surgical care in district hospitals of Sarawak Malaysia: outcomes of an audit and the need for urgent attention. ANZ J Surg 2022; 92:1692-1699. [DOI: 10.1111/ans.17705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 02/02/2022] [Accepted: 03/27/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Sze Li Siow
- Department of General Surgery Sarawak General Hospital Kuching Sarawak Malaysia
| | | | - Jun Sen Chuah
- Department of General Surgery Sarawak General Hospital Kuching Sarawak Malaysia
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19
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Jumbam DT, Kanmounye US, Alayande B, Bekele A, Maswime S, Makasa EMM, Park KB, Ayala R, Onajin-Obembe B, Samad L, Roy N, Chu K. Voices beyond the Operating Room: centring global surgery advocacy at the grassroots. BMJ Glob Health 2022; 7:bmjgh-2022-008969. [PMID: 35332056 PMCID: PMC8948410 DOI: 10.1136/bmjgh-2022-008969] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/04/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Desmond T Jumbam
- Operation Smile Ghana, Accra, Greater Accra Region, Ghana .,Department of Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
| | | | - Barnabas Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Gasabo, Rwanda.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Abebe Bekele
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Gasabo, Rwanda.,University of Global Health Equity, Kigali, Rwanda.,Department of Surgery, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Salome Maswime
- Global Surgery Division, Department of Surgery, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Emmanuel Mwenda Malabo Makasa
- SADC Regional Collaboration, Centre for Surgical Healthcare, University of Witwatersrand, Johannesburg, South Africa.,University Teaching Hospital, Lusaka, Zambia
| | - Kee B Park
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Ruben Ayala
- Department of Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
| | - Bisola Onajin-Obembe
- Department of Anaesthesiology, Faculty of Clinical Sciences, College of Health Sciences, University of Port Harcourt, Port Harcourt, Nigeria
| | - Lubna Samad
- Interactive Research and Development, Karachi, Pakistan
| | - Nobhojit Roy
- World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
| | - Kathryn Chu
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa.,Department of Surgery, University of Botswana, Gaborone, Botswana
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20
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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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21
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Sam-Agudu NA. Applying an Implementation Science Framework to Surgical Research and Practice in Tanzania. J Am Coll Surg 2021; 233:191-192. [PMID: 34304815 DOI: 10.1016/j.jamcollsurg.2021.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 11/30/2022]
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Alidina S, Menon G, Staffa SJ, Alreja S, Barash D, Barringer E, Cainer M, Citron I, DiMeo A, Ernest E, Fitzgerald L, Ghandour H, Gruendl M, Hellar A, Jumbam DT, Katoto A, Kelly L, Kisakye S, Kuchukhidze S, Lama T, Lodge Ii W, Maina E, Massaga F, Mazhiqi A, Meara JG, Mshana S, Nason I, Reynolds C, Reynolds C, Segirinya H, Simba D, Smith V, Strader C, Sydlowski M, Tibyehabwa L, Tinuga F, Troxel A, Ulisubisya M, Varallo J, Wurdeman T, Zanial N, Zurakowski D, Kapologwe N, Maongezi S. Outcomes of a multicomponent safe surgery intervention in Tanzania's Lake Zone: a prospective, longitudinal study. Int J Qual Health Care 2021; 33:6289905. [PMID: 34057187 PMCID: PMC8240014 DOI: 10.1093/intqhc/mzab087] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/12/2021] [Accepted: 05/30/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Evidence-based strategies for improving surgical quality and patient outcomes in low-resource settings are a priority. OBJECTIVE To evaluate the impact of a multicomponent safe surgery intervention (Safe Surgery 2020) on (1) adherence to safety practices, teamwork and communication, and documentation in patient files, and (2) incidence of maternal sepsis, postoperative sepsis, and surgical site infection. METHODS We conducted a prospective, longitudinal study in 10 intervention and 10 control facilities in Tanzania's Lake Zone, across a 3-month pre-intervention period in 2018 and 3-month post-intervention period in 2019. SS2020 is a multicomponent intervention to support four surgical quality areas: (i) leadership and teamwork, (ii) evidence-based surgery, anesthesia and equipment sterilization practices, (iii) data completeness and (iv) infrastructure. Surgical team members received training and mentorship, and each facility received up to a $10 000 infrastructure grant. Inpatients undergoing major surgery and postpartum women were followed during their stay up to 30 days. We assessed adherence to 14 safety and teamwork and communication measures through direct observation in the operating room. We identified maternal sepsis (vaginal or cesarean delivery), postoperative sepsis and SSIs prospectively through daily surveillance and assessed medical record completeness retrospectively through chart review. We compared changes in surgical quality outcomes between intervention and control facilities using difference-in-differences analyses to determine areas of impact. RESULTS Safety practices improved significantly by an additional 20.5% (95% confidence interval (CI), 7.2-33.7%; P = 0.003) and teamwork and communication conversations by 33.3% (95% CI, 5.7-60.8%; P = 0.02) in intervention facilities compared to control facilities. Maternal sepsis rates reduced significantly by 1% (95% CI, 0.1-1.9%; P = 0.02). Documentation completeness improved by 41.8% (95% CI, 27.4-56.1%; P < 0.001) for sepsis and 22.3% (95% CI, 4.7-39.8%; P = 0.01) for SSIs. CONCLUSION Our findings demonstrate the benefit of the SS2020 approach. Improvement was observed in adherence to safety practices, teamwork and communication, and data quality, and there was a reduction in maternal sepsis rates. Our results support the emerging evidence that improving surgical quality in a low-resource setting requires a focus on the surgical system and culture. Investigation in diverse contexts is necessary to confirm and generalize our results and to understand how to adapt the intervention for different settings. Further work is also necessary to assess the long-term effect and sustainability of such interventions.
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Affiliation(s)
- Shehnaz Alidina
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Gopal Menon
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02215, USA
| | - Sakshie Alreja
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - David Barash
- GE Foundation, 5 Necco Street, Boston, MA 02210, USA
| | - Erin Barringer
- Dalberg Implement-Dalberg, Indian Ocean Building, Block C, 4th Floor, 383 Toure Drive, Dar es Salaam, Tanzania
| | - Monica Cainer
- Assist International, 800 South Stockton Avenue, Ripon, CA 95366, USA
| | - Isabelle Citron
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Amanda DiMeo
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Edwin Ernest
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Laura Fitzgerald
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Hiba Ghandour
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Magdalena Gruendl
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Audustino Hellar
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Desmond T Jumbam
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Adam Katoto
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Lauren Kelly
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Steve Kisakye
- Dalberg Implement-Dalberg, Indian Ocean Building, Block C, 4th Floor, 383 Toure Drive, Dar es Salaam, Tanzania
| | - Salome Kuchukhidze
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Tenzing Lama
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - William Lodge Ii
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Erastus Maina
- Dalberg Implement-Dalberg, Indian Ocean Building, Block C, 4th Floor, 383 Toure Drive, Dar es Salaam, Tanzania
| | - Fabian Massaga
- Department of Surgery, Bugando Medical Center, Block Z, Plot 229 Wurzbarg Road, Mwanza, Tanzania
| | - Adelina Mazhiqi
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02215, USA
| | - Stella Mshana
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Ian Nason
- Department of Health Policy and Management, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, USA
| | - Chase Reynolds
- Assist International, 800 South Stockton Avenue, Ripon, CA 95366, USA
| | - Cheri Reynolds
- Assist International, 800 South Stockton Avenue, Ripon, CA 95366, USA
| | | | - Dorcas Simba
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Victoria Smith
- Assist International, 800 South Stockton Avenue, Ripon, CA 95366, USA
| | - Christopher Strader
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Meaghan Sydlowski
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Leopold Tibyehabwa
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Florian Tinuga
- Department of Health, Social Welfare and Nutrition Service, President's Office-Regional Administration and Local Government, Tamisemi Street, Government City-Mtumba, Dodoma, Tanzania
| | - Alena Troxel
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Mpoki Ulisubisya
- Department of Curative Services, Ministry of Health, Community Development, Gender, Elderly and Children, Government City-Mtumba, Dodoma, Tanzania
| | - John Varallo
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Taylor Wurdeman
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Noor Zanial
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02215, USA
| | - Ntuli Kapologwe
- Department of Health, Social Welfare and Nutrition Service, President's Office-Regional Administration and Local Government, Tamisemi Street, Government City-Mtumba, Dodoma, Tanzania
| | - Sarah Maongezi
- Department of Curative Services, Ministry of Health, Community Development, Gender, Elderly and Children, Government City-Mtumba, Dodoma, Tanzania
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Landrum K, Cotache-Condor CF, Liu Y, Truche P, Robinson J, Thompson N, Granzin R, Ameh E, Bickler S, Samad L, Meara J, Rice HE, Smith ER. Global and regional overview of the inclusion of paediatric surgery in the national health plans of 124 countries: an ecological study. BMJ Open 2021; 11:e045981. [PMID: 34135040 PMCID: PMC8211076 DOI: 10.1136/bmjopen-2020-045981] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE This study evaluates the priority given to surgical care for children within national health policies, strategies and plans (NHPSPs). PARTICIPANTS AND SETTING We reviewed the NHPSPs available in the WHO's Country Planning Cycle Database. Countries with NHPSPs in languages different from English, Spanish, French or Chinese were excluded. A total of 124 countries met the inclusion criteria. PRIMARY AND SECONDARY OUTCOME MEASURES We searched for child-specific and surgery-specific terms in the NHPSPs' missions, goals and strategies using three analytic approaches: (1) count of the total number of mentions, (2) count of the number of policies with no mentions and (3) count of the number of policies with five or more mentions. Outcomes were compared across WHO regional and World Bank income-level classifications. RESULTS We found that the most frequently mentioned terms were 'child*', 'infant*' and 'immuniz*'. The most frequently mentioned surgery term was 'surg*'. Overall, 45% of NHPSPs discussed surgery and 7% discussed children's surgery. The majority (93%) of countries did not mention selected essential and cost-effective children's procedures. When stratified by WHO region and World Bank income level, the West Pacific region led the inclusion of 'pediatric surgery' in national health plans, with 17% of its countries mentioning this term. Likewise, low-income countries led the inclusion of surg* and 'pediatric surgery', with 63% and 11% of countries mentioning these terms, respectively. In both stratifications, paediatric surgery only equated to less than 1% of the total terms. CONCLUSION The low prevalence of children's surgical search terms in NHPSPs indicates that the influence of surgical care for this population remains low in the majority of countries. Increased awareness of children's surgical needs in national health plans might constitute a critical step to scale up surgical system in these countries.
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Affiliation(s)
- Kelsey Landrum
- Global Health Institute, Duke University, Durham, North Carolina, USA
| | | | - Yingling Liu
- Department of Sociology, Baylor University, Waco, Texas, USA
| | - Paul Truche
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Julia Robinson
- Department of Public Health, Baylor University, Waco, Texas, USA
| | - Nealey Thompson
- Department of Public Health, Baylor University, Waco, Texas, USA
| | - Ryann Granzin
- Department of Public Health, Baylor University, Waco, Texas, USA
| | - Emmanuel Ameh
- Division of Pediatric Surgery, Department of Surgery, National Hospital, Abuja, Nigeria
| | - Steve Bickler
- Division of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, California, USA
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Lubna Samad
- Department of Pediatric Surgery, Indus Hospital, Karachi, Pakistan
| | - John Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Henry E Rice
- Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Emily R Smith
- Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Public Health, Baylor University, Waco, Texas, USA
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Potentially Avertable Child Mortality Associated with Surgical Workforce Scale-up in Low- and Middle-Income Countries: A Global Study. World J Surg 2021; 45:2643-2652. [PMID: 34110458 DOI: 10.1007/s00268-021-06181-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Expansion of access to surgical care can improve health outcomes, although the impact that scale-up of the surgical workforce will have on child mortality is poorly defined. In this study, we estimate the number of child deaths potentially avertable by increasing the surgical workforce globally to meet targets proposed by the Lancet Commission on Global Surgery. METHODS To estimate the number of deaths potentially avertable through increases in the surgical workforce, we used log-linear regression to model the association between surgeon, anesthetist and obstetrician workforce (SAO) density and surgically amenable under-5 mortality rate (U5MR), infant mortality rate (IMR), and neonatal mortality rate (NMR) for 192 countries adjusting for potential confounders of childhood mortality, including the non-surgical workforce (physicians, nurses/midwives, community health workers), gross national income per capita, poverty rate, female literacy rate, health expenditure per capita, percentage of urban population, number of surgical operations, and hospital bed density. Surgically amenable mortality was determined using mortality estimates from the UN Inter-agency Group for Child Mortality Estimation adjusted by the proportion of deaths in each country due to communicable causes unlikely to be amenable to surgical care. Estimates of mortality reduction due to upscaling surgical care to support the Lancet Commission on Global Surgery (LCoGS) minimum target of 20-40 SAO/100,000 were calculated accounting for potential increases in surgical volume associated with surgical workforce expansion. RESULTS Increasing SAO workforce density was independently associated with lower surgically amenable U5MR as well as NMR (p < 0.01 for each model). When accounting for concomitant increases in surgical volume, scale-up of the surgical workforce to 20-40 SAO/100,000 could potentially prevent between 262,709 (95% CI 229,643-295,434) and 519,629 (465,046-573,919) under 5 deaths annually. The majority (61%) of deaths averted would be neonatal deaths. CONCLUSION Scale up of surgical workforce may substantially decrease childhood mortality rates around the world. Our analysis suggests that scale-up of surgical delivery through increase in the SAO workforce could prevent over 500,000 children from dying before the age of 5 annually. This would represent significant progress toward meeting global child mortality reduction targets.
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25
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Manzano-Nunez R, Sarmiento C, Villegas-Vargas S, Angel-Barrios JA, Puyana JC, Peck G, Castro F, Gaviria A, García AF. Emergency surgery workforce and its inverse relationship with multidimensional poverty in Colombia. Eur J Trauma Emerg Surg 2021; 48:1159-1165. [PMID: 33961072 DOI: 10.1007/s00068-021-01690-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/28/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE General surgeons, anesthesiologists, obstetricians and gynecologists (ob-gyns), and orthopedic surgeons are the vital disciplines to provide emergency surgery within a healthcare system. This paper aims to examine the relationship (if any) between multidimensional poverty (MDP) and GDP per-capita with the emergency surgery workforce density in Colombia. METHODS We performed an ecological study, where the observation units were the 32 Colombian departments. The total numbers of general surgeons, anesthesiologists, ob-gyns, and orthopedic surgeons were obtained from the "Registro Unico Nacional de Talento Humano en Salud" (ReTHUS) registry. The 2020 population projections, the incidence of MDP and the GDP per capita were obtained from the Colombian National Administrative Department of Statistics. A spearman's correlation coefficient was calculated to measure the strength of the correlations between the surgical workforce density with MDP and GDP per-capita. RESULTS There were significant moderate inverse linear correlations between the incidence of multidimensional poverty and workforce density. The correlation coefficients for the incidence of multidimensional poverty and the workforce density were - 0.5273, - 0.5620, - 0.4704, and - 0.4612 for surgeons, anesthesiologists, ob-gyns, and orthopedic surgeons, respectively. Conversely, the correlation coefficients for the GDP per-capita and the workforce density were 0.4045, 0.3822, 0.4404, and 0.3742 for surgeons, anesthesiologists, ob-gyns, and orthopedic surgeons, respectively. CONCLUSION This study found that Colombian trauma and emergency surgery workforce density was inversely and directly correlated with multidimensional poverty and GDP per-capita levels, respectively. The relationship of these economic indicators with the surgical capacity deserves further investigation.
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Affiliation(s)
- Ramiro Manzano-Nunez
- Center for Sustainable Development Objectives, Universidad de Los Andes, Bogotá, Colombia.
| | | | - Sofía Villegas-Vargas
- Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | | | - Juan C Puyana
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gregory Peck
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Felipe Castro
- Center for Sustainable Development Objectives, Universidad de Los Andes, Bogotá, Colombia
| | - Alejandro Gaviria
- Center for Sustainable Development Objectives, Universidad de Los Andes, Bogotá, Colombia.,Universidad de Los Andes, Bogotá, Colombia
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Applying the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework to Safe Surgery 2020 Implementation in Tanzania's Lake Zone. J Am Coll Surg 2021; 233:177-191.e5. [PMID: 33957259 DOI: 10.1016/j.jamcollsurg.2021.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Access to safe, high-quality surgical care in sub-Saharan Africa is a critical gap. Interventions to improve surgical quality have been developed, but research on their implementation is still at a nascent stage. We retrospectively applied the Exploration, Preparation, Implementation, Sustainment framework to characterize the implementation of Safe Surgery 2020, a multicomponent intervention to improve surgical quality. METHODS We used a longitudinal, qualitative research design to examine Safe Surgery 2020 in 10 health facilities in Tanzania's Lake Zone. We used documentation analysis with confirmatory key informant interviews (n = 6) to describe the exploration and preparation phases. We conducted interviews with health facility leaders and surgical team members at 1, 6, and 12 months (n = 101) post initiation to characterize the implementation phase. Data were analyzed using the constant comparison method. RESULTS In the exploration phase, research, expert consultation, and scoping activities revealed the need for a multicomponent intervention to improve surgical quality. In the preparation phase, onsite visits identified priorities and barriers to implementation to adapt the intervention components and curriculum. In the active implementation phase, 4 themes related to the inner organizational context-vision for safe surgery, existing surgical practices, leadership support, and resilience-and 3 themes related to the intervention-innovation-value fit, holistic approach, and buy-in-facilitated or hindered implementation. Interviewees perceived improvements in teamwork and communication and intra- and inter-facility learning, and their need to deliver safe surgery evolved during the implementation period. CONCLUSIONS Examining implementation through the exploration, preparation, implementation, and sustainment phases offers insights into the implementation of interventions to improve surgical quality and promote sustainability.
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Abstract
Introduction: Global surgical care is increasingly recognized in the global health agenda and requires multidisciplinary engagement. Despite high interest among medical students, residents and other learners, many surgical faculty and health experts remain uniformed about global surgical care. Methods: We have operated an interdisciplinary graduate-level course in Global Surgical Care based on didactics and interactive group learning. Students completed a pre- and post-course survey regarding their learning experiences and results were analyzed using the Wilcoxon signed-rank test. Results: Fourteen students completed the pre-course survey, and 11 completed the post-course survey. Eleven students (79%) were enrolled in a Master’s degree program in global health, with eight students (57%) planning to attend medical school. The median ranking of surgery on the global health agenda was fifth at the beginning of the course and third at the conclusion (p = 0.11). Non-infectious disease priorities tended to stay the same or increase in rank from pre- to post-course. Infectious disease priorities tended to decrease in rank (HIV/AIDS, p = 0.07; malaria, p = 0.02; neglected infectious disease, p = 0.3). Students reported that their understanding of global health (p = 0.03), global surgery (p = 0.001) and challenges faced by the underserved (p = 0.03) improved during the course. When asked if surgery was an indispensable part of healthcare, before the course 64% of students strongly agreed, while after the course 91% of students strongly agreed (p = 0.3). Students reported that the interactive nature of the course strengthened their skills in collaborative problem-solving. Conclusions: We describe an interdisciplinary global surgery course that integrates didactics with team-based projects. Students appeared to learn core topics and held a different view of global surgery after the course. Similar courses in global surgery can educate clinicians and other stakeholders about strategies for building healthy surgical systems worldwide.
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Gathege D, Abdulkarim A, Odaba D, Mugambi S. Effectiveness of Pain Control of Local Anaesthetic Wound Infusion Following Elective Midline Laparotomy: A Randomized Trial. World J Surg 2021; 45:2100-2107. [PMID: 33763741 DOI: 10.1007/s00268-021-06072-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Post-operative pain control is an important pillar in enhanced recovery after surgery. There is a paucity of data that compares efficacy of pain control between continuous local anaesthetic wound infusion and thoracic epidural analgesia in elective midline laparotomy patients OBJECTIVE: To evaluate pain control between continuous local anaesthetic wound infusion and thoracic epidural analgesia in elective laparotomy patients. DESIGN A randomized, single-blind, controlled clinical trial. SETTING Aga Khan University Hospital, Nairobi, Kenya. POPULATION Patients underwent elective laparotomy. METHODS Thirty-eight patients scheduled for elective laparotomy were randomized into two equal groups to receive either continuous local anaesthetic wound infusion or thoracic epidural analgesia. Data on the baseline patient characteristics, total morphine consumption at 72 h, visual analogue scores and rates of adverse effects were collected. RESULTS Baseline characteristics of the participants were similar. Continuous local anaesthetic wound infusion was equivalent to thoracic epidural analgesia in terms of pain scores and total morphine consumption at 72 h. Duration of hospital stay was shorter in the intervention arm. There were more surgical site infections in the intervention arm, while catheter dislodgement rate was higher in the thoracic epidural arm. CONCLUSION Continuous local anaesthetic wound infusion is equivalent to thoracic epidural analgesia in management of post-operative pain following elective midline laparotomy. CLINICAL TRIAL REGISTRATION Pan African Clinical Trial registry, number PACTR201808607220790.
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Affiliation(s)
| | | | - David Odaba
- Aga Khan University Hospital, Nairobi, Kenya
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Clarke M, Pittalis C, Borgstein E, Bijlmakers L, Cheelo M, Ifeanyichi M, Mwapasa G, Juma A, Broekhuizen H, Drury G, Lavy C, Kachimba J, Mkandawire N, Chilonga K, Brugha R, Gajewski J. Surgical service monitoring and quality control systems at district hospitals in Malawi, Tanzania and Zambia: a mixed-methods study. BMJ Qual Saf 2021; 30:950-960. [PMID: 33727414 PMCID: PMC8606427 DOI: 10.1136/bmjqs-2020-012751] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/22/2021] [Accepted: 03/07/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND In low-income and middle-income countries, an estimated one in three clinical adverse events happens in non-complex situations and 83% are preventable. Poor quality of care also leads to inefficient use of human, material and financial resources for health. Improving outcomes and mitigating the risk of adverse events require effective monitoring and quality control systems. AIM To assess the state of surgical monitoring and quality control systems at district hospitals (DHs) in Malawi, Tanzania and Zambia. METHODS A mixed-methods cross-sectional study of 75 DHs: Malawi (22), Tanzania (30) and Zambia (23). This included a questionnaire, interviews and visual inspection of operating theatre (OT) registers. Data were collected on monitoring and quality systems for surgical activity, processes and outcomes, as well as perceived barriers. RESULTS 53% (n=40/75) of DHs use more than one OT register to record surgical operations. With the exception of standardised printed OT registers in Zambia, the register format (often handwritten books) and type of data collected varied between DHs. Monthly reports were seldom analysed by surgical teams. Less than 30% of all surveyed DHs used surgical safety checklists (n=22/75), and <15% (n=11/75) performed surgical audits. 73% (n=22/30) of DHs in Tanzania and less than half of DHs in Malawi (n=11/22) and Zambia (n=10/23) conducted surgical case reviews. Reports of surgical morbidity and mortality were compiled in 65% (n=15/23) of Zambian DHs, and in less than one-third of DHs in Tanzania (n=9/30) and Malawi (n=4/22). Reported barriers to monitoring and quality systems included an absence of formalised guidelines, continuous training opportunities as well as inadequate accountability mechanisms. CONCLUSIONS Surgical monitoring and quality control systems were not standard among sampled DHs. Improvements are needed in standardisation of quality measures used; and in ensuring data completeness, analysis and utilisation for improving patient outcomes.
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Affiliation(s)
- Morgane Clarke
- Department of Epidemiology & Public Health, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Leinster, Ireland
| | - Chiara Pittalis
- Department of Epidemiology & Public Health, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Leinster, Ireland
| | - Eric Borgstein
- Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi
| | - Leon Bijlmakers
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Mweene Cheelo
- Department of Surgery, Surgical Society of Zambia, University of Zambia University Teaching Hospital, Lusaka, Zambia
| | - Martilord Ifeanyichi
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Gerald Mwapasa
- Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi
| | - Adinan Juma
- East Central and Southern Africa Health Community, Arusha, United Republic of Tanzania
| | - Henk Broekhuizen
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Grace Drury
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Chris Lavy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - John Kachimba
- Department of Surgery, Surgical Society of Zambia, University of Zambia University Teaching Hospital, Lusaka, Zambia
| | - Nyengo Mkandawire
- Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi
| | - Kondo Chilonga
- Department of Surgery, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Ruairí Brugha
- Department of Epidemiology & Public Health, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Leinster, Ireland
| | - Jakub Gajewski
- Department of Epidemiology & Public Health, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Leinster, Ireland
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Dahir S, Cotache-Condor CF, Concepcion T, Mohamed M, Poenaru D, Adan Ismail E, Leather AJM, Rice HE, Smith ER. Interpreting the Lancet surgical indicators in Somaliland: a cross-sectional study. BMJ Open 2020; 10:e042968. [PMID: 33376180 PMCID: PMC7778782 DOI: 10.1136/bmjopen-2020-042968] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The unmet burden of surgical care is high in low-income and middle-income countries. The Lancet Commission on Global Surgery (LCoGS) proposed six indicators to guide the development of national plans for improving and monitoring access to essential surgical care. This study aimed to characterise the Somaliland surgical health system according to the LCoGS indicators and provide recommendations for next-step interventions. METHODS In this cross-sectional nationwide study, the WHO's Surgical Assessment Tool-Hospital Walkthrough and geographical mapping were used for data collection at 15 surgically capable hospitals. LCoGS indicators for preparedness was defined as access to timely surgery and specialist surgical workforce density (surgeons, anaesthesiologists and obstetricians/SAO), delivery was defined as surgical volume, and impact was defined as protection against impoverishment and catastrophic expenditure. Indicators were compared with the LCoGS goals and were stratified by region. RESULTS The healthcare system in Somaliland does not meet any of the six LCoGS targets for preparedness, delivery or impact. We estimate that only 19% of the population has timely access to essential surgery, less than the LCoGS goal of 80% coverage. The number of specialist SAO providers is 0.8 per 100 000, compared with an LCoGS goal of 20 SAO per 100 000. Surgical volume is 368 procedures per 100 000 people, while the LCoGS goal is 5000 procedures per 100 000. Protection against impoverishing expenditures was only 18% and against catastrophic expenditures 1%, both far below the LCoGS goal of 100% protection. CONCLUSION We found several gaps in the surgical system in Somaliland using the LCoGS indicators and target goals. These metrics provide a broad view of current status and gaps in surgical care, and can be used as benchmarks of progress towards universal health coverage for the provision of safe, affordable, and timely surgical, obstetric and anaesthesia care in Somaliland.
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Affiliation(s)
- Shukri Dahir
- Edna Adan University Hospital, Hargeisa, Somaliland
| | | | - Tessa Concepcion
- Global Health Institute, Duke University, Durham, North Carolina, USA
| | | | - Dan Poenaru
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, McGill University, Montreal, Québec, Canada
| | | | - Andy J M Leather
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - Henry E Rice
- Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Emily R Smith
- Department of Public Health, Baylor University, Waco, Texas, USA
- Global Health Institute, Duke University, Durham, North Carolina, USA
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Reddy CL, Vervoort D, Meara JG, Atun R. Surgery and universal health coverage: Designing an essential package for surgical care expansion and scale-up. J Glob Health 2020; 10:020341. [PMID: 33110540 PMCID: PMC7562729 DOI: 10.7189/jogh.10.02034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ché L Reddy
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dominique Vervoort
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rifat Atun
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Reddy CL, Vervoort D, Meara JG, Atun R. Surgery and universal health coverage: Designing an essential package for surgical care expansion and scale-up. J Glob Health 2020. [PMID: 33110540 PMCID: PMC7562729 DOI: 10.7189/jogh.10.020349] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Ché L Reddy
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dominique Vervoort
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rifat Atun
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Hanna JS, Herrera-Almario GE, Pinilla-Roncancio M, Tulloch D, Valencia SA, Sabatino ME, Hamilton C, Rehman SU, Mendoza AK, Gómez Bernal LC, Salas MFM, Navarro MAP, Nemoyer R, Scott M, Pardo-Bayona M, Rubiano AM, Ramirez MV, Londoño D, Dario-Gonzalez I, Gracias V, Peck GL. Use of the six core surgical indicators from the Lancet Commission on Global Surgery in Colombia: a situational analysis. LANCET GLOBAL HEALTH 2020; 8:e699-e710. [PMID: 32353317 DOI: 10.1016/s2214-109x(20)30090-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 02/28/2020] [Accepted: 03/02/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Surgical, anaesthetic, and obstetric (SAO) health-care system strengthening is needed to address the emergency and essential surgical care that approximately 5 billion individuals lack globally. To our knowledge, a complete, non-modelled national situational analysis based on the Lancet Commission on Global Surgery surgical indicators has not been done. We aimed to undertake a complete situation analysis of SAO system preparedness, service delivery, and financial risk protection using the core surgical indicators proposed by the Commission in Colombia, an upper-middle-income country. METHODS Data to inform the six core surgical system indicators were abstracted from the Colombian national health information system and the most recent national health survey done in 2007. Geographical access to a Bellwether hospital (defined as a hospital capable of providing essential and emergency surgery) within 2 h was assessed by determining 2 h drive time boundaries around Bellwether facilities and the population within and outside these boundaries. Physical 2 h access to a Bellwether was determined by the presence of a motor vehicle suitable for individual transportation. The Department Administrativo Nacional de Estadística population projection for 2016 and 2018 was used to calculate the SAO provider density. Total operative volume was calculated for 2016 and expressed nationally per 100 000 population. The total number of postoperative deaths that occurred within 30 days of a procedure was divided by the total operative volume to calculate the all-cause, non-risk-adjusted postoperative mortality. The proportion of the population subject to impoverishing costs was calculated by subtracting the baseline number of impoverished individuals from those who fell below the poverty line once out-of-pocket payments were accounted for. Individuals who incurred out-of-pocket payments that were more than 10% of their annual household income were considered to have experienced catastrophic expenditure. Using GIS mapping, SAO system preparedness, service delivery, and cost protection were also contextualised by socioeconomic status. FINDINGS In 2016, at least 7·1 million people (15·1% of the population) in Colombia did not have geographical access to SAO services within a 2 h driving distance. SAO provider density falls short of the Commission's minimum target of 20 providers per 100 000 population, at an estimated density of 13·7 essential SAO health-care providers per 100 000 population in 2018. Lower socioeconomic status of a municipality, as indicated by proportion of people enrolled in the subsidised insurance regime, was associated with a smaller proportion of the population in the municipality being within 2 h of a Bellwether facility, and the most socioeconomically disadvantaged municipalities often had no SAO providers. Furthermore, Colombian providers appear to be working at or beyond capacity, doing 2690-3090 procedures per 100 000 population annually, but they have maintained a relatively low median postoperative mortality of 0·74% (IQR 0·48-0·84). Finally, out-of-pocket expenses for indirect health-care costs were a key barrier to accessing surgical care, prompting 3·1 million (6·4% of the population) individuals to become impoverished and 9·5 million (19·4% of the population) individuals to incur catastrophic expenditures in 2007. INTERPRETATION We did a non-modelled, indicator-based situation analysis of the Colombian SAO system, finding that it has not yet met, but is working towards achieving, the targets set by the Lancet Commission on Global Surgery. The observed interdependence of these indicators and correlation with socioeconomic status are consistent with well recognised factors and outcomes of social, health, and health-care inequity. The internal consistency observed in Colombia's situation analysis validates the use of the indicators and has now informed development of an early national SAO plan in Colombia, to set a data-informed stage for implementation and evaluation of timely, safe, and affordable SAO health care, within the National Public Health Decennial Plan, which is due in 2022. FUNDING Zoll Medical.
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Affiliation(s)
- Joseph S Hanna
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA.
| | - Gabriel E Herrera-Almario
- Fundación Santa Fe de Bogotá, Bogotá, Colombia; School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | | | - David Tulloch
- Center for Remote Sensing and Spatial Analysis, Rutgers School of Environmental and Biological Sciences, The State University of New Jersey, New Brunswick, NJ, USA
| | | | - Marlena E Sabatino
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Charles Hamilton
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Shahyan U Rehman
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Ardi Knobel Mendoza
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | | | | | | | - Rachel Nemoyer
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Michael Scott
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | | | - Andres M Rubiano
- School of Medicine and Neuroscience Institute, Universidad el Bosque, Bogotá, Colombia
| | | | | | | | - Vicente Gracias
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA; Rutgers New Jersey Medical School, Rutgers University, Newark, NJ, USA
| | - Gregory L Peck
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA; Rutgers School of Public Health, Rutgers Biomedical and Health Sciences, Piscataway, NJ, USA
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Ng-Kamstra JS, Nepogodiev D, Lawani I, Bhangu A. Perioperative mortality as a meaningful indicator: Challenges and solutions for measurement, interpretation, and health system improvement. Anaesth Crit Care Pain Med 2020; 39:673-681. [PMID: 32745634 DOI: 10.1016/j.accpm.2019.11.005] [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] [Received: 07/21/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 12/20/2022]
Abstract
Expanding global access to safe surgical and anaesthesia care is crucial to meet the health targets of the Sustainable Development Goals (SDGs). As global surgical volume increases, improving safety throughout the patient care pathway is a public health priority. At present, an estimated 4.2 million individuals die within 30 days of surgery each year, and many of these deaths are preventable. Important considerations for the collection and reporting of perioperative mortality data have been identified in the literature, but consensus has not been established on the best methodology for the quantification of excess surgical mortality at a hospital or health system level. In this narrative review, we address challenges in the use of perioperative mortality rates (POMR) for improving patient safety. First, we discuss controversies in the use of POMR as a health system indicator and suggest advantages for using a "basket" of procedure-specific mortality rates as an adjunct to gross POMR. We offer then solutions to challenges in the collection and reporting of POMR data, and propose interventions for improving care in the preoperative, operative, and postoperative periods. Finally, we discuss how health systems leaders and frontline clinicians can integrate surgical safety into both national health plans and patient care pathways to drive a sustainable safety revolution in perioperative care.
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Affiliation(s)
- Joshua S Ng-Kamstra
- Department of Critical Care Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada.
| | - Dmitri Nepogodiev
- National Institute for Health Research Global Health Research Unit on Global Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Ismaïl Lawani
- Department of Surgery and Surgical Specialties, Faculty of Health Sciences, University of Abomey Calavi, Cotonou, Benin; Rediet Shimeles Workneh, MD, Department of Anaesthesiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Aneel Bhangu
- National Institute for Health Research Global Health Research Unit on Global Surgery, University of Birmingham, Birmingham, United Kingdom
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36
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Reddy CL, Peters AW, Jumbam DT, Caddell L, Alkire BC, Meara JG, Atun R. Innovative financing to fund surgical systems and expand surgical care in low-income and middle-income countries. BMJ Glob Health 2020; 5:e002375. [PMID: 32546586 PMCID: PMC7299051 DOI: 10.1136/bmjgh-2020-002375] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 02/02/2023] Open
Abstract
Strong surgical systems are necessary to prevent premature death and avoidable disability from surgical conditions. The epidemiological transition, which has led to a rising burden of non-communicable diseases and injuries worldwide, will increase the demand for surgical assessment and care as a definitive healthcare intervention. Yet, 5 billion people lack access to timely, affordable and safe surgical and anaesthesia care, with the unmet demand affecting predominantly low-income and middle-income countries (LMICs). Rapid surgical care scale-up is required in LMICs to strengthen health system capabilities, but adequate financing for this expansion is lacking. This article explores the critical role of innovative financing in scaling up surgical care in LMICs. We locate surgical system financing by using a modified fiscal space analysis. Through an analysis of published studies and case studies on recent trends in the financing of global health systems, we provide a conceptual framework that could assist policy-makers in health systems to develop innovative financing strategies to mobilise additional investments for scale-up of surgical care in LMICs. This is the first time such an analysis has been applied to the funding of surgical care. Innovative financing in global surgery is an untapped potential funding source for expanding fiscal space for health systems and financing scale-up of surgical care in LMICs.
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Affiliation(s)
- Ché L Reddy
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alexander W Peters
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Desmond Tanko Jumbam
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Luke Caddell
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Blake C Alkire
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Center for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
- Department of Global Health Equity, Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rifat Atun
- Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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37
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Peters AW, Roa L, Rwamasirabo E, Ameh E, Ulisubisya MM, Samad L, Makasa EM, Meara JG. National Surgical, Obstetric, and Anesthesia Plans Supporting the Vision of Universal Health Coverage. GLOBAL HEALTH, SCIENCE AND PRACTICE 2020; 8:1-9. [PMID: 32234839 PMCID: PMC7108944 DOI: 10.9745/ghsp-d-19-00314] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 03/02/2020] [Indexed: 12/11/2022]
Abstract
Developing a national surgical, obstetric, and anesthesia plan is an important first step for countries to strengthen their surgical systems and improve surgical care. Barriers to successful implementation of these plans include data collection, scalability, and financing, yet surgical system strengthening efforts are gaining momentum in achieving universal access to emergency and essential surgical care.
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Affiliation(s)
- Alexander W Peters
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA.
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Lina Roa
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Emmanuel Ameh
- Department of Surgery, National Hospital, Abuja, Nigeria
| | - Mpoki M Ulisubisya
- Ministry of Health Community Development Gender Elderly and Children, Dar es Salaam, Tanzania
| | - Lubna Samad
- Center for Essential Surgical and Acute Care, Indus Health Network, Karachi, Pakistan
| | - Emmanuel M Makasa
- Public Service Management Division Cabinet Office, Office of the President, Lusaka, Zambia
- Wits Centre of Surgical Care for Primary Health & Sustainable Development, School of Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - John G Meara
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
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38
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Philipo GS, Nagraj S, Bokhary ZM, Lakhoo K. Lessons from developing, implementing and sustaining a participatory partnership for children's surgical care in Tanzania. BMJ Glob Health 2020; 5:e002118. [PMID: 32206345 PMCID: PMC7078648 DOI: 10.1136/bmjgh-2019-002118] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 02/13/2020] [Accepted: 02/15/2020] [Indexed: 12/15/2022] Open
Abstract
Global surgery is an essential component of Universal Health Coverage. Surgical conditions account for almost one-third of the global burden of disease, with the majority of patients living in low-income and middle-income countries (LMICs). Children account for more than half of the global population; however, in many LMIC settings they have poor access to surgical care due to a lack of workforce and health system infrastructure to match the need for children's surgery. Surgical providers from high-income countries volunteer to visit LMICs and partner with the local providers to deliver surgical care and trainings to improve outcomes. However, some of these altruistic efforts fail. We aim to share our experience on developing, implementing and sustaining a partnership in global children's surgery in Tanzania. The use of participatory methods facilitated a successful 17-yearlong partnership, ensured a non-hierarchical environment and encouraged an understanding of the context, local needs, available resources and hospital capacity, including budget constraints, when codesigning solutions. We believe that participatory approaches are feasible and valuable in developing, implementing and sustaining global partnerships for children's surgery in LMICs.
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Affiliation(s)
- Godfrey Sama Philipo
- Biostatistcs and Epidemiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Shobhana Nagraj
- Oxford University Global Surgery Group, University of Oxford, University of Oxford, Oxford, UK
| | - Zaitun M Bokhary
- Department of Paediatirc Surgery, Muhimbili National Hospital, Dar es Salaam, Dar es Salaam, United Republic of Tanzania
| | - Kokila Lakhoo
- Oxford University Global Surgery Group, University of Oxford, University of Oxford, Oxford, UK
- Department of Paediatirc Surgery, Muhimbili National Hospital, Dar es Salaam, Dar es Salaam, United Republic of Tanzania
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Truché P, Shoman H, Reddy CL, Jumbam DT, Ashby J, Mazhiqi A, Wurdeman T, Ameh EA, Smith M, Lugazia E, Makasa E, Park KB, Meara JG. Globalization of national surgical, obstetric and anesthesia plans: the critical link between health policy and action in global surgery. Global Health 2020; 16:1. [PMID: 31898532 PMCID: PMC6941290 DOI: 10.1186/s12992-019-0531-5] [Citation(s) in RCA: 198] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 11/13/2019] [Indexed: 11/17/2022] Open
Abstract
Efforts from the developed world to improve surgical, anesthesia and obstetric care in low- and middle-income countries have evolved from a primarily volunteer mission trip model to a sustainable health system strengthening approach as private and public stakeholders recognize the enormous health toll and financial burden of surgical disease. The National Surgical, Obstetric and Anesthesia Plan (NSOAP) has been developed as a policy strategy for countries to address, in part, the health burden of diseases amenable to surgical care, but these plans have not developed in isolation. The NSOAP has become a phenomenon of globalization as a broad range of partners - individuals and institutions - help in both NSOAP formulation, implementation and financing. As the nexus between policy and action in the field of global surgery, the NSOAP reflects a special commitment by state actors to make progress on global goals such as Universal Health Coverage and the United Nations Sustainable Development Goals. This requires a continued global commitment involving genuine partnerships that embrace the collective strengths of both national and global actors to deliver sustained, safe and affordable high-quality surgical care for all poor, rural and marginalized people.
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Affiliation(s)
- Paul Truché
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Haitham Shoman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Ché L. Reddy
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Desmond T. Jumbam
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA USA
| | - Joanna Ashby
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Adelina Mazhiqi
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Taylor Wurdeman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | | | - Martin Smith
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Edwin Lugazia
- Department of Anaesthesiology, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Emmanuel Makasa
- PSMD-Cabinet Office, Office of the President, Lusaka, Zambia
- Wits Centre of Surgical Care for Primary Health and Sustainable Development, University of the Witwatersrand, Johannesburg, South Africa
| | - Kee B. Park
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - John G. Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA USA
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40
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Jumbam DT, Reddy CL, Roa L, Meara JG. How much does it cost to scale up surgical systems in low-income and middle-income countries? BMJ Glob Health 2019; 4:e001779. [PMID: 31478016 PMCID: PMC6703298 DOI: 10.1136/bmjgh-2019-001779] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/09/2019] [Accepted: 07/12/2019] [Indexed: 11/22/2022] Open
Affiliation(s)
- Desmond T Jumbam
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ché Len Reddy
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lina Roa
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - John G Meara
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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