International consensus recommendations for the optimal prioritisation and distribution of surgical services in low-income and middle-income countries: a modified Delphi process.

OBJECTIVES: To develop consensus statements regarding the regional-level or district-level distribution of surgical services in low and middle-income countries (LMICs) and prioritisation of service scale-up. DESIGN: This work was conducted using a modified Delphi consensus process. Initial statements were developed by the International Standards and Guidelines for Quality Safe Surgery and Anesthesia Working Group of the Global Alliance for Surgical, Obstetric, Trauma and Anesthesia Care (G4 Alliance) and the International Society of Surgery based on previously published literature and clinical expertise. The Guidance on Conducting and REporting DElphi Studies framework was applied. SETTING: The Working Group convened in Suva, Fiji for a meeting hosted by the Ministry of Health and Medical Services to develop the initial statements. Local experts were invited to participate. The modified Delphi process was conducted through an electronically administered anonymised survey. PARTICIPANTS: Expert LMIC surgeons were nominated for participation in the modified Delphi process based on criteria developed by the Working Group. PRIMARY OUTCOME MEASURES: The consensus panel voted on statements regarding the organisation of surgical services, principles for scale-up and prioritisation of scale-up. Statements reached consensus if there was ≥80% agreement among participants. RESULTS: Fifty-three nominated experts from 27 LMICs voted on 27 statements in two rounds. Ultimately, 26 statements reached consensus and comprise the current recommendations. The statements covered three major themes: which surgical services should be decentralised or regionalised; how the implementation of these services should be prioritised; and principles to guide LMIC governments and international visiting teams in scaling up safe, accessible and affordable surgical care. CONCLUSIONS: These recommendations represent the first step towards the development of international guidelines for the scaling up of surgical services in LMICs. They constitute the best available basis for policymaking, planning and allocation of resources for strengthening surgical systems.

The Impact of Quality Improvement Interventions in Improving Surgical Infections and Mortality in Low and Middle-Income Countries: A Systematic Review and Meta-Analysis.

BACKGROUND: Morbidity and mortality in surgical systems in low- and middle-income countries (LMICs) remain high compared to high-income countries. Quality improvement processes, interventions, and structure are essential in the effort to improve peri-operative outcomes. METHODS: A systematic review and meta-analysis of interventional studies assessing quality improvement processes, interventions, and structure in developing country surgical systems was conducted according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they were conducted in an LMIC, occurred in a surgical setting, and measured the effect of an implementation and its impact. The primary outcome was mortality, and secondary outcomes were rates of rates of hospital-acquired infection (HAI) and surgical site infections (SSI). Prospero Registration: CRD42020171542. RESULT: Of 38,273 search results, 31 studies were included in a qualitative synthesis, and 28 articles were included in a meta-analysis. Implementation of multimodal bundled interventions reduced the incidence of HAI by a relative risk (RR) of 0.39 (95%CI 0.26 to 0.59), the effect of hand hygiene interventions on HAIs showed a non-significant effect of RR of 0.69 (0.46-1.05). The WHO Safe Surgery Checklist reduced mortality by RR 0.68 (0.49 to 0.95) and SSI by RR 0.50 (0.33 to 0.63) and antimicrobial stewardship interventions reduced SSI by RR 0.67 (0.48-0.93). CONCLUSION: There is evidence that a number of quality improvement processes, interventions and structural changes can improve mortality, HAI and SSI outcomes in the peri-operative setting in LMICs.

Effectiveness of Quality Improvement Processes, Interventions, and Structure in Trauma Systems in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis.

BACKGROUND: Trauma mortality in low- and middle-income countries (LMICs) remains high compared to high-income countries. Quality improvement processes, interventions, and structure are essential in the effort to decrease trauma mortality. METHODS: A systematic review and meta-analysis of interventional studies assessing quality improvement processes, interventions, and structure in developing country trauma systems was conducted from November 1989 to August 2020 according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they were conducted in an LMIC population according to World Bank Income Classification, occurred in a trauma setting, and measured the effect of implementation and its impact. The primary outcome was trauma mortality. RESULTS: Of 37,575 search results, 30 studies were included from 15 LMICs covering five WHO regions in a qualitative synthesis. Twenty-seven articles were included in a meta-analysis. Implementing a pre-hospital trauma system reduced overall trauma mortality by 45% (risk ratio (RR) 0.55, 95% CI 0.4 to 0.75). Training first responders resulted in an overall decrease in mortality (RR 0.47, 95% CI 0.28 to 0.78). In-hospital trauma training with certified courses resulted in a reduction of mortality (RR 0.71, 95% CI 0.62 to 0.78). Trauma audits and trauma protocols resulted in varying improvements in trauma mortality. CONCLUSION: There is evidence that quality improvement processes, interventions, and structure can improve mortality in the trauma systems in LMICs.

Development of a Unifying Target and Consensus Indicators for Global Surgical Systems Strengthening: Proposed by the Global Alliance for Surgery, Obstetric, Trauma, and Anaesthesia Care (The G4 Alliance).

After decades on the margins of primary health care, surgical and anaesthesia care is gaining increasing priority within the global development arena. The 2015 publications of the Disease Control Priorities third edition on Essential Surgery and the Lancet Commission on Global Surgery created a compelling evidenced-based argument for the fundamental role of surgery and anaesthesia within cost-effective health systems strengthening global strategy. The launch of the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care in 2015 has further coordinated efforts to build priority for surgical care and anaesthesia. These combined efforts culminated in the approval of a World Health Assembly resolution recognizing the role of surgical care and anaesthesia as part of universal health coverage. Momentum gained from these milestones highlights the need to identify consensus goals, targets and indicators to guide policy implementation and track progress at the national level. Through an open consultative process that incorporated input from stakeholders from around the globe, a global target calling for safe surgical and anaesthesia care for 80% of the world by 2030 was proposed. In order to achieve this target, we also propose 15 consensus indicators that build on existing surgical systems metrics and expand the ability to prioritize surgical systems strengthening around the world.

Global Surgery 2030: a roadmap for high income country actors.

The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the world's new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future.

General surgery education: a systematic review of training worldwide.

BACKGROUND: Surgical care is an essential component of health management worldwide. As the prevalence of injuries and non-communicable diseases increases, the provision of effective surgical care will become an increasingly important priority to reduce death and disability. To assess the ability of health systems to meet current surgical needs, we did a review of surgical training programmes worldwide. METHODS: We searched Medline, EMBASE, and the Global Health Library databases with the search terms "surgical training" and "surgeon training" for abstracts and citations in all languages published between Jan 1, 1998, and Dec 31, 2013, describing a national general surgery training system. We extracted the following data: a brief description of the programme, years of training required, year after medical school graduation when training begins, name of national oversight organisation(s), in-country opportunities for subspecialty training, and whether programmes self-identified as being similar to or affected by the surgical education system in the USA or the UK. FINDINGS: We identified 5229 abstracts (3888 from Medline, 971 from EMBASE, and 726 from the Global Health Library databases). 228 (4·4%) articles underwent full text review. 60 articles were included for data extraction. We identified descriptions of general surgery training programmes in 52 countries. Data from an additional 17 countries represented by a regional college of surgeons were also recorded. Training duration ranged from 2-8 years (median total training, 6 years; median surgical training, 5 years), and lasted on average 6 years after medical school graduation. 19 countries self-identified as being similar to or affected by the US or UK training model. Many low-income and middle-income countries (LMICs) are working to expand access to surgical care through programmes, often focusing on training non-physician clinicians. Programmes in high-income countries have also undergone substantial reforms, affected by evolving practice environments, trainee preferences, and training bottlenecks. INTERPRETATION: General surgery training programmes are often responsive to national health care needs. We show a global trend towards standardisation of curricula and competency-based training. Countries expanding or developing their programmes show benefit from association or partnership with larger surgical organisations and academic institutions, but there are questions of sustainability. Both LMICs and high-income countries stand to benefit from coordinating development of global training standards and educational exchanges. Although more research is needed to understand the role of surgical education in meeting the demand for surgical care, it is clear that a cross-nationally coordinated strategy will be important to address the burden of surgical disease. FUNDING: None.

Terrorism-related trauma in Africa, an increasing problem.

Global terrorist activities have increased significantly over the past decade. The impact of terrorism-related trauma on the health of individuals in low- and middle-income countries is under-reported. Trauma management in African countries in particular is uncoordinated, with little or no infrastructure to cater for emergency surgical needs. This article highlights the need for education, training and research to mitigate the problems related to terrorism and surgical public health.

An assessment of surgical and anesthesia staff at 10 government hospitals in Sierra Leone.

IMPORTANCE: Strengthening workforce capacity to deliver essential surgical and anesthesia care has been identified as a strategy for addressing the unmet burden of morbidity and mortality in under-resourced countries. Sierra Leone is one of the poorest countries in the world and faces the challenge of stretching limited resources to provide appropriate health care for a population of 6 million. OBJECTIVES: To investigate the training of surgical and anesthesia staff in Sierra Leone and to build an evidence base for future health care policy and training programs tailored to local needs. DESIGN, SETTING, AND PARTICIPANTS: Health care professionals who conduct surgery or deliver anesthesia at 10 of the 23 government hospitals in Sierra Leone were surveyed regarding training and clinical practices. This study surveyed 36 of 70 surgical staff (51%) and 38 of 68 nurse specialists (56%) nationally. MAIN OUTCOMES AND MEASURES: Descriptive analysis of demographic details, training levels, and reported needs for future development. RESULTS: Thirty-six surgeons were surveyed in study hospitals, of whom the majority had limited surgical specialization training, whereas most anesthesia was provided by 47 nurse specialists. All consultants had postgraduate qualifications, but 4 of 6 medical superintendents (67%) and all medical officers lacked postgraduate surgical qualifications or formal surgical specialist training. The number of trained anesthesia staff increased after the introduction of the Nurse Anesthesia Training Program in 2008, funded by the United Nations Fund for Population Activities, increasing the number from 2 to 47 anesthesia staff based at the study hospitals. Although 32 of 37 nurse anesthetists (86%) reported having attended training workshops, 30 of 37 (>80%) described anesthesia resources as "poor," reporting a critical need for anesthesia machines and continual oxygen supply. Of the 37, 25 specifically mentioned the need for a better-functioning anesthesia machine and 16 mentioned the need for oxygen. CONCLUSIONS AND RELEVANCE: To address unmet surgical need in the long term, accredited local surgical specialization programs are required; training of nonphysician surgical practitioners may offer a short-term solution. To develop safe anesthesia care, governments and donors should focus on providing health care professionals with essential equipment and resources.

Evidence-based training and mentorship combined with enhanced outcomes surveillance to address the leading causes of neonatal mortality at the district hospital level in Ghana.

OBJECTIVE: To evaluate the impact of a district hospital intervention focused on enhancing healthcare provider capacity to address leading causes of neonatal death: birth asphyxia, infection and prematurity. METHODS: The neonatal quality improvement initiative was launched at two intervention referral district hospitals in Ghana. Local Health and Demographic Surveillance Systems were enlisted to enhance recording of neonatal and infant deaths in the community and at the facility. After baseline site assessments, a team of local paediatric experts conducted three clinical trainings on-site at each intervention hospital. Assessments were conducted to evaluate participant knowledge before and after participation in training modules. Monthly mentorship visits provided additional training to support the adoption of essential early neonatal care practices. RESULTS: In the first year of implementation, the initiative provided focused clinical training to 278 participants. A comparison of pre- and post-training test results demonstrates significant improvement in provider knowledge (73% vs. 89% correct, P < 0.001), with even greater improvement among trainees receiving recurrent refresher training (86% vs. 94% correct, P < 0.001). Participant feedback following training revealed enthusiasm about the programme and improved confidence. CONCLUSIONS: Locally led initiatives that invest directly in healthcare provider education and health systems strengthening represent a promising avenue for reducing neonatal morbidity and mortality. The NQI initiative demonstrates the positive impact of a district hospital intervention that combines on-site training, mentorship and enhanced demographic surveillance.

Assessing the surgical and obstetrics-gynecology workload of medical officers: findings from 10 district hospitals in Ghana.

HYPOTHESIS: Surgical and obstetrics-gynecology (Ob-Gyn) workload of medical officers (MOs) is substantial and may inform policies for training investment and surveillance to strengthen surgical care at district hospitals in Ghana. DESIGN: Observational study. SETTING: Academic research. PARTICIPANTS: Using standardized criteria, 12 trained on-site observers assessed the surgical and Ob-Gyn workload of MOs at 10 district hospitals in each of 10 administrative regions in Ghana, West Africa. The number of patients seen by MOs and the time spent managing each patient were recorded. According to each patient's diagnosis, the encounters were categorized as medical/nonsurgical, Ob-Gyn, or surgical. MAIN OUTCOME MEASURES: The proportions of patients having Ob-Gyn and surgical conditions and the time expended providing care to Ob-Gyn and surgical patients. RESULTS: Of the observed patient encounters, 1600 (64.5%) were classified as medical or nonsurgical, 514 (20.7%) as Ob-Gyn, and 368 (14.8%) as surgical (9.0% nontrauma and 5.8% trauma). The most common diagnosis among Ob-Gyn patients was obstetric complication requiring cesarean section. The most common diagnosis among surgical patients was inguinal hernia. Medical officers devoted 24.8% of their time to managing Ob-Gyn patients and 18.9% to managing surgical patients (which included 5.4% for the management of traumatic injuries). CONCLUSIONS: Surgical and Ob-Gyn patients represent a substantial proportion of the workload among MOs at district hospitals in Ghana. Strategies to increase surgical capacity at these facilities must include equipping MOs with the appropriate training and resources to address the significant surgical and Ob-Gyn workload they face.