Economic Impact of surgery on households and individuals in low income countries: A systematic review

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 perspectiv

Organized breast cancer screening not only reduces mortality from breast cancer but also significantly decreases disability-adjusted life years: analysis of the Global Burden of Disease Study and screening programme availability in 130 countries

Multiple studies over the past 4 decades have shown the significant benefit of breast cancer screening (BCS) in reducing mortality rates from breast cancer (BC). However, significant debate exists about the role of BCS in this regard, with some studies also showing no benefit in terms of mortality along with issues such as overdiagnosis, health care utilisation costs, psychological distress or overtreatment. To date, no BCS study has focused on disability. Hence the aim of this study is to evaluate the relative contribution of BCS approaches to age-standardized mortality and disability-adjusted life years (DALYs) rates along with other related risk factors, from a country-level perspective.

Patients and methods
This study created a country-dataset by merging information from the Global Burden of Disease study regarding female age-standardized BC mortality, DALYs rates and other risk factors with the BCS programme availability at the national or regional level (versus no or only pilot such programme), BCS type (mammography, digital screening, breast self-examination and clinical breast examination) and other BCS-related information among 130 countries. Mixed-effect multilevel regression models were run to examine the associations of interest.

Results
The most important factor predictive of lower mortality was the more advanced type of BCS programme availability [mammography: −4.16, 95% CI −6.76 to −1.55; digital mammography/ultrasound: −3.64, 95% CI −6.59 to −0.70] when compared with self- or clinical breast examinations. High levels of low-density lipoprotein cholesterol (LDL-c) and smoking were also related to higher mortality and DALYs from BC. In terms of BC DALYs, BCS had a 21.9 to 22.3-fold increase in the magnitude of effect compared with that in terms of mortality. Data on mortality and DALYs in relation to BCS programmes were also calculated for high-, middle- and low-income countries.

Conclusions
These data further support the positive effects of BCS in relation to age-standardized BC mortality rates, and for the first time show the impact of BCS on DALYs too. Additional factors, such as diabetes, high levels of LDL-c or smoking seemed to be related to BC mortality and disability, and could be considered as additional components of possible interventions to be used alongside BCS to optimize the BCS benefit on patients.

Foundation for International Education in Neurosurgery: The Next Half-Century of Service Through Education

The Foundation for International Education in Neurological Surgery (FIENS) was founded in 1969, decades before globalization became a worldwide phenomenon (1–3). Initially, efforts were focused on service delivery in under-resourced areas via short mission trips by individual neurosurgeons. The wisdom of furthering the impact by creating sustainable training programs in partnership with host organizations developed over time (3). FIENS is a neurosurgeons foundation working in partnership with various organizations to increase global access to neurosurgery missions through the principle of “service through education (3).” FIENS shifted its focus from a service delivery-centered approach to an approach centered on global health systems strengthening by emphasizing local neurosurgery resident education and residency program development (3). It has become clear that the integration of neurosurgical efforts within the local health system amplifies the overall impact of FIENS initiatives by promoting sustainable change through collaborative action in the service of local health system goals. From this point forward, initiatives coordinated by FIENS incorporated local stakeholders and workforce in addition to mechanisms for service delivery, health infrastructure, information management, governance, and funding.

Additionally, FIENS-supported trainees expressed the need for ongoing support in the early stages of their careers. In response, the Foundation expanded its scope to include postgraduate education, evolved, as global health organizations must, understand that lasting impact occurs through teaching, leading to self-sustaining health systems in regions of need.

The Role of Young Neurosurgeons in Global Surgery: A Unified Voice for Health Care Equity

Health care equity pursues the elimination of health disparities or inequalities. One of the most significant challenges is the inequality shaped by policies, for which systemic change is needed. Historically, non-surgical pathologies have received greater political priority than surgical pathologies, but we have begun to see a paradigm shift over the past decade. In 2010, Shrime et al. showed that 32.9% of all global deaths were attributed to surgically related conditions, which equated to three times more deaths than that due to non-surgical pathologies such as tuberculosis, malaria, and HIV/AIDS combined (1). When the Lancet Commission on Global Surgery was published in 2015 (2), a new era in global health emerged. The message was clear: surgical diseases could no longer be neglected. The report emphasized the importance of systems-level improvements in service delivery, workforce training, financing, information management, infrastructure, health policy, and governance.

In neurosurgery, over five million patients present with treatable conditions each year but do not have access to surgical intervention (3). Most of these patients live in low- and middle-income countries (LMICs), particularly in Africa and South-East Asia. For a hospital to offer neurosurgical services, substantial investment in infrastructure and human resources is required. Hence, most neurosurgical services tend to be concentrated in tertiary hospitals or academic centers located in cities or urban regions. Moreover, the comprehensive management of a patient’s neurosurgical disease relies heavily on a functioning health care system, often requiring a multidisciplinary team approach, whether in children or adults.

A Seat at the Table: Representation of Global Neurosurgery in the G4 Alliance

The Global Alliance for Surgical, Obstetric, Trauma and Anaesthesia Care (G4 Alliance, http://www.theg4alliance.org/) is the preeminent global surgery advocacy organization (1) dedicated to eliminating disparities in surgical care around the world. A coalition of over 60 non-profit organizations, professional societies, academic centers, and other groups, the G4 Alliance represents civil society interests in global surgery from the grassroots to the international level. The organization convenes its membership to address common interests and concerns, facilitates knowledge and resource sharing, builds consensus and alignment, and conducts outreach with multilateral organizations, donors, and other global health programs and advocacy initiatives. In a sector characterized by diverse actors and fragmentation of care delivery, scholarship, and funding (2,3), the G4 Alliance provides communication and coordination around a common surgical and health system strengthening agenda. The purpose of this paper is to highlight the multiple organizations that specifically contribute to neurosurgical advocacy within the G4 Alliance.

Global Neurosurgery: the role of WFNS Foundation

The World Federation of Neurosurgical Societies (WFNS) is the largest neurosurgical organization gathering more than 49.000 neurosurgeons belonging to almost all existing neurosurgical societies worldwide, created in 1955 to promote neurosurgery camaraderie among neurosurgeons. In 90’s beginnings, the visionary leadership of professor “Pepe” Martin-Rodriguez and professor Madjid Samii made possible the creation of the WFNS Foundation; its mission can be defined as an improvement of neurosurgical care in developing countries (education, training and, intraoperative neurosurgical technology), with the vision to become the worldwide leader neurosurgical organization in the promotion of education and neurosurgical care in that countries. It is essential to mention the name of professor Armando Basso, who exemplarily created the modern and current Foundation structure that nowadays is helping thousands of patients and neurosurgeons.

The Executive Board governs the WFNS Foundation (seven persons, three of them being the President, Secretary, and Treasurer of WFNS). Also, it has the support of the Advisory Board, composed of a group of neurosurgeons who enthusiastically contribute to WFNS Foundation goals. A few years ago, a strategic plan was devised considering the Foundation’s activity based on three pillars: Education, the development of a network of training centers, and the provision of neurosurgical equipment to developing countries. Recent publications (1–6) have pointed out the current unmet needs in developing countries, hence the interest of WFNS Foundation to comply with the context and definition of Global Neurosurgery (“the clinical and public health practice of neurosurgery with the primary purpose of ensuring timely, safe, and affordable neurosurgical care to all who need it”).

Gaps in surgical competencies of general surgeons deployed on humanitarian missions in disaster settings

Introduction:As the access to surgery differs geographically, its disparity is even more pronounced in disaster settings. With the increasing interest of surgeons from high-income countries (HIC) to respond to these surgical disparities, non-governmental organizations (NGOs) often send teams of health practitioners to provide healthcare aid to the most unstable regions of the world. However, surgeons participating in these missions rarely get the medical training necessary to face the large scope of procedures they can encounter in humanitarian settings. This research aims to create a framework of the necessary skills needed for surgeons to provide proper surgical care in disaster settings.Methodology:This is a descriptive qualitative study to outline the differences between the surgical procedures general surgeons in HICs are being trained on during their surgical training with the surgical procedures required in disaster settings. After identifying the main surgical procedures general surgeons are expected to be trained on before their deployment to a disaster setting in an LMICs, a survey was sent to participants to assess their competency level in these procedures and the likelihood of them performing these procedures in their home country compared to on the mission.Results:Participants indicated the high frequency of performing several surgical procedures from different surgical specialties on humanitarian missions. The most common of these procedures are cesarean section, fracture reduction, skeletal retraction, wound debridement, burn dressing, application of skin and graft, and performing emergency laparotomies. However, only wound debridement and emergency laparotomy were performed more than 10-20 times/ year by the participants in their daily practice in the past 5 years. The rest of the procedures in this list were never performed by the participants in their daily practice. Obstetrical and orthopedic procedures are amongst the most common procedures a general surgeon must perform when deployed on a mission in a disaster setting. However, they are rarely, if ever, performed by the surgeons in their daily practice. Looking at the requirements to complete general surgery training in most HICs, it is clear that the focus has shifted to training in advanced procedures and away from surgical training in other specialty procedures such as obstetrics, plastic surgery, orthopedic, and neurosurgery. Discussion:This study proves the perception that there is a gap in the training of surgeons who engage in health missions abroad compared to the scope of practice expected of them during these missions. This gap is more present in subspecialties such as obstetrics, orthopedics, urology, and neurosurgery. This shows the importance of surgeons who participate in these missions to have broad-based training that includes the most encountered surgical procedures in disaster settings. Acquiring skills in these life-saving procedures before being deployed on a surgical mission will improve the mortality and morbidity outcomes of these missions and create an ethical space where surgeons from high-income countries only perform procedures they have been adequately trained on

Global Neurosurgery and the Congress of Neurological Surgeons: Collaboration, Innovation, and Opportunity to Improve Care, Education, and Access.

Global neurosurgery encompasses the neurosurgical care and public health efforts to ensure timely and safe neurosurgical care access for all who need it (1). Over the past several decades, global neurosurgery has been championed by many individuals, which has led to a broader interest in developing larger collaborative, sustainable neurosurgical care efforts. On a national level, neurosurgical educational opportunities have grown through courses, online education, and fellowships. Given the growing global burden of neurosurgical disease, there is a significant opportunity and need for worldwide neurosurgery and neurosurgical education worldwide, especially in low- and middle-income countries (LMICs).
To advance global neurosurgery from an educational standpoint, the Congress of Neurological Surgeons (CNS), American Association of Neurological Surgeons (AANS), World Federation of Neurological Surgeons (WFNS), and other international neurosurgical societies have successfully developed programming. The CNS has led with a robust educational platform and offerings for neurosurgeons through in-person courses, fellowships, webinars, online case databases (2), publications, guidelines, and virtual grand rounds. SANS online education and questions modules offer neurosurgeons the ability to learn and self-test to advance their fund of knowledge, education, and continuing education

Equity in Global Neurosurgery Publications: Breaking Down Barriers in Discourse

As neurosurgery steps into a new era of global collaboration in clinical care and teaching, the academic opportunities for neurosurgeons in lower resource countries lag behind their counterparts in higher income countries. Halting the perpetuation of this historical divide requires a conscious effort in our community to equalize opportunities – not only in clinical care, but in research, publication, and mentorship opportunities. How can we render access to scientific opportunities more equitable worldwide? One solution is to give neurosurgeons an open platform that supports those interested in the global-scale advancement of our field, such as the Journal of Global Neurosurgery. This inaugural issue signals an important step in broadening research horizons and opportunities in neurosurgery across regions and national borders.

Online action planning forums to develop a roadmap to mitigate the impact of COVID-19 on the delivery of global children’s surgical care

Purpose
We aimed to understand the challenges facing children’s surgical care providers globally and realistic interventions to mitigate the catastrophic impact of COVID-19 on children’s surgery.

Methods
Two online Action Planning Forums (APFs) were organized by the Global Initiative for Children’s Surgery (GICS) with a geographically diverse panel representing four children’s surgical, anesthesia, and nursing subspecialties. Qualitative analysis was performed to identify codes, themes, and subthemes.

Results
The most frequently reported challenges were delayed access to care for children; fear among the public and patients; unavailability of appropriate personal protective equipment (PPE); diversion of resources toward COVID-19 care; and interruption in student and trainee hands-on education. To address these challenges, panelists recommended human resource and funding support to minimize backlog; setting up international, multi-center studies for systematic data collection specifically for children; providing online educational opportunities for trainees and students in the form of large and small group discussions; developing best practice guidelines; and, most importantly, adapting solutions to local needs.

Conclusion
Identification of key challenges and interventions to mitigate the impact of the COVID-19 pandemic on global children’s surgery via an objective, targeted needs assessment serves as an essential first step. Key interventions in these areas are underway.