Some surgeons believe that internal fixation of fractures carries too high a risk of infection in low-income countries (LICs) to merit its use there. However, there have been too few studies from LICs with sufficient follow-up to support this belief. We first wanted to determine whether complete follow-up could be achieved in an LIC, and secondly, we wanted to find the true microbial infection rate at our hospital and to examine the influence of HIV infection and lack of follow-up on outcomes.137 patients with 141 femoral fractures that were treated with intramedullary (IM) nailing were included. We compared outcomes in patients who returned for scheduled follow-up and patients who did not return but who could be contacted by phone or visited in their home village.79 patients returned for follow-up as scheduled; 29 of the remaining patients were reached by phone or outreach visits, giving a total follow-up rate of 79%. 7 patients (5%) had a deep postoperative infection. All of them returned for scheduled follow-up. There were no infections in patients who did not return for follow-up, as compared to 8 of 83 nails in the group that did return as scheduled (p = 0.1). 2 deaths occurred in HIV-positive patients (2/23), while no HIV-negative patients (0/105) died less than 30 days after surgery (p = 0.03).We found an acceptable infection rate. The risk of infection should not be used as an argument against IM nailing of femoral fractures in LICs. Many patients in Malawi did not return for follow-up because they had no complaints concerning the fracture. There was an increased postoperative mortality rate in HIV-positive patients.
Recent health policy efforts have sought to promote universal health coverage (UHC) as a means of providing affordable access to health services to populations. However, insurance schemes are heterogeneous, and some schemes may not provide necessary services to those covered. We explored the prevalence and determinants of ineffective insurance across 42 lower and middle income countries (LMICs) from the 2002-2004 World Health Survey.Respondents were defined as having ineffective health insurance if they reported being insured and: were forced to borrow or sell personal items to pay for health services; had an untreated chronic condition; or had recently delivered a child outside of a skilled health facility (women only).Among the insured, 13% had ineffective insurance, which was most commonly due to having to borrow or sell to pay for health care. The likelihood of ineffective insurance was lowest in upper-middle income countries and higher in other lower-middle and low-income countries. Ineffective insurance also decreased with family wealth and was higher among rural residents.Our findings suggest that a high proportion of insurance in LMICs is ineffective, particularly among those who need it most, and that attention should be paid to effectiveness when defining health insurance in policy conversations about UHC.