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Adde HA, Oghogho MD, van Duinen AJ, Grimes CE, Hampaye TC, Quaife M, Bolkan HA. The economic burden associated with unmet surgical needs in Liberia: a retrospective macroeconomic analysis based on a nationwide enumeration of surgical procedures. BMJ Open 2024; 14:e076293. [PMID: 38191260 PMCID: PMC10806694 DOI: 10.1136/bmjopen-2023-076293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 12/15/2023] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVES The economic consequences of untreated surgical disease are potentially large. The aim of this study was to estimate the economic burden associated with unmet surgical needs in Liberia. DESIGN A nationwide enumeration of surgical procedures and providers was conducted in Liberia in 2018. We estimated the number of disability-adjusted life years (DALYs) saved by operative activities and converted these into economic losses averted using gross national income per capita and value of a statistical life (VSL) approaches. The total, the met and the unmet needs for surgery were determined, and economic losses caused by unmet surgical needs were estimated. Finally, we valued the economic losses avoided by various surgical provider groups. RESULTS A total of 55 890 DALYs were averted by surgical activities in 2018; these activities prevented an economic loss of between US$35 and US$141 million. About half of these values were generated by the non-specialist physician workforce. Furthermore, a non-specialist physician working a full-time position for 1 year prevented an economic loss of US$717 069 using the VSL approach, while a specialist resident and a certified specialist saved US$726 606 and US$698 877, respectively. The burden of unmet surgical need was associated with productivity losses of between US$388 million and US$1.6 billion; these losses equate to 11% and 46% of the annual gross domestic product for Liberia. CONCLUSION The economic burden of untreated surgical disease is large in Liberia. There is a need to strengthen the surgical system to reduce ongoing economic losses; a framework where specialist and non-specialist physicians collaborate may result in better economic return than a narrower focus on training specialists alone.
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Affiliation(s)
- Håvard A Adde
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- CapaCare, Trondheim, Norway, & Tappita, Liberia
| | | | - Alex J van Duinen
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- CapaCare, Trondheim, Norway, & Tappita, Liberia
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Surgery, ELWA Hospital, Monrovia, Liberia
| | - Caris E Grimes
- King's Centre for Global Health and Health Partnerships, King's College, London, UK
- Medway NHS Foundation Trust, Gillingham, UK
| | | | - Matthew Quaife
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- Evidera Ltd, London, UK
| | - Håkon A Bolkan
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- CapaCare, Trondheim, Norway, & Tappita, Liberia
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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Adde HA, van Duinen AJ, Andrews BC, Bakker J, Goyah KS, Salvesen Ø, Sheriff S, Utam T, Yaskey C, Weiser TG, Bolkan HA. Mapping population access to essential surgical care in Liberia using equipment, personnel, and bellwether capability standards. Br J Surg 2023; 110:169-176. [PMID: 36469530 PMCID: PMC10364551 DOI: 10.1093/bjs/znac377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 10/02/2022] [Accepted: 10/20/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND Accurate surveillance of population access to essential surgery is key for strategic healthcare planning. This study aimed to estimate population access to surgical facilities meeting standards for safe surgery equipment, specialized surgical personnel, and bellwether capability, cesarean delivery, emergency laparotomy, and long-bone fracture fixation and to evaluate the validity of using these standards to describe the full breadth of essential surgical care needs in Liberia. METHOD An observational study of surgical facilities was conducted in Liberia between 20 September and 8 November 2018. Facility data were combined with geospatial data and analysed in an online visualization platform. RESULTS Data were collected from 51 of 52 surgical facilities. Nationally, 52.9 per cent of the population (2 392 000 of 4 525 000 people) had 2-h access to their closest surgical facility, whereas 41.1 per cent (1 858 000 people) and 48.6 per cent (2 199 000 people) had 2-h access to a facility meeting the personnel and equipment standards respectively. Six facilities performed all bellwether procedures; 38.7 per cent of the population (1 751 000 people) had 2-h access to one of these facilities. Bellwether-capable facilities were more likely to perform other essential surgical procedures (OR 3.13, 95 per cent c.i. 1.28 to 7.65; P = 0.012). These facilities delivered a median of 13.0 (i.q.r. 11.3-16.5) additional essential procedures. CONCLUSION Population access to essential surgery is limited in Liberia; strategies to reduce travel times ought to be part of healthcare policy. Policymakers should also be aware that bellwether capability might not be a valid proxy for the full breadth of essential surgical care in low-income settings.
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Affiliation(s)
- Håvard A Adde
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Alex J van Duinen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.,Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | | | - Juul Bakker
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Kezelebah S Goyah
- Lifebox Foundation, Monrovia, Liberia.,F. J. Grante Memorial Hospital, Greenville, Liberia
| | - Øyvind Salvesen
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Swaliho Sheriff
- Lifebox Foundation, Monrovia, Liberia.,Department of Surgery, Liberia Governmental Hospital, Tubmanburg, Liberia
| | - Terseer Utam
- Lifebox Foundation, Monrovia, Liberia.,Department of Surgery and Traumatology, Redemption Hospital, Monrovia, Liberia
| | | | - Thomas G Weiser
- Department of Surgery, Stanford University, Stanford, California, USA.,Department of Surgery, Stanford-Surgery Policy Improvement Research and Education Center, Stanford University, Palo Alto, California, USA.,Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK.,Lifebox Foundation, London, UK
| | - Håkon A Bolkan
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
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van Duinen AJ, Adde HA, Fredin O, Holmer H, Hagander L, Koroma AP, Koroma MM, Leather AJ, Wibe A, Bolkan HA. Travel time and perinatal mortality after emergency caesarean sections: an evaluation of the 2-hour proximity indicator in Sierra Leone. BMJ Glob Health 2020; 5:e003943. [PMID: 33355267 PMCID: PMC7754652 DOI: 10.1136/bmjgh-2020-003943] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/22/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Longer travel times are associated with increased adverse maternal and perinatal outcomes. Geospatial modelling has been increasingly used to estimate geographic proximity in emergency obstetric care. In this study, we aimed to assess the correlation between modelled and patient-reported travel times and to evaluate its clinical relevance. METHODS Women who delivered by caesarean section in nine hospitals were followed up with home visits at 1 month and 1 year. Travel times between the location before the delivery and the facility where caesarean section was performed were estimated, based on two models (model I Ouma et al; model II Munoz et al). Patient-reported and modelled travel times were compared applying a univariable linear regression analysis, and the relation between travel time and perinatal mortality was assessed. RESULTS The median reported travel time was 60 min, compared with 13 and 34 min estimated by the two models, respectively. The 2-hour access threshold correlated with a patient-reported travel time of 5.7 hours for model I and 1.8 hours for model II. Longer travel times were associated with transport by boat and ambulance, visiting one or two facilities before reaching the final facility, lower education and poverty. Lower perinatal mortality was found both in the group with a reported travel time of 2 hours or less (193 vs 308 per 1000 births, p<0.001) and a modelled travel time of 2 hours or less (model I: 209 vs 344 per 1000 births, p=0.003; model II: 181 vs 319 per 1000 births, p<0.001). CONCLUSION The standard model, used to estimate geographical proximity, consistently underestimated the travel time. However, the conservative travel time model corresponded better to patient-reported travel times. The 2-hour threshold as determined by the Lancet Commission on Global Surgery, is clinically relevant with respect to reducing perinatal death, not a clear cut-off.
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Affiliation(s)
- Alex J van Duinen
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Håvard A Adde
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ola Fredin
- Geological Survey of Norway, Trondheim, Norway
- Department of Geography, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hampus Holmer
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Lars Hagander
- Centre for Surgery and Public Health, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Alimamy P Koroma
- Ministry of Health and Sanitation, Freetown, Sierra Leone
- Department of Obstetrics and Gynaecology, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone
| | - Michael M Koroma
- Ministry of Health and Sanitation, Freetown, Sierra Leone
- Department of Obstetrics and Gynaecology, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone
| | - Andrew Jm Leather
- King's Centre for Global Health & Health Partnerships, King's College London, London, UK
| | - Arne Wibe
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Håkon A Bolkan
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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