Access delays to essential surgical care using the Three Delays Framework and Bellwether procedures at Timor Leste’s national referral hospital

Abstract

ObjectivesOur objectives were to characterise the nature and extent of delay times to essential surgical care in a developing nation by measuring the actual stages of delay for patients receiving Bellwether procedures.SettingThe study was conducted at Timor Leste’s national referral hospital in Dili, the country’s capital.ParticipantsAll patients requiring a Bellwether procedure over a 2-month period were included in the study. Participants whose procedure was undertaken more than 24 hours from initial hospital presentation were excluded.Primary and secondary outcome measuresData pertaining to the patient journey from onset of symptoms to emergency procedure was collected by interview of patients, their treating surgeons or anaesthetists and the medical records. Timelines were then calculated against the Three Delays Framework.ResultsFifty-six patients were entered into the study. Their mean delay from symptom onset to entering the anaesthesia bay for a procedure was 32.3 hours (+/-11.6). The second delay (4.1+/-2.5 hours) was significantly less than the first (20.9+/-11.5 hours; p<0.005) and third delays (7.2+/-1.2 hours; p<0.05). Additionally, patients with acute abdominal pain (of which 18/20 ultimately had open appendicectomy and two emergency laparotomies) had a delay time of 53.3 hours (+/-21.3), significantly more than that for emergency caesarean (22.9+/-18.6 hours; p<0.05) or management of an open long-bone fracture (15.5+/-5.56 hours; p<0.05).ConclusionsSubstantial delays were observed for all three stages and each Bellwether procedure. This study methodology could be used to measure access and the three delays to emergency surgical care in low/middle-income countries, although the actual reasons for delay may vary between regions and countries and would require a qualitative study.

Breast disease in Timor‐Leste

“…These include low numbers and inadequate training of many health professionals, poor infrastructure and equipment, and access barriers for patients including geographic, financial and cultural. 15,16 We acknowledge shortcomings in our datawe were unable to infer or explore the reasons why all patients with clinically concerning breast symptoms did not proceed to biopsy. Surgical management (inclusive of support services such as pathology, radiology, wound care in the community and rehabilitation) has been under-resourced, partly as a result of inaccurate assumptions and competing priorities; similar to much of the developing world, there is a presumption that surgery is too costly for the benefits accrued, with many agencies and health professionals focusing on more 'cost-effective interventions'.…”

“…However, the data were highly skewed and suggest there are residents who may face transportation challenges, with even relatively short journeys sometimes being very difficult to undertake. 15,16 Time traveled is more important than distance, as time and difficulty would be seen as the barrier rather than the nominal distance. This reinforces the importance for more accessible breast services in the primary and secondary health clinics in order to promote breast health and diagnosis.…”

“…14 Timorese people experience delays in reaching urgent surgical care from onset of their disease until the surgical management of that disease in hospital. 15,16 There is only one tertiary national hospital (GVNH), five secondary level health centres and over 302 primary health posts. 14 The surgical service of GVNH has 14 surgeons, three anaesthetists and three obstetricians amongst the Timorese trained team and 18 expatriate surgeons and anaesthetists.…”

“…For a population of 1.2 million, the health services nationally perform 315 procedures per 100 000 . Timorese people experience delays in reaching urgent surgical care from onset of their disease until the surgical management of that disease in hospital . There is only one tertiary national hospital (GVNH), five secondary level health centres and over 302 primary health posts .…”

Advocacy for global surgery: a Pacific perspective

“…34 Academic surgery and research capability in the Pacific and PNG require further development as this will strengthen local leadership and provide evidence on which to base NSOAPs and other capacity building initiatives. Nonetheless, Global Surgical Research from Australia, NZ, Timor, PNG and the Pacific published papers on POMR, 20,[29][30][31][32][33] Bellwether access, 36 the global burden of surgical disease [37][38][39] and the graduation and retention of surgical, obstetric and anaesthesia specialists. 7,40 Lessons learned from the introduction of emergency medicine specialists and their training in PNG, 41,42 informed a successful and rapid implementation in Myanmar.…”