An opportunity for diagonal development in global surgery: cleft lip and palate care in resource-limited settings

Cleft Lip and Palate Surgery at a Rural African Hospital: A 13-Year Experience From Western Kenya

INTRODUCTION

Most studies on the treatment of cleft lip and palate (CLP) in low-income and middle-income countries have reported on the experience of urban centers or surgical mission trips to rural locations. There is a paucity of literature on the experience of local teams providing orofacial cleft surgery in rural Sub-Saharan Africa. This study reports the efficacy and cost-effectiveness of cleft surgery performed by an all-local team in rural Kenya.

METHODS

A retrospective chart review was performed on all patients who received CLP repair at Kapsowar Hospital between 2011 and 2023. Information regarding patient age, sex, cleft etiology, surgical management, and home location was retrieved. For the most recent year of study (2023), the authors performed a financial audit of all costs related to the performance of unilateral cleft lip surgery. Descriptive statistics were performed.

RESULTS

The authors identified 381 CLP surgeries performed on 311 patients (197 male, 63.3%). The most common etiology of the cleft was left unilateral (28.3%). The average age of primary lip repair decreased from 46.3 months in 2008 to 2009 to 20.2 months in 2022 to 2023 (P<0.001). The average age of primary cleft palate repair decreased from 38.0 months in 2008 to 2009 to 25.3 months in 2022 to 2023 (P<0.001). Patients traveled from 23 districts to receive treatment. Age of treatment was not different when distinguished by sex, county poverty level, or travel time from the hospital. The total costs associated with cleft lip repair was $201.6.

CONCLUSIONS

Adequately staffed hospitals in rural locations can meaningfully address a regional CLP backlog more cost-effectively than surgical mission trips.

The Pattern and Profile of Orofacial Clefts in Somaliland: A Review of 40 Consecutive Cleft Lip and Palate Surgical Camps

INTRODUCTION

Somaliland is an autonomously run country that is not internationally recognized. As such, it has been largely excluded by global health development programs despite being the world's fourth poorest country. The purpose of this study was to provide the first known description of the pattern and clinical profile of patients with cleft lip and palate from this nation.

METHODS

The authors performed a retrospective chart review on all patients who received cleft lip and palate repair by a single surgeon in 40 separate surgical camps at Edna Adan University Hospital in Hargeisa, Somaliland, between 2011 and 2024. Information regarding patient age, sex, cleft etiology, surgical management, and home location was retrieved. Descriptive statistical analysis was performed.

RESULTS

A total of 767 patients (495 male, 64.5%) received 787 surgical procedures. The average age of primary surgery was 73.7 months. The most common chief complaint was left cleft lip with cleft palate (316, 41.2%). Males received primary surgery 19.2 months later than did females (73.7 and 54.6 mo, respectively, P<0.001). Patients residing in Hargeisa received their initial procedure an average of 17.8 months younger than those who lived elsewhere in Somaliland (62.9 and 80.7 mo, respectively, P=0.004).

CONCLUSIONS

In this severely economically depressed region, patients received treatment at ages that lagged far beyond recommended guidelines. Our finding of earlier treatment for females than males is rare in the literature and likely relates to cultural sex expectations. Patients from rural locations were especially vulnerable to receiving delayed treatment. Further efforts to decrease the burden of craniofacial deformities in Somaliland should be pursued in earnest.

The state of cardiac surgery in Ethiopia

Objectives

Six billion people globally do not have access to cardiac surgical care. In this study, we aimed to describe state of cardiac surgery in Ethiopia.

Methods

Data on status of local cardiac surgery collected from surgeons and cardiac centers. Medical travel agents were interviewed about number of cardiac patients who were assisted to travel abroad for surgery. Historical data and number of patients treated by non-governmental organizations were collected via interviews and by accessing existing databases.

Results

Patients access cardiac care via 3 avenues: mission-based, abroad referral, and care at local centers. Traditionally, the first 2 have been the main mode of access; however, since 2017, an entirely local team has begun performing heart surgery in the country. Currently, surgical cardiac care is provided at 4 local centers: a charity organization, a tertiary public hospital, and 2 for-profit centers. Procedures at the charity center are provided for free, whereas in others, patients mostly pay out of pocket. There are only 5 cardiac surgeons for 120 million people. More than 15,000 patients are on waitlist for surgery, mainly because of lack of consumables and limited numbers of centers and workforce.

Conclusions

There is a change in the trend from non-governmental mission- and referral-based care toward care in local centers in Ethiopia. The local cardiac surgery workforce is growing but still insufficient. The number of procedures is limited with long wait lists due to limited workforce, infrastructure, and resources. All stakeholders should work on training more workforce, providing consumables, and creating feasible financing schemes.

Global Smile Foundation's Cleft Surgical Outreach Program: Clinical and Economic Impact During the Past 14 Years

Clefts of the lip and/or palate can result in significant morbidity as well as economic and psychosocial distress for patients and families. Global Smile Foundation is a non-profit organization committed to providing comprehensive cleft care to patients with cleft of the lip/palate around the world. Primary cleft lip and primary cleft palate repairs performed by the Global Smile Foundation in the last decade were reviewed. Averted disability-adjusted life years were estimated and assessed for their economic value. A total of 15,310 disability-adjusted life years were averted. The financial gain was estimated between $78,323,624 and $152,906,604, with an average financial benefit of $48,021 to $93,750 per patient.

Capacity Building During Short-Term Surgical Outreach Trips: A Review of What Guidelines Exist

INTRODUCTION

While short-term surgical outreach trips improve access to care in low- and middle-income countries (LMIC), there is rising concern about their long-term impact. In response, many organizations seek to incorporate capacity building programs into their outreach efforts to help strengthen local health systems. Although leading organizations, like the World Health Organization (WHO), advocate for this approach, uniform guidelines are absent.

METHODS

We performed a systematic review, using search terms pertaining to capacity building guidelines during short-term surgical outreach trips. We extracted information on authorship, guideline development methodology, and guidelines relating to capacity building. Guidelines were classified according to the Global-QUEST framework, which outlines seven domains of capacity building on surgical outreach trips. Guideline development methodology frequencies and domain classifications frequencies were calculated; subsequently, guidelines were aggregated to develop a core guideline for each domain.

RESULTS

A total of 35 studies were included. Over 200 individual guidelines were extracted, spanning all seven framework domains. Guidelines were most frequently classified into Coordination and Community Impact domains and least frequently into the Finance domain. Less than half (46%) of studies collaborated with local communities to design the guidelines. Instead, guidelines were predominantly developed through author trip experience.

CONCLUSION

As short-term surgical trips increase, further work is needed to standardize guidelines, create actionable steps, and promote collaborations in order to promote accountability during short-term surgical outreach trips.

Patient Follow-up After Orthopaedic Outreach Trips - Do We Know Whether Patients are Improving?

Background

The burden of traumatic musculoskeletal injuries falls greatest on low- and middle-income countries (LMICs). To help address this burden, organizations host over 6,000 outreach trips annually, 20% of which are orthopaedic. Monitoring post-surgical outcomes is critical to ensuring care quality; however, the implementation of such monitoring is unknown. The purpose of this review is to identify published follow-up practices of short-term orthopaedic surgery outreach trips to LMICs.

Methods

We completed a systematic review of Pubmed, Web of Science, EMBASE, and ProQuest following PRISMA guidelines. Follow-up method, rate, duration, and types of outcomes measured along with barriers to follow-up were collected and reported.

Results

The initial search yielded 1,452 articles, 18 of which were eligible. The mean follow-up time was 5.4 months (range: 15 days-7 years). The mean follow-up rate was 65.8% (range: 22%-100%), the weighted rate was 57.5%. Fifteen studies reported follow-up at or after 3 months while eight studies reported follow-up at or after 9 months. Fifteen studies reported follow-up in person, three reported follow-up via phone call or SMS. Outcome reporting varied among mortality, complications, and patient-reported outcomes. The majority (75%) outlined barriers to follow-up, most commonly noting transportation and costs of follow-up to the patient.

Conclusions

There is minimal and heterogeneous public reporting of patient outcomes and follow-up after outreach trips to LMICs, limiting quality assessment and improvement. Future work should address the design and implementation of tools and guidelines to improve follow-up as well as outcome measurement to ensure provision of high-quality care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06630-w.

Update on Noma: systematic review on classification, outcomes and follow-up of patients undergoing reconstructive surgery after Noma disease

INTRODUCTION

Noma is a significant yet neglected disease which affects some of the least developed countries in the world. The long-term benefit and safety of Noma surgical reconstructive missions have recently been under scrutiny due to a perceived lack of measurable outcomes and appropriate follow-up. This study analyses and reports on classifications, outcome measurement tools and follow-up for reconstructive surgery after Noma disease.

METHODS

This systematic review was undertaken following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The three medical databases Medline, EMBASE and Web of Sciences were searched, articles published between 1 January 1983 and 15 April 2020 were included. All primary evidence on reconstructive surgery following Noma disease, reporting data on outcome after surgery, follow-up time and complications were included. Extracted data were aggregated to generate overall and population corrected mean outcomes and complication rates.

RESULTS

Out of 1393 identified records, 31 studies including 1110 Noma patients were analysed. NOITULP and Montandon/WHO were the most commonly used classification systems. Mouth opening (MO) and complication rates were the two most often reported outcomes. Overall mean complication rate was 44%, reported by 24 studies. Postoperative MO was reported by eight publications, of which, five reported long-term outcomes (>12 months). Mean MO improved by 20 mm when compared with mean population weighted preoperative MO (7 mm). At long-term follow-up, MO decreased to 20 mm.

CONCLUSIONS

Studies reporting on neglected diseases in developing countries often lack methodological rigour. Surgeons should be mindful during patient examination by using a classification system that allows to compare preoperative versus postoperative state of disease. Short-term mission surgery is a vital part of healthcare delivery to underdeveloped and poor regions. Future missions should aim at sustainable partnerships with local healthcare providers to ensure postoperative care and long-term patient-oriented follow-up. A shift towards a diagonal treatment delivery approach, whereby local surgeons and healthcare staff are educated and empowered, should be actively promoted.

PROSPERO REGISTRATION NUMBER

CRD42020181931.

Medical Documentation in Low- and Middle-income Countries: Lessons Learned from Implementing Specialized Charting Software

Background:

The implementation of electronic health record (EHR) software at healthcare facilities in low- and middle-income countries (LMICs) is limited by financial and technological constraints. Smile Train, the world’s largest cleft charity, developed a cleft treatment EHR system, Smile Train Express (STX), and distributed it to their partnered institutions. The purpose of this study was to investigate trends in medical documentation practices amongst Smile Train-partner institutions to characterize the impact that specialized EHR software has on medical documentation practices at healthcare facilities in LMICs.

Methods:

Surveys were administered electronically to 843 Smile Train-partnered institutions across 68 LMICs. The survey inquired about institutions’ internet connection, documentation methods used during patient encounters, rationale for using said methods, and documentation methods for cloud-based storage of healthcare data. Institutions were grouped by economic and geographic subgroups for analysis.

Results:

A total of 162 institutions (19.2%) responded to the survey. Most institutions employed paper charting (64.2%) or institutional EHR software (25.9%) for data entry during a patient encounter with the latter’s use varying significantly across geographical subgroups (P = 0.01). STX was used by 18 institutions (11.1%) during a patient encounter. Workflow was the most frequently cited reason for institutions to employ their entry method during a patient encounter (51.4%).

Conclusions:

The provision of STX to partnered institutions influenced medical documentation practices at several institutions; however, regulations and guidelines have likely limited its complete integration into clinical workflows. Further studies are needed to characterize trends in medical documentation in LMICs at a more granular level.

The Local Mission: Improving Access to Surgical Care in Middle-Income Countries

BACKGROUND

Billions of people lack access to quality surgical care. Short-term missions are used to supplement the delivery of surgical care in regions with poor access to care. Traditionally known for using international teams, Operation Smile has transitioned to using a local mission model, where surgical service is delivered to areas of need by teams originating within that country. This study investigates the proportion and location of Operation Smile missions that use the local mission model.

METHODS

A retrospective review was performed of the Operation Smile mission database for fiscal years 2014 to 2019. Missions were classified into local or international missions. Countries were also classified by their income levels as well as their specialist surgical workforce (SAO) density. As no individual patient or provider data was recorded, ethics board approval was not warranted.

RESULTS

Between 2014 and 2019, Operation Smile held an average of 144.8 (range 135-154) surgical missions per year. Local missions accounted for 97 ± 5.6 (67%) of the missions. Of the 34 program countries, 26 (76%) used local missions. Of the countries that had only international missions, six (75%) were low-income countries and the average SAO density was 1.54 (range 0.19-5.88) providers per 100,000 people. Of the countries with local missions, 24 (92%) were middle-income, and the average SAO density was 30.9 (range 3.4-142.4).

CONCLUSION

International investments may assist in the creation of local surgical teams. Once teams are established, local missions are a valuable way to provide specialized surgical care within a country's own borders.

Orofacial clefts in low- and middle-income countries: A scoping review of quality and quantity of research based on literature between 2010-2019

This paper assesses the research literature on OFC in LMIC over the last decade across various geographical settings and project focus of the indexed literature. A scoping review of the indexed literature was performed using a set of predefined keywords. The articles were filtered by a ten-year time frame (2010-2019) and a strict inclusive-exclusive criterion. Two authors screened the titles/abstracts/full text of the final included papers and input the desired data (year of publication, type of publication, geographical country/region and project focus to a coded spreadsheet). Six hundred and twenty publications were inventoried from the indexed literature on OFC in LMIC settings over the 10-year period. Five hundred and eighty-three derived from single LMIC countries and 37 from multi-settings. More than half of the articles were reported from Asia (57%), then from Americas (22.8%), Africa (15.4%) and the rest from cross-regional, Europe and Oceania (4.9%). The top 3 LMIC contributors towards OFC publications were China (21.5%), Brazil (13.1%) and India (11.6%). The most discussed OFC project themes were prevalence, surgical repair, aetiology and genetics. This study helps OFC researchers, humanitarian missions and research grant funders to identify gaps in the literature on issues impacting on children and adults born with OFC, in which issues were subjected to research and which were less explored in which LMIC regions. In addition, this study offers recommendations for established OFC researchers and international research bodies to identify areas of deficiency in the literature and what information is required to support LMIC governments achieve SDGs by 2030.

The Effectiveness of Burn Scar Contracture Release Surgery in Low- and Middle-income Countries

Supplemental Digital Content is available in the text.

Worldwide, many scar contracture release surgeries are performed to improve range of motion (ROM) after a burn injury. There is a particular need in low- and middle-income countries (LMICs) for such procedures. However, well-designed longitudinal studies on this topic are lacking globally. The present study therefore aimed to evaluate the long-term effectiveness of contracture release surgery performed in an LMIC.

Impact of short-term reconstructive surgical missions: a systematic review

Introduction

Short-term missions providing patients in low-income countries with reconstructive surgery are often criticised because evidence of their value is lacking. This study aims to assess the effectiveness of short-term reconstructive surgical missions in low-income and middle-income countries.

Methods

A systematic review was conducted according to PRISMA guidelines. We searched five medical databases from inception up to 2 July 2018. Original studies of short-term reconstructive surgical missions were included, which reported data on patient safety measurements, health gains of individual patients and sustainability. Data were combined to generate overall outcomes, including overall complication rates.

Results

Of 1662 identified studies, 41 met full inclusion criteria, which included 48 546 patients. The overall study quality according to Oxford CEBM and GRADE was low. Ten studies reported a minimum of 6 months’ follow-up, showing a follow-up rate of 56.0% and a complication rate of 22.3%. Twelve studies that did not report on duration or follow-up rate reported a complication rate of 1.2%. Fifteen out of 20 studies (75%) that reported on follow-up also reported on sustainable characteristics.

Conclusions

Evidence on the patient outcomes of reconstructive surgical missions is scarce and of limited quality. Higher complication rates were reported in studies which explicitly mentioned the duration and rate of follow-up. Studies with a low follow-up quality might be under-reporting complication rates and overestimating the positive impact of missions. This review indicates that missions should develop towards sustainable partnerships. These partnerships should provide quality aftercare, perform outcome research and build the surgical capacity of local healthcare systems.

PROSPERO registration number

CRD42018099285.

Plastic and Reconstructive Surgery in Global Health: Let's Reconstruct Global Surgery

Since the inception of the Lancet Commission in 2013 and consequent prioritization of Global Surgery at the World Health Assembly, international surgical outreach efforts have increased and become more synergistic. Plastic surgeons have been involved in international outreach for decades, and there is now a demand to collaborate and address local need in an innovative way. The aim of this article was to summarize new developments in plastic and reconstructive surgery in global health, to unify our approach to international outreach. Specifically, 5 topics are explored: current models in international outreach, benefits and concerns, the value of research, the value of international surgical outreach education, and the value of technology. A “Let’s Reconstruct Global Surgery” network has been formed using Facebook as a platform to unite plastic and reconstructive surgeons worldwide who are interested in international outreach. The article concludes with actionable recommendations from each topic.

Orthopaedic Trauma Care Capacity Assessment and Strategic Planning in Ghana: Mapping a Way Forward

BACKGROUND

Orthopaedic conditions incur more than 52 million disability-adjusted life years annually worldwide. This burden disproportionately affects low and middle-income countries, which are least equipped to provide orthopaedic care. We aimed to assess orthopaedic capacity in Ghana, describe spatial access to orthopaedic care, and identify hospitals that would most improve access to care if their capacity was improved.

METHODS

Seventeen perioperative and orthopaedic trauma care-related items were selected from the World Health Organization's Guidelines for Essential Trauma Care. Direct inspection and structured interviews with hospital staff were used to assess resource availability and factors contributing to deficiencies at 40 purposively sampled facilities. Cost-distance analyses described population-level spatial access to orthopaedic trauma care. Facilities for targeted capability improvement were identified through location-allocation modeling.

RESULTS

Orthopaedic trauma care assessment demonstrated marked deficiencies. Some deficient resources were low cost (e.g., spinal immobilization, closed reduction capabilities, and prosthetics for amputees). Resource nonavailability resulted from several contributing factors (e.g., absence of equipment, technology breakage, lack of training). Implants were commonly prohibitively expensive. Building basic orthopaedic care capacity at 15 hospitals without such capacity would improve spatial access to basic care from 74.9% to 83.0% of the population (uncertainty interval [UI] of 81.2% to 83.6%), providing access for an additional 2,169,714 Ghanaians.

CONCLUSIONS

The availability of several low-cost resources could be better supplied by improvements in organization and training for orthopaedic trauma care. There is a critical need to advocate and provide funding for orthopaedic resources. These initiatives might be particularly effective if aimed at hospitals that could provide care to a large proportion of the population.

International short-term medical missions: a systematic review of recommended practices

OBJECTIVES

To identify practices for conducting international short-term medical missions (STMMs) recommended in the literature and examine how these link STMMs to recipient countries' existing health systems.

METHODS

Systematic review of PubMed-indexed articles on STMMs and their bibliographies using preferred reporting items for systematic reviews and meta-analyses guidelines. Recommendations were organized using the World Health Organization Health Systems Framework.

RESULTS

In 92 publications, 67 % offered at least one recommendation that would link STMMs to the recipient country's health system. Among these recommendations, most focused on service delivery and few on health financing and governance. There is a lack of consensus around a proper standard of care, patient selection, and trip duration.

CONCLUSIONS

Comprehensive global standards are needed for STMM work to ensure that services are beneficial both to patients and to the broader healthcare systems of recipient countries. By providing an overview of the current recommendations and important gaps where practice recommendations are needed, this study can provide relevant input into the development of global standards for STMMs.

The Role of Plastic Surgeons in Advancing Development Global

In September 2015, the international community came together to agree on the 2030 Agenda for Sustainable Development, a plan of action for people, the planet, and prosperity. Ambitious and far-reaching as they are, they are built on three keystones: the elimination of extreme poverty, fighting climate change, and a commitment to fighting injustice and inequality. Critical to the achievement of the Agenda is the global realization of access to safe, affordable surgical and anesthesia care when needed. The landmark report by the Lancet Commission on Global Surgery estimated that between 28 and 32 percent of the global burden of disease is amenable to surgical treatment. However, as many as five billion people lack access to safe, timely, and affordable surgical care, a burden felt most severely in low- and middle-income countries (LMICs). Surgery, and specifically plastic surgery, should be incorporated into the international development and humanitarian agenda. As a community of care providers dedicated to the restoration of the form and function of the human body, plastics surgeons have a collective opportunity to contribute to global development, making the world more equitable and helping to reduce extreme poverty. As surgical disease comprises a significant burden of disease and surgery can be delivered in a cost-effective manner, surgery must be considered a public health priority.

Strategic Assessment of Trauma Care Capacity in Ghana

BACKGROUND

This study aimed to assess availability of trauma care technology in Ghana. In addition, factors contributing to deficiencies were evaluated. By doing so, potential solutions to inefficient aspects of health systems management and maladapted technology for trauma care in low- and middle-income countries (LMICs) could be identified.

METHODS

Thirty-two items were selected from the World Health Organization's Guidelines for Essential Trauma Care. Direct inspection and structured interviews with administrative, clinical, and biomedical engineering staff were used to assess the challenges and successes of item availability at 40 purposively sampled district, regional, and tertiary hospitals.

RESULTS

Hospital assessments demonstrated marked deficiencies. Some of these were low cost, such as basic airway supplies, chest tubes, and cervical collars. Item non-availability resulted from several contributing factors, namely equipment absence, lack of training, frequent stock-outs, and technology breakage. A number of root causes for these factors were identified, including ineffective healthcare financing by way of untimely national insurance reimbursements, procurement and stock-management practices, and critical gaps in local biomedical engineering and trauma care training. Nonetheless, local examples of successfully overcoming deficiencies were identified (e.g., public-private partnering, ensuring company engineers trained technicians on-the-job during technology installation or servicing).

CONCLUSION

While availability of several low-cost items could be better supplied by improvements in stock-management and procurement policies, there is a critical need for redress of the national insurance reimbursement system and trauma care training of district hospital staff. Further, developing local service and technical support capabilities is more and more pressing as technology plays an increasingly important role in LMIC healthcare systems.

30-year International Pediatric Craniofacial Surgery Partnership: Evolution from the "Third World" Forward

Background:

Craniofacial diseases constitute an important component of the surgical disease burden in low- and middle-income countries. The consideration to introduce craniofacial surgery into such settings poses different questions, risks, and challenges compared with cleft or other forms of plastic surgery. We report the evolution, innovations, and challenges of a 30-year international craniofacial surgery partnership.

Methods:

We retrospectively report a partnership between surgeons at the Uniwersytecki Szpital Dzieciecy in Krakow, Poland, and a North American craniofacial surgeon. We studied patient conditions, treatment patterns, and associated complications, as well as program advancements and limitations as perceived by surgeons, patient families, and hospital administrators.

Results:

Since partnership inception in 1986, the complexity of cases performed increased gradually, with the first intracranial case performed in 1995. In the most recent 10-year period (2006–2015), 85 patients have been evaluated, with most common diagnoses of Apert syndrome, Crouzon syndrome, and single-suture craniosynostosis. In the same period, 55 major surgical procedures have been undertaken, with LeFort III midface distraction, posterior vault distraction, and frontoorbital advancement performed most frequently. Key innovations have been the employment of craniofacial distraction osteogenesis, the use of Internet communication and digital photography, and increased understanding of how craniofacial morphology may improve in the absence of surgical intervention. Ongoing challenges include prohibitive training pathways for pediatric plastic surgeons, difficulty in coordinating care with surgeons in other institutions, and limited medical and material resources.

Conclusion:

Safe craniofacial surgery can be introduced and sustained in a resource-limited setting through an international partnership.

Surgery for children in low-income countries affected by humanitarian emergencies from 2008 to 2014: The Médecins Sans Frontières Operations Centre Brussels experience

PURPOSE

Pediatric surgical care is deficient in developing countries disrupted by crisis. We aimed to describe pediatric surgical care at Médecins Sans Frontières-Brussels (MSF-OCB) projects to inform resource allocation and define the pediatric-specific skillset necessary for humanitarian surgical teams.

METHODS

Procedures performed by MSF-OCB from July 2008 to December 2014 were reviewed. Project characteristics, patient demographics and clinical data were described. Multivariable logistic regression was performed to determine predictors of perioperative death.

RESULTS

Of 109,828 procedures, 26,284 were performed for 24,576 children (22% of all procedures). The most common pediatric operative indication was trauma (13,984; 57%). Nine percent of all surgical indications were due to violence (e.g., land mines, firearms, gender-based violence, etc.). The majority of procedures (19,582; 75%) were general surgical, followed by orthopedic (4350; 17%), and obstetric/gynecologic/urologic (2135; 8%). Perioperative death was low (42; 0.17%); independent predictors of death included age <1year, use of general anesthesia with a definitive airway, and operation during conflict.

CONCLUSION

Surgical care for children comprised nearly a quarter of all procedures performed by MSF-OCB between 2008 and 2014. Attention to trauma surgery and infant perioperative care is particularly needed. These findings are important when resourcing projects and training surgical staff for humanitarian missions.

Financing pediatric surgery in low-, and middle-income countries

Congenital anomalies once considered fatal, are now surgically correctable conditions that now allow children to live a normal life. Pediatric surgery, traditionally thought of as a privilege of the rich, as being too expensive and impractical, and which has previously been overlooked and excluded in resource-poor settings, is now being reexamined as a cost-effective strategy to reduce the global burden of disease-particularly in low, and middle-income countries (LMICs). However, to date, global pediatric surgical financing suffers from an alarming paucity of data. To leverage valuable resources and prioritize pediatric surgical services, timely, accurate and detailed global health spending and financing for pediatric surgical care is needed to inform policy making, strategic health-sector budgeting and resource allocation. This discussions aims to characterize and highlight the evidence gaps that currently exist in global financing and funding flow for pediatric surgical care in LMICs.

Assessment of risk of peripheral vascular disease and vascular care capacity in low- and middle-income countries

BACKGROUND

This study aimed to describe national peripheral vascular disease (PVD) risk and health burden, and vascular care capacity in Ghana. The gap between PVD burden and vascular care capacity in low- and middle-income countries was defined, and capacity improvement priorities were identified.

METHODS

Data to estimate PVD risk factor burden were obtained from the World Health Organization Study on Global Ageing and Adult Health (SAGE), Ghana, and the Institute of Health Metrics and Evaluation Global Burden of Disease (IHME GBD) database. In addition, a novel nationwide assessment of vascular care capacity was performed, with 20 vascular care items assessed at 40 hospitals in Ghana. Factors contributing to specific item deficiency were described.

RESULTS

From the SAGE database, there were 4305 respondents aged at least 50 years with data to estimate PVD risk. Of these, 57·4 per cent were at moderate to risk high of PVD with at least three risk factors; extrapolating nationally, the estimate was 1 654 557 people. Based on IHME GBD data, the estimated disability-adjusted life-years incurred from PVD increased fivefold from 1990 to 2010 (from 6·3 to 31·7 per 100 000 persons respectively). Vascular care capacity assessment demonstrated marked deficiencies in items for diagnosis, and in perioperative and vascular surgical care. Deficiencies were most often due to absence of equipment, lack of training and technology breakage.

CONCLUSION

Risk factor reduction and management as well as optimization of current resources are paramount to avoid the large burden of PVD falling on healthcare systems in low- and middle-income countries. These countries are not well equipped to handle vascular surgical care, and rapid development of such capacity would be difficult and expensive.

Building neurosurgical capacity in low and middle income countries

Neurosurgery capacity in low- and middle-income countries is far from adequate; yet burden of neurological diseases, especially neuro-trauma, is projected to increase exponentially. Previous efforts to build neurosurgical capacity have typically been individual projects and short-term missions. Recognizing the dual needs of addressing disease burden and building sustainable, long-term neurosurgical care capacity, we describe in this paper an ongoing collaboration between the Mulago Hospital Department of Neurosurgery (Kampala, Uganda) and Duke University Medical Center (Durham, NC, USA) as a replicable model to meet the dual needs. The collaboration employs a threefold approach to building capacity: technology, twinning, and training performed together in a top-down approach. Also described are lessons learned to date by Duke Global Neurosurgery and Neurosciences (DGNN) and applicability beyond Kampala.