Towards equitable surgical systems: development and outcomes of a national surgical, obstetric and anaesthesia plan in Tanzania

Citron, Isabelle; Jumbam, Desmond T.; Dahm, James; Mukhopadhyay, Swagoto; Nyberger, Karolina; Iverson, Katherine R.; Akoko, Larry; Lugazia, Edwin; Dmello, Brenda Sequeira; Maongezi, Sarah; Nguhuni, Boniface; Kapologwe, Ntuli; Hellar, Augustino; Maina, Erastus; Kisakye, Steve; Mwai, Patrick; Reynolds, Cheri; Varghese, Asha; Barash, David; Steer, Michael L.; Meara, John G.; Ulisubisya, Mpoki

doi:10.1136/bmjgh-2018-001282

Cited by 49 publications

(45 citation statements)

References 11 publications

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“… 54 In Tanzania, the NSOAP emphasises the coverage of essential surgical care in national health insurance schemes, implementation of electronic medical records for surgery-related data, simultaneous strengthening of lower-level and higher-level hospitals to reinforce referral pathways, and implementation of regional training to improve local retention of SAO providers. 56 …”

Section: Discussionmentioning

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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Section: Discussionmentioning

confidence: 99%

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

et al. 2020

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“…The Tanzania–Oxford children’s surgery partnership used a model of participatory learning and action cycles to build healthcare infrastructure and workforce relating to children’s surgery, focusing on three of the six pillars of surgical health systems: infrastructure, workforce and service delivery 14…”

Section: Participatory Approaches To Partnership Building and Health mentioning

confidence: 99%

Lessons from developing, implementing and sustaining a participatory partnership for children’s surgical care in Tanzania

et al. 2020

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Global surgery is an essential component of Universal Health Coverage. Surgical conditions account for almost one-third of the global burden of disease, with the majority of patients living in low-income and middle-income countries (LMICs). Children account for more than half of the global population; however, in many LMIC settings they have poor access to surgical care due to a lack of workforce and health system infrastructure to match the need for children’s surgery. Surgical providers from high-income countries volunteer to visit LMICs and partner with the local providers to deliver surgical care and trainings to improve outcomes. However, some of these altruistic efforts fail. We aim to share our experience on developing, implementing and sustaining a partnership in global children’s surgery in Tanzania. The use of participatory methods facilitated a successful 17-yearlong partnership, ensured a non-hierarchical environment and encouraged an understanding of the context, local needs, available resources and hospital capacity, including budget constraints, when codesigning solutions. We believe that participatory approaches are feasible and valuable in developing, implementing and sustaining global partnerships for children’s surgery in LMICs.

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“…9 Other proposals focus on governance of the surgical system, with effort directed toward the development of national surgical, anesthetic, and obstetric plans. 10,11 These supply-side and governance interventions fail to account for a patient's ability to get to a surgical appointment. In fact, patients most often cite demand-side barriers, such as cost, rather than supply-side barriers as the primary reason they do not seek surgical care.…”

Section: Introductionmentioning

confidence: 99%

Cash transfers may increase the no-show rate for surgical patients in low-resource settings: A randomized trial

Shrime

Harter

Handforth

et al. 2021

Preprint

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Background: Over two-thirds of the world's population cannot access surgery when needed. Interventions to address this gap have primarily focused on surgical training and ministry-level surgical planning. However, patients more commonly cite cost--rather than governance or surgeon availability--as their primary access barrier. We undertook a randomized, controlled trial (RCT) to evaluate the effect on compliance with scheduled surgical appointments of addressing this barrier through a cash transfer. Methods: 453 patients who were deemed surgical candidates by a nursing screening team in Guinea, West Africa, were randomized into three study arms: control, conditional cash transfer, and labeled unconditional cash transfer. Arrival to a scheduled surgical appointment was the primary outcome. The study was performed in conjunction with Mercy Ships. Results: The overall no-show rate was five-fold lower in Guinea than previously published estimates, leading to an underpowered study. In a post-hoc analysis, which included non-randomized patients, patients in the control group and the conditional cash transfer group demonstrated no effect from the cash transfer. Patients in the unconditional cash transfer group were significantly less likely to arrive for their scheduled appointment. Subgroup analysis suggested that actual receipt of the unconditional cash transfer, instead of a lapse in the transfer mechanism, was associated with failure to show. Conclusion: We find that cash transfers are feasible for surgical patients in a low-resource setting, but that unconditional transfers may have negative effects on compliance. Although demand-side barriers are large for surgical patients in low-resource settings, interventions to address them must be designed with care.

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Towards equitable surgical systems: development and outcomes of a national surgical, obstetric and anaesthesia plan in Tanzania

Cited by 49 publications

References 11 publications

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

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

Lessons from developing, implementing and sustaining a participatory partnership for children’s surgical care in Tanzania

Cash transfers may increase the no-show rate for surgical patients in low-resource settings: A randomized trial

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