South Africa and the Surgical Diaspora-A Hub for Surgical Migration and Training.

BACKGROUND: The shortage of trained surgeons, anesthesiologists, and obstetricians is a major contributor to the unmet need for surgical care in low- and middle-income countries, and the shortage is aggravated by migration to higher-income countries. METHODS: We performed a cross-sectional observational study, combining individual-level data of 43,621 physicians from the Health Professions Council of South Africa with data from the registers of 14 high-income countries, and international statistics on surgical workforce, in order to quantify migration to and from South Africa in both absolute and relative terms. RESULTS: Of 6670 surgeons, anesthesiologists, and obstetricians in South Africa, a total of 713 (11%) were foreign medical graduates, and 396 (6%) were from a low- or middle-income country. South Africa was an important destination primarily for physicians originating from low-income countries; 2% of all surgeons, anesthesiologists, and obstetricians from low- and middle-income countries were registered in South Africa, and 6% in the other 14 recipient countries. A total of 1295 (16%) South African surgeons, anesthesiologists, and obstetricians worked in any of the 14 studied high-income countries. CONCLUSION: South Africa is an important regional hub for surgical migration and training. A notable proportion of surgical specialists in South Africa were medical graduates from other low- or middle-income countries, whereas migration out of South Africa to high-income countries was even larger.

Operative Trauma Courses: A Scoping Review to Inform the Development of a Trauma Surgery Course for Low-Resource Settings.

BACKGROUND: A multitude of operative trauma courses exist, most of which are designed for and conducted in high-resource settings. There are numerous barriers to adapting such courses to low- and low-middle-income countries (LMICs), including resource constraints and contextual variations in trauma care. Approaches to implementing operative trauma courses in LMICs have not been evaluated in a structured manner. METHODS: We conducted a scoping review of the literature including databases (e.g., PubMed, Web of Science, EMBASE), grey literature repositories, and structured queries of publicly available course materials to identify records that described operative trauma courses offered since 2000. RESULTS: The search identified 3,518 non-duplicative records, of which 48 relevant reports were included in analysis. These reports represented 23 named and 11 unnamed operative trauma courses offered in 12 countries. Variability existed in course format and resource requirements, ranging from USD 40 to 3,000 per participant. Courses incorporated didactic and laboratory components, which utilized simulations, cadavers, or live animals. Course content overlapped significantly but was not standardized. Data were lacking on course implementation and promulgation, credentialing of instructors, and standardized evaluation metrics. CONCLUSIONS: While many operative trauma courses have been described, most are not directly relatable to LMICs. Barriers include cost-prohibitive fees, lack of resources, limited data collection, and contextual variability that renders certain surgical care inappropriate in LMICs. Gaps exist in standardization of course content as well as transparency of credentialing and course implementation strategies. These issues can be addressed through developing an open-access operative trauma course for low-resource settings.

Surgical management of necrotising enterocolitis in Sweden: A national cohort study.

AIM: Necrotising enterocolitis (NEC) is the dominating surgical emergency in preterm neonates. The aims were to investigate indications, surgical management and mortality for surgically treated neonates with NEC. METHODS: Data were retrieved from the Swedish Neonatal Quality Register for Swedish neonates with surgically treated NEC from 1 January 2017 to 31 December 2021. Diagnosis was validated by surgical records and histopathology. Neonates with isolated spontaneous intestinal perforation were excluded. RESULTS: In total, 109 neonates were included. Median gestational age was 25 weeks (22-38), and median birth weight was 771 g (269-3920). Preoperative pneumoperitoneum was found in 32%, portal venous gas in 25% and clinical deterioration on conservative treatment in 26% of the neonates. Among the 97 neonates presenting with small bowel necrosis, single-focal NEC occurred in 38 (39%), multifocal NEC in 35 (36%) and panintestinal NEC in 24 (25%). A primary anastomosis was performed in 10/87 (11%) of the neonates with bowel resection at primary surgery. Clip-and-drop technique was applied in 24/87 (28%).Mortality rate was 37%. CONCLUSION: Mortality was well comparable with earlier reports considering exclusion of spontaneous intestinal perforation (SIP) and the low gestational age of the study population. Resection of necrotic bowel with stoma formation was the dominating surgical method.

Differential Activation of Immune Effector Processes in Mature Compared to Immature Sacrococcygeal Teratomas.

Objective: This study aims to characterize the molecular signatures of sacrococcygeal teratomas (SCTs). Methods: Three SCTs were analyzed with whole genome genotyping. RNA sequencing of 10 SCTs dominated by mature, immature and neuroglial elements was analyzed. Expression in SCT-samples with different elements were compared to each other and to a reference group of malignant pediatric tumors. Macrophages, T- and B-lymphocytes were detected by immunohistochemistry. Results: No chromosomal imbalances were detected. SCTs showed overexpression of genes involved in neurosignaling, DNA-binding molecules and pathways of early germ cells. Genes associated with immune effector processes were overexpressed in mature compared to immature SCTs, and immune cell infiltration was found predominantly around mature epithelial elements. Conclusion: The broad repertoire of histological elements in SCTs reflects differences in transcriptional regulation rather than differences in gene copy numbers. A paucity of immune response in immature SCTs may be a factor contributing to their uninhibited growth.

Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report.

BACKGROUND: Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally. METHODS AND FINDINGS: The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees. CONCLUSIONS: To track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.

Sustainable care for children with cancer: a Lancet Oncology Commission.

We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020-50 would be four times greater than the cumulative treatment costs of $594 billion, producing a net benefit of $1986 billion on the global investment: a net return of $3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths.

Health-related quality of life and scar satisfaction in a cohort of children operated on for sacrococcygeal teratoma.

AIM: The aims of this study were to evaluate health-related quality of life (HRQoL) in children with sacrococcygeal teratoma and to explore the effect of the scar on physical, emotional and behavioral aspects. METHODS: A cohort of children operated on for sacrococcygeal teratoma between 2000 and 2013 at Lund University Hospital, Sweden, and their parents were interviewed. HRQoL was evaluated with PedsQL, and scar satisfaction was estimated through Patient Observer Scar Assessment Score (POSA). RESULTS: All eligible children (n = 17) were included (100% response rate). Median age was 7.3 years (range 3.5-16.0). Mean total PedsQL score was 92.3 (range 72.0 to 99.0). Patients with comorbidity scored lower (87.5) than those without (95.0) (p < 0.05). Pain during sitting down was reported by two (20%) patients, and itching was reported by another two patients (20%) aged > 8 years. No children reported that they avoided situations due to the scar, and most (80% of children and 90% of parents) reported absent or only mild negative emotions when considering the scar. CONCLUSION: Children with sacrococcygeal teratoma had a good overall HRQoL, but comorbidity reduced the outcome. A few children reported scar-related impact on physical, behavioral and emotional aspects.

Correction to: The Met Needs for Pediatric Surgical Conditions in Sierra Leone: Estimating the Gap.

In the original article, Johan von Schreeb's last name was spelled incorrectly. It is correct as reflected here.

The need to collect, aggregate, and analyze global anesthesia and surgery data.

In the Sustainable Development Goals era, there is a new awareness of the need for an integrated approach to healthcare interventions and a strong commitment to Universal Health Coverage. To achieve the goal of strengthening entire health systems, surgery, as a crosscutting treatment modality, is indispensable. For any health system strengthening exercise, baseline data and longitudinal monitoring of progress are necessary. With improved data capabilities, there are unparalleled possibilities to map out and understand systems, integrating data from many sources and sectors. Nevertheless, there is also a need to prioritize among indicators to avoid information overload and data collection fatigue. There is a similar need to define indicators and collection methodology to create standardized and comparable data. Finally, there is a need to establish data pathways to ensure clear responsibilities amongst national and international institutions and integrate surgical metrics into existing mechanisms for sustainable data collection. This is a call to collect, aggregate, and analyze global anesthesia and surgery data, with an account of existing data sources and a proposed way forward.

RéSUMé: À l'époque des objectifs du développement durable, on constate une nouvelle sensibilisation au besoin d'une approche intégrée dans les interventions en soins de santé et un fort engagement en faveur d'une couverture médicale universelle. Pour atteindre l'objectif du renforcement de systèmes entiers de santé, la chirurgie en tant que modalité thérapeutique transversale est indispensable. Pour toute activité de renforcement du système de santé, des données de référence et un suivi longitudinal des progrès sont nécessaires. Avec de meilleures données, il existe des possibilités sans équivalent de cartographier et de comprendre les systèmes, en intégrant des données provenant de multiples sources et secteurs. Néanmoins, il est également nécessaire de prioriser les indicateurs pour éviter une surcharge d'informations et une fatigue dans la collecte des données. Il existe un besoin similaire de définition des indicateurs et de la méthodologie de collecte afin de créer des données standardisées et comparables. Enfin, il est nécessaire d'établir des cheminements de données pour garantir des responsabilités claires entre les institutions nationales et internationales et intégrer les paramètres chirurgicaux dans les mécanismes existants pour une collecte durable des données. Ceci est un appel à la collecte, au regroupement et à l'analyse de données globales en anesthésie et en chirurgie avec un compte rendu des sources de données existantes et une proposition d'avancée.

Long-Term Outcome of Sacrococcygeal Teratoma: A Controlled Cohort Study of Urinary Tract and Bowel Dysfunction and Predictors of Poor Outcome.

OBJECTIVE: To evaluate urinary tract and bowel function in children with sacrococcygeal teratoma, compare the findings with healthy children, and assess predictors of poor outcome. STUDY DESIGN: This was a controlled cohort study of all patients operated for sacrococcygeal teratoma at a tertiary pediatric surgery center, 2000-2013. Urinary and bowel function were compared with healthy control patients matched for age and sex. Perioperative and histopathologic risk factors were analyzed. RESULTS: In total, 17 patients with sacrococcygeal teratoma and 85 healthy control patients were included in the study. Patients with sacrococcygeal teratoma more often were reported to have uncontrolled voiding (12% vs 0%, P < .01), difficulty in bladder emptying (24% vs 0%, P < .001), and pyelonephritis (18% vs 1%, P < .05). Constipation was more common in patients with sacrococcygeal teratoma (47 % vs 14%, P < .05), but the overall bowel function score was equal in the 2 groups. Children with large tumors and immature histology were more likely to have a dysfunctional outcome (P < .05). CONCLUSIONS: Uncontrolled voiding, difficulty in bladder emptying, pyelonephritis, and constipation were more common in patients with sacrococcygeal teratoma than in healthy children. Dysfunctional outcome was more prevalent in children with large and immature teratomas.

Cryptorchidism in Sweden: A Nationwide Study of Prevalence, Operative Management, and Complications.

OBJECTIVES: To review the cumulative prevalence, operative management, and complications of treatment for cryptorchidism in Sweden. STUDY DESIGN: A nationwide observational study from longitudinal register data of all Swedish-born boys 0-18 years of age, diagnosed with cryptorchidism from 2001 to 2014. Primary outcomes were occurrence and age at primary surgery. Secondary outcomes included type of procedure and surgical site infection. RESULTS: Of 20 375 boys diagnosed with cryptorchidism in 2001-2014, 12 766 were surgically treated. The cumulative childhood prevalence was 1.8% (95% CI, 1.5-2.0), with a higher prevalence in boys born prematurely, small for gestational age, or with low birth weight. The median age at treatment decreased from 6.2 years in 2001 to 3.4 years in 2014 (P < .001). Still, 94.1% (95% CI, 92.7-95.6) had surgery after the recommended 1 year of age in 2014. Variations in age at surgery between Swedish counties were great (range, 2.9-5.9 years of age). There were no deaths within 30 days after surgery and the frequency of surgical site infection was low (1.4%; 95% CI, 1.1-1.6). CONCLUSIONS: The cumulative childhood prevalence of cryptorchidism was high, and complications were rare. Few boys underwent surgery in a timely manner according to clinical guidelines, and standards of care varied considerably across the country. Further research and collective actions are needed to improve the detection and management of congenital cryptorchidism.

The Met Needs for Pediatric Surgical Conditions in Sierra Leone: Estimating the Gap.

BACKGROUND: In low- and middle-income countries, there is a gap between the need for surgery and its equitable provision, and a lack of proxy indicators to estimate this gap. Sierra Leone is a West African country with close to three million children. It is unknown to what extent the surgical needs of these children are met. AIM: To describe a nationwide provision of pediatric surgical procedures and to assess pediatric hernia repair as a proxy indicator for the shortage of surgical care in the pediatric population in Sierra Leone. METHODS: We analyzed results from a nationwide facility survey in Sierra Leone that collected data on surgical procedures from operation and anesthesia logbooks in all facilities performing surgery. We included data on all patients under the age of 16 years undergoing surgery. Primary outcomes were rate and volume of surgical procedures. We calculated the expected number of inguinal hernia in children and estimated the unmet need for hernia repair. RESULTS: In 2012, a total of 2381 pediatric surgical procedures were performed in Sierra Leone. The rate of pediatric surgical procedures was 84 per 100,000 children 0-15 years of age. The most common pediatric surgical procedure was hernia repair (18%), corresponding to a rate of 16 per 100,000 children 0-15 years of age. The estimated unmet need for inguinal hernia repair was 88%. CONCLUSIONS: The rate of pediatric surgery in Sierra Leone was very low, and inguinal hernia was the single most common procedure noted among children in Sierra Leone.

Prioritizing Surgical Care on National Health Agendas: A Qualitative Case Study of Papua New Guinea, Uganda, and Sierra Leone.

BACKGROUND: Little is known about the social and political factors that influence priority setting for different health services in low- and middle-income countries (LMICs), yet these factors are integral to understanding how national health agendas are established. We investigated factors that facilitate or prevent surgical care from being prioritized in LMICs. METHODS AND FINDINGS: We undertook country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. We conducted 74 semi-structured interviews with stakeholders involved in health agenda setting and surgical care in these countries. Interviews were triangulated with published academic literature, country reports, national health plans, and policies. Data were analyzed using a conceptual framework based on four components (actor power, ideas, political contexts, issue characteristics) to assess national factors influencing priority for surgery. Political priority for surgical care in the three countries varies. Priority was highest in Papua New Guinea, where surgical care is firmly embedded within national health plans and receives significant domestic and international resources, and much lower in Uganda and Sierra Leone. Factors influencing whether surgical care was prioritized were the degree of sustained and effective domestic advocacy by the local surgical community, the national political and economic environment in which health policy setting occurs, and the influence of international actors, particularly donors, on national agenda setting. The results from Papua New Guinea show that a strong surgical community can generate priority from the ground up, even where other factors are unfavorable. CONCLUSIONS: National health agenda setting is a complex social and political process. To embed surgical care within national health policy, sustained advocacy efforts, effective framing of the problem and solutions, and country-specific data are required. Political, technical, and financial support from regional and international partners is also important.

Towards closing the gap of the global surgeon, anaesthesiologist, and obstetrician workforce: thresholds and projections towards 2030.

BACKGROUND: Billions of people are without access to surgical care, in part because of the inequitable distribution of the surgical workforce. Drawing on recently collected data for the number of surgeons, anaesthesiologists, and obstetricians worldwide, we sought to show their global maldistribution by identifying thresholds of surgical workforce densities, and by calculating the number of additional providers needed to reach those thresholds. METHODS: From the WHO Global Surgical Workforce Database, national data for the number of specialist surgeons, anaesthesiologists, and obstetricians per 100 000 population (density) were compared with the number of maternal deaths per 100 000 live births (maternal mortality ratio; MMR) in WHO member countries. A regression line was fit between density of specialist surgeons, anaesthesiologists, and obstetricians and the logarithm of MMR, and we explored the correlation for an upper and a lower density threshold. Based on previous estimates of the global volume of surgical procedures, a global average productivity per specialist was derived. We then multiplied the average productivity with the derived upper and lower threshold densities, and compared these numbers to previously estimated global need of surgical procedures (4664 procedures per 100 000 population). Finally, the numbers of additional providers needed to reach the thresholds in countries with a density below the respective threshold were calculated. FINDINGS: Each 10-unit increase in density of surgeons, anaesthesiologists, and obstetricians, corresponded to a 13·1% decrease in MMR (95% CI 11·3-14·8). We saw particularly steep improvements in MMR from 0 to roughly 20 per 100 000 population. Above roughly 40 per 100 000 population, higher density was associated with relatively smaller improvements in MMR. These arbitrary thresholds of 20 and 40 specialists per 100 000 corresponded with a volume of surgery of 2917 and 5834 procedures per 100 000 population, respectively, and were symmetrically distributed around the estimated global need of 4664 surgical procedures per 100 000 population. Our density thresholds are slightly higher than the current average in lower-middle income countries (16 per 100 000) and upper-middle-income countries (38 per 100 000), respectively. To reach the threshold of at least 20 per 100 000 in each country today, another 440 231 (IQR 438 900-443 245) providers would be needed. To reach 40 per 100 000, 1 110 610 (IQR 1 095 376-1 183 525) providers would be needed. INTERPRETATION: Assuming uniform productivity, a global surgical workforce between 20 and 40 per 100 000 would suffice to provide the world's missing surgical procedures. We concede that causality cannot be implied, but our results suggest that countries with a workforce density above certain thresholds have better health outcomes. Although the thresholds cannot be interpreted as a minimum standard, they are useful to characterise the global surgical workforce and its deficits. Such thresholds could also be used as markers for health system capacity. FUNDING: None.

Surgical care by non-surgeons in low-income and middle-income countries: a systematic review.

BACKGROUND: Anecdotal evidence suggests that task-shifting or the redistribution of responsibilities from fully-trained surgeons to clinicians with fewer qualifications could become a major component of surgical care delivery in many low-income and middle-income countries (LMICs). Our goal was to summarise the scope of surgical task-shifting in LMICs through a systematic review of the medical literature. METHODS: We searched PubMed, EMBASE, CINAHL, LILACS, and African Index Medicus databases for papers and abstracts published between 1975, and November, 2014, that provided original data regarding non-surgeon providers, the type and volume of operations they perform, and the outcomes they achieve. The search was done in English, French, Spanish, and Portuguese, and included terms related to surgery, non-physician providers, and LMIC country names. Outcomes included the number of non-physicians and non-surgeons practicing surgery in LMICs, their qualifications, practice models and locations, and the types and volume of operations performed. FINDINGS: We identified 65 articles and 14 abstracts that described non-surgeon and non-physician providers performing 46 types of surgical procedures, across eight surgical disciplines, in 41 LMICs. These procedures extended beyond those recommended by WHO, such as male circumcision and emergency obstetric surgery. Non-surgeons and non-physicians provided a large amount of surgical care in some locations, including 90% of obstretric surgeries, 38·5% of general surgery procedures, and 43% of non-obstetric laparotomies at three separate hospitals. Of the 38 papers that specified urban or rural locations, 35 described task-shifting in rural areas or district hospitals. A variety of formal training models for surgical task-shifting were noted, including collaborations between national governments, WHO, and private non-governmental organisations. Surgical providers often had no formal surgical training, and did not operate under the supervision of a fully trained provider. INTERPRETATION: Our results suggest that non-surgeon physicians and non-physician clinicians provide surgical care many in low-resource settings. A limitation of our study is that our search was conducted in only four languages. Because many studies described the same country, countries or regions in overlapping time frames, it was not possible to determine the total number of task-shifting providers. In view of the shortage of fully-trained surgeons in many LMICs, it seems likely that task-shifting is far more widespread than is indicated by the medical literature. More research is needed to accurately determine the full extent and implications of surgical task-shifting in LMICs worldwide. FUNDING: None.

Who is performing surgery in low-income settings: a countrywide inventory of the surgical workforce distribution and scope of practice in Sierra Leone.

BACKGROUND: Scope of practice and in-country distribution of surgical providers in low-income countries remains insufficiently described. Through a nationwide comprehensive inventory of surgical procedures and providers in Sierra Leone, we aimed to present the geographic distribution, medical training, and productivity of surgical providers in a low-income country. METHODS: Following exhaustive sampling, a total of 60 facilities performing surgery in Sierra Leone 2012 was identified. Annual surgical activity was obtained from 58 (97%) facilities, while institution and workforce data was retrieved from 56 (93%). Characteristics of patients, facilities, procedures, and surgical providers were collected retrospectively from operation theatre logbooks and by interviewing facility directors. FINDINGS: In 2012, 164 full-time positions of surgical providers performed 24 152 surgeries in Sierra Leone. Of those, 58 (35·6%) were consultant surgeons, obstetricians, or gynaecologists (population density: 0·97 per 100 000 inhabitants). 86 (52·9%) were medical doctors (1·42 per 100 000), whereas the 14 (8·4%) associate clinicians and six (3·8%) nurses represented a density of 0·23 and 0·10 per 100 000 inhabitants, respectively. Almost half of the districts (46%), representing more than 2 million people (34% of the population), had less than one fully trained consultant. Density of consultant and medical doctors were 27 and six times higher in urban areas compared with rural areas, respectively. The surgical providers performed 144 surgeries per position in 2012 (2·8 surgeries per week). Nurses performed 6·6% and associate clinicians 6·8% of the total national volume of surgeries. Districts with lower surgical rates had a significant lower productivity per surgical provider (Rho=0·650, p=0·022). We noted a significant positive correlation between the facility volume of surgery and the productivity of each surgical provider (p<0·001). INTERPRETATION: Surgical providers with higher qualifications seem to have a preference for urban settlements. Increasing the output of the existing workforce can contribute to expansion of surgical services. FUNDING: Norwegian University of Science and Technology.

Monitoring and evaluating surgical care: defining perioperative mortality rate and standardising data collection.

BACKGROUND: Case volume per 100 000 population and perioperative mortality rate (POMR) are key indicators to monitor and strengthen surgical services. However, comparisons of POMR have been restricted by absence of standardised approaches to when it is measured, the ideal denominator, need for risk adjustment, and whether data are available. We aimed to address these issues and recommend a minimum dataset by analysing four large mixed surgical datasets, two from well-resourced settings with sophisticated electronic patient information systems and two from resource-limited settings where clinicians maintain locally developed databases. METHODS: We obtained data from the New Zealand (NZ) National Minimum Dataset, the Geelong Hospital patient management system in Australia, and purpose-built surgical databases in Pietermaritzburg, South Africa (PMZ) and Port Moresby, Papua New Guinea (PNG). Information was sought on inclusion and exclusion criteria, coding criteria, and completeness of patient identifiers, admission, procedure, discharge and death dates, operation details, urgency of admission, and American Society of Anesthesiologists (ASA) score. Date-related errors were defined as missing dates and impossible discrepancies. For every site, we then calculated the POMR, the effect of admission episodes or procedures as denominator, and the difference between in-hospital POMR and 30-day POMR. To determine the need for risk adjustment, we used univariate and multivariate logistic regression to assess the effect on relative POMR for each site of age, admission urgency, ASA score, and procedure type. FINDINGS: 1 365 773 patient admissions involving 1 514 242 procedures were included, among which 8655 deaths were recorded within 30 days. Database inclusion and exclusion criteria differed substantially. NZ and Geelong records had less than 0·1% date-related errors and greater than 99·9% completeness. PMZ databases had 99·9% or greater completeness of all data except date-related items (94·0%). PNG had 99·9% or greater completeness for date of birth or age and admission date and operative procedure, but 80-83% completeness of patient identifiers and date related items. Coding of procedures was not standardised, and only NZ recorded ASA status and complete post-discharge mortality. In-hospital POMR range was 0·38% in NZ to 3·44% in PMZ, and in NZ it underestimated 30-day POMR by roughly a third. The difference in POMR by procedures instead of admission episodes as denominator ranged from 10% to 70%. Age older than 65 years and emergency admission had large independent effects on POMR, but relatively little effect in multivariate analysis on the relative odds of in-hospital death at each site. INTERPRETATION: Hospitals can collect and provide data for case volume and POMR without sophisticated electronic information systems. POMR should initially be defined by in-hospital mortality because post-discharge deaths are not usually recorded, and with procedures as denominator because details allowing linkage of several operations within one patient's admission are not always present. Although age and admission urgency are independently associated with POMR, and ASA and case mix were not included, risk adjustment might not be essential because the relative odds between sites persisted. Standardisation of inclusion criteria and definitions is needed, as is attention to accuracy and completeness of dates of procedures, discharge and death. A one-page, paper-based form, or alternatively a simple electronic data collection form, containing a minimum dataset commenced in the operating theatre could facilitate this process. FUNDING: None.

Generation of national political priority for surgery: a qualitative case study of three low-income and middle-income countries.

BACKGROUND: Surgical conditions exert a major health burden in low-income and middle-income countries (LMICs), yet surgery remains a low priority on national health agendas. Little is known about the national factors that influence whether surgery is prioritised in LMICs. We investigated factors that could facilitate or prevent surgery from being a health priority in three LMICs. METHODS: We undertook three country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. In total 72 semi-structured interviews were conducted between March and June, 2014, in the three countries. Interviews were designed to query informants' attitudes, values, and beliefs about how and why different health issues, including surgical care, were prioritised within their country. Informants were providers, policy makers, civil society, funders, and other stakeholders involved with health agenda setting and surgical care. Interviews were analysed with Dedoose, a qualitative data analysis tool. Themes were organised into a conceptual framework adapted from Shiffman and Smith to assess the factors that affected whether surgery was prioritised. FINDINGS: In all three countries, effective political and surgical leadership, access to country-specific surgical disease indicators, and higher domestic health expenditures are facilitating factors that promote surgical care on national health agendas. Competing health and policy interests and poor framing of the need for surgery prevent the issue from receiving more attention. In Papua New Guinea, surgical care is a moderate-to-high health priority. Surgical care is embedded in the national health plan and there are influential leaders with surgical interests. Surgical care is a low-to-moderate health priority in Uganda. Ineffectively used policy windows and little national data on surgical disease have impeded efforts to increase priority for surgery. Surgical care remains a low health priority in Sierra Leone. Resource constraints and competing health priorities, such as infectious disease challenges, prevent surgery from receiving attention. INTERPRETATION: Priority for surgery on national health agendas varies across LMICs. Increasing dialogue between surgical providers and political leaders can increase the power of actors who advocate for surgical care. Greater emphasis on the importance of surgical care in achieving national health goals can strengthen internal and external framing of the issue. Growing political recognition of non-communicable diseases provides a favourable political context to increase attention for surgery. Lastly, increasing internally generated issue characteristics, such as improved tracking of national surgical indicators, could increase the priority given to surgery within LMICs. FUNDING: The Bill & Melinda Gates Foundation, King's Health Partners/King's College London, and Lund University.

The Surgical Workforce and Surgical Provider Productivity in Sierra Leone: A Countrywide Inventory.

BACKGROUND: Limited data exist on surgical providers and their scope of practice in low-income countries (LICs). The aim of this study was to assess the distribution and productivity of all surgical providers in an LIC, and to evaluate correlations between the surgical workforce availability, productivity, rates, and volume of surgery at the district and hospital levels. METHODS: Data on surgeries and surgical providers from 56 (93.3 %) out of 60 healthcare facilities providing surgery in Sierra Leone in 2012 were retrieved between January and May 2013 from operation theater logbooks and through interviews with key informants. RESULTS: The Sierra Leonean surgical workforce consisted of 164 full-time positions, equal to 2.7 surgical providers/100,000 inhabitants. Non-specialists performed 52.8 % of all surgeries. In rural areas, the densities of specialists and physicians were 26.8 and 6.3 times lower, respectively, compared with urban areas. The average individual productivity was 2.8 surgeries per week, and varied considerably between the cadres of surgical providers and locations. When excluding four centers that only performed ophthalmic surgery, there was a positive correlation between a facility's volume of surgery and the productivity of its surgical providers (r s = 0.642, p < 0.001). CONCLUSIONS: Less than half of all of the surgery in Sierra Leone is performed by specialists. Surgical providers were significantly more productive in healthcare facilities with higher volumes of surgery. If all surgical providers were as productive as specialists in the private non-profit sector (5.1 procedures/week), the national volume of surgery would increase by 85 %.