A profile of surgical burden and anaesthesia services at Mozambique's Central Hospital: A review.

BACKGROUND: Surgical and anaesthesia data, including outcomes, remain limited in low-income countries (LIC). This study reviews the surgical burden and anaesthesia services at a tertiary care hospital in Mozambique. METHODS: Information on activities within the department of anaesthesia at Maputo Central Hospital for 2014-15 was collected from its annual report and verified by the Chairman of Anaesthesia. Personnel information and health care metrics for the hospital in 2015 were collected and verified by hospital leadership. RESULTS: Maputo Central Hospital has 1423 beds with 50.1% allocated to primary surgical services. 39.7% of total admissions were to surgical services, and in 2015 the hospital performed 10,049 major operations requiring anaesthesia. The OB/GYN service had the most operations with 2894 (28.8%), followed by general surgery (1665, 16.6%). Inpatient surgical mortality was 4.1% and surgical-related diagnoses comprised two of the top 9 causes of death, with malignant neoplasms and hemorrhage from trauma causing the highest mortality. In 2014-15, Maputo Central Hospital employed 15 anesthesiologists, with 4 advanced and 23 basic mid-level anaesthesia providers. Of 10,897 total anaesthesia cases in 2014, 6954 were general anaesthesia and 3925 were neuraxial anaesthesia. Other anaesthesia services included chronic pain and intensive care consultation. Anaesthesia department leadership noted a strong desire to improve data collection and analysis for anaesthesia outcomes and complications, requested an additional administrator for statistical analysis. DISCUSSION: This profile of anaesthesia services at a large tertiary hospital in Mozambique highlights several features of anaesthesia care and surgical burden in LICs, including challenges of resource limitations, patient comorbidity, and social dynamics present in Mozambique that contribute to prolonged hospital stays. As noted, enhanced data collection and analysis within the department and the hospital may be useful in identifying strategies to improve outcomes and patient safety.

Chronic Pain and Associated Factors in India and Nepal: A Pilot Study of the Vanderbilt Global Pain Survey.

BACKGROUND: Evaluation and treatment of chronic pain worldwide are limited by the lack of standardized assessment tools incorporating consistent definitions of pain chronicity and specific queries of known social and psychological risk factors for chronic pain. The Vanderbilt Global Pain Survey (VGPS) was developed as a tool to address these concerns, specifically in the low- and middle-income countries where global burden is highest. METHODS: The VGPS was developed using standardized and cross-culturally validated metrics, including the Brief Pain Inventory and World Health Organization Disability Assessment Scale, as well as the Pain Catastrophizing Scale, the Fibromyalgia Survey Questionnaire along with queries about pain attitudes to assess the prevalence of chronic pain and disability along with its psychosocial and emotional associations. The VGPS was piloted in both Nepal and India over a 1-month period in 2014, allowing for evaluation of this tool in 2 distinctly diverse cultures. RESULTS: Prevalence of chronic pain in Nepal and India was consistent with published data. The Nepali cohort displayed a pain point prevalence of 48%-50% along with some form of disability present in approximately one third of the past 30 days. Additionally, 11% of Nepalis recorded pain in 2 somatic sites and 39% of those surveyed documented a history of a traumatic event. In the Indian cohort, pain point prevalence was approximately 24% to 41% based on the question phrasing, and any form of disability was present in 6 of the last 30 days. Of the Indians surveyed, 11% reported pain in 2 somatic sites, with only 4% reporting a previous traumatic event. Overall, Nepal had significantly higher chronic pain prevalence, symptom severity, widespread pain, and self-reported previous traumatic events, yet lower reported pain severity. CONCLUSIONS: Our findings confirm prevalent chronic pain, while revealing pertinent cultural differences and survey limitations that will inform future assessment strategies. Specific areas for improvement identified in this VGPS pilot study included survey translation methodology, redundancy of embedded metrics and cultural limitations in representative sampling and in detecting the prevalence of mental health illness, catastrophizing behavior, and previous traumatic events. International expert consensus is needed.

International Disease Burden of Hand Burns: Perspective from the Global Health Arena.

Measuring the extent and impact of a health problem is key to being able to address it appropriately. This review uses available information within the framework of the Global Burden of Disease studies to estimate the disease burden due to burn injuries of the hands. The GBD indicates that since 1990 there has been an approximately 30% decrease in the disease burden related to burn injuries. The GBD methods have not been applied specifically to hand burns, but from available data, it is estimated that about 18 million people in the world suffer from sequelae of burns to the hands.

Access to Cesarean Section Will Reduce Maternal Mortality in Low-Income Countries: A Mathematical Model.

BACKGROUND: Despite global efforts to reduce the maternal mortality ratio (MMR) through the World Health Organization's (WHO) Millennium Development Goal 5 (MDG5), MMR remains unacceptably high in low-income countries (LICs). Maternal death and disability from hemorrhage, infection, and obstructed labor may be averted by timely cesarean section (CS). Most LICs have CS rates less than that recommended by the WHO. Without access to timely CS, it is unlikely that MMR in LICs will be further reduced. Our purpose was to measure the MMR gap between the current MMR in LICs and the MMR if LICs were to raise their CS rates to the WHO recommended levels (10-15 %). METHODS: This model makes the assumption that increasing the CS rates to the recommended rates of 10-15 % will similarly decrease the MMR in these LICs. WHO health statistics were used to generate estimated MMRs for countries with CS rates between 10 and 15 % (N = 14). A weighted MMR average was determined for these countries. This MMR was subtracted from the MMR of each LIC to determine the MMR gap. The percent decrease in MMR due to increasing CS rate was calculated and averaged across the LICs. RESULTS: We found an average 62.75 %, 95 %CI [56.38, 69.11 %] reduction in MMR when LICs increase their CS rates to WHO recommended levels (10-15 %). CONCLUSIONS: Maternal mortality is unacceptably high in LICs. Increasing CS rates to WHO recommended rates will decrease the maternal mortality in these countries, significantly decreasing the mortality ratio toward the projected MDG5.

Anesthetic Care in Mozambique.

BACKGROUND: The World Bank and Lancet Commission in 2015 have prioritized surgery in Low-Income Countries (LIC) and Lower-Middle Income Countries (LMICs). This is consistent with the shift in the global burden of disease from communicable to noncommunicable diseases over the past 20 years. Essential surgery must be performed safely, with adequate anesthesia monitoring and intervention. Unfortunately, a huge barrier to providing safe surgery includes the paucity of an anesthesia workforce. In this study, we qualitatively evaluated the anesthesia capacity of Mozambique, a LIC in Africa with limited access to anesthesia and safe surgical care. Country-based solutions are suggested that can expand to other LIC and LMICs. METHODS: A comprehensive review of the Mozambique anesthesia system was conducted through interviews with personnel in the Ministry of Health (MOH), a school of medicine, a public central referral hospital, a general first referral hospital, a private care hospital, and leaders in the physician anesthesia community. Personnel databases were acquired from the MOH and Maputo Central Hospital. RESULTS: Quantitative results reveal minimal anesthesia capacity (290 anesthesia providers for a population of >25 million or 0.01:10,000). The majority of physician anesthesiologists practice in urban settings, and many work in the private sector. There is minimal capacity for growth given only 1 Mozambique anesthesia residency with inadequate resources. The most commonly perceived barriers to safe anesthesia in this critical shortage are lack of teachers, lack of medical student interest in and exposure to anesthesia, need for more schools, low allocation to anesthesia from the list of available specialist prospects by MOH, and low public payments to anesthesiologists. Qualitative results show assets of a good health system design, a supportive environment for learning in the residency, improvement in anesthetic care in past decades, and a desire for more educational opportunities and teachers. CONCLUSIONS: Mozambique has a strong health system design but few resources for surgery and safe anesthesia. At present, similar to other LICs, human resources, access to essential medicines, and safety monitoring limit safe anesthesia in Mozambique.

Patient safety challenges in low-income and middle-income countries.

PURPOSE OF REVIEW: The global burden of surgical disease is significant and growing. As a result, the vital role of essential surgical care and safe anesthesia in low-income and middle-income countries is gaining increasing attention. Importantly, vast disparities in access to essential surgery and safe anesthesia exist. In this review, we summarize the current knowledge surrounding the global crisis of inadequate anesthesia capacity and barriers to patient safety in low-income and middle-income countries. RECENT FINDINGS: The major patient safety challenges in low-income and middle-income countries include a lack of well trained anesthesia providers, inadequate infrastructure, equipment, monitors, medicines, oxygen, and blood products, and an absence of meaningful data to guide policies and programs. SUMMARY: Explicit mention of essential surgery and safe anesthesia in the Post-2015 Development Agenda is a critical step forward in advancing the cause of global perioperative care. Tracking surgical and anesthesia outcomes with a metric, such as the perioperative mortality rate, must be required at the hospital, country, and global level to guide improvement of surgical and anesthetic interventions aimed at the burden of surgical disease.

Prioritizing essential surgery and safe anesthesia for the Post-2015 Development Agenda: operative capacities of 78 district hospitals in 7 low- and middle-income countries.

BACKGROUND: Surgery has been neglected in low- and middle-income countries for decades. It is vital that the Post-2015 Development Agenda reflect that surgery is an important part of a comprehensive global health care delivery model. We compare the operative capacities of multiple low- and middle-income countries and identify critical gaps in surgical infrastructure. METHODS: The Harvard Humanitarian Initiative survey tool was used to assess the operative capacities of 78 government district hospitals in Bangladesh (n = 7), Bolivia (n = 11), Ethiopia (n = 6), Liberia (n = 11), Nicaragua (n = 10), Rwanda (n = 21), and Uganda (n = 12) from 2011 to 2012. Key outcome measures included infrastructure, equipment availability, physician and nonphysician surgical providers, operative volume, and pharmaceutical capacity. RESULTS: Seventy of 78 district hospitals performed operations. There was fewer than one surgeon or anesthesiologist per 100,000 catchment population in all countries except Bolivia. There were no physician anesthesiologists in any surveyed hospitals in Rwanda, Liberia, Uganda, or in the majority of hospitals in Ethiopia. Mean annual operations per hospital ranged from 374 in Nicaragua to 3,215 in Bangladesh. Emergency operations and obstetric operations constituted 57.5% and 40% of all operations performed, respectively. Availability of pulse oximetry, essential medicines, and key infrastructure (water, electricity, oxygen) varied widely between and within countries. CONCLUSION: The need for operative procedures is not being met by the limited operative capacity in numerous low- and middle-income countries. It is of paramount importance that this gap be addressed by prioritizing essential surgery and safe anesthesia in the Post-2015 Development Agenda.

Measuring global surgical disparities: a survey of surgical and anesthesia infrastructure in Bangladesh.

BACKGROUND: Surgically treatable diseases weigh heavily on the lives of people in resource-poor countries. Though global surgical disparities are increasingly recognized as a public health priority, the extent of these disparities is unknown because of a lack of data. The present study sought to measure surgical and anesthesia infrastructure in Bangladesh as part of an international study assessing surgical and anesthesia capacity in low income nations. METHODS: A comprehensive survey tool was administered via convenience sampling at one public district hospital and one public tertiary care hospital in each of the seven administrative divisions of Bangladesh. RESULTS: There are an estimated 1,200 obstetricians, 2,615 general and subspecialist surgeons, and 850 anesthesiologists in Bangladesh. These numbers correspond to 0.24 surgical providers per 10,000 people and 0.05 anesthesiologists per 10,000 people. Surveyed hospitals performed a large number of operations annually despite having minimal clinical human resources and inadequate physical infrastructure. Shortages in equipment and/or essential medicines were reported at all hospitals and these shortages were particularly severe at the district hospital level. CONCLUSIONS: In order to meet the immense demand for surgical care in Bangladesh, public hospitals must address critical shortages in skilled human resources, inadequate physical infrastructure, and low availability of equipment and essential medications. This study identified numerous areas in which the international community can play a vital role in increasing surgical and anesthesia capacity in Bangladesh and ensuring safe surgery for all in the country.

Surgical and anesthesia capacity in Bolivian public hospitals: results from a national hospital survey.

BACKGROUND: Underdeveloped nations suffer from significant deficiencies in surgical and anesthesia care. Although surgical inequities are a pressing issue internationally, the extent of these inequities is unknown due to a lack of data. The aim of this study was to assess surgical and anesthesia capacity in Bolivia as part of a multinational study assessing surgical and anesthesia infrastructure in Africa, Latin America, and South Asia. METHODS: A standardized survey tool was used to obtain national-level health-care data at the Bolivian Ministry of Health. Hospital-specific data were obtained through interviews with key administrators and providers at 18 public basic and general hospitals in Bolivia. RESULTS: There are 1,270 obstetrician/gynecologists and 1,807 surgeons in Bolivia. In contrast, there are 500 anesthesiologists, placing a large anesthesia burden on the country. Basic hospitals and general hospitals performed an average of 730 and 2,858 operations per year, respectively. One basic hospital was unable to perform any surgeries due to a lack of surgical manpower. All but two hospitals reported some lack of infrastructure, equipment, or pharmaceutical capacity. The ability to collect health outcomes was inconsistent in most hospitals. CONCLUSIONS: Surgical capacity varies throughout Bolivia. There are relatively large numbers of surgery providers but an insufficient number of anesthesiologists, suggesting a specific need for further development in anesthesia. Though there are many areas of strength within the Bolivian public health-care system, this survey identified several areas to which national policy and international collaboration can contribute in order to more adequately address major causes of surgical morbidity and mortality.

Challenges of surgery in developing countries: a survey of surgical and anesthesia capacity in Uganda's public hospitals.

BACKGROUND: There are large disparities in access to surgical services due to a multitude of factors, including insufficient health human resources, infrastructure, medicines, equipment, financing, logistics, and information reporting. This study aimed to assess these important factors in Uganda's government hospitals as part of a larger study examining surgical and anesthesia capacity in low-income countries in Africa. METHODS: A standardized survey tool was administered via interviews with Ministry of Health officials and key health practitioners at 14 public government hospitals throughout the country. Descriptive statistics were used to analyze the data. RESULTS: There were a total of 107 general surgeons, 97 specialty surgeons, 124 obstetricians/gynecologists (OB/GYNs), and 17 anesthesiologists in Uganda, for a rate of one surgeon per 100,000 people. There was 0.2 major operating theater per 100,000 people. Altogether, 53% of all operations were general surgery cases, and 44% were OB/GYN cases. In all, 73% of all operations were performed on an emergency basis. All hospitals reported unreliable supplies of water and electricity. Essential equipment was missing across all hospitals, with no pulse oximeters found at any facilities. A uniform reporting mechanism for outcomes did not exist. CONCLUSIONS: There is a lack of vital human resources and infrastructure to provide adequate, safe surgery at many of the government hospitals in Uganda. A large number of surgical procedures are undertaken despite these austere conditions. Many areas that need policy development and international collaboration are evident. Surgical services need to become a greater priority in health care provision in Uganda as they could promise a significant reduction in morbidity and mortality.

Surgery, public health, and Pakistan.

BACKGROUND: Surgical healthcare is rapidly gaining recognition as a major public health issue. Surgical disparities are large, with poorest populations receiving the least amount of emergency and essential surgical care. In light of recent evidence, developing countries, such as Pakistan, must acknowledge surgical disease as a major public health issue and prioritize research and intervention accordingly. METHODS: We review information from various sources and describe the current situation of surgical health care in Pakistan and highlight areas of neglect. RESULTS: Pakistan suffers an annual deficit of 17 million surgeries. Surgical disease kills more people than infectious diseases inclusive of tuberculosis, HIV/AIDS, diarrheal disease, and childhood infections. The incidence of trauma and maternal mortality ratio are staggeringly high. There is a severe dearth of surgical and anesthesia-related epidemiological data. Important information that would help to drive policy and planning is not available. Corruption and neglect have led to a dilapidated health care infrastructure. Surgical care is largely inaccessible to the poor, especially those living in rural areas. The country faces a dearth of healthcare professionals, especially paramedics, anesthetists, and surgeons. Unsafe surgery and anesthesia poses a significant risk to patients. There is no national policy on surgical illness and the preventive aspects of surgery are nonexistent. CONCLUSIONS: Consistent with other underdeveloped countries, surgical care in Pakistan is dismal. Neglecting surgery and safe anesthesia has led to countless deaths and disability. Physicians, researchers, policy makers, and the government health care system must engage and commit to provide access to emergency, essential, and safe surgical care.

Essential surgery: Integral to the right to health.

In a rights-based approach to health, the provision of essential surgical services is not a luxury, but a critical component of the "highest attainable standard of health." Yet while access to select basic health care interventions has increasingly been discussed as part of the human right to health, essential surgical services have generally not been part of this discussion. This is despite the substantial global burden of surgical conditions in low- and middle-income countries, extreme global disparities in access to surgical care, and the fact that relatively simple, cost-effective, and curative surgical procedures can avert disability and premature death from many life-threatening emergencies and other conditions. Many barriers, both supply and demand-related, such as constraints in human resources, infrastructure, and access to care, have limited the ability of health systems to deliver surgical services. In this paper, the authors share their experience - as a group of surgeons, anesthesiologists, emergency physicians, and public health experts working with colleagues in varied resource-constrained settings to provide basic surgical care - in addressing the challenge of realizing the right to surgery in resource-poor settings. We argue that essential surgical care should be included in the basic human right to health, and that the current emphasis on "vertical" disease-specific models of health service delivery should be broadened to include systems needed to provide surgical services. We outline the global burden of surgical conditions, discuss the public health importance of surgery, identify the most significant global disparities in access to surgical care, and provide economic arguments for surgical delivery.