Hospitalized for poverty: orthopaedic discharge delays due to financial hardship in a tertiary hospital in Northern Tanzania

Background
Musculoskeletal injury contributes significantly to the burden of disease in Tanzania and other LMICs. For hospitals to cope financially with this burden, they often mandate that patients pay their entire hospital bill before leaving the hospital. This creates a phenomenon of patients who remain hospitalized solely due to financial hardship. This study aims to characterize the impact of this policy on patients and hospital systems in resource-limited settings.

Methods
A mixed-methods study using retrospective medical record review and semi-structured interviews was conducted at a tertiary hospital in Moshi, Tanzania. Information regarding patient demographics, injury type, days spent in the ward after medical clearance for discharge, and hospital invoices were collected and analyzed for orthopaedic patients treated from November 2016 to June 2017.

Results
346 of the 867 orthopaedic patients (39.9%) treated during this time period were found to have spent additional days in the hospital due to their inability to pay their hospital bill. Of these patients, 72 patient charts were analyzed. These 72 patients spent an average of 9 additional days in the hospital due to financial hardship (range: 1–64 days; interquartile range: 2–10.5 days). They spent an average of 112,958 Tanzanian Shillings (TSH) to pay for services received following medical clearance for discharge, representing 12.3% of the average total bill (916,840 TSH). 646 hospital bed-days were spent on these 72 patients when they no longer clinically required hospitalization. 7 (9.7%) patients eloped from the hospital without paying and 24 (33.3%) received financial assistance from the hospital’s social welfare office.

Conclusions
Many patients do not have the financial capacity to pay hospital fees prior to discharge. This reality has added significantly to these patients’ overall financial hardship and has taken hundreds of bed-days from other critically ill patients. This single-institution, cross-sectional study provides a deeper understanding of this phenomenon and highlights the need for changes in the healthcare payment structure in Tanzania and other comparable settings.

Telesurgery’s potential role in improving surgical access in Africa

An estimated five billion people worldwide lack access to surgical care, while LMICs including African nations require an additional 143 million life-saving surgical procedures each year.African hospitals are under-resourced and understaffed, causing global attention to be focused on improving surgical access in the continent. The African continent saw its first telesurgery application when the United States Army Special Operations Forces in Somalia used augmented reality to stabilize lifethreatening injuries.Various studies have been conducted since the first telesurgery implementation in 2001 to further optimize its application.In context of a relative shortage of healthcare resources and personnel telesurgery can considerably improve quality and access to surgical services in Africa.telesurgery can provide remote African regions with access to knowledge and tools that were previously unavailable, driving innovative research and professional growth of surgeons in the region.At the same time, telesurgery allows less trained surgeons in remote areas with lower social determinants of health, such as access, to achieve better health outcomes. However, lack of stable internet access, expensive equipment costs combined with low expenditure on healthcare limits expansive utilization of telesurgery in Africa. Regional and international policies aimed at overcoming these obstacles can improve access, optimize surgical care and thereby reduce disease burden associated with surgical conditions in Africa.

Early treatment of corneal abrasions and ulcers–estimating clinical and economic outcomes

Background
In low-and-middle income countries, corneal abrasions and ulcers are common and not always well managed. Previous studies showed better clinical outcomes with early presentation and treatment of minor abrasions, however, there have been no formal studies estimating the financial impact of early treatment of abrasions and ulcers compared to delayed treatment.

Methods
We used the LV Prasad Eye Institute’s (LVPEI’s) electronic health record system (eyeSmart) to estimate the impact of early presentation on clinical outcomes associated with abrasions and ulcers. 861 patients with corneal abrasion and 1821 patients with corneal ulcers were studied retrospectively, and 134 patients with corneal abrasion prospectively. A health economic model was constructed based on LVPEI cost data for a range of patient scenarios (from early presentation with abrasion to late presentation with ulcer).

Findings
Our findings suggest that delayed presentation of corneal abrasion results in poor clinical and economic outcomes due to increased risk of ulceration requiring more extensive surgical management, increasing associated costs to patients and the healthcare system. However, excellent results at low cost can be achieved by treatment of patients with early presentation of abrasions at village level health care centres.

Interpretation
Treatment of early minor corneal abrasions, particularly using local delivery of treatment, is effective clinically and economically. Future investment in making patients aware of the need to react promptly to corneal abrasions by accessing local healthcare resources (coupled with a campaign to prevent ulcerations occurring) will continue to improve clinical outcomes for patients at low cost and avoid complex and more expensive treatment to preserve sight.

Funding
This research was funded by the Medical Research Council, grant MR/S004688/1.

Global Neurosurgery in the Context of Global Public Health Practice–A Literature Review of Case Studies

Neurosurgical conditions are a substantial contributor to surgical burden worldwide, with low- and middle-income countries carrying a disproportionately large part. Policy initiatives such as the National Surgical, Obstetrics and Anesthesia Plans and Comprehensive Policy Recommendations for the Management of Spina Bifida and Hydrocephalus in Low-and-Middle-Income countries have highlighted the need for an intersectoral approach, not just at the hospital level but on a large scale encompassing national public health strategies. This article aims to show through case studies how addressing this surgical burden is not limited to the clinical context but extends to public health strategies as well.

For example, vitamin B12 and folic acid are micronutrients that, if not at adequate levels, can result in debilitating neurosurgical conditions. In Ethiopia, through coalesced efforts between neurosurgeons and policy makers, the government has made strides in implementing food fortification programs at a national level to address the neurosurgical burden. Traumatic brain injuries (TBIs) are another neurosurgical burden that unevenly affects LMICs. Countries such as Colombia and India have shown the importance of legislation and enforcement, coupled with robust data collection and auditing systems; strong academic advocacy of neurosurgeons can drastically reduce TBIs.

Despite the importance of public health efforts in addressing neurosurgical conditions, there is a lack of neurosurgeon involvement in public health and lack of integration of neurosurgical burden in national health planning systems. It is imperative that neurosurgeons advocate for and are included in aspects of public health policy. Neurosurgery does not stop within the bounds of the hospital, and neither should the role of a neurosurgeons

Two decades of Tanzanian health policy

Tanzania has undertaken important health sector reforms in the new millennium, and the most recent Health Sector Strategic Plan (2021–26) lays out ambitious targets to achieve universal health coverage. Yet, women in Tanzania continue to face significant barriers in accessing healthcare and the country is grappling with important gender-biased health challenges disadvantaging women. The aims of this paper are two-fold. First, we examine the evolution of Tanzania’s health policy over the past two decades (2000–21) from the perspective of enhancing financial protection for working-age women. Second, we explore policy options for genderresponsive health insurance expansion in the context of Tanzania. Methodologically, the paper draws on a scoping study of diverse literature and data and a review of evidence from other contexts with public health insurance schemes. We find that Tanzania has a fragmented health system that relies on several independent schemes introduced throughout the years, characterized by insufficient risk-pooling. Such a system provides insufficient financial protection for workingage women and female-headed households, which are financially less secure than dual-earner households. Although expanding health insurance coverage represents a viable corrective measure, future reforms must account for women’s lower financial contribution capacity to enable equitable access. Additionally, the policy design requires gender-mainstreamed investments in awarenessraising, service quality, and benefit packages

Estimating the emergency care workforce in South Africa

Background: Emergency care is viewed as a fundamental human right in South Africa’s constitution. In the public sector, all emergency medical services (EMS) come under the Directorate: Emergency Medical Services and Disaster Medicine at the National Department of Health (NDoH), which provides regulation, policy and oversight guidance to provincial structures.

Aim: The aim of the study is to understand the supply and status of human resources for EMS in South Africa.

Setting: This research was undertaken for South Africa using the Health Professions Council of South Africa (HPCSA) database from 2002 to 2019.

Methods: A retrospective record-based review of the HPCSA database was undertaken to estimate the current registered and future need for emergency care personnel forecasted up to 2030.

Results: There are 76% Basic Ambulance Assistants registered with HPCSA. An additional 96 000 personnel will be required in 2030 to maintain the current ratio of 95.9 registered emergency care personnel per 100 000 population. The profile of an emergency care personnel employed in South Africa is likely to be a black male in the age group of 30–39-years, residing in one of the economically better-resourced provinces.

Conclusion: It is time that the current educational framework is revised. Policy interventions must be undertaken to avoid future shortages of the trained emergency care personnel within South Africa.

Association between government policy and delays in emergent and elective surgical care during the COVID-19 pandemic in Brazil: a modeling study

Background
The impact of public health policy to reduce the spread of COVID-19 on access to surgical care is poorly defined. We aim to quantify the surgical backlog during the COVID-19 pandemic in the Brazilian public health system and determine the relationship between state-level policy response and the degree of state-level delays in public surgical care.

Methods
Monthly estimates of surgical procedures performed per state from January 2016 to December 2020 were obtained from Brazil’s Unified Health System Informatics Department. Forecasting models using historical surgical volume data before March 2020 (first reported COVID-19 case) were constructed to predict expected monthly operations from March through December 2020. Total, emergency, and elective surgical monthly backlogs were calculated by comparing reported volume to forecasted volume. Linear mixed effects models were used to model the relationship between public surgical delivery and two measures of health policy response: the COVID-19 Stringency Index (SI) and the Containment & Health Index (CHI) by state.

Findings
Between March and December 2020, the total surgical backlog included 1,119,433 (95% Confidence Interval 762,663–1,523,995) total operations, 161,321 (95%CI 37,468–395,478) emergent operations, and 928,758 (95%CI 675,202–1,208,769) elective operations. Increased SI and CHI scores were associated with reductions in emergent surgical delays but increases in elective surgical backlogs. The maximum government stringency (score = 100) reduced emergency delays to nearly zero but tripled the elective surgical backlog.

Interpretation
Strong health policy efforts to contain COVID-19 ensure minimal reductions in delivery of emergent surgery, but dramatically increase elective backlogs. Additional coordinated government efforts will be necessary to specifically address the increased elective backlogs that accompany stringent responses.

Barriers and enablers to country adoption of National Surgical, Obstetric, and Anesthesia Plans

This paper examines the adoption and diffusion of National Surgical Obstetric and Anaesthesia Plans (NSOAPs), a policy instrument, to improve surgical healthcare services in low- and middle-income countries (LMICs). It draws on recent trends in health system reform and empiricism to understand NSOAP effectiveness for large-scale improvement in surgical system objectives (surgical outcomes, patient satisfaction and financial risk protection). While the study reveals that NSOAP adoption has occurred in several countries, its translation into effective, responsive and equitable coverage of surgical healthcare services (diffusion) with enduring impact has yet to occur on a large-scale. NSOAP adoption and diffusion has been constrained by two principal considerations: (I) suboptimal funding allocation to develop NSOAPs and implement within a health system context; (II) inadequate translation of the NSOAP into implementable activities that lead to improved health system performance. We argue that a systems perspective—dynamically optimizing the NSOAP in relation to specific health system, adoption system, and contextual factors—may enhance the scale-up of NSOAPs and lead to sustainably funded programs that enhance the effectiveness, efficiency, responsiveness and equity of surgical healthcare service over the long-term. We explore three specific areas—technology, financing, governance—which could be harnessed to enhance the adoption and diffusion of NSOAPs.

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.

Shared learning in and beyond the COVID-19 pandemic

The COVID-19 pandemic has cost the lives of over 1.5 million people to date and resulted in severe surgical backlogs up to tens of millions of surgeries worldwide [1]. Steinmaurer and Bley [2] appropriately question whether the transformability of cardiac surgery in high-income country epicentres of the COVID-19 pandemic can lead to changes elsewhere in the world. Six billion people lack access to safe, timely and affordable cardiac surgical care when needed, and this pandemic has only aggravated disparities in access to care [3, 4]. As countries have adapted and vaccines are on the horizon, it is paramount to think above and beyond what we have learned in our specialty during these challenging times and recognize the sustained disparities across the globe.

These disparities can be further explored by assessing service provision and workforce capacity in low- and middle-income countries (LMICs). This is especially prominent in low-income countries, where 0.04 cardiac surgeons are available per million population compared to 7.15 in high-income countries [4]. The loss of even 1 surgeon can lead to disastrous consequences in service provision. Now, travel restrictions imposed due to the pandemic have substantially increased these discrepancies. LMIC centres acting as regional hubs, often offering free or subsidized surgery, have experienced significant volume reductions while adapting to COVID-19 responses [4]. The pandemic also affected visiting teams, who have been unable to reach regions where local capacity is scant. These issues signpost the need for urgent solutions.

The pandemic has emphasized the importance of a global health view for cardiac surgery. Mutual learning can act as a vector for exponential change and improvement in meeting these disparities. George et al. [5] have described multiple strategies used in the New-York Presbyterian Hospital within their cardiac surgical service such as split ventilation and using additional operating room space for intensive care beds. Such innovations may be utilized to increase the long-term cardiac surgical capacity in LMICs in intensive care units, which can be rate-limiting factors when deciding to take on new patients. In addition, personal protective equipment may be preserved by reducing the number of personnel scrubbed in and switching between operations [5]. This was mirrored in Boston Children’s Hospital, where do-it-yourself elastomeric respirators were developed as a result of N95 shortages [6]. With such low-cost options being successfully incorporated into high-performance units, these examples highlight the importance of shared learning and its symbiotic relationship.

The COVID-19 era has facilitated change in clinical practice to reach a new normal, but with recent developments of imminent vaccine rollout, there is hope for resolving the challenges presented to us both in the short and long terms. With high-income countries dictating and dominating vaccine distribution, we can expect a significant hiatus before adequate herd immunity can be established in LMICs. As a result of these economic imbalances, cardiovascular care disparities will continue to pose a substantial burden. It is our moral responsibility to recognize the privileged position we inhabit and use the experiences from this pandemic to fuel shared learning and bilateral partnerships.