Understanding surgical care delivery in Sub-Saharan Africa: a cross-sectional analysis of surgical volume, operations, and financing at a tertiary referral hospital in rural Tanzania

Reaching consensus on factors impacting optimal use of an orthopaedic emergency theatre in a public hospital

Background

The operating theatre (OT) complex of hospitals represents areas of considerable expenditure with regard to costs and requires maximum use to ensure optimum cost benefit for both patients and the hospital. Inefficient use of an operating theatre room (OTR) may result in hospital wasteful expenditure and frustrations for patients owing to surgery delays, cancellations and prolonged hospitalisation while waiting.

Aim

The aim of the study was to explore and describe using a consensus method, factors impacting the use of an emergency orthopaedic theatre that can be optimised in a selected public hospital in Gauteng province.

Setting

The study was conducted by a professional nurse and orthopaedic surgeon working in the theatre of a selected public hospital in Gauteng province.

Method

A qualitative, explorative and descriptive design was adopted. Data were collected using a nominal group technique (NGT) among professional nurses and orthopaedic surgeons. Data analysis was done through cross-analysis where participants reached a consensus on the voted ideas from the group.

Results

Consensus was reached and three main themes emerged: (1) inadequate resources; (2) poor organisation and (3) communication.

Conclusion

The optimal use of an emergency orthopaedic theatre is influenced by the availability of resources being human and material, good organisation and clear communication.

Contribution

The study has demonstrated that a variety of factors needs to be considered to optimise the use of an orthopaedic emergency theatre. The management of an OT requires a concerted effort from the nurses and doctors.

Resource use, availability and cost in the provision of critical care in Tanzania: a systematic review

OBJECTIVES

Critical care is essential in saving lives of critically ill patients, however, provision of critical care across lower resource settings can be costly, fragmented and heterogenous. Despite the urgent need to scale up the provision of critical care, little is known about its availability and cost. Here, we aim to systematically review and identify reported resource use, availability and costs for the provision of critical care and the nature of critical care provision in Tanzania.

DESIGN

This is a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

Medline, Embase and Global Health databases were searched covering the period 2010 to 17 November 2020.

ELIGIBILITY CRITERIA

We included studies that reported on forms of critical care offered, critical care services offered and/or costs and resources used in the provision of care in Tanzania published from 2010.

DATA EXTRACTION AND SYNTHESIS

Quality assessment of the articles and data extraction was done by two independent researchers. The Reference Case for Estimating the Costs of Global Health Services and Interventions was used to assess quality of included studies. A narrative synthesis of extracted data was conducted. Costs were adjusted and reported in 2019 US$ and TZS using the World Bank GDP deflators.

RESULTS

A total 31 studies were found to fulfil the inclusion and exclusion criteria. Critical care identified in Tanzania was categorised into: intensive care unit (ICU) delivered critical care and non-ICU critical care. The availability of ICU delivered critical care was limited to urban settings whereas non-ICU critical care was found in rural and urban settings. Paediatric critical care equipment was more scarce than equipment for adults. 15 studies reported on the costs of services related to critical care yet no study reported an average or unit cost of critical care. Costs of medication, equipment (eg, oxygen, personal protective equipment), services and human resources were identified as inputs to specific critical care services in Tanzania.

CONCLUSION

There is limited evidence on the resource use, availability and costs of critical care in Tanzania. There is a strong need for further empirical research on critical care resources availability, utilisation and costs across specialties and hospitals of different level in low/middle-income countries like Tanzania to inform planning, priority setting and budgeting for critical care services.

PROSPERO REGISTRATION NUMBER

CRD42020221923.

Teaching Thoracic Surgery in a Low-Resource Setting:: Creation of a Simulation Curriculum in Rwanda

Surgical education and global health partnerships have evolved over the years. There is growing recognition of the importance of in-country training of surgeons and surgeon specialists in low-resource settings to support the local health care system. There are numerous ways in which high-income partners can support local training programs. The Human Resources for Health program was initiated in 2012 to advance in-country training of health care professionals in Rwanda. As there was a limited in-country operative experience for teaching general thoracic surgery, simulation models were developed, influenced by a prior course developed for American cardiothoracic trainees. Local Rwandan faculty were engaged. Adaptations from the American version included constructing models from inexpensive materials to make the simulation more feasible in the Rwanda setting.

A Journey Undertaken by Families to Access General Surgical Care for their Children at Muhimbili National Hospital, Tanzania; Prospective Observational Cohort Study

BACKGROUND

A majority of the 2 billion children lacking access to safe, timely and affordable surgical care reside in low-and middle-income countries. A barrier to tackling this issue is the paucity of information regarding children's journey to surgical care. We aimed to explore children's journeys and its implications on accessing general paediatric surgical care at Muhimbili National Hospital (MNH), a tertiary centre in Tanzania.

METHODS

A prospective observational cohort study was undertaken at MNH, recruiting patients undergoing elective and emergency surgeries. Data on socio-demographic, clinical, symptoms onset and 30-days post-operative were collected. Descriptive statistics and Mann-Whitney, Kruskal-Wallis and Fisher's exact tests were used for data analysis.

RESULT

We recruited 154 children with a median age of 36 months. The majority were referred from regional hospitals due to a lack of paediatric surgery expertise. The time taken to seeking care was significantly greater in those who self-referred (p = 0.0186). Of these participants, 68.4 and 31.1% were able to reach a referring health facility and MNH, respectively, within 2 h of deciding to seek care. Overall insurance coverage was 75.32%. The median out of pocket expenditure for receiving care was $69.00. The incidence of surgical site infection was 10.2%, and only 2 patients died.

CONCLUSION

Although there have been significant efforts to improve access to safe, timely and affordable surgical care, there is still a need to strengthen children's surgical care system. Investing in regional hospitals may be an effective approach to improve access to children surgical care.

Barriers to increase surgical productivity in Sierra Leone: a qualitative study

OBJECTIVE

To explore factors influencing surgical provider productivity and identify barriers against and opportunities to increase individual surgical productivity in Sierra Leone, in order to explain the observed increase in unmet surgical need from 92.2% to 92.7% and the decrease in surgical productivity to 1.7 surgical procedures per provider per week between 2012 and 2017.

DESIGN AND METHODS

This explanatory qualitative study consisted of in-depth interviews about factors influencing surgical productivity in Sierra Leone. Interviews were analysed with a thematic network analysis and used to develop a conceptual framework.

PARTICIPANTS AND SETTING

21 surgical providers and hospital managers working in 12 public and private non-profit hospitals in all regions in Sierra Leone.

RESULTS

Surgical providers in Sierra Leone experience a broad range of factors within and outside the health system that influence their productivity. The main barriers involve both patient and facility financial constraints, lack of equipment and supplies, weak regulation of providers and facilities and a small surgical workforce, which experiences a lack of recognition. Initiation of a Free Health Care Initiative for obstetric and paediatric care, collaborations with partners or non-governmental organisations, and increased training opportunities for highly motivated surgical providers are identified as opportunities to increase productivity.

DISCUSSION

Broader nationwide health system strengthening is required to facilitate an increase in surgical productivity and meet surgical needs in Sierra Leone. Development of a national strategy for surgery, obstetrics and anaesthesia, including methods to reduce financial barriers for patients, improve supply-mechanisms and expand training opportunities for new and established surgical providers can increase surgical capacity. Establishment of legal frameworks and appropriate remuneration are crucial for sustainability and retention of surgical health workers.

Financing of surgery and anaesthesia in sub-Saharan Africa: a scoping review

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.

Definitive surgical femur fracture fixation in Northern Tanzania: implications of cost, payment method and payment status

Introduction

Kilimanjaro Christian Medical Centre (KCMC) covers major orthopaedic trauma for a catchment population of 12.5 million people in northern Tanzania. Femur fractures, the most common traumatic orthopaedic injury at KCMC (39%), require open reduction and internal fixation (ORIF) for definitive treatment. It is unclear whether payment affects care. This study sought to explore associations of payment method with episodes of care for femur fracture ORIFs at KCMC.

Methods

we performed a retrospective review of orthopaedic records between February 2018 and July 2018. Patients with femur fracture ORIF were eligible; patients without charts were excluded. Ethical clearance was obtained from the KCMC ethics committee. Statistical analysis utilized descriptive statistics, Chi-squared and Fisher’s exact Tests, and Student´s t-tests where appropriate.

Results

of 76 included patients, 17% (n=13) were insured, 83% (n=63) paid out-of-pocket, 11% (n=8) had unpaid balance, and 89% (n=68) fully paid. Average patient charge ($417) was 42% of per capita GDP ($998). Uninsured patients had higher bills ($429 vs $356; p=0.27) and were significantly more likely to pay an advance payment (95.2% vs 7.7%; p<0.001). Inpatient care was equivalent regardless of payment. Unpaid patients were less likely to receive follow-up (76.5% vs. 25%; p=0.006) and waited longer from injury to admission (31.5 vs 13.3 days; p<0.001), from admission to surgery (30.1 vs 11.1 days; p<0.001), and from surgery to discharge (18.4 vs 7.1 days; p<0.001).

Conclusion

equal standard of care is provided to all patients. However, future efforts may decrease disparities in advance payment, timeliness, and follow-up.

Prevalence and factors associated with cancellation and deferment of elective surgical cases at a rural private tertiary hospital in Western Uganda: a cross-sectional study

Introduction

the cancellation of elective surgery is still a worldwide challenge and this is associated with emotional and economical trauma for the patients and their families as well as a decrease in the efficiency of the operating theatre. This study aimed at determining the prevalence and factors associated with cancellation and deferment of elective surgery in a rural private tertiary teaching hospital in Western Uganda.

Methods

a cross-sectional study design was conducted. Data was collected from 1^st July 2019 to 31^st December 2019. Patients scheduled for elective surgery and either cancelled or deferred on the actual day of surgery were included in the study. Statistical analysis was done using STATA version 15.

Results

four hundred patients were scheduled for elective surgery during the study period, among which 90 (22.5%) were cancelled and 310 (78.5%) had their surgeries as scheduled. The highest cancellation of elective surgical operations was observed in general surgery department with 81% elective cases cancelled or deferred, followed by orthopedic department 10% and gynecology department 9%. The most common reasons for cancellation were patient-related (39%) and health worker-related (35%) factors. Other factors included administrative (17%) and anesthesia related factors (9%). Cancellation was mainly due to lack of finances which accounted for 23.3% of the patients, inadequate patient preparation (16.6%) and unavailability of surgeons (15.5%). Major elective surgeries were cancelled 1.7 times more than minor electives surgeries [adjusted prevalence ratio 1.7 (95%CI: 1.07-2.73) and p-value: 0.024].

Conclusion

cancellation and deferment of elective surgeries is still of a major concern in this private rural tertiary hospital with most of the reasons easily preventable through proper scheduling of patients, improved communication between surgical teams and with patients; and effective utilization of available resources and man power.

Evaluating factors associated with the cancellation and delay of elective surgical procedures: a systematic review

BACKGROUND

Elective surgery cancellation is considered a fundamental problem in health care services-it causes considerable disruption to patient flow, further eroding often already stretched operating capacity, and consequentially reduces both hospital performance and patient satisfaction. This research presents a systematic review (SR) of the reasons for surgery cancellation among different hospitals and countries. By highlighting these causes, we identify how to reduce cancellations, thereby improving the use of surgical capacity and resources and creating a more predicable patient flow.

METHODS

An SR was performed on elective surgery cancellation in compliance with the Preferred Reporting Items for Systematic Review and Meta-Analysis and by assessing the methodological quality of SR with Measurement Tool to Assess Systematic Reviews guidelines.

RESULTS

There are different reasons for surgery cancellation that vary between hospitals. This SR demonstrates that hospital-related causes (e.g. unavailable operation room time, inappropriate scheduling policy and lack of beds) are the primary reason for surgery cancellation, followed by work-up related causes (e.g. medically unfit and changes in the treatment plan) and patient-related causes (e.g. absence of a patient and patient refusal).

CONCLUSION

This review demonstrates that the main causes for surgery cancellation can be controlled by hospital managers, who can aim to improve areas such as patient flow and capacity management. Ultimately, this will improve the quality of healthcare delivered by hospitals.

Construction of Rural Financial Organization Spatial Structure and Service Management Model Based on Deep Convolutional Neural Network

Local credit cooperatives have long played an important role in local financial services. It has made a significant contribution to agricultural production, farmers' incomes, and the economic development of rural areas. In particular, as a financial instrument serving farmers, microfinance management by local credit cooperatives plays a key role in pursuing profits and fulfilling social responsibility. It was therefore important to obtain effective instruments for combating poverty in rural areas from all walks of society. This paper first outlines the development of microfinance loans in Germany and other countries and describes the current situation and some of the challenges facing local credit cooperatives in financial management. Next, we present the basic concepts of data mining, describe the common methods and key techniques of data mining, analyze and compare the properties of the individual data, and show how the associated mining can actually be performed. Next, we will explain the basic model of microfinance for farmers and some risks in detail and analyze and evaluate the characteristics of these risks in the context of local credit cooperatives. As a result, this paper proposes an improved deep convolutional neural network. The optimized algorithm selects the optimal weight threshold value and different iteration times. The results are fewer errors, the results are closer to the correct data, and the efficiency is better than before. The algorithm is more efficient because errors have been greatly reduced and the time spent on them has been slightly reduced.

Root causes of elective surgical case cancellation in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Cancellation of elective surgical operation recognized as a major cause of emotional trauma to patients as well as their families. In Ethiopia, prevalence and root causes for elective surgical case cancellation varies from time to time in different settings. This systematic review and meta-analysis aimed to find the pooled prevalence and root causes for elective surgical case cancellation in Ethiopia.

METHODS

The databases for the search were Web of Science, PubMed, and Google Scholar. The last literature search was performed on February 8, 2020. To assess publication bias Egger's regression analysis was applied. The pooled estimation was estimated using random-effects model meta-analysis. Subgroup analysis was also done based on the root causes of surgical case cancellation.

RESULTS

This meta-analysis included a total of 5 studies with 5591 study participants. The pooled prevalence of elective surgical case cancellation was 21.41% (95% CI: 12.75 to 30.06%). Administration-related reason (34.50%) was the most common identified root cause, followed by surgeon (25.29%), medical (13.90%), and patient-related reasons (13.34%).

CONCLUSION

The prevalence of elective surgical case cancellation was considerable. The most common root cause for elective surgical case cancellation was administration-related reasons, followed by the surgeon, medical and patient-related reasons. The causes for the surgical cancellations are potentially preventable. Thus, efforts should be made to prevent unnecessary cancellations through careful planning.

Financial Risk Protection and Hospital Admission for Trauma in Cameroon: An Analysis of the Cameroon National Trauma Registry

BACKGROUND

Half of the global population is at risk for catastrophic health expenditure (CHE) in the event that they require surgery. Universal health coverage fundamentally requires protection from CHE, particularly in low- and middle-income countries (LMICs). Financial risk protection reports in LMICs covering surgical care are limited. We explored the relationship between financial risk protection and hospital admission among injured patients in Cameroon to understand the role of health insurance in addressing unmet need for surgery in LMICs.

METHODS

The Cameroon National Trauma Registry, a database of all injured patients presenting to the emergency departments (ED) of three Cameroonian hospitals, was retrospectively reviewed between 2015 and 2017. Multivariate regression analysis identified predictors of hospital admission after injury and of patient report of cost inhibiting their care.

RESULTS

Of the 7603 injured patients, 95.7% paid out-of-pocket to finance ED care. Less than two percent (1.42%) utilized private insurance, and more than half (54.7%) reported that cost inhibited their care. In multivariate analysis, private insurance coverage was a predictor of hospital admission (OR 2.17, 95% CI: 1.26, 3.74) and decreased likelihood of cost inhibiting care (OR 0.34, 95% CI: 0.20, 0.60) when compared to individuals paying out-of-pocket.

CONCLUSION

The prevalence of out-of-pocket spending among injured patients in Cameroon highlights the need for financial risk protection that encompasses surgical care. Patients with private insurance were more likely to be admitted to the hospital, and less likely to report that cost inhibited care, supporting private health insurance as a potential financing strategy.