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Klazura G, Wong LY, Ribeiro LLPA, Kojo Anyomih TT, Ooi RYK, Berhane Fissha A, Alam SF, Daudu D, Nyalundja AD, Beltrano J, Patil PP, Wafford QE, Rapolti DI, Sullivan GA, Graf A, Veras P, Nico E, Sheth M, Shing SR, Mathur P, Langer M. Measurements of Impoverishing and Catastrophic Surgical Health Expenditures in Low- and Middle-Income Countries and Reduction Interventions in the Last 30 Years: A Systematic Review. J Surg Res 2024; 299:163-171. [PMID: 38759332 DOI: 10.1016/j.jss.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/14/2024] [Accepted: 04/18/2024] [Indexed: 05/19/2024]
Abstract
INTRODUCTION Approximately 33 million people suffer catastrophic health expenditure (CHE) from surgery and/or anesthesia costs. The aim of this systematic review is to evaluate catastrophic and impoverishing expenditure associated with surgery and anesthesia in low- and middle-income countries (LMICs). METHODS We performed a systematic review of all studies from 1990 to 2021 that reported CHE in LMICs for treatment of a condition requiring surgical intervention, including cesarean section, trauma care, and other surgery. RESULTS 77 studies met inclusion criteria. Tertiary facilities (23.4%) were the most frequently studied facility type. Only 11.7% of studies were conducted in exclusively rural health-care settings. Almost 60% of studies were retrospective in nature. The cost of procedures ranged widely, from $26 USD for a cesarean section in Mauritania in 2020 to $74,420 for a pancreaticoduodenectomy in India in 2018. GDP per capita had a narrower range from $315 USD in Malawi in 2019 to $9955 USD in Malaysia in 2015 (Median = $1605.50, interquartile range = $1208.74). 35 studies discussed interventions to reduce cost and catastrophic expenditure. Four of those studies stated that their intervention was not successful, 18 had an unknown or equivocal effect on cost and CHE, and 13 concluded that their intervention did help reduce cost and CHE. CONCLUSIONS CHE from surgery is a worldwide problem that most acutely affects vulnerable patients in LMICs. Existing efforts are insufficient to meet the true need for affordable surgical care unless assistance for ancillary costs is given to patients and families most at risk from CHE.
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Affiliation(s)
- Greg Klazura
- University of Illinois at Chicago, Chicago, Illinois
| | - Lye-Yeng Wong
- Department of Cardiothoracic Surgery, Stanford Hospital, Stanford, California.
| | | | | | | | - Aemon Berhane Fissha
- Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
| | - Syeda Fatema Alam
- Department of Public Health, North South University, Dhaka, Bangladesh
| | - Davina Daudu
- Faculty of Surgery, University of Western Australia, Nedlands, Western Australia, Australia
| | - Arsene Daniel Nyalundja
- Faculty of Medicine, Université Catholique de Bukavu, Bukavu, South Kivu, Democratic Republic of Congo
| | | | - Poorvaprabha P Patil
- Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | | | | | - Gwyneth A Sullivan
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Akua Graf
- University of Illinois at Chicago, Chicago, Illinois
| | - Perry Veras
- Loyola Stritch School of Medicine, Maywood, Illinois
| | - Elsa Nico
- University of Illinois at Chicago, Chicago, Illinois
| | - Monica Sheth
- Loyola Stritch School of Medicine, Oak Park, Illinois
| | - Samuel R Shing
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Priyanka Mathur
- Northwestern University Feinberg School of Medicine, Chicago Illinois
| | - Monica Langer
- Lurie Children's Hospital of Chicago, Chicago, Illinois
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Balogun JA, Udayakumaran S, Collange NZ. Surgical treatment of pediatric low-grade glioma in developing countries. Childs Nerv Syst 2024:10.1007/s00381-024-06448-y. [PMID: 38709257 DOI: 10.1007/s00381-024-06448-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/01/2024] [Indexed: 05/07/2024]
Abstract
Pediatric low-grade gliomas constitute the most common brain tumors worldwide, though with some peculiarities in the presentation and surgical care in different parts of the world. The symptomatology in developing countries is likely to be over longer periods with a tendency to delayed diagnosis due to cultural, religious beliefs, manpower, and infrastructural deficits. Thus, the children present with large tumors with attendant morbidities and an increased risk of mortalities from surgery. Surgery is mainly by "general" neurosurgeons due to the paucity of trained pediatric neurosurgeons. The pre-operative imaging may be limited to anatomic MR imaging, and in some cases, CT scans, without expansive neuropsychological evaluation. The armamentarium available to the neurosurgeon may warrant large openings to access the tumor, and there may be limited possibility for intra-operative mapping of "eloquent" brain functions when this is deemed necessary. Complicating pre-operative acute hydrocephalus can result in two operations that further worsen the catastrophic spending associated with brain tumor surgeries in these climes. While these challenges appear daunting but certainly have not been enough to deter the "can do" spirit of neurosurgeons in developing countries, it is essential to strengthen the training of pediatric neurosurgeons in LMICs and provide a platform for the advocacy of better infrastructure for the surgical management of these tumors.
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Affiliation(s)
- James A Balogun
- Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria.
- Division of Neurosurgery, Department of Surgery, College of Medicine, University of Ibadan, No 1 Queen Elizabeth Road, Mokola, Ibadan, Nigeria.
| | - Suhas Udayakumaran
- Division of Paediatric Neurosurgery, Department of Neurosurgery, Amrita Institute of Medical Sciences and Research Centre, Kochi, India
| | - Nelci Z Collange
- Centro de Neurocirurgia Pediátrica (CENEPE), Pediatric Neurosurgical Center, São Paulo, Brazil
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Dau H, Nankya E, Naguti P, Basemera M, Payne BA, Vidler M, Singer J, McNair A, AboMoslim M, Smith L, Orem J, Nakisige C, Ogilvie G. The economic burden of cervical cancer on women in Uganda: Findings from a cross-sectional study conducted at two public cervical cancer clinics. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002554. [PMID: 38489259 PMCID: PMC10942052 DOI: 10.1371/journal.pgph.0002554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/25/2024] [Indexed: 03/17/2024]
Abstract
There is limited research on how a cervical cancer diagnosis financially impacts women and their families in Uganda. This analysis aimed to describe the economic impact of cervical cancer treatment, including how it differs by socio-economic status (SES) in Uganda. We conducted a cross-sectional study from September 19, 2022 to January 17, 2023. Women were recruited from the Uganda Cancer Institute and Jinja Regional Referral Hospital, and were eligible if they were ≥ of 18 years and being treated for cervical cancer. Participants completed a survey that included questions about their out-of-pocket costs, unpaid labor, and family's economic situation. A wealth index was constructed to determine their SES. Descriptive statistics were reported. Of the 338 participants, 183 were from the lower SES. Women from the lower SES were significantly more likely to be older, have ≤ primary school education, and have a more advanced stage of cervical cancer. Over 90% of participants in both groups reported paying out-of-pocket for cervical cancer. Only 15 participants stopped treatment because they could not afford it. Women of a lower SES were significantly more likely to report borrowing money (higher SES n = 47, 30.5%; lower SES n = 84, 46.4%; p-value = 0.004) and selling possessions (higher SES n = 47, 30.5%; lower SES n = 90, 49.7%; p-value = 0.006) to pay for care. Both SES groups reported a decrease in the amount of time that they spent caring for their children since their cervical cancer diagnosis (higher SES n = 34, 31.2%; lower SES n = 36, 29.8%). Regardless of their SES, women in Uganda incur out-of-pocket costs related to their cervical cancer treatment. However, there are inequities as women from the lower SES groups were more likely to borrow funds to afford treatment. Alternative payment models and further economic support could help alleviate the financial burden of cervical cancer care in Uganda.
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Affiliation(s)
- Hallie Dau
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Women’s Health Research Institute, Vancouver, British Columbia, Canada
| | | | | | - Miriam Basemera
- Cancer Unit, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Beth A. Payne
- Women’s Health Research Institute, Vancouver, British Columbia, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Advancing Health Outcomes, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Avery McNair
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Women’s Health Research Institute, Vancouver, British Columbia, Canada
| | - Maryam AboMoslim
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Women’s Health Research Institute, Vancouver, British Columbia, Canada
| | - Laurie Smith
- Women’s Health Research Institute, Vancouver, British Columbia, Canada
- BC Cancer, Vancouver, British Columbia, Canada
| | | | | | - Gina Ogilvie
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Women’s Health Research Institute, Vancouver, British Columbia, Canada
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
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Abasi U, Okello Damoi J, Turumanya Kalumuna A, Giibwa A, Park S, Cuva D, Yu AT, Emoru A, Bakaleke Binoga M, Villavisanis D, Kiani SN, Glerum K, Waye J, Marin M, Zhang L. Ambulatory Surgery Center in Rural Uganda: A Novel Approach to Providing Surgical Care. Cureus 2024; 16:e55848. [PMID: 38590474 PMCID: PMC11001256 DOI: 10.7759/cureus.55848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Despite evidence that ambulatory surgery is safe with faster recovery compared to in-patient hospitalization, surgeons in low- and middle-income countries like Uganda have been hesitant to embrace this practice. Kyabirwa Surgical Center (KSC) is the first freestanding ambulatory surgery center (ASC) in rural Uganda. We aim to report the impact of a rural ASC since its establishment, in alleviating surgically-treatable morbidity within its catchment area. METHODS KSC is located in Jinja, Uganda. The center's electronic medical record was used to analyze the utilization of services, and the Uganda Bureau of Statistics was used to calculate KSC's catchment area. Effectiveness was calculated using disability-adjusted life years (DALYs) averted. RESULTS Between July 2019 and December 2021, 7,391 patients (57.7% female, 42.3% male) visited KSC from a catchment area of 570,790 people. Of 1,355 procedures, 64.6% were general surgery, 21.3% endoscopy, 9.2% gynecological/genitourinary), 2.8% ENT, 1.5% colorectal, and 0.6% orthopedics. There were no postoperative hospital admissions for complications or mortalities. From the seven most common procedures with an associated disability weight, 2,193.16 total DALYs were averted. CONCLUSION ASCs can be effective in addressing surgical care gaps in Uganda by increasing the yearly surgical capacity of the local catchment area and averting DALYs within the population.
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Affiliation(s)
- Unwana Abasi
- Surgery, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | | | | | - So Park
- Surgery, Mount Sinai Hospital, New York, USA
| | - Dylan Cuva
- Surgery, Mount Sinai Hospital, New York, USA
| | - Allen T Yu
- Surgery, Mount Sinai Hospital, New York, USA
| | - Arthur Emoru
- Anesthesiology, Kyabirwa Surgical Center, Jinja, UGA
| | | | - Dillan Villavisanis
- Plastic and Reconstructive Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Sara N Kiani
- Surgery, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Jerome Waye
- Gastroenterology, Mount Sinai Hospital, New York, USA
| | | | - Linda Zhang
- Surgery, Mount Sinai Hospital, New York, USA
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Binde AH, Oyania F, Ullrich S, Situma M, Kotagal M, Mulogo EM. Hirschsprung disease: a cost analysis study of the direct, indirect costs and financial coping strategies for the surgical management in Western Uganda. Pediatr Surg Int 2024; 40:37. [PMID: 38252165 DOI: 10.1007/s00383-023-05571-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Surgical management of Hirschsprung disease (HD) in low- and middle-income countries is typically a staged procedure, necessitating multiple hospitalizations and clinic visits increasing family financial burden. Currently, there is limited information on the costs borne by caretakers of children with Hirschsprung disease seeking surgical intervention. This study seeks to measure the costs and economic burden of surgical treatment for Hirschsprung disease in western Uganda. METHODS A cross-sectional study using cost analysis was conducted among caretakers of patients who completed surgical treatment of HD between January 2017 and December 2021 at two hospitals in western Uganda. The average direct and indirect costs incurred by caretakers presenting at a public and private hospital were computed. RESULTS A total of 69 patients (M: F = 7:1) were enrolled in the study. The median age at diagnosis was 60.5 (IQR 3-151.25) days for children and two-staged pull-through procedure was the common surgery performed. The mean overall cost for treatment was US $960 (SD = $720), with the majority of costs coming from direct medical costs. Nearly half (48%) of participants resorted to distress financing to finance their child's surgical care. The overwhelming majority of patients (n = 64, 93%) incurred catastrophic expenditure from the total costs of surgery for HD, and 97% of participants fell below the international poverty line at the time treatment was completed. CONCLUSION Despite the availability of 'free care' from government hospital and non-profit services, this study found that surgical management of Hirschsprung disease imposed substantial cost burden on families with Hirschsprung disease patients.
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Affiliation(s)
| | - Felix Oyania
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Martin Situma
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Meera Kotagal
- Cincinnati Children's Hospital Medical Center, Cincinnati, USA
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Nabanoba C, Zakumumpa H. Experiences of membership in munno mubulwadde (your friend indeed) - a novel community-based health insurance scheme in Luwero district in rural central Uganda. BMC Health Serv Res 2024; 24:89. [PMID: 38233909 PMCID: PMC10792776 DOI: 10.1186/s12913-023-10517-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 12/21/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Community-Based Health Insurance (CBHI) schemes are recognized as an important health financing pathway to achieving universal health coverage (UHC). Although previous studies have documented CBHIs in low-income countries, the majority of these have been provider-based. Non-provider based schemes have received comparatively less empirical attention. We sought to describe a novel non-provider based CBHI munno mubulwadde (your friend indeed) comprising informal sector members in rural central Uganda to understand the structure of the scheme, the experiences of scheme members in terms of the perceived benefits and barriers to retention in the scheme. METHODS We report qualitative findings from a larger mixed-methods study. We conducted in-depth interviews with insured members (n = 18) and scheme administrators (n = 12). Four focus groups were conducted with insured members (38 participants). Data were inductively analyzed by thematic approach. RESULTS Munno mubulwadde is a union of ten CBHI schemes coordinated by one administrative structure. Members were predominantly low-income rural informal sector households who pay annual premiums ranging from $17 and $50 annually and received medical care at 13 scheme-contracted private health facilities in Luwero District in Central Uganda. Insured members reported that scheme membership protected them from catastrophic health expenditure during episodes of sickness among household members, and especially so among households with children under-five who were reported to fall sick frequently, the scheme enabled members to receive perceived better quality health care at private providers in the study district relative to the nearest public facilities. The identified barriers to retention in the scheme include inconvenient dates for premium payment that are misaligned with harvest periods for cash crops (e.g. maize corn) on which members depended for their agrarian livelihoods, long distances to insurance-contracted private providers, falling prices of cash crops which diminished real incomes and affordability of insurance premiums in successive years after initial enrolment. CONCLUSION Munno mubulwadde was perceived by as a valuable financial cushion during episodes of illness by rural informal sector households. Policy interventions for promoting price stability of cash crops in central Uganda could enhance retention of members in this non-provider CBHI which is worthy of further research as an additional funding pathway for realizing UHC in Uganda and other low-income settings.
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Affiliation(s)
- Christine Nabanoba
- Department of Social Work and Social Administration, Makerere University, Kampala, Uganda
| | - Henry Zakumumpa
- School of Public Health, Makerere University, Kampala, Uganda.
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Egas D, Rodriguez F, Jaswal A, Jeilan M, Milasinovic G, Al Fagih A. Burden of bradycardia and barriers to accessing bradycardia therapy in underserved countries. Eur Heart J Suppl 2023; 25:H1-H17. [PMID: 38046890 PMCID: PMC10689927 DOI: 10.1093/eurheartjsupp/suad125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Bradycardia, a condition characterized by an abnormally slow heart rate, poses significant challenges in terms of diagnosis and treatment. While it is a concern world-wide, low- and middle-income countries (LMICs) face substantial barriers in accessing appropriate bradycardia therapy. This article aims to explore the global aetiology and incidence of bradycardia, compare the prevalence and management of the condition in high-income countries versus LMICs, identify the key reasons behind the disparities in access to bradycardia therapy in LMICs, and emphasize the urgent need to address these disparities to ensure equitable healthcare on a global scale.
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Affiliation(s)
- Diego Egas
- Impulso Especialistas en Enfermedades Cardíacas, Department of Cardiology and Electrophysiology, Metropolitano Hospital of Quito, Ecuador, Medical Towers Metropolitano Hospital, Office 214, Quito 170135, Ecuador
- PUCE-TEC Technologies, Pontifical Catholic University of Ecuador, Quito 170143, Ecuador
| | - Francisco Rodriguez
- Impulso Especialistas en Enfermedades Cardíacas, Department of Cardiology and Electrophysiology, Metropolitano Hospital of Quito, Ecuador, Medical Towers Metropolitano Hospital, Office 214, Quito 170135, Ecuador
| | - Aparna Jaswal
- Department of Cardiac Pacing & Electropysiology, Fortis Escorts Heart Institute, New Delhi, Delhi 110025, India
| | - Mohamed Jeilan
- Section of Cardiology, Aga Khan University Hospital, Box 30270, Nairobi, Kenya
| | - Goran Milasinovic
- Referral Pacemaker Center, Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Ahmed Al Fagih
- Electrophysiology Division, Prince Sultan Cardiac Center, As Sulimaniyah, Riyadh 13213, Saudi Arabia
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Yap A, Olatunji BT, Negash S, Mweru D, Kisembo S, Masumbuko F, Ameh EA, Lebbie A, Bvulani B, Hansen E, Philipo GS, Carroll M, Hsu PJ, Bryce E, Cheung M, Fedatto M, Laverde R, Ozgediz D. Out-of-pocket costs and catastrophic healthcare expenditure for families of children requiring surgery in sub-Saharan Africa. Surgery 2023; 174:567-573. [PMID: 37385869 DOI: 10.1016/j.surg.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/04/2023] [Accepted: 05/24/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Out-of-pocket healthcare costs leading to catastrophic healthcare expenditure pose a financial threat for families of children undergoing surgery in Sub-Saharan African countries, where universal healthcare coverage is often insufficient. METHODS A prospective clinical and socioeconomic data collection tool was used in African hospitals with dedicated pediatric operating rooms installed philanthropically. Clinical data were collected via chart review and socioeconomic data from families. The primary indicator of economic burden was the proportion of families with catastrophic healthcare expenditures. Secondary indicators included the percentage who borrowed money, sold possessions, forfeited wages, and lost a job secondary to their child's surgery. Descriptive statistics and multivariate logistic regression were performed to identify predictors of catastrophic healthcare expenditure. RESULTS In all, 2,296 families of pediatric surgical patients from 6 countries were included. The median annual income was $1,000 (interquartile range 308-2,563), whereas the median out-of-pocket cost was $60 (interquartile range 26-174). Overall, 39.9% (n = 915) families incurred catastrophic healthcare expenditure, 23.3% (n = 533) borrowed money, 3.8% (n = 88%) sold possessions, 26.4% (n = 604) forfeited wages, and 2.3% (n = 52) lost a job because of the child's surgery. Catastrophic healthcare expenditure was associated with older age, emergency cases, need for transfusion, reoperation, antibiotics, and longer length of stay, whereas the subgroup analysis found insurance to be protective (odds ratio 0.22, P = .002). CONCLUSION A full 40% of families of children in sub-Saharan Africa who undergo surgery incur catastrophic healthcare expenditure, shouldering economic consequences such as forfeited wages and debt. Intensive resource utilization and reduced insurance coverage in older children may contribute to a higher likelihood of catastrophic healthcare expenditure and can be insurance targets for policymakers.
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Affiliation(s)
- Ava Yap
- Center of Health Equity in Surgery and Anesthesia, University of California San Francisco, San Francisco, CA.
| | | | - Samuel Negash
- Department of Paediatric Surgery, Menelik II Hospital, Addis Ababa, Ethiopia
| | - Dilon Mweru
- Department of Surgery, Centre Hospitalier Bethesda, Goma, Democratic Republic of Congo
| | - Steve Kisembo
- Department of Surgery, Centre Hospitalier Bethesda, Goma, Democratic Republic of Congo
| | - Franck Masumbuko
- Department of Surgery, Hôpital Provincial Général de Reférence de Bukavu, Bukavu, Democratic Republic of Congo
| | - Emmanuel A Ameh
- Department of Paediatric Surgery, National Hospital Abuja, Abuja, Nigeria
| | - Aiah Lebbie
- Department of Surgery, Connaught Hospital, Freetown, Sierra Leone
| | - Bruce Bvulani
- Department of Surgery, University Teaching Hospital, Lusaka, Zambia
| | - Eric Hansen
- Department of Surgery, Kijabe Hospital, Kijabe, Kenya
| | | | - Madeleine Carroll
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Phillip J Hsu
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Emma Bryce
- Kids Operating Room, Edinburgh, Scotland, United Kingdom; Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Maija Cheung
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Maira Fedatto
- Kids Operating Room, Edinburgh, Scotland, United Kingdom
| | - Ruth Laverde
- Center of Health Equity in Surgery and Anesthesia, University of California San Francisco, San Francisco, CA
| | - Doruk Ozgediz
- Center of Health Equity in Surgery and Anesthesia, University of California San Francisco, San Francisco, CA
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Rauschendorf P, Nume R, Bruchhausen W. Acceptability of surgical care in Uganda: a qualitative study on users and providers. BMJ Open 2023; 13:e070479. [PMID: 37524548 PMCID: PMC10391825 DOI: 10.1136/bmjopen-2022-070479] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
OBJECTIVES This study was conducted to assess acceptability of surgical care in Eastern Uganda and enable better allocation of resources, and to guide health policy towards increased surgical care seeking. DESIGN This qualitative study used semistructured in-depth interviews that were transcribed and analysed by coding according to grounded theory. SETTING The study was set in Eastern Uganda in the districts of Jinja, Mayuge, Kamuli, Iganga, Luuka, Buikwe and Buvuma. PARTICIPANTS Interviews were conducted with 32 past surgical patients, 16 community members who had not undergone surgery, 17 healthcare professionals involved in surgical treatment and 7 district health officers or their deputies. RESULTS The five intersecting categories that emerged were health literacy, perceptions, risks and fears, search for alternatives, care/treatment and trust in healthcare workers. It was also demonstrated that considering the user and provider side at the same time is very useful for a more extensive understanding of surgical care-seeking behaviour and the impact of user-provider interactions or lack thereof. CONCLUSION While affordability and accessibility are well defined and therefore easier to assess, acceptability is a much less quantifiable concept. This study breaks it down into tangible concepts in the form of five categories, which provide guidance for future interventions targeting acceptability of surgical care. We also demonstrated that multiple perspectives are beneficial to understanding the multifactorial nature of healthcare seeking and provision.
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Affiliation(s)
- Paula Rauschendorf
- Section Global Health, Institute of Hygiene and Public Health, University of Bonn, Bonn, Germany
| | - Rosette Nume
- School of Women and Gender Studies, Makerere University, Kampala, Uganda
| | - Walter Bruchhausen
- Section Global Health, Institute of Hygiene and Public Health, University of Bonn, Bonn, Germany
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Nwanna-Nzewunwa O, Agwang E, Carvalho M, Ajiko MM, Oke R, Yoon C, Diab MM, Kirya F, Marseille E, Juillard C, Dicker RA. A cost-effectiveness analysis of surgical care delivery in Eastern Uganda-a societal perspective. BMC Health Serv Res 2023; 23:256. [PMID: 36918844 PMCID: PMC10015833 DOI: 10.1186/s12913-023-09216-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/24/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND The mismatch between the global burden of surgical disease and global health funding for surgical illness exacerbates disparities in surgical care access worldwide. Amidst competing priorities, governments need to rationally allocate scarce resources to address local needs. To build an investment case for surgery, economic data on surgical care delivery is needed. This study focuses on femur fractures. METHODS This prospective cohort study at Soroti Regional Referral Hospital (SRRH), captured demographic, clinical, and cost data from all surgical inpatients and their caregivers at SRRH from February 2018 through July 2019. We performed descriptive and inferential analyses. We estimated the cost effectiveness of intramedullary nailing relative to traction for femur fractures by using primary data and making extrapolations using regional data. RESULTS Among the 546 patients, 111 (20.3%) had femur fractures and their median [IQR] length of hospitalization was 27 days [14, 36 days]. The total societal cost and Quality Adjusted Life Year (QALY) gained was USD 61,748.10 and 78.81 for femur traction and USD 23,809 and 85.47 for intramedullary nailing. Intramedullary nailing was dominant over traction of femur fractures with an Incremental Cost Effectiveness Ratio of USD 5,681.75 per QALY gained. CONCLUSION Femur fractures are the most prevalent and most expensive surgical condition at SRRH. Relative to intramedullary nailing, the use of femur traction at SRRH is not cost effective. There is a need to explore and adopt more cost-effective approaches like internal fixation.
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Affiliation(s)
- Obieze Nwanna-Nzewunwa
- Department of Surgery, Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA
| | - Esther Agwang
- Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda
| | - Melissa Carvalho
- Program for the Advancement of Surgical Equity (PASE), University of California Los Angeles, Los Angeles, CA, USA
| | | | - Rasheedat Oke
- Program for the Advancement of Surgical Equity (PASE), University of California Los Angeles, Los Angeles, CA, USA
| | - Christopher Yoon
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Mohamed M Diab
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Fred Kirya
- Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda
| | - Elliot Marseille
- Principal, Health Strategies International, 555 59th Street, Oakland, CA, USA
| | - Catherine Juillard
- Program for the Advancement of Surgical Equity (PASE), University of California Los Angeles, Los Angeles, CA, USA
| | - Rochelle A Dicker
- Program for the Advancement of Surgical Equity (PASE), University of California Los Angeles, Los Angeles, CA, USA.
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Poppens M, Oke R, Carvalho M, Ledesma Y, Okullu S, Ariokot MG, Agwang E, Ekuchu P, Wange H, Boeck M, Juillard C, Ajiko MM, Dicker R. In-Hospital Obstetric Delays in Rural Uganda: A Cross-Sectional Analysis of a Hospital Cohort. World J Surg 2023; 47:1426-1435. [PMID: 36897375 PMCID: PMC10156771 DOI: 10.1007/s00268-023-06964-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Deaths related to pregnancy and childbirth are extremely high in low-resource countries such as Uganda. Maternal mortality in low- and middle-income countries is related to delays in seeking, reaching, and receiving adequate health care. This study aimed to investigate the in-hospital delays to surgical care for women in labor arriving to Soroti Regional Referral Hospital (SRRH). METHODS From January 2017 to August 2020, we collected data on obstetric surgical patients in labor using a locally developed, context-specific obstetrics surgical registry. Data regarding patient demographics, clinical and operative characteristics, as well as delays in care and outcomes were documented. Descriptive and multivariate statistical analyses were conducted. RESULTS A total of 3189 patients were treated during our study period. Median age was 23 years, most gestations were at term (97%) at the time of operation, and nearly all patients underwent Cesarean Section (98.8%). Notably, 61.7% of patients experienced at least one delay in their surgical care at SRRH. Lack of surgical space was the greatest contributor to delay (59.9%), followed by lack of supplies or personnel. The significant independent predictors of delayed care were having a prenatal acquired infection (AOR 1.73, 95% CI 1.43-2.09) and length of symptoms less than 12 h (AOR 0.32, 95% CI 0.26-0.39) or greater than 24 h (AOR 2.61, 95% CI 2.18-3.12). CONCLUSION In rural Uganda, there is a significant need for financial investment and commitment of resources to expand surgical infrastructure and improve care for mothers and neonates.
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Affiliation(s)
- McKayla Poppens
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.,Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Rasheedat Oke
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Melissa Carvalho
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Yeranui Ledesma
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Silas Okullu
- Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda
| | | | - Esther Agwang
- Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda
| | - Peter Ekuchu
- Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda
| | - Hyginus Wange
- Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda
| | - Marissa Boeck
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Catherine Juillard
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Rochelle Dicker
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA.
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12
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Seward N, Hanlon C, Abdella A, Abrahams Z, Alem A, Araya R, Bachmann M, Bekele A, Bogale B, Brima N, Chibanda D, Curran R, Davies J, Beyene A, Fairall L, Farrant L, Frissa S, Gallagher J, Gao W, Gwyther L, Harding R, Kartha MR, Leather A, Lund C, Marx M, Nkhoma K, Murdoch J, Petersen I, Petrus R, van Rensburg A, Sandall J, Sevdalis N, Sheenan A, Tadesse A, Thornicroft G, Verhey R, Willott C, Prince M. HeAlth System StrEngThening in four sub-Saharan African countries (ASSET) to achieve high-quality, evidence-informed surgical, maternal and newborn, and primary care: protocol for pre-implementation phase studies. Glob Health Action 2022; 15:1987044. [PMID: 35037844 PMCID: PMC8765245 DOI: 10.1080/16549716.2021.1987044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 09/25/2021] [Indexed: 12/03/2022] Open
Abstract
To achieve universal health coverage, health system strengthening (HSS) is required to support the of delivery of high-quality care. The aim of the National Institute for Health Research Global Research Unit on HeAlth System StrEngThening in Sub-Saharan Africa (ASSET) is to address this need in a four-year programme, with three healthcare platforms involving eight work-packages. Key to effective health system strengthening (HSS) is the pre-implementation phase of research where efforts focus on applying participatory methods to embed the research programme within the existing health system. To conceptualise the approach, we provide an overview of the key methods applied across work-package to address this important phase of research conducted between 2017 and 2021.Work-packages are being undertaken in publicly funded health systems in rural and urban areas in Ethiopia, Sierra Leone, South Africa, and Zimbabwe. Stakeholders including patients and their caregivers, community representatives, clinicians, managers, administrators, and policymakers are the main research participants.In each work-package, initial activities engage stakeholders and build relationships to ensure co-production and ownership of HSSIs. A mixed-methods approach is then applied to understand and address determinants of high-quality care delivery. Methods such as situation analysis, cross-sectional surveys, interviews and focus group discussions are adopted to each work-package aim and context. At the end of the pre-implementation phase, findings are disseminated using focus group discussions and participatory Theory of Change workshops where stakeholders from each work package use findings to select HSSIs and develop a programme theory.ASSET places a strong emphasis of the pre-implementation phase in order to provide an in-depth and systematic diagnosis of the existing heath system functioning, needs for strengthening and stakeholder engagement. This common approach will inform the design and evaluation of the HSSIs to increase effectiveness across work packages and contexts, to better understand what works, for whom, and how.
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Affiliation(s)
- Nadine Seward
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Charlotte Hanlon
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ahmed Abdella
- Department of Obstetrics and Gynaecology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Zulfa Abrahams
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Atalay Alem
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ricardo Araya
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Max Bachmann
- Department of Population Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Alemayehu Bekele
- Department of Obstetrics and Gynaecology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Birke Bogale
- Faculty of Dentistry, Oral & Craniofacial Sciences, Centre for Host Microbiome Interactions, King’s College London, London, UK
- Department of Dentistry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Nataliya Brima
- King’s Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Dixon Chibanda
- University of Zimbabwe, Harare, Zimbabwe
- Psychology Department, School of Applied Human Science College of Humanities, University of KwaZulu Natal, London, UK
| | - Robyn Curran
- Knowledge Translation Unit, University of Cape Town Lung Institute and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Justine Davies
- Centre for Applied Health Research, University of Birmingham, Birmingham, UK
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - Andualem Beyene
- Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute and Department of Medicine, University of Cape Town, Cape Town, South Africa
- King’s Global Health Institute, King’s College London, London, UK
| | - Lindsay Farrant
- Division of Family Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Souci Frissa
- King’s Global Health Institute, King’s College London, London, UK
| | - Jennifer Gallagher
- Faculty of Dentistry, Oral & Craniofacial Sciences, Centre for Host Microbiome Interactions, King’s College London, London, UK
| | - Wei Gao
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, Cicely Saunders Institute, King’s College London, London, UK
| | - Liz Gwyther
- Division of Family Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Richard Harding
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, Cicely Saunders Institute, King’s College London, London, UK
| | | | - Andrew Leather
- King’s Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Crick Lund
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Maggie Marx
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Kennedy Nkhoma
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, Cicely Saunders Institute, King’s College London, London, UK
| | - Jamie Murdoch
- Department of Population Health Science, Kings College London, London, UK
| | - Inge Petersen
- Centre for Rural Health, University of KwaZulu-Natal, Berea, Durban, South Africa
| | - Ruwayda Petrus
- Psychology Department, School of Applied Human Science College of Humanities, University of KwaZulu Natal, Berea, Durban, South Africa
| | - André van Rensburg
- Centre for Rural Health, University of KwaZulu-Natal, Berea, Durban, South Africa
| | - Jane Sandall
- Department of Women and Children’s Health, School of Life Course Science, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Andrew Sheenan
- Department of Women and Children’s Health, School of Life Course Science, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Amezene Tadesse
- Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Graham Thornicroft
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | | | - Chris Willott
- King’s Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Martin Prince
- King’s Global Health Institute, King’s College London, London, UK
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Aye TT, Nguyen HT, Brenner S, Robyn PJ, Tapsoba LDG, Lohmann J, Allegri MD. To What Extent Do Free Healthcare Policies and Performance-Based Financing Reduce Out-of-Pocket Expenditures for Outpatient services? Evidence From a Quasi-experimental Study in Burkina Faso. Int J Health Policy Manag 2022; 12:6767. [PMID: 37579448 PMCID: PMC10125104 DOI: 10.34172/ijhpm.2022.6767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/22/2022] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Burkina Faso has been implementing financing reforms towards universal health coverage (UHC) since 2006. Recently, the country introduced a performance-based financing (PBF) program as well as user fee removal (gratuité) policy for health services aimed at pregnant and lactating women and children under 5. We aim to assess the effect of gratuité and PBF policies on facility-based out-of-pocket expenditures (OOPEs) for outpatient services. METHODS Our study is a controlled pre- and post-test design using healthcare facility data from the PBF program's impact evaluation collected in 2014 and 2017. We compared OOPE related to primary healthcare use incurred by children under 5 and individuals above 5 to assess the effect of the gratuité policy on OOPE. We further compared OOPE incurred by individuals residing in PBF districts and non-PBF districts to estimate the effect of the PBF on OOPE. Effects were estimated using difference-in-differences models, distinguishing the estimation of the probability of incurring OOPE from the estimation of the magnitude of OOPE using a generalized linear model (GLM). RESULTS The proportion of children under 5 incurring OOPE declined significantly from 90% in 2014 to 3% in 2017. Concurrently, mean OOPE also decreased. Differences in both the probability of incurring OOPE and mean OOPE between PBF and non-PBF facilities were small. Our difference in differences estimates indicated that gratuité produced an 84% (CI -86%, -81%) reduction in the probability of incurring OOPE and reduced total OOPE by 54% (CI 63%, 42%). We detected no significant effects of PBF, either in reducing the probability of incurring OOPE or in its magnitude. CONCLUSION User fee removal is an effective demand-side intervention for enhancing financial accessibility. As a supply-side intervention, PBF appears to have limited effects on reducing financial burden.
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Affiliation(s)
- Thit Thit Aye
- Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany
| | - Hoa Thi Nguyen
- Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany
| | - Stephan Brenner
- Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany
| | - Paul Jacob Robyn
- Health, Nutrition and Population Global Practice, World Bank, Washington, DC, USA
| | | | - Julia Lohmann
- Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany
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14
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Natuhwera G, Ellis P, Wilson Acuda S, Namukwaya E. Psychosocial and emotional morbidities after a diagnosis of cancer: Qualitative evidence from healthcare professional cancer patients. Nurs Open 2022; 10:2971-2982. [PMID: 36539936 PMCID: PMC10077364 DOI: 10.1002/nop2.1541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022] Open
Abstract
AIM This inquiry aimed to; (1) examine the psychosocial and emotional sequelae associated with cancer patient-hood experience in healthcare professionals (HCPs) in Uganda, (2) generate evidence to inform clinical and nursing practice about the needs of HCP patients with cancer. DESIGN This was a qualitative phenomenological study. METHODS The study was conducted among HCP cancer patients and survivors recruited from oncology and palliative care settings in Uganda. Data were collected via audio-taped, face-to-face or telephone open-ended interviews. Interviews were transcribed verbatim. Thematic analysis was used. RESULTS Eight HCP cancer patients and survivors participated in the study. Their mean age was 56 years, range 29-85 years. Three major themes emerged: (1) From a healthcare provider to a patient, (2) Socioeconomic challenges, and (3) Coping and support strategies.
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Affiliation(s)
| | - Peter Ellis
- CEO Intelligent Care Software Canterbury Christ Church University Canterbury UK
| | - Stanley Wilson Acuda
- Institute of Hospice and Palliative Care in Africa Hospice Africa Uganda Kampala Uganda
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15
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King J, Prabhakar P, Singh N, Sulaiman M, Greco G, Mounier-Jack S, Borghi J. Assessing equity of access and affordability of care among South Sudanese refugees and host communities in two districts in Uganda: a cross-sectional survey. BMC Health Serv Res 2022; 22:1165. [PMID: 36114536 PMCID: PMC9482210 DOI: 10.1186/s12913-022-08547-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background The vast majority of refugees are hosted in low and middle income countries (LMICs), which are already struggling to finance and achieve universal health coverage for their own populations. While there is mounting evidence of barriers to health care access facing refugees, there is more limited evidence on equity in access to and affordability of care across refugee and host populations. The objective of this study was to examine equity in terms of health needs, service utilisation, and health care payments both within and between South Sudanese refugees and hosts communities (Ugandan nationals), in two districts of Uganda. Methods Participants were recruited from host and refugee villages from Arua and Kiryandongo districts. Twenty host villages and 20 refugee villages were randomly selected from each district, and 30 households were sampled from each village, with a target sample size of 2400 households. The survey measured condition incidence, health care seeking and health care expenditure outcomes related to acute and chronic illness and maternal care. Equity was assessed descriptively in relation to household consumption expenditure quintiles, and using concentration indices and Kakwani indices (for expenditure outcomes). We also measured the incidence of catastrophic health expenditure- payments for healthcare and impoverishment effects of expenditure across wealth quintiles. Results There was higher health need for acute and chronic conditions in wealthier groups, while maternal care need was greater among poorer groups for refugees and hosts. Service coverage for acute, chronic and antenatal care was similar among hosts and refugee communities. However, lower levels of delivery care access for hosts remain. Although maternal care services are now largely affordable in Uganda among the studied communities, and service access is generally pro-poor, the costs of acute and chronic care can be substantial and regressive and are largely responsible for catastrophic expenditures, with service access benefiting wealthier groups. Conclusions Efforts are needed to enhance access among the poorest for acute and chronic care and reduce associated out-of-pocket payments and their impoverishing effects. Further research examining cost drivers and potential financing arrangements to offset these will be important.
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16
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Obayemi JE, Card EB, Shirima O, Premkumar A, Massawe H, Sheth NP. Hospitalized for poverty: orthopaedic discharge delays due to financial hardship in a tertiary hospital in Northern Tanzania. Glob Health Res Policy 2022; 7:31. [PMID: 36050802 PMCID: PMC9438232 DOI: 10.1186/s41256-022-00265-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 07/17/2022] [Indexed: 11/23/2022] Open
Abstract
Background Musculoskeletal injury contributes significantly to the burden of disease in Tanzania and other LMICs. For hospitals to cope financially with this burden, they often mandate that patients pay their entire hospital bill before leaving the hospital. This creates a phenomenon of patients who remain hospitalized solely due to financial hardship. This study aims to characterize the impact of this policy on patients and hospital systems in resource-limited settings. Methods A mixed-methods study using retrospective medical record review and semi-structured interviews was conducted at a tertiary hospital in Moshi, Tanzania. Information regarding patient demographics, injury type, days spent in the ward after medical clearance for discharge, and hospital invoices were collected and analyzed for orthopaedic patients treated from November 2016 to June 2017. Results 346 of the 867 orthopaedic patients (39.9%) treated during this time period were found to have spent additional days in the hospital due to their inability to pay their hospital bill. Of these patients, 72 patient charts were analyzed. These 72 patients spent an average of 9 additional days in the hospital due to financial hardship (range: 1–64 days; interquartile range: 2–10.5 days). They spent an average of 112,958 Tanzanian Shillings (TSH) to pay for services received following medical clearance for discharge, representing 12.3% of the average total bill (916,840 TSH). 646 hospital bed-days were spent on these 72 patients when they no longer clinically required hospitalization. 7 (9.7%) patients eloped from the hospital without paying and 24 (33.3%) received financial assistance from the hospital’s social welfare office. Conclusions Many patients do not have the financial capacity to pay hospital fees prior to discharge. This reality has added significantly to these patients’ overall financial hardship and has taken hundreds of bed-days from other critically ill patients. This single-institution, cross-sectional study provides a deeper understanding of this phenomenon and highlights the need for changes in the healthcare payment structure in Tanzania and other comparable settings.
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Affiliation(s)
- Joy E Obayemi
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.
| | - Elizabeth B Card
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | | | | | - Honest Massawe
- Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania
| | - Neil P Sheth
- Pennsylvania Hospital, Hospital of the University of Pennsylvania, Philadelphia, USA
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17
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Genetu A, Gezahegn D, Getachew H, Deneke A, Bekele A. Financial risk of emergency abdominal surgery: a cross sectional study from Ethiopia. BMC Health Serv Res 2022; 22:1090. [PMID: 36028811 PMCID: PMC9413941 DOI: 10.1186/s12913-022-08480-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/23/2022] [Indexed: 11/23/2022] Open
Abstract
Background The Lancet Commission on Global Surgery suggested six indicators every country should use to measure their surgical systems. One of these indicators, catastrophic expenditure (CE), is defined as money paid for service which amounts to more than 10% of the patient’s total annual expenditure, or more than 40% of annual non-food household expenditure. Ethiopian Ministry of Health has set a target of 100% protection from CE by 2030. However, so far there is lack of studies that assess financial risk of surgery. Methods Using a cross sectional study design, financial risk assessment was carried out on 142 patients from Yekatit 12 and Zewditu Memorial hospitals in Addis Ababa, Ethiopia from May 15 to September 15, 2021. Results Appendectomy (69.0%), emergency laparotomy (26.1%) and cholecystectomy (4.9%) resulted in mean direct medical expenditures of 111.7USD, 200.70USD and 224.60USD, respectively. Medications and imaging accounted for 60.8 and 13.9% of total treatment cost. By applying the two definitions of catastrophic expenditure, 67.6 and 62.7% of patients sustained CE, respectively Overall rates of CE across procedures were 67.3 and 59.1% for appendectomy, 70.2 and 70.2% for laparotomy, 57.0 and 71.2% for cholecystectomy. Thirty-five (24.6%) patients had some form of insurance, with Community Based Health Insurance being the most common form (57%). Insured patients were less likely to sustain CE with both definitions (AOR 0.09, p = 0.002 and AOR 0.10, p = 0.006 respectively). Conclusion and recommendations Substantial proportion of patients undergoing emergency abdominal surgery sustain CE in Addis Ababa. Medications and imaging take major share of total cost mainly because patients have to acquire them from private set ups. Policy makers should work on availing medications and imaging in public hospitals as well as expand insurance and other forms of surgical care financing to protect patients from CE.
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Affiliation(s)
- Abraham Genetu
- College of Health Sciences, Addis Ababa University, Zambia Street, P.O.Box 8977, Addis Ababa, Ethiopia.
| | - Demmelash Gezahegn
- College of Health Sciences, Addis Ababa University, Zambia Street, P.O.Box 8977, Addis Ababa, Ethiopia
| | - Hana Getachew
- St Paul's Millennium Medical College, Addis Ababa, Ethiopia
| | - Andualem Deneke
- College of Health Sciences, Addis Ababa University, Zambia Street, P.O.Box 8977, Addis Ababa, Ethiopia
| | - Abebe Bekele
- College of Health Sciences, Addis Ababa University, Zambia Street, P.O.Box 8977, Addis Ababa, Ethiopia.,University of Global Health Equity, Kigali, Rwanda
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18
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Katabogama JB, Mpirimbanyi C, Cyuzuzo T, Muvunyi V, Urimubabo C, Rickard J. Costs Associated With Surgical Infections at a Tertiary Referral Hospital in Rwanda. J Surg Res 2022; 280:94-102. [PMID: 35964487 DOI: 10.1016/j.jss.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 06/04/2022] [Accepted: 07/08/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION In low-income and middle-income countries, there is a high demand for surgical care, although many individuals lack access due to its affordability, availability, and accessibility. Costs are an important metric in healthcare and can influence healthcare access and outcomes. The aim of this study was to determine the financial impact of infections in acute care surgery patients and factors associated with inability to pay the hospital bill at a Rwandan referral hospital. MATERIALS AND METHODS This was a prospective observational study of acute care surgery patients at a tertiary referral hospital in Rwanda with infections. Data were collected on demographics, clinical features, hospital charges, and expenses. Factors associated with inability to pay the hospital bill were analyzed using Chi-squared and Wilcoxon rank sum tests. RESULTS Over 14 mo, 191 acute care surgery patients with infections were enrolled. Most (n = 174, 91%) patients had health insurance. Median total hospital charges were 414.24 United States Dollars (interquartile range [IQR]: 268.20, 797.48) and median patient charges were 41.53 USD (IQR: 17.15, 103.09). At discharge, 53 (28%) patients were unable to pay their hospital bill. On a univariate analysis actors associated with inability to pay the bill included transportation via ambulance, occupation as a farmer, diagnosis, complications, surgical site infection, and length of hospital stay. On a multivariable analysis, intestinal obstruction (adjusted odds ratio 4.56, 95% confidence interval 1.16, 17.95, P value 0.030) and length of hospital stay more than 7 d (adjusted odds ratio 2.95, 95% confidence interval 1.04, 8.34, P value 0.042) were associated with inability to pay the final hospital bill. CONCLUSIONS Although there is broad availability of health insurance in Rwanda, hospital charges and other expenses remain a financial burden for many patients seeking surgical care. Further innovative efforts are needed to mitigate expenses and minimize financial risk.
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Affiliation(s)
| | | | - Thierry Cyuzuzo
- University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda
| | - Vital Muvunyi
- University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda
| | - Christian Urimubabo
- University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda; Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Jennifer Rickard
- University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda; Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda; Department of Surgery, University of Minnesota, Minneapolis, Minnesota.
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19
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Koch R, Nkurunziza T, Rudolfson N, Nkurunziza J, Bakorimana L, Irasubiza H, Sonderman K, Riviello R, Hedt-Gauthier BL, Shrime M, Kateera F. Does community-based health insurance protect women from financial catastrophe after cesarean section? A prospective study from a rural hospital in Rwanda. BMC Health Serv Res 2022; 22:717. [PMID: 35642031 PMCID: PMC9153099 DOI: 10.1186/s12913-022-08101-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 05/18/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The implementation of community-based health insurance in (CBHI) in Rwanda has reduced out of pocket (OOP) spending for the > 79% of citizens who enroll in it but the effect for surgical patients is not well described. For all but the poorest citizens who are completely subsidized, the OOP (out of pocket) payment at time of service is 10%. However, 55.5% of the population is below the international poverty line meaning that even this copay can have a significant impact on a family's financial health. The aim of this study was to estimate the burden of OOP payments for cesarean sections in the context of CBHI and determine if having it reduces catastrophic health expenditure (CHE). METHODS This study is nested in a larger randomized controlled trial of women undergoing cesarean section at a district hospital in Rwanda. Eligible patients were surveyed at discharge to quantify household income and routine monthly expenditures and direct and indirect spending related to the hospitalization. This was used in conjunction with hospital billing records to calculate the rate of catastrophic expenditure by insurance group. RESULTS About 94% of the 340 women met the World Bank definition of extreme poverty. Of the 330 (97.1%) with any type of health insurance, the majority (n = 310, 91.2%) have CBHI. The average OOP expenditure for a cesarean section and hospitalization was $9.36. The average cost adding transportation to the hospital was $19.29. 164 (48.2%) had to borrow money and 43 (12.7%) had to sell possessions. The hospital bill alone was a CHE for 5.3% of patients. However, when including transportation costs, 15.4% incurred a CHE and including lost wages, 22.6%. CONCLUSION To ensure universal health coverage (UHC), essential surgical care must be affordable. Despite enrollment in universal health insurance, cesarean section still impoverishes households in rural Rwanda, the majority of whom already lie below the poverty line. Although CBHI protects against CHE from the cost of healthcare, when adding in the cost of transportation, lost wages and caregivers, cesarean section is still often a catastrophic financial event. Further innovation in financial risk protection is needed to provide equitable UHC.
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Affiliation(s)
- Rachel Koch
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.
- University of Utah, Salt Lake City, USA.
| | - Theoneste Nkurunziza
- Department for Sport and Health Sciences, Epidemiology, Technical University of Munich, Munich, Germany
| | - Niclas Rudolfson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- WHO Collaborating Centre for Surgery and Public Health, Lund University, Lund, Sweden
| | | | | | | | - Kristin Sonderman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
| | - Robert Riviello
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Bethany L Hedt-Gauthier
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Mark Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Center for Global Surgery Evaluation, Boston, USA
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Padovany MM, Patterson RH, Bowder AN, O'Brien E, Alkire BC, Katz AM, Mitnick CD, Lu C. Impact of out-of-pocket expenses for surgical care on households in rural Haiti: a mixed-methods study. BMJ Open 2022; 12:e061731. [PMID: 35613787 PMCID: PMC9125749 DOI: 10.1136/bmjopen-2022-061731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/06/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES This study aimed to report household catastrophic spending on surgery and the experiences of patients and families seeking surgical care in rural Haiti. DESIGN The study used an explanatory, sequential mixed-methods approach. We collected both quantitative and qualitative data from the participants through interviews. SETTING A rural tertiary hospital (St. Boniface Hospital) in southern Haiti. PARTICIPANTS There were 200 adult Haitian surgical patients who entered the study. Of these, 41 were excluded due to missing variables or health expenditure outliers. The final sample included 159 participants. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcomes were (1) direct and indirect payments for surgical care; (2) the rate of catastrophic health expenditure (CHE) (as defined by the Sustainable Development Goals (10% of total household expenditure) and WHO (10%, 20%, 30% and 40% of household capacity to pay)) due to surgical care; and (3) common themes across the lived experiences of households of surgical patients seeking care. RESULTS The median household expenditure on surgery-related expenses was US$385.6, slightly more than half of per capita gross domestic product in Haiti (US$729.3). Up to 86% of households experienced CHE, as defined by the Sustainable Development Goals, due to receiving surgical care. Patients commonly paid for surgical costs through loans and donations (69.8%). The qualitative analysis revealed prominent themes related to barriers to care including the burden of initiating care-seeking, care-seeking journeys and social suffering. CONCLUSIONS CHE is common for Haitian surgical patients, and the associated care-seeking experiences are often arduous. These findings suggest that low, flat fees in non-profit hospital settings may not be sufficient to mitigate the costs of surgical care or the resulting challenges that patients experience.
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Affiliation(s)
| | - Rolvix H Patterson
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alexis N Bowder
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Eva O'Brien
- University of Miami Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Blake C Alkire
- Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Arlene M Katz
- Department of Global Health & Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Carole D Mitnick
- Department of Global Health & Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Chunling Lu
- Department of Global Health & Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, MA, USA
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Franke MA, Ranaivoson RM, Rebaliha M, Rasoarimanana S, Bärnighausen T, Knauss S, Emmrich JV. Direct patient costs of maternal care and birth-related complications at faith-based hospitals in Madagascar: a secondary analysis of programme data using patient invoices. BMJ Open 2022; 12:e053823. [PMID: 35459664 PMCID: PMC9036443 DOI: 10.1136/bmjopen-2021-053823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES We aimed to determine the rate of catastrophic health expenditure incurred by women using maternal healthcare services at faith-based hospitals in Madagascar. DESIGN This was a secondary analysis of programmatic data obtained from a non-governmental organisation. SETTING Two faith-based, secondary-level hospitals located in rural communities in southern Madagascar. PARTICIPANTS All women using maternal healthcare services at the study hospitals between 1 March 2019 and 7 September 2020 were included (n=957 women). MEASURES We collected patient invoices and medical records of all participants. We then calculated the rate of catastrophic health expenditure relative to 10% and 25% of average annual household consumption in the study region. RESULTS Overall, we found a high rate of catastrophic health expenditure (10% threshold: 486/890, 54.6%; 25% threshold: 366/890, 41.1%). Almost all women who required surgical care, most commonly a caesarean section, incurred catastrophic health expenditure (10% threshold: 279/280, 99.6%; 25% threshold: 279/280, 99.6%). The rate of catastrophic health expenditure among women delivering spontaneously was 5.7% (14/247; 10% threshold). CONCLUSIONS Our findings suggest that direct patient costs of managing pregnancy and birth-related complications at faith-based hospitals are likely to cause catastrophic health expenditure. Financial risk protection strategies for reducing out-of-pocket payments for maternal healthcare should include faith-based hospitals to improve health-seeking behaviour and ultimately achieve universal health coverage in Madagascar.
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Affiliation(s)
- Mara Anna Franke
- Charité Global Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | - Till Bärnighausen
- Medical Faculty, University of Heidelberg, Institute of Global Health, Heidelberg, Germany
- University of Heidelberg, University Hospital, Heidelberg, Germany
- Department of Global Health and Population, Chan School of Public Health, Boston, Massachusetts, USA
- Africa Health Research Institute, Somkhele and Durban, South Africa
| | - Samuel Knauss
- Charité Global Health, Charité Universitätsmedizin Berlin, Berlin, Germany
- University of Heidelberg, University Hospital, Heidelberg, Germany
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Julius Valentin Emmrich
- Charité Global Health, Charité Universitätsmedizin Berlin, Berlin, Germany
- University of Heidelberg, University Hospital, Heidelberg, Germany
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
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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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Vahwere BM, Sikakulya FK, Ssebuufu R, Jorge S, Okedi XF, Abdullah S, Kyamanywa P. 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. Pan Afr Med J 2021; 39:139. [PMID: 34527155 PMCID: PMC8418158 DOI: 10.11604/pamj.2021.39.139.24667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 05/27/2021] [Indexed: 11/28/2022] Open
Abstract
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 1st July 2019 to 31st 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.
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Affiliation(s)
| | - Franck Katembo Sikakulya
- Department of Surgery, Kampala International University, Kampala, Uganda.,Faculty of Medicine, Catholic University of Graben, Butembo, Democratic Republic of Congo
| | - Robinson Ssebuufu
- Department of Surgery, Kampala International University, Kampala, Uganda
| | - Soria Jorge
- Department of Surgery, Kampala International University, Kampala, Uganda
| | | | - Shaban Abdullah
- Department of Surgery, Kampala International University, Kampala, Uganda
| | - Patrick Kyamanywa
- Department of Surgery, Kampala International University, Kampala, Uganda
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Ferraris KP, Yap MEC, Bautista MCG, Wardhana DPW, Maliawan S, Wirawan IMA, Rosyidi RM, Seng K, Navarro JE. Financial Risk Protection for Neurosurgical Care in Indonesia and the Philippines: A Primer on Health Financing for the Global Neurosurgeon. Front Surg 2021; 8:690851. [PMID: 34568413 PMCID: PMC8461295 DOI: 10.3389/fsurg.2021.690851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022] Open
Abstract
Which conditions treated by neurosurgeons cause the worst economic hardship in low middle-income in countries? How can public health financing be responsive to the inequities in the delivery of neurosurgical care? This review article frames the objectives of equity, quality, and efficiency in health financing to the goals of global neurosurgery. In order to glean provider perspectives on the affordability of neurosurgical care in low-resource settings, we did a survey of neurosurgeons from Indonesia and the Philippines and identified that the care of socioeconomically disadvantaged patients with malignant intracranial tumors were found to incur the highest out-of-pocket expenses. Additionally, the surveyed neurosurgeons also observed that treatment of traumatic brain injury may have to require greater financial subsidies. It is therefore imperative to frame health financing alongside the goals of equity, efficiency, and quality of neurosurgical care for the impoverished. Using principles and perspectives from managerial economics and public health, we conceptualize an implementation framework that addresses both the supply and demand sides of healthcare provision as applied to neurosurgery. For the supply side, strategic purchasing enables a systematic and contractual management of payment arrangements that provide performance-based economic incentives for providers. For the demand side, conditional cash transfers similarly leverages on financial incentives on the part of patients to reward certain health-seeking behaviors that significantly influence clinical outcomes. These health financing strategies are formulated in order to ultimately build neurosurgical capacity in LMICs, improve access to care for patients, and ensure financial risk protection.
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Affiliation(s)
- Kevin Paul Ferraris
- Section of Neurosurgery, Department of Surgery, Jose R. Reyes Memorial Medical Center, Manila, Philippines
- Department of Surgery, Las Piñas General Hospital and Satellite Trauma Center, Las Piñas, Philippines
| | | | - Maria Cristina G. Bautista
- Department of Economics, Finance and Accounting, Graduate School of Business, Ateneo de Manila University, Makati, Philippines
| | - Dewa Putu Wisnu Wardhana
- Faculty of Medicine, Division of Neurosurgery, Department of Surgery, Udayana University Hospital, Udayana University, Bali, Indonesia
| | - Sri Maliawan
- Faculty of Medicine, Division of Neurosurgery, Department of Surgery, Sanglah General Hospital, Udayana University, Bali, Indonesia
| | - I Made Ady Wirawan
- Faculty of Medicine, Department of Public Health, Udayana University, Bali, Indonesia
| | - Rohadi Muhammad Rosyidi
- Faculty of Medicine, Department of Neurosurgery, West Nusa Tenggara Province Hospital, Mataram University, Mataram, Indonesia
| | - Kenny Seng
- Section of Neurosurgery, Department of Surgery, Jose R. Reyes Memorial Medical Center, Manila, Philippines
- Division of Neurosurgery, Department of Neurosciences, University of the Philippines–Philippine General Hospital, University of the Philippines College of Medicine, Manila, Philippines
| | - Joseph Erroll Navarro
- Section of Neurosurgery, Department of Surgery, Jose R. Reyes Memorial Medical Center, Manila, Philippines
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Ferraris KP, Palabyab EPM, Kim S, Matsumura H, Yap MEC, Cloma-Rosales VO, Letyagin G, Muroi A, Baticulon RE, Alcazaren JC, Seng K, Navarro JE. Global Surgery Indicators and Pediatric Hydrocephalus: A Multicenter Cross-Country Comparative Study Building the Case for Health System Strengthening. Front Surg 2021; 8:704346. [PMID: 34513913 PMCID: PMC8428174 DOI: 10.3389/fsurg.2021.704346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/29/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: The aim of this study is to compare specific three-institution, cross-country data that are relevant to the Global Surgery indicators and the functioning of health systems. Methods: We retrospectively reviewed the clinical and socioeconomic characteristics of pediatric patients who underwent cerebrospinal fluid (CSF) diversion surgery for hydrocephalus in three different centers: the University of Tsukuba Hospital in Ibaraki, Japan (HIC), the Jose R. Reyes Memorial Medical Center in Manila, Philippines [low-to-middle-income country (LMIC)], and the Federal Neurosurgical Center in Novosibirsk, Russia (UMIC). The outcomes of interest were the timing of CSF diversion surgery and mortality. Statistical tests included descriptive statistics, Cox proportional hazards model, and logistic regression. Nation-level data were also obtained to provide the relevant socioeconomic contexts in discussing the results. Results: In total, 159 children were included, where 13 are from Japan, 99 are from the Philippines, and 47 are from the Russian Federation. The median time to surgery at the specific neurosurgical centers was 6 days in the Philippines and 1 day in both Japan and Russia. For the cohort from the Philippines, non-poor patients were more likely to receive CSF diversion surgery at an earlier time (HR = 4.74, 95% CI 2.34-9.61, p <0.001). In the same center, those with infantile or posthemorrhagic hydrocephalus (HR = 3.72, 95% CI 1.70-8.15, p = 0.001) were more likely to receive CSF diversion earlier compared to those with congenital hydrocephalus, and those with postinfectious (HR = 0.39, 95% CI 0.22-0.70, p = 0.002) or myelomeningocele-associated hydrocephalus (HR = 0.46, 95% CI 0.22-0.95, p = 0.037) were less likely to undergo surgery at an earlier time. For Russia, older patients were more likely to receive or require early CSF diversion (HR = 1.07, 95% CI 1.01-1.14, p = 0.035). External ventricular drain (EVD) insertion was found to be associated with mortality (cOR 14.45, 95% CI 1.28-162.97, p = 0.031). Conclusion: In this study, Filipino children underwent late time-interval of CSF diversion surgery and had mortality differences compared to their Japanese and Russian counterparts. These disparities may reflect on the functioning of the health systems of respective countries.
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Affiliation(s)
- Kevin Paul Ferraris
- Section of Neurosurgery, Department of Surgery, Jose R. Reyes Memorial Medical Center, Manila, Philippines
| | - Eric Paolo M. Palabyab
- Section of Neurosurgery, Department of Surgery, Jose R. Reyes Memorial Medical Center, Manila, Philippines
| | - Sergei Kim
- Department of Pediatric Neurosurgery, Federal Neurosurgical Center of Ministry of Public Health, Novosibirsk, Russia
| | - Hideaki Matsumura
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | | | | | - German Letyagin
- Department of Pediatric Neurosurgery, Federal Neurosurgical Center of Ministry of Public Health, Novosibirsk, Russia
| | - Ai Muroi
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Ronnie E. Baticulon
- Section of Neurosurgery, Department of Surgery, Jose R. Reyes Memorial Medical Center, Manila, Philippines
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines, Manila, Philippines
| | - Jose Carlos Alcazaren
- Section of Neurosurgery, Department of Surgery, Jose R. Reyes Memorial Medical Center, Manila, Philippines
| | - Kenny Seng
- Section of Neurosurgery, Department of Surgery, Jose R. Reyes Memorial Medical Center, Manila, Philippines
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines, Manila, Philippines
| | - Joseph Erroll Navarro
- Section of Neurosurgery, Department of Surgery, Jose R. Reyes Memorial Medical Center, Manila, Philippines
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Okullo GO, Flores MJ, Peck CJ, Socci AR, Kisitu DK. Adverse events in the treatment of motorcycle-related isolated limb injuries at a regional hospital in Uganda: a prospective clinical analysis. INTERNATIONAL ORTHOPAEDICS 2021; 46:71-77. [PMID: 34296324 DOI: 10.1007/s00264-021-05060-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 04/23/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Although motorcycle accidents are a leading cause of limb injury in Uganda, little is known about injury care quality at regional hospitals. This study measured the incidence of clinical adverse events (CAEs) and identified associated treatment barriers surrounding motorcycle-related isolated limb injuries at a regional hospital. METHODS A prospective descriptive study was conducted among patients with motorcycle-related isolated limb injuries at a Ugandan regional hospital between September 2017 and February 2018. Patients were surveyed upon admission and monitored throughout their course of treatment. Weight-bearing status and quality of life measures (EQ-5D) were assessed at four and 12 weeks. RESULTS One hundred twenty-four participants enrolled. Of the total participants, 12% refused definitive treatment. Among 108 treated patients, six experienced CAEs: four wound infections, one amputation, and one death. At 12 weeks follow-up, the majority of patients had no difficulty with mobility, pain/discomfort, or self-care, but 51% endorsed challenges completing certain daily chores, and 40% of patients could ambulate without an assistive device with restoration of pre-fracture gait. Both longer hospital stays and poorer 12-week functional recovery were seen among patients sustaining open fracture (p < 0.001). CONCLUSION Treatment of isolated limb injuries at a Ugandan Regional Hospital was associated with minimal short-term CAEs. However, patients with more severe injuries may be at risk for delayed post-operative recovery. Future studies measuring long-term functional outcomes should be performed to better understand and optimize injury care in this population.
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Affiliation(s)
- Geoffrey O Okullo
- Department of Surgery, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Michael J Flores
- Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Connor J Peck
- Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Adrienne R Socci
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06520, USA
| | - Daniel K Kisitu
- Department of Surgery, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda.
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Nwanna-Nzewunwa O, Oke R, Agwang E, Ajiko MM, Yoon C, Carvalho M, Kirya F, Marseille E, Dicker RA. The societal cost and economic impact of surgical care on patients' households in rural Uganda; a mixed method study. BMC Health Serv Res 2021; 21:568. [PMID: 34107950 PMCID: PMC8190862 DOI: 10.1186/s12913-021-06579-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background The epidemiology and cost of surgical care delivery in low-and middle-income countries (LMICs) is poorly understood. This study characterizes the cost of surgical care, rate of catastrophic medical expenditure and medical impoverishment, and impact of surgical hospitalization on patients’ households at Soroti Regional Referral Hospital (SRRH), Uganda. Methods We prospectively collected demographic, clinical, and cost data from all surgical inpatients and caregivers at SRRH between February 2018 and January 2019. We conducted and thematically analyzed qualitative interviews to discern the impact of hospitalization on patients’ households. We employed the chi-square, t-test, ANOVA, and Bonferroni tests and built regression models to identify predictors of societal cost of surgical care. Out of pocket spending (OOPS) and catastrophic expenses were determined. Results We encountered 546 patients, mostly male (62%) peasant farmers (42%), at a median age of 22 years; and 615 caregivers, typically married (87%), female (69%), at a median age of 35 years. Femur fractures (20.4%), soft tissue infections (12.3%), and non-femur fractures (11.9%) were commonest. The total societal cost of surgical care was USD 147,378 with femur fractures (USD 47,879), intestinal obstruction (USD 18,737) and non-femur fractures (USD 10,212) as the leading contributors. Procedures (40%) and supplies (12%) were the largest components of societal cost. About 29% of patients suffered catastrophic expenses and 31% were medically impoverished. Conclusion Despite free care, surgical conditions cause catastrophic expenses and impoverishment in Uganda. Femur fracture is the most expensive surgical condition due to prolonged hospitalization associated with traction immobilization and lack of treatment modalities with shorter hospitalization. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06579-x.
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Affiliation(s)
- Obieze Nwanna-Nzewunwa
- Department of Surgery, Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA
| | - Rasheedat Oke
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Esther Agwang
- Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda
| | | | - Christopher Yoon
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Melissa Carvalho
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Fred Kirya
- Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda
| | - Elliot Marseille
- Principal, Health Strategies International, Oakland, California, USA
| | - Rochelle A Dicker
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, CA, 90095, USA.
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Huang Y, Mian Q, Conradi N, Opoka RO, Conroy AL, Namasopo S, Hawkes MT. Estimated Cost-effectiveness of Solar-Powered Oxygen Delivery for Pneumonia in Young Children in Low-Resource Settings. JAMA Netw Open 2021; 4:e2114686. [PMID: 34165579 PMCID: PMC8226423 DOI: 10.1001/jamanetworkopen.2021.14686] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
IMPORTANCE Pneumonia is the leading cause of childhood mortality worldwide. Severe pneumonia associated with hypoxemia requires oxygen therapy; however, access remains unreliable in low- and middle-income countries. Solar-powered oxygen delivery (solar-powered O2) has been shown to be a safe and effective technology for delivering medical oxygen. Examining the cost-effectiveness of this innovation is critical for guiding implementation in low-resource settings. OBJECTIVE To determine the cost-effectiveness of solar-powered O2 for treating children in low-resource settings with severe pneumonia who require oxygen therapy. DESIGN, SETTING, AND PARTICIPANTS An economic evaluation study of solar-powered O2 was conducted from January 12, 2020, to February 27, 2021, in compliance with the World Health Organization Choosing Interventions That Are Cost-Effective (WHO-CHOICE) guidelines. Using existing literature, plausible ranges for component costs of solar-powered O2 were determined in order to calculate the expected total cost of implementation. The costs of implementing solar-powered O2 at a single health facility in low- and middle-income countries was analyzed for pediatric patients younger than 5 years who required supplemental oxygen. EXPOSURES Treatment with solar-powered O2. MAIN OUTCOMES AND MEASURES The incremental cost-effectiveness ratio (ICER) of solar-powered O2 was calculated as the additional cost per disability-adjusted life-year (DALY) saved. Sensitivity of the ICER to uncertainties of input parameters was assessed through univariate and probabilistic sensitivity analyses. RESULTS The ICER of solar-powered O2 was estimated to be $20 (US dollars) per DALY saved (95% CI, $2.83-$206) relative to the null case (no oxygen). Costs of solar-powered O2 were alternatively quantified as $26 per patient treated and $542 per life saved. Univariate sensitivity analysis found that the ICER was most sensitive to the volume of pediatric pneumonia admissions and the case fatality rate. The ICER was insensitive to component costs of solar-powered O2 systems. In secondary analyses, solar-powered O2 was cost-effective relative to grid-powered concentrators (ICER $140 per DALY saved) and cost-saving relative to fuel generator-powered concentrators (cost saving of $7120). CONCLUSIONS AND RELEVANCE The results of this economic evaluation suggest that solar-powered O2 is a cost-effective solution for treating hypoxemia in young children in low- and middle-income countries, relative to no oxygen. Future implementation should prioritize sites with high rates of pediatric pneumonia admissions and mortality. This study provides economic support for expansion of solar-powered O2 and further assessment of its efficacy and mortality benefit.
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Affiliation(s)
| | - Qaasim Mian
- University of Alberta, Edmonton, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Nicholas Conradi
- University of Alberta, Edmonton, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, Kampala, Uganda
| | - Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis
| | - Sophie Namasopo
- Department of Paediatrics, Kabale District Hospital, Kabale, Uganda
| | - Michael T. Hawkes
- University of Alberta, Edmonton, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Canada
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, Canada
- University of Alberta School of Public Health, Edmonton, Canada
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Platt E, Doe M, Kim NE, Chirengendure B, Musonda P, Kaja S, Grimes CE. Economic impact of surgery on households and individuals in low income countries: A systematic review. Int J Surg 2021; 90:105956. [PMID: 33940199 DOI: 10.1016/j.ijsu.2021.105956] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/01/2021] [Accepted: 04/22/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Surgical disease in Low Income Countries (LIC) is common, and overall provision of surgical care is poor. A key component of surgical health systems as part of universal health coverage (UHC) is financial risk protection (FRP) - the need to protect individuals from financial hardship due to accessing healthcare. We performed a systematic review to amalgamate current understanding of the economic impact of surgery on the individual and household. Our study was registered on Research registry (www.researchregistry.com). METHODS We searched Pubmed and Medline for articles addressing economic aspects of surgical disease/care in low income countries. Data analysis was descriptive in light of a wide range of methodologies and reporting measures. Quality assessment and risk of bias analysis was performed using study design specific Joanna-Briggs Institute checklists. This study has been reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines. RESULTS 31 full text papers were identified for inclusion; 22 descriptive cross-sectional studies, 4 qualitative studies and 5 economic analysis studies of varying quality. Direct medical, direct non-medical and indirect costs were variably reported but were substantial, resulting in catastrophic expenditure. Costs had far reaching economic impacts on individuals and households, who used entire savings, took out loans, reduced essential expenditure and removed children from school to meet costs. CONCLUSION Seeking healthcare for surgical disease is economically devastating for individuals and households in LICs. Policies directed at strengthening surgical health systems must seek ways to reduce financial hardship on individuals and households from both direct and indirect costs and these should be monitored and measured using defined instruments from the patient perspective.
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Affiliation(s)
- Esther Platt
- Imperial College Healthcare NHS Trust, South Wharf Road, Paddington, W2 INY, UK.
| | | | | | - Bright Chirengendure
- Consultant General Surgeon, Ndola Teaching Hospital, Zambia; Copperbelt Medical University, Zambia.
| | - Patrick Musonda
- Consultant General Surgeon, Ndola Teaching Hospital, Zambia.
| | - Simba Kaja
- Consultant Orthopaedic Surgeon, Ndola Teaching Hospital, Zambia.
| | - Caris E Grimes
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, SE5 9RJ, UK; Medway NHS Foundation Trust, Windmill Road, Gillingham, Kent, ME7 5NY, UK.
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Phull M, Grimes CE, Kamara TB, Wurie H, Leather AJM, Davies J. What is the financial burden to patients of accessing surgical care in Sierra Leone? A cross-sectional survey of catastrophic and impoverishing expenditure. BMJ Open 2021; 11:e039049. [PMID: 34006018 PMCID: PMC7942261 DOI: 10.1136/bmjopen-2020-039049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To measure the financial burden associated with accessing surgical care in Sierra Leone. DESIGN A cross-sectional survey conducted with patients at the time of discharge from tertiary-level care. This captured demographics, yearly household expenditure, direct medical, direct non-medical and indirect costs for surgical care, and summary household assets. Missing data were imputed. SETTING The main tertiary-level hospital in Freetown, Sierra Leone. PARTICIPANTS 335 surgical patients under the care of the hospital surgical team receiving operative or non-operative surgical care on the surgical wards. OUTCOME MEASURES Rates of catastrophic expenditure (a cost >10% of annual expenditure), impoverishment (being pushed into, or further into, poverty as a result of surgical care costs), amount of out-of-pocket (OOP) costs and means used to meet these costs were derived. RESULTS Of 335 patients interviewed, 39% were female and 80% were urban dwellers. Median yearly household expenditure was US$3569. Mean OOP costs were US$243, of which a mean of US$24 (10%) was spent prehospital. Of costs incurred during the hospital admission, direct medical costs were US$138 (63%) and US$34 (16%) were direct non-medical costs. US$46 (21%) were indirect costs. Catastrophic expenditure affected 18% of those interviewed. Concerning impoverishment, 45% of patients were already below the national poverty line prior to admission, and 9% of those who were not were pushed below the poverty line following payment for surgical care. 84% of patients used household savings to meet OOP costs. Only 2% (six patients) had health insurance. CONCLUSION Obtaining surgical care has substantial economic impacts on households that pushes them into poverty or further into poverty. The much-needed scaling up of surgical care needs to be accompanied by financial risk protection.
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Affiliation(s)
- Manraj Phull
- Department of Surgery, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | - Caris E Grimes
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Surgery, Medway NHS Foundation Trust, Gillingham, UK
| | - Thaim B Kamara
- Department of Surgery, University of Sierra Leone College of Medicine and Allied Health Sciences, Freetown, Sierra Leone
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Andy J M Leather
- King's Centre for Global Health, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Justine Davies
- Centre of Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Nakaganda A, Solt K, Kwagonza L, Driscoll D, Kampi R, Orem J. Challenges faced by cancer patients in Uganda: Implications for health systems strengthening in resource limited settings. J Cancer Policy 2021; 27:100263. [DOI: 10.1016/j.jcpo.2020.100263] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/04/2020] [Accepted: 11/18/2020] [Indexed: 12/24/2022]
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Stewart BT, Gyedu A, Goodman SK, Boakye G, Scott JW, Donkor P, Mock C. Injured and broke: The impacts of the Ghana National Health Insurance Scheme (NHIS) on service delivery and catastrophic health expenditure among seriously injured children. Afr J Emerg Med 2021; 11:144-151. [PMID: 33680736 PMCID: PMC7910164 DOI: 10.1016/j.afjem.2020.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/28/2020] [Accepted: 09/21/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction Ghana implemented a National Health Insurance Scheme (NHIS) in 2003 as a step toward universal health coverage. We aimed to determine the effect of the NHIS on timeliness of care, mortality, and catastrophic health expenditure (CHE) among children with serious injuries at a trauma center in Ghana. Methods We performed a retrospective cohort study of injured children aged <18 years who required surgery (i.e., proxy for serious injury) at Komfo Anokye Teaching Hospital from 2015 to 2016. Household income data was obtained from the Ghana Statistical Service. CHE was defined as out-of-pocket payments to annual household income ≥10%. Differences in insured and uninsured children were described. Multivariable regression was used to assess the effect of NHIS on time to surgery, length of stay, in-hospital mortality, out-of-pocket expenditure and CHE. Results Of the 263 children who met inclusion criteria, 70% were insured. Mechanism of injury, triage scores and Kampala Trauma Score II were similar in both groups (all p > 0.10). Uninsured children were more likely to have a delay in care for financial reasons (17.3 vs 6.4%, p < 0.001) than insured children, and the families of uninsured children paid a median of 1.7 times more out-of-pocket costs than families with insured children (p < 0.001). Eighty-six percent of families of uninsured children experienced CHE compared to 54% of families of insured children (p < 0.001); however, 64% of all families experienced CHE. Insurance was protective against CHE (aOR 0.21, 95%CI 0.08–0.55). Conclusions NHIS did not improve timeliness of care, length of stay or mortality. Although NHIS did provide some financial risk protection for families, it did not eliminate out-of-pocket payments. The families of most seriously injured children experienced CHE, regardless of insurance status. NHIS and similar financial risk pooling schemes could be strengthened to better provide financial risk protection and promote quality of care for injured children. Despite strides toward universal health coverage with the National Health Insurance Scheme (NHIS) in Ghana, one third of injured children did not have insurance. Families on uninsured injured children pay markedly more out-of-pocket costs than families of insured children. Although families of uninsured children were more likely to experience catastrophic health expenditure (CHE), CHE was commonly experienced regardless of insurance. These findings have useful implications for NHIS, agencies working toward universal health coverage, and trauma systems generally.
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Okoroh JS, Riviello R. Challenges in healthcare financing for surgery in sub-Saharan Africa. Pan Afr Med J 2021; 38:198. [PMID: 33995804 PMCID: PMC8106793 DOI: 10.11604/pamj.2021.38.198.27115] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/05/2021] [Indexed: 01/14/2023] Open
Abstract
One-third of the global burden of disease is attributed to surgical conditions yet, 5 billion people globally, lack access to surgery. The Lancet Commission on Global Surgery, Obstetrics, and Anesthesia (LCOGS) published guidelines for improving access by reducing catastrophic health expenditures (CHEs) by 2030. This is especially important in sub-Saharan Africa (SSA) where 90% of the extreme poor reside. In this paper, we provide a narrative review of four studies on CHEs for surgical care in SSA published since 2015. We discuss healthcare financing in the countries and summarize the authors’ key findings of out-of-pocket payments (OOP) and CHEs. Briefly, the studies enrolled 130 to 300 patients and collected direct OOPs via chart review of health costs or patient interviews. Indirect costs were calculated from lost wages and transportation costs. CHEs were defined as health costs exceeding 10% of the GDP per capita or the household income. Despite healthcare being reported as free in all studies, 60%-90% of surgical patients had CHEs with all costs considered. OOPs persists for medicines and anesthesia that should be covered under any health insurance scheme. In some cases, indirect costs associated with transportation and wages were major drivers of CHEs for surgery. Without addressing these gaps in coverage, more people will risk impoverishment in seeking surgical care in SSA.
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Affiliation(s)
- Juliet Siena Okoroh
- University of Alabama, Department of Surgery, Birmingham, Alabama, United States of America
| | - Robert Riviello
- Brigham and Women´s Hospital, Division of Trauma, Burn, Surgical Critical Care, Boston, Massachusetts, United States of America
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Cesarean delivery in low- and middle-income countries: A review of quality of care metrics and targets for improvement. Semin Fetal Neonatal Med 2021; 26:101199. [PMID: 33546999 PMCID: PMC8026747 DOI: 10.1016/j.siny.2021.101199] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Improving quality of care in low-and middle-income countries (LMICs) is a global priority, specifically around maternal and newborn care, where mortality and morbidity remain unacceptably high. Cesarean delivery is the most common procedure in women, thus evaluating quality around the provision of this intervention provides insight into overall quality of care around childbirth. In this review we provide an overview on the quality of care around cesarean delivery using the six domains of quality proposed by the Institute of Medicine: equity, effectiveness, efficiency, safety, timeliness and patient-centered care. We review evidence of potential quality gaps in each of these domains around cesarean delivery in LMICs, discuss opportunities for improvement and provide suggestions on metrics for tracking quality in each of these domains. As cesarean delivery rates increase globally, efforts to ensure quality will be essential to drive continued and sustained improvements in global maternal and newborn outcomes.
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Dahir S, Cotache-Condor CF, Concepcion T, Mohamed M, Poenaru D, Adan Ismail E, Leather AJM, Rice HE, Smith ER. Interpreting the Lancet surgical indicators in Somaliland: a cross-sectional study. BMJ Open 2020; 10:e042968. [PMID: 33376180 PMCID: PMC7778782 DOI: 10.1136/bmjopen-2020-042968] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The unmet burden of surgical care is high in low-income and middle-income countries. The Lancet Commission on Global Surgery (LCoGS) proposed six indicators to guide the development of national plans for improving and monitoring access to essential surgical care. This study aimed to characterise the Somaliland surgical health system according to the LCoGS indicators and provide recommendations for next-step interventions. METHODS In this cross-sectional nationwide study, the WHO's Surgical Assessment Tool-Hospital Walkthrough and geographical mapping were used for data collection at 15 surgically capable hospitals. LCoGS indicators for preparedness was defined as access to timely surgery and specialist surgical workforce density (surgeons, anaesthesiologists and obstetricians/SAO), delivery was defined as surgical volume, and impact was defined as protection against impoverishment and catastrophic expenditure. Indicators were compared with the LCoGS goals and were stratified by region. RESULTS The healthcare system in Somaliland does not meet any of the six LCoGS targets for preparedness, delivery or impact. We estimate that only 19% of the population has timely access to essential surgery, less than the LCoGS goal of 80% coverage. The number of specialist SAO providers is 0.8 per 100 000, compared with an LCoGS goal of 20 SAO per 100 000. Surgical volume is 368 procedures per 100 000 people, while the LCoGS goal is 5000 procedures per 100 000. Protection against impoverishing expenditures was only 18% and against catastrophic expenditures 1%, both far below the LCoGS goal of 100% protection. CONCLUSION We found several gaps in the surgical system in Somaliland using the LCoGS indicators and target goals. These metrics provide a broad view of current status and gaps in surgical care, and can be used as benchmarks of progress towards universal health coverage for the provision of safe, affordable, and timely surgical, obstetric and anaesthesia care in Somaliland.
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Affiliation(s)
- Shukri Dahir
- Edna Adan University Hospital, Hargeisa, Somaliland
| | | | - Tessa Concepcion
- Global Health Institute, Duke University, Durham, North Carolina, USA
| | | | - Dan Poenaru
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, McGill University, Montreal, Québec, Canada
| | | | - Andy J M Leather
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - Henry E Rice
- Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Emily R Smith
- Department of Public Health, Baylor University, Waco, Texas, USA
- Global Health Institute, Duke University, Durham, North Carolina, USA
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Farrow NE, Commander SJ, Reed CR, Mueller JL, Gupta A, Loh AHP, Sekabira J, Fitzgerald TN. Laparoscopic experience and attitudes toward a low-cost laparoscopic system among surgeons in East, Central, and Southern Africa: a survey study. Surg Endosc 2020; 35:6539-6548. [PMID: 33201314 DOI: 10.1007/s00464-020-08151-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/04/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Laparoscopic surgery has become standard of care in high-income countries but is rarely accessible in low- and middle-income countries (LMICs). This study assessed experience with laparoscopy and attitudes toward a low-cost laparoscopic system among surgeons in sub-Saharan Africa. METHODS A survey assessing current laparoscopic practice and feedback on a low-cost laparoscopic system was administered to attendees of the College of Surgeons of East, Central, and Southern Africa (COSECSA) Scientific Conference between December 4 and December 6, 2019 in Kampala, Uganda. RESULTS Fifty-six surgeons from 14 countries participated. A majority were male (n = 46, 82%) general surgeons (n = 37, 66%) from tertiary/teaching hospitals (n = 36, 64%). For those with training in laparoscopy (n = 33, 59%), 22 (67%) reported less than 1 year of training and over half (n = 17, 52%) reported 1 month or less. Overall, a minority (n = 21, 38%) used laparoscopy in current practice, with 57% (n = 12) of those performing laparoscopy less than once per week. The most common laparoscopic surgeries performed were cholecystectomy (n = 15), diagnostic laparoscopy (n = 14), and appendectomy (n = 12). Few surgeons were performing more complex cases (n = 5). Barriers to laparoscopy included poor access to training equipment (n = 34, 61%), mentors (n = 33, 59%), laparoscopic equipment (n = 31, 55%), equipment maintenance (n = 25, 45%), access to consumable supplies (n = 21, 38%), and cost (n = 31, 55%). Fifty-two participants (93%) were interested in increasing their use of laparoscopy; the majority felt that a low-cost laparoscope (n = 52, 93%) and lift retractor for gasless laparoscopy (n = 46, 82%) would serve an unmet need in their practice. CONCLUSIONS While the use of laparoscopy is currently limited in COSECSA countries, there is a significant interest among surgeons to increase implementation. A low-cost, durable laparoscopic system was viewed as a potential solution to the current barriers and could improve implementation in LMICs.
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Affiliation(s)
- Norma E Farrow
- Department of Surgery, DUMC, Duke University, Box 3815, Durham, NC, 27710, USA
| | - Sarah J Commander
- Department of Surgery, DUMC, Duke University, Box 3815, Durham, NC, 27710, USA
| | - Christopher R Reed
- Department of Surgery, DUMC, Duke University, Box 3815, Durham, NC, 27710, USA
| | - Jenna L Mueller
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Aryaman Gupta
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Amos H P Loh
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore.,Duke NUS Medical School, SingHealth Duke NUS Global Health Institute, Singapore, Singapore
| | - John Sekabira
- Pediatric Surgery Unit, Mulago Hospital, Kampala, Uganda
| | - Tamara N Fitzgerald
- Department of Surgery, DUMC, Duke University, Box 3815, Durham, NC, 27710, USA. .,Duke Global Health Institute, Duke University, Durham, NC, USA.
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Gyedu A, Goodman SK, Katz M, Quansah R, Stewart BT, Donkor P, Mock C. National health insurance and surgical care for injured people, Ghana. Bull World Health Organ 2020; 98:869-877. [PMID: 33293747 PMCID: PMC7716100 DOI: 10.2471/blt.20.255315] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 11/27/2022] Open
Abstract
Objective To determine the association between having government health insurance and the timeliness and outcome of care, and catastrophic health expenditure in injured patients requiring surgery at a tertiary hospital in Ghana. Methods We reviewed the medical records of injured patients who required surgery at Komfo Anokye Teaching Hospital in 2015-2016 and extracted data on sociodemographic and injury characteristics, outcomes and out-of-pocket payments. We defined catastrophic health expenditure as ≥ 10% of the ratio of patients' out-of-pocket payments to household annual income. We used multivariable regression analyses to assess the association between having insurance through the national health insurance scheme compared with no insurance and time to surgery, in-hospital mortality and experience of catastrophic health expenditure, adjusted for potentially confounding variables. Findings Of 1396 patients included in our study, 834 (60%) were insured through the national health insurance scheme. Time to surgery and mortality were not statistically different between insured and uninsured patients. Insured patients made smaller median out-of-pocket payments (309 United States dollars, US$) than uninsured patients (US$ 503; P < 0.001). Overall, 45% (443/993) of patients faced catastrophic health expenditure. A smaller proportion of insured patients (33%, 184/558) experienced catastrophic health expenditure than uninsured patients (60%, 259/435; P < 0.001). Insurance through the national health insurance scheme reduced the likelihood of catastrophic health expenditure (adjusted odds ratio: 0.27; 95% confidence interval: 0.20 to 0.35). Conclusion The national health insurance scheme needs strengthening to provide better financial risk protection and improve quality of care for patients presenting with injuries that require surgery.
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, KNUST School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Postal Mail Bag, University Campus, Kumasi, Ghana
| | | | - Micah Katz
- Department of Surgery, University of Utah, Salt Lake City, USA
| | - Robert Quansah
- Department of Surgery, KNUST School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Postal Mail Bag, University Campus, Kumasi, Ghana
| | | | - Peter Donkor
- Department of Surgery, KNUST School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Postal Mail Bag, University Campus, Kumasi, Ghana
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, USA
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Nataraja RM, Yin Mar Oo, Andolfatto L, Moore EM, Watters D, Aye Aye, Htun Oo, Moe Moe Tin, Shrime M, McLeod E. Analysis of Financial Risk Protection Indicators in Myanmar for Paediatric Surgery. World J Surg 2020; 44:3986-3992. [PMID: 32920705 DOI: 10.1007/s00268-020-05775-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To estimate proportion of Myanmar paediatric population at risk of impoverishment and catastrophic expenditure due to emergency surgical intervention. METHODS Prospective data were collected at two tertiary surgical centres including income, household expenses, expenses related to surgery. Data analysis was performed to estimate out-of-pocket (OOP) direct medical costs and OOP total costs. Catastrophic expenditure: expense exceeded 10% of household income. Risk of impoverishment: net income drops were below an impoverishment threshold (PPP-purchasing power parity): I$ 2.00 PPP/day, I$ 1.25/day PPP, national poverty line. Distribution of income was estimated using a gamma distribution. Comparison to an adult cohort was performed using Chi-square test with a p value of <0.05 being significant. RESULTS A total of 145 surveys were collected, and 119 (82.1%) contained sufficient data: Paediatric Centre (n = 99) and Adult Centre (n = 20). Overall average per patient direct medical and non-medical OOP costs was I$493: Centre 1: I$540 PPP (range I$41-6,588 PPP) and Centre 2: I$437 PPP (range I$ 36-1,405 PPP). 64% experienced catastrophic expense. There is no significant difference between the centres in the risks of impoverishment or catastrophic expenditure (p = 0.05). Up to 44% are at risk of catastrophic expenditure should surgery be required. Most of the risk (90%) is derived from direct non-medical costs. A high proportion were at the national poverty line threshold (36.1%). Seeking surgical treatment would imperil up to 37% at the national poverty line threshold, and up to 5.7% at the I$2 PPP per day limit. CONCLUSIONS A large proportion of the Myanmar population are at risk of impoverishment or catastrophic expenditure should they require surgery. Financial risk protection mechanisms are needed.
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Affiliation(s)
- Ramesh Mark Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, 246 Clayton Road, Clayton, Melbourne, 3168, Australia. .,Departments of Paediatrics & Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.
| | - Yin Mar Oo
- Department of Paediatric Surgery, Yangon Children's Hospital, Yangon, Myanmar
| | - Lilly Andolfatto
- The Faculty of Medicine, Dentistry and Health Sciences, Melbourne University, Melbourne, Australia
| | - Eileen M Moore
- Department of General Surgery, Barwon Health, Geelong, Australia.,Department of General Surgery, Deakin University, Geelong, Australia
| | - David Watters
- Department of General Surgery, Barwon Health, Geelong, Australia.,Department of General Surgery, Deakin University, Geelong, Australia
| | - Aye Aye
- Department of Paediatric Surgery, Yangon Children's Hospital, Yangon, Myanmar
| | - Htun Oo
- Department of ENT Surgery, NOGH, Yangon, Myanmar
| | - Moe Moe Tin
- Department of General Surgery, North Okkalapa General Hospital, Yangon, Myanmar
| | - Mark Shrime
- Center for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Boston, USA.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Center for Health and Well-Being, Princeton University, Princeton, USA
| | - Elizabeth McLeod
- Department of Paediatric Surgery, Monash Children's Hospital, 246 Clayton Road, Clayton, Melbourne, 3168, Australia
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Prevalence, Indications, and Community Perceptions of Caesarean Section Delivery in Ngora District, Eastern Uganda: Mixed Method Study. Obstet Gynecol Int 2020; 2020:5036260. [PMID: 32765611 PMCID: PMC7387994 DOI: 10.1155/2020/5036260] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/19/2020] [Indexed: 11/20/2022] Open
Abstract
Background Uganda has a high maternal mortality ratio (MMR) of 336/100,000 live births. Caesarean section is fundamental in achieving equity and equality in emergency obstetric care services. Despite it being a lifesaving intervention, it is associated with risks. There has been a surge in caesarean section rates in some areas, yet others remain underserved. Studies have shown that rates exceeding 15% do not improve maternal and neonatal morbidity and mortality. Our study aimed at determining the prevalence, indications, and community perceptions of caesarean section delivery in Eastern Uganda. Methods and Materials It was both health facility and commuity based cross-sectional descriptive study in Ngora district, Eastern Uganda. Mixed methods of data collection were employed in which quantitative data were collected by retrospectively reviewing all charts of all the mothers that had delivered at the two comprehensive emergency obstetric care service facilities between April 2018 and March 2019. Qualitative data were collected by focus group discussions till point of saturation. Data were entered into EpiData (version 3.1) and analyzed using SPSS software (version 24). Qualitative data analysis was done by transcribing and translating into English verbatim and then analyzed into themes and subthemes with the help of NVIVO 12. Results Of the total 2573 deliveries, 14% (357/2573) were by CS. The major single indications were obstructed labour 17.9%, fetal distress 15.3%, big baby 11.6%, and cephalopelvic disproportion (CPD) 11%. Although appreciated as lifesaving for young mothers, those with diseases and recurrent intrauterine fetal demise, others considered CS a curse, marriage-breaker, misfortune, money-maker and a sign of incompetent health workers, and being for the lazy women and the rich civil servants. The rise was also attributed to intramuscular injections and contraceptive use. Overall, vaginal delivery was the preferred route. Conclusion Several misconceptions that could hinder access to CS were found which calls for more counseling and male involvement. Although facility based, the rate is higher than the desired 5–15%. It is higher than the projected increase of 36% by 2021. It highlights the need for male involvement during counseling and consent for CS and concerted efforts to demystify community misconceptions about women that undergo CS. These misconceptions may be a hindrance to access to CS.
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Kakama AA, Namyalo PK, Basaza RK. Feasibility and desirability of scaling up Community-based Health Insurance (CBHI) in rural communities in Uganda: lessons from Kisiizi Hospital CBHI scheme. BMC Health Serv Res 2020; 20:662. [PMID: 32680506 PMCID: PMC7367343 DOI: 10.1186/s12913-020-05525-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/09/2020] [Indexed: 12/03/2022] Open
Abstract
Background Community-based Health Insurance (CBHI) schemes have been implemented world over as initial steps for national health insurance schemes. The CBHI concept developed out of a need for financial protection against catastrophic health expenditures to the poor after failure of other health financing mechanisms. CBHI schemes reduce out-of-pocket payments, and improve access to healthcare services in addition to raising additional revenue for the health sector. Kisiizi Hospital CBHI scheme which was incepted in 1996, has 41,500 registered members, organised in 210 community associations known as ‘Bataka’ or ‘Engozi’ societies. Members pay annual premiums and a co-payment fee before service utilisation. This study aimed at exploring the feasibility and desirability of scaling up CBHI in Rubabo County, with specific objectives of: exploring community perceptions and determining acceptability of CBHI, identifying barriers, enablers to scaling up CBHI and documenting lessons regarding CBHI expansion in a rural community. Methods Explorative study using qualitative methods of Key informant interviews and Focus Group Discussions (FGDs). Seventeen key informant interviews, three focus group discussions for scheme members and three for non-scheme members were conducted using a topic guide. Data was analysed using thematic approach. Results Scaling up Kisiizi Hospital CBHI is desirable because: it conforms to the government social protection agenda, society values, offers a comprehensive benefits package, and is a better healthcare financing alternative for many households. Scaling up Kisiizi Hospital CBHI is largely feasible because of a strong network of community associations, trusted quality healthcare services at Kisiizi Hospital, affordable insurance fees, trusted leadership and management systems. Scheme expansion faces some obstacles that include: long distances and high transport costs to Kisiizi Hospital, low levels of knowledge about health insurance, overlapping financial priorities at household level and inability of some households to pay premiums. Conclusions CBHI implementation requires the following considerations: conformity with society values and government priorities, a comprehensive benefits package, trusted quality of healthcare services, affordable fees, trusted leadership and management systems.
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Affiliation(s)
- Alex A Kakama
- Kisiizi Hospital Community-based Health Insurance Scheme, Kisiizi Hospital, Kabale, Uganda
| | - Prossy K Namyalo
- Department of Social Sciences, Ndejje University, Kampala, Uganda
| | - Robert K Basaza
- Gudie Incubation Centre, Kira Municipality, Uganda. .,Uganda Christian University Mukono, Masters of Public Health Leadership Program, Mukono, Uganda.
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Arivoli M, Biswas A, Burroughs N, Wilson P, Salzman C, Kakembo N, Mugaga J, Ssekitoleko RT, Saterbak A, Fitzgerald TN. Multidisciplinary Development of a Low-Cost Gastroschisis Silo for Use in Sub-Saharan Africa. J Surg Res 2020; 255:565-574. [PMID: 32645490 DOI: 10.1016/j.jss.2020.05.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/01/2020] [Accepted: 05/03/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Gastroschisis silos are often unavailable in sub-Saharan Africa (SSA), contributing to high mortality. We describe a collaboration between engineers and surgeons in the United States and Uganda to develop a silo from locally available materials. METHODS Design criteria included the following: < $5 cost, 5 ± 0.25 cm opening diameter, deformability of the opening construct, ≥ 500 mL volume, ≥ 30 N tensile strength, no statistical difference in the leakage rate between the low-cost silo and preformed silo, ease of manufacturing, and reusability. Pugh scoring matrices were used to assess designs. Materials considered included the following: urine collection bags, intravenous bags, or zipper storage bags for the silo and female condom rings or O-rings for the silo opening construct. Silos were assembled with clothing irons and sewn with thread. Colleagues in Uganda, Malawi, Tanzania, and Kenya investigated material cost and availability. RESULTS Urine collection bags and female condom rings were chosen as the most accessible materials. Silos were estimated to cost < $1 in SSA. Silos yielded a diameter of 5.01 ± 0.11 cm and a volume of 675 ± 7 mL. The iron + sewn seal, sewn seal, and ironed seal on the silos yielded tensile strengths of 31.1 ± 5.3 N, 30.1 ± 2.9 N, and 14.7 ± 2.4 N, respectively, compared with the seal of the current standard-of-care silo of 41.8 ± 6.1 N. The low-cost silos had comparable leakage rates along the opening and along the seal with the spring-loaded preformed silo. The silos were easily constructed by biomedical engineering students within 15 min. All silos were able to be sterilized by submersion. CONCLUSIONS A low-cost gastroschisis silo was constructed from materials locally available in SSA. Further in vivo and clinical studies are needed to determine if mortality can be improved with this design.
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Affiliation(s)
| | - Arushi Biswas
- Pratt School of Engineering, Duke University, Durham, North Carolina
| | - Nolan Burroughs
- Pratt School of Engineering, Duke University, Durham, North Carolina
| | - Patrick Wilson
- Pratt School of Engineering, Duke University, Durham, North Carolina
| | - Caroline Salzman
- Pratt School of Engineering, Duke University, Durham, North Carolina
| | - Nasser Kakembo
- Department of Surgery, Makerere University, Kampala, Uganda
| | - Julius Mugaga
- Makerere University College of Health Sciences, Kampala, Uganda; Duke-Makerere University Biomedical Engineering Partnership, Durham, North Carolina and Kampala, Uganda
| | - Robert T Ssekitoleko
- Makerere University College of Health Sciences, Kampala, Uganda; Duke-Makerere University Biomedical Engineering Partnership, Durham, North Carolina and Kampala, Uganda
| | - Ann Saterbak
- Pratt School of Engineering, Duke University, Durham, North Carolina; Duke-Makerere University Biomedical Engineering Partnership, Durham, North Carolina and Kampala, Uganda
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University, Durham, North Carolina; Duke Global Health Institute, Duke University, Durham, North Carolina.
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O'Donovan J, Namanda AS, Hamala R, Winters N, Bhutta MF. Exploring perceptions, barriers, and enablers for delivery of primary ear and hearing care by community health workers: a photovoice study in Mukono District, Uganda. Int J Equity Health 2020; 19:62. [PMID: 32381090 PMCID: PMC7203865 DOI: 10.1186/s12939-020-01158-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 03/09/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Hearing loss is a prevalent but neglected disease, especially in low- or middle-income countries. The role of Community Health Workers (CHWs) to deliver primary ear and hearing care has been explored in several studies from a technical standpoint, but understanding perceptions, barriers, and enablers of such an approach from the perspective of CHWs themselves through a health equity lens has been less well documented. METHODS This qualitative study used photovoice to explore the views and experiences of CHWs in the Seeta Nazigo Parish of Mukono District in the delivery of ear and hearing care in the community. CHWs were trained in ear and hearing care, and provided with digital cameras to capture photographs related to their work in the community over the following 3 months. Individual interviews regarding the photographs were held at the end of each month, in addition to one focus group discussion. A community workshop was convened at the end of the study to display the photos. Thematic analysis of photographs was conducted using Braune and Clarkes six-step framework. We also used the data to explore potential roles for key stakeholders in primary ear and hearing care, and how photovoice may facilitate their engagement. RESULTS 13 CHWs participated in the study. Several themes were generated from analysis. CHWs perceived a high burden of ear and hearing disorders in their community and recognised the role they could play in tackling that burden. Potential barriers identified included a lack of equipment, training, and supervision of CHWs; logistical, financial, or psychological barriers to community participation; and the widespread use of traditional medicine. CHWs identified roles for the government and NGO bodies to enable and support delivery of ear and hearing care in the community. The community workshop was a useful method to engage key stakeholders in this topic. CONCLUSIONS Photovoice is a powerful method to capture issues affecting CHWs. Here it was used to identify a number of perceptions, barriers and enablers to the delivery of ear and hearing care. Our results may inform future strategy in the field of ear and hearing care, and the potential use of photovoice to enact sociocultural change.
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Affiliation(s)
- James O'Donovan
- Department of Education, The University of Oxford, Norham Gardens, Oxford, OX2 6PS, UK.
- Division of Research and Health Equity, Omni Med Uganda, Makata, Mukono District, Mukono, Uganda.
| | - Allan S Namanda
- Division of Research and Health Equity, Omni Med Uganda, Makata, Mukono District, Mukono, Uganda
| | - Rebecca Hamala
- Division of Research and Health Equity, Omni Med Uganda, Makata, Mukono District, Mukono, Uganda
| | - Niall Winters
- Department of Education, The University of Oxford, Norham Gardens, Oxford, OX2 6PS, UK
| | - Mahmood F Bhutta
- Department of ENT, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Roa L, Citron I, Ramos JA, Correia J, Feghali B, Amundson JR, Saluja S, Alonso N, Vaz Ferreira R. Cross-sectional study of surgical quality with a novel evidence-based tool for low-resource settings. BMJ Open Qual 2020; 9:e000880. [PMID: 32188740 PMCID: PMC7078697 DOI: 10.1136/bmjoq-2019-000880] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/14/2020] [Accepted: 02/07/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Adverse events from surgical care are a major cause of death and disability, particularly in low-and-middle-income countries. Metrics for quality of surgical care developed in high-income settings are resource-intensive and inappropriate in most lower resource settings. The purpose of this study was to apply and assess the feasibility of a new tool to measure surgical quality in resource-constrained settings. METHODS This is a cross-sectional study of surgical quality using a novel evidence-based tool for quality measurement in low-resource settings. The tool was adapted for use at a tertiary hospital in Amazonas, Brazil resulting in 14 metrics of quality of care. Nine metrics were collected prospectively during a 4-week period, while five were collected retrospectively from the hospital administrative data and operating room logbooks. RESULTS 183 surgeries were observed, 125 patient questionnaires were administered and patient charts for 1 year were reviewed. All metrics were successfully collected. The study site met the proposed targets for timely process (7 hours from admission to surgery) and effective outcome (3% readmission rate). Other indicators results were equitable structure (1.1 median patient income to catchment population) and equitable outcome (2.5% at risk of catastrophic expenditure), safe outcome (2.6% perioperative mortality rate) and effective structure (fully qualified surgeon present 98% of cases). CONCLUSION It is feasible to apply a novel surgical quality measurement tool in resource-limited settings. Prospective collection of all metrics integrated within existing hospital structures is recommended. Further applications of the tool will allow the metrics and targets to be refined and weighted to better guide surgical quality improvement measures.
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Affiliation(s)
- Lina Roa
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Isabelle Citron
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jania A Ramos
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jessica Correia
- Department of General Surgery, Universidade do Estado do Amazonas, Manaus, Amazonas, Brazil
| | - Berenice Feghali
- Department of General Surgery, Universidade do Estado do Amazonas, Manaus, Amazonas, Brazil
| | - Julia R Amundson
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Saurabh Saluja
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Nivaldo Alonso
- Department of Plastic Surgery, Universidade de Sao Paulo Hospital das Clinicas, Sao Paulo, São Paulo, Brazil
| | - Rodrigo Vaz Ferreira
- Department of General Surgery, Universidade do Estado do Amazonas, Manaus, Amazonas, Brazil
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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
Investing in surgery has been highlighted as integral to strengthening overall health systems and increasing economic prosperity in low-income and middle-income countries (LMICs). The provision of surgical care in LMICs not only affects economies on a macro-level, but also impacts individual families within communities at a microeconomic level. Given that children represent 50% of the population in LMICs and the burden of unmet surgical needs in these areas is high, investing pediatric-specific components of surgical and anesthesia care is needed. Implementation efforts for pediatric surgical care include incorporating surgery-specific priorities into the global child health initiatives, improving global health financing for scale-up activities for children, increasing financial risk protection mechanisms for families of children with surgical needs, and including comprehensive pediatric surgical models of care into country-level plans.
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Rajaguru PP, Jusabani MA, Massawe H, Temu R, Sheth NP. 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. Glob Health Res Policy 2019; 4:30. [PMID: 31673630 PMCID: PMC6816166 DOI: 10.1186/s41256-019-0122-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 10/01/2019] [Indexed: 11/10/2022] Open
Abstract
Background Access to surgical care in Low- and Middle-Income Countries (LMICs) such as Tanzania is extremely limited. Northern Tanzania is served by a single tertiary referral hospital, Kilimanjaro Christian Medical Centre (KCMC). The surgical volumes, workflow, and payment mechanisms in this region have not been characterized. Understanding these factors is critical in expanding access to healthcare. The authors sought to evaluate the operations and financing of the main operating theaters at KCMC in Sub-Saharan Africa. Methods The 2018 case volume and specialty distribution (general, orthopaedic, and gynecology) in the main operating theaters at KCMC was retrieved through retrospective review of operating report books. Detailed workflow (i.e. planned and cancelled cases, lengths of procedures, lengths of operating days) and financing data (patient payment methods) from the five KCMC operating theater logs were retrospectively reviewed for the available five-month period of March 2018 to July 2018. Descriptive statistics and statistical analysis were performed. Results In 2018, the main operating theaters at KCMC performed 3817 total procedures, with elective procedures (2385) outnumbering emergency procedures (1432). General surgery (1927) was the most operated specialty, followed by orthopaedics (1371) and gynecology (519). In the five-month subset analysis period, just 54.6% of planned operating days were fully completed. There were 238 cancellations (20.8% of planned operations). Time constraints (31.1%, 74 cases) was the largest reason; lack of patient payment accounted for as many cancellations as unavailable equipment (6.3%, 15 cases each). Financing for elective theater cases included insurance 45.5% (418 patients), and cash 48.4% (445 patients). Conclusion While surgical volume is high, there are non-physical inefficiencies in the system that can be addressed to reduce cancellations and improve capacity. Improving physical resources is not enough to improve access to care in this region, and likely in many LMIC settings. Patient financing and workflow will be critical considerations to truly improve access to surgical care.
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Affiliation(s)
- Praveen Paul Rajaguru
- 1Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA USA
| | | | - Honest Massawe
- Department of Orthopaedic Surgery, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Rogers Temu
- Department of Orthopaedic Surgery, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Neil Perry Sheth
- 3Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA USA
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Bijlmakers L, Wientjes M, Mwapasa G, Cornelissen D, Borgstein E, Broekhuizen H, Brugha R, Gajewski J. Out-of-pocket payments and catastrophic household expenditure to access essential surgery in Malawi - A cross-sectional patient survey. Ann Med Surg (Lond) 2019; 43:85-90. [PMID: 31304010 PMCID: PMC6580231 DOI: 10.1016/j.amsu.2019.06.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/31/2019] [Accepted: 06/02/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Having to pay out-of-pocket for health care can be prohibitive and even cause financial catastrophe for patients, especially those with low and irregular incomes. Health services at Government-owned hospitals in Malawi are provided free of charge but patients do incur costs when they access facilities and some of them forego income. This research paper presents findings on the direct and indirect expenditure incurred by patients who underwent hernia surgery at district and central hospitals in Malawi. It reports the main cost drivers, how costs relate to patients' household incomes, the financial burden of undergoing surgery and the extent to which hernia patients had recovered and restored their capacity to work and earn an income. MATERIALS AND METHODS Using a cross-sectional study design, surveys were held with patients who had undergone hernia surgery in four district and two central hospitals in Malawi. Interviews were conducted by surgically trained clinical officers, trained in survey administration, and included, inter alia, questions about patients' hospital stay, the direct and indirect cost they incurred in accessing surgery, and how they financed the expenditure. Follow-up interviews by telephone were held 8-10 weeks after discharge. RESULTS The sample included 137 patients from district and 86 patients from central hospitals. The main direct cost drivers were transport and food & groceries. More than three quarters of patients who had their surgery at a district hospital incurred indirect costs, because of income lost due to hospital admission, compared with just over a third among central hospital patients. Median reported income losses were US$ 90 and US$ 71, respectively. Catastrophic expenditure for surgery occurred in 94% of district and 87% of central hospital patients. When indirect costs are added to the out-of-pocket expenditure, it constituted more than 10% of the monthly per capita income for 97% and 90% of the district and central hospital patients, respectively. CONCLUSION Out-of-pocket household expenditure associated with essential surgery in Malawi is high and in many instances catastrophic, putting households, especially those who are already poor, at risk of further impoverishment. The much needed scaling-up of surgical services in rural areas of Malawi needs to be accompanied by financial risk protection measures.
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Affiliation(s)
- Leon Bijlmakers
- Radboud University Medical Centre Netherlands, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, the Netherlands
| | - Maike Wientjes
- Radboud University Medical Centre Netherlands, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, the Netherlands
| | - Gerald Mwapasa
- College of Medicine, Malawi, Mahatma Gandhi, Blantyre, Malawi
| | - Dennis Cornelissen
- Radboud University Medical Centre Netherlands, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, the Netherlands
| | - Eric Borgstein
- College of Medicine, Malawi, Mahatma Gandhi, Blantyre, Malawi
| | - Henk Broekhuizen
- Radboud University Medical Centre Netherlands, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, the Netherlands
| | - Ruairi Brugha
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland
| | - Jakub Gajewski
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland
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Kayima P, Kitya D, Punchak M, Anderson GA, Situma M. Patterns and treatment outcomes of anorectal malformations in Mbarara Regional Referral Hospital, Uganda. J Pediatr Surg 2019; 54:838-844. [PMID: 30153942 DOI: 10.1016/j.jpedsurg.2018.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/23/2018] [Accepted: 07/26/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND/PURPOSE Anorectal malformation (ARM) is a common condition. Owing to scarcity of pediatric surgery services in Uganda, however, relatively little is known about this condition. METHODS This was a retrospective review of medical records of all patients admitted to Mbarara Regional Referral Hospital (MRRH) from January 2014 to May 2016. MRRH serves 3-8 million people in southwest Uganda. We also enrolled patients prospectively from June 2016 to December 2016. RESULTS 78 patients were enrolled in the study. 63.38% had delayed diagnosis (presenting >48 h after birth), and most of these were self-referrals from home. The most common malformation was a vestibular fistula. Associated congenital anomalies were seen in 20% of patients, and this was associated with increased mortality. These anomalies included limb, eye, ear and genitourinary anomalies as well as ventricular septal defects, patent ductus arteriosus, spina bifida and tracheoesophageal fistula. Posterior sagittal anorectoplasty (PSARP) was the definitive surgery used. It was performed in 58.97% of the patients. Median age of patients who underwent PSARP was 11 months. 73.91% of PSARP patients had their colostomies closed and 62.5% of these who were ≥3 years old had good continence outcomes. Overall mortality rate was 8.97%. CONCLUSION The majority of patients are diagnosed late. Vestibular fistula is the overall most common type of ARM. In males, however, rectourethral fistula is the most common type. Definitive surgery at MRRH is performed late. Continence outcomes are good and comparable to other countries with more resources. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Peter Kayima
- Department of Surgery, St Mary's Hospital Lacor, Gulu University Medical School, Gulu, Uganda
| | - David Kitya
- Department of Surgery, Mbarara University of Science and Technology, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Maria Punchak
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA
| | - Geoffrey A Anderson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Martin Situma
- Department of Surgery, Mbarara University of Science and Technology, Mbarara Regional Referral Hospital, Mbarara, Uganda
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Diaz MM. Global & Community Health: A perspective on neurologic care at Mulago Hospital in Uganda. Neurology 2019; 92:579-581. [PMID: 30886072 DOI: 10.1212/wnl.0000000000007149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Monica M Diaz
- From the Department of Neurology and Johnson and Johnson Global Scholars Program, Yale School of Medicine; and Yale New Haven Hospital, New Haven, CT.
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