Meena Cherian

The burden of surgical conditions and access to surgical care in low- and middle-income countries

Surgery is an essential component of health systems but has generally been neglected within global public health. This is despite growing evidence documenting the cost-effectiveness of essential surgical care in low- and middle-income countries (LMICs).1 The overall burden of disease that may be cured, palliated or treated with surgical intervention is large and (probably) rapidly growing, and this concept must therefore be revisited. There are major gaps in knowledge related to surgery in LMICs. What exactly is the burden and distribution of surgical conditions in LMICs? What is the unmet surgical need? What resources (human, financial, physical) are required to improve access to surgical care? What impact would this have on global health disparities, and how does this compare with other interventions? How can essential surgical services be integrated into health systems’ surveillance and evaluation? This paper outlines a research agenda and argues that enough is already known to justify accelerated action.

Addressing the Millennium Development Goals From a Surgical Perspective Essential Surgery and Anesthesia in 8 Low- and Middle-Income Countries

HYPOTHESIS Surgical and anesthetic care is increasingly recognized as a neglected but cost-effective component of primary health care in low- and middle-income countries (LMICs). Strengthening delivery can help achieve Millennium Development Goals 4, 5, and 6. Large gaps in access to essential surgical care in LMICs result in considerable morbidity and mortality. The goal of this study was to provide a baseline overview of essential surgical and anesthetic capacity at district-level health facilities in multiple LMICs. DESIGN Survey. SETTING District-level health facilities in multiple LMICs MAIN OUTCOME MEASURES A standardized World Health Organization tool was used at selected district-level hospitals to assess infrastructure, supplies, and procedures relating to essential surgical and anesthetic capacity. The analysis included facilities from countries that assessed more than 5 health facilities. All data were aggregated and blinded to avoid intercountry comparisons. RESULTS Data from 132 facilities were analyzed from 8 countries: Democratic Socialist Republic of Sri Lanka (n = 32), Mongolia (n = 31), United Republic of Tanzania (n = 25), Islamic State of Afghanistan (n = 13), Republic of Sierra Leone (n = 11), Republic of Liberia (n = 9), Republic of The Gambia (n = 6), and Democratic Republic of São Tomé and Príncipe (n = 5). Universally, facilities demonstrated shortfalls in basic infrastructure (water, electricity, oxygen) and functioning anesthesia machines. Although 73% of facilities reported performing incision and drainage of abscesses, only 48% were capable of undertaking an appendectomy. In line with Millennium Development Goals 4, 5, and 6, only 32% of facilities performed congenital hernia repairs, 44% of facilities performed cesarean sections, and few facilities always had goggles and aprons to protect surgical health care workers from human immunodeficiency virus. CONCLUSION Enormous shortfalls in infrastructure, supplies, and procedures undertaken are common at district-level health facilities in LMICs.

Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care.

HYPOTHESIS Lack of access to surgical care is a public health crisis in developing countries. There are few data that describe a nations ability to provide surgical care. This study combines information quantifying the infrastructure, human resources, interventions (ie, procedures), emergency equipment and supplies for resuscitation, and surgical procedures offered at many government hospitals in Sierra Leone. SETTING Site visits were performed in 2008 at 10 of the 17 government civilian hospitals in Sierra Leone. MAIN OUTCOME MEASURES The World Health Organizations Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was used to assess surgical capacity. RESULTS There was a paucity of electricity, running water, oxygen, and fuel at the government hospitals in Sierra Leone. There were only 10 Sierra Leonean surgeons practicing in the surveyed government hospitals. Many procedures performed at most of the hospitals were cesarean sections, hernia repairs, and appendectomies. There were few supplies at any of the hospitals, forcing patients to provide their own. There was a disparity between conditions at the government hospitals and those at the private and mission hospitals. CONCLUSION There are severe shortages in all aspects of infrastructure, personnel, and supplies required for delivering surgical care in Sierra Leone. While it will be difficult to improve the infrastructure of government hospitals, training additional personnel to deliver safe surgical care is possible. The situational analysis tool is a valuable mechanism to quantify a nations surgical capacity. It provides the background data that have been lacking in the discussion of surgery as a public health problem and will assist in gauging the effectiveness of interventions to improve surgical infrastructure and care.

The Global Burden of Musculoskeletal Injuries: Challenges and Solutions

Musculoskeletal injuries are a major public health problem globally, contributing a large burden of disability and suffering. This burden could be considerably lowered by implementation of affordable and sustainable strategies to strengthen orthopaedic trauma care, especially in low- and middle-income countries. This article summarizes the global burden of musculoskeletal injuries and provides several examples of successful programs that have improved care of injuries in health facilities in low- and middle-income countries. Finally, it discusses WHO efforts to build on the country experiences and to make progress in lowering the burden of musculoskeletal injuries globally.

Increasing access to surgical services in sub-saharan Africa: priorities for national and international agencies recommended by the Bellagio Essential Surgery Group.

In this Policy Forum, the Bellagio Essential Surgery Group, which was formed to advocate for increased access to surgery in Africa, recommends four priority areas for national and international agencies to target in order to address the surgical burden of disease in sub-Saharan Africa.

Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hospitals using a WHO assessment tool

Objectives  To survey infrastructure characteristics, personnel, equipment and procedures of surgical, obstetric and anaesthesia care in 17 hospitals in Ghana.

Developing Priorities for Addressing Surgical Conditions Globally: Furthering the Link Between Surgery and Public Health Policy

BackgroundEfforts to promote wider access to surgical services globally would be aided by developing consensus among clinicians, the public health policy community, and other stakeholders as to which surgical conditions warrant the most focused attention and investment. This would add value to other, ongoing efforts, especially in helping to define unmet need and effective coverage.MethodsIn this concept paper, we introduce preliminary ideas on how priorities for surgical care could be better defined, especially as regards the interface between the surgical and public health worlds. Factors that would come into play in this process include the public health burden of the condition and the successfulness and feasibility of the procedures to treat those conditions.Results and conclusionsThe implications of the prioritization process are that those conditions with the highest public health burden and that have procedures that are highly successful and feasible to promote globally, including in the most resource-constrained environments, should be the main focus of national and international efforts.

Quantifying Surgical and Anesthetic Availability at Primary Health Facilities in Mongolia

BackgroundSignificant barriers limit the safe and timely provision of surgical and anaesthetic care in low- and middle-income countries. Nearly one-half of Mongolia’s population resides in rural areas where the austere geography makes travel for adequate surgical care very difficult. Our goal was to characterize the availability of surgical and anaesthetic services, in terms of infrastructure capability, physical resources (supplies and equipment), and human resources for health at primary level health facilities in Mongolia.MethodsA situational analysis of the capacity to deliver emergency and essential surgical care (EESC) was performed in a nonrandom sample of 44 primary health facilities throughout Mongolia.ResultsSignificant shortfalls were noted in the capacity to deliver surgical and anesthetic services. Deficiencies in infrastructure and supplies were common, and there were no trained surgeons or anaesthesiologists at any of the health facilities sampled. Most procedures were performed by general doctors and paraprofessionals, and occasionally visiting surgeons from higher levels of the health system. While basic interventions such as suturing or abscess drainage were commonly performed, the availability of many essential interventions was absent at a significant number of facilities.ConclusionsThis situational analysis of the availability of essential surgical and anesthetic services identified significant deficiencies in infrastructure, supplies, and equipment, as well as a lack of human resources at the primary referral level facilities in Mongolia. Given the significant travel distances to secondary level facilities for the majority of the rural population, there is an urgent need to strengthen the delivery of essential surgical and anaesthetic services at the primary referral level (soum and intersoum). This will require a multidisciplinary, multi-sectoral effort aimed to improve infrastructure, procure and maintain essential equipment and supplies, and train appropriate health professionals.

Implementing Liberia's poverty reduction strategy: An assessment of emergency and essential surgical care.

OBJECTIVE To document infrastructure, personnel, procedures performed, and supplies and equipment available at all county hospitals in Liberia using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. DESIGN Survey of county hospitals using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. SETTING Sixteen county hospitals in Liberia. MAIN OUTCOME MEASURES Infrastructure, personnel, procedures performed, and supplies and equipment available. RESULTS Uniformly, gross deficiencies in infrastructure, personnel, and supplies and equipment were identified. CONCLUSIONS The World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care was useful in identifying baseline emergency and surgical conditions for evidenced-based planning. To achieve the Poverty Reduction Strategy and delivery of the Basic Package of Health and Social Welfare Services, additional resources and manpower are needed to improve surgical and anesthetic care.

Emergency and surgery services of primary hospitals in the United Republic of Tanzania

Objective The primary objective was to evaluate the capacity of first-referral health facilities in Tanzania to perform basic surgical procedures. The intent was to assist in planning strategies for universal access to life-saving and disability-preventing surgical services. Design Cross-sectional survey. Setting First-referral health facilities in the United Republic of Tanzania. Participants 48 health facilities. Measures The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was employed to capture a health facilitys capacity to perform basic surgical (including obstetrics and trauma) and anaesthesia interventions by investigating four categories of data: infrastructure, human resources, interventions available and equipment. The tool queried the availability of eight types of care providers, 35 surgical interventions and 67 items of equipment. Results The 48 facilities surveyed served 18.6 million residents (46% of the population). Supplies for basic airway management were inconsistently available. Only 42% had consistent access to oxygen, and only six functioning pulse oximeters were located in all facilities surveyed. 37.5% of facilities reported both consistent running water and electricity. While very basic interventions (suturing, wound debridement, incision and drainage) were provided in nearly all facilities, more advanced life-saving procedures including chest tube thoracostomy (30/48), open fracture management (29/48) and caesarean section delivery (32/48) were not consistently available. Conclusions Based on the results in this WHO country survey, significant gaps exist in the capacity for emergency and essential surgical services in Tanzania including deficits in human resources, essential equipment and infrastructure. The information in this survey will provide a foundation for evidence-based decisions in country-level policy regarding the allocation of resources and provision of emergency and essential surgical services.