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Mukumbya B, Kitya D, Trillo-Ordonez Y, Sun K, Obiga O, Deng DD, Stewart KA, Ukachukwu AEK, Haglund MM, Fuller AT. The feasibility, appropriateness, and usability of mobile neuro clinics in addressing the neurosurgical and neurological demand in Uganda. PLoS One 2024; 19:e0305382. [PMID: 38913633 PMCID: PMC11195962 DOI: 10.1371/journal.pone.0305382] [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] [Received: 01/02/2024] [Accepted: 05/28/2024] [Indexed: 06/26/2024] Open
Abstract
INTRODUCTION Uganda has a high demand for neurosurgical and neurological care. 78% of the over 50 million population reside in rural and remote communities where access to neurosurgical and neurological services is lacking. This study aimed to determine the feasibility, appropriateness, and usability of mobile neuro clinics (MNCs) in providing neurological care to rural and remote Ugandan populations. METHODS Neurosurgery, neurology, and mobile health clinic providers participated in an education and interview session to assess the feasibility, appropriateness, and usability of the MNC intervention. A qualitative analysis of the interview responses using the constructs in the updated Consolidated Framework for Implementation Research was performed. Providers' opinions were weighted using average sentiment scores on a novel sentiment-weighted scale adapted from the CFIR. A stakeholder analysis was also performed to assess the power and interest of the actors described by the participants. RESULTS Twenty-one healthcare providers completed the study. Participants discussed the potential benefits and concerns of MNCs as well as potential barriers and critical incidents that could jeopardize the intervention. Of the five CFIR domains evaluated, variables in the implementation process domain showed the highest average sentiment scores, followed by the implementation climate constructs, inner setting, innovation, and outer setting domains. Furthermore, many interested stakeholders were identified with diverse roles and responsibilities for implementing MNCs. These findings demonstrate that MNC innovation is feasible, appropriate, and usable. CONCLUSION The findings of this study support the feasibility, appropriateness, and usability of MNCs in Uganda. However, integration of this innovation requires careful planning and stakeholder engagement at all levels to ensure the best possible outcomes.
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Affiliation(s)
- Benjamin Mukumbya
- Duke Global Neurosurgery and Neurology, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
| | - David Kitya
- Duke Global Neurosurgery and Neurology, Durham, NC, United States of America
- Department of Neurosurgery, Mbarara Regional Referral Hospital, Mbarara, Uganda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Yesel Trillo-Ordonez
- Duke Global Neurosurgery and Neurology, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
| | - Keying Sun
- Duke Global Health Institute, Durham, NC, United States of America
- Duke University School of Medicine, Durham, NC, United States of America
| | - Oscar Obiga
- Duke Global Neurosurgery and Neurology, Durham, NC, United States of America
- Department of Neurosurgery, Mulago National Referral Hospital, Kampala, Uganda
| | - Di D. Deng
- Duke Global Neurosurgery and Neurology, Durham, NC, United States of America
| | | | - Alvan-Emeka K. Ukachukwu
- Duke Global Neurosurgery and Neurology, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
- Department of Neurosurgery, Duke University Health System, Durham, NC, United States of America
| | - Michael M. Haglund
- Duke Global Neurosurgery and Neurology, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
- Department of Neurosurgery, Duke University Health System, Durham, NC, United States of America
| | - Anthony T. Fuller
- Duke Global Neurosurgery and Neurology, Durham, NC, United States of America
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Saunders AC, Mutebi M, Rao TS. A Review of the Current State of Global Surgical Oncology and the Role of Surgeons Who Treat Cancer: Our Profession’s Imperative to Act Upon a Worldwide Crisis in Evolution. Ann Surg Oncol 2023; 30:3197-3205. [PMID: 36973564 PMCID: PMC10175401 DOI: 10.1245/s10434-023-13352-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 02/19/2023] [Indexed: 03/29/2023]
Abstract
AbstractWorldwide, the capacity of healthcare systems and physician workforce is woefully inadequate for the surgical treatment of cancer. With major projected increases in the global burden of neoplastic disease, this inadequacy is expected to worsen, and interventions to increase the workforce of surgeons who treat cancer and strengthen the necessary supporting infrastructure, equipment, staffing, financial and information systems are urgently called for to prevent this inadequacy from deepening. These efforts must also occur in the context of broader healthcare systems strengthening and cancer control plans, including prevention, screening, early detection, safe and effective treatment, surveillance, and palliation. The cost of these interventions should be considered a critical investment in healthcare systems strengthening that will contribute to improvement in the public and economic health of nations. Failure to act should be seen as a missed opportunity, at the cost of lives and delayed economic growth and development. Surgeons who treat cancer must engage with a diverse array of stakeholders in efforts to address this critical need and are indispensably positioned to participate in collaborative approaches to influence these efforts through research, advocacy, training, and initiatives for sustainable development and overall systems strengthening.
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Affiliation(s)
| | | | - T Subramanyeshwar Rao
- Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, India
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Makene FS, Ngilangwa R, Santos C, Cross C, Ngoma T, Mujinja PGM, Wuyts M, Mackintosh M. Patients' pathways to cancer care in Tanzania: documenting and addressing social inequalities in reaching a cancer diagnosis. BMC Health Serv Res 2022; 22:189. [PMID: 35151290 PMCID: PMC8841053 DOI: 10.1186/s12913-021-07438-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/21/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND This article investigates the extent and sources of late diagnosis of cancer in Tanzania, demonstrating how delayed diagnosis was patterned by inequities rooted in patients' socio-economic background and by health system responses. It provides evidence to guide equity-focused policies to accelerate cancer diagnosis. METHODS Tanzanian cancer patients (62) were interviewed in 2019. Using a structured questionnaire, respondents were encouraged to recount their pathways from first symptoms to diagnosis, treatment, and in some cases check-ups as survivors. Patients described their recalled sequence of events and actions, including dates, experiences and expenditures at each event. Socio-demographic data were also collected, alongside patients' perspectives on their experience. Analysis employed descriptive statistics and qualitative thematic analysis. RESULTS Median delay, between first symptoms that were later identified as indicating cancer and a cancer diagnosis, was almost 1 year (358 days). Delays were strongly patterned by socio-economic disadvantage: those with low education, low income and non-professional occupations experienced longer delays before diagnosis. Health system experiences contributed to these socially inequitable delays. Many patients had moved around the health system extensively, mainly through self-referral as symptoms worsened. This "churning" required out-of-pocket payments that imposed a severely regressive burden on these largely low-income patients. Causes of delay identified in patients' narratives included slow recognition of symptoms by facilities, delays in diagnostic testing, delays while raising funds, and recourse to traditional healing often in response to health system barriers. Patients with higher incomes and holding health insurance that facilitated access to the private sector had moved more rapidly to diagnosis at lower out-of-pocket cost. CONCLUSIONS Late diagnosis is a root cause, in Tanzania as in many low- and middle-income countries, of cancer treatment starting at advanced stages, undermining treatment efficacy and survival rates. While Tanzania's policy of free public sector cancer treatment has made it accessible to patients on low incomes and without insurance, reaching a diagnosis is shown to have been for these respondents slower and more expensive the greater their socio-economic disadvantage. Policy implications are drawn for moving towards greater social justice in access to cancer care.
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Affiliation(s)
- Fortunata Songora Makene
- Economic and Social Research Foundation, 51 Uporoto Street, Ursino Estate, P.O Box 31226, Dar es Salaam, Tanzania
| | - Richard Ngilangwa
- Economic and Social Research Foundation, 51 Uporoto Street, Ursino Estate, P.O Box 31226, Dar es Salaam, Tanzania
| | - Cristina Santos
- Faculty of Arts and Social Sciences, The Open University, Walton Hall, Milton Keynes, MK7 6AA UK
| | - Charlotte Cross
- Faculty of Arts and Social Sciences, The Open University, Walton Hall, Milton Keynes, MK7 6AA UK
| | - Twalib Ngoma
- Department of Behavioural Sciences, Muhimbili University of Heath and Allied Sciences, United Nations Rd, Dar es Salaam, Tanzania
| | - Phares G. M. Mujinja
- Department of Behavioural Sciences, Muhimbili University of Heath and Allied Sciences, United Nations Rd, Dar es Salaam, Tanzania
| | - Marc Wuyts
- International Institute of Social Studies, Erasmus University Rotterdam, Kortenaerkade 12, The Hague, 2518 AX The Netherlands
| | - Maureen Mackintosh
- Faculty of Arts and Social Sciences, The Open University, Walton Hall, Milton Keynes, MK7 6AA UK
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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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Reichl A, Schutt R, Walsh J, Prieto J, Sykes AG, Bickler S, Ignacio R. Challenges in Oncologic Preparedness: A Retrospective Review of Incident Surgical Cancers During Pacific Partnership Missions, 2008-2016. Mil Med 2020; 187:e76-e81. [PMID: 33372673 DOI: 10.1093/milmed/usaa488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/26/2020] [Accepted: 11/16/2020] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION For over 30 years, the USNS Mercy hospital ship has provided surgical care on multiple humanitarian aid and disaster relief missions. During these missions, surgical support varies according to host nation needs, and the operative treatment of cancer patients remains controversial. We report the number of incidentally discovered surgical oncologic cases treated aboard the USNS Mercy on four missions and discuss challenges regarding oncologic care on these missions. MATERIALS AND METHODS Between 2008 and 2016, operative cases and surgical pathology results from four multinational humanitarian missions were analyzed according to organ system, patient's geographic location, and diagnosis. Primary outcomes were total number and proportion of malignant cases, analyzed yearly and over all four missions. Secondary outcomes were malignant diagnoses by organ system and host nation health capacities (based on indicators from the WHO). RESULTS A total of 2,767 operations were performed during 18 port visits in 8 countries in Southeast Asia. In total, 1,193 pathology specimens (surgical biopsies, fine needle aspirations, etc.) were obtained. Overall malignancy rate across all organ systems was 9%. Yearly malignancy rates ranged from 2% to 13%. The highest malignancy rates were found in thyroid (33%), breast (20%), and parotid and salivary gland cases (19%). All host nations had operational strategies for cancer in place (n = 8, 100%), but few had national infrastructures to treat noncommunicable diseases (n = 2, 25%). CONCLUSIONS Despite current policies to screen out cancer patients on USNS Mercy missions, 9% of surgical biopsies were malignant. Cancer management during these missions presents a unique challenge because of limited resources for surgery, chemoradiotherapy, and follow-up care. Contingency plans must be considered to provide completion of care for these patients whose cancers are discovered incidentally. Furthermore, an understanding of host nation capabilities in relation to medical and surgical care is crucial to providing treatment in resource-limited areas.
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Affiliation(s)
- Allison Reichl
- Department of Surgery, University of California San Diego School of Medicine, La Jolla, CA 92093, USA
| | - Ryan Schutt
- Department of Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - John Walsh
- Department of Pathology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - James Prieto
- Department of Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA.,Department of Pathology, Rady Children's Hospital, San Diego, CA 92123, USA
| | - Alicia G Sykes
- Department of Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA.,Department of Pathology, Rady Children's Hospital, San Diego, CA 92123, USA
| | - Stephen Bickler
- Department of Surgery, University of California San Diego School of Medicine, La Jolla, CA 92093, USA.,Department of Pathology, Rady Children's Hospital, San Diego, CA 92123, USA
| | - Romeo Ignacio
- Department of Surgery, University of California San Diego School of Medicine, La Jolla, CA 92093, USA.,Department of Pathology, Rady Children's Hospital, San Diego, CA 92123, USA
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Bunkley N, Bissett I, Buka M, Bong J, Leodoro B, Dare A, Perry W. A Household Survey to Evaluate Access to Surgical Care in Vanuatu. World J Surg 2020; 44:3237-3244. [PMID: 32462217 DOI: 10.1007/s00268-020-05608-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Surgical care is an integral part of any healthcare system, yet there is a paucity of data on the burden of surgical disease, surgical capacity and access to surgical services in the Pacific region. This study aimed to evaluate access to surgical care through a pilot household survey in the Vanuatu island of Efate and five of its surrounding islands. METHODS The 2009 Vanuatu census' GPS coordinates were used to randomly select 150 rural and 150 urban households from Efate and its surrounding islands. A total of 143 urban households and 142 rural households were available for inclusion in this study. A household questionnaire was developed to evaluate access to surgical care and included information regarding household demographics, socio-economic indicators and perceived and realised barriers to accessing care. The questionnaire was administered by local health workers, and data were collected electronically. RESULTS Questionnaires were completed by 285 households. Two hundred and forty-one out of 254 (94.8%) households reported being able to access Port Vila Hospital, if required. The most commonly cited potential barriers to accessing surgical care were financial constraints (42.4%) and transport (26.4%). CONCLUSION Our results provide important insights into the geographic, sociocultural and economic barriers to seeking, reaching and receiving surgical care in this region of Vanuatu. Identifying specific areas and communities with poor access to care, alongside the determinants of access, will help in designing both clinical and policy interventions to improve access to surgical care.
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Affiliation(s)
- N Bunkley
- Global Surgery Group, Department of Surgery, Faculty of Medical and Health Sciences, Surgical and Translational Research Centre, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
| | - I Bissett
- Global Surgery Group, Department of Surgery, Faculty of Medical and Health Sciences, Surgical and Translational Research Centre, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - M Buka
- Northern Provincial Hospital, Luganville, Sanma Province, Vanuatu
| | - J Bong
- Northern Provincial Hospital, Luganville, Sanma Province, Vanuatu
| | - B Leodoro
- Northern Provincial Hospital, Luganville, Sanma Province, Vanuatu
| | - A Dare
- Department of Surgery, University of Toronto, 27 King's College Circle, Toronto, ON, M5S 1A1, Canada
| | - W Perry
- Global Surgery Group, Department of Surgery, Faculty of Medical and Health Sciences, Surgical and Translational Research Centre, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
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Predicted effect of regionalised delivery care on neonatal mortality, utilisation, financial risk, and patient utility in Malawi: an agent-based modelling analysis. LANCET GLOBAL HEALTH 2020; 7:e932-e939. [PMID: 31200892 PMCID: PMC6581692 DOI: 10.1016/s2214-109x(19)30170-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 02/27/2019] [Accepted: 03/21/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Health-care regionalisation, in which selected services are concentrated in higher-level facilities, has successfully improved the quality of complex medical care. However, the effectiveness of this strategy in routine maternal care is unknown. Malawi has established a national goal of halving its neonatal mortality by 2030. In this study, we aimed to assess the effect of obstetric service regionalisation in pregnant women and their newborn babies in Malawi. METHODS In this analysis, we assessed regionalisation through the use of an agent-based simulation model. We used a previously estimated utilisation function, incorporating both patient-specific and health-facility-specific characteristics, to inform patient choice. The model was validated against known utilisation patterns in Malawi. Four regionalisation scenarios were compared with the status quo: scenario 1 restricted deliveries to facilities currently capable of providing caesarean sections; scenario 2 had the same restrictions as scenario 1, but with selected facilities upgraded to provide caesarean sections; scenario 3 restricted delivery to facilities that provided five or more basic emergency obstetric and neonatal care services in the preceding 3 months; and scenario 4 had the same restrictions as scenario 3, but with selected facilities upgraded to provide at least five basic emergency obstetric and neonatal care services. We assessed neonatal mortality, utilisation, travel distance, median out-of-pocket expenditure, and proportion of women facing catastrophic expenditure. The effects of upgrading the obstetric readiness of all facilities, of removing all user fees, and of upgrading without restriction were considered in scenario analyses. Heterogeneity and parameter uncertainty were incorporated to create 95% posterior credible intervals (PCIs). FINDINGS Scenarios restricting women to give birth in facilities with caesarean section capabilities reduced neonatal mortality by 11·4 deaths per 1000 livebirths (scenario 1; 95% PCI 9·8-13·1) and 11·6 deaths per 1000 livebirths (scenario 2; 10·2-13·1), whereas scenarios restricting women to facilities that provided five or more basic emergency obstetric and neonatal care services did not affect neonatal mortality. Similarly, the caesarean section rate in Malawi, which is 4·6% under the status quo, was predicted to rise significantly in scenario 1 (14·7%, 95% PCI 14·5-14·9; p<0·0001) and scenario 2 (10·4%, 10·2-10·6; p<0·0001), but not in scenarios 3 and 4. Women were required to travel longer distances in scenario 1 (increase of 7·2 km, 95% PCI 4·5-9·9) and in scenario 2 (4·4 km, 1·5-7·2) than in the status quo (p<0·0001). Out-of-pocket costs tripled (p<0·0001; status quo vs scenario 1 and scenario 2), and the risk of catastrophic expenditure significantly increased from a baseline of 6·4% (95% PCI 6·1-6·6) to 14·7% (14·5-14·9) in scenario 1 and 11·3% (11·0-11·5) in scenario 2. This increase was especially pronounced among the poor (p<0·0001; status quo vs scenario 1 and scenario 2). INTERPRETATION Policies restricting women to give birth in facilities with caesarean section capabilities is likely to result in significant decreases in neonatal mortality and might allow Malawi to meet its goal of halving its neonatal mortality by 2030. However, this improvement comes at the cost of increased distances to care and worsening financial risks among women. FUNDING Bill & Melinda Gates Foundation, Damon Runyon Cancer Research Foundation.
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Strader C, Ashby J, Vervoort D, Ebrahimi A, Agbortoko S, Lee M, Reiner N, Zeme M, Shrime MG. How much is enough? Exploring the dose-response relationship between cash transfers and surgical utilization in a resource-poor setting. PLoS One 2020; 15:e0232761. [PMID: 32407327 PMCID: PMC7224483 DOI: 10.1371/journal.pone.0232761] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/21/2020] [Indexed: 11/25/2022] Open
Abstract
Objective Cash transfers are a common intervention to incentivize salutary behavior in resource-constrained settings. Many cash transfer studies do not, however, account for the effect of the size of the cash transfer in design or analysis. A randomized, controlled trial of a cash-transfer intervention is planned to incentivize appropriate surgical utilization in Guinea. The aim of the current study is to determine the size of that cash transfer so as to maximize compliance while minimizing cost. Methods Data were collected from nine coastal Guinean hospitals on their surgical capabilities and the cost of receiving surgery. These data were combined with publicly available data about the general Guinean population to create an agent-based model predicting surgical utilization. The model was validated to the available literature on surgical utilization. Cash transfer sizes from 0 to 1,000,000 Guinean francs were evaluated, with surgical compliance as the primary outcome. Results Compliance with scheduled surgery increases as the size of a cash transfer increases. This increase is asymptotic, with a leveling in utilization occurring when the cash transfer pays for all the costs associated with surgical care. Below that cash transfer size, no other optima are found. Once a cash transfer completely covers the costs of surgery, other barriers to care such as distance and hospital quality dominate Conclusion Cash transfers to incentivize health-promoting behavior appear to be dose-dependent. Maximal impact is likely only to occur when full patient costs are eliminated. These findings should be incorporated in the design of future cash transfer studies.
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Affiliation(s)
- Christopher Strader
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
- Department of General Surgery, University of Massachusetts, Worcester, MA, United States of America
| | - Joanna Ashby
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
- School of Medicine, University of Glasgow, Scotland, United Kingdom
| | - Dominique Vervoort
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Aref Ebrahimi
- Joslin Diabetes Center, Harvard Medical School, Boston, MA, United States of America
| | | | - Melissa Lee
- Harvard College, Cambridge, MA, United States of America
| | - Naomi Reiner
- Harvard Graduate School of Education, Cambridge, MA, United States of America
| | - Molly Zeme
- Harvard College, Cambridge, MA, United States of America
| | - Mark G. Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
- Center for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Boston, MA, United States of America
- Center for Health and Wellbeing, Princeton University, Princeton, NJ, United States of America
- * E-mail:
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Discussion: Development and Validation of the Data Instrument for Surgical Global Outreach. Plast Reconstr Surg 2020; 145:865e-866e. [PMID: 32221242 DOI: 10.1097/prs.0000000000006701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The willingness of orthopaedic trauma patients in Uganda to accept financial loans following injury. OTA Int 2019; 2:e028. [PMID: 33937660 PMCID: PMC7997123 DOI: 10.1097/oi9.0000000000000028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/22/2018] [Indexed: 11/26/2022]
Abstract
Background: Early access to a monetary loan may mitigate some of the socioeconomic burden associated with surgical treatment and lost wages following injury. The primary objective of this study was to determine the willingness of orthopaedic trauma patients in Uganda to accept a formal financial loan shortly after their time of injury. Methods: A consecutive sample of adult orthopaedic trauma patients admitted to Uganda's national referral hospital was included in the survey. The primary outcome was the self-reported willingness to accept a financial loan. Secondary outcomes included the preferred loan terms, fracture treatment costs, and the factors associated with loan willingness. Results: Of the 40 respondents (mean age, 40 years; 58% male), the median annual income was $582 United States dollars (USD) (range: $0–$6720). Around 50% reported a willingness to accept a loan with any terms. Patients requested loans with a median principal of $500 USD and a median interest rate of 5% with 12 months to pay back. Patients had received loans with a median principal of $142 USD, an interest rate of 10%, and payback of 6 months. These received loans covered a mean of 63% of the treatment costs. Patients with higher median incomes ($857 USD vs $342 USD) were more willing to accept a loan. Conclusion: This study demonstrated a limited interest of orthopaedic trauma patients in Uganda to procure loans through formalized lending. This observed resistance must be overcome in future programs that rely on mechanisms such as conditional cash transfers or microfinancing to improve clinical and socioeconomic outcomes after injury.
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Abstract
There is a need for relevant, valid, and practical metrics to better quantify both need and progress in global pediatric surgery and for monitoring systems performance. There are several existing surgical metrics in use, including disability-adjusted life years (DALYs), surgical backlog, effective coverage, cost-effectiveness, and the Lancet Commission on Global Surgery indicators. Most of these have, however, not been yet applied to children's surgery, leaving therefore significant data gaps in the burden of disease, infrastructure, human resources, and quality of care assessments in the specialty. This chapter reviews existing global surgical metrics, identifies settings where these have been already applied to children's surgery, and highlights opportunities for further inquiry in filling the knowledge gaps. Directing focused, intentional knowledge translation efforts in the identified areas of deficiency will foster the maturation of global pediatric surgery into a solid academic discipline able to contribute directly to the cause of improving the lives of children around the world.
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Ameh EA, Butler MW. Infrastructure Expansion for Children’s Surgery: Models That are Working. World J Surg 2019; 43:1426-1434. [DOI: 10.1007/s00268-018-04894-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Barthélemy EJ, Park KB, Johnson W. Neurosurgery and Sustainable Development Goals. World Neurosurg 2018; 120:143-152. [DOI: 10.1016/j.wneu.2018.08.070] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/09/2018] [Accepted: 08/11/2018] [Indexed: 12/14/2022]
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Shrime MG, Mukhopadhyay S, Alkire BC. Health-system-adapted data envelopment analysis for decision-making in universal health coverage. Bull World Health Organ 2018; 96:393-401. [PMID: 29904222 PMCID: PMC5996217 DOI: 10.2471/blt.17.191817] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/02/2018] [Accepted: 03/05/2018] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To develop and test a method that allows an objective assessment of the value of any health policy in multiple domains. METHODS We developed a method to assist decision-makers with constrained resources and insufficient knowledge about a society's preferences to choose between policies with unequal, and at times opposing, effects on multiple outcomes. Our method extends standard data envelopment analysis to address the realities of health policy, such as multiple and adverse outcomes and a lack of information about the population's preferences over those outcomes. We made four modifications to the standard analysis: (i) treating the policy itself as the object of analysis, (ii) allowing the method to produce a rank-ordering of policies; (iii) allowing any outcome to serve as both an output and input; and (iv) allowing variable return to scale. We tested the method against three previously published analyses of health policies in low-income settings. RESULTS When applied to previous analyses, our new method performed better than traditional cost-effectiveness analysis and standard data envelopment analysis. The adapted analysis could identify the most efficient policy interventions from among any set of evaluated policies and was able to provide a rank ordering of all interventions. CONCLUSION Health-system-adapted data envelopment analysis allows any quantifiable attribute or determinant of health to be included in a calculation. It is easy to perform and, in the absence of evidence about a society's preferences among multiple policy outcomes, can provide a comprehensive method for health-policy decision-making in the era of sustainable development.
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Affiliation(s)
- Mark G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave #411, Boston, Massachusetts, 02115, United States of America (USA)
| | | | - Blake C Alkire
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave #411, Boston, Massachusetts, 02115, United States of America (USA)
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16
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Saluja S, Nwomeh B, Finlayson SRG, Holterman AL, Jawa RS, Jayaraman S, Juillard C, Krishnaswami S, Mukhopadhyay S, Rickard J, Weiser TG, Yang GP, Shrime MG. Guide to research in academic global surgery: A statement of the Society of University Surgeons Global Academic Surgery Committee. Surgery 2017; 163:463-466. [PMID: 29221877 DOI: 10.1016/j.surg.2017.10.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/09/2017] [Accepted: 10/04/2017] [Indexed: 11/15/2022]
Abstract
Global surgery is an emerging academic discipline that is developing in tandem with numerous policy and advocacy initiatives. In this regard, academic global surgery will be crucial for measuring the progress toward improving surgical care worldwide. However, as a nascent academic discipline, there must be rigorous standards for the quality of work that emerges from this field. In this white paper, which reflects the opinion of the Global Academic Surgery Committee of the Society for University Surgeons, we discuss the importance of research in global surgery, the methodologies that can be used in such research, and the challenges and benefits associated with carrying out this research. In each of these topics, we draw on existing examples from the literature to demonstrate our points. We conclude with a call for continued, high-quality research that will strengthen the discipline's academic standing and help us move toward improved access to and quality of surgical care worldwide.
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Affiliation(s)
- Saurabh Saluja
- Department of Surgery, Weill Cornell Medicine, New York, NY; Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA.
| | - Benedict Nwomeh
- Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH
| | | | - AiXuan L Holterman
- Department of Surgery, University of Illinois College of Medicine at Peoria, Peoria, IL
| | - Randeep S Jawa
- Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY
| | - Sudha Jayaraman
- VCU Program for Global Surgery, Department of Surgery, VCU School of Medicine, Richmond, VA
| | - Catherine Juillard
- Center for Global Surgical Studies, University of California, San Francisco, San Francisco, CA
| | | | - Swagoto Mukhopadhyay
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Surgery, University of Connecticut, West Hartford, CT
| | - Jennifer Rickard
- Department of Surgery and Critical Care, University of Minnesota, Minneapolis, MN
| | - Thomas G Weiser
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - George P Yang
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Mark G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA
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17
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White MC, Hamer M, Biddell J, Claus N, Randall K, Alcorn D, Parker G, Shrime MG. Facilitating access to surgical care through a decentralised case-finding strategy: experience in Madagascar. BMJ Glob Health 2017; 2:e000427. [PMID: 29071129 PMCID: PMC5640035 DOI: 10.1136/bmjgh-2017-000427] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/26/2017] [Accepted: 08/31/2017] [Indexed: 11/18/2022] Open
Abstract
Over two-thirds of the world’s population lack access to surgical care. Non-governmental organisation’s providing free surgeries may overcome financial barriers, but other barriers to care still exist. This analysis paper discusses two different case-finding strategies in Madagascar that aimed to increase the proportion of poor patients, women and those for whom multiple barriers to care exist. From October 2014 to June 2015, we used a centralised selection strategy, aiming to find 70% of patients from the port city, Toamasina, and 30% from the national capital and two remote cities. From August 2015 to June 2016, a decentralised strategy was used, aiming to find 30% of patients from Toamasina and 70% from 11 remote locations, including the capital. Demographic information and self-reported barriers to care were collected. Wealth quintile was calculated for each patient using a combination of participant responses to asset-related and demographic questions, and publicly available data. A total of 2971 patients were assessed. The change from centralised to decentralised selection resulted in significantly poorer patients undergoing surgery. All reported barriers to prior care, except for lack of transportation, were significantly more likely to be identified in the decentralised group. Patients who identified multiple barriers to prior surgical care were less likely to be from the richest quintile (p=0.037) and more likely to be in the decentralised group (p=0.046). Our country-specific analysis shows that decentralised patient selection strategies may be used to overcome barriers to care and allow patients in greatest need to access surgical care.
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Affiliation(s)
- Michelle C White
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK.,Hospital Department, Mercy Ships, Cotonou, Benin.,Hospital Department, Mercy Ships, Toamasina, Madagascar
| | - Mirjam Hamer
- Hospital Department, Mercy Ships, Toamasina, Madagascar.,Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jasmin Biddell
- Hospital Department, Mercy Ships, Toamasina, Madagascar.,Department of Emergency Care, Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia
| | - Nathan Claus
- Hospital Department, Mercy Ships, Cotonou, Benin.,Hospital Department, Mercy Ships, Toamasina, Madagascar
| | - Kirsten Randall
- Hospital Department, Mercy Ships, Cotonou, Benin.,Hospital Department, Mercy Ships, Toamasina, Madagascar
| | | | - Gary Parker
- Hospital Department, Mercy Ships, Cotonou, Benin.,Hospital Department, Mercy Ships, Toamasina, Madagascar
| | - Mark G Shrime
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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Global surgery: current evidence for improving surgical care. Curr Opin Otolaryngol Head Neck Surg 2017; 25:300-306. [DOI: 10.1097/moo.0000000000000374] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Surgical Outreach for Children by International Humanitarian Organizations: A Review. CHILDREN-BASEL 2017; 4:children4070053. [PMID: 28657589 PMCID: PMC5532545 DOI: 10.3390/children4070053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 05/17/2017] [Accepted: 06/23/2017] [Indexed: 11/17/2022]
Abstract
Low- and middle-income countries carry a disproportionate share of the global burden of pediatric surgical disease and have limited local healthcare infrastructure and human resources to address this burden. Humanitarian efforts that have improved or provided access to necessary basic or emergency surgery for children in these settings have included humanitarian assistance and disaster relief, short-term surgical missions, and long-term projects such as building pediatric specialty hospitals and provider networks. Each of these efforts may also include educational initiatives designed to increase local capacity. This article will provide an overview of pediatric humanitarian surgical outreach including reference to available evidence-based analyses of these platforms and make recommendations for surgical outreach initiatives for children.
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