Barriers to Surgical Care Among Children in Somaliland: An Application of the Three Delays Framework

Concepcion, Tessa; Dahir, Shukri; Mohamed, Mubarak; Hiltbrunn, Kyle; Ismail, Edna Adan; Poenaru, Dan; Rice, Henry E.; Smith, Emily R.; Surgery, Global Initiative for Children’s

doi:10.1007/s00268-020-05414-4

Cited by 22 publications

(24 citation statements)

References 47 publications

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“…Data collection was at an institutional level rather than population level and some patients may have died before reaching the study centres. 55 56 In contrast, the hospital data from HICs likely reflects the population mortality due to better access and higher-quality antenatal services, district-level care and transportation. Indeed the HIC comparator mortality rates used may be an overestimate of the current mortality in these regions due to further reductions over time, particularly for the ARM data, which was published in 2008.…”

Section: Discussionmentioning

confidence: 99%

Paediatric surgical outcomes in sub-Saharan Africa: a multicentre, international, prospective cohort study

2021

BMJ Glob Health

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IntroductionAs childhood mortality from infectious diseases falls across sub-Saharan Africa (SSA), the burden of disease attributed to surgical conditions is increasing. However, limited data exist on paediatric surgical outcomes in SSA. We compared the outcomes of five common paediatric surgical conditions in SSA with published benchmark data from high-income countries (HICs).MethodsA multicentre, international, prospective cohort study was undertaken in hospitals providing paediatric surgical care across SSA. Data were collected on consecutive children (birth to 16 years), presenting with gastroschisis, anorectal malformation, intussusception, appendicitis or inguinal hernia, over a minimum of 1 month, between October 2016 and April 2017. Participating hospitals completed a survey on their resources available for paediatric surgery.The primary outcome was all-cause in-hospital mortality. Mortality in SSA was compared with published benchmark mortality in HICs using χ2 analysis. Generalised linear mixed models were used to identify patient-level and hospital-level factors affecting mortality. A p<0.05 was deemed significant.Results1407 children from 51 hospitals in 19 countries across SSA were studied: 111 with gastroschisis, 188 anorectal malformation, 225 intussusception, 250 appendicitis and 633 inguinal hernia. Mortality was significantly higher in SSA compared with HICs for all conditions: gastroschisis (75.5% vs 2.0%), anorectal malformation (11.2% vs 2.9%), intussusception (9.4% vs 0.2%), appendicitis (0.4% vs 0.0%) and inguinal hernia (0.2% vs 0.0%), respectively. Mortality was 41.9% (112/267) among neonates, 5.0% (20/403) in infants and 1.0% (7/720) in children. Paediatric surgical condition, higher American Society of Anesthesiologists score at primary intervention, and needing/receiving a blood transfusion were significantly associated with mortality on multivariable analysis.ConclusionMortality from common paediatric surgical conditions is unacceptably high in SSA compared with HICs, particularly for neonates. Interventions to reduce mortality should focus on improving resuscitation and timely transfer at the district level, and preoperative resuscitation and perioperative care at paediatric surgical centres.

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Section: Discussionmentioning

confidence: 99%

Paediatric surgical outcomes in sub-Saharan Africa: a multicentre, international, prospective cohort study

2021

BMJ Glob Health

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“…Children in Somaliland experience additional barriers that prevent them from receiving surgery, including financial hardship, lack of time, lack of trust and cultural beliefs. 33 In addition, there is a lack of surgical infrastructure and workforce across the country. Complex surgical care, including neonatal surgery, neurosurgical and cardiac procedures, involve a multidisciplinary team and highly specialised infrastructure, equipment and supplies.…”

Section: Discussionmentioning

confidence: 99%

Geospatial analysis of pediatric surgical need and geographical access to care in Somaliland: a cross-sectional study

et al. 2021

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BackgroundThe global burden of disease in children is large and disproportionally affects low-income and middle-income countries (LMICs). Geospatial analysis offers powerful tools to quantify and visualise disparities in surgical care in LMICs. Our study aims to analyse the geographical distribution of paediatric surgical conditions and to evaluate the geographical access to surgical care in Somaliland.MethodsUsing the Surgeons OverSeas Assessment of Surgical Need survey and a combined survey from the WHO’s (WHO) Surgical Assessment Tool—Hospital Walkthrough and the Global Initiative for Children’s Surgery Global Assessment in Paediatric Surgery, we collected data on surgical burden and access from 1503 children and 15 hospitals across Somaliland. We used several geospatial tools, including hotspot analysis, service area analysis, Voronoi diagrams, and Inverse Distance Weighted interpolation to estimate the geographical distribution of paediatric surgical conditions and access to care across Somaliland.ResultsOur analysis suggests less than 10% of children have timely access to care across Somaliland. Patients could travel up to 12 hours by public transportation and more than 2 days by foot to reach surgical care. There are wide geographical disparities in the prevalence of paediatric surgical conditions and access to surgical care across regions. Disparities are greater among children travelling by foot and living in rural areas, where the delay to receive surgery often exceeds 3 years. Overall, Sahil and Sool were the regions that combined the highest need and the poorest surgical care coverage.ConclusionOur study demonstrated wide disparities in the distribution of surgical disease and access to surgical care for children across Somaliland. Geospatial analysis offers powerful tools to identify critical areas and strategically allocate resources and interventions to efficiently scale-up surgical care for children in Somaliland.

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“…21 Somaliland is made up of six regions-Awdal, Maroodi Jeex (containing the capital city of Hargeisa), Sahil, Sanaag, Sool and Togdheer-with 40% of the population living in Hargeisa. 22 The public health system is comprised of primary health units, health centres, referral health centres, regional hospitals and one national referral hospital. Specialty hospitals include seven tuberculosis hospitals, one female fistula hospital, one children's hospital and one mental health hospital.…”

Section: Settingmentioning

confidence: 99%

Interpreting the Lancet surgical indicators in Somaliland: a cross-sectional study

et al. 2020

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BackgroundThe unmet burden of surgical care is high in low-income and middle-income countries. The Lancet Commission on Global Surgery (LCoGS) proposed six indicators to guide the development of national plans for improving and monitoring access to essential surgical care. This study aimed to characterise the Somaliland surgical health system according to the LCoGS indicators and provide recommendations for next-step interventions.MethodsIn this cross-sectional nationwide study, the WHO’s Surgical Assessment Tool–Hospital Walkthrough and geographical mapping were used for data collection at 15 surgically capable hospitals. LCoGS indicators for preparedness was defined as access to timely surgery and specialist surgical workforce density (surgeons, anaesthesiologists and obstetricians/SAO), delivery was defined as surgical volume, and impact was defined as protection against impoverishment and catastrophic expenditure. Indicators were compared with the LCoGS goals and were stratified by region.ResultsThe healthcare system in Somaliland does not meet any of the six LCoGS targets for preparedness, delivery or impact. We estimate that only 19% of the population has timely access to essential surgery, less than the LCoGS goal of 80% coverage. The number of specialist SAO providers is 0.8 per 100 000, compared with an LCoGS goal of 20 SAO per 100 000. Surgical volume is 368 procedures per 100 000 people, while the LCoGS goal is 5000 procedures per 100 000. Protection against impoverishing expenditures was only 18% and against catastrophic expenditures 1%, both far below the LCoGS goal of 100% protection.ConclusionWe found several gaps in the surgical system in Somaliland using the LCoGS indicators and target goals. These metrics provide a broad view of current status and gaps in surgical care, and can be used as benchmarks of progress towards universal health coverage for the provision of safe, affordable, and timely surgical, obstetric and anaesthesia care in Somaliland.

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Barriers to Surgical Care Among Children in Somaliland: An Application of the Three Delays Framework

Cited by 22 publications

References 47 publications

Paediatric surgical outcomes in sub-Saharan Africa: a multicentre, international, prospective cohort study

Paediatric surgical outcomes in sub-Saharan Africa: a multicentre, international, prospective cohort study

Geospatial analysis of pediatric surgical need and geographical access to care in Somaliland: a cross-sectional study

Interpreting the Lancet surgical indicators in Somaliland: a cross-sectional study

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