The true costs of cesarean delivery for patients in rural Rwanda: Accounting for post-discharge expenses in estimated health expenditures

Introduction
While it is recognized that there are costs associated with postoperative patient follow-up, risk assessments of catastrophic health expenditures (CHEs) due to surgery in sub-Saharan Africa rarely include expenses after discharge. We describe patient-level costs for cesarean section (c-section) and follow-up care up to postoperative day (POD) 30 and evaluate the contribution of follow-up to CHEs in rural Rwanda.

Methods
We interviewed women who delivered via c-section at Kirehe District Hospital between September 2019 and February 2020. Expenditure details were captured on an adapted surgical indicator financial survey tool and extracted from the hospital billing system. CHE was defined as health expenditure of ≥ 10% of annual household expenditure. We report the cost of c-section up to 30 days after discharge, the rate of CHE among c-section patients stratified by in-hospital costs and post-discharge follow-up costs, and the main contributors to c-section follow-up costs. We performed a multivariate logistic regression using a backward stepwise process to determine independent predictors of CHE at POD30 at α ≤ 0.05.

Results
Of the 479 participants in this study, 90% were classified as impoverished before surgery and an additional 6.4% were impoverished by the c-section. The median out-of-pocket costs up to POD30 was US$122.16 (IQR: $102.94, $148.11); 63% of these expenditures were attributed to post-discharge expenses or lost opportunity costs (US$77.50; IQR: $67.70, $95.60). To afford c-section care, 64.4% borrowed money and 18.4% sold possessions. The CHE rate was 27% when only considering direct and indirect costs up to the time of discharge and 77% when including the reported expenses up to POD30. Transportation and lost household wages were the largest contributors to post-discharge costs. Further, CHE at POD30 was independently predicted by membership in community-based health insurance (aOR = 3.40, 95% CI: 1.21,9.60), being a farmer (aOR = 2.25, 95% CI:1.00,3.03), primary school education (aOR = 2.35, 95% CI:1.91,4.66), and small household sizes had 0.22 lower odds of experiencing CHE compared to large households (aOR = 0.78, 95% CI:0.66,0.91).

Conclusion
Costs associated with surgical follow-up are often neglected in financial risk calculations but contribute significantly to the risk of CHE in rural Rwanda. Insurance coverage for direct medical costs is insufficient to protect against CHE. Innovative follow-up solutions to reduce costs of patient transport and compensate for household lost wages need to be considered.

Effect of Door-to-Door Screening and Awareness Generation Activities in the Catchment Areas of Vision Centers on Service Use: Protocol for a Randomized Experimental Study

Background:
A vision center (VC) is a significant eye care service model to strengthen primary eye care services. VCs have been set up at the block level, covering a population of 150,000-250,000 in rural areas in North India. Inadequate use by rural communities is a major challenge to sustainability of these VCs. This not only reduces the community’s vision improvement potential but also impacts self-sustainability and limits expansion of services in rural areas. The current literature reports a lack of awareness regarding eye diseases and the need for care, social stigmas, low priority being given to eye problems, prevailing gender discrimination, cost, and dependence on caregivers as factors preventing the use of primary eye care.

Objective:
Our organization is planning an awareness-cum-engagement intervention—door-to-door basic eye checkup and visual acuity screening in VCs coverage areas—to connect with the community and improve the rational use of VCs.

Methods:
In this randomized, parallel-group experimental study, we will select 2 VCs each for the intervention arm and the control arm from among poor, low-performing VCs (ie, walk-in of ≤10 patients/day) in our 2 operational regions (Vrindavan, Mathura District, and Mohammadi, Kheri District) of Uttar Pradesh. Intervention will include door-to-door screening and awareness generation in 8-12 villages surrounding the VCs, and control VCs will follow existing practices of awareness generation through community activities and health talks. Data will be collected from each VC for 4 months of intervention. Primary outcomes will be an increase in the number of walk-in patients, spectacle advise and uptake, referral and uptake for cataract and specialty surgery, and operational expenses. Secondary outcomes will be uptake of refraction correction and referrals for cataract and other eye conditions. Differences in the number of walk-in patients, referrals, uptake of services, and cost involved will be analyzed.

Results:
Background work involved planning of interventions and selection of VCs has been completed. Participant recruitment has begun and is currently in progress.

Conclusions:
Through this study, we will analyze whether our door-to-door intervention is effective in increasing the number of visits to a VC and, thus, overall sustainability. We will also study the cost-effectiveness of this intervention to recommend its scalability.

The True Costs of Cesarean Sections for Patients in Rural Rwanda: Accounting for Post-Discharge Expenses in Estimated Health Expenditures

Introduction: While it is recognized that there are costs associated with postoperative patient follow-up, risk assessments of catastrophic health expenditures (CHEs) due to surgery in sub-Saharan Africa rarely include expenses after discharge. We describe patient-level costs for cesarean section (c-section) and follow-up care up to postoperative day (POD) 30 and evaluate the contribution of follow-up to CHEs in rural Rwanda.

Methods: We interviewed women who delivered via c-section at Kirehe District Hospital between September 2019 and February 2020. Expenditure details were captured on an adapted surgical indicator financial survey tool and extracted from the hospital billing system. CHE was defined as health expenditure of ≥ 10% of annual household expenditure. We report the cost of c-section up to 30 days after discharge, the rate of CHE among c-section patients stratified by in-hospital costs and post-discharge follow-up costs, and the main contributors to c-section follow-up costs.

Results: Of the 479 participants in this study, 90% were classified as impoverished before surgery and an additional 6.4% were impoverished by the c-section. The median out-of-pocket costs up to POD30 was US$122.16 (IQR: $102.94, $148.11); 63% of these expenditures were attributed to post-discharge expenses or lost opportunity costs (US$77.50; IQR: $67.70, $95.60). To afford c-section care, 64.4% borrowed money and 18.4% sold possessions. The CHE rate was 27% when only considering direct and indirect costs up to the time of discharge and 77% when including the reported expenses up to POD30. Transportation and lost household wages were the largest contributors to post-discharge costs.

Conclusion: Costs associated with surgical follow-up are often neglected in financial risk calculations but contribute significantly to the risk of CHE in rural Rwanda. Insurance coverage for direct medical costs is insufficient to protect against CHE. Innovative follow-up solutions to reduce costs of patient transport and compensate for household lost wages need to be considered.

Interventions for health workforce retention in rural and remote areas: a systematic review

Background
Attracting and retaining sufficient health workers to provide adequate services for residents of rural and remote areas has global significance. High income countries (HICs) face challenges in staffing rural areas, which are often perceived by health workers as less attractive workplaces. The objective of this review was to examine the quantifiable associations between interventions to retain health workers in rural and remote areas of HICs, and workforce retention.

Methods
The review considers studies of rural or remote health workers in HICs where participants have experienced interventions, support measures or incentive programs intended to increase retention. Experimental, quasi-experimental and observational study designs including cohort, case–control, cross-sectional and case series studies published since 2010 were eligible for inclusion. The Joanna Briggs Institute methodology for reviews of risk and aetiology was used. Databases searched included MEDLINE (OVID), CINAHL (EBSCO), Embase, Web of Science and Informit.

Results
Of 2649 identified articles, 34 were included, with a total of 58,188 participants. All study designs were observational, limiting certainty of findings. Evidence relating to the retention of non-medical health professionals was scant. There is growing evidence that preferential selection of students who grew up in a rural area is associated with increased rural retention. Undertaking substantial lengths of rural training during basic university training or during post-graduate training were each associated with higher rural retention, as was supporting existing rural health professionals to extend their skills or upgrade their qualifications. Regulatory interventions requiring return-of-service (ROS) in a rural area in exchange for visa waivers, access to professional licenses or provider numbers were associated with comparatively low rural retention, especially once the ROS period was complete. Rural retention was higher if ROS was in exchange for loan repayments.

Conclusion
Educational interventions such as preferential selection of rural students and distributed training in rural areas are associated with increased rural retention of health professionals. Strongly coercive interventions are associated with comparatively lower rural retention than interventions that involve less coercion. Policy makers seeking rural retention in the medium and longer term would be prudent to strengthen rural training pathways and limit the use of strongly coercive interventions.

Does health insurance contribute to improved utilization of health care services for the elderly in rural Tanzania? A cross-sectional study

Background: Health care systems in developing countries such as Tanzania depend heavily on out-of-pocket payments. This mechanism contributes to inefficiency, inequity and cost, and is a barrier to patients seeking access to care. There are efforts to expand health insurance coverage to vulnerable groups, including older adults, in Sub-Saharan African countries.

Objective: To analyse the association between health insurance and health service use in rural residents aged 60 and above in Tanzania.

Methods: Data were obtained from a household survey conducted in the Nzega and Igunga districts. A standardised survey instrument from the World Health Organization Study on global AGEing and adult health was used. This comprised of questions regarding demographic and socio-economic characteristics, health and insurance status, health seeking behaviours, sickness history (three months and one year prior to the survey), and the receipt of health care. A multistage sampling method was used to select wards, villages and respondents in each district. Local ward and hamlet officers guided the researchers in identifying households with older people. Crude and adjusted logistic regression methods were used to explore associations between health insurance and outpatient and inpatient health care use.

Results: The study sample comprised 1,899 people aged 60 and above of whom 44% reported having health insurance. A positive statistically significant association between health insurance and the utilisation of outpatient and inpatient care was observed in all models. The odds of using outpatient (adjusted OR = 2.20; 95% CI: 1.54, 3.14) and inpatient services (adjusted OR = 3.20; 95% CI: 2.46, 4.15) were higher among the insured.

Conclusion: Health insurance is a predictor of outpatient and inpatient health services in people aged 60 and above in rural Tanzania. Further research is needed to understand the perceptions of both the insured and uninsured regarding the quality of care received.

Safe Laparoscopy in Low and Middle Income Countries by reducing Surgical Site Infections through Laparoscopic Instrument Cleaning

Access to safe and affordable surgery is nothing short of a basic human right and people from all walks of life are entitled to it. But, five people from resource-constrained low and middle-income countries are vulnerable and left to fend for themselves when the need for surgery is a life governing event. Inhabitants of these regions are scourged by high mortality and morbidity due to surgical infection caused by the use of unclean and unsterile surgical instruments. Reduction in infections can be achieved by using clean and sterile surgical instruments. Laparoscopy, is a promising technique of surgery developed to efficiently perform complex abdominal surgeries with the use of small and minimum incisions on the patient. Laparoscopy’s minimally invasive nature allows complex surgeries to take place without the need of an absolutely sterile operating room, although the sterility of the surgical instruments cannot be compromised. The added benefit of faster recovery from smaller wounds makes it even more desirable for this context. The Minimally Invasive Surgery and Interventional Techniques Lab of the TU Delft has initiated projects addressing the health and well-being of resource-constrained, underdeveloped communities like rural India through frugal innovation. Rural Indian hospitals are grossly underfunded, under-maintained, and understaffed. Sterile processing practices in rural India are rudimentary compared to high-income hospitals like the ones in the Netherlands. In high-income hospitals, all used surgical instruments are cleaned and sterilized in dedicated central sterile processing departments (CSSD) by highly trained and well protected sterile processing technicians. However, rural India usually employs small teams of local undertrained and semi-literate nurses to carry out every primary and ancillary duty in the hospital. The lack of dedicated CSSDs exacerbates the nurse’s workload and exposure to harmful pathogenic surgical instruments. Laparoscopic instruments developed in high-income nations are seldom designed keeping low resource contexts in mind. The geometrical complexity of instruments keeps increasing but cleaning methods in rural India have stagnated. Resource constraints are a major reason as to why proper international and national guidelines for reprocessing cannot be followed. Hence hospitals cannot guarantee 100% safe and sterile instruments as compared so standardized outcomes in high-income hospitals. In this graduation project, the distinct reprocessing journey of surgical instruments for the two diverse economic contexts were studied. A comparative analysis of both reprocessing journeys uncovered severe unsafe and unfavorable practices in rural India. Significant data and insights from the research have hence paved the way for focusing on the “Cleaning” stage of the laparoscopic instrument reprocessing journey in rural India. This MSc graduation project aims at designing a frugal solution for cleaning and repurposing laparoscopic instruments, dedicated to hospitals in rural India where the demand for laparoscopy is high but surgeries are less due to resource constraints like lack of laparoscopic instruments and repurposing devices. The involvement of an Indian nurse and laparoscopic surgeon provided first-hand information about the problems and requirements in the rural Indian context. Prototyping and testing of various cleaning setups were conducted to extract the most viable design solution. Insights from the research and testing were combined into the concept design of a frugal mechanical washer and subsequently an “Envisioned Reprocessing Journey” for rural Indian hospitals to suggest a standard protocol for keeping most of their existing infrastructure in mind. Evaluations with the Indian nurse revealed that this device could indeed be a game-changer to the existing practices of reprocessing laparoscopic instruments in rural India.

Appendicitis: Rural Patient Status is Associated with Increased Duration of Prehospital Symptoms and Worse Outcomes in High- and Low-Middle-Income Countries.

Introduction
Appendicitis is a significant economic and healthcare burden in low-, middle-, and high-income countries. We aimed to determine whether urban and rural patient status would affect outcomes in appendicitis in a combined population regardless of country of economic status. We hypothesize that patients from rural areas and both high- and low-middle-income countries would have disproportionate outcomes and duration of symptoms compared to their urban counterparts.

Methods
Adults (≥18 years) with appendicitis during 2010–2016 in South Africa and USA were reviewed using multi-institutional data. Baseline demographic, operative details, durations of stay, and complications (Clavien–Dindo index) were collected. AAST grades were assigned by two independent reviewers based on operative findings. Summary, univariate, and multivariable analyses of rural and urban patients in both countries were performed.

Results
There were 2602 patients with a median interquartile range [IQR] of 26 [18–40] years; 45% were female. Initial management included McBurney incisions (n = 458, 18%), laparotomy (n = 915, 35%), laparoscopic appendectomy (n = 1185, 45%), and laparoscopy converted to laparotomy (n = 44, 2%). Comparing rural versus urban patient status, there were increased overall median [IQR] AAST grades (3 [1–5] vs. 2 [1–3], p = 0.001), prehospital duration of symptoms (2 [1–5] vs. 2 [1–3], p = 0.001), complications (44.3 vs. 23%, p = 0.001), and need for temporary abdominal closure (20.3 vs. 6.9%, p = 0.001).

Conclusion
Despite socioeconomic status and country of origin, patients from more rural environments demonstrate poorer outcomes notwithstanding significant differences in overall disease severity. The AAST grading system may serve a potential benchmark to recognize areas with disparate disease burdens. This information could be used for strategic improvements for surgeon placement and availability.

Exploring perceptions of common practices immediately following burn injuries in rural communities of Bangladesh

Background
Burns can be the most devastating injuries in the world, they constitute a global public health problem and cause widespread public health concern. Every year in Bangladesh more than 365,000 people are injured by electrical, thermal and other causes of burn injuries. Among them 27,000 need hospital admission and over 5600 people die. Immediate treatment and medication has been found to be significant in the success of recovering from a burn. However, common practices used in the treatment of burn injuries in the community is not well documented in Bangladesh. This study was designed to explore the perception of local communities in Bangladesh the common practices used and health-seeking behaviors sought immediately after a burn injury has occurred.

Methods
A qualitative study was conducted using Focus Group Discussions (FGD) as the data collection method. Six unions of three districts in rural Bangladesh were randomly selected and FGDs were conducted in these districts with six burn survivors and their relatives and neighbours. Data were analyzed manually, codes were identified and the grouped into themes.

Results
The participants stated that burn injuries are common during the winter in Bangladesh. Inhabitants in the rural areas said that it was common practice, and correct, to apply the following to the injured area immediately after a burn: egg albumin, salty water, toothpaste, kerosene, coconut oil, cow dung or soil. Some also believed that applying water is harmful to a burn injury. Most participants did not know about any referral system for burn patients. They expressed their dissatisfaction about the lack of available health service facilities at the recommended health care centers at both the district level and above.

Conclusions
In rural Bangladesh, the current first-aid practices for burn injuries are incorrect; there is a widely held belief that using water on burns is harmful.