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

The evaluation of a surgical task-sharing program in South Sudan

Background: Five billion people lack timely, affordable, and safe surgical services. Sub-Saharan Africa (SSA) is the region with the scarcest access to surgical care. The surgical workforce is crucial in closing this gap. In SSA, South Sudan has one of the lowest surgical workforce density. Task-sharing being a cost-effective training method, in 2019, the University of British Columbia collaborated with Médecins Sans Frontières to create the Essential Surgical Skills program and launched it in South Sudan. This study aims to evaluate this pilot program. Methods: This is a mixed-method prospective cohort study. Quantitative data include pre- and post-training outputs (number and types of surgeries, complication, re-operation, and mortality) and surgical proficiency of the trainees (quiz, Entrustable Professional Activity (EPA), and logbook data), and online survey for trainers. Semi-structured interviews were performed with trainees at the program completion. Results: Since July 2019, trainees performed 385 operations. The most common procedures were skin graft (14.8%), abscess drainage (9.61%), wound debridement and transverse laparotomy (7.79% each). 172 EPAs have been completed, out of which 136 (79%) showed that the trainee could independently perform the procedure. During the training, the operating room and surgical ward mortality remained similar to the pre-training phase. Furthermore, the surgical morbidity decreased from 25% to less than 5%. The pass rate for all quizzes was 100%. Interviews and survey showed that trainees’ surgical knowledge, interprofessional teamwork, trainers’ global insight on surgical training in Low- and Middle-Income Countries (LMICs), and patient care has improved. Also, the program empowered trainees, developed career path, and local acceptance and retention. The modules were relevant to community needs. Conclusions: This study casts light on the feasibility of training surgeons through a virtual platform in under-resourced regions. The COVID-19 global pandemic highlighted the need to make LMICs independent from fly-in trainers and traditional apprenticeship. Knowledge translation of this training platform’s evaluation will hopefully inform Ministries of Health and their partners to develop their National Surgical, Obstetric and Anesthesia Plans (NSOAPs). Furthermore, thanks to its scalability, both across levels of training and geography, it paves the way for virtual surgical education everywhere in the world.

Infection Prevention and Control at Lira University Hospital, Uganda: More Needs to Be Done

Globally, 5%–15% of hospitalized patients acquire infections (often caused by antimicrobial-resistant microbes) due to inadequate infection prevention and control (IPC) measures. We used the World Health Organization’s (WHO) ‘Infection Prevention and Control Assessment Framework’ (IPCAF) tool to assess the IPC compliance at Lira University hospital (LUH), a teaching hospital in Uganda. We also characterized challenges in completing the tool. This was a hospital-based, cross-sectional study conducted in November 2020. The IPC focal person at LUH completed the WHO IPCAF tool. Responses were validated, scored, and interpreted per WHO guidelines. The overall IPC compliance score at LUH was 225/800 (28.5%), implying a basic IPC compliance level. There was no IPC committee, no IPC team, and no budgets. Training was rarely or never conducted. There was no surveillance system and no monitoring/audit of IPC activities. Bed capacity, water, electricity, and disposal of hospital waste were adequate. Disposables and personal protective equipment were not available in appropriate quantities. Major challenges in completing the IPCAF tool were related to the detailed questions requiring repeated consultation with other hospital stakeholders and the long time it took to complete the tool. IPC compliance at LUH was not optimal. The gaps identified need to be addressed urgently.

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.

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.

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

Role of North America and AANS in Global Neurosurgery

Approximately 28% of the global burden of disease is surgical (1). There is an estimated deficit of 90,909 neurosurgeons globally, who must care for an additional 14 million neurosurgical patients annually (2). In a study published by Alkire et al. on global access to surgical care, it was revealed that approximately two-thirds of the world’s population, comprising 4.8 billion people, do not have access to timely, affordable, or safe surgical care. The study also concluded that 99.3% of Lower-Income Countries (LICs) and 96.7% of Lower Middle-Income Countries (LMICs) populations do not have access to safe surgery (3).

Historically, global health policies focused on specific issues like access to healthcare and outcomes of infectious disease treatment and vaccinations. In January 2014, the Lancet Commission on Global Surgery (LCoGS), headed by healthcare leaders from 111 countries, gathered in Boston to research and propose strategies to improve surgery access globally. One of the committee’s goals was to bring surgeons from different socio-economic strata under one roof to facilitate collaboration and fruitful exchange of ideas. The committee also motivated the higher-income countries of North America to collaborate and shrink the existing hiatus in surgical access present in lower and middle-income countries (4). Since then, significant progress has been achieved in this regard under the leadership of North American academic institutes, neurosurgical societies, non-governmental organizations (NGOs), and even individual surgeons

Tracking global development assistance for trauma care: A call for advocacy and action

Background: This study aimed to track development assistance for trauma care (DAH-TC), uncover funding trends and gaps, and compare DAH-TC to development assistance for other health conditions.

Methods: A systematic search of the OECD Creditor Reporting System (CRS) and Development Assistance Committee (DAC) databases was performed to capture projects related to trauma care. Reports from large foundations and public-private partnerships were also searched. DAH-TC was described, and comparisons were made between DAH-TC and other health conditions.

Results: The search yielded 1754 records; after applying exclusion criteria, 301 records were included for analysis. During the 25-year period, US$93.7M of DAH-TC was disbursed to low- and middle-income countries (LMICs) (0.02% of total DAH). Contributions were dominated by a few donors and fluctuated dramatically over time. A sizable portion of DAH-TC came in the form of investments to build infrastructure (38% of DAH-TC); information and research activities (17%); and training (16%). Nearly US$58M (62% of DAH-TC) was funneled to projects that targeted victims of war. Trauma care received US$0.04 per DALY incurred, while malaria, TB, HIV and MCH received US$9.62 per DALY, US$25.09 per DALY, US$4.05 per DALY and US$45.75 per DALY, respectively.

Conclusions: DAH-TC is critically underfunded, particularly compared to other health foci. To improve the DAH-TC landscape, stakeholders can better mobilize domestic resources; use advocacy more effectively by catalyzing network convergence, grafting trauma care onto related high-priority issues, and seeking broader coalitions; and develop partners within the donor and channel communities to promote strategic DAH-TC disbursements.

Global Neurosurgery: A call to Action

Global health organizations have highlighted the inequalities that exist in health services around the globe. Although the disparities in medical care are real, the differences in surgical care are often more significant but do not receive the same attention and resources, and only as recently as 2015 was surgery established as a global health priority. That year, the Lancet Commission released their Global Surgery 2030 instrumental report on the tremendous lack of surgical care globally and the need for a focus on addressing this issue: 5 billion people do not have access to safe and affordable surgical and anesthetic care, 143 million additional surgeries are needed each year, and 33 million people face catastrophic health expenditure each year due to payments for such care (1).

When it comes to surgical subspecialties such as neurological surgery, access to care goes from being a disparity to a complete absence in some cases. Large areas of the world, especially in low and middle-income countries (LMIC’s), suffer ratios of one neurosurgeon for every 10 million people, in which case access to neurosurgical care is no longer a right but a luxury

Development and content validation of the Safe Surgery Organizational Readiness Tool: A quality improvement study

Background
Recent efforts to increase access to safe and high-quality surgical care in low- and middle-income countries have proven successful. However, multiple facilities implementing the same safety and quality improvement interventions may not all achieve successful outcomes. This heterogeneity could be explained, in part, by pre-intervention organizational characteristics and lack of readiness of surgical facilities. In this study, we describe the process of developing and content validating the Safe Surgery Organizational Readiness Tool.

Materials and methods
The new tool was developed in two stages. First, qualitative results from a Safe Surgery 2020 intervention were combined with findings from a literature review of organizational readiness and change. Second, through iterative discussions and expert review, the Safe Surgery Organizational Readiness Tool was content validated.

Results
The Safe Surgery Organizational Readiness Tool includes 14 domains and 56 items measuring the readiness of surgical facilities in low- and middle-income countries to implement surgical safety and quality improvement interventions. This multi-dimensional and multi-level tool offers insights into facility members’ beliefs and attitudes at the individual, team, and facility levels. A panel review affirmed the content validity of the Safe Surgery Organizational Readiness Tool.

Conclusion
The Safe Surgery Organizational Readiness Tool is a theory- and evidence-based tool that can be used by change agents and facility leaders in low- and middle-income countries to assess the baseline readiness of surgical facilities to implement surgical safety and quality improvement interventions. Next steps include assessing the reliability and validity of the Safe Surgery Organizational Readiness Tool, likely resulting in refinements.