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.

Beyond Policy: Strengthening District Level Access to Surgery Is Critical to Achieving Surgical Equity in Universal Health Coverage Comment on "Improving Access to Surgery Through Surgical Team Mentoring - Policy Lessons From Group Model Building With Local Stakeholders in Malawi".

District level access to surgical care has been identified as the rate limiting step to increasing access to the bottom billion and relies on a complex interplay of patient-related and system-based factors that underlie the provision of quality surgical care at point of care. Surgical mentoring via visiting teams, use of current proprietary technologies to enhance communication, establishment of a national surgical coordinator and multi-stakeholder engagement with creative cost-sharing have all demonstrated promising results. Regardless of strategic implementation frameworks, system-based thinking coupled with implementation science with practical solutions will be necessary to inform stakeholders on the best way forward in their respective geographic field of work charting a path towards surgical equity in universal health coverage (UHC).

Ending Neglected Surgical Diseases (NSDs): Definitions, Strategies, and Goals for the Next Decade.

While there has been overall progress in addressing the lack of access to surgical care worldwide, untreated surgical conditions in developing countries remain an underprioritized issue. Significant backlogs of advanced surgical disease called neglected surgical diseases (NSDs) result from massive disparities in access to quality surgical care. We aim to discuss a framework for a public health rights-based initiative designed to prevent and eliminate the backlog of NSDs in developing countries. We defined NSDs and set forth six criteria that focused on the applicability and practicality of implementing a program designed to eradicate the backlog of six target NSDs from the list of 44 Disease Control Priorities 3rd edition (DCP3) surgical interventions. The human rights-based approach (HRBA) was used to clarify NSDs role within global health. Literature reviews were conducted to ascertain the global disease burden, estimated global backlog, average cost per treatment, disability-adjusted life-years (DALYs) averted from the treatment, return on investment, and potential gain and economic impact of the NSDs identified. Six index NSDs were identified, including neglected cleft lips and palate, clubfoot, cataracts, hernias and hydroceles, injuries, and obstetric fistula. Global definitions were proposed as a starting point towards the prevention and elimination of the backlog of NSDs. Defining a subset of neglected surgical conditions that illustrates society's role and responsibility in addressing them provides a framework through the HRBA lens for its eventual eradication.

Decentralization and Regionalization of Surgical Care as a Critical Scale-up Strategy in Low- and Middle-Income Countries Comment on "Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries".

As global attention to improve the quality, safety and access to surgical care in low- and middle-income countries (LMICs) increases, the need for evidence-based strategies to reliably scale-up the quality and quantity of surgical services becomes ever more pertinent. Iversen et al discuss the optimal distribution of surgical services, whether through decentralization or regionalization, and propose a strategy that utilizes the dimensions of acuity, complexity and prevalence of surgical conditions to inform national priorities. Proposed expansion of this strategy to encompass levels of scale-up prioritization is discussed in this commentary. The decentralization of emergency obstetric services in LMICs shows promising results and should be further explored. The dearth of evidence of regionalization in LMICs, on the other hand, limits extrapolation of lessons learned. Nevertheless, principles from the successful regionalization of certain services such as trauma care in high-income countries (HICs) can be adapted to LMIC settings and can provide the backbone for innovation in service delivery and safety.

Global Surgery - Redirecting Strategies for a Global Research Agenda Comment on "Global Surgery - Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa".

More than three years have passed since the publication of the Lancet Commission on Global Surgery and its recommendations on scaling up surgery in sub-Saharan Africa (SSA). An important gap, the voice of the districts as well as lack of contextualized research, has been noted in its support of national surgical plans that run the risk of being at best, aspirational. Moreover, a 'one-size-fits-all approach' may not adequately address country-specific challenges on the ground. There is a need to redirect attention, effort, and funding in creating a global mechanism to gather baseline country information documenting every single district level government health facility's ability and readiness to provide safe surgical, obstetric, trauma, and anesthesia care using the World Health Organization (WHO) Service Availability and Readiness Assessment (SARA) tool to aid in directing country-specific efforts in surgical systems strengthening and ensuring that a basic package of essential surgical and anesthesia services is made available to each citizen with adequate financial protection by 2030. This global mechanism will enable benchmarking, accountability, and streamlining of the work of the global surgical community to achieve true progress in scaling up surgery not only in SSA, but for the rest of the developing world.

Implementation of the World Health Organization Trauma Care Checklist Program in 11 Centers Across Multiple Economic Strata: Effect on Care Process Measures.

BACKGROUND: Trauma contributes more than ten percent of the global burden of disease. Initial assessment and resuscitation of trauma patients often requires rapid diagnosis and management of multiple concurrent complex conditions, and errors are common. We investigated whether implementing a trauma care checklist would improve care for injured patients in low-, middle-, and high-income countries. METHODS: From 2010 to 2012, the impact of the World Health Organization (WHO) Trauma Care Checklist program was assessed in 11 hospitals using a stepped wedge pre- and post-intervention comparison with randomly assigned intervention start dates. Study sites represented nine countries with diverse economic and geographic contexts. Primary end points were adherence to process of care measures; secondary data on morbidity and mortality were also collected. Multilevel logistic regression models examined differences in measures pre- versus post-intervention, accounting for patient age, gender, injury severity, and center-specific variability. RESULTS: Data were collected on 1641 patients before and 1781 after program implementation. Patient age (mean 34 ± 18 vs. 34 ± 18), sex (21 vs. 22 % female), and the proportion of patients with injury severity scores (ISS) ≥ 25 (10 vs. 10 %) were similar before and after checklist implementation (p > 0.05). Improvement was found for 18 of 19 process measures, including greater odds of having abdominal examination (OR 3.26), chest auscultation (OR 2.68), and distal pulse examination (OR 2.33) (all p < 0.05). These changes were robust to several sensitivity analyses. CONCLUSIONS: Implementation of the WHO Trauma Care Checklist was associated with substantial improvements in patient care process measures among a cohort of patients in diverse settings.

The benefits of international rotations to resource-limited settings for U.S. surgery residents.

BACKGROUND: U.S. surgery residents increasingly are interested in international experiences. Recently, the Residency Review Committee approved international surgery rotations for credit toward graduation. Despite this growing interest, few U.S. surgery residency programs offer formal international rotations. We aimed to present the benefits of international surgery rotations and how these rotations contribute to the attainment of the 6 Accreditation Council for Graduate Medical Education (ACGME) competencies. METHODS: An e-mail-based survey was sent in November 2011 to the 188 members of Surgeons OverSeas, a group of surgeons, residents, fellows, and medical students with experience working in resource-limited settings. They were asked to list 5 benefits of international rotations for surgery residents. The frequency of benefits was qualitatively grouped into 4 major categories: educational, personal, benefits to the foreign institution/Global Surgery, and benefits to the home institution. The themes were correlated with the 6 ACGME competencies. RESULTS: The 58 respondents (31% response rate) provided a total of 295 responses. Fifty themes were identified. Top benefits included learning to optimally function with limited resources, exposure to a wide variety of operative pathology, exposure to a foreign culture, and forming relationships with local counterparts. All ACGME competencies were covered by the themes. CONCLUSION: International surgery rotations to locations in which resources are constrained, operative diseases vary, and patient diversity abound provide unique opportunities for surgery residents to attain the 6 ACGME competencies. General surgery residency programs should be encouraged to establish formal international rotations as part of surgery training to promote resident education and assist with necessary oversight.

A survey of surgical capacity in rural southern Nigeria: opportunities for change.

BACKGROUND: Despite growing recognition of the massive surgical burden of disease, unmet need, and disparities in access to care in many African countries, little is known about their capacity to deliver surgical, obstetric, emergency, and anesthetic care, particularly in the rural areas where up to 50% of the population lives. This study aimed to quantify the surgical capacity of select healthcare facilities in rural southern Nigeria in five key areas: Workforce, Infrastructure, Skill, Equipment, and Supplies. METHODS: We assessed the surgical capacity of 41 private, rural hospitals in southern Nigeria using the Personnel, Infrastructure, Procedures, Equipment, and Supplies survey tool developed by Surgeons OverSeas. The survey was administered to surgical practitioners during their annual conference in November 2011. RESULTS: Among the 41 hospitals surveyed, general practitioners (52.1%) constituted most of the surgical workforce. Only one anesthesiologist was available in 16 secondary hospitals. Although most of the primary and secondary hospitals had running water (82.3%), a designated emergency room (80.5%), and medical records (95.9%), only 50.3% of all hospitals had electricity through the power grid. Also, only 37.5% of all facilities had a blood bank and 43.8% had an X-ray machine. Common surgical procedures were done by most of the facilities; however, cricothyroidotomy, clubfoot repair, and obstetric fistula repair were scarcely done. Less than half of the facilities provided general anesthesia, only 20% have an anesthesia machine, and 44.5% have a pulse oximeter. CONCLUSION: Severe shortages in key areas should motivate stakeholders to devote more effort and resources to strengthening surgical capacity in rural southern Nigeria.

Strengthening surgical services at the soum (first-referral) hospital: the WHO emergency and essential surgical care (EESC) program in Mongolia.

BACKGROUND: Provision of surgical care continues to receive little attention and funding despite the growing burden of surgical disease worldwide. In 2004, The World Health Organization (WHO) established the Emergency and Essential Surgical Care (EESC) program, which was designed to strengthen surgical services at the first-referral hospital. There are limited data documenting the implementation and scale-up of such services. We describe the nationwide implementation of the EESC program in Mongolia over a 6 year period. METHODS: Surgical services were increased in rural areas of Mongolia using the WHO Integrated Management of Emergency and Essential Surgical Care (IMEESC) toolkit from 2004 to 2010. Fund of knowledge tests and program evaluation was done to measure uptake, response, and perceived importance of the program. Two years after the pilot sites were launched, programmatic impact on short-term process measures was evaluated using the WHO Monitoring and Evaluation form. RESULTS: The program was implemented in 14 aimags/provinces (66.67 %) and 178 soum hospitals (52.66 %). Fund of knowledge scores increased from 47.72 % (95 % confidence interval (CI) 40.7-54.7) to 77.9 % (95 % CI 70.1-85.7, p = 0.0001) after the training program. 1 year post-training, there was a 57.1 % increase in the availability of emergency rooms, 59.1 % increase in the supply of emergency kits, a 73.64 % increase in the recording of emergency care cases, and a 46.66 % increase in the provision of facility and instrument usage instructions at the pilot sites. CONCLUSIONS: The EESC program was successfully implemented and scaled up at a national level with improvements in short-term process measures.