Estimating access to surgical care: A community centered national household survey from Pakistan.

Pakistan is a lower middle-income country in South Asia with a population of 225 million. No estimate for surgical care access exists for the country. We postulate the estimated access to surgical care is less than the minimum 80% to be achieved by 2030. We conducted a randomized, stratified two-stage cluster household survey. A sample of 770 households was selected using 2017 census frames from the Pakistan Bureau of Statistics. Data was collected on choice of hospital and travel time to the chosen hospital for C-section, laparotomy, open fracture repair (OFR), and specialized surgery. Analysis was conducted using Stata 14. Access to all Bellwether surgeries (C-section, laparotomy, and open fracture repair) in Pakistan is estimated to be 74.8%. However, estimated access in rural areas and the provinces of Balochistan, Khyber Pakhtunkhwa (KP) and Sindh is far less than in urban areas and in Punjab and Islamabad. Estimated access to C-sections is more compared to OFR, laparotomy, and specialized surgery. Health system strengthening efforts should focus on improving surgical care access in rural areas and in Balochistan, KP, and Sindh. More focus is required on standardizing the availability and quality of surgical services in secondary-level hospitals.

Maximising access to timely trauma care across population of Karachi and its districts: a geospatial approach to develop a trauma care network.

OBJECTIVES: To develop and propose a cost-effective trauma care network for Karachi, Pakistan, by calculating maximum timely trauma care (TTC) coverage achieved with the addition of potential designated private and public level 1 and level 2 trauma centres (TCs). SETTING: A lower middle-income country metropolis, Karachi is Pakistan's largest city with a population of 16 million and a total of 56 hospitals as per government registry data. PARTICIPANTS: 41 potential TCs selected using a two-level, contextually-relevant TC designation criteria adapted from various international guidelines. PRIMARY AND SECONDARY OUTCOME MEASURES: Maximum TTC coverage achievable with the addition of potential TCs. Proposed trauma care network composition to achieve maximum TTC coverage. RESULTS: Coverage with five public level 1 hospitals alone is 74.4%. Marginal benefit with stepwise addition of five potential private level 1 TCs, four public level 2 TCs and two private level 2 TCs is 12.2%, 7.1% and 3.1%, respectively. Maximum possible TTC coverage is 96.7%. Poorest coverage with the proposed 16 hospital network is noted in Malir district while 100% coverage is achieved in the centrally located South, Central and East districts. CONCLUSION: Addition of private level 1 and private and public level 2 hospitals to the trauma care network is necessary. Implementation of the proposed trauma care network requires strong stewardship from the government and coordinated effort of multiple stakeholders is needed to ensure standard TC designation. The study exhibits an effective method to scientifically plan and develop a cost-effective trauma system which can be applied in other resource-limited geographical areas.

Access and Financial Burden for Patients Seeking Essential Surgical Care in Pakistan.

Background: Pakistan is a lower middle-income country in South Asia with a population of over 220 million. With the recent development of national health programs focusing on surgical care, two areas of high priority for research and policy are access and financial risk protection related to surgery. This is the first study in Pakistan to nationally assess geographic access and expenditures for patients undergoing surgery. Methods: This is a cross-sectional study of patients undergoing laparotomy, cesarean section, and surgical management of a fracture at public tertiary care hospitals across the country. A validated financial risk protection tool was adapted for our study to collect data on the socio-economic characteristics of patients, geographic access, and out-of-pocket expenditure. Results: A total of 526 patients were surveyed at 13 public hospitals. 73.8% of patients had 2-hour access to the facility where they underwent their respective surgical procedures. A majority (53%) of patients were poor at baseline, and 79.5% and 70.3% of patients experienced catastrophic health expenditure and impoverishing health expenditure, respectively. Discussion: A substantial number of patients face long travel times to access essential surgical care and face a high percentage of impoverishing health expenditure and catastrophic health expenditure during this process. This study provides valuable baseline data to health policymakers for reform efforts that are underway. Conclusions: Strengthening surgical infrastructure and services in the existing network of public sector first-level facilities has the potential to dramatically improve emergency and essential surgical care across the country.

Assessment of Trauma Care Capacity in Karachi, Pakistan: Toward an Integrated Trauma Care System.

BACKGROUND: Pakistan is a lower-middle-income country with a high burden of injuries. Karachi, its most populated city, lacks a trauma care system due to which trauma patients do not receive the required care. We conducted an assessment of the existing facilities for trauma care in Karachi. METHODS: Twenty-two tertiary and secondary hospitals from public and private sectors across Karachi were assessed. The Guidelines for Essential Trauma Care (GETC) tool was used to collect information about the availability of skills, knowledge, and equipment at these facilities. RESULTS: Among tertiary hospitals (n = 7), private sector hospitals had a better median (IQR) score, 90.4 (81.8-93.1), as compared to the public sector hospitals, 44.1 (29.3-75.8). Among secondary hospitals (n = 15), private sector hospitals had a better median (IQR) score, 70.3 (67.8-77.7), as compared to the public sector hospitals, 39.7 (21.9-53.3). DISCUSSION: This study identifies considerable deficiencies in trauma care in Karachi and provides objective data that can guide urgently needed reforms tailored to this city's needs. On a systems level, it delineates the need for a regulatory framework to define trauma care levels and designate selected hospitals across the city accordingly. Using these data, improvement in trauma care systems can be achieved through collaboration and partnership between public and private stakeholders.

Prophylactic Antibiotics for Reducing Central Line-associated Blood Stream Infection in Children with Totally Implantable Venous Access Devices.

OBJECTIVE: To analyse the need of prophylactic antibiotic before the insertion of totally implantable venous access devices (TIVADs) in terms of preventing central line-associated blood stream infection (CLABSI) in early postoperative period in pediatric oncology patients. STUDY DESIGN: A cohort study. PLACE AND DURATION OF STUDY: Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore from January 2005 to June 2016. METHODOLOGY: A total of 645 consecutive children with malignancy, who were implanted with TIVAD, were included in the study. The data were collected retrospectively and divided into two groups on the basis of prophylactic antibiotic administration (Group A) received the antibiotic; and Group B did not receive the antibiotic. Both the groups were compared in terms of positive central blood cultures in the absence of any other clinical source of infection during the early postoperative period of 30 days. RESULTS: The overall infection rate was 12.54% (35 out of 279) in Group B (did not receive prophylactic antibiotic) and 11.68% (41 out of 351) in Group A (received prophylactic antibiotic) without any significant difference (p = 0.741). CONCLUSION: There was no advantage of the use of prophylactic antibiotic before TIVAD insertion in preventing early postoperative CLABSI.