Mapping Disparities in Access to Safe, Timely, and Essential Surgical Care in Zambia

Abstract

IMPORTANCE Surgical care is widely unavailable in developing countries; advocates recommend that countries evaluate and report on access to surgical care to improve availability and aid health planners in decision making. OBJECTIVE To analyze the infrastructure, capacity, and availability of surgical care in Zambia to inform health policy priorities. DESIGN, SETTING, AND PARTICIPANTS In this observational study, all hospitals providing surgical care were identified in cooperation with the Zambian Ministry of Health. On-site data collection was conducted from February 1 through August 30, 2011, with an adapted World Health Organization Global Initiative for Emergency and Essential Surgical Care survey. Data collection at each facility included interviews with hospital personnel and assessment of material resources. Data were geocoded and analyzed in a data visualization platform from March 1 to December 1, 2015. We analyzed time and distance to surgical services, as well as the proportion of the population living within 2 hours from a facility providing surgical care. MAIN OUTCOMES AND MEASURES Surgical capacity, supplies, human resources, and infrastructure at each surgical facility, as well as the population living within 2 hours from a hospital providing surgical care. RESULTS Data were collected from all 103 surgical facilities identified as providing surgical care. When including all surgical facilities (regardless of human resources and supplies), 14.9% of the population (2 166 460 of 14 500 000 people) lived more than 2 hours from surgical care. However, only 17 hospitals (16.5%) met the World Health Organization minimum standards of surgical safety; when limiting the analysis to these hospitals, 65.9%of the population (9 552 780 people) lived in an area that was more than 2 hours from a surgical facility. Geographic analysis of emergency and essential surgical care, defined as access to trauma care, obstetric care, and care of common abdominal emergencies, found that 80.7% of the population (11 704 700 people) lived in an area that was more than 2 hours from these surgical facilities. CONCLUSIONS AND RELEVANCE A large proportion of the population in Zambia does not have access to safe and timely surgical care; this percentage would change substantially if all surgical hospitals were adequately resourced. Geospatial visualization tools assist in the evaluation of surgical infrastructure in Zambia and can identify key areas for improvement.

Validating the Global Surgery Geographical Accessibility Indicator: Differences in Modeled Versus Patient‐Reported Travel Times

“…However, most of sub-Saharan Africa does require the health center-to-hospital referral for surgical care and we posit that the failure to account for this in model estimates will result in systematic underestimates even if the exact parameters are not generalizable. We note that we only modeled one set of travelling speed assumptions, chosen due to its predominance in the literature [9,[13][14][15][16] but that in theory a Rwanda-specific set of speeds could be generated and could yield more accurate results. Further, self-reported travel time may contain recall bias or rounding errors, but were collected within days of the trip.…”

Who accesses surgery at district level in sub‐Saharan Africa? Evidence from Malawi and Zambia

“…Two‐thirds of all major surgical cases undertaken at the district level in Malawi and one‐third in Zambia were females in their mid‐twenties obtaining emergency obstetric care; neither country has met the WHO‐recommended 10–15% of deliveries by Caesarean section . Building surgical capacity to manage rising obstetric demand requires investments in infrastructure , training and supervision of district hospital staff . In Zambia, the higher proportion of general surgical procedures and the more diverse set of surgical procedures, categorised as ‘other’, suggest a greater capacity to deliver a broader range of surgical procedures at Zambia's district‐level hospitals.…”

“…Four central hospitals in urban areas are staffed by specialist surgeons who manage referred cases and patients who bypass lower‐level facilities . Zambia, where 60.5% of its population of 16 million live in rural areas , has a network of 103 district‐level hospitals, comprising 84 government‐owned and 19 faith‐based district hospitals that provide first‐level surgical care . Because of the greater dispersal of the population, some people travel up to 100 km to reach a surgical facility .…”

“…Surgery and surgical patients have for long been invisible in the global health policy arena , despite evidence of the inability of rural populations in most sub‐Saharan African (SSA) countries to access surgical services . However, over the last decade, treatable surgical conditions have gained recognition, as they contribute to 11% of the global burden of disease (BoD) and are central to achieving global health goals ; much of the burden of surgically avoidable morbidity and mortality in low‐ and middle‐income countries (LMICs) can be tackled .…”

Evaluating the collection, comparability and findings of six global surgery indicators

“…Whether these procedures were performed was not validated further. A previously published methodology for calculating the proportion of the population within 2 hours of these facilities was employed. For countries with data, facility coordinates were plotted using Redivis (Redivis, Palo Alto, California, USA), an online data visualization platform.…”