Factors Contributing to and Reducing Delays in the Provision of Adequate Care in Ghana: A Qualitative Study of Trauma Care Providers.

BACKGROUND: Ghana has a large and growing burden of injury morbidity and mortality. There is a substantial unmet need for trauma surgery, highlighting a need to understand gaps in care. METHODS: We conducted 8 in-depth interviews with trauma care providers (surgeons, nurses, and specialists) at a large teaching hospital to understand factors that contribute to and reduce delays in the provision of adequate trauma care for severely injured patients. The study aimed to understand whether providers thought factors differed between patients that were enrolled in the National Health Insurance Scheme (NHIS) and those that were not. Findings were presented for the third delay (provision of appropriate care) in the Three Delays Framework. RESULTS: Key findings included that most factors contributing delays in the provision of adequate care were related to the costs of care, including for diagnostics, medications, and treatment for patients with and without NHIS subscription. Other notable factors included conflicts between providers, resource constraints, and poor coordination of care at the facility. Factors which reduce delays included advocacy by providers and informal processes for prioritizing critical injuries. CONCLUSION: We recommend facility-level changes including increasing equity in access to trauma and elective surgery through targeted system strengthening efforts (e.g., a scheduled back-up call system for surgeons, anesthetists, other specialists, and nurses; designated operating theatres and staff for emergencies; training of staff), policy changes to simplify the insurance renewal and subscription processes, and future research on the costs and benefits of including diagnostics, medications, and common trauma services into the NHIS benefits package.

Improving Global Surgical Oncology Benchmarks: Defining the Unmet Need for Cancer Surgery in Ghana.

BACKGROUND: The Lancet Commission on Global Surgery (LCoGS) recommended an annual surgical rate at which low- and middle-income countries (LMICs) could achieve most of the population-wide benefits of surgery. However, condition-specific guidelines were not proposed. To inform rates of surgery for cancer, we sought to assess the current met and unmet need for oncologic surgery in Ghana. METHODS: Data on all operations performed in Ghana over a one-year period (2014-15) were obtained from representative samples of 48/124 first-level and 12/16 referral hospitals and scaled-up for nationwide estimates. Procedures for cancer were identified by indication. Using modified LCoGS methodology with disease prevalence, Ghana's annual rate of cancer surgery was compared to that of New Zealand to quantify current unmet needs. RESULTS: 232,776 surgical procedures were performed in Ghana; 2,562 procedures (95%UI 1878-3255) were for cancer. Of these, 964 (37%) were surgical biopsies. The annual rate of procedures treating cancer was 2115 surgeries/100,000 cancer cases, or 21% of the New Zealand benchmark. Cervical, breast, and prostate cancer were found to meet 2.1%, 17.2%, and 32.1% of their respective surgical need. CONCLUSIONS: There is a large unmet need for cancer surgery in Ghana. Cancer surgery constitutes under 2% of the total surgeries performed in Ghana, an important proportion of which are used for biopsies. Therapeutic operative rate is deficient across most cancer types, and may lag behind improvements in screening efforts. As cancer prevalence and diagnosis increase in LMICs, cancer-specific surgical capacity must be increased to meet these evolving needs.

National health insurance and surgical care for injured people, Ghana.

OBJECTIVE: To determine the association between having government health insurance and the timeliness and outcome of care, and catastrophic health expenditure in injured patients requiring surgery at a tertiary hospital in Ghana. METHODS: We reviewed the medical records of injured patients who required surgery at Komfo Anokye Teaching Hospital in 2015-2016 and extracted data on sociodemographic and injury characteristics, outcomes and out-of-pocket payments. We defined catastrophic health expenditure as ≥ 10% of the ratio of patients' out-of-pocket payments to household annual income. We used multivariable regression analyses to assess the association between having insurance through the national health insurance scheme compared with no insurance and time to surgery, in-hospital mortality and experience of catastrophic health expenditure, adjusted for potentially confounding variables. FINDINGS: Of 1396 patients included in our study, 834 (60%) were insured through the national health insurance scheme. Time to surgery and mortality were not statistically different between insured and uninsured patients. Insured patients made smaller median out-of-pocket payments (309 United States dollars, US$) than uninsured patients (US$ 503; P < 0.001). Overall, 45% (443/993) of patients faced catastrophic health expenditure. A smaller proportion of insured patients (33%, 184/558) experienced catastrophic health expenditure than uninsured patients (60%, 259/435; P < 0.001). Insurance through the national health insurance scheme reduced the likelihood of catastrophic health expenditure (adjusted odds ratio: 0.27; 95% confidence interval: 0.20 to 0.35). CONCLUSION: The national health insurance scheme needs strengthening to provide better financial risk protection and improve quality of care for patients presenting with injuries that require surgery.

Benchmarking Global Trauma Care: Defining the Unmet Need for Trauma Surgery in Ghana.

BACKGROUND: The Lancet Commission on Global Surgery recommended 5000 operations/100,000 persons annually, but did not define condition-specific guidelines. New Zealand, Lancet Commission on Global Surgery's benchmark country, documented 1158 trauma operations/100,000 persons, providing a benchmark for trauma surgery needs. We sought to determine Ghana's annual trauma operation rate compared with this benchmark. METHODS: Data on all operations performed in Ghana from June 2014 to May 2015 were obtained from representative sample of 48/124 district (first level), 8/11 regional, and 3/5 tertiary hospitals and scaled up for nationwide estimates. Trauma operations were grouped by hospital level and categorized into "essential" (most cost-effective, highest population impact) versus "other" (specialized) as per the World Bank's Disease Control Priorities Project. Ghana's annual trauma operation rate was compared with the New Zealand benchmark to quantify current met needs for trauma surgery. RESULTS: About 232,776 operations were performed in Ghana; 35,797 were for trauma. Annual trauma operation rate was 134/100,000 (95% UI: 98-169), only 12% of the New Zealand benchmark. District hospitals performed 62% of all operations in the country, but performed only 38% of trauma operations. Eighty seven percentage of trauma operations were deemed "essential". Among specialized trauma operations, only open reduction and internal fixations had even modest numbers (3483 operations). Most other specialized trauma operations were rare. CONCLUSIONS: Ghana has a large unmet need for operative trauma care. The low percentage of trauma operations in district hospitals indicates an even greater unmet need in rural areas. Future global surgery benchmarking should consider benchmarks for trauma and other specialties, as well as for different hospital levels.

Improving Benchmarks for Global Surgery: Nationwide Enumeration of Operations Performed in Ghana.

OBJECTIVE: To evaluate the operation rate in Ghana and characterize it by types of procedures and hospital level. BACKGROUND: The Lancet Commission on Global Surgery recommended an annual rate of 5000 operations/100,000 people as a benchmark at which low- and middle-income countries could achieve most of the population-wide benefits of surgery, but did not define procedure-type benchmarks. METHODS: Data on operations performed from June 2014 to May 2015 were obtained from representative samples of 48 of 124 district-level (first-level) hospitals, 9 of 11 regional (referral) hospitals, and 3 of 5 tertiary hospitals, and scaled-up to nationwide estimates. Operations were categorized into those deemed as essential procedures (most cost-effective, highest population impact) by the World Bank's Disease Control Priorities Project versus other. RESULTS: An estimated 232,776 [95% uncertainty interval (95% UI) 178,004 to 287,549] operations were performed nationally. The annual rate of operations was 869 of 100,000 (95% UI 664 to 1073). The rate fell well short of the benchmark. 77% of the estimated annual national surgical output was in the essential procedure category. Most operations (62%) were performed at district-level hospitals. Most district-level hospitals (54%) did not have fully trained surgeons, but nonetheless performed 36% of district-level hospital operations. CONCLUSION: The operation rate was short of the Lancet Commission benchmark, indicating large unmet need, although most operations were in the essential procedure category. Future global surgery benchmarking should consider both total numbers and priority levels. Most surgical care was delivered at district-level hospitals, many without fully trained surgeons. Benchmarking to improve surgical care needs to address both access deficiencies and hospital and provider level.

Exploring the Relationship Between Surgical Capacity and Output in Ghana: Current Capacity Assessments May Not Tell the Whole Story.

OBJECTIVE: Capacity assessments serve as surrogates for surgical output in low- and middle-income countries where detailed registers do not exist. The relationship between surgical capacity and output was evaluated in Ghana to determine whether a more critical interpretation of capacity assessment data is needed on which to base health systems strengthening initiatives. METHODS: A standardized surgical capacity assessment was performed at 37 hospitals nationwide using WHO guidelines; availability of 25 essential resources and capabilities was used to create a composite capacity score that ranged from 0 (no availability of essential resources) to 75 (constant availability) for each hospital. Data regarding the number of essential operations performed over 1 year, surgical specialties available, hospital beds, and functional operating rooms were also collected. The relationship between capacity and output was explored. RESULTS: The median surgical capacity score was 37 [interquartile range (IQR) 29-48; range 20-56]. The median number of essential operations per year was 1480 (IQR 736-1932) at first-level hospitals; 1545 operations (IQR 984-2452) at referral hospitals; and 11,757 operations (IQR 3769-21,256) at tertiary hospitals. Surgical capacity and output were not correlated (p > 0.05). CONCLUSIONS: Contrary to current understanding, surgical capacity assessments may not accurately reflect surgical output. To improve the validity of surgical capacity assessments and facilitate maximal use of available resources, other factors that influence output should also be considered, including demand-side factors; supply-side factors and process elements; and health administration and management factors.

Uptake of the World Health Organization's trauma care guidelines: a systematic review.

OBJECTIVE: To understand the degree to which the trauma care guidelines released by the World Health Organization (WHO) between 2004 and 2009 have been used, and to identify priorities for the future implementation and dissemination of such guidelines. METHODS: We conducted a systematic review, across 19 databases, in which the titles of the three sets of guidelines - Guidelines for essential trauma care, Prehospital trauma care systems and Guidelines for trauma quality improvement programmes - were used as the search terms. Results were validated via citation analysis and expert consultation. Two authors independently reviewed each record of the guidelines' implementation. FINDINGS: We identified 578 records that provided evidence of dissemination of WHO trauma care guidelines and 101 information sources that together described 140 implementation events. Implementation evidence could be found for 51 countries - 14 (40%) of the 35 low-income countries, 15 (32%) of the 47 lower-middle income, 15 (28%) of the 53 upper-middle-income and 7 (12%) of the 59 high-income. Of the 140 implementations, 63 (45%) could be categorized as needs assessments, 38 (27%) as endorsements by stakeholders, 20 (14%) as incorporations into policy and 19 (14%) as educational interventions. CONCLUSION: Although WHO's trauma care guidelines have been widely implemented, no evidence was identified of their implementation in 143 countries. More serial needs assessments for the ongoing monitoring of capacity for trauma care in health systems and more incorporation of the guidelines into both the formal education of health-care providers and health policy are needed.

Strategic Assessment of Trauma Care Capacity in Ghana.

BACKGROUND: This study aimed to assess availability of trauma care technology in Ghana. In addition, factors contributing to deficiencies were evaluated. By doing so, potential solutions to inefficient aspects of health systems management and maladapted technology for trauma care in low- and middle-income countries (LMICs) could be identified. METHODS: Thirty-two items were selected from the World Health Organization's Guidelines for Essential Trauma Care. Direct inspection and structured interviews with administrative, clinical, and biomedical engineering staff were used to assess the challenges and successes of item availability at 40 purposively sampled district, regional, and tertiary hospitals. RESULTS: Hospital assessments demonstrated marked deficiencies. Some of these were low cost, such as basic airway supplies, chest tubes, and cervical collars. Item non-availability resulted from several contributing factors, namely equipment absence, lack of training, frequent stock-outs, and technology breakage. A number of root causes for these factors were identified, including ineffective healthcare financing by way of untimely national insurance reimbursements, procurement and stock-management practices, and critical gaps in local biomedical engineering and trauma care training. Nonetheless, local examples of successfully overcoming deficiencies were identified (e.g., public-private partnering, ensuring company engineers trained technicians on-the-job during technology installation or servicing). CONCLUSION: While availability of several low-cost items could be better supplied by improvements in stock-management and procurement policies, there is a critical need for redress of the national insurance reimbursement system and trauma care training of district hospital staff. Further, developing local service and technical support capabilities is more and more pressing as technology plays an increasingly important role in LMIC healthcare systems.

An estimate of the number of lives that could be saved through improvements in trauma care globally.

BACKGROUND: Reducing the global burden of injury requires both injury prevention and improved trauma care. We sought to provide an estimate of the number of lives that could be saved by improvements in trauma care, especially in low income and middle income countries. METHODS: Prior data showed differences in case fatality rates for seriously injured persons (Injury Severity Score ≥ 9) in three separate locations: Seattle, WA (high income; case fatality 35%); Monterrey, Mexico (middle income; case fatality 55%); and Kumasi, Ghana (low income; case fatality 63%). For the present study, total numbers of injury deaths in all countries in different economic strata were obtained from the Global Burden of Disease study. The number of lives that could potentially be saved from improvements in trauma care globally was calculated as the difference in current number of deaths from trauma in low income and middle income countries minus the number of deaths that would have occurred if case fatality rates in these locations were decreased to the case fatality rate in high income countries. RESULTS: Between 1,730,000 and 1,965,000 lives could be saved in low income and middle income countries if case fatality rates among seriously injured persons could be reduced to those in high income countries. This amounts to 34-38% of all injury deaths. CONCLUSIONS: A significant number of lives could be saved by improvements in trauma care globally. This is another piece of evidence in support of investment in and greater attention to strengthening trauma care services globally.

Unintentional falls among children in rural Ghana and associated factors: a cluster-randomized, population-based household survey.

INTRODUCTION: falls contribute to almost one-fifth of injury-related deaths. The majority of these occur in low- and middle-income countries. The impact of fall injury in low- and middle-income countries is greater in younger individuals. We aimed to determine the epidemiology of falls among rural Ghanaian children. METHODS: from March to May, 2018, we conducted a cluster-randomized household survey of caregivers in a rural Ghanaian sub-district, regarding household child falls and their severity. We utilized a previously validated survey tool for household child injury. Associations between household child falls and previously described predictors of household child injury were examined with multivariable logistic regression. These included age and gender of the child, household socioeconomic status, caregiver education, employment status, and their beliefs on why household child injuries occur. RESULTS: three hundred and fifty-seven caregivers of 1,016 children were surveyed. One hundred and sixty-four children under 18 years had sustained a household fall within the past six months, giving a household child fall prevalence of 16% (95% C.I, 14%-19%). Mean age was 4.4 years; 59% were males. Ground level falls were more common (80%). Severity was mostly moderate (86%). Most caregivers believed household child injuries occurred due to lack of supervision (85%) or unsafe environment (75%); only 2% believed it occurred because of fate. Girls had reduced odds of household falls (adjusted O.R 0.6; 95% C.I 0.4-0.9). Five to nine year-old and 15-17 year-old children had reduced odds of household falls (adjusted O.R 0.4; 95% C.I 0.2-0.7 and 0.1; 95% C.I 0.02-0.3, respectively) compared to 1-4 year-olds. Caregiver engagement in non-salary paying work was associated with increased odds of household child falls (adjusted O.R 2.2; 95% C.I 1.0-4.7) compared to unemployed caregivers. There was no association between household child falls and caregiver education, socioeconomic status and beliefs about why household child injuries occurred. CONCLUSION: the prevalence of household child falls in rural Ghana was 16%. This study confirms the need to improve supervision of all children to reduce household falls, especially younger children and particularly boys. Majority of caregivers also acknowledge the role of improper child supervision and unsafe environments in household child falls. These beliefs should be reinforced and emphasized in campaigns to prevent household child falls in rural communities.

Nationwide enumeration of emergency operations performed in Ghana.

PURPOSE: To determine the population-based rate of emergency surgery performed in Ghana, categorized by hospital level. METHODS: Data on operations performed from June 2014 to May 2015 were obtained from a nationally representative sample of hospitals and scaled up to nationwide estimates. Operations were categorized as to: "emergency" or "elective" and as to "essential" (most cost-effective, highest population impact) or "other" according to the World Bank's Disease Control Priorities project. RESULTS: Of 232,776 (95% UI 178,004-287,549) total operations performed nationally, 48% were emergencies. 112,036 emergency operations (95% UI 92,105-131,967) were performed and the annual national rate was 416 per 100,000 population (95% UI 342-489). Most emergency operations (87%) were in the essential category. Of essential emergency procedures, 47% were obstetric and gynecologic, 22% were general surgery, and 31% were trauma. District (first-level) hospitals performed 54%, regional hospitals 10%, and tertiary hospitals 36% of all emergency operations. About half (54%) of district hospitals did not have a fully trained surgeon, however, these hospitals performed 36% of district hospital emergency operations and 20% of all emergency operations. CONCLUSIONS: Emergency operations make up nearly half of all operations performed in Ghana. Most are performed at district hospitals, many of which do not have fully trained surgeons. Obstetric procedures make up a large portion of emergency operations, indicating a need for improved provision of non-obstetric emergency surgical care. These data are useful for future benchmarking efforts to improve availability of emergency surgical care in Ghana and other low- and middle-income countries.

Assessing the appropriateness of blood transfusion among injured patients at a Ghanaian tertiary hospital: Time for clarity on the use of a scarce resource.

INTRODUCTION: Hemorrhage is an important cause of preventable injury-related death. Many low- and middle-income country (LMIC) patients do not have timely access to safe blood. We sought to determine the degree of appropriateness of blood transfusion among patients with injuries requiring surgical intervention at presentation to a tertiary hospital in Ghana. METHODS: We performed a retrospective review of such patients presenting to Komfo Anokye Teaching Hospital (KATH), from January 2015 to December 2016. Patients' hemoglobin levels at presentation were determined as the first record of hemoglobin after presentation and their receipt of blood transfusion was determined by explicit documentation in the chart. We defined appropriate blood transfusion practice as patients receiving transfusion when hemoglobin was equal or below a threshold, or patients not being transfused when hemoglobin was above the threshold. We considered both restrictive (hemoglobin ≤7 g/dL) and liberal (hemoglobin ≤10 g/dL) transfusion thresholds. RESULTS: There were 1,408 patients who presented to KATH with injuries that met inclusion criteria. Two hundred and ninety two (292) patients were excluded because of missing hemoglobin information. Four hundred and fifty eight (458;41%) patients received blood transfusion. Transfused patients had a higher mean age (38 vs 35 years) and were less likely to be male (62% vs 71%). Transfused patients underwent more external fixation procedures (28% vs 19%), trauma amputations (5% vs 1%) and trauma laparotomies (3% vs 1%). At a restrictive transfusion threshold (hemoglobin ≤7 g/dL), 20% of patients who needed a transfusion did not receive one and 39% of patients who did not need a transfusion received one. At a liberal threshold (hemoglobin ≤10 g/dL), 33% of patients who needed a transfusion did not receive one and 30% of patients who did not need a transfusion received one. Blood transfusion practice was inappropriate in 31%-39% of all patients. CONCLUSION: Our data suggest that clearer guidelines for blood transfusion among emergency surgery patients are needed in Ghana and similar LMICs to avoid inappropriate use of blood as a scarce resource.

Reporting on road traffic injury: content analysis of injuries and prevention opportunities in Ghanaian newspapers.

In order to analyse traffic injury reporting in Ghanaian newspapers and identify opportunities for improving road safety, the content of 240 articles on road traffic injury was reviewed from 2005 to 2006 editions of two state-owned and two privately owned newspapers. The articles comprised reports on vehicle crashes (37%), commentaries (33%), informational pieces (12%), reports on pedestrian injury (10%), and editorials (8%). There was little coverage of pedestrian injuries, which account for half of the traffic fatalities in Ghana, but only 22% of newspaper reports. Only two articles reported on seatbelt use. Reporting patterns were similar between public and private papers, but private papers more commonly recommended government action (50%) than did public papers (32%, p=0.006). It is concluded that Ghanaian papers provide detailed coverage of traffic injury. Areas for improvement include pedestrian injury and attention to preventable risk factors such as road risk factors, seatbelt use, speed control, and alcohol use.

Increasing the use of continuing professional development courses to strengthen trauma care in Ghana.

Injury is a major cause of death and disability in Ghana. Strengthening care of the injured is essential to reduce this burden. Trauma continuing professional development (CPD) courses are an important component of strengthening trauma care. In many countries, including Ghana, their use needs to be more uniformly promoted. We propose lowcost strategies to increase the utilization of trauma CPD in Ghana, especially in district hospitals and higher need areas. These strategies include developing plans by regional health directorates and teaching hospitals for the regions for which they are responsible. Lists could be kept and monitored of which hospitals have doctors with which type of training. Those hospitals that need to have at least one doctor trained could be flagged for notice of upcoming courses in the area and especially encouraged to have the needed doctors attend. The targets should include at least one surgeon or one emergency physician at all regional or large district hospitals who have taken the Advanced Trauma Life Support (ATLS) (or locally-developed alternative) in the past 4 years, and each district hospital should have at least one doctor who has taken the Primary Trauma Care (PTC) or Trauma Evaluation and Management (TEAM) (or locally-developed alternatives) in the past 4 years. Parallel measures would increase enrollment in the courses during training, such as promoting TEAM for all medical students and ATLS for all surgery residents. It is important to develop and utilize more "home grown" alternatives to increase the long-term sustainability of these efforts. FUNDING: None.

Estimating obstetric and gynecologic surgical rate: A benchmark of surgical capacity building in Ghana.

OBJECTIVE: To estimate the annual rate of obstetric and gynecologic (ObGyn) operations performed in Ghana and establish a baseline for tracking the expansion of Ghana's surgical capacity. METHODS: Data were obtained for ObGyn operations performed in Ghana between 2014 and 2015 from a nationally representative sample of hospitals and scaled up for national estimates. Operations were classified as "essential" or "other" according to The World Bank's Disease Control Priorities Project. Data were used to calculate cesarean-to-total-operation ratio (CTR) and estimate the rate of cesarean deliveries based on the number of live births in 2014. RESULTS: A total of 90 044 (95% uncertainty interval [UI] 69 461-110 628) ObGyn operations were performed nationally over the 1-year period, yielding an annual national ObGyn operation rate of 881/100 000 females aged 12 years and over (95% UI 679-1082). Eighty-seven percent were essential procedures, 80% of which were cesarean deliveries. District hospitals performed 71% of ObGyn operations. The national rate of cesarean deliveries was 7.2% and the CTR was 0.27. CONCLUSION: The cesarean delivery rate of 7.2% suggests inadequate access to obstetric care. The CTR of 0.27 suggests inadequate overall surgical capacity. These measures, along with estimates of distribution of procedures by hospital level, provide useful baseline data to support surgical capacity building efforts in Ghana and similar countries.

Trauma training for nonorthopaedic doctors in low- and middle-income countries.

Increasingly, nonspecialist Ghanaian doctors in district hospitals are called upon to perform a variety of surgical procedures for which they have little or no training. They are also required to provide initial stabilization for the injured and, in some cases, provide definitive management where referral is not possible. Elsewhere continuing medical education courses in trauma have improved the delivery of trauma care. Development of such courses must meet the realities of a low-income country. The Department of Surgery, Kwame Nkrumah University of Science and Technology developed a week-long trauma continuing medical education course for doctors in rural districts. The course was introduced in 1997, and has been run annually since. The trauma course specifically addresses the critical issues of trauma care in Ghana. It has improved the knowledge base of doctors, as well as their self-reported process of trauma care. Through the process we have learned lessons that could help in the efforts to improve trauma training and trauma care in other low-income countries.

Advancing injury prevention and trauma care in North America and globally.

Injury is a major global health problem. This article reviews ways in which the toll from injury can be lowered through the spectrum of injury control, including surveillance, prevention, and trauma care. There is room for improvement in the application of scientifically based, proved interventions at all points in the spectrum in all countries. The greatest attention is needed in low- and middle-income countries, however, where most of the world's people live, where injury rates are higher, and where few injury control activities have yet been undertaken.

Serial Assessment of Trauma Care Capacity in Ghana in 2004 and 2014.

IMPORTANCE: Trauma care capacity assessments in developing countries have generated evidence to support advocacy, detailed baseline capabilities, and informed targeted interventions. However, serial assessments to determine the effect of capacity improvements or changes over time have rarely been performed. OBJECTIVE: To compare the availability of trauma care resources in Ghana between 2004 and 2014 to assess the effects of a decade of change in the trauma care landscape and derive recommendations for improvements. DESIGN, SETTING, AND PARTICIPANTS: Capacity assessments were performed using direct inspection and structured interviews derived from the World Health Organization's Guidelines for Essential Trauma Care. In Ghana, 10 hospitals in 2004 and 32 hospitals in 2014 were purposively sampled to represent those most likely to care for injuries. Clinical staff, administrators, logistic/procurement officers, and technicians/biomedical engineers who interacted, directly or indirectly, with trauma care resources were interviewed at each hospital. MAIN OUTCOMES AND MEASURES: Availability of items for trauma care was rated from 0 (complete absence) to 3 (fully available). Factors contributing to deficiency in 2014 were determined for items rated lower than 3. Each item rated lower than 3 at a specific hospital was defined as a hospital-item deficiency. Scores for total number of hospital-item deficiencies were derived for each contributing factor. RESULTS: There were significant improvements in mean ratings for trauma care resources: district-level (smaller) hospitals had a mean rating of 0.8 for all items in 2004 vs 1.3 in 2014 (P = .002); regional (larger) hospitals had a mean rating of 1.1 in 2004 vs 1.4 in 2014 (P = .01). However, a number of critical deficiencies remain (eg, chest tubes, diagnostics, and orthopedic and neurosurgical care; mean ratings ≤ 2). Leading contributing factors were item absence (503 hospital-item deficiencies), lack of training (335 hospital-item deficiencies), and stockout of consumables (137 hospital-item deficiencies). CONCLUSIONS AND RELEVANCE: There has been significant improvement in trauma care capacity during the past decade in Ghana; however, critical deficiencies remain and require urgent redress to avert preventable death and disability. Serial capacity assessment is a valuable tool for monitoring efforts to strengthen trauma care systems, identifying what has been successful, and highlighting needs.

Mapping Population-Level Spatial Access to Essential Surgical Care in Ghana Using Availability of Bellwether Procedures.

IMPORTANCE: Conditions that can be treated by surgery comprise more than 16% of the global disease burden. However, 5 billion people do not have access to essential surgical care. An estimated 90% of the 87 million disability-adjusted life-years incurred by surgical conditions could be averted by providing access to timely and safe surgery in low-income and middle-income countries. Population-level spatial access to essential surgery in Ghana is not known. OBJECTIVES: To assess the performance of bellwether procedures (ie, open fracture repair, emergency laparotomy, and cesarean section) as a proxy for performing essential surgery more broadly, to map population-level spatial access to essential surgery, and to identify first-level referral hospitals that would most improve access to essential surgery if strengthened in Ghana. DESIGN, SETTING, AND PARTICIPANTS: Population-based study among all households and public and private not-for-profit hospitals in Ghana. Households were represented by georeferenced census data. First-level and second-level referral hospitals managed by the Ministry of Health and all tertiary hospitals were included. Surgical data were collected from January 1 to December 31, 2014. MAIN OUTCOMES AND MEASURES: All procedures performed at first-level referral hospitals in Ghana in 2014 were used to sort each facility into 1 of the following 3 hospital groups: those without capability to perform all 3 bellwether procedures, those that performed 1 to 11 of each procedure, and those that performed at least 12 of each procedure. Candidates for targeted capability improvement were identified by cost-distance and network analysis. RESULTS: Of 155 first-level referral hospitals managed by the Ghana Health Service and the Christian Health Association of Ghana, 123 (79.4%) reported surgical data. Ninety-five (77.2%) did not have the capability in 2014 to perform all 3 bellwether procedures, 24 (19.5%) performed 1 to 11 of each bellwether procedure, and 4 (3.3%) performed at least 12. The essential surgical procedure rate was greater in bellwether procedure-capable first-level referral hospitals than in noncapable hospitals (median, 638; interquartile range, 440-1418 vs 360; interquartile range, 0-896 procedures per 100 000 population; P = .03). Population-level spatial access within 2 hours to a hospital that performed 1 to 11 and at least 12 of each bellwether procedure was 83.2% (uncertainty interval [UI], 82.2%-83.4%) and 71.4% (UI, 64.4%-75.0%), respectively. Five hospitals were identified for targeted capability improvement. CONCLUSIONS AND RELEVANCE: Almost 30% of Ghanaians cannot access essential surgery within 2 hours. Bellwether capability is a useful metric for essential surgery more broadly. Similar strategic planning exercises might be useful for other low-income and middle-income countries aiming to improve access to essential surgery.

Orthopaedic Trauma Care Capacity Assessment and Strategic Planning in Ghana: Mapping a Way Forward.

BACKGROUND: Orthopaedic conditions incur more than 52 million disability-adjusted life years annually worldwide. This burden disproportionately affects low and middle-income countries, which are least equipped to provide orthopaedic care. We aimed to assess orthopaedic capacity in Ghana, describe spatial access to orthopaedic care, and identify hospitals that would most improve access to care if their capacity was improved. METHODS: Seventeen perioperative and orthopaedic trauma care-related items were selected from the World Health Organization's Guidelines for Essential Trauma Care. Direct inspection and structured interviews with hospital staff were used to assess resource availability and factors contributing to deficiencies at 40 purposively sampled facilities. Cost-distance analyses described population-level spatial access to orthopaedic trauma care. Facilities for targeted capability improvement were identified through location-allocation modeling. RESULTS: Orthopaedic trauma care assessment demonstrated marked deficiencies. Some deficient resources were low cost (e.g., spinal immobilization, closed reduction capabilities, and prosthetics for amputees). Resource nonavailability resulted from several contributing factors (e.g., absence of equipment, technology breakage, lack of training). Implants were commonly prohibitively expensive. Building basic orthopaedic care capacity at 15 hospitals without such capacity would improve spatial access to basic care from 74.9% to 83.0% of the population (uncertainty interval [UI] of 81.2% to 83.6%), providing access for an additional 2,169,714 Ghanaians. CONCLUSIONS: The availability of several low-cost resources could be better supplied by improvements in organization and training for orthopaedic trauma care. There is a critical need to advocate and provide funding for orthopaedic resources. These initiatives might be particularly effective if aimed at hospitals that could provide care to a large proportion of the population.