Charitable Platforms in Global Surgery: A Systematic Review of their Effectiveness, Cost‐Effectiveness, Sustainability, and Role Training

Abstract

ObjectiveThis study was designed to propose a classification scheme for platforms of surgical delivery in low- and middle-income countries (LMICs) and to review the literature documenting their effectiveness, cost-effectiveness, sustainability, and role in training. Approximately 28 % of the global burden of disease is surgical. In LMICs, much of this burden is borne by a rapidly growing international charitable sector, in fragmented platforms ranging from short-term trips to specialized hospitals. Systematic reviews of these platforms, across regions and across disease conditions, have not been performed.MethodsA systematic review of MEDLINE and EMBASE databases was performed from 1960 to 2013. Inclusion and exclusion criteria were defined a priori. Bibliographies of retrieved studies were searched by hand. Of the 8,854 publications retrieved, 104 were included.ResultsSurgery by international charitable organizations is delivered under two, specialized hospitals and temporary platforms. Among the latter, short-term surgical missions were the most common and appeared beneficial when no other option was available. Compared to other platforms, however, worse results and a lack of cost-effectiveness curtailed their role. Self-contained temporary platforms that did not rely on local infrastructure showed promise, based on very few studies. Specialized hospitals provided effective treatment and appeared sustainable; cost-effectiveness evidence was limited.ConclusionsBecause the charitable sector delivers surgery in vastly divergent ways, systematic review of these platforms has been difficult. This paper provides a framework from which to study these platforms for surgery in LMICs. Given the available evidence, self-contained temporary platforms and specialized surgical centers appear to provide more effective and cost-effective care than short-term surgical mission trips, except when no other delivery platform exists.

Long-term follow-up is possible for short-term surgical trips

“…The cost-effectiveness of STSMs (14) 1 (14) 2 ( Table 2. Postoperative Complications has frequently been questioned; however, limited reported methods and outcomes data make such analysis incomplete [2]. One study conducted by Torchia et al [6] successfully achieved interval patient follow-up one year postoperatively utilizing an in-country physician to conduct follow-up at a mean cost of $20,000 per year.…”

“…Much has been written about the challenges of global surgery, and of STSMs in particular [1][2][3][4]. One of the major challenges for STSMs is obtaining adequate patient follow-up, which is necessary to measure patient outcomes and quantify impact.…”

“…"Global surgery" encompasses a variety of interventions that have attempted to address that need, including short-term surgical missions (STSM) [1]. Methods can vary greatly between STSMs, but most share the goal of delivering quality care in the context of limited resources and time with the hope of long-lasting impact for patients [2][3][4][5]. However, obtaining long-term follow-up of patients is challenging for STSMs-and there are few descriptions of the methods used to achieve such follow-up and even fewer reports of clinical outcomes-making determination of their success challenging [3,6].…”

“…The unmet need for surgical services worldwide, particularly in low-and middle-income countries (LMICs), is profound, with an estimated 5 billion people without adequate access [1,2]. "Global surgery" encompasses a variety of interventions that have attempted to address that need, including short-term surgical missions (STSM) [1].…”

Anaesthesia in outreach surgical camps: more of arts than science

“…Initial estimate suggested 11 % of global burden of diseases is treatable with surgical interventions 3 but experts estimate some 28% of global burden of diseases to be surgical. 4 Treatable surgical conditions are estimated to be responsible for 1.8 million deaths in low-and middleincome countries. In other words, one death occurs every second in those countries of which 85% are treatable by basic surgical care.…”