Primary Health Care That Works: The Costa Rican Experience.

Long considered a paragon among low- and middle-income countries in its provision of primary health care, Costa Rica reformed its primary health care system in 1994 using a model that, despite its success, has been generally understudied: basic integrated health care teams. This case study provides a detailed description of Costa Rica's innovative implementation of four critical service delivery reforms and explains how those reforms supported the provision of the four essential functions of primary health care: first-contact access, coordination, continuity, and comprehensiveness. As countries around the world pursue high-quality universal health coverage to attain the Sustainable Development Goals, Costa Rica's experiences provide valuable lessons about both the types of primary health care reforms needed and potential mechanisms through which these reforms can be successfully implemented.

Proposed Minimum Rates of Surgery to Support Desirable Health Outcomes: An Observational Study Based on Three Strategies.

BACKGROUND: The global volume of surgery is estimated at 312.9 million operations annually, but rates of surgery vary dramatically. Identifying surgical rates associated with improved health outcomes would be useful for benchmarking and targeted health system strengthening. METHODS: We identified rates of surgery associated with a life expectancy (LE) of 74-75 years, a maternal mortality ratio (MMR) of less than or equal to 100 per 100,000 live births, and the estimated need for surgery in the seven global burden of disease (GBD) super-regions based on the prevalence of surgical conditions. We compared our findings to surgical rates from Chile, China, Costa Rica, and Cuba ("4C"), countries with moderate resources but high health outcomes. RESULTS: The median surgical rates associated with LE of 74-75 years (N = 17) and MMR below 100 (N = 109) are 4392 (IQR 2897-4873) and 5028 (IQR 4139-6778) operations per 100,000 people annually, respectively. The mean surgical rate estimated for the seven super-regions was 4723 (95% CI 3967-5478) operations per 100,000 people annually. The "4C" countries had a mean surgical rate of 4344 (95% CI 2620-6068) operations per 100,000 people annually. Thirteen of the twenty-one GBD regions, accounting for 78% of the world's population, do not achieve rates of surgery at the lowest end of this range. CONCLUSIONS: We identified a narrow range of surgical rates associated with important health indicators. This target range can be used for benchmarking of surgical services, and as part of a policy aimed at strengthening health care systems and surgical capacity.

Evaluation of surgical care in El Salvador using the WHO surgical vital statistics.

OBJECTIVE: Vital statistics to assess surgical care worldwide have been published by the World Health Organization. These data have not been reported for any Latin American country. We sought to measure these metrics as a starting point for understanding how to improve the safety of surgery in El Salvador. METHODS: We designed an institutional survey that was sent to 21 hospitals and used national administrative data sources to estimate the number of surgeons, anesthesia professionals, operating rooms, and annual surgical volume for El Salvador. We reviewed surgical and death logs for 12 Ministry of Health hospitals to calculate day-of-surgery and postoperative in-hospital mortality ratios for a 6-month period (October 2009-March 2010). FINDINGS: We estimate there to be 1,222 surgeons [95 % confidence interval (CI) 1,137-1,307], 539 anesthesia providers, 168 operating rooms (95 % CI 136-199), and 172,972 operations (95 % CI 171,961-173,983) annually in El Salvador. There were on average 1,197 annual cases per operating room and 436 annual cases per surgeon in the 21 hospitals we studied. The day-of-surgery mortality ratio was 0.42 % (95 % CI 0.35-0.5), whereas the postoperative in-hospital mortality ratio was 1.58 % (95 % CI 1.44-1.72). The postoperative in-hospital mortality ratio was higher for hospitals with a greater number of hospital beds (p = 0.01) and operating rooms (p = 0.02). CONCLUSIONS: Despite the challenges that El Salvador faces to provide surgical care, national collection of surgical vital statistics is feasible. Collection of additional process and outcome measures may be insightful for improving the surgical safety in El Salvador and elsewhere.