Surgical Human Resources According to Types of Health Care Facility: An Assessment in Low- and Middle-Income Countries.

BACKGROUND: A robust health care system providing safe surgical care to a population can only be achieved in conjunction with access to competent surgical personnel. It has been reported that 5 billion people do not have access to safe, affordable surgical and anaesthesia care when needed. This study aims to fill the existing gap in evidence by quantifying shortfalls in trained personnel delivering safe surgical and anaesthetic care in low- and middle-income countries (LMICs) according to the type of health care facility. METHODS: We conducted secondary analysis of 1323 health facilities, in 35 low- and middle-income countries using facility-based cross-sectional data from the World Health Organization Situational Analysis Tool to Assess Emergency and Essential Surgical Care. RESULTS: The majority of surgical and anaesthetic care in LMICs was provided by general doctors (range 13.8-41.1%; mean 27.1%). Non-physicians made up a significant proportion of the surgical workforce in LMICs. 26.76% of the surgical and anaesthetic workforce was provided by clinical medical officers and nurses. Private/NGO/mission hospitals, large, well-resourced institutions had the highest proportion of surgeons compared to any other type of health care facility at 27.92%. This compares to figures of 18.2 and 19.96% of surgeons at health centres and subdistrict/community hospitals, respectively, representing the lowest level of health facility. CONCLUSIONS: We highlight the significant proportion of non-physicians delivering surgical and anaesthetic care in LMICs and illustrate wide variations according to the type of health care facility.

Survey of Emergency and Essential Surgical, Obstetric and Anaesthetic Services Available in Bangladeshi Government Health Facilities.

OBJECTIVE: Evaluate the capacity of government-run hospitals in Bangladesh to provide emergency and essential surgical, obstetric and anaesthetic services. METHODS: Cross-sectional survey of 240 Bangladeshi Government healthcare facilities using the World Health Organisation Situational Analysis Tool to Assess Emergency and Essential Surgical Care (SAT). This tool evaluates the ability of a healthcare facility to provide basic surgical, obstetric and anaesthetic care based on 108 queries that detail the infrastructure and population demographics, human resources, surgical interventions and reason for referral, and available surgical equipment and supplies. For this survey, the Bangladeshi Ministry of Health sent the SAT to sub-district, district/general and teaching hospitals throughout the country in April 2013. RESULTS: Responses were received from 240 healthcare facilities (49.5% response rate): 218 sub-district and 22 district/general hospitals. At the sub-district level, caesarean section was offered by 55% of facilities, laparotomy by 7% and open fracture repair by 8%. At the district/general hospital level, 95% offered caesarean section, 86% offered laparotomy and 77% offered open fracture treatment. Availability of anaesthesia services, general equipment and supplies reflected this trend, where district/general hospitals were better equipped than sub-district hospitals, though equipment and infrastructure shortages persist. CONCLUSION: There has been overall impressive progress by the Bangladeshi Government in providing essential surgical services. Areas for improvement remain across all key areas, including infrastructure, human resources, surgical interventions offered and available equipment. Investment in surgical services offers a cost-effective opportunity to continue to improve the health of the Bangladeshi population and move the country towards universal healthcare coverage.

Estimation of Surgery Capacity in Haiti: Nationwide Survey of Hospitals.

BACKGROUND: Haiti's surgical capacity was significantly strained by the 2010 earthquake. As the government and its partners rebuild the health system, emergency and essential surgical care must be a priority. METHODS: A validated, facility-based assessment tool developed by WHO was completed by 45 hospitals nationwide. The hospitals were assessed for (1) infrastructure, (2) human resources, (3) surgical interventions and emergency care, and (4) material resources for resuscitation. Fisher's exact test was used to compare hospitals by sectors: public compared to private and mixed (public-private partnerships). RESULTS: The 45 hospitals included first-referral level to the national referral hospital: 20 were public sector and 25 were private or mixed sector. Blood banks (33% availability) and oxygen concentrators (58%) were notable infrastructural deficits. For human resources, 69% and 33% of hospitals employed at least one full-time surgeon and anaesthesiologist, respectively. Ninety-eight percent of hospitals reported capacity to perform resuscitation. General and obstetrical surgical interventions were relatively more available, for example 93% provided hernia repairs and 98% provided cesarean sections. More specialized interventions were at a deficit: cataract surgery (27%), cleft repairs (31%), clubfoot (42%), and open treatment of fractures (51%). CONCLUSION: Deficiencies in infrastructure and material resources were widespread and should be urgently addressed. Physician providers were mal-distributed relative to non-physician providers. Formal task-sharing to midlevel and general physician providers should be considered. The parity between public and private or mixed sector hospitals in availability of Ob/Gyn surgical interventions is evidence of concerted efforts to reduce maternal mortality. This ought to provide a roadmap for strengthening of surgical care capacity.

Assessment of cesarean delivery availability in 26 low- and middle-income countries: a cross-sectional study.

OBJECTIVE: We sought to assess the capacity to provide cesarean delivery (CD) in health facilities in low- and middle-income countries. STUDY DESIGN: We conducted secondary analysis of 719 health facilities, in 26 countries in Africa, the Pacific, Asia, and the Mediterranean, using facility-based cross-sectional data from the World Health Organization Situational Analysis Tool to Assess Emergency and Essential Surgical Care. RESULTS: A total of 531 (73.8%) facilities reported performing CD. In all, 126 (17.5%) facilities did not perform but referred CD; the most common reasons for doing so were lack of skills (53.2%) and nonfunctioning equipment (42.9%). All health facilities surveyed had at least 1 operating room. Of the facilities performing CD, 47.3% did not report the presence of any type of anesthesia provider and 17.9% did not report the presence of any type of obstetric/gynecological or surgical care provider. In facilities reporting a lack of functioning equipment, 26.4% had no access to an oxygen supply, 60.8% had no access to an anesthesia machine, and 65.9% had no access to a blood bank. CONCLUSION: Provision of CD in facilities in low- and middle-income countries is hindered by a lack of an adequate anesthetic and surgical workforce and availability of oxygen, anesthesia, and blood banks.

Implementing Liberia's poverty reduction strategy: An assessment of emergency and essential surgical care.

OBJECTIVE: To document infrastructure, personnel, procedures performed, and supplies and equipment available at all county hospitals in Liberia using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. DESIGN: Survey of county hospitals using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. SETTING: Sixteen county hospitals in Liberia. MAIN OUTCOME MEASURES: Infrastructure, personnel, procedures performed, and supplies and equipment available. RESULTS: Uniformly, gross deficiencies in infrastructure, personnel, and supplies and equipment were identified. CONCLUSIONS: The World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care was useful in identifying baseline emergency and surgical conditions for evidenced-based planning. To achieve the Poverty Reduction Strategy and delivery of the Basic Package of Health and Social Welfare Services, additional resources and manpower are needed to improve surgical and anesthetic care.

The political economy of emergency and essential surgery in global health.

Emergency and essential surgery (EES) remains a low priority on global health agendas even though a growing body of evidence demonstrates that EES is a cost-effective public health intervention and that it holds the potential to prevent a sizable number of deaths and disabilities. The inferior status of EES should be considered, in part, a political problem and subject to political analysis. This type of political economy examination has been used for other important global health issues but has not been applied to EES. By addressing political concerns and prospects, EES can be better positioned on international agendas, thus improving surgical care delivered to the poor.

Addressing the Millennium Development Goals from a surgical perspective: essential surgery and anesthesia in 8 low- and middle-income countries.

HYPOTHESIS: Surgical and anesthetic care is increasingly recognized as a neglected but cost-effective component of primary health care in low- and middle-income countries (LMICs). Strengthening delivery can help achieve Millennium Development Goals 4, 5, and 6. Large gaps in access to essential surgical care in LMICs result in considerable morbidity and mortality. The goal of this study was to provide a baseline overview of essential surgical and anesthetic capacity at district-level health facilities in multiple LMICs. DESIGN: Survey. SETTING: District-level health facilities in multiple LMICs MAIN OUTCOME MEASURES: A standardized World Health Organization tool was used at selected district-level hospitals to assess infrastructure, supplies, and procedures relating to essential surgical and anesthetic capacity. The analysis included facilities from countries that assessed more than 5 health facilities. All data were aggregated and blinded to avoid intercountry comparisons. RESULTS: Data from 132 facilities were analyzed from 8 countries: Democratic Socialist Republic of Sri Lanka (n = 32), Mongolia (n = 31), United Republic of Tanzania (n = 25), Islamic State of Afghanistan (n = 13), Republic of Sierra Leone (n = 11), Republic of Liberia (n = 9), Republic of The Gambia (n = 6), and Democratic Republic of São Tomé and Príncipe (n = 5). Universally, facilities demonstrated shortfalls in basic infrastructure (water, electricity, oxygen) and functioning anesthesia machines. Although 73% of facilities reported performing incision and drainage of abscesses, only 48% were capable of undertaking an appendectomy. In line with Millennium Development Goals 4, 5, and 6, only 32% of facilities performed congenital hernia repairs, 44% of facilities performed cesarean sections, and few facilities always had goggles and aprons to protect surgical health care workers from human immunodeficiency virus. CONCLUSION: Enormous shortfalls in infrastructure, supplies, and procedures undertaken are common at district-level health facilities in LMICs.

Survey of emergency and surgical capacity in the conflict-affected regions of Sri Lanka.

BACKGROUND: Three decades of internal conflict in the North and East of Sri Lanka have taken a toll on the health care system in that area. METHODS: We proposed to quantify the current status of capacity to deliver emergency, anesthesia, and surgical interventions in the conflict affected areas of Sri Lanka. The World Health Organization (WHO) Tool for Situational Analysis to Assess Emergency and Essential Surgical Care (EESC) was used to evaluate 47 health facilities. RESULTS: Although most have trained health care providers capable of basic procedures, infrastructure and supplies were severely lacking. CONCLUSION: These data can be used as a basis for the recovery and rebuilding of EESC capacity in conflict-affected areas of Sri Lanka.

Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care.

HYPOTHESIS: Lack of access to surgical care is a public health crisis in developing countries. There are few data that describe a nation's ability to provide surgical care. This study combines information quantifying the infrastructure, human resources, interventions (ie, procedures), emergency equipment and supplies for resuscitation, and surgical procedures offered at many government hospitals in Sierra Leone. SETTING: Site visits were performed in 2008 at 10 of the 17 government civilian hospitals in Sierra Leone. MAIN OUTCOME MEASURES: The World Health Organization's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was used to assess surgical capacity. RESULTS: There was a paucity of electricity, running water, oxygen, and fuel at the government hospitals in Sierra Leone. There were only 10 Sierra Leonean surgeons practicing in the surveyed government hospitals. Many procedures performed at most of the hospitals were cesarean sections, hernia repairs, and appendectomies. There were few supplies at any of the hospitals, forcing patients to provide their own. There was a disparity between conditions at the government hospitals and those at the private and mission hospitals. CONCLUSION: There are severe shortages in all aspects of infrastructure, personnel, and supplies required for delivering surgical care in Sierra Leone. While it will be difficult to improve the infrastructure of government hospitals, training additional personnel to deliver safe surgical care is possible. The situational analysis tool is a valuable mechanism to quantify a nation's surgical capacity. It provides the background data that have been lacking in the discussion of surgery as a public health problem and will assist in gauging the effectiveness of interventions to improve surgical infrastructure and care.