Isabelle Citron

Safe Surgery for All: Early Lessons from Implementing a National Government-Driven Surgical Plan in Ethiopia

Recognizing the unmet need for surgical care in Ethiopia, the Federal Ministry of Health (FMOH) has pioneered innovative methodologies for surgical system development with Saving Lives through Safe Surgery (SaLTS). SaLTS is a national flagship initiative designed to improve access to safe, essential and emergency surgical and anaesthesia care across all levels of the healthcare system. Sustained commitment from the FMOH and their recruitment of implementing partners has led to notable accomplishments across the breadth of the surgical system, including but not limited to: (1) Leadership, management and governance—a nationally scaled surgical leadership and mentorship programme, (2) Infrastructure—operating room construction and oxygen delivery plan, (3) Supplies and logistics—a national essential surgical procedure and equipment list, (4) Human resource development—a Surgical Workforce Expansion Plan and Anaesthesia National Roadmap, (5) Advocacy and partnership—strong FMOH partnership with international organizations, including GE Foundation’s SafeSurgery2020 initiative, (6) Innovation—facility-driven identification of problems and solutions, (7) Quality of surgical and anaesthesia care service delivery—a national peri-operative guideline and WHO Surgical Safety Checklist implementation, and (8) Monitoring and evaluation—a comprehensive plan for short-term and long-term assessment of surgical quality and capacity. As Ethiopia progresses with its commitment to prioritize surgery within its Health Sector Transformation Plan, disseminating the process and outcomes of the SaLTS initiative will inform other countries on successful national implementation strategies. The following article describes the process by which the Ethiopian FMOH established surgical system reform and the preliminary results of implementation across these eight pillars.

Pathology and laboratory medicine in partnership with global surgery: working towards universal health coverage

www.thelancet.com Published online March 15,2018 http://dx.doi.org/10.1016/S0140-6736(18)30457-4 1 Pathology and laboratory medicine (PALM) is the backbone of high-quality care across many specialties, particularly surgery. In surgery, PALM provides the crossmatch to keep patients with bleeding ectopic pregnancies alive, the histopathology that differentiates a benign colonic polyp from a malignancy, the biochemistry that allows safe titration of anaesthetics, and the forensic pathology that quantifies the burden of disease. PALM and surgery, which both require substantial capital and infrastructure, share similarities as to the next phases of their expansion. Investment in equipment can only be cost-effective when the equipment is co-located with a well trained staff and a functioning supply chain to keep the equipment in use. All too often in lowincome and middle-income countries (LMICs), patients remain in need while analysers sit idly without reagents, or operating theatres are vacant without surgeons or equipment as coordination is lacking to simultaneously bring together these building blocks. Both specialties will benefit from delivery science research that addresses best practices for equipment standardisation, procurement, training, and service contracts, and the strengthening of biomedical engineering services. As the surgery community has found, getting from here to there will require PALM to coordinate the workforce, supplies, equipment, training, and the information and governance systems with national level planning. Strategic national planning in PALM and surgery must also include leveraging the fast pace of technology innovation. Technology in LMICs often undergoes so-called leapfrogging, in which new technologies are rapidly adopted without going through linear intermediary steps. In this Lancet Series on PALM in LMICs, Shahin Sayed and colleagues describe how point-of-care testing with HIV and malaria is likely to prove a leapfrog technology that could be adopted in areas where no testing previously existed without a traditional laboratory testing phase. Similarly, in Mongolia, open surgical techniques are being leapfrogged in favour of direct adoption of costeffective laparoscopic surgeries. PALM and the surgical, anaesthesia, and obstetrics communities encourage industry to recognise the large potential markets in LMICs and collaborate in research, development, trialling, and adopting new disruptive technologies. Workforce expansion in LMICs will also entail leapfrogging with the training of cost-effective task shifters, such as laboratory technicians, cancer histopathology technicians, nurse anaesthetists, and surgical officers. PALM and surgery seek resources not only for the community level but also for higher levels of care such as district and regional hospitals. Certain services within laboratory testing, pathology, and surgery are not needed at all levels of care, instead judicious deployment at specific levels of care and a functioning referral system are required. Working together, PALM and surgery and anaesthesia can shine a spotlight on the district hospital—a crucial but often neglected phase of the health-care system caught between a decentralisation agenda focused on the community and a super-specialisation agenda focused on national hospitals. The challenges that PALM and surgery face in advocating for resources are similar given their crosscutting nature and the breadth of diseases served, including cancer, heart disease, tuberculosis, trauma, and obstetrics. Both specialties are also excellent vehicles for health systems strengthening and can contribute to public health priorities, including the Sustainable Development Goals, non-communicable disease control, and universal health coverage. At the Pathology and laboratory medicine in partnership with global surgery: working towards universal health coverage

Authors’ Reply: Safe Surgery for All: Early Lessons from Implementing a National Government-Driven Surgical Plan in Ethiopia

We appreciate the summary of anesthesia-related activities in Ethiopia and support the advocacy of anesthesia by Drs. Drum, Shimeles, Tilahun, and McQueen. Representatives of the Ethiopian Society of Anesthesiologists Professional Association (ESAPA) and the Ethiopian Association of Anesthetists (EAA) have been instrumental in the formation and implementation of the national Saving Lives through Safe Surgery (SaLTS) initiative. The SaLTS technical working group includes permanent members from both societies. While we were unable to highlight all the accomplishments in the field of anesthesia in this article, we recognize that surgery is not possible without anesthesia. In Ethiopia, as is often the case throughout much of East Africa, inadequate numbers of anesthesia providers are a major bottleneck to receiving surgical care [1, 2]. As the authors note, these workforce challenges often drive a lack of surgical provision [2, 3]. We are pleased to see the authors and their institutions take an active role in implementing the Ministry’s National Anesthesia Roadmap. Additionally, while we were unable to include all data obtained from Ethiopia’s Hospital Assessment Tool in this article, questions about anesthesia-specific workforce, equipment, supplies, medicines, procedures, and infrastructure are included in the assessment tool. At each hospital, the anesthetist is surveyed for their part of the Hospital Assessment Tool. For example, the anesthesia provider is asked about functional anesthesia machines, pulse oximetry, spinal and regional anesthesia availability, and medications for sedation, paralysis, anesthesia, and analgesia. Members of both anesthesia associations are valuable contributors to Safe Surgery 2020’s and SaLTS’s current monitoring and evaluation programs. Given the call for more collaboration, a new movement in Ethiopia deserves special mention. A national professional association dedicated to improving surgical and anesthesia care has emerged in the past few months. This consortium of professional societies for surgery in Ethiopia, including ESAPA and the Ethiopian Association of Anesthetists, will be a powerful force for cooperation to advance the agenda on safe surgical and anesthetic care in the country in a multi-disciplinary way.

Healthcare Leaders Develop Strategies for Expanding National Surgical, Obstetric, and Anaesthesia Plans in WHO AFRO and EMRO Regions

BackgroundWorldwide, five billion people lack access to safe, affordable surgical, obstetric, and anaesthesia (SOA) care when needed. In many countries, a growing commitment to SOA care is culminating in the development of national surgical, obstetric, and anaesthesia plans (NSOAPs) that are fully embedded in the National Health Strategic Plan. This manuscript highlights the content and outputs from a World Health Organization (WHO) lead workshop that supported country-led plans for improving SOA care as a component of health system strengthening.MethodsIn March 2018, a group of 79 high-level global SOA stakeholders from 25 countries in the WHO AFRO and EMRO regions gathered in Dubai to provide technical and strategic guidance for the creation and expansion of NSOAPs.ResultsDrawing on the experience and expertise of represented countries that are at different stages of the NSOAP process, topics covered included (1) the global burden of surgical, obstetric, and anaesthetic conditions; (2) the key principles and components of NSOAP development; (3) the critical evaluation and feasibility of different models of NSOAP implementation; and (4) innovative financing mechanisms to fund NSOAPs.ConclusionsLessons learned include: (1) there is unmet need for the establishment of an NSOAP community in order to provide technical support, expertise, and mentorship at a regional level; (2) data should be used to inform future priorities, for monitoring and evaluation and to showcase advances in care following NSOAP implementation; and (3) SOA health system strengthening must be uniquely prioritized and not hidden within other health strategies.

The Situation of Safe Surgery and Anaesthesia in Tanzania: A Systematic Review

BackgroundImprovement in the surgical system requires intersectoral coordination. To achieve this, the development of National Surgical, Obstetric, and Anaesthesia Plans (NSOAPS) has been recommended. One of the first steps of NSOAP development is situational analysis. On the ground situational analyses can be resource intensive and often duplicative. In 2016, the Ministry of Health of Tanzania issued a directive for the creation of an NSOAP. This systematic review aimed to assess if a comprehensive situational analysis could be achieved with existing data. These data would be used for evidence-based priority setting for NSOAP development and streamline any additional data collection needed.MethodsA systematic literature review of scientific literature, grey literature, and policy documents was performed as per PRISMA. Extraction was performed for all articles relating to the five NSOAPS domains: infrastructure, service delivery, workforce, information management, and financing.Results1819 unique articles were generated. Full-text screening produced 135 eligible articles; 46 were relevant to surgical infrastructure, 53 to workforce, 81 to service delivery, 11 to finance, and 15 to information management. Rich qualitative and quantitative data were available for each domain.ConclusionsDespite little systematic data collection around SOA, a thorough literature review provides significant evidence which often have a broader scope, longer timeline and better coverage than can be achieved through snapshot-stratified samples of directed on the ground assessments. Evidence from the review was used during stakeholder discussion to directly inform the NSOAP priorities in Tanzania.

Patient-Perceived Barriers to Accessing Cleft Care at a Tertiary Referral Center in São Paulo, Brazil

Background: In low- and middle-income countries, poor access to care can result in delayed surgical repair of orofacial clefts leading to poor functional outcomes. Even in Brazil, an upper middle-income country with free comprehensive cleft care, delayed repair of orofacial clefts commonly occurs. This study aims to assess patient-perceived barriers to cleft care at a referral center in São Paulo. Methods: A 29-item questionnaire assessing the barriers to care was administered to 101 consecutive patients (or their guardians) undergoing orofacial cleft surgery in the Plastic Surgery Department in Hospital das Clínicas, in São Paulo, Brazil, between February 2016 and January 2017. Results: A total of 54.4% of patients had their first surgery beyond the recommended time frame of 6 months for a cleft lip or cleft lip and palate and 18 months for a cleft palate. There was a greater proportion of isolated cleft palates in the delayed group (66.7% vs 33.3%). Almost all patients had a timely diagnosis, but delays occurred from diagnosis to repair. The mean number of barriers reported for each patient was 3.8. The most frequently cited barriers related to lack of access to care include (1) lack of hospitals available to perform the surgery (54%) and (2) lack of availability of doctors (51%). Conclusion: Delays from diagnosis to treatment result in patients receiving delayed primary repairs. The commonest patient-perceived barriers are related to a lack of access to cleft care, which may represent a lack of awareness of available services.

Assessing burn care in Brazil: An epidemiologic, cross-sectional, nationwide study

Background: The aim of this study was to describe the national epidemiology of burns in Brazil and evaluate regional access to care by defining the contribution of out‐of‐hospital mortality to total burn deaths. Methods: We reviewed admissions data for Brazils single‐payer, free‐at‐point‐of‐care, public‐sector provider and national death registry data abstracted from DATASUS for 2008–2014. Admissions, in‐hospital mortality, hospital reimbursement, and total deaths from the death registry were assessed for records coded under ICD‐10 codes corresponding to flame, scald, contact, and electrical burns. Results: A total of 17,264 burn deaths occurred between 2008–2014 (mean annual 2,466 [SD 202]). Of all burns deaths 79.1% occurred out of hospital, with marked regional differences in the proportion of out‐of‐hospital deaths (P < 0.001), the greatest being in the North region. The mean annual number of admissions >24 hours was 18,551 (SD 1,504) with the greatest prevalence of flame burns overall (43.98%) and scalds prevailing in < 5 years (57.8%). Regional differences were found in per‐capita admissions (P < 0.001) with the greatest number in the Central‐West region. A mean of

Surgical quality indicators in low-resource settings: A new evidence-based tool

1,022 (SD

Development of a Novel Global Surgery Course for Medical Schools

94) US dollars was reimbursed per burn admission. Conclusion: Given that nearly 80% of burns mortalities occurred out of hospital, prevention of burns alongside interventions improving prehospital and access to care have potential for the greatest impact.

USAID: Current support for global surgery and implications of reform

Background Worldwide efforts to improve access to surgical care must be accompanied by improvements in the quality of surgical care; however, these efforts are contingent on the ability to measure quality. This report describes a novel, evidence‐based tool to measure quality of surgical care in low‐resource settings. Methods We defined a widely applicable, multidimensional conceptual framework for quality. The suitability of currently available quality metrics to low‐resource settings was evaluated. Then we developed new indicators with sufficient supportive evidence to complete the framework. The complete set of metrics was condensed into four collection sources and tools. Results The following 15 final evidence‐based indicators were defined: (1) Safe structure: morbidity and mortality conference; (2) safe process: use of the safe surgery checklist; (3) (4) safe outcomes: perioperative mortality rate and proportion of cases with complications graded >2 on the Clavien‐Dindo scale; (5) effective structure: provider density; (6) effective process: procedure rate; (7) effective outcome: rate of caesarean sections; (8) patient‐centered process: use of informed consent; (9) patient‐centered outcome: patient hospital satisfaction questionnaire; (10) timely structure: travel time to hospital; (11) timely process: time from emergency department presentation to non‐elective abdominal surgery; (12) timely outcome: patient follow‐up plan; (13) efficient process: daily operating room usage; (14) equitable outcome: comparative income of patients compared with population; and (15) proportion of patients facing catastrophic expenditure because of surgical care. Conclusion This tool provides an evidence‐based conceptual tool to assess the quality of surgical care in diverse low‐resource settings.