Surgical Capacity Building Research Articles

Surgical capacity building in Timor-Leste: a review of the first 15 years of the Royal Australasian College of Surgeons-led Australian Aid programme.

Timor-Leste suffered a destructive withdrawal by the Indonesian military in 1999, leaving only 20 Timorese-based doctors and no practising specialists for a population of 700 000 that has now grown to 1.2 million. This article assesses the outcomes and impact of Royal Australasian College of Surgeons (RACS) specialist medical support from 2001 to 2015. Three programmes were designed collaboratively with the Timor-Leste Ministry of Health and Australian Aid. The RACS team began to provide 24/7 resident surgical and anaesthesia services in the capital, Dili, from July 2001. The arrival of the Chinese and Cuban Medical Teams provided a medical workforce, and the Cubans initiated undergraduate medical training for about 1000 nationals both in Cuba and in Timor-Leste, whilst RACS focused on specialist medical training. Australian Aid provided AUD$20 million through three continuous programmes over 15 years. In the first 10 years over 10 000 operations were performed. Initially only 10% of operations were done by trainees but this reached 77% by 2010. Twenty-one nurse anaesthetists were trained in-country, sufficient to cover the needs of each hospital. Seven Timorese doctors gained specialist qualifications (five surgery, one ophthalmology and one anaesthesia) from regional medical schools in Papua New Guinea, Fiji, Indonesia and Malaysia. They introduced local specialist and family medicine diploma programmes for the Cuban graduates. Timor-Leste has developed increasing levels of surgical and anaesthetic self-sufficiency through multi-level collaboration between the Ministry of Health, Universidade Nacional de Timor Lorosa'e, and sustained, consistent support from external donors including Australian Aid, Cuba and RACS.

Can Economic Performance Predict Pediatric Surgical Capacity in Sub-Saharan Africa?

The relationship between economic status and pediatric surgical capacity in low- and middle-income countries (LMICs) is poorly understood. In sub-Saharan Africa (SSA), Nigeria accounts for 20% of the population and has the highest Gross Domestic Product (GDP), but whether this economic advantage translates to increased pediatric surgical capacity is unknown. This study compares the pediatric surgical capacity between Nigeria and other countries within the region. The Pediatric Personnel, Infrastructure, Procedures, Equipment and Supplies (PediPIPES) survey, a recent tool that is useful in assessing and comparing the capacity of health facilities to deliver essential and emergency surgical care (EESC) to children in LMICs, was used for this evaluation. Data from hospitals in Nigeria (n=24) and hospitals in 17 other sub-Saharan African countries (n=25) were compared. The GDP of Nigeria was approximately twenty-five times the average GDP of the 17 other countries represented in our survey. Running water was unavailable in 58% of the hospitals in Nigeria compared to 20% of the hospitals in the other countries. Most hospitals in Nigeria and in the other countries did not have a CT scan (67 and 60%, respectively). Endoscopes were unavailable in 58% of the hospitals in Nigeria and 44% of the hospitals in the other countries. Despite better economic indicators in Nigeria, there were no distinct advantages over the other countries in the ability to deliver EESC to children. Our findings highlighted the urgent need for specific allocation of more resources to pediatric surgical capacity building efforts across the entire region.

Validation of a community-based survey assessing nonobstetric surgical conditions in Burera District, Rwanda

Validated, community-based surveillance methods to monitor epidemiologic progress in surgery have not yet been employed for surgical capacity building. The goal of this study was to create and assess the validity of a community-based questionnaire collecting data on untreated surgically correctable disease throughout Burera District, Rwanda, to accurately plan for surgical services at a district hospital. A structured interview to assess for 10 index surgically treatable conditions was created and underwent local focus group and pilot testing. Using a 2-stage cluster sampling design, Rwandan data collectors conducted the structured interview in 30 villages throughout the Burera District. Rwandan physicians revisited the surveyed households to perform physical examinations on all household members, used as the gold standard to validate the structured interview. A total of 2,990 individuals were surveyed and 2,094 (70%) were available for physical examination. The calculated sensitivity and specificity of the survey tool were 44.5% (95% CI, 38.9-50.2%) and 97.7% (95% CI, 96.9-98.3%), respectively. The conditions with the highest sensitivity and specificity were hydrocephalus, clubfoot, and injuries/infections. Injuries/infections and hernias/hydroceles were the conditions most frequently found on examination that were not reported during the interview. This study provides the first attempt to validate a community-based surgical surveillance tool. The finding of low sensitivity was likely related to limited access to care and poor health literacy. Accurate community-based surveys are critical to planning integrated health systems that include surgical care as a core component.

Funding allocation to surgery in low and middle-income countries: a retrospective analysis of contributions from the USA

ObjectiveThe funds available for global surgical delivery, capacity building and research are unknown and presumed to be low. Meanwhile, conditions amenable to surgery are estimated to account for nearly 30%...

Funding flows to global surgery: an analysis of contributions from the USA

BackgroundIn recent years, funds for global health have risen substantially, particularly for infectious diseases. Although conditions amenable to surgery account for 28% of the global burden of disease, the external funds directed towards global surgical delivery, capacity building, and research are currently unknown and presumed to be low. We aimed to describe external funds given to these efforts from the USA, the world's largest donor nation. MethodsWe searched the United States Agency for International Development (USAID), National Institute of Health (NIH), Foundation Center, and registered US charitable organisations databases for financial data on any giving exclusively to surgical care in low-income and middle-income countries (LMICs). All nominal dollars were adjusted for inflation by converting to 2014 US dollars. FindingsAfter adjustment for inflation, 22 NIH funded projects (totalling US$31·3 million, 1991–2014) were identified; 78·9% for trauma and injury, 12·5% for general surgery, and 8·6% for ophthalmology. Six relevant USAID projects were identified; all related to obstetric fistula care totalling US$438 million (2006–13). US$105 million (2003–13) was given to universities and charitable organisations by US foundations for 14 different surgical specialties (ophthalmology, cleft lip/palate, multidisciplinary teams, orthopaedics, cardiac, paediatric, reconstructive, obstetric fistula, neurosurgery, burn, general surgery, obstetric emergency procedures, anaesthesia, and unspecified specialty). 95 US charitable organisations representing 14 specialties (ophthalmology, cleft lip/palate, multidisciplinary teams, orthopaedics, cardiac, paediatric, reconstructive, obstetric fistula, neurosurgery, urology, ENT, craniofacial, burn, and general surgery) totalled revenue of US$2·67 billion and expenditure of US$2·5 billion (2007–13). InterpretationA strong surgical system is an indispensable part of any health system and requires financial investment. Tracking funds targeting surgery helps not only to quantify and clarify this investment, but also to ultimately serve as a platform to integrate surgical spending within health system strengthening. Although USAID is a vital foreign aid service and the NIH is a leader in biomedical and health research, their surgical scopes are restricted both financially (less than 1% of respective total budgets over the study years) and in surgical specialty. By contrast, the private charitable sector has contributed more financially and to more specialties. Still, current financial global health databases do not have precise data for surgery. To improve population health in LMICs, more resources should be dedicated to surgical system strengthening. Furthermore, exact classification measures should be implemented to track these important resources. FundingNone.

Validation of a community-based survey assessing non-obstetric surgical conditions in Burera District, Rwanda

BackgroundCommunity-based surveillance methods to monitor epidemiological progress in surgery have not yet been employed for surgical capacity building. The aim of this study was to create and assess the validity of a questionnaire that collected data for untreated surgically correctable diseases throughout Burera District, northern Rwanda, to accurately plan for surgical services. MethodsA structured interview to assess for the presence or absence of ten index surgically treatable conditions (breast mass, cleft lip/palate, club foot, hernia or hydrocele [adult and paediatric]), hydrocephalus, hypospadias, injuries or wounds, neck mass, undescended testes, and vaginal fistula) was created. The interview was built based on previously validated questionnaires, forward and back translated into the local language and underwent focus group augmentation and pilot testing. In March and May, 2012, data collectors conducted the structured interviews with a household representative in 30 villages throughout Burera District, selected using a two-stage cluster sampling design. Rwandan physicians revisited the surveyed households to perform physical examinations on all household members, used as the gold standard to validate the structured interview. Ethical approval was obtained from Boston Children's Hospital (Boston, MA, USA) and the Rwandan National Ethics Committee (Kigali, Rwanda). Informed consent was obtained from all households. Findings2990 individuals were surveyed, a 97% response rate. 2094 (70%) individuals were available for physical examination. The calculated overall sensitivity of the structured interview tool was 44·5% (95% CI 38·9–50·2) and the specificity was 97·7% (96·9–98·3%; appendix). The positive predictive value was 70% (95% CI 60·5–73·5), whereas the negative predictive value was 91·3% (90·0–92·5). The conditions with the highest sensitivity and specificity, respectively, were hydrocephalus (100% and 100%), clubfoot (100% and 99·8%), injuries or wounds (54·7% and 98·9%), and hypospadias (50% and 100%). Injuries or wounds and hernias or hydroceles were the conditions most frequently identified on examination that were not reported during the interview (appendix). InterpretationTo the best of our knowledge, this study provides the first attempt to validate a community-based surgical surveillance tool. The finding of low sensitivity limits the use of the tool, which will require further revision, and calls into question previously published unvalidated community surgical survey data. To improve validation of community-based surveys, community education efforts on common surgically treatable conditions are needed in conjunction with increased access to surgical care. Accurate community-based surveys are crucial to integrated health system planning that includes surgical care as a core component. FundingThe Harvard Sheldon Traveling Fellowship.

Building Surgical Capacity in Low-Resource Countries

Surgical volunteer organizations (SVOs) focus considerable resources on addressing the backlog of cases in low-resource countries. This model of service may perpetuate dependency. Efforts should focus on models that establish independence in providing surgical care. Independence could be achieved through surgical capacity building. However, there has been scant discussion in literature on SVO involvement in surgical capacity building. Using qualitative methods, we evaluated the perspectives of surgeons with extensive volunteer experience in low-resource countries. We collected data through in-depth interviews that centered on SVOs using task shifting as a tool for surgical capacity building. Some of the key themes from our analysis include the ethical ramifications of task shifting, the challenges of addressing technical and clinical education in capacity building for low-resource settings, and the allocation of limited volunteer resources toward surgical capacity building. These themes will be the foundation of subsequent studies that will focus on other stakeholders in surgical capacity building including host communities and SVO administrators.

A validated community-based survey to measure surgical epidemiology in northern Rwanda

INTRODUCTION: Community-based surveillance methods to monitor epidemiological progress in surgery have not yet been employed for surgical capacity building. The goals of this study are twofold: to create a validated survey tool to easily measure surgical disease; and to accurately define the surgical epidemiology of a catchment population for a Partners In Health-supported district hospital in northern Rwanda.

Geospatial analysis of trauma referrals in a low-resource setting: implications for health system strengthening

INTRODUCTION: Community-based surveillance methods to monitor epidemiological progress in surgery have not yet been employed for surgical capacity building. The goals of this study are twofold: to create a validated survey tool to easily measure surgical disease; and to accurately define the surgical epidemiology of a catchment population for a Partners In Health-supported district hospital in northern Rwanda.

Defining the role of surgery in global health: a systematic review of cost-effectiveness of surgery in developing countries

INTRODUCTION: Community-based surveillance methods to monitor epidemiological progress in surgery have not yet been employed for surgical capacity building. The goals of this study are twofold: to create a validated survey tool to easily measure surgical disease; and to accurately define the surgical epidemiology of a catchment population for a Partners In Health-supported district hospital in northern Rwanda.

Qualitative Analysis of the Perspectives of Volunteer Reconstructive Surgeons on Participation in Task‐Shifting Programs for Surgical‐Capacity Building in Low‐Resource Countries

Experts agree that the global burden of untreated surgical disease is disproportionately borne by the world's poorest. This is partly because of a severe shortage of surgical care providers. Several experts have emphasized the need to research solutions for surgical-capacity building in developing countries. Volunteer surgeons already contribute significantly to directly tackling surgical disease burden in developing countries. We qualitatively evaluated their interest in participating in task-shifting programs as a surgical capacity-building strategy. We conducted semi-structured interviews with surgeons familiar with delivery of surgical care in developing countries through their extensive volunteer experiences. The interviews followed a structured guide that centered on task shifting as a model for surgical capacity-building in developing countries. We analyzed the interview transcripts using established qualitative methods to identify themes relevant to the interest of volunteer surgeons to participate in task-shifting programs. Most participants were open to involvement in task-shifting programs as a feasible way for surgical capacity-building in low-resource communities. However, they thought that surgical task shifting would need to be implemented with some important requisites. The most strongly emphasized condition was direct supervision of lower-skilled providers by fully trained surgeons. There is a favorable view regarding the involvement of surgeon volunteers in capacity-building efforts. Additionally, volunteer surgeons view task shifting as a feasible way to accomplish surgical capacity building in developing countries-provided that surgical tasks are assigned appropriately, and lower level providers are adequately supervised.

Healthcare worker safety: a vital component of surgical capacity development in low-resource settings

A disparate number of occupational exposures to bloodborne pathogens occur in low-income countries where disease prevalence is high and healthcare provider-per-population ratios are low. In an effort to highlight the important role of healthcare worker safety in surgical capacity building in Rwanda, we measured self-reported presence of safety materials and compliance with personal protective equipment in the operating theatre as part of a nationwide survey to characterize emergency and essential surgical capacity in all government hospitals. We surveyed 44 hospitals. While staff report general availability of safe disposal of sharps and hazardous waste, presence of and compliance with eye protection was lacking. Staff were cognizant of prevention measures such as double-gloving and 'safe receptacles', as well as hospital policies for post-exposure prophylaxis for HIV following needlesticks, but there was little awareness of hepatitis exposure. Healthcare worker safety should be a key component of hospital-level surgical capacity.

Collaboration in Surgical Capacity Development: A Report of the Inaugural Meeting of the Strengthening Rwanda Surgery Initiative

Increasing access to surgical care is among the prioritized healthcare initiatives in Rwanda and other low income countries, where only 3.5 % of surgical procedures worldwide are being performed. Partnerships among surgeons at academic medical centers, non-governmental organizations, and representatives of industry for building sustainable local surgical capacity in developing settings should be explored. With the goal of improving collaboration and coordination among the many stakeholders in Rwandan surgery, the Rwanda Surgical Society (RSS) convened a participatory workshop of these groups in Kigali in March 2011. The meeting consisted of presentations from Rwandan surgical leaders and focused brainstorming sessions on collaborative methods for surgical capacity building. The outcome of the meeting was a set of recommendations to the Rwandan Ministry of Health (MOH) and the formation of an ad hoc team, the Strengthening Rwanda Surgery (SRS) Advising Group. The inaugural meeting of the advising group served to establish common goals, a framework for ongoing communication and collaboration, and commitment to a fully Rwandan agenda for surgical and anesthesia capacity development. The SRS Advising Group continues to meet and collaborate on training initiatives and has been integrated into the MOH plan to scale up human resources across disciplines. The SRS Initiative serves as an example of the concept of early communication and international collaboration in global surgical and anesthesia capacity building partnerships.

Surgical Capacity Building in Uganda Through Twinning, Technology, and Training Camps

Neurosurgical capacity is extremely deficient in East African countries where 27 neurosurgeons serve more than 250 million people. To build capacity, the Duke University Medical Center and New Mulago Hospital in Uganda applied a two-pronged twinning approach that placed usable surplus equipment in a developing country's National Hospital, combined with dedicated comprehensive surgical training camps. Neurosurgery, anesthesiology, nursing, and clinical engineering personnel supported three training camps. More than 21 tons of essential equipment was delivered to New Mulago Hospital in Uganda. Data was collected during the 2-year period preceding and following the initiation of the program. During the 2 years after the program began, neurosurgery demonstrated a significant increase (180%) in the number and complexity of cases performed (p<0.0001). Multiple cases performed in a single day increased eightfold (p<0.0001), with utilization of elective operating room days improving from 43 to 98%. There was no change in the number of hospital admissions over the 4 years (p>0.1), but there was a dramatic increase in the overall number of procedures performed by all surgical specialties (106%, p<0.0001). Through a twinning program combining delivery of surplus equipment and training camps, capacity building was accomplished and maintained. The program not only built overall surgical capacity, it improved the efficiency and increased the complexity of operative cases performed at the National Hospital in Uganda. This program could serve as a model for twinning, capacity building, and training in other developing countries where surgical disparities are among the greatest.