BackgroundAccess to surgical care in Low- and Middle-Income Countries (LMICs) such as Tanzania is extremely limited. Northern Tanzania is served by a single tertiary referral hospital, Kilimanjaro Christian Medical Centre (KCMC). The surgical volumes, workflow, and payment mechanisms in this region have not been characterized. Understanding these factors is critical in expanding access to healthcare. The authors sought to evaluate the operations and financing of the main operating theaters at KCMC in Sub-Saharan Africa.MethodsThe 2018 case volume and specialty distribution (general, orthopaedic, and gynecology) in the main operating theaters at KCMC was retrieved through retrospective review of operating report books. Detailed workflow (i.e. planned and cancelled cases, lengths of procedures, lengths of operating days) and financing data (patient payment methods) from the five KCMC operating theater logs were retrospectively reviewed for the available five-month period of March 2018 to July 2018. Descriptive statistics and statistical analysis were performed.ResultsIn 2018, the main operating theaters at KCMC performed 3817 total procedures, with elective procedures (2385) outnumbering emergency procedures (1432). General surgery (1927) was the most operated specialty, followed by orthopaedics (1371) and gynecology (519). In the five-month subset analysis period, just 54.6% of planned operating days were fully completed. There were 238 cancellations (20.8% of planned operations). Time constraints (31.1%, 74 cases) was the largest reason; lack of patient payment accounted for as many cancellations as unavailable equipment (6.3%, 15 cases each). Financing for elective theater cases included insurance 45.5% (418 patients), and cash 48.4% (445 patients).ConclusionWhile surgical volume is high, there are non-physical inefficiencies in the system that can be addressed to reduce cancellations and improve capacity. Improving physical resources is not enough to improve access to care in this region, and likely in many LMIC settings. Patient financing and workflow will be critical considerations to truly improve access to surgical care.

Background: In low and middle-income countries, country specific data is scarce regarding the burden of surgical disease, with most estimates extrapolated from indirect methods. Kilimanjaro Christian Medical Center (KCMC) is the only tertiary referral hospital for a population of over 11 million in Northern Tanzania. This study aims to directly quantify the current orthopaedic burden of disease at KCMC and provide a foundation to estimate the magnitude and potential benefit of improving access to orthopaedic surgical care in the northern regions of Tanzania.

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Summary: There is a devastating lack of access to surgical care, including orthopaedic surgery, in low- and middle-income countries. Similar to other low- and middle-income countries, Tanzania has a severe shortage of trained orthopaedic surgeons. The surgeons available are inundated with acute trauma care and musculoskeletal infections; elective procedures are infrequently performed and the burden of neglected care continues to rise annually. Over the past several years, our interdisciplinary team of both American and Tanzanian members has worked to understand the current local cultural and economic barriers to increasing surgical capacity, ensuring surgical safety, delivering affordable care, providing adequate patient follow-up, and improving surgical education. We propose a new paradigm for the delivery of musculoskeletal care and creation of sustained surgical capacity in this setting by building an Orthopaedic Center of Excellence in Moshi, Tanzania, augmented by international partner institutions year-round. This initiative is a public–private partnership led by the University of Pennsylvania in conjunction with Kilimanjaro Christian Medical Center. A growing number of contributors, including the Tanzanian Health Ministry, several universities, and industry partners, including general electric (GE) Health Care Africa, are currently helping to advance this concept into reality. Through our model, we aim to increase surgical capacity and quality, as well as enhance local surgical education, with the ultimate objective of training the next generation of African surgeons in the latest surgical techniques and equipment.

There is a near absence of access to orthopaedic surgical care in Northern Tanzania. These findings utilize more precise country and region-specific data and are consistent with prior published global trends regarding surgical access in Sub-Saharan Africa. As the global health community must develop innovative solutions to address the rising burden of musculoskeletal disease and support the advancement of universal health coverage, increasing access to orthopaedic surgical services will play a central role in improving health care in the world's developing regions.

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Background: Traditional health practitioners remain a critical source of care in Tanzania, more than 50% of Tanzanians frequently using their services. With a severe shortage of orthopaedic surgeons (1:3.3 million Tanzanians) traditional bone setters (TBSs) could potentially expand access to musculoskeletal care and improve outcomes for morbidity as a result of trauma. Objective: We sought to identify the advantages and disadvantages of traditional bone setting in Tanzania and to assess potential for collaboration between TBSs and allopathic orthopaedic surgeons. Methods: Between June and July 2017 we interviewed six TBSs identified as key informants in the regions of Kilimanjaro, Arusha, and Manyara. We conducted semi-structured interviews about practices and perspectives on allopathic healthcare, and analyzed the data using a deductive framework method. Findings: The TBSs reported that their patients were primarily recruited from their local communities via word-of-mouth communication networks. Payment methods for services included bundling costs, livestock barter, and sliding scale pricing. Potentially unsafe practices included lack of radiographic imaging to confirm reduction; cutting and puncturing of skin with unsterile tools; and rebreaking healed fractures. The TBSs described past experience collaborating with allopathic healthcare providers, referring patients to hospitals, and utilizing allopathic techniques in their practice. All expressed enthusiasm in future collaboration with allopathic hospitals. Conclusions: TBSs confer the advantages of word-of-mouth communication networks and greater financial and geographic accessibility. However, some of their practices raise concerns relating to infection, fracture malunion or nonunion, and iatrogenic trauma from manipulating previously healed fractures. A formal collaboration between TBSs and orthopaedic surgeons, based on respect and regular communication, could alleviate concerns through the development of care protocols and increase access to optimal orthopaedic care through a standardized triage and follow-up system.

barriers. Barriers may be more complex, relating to: healthcare decisionmaking, perceptions of quality and traditional culture and beliefs. It is noted that many patients die before reaching care at the facility level.Going Forward: Multiple methods will provide perspectives from the community on barriers to optimal EC access.d Case studies: Cases that present to the ED late in the course of illness will be utilized to understand aspects such as recognition of symptoms and severity, first aid administered and deliberations of the patient or caregivers. d Focus Groups: Emergency scenarios will be utilized to explore the course of action that would be taken by community members. d Community Survey: Hypothesis will be drawn from the qualitative data and tested with a quantitative survey implemented in locations frequented by a wide cross-section of the community.This program has potential to increase understanding of rural Ugandan sociocultural factors in EC seeking, impact EC implementation and increase mutual understanding between providers and similar underserved populations.