A systems approach to trauma care in Myanmar: from health partnership to academic collaboration.

Experience from a variety of disciplines suggests that improving healthcare, particularly in resource-poor environments, can benefit from a systems approach. However, putting this into practice is challenging, especially in the context of an international institutional health partnership. In this article, we outline how a systems approach to the improvement of trauma care has informed both clinical improvement and academic collaboration as part of an ongoing partnership involving Cambridge University Hospitals NHS Foundation Trust, the University of Cambridge, and Cambridge Global Health Partnerships in the UK, and Yangon General Hospital, University of Medicine 1, and the Tropical Health and Education Trust (THET) in Myanmar. Improving and researching trauma care is an exemplar of a systems problem, requiring an understanding of the relevant people, equipment, processes, institutions, and power structures that result in the delivery of care at all points of the patient's journey from injury to rehabilitation. Exploring this in the explicit context of traumatic brain injury is one of the research themes of the NIHR Global Health Research Group on Neurotrauma, allowing systems research to directly inform efforts at practical improvement.

The Capacity of Eye Care Services for Patients with Glaucoma in Botswana.

PURPOSE: To evaluate current delivery of glaucoma care in Botswana; in particular, the service infrastructure available and glaucoma-related workload. METHODS: A multi-center cross-sectional study was undertaken comprising government eye care institutions and ophthalmic personnel across Botswana. Data on human resources, equipment types and numbers, diagnostic criteria routinely used, treatments routinely provided, and new and repeat glaucoma consultations were obtained through quantitative and qualitative surveys. RESULTS: In 27 government eye care institutions there were two general ophthalmologists, neither of whom had a subspecialty interest in glaucoma, 64 ophthalmic nurses, two optometrists, one low vision therapist, one refractionist, and two equipment technicians. Only 8.5% of available ophthalmic human resources were taken up with provision of glaucoma care. About 1/3 of hospitals did not have tonometers, most primary hospitals lacked slit lamp biomicroscopes and most hospitals lacked sensitive diagnostic equipment. A diagnosis of glaucoma was made by either an ophthalmic nurse or an ophthalmologist, but only 10% of institutions could meet recommendations for follow-up assessment. Topical glaucoma medications were prescribed by almost all hospital clinics, usually by ophthalmic nurses. Drug choices were largely determined by local availability. Glaucoma surgery accounted for 0.8% of total eye operations. Glaucoma patients took up 8.5% of total clinic visits. The total number of glaucoma visits was highest in the two hospitals with ophthalmologists. New glaucoma cases took up 10.3% of total glaucoma visits. CONCLUSION: This study highlights the challenges faced in caring for glaucoma patients in Botswana; in particular, lack of professional human resources, equipment and availability of effective treatments.

The clinical characteristics of patients with glaucoma presenting to Botswana healthcare facilities: an observational study.

OBJECTIVE: This study aimed to establish the clinical characteristics of patients with glaucoma attending eye care facilities in Botswana, and management of glaucoma among patients who received care in these facilities. The study also aimed to calculate the number of new diagnoses of glaucoma within the glaucoma service. DESIGN: A prospective, hospital-based, observational study. SETTING: A multicentre study was undertaken in government-run eye departments in Botswana from June to August 2012. PARTICIPANTS: All patients with a diagnosis of glaucoma attending clinics at seven study sites were invited to participate. OUTCOME MEASURES: Examination findings, diagnosis and management were extracted from individual patient-held medical charts. Sociodemographic characteristics, patient knowledge and understanding of glaucoma were assessed through face-to-face interviews. In addition, details of outpatient attendances for 2011 were collected from 21 government-run hospitals. RESULTS: The majority of the 366 patients interviewed had a diagnosis of primary glaucoma (86.6%). The diagnoses were mainly made by ophthalmologists (48.6%) and ophthalmic nurses (44.0%). Many patients (38.5%) had been symptomatic for over 6 months before visiting an eye clinic. The mean presenting intraocular pressure was 28.2 mm Hg (SD 11.9 mm Hg). Most follow-up patients (79.2%) had not received surgery, however, many (89.5%) would accept surgery. Only 11.5% of participants had heard of glaucoma prior to diagnosis. Many participants (35.9%) did not understand glaucoma after being diagnosed. The majority (94.9%) of living first-degree relatives had never been examined. The number of newly diagnosed glaucoma cases for 2011 in the south of the country was 14.1/100,000; 95% CI (12.0 to 16.5), in the north it was 16.2/100,000; 95% CI (13.8 to 19.0). CONCLUSIONS: Glaucoma is a significant burden that presents challenges to ophthalmic services in Botswana. Many patients have limited understanding of the condition and poor access to services. There is a need to develop a treatment infrastructure to include safe surgery and a reliable supply of effective medication.