Surgical care at rural district hospitals in low- and middle-income countries: an essential component of universal health coverage (original) (raw)
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Introduction Universal health coverage (UHC) has its roots in the Universal Declaration of Human Rights and has recently gained momentum. Out-of-pocket payments (OPP) remain a significant barrier to care. There is an increasing global prevalence of non-communicable diseases, many of which are surgically treatable. We sought to provide a comparative analysis of the inclusion of surgical care in operating plans for UHC in low-and middleincome countries (LMIC). Methods We systematically searched PubMed and Google Scholar using pre-defined criteria for articles published in EnglishUHC websites were searched for supporting documents. Ministries of Health were contacted to provide further information on the inclusion of surgery. Results We found 696 articles and selected 265 for full-text review based on our criteria. Some countries enumerated surgical conditions in detail (India, 947 conditions). Other countries mentioned surgery broadly. Obstetric care was most commonly covered (19 countries). Solid organ transplantation was least covered. Cancer care was mentioned broadly, often without specifying the therapeutic modality. No countries were identified where hospitals are required to provide emergency care regardless of insurance coverage. OPP varied greatly between countries. Eighty percent of countries had OPP of 60 % or more, making these services, even if partially covered, largely inaccessible. Conclusion While OPP, delivery, and utilization continue to represent challenges to health care access in many LMICs, the inclusion of surgery in many UHC policies sets an important precedent in addressing a growing global prevalence of surgically treatable conditions. Barriers to access, including inequalities in financial protection in the form of high OPP, remain a fundamental challenge to providing surgical care in LMICs.
World journal of surgery, 2010
In response to increasing evidence that surgical conditions are an important global public health problem, and data suggesting that essential surgical services can be delivered in a cost-effective manner in low- and middle-income countries, the World Health Organization (WHO) has expanded its interest in surgical care. In 2004, WHO established a Clinical Procedures Unit within the Department of Essential Health Technologies. This unit has developed the Emergency and Essential Surgical Project (EESC), which includes a basic surgical training program based on the "Integrated Management of Emergency and Essential Surgical Care" Toolkit and the textbook "Surgery at the District Hospital." To promote the importance of emergency and essential surgical care, a Global Initiative for Emergency and Essential Care was launched in 2005. In what maybe the most important development, surgical care is included in WHO's new comprehensive primary health care plan. Given these...
Disparities in Access to Surgical Care within a Lower Income Country: An Alarming Inequity
2012
Background Surgical care is not uniformly available worldwide. Inequities in surgical care and access may also vary within countries, and the present study aimed to explore these disparities in Pakistan. Methods The National Health Survey of Pakistan was analyzed. The proportion of people with a history of abdominal surgery (AS) was calculated and associated factors were determined by weighted multivariate logistic regression. Factors tested were age, gender, urban/rural residence, province, literacy, community development index (CDI), and economic status (ES). The CDI was developed for each sampling unit from select household and individual data. The ES was constructed from ownership of assets. Results A total of 59 million adults were represented. Abdominal surgery had been performed in 3.2 % adults (95 % confidence interval [CI] = 2.67, 3.84), which corresponded to an annual rate of 85.9 abdominal surgeries per 100,000 population. Wide disparities were noted, with annual rates of AS varying from 37.8 to 215.6 per 100,000 population. Urban residents were independently twice as likely as rural populations to have had AS (95 % CI = 1.3, 2.8). Higher age (OR = 2.6; 95 % CI = 1.7, 4.0), female gender (OR = 1.5; 95 % CI = 1.1, 2.1), and higher ES (OR = 1.9; 95 % CI = 1.2, 2.9) were also independently associated with AS. In rural populations ES was the only factor associated with surgery, whereas in urban populations gender and CDI had important roles to play. Conclusions Access to surgical care is disparate and grossly inadequate in Pakistan. This likely contributes to significant preventable morbidity and death. Physical access to surgical facilities, especially in rural areas and for those with a low CDI, is an important concern and should be prioritized in any forthcoming national policies.
Implementing surgical services in a rural, resource-limited setting: a study protocol
BMJ Open, 2011
Introduction: There are well-established protocols and procedures for the majority of common surgical diseases, yet surgical services remain largely inaccessible for much of the world's rural poor. Data on the process and outcome of surgical care expansion, however, are very limited, and the roll-out process of rural surgical implementation in particular has never been studied. Here, we propose the first implementation research study to assess the surgical scale-up process in the rural district of Achham, Nepal.
International health, 2015
High disease burden and inadequate resources have formed the basis for advocacy to improve surgical care in low- and middle-income countries (LMICs). Current measures are heavily focused on availability of resources rather than impact and fail to fully describe how surgery can be more integrated into health systems. We propose a new monitoring and evaluation framework of surgical care in LMICs to integrate surgical diseases into broader health system considerations and track efforts toward improved population health. Although more discussion is required, we seek to broaden the dialogue of how to improve surgical care in LMICs through this comprehensive framework.
East and Central African Journal of Surgery
Health care delivery systems are organized at several levels with the district hospital serving as the first referral for comprehensive care in the majority of countries worldwide. The provision of comprehensive surgical services requires several inputs and tools to be in place, among which are an adequately trained surgical, anaesthesia and obstetric healthcare workforce, infrastructure and functioning equipment, and essential medicines and supplies. These, however, are not in place in the majority of commonly received surgical cases, such as trauma, obstetric, abdominal and orthopedic emergencies, thus limiting the capacity of district hospitals to address them. Global and regional public health initiatives have traditionally neglected the necessity of the provision of surgical services despite the fact that these constitute an essential component of comprehensive primary healthcare (PHC) 1. In fact, because surgery so frequently cannot be safely postponed, this deficiency prevents the transfer of patients to a secondary or tertiarylevel hospital where further care can be provided. 2
Practice of anaesthesia and surgery in a rural clinic: meeting the challenge
Turkish journal of family medicine and primary care, 2014
Practice of Anaesthesia and Surgery in a Rural Clinic: Meeting the Challenge This is a descriptive prospective study aimed at describing the scope of surgery and anaesthetic practice in a rural clinic in Ngo, Nigeria. All the medical records of patients that fulfilled the inclusion criteria and managed in the clinic were retrieved and analysed. Out of 6911 patients who attended the clinic within the period, 575 (8.32%) medical records of surgical patients were retrieved. Fifteen (2.60%) were referred to tertiary health centres for expert management of their surgical conditions. Of the remaining 560 medical records that were retrieved 551(98.4%) met the criteria for inclusion and had their surgical pathology treated in 583 procedures. The most common surgical problem encountered in the rural clinic was hernias(39.75%) done mainly using 1% xylocaine local anaesthesia (63.64%). The most commontype of anaesthesia used in the clinic was ketamine anaesthesia(53.90%). Mortality recorded within the period was in two (0.4%) women who had eclampsia and severe post partum haemorhage. The result suggests that adequately trained family physicians can meet the challenge of scarcity of surgeons and anaesthesiologists in the rural areas satisfactorily.
Where there is no specialist: surgical care in a secondary health facility in a developing country
Background A major deterrent to providing qualitative surgical care in developing countries is the lack of adequate facilities and severe shortage of human resources. Therefore, most of the surgical workforce in rural areas and urban slums predominantly includes general practitioners with little formal training in providing surgical care. There is a need for constant review of patients’ care in this setting with the aim of improving service delivery and conforming to the internationally acceptable standard of practice. Materials and methods A 5-year descriptive retrospective study, from January 2007 to December 2011, of general surgery cases at State Specialist Hospital Ikere-Ekiti (Nigeria) was carried out. Results A total of 80 patients underwent 85 surgical operations. Most of them (86.2%) had ward admission for a mean duration of 4.6±1.4 days. The most frequent elective operation was hernia repair [66 (77.7%)]; whereas that of emergency was appendectomy [seven (8.2%)]. Other operations included lumpectomy [three (3.5%)], hydrocelectomy [two (2.4%)] and orchidectomy and laparotomy [three (3.5%) each]. All patients received postoperative antibiotics, with 71.3% receiving two or more antibiotics. Fifteen (18.8%) patients had surgically excised specimens with no histopathological evaluation. Only four (5%) patients were followed up beyond 4 weeks. No mortality was recorded. Conclusion Surgical volume was grossly low and there is a need for the government to equip secondary healthcare centres with basic facilities and strengthen surgical capacity for maximum utilization and improved quality of care. Periodic training programmes for general practitioners to ensure strict adherence to the international best practices will be helpful. In addition, health education should be available for everyone to reduce sociocultural-related problems.