Mapping population access to essential surgical care in Liberia using equipment, personnel, and bellwether capability standards

Abstract

Background Accurate surveillance of population access to essential surgery is key for strategic healthcare planning. This study aimed to estimate population access to surgical facilities meeting standards for safe surgery equipment, specialized surgical personnel, and bellwether capability, cesarean delivery, emergency laparotomy, and long-bone fracture fixation and to evaluate the validity of using these standards to describe the full breadth of essential surgical care needs in Liberia. Method An observational study of surgical facilities was conducted in Liberia between 20 September and 8 November 2018. Facility data were combined with geospatial data and analysed in an online visualization platform. Results Data were collected from 51 of 52 surgical facilities. Nationally, 52.9 per cent of the population (2 392 000 of 4 525 000 people) had 2-h access to their closest surgical facility, whereas 41.1 per cent (1 858 000 people) and 48.6 per cent (2 199 000 people) had 2-h access to a facility meeting the personnel and equipment standards respectively. Six facilities performed all bellwether procedures; 38.7 per cent of the population (1 751 000 people) had 2-h access to one of these facilities. Bellwether-capable facilities were more likely to perform other essential surgical procedures (OR 3.13, 95 per cent c.i. 1.28 to 7.65; P = 0.012). These facilities delivered a median of 13.0 (i.q.r. 11.3–16.5) additional essential procedures. Conclusion Population access to essential surgery is limited in Liberia; strategies to reduce travel times ought to be part of healthcare policy. Policymakers should also be aware that bellwether capability might not be a valid proxy for the full breadth of essential surgical care in low-income settings.

The economic burden associated with unmet surgical needs in Liberia: a retrospective macroeconomic analysis based on a nationwide enumeration of surgical procedures

“…Large disparities were observed between geographic areas (online supplemental figure 1). The number of DALYs averted per 100 000 population can be seen in context with population access to surgery, as presented elsewhere 20. Caesarean sections, representing 43% of all operations, contributed with the highest number of DALYs averted (table 2).…”

“…The number of DALYs averted per 100 000 population can be seen in context with population access to surgery, as presented elsewhere. 20 Caesarean sections, representing 43% of all operations, contributed with the highest number of DALYs averted ( table 2 ). Furthermore, there were large differences in the number of DALYs averted per procedure for various operations.…”

“…The surgical system is undersized with a density of 1.6 specialist surgical providers per 100 000 population18 and a surgical volume of 462 surgical procedures per 100 000 population,19 resulting in a high unmet need for surgery. Long travel times delay surgical treatment, and many patients lack coverage of essential surgical care 20. It is unknown how the limited coverage of surgery affects the national economy.…”

“…Long travel times delay surgical treatment, and many patients lack coverage of essential surgical care. 20 It is unknown how the limited coverage of surgery affects the national economy. The aim of this study was to estimate the burden of premature death and disability averted by surgical activities in Liberia and value the economic costs associated with unmet surgical needs.…”