1. science
2. medicine
3. surgery

Supplementary appendix
This appendix formed part of the original submission and has been peer reviewed.
We post it as supplied by the authors.
Supplement to: Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: evidence
and solutions for achieving health, welfare, and economic development. Lancet 2015;
published online April 27. http://dx.doi.org/10.1016/S0140-6736(15)60160-X.
The Lancet Commission on Global Surgery Appendix
1
The Lancet Commission on Global Surgery Appendix .................................................................................. 1
Introduction ............................................................................................................................................... 3
Appendix 0.0: Commission Methods and Scope .................................................................................. 4
Appendix 0.1 Methods for assessing the global volume of surgery in 2012 and its relationship to
cesarean delivery and life expectancy ................................................................................................... 8
Key Messages (KM) .................................................................................................................................10
Appendix 1.0: Measuring Burden of Disease ......................................................................................11
Appendix 1.1 Deaths from acute abdominal conditions and geographic access to surgical care in
India: a nationally representative population-based spatial analysis ....................................................13
Appendix 1.2: New Zealand Data Set ..................................................................................................14
Health Delivery and Management (HDM) ...............................................................................................15
Appendix 2.0: Healthcare Delivery and Management Key Findings ...................................................16
Appendix 2.1: Health Delivery and Management Supplemental Core Content...................................17
Appendix 2.2: Situational Analysis Tool .............................................................................................30
Appendix 2.3: Infrastructure Literature Review ..................................................................................36
Appendix 2.4: The How Project ..........................................................................................................47
Appendix 2.5: Provider Surveys Summary ..........................................................................................49
Appendix 2.6: Blood ............................................................................................................................51
Appendix 2.7: First Level Referral Hospital Procedures .....................................................................77
Appendix 2.8: A Novel Web-Based Strategy to Identify Non-Governmental Actors in Global
Surgery. ..............................................................................................................................................104
Workforce, Training, and Education (WTE) ..........................................................................................106
Appendix 3.0: Workforce, Training And Education Key Findings ...................................................107
Appendix 3.1: The Surgical Workforce .............................................................................................108
Appendix 3.2: The Global Surgeon, Anaesthesiologist, and Obstetrician Workforce Thresholds and
2030 Projections ................................................................................................................................109
Appendix 3.3: Surgical Volume and The Surgical Workforce ..........................................................111
Appendix 3.4: Geospatial Mapping to Estimate Timely Access to Surgical Care in Nine Low-andMiddle Income Countries...................................................................................................................112
Appendix 3.5: Task Shifting Around the World ................................................................................113
Appendix 3.6: Surgical, Anaesthetic, and Obstetric Training Paradigms ..........................................115
Appendix 3.7: A Systematic Literature Review on Methods for Scaling up the Anaesthesia
Workforce ..........................................................................................................................................118
Appendix 3.8: The Scale-up of the Surgical Workforce ....................................................................120
Appendix 3.9: Increasing Access To Surgical Care Through Task Sharing in Malawi .....................123
Appendix 3.10 Partnering with the NGO sector for Training and Education ....................................124
Appendix 3.11: Tanzanian Tele-Education for Laparoscopic Surgery ..............................................126
Appendix 3.12: Health Worker Retention in The University of West Indies ....................................127
Economics and Financing (EF)...............................................................................................................128
Appendix 4.0: Economics and Financing Key Findings ....................................................................129
Appendix 4.1: Funding Flows to Global Surgery ..............................................................................130
Appendix 4.2: Operative Volumes and per capita Government Health Expenditure.........................132
Appendix 4.3: Surgical Procedures, Packages, and Platforms ...........................................................133
Information Management .......................................................................................................................134
Appendix 5.0: Information Management Key Findings ....................................................................135
Appendix 5.1: Surgical Inclusion Household Surveys .......................................................................136
Appendix 5.2: Validation of Household Surveys...............................................................................137
Appendix 5.3: Facility Surveys and Surgery .....................................................................................138
Appendix 5.4: Registries ....................................................................................................................139
Appendix 5.5: Indicator Search .........................................................................................................140
Appendix 5.6: Indicator Development ...............................................................................................142
Appendix 5.7: Literature Review of Utilization Of Metrics For Surgery In Low- And Middle-Income
Countries ............................................................................................................................................144
Appendix 5.8: Use and Definitions of Perioperative Mortality Rates In Low-Income And MiddleIncome Countries: A Systematic Review ..........................................................................................150
Research..................................................................................................................................................156
2
Appendix 6.0: Research Key Findings...............................................................................................157
Appendix 6.1: Bibliometrics; Surgery And Surgical Oncology Research Outputs 2009-2013 .........158
The Patient Voice ...................................................................................................................................165
Appendix 7: Patient Quotations .........................................................................................................166
Acknowledgements.................................................................................................................................175
Appendix 8: Acknowledgements .......................................................................................................176
Introduction
3
Appendix 0.0: Commission Methods and Scope
BEGINNINGS
At the beginning of 2013, a small group of global surgery advocates initiated discussions with The Lancet
regarding a crucial need for improvements in access to and delivery of surgical care around the world. The
Lancet acknowledged this need and plans for the Lancet Commission on Global Surgery were developed
through 2013 leading up to the first official meeting and launch in January 2014.
COMPOSITION
A total of twenty-five Commissioners were recruited from geographically and categorically diverse
networks involved with key issues pertaining to global surgery including governments, academic
institutions, international bodies, policy groups, and surgical establishments. Commissioners included
three Chairs who led the Commission process, as well as four Facilitators who conducted the day-to-day
work of the Commission. The Chairs and Facilitators formed the Commission’s Core Implementation
Team. All Commissioners were responsible for providing expertise and guidance to determine the course
and content of the project and were divided into four working groups: Healthcare Delivery and
Management, Workforce Training and Education, Economics and Financing and Information Management.
A Working Group Lead directed each working group supported by a Research Team responsible for
generating new data and completing necessary reviews. This research arm consisted of Modelling Experts,
an Epidemiologist, a Health Economist, a Statistician, and numerous Research Assistants. Finally, a
number of key advisors were engaged to provide additional external feedback on the Commission content
and process.
PROCESS
Three structured Commissioner Meetings attended by all Commissioners and a number of nonCommissioner contributors were held during 2014. The first meeting took place in Boston, USA in January
2014 with attendees from eighteen countries. It provided an introduction to the process, developed a
framework for subsequent work, and established the main directions and policy foci of the Commission.
The second meeting was held in Freetown, Sierra Leone in June with participants from twenty-eight
countries. Commissioners discussed the results of their work from the prior five months, and determined
the Commission’s key messages and recommendations. The third and final structured meeting occurred in
Dubai, UAE in November. Results from the first round of peer review were discussed and necessary report
modifications made. An Implementation Meeting was held in February 2015 in Bellagio, Italy with a small
group of key policy makers, funders and process experts in order to support the implementation of the
Commission’s recommendations. In addition to the three primary meetings, a number of Regional Meetings
were held throughout 2014 to engage and generate feedback from additional interested parties. These
occurred in Cartagena, Colombia; São Paulo, Brazil; Chhattisgarh, India; and Singapore. The
Commission work was also presented at a number of prominent health and policy meetings in 2013 and
2014, including the 1000+ OBGYN Conference in Accra, Ghana; the West African College of Surgeons
meeting in Kumasi, Ghana the American College of Surgeons Annual Clinical Congress in Washington
DC, USA (2013), and San Francisco, CA (2014); side events to the World Health Assembly in Geneva,
Switzerland; the Swedish Annual Surgical Conference in Sweden; and a Surgical Summit in Cape Town,
South Africa.
ENGAGEMENT
In order to animate the global health community, engage additional participants, gain knowledge, and build
an inclusive global surgical movement, widespread efforts were employed to generate discussion and share
Commission information. Commissioners engaged in direct outreach efforts with Ministries of Health,
frontline providers and implementers, global health organizations, funders, professional societies,
associated institutions, surgical colleges, academic establishments, industry, educators and students, and
patients. An active social media campaign using Facebook and Twitter was instituted, generating over
4
1 400 Twitter followers and 500 Facebook likes. A website with Commission information and portals for
discussion and input was maintained. Updates were distributed through monthly newsletters, intermittent
emails, social media endeavours and website newsfeeds. A number of quantitative and qualitative surveys
were employed to assess opinions regarding areas of global surgical import. A total of 666 online surveys
from 72 countries and 145 qualitative interviews in 23 countries were completed. In addition, rolling
discussions pertaining to Commission content and processes were held with a number of key health related
institutions including the World Bank, the World Health Organization and USAID. Finally, groups and
individuals were asked to generate standalone global surgery publications and teaching cases to support the
overall Commission momentum and output. Five business schools from three different countries engaged
to create fifteen business-style teaching cases on global surgery topics, and numerous global surgery
papers were published alongside the Commission.
PATIENT VOICE
The patient is central to virtually all health-related movements. Yet what is meaningful to the patient is too
often lost in academic pursuits and publications. Therefore, we attempted to solicit and record direct
quotations from real surgical patients and family members of those undergoing surgical procedures to
represent the “patient voice” throughout The Lancet Commission on Global Surgery. Quotations and
stories generated from in person interviews are included in both the appendix (page 165) and the social
media campaign. Written or verbal consent was obtained for all patient voice interviews.
FUNDING
Funding was acquired by the Core Team from grants, individual donors, academic partners and supporting
institutions. These are listed on the main report and in the acknowledgements.
SCOPE
The Commission defined global surgery in detail in a preceding publication.1 In brief, “global surgery is an
area of study, research, practice, and advocacy that seeks to improve health outcomes and achieve health
equity for all people who require surgical care, with a special emphasis on underserved populations and
populations in crisis.”1 This definition encompasses all members of the surgical workforce, includes all
surgical and perioperative specialties as well as non-procedural aspects of surgical care, extends to all
underserved populations and populations in crisis regardless of geographic location, and recognizes the
numerous direct and indirect interdisciplinary factors that affect health from individual to supra-territorial
levels.
Although the scope of global surgery extends across countries of all income-levels, the largest area of
unmet need currently exists within LMICs. Therefore, surgical care delivery within LMICs, rather than
HICs, was the primary focus of this Commission (Figure 1). Similarly, global surgery refers to all groups
facing inequitable or inadequate surgical care delivery, whether they are chronically underserved
populations or those in more acute crisis, conflict or disaster settings. Factors influencing and methods for
care delivery in these two rudimentary designated settings can be quite different. Therefore, the scope of
this commission was primarily on underserved populations.
5
Figure 1. Global surgery definition and scope
Global
Surgery
Improved health
& health equity
for all
Underserved
populations
LMICs
Populations
in crisis
HICs
Conflict &
Displacement
Disaster
Global surgery aims to improve health and health equity for all who are affected by surgical conditions or
have a need for surgical care, with a special focus on underserved populations in both LMICs and HICs
and populations in crisis, such as those experiencing conflict, displacement and disaster. The scope of this
particular Commission is highlighted in red.
6
Figure 2. Scope of global surgical care
The scope and reach of processes involved in global surgery and global surgical care extend from those
occurring at the level of the individual to those which are supra-territorial (transcend geography), and are
influenced by the many interactions that occur between and across the different levels.
REFERENCES
1.
Dare AJ GC, Gillies R, Greenberg SL, Hagander L, Meara JG, Leather AJ. Global
surgery: defining an emerging global health field. The Lancet Global Health. 2014.
7
Appendix 0.1 Methods for assessing the global volume of surgery in 2012 and its relationship to
cesarean delivery and life expectancy
TOM WEISER, ALEX B HAYNES, GEORGE MOLINA, et al.
POPULATION AND HEALTH DATABASES
We obtained 2012 population and health data for all 194 World Health Organization (WHO) member
states. These data included total population, life expectancy (LE) at birth, percent of total urban population,
gross domestic product per capita in US$, and total health expenditure per capita in US$. We used data
from similar sources for countries (n=11) missing population or health data from WHO or the World Bank.
All dollar values were adjusted for inflation to 2012 using the consumer price index. For countries with
reported surgical data we also obtained population and health data from the year for which surgical volume
is reported. We classified countries as poor- (n=50), low- (n=54), middle- (n=46), or high- (n=44)
expenditure based on per capita health spending of $0-$100, $101-$400, $401-$1000, and >$1000
respectively.
SURGICAL DATA SOURCES
Operations were defined as procedures performed in operating theatres that require general or regional
anesthesia, or profound sedation to control pain. We searched for the most recent annual surgical volume in
PubMed for all 194 WHO member states, with the earliest cut off date being 2005. We also searched the
internet for each ministry of health or national statistical office website to identify available data and to
obtain email addresses for ministers of health, ministry of health officials, or individuals responsible for
auditing surgical data at a national level. We contacted these officials to request the total volume of
operations (using the above definition) for the most recent year. Letters were written in English, Spanish,
French, Arabic, and Chinese. Surgical volume for 26 countries from the Organization for Economic CoOperation and Development (OECD) was obtained and calculated from the OECD database. For all
countries from which we obtained surgical data between 2005 and 2013, we calculated the surgical rate per
100,000 population for the year that the data was reported by using the annual surgical volume and total
population estimate.
STATISTICAL ANALYSIS
We developed a predictive model for surgical rates using the bivariate Spearman association between
surgical rate and five a priori country-level variables: total population, LE, percent urbanization, gross
domestic product per capita, and total health expenditure per capita. As we found previously, total health
expenditure per capita was the most highly correlated variable with surgical rate (Spearman R=0.87297,
p<0.001). We then considered Spearman partial correlation coefficients between surgical rate and each of
the other five variables after adjusting for total health expenditure per capita; none of these variables
remained significant. We then investigated the bivariate relationship between region (six levels) and
surgical rate after controlling for total health expenditure per capita using rank regression and noted no
significant association. Thus our final predictive model contained only total health expenditure per capita.
We log-transformed total health expenditure per capita and surgical rate to account for their right-skewed
distribution.
We build a spine model, positing zero to three inflection points, to find the best fitting model for the
relation of these two variables, which we defined by maximizing the adjusted cross validation R2 (CVR2)
where the predicted surgical rate value for a country is calculated without that country in the regression
model. The spline model with two inflection points had the highest adjusted CVR2 (0.7449) while the
models with zero, one and three inflection points had adjusted CVR2 of 0.7064, 0.7071 and 0.7332
respectively.
We fit a multivariable logistic regression model to determine if the probability that a country’s surgical rate
is missing is related to any of the same a priori predictors identified above. This multivariable logistic
regression model allowed us to determine important variables associated with surgical rate that could then
be included in an imputation model to predict the rates for the countries with missing data. The only
variable significantly associated with whether a country’s surgical rate was missing was total health
expenditure per capita, which was already included in the imputation model.
8
We used total per capita health expenditure from 2012 and our predictive model to impute estimates of
surgical rates for all countries with missing surgical data. We produced 300 imputed datasets to estimate
the mean global surgical volume and its corresponding 95% confidence interval. Using the imputed
country-level surgical rates and population estimates for 2012 we calculated the number of operations
performed in each country in 2012. We also used published cesarean delivery data to calculate the
proportion of surgical volume accounted for by cesarean delivery for each country. These data came
primarily from the WHO Global Health Observatory Data Repository, WHO World Health Statistics and
World Health Reports from 2010, the Demographic and Health Surveys Program, and OECD data.
We fit a spline regression model with zero, one, two, or three inflection points to assess the general
relationship between imputed surgical rates and national life expectancy. Once again, the best-fitting spline
model was found by maximizing the adjusted CVR2. The spline model with three inflection points had the
highest adjusted CVR2 (0.4838) while the models with zero, one and two inflection points had adjusted
CVR2 of 0.3224, 0.4727, and 0.4805, respectively.
In order to compare estimated surgical rates and global surgical volume from 2012 to that of 2004, we
performed a similar spline regression analysis described above on the 56 countries with reported surgical
rate data from our 2008 analysis. We evaluated the change in surgical rates that occurred for each health
expenditure group between 2004 and 2012. This provided a sensitivity analysis to assess if the observed
changes in surgical rates and global surgical volume from 2004 to 2012 were due to the new modeling
approach used in this current study.
All p-value <0.05 were considered statistically significant. Statistical tests were 2-sided. We used SAS
software version 9.2 (SAS Institute Inc., Cary, NC) for all statistical analyses.
9
Key Messages (KM)
10
Appendix 1.0: Measuring Burden of Disease
BLAKE ALKIRE
The burden of disease (BoD) enterprise dates back to 1990, when the World Bank commissioned a study
(GBD1990) to quantify the magnitude of lost health secondary to disease and injury.1,2 The 1993 World
Development Report featured this analysis, and through multiple iterations, BoD studies have gone on to
play an essential role in global health research, policy-making, and resource allocation.3-5
Collection of national health statistics from various sources is fundamental to BoD studies. However,
mathematical modelling is also critical when raw data does not exist. Although successive revisions with
“piecemeal”2 improvements in methodology have been published since GBD1990,1,6-9 the first complete
overhaul was the global burden of disease study 2010 (GBD2010). Overseen by the Institute for Health
Metrics and Evaluation (IHME), GBD2010 assessed 291 cause groups and 1160 disease sequelae at the
country level for 20 age groups for the years 1990, 1995, 2000, 2005, and 2010.2 GBD 2010 was the first of
the BoD studies to systematically account for uncertainty with confidence intervals, overhauled the method
of formulating disability weights from an expert-based to a population-based approach, simplified the
assumptions for calculating disability adjusted live years (DALYs), accounted for comorbidities, and
created a number of new modelling techniques to account for data scarcity. While lauded as an important
achievement,10,11 there were notable and sometimes substantial differences between IHME and United
Nations interagency estimates of cause-specific mortality, particularly with respect to adult malaria,12
conflict-related mortality,13 the attribution of cause of maternal death in sub-Saharan Africa,12 and overall
under-5 mortality.5 Although the WHO was one of the main original collaborators with IHME for
GBD2010, the organization did not endorse the final results and continues to produce its own global burden
of disease estimates, termed the Global Health Estimates (GHEs).14 Although differences remain in some
cause-specific estimates, there is considerable overlap in results between the two groups’ results.14 Further,
data sources and methods, especially with respect to YLDs and countries with sparse data, are often
shared.14 Major updates of BoD estimates have historically occurred every decade. However, IHME has
signalled its intention to continuously incorporate new data with a goal of at least annual updates,15 the first
of which was already published in May 2014.16-18
REFERENCES
1.
Murray CJ LA. The global burden of disease: a comprehensive assessment of mortality and
disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA:
Harvard School of Public Health on behalf of the World Health Organization and the World Bank,
1996.
2.
Murray CJ EM, Flaxman AD, Lim S, Lozano R, Michaud C, et al. GBD 2010: design, definitinos,
and metrics. The Lancet 2012; 380(9859): 2063-6.
3.
World Development Report 1993: Investing in Health. New York: The World Bank, 1993.
4.
Farmer P. Reimaging global health: an introduction. Berkeley: University of California Press;
2013.
5.
Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a
generation. Lancet 2013; 382(9908): 1898-955.
6.
The World Health Repot 2001 - Mental Health, New Understanding, New Hope. Geneva,
Switzerland: The World Health Organization, 2001.
7.
Lopez A, Mathers CD, Ezzat M, Jamison DT, Murray CJL. Disease Control Priorities Project.
Global burden of disease and risk factors. . New York, NY; Washington, DC: Oxford University
Press and World Bank; 2006.
8.
Mathers C FD, Organization WH, Boerma JT. The global burden of disease: 2004 update: The
World Health Organization, 2008.
9.
The World Health Report 2000 - Health systems: improving performance. Geneva, Switzerland:
The World Health Organization.
10.
Horton R. GBD 2010: understanding disease, injury and risk. The Lancet 2012; 380(9859): 20534.
11.
Kim J. Data for better health - and to help end poverty. The Lancet 2012; 380(9859): 2055.
11
12.
13.
14.
15.
16.
17.
18.
P B. The imperfect world of global health estimates. PLoS medicine 2010; 7(11).
Mathers C SG, Fat DM. WHO methods and data sources for global causes of death 2000-2011.
Geneva, Switzerland: The World Health Organization, 2013.
Mathers C SG. WHO methods and data sources for global burden of disease estimates 2000-2011.
Geneva, Switzerland: The World Health Organization, 2013.
Murray CJ FJ, Piot P, Mundel T. GBD 2.0: a continuously updated global resource. The Lancet;
382(9886): 9-11.
Murray CJ OK, Guinovart C, et al. Global, regional, and national incidence and mortality for HIV,
tuberculosis, and malaria during 1990-2013: a systematic analysis for the Global Burden of
Disease Study 2013. The Lancet 2014; S0140-6736(14): 60844-8.
Wang H LC, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and
under-5 mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study
2013. The Lancet 2014; S0140-6736(14): 60497-9.
Kassebaum NJ B-VA, Coggeshall MS, et al. Global, regional, and national levels and causes of
maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease
Study 2013. The Lancet 2014; S0140-6736(14): 60696-6.
12
Appendix 1.1 Deaths from acute abdominal conditions and geographic access to
surgical care in India: a nationally representative population-based spatial analysis
JOSHUA S NG-KAMSTRA, ANNA J DARE, JAYADEEP PATRA, SZE HANG FU, PETER S
RODRIGUEZ, MARVIN HSIAO, RAJU M JOTKAR, J S THAKUR, JAY K SHETH, PRABHAT JHA,
FOR THE MILLION DEATH STUDY COLLABORATORS
STUDY METHODOLOGY
The Million Death Study is a nationally representative mortality survey of over 1.1 million homes in India.
Its methodology has been described previously.1, 2 Briefly, 8000 small areas in India were randomly
selected for continuous monitoring of births and deaths through six-monthly household visits by 800 nonmedical staff.1 A validated Verbal Autopsy tool was used to determine cause of death for each decedent
during the study period.1
All deaths attributed to a pre-selected list of time-critical acute abdominal diagnoses (ICD-10 codes3) in
individuals aged 0-69 years were included in this analysis and were termed Deaths from Acute Abdomen
(DAA). Postal-code level population data were derived from a national household survey,4 and agestandardized DAA-specific mortality rates were calculated for each sampled postal code. The Getis-Ord
Gi* statistic5 was used to identify spatial clusters with higher or lower rates of DAA. This yielded clusters
of high– and low–DAA mortality areas at the 99% confidence level.
Health facility data were drawn from the District-Level Health and Facility Survey (DLHS-3), which
provides information on District Hospital (DH) surgical capacity and hospital resources.6 We classified DH
according to available resources. Well-resourced DH had 24 hour surgical and anaesthetic services, critical
care beds, a blood bank, and basic laboratory and radiology services. Hospitals were geocoded using data
from a commercial data vendor.
Odds ratios (OR) for spatial access to DH in high–mortality versus low–mortality clusters were estimated
by multivariate logistic regression. The main model included Euclidean distance to the nearest wellresourced district hospital as the primary predictor variable, with adjustment for poverty and the proportion
of the population belonging to a scheduled caste or tribe. Calculation of avertable deaths at the population
level under the scenario of full coverage of well-resourced DH within 50km was made on the basis that
odds of mortality for those currently living >50 km from a well-resourced DH would fall to the level of
those living within 50 km of a well-resourced DH.
REFERENCES:
1.
Aleksandrowicz L, Malhotra V, Dikshit R, et al. Performance criteria for verbal autopsy-based
systems to estimate national causes of death: development and application to the Indian Million
Death Study. BMC medicine 2014; 12: 21.
2.
Hsiao M, Malhotra A, Thakur JS, et al. Road traffic injury mortality and its mechanisms in India:
nationally representative mortality survey of 1.1 million homes. BMJ open 2013; 3(8): e002621.
3.
World Health Organization. International Statistical Classification of Diseases and Related Health
Problems, ICD-10: Three Volume Set. Geneva: WHO; 2010.
4.
Registrar General of India. Special fertility and mortality survey, 1998: A report of 1.1 million
households. New Delhi: Registrar General; 2005. p. 302.
5.
Getis A, Ord J. The analysis of spatial association by use of distance statistics. Geographical
analysis 1992.
6.
International Institute for Population Sciences. District Level Household and Facility Survey
(DLHS-3), 2007-2008: India. Mumbai: IIPS; 2010.
13
Appendix 1.2: New Zealand Data Set
To estimate global surgical need, we used a New Zealand-based dataset to estimate the "surgical
incidence", defined as the procedure:diagnosis ratio, for each diagnosis. The following briefly outlines our
rationale for using this dataset. Additional details can be found in the accompanying paper.1,2 New Zealand
has a healthcare system that is primarily (~83%) funded by government expenditure (general tax revenue)
and although inequities exist,3,4 it is generally considered to provide extensive and high quality hospitallevel care with good population coverage. New Zealand has low per capita spending on health compared to
other OECD (Organisation for Economic Co-operation and Development) countries, with comparable or
better life-expectancy.5 Access to elective surgical care within the public system follows national criteria
for need and priority, which limits unnecessary operations within this sector. However, long waiting times
for elective surgical operations exist.6 Consequently excess surgical procedures are not considered to be a
prominent feature of the health system. Additionally, the New Zealand surgical admissions and procedures
dataset is publically available and based on ICD-10 (International Statistical Classification of Diseases and
Related Health Problems version 10) codes, facilitating data use and comparison.
REFERENCES
1.
Rose J WT, Hider P, Wilson L, Gruen R, Bickler SW. Estimated need for surgery worldwide
based on prevalence of diseases: implications for public health planning of surgical services.
Submitted to The Lancet Global Health 2014.
2.
Hider P WL, Rose J, Weiser TG, Gruen R, Bickler SW. The role of facility-based surgical services
in addressing the national burden of disease in New Zealand: an index of procedure frequency
based on country-specific disease prevalence. Submitted as a conference abstract to The Lancet;
2014.
3.
JC G. Rural surgery and rural surgeons: meeting the need. ANZ J Surg 2007; 77(11): 919-20.
4.
Sheridan NF KT, Connolly MJ, Mahony F, Barber PA, Boyd MA, Carswell P, Clinton J, Devlin
G, Doughty R, Dyall L, Kerse N, Kolbe J, Lawrenson R, Moffitt A. Health equity in the New
Zealand health care system: a national survey. Int J Equity Health 2011; 10(45).
5.
Health Services Delivery Profile, New Zealand. Accessed Online:
http://www.wpro.who.int/health_services/service_delivery_profile_new_zealand.pdf: WHO and
the Ministry of Health, New Zealand, 2012.
6.
Assessing the demand for elective surgery amongst New Zealanders. Accessed online (26/09/14):
http://www.healthfunds.org.nz/pdf/Assessing the demand for Elective Surgery for release.pdf:
TNS New Zealand, 2013.
14
Health Delivery and Management (HDM)
15
Appendix 2.0: Healthcare Delivery and Management Key Findings
•
•
•
•
•
•
Patients face significant barriers to accessing surgical care, including financial, geographic, and
cultural factors, and poor pre-hospital transportation systems
Poor connectivity between traditional healthcare providers, community health workers, and the formal
health system compromises surgical care delivery
Most hospitals lack the necessities for surgical care provision including basic physical infrastructure,
equipment, supplies, and support services such as radiology, pathology and equipment maintenance
Limited focus on leadership, management, and research leads to process inefficiencies, poor system
performance, and suboptimal safety
International assistance in the form of equipment donations and visiting surgical teams is often not
designed to contribute towards long-lasting system improvement
Performance of the Bellwether Procedures (laparotomy, caesarean delivery, and open fracture fixation)
serves as a proxy indicator for delivery of a broad range of surgical care; 80-90% of which can be
provided in well-equipped first-level hospitals
16
Appendix 2.1: Health Delivery and Management Supplemental Core Content
NAKUL RAYKAR, ROWAN GILLIES, EDGAR RODAS, SHENAAZ EL-HALABI, GANBOLD
LUNDEG, RACHEL YORLETS, AND NOBHOJIT ROY
Contributing Authors: MOSIUR RAHMAN, DAVID BARASH, KRISTIN HATCHER, MAGEE,
RICHARD VANDER BURG, LUCAS CARLSON, DAVID WATTERS, SAM ENUMAH AND
BRIGITTE FRETT
2.1.1 The Three Delays In Context
A case vignette, grounded in real-life experiences, can be useful to put a theoretical framework into
context. Here we present the case of Sydney, a Zimbabwean labourer who is failed by a weak health system
and poor access to surgical services, a scenario familiar to billions of individuals worldwide. Through the
Commission process, the Commission had the opportunity to engage with hundreds of front-line clinicians
and their patients around the world, through both in-depth, semi-structured qualitative interviews (The How
Project, Appendix 2.3) and countless undocumented conversations in person and over the phone. Sydney,
then, is a composite of thousands of patient interactions and experiences relayed to the Commission or
experienced first-hand by the Commissioners, many of whom have had decades of experience in serving
low-resource populations. The vignette of Sydney is arbitrarily set in Zimbabwe, but would not be out of
place in any of the world’s many resource-poor systems.
The three delays are used in the Health Delivery & Management section as a framework to
describe the numerous challenges to access and availability of surgical care. Figure 1 summarizes
the three delays as they pertain to surgical care.
Figure 1. The Three Delays and Surgery
17
The First Delay
Sydney is a 41-year-old man who lives in the rural regions of eastern Mashonaland, Zimbabwe. Sydney is a
daily wageworker who puts in long hours of manual labour in various construction jobs in the region. For
the past year, Sydney has been experiencing a bulge in his right groin accompanied by progressively
worsening pain. Several months ago, he had visited the local healer who suggested he wrap his groin with a
tight towel around his waist. Unable to sacrifice a day’s wages, and without a means of transportation, he
works through the pain and puts off visiting the nearest health centre located 100 kilometres away.
The Second Delay
One day, however, he experiences a sharp and persistent pain. The lump, previously reducible, is now hard
and does not slide back to its normal size. Unable to continue work, he takes the advice of the village elders
who send him to the primary health centre 20 kilometres away. A nurse at the facility tells him he needs to
see a doctor, and possibly a surgeon, but they are only available at the district hospital, which is 100
kilometres away. Without his own means of transportation, the clinic staff arrange for him to ride with the
supply truck, which is expected the next day. He spends the night in excruciating pain. Fortunately, Sydney
is able to find transportation to the district hospital with the clinic supply vehicle the next afternoon.
The Third Delay
Sydney reaches the district hospital in persistent pain, accompanied by his wife. It has now been almost two
full days. He is running a slight fever, feels weak and the bulge in his groin is hot to the touch and very
tender. The physician at the hospital tells him he needs an operation, but there is neither electricity nor the
required surgical supplies. The operating theatre has not been functional for months, and the surgeons no
longer come to the hospital. He tells Sydney that he must go to the tertiary hospital in the capital city.
The Second and Third Delays, again
Fortunately, Sydney is able to take a bus to the capital, which takes only five hours. By his arrival at the
tertiary hospital, though, Sydney is lethargic and febrile. After waiting in a busy waiting area with many ill
patients, he is seen by a surgeon. Unfortunately, the operating rooms are full, he is told, and he will be
slotted in as soon as possible, but probably not until the morning. He is started on some intravenous fluids.
At this point, he has had a strangulated hernia for days. “You came too late,” admonishes the surgeon. “We
could have treated this if you had come sooner.”
Treatment
Sydney is lucky. He was taken to the operating room the next morning where the surgeon found necrotic
bowel, which was resected. Post-operatively, he was able to stay in the hospital for his recovery.
Unfortunately, he and his wife spent their full savings on the ordeal of travel to the hospital and there is
none remaining for fees. Seven days after his operation, the care staff at the hospital advises him to abscond
to avoid harassment from revenue collectors.
18
2.1.2 The View from a Crowded LMIC Tertiary Hospital
Constructed from interviews from the LCoGS Qualitative Interview (The How Project) (Appendix
2.3), a description of a tertiary centre in a busy LMIC environment:
At a tertiary public hospital in a major South Asian city, a team of four faculty surgeons is
responsible for seeing 400 outpatient surgical appointments daily. The inpatient service is no
less busy. The result is that the hospital “floor” is very much the physical floor, and doubles
as a bed; patients are left on a stretcher in the hall, minimally attended, only hours after a
craniotomy. A single nurse and resident physician will be responsible for hundreds of
patients, and relatives of patients must provide bag-mask ventilation given insufficient
ventilator capacity. Faculty and trainees lose the ability to perform non-clinical tasks, such
research or administrative duties.
2.1.3 Examples of Context-Specific Strategies to Mitigate the First Delay
Contextually and culturally appropriate interventions can mitigate the first delay. The Commission learned
of many such interventions, many of them small-scale and sparsely evaluated but nonetheless
demonstrating value to the providers and communities in which they were applied. Outreach efforts
consisting of taking hospital personnel into communities, for example, to set up diagnostic or treatment
camps are common and can be used to engage the community and build awareness of services. This is an
important mode of outreach of the Jan Swasthya Sahyog, a private/NGO rural hospital that provides free
surgical services in rural India, as well as that of many rural providers in African countries whom the
Commission interviewed in the How Project (Appendix 2.3).1
An outreach effort in Pakistan through community health workers that engaged traditional healers led to
increased care-seeking behaviour, greater utilization of skilled care providers and improved neonatal
mortality rates.2 World Health Partners is one of many NGOs that has used telemedicine to strengthen
existing informal health networks through improved connectivity with the formal health system.3 Satellite
dishes adorn the top of the mud huts of traditional healers in rural Bihar and Uttar Pradesh, India, and serve
as a conduit for consultations from infectious disease to psychiatry, and to assess need for referrals to a
hospital. Consultants are located worldwide.
In rural Bangladesh and eastern Uganda, groups of women participate in a facilitated process to prioritize
local issues affecting women’s and neonatal health.4Some of these interventions occur at socially
convenient times of the day, for example, during a break in afternoon agricultural activity. Community
outreach designed to build trust in the system is also important to mitigate the first delay. In rural Nigeria,
the Awojobi Clinic Eruwa established ‘village square consultations’ in the 1980s, a forms of a communitybased monitoring board, where members of the community were participatory in the running of the
hospital.5
19
Table 1. First-Delay Mitigation Strategies from Commission Qualitative Interviews
Barriers contributing to the first delay
Financial
Geographic
Cultural and patient education
Interventions (The How Project)
Donations, subsidized or free care (in some cases, free care is
provided if the patient presents letters from community members
stating that the patient is poor)
Church in rural area donates a piglet to be raised and sold to fund
planned surgery
Use less expensive materials (i.e.; mosquito net instead of hernia
mesh) and avoid diagnostic tests
Hospital accepts payment in animals or maize, or in patients
working in the hospital garden
Providers pay on behalf of patients
Satellite clinics
Community health workers
Mobile clinic
Social workers meet with patients to discuss need for care (in
patient’s first language)
Increase positive experiences – when patients experience the
benefits of surgery, they share their story with their community
Increase education and literacy through seminars and community
outreach, including posters and radio
Diagnostic camps in rural areas
20
2.1.4 A Model for a Pre-Hospital Surgical Referral System from BRAC Health
Contributing Author: Mosiur Rahman
Community health workers (CHWs) empowered with mobile phones and connected to the health system
can have powerful implications for surgical referral.6 BRAC, a Bangladeshi NGO based in Dhaka, reports
that more than 90% of rural households have access to a mobile phone.7 BRAC has devised a
comprehensive system of referral that, accordingly, leverages connectivity to systematically target the first,
second and third delays of care.8 Pregnant women are provided with the phone numbers of their community
health worker as well as the BRAC call centre, which is located in Dhaka and staffed around the clock to
field calls from pregnant women and CHWs. Women are counselled to use the phone to call their CHW at
the onset of labor. CHWs also engage with the traditional birth attendants and ask to be called during any
delivery in order to optimize safety.
At the time of delivery, if the community health worker recognizes a complication, she will initiate referral
to the hospital by calling the BRAC call centre. The call centre staffer can determine the appropriate
hospital for referral and will call one of the hundreds of local, private vehicle owners (with whom BRAC
has signed memoranda of understanding to provide transportation in emergency situations). The vehicle
owner is instructed to meet the patient and CHW at a pre-determined landmark within the village. While
the patient is en route, the call centre will alert a program officer (PO), located at the first-level hospital to
communicate with hospital staff in order to alert them of the situation and impending arrival of the patient.
This allows the hospital to gather necessary supplies and personnel, and be prepared for patient arrival,
thereby addressing the beginnings of the third delay. In program evaluations, the referral program has
demonstrated reductions in the first and second delays, in the rural and in the urban environment.9,10
Figure 2. Schematic of BRAC Referral System.
Source: BRAC Health
21
2.1.4 Community-based (Lay) Responder Trauma Programs
Community-based trauma response, or lay responder programs, have been attempted in many parts of the
world without formal emergency medical systems, often to strengthen an existing mode of pre-hospital
transportation.11 Bus and taxi drivers, for example, were trained in first aid and rescue in Ghana, as they
were the dominant mode of pre-hospital transport for road traffic victims.12 A similar program was
developed in Madagascar 13 and Uganda, though the trainee base in Uganda was wider and included city
police and city council members.14 SaveLIFE Foundation in New Delhi is an NGO that exclusively focuses
on training city police, given the size and presence of the Delhi Police force.15 This has reduced response
time within the congested traffic environment, as traffic police now serve as first-responders and police
vehicles now serve as ambulances. Likewise, programs in Iraq and Cambodia have taught villagers to
respond to trauma from mine injuries (in addition to training paramedics).16 Most of these programs have
undergone varying levels evaluation for process measures demonstrating that lay responders can be trained
in first aid, and some programs demonstrate long-term improvement in outcomes. Variation in individual
program design and individual study design, however, make it challenging to make broad conclusions
besides the fact that these interventions, adapted to local context and culture, can be valuable additions to
improving a pre-hospital transportation network.
2.1.5 A Model for Mobile Surgery from Cinterandes
Contributing Author: Edgar Rodas
Difficulties in accessing the formal health system contribute to the first delay, and geographic challenges
with poor transportation infrastructure contribute to the second delay. Cinterandes
(http://www.cinterandes.org/), an Ecuadorian NGO founded in 1994, uses “mobile surgery” to combat both
by taking surgical care directly to the patient.
The mobile surgical unit (MSU) consists of a 24-foot Isuzu truck that houses the operating room213. It
provides balance between the size needed for an operating room and the manoeuvrability needed to deal
with the narrow and winding Andean roads. The van is outfitted with basic surgical and anaesthetic
equipment, a scrub sink, an autoclave and cabinets for supplies. It also includes a laparoscopic tower.
The process from referral to treatment is multi-staged. First, rural physicians and traditional providers are
contacted to identify patients in need of planned surgical treatment. A surgeon and anaesthesiologist from
Cinterandes then travel to communities to perform a second screening and to make arrangements for
laboratories and/or imaging, when needed. Patients with multiple comorbidities or requiring specialized
attention are referred to the referral hospital. Finally, the MSU is brought to the community and parked at a
rural hospital, clinic, school or community centre to provide surgery.
The team will perform an average of 22 cases per trip, ranging from hernia repairs to laparoscopic
cholecystectomy. The team can provide a broad range of anaesthetic services including spinal and general
anaesthesia. Mobile surgery patients are monitored in the short term before being left in the care of the
local medical team. Follow-up is conducted jointly with the local medical team through the use of
telemedicine services with videoconferencing capabilities.298 The Cinterandes surgeon and
anaesthesiologist is also available by phone or for home visit.
Since 1994, Cinterandes has performed more than 7,500 surgeries using a model that integrates mobile
surgery with strong engagement of local health providers and the incorporation of telemedicine to optimize
pre and post-operative evaluations. The mobile surgery program includes teaching for surgical trainees and
students from both local and international universities.299 Mobile surgery is an innovative platform to
deliver planned surgical care to particularly remote patient populations around the world.
22
Figure 3. Inside the Cinterandes Mobile Surgery Unit is a fully functioning operating room.
Photo courtesy of Cinterandes
Figure 4. The Cinterandes Mobile Surgical Unit is a truck, nimble enough to navigate mountainous
terrain. Photo courtesy of Cinterandes
23
2.1.6 A Multi sectorial Partnership for Biomedical Equipment Maintenance
Author: David Barash MD, GE Foundation; Ed Hutton, Engineering World Health; Robert Malkin PhD,
Duke University
For months, Rwamagana Hospital, a district hospital in Rwanda, did not have a working anaesthesia
machine. Among the broken equipment were shattered lights, a non-functioning aspirator, and an out-ofcommission X-ray machine. This severely curtailed the hospital’s ability to offer surgical care. Patients
with life-threatening conditions could not be treated; the next referral facility was 60 km away.
In 2010, the GE Foundation (www.gefoundation.com), Engineering World Health (www.ewh.org/), and
Duke University (www.duke.edu) began an evidence-based training program for biomedical equipment
technicians (BMET). The training is delivered in 18 four-week modules over three years of classroom,
laboratory, and field practicum work. Students are high-school graduates who learn about healthcare
technology management, computer skills, device operation, and professional development. Individuals are
taught skills to maintain and repair biomedical equipment, and earn a nationally recognized certificate. In
addition to basic BMET training, the effort focuses on creating the next generation of BMET educators,
such that the program is self-sustaining.
Rwamagana Hospital technicians were among the BMET program’s first cohort. It has since been
expanded to Honduras, Ghana, Cambodia, and Nigeria. Rwandan hospitals with a BMET-trained
technician have almost halved the amount of out-of-service equipment compared to those without
technicians (17·8% vs. 10·2%).17
2.1.7 Common Protocols and Clinical Practice Guidelines
Published guidelines for clinical management and hospital processes abound; however, they tend to reflect
the high-income standard. Fewer published clinical management and process guidelines are based on care
practices and resources more typical of the low-and-middle income environments. Listed below are a
sampling of clinical guidelines developed for the low-resource setting. This is not an exhaustive list. Many
hospitals and organizations that provide care in these settings have developed their own internal guidelines,
though few find avenues for publication or public posting. This is unfortunate, as they could be of broad
value to clinicians practicing in remote or low-resource environments. The Commission suggests
organizations make these freely available (to LMIC providers), and academic and professional societies
create forums to catalogue these for easy access.
• The World Health Organization’s Integrated Management for Emergency and Essential Surgical
Care (IMEESC) toolkit provides a wide variety of relevant guidelines for the low-resource
environment. These range from best practices in safety processes to clinical management of
trauma. http://www.who.int/surgery/publications/imeesc/en/
• Tata Memorial Hospital in Mumbai, India, lists extensive clinical management guidelines on a
broad range of topics related to oncologic care, on its website Tata Memorial Hospital Evidence
Based Management Guidelines, https://tmc.gov.in/clinicalguidelines/clinical.htm.
• The American College of Surgeons has developed a Rural Trauma Training Development Team
Course (https://www.facs.org/quality%20programs/trauma/education/rttdc). Access to course
materials is available for a fee.
• A rural NGO surgical hospital in India, Jan Swasthya Sahyog, makes its research efforts and
clinical practices available through its website (http://www.jssbilaspur.org/media/reports.php).
Reports such as the ‘Appropriate Technologies Catalog’ provide low-cost adaptations to
common clinical practices.
24
2.1.8 A Model for Contextually-Sensitive NGO Assistance with Surgical Volume: Lessons Learned
from Operation Smile
Contributing Authors: Kristin Hatcher, Bill Magee, Richard Vander Burg, Lucas Carlson
Operation Smile has worked to expand access to safe, well-timed and effective care for cleft lip and/or
palate (CL/P) in resource-poor settings for over 32 years.18 Central to this evolution have been institutional
efforts to build and support local capacity for CL/P and surgical care, consisting of infrastructure
investments, education efforts and mission-based support. Operation Smile operates multiple permanent
care centres in low- and middle-income countries (LMICs). These facilities are staffed by local volunteers,
as well as full-time personnel and medical providers, and deliver care that is directly aligned with local
needs. The goal of these centres is to serve as a dedicated space for patients and families to receive reliable
medical services, support and information related to CL/P care. Centre staff provide feeding and nutritional
support; dispel myths related to CL/P aetiology; connect patients with medical services; and help
coordinate CL/P surgical care. Several of these institutions were built as Comprehensive Care Centers,
which mirror the multidisciplinary approach employed in most high-income countries such as the U.S. or
U.K.19 Within these centres, patients can access services which address the multifaceted health needs
associated with CL/P, such as speech therapy, dental care and psychological counselling.
While the infrastructure of the permanent care centres represents a substantial component of Operation
Smile’s strategy to build local capacity, the indirect impact of the organization’s education and missionbased efforts have also had a significant impact. While directly providing surgical care to over 220,000
children with CL/P, Operation Smile has cultivated a powerful network of local partners and providers.
Today, nearly three-quarters of the all surgical and medical services sponsored by Operation Smile are
provided by local clinicians. This has occurred through substantial investments in education, regionallyhoused surgical equipment, and reliable donations of consumable supplies.20 As a whole, the organization’s
education and mission-based efforts have served the dual purpose of ensuring access to CL/P care and
building local capacity to respond to the growing global burden of surgical disease.
Operation Smile has learned many valuable lessons about care delivery in low-resource settings since its
inception in the early 1980s.21,22 First, organizations must listen to patients and acknowledge the complex
environments in which the poor live. Investment in local capacity must be congruent with the needs, culture
and context of the local population.23 Second, organizations must strive to deliver services that reduce
barriers and allow even the most marginalized to reach needed care. A combination approach of
Comprehensive Care Centers, mission-based diagnostic and surgical camps have worked well to equitably
increase access to a broad population. Third, coordinating efforts with local governmental structures is
important to minimize service duplication, optimize use of existing resources and avoid detracting from
other important health services. Further work is necessary to optimize local infrastructure development and
surgical system strengthening, recognizing that the patient voice and community perspective are central to
the conversation.
2.1.9 Pacific Islands Program: Coordinated volunteerism supported by The Royal Australasian
College of Surgeons
Contributing Author: David Watters
Along with hospitals and Ministries of Health, the Pacific Islands Program (PIP) works to coordinate with
medical volunteers to provide care in 10 medical and 9 surgical specialties in the following countries:
Micronesia, Fiji, Kiribati, Cook Islands, Marshall Islands, Tuvalu, Tonga, Vanuatu, Solomon Islands,
Samoa, and Nauru. Volunteer teams work towards durable commitments through provision of educational
courses, workshops, and conferences for local teams. Financial support, travel, and accommodations for
local staff are often provided when there are no local options for courses.
Since 1995, PIP has facilitated the volunteer provision of over 19,000 surgeries and 74,000 consults on
non-surgical cases. In 2014 alone, 188 volunteers performed 1,415 operations, 5,385 consultations, and 32
25
deliveries. Three hundred staff members participated in the trainings and educational offerings. The
program was delivered at a cost to Australian Aid of AUD$ 7.2m, ranging from $1.37m in 2011 to $2.2m
in 2014 (Currently 1AUD = 0.85USD though over the four years the currencies would have averaged out
on parity). During this period 17 candidates completed their MMed (4 years of Surgical Specialty Training)
as did 13 in anaesthesia (4 years specialty training).
Data for the first fifteen years of the program is discussed in a 2012 paper by Watters et al.in the ANZ
Journal of Surgery.24 Data from 2011-2014 is shown in the table below.
Learn more: http://www.surgeons.org/for-the-public/racs-global-health/pacific-island-countries/
Table 1. Summary Statistics, Pacific Islands Program 2011-2014. Source: Royal Australasian College
of Surgery
YEAR
CLINICAL VISITS
NO. VISITS
CONSULTATIONS
OPERATIONS
VOLUNTEERS
WEEKS
2011
37
3777
1099
237
48
TRAINING
OPPORTUNITIES
NO.
ATTE
DELIVERED
NDEE
S
29
501
2012
43
4332
1178
205
50.5
32
455
2013
45
4862
1179
256
54
40
632
2014
43
5385
1415
188
58
32
300
26
2.1.10 Minimum Operating Theatre Standards
Contributing Authors: Brigitte Frett and Sam Enumah
Several organizations have listed infrastructure, equipment, supply and medicine requirements for surgical
functionality. The Commission used panel discussions to identify all known minimum operating theatre
standards (MOTS) around the world. The scope of this review was to focus specifically on the minimum
items needed to provide regular access to non-specialty surgical care within a country and therefore
excluded documents that focused on specialty services and short-term specialty visiting teams. Any MOTS
utilized for groups treating specific populations (e.g. civilian war casualties) were included if the
documents discussed the supplies needed to treat essential surgical conditions. Many of these are in the
published literature, several are internal lists.
Source Lists for Suggested Surgical Infrastructure Requirements
1. Paediatric emergency and essential surgical care in Zambian Hospitals 25
2. Anaesthesia services in developing countries: defining the problems 26
3. International Standards for a Safe Practice of Anaesthesia 2010 (Small Health Center, district or
provincial hospital, referral hospital) 27
4. GIEESC IMEESC Toolkit (Small Hospital/Health Centre, District Hospital, Referral Hospital
(http://www.who.int/surgery/publications/imeesc/en/)
5. Doctors Without Borders (MSF) Standards and Protocols
6. Disease Control Priorities for Developing Countries, 2nd Ed. Chapter 67: Surgery (Community
clinic, 100 Bed Hospital, tertiary hospital) 28
7. Harvard Humanitarian Initiative Survey (http://hhi.harvard.edu/publications)
8. Surgeons Over Seas (SOS) PediPIPES (http://www.adamkushnermd.com/files/PediPIPES.pdf)
9. SOS PIPES (http://www.adamkushnermd.com/files/PIPES_tool_103111.pdf)
10. WHO Guidelines for Essential Trauma Care: Basic (Health Outposts, Clinics, General practitioner
hospitals, specialty hospitals, tertiary hospitals) 29
11. WHO Guidelines for Safe Surgery: Local Health Center, District Hospital, Tertiary Hospital 30
12. WHO Surgical Care at the District Hospital Chapter 15 31
13. WHO Service Availability and Readiness Assessment
(http://www.who.int/healthinfo/systems/sara_introduction/en/)
14. WHO Situational Analysis Tool
(http://www.who.int/surgery/publications/QuickSitAnalysisEESCsurvey.pdf)
27
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29
Appendix 2.2: Situational Analysis Tool
KATHLEEN O’NEILL, KIMBERLY M. DANIELS, SARAH GREENBERG AND NAKUL RAYKAR
BACKGROUND:
The World Health Organization’s Emergency and Essential Surgical Care Situational Analysis Tool (SAT)
database is the largest multi-country dataset of surgical infrastructure and workforce. It represents a
convenience sample of self and researcher-reported facility surveys from participating nations and
organizations. At the first meeting of the Lancet Commission on Global Surgery, a working group of
experts theorized that performance of caesarean section, laparotomy and open fracture repair (the
Bellwether Procedures) at the facility level would indicate the presence of systems, resources, and skill sets
needed to treat a broad range of additional essential and emergent surgical conditions. The SAT database
was used to (1) assess the utility of these core indicator procedures to predict the performance of a wide
range of other surgical services and (2) gain insight into the infrastructure of reporting facilities that offer
surgical services.
METHODS:
We performed a retrospective analysis of facility-level survey data of the WHO SAT database. The SAT
itself has a total of 256 unique data points within the categories of facility demographics, infrastructure,
human resources, equipment and supplies, and procedure performance. At the time of our analysis in April
2014, the WHO SAT database contained information from 1357 unique facilities in 54 different countries.
Since inception of the SAT in 2007, there has been one revision of the survey. Our analysis included data
from both the initial survey (968 facilities), as well as the revised survey (389 facilities). When analysis is
restricted solely to hospital level facilities, there were 1009 facilities in 52 countries. We made several
small changes, described below, to the categorization and presentation of data from the second version so
that it could be analyzed in concert with data from the first version.
There were slight variations between the two survey versions. The first version used ranges to estimate the
number of operating rooms (ORs), admissions, beds, average distance travelled and the estimated
population served. In the second version, these data points were collected as exact numbers. For our
analysis, the middle point of each range from the first survey was used for ease of comparison and
computation using both datasets. In addition, there were minor changes to the ways in which facilities were
classified between the two survey versions. In the second version, the category “District/Rural/Community
Hospital” was split into “Subdistrict/Community Hospital” and “District/Rural Hospital.” For our analysis,
these two categories were re-combined to match the first survey version.
Statistical Analysis Software (SAS) version 9.3 and Stata 12 were used to calculate conditional
probabilities with confidence intervals to determine the strength of relationships between performance of
the bellwether procedures (both as a group of three as well as individually) and performance of each of the
other surgical procedures included in the SAT. Procedures included within the SAT are what we define as
“essential and emergent surgical procedures.” The p-values were calculated for the hypothesis that the
conditional frequency will not be random (>50%). In addition, we used the same method to analyse other
data points gathered in the WHO SAT including infrastructure availability as well as the estimated
distances that patients travel to get to each facility.
30
RESULTS:
Table 1. Demographics of all facilities in the database
FACILITY INFORMATION
COUNTRY INCOME GROUPING*
LIC
LMIC
UMIC
HIC
Total – N (%)
155
87
52
396
93
10
793 (58)
7
5
5
3
4
0
24 (2)
50
4
0
1
0
0
55 (4)
316 (23)
549 (40)
86 (6)
133 (10)
241 (18)
32 (2)
1357
Type of facility
Health centre
District/Rural/Community Hospital
Provincial Hospital
General/Teaching Hospital
Private/NGO/Mission Hospital
No response
Total – N (%)
104
142
29
44
144
22
485 (36)
31
Table 2. Proportion of Hospitals with a Blood Bank
Income Status
Surveys
% Blood Bank
626
# Hospitals Reporting Blood
Bank
175
LIC
LMIC
361
97
26.87
27.96
Median Distance to a Facility that
Provides These Procedures
100
Kilometers
90
80
70
60
50
40
30
20
10
0
C-section
Laparotomy
Open Fracture
Figure 1. Distance to facilities that offer the Bellwether procedures. Horizontal line indicates median,
box indicates interquartile range.
32
0
Acute burn management
Amputation
Appendectomy
Biopsy
Cataract surgery
Chest tube insertion
Cleft lip
Closed treatment of fracture
Clubfoot repair
Contracture release/Skin Grafting
Cricothyroidotomy/Tracheostomy
Cystostomy
Dilatation and Curettage
Drainage of osteomyelitis/septic…
General anesthesia
Hernia
Hydrocele
Incision & drainage of abscess
Joint dislocation treatment
Ketamine IV anesthesia
Male circumcision
Neonatal surgery
Obstetric fistula
Regional anesthesia
Removal of foreign body
Resuscitation
Spinal anesthesia
Suturing for wounds
Tubal ligation/Vasectomy
Urethral stricture dilatation
Wound debridement
Conditional Frequency
100
90
80
70
60
50
40
30
20
10
Figure 2. Frequency of performance of essential and emergent surgical procedures at facilities that
perform the three Bellwether procedures.
33
Median Distance (km) to a Hospital
in Each Income Level
70
60
50
40
30
20
10
0
Low
Middle
High
Figure 3. Distance to a hospital. Median and Interquartile Range of the distance to a hospital per the
WHO Situational Analysis Tool database. Distance range for each income level: Low: 0 to 5000, Middle: 0
to 760, and High: 10 to 20.
Physical Infrastructure
(% Hospitals Reporting Absence)
60
50
40
30
20
10
0
Figure 4. Proportion of hospitals reporting the absence of physical infrastructure
34
Equipment
(% Hospitals Reporting Absence)
120
100
80
60
40
20
0
HB/Urine Test
Autoclave
Oxygen
Concentrator
Anesthesia
Machine
Figure 5. Proportion of Hospitals Reporting an Absence of Equipment
Pulse
Oxymeter
Supplies
(% Hospitals Reporting Absence)
80
70
60
50
40
30
20
10
0
Adult ETT
Sterile Gloves
Exam Gloves
Figure 6. Proportion of Hospitals Reporting an Absence of Supplies
Eye Protection
35
Appendix 2.3: Infrastructure Literature Review
PENELOPE MILSOM, SWAGOTO MUKHOPADHYAY, FREDERICK FEDERSPIEL, SARAH LM
GREENBERG, AND NAKUL RAYKAR
BACKGROUND
The provision of surgical care requires basic infrastructural, equipment, and supply needs. Several survey
methodologies have been developed to assess surgical infrastructure in LMICs. We perform a systematic
review of the published literature on this topic.
METHODS
Search Strategy
We searched Pubmed, Embase, Cochrane, WHOLIS, and five regional databases (AIM, LILAC, IMEMR,
IMSEAR and WPRIM) for studies published with data collected after 1999 that described existing
comprehensive surgical care delivery in LMICs and the necessary equipment and supplies to safely and
effectively provide these services.
The PubMed search string included a search for titles and abstracts including any of the existing published
standardized surgical infrastructure assessment tools including the Tool for Situational Analysis to Access
to Emergency and Essential Surgical Care, the Service Availability and Readiness Assessment, the
Personnel, Infrastructure, Procedures, Equipment and Supplies assessment and the Harvard Humanitarian
Initiative tool. It also included 9 MeSH terms for variations on surgery, anaesthesia and caesarean section,
and 7 MeSH terms for variations on health services, equipment and supplies and 142 MeSH terms for
developing countries, including all 139 low, low-middle and high-middle income countries as classified by
the World Bank. This search string was adapted for use in all other data bases searched.
Across all nine databases our search yielded a total of 4293 publications after removal of duplicates. All
articles and citations were downloaded to Endnote (Version X4) for initial screening and sorting.
Additional to the database review, the WHO Emergency and Essential Surgical Care list of research
publications by topic was searched yielding an additional 6 non-duplicate articles. The WHO health
statistic and information systems Service Availability And Readiness Assessment tool webpage was also
searched yielding an additional 6 relevant, non-duplicate publications. References of included publications
were also assessed for relevant articles and resulted in a further 12 articles being included.
In total 4319 publications were included in the initial screening phase. Articles were screened based on the
inclusion and exclusion criteria outlined below.
Inclusion criteria:
• English language
• Studies reporting data collected after 1999
• Surveys that specifically report on quantitative data that describes provision of comprehensive
surgical services and availability of equipment and supplies essential to comprehensive surgical
care delivery in LMICs
• Surveys expressing comprehensive surgical care delivery and/or availability of equipment and
supplies essential for comprehensive surgery as a percentage or fraction of all hospitals surveyed
or reporting data that can be converted to such
• Surveys that disaggregate data by facility type and report data on hospitals (of any level)
36
• Surveys of as few as one hospital were included
Exclusion criteria:
• Surveys reporting on ophthalmological services
• Surveys only reporting population or national level data
• Surveys reporting only on non-hospital facilities including health centres, primary health care
centres/ facilities not deemed suitable for the safe and effective provision of comprehensive
surgical and anaesthetic care
• Surveys that aggregate all healthcare facilities types during analysis
• Surveys inclusive of facility level infrastructure data in LMICs but focused on readiness for
medical health care delivery with no mention of surgical or anaesthetic services available within
the facilities surveyed (e.g. management of sepsis)
• Surveys primarily reporting on comprehensive EmoC without discussion of other surgical service
availability
• Studies providing only descriptive information on surgical and anaesthesia infrastructure
Screening and data extraction
Initial screening involved a systematic review of all publication titles by two independent reviewers based
on the discussed inclusion and exclusion criteria. When article titles were ambiguous, reviewers examined
the abstract to ascertain their suitability for inclusion. For those articles considered relevant by both
reviewers after the initial screen, the full texts were retrieved for a complete review and potential data
extraction. For those articles on which the reviewers initially disagreed, the decision to include the article
was made after three reviewers read the abstract and a consensus reached. A total of 184 publications were
selected for retrieval in full-text and examined by a single reviewer before the final decision to include the
articles was made. After full-text reviews were completed a total of 46 articles were ultimately selected for
inclusion. Data was extracted from each article by three trained coders using a standardized Excel
spreadsheet containing variables on the country surveyed, hospital type and number, the surgical
infrastructure tool used, provision of 3 essential comprehensive surgical procedures, basic hospital
infrastructure, surgical equipment and supplies, anaesthetic equipment and supplies, blood bank services
and ICU services. Where the original article did not present results as a percentage value, this was
calculated for each variable using the number of responding hospitals as the denominator. When possible,
data was presented both disaggregated by hospital type and as a calculated weighted average.
Table 1. Screening process
Total identified
PubMed
Embase
Regional*
WHOLIS
Cochrane Library
WHO Emergency and Essential Surgery
publication list
WHO Health Statistic & Information
website
References
Number of records
retrieved in full text
Number of records
included after
reading full text
3234
534
99
16
429
14
Number of unique
records identified
and screened
(title/abstract)
3234
531
99
0
429
6
157
1
0
0
0
6
32
0
0
0
0
4
8
8
8
6
14
Total
4348
12
Total
4319
12
Total
184
4
Total
46
37
Variable definitions
Essential Surgery
To date no consensus has been reached on a single definition of essential surgery. For the purposes of this
review we selected three acute, emergent surgical procedures to indicate the current state of essential,
comprehensive surgical service provision at a facility level. These include laparotomy, treatment of an open
fracture and caesarean section. These procedures were specifically selected by the Lancet Commission
researchers based on the rationale that if a facility can provide these services, it is a reasonable assumption
that they either do perform or at least have the capacity to perform most other general surgical, orthopaedic
and obstetric procedures.
Health care facilities
A consensus was reached amongst the researchers that district hospitals were considered the lowest level
facility capable of safely providing comprehensive surgical services. Therefore this literature review
reports data only on district hospitals and above. Level of facility was disaggregated using the WHO
definitions as described below.
WHO definitions of District Hospitals, Regional Hospitals, and Referral-level hospitals were used
(http://www.who.int/management/facility/ReferralDefinitions.pdf)
District hospital: hospitals with few specialties usually including obstetrics and general surgery. Receives
referrals from primary health care centres. Functionally similar to rural and community hospitals.
Regional hospitals: hospitals with a greater differentiation by function and 5-10 specialty services
provided. Functionally similar to provincial, and general hospitals.
Referral-level hospitals: hospitals with highly specialized staff and equipment and highly differentiated by
function. Functionally similar to national, central and academic, teaching or university hospitals.
Basic surgical and anaesthetic infrastructure, equipment and supplies
Selection of relevant variables for data extraction was based on a review of the existing published
standardized survey tools available for assessing surgical capacity. These include the WHO Tool for
Situational Analysis to Assess Emergency and Essential Surgical Care, the Surgeons OverSeas Personnel,
Infrastructure, Procedures, Equipment and Supplies tool, the WHO Service Availability and Readiness
Assessment tool, the Harvard Health Initiative Burden of Surgical Care Survey. Attempts were made to
develop common variables that would capture as much of the heterogeneous data as possible from across
all the mentioned survey tools. See appendix 2 for a complete list of the variable definitions.
38
SELECTED RESULTS
Table 2. Percentage of hospitals providing comprehensive surgery
39
Table 2A. Percentage of hospitals with basic infrastructure for surgery
40
Table 2B. Percentage of hospitals with basic infrastructure for surgery
41
Table 3A. Percentage of Hospitals with safe anaesthetic equipment and supplies
Laryngoscope*
Country
Author
Tool used★
Number of hospitals∞
by hospital type (%) ∞
total (%)
WHO Trauma
16(PM), 9(D), 2(RF)
Botswana
Hanche-Olsen, 2012
94(PM), 100(D), 100(RF)
96
Nigeria
Adudu, 2012
unique
30(NS)
x
100
Zambia
MoH, 2010
SARA
28(D), 8(RG), 3(RF)
65(D), 88(RG), 67(RF)
70
Somalia
Elkheir, 2014
WHO
5(PR), 5(P), 3(RG)
x
21
LMIC countries with data
LMIC without hospital level data
4
135
* largynoscope reported as being available in the hospitals
∞ D= district, RG= regional, RF= referral, P=private, PR= provincial, PM= primary hospital,
NGO= non-government organization, NS= non-specified
weighted average
 type of systematic tool used to assess surgical and anaesthetic infrastructure, WHO= Tool for Situational Analysis to Assess
Emergency and Essential Surgical Care (WHO), PIPES= Surgeons Pesonnel, Infrastructure, Procedures, Equipment and Supplies (Surgeons OverSeas),
SARA=Service Availability and Readiness Assessment (WHO), HHI= Burden of Surgical Care Survey (HHI),
WHO Trauma= survey developed from WHO Guidelines for Essential Trauama Care, Unique= unique survey developed specifically for the given study
42
Table 3B. Percentage of hospitals with safe anaesthetic equipment
Pulse oximeter*
Country
Author
Tool used★
Number of hospitals∞
by hospital type (%) ∞
total (%)
Bangladesh
LeBrun, 2014
HHI
7(D)
x
71
Bolivia
LeBrun, 2014
HHI
11(D)
x
100
Botswana
Hanche-Olsen, 2012
WHO Trauma
16(PM), 9(D), 2(RF)
x
85
HHI
6(D)
x
50
Ethiopia
LeBrun, 2014
Liberia
LeBrun, 2014
HHI
11(D)
x
64
Nicaragua
LeBrun, 2014
HHI
10(D)
x
100
Nigeria
Adudu, 2012
Unique
30(NS)
x
100
PIPES
24 (D), 16(RG)
69(D), 90(RG)
77
Henry, 2012
Nigeria
Rwanda
LeBrun, 2014
HHI
21(D)
x
57
Rwanda
Notrica, 2011
Unique
21(D)
x
57
Unique
4(D), 3(RG), 2(RF)
57(D, RG), 100(RF)
43
WHO
48(US)
x
17
Tanzania
Baker, 2013
Tanzania
Peyonr, 2012
Uganda
LeBrun, 2014
HHI
12(D)
x
0
Zambia
Bowman, 2013
WHO
79(D), 20(RG), 4(RF)
x
54
Zambia
Jochberger, 2008
Unique
24(NS)
x
40
LMIC countries with data
LMIC without hospital level data
11
128
*Pulse oximeter reported as being available in the hospital
∞ D= district, RG= regional, RF= referral, P=private, PR= provincial, PM= primary hospital,
NGO= non-government organization, NS= non-specified
weighted average
type of systematic tool used to assess surgical and anaesthetic infrastructure, WHO= Tool for Situational Analysis to Assess
Emergency and Essential Surgical Care (WHO), PIPES= Surgeons Pesonnel, Infrastructure, Procedures, Equipment and Supplies (Surgeons OverSeas),
SARA=Service Availability and Readiness Assessment (WHO), HHI= Burden of Surgical Care Survey (HHI),
WHO Trauma= survey developed from WHO Guidelines for Essential Trauama Care, Unique= unique survey developed specifically for the given study
43
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46
Appendix 2.4: The How Project
NAKUL RAYKAR, RACHEL YORLETS, CHARLES LIU, ALIREZA SHIRAZIAN, DIMPLE
MIRCHANDANI, SARAH GREENBERG, MEERA KOTAGAL, NOBHOJIT ROY, JOHN MEARA,
ROWAN GILLIES
BACKGROUND:
The challenges in safe access to surgical and anaesthetic care worldwide are varied, differing across the
context of local customs, environments, and resources. In initial conversations with surgeons from around
the globe, the Commission repeatedly heard from frontline providers that their voice was not reflected in
the published academic literature. The How Project was an attempt to elicit opinions, input, and
involvement in the Commission process from healthcare workers, a powerful mechanism to provide a
‘reality check’ for the Commission. It provided a window into what clinicians and administrators see every
day but do not write about.
METHODS
A semi-structured interview was designed in order to collect qualitative data from different types of
providers in urban and rural facilities in low- and middle-income countries. An implementation manual
was created to standardize the interview process, and interviewers were trained to ensure consistency in
asking questions and recording data. Interviewers were recruited through contacts of the Lancet
Commission on Global Surgery, and initial interviewees were identified through additional local contacts.
Stratified purposive sampling and reputational case selection were used to identify the full set of contacts
for interviews between urban and rural zones; data collection continued until saturation was reached in each
country’s data.
A coding manual was created to identify the major themes and sub-themes that arose from the interviews,
and they were stratified by those involving access to safe, timely surgery and anaesthesia, in-hospital
delivery of care, and policy and governance surrounding healthcare. The qualitative data was analysed
using the coding manual, and this facilitated the summary of country-specific data, as well as the results
from the overall project.
Over 137 interviews were conducted in 19 countries: Argentina (5), Botswana (3), Brazil (10), China (14),
Colombia (4), Ecuador (6), Ethiopia (10), India (15), Indonesia (1), Mexico (9), Mongolia (4), Namibia (2),
Pakistan (11), Peru (5), Philippines (1), Sierra Leone (11), Thailand (2), Uganda (9), and Zimbabwe (15).
RESULTS
Tables 1-3 highlight prominent themes and workarounds in the areas of access, hospital and policy
challenges.
47
Table 1. Access Challenges
Access
Challenge
Patient financial constraints
Geographic restrictions
Patient education and delayed
presentation
Workarounds
•
Refer to public hospitals
•
Limit length of stay
•
Use less expensive materials and reduce unnecessary tests
•
Satellite clinics or community health workers for follow-up
•
Provide accommodations for family and pregnant women
•
Educate patients in their own language
•
Seminars and awareness campaigns
Table 2. Hospital Challenges
Hospital
Challenge
Insufficient infrastructure
Limited resources
Insufficient capacity
Workarounds
•
Transfer
•
Torches, carry-on lights, and bucketed water
•
Improvise
•
Borrow
•
Re-sterilize single-use materials
•
Black market
•
Transfer
•
Work overtime
Table 3. Policy and Governance Challenges
Policy and Governance
Challenge
Lack of context-specificity
Training programs
Lack of provider incentives
Workarounds
•
Protocols that require unavailable supplies
•
No relevant standardized practices
•
Priorities do not align with distribution of burden
•
Programs are few, and of poor quality
•
Limited continuing education
•
Low pay and long hours without support staff
•
Bans on recruitment
•
Medical malpractice
48
Appendix 2.5: Provider Surveys Summary
RACHEL YORLETS, SARAH GREENBERG, NAKUL RAYKAR, AND IAIN WILSON
BACKGROUND
In addition to the How Project, which used interview-based methodology to examine the challenges
inherent to the delivery of surgical and anaesthetic care and their workarounds, the Lancet Commission on
Global Surgery conducted an online Provider Survey. We asked frontline providers working in or with
experience working in low-resource areas their thoughts, opinions, and inputs on the state of surgical care
delivery, key obstacles, metrics to track progress, and strategies for improvement.
METHODS
This questionnaire was designed in REDCap, and offered to all levels of providers in all countries, and
specifically asked about time spent practicing in low- and middle-income countries. It was translated, and
offered in the 6 WHO languages: Arabic, Chinese, English, French, Russian, and Spanish. It was widely
distributed through a number of channels. Results were then compiled at the beginning of September 2014,
and the quantitative and qualitative data were analyzed. No identifiable data were collected or presented.
The purpose of this questionnaire was to learn about perceptions, celebrate the current workarounds that
providers use, while highlighting areas of need, and engaging a wider audience in the overall process of the
Commission.
RESULTS
Demographics of Participants
The first questions asked participants whether or not they worked in an LMIC for the majority of the time,
and in which country they worked. For those who did not spend most of their time working in LMICs, the
majority of them (68%) said that they had spent less than 6 months working in an LMIC during the
previous two years. From this data, we identified that 133 participants were from high-income countries,
and were discussing their time working as part of a visiting team. A total of 666 providers from 72
different countries responded to the questionnaire.
Most (79%) providers said that they worked in a healthcare facility in an urban area, while few (17%) said
that they work in a rural area. Most commonly, respondents said that they work in a teaching or tertiary
hospital (46%) or a private facility (24%). Most respondents (79%) were doctors, and almost half of all
respondents (49%) said that their specialty was surgery, while about a third (30%) said they specialized in
anaesthesia.
49
Perceptions of surgery and anaesthesia within country of practice.
When asked if at least 90% of people in their country have access to safe, high-quality, affordable surgery
and anaesthesia when needed, most (85%) said no, while few said yes (10%) or that they did not know
(5%). These answers align with those received when we asked providers to describe their Ministry of
Health’s focus on access to surgical services: the majority said that it was either a moderate (27%) or low
(37%) priority, while some (16%) said it was not a priority at all. When asked to describe the practice of
surgery and anaesthesia in at least 90% of hospitals in their country, both were considered by respondents
to be mostly safe:
Very safe
Mostly safe
Mostly not safe
Very unsafe
I do not know
Surgery
4%
56%
26%
2%
12%
Anesthesia
8%
50%
27%
6%
9%
Table 1. Perceptions of surgery and anaesthesia
Role of outside resources
Participants were asked what role non-governmental organizations, industry, and the private sector should
have in helping to deliver surgical services.
Table 2. Role of outside resources
Improving
accessibility
Addressing inhospital challenges
NGOs
•
•
•
•
•
Policy &
governance reform
•
•
•
Provide ambulances
Advocacy campaigns
Provide skilled workforce
and new facilities
Create low-cost
alternatives
Help promote selfsufficiency
Create quality and safety
standards
Facilitate education
Define priorities and
pathways for
implementation
Industry
•
Provide educational
literature
•
Improve roads
•
Sponsor patients for
procedures
•
Provide high-quality
equipment and
maintenance
•
Reduce costs and increase
production and distribution
•
Increase capacity
•
Support conferences
•
Identify opportunities for
efficiency, quality control
•
Avoid giving money
•
Corporate responsibility
Private Sector
•
Advocacy campaigns
•
Waive or reduce costs of
care
•
Provide ambulances and
roads
•
Provide trained
workforce
•
Reduce waiting lists
•
Create an “ideal”
environment for safe
surgery and anesthesia
•
Partner with medical
schools to facilitate
training
•
Provide expertise
•
Build and maintain highquality facilities
50
Appendix 2.6: Blood
An estimation of Optimal Blood Donation Rate and a Review of the Blood Supply Literature
KATHERINE KRALIEVITS, NAKUL RAYKAR, MARK SHRIME, NOBHOJIT ROY, ROWAN
GILLIES, JOHN MEARA
Background:
Blood is an essential need for surgery; a safe and adequate blood supply is an essential need for a surgical
system. Massive disparity exists in the safety and adequacy of the global blood supply. The WHO
recommends at least 10 units/1000 population as a population donation rate. We undertook a literature
review to assess the current state of blood donation, banking and safety worldwide, and performed a
regression analysis to find an optimum target blood donation rate.
Methods:
Optimum Blood Donation Rate Methods: Life expectancy data was obtained from the World Bank global
indicator database (http://data.worldbank.org/indicator). Data on blood donation rates per country was
obtained from the World Health Organization from Global Database on Blood Safety
(http://www.who.int/bloodsafety/global_database/en/). Missing values per country were imputed based on
a linear regression of blood donation rate against gross domestic product. Blood donation rate was then
log-transformed and a linear regression was fitted of the form LE = ln(donation rate) + e. The resultant fit
had an R2 value of 0.602.
Literature Review Methods: A review of the literature was conducted using electronic databases, including
PubMed, MEDLINE and Google Scholar. Search terms used were “blood donor”, “blood donation”,
“blood safety”, “blood bank”, “transfusion safety”, “blood services”. Advanced search options were used
to streamline results for the low-resource setting or LMICs. Additionally, World Health Organization
reports, country-specific Ministry of Health websites and national blood services websites were searched.
Specifically, data targeted on these websites were indicators for comparing the blood supply across
countries: donation rate, % voluntary non-remunerated donors, number of blood banks/centres, and national
blood policies. Both quantitative and descriptive data was used for inclusion in the summary table.
Results:
Figure 1 presents the regression output. Figures 2 and 3 highlight the disparity in blood donation rates from
around the country from existing data.Table 1 presents the results of the literature review.
51
Figure 1. Optimal Donation Rate
Life expectancy fitted to a linear regression against blood donation rate. There is not a single ‘optimal
blood donation rate, though a rate of 15 donations/1000 people/year correlates with diminishing returns on
life expectancy.
Figure 2. Blood Donation Rates per World Bank Income group
Range of annual blood donation rates/1000 population in low, middle and high-income countries. Yellow
line denotes average for that income group. Source: World Health Organization
52
Figure 3. Map of worldwide blood donation rates
Sub-Saharan Africa, in particular, has critically low donation rates. Source: World Health Organization
53
Table 1. Review of Global Blood Supply and Safety
BDR
per
1000
%
VNRBD
No.
Blood
Banks
National
Policy
Country
Income
Group
Afghanistan
Low
Income
30550000
0.8
5
8
Yes
Benin
Low
Income
10050702
6.6
92.1
2
Yes
Burkina Faso
Low
Income
16460141
3.7
100
4
Yes
Population
Notes
243 facilities total (27 public, 105 private);
63% in urban cities (24% in Kabul); private
facilities less likely to have adequate supplies
(GF Mansoor et al. 2013)
33.5% of donors harbored trophozoites and
were capable of transmitting malaria via blood
donation (Kinde-Gazard et al. 2014)
The National Blood Transfusion Centre of
Burkina Faso (CNTS) established centralized
system with four regional blood transfusion
centres; however, 40% of the blood was
collected in other institutions, mostly hospitals
relying on family⁄replacement donors
(Dahourou et al. 2010).
24.0% of donors infected with at least one
TTI; NAT might significantly improve the
situation. (Nagalo et al. 2012)
Burundi
Cambodia
Low
Income
Low
Income
9849569
14864646
4.4
3.1
99.9
80.4
7
23
Central African
Republic
Low
Income
4525209
2.5
68
2
Chad
Low
Income
12448175
2.7
4.7
43
Yes
Yes
Comoros
Low
Income
717503
3.7
15.7
5
Yes
Congo, Dem. Rep
Low
Income
65705093
4.7
35.5
577
Yes
Eritrea
Low
Income
6130922
2.8
88.4
1
Yes
91728849
0.6
23.5
14
Yes
1791225
7.2
24.1
7
Yes
11451273
2.4
14.7
19
1663558
2.7
19.9
7
Ethiopia
Gambia, The
Guinea
Guinea-Bisau
Low
Income
Low
Income
Low
Income
Low
Income
No
KAP: blood is one’s “power” and when
someone donates, he or she loses power and
gives it to someone else; in Cambodia, more
than 80% of the blood is donated by
foreigners. (Keating et al. 2012)
9% of blood supply infected with TTIs
(Cambodia MOH)
WHO supports the establishment of a
centralized national transfusion service;
donates test kits, blood bags, and consumables
(WHO 2014)
There is a national infection control policy for
blood banks. All donated blood units
(including family donations) and blood
products nationwide are screened for hepatitis
B, but not for hepatitis C (Global Policy
Report On The Prevention And Control Of
Viral Hepatitis)
4.7% of the donors positive for HIV, 5.4% for
HBV and 3.7% for syphilis; lower in VNRBD
(A Batina et al. 2007)
Over all prevalence of TTI's is 3.8% 3.5% in
voluntary blood donors and 5.1% in family
replacement donors (Fessehaye et al. 2011)
Prevalence of HIV is 4·3% in blood donor
pool (Kassu et al. 2006).
Prevalence of hepatitis C is 1.1% and lower
than average in SSA (CI Mboto et al. 2005)
14.81% of blood discared due to TTIs; 2.2% of
donors infected with HIV (WHO GDBS 2012)
No
Haiti
Low
Income
10173775
0.7
85
31
Yes
The Haitian blood service, in conjunction with
the Haitian Red Cross, used mobile blood
drives to meet blood donors in secure parts of
the capital, Port-au-Prince (PEPFAR)
Kenya
Low
43178141
3.5
100
6
Yes
Blood donations from volunteer donors nearly
54
Income
Korea, Dem Rep.
Low
Income
24763188
Liberia
Low
Income
4190435
Madagascar
Low
Income
22293914
1.2
18.4
42
Yes
Malawi
Low
Income
15906483
5.5
57.3
38
Yes
Mali
Low
Income
14853572
3.1
30.4
7
Yes
Mozambique
Low
Income
25203395
4.7
61.2
149
Yes
Myanmar
Low
Income
52797319
1.1
359
Yes
Nepal
Low
Income
27474377
3.2
5.2
70
Yes
Niger
Low
Income
17157042
3.5
36.3
5
Rwanda
Low
Income
11457801
5
15
Yes
Yes
3.6
100
3
Yes
tripled in two years, from 43,000 units to
117,482 units. The NBTS now supplies 125
healthcare facilities with at least 80 percent of
their blood needs, up from only eight sites in
2004 (PEPFAR).
Very little information available; BTS is a
centrally coordinated and monitored blood
transfusion service under the Ministry of
Public Health (Choudbury 2011).
The national Blood Transfusion Service is not
well developed; capacity for transfusing,
storing and managing blood is limited. (WHO
2012)
Prevalence of HBV in blood supply 3.84%
(RZ Arivelo et al. 2011)
Mean Hb of transfused patients was 4·8 g/dl.
Fifty-seven percent of the transfusions were
given to children diagnosed with malaria, and
17% were given to pregnant women. During
the study period, blood was in stock and
available for transfusion within 1 h of
requisition (HF Bugge et al. 2013).
Rate of positive donations per blood unit
collected was 2.6% for HIV, 3.3% for HCV,
13.9% for HBV and 0.3% for syphilis (A
Diarra et al. 2009)
Prevalence of HIV, HBV and syphilis
infections was 8.5%, 10.6 % and 1.2% (J
Stokx et al. 2011)
National Blood Center at Yangon is the
technical hub for development of the BTS in
the country. Blood and blood product law was
enacted in 2003 for implementing regulatory
mechanism in the country. The Blood Policy is
in the stage of finalization and subsequent
implementation.
Voluntary blood donation in the country is
about 85%. National Blood Center coordinates
with Red Cross and other organizations for
voluntary blood donation. It distributes
components only in the capital Yangon and
more than 20,000 blood units are distributed
per year. As per the report of 2007, 100%
blood units are tested for HIV and syphilis
infections. However, only 85 and 65% blood
units are tested for HBsAg and anti HCV
antibody, respectively (Choudbury 2011).
There are about 70 blood centres in 50
districts; no blood banks in 25 districts. There
is one Central Blood Transfusion service in the
capital Kathmandu and four regional BTS
(Pokhra, Nepalganj, Biratnagar, Citwan).
There are 21 district blood transfusion
services; 19 emergency BTS and 25 hospitalbased blood transfusion services. The central
blood transfusion service at Kathmandu
collects more than 300 units per day and out of
which about 200-250 units are collected from
mobile blood collection units. National blood
policy was enacted in 2006 and national
guideline for BTS was published in 2008
(Choudbury 2011).
More than 75% of blood donors are less than
30 years of age; mean ages are 10 – 15 years
less than those observed in European countries
(Tagney et al. 2009).
55
Sierra Leone
Somalia
Low
Income
Low
Income
5978727
5.2
10195134
2.4
9.7
30
Yes
36
Yes
The Blood Service of Tajikistan is composed
of 1 Republican Research Blood Centre, 3
regional centres, 44 departments of blood
transfusion in medical establishments and 29
cabinets of transfusion therapy.
To ensure quality and safety, the decision was
made to centralize the collection of blood at
two regional blood centres and to re-organize
the departments of blood transfusion into
departments of clinical transfusiology and
transfusion therapy. The new organizational
structure will be upgraded with modern
technologies, to provide an increased quality
output.
Tajikistan
Low
Income
8008990
5
47
Yes
Tanzania
Low
Income
47783107
2.7
94.9
7
Yes
Togo
Low
Income
6642928
5.9
98.3
4
Yes
Uganda
Low
Income
36345860
6
100
7
Yes
Zimbabwe
Low
Income
13724317
5.1
100
8
Yes
Armenia
LowerMiddle
Income
2969081
4.2
4
Bhutan
LowerMiddle
Income
741822
10.8
46
Yes
27
Yes
In 2009, the government adopted the law on
donating blood and its components, and
approved a programme to develop blood
donation and improve the blood services for
the period 2010–2014. It also adopted a
programme for blood safety control and a
programme for the rational use of blood.
The number of donations did undergo
substantial decrease from 32/1000 population
in 1991, to 5/1000 in 2009. The quality of
work on recruitment, selection and retention of
safe donors needs to be urgently scaled up,
considering also the 5.04% discard rate of
collected blood due to infectious markers
(WHO EURO 2010).
Criteria for blood transfusion are not always
fulfilled; time to initiate and complete the
transfusion is often unacceptable long and
monitoring of vital signs during transfusion is
poor. Blood from the blood bank was often not
available and transfusion often depended on
local donors which implied lack of screening
for hepatitis B and C (D Mosha et al. 2009).
In 2003, 24% of the blood products were
rejected for positive viral markers against
8.37% in 2008 in relation with the
improvement of blood safety (AY Ségbéna et
al. 2009).
"Bottleneck": limited amount of blood makes
it from blood bank to hospital (I Kajja et al.
2010)
The Club 25 concept where teenagers 16 years
and above are encouraged to donate 25 times
in their life times, has increased voluntary
units of blood and forms a vital part of the
NBTS (Mvere, 2002).
In 2009, 12 560 units of blood were collected,
of which 54.6% from paid donors (US$ 30 is
paid per donation), 40.4% from family/
replacement donors and 5% from voluntary
non-remunerated donors (WHO EURO 2012).
All blood banks are hospital based and
managed by the Royal Bhutan Government.
There are two qualified and dedicated
transfusion medicine specialists in the country
and there are other trained doctors to run the
BTS. Because of geographical terrain, 50%
blood donation from relative donors,
56
inconsistent supplies of test reagents and
consumables and awareness on rational use of
blood/ components by clinicians and nurses
(Choudhury 2011).
Bolivia
Cameroon
LowerMiddle
Income
LowerMiddle
Income
10496285
7
35.1
19
Yes
21699631
2.7
10
15
No
No
Cabo Verde
LowerMiddle
Income
494401
5.6
77.3
2
Congo, Rep.
LowerMiddle
Income
4337051
10.1
35.5
23
Côte d'Ivoire
LowerMiddle
Income
19839750
4.5
100
14
Djibouti
LowerMiddle
Income
859652
3.1
20
1
Yes
Egypt, Arab Rep.
LowerMiddle
Income
80721874
8.8
63.6
100
Yes
El Salvador
LowerMiddle
Income
6297394
13.43
11.7
27
No
Georgia
LowerMiddle
Income
4490700
7.9
5
Ghana
LowerMiddle
Income
25366462
5.4
27.1
15082831
6.53
4.51
62
Yes
795369
10.1
80
6
Yes
7935846
7.8
17.38
22
Yes
Guatemala
Guyana
Honduras
LowerMiddle
Income
LowerMiddle
Income
LowerMiddle
2
Yes
Yes
Blood seen as something common to families
and kin and to possess inherited character and
physical traits
Absence of national blood transfusion policy;
deficit in number and training of blood bank
staff and in the number of facilities; deficient
supply of reagents to the laboratories;
inadequate application of asepsis and
sterilization rules in health centres (National
Strategic Plan Against AIDS)
The most frequent reason for donor deferral
was a low hemoglobin level (42.5%), with
females constituting the majority of those
deferred. The second most frequent reason for
deferral was a reported change of or new
sexual partner (34.3%); male donors were
predominant in this group (MD Kouao et al.
2012).
Blood transfusion system is based on family
donors (one tested unit of blood for every two
untested units donated); spontaneous donations
mainly from the police and army personnel
account for only 20% of the 2500 units
collected each year (O Erhabor et al. 2011).
Blood safety presents a serious challenge in
Egypt, having the highest recorded prevalence
of HCV antibodies in the world. Prevalence of
HCV was reported to be 20% among healthy
populations (D Omran et al. 2013).
No paid donors; majority replacement/family
(Cruz et al. 2003).
Blood transfusion system is privately managed
and there is government funding for blood
donation and tests. The main challenges are a
lack of modern quality assurance systems in
the blood service, frequent use of rapid tests
for blood borne pathogen identification, and
paid donation. In addition, there is a very high
prevalence (approximately 6%) of Hepatitis C
carriers (WHO EURO 2012).
In rural hospital, all donors were family or
replacement donors. Positivity rates for
infectious disease markers were 7.5% for
HBV, 6.1% for hepatitis C virus, 3.9% for
HIV, and 4.7% for syphilis; lack of
refrigeration and difficulties in sample
labeling, storage of blood and laboratory
supplies, and disposal of waste (Kubio et al.
2012)
1 in 286 donations tested positive for
antibodies to T cruzi (Bwititi et al. 2012)
57
Income
Indonesia
LowerMiddle
Income
246864191
8
82
312
Yes
211 blood banks under Indonesian Red Cross
(IRC) and another 150 hospital-based blood
banks under government control. Governmentcontrolled blood banks are gradually becoming
operational and IRC blood banks take care of
major part of the blood supply. IRC blood
banks collect more than 2 million units per
year and 87% donation comes from voluntary
source.
About 70% of total collection is separated into
components (Choudbury 2011).
Collecting blood is difficult during Ramadan.
Low haemoglobin levels and low body weight
in females contributes to the low proportion of
females in the donor population. Problems
include limited facilities and an inadequate
system to promote voluntary donation.
Financial resources are also limited and a
significant constraint to improving the overall
system (WHO Global Consulation 2009).
The India BTS is highly fragmented and there
are about 2750 blood banks in the country in
an unofficial estimate.
Nationally coordinated by the National AIDS
Control Organization (NACO) which is under
government of India.
India
Kiribati
Kosovo
Kyrgyzstan
LowerMiddle
Income
LowerMiddle
Income
LowerMiddle
Income
LowerMiddle
Income
1236686732
4
80
2545
Yes
100786
Yes
1807106
Yes
5607200
45
Yes
There are about 940 (39.4%) blood banks
managed by the central or provincial
governments; 376 (14.4%) blood banks are
voluntary in nature; 753 (28.8%) blood banks
are private, hospital-based blood banks and
540 (20.7%) blood banks are designated as
private charitable type.
About 35% blood units are separated into
components and all collected units are tested
for five transfusion-associated infections as on
record.
BTS in India is in fairly advanced stage which
is mainly concentrated in metros and major
cities. BTS at sub-urban and rural areas need
improvement. National blood policy was
adopted in 2003 and firm regulatory
mechanism is in place (Choudbury 2011).
All donated blood units (including family
donations) and blood products nationwide are
screened for hepatitis B and hepatitis C.
HBV prevalence among donors is 4.2%; HCV
prevalence is 0.3% (Fejza et al. 2009).
The blood services in Kyrgyzstan are under
the responsibility of the Ministry of Health.
There is one new large Republican Blood
Centre, 5 regional blood centres, and 39 local
clinical transfusion departments. There is also
one bus for blood drives.
In 2009, 4141 litres of blood (13.79 % of the
total amount of collected blood) were rejected
mainly due to positive tests for hepatitis B
(WHO EURO 2010).
Lao PDR
LowerMiddle
6645827
4.8
60
66
Yes
58
Income
Lesotho
Mauritania
Micronesia, Fed.
Sts.
Moldova
Mongolia
Morocco
Nicaragua
LowerMiddle
Income
LowerMiddle
Income
LowerMiddle
Income
LowerMiddle
Income
LowerMiddle
Income
LowerMiddle
Income
LowerMiddle
Income
2051545
2.1
93.8
1
Yes
70% of the blood is collected from blood
collecting campaigns in institutions all around
the country, whilst 25-30% is collected at the
LBTS. Replacement/family donors form about
5%. About 20% of donors are first time donors
interested in ascertaining their HIV status
(Lesotho BTS).
3796141
2.5
31.3
1
Yes
Mauritania discards 26.63% of blood supply
due to TTIs (WHO GDBS 2012).
2796484
22
16.7
2796484
7.3
621081
6
80
5991733
12.12
103395
Yes
Yes
High prevalence (9.6%) of HCV among
donors (Tserenpuntsag et al. 2010).
53
Yes
Four blood banks in University hospitals
closed down because of low collection
volume; solution = mobile clinics
100
3
Yes
Nigeria
LowerMiddle
Income
168833776
0.2
94.2
16
Yes
Pakistan
LowerMiddle
Income
179160111
3.3
0
620
Yes
7167010
3.8
34
Yes
6687361
10.53
57
Yes
96706764
5.4
Papua New Guinea
Paraguay
Philippines
Samoa
LowerMiddle
Income
LowerMiddle
Income
LowerMiddle
Income
LowerMiddle
Income
188889
5.71
Willingness to donate was positively
associated with being a male, single and
Christian; more willing for family/friends than
voluntarily (Sekoni et al. 2014)
The BTS is not nationally coordinated and
proper regulatory mechanism is not available.
As per unofficial sources, there are 450
hospital-based blood banks and 2357 private
blood banks. Many private blood banks
maintain questionable quality standard and
ethics. About 90% blood is collected from
family replacement donors and out of which
10% comes thorough ‘unsafe’ paid donors.
Disease burden among blood donor is high and
needs screening of all units with sensitive
tests. 20-40% blood collected is not even
screened for disease markers especially in nonregulated private sectors. There are 13 regional
blood centres and under which 78 hospitalbased blood banks are operating mainly in
public sector. Two policies are designed, one
at national and another in ground level. Proper
degree or diploma courses in transfusion
medicine for medical graduate and
technologists are the need of the hour
(Choudbury 2011).
The Blood Transfusion Service remains
fragmented and hospital-based, and the
network is very weak (WHO 2014)
Yes
Red Cross provides 15% all blood donors and
is advocating for a greater pool of voluntary
blood donations (VNRBD). The majority of
blood provided is from family replacement
donors. All blood donors are screened for
HIV, syphilis, HBV, and HCV (Global AIDS
Country Progress Report)
59
São Tomé and
Principe
LowerMiddle
Income
Senegal
LowerMiddle
Income
Solomon Islands
South Sudan
LowerMiddle
Income
LowerMiddle
Income
188098
13726021
5.4
4.5
53.4
79.4
1
18
Yes
Does not carry out ABO serum grouping of the
donations (WHO AFRO 2014).
No
Plasmodium represents the third most common
risk in Senegalese donors of blood-transmitted
infectious agents after HBV and syphilis, and
more common than HCV and HIV (S Diop et
al. 2009).
549598
10837527
77 hospital-based blood banks in public
sectors and 6 blood banks in private sector.
There is no stand-alone blood bank in NGO or
private sector. There are a total of 83 blood
banks across the country in 16 clusters. Sri
Lankan BTS is the sole supplier of blood and
components to all public sectors and majority
of private sector hospitals.
Sri Lanka
Sudan
Swaziland
LowerMiddle
Income
LowerMiddle
Income
LowerMiddle
Income
20328000
17.1
100
83
Yes
8.4
100
1
Yes
The BTS has established a system of
functional hospital transfusion committee in
all hospitals. It has also established
hemovigilance system and irradiation facility
in the center (Choudhury 2011)
Every month, on the day there is a full moon,
people are encouraged to give blood. Social
groups organize blood donation sessions on
this day on their own premises - often temples,
schools or universities – which results in 85%
of all donations in Sri Lanka being collected at
mobile sessions (WHO 2014).
37195349
1230985
In order to increase blood safety, WHO is
providing essential reagents, diagnostic kits
(rapid testing kits for Hep B and C, HIV), and
equipment. The WHO procured safety blood
kits for both the central blood bank and hardto-reach areas, including equipment for ELIZA
testing for the Hepatitis C Virus (HCV). The
current procured quantity will serve about
100,000 blood recipients (WHO 2014).
Syrian Arab
Republic
LowerMiddle
Income
22399254
Timor-Leste
LowerMiddle
Income
1148958
1.3
20
4
Yes
Ukraine
LowerMiddle
Income
45593300
16
9
520
Yes
Uzbekistan
LowerMiddle
Income
29774500
4
6
Yes
Blood transfusion network includes 3
institutes, 24 regional blood centers, and 493
hospital based centers, many of which are
currently being closed (WHO 2012).
The national structure includes five regional
blood centres and one national blood centre
reporting to the Ministry of Health
27 blood transfusion stations and 187 blood
transfusion departments in Uzbekistan
Vanuatu
Vietnam
LowerMiddle
Income
LowerMiddle
247262
88772900
8.6
93
4
Yes
HBV is endemic in rural areas of Vietnam
almost half of the population is or has been
60
Income
West Bank and
Gaza
Yemen, Rep.
Zambia
Angola
Albania
Algeria
American Samoa
Argentina
Azerbaijan
Belarus
Belize
LowerMiddle
Income
LowerMiddle
Income
LowerMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
infected. HCV is rare, but false negative test
results cannot be ruled out. NAT for HBV
should be considered for blood donor
screening in Vietnam (L Viet et al. 2012).
4046901
No
23852409
Yes
14075099
6.8
20820525
5
2801681
5
38481705
11.9
99.9
19.3
9
31
Yes
Yes
Supply collected from 59.5% family
replacement donors, and 19.3 % voluntary
donors (78.5% first time donors). Since 2003,
total blood collection has doubled, and unpaid
donation has been raised 5.7 times (WHO
EURO 2010).
187
55128
41086927
9295784
15.36
34.04
4.9
364
90
Yes
Yes
There are 70 blood service establishments, 4
blood banks and 86 blood banks for treatment
prophylaxis. In the population, there is a
sizeable prevalence of haemophilia, sickle cell
anaemia and thalassemia.
In 2008, law was passed for blood from only
non-paid donors. There is no remuneration for
donors other than in some cases travel
expenses (WHO EURO 2010).
9464000
324060
12.96
6
Yes
100
Bosnia and
Herzegovina
UpperMiddle
Income
3833916
10
Botswana
UpperMiddle
Income
2003910
10
Brazil
UpperMiddle
Income
198656019
18.9
Bulgaria
UpperMiddle
7305888
19
100
59.66
12
Yes
2
Yes
585
Yes
56
Yes
Blood donation campaigns are organized via
the government, NGOs, the Association of
Voluntary Blood Donors of Sarajevo canton,
the Federal Red Cross, the private sector and
media support. The Federal Red Cross
organizes 10–12 blood donation campaigns
per year in association with the Federal
Institute (WHO EURO 2010).
Blood banks in Brazil provide safe and
reputable services for test seekers. In order to
prevent people from going to blood banks for
testing, offering alternative locations that
provide comparable service is crucial. Male
gender, lower education, and lower income
were also significantly associated with test
seeking (Oliveira et al. 2013).
61
Income
China
UpperMiddle
Income
1350695000
4
99
452
Yes
452 centres (32 provincial, 321 regional, 99
county)
Challenges:
•
Increasing clinical demand and
shortage of supply
•
Seasonal blood supply shortage
(summer and winter because
majority of donors are college
students)
•
Continuing existence of paid
donations
•
Cultural barriers to donation (belief
of loss of health and vitality from
blood donation)
•
Idea of blood gifting / altruism
•
Inappropriate blood utilization
(L Shi 2014)
Colombia
UpperMiddle
Income
47704427
15.17
82.54
94
Yes
Costa Rica
UpperMiddle
Income
4805295
12.96
61.5
34
No
Cuba
UpperMiddle
Income
11270957
35.97
100
46
Yes
1
No
71684
13.4
8.93
10276621
8.4
18.24
58
Yes
Dominica
Dominican
Republic
Ecuador
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
15492264
12.84
49.95
17
Yes
TTI prevalence was 2.95%: Chagas disease
0.49%, HbsAg 0.21%, HCV 0.45%, HIV
0.12%, and syphilis 1.68%. Reactivity was
more frequent in men with a mean age of
36.35 years. HIV was present in the youngest
donors with a mean age of 26.5 year; Chagas
disease was found in the oldest donor
population, with a mean age of 40 years
(Gomez et al. 2013).
Case study of P. malariae infection in a nonimmune traveller that occurred without
symptoms and persisted subclinically for
months. This case shows that these infections
pose a threat to transfusion safety when
subclinically infected persons donate blood
after their return in a non-endemic malaria
region. An unexplained low platelet count
after a visit to malaria-endemic countries may
be an indicator for asymptomatic malaria even
when caused by non-falciparum Plasmodium
species (EE Brouwer et al. 2013).
Since 1997 approximately 5% of the
population per year has donated blood, thus
meeting the goal recommended by the Pan
American Health Organization of one
voluntary blood donation annually for every
20 persons. During 2002, 563,204 blood
donations were received, and there were
445,898 transfusions of blood or blood
components. All donations are individually
screened for HIV 1 and 2, hepatitis B, hepatitis
C, and syphilis, thus meeting the country's
current regulations. In 2002 these screening
measures led to discarding, respectively,
0.12%, 0.60%, 0.71%, and 1.8% of the blood
donations (JM Ballester Satovenia et al. 2003.
1 hospital-based blood bank nationwide.
The Ecuadorian National Blood System
screens for infectious a using different
methodologies and reagents. Large and
medium blood banks obtained better results
than small ones. Small laboratories reported
62
all of the 37 HIV antibody false negative
results and all of the 20 HBsAg false negative
results. False negative results were associated
with the use of rapid tests Laboratories using
rapid tests failed to detect HCV reactive
serum. The high number of incorrect results in
small blood services indicates weaknesses in
blood screening. The National Blood System
has implemented on-site audits, training,
technical assistance, and increased oversight.
The long-term proposal is to centralize blood
testing in two large blood centres (Grijalva et
al. 2005).
Fiji
Gabon
Grenada
Hungary
Iran, Islamic Rep.
Iraq
Jamaica
Jordan
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
874742
10
1632572
8.4
105483
13.3
9920362
9.15
6318000
17
Lebanon
4424888
Libya
UpperMiddle
Income
6154623
Maldives
100
44
Yes
16.07
10
No
26.9
2707805
UpperMiddle
Income
Malaysia
NR
Established in 2000, the HNBTS now consists
of 5 regional and 18 local institutions linked to
the nearest regional centre and 21 hospital
blood banks. The regional centre are located in
the main towns of the country (Budapest,
Debrecen, Győr, Pécs, Szeged). (European
Blood Alliance 2014).
32578209
Kazakhstan
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
NR
7624443
UpperMiddle
Income
Macedonia, FYR
1
16791425
18
89
26
No
5.76
100
12
Yes
2105575
11.6
29239927
19.7
338442
There are 14 regional blood centres and 12
urban blood centres. The funding for the blood
service in Kazakhstan is shared between the
Republican budget, the local budget and other
sources (investors).
The Lebanese Red Cross had started blood
transmission service in 1964 by opening its
centre in Beirut. Blood can be donated at the
Lebanese Red Cross blood transfusion centres
or at hospitals (Lebanese Red Cross).
Frequency of HBV, HCV, and HIV in blood
donors was 12.8, 6.9, and 0.9 per 1,000,
respectively. In Libya, most of the blood
donors are young men (20–40 years of age). It
is known that this age group is usually in the
high-risk group for drug abuse, unprotected
sex, and other unsecure habits for the
transmission of the virus (Khmmaj et al.
2010).
There are two multi-specialty hospitals, one in
government sector i.e. Indira Gandhi
63
Income
Marshall Islands
Mauritius
Mexico
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
Memorial Hospital (IGMH) and another one in
private sector. IGMH has a basic level of
modern blood bank with component
preparation facility. Blood collection by
IGMH is about 300 units per month. There is
another blood bank attached to National
Thalassaemia Center (NTC) which caters to
only thalassaemia patients in the city as well as
from other parts of the country. NTC collects
about 500 units per months. Both the blood
banks collect blood mainly from family
replacement donors and directed donors for
their own patients. About 80% blood units are
collected by this mechanism. There are few
blood banks in other islands of Maldives
(Choudbury 2011).
14853572
1291167
33.8
88.6
1
Yes
120847477
14.62
2.45
558
Yes
16 medical doctors who are specialists in
blood transfusion and 32 technicians educated
to work in the Transfusion Service along with
16 technicians with laboratory and general
education. There are currently two people who
work on promoting voluntary blood donation.
Montenegro
UpperMiddle
Income
621081
21
26.5
9
No
The blood transfusion service is not organised
on a national level yet but functions through
the work of nine independent blood
establishments that are hospital based, which
collect and process blood for their own use.
There is no specific fund allocated to finance
the transfusion activities in Montenegro. These
services are financed from resources allocated
to the host hospitals by the republic Fund for
Health Insurance (WHO EURO 2010).
Namibia
Palau
Panama
Peru
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
2303000
9.6
100
1
Yes
3802281
14.92
5.95
26
No
29987800
7.59
4.08
NR
No
20754
20
Romania
UpperMiddle
Income
Serbia
UpperMiddle
Income
20076727
7199077
100
31
100
41
47
Yes
Yes
Predicted decrease in Romanian population by
2018, but slight increase in blood donations
due to retention of younger voluntary blood
donors (Burta et al. 2013).
BTS is decentralized and organized on three
levels:
1. Departments/laboratories for blood
transfusion, that receive blood and blood
products from the Centres and Institutes for
blood transfusion
64
2. Centres for Blood Transfusion in general
hospitals, health centres, and clinical centres,
that perform core transfusion activities
3. Institutes for Blood Transfusion which are
independent institutions in University centres
that perform highly specialized activities, such
as tissue typing and quality control, as well as
coordinating activities between laboratories
and Centres.
Seychelles
UpperMiddle
Income
88303
South Africa
UpperMiddle
Income
St. Lucia
St. Vincent and the
Grenadines
Suriname
Thailand
Tonga
Tunisia
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
UpperMiddle
Income
16.9
0
1
No
52274945
18.6
100
11
Yes
180870
15.3
66.94
3
No
109373
9.4
5.97
1
No
53584
18.8
100
1
Yes
100
13
66785001
8.7
The main challenge is the fragmentation of the
service (44 blood hospital based transfusion
services, 3 blood transfusion institutes Belgrade, Novi Sad, Niš; and 70 clinical
transfusion departments without clearly
defined responsibilities). (WHO EURO 2010)
Received first mobile blood collection unit
from WHO to facilitate blood services (WHO
2014).
Cultural obstacles are often an enormous
problem with respect to donation: “In South
Africa, because of history of interracial
tensions, we have to deal with the cultural
issues, population diversity, and beliefs about
getting blood from anonymous donors,” says
Dr. Loyiso Mpuntsha, CEO of the South
African National Blood Service. (CMAJ
2010).
National Blood center is in the capital
Bangkok and there are 12 other regional
centers in provinces
Yes
104941
The National Center collected about 539,094
units in 2009. More than 93% of total
collected blood in the country is separated into
components. In 2008, the rate of syphilis,
HBsAg, HIV and HCV seroreactive is
approximately 0.28, 1.01, 0.15 and 0.19%,
respectively. All blood collected by National
Blood Center is screened by NAT test and
44.5% blood from rest of the country is also
tested by the same test (Choudbury 2011).
In 2009, 100% of blood donations were
screened for HIV in quality-assured manner
(UNAIDS Country Progress Report).
10777500
Turkey
UpperMiddle
Income
73997128
Turkmenistan
UpperMiddle
5172931
24.3
4
Yes
Donor characteristics: 89.1% male donors and
59.9% between 30 to 49 years old. Female
donors were deferred more frequently than
male donors. Donor education level had no
effect on the deferral rates. The main reason
for deferral was common cold and/or sore
throat or elevated temperature (20.4%) in male
donors and low hemoglobin (51.6%) in female
donors (O. Arslan 2007).
The Turkmen blood service is organized on a
national basis, supported by dedicated
65
Income
Tuvalu
Venezuela, RB
Andorra
Antigua and
Barbuda
Aruba
UpperMiddle
Income
UpperMiddle
Income
High
Income
High
Income
High
Income
legislation and regulatory documents approved
by the Ministry of Health and Medical
Industry, and fully funded from the state
budget. The national health authority started
reconstructing/refurbishing health facilities
and selected blood banks and a new blood
center is being built in Ashgabat, in
accordance with the highest quality and safety
requirements (WHO EURO 2012)
The national blood service comprises 4
regional blood banks, 38 offices and 18
ambulatory blood transfusion departments,
with additional blood transfusion service units
in many large medical institutions
(Turkmenistan Ministry of Health).
9860
29954782
16.14
6.38
313
No
78360
89069
13.36
102384
15.3
1
100
1
No
Australia
High
Income
22723900
58
Austria
High
Income
8429991
40.7
371960
20.2
43.95
3
No
283221
16.8
NR
NR
NR
11128246
28.5
Bahamas, The
Bahrain
Barbados
Belgium
High
Income
High
Income
High
Income
High
Income
100
Yes
Yes
Blood supply is managed by the Australian
Red Cross Blood Service (ARCBS). Blood is
donated by non-remunerated, volunteer
donors. Donors undergo a rigorous screening
process that involves a questionnaire and an
interview to identify relevant medical history
and risk factors that could influence the quality
or safety of the donated blood, or the health of
the donor.
Every unit of donated blood is also screened
for HIV 1 and 2, HBV and HCV, syphilis.
In addition, 1% of blood products undergo
additional, quality assurance testing including
volume and cell counts in addition to
haemolysis and haematocrit for red cell
concentrates, pH for platelet concentrates and
clotting factors for plasma products. Donations
are also screened for bacteria (Greening et al.
2010).
In Austria, over 90 % of the processed whole
blood is collected by blood services of the
Austrian Red Cross. Four of these services, the
Blood Donation Center for Vienna, Lower
Austria & Burgenland, the Blood Center for
Upper Austria, the Blood Center for Carinthia
as well as the Blood Center for Vorarlberg
cover the whole range of activities from
collection, testing, production to distribution.
The Red Cross Blood Centers for Styria,
Salzburg and Tyrol collaborate with the
Regional University Hospitals and are
responsible for collection and distribution
(European Blood Alliance).
1317828
The French and Flemish sections of the
Belgian Red Cross have their own blood
institutes.
66
The French section has three blood centers, 20
fixed collection sites and 600 mobile sites to
cover the operations.
The Flemish section has four blood centers to
cover collection of blood, plasma and platelets,
processing of blood, storage and delivery to
the hospitals. In addition blood and plasma are
collected in 12 fixed donor centers. The testing
lab of the Flemish blood institute, the quality
assurance and the donor recruitment are
centralized.
Approximately 85% of blood collection comes
from the different mobile collections in
Flanders and Brussels (European Blood
Alliance).
Bermuda
Brunei Darussalam
Canada
Cayman Islands
Channel Islands
High
Income
High
Income
High
Income
High
Income
High
Income
64798
16.6
100
1
No
412238
34754312
55
100
57570
19.7
100
Yes
2
The Canadian Blood Services (CBS) is
responsible for the collection and provision of
blood and blood products to nine provinces
and the territories.
In Canada, the blood products are purchased
by the CBS. The prices are negotiated with
the supplier. The blood products are then
issued to blood centers and provided to the
hospitals free of charge. Patients will not be
billed for bloo and blood is given only on
prescription by a physician.
Blood was declared a drug in 1989 and, as
such, falls under the regulatory control of the
Bureau of Biologics and Radiopharmaceuticals
(BBR) of Health Canada. The BBR stipulates
the required testing for infectious diseases.
The required tests are HIV, HBV, HCV, and
syphilis (Rock et al. 2000).
No
161235
Rural Chile:
•
Low blood donation rate (14.3 per
1000)
Chile
High
Income
17464814
12.2
21.17
76
Yes
•
Low % of voluntary donors (10%)
•
Excessive amount of blood banks à
non-centralized system
No national IT system and lack of
standards
•
(C Herrera 2010)
Croatia
Curaçao
Cyprus
Czech Republic
Denmark
High
Income
High
Income
High
Income
High
Income
High
Income
4267558
36
152056
40.7
1128994
63.3
10510785
35.3
5591572
67.6
100
13
Yes
1
Yes
Yes
The Organization of Transfusion Centres in
Denmark (OTCD) was established in 2001 to
coordinate countrywide responsibility for the
blood transfusion services and to represent the
interests of blood program of the country. The
members of the OTCD represent 100 % of
blood collection in Denmark (European Blood
Alliance).
67
The Estonian Blood Transfusion Service
consists of four separated blood centers
merged to main hospitals: North Estonia Blood
Center located in capital city Tallinn, Tartu
University Clinic’s Blood Center, Pärnu
Hospital Blood Center and East-Viru Hospital
Blood Center.
Estonia
High
Income
1325016
25.4
Yes
Blood components are used in 23 hospitals in
Estonia, most of them (20) are supplied by
Tallinn’s and Tartu’s Blood Centers.
The Blood Transfusion Service action is
regulated by the Blood Act and bylaws (since
May 2008). The Estonian Blood Act is in
accordance with related European Directives
(European Blood Alliance).
Equatorial Guinea
Faeroe Islands
Finland
High
Income
High
Income
High
Income
736296
5413971
High
Income
65676758
French Polynesia
High
Income
273814
High
Income
0
3
49506
France
Germany
0.9
80425823
30.5
23.5
35.9
100
100
100
13
17
Yes
Yes
Yes
The Finnish Red Cross Blood Service is the
nationwide blood service operator in Finland.
It provides Finnish hospitals with all the blood
products they need. It also offers hospitals a
range of laboratory and specialist services,
including laboratory tests relating to blood
transfusion, stem cell and organ
transplantation and haemostasis, and
distribution of many plasma derived and
recombinant pharmaceuticals.
Many functions of the Blood Service, such as
testing, quality control and administrative
support functions, are centralized to the
Helsinki Blood Centre. In addition to the
Helsinki Blood Centre, operations are carried
out in four regional centers and 12 collection
centers (European Blood Alliance).
The French National Blood Service (EFS) is a
public organization established in January
2000 and has the monopoly on collection,
testing, preparation and distribution of blood
products to some 1900 health care facilities
(these activities can be made only by blood
transfusion establishments approved by the
competent authority).
The issuing of the majority of blood
components is carried out by the blood
transfusion establishments directly to patients
in hospitals from orders received from the
prescribers.
The 17 regional centres of the EFS (14 in the
metropolitean area) are headed by directors
appointed by the President of EFS and acting
by delegation from him in regard to
management and operations (European Blood
Alliance).
In Germany, blood services are provided by
four types of organizations: German Red Cross
Blood Transfusion Services, state and
communal blood transfusion services,
commercial blood centers, and plasmapheresis
centers.
The German Red Cross Blood Transfusion
68
Services is a non-profit organization and they
do not receive any funds from the government
(European Blood Alliance).
Greece
Greenland
Guam
Hong Kong SAR,
China
Iceland
Ireland
Isle of Man
Israel
High
Income
High
Income
High
Income
High
Income
High
Income
High
Income
High
Income
High
Income
11092771
39.3
56810
162810
7154600
27
320716
29.7
4586897
21.8
100
9
Yes
The Irish Blood Transfusion Service,
established in 1965, is headed nationally by
the Chief Executive who reports to the Board
of the IBTS. The twelve Board members,
including the Chairman, are appointed by the
Minister for Health & Children.
IBTS has its headquarters in Dublin and a
regional centre in Cork. In addition there are
six local centers from where procurement
teams depart to collect donations in their
respective regions and three fixed centers
(European Blood Alliance).
85284
7910500
In Italy, the Blood System is part of the
National Health Service.
National Blood Centre (Centro Nazionale
Sangue – CNS): the national coordinating
organization in the country. It is one of the
national technical centers of the Ministry of
Health and it operates at the National Institute
of Health in autonomous position. It is
responsible for coordination as well as
scientific and technical control of the national
Blood System. It also provides blood
inspectors education and qualification and
manages a national register of qualified blood
inspectors as well as the periodic assessment
of their activities and skills.
Italy
High
Income
59539717
27
100
400
Yes
Regional Health Authorities: inspect,
authorize and accredit Blood Establishments
and Blood Collection Units, according to
regional, national and European regulation.
Each regional inspection team must include at
least one nationally qualified blood inspector
from the CNS register
Regional Blood Centers: in each of the 21
regions, a Regional Blood Centre is instituted
by law. Regional Blood Centers coordinate the
respective local networks of Blood
Establishments and Blood Collection Units,
complying with national regulation and selfsufficiency, quality and safety plans. Blood Establishments: beyond performing
blood and blood component collection,
processing, testing, storage and distribution,
most BEs also function as hospital blood
banks. They are being progressively reorganized in local/regional blood departments,
merging processing and testing activities in a
69
limited number of establishments. Blood donors associations: in Italy there are
four main blood donors organizations (AVIS,
FIDAS, FRATRES, CRI), highly involved in
blood donor management. By law, they can
run BCUs upon specific regional authorization
and accreditation, under the technical control
of BEs and Regional Blood Centers (European
Blood Alliance).
Japan
Korea, Rep.
Kuwait
High
Income
High
Income
High
Income
127561489
70
50004441
53
3250496
Latvian National blood service is a healthcare
institution financed by state budget in
accordance with Latvian Blood Centre
operation and structure optimization concept
for 2006 – 2010.
Latvia
High
Income
2034319
23.9
100
11
Yes
There are 10 blood establishments in hospitals
and State Blood Centre with its branch in
Eastern part of the state. The organization of
blood donations, collection, testing, blood
processing is centralized and it is used unified
technologies.
The blood products’ quality control is
managed by the accredited laboratory
(European Blood Alliance).
Liechtenstein
High
Income
36656
Two blood establishments, one private and one
public, covering the needs of 97 hospitals and
collecting 96.5% of total blood donations. In
addition, two hospitals collect and process
blood for their own purposes, representing the
remaining 3.5% of the national volume of
blood transfused.
Lithuania
High
Income
2987773
17.7
33.3
2
Yes
The National Blood Centre is a public
institution (not for profit) and was established
by the Ministry of Health of Lithuania. It is the
largest blood establishment in Lithuania and
covers up to 60% of blood donations. The
National Blood Centre covers transfusion
needs in three cities: Vilnius (the largest city),
Klaipeda (the third largest) and Panev žys (the
fifth largest). It is the only blood establishment
in the country, which is licensed (including the
laboratory) and it is also licensed for
manufacturing plasma derivatives.
The Centre performs individual nucleic acid
tests for HBV, HCV and HIV (ID-NAT),
which significantly reduce the “window
period”.
Luxembourg
High
Income
530946
29.8
1
Yes
Payment for blood donations started in 1995
and has been reduced several times until 2004.
It is currently equal to €11 and is regarded as
compensation for travel and time. In 2009,
approximately 60 000 units were collected
from paid donors and 32 000 from unpaid
voluntary donors (WHO EURO 2010).
The Luxembourg Red Cross is in charge of the
blood program and operates one single blood
70
center to meet the demand for blood
components and plasma derivatives.
The blood program has a national
responsibility to supply all blood and plasma
products requested by the hospitals
(Luxembourg Red Cross).
Macao SAR,
China
High
Income
556783
Malta
High
Income
419455
Monaco
High
Income
37579
23
37.8
Netherlands
High
Income
16754962
New Caledonia
High
Income
258000
New Zealand
High
Income
4433000
Northern Mariana
Islands
High
Income
53305
Norway
High
Income
5018573
22.3
Oman
High
Income
3314001
14.2
Poland
High
Income
38535873
23.5
5
Yes
Sanquin was established in 1998 through a
merger between the Dutch blood banks and the
Central Laboratory of the Netherlands Red
Cross Blood Transfusion Service (CLB).
On the basis of the Blood Supply Act, Sanquin
is the only organization in the Netherlands
authorized to manage our need for blood and
blood products.
The Sanquin organization is constantly
conducting research and developing new and
improved blood products. There is also a
constant search to replace the roughly 10% of
the donors who become unavailable due to
age, pregnancy, illness or relocation (European
Blood Alliance).
23.8
28.2
The Islands have always been self-sufficient
with regards to blood products.
There is one government funded Blood
Establishment which collects (2 fixed donation
sites, one mobile unit), processes, screens and
distributes blood. There are four Hospital
Blood Banks that are mainly involved with
patient care. The Blood Establishment and the
main Public Teaching Hospital Blood Bank,
which receives over 90% of blood products
manufactured, work closely together but are
administratively separate and autonomous.
A national haemovigilance system lead by the
Public Health Regulation Division captures the
adverse events and reactions reported by all
hospitals (European Blood Alliance).
100
73.9
12
Yes
50+
Yes
14
Yes
23
Yes
Established in 1996, the New Zealand Blood
Service is the sole provider of blood products
to hospitals in New Zealand (NZBS 2014).
All blood banks are integrated to hospitals and
owned by regional health trusts. Around 75%
of blood is collected by 14 blood banks in
major cities (European Blood Alliance).
A modest start by providing blood units
through import from the US, Oman is now
self-reliant on procuring blood units from
voluntary non-remunerated blood donors. A
steady growth of blood banks is witnessed in
every aspect of blood banking including blood
collection, blood processing and supply.
Various modalities are adapted in promoting
voluntary blood donation program (S Joshi et
al. 2010).
The activity of the Polish Blood Transfusion
Service (BTS) is based on the Public Blood
Transfusion Service Act sanctioned by the
Polish Parliament. There are 21 regional Blood
Transfusion Centers (BTCs), 1 Military BTC
and 1 BTC of the Ministry of Internal Affairs.
71
The Institute of Hematology and Transfusion
Medicine (IHTM) is responsible for issuing
guidelines for blood transfusion medicine. All
BTCs must have an accreditation from the
Ministry of Health. Poland has a national
system of hemovigilance. Hospitals are
obliged to immediately report all posttransfusion complications and adverse events
(Antoniewicz-Papis et al. 2006).
Portugal
High
Income
10514844
Puerto Rico
High
Income
3615450
Qatar
High
Income
2050514
Russian Federation
High
Income
143178000
San Marino
High
Income
31247
38
100
Yes
Notable prevalence of dengue virus in blood
donations in Puerto Rico: daily maximum of
45.0 per 10,000 donations and daily mean of
7.0 per 10,000 donations. Prevalence varied
considerably by season and year (Petersen et
al. 2012).
For 20 years after collapse of the Soviet
Union, blood donation in Russia was based
solely on fee-based services; blood donors
received fees for each unit given (Russian
Ministry of Health).
12
Saudi Arabian blood services are divided into
four departments: Donor Services, Processing,
Transfusion Services and Administration and
Quality Control.
All departments are hospital-based; no
centralized blood bank.
Saudi Arabia
High
Income
28287855
14.7
100
Yes
Each hospital, tertiary or secondary, has its
own Blood Bank and its own policies and
procedures.
Blood Banks can supply the other primary and
satellite hospitals that may not have their own
facilities.
Singapore
Slovakia
Slovenia
Spain
St. Kitts and Nevis
St. Martin
High
Income
High
Income
High
Income
High
Income
High
Income
High
Income
5312400
21.2
5407579
19.8
2057159
57.4
100
Yes
46761264
21
100
24
Yes
53584
10.4
11.69
1
No
Approximately 98% of donors are male
(Saudi Arabia Ministry of Health)
The Blood Services Group (BSG) of the
Health Sciences Authority is responsible for
collecting, processing and distributing blood
and blood components to all public and private
hospitals in Singapore.
In Spain, a highly decentralized country, blood
components and services are provided by 17
Regional Blood Transfusion Services (regional
governments). Despite their autonomous
operations management, every Regional Blood
Transfusion Service is fully incorporated into a
unique and common Public National Health
System, supplying a cohesive blood
transfusion care to all citizens, residents, and
visitors in Spain based on 100% voluntary and
non-remunerated blood donation (European
Blood Alliance).
30959
72
Blood centers in Sweden are integrated parts
of the public health hospital organization. The
governments in the 21 counties are responsible
for the hospitals (Rock et al. 2010).
The Swedish Blood Alliance (SweBA) was
formed September 1st 2004 as a non-profit
organization and is responsible for blood
safety.
Sweden
High
Income
9519374
31.4
Switzerland
High
Income
7996861
33
100
14
Yes
Trinidad and
Tobago
Turks and Caicos
Islands
United Arab
Emirates
High
Income
High
Income
High
Income
1337439
16.7
NR
6
No
32427
3.5
57.7
1
No
9205651
9.34
99
United Kingdom
United States
High
Income
High
Income
63695687
313873685
40
65
Yes
100
Among the national services presently
maintained by SweBA the SBS,
“Samverkande Blodsystem,” a web-based
system for safe exchange of blood donor
information between IT systems in different
blood establishments. SweBA also administers
the translation, incorporation and availability
of ISBT 128 codes through a web-based
database (European Blood Alliance).
Each year around 380,000 blood donations are
procured in Switzerland, around 40% by
mobile blood donating units and another 60%
at stationary centers. The supply of blood for
the Swiss population has been met at all times.
(European Blood Alliance).
Prices for blood products are set by the Swiss
Red Cross Blood Transfusion Service, which
is the only supplier, other than some state
hospital blood banks.
Federal Regulations on blood, blood products
and transplants have been in place since 1
January 1996. Blood products are given only
on prescription by a physician (Rock et al.
2010).
Yes
Yes
The United Kingdom has four Blood
Transfusion Services based largely on the
devolved political bodies of the United
Kingdom: NHS Blood and Transplant
(NHSBT) for England and North Wales, the
Scottish National Blood Transfusion Service
(SNBTS), the Welsh Blood Service (WBS)
and the Northern Ireland Blood Transfusion
Service (NIBTS). (European Blood Alliance).
Blood is a national resource that is collected
and banked locally through England’s network
of 14 local blood centers. Generally each
hospital has a blood bank holding an average
of 8—10 days of stock of red cells with a
further five days held in the Blood centers
(Rock et al. 2010).
There are about 6000 hospitals in the US that
purchase the majority of blood products. The
vast majority of these facilities are privately
held and not-for-profit.
The government (through Medicare, Medicaid,
the VA system, and the military) pays for
about 65% of blood transfusions. Private thirdparty payers, both not-for-profit (like Blue
Cross) and for profit (like US Healthcare/
Aetna), pay for the rest.
The major suppliers of blood for transfusions
in the US are the independent, not-for-profit
73
community centers, as represented by
America’s Blood Centers (ABC) that provides
6.7 million donations (about half of the US
blood supply). The American Red Cross
(ARC) provides about 6 million donations
with the remainder coming from hospitals that
collect their own blood and from the military
(about 1%) which runs its own comprehensive
transfusion service.
There is no payment for blood for transfusion.
Hospitals are turning to suppliers, including
blood centers, trying to reduce costs.
Approximately 90 – 95% of blood and its
components are transfused within 100 miles of
where they are collected.
The US market is essentially based on supply
and demand. There have been increasing
shortages of RBCs due to increasing demand
and shortfalls especially because of declining
blood collections by the Red Cross (Rock et al.
2010).
Uruguay
Virgin Islands
(U.S.)
High
Income
High
Income
3395253
27.39
NR
75
Yes
105275
11
0
1
No
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76
Appendix 2.7: First Level Referral Hospital Procedures
The Lancet Commission on Global Surgery’s Health Delivery & Management Working Group:
NOBHOJIT ROY, ROWAN GILLIES, EDGAR RODAS, GANBOLD LUNDEG, EDNA ADAN
ISMAIL, SHENAAZ EL-HALABI, PAUL FARMER, NAKUL RAYKAR
BACKGROUND
The first-level hospital is the first point of referral from the community for surgical care. In order to realize
the Commission’s vision of universal access to safe, timely, and affordable surgical care, the first-level
hospital must provide broad-based services, including the vast majority of emergent and planned surgical
procedures. The Health Delivery & Management (HDM) Group was asked to assess which procedures
could (and hence, should) reasonably be offered at the first-referral level.
METHODS
A list of procedures was obtained from a LMIC tertiary center (Jaslok Hospital, Mumbai, India;
www.jaslokhospital.net). The list, part of a billing manual for the tertiary center, listed 792 procedures
across 13 specialties. Each specialty’s procedures were broken down into six grades of complexity,
ranging from “Supra-Major” (most complex) to “Grade V” (least complex). HDM participants were asked
to classify each procedure as whether it was possible to do at a district hospital, taking into account case
complexity, operative equipment needs, and post-operative care needs. Where classification was not
unanimous, consensus was achieved through discussion.
RESULTS
Table 1 lists procedure categories as defined by the tertiary center list of procedures. Table 2 lists
procedures that were evaluated. Of 792 procedures on the list, 682 (86%) were deemed appropriate for
delivery at the first-level hospital, given it was structurally equipped and staffed with workforce. In some
cases, the services of a surgeon with a broad skillset or specialist support would be needed (e.g. cleft lip
and palate repair).
CONCLUSION
The majority of surgical procedures can be delivered at the ideal first-referral hospital.
77
Table 1. Number of Procedures by Specialty and Grade, classified as appropriate for the average LMIC first-level or tertiary hospital.
Supra-Major
FirstTertiary
Level
Grade I
Tertiary
Grade II
First-Level
Tertiary
Grade III
First-Level
Tertiary
Grade IV
First-Level
Tertiary
Grade V
First-Level
Tertiary
First-Level
13
1
11
3
9
3
6
6
3
3
4
4
Ear
2
0
7
2
2
2
4
4
5
5
0
0
Nose
1
0
4
2
3
3
8
7
2
2
5
5
Throat
0
0
2
2
3
3
3
3
5
5
0
0
General Surgery
10
5
15
12
34
34
32
32
17
17
9
9
Head Face Neck
2
2
3
3
9
9
6
6
2
2
1
1
NeuroSurgery
8
1
8
3
5
5
2
2
4
4
0
0
ObGyn
2
2
6
6
17
17
30
30
13
13
2
2
11
2
37
30
9
9
11
11
7
7
7
7
Ophthalmology
0
0
0
0
14
11
7
7
21
18
8
8
FacioMax
7
4
5
5
8
8
4
4
5
5
2
2
Orthopaedics
10
5
12
12
24
24
12
12
9
9
1
1
Pediatric Surg
13
9
12
10
19
19
14
14
7
7
3
3
Reconstructive
9
1
10
9
12
12
18
18
4
4
0
0
Urology
2
0
16
10
19
19
33
33
22
22
9
9
90
32
148
109
187
178
190
189
126
123
51
51
Cardiothoracic
Oncology
Percentage of surgeries
that can be done at the
First-Level Hospital
35.6
73.6
95.2
99.5
97.6
100.0
TOTAL PERCENTAGE THAT CAN BE PERFORMED AT FIRST-LEVEL
78
86
Table 2. Procedure List
CARDIOTHORACIC SURGERY
Supra-Major
Coronary artery bypass grafting
All open heart surgery for congenital heart disease
Redo bypass surgery
Total arterial revascularization
Left ventricular revascularization
Post infarction ventricular septal defect
Sympathectomy
Excision of paraspinal mass
Repair of aortic tear
Tetrology of Fallot
Double valve repair and replacement surgeries
Surgery for aneurysm of aortic arch and thoracic aorta
Reconstruction of trachea
Grade 1
Single valve replacement and repair
Coarctation of aorta
Pericardiectomy
Resection of aneurysm of abdominal aorta
Aortofemoral bypass
Operations for oesophageal varices
Pneumonectomy
Closed heart valvotomy
Repair of patent ductus arteriosus
Open thoracotomy
Thorascopic lung biopsy
Grade 2
Blalock Taussig shunt
Femoropopliteal bypass
Carotid endarterectomy
Pleurectomy
Removal of mediastinal mass
Repair of diaphragmatic hernia
Segmental resection of the lung
Lobectomy
Arteriovenous graft
Grade 3
Decortication
Embolectomy
Venous thrombectomy
79
Ligation and stripping of varicose veins
Ligation or plication of vena cava
Re-exploration
Grade 4
Bronchoscopy
Removal of sternal wires
Intercostal drainage
Grade 5
Tube thoracotomy
Pleural tapping
Pericardiocentesis
Secondary suturing
80
ENT
Supra-Major
Translabyrinthine/retrosigmoid approaches to cerebellopontine angle tumour
Cochlear implant surgery
Transphinoidal pituitary surgery
Grade 1
Tympanoplasty with mastoidectomy
Stapedectomy
Labyrinthectomy
Facial nerve decompression
Jugulobulbar tumour
Congenital ear excision surgery
Endolymphatic sac decompression
Maxillectomy
Excision of a nasopharyngeal tumour
Excision of ethmoid tumour
Cerebrospinal leak closure
Uvuloplatopharyngopasty
Cleft palate and cleft lip
Grade 2
Tympanoplasty
Mastoidectomy
Pan endoscopic nasal surgery
External ethmoidectomy
Endoscopic dcr
Tonsillectomy with adenoidectomy
Cleft lip only
Cleft palate only
Grade 3
Myringoplasty
Grommet insertion
Auroplasty
Ear polypectomy
Rhinoplasty
Caldwell-Luc operation
Ethmoidectomy - intranasal
Vidian neurectomy
Rhinosporidosis
Septoplasty
Functional endoscopic sinus surgery
Acrylic grafting
Uvulectomy
Adenoidectomy
81
Tonsillectomy
Grade 4
Myringotomy
Wax granuloma excision
Incision and drainage of furuncle abscess
Piercing of ear lobule
Removal of foreign body
Polypectomy
Laser excision of small nasal mass
Throat biopsy
Incision and drainage of a peritonsillar abscess
Removal of foreign body
Cauterization of pharyngeal granules
Post nasal pack removal
Grade 5
Antrum puncture
Incision and drainage of abscess
Cauterization of inferior turbinate
82
GENERAL SURGERY
Supra-Major
Total thyroidectomy with radical neck dissection
Total radical gastrectomy
Oesophageal resection
Total pancreatectomy
Total colectomy
Hepatic lobectomy
Liver transplant
Liver resection
Pancreatic necrosectomy
Grade 1
Surgery for portal hypertension
Abdominoperineal resection
Pancreatico-jejunostomy
Distal pancreatectomy
Hepaticojejunostomy
Choledochojejunostomy
Partial gastrectomy
Anterior resection of left colon
Excision retroperitoneal tumours
Total thyroidectomy
Parathyroid surgery
Multiple organ surgery (polytrauma)
Bilateral block dissection of lymph nodes of neck, axilla, groin
Total parotidectomy
Right hemicolectomy
GRADE 2
Modifed radical mastectomy
Bilateral partial/subtotal thyroidectomy
Superficial parotidectomy
Choledochoduodenostomy
Sphinteroplasty of sphincter of Oddi
Partial gastrectomy
Hemi/partial colectomy
Small intestine resection and anastamosis
Abdominal repair of rectal prolapse
Surgery for achalasia cardia (Heller's cardiomyotomy)
Surgery for hiatus hernia
Operation for hydatid cyst liver
Ventral incisional hernia
Paraumbilical hernia
83
Umbilical hernia
Laparoscopic repair of inguinal hernia
Bilateral inguinal/femoral hernia
Splenectomy (no portal hypertension)
Vagotomy and bypass
Proximal gastric vagotomy (highly selective vagotomy)
Pancreatic cyst/abscess-drainage
Block dissection lymph nodes of neck, axilla, or groin
Hemithyroidectomy
Laparotomy for abdominal trauma - single organ injury
Exploratory laparotomy
Cholecsystectomy/cholecystostomy
Repair of fecal fistula
Cholecystojejunostomy/choledochojejunostomy
Gastrojejunostomy
Entero-enterostomy
Near total thyroidectomy
Peritoneal - venous shunt
Ileostomy closure
Lap cholecystectomy
Grade 3
Excision of sinus/bursa/ganglion/scar
Excision of submandibular salivary gland
Cervical oesophagostomy
Simple mastectomy
Hydrocele (unilateral or bilateral)
Varicocelectomy
Fistulectomy
Excison of pilonidal sinus
Varicose vein (ligation of sfa and perforation)
Orchidopexy
Excision of surface tumour with skin grafting
Sistrunk operation
Laparotomy for liver abscess, liver biopsy
Appendicectomy
Drainage of subphrenic abscess
Gastrostomy/colostomy/ileostomy
Inguinal/femoral hernia (unilateral)
Open operation for piles
Wide excision of malignant tumor of skin
Lipectomy
Partial glossectomy
Branchial cyst/fistula
84
Excision of multiple lymph glands neck/axilla/inguinal region
Orchidectomy (unilateral or bilateral)
Repair of "burst abdomen"
Circumcision
Evacuation/excision of superficial haematoma
Secondary suturing
Excision of neurofibroma
Closure of gastric fistula
Lords procedure for haemorrhoidectomy
Lap adhesiolysis
Grade 4
Stricturoplasty
Removal of foreign body from muscles tendons
Multiple tumors/cysts excision
Fissurectomy
Anal dilation, sclerosant injection of piles
CO2 laser (surgery for superficial lesions)
Excisions of warts/keloids
Sphinterotomy (lateral)
Banding piles
Thierson's operation
Excision of nodule
Excision of sebaceous cyst
Rectal biopsy
Excision of breast lump
Evacuation/excision of superficial hematoma
Grade 5
Lacerated wound suturing
Foreign body removal from skin/subcutaneous tissues
Biopsy of skin, mucosa, muscle, gland
Release of tongue tie
Dilation of salivary duct
Excision of ranula
Incision and drainage of abscess
Sigmoidoscopy and biopsy
Perianal abscess-drainage
85
HEAD AND NECK
Supra-Major
Laryngopharyngectomy with block dissection
Total thyroidectomy with block dissection
Grade 1
Total thyroidectomy
Hemimandibulectomy
Total parotidectomy
Grade 2
Thyroplasty
Partial/subtotal thyroidectomy
Laryngopharyngectomy
Submandibular gland excision
Tracheal repair and reconstruction
Excision of cystic hygroma
Excision of paraphyrengeal tumour
Excision of parathyroid adenoma unilateral
Microlaryngealscopy with laser excision of subglottic stensosis
Grade 3
Excision of thyroglossal fistula
Excision of branchial sinus
Micro laryngoscopy
Bronchoscopy
Oesophagoscopy
Lymphnode biopsy
Grade 4
Tracheostomy
Direct laryngoscopy
Grade 5
Incision and drainage of abscess
NEUROSURGERY
Supra-Major
Craniotomies for cerebral aneurysms
Excision of spinal av malformations
Spinal intramedullary tumors
Post-lumbar interbody fusion
Transnasal/transphenoidal pituitary tumor
Epileptic surgery involving hemispherectomy
Grade 1
Craniotomies for intracerebral/extracerebral clots
Stereotactic surgery
Cranioplasty
Epilepsy surgery temporal lobectomy or similar ablative procedure
Decrompressive laminectomies for stenosis, surgery for discs
Other spinal fusion, procedures apart from posterior lumbar fusion
Peripheral nerve injury
Endoscopic 3rd ventriculoscopy and aqueduct stenting
Grade 2
Subtemporal/suboccipital decompression and other craniotomies
Operation for simple depressed fractures of the skull
Decompression of peripheral nerve entrapments
Carotid ligation and thromboembolectomy
Shunts: ventriculoperitoneal,
Grade 3
Radiofrequency or chemical lysis of trigeminal nerve
Burr holes followed by various procedures like evacuation of subdural hematoma, intracranial cyst, aspiration of abscesses
Grade 4
Skull traction
Aspiration: abscess, subdural hematoma or cysts through existing burr holes
Burr holes for ventricular taps
87
OBSTETRICS AND GYNAECOLOGY
Supra-Major
Wertheim’s hysterectomy
Panhysterectomy with omentectomy and lymphnode dissection
(by laparotomy – laparoscopic) for carcinoma ovary
Grade 1
Radical vulvectomy
Presacral neurectomy for grade 4 endometriosis
Abdominal hysterectomy
Vaginal hysterectomy
Lap. Assisted vaginal hysterectomy
Laparoscopic hysterectomy
Grade 2
Repair of vesicovaginal and rectovaginal fistulae
Tuboplasty
Laparoscopic hysterectomy with laparascopic burch
Calposuspension
Laparoscopic tubal recanalization
Operative laparoscoy for moderate to severe endometriosis
Operative laparoscopy for vault prolapse hysteroscopic
Myomectomy with transcervical resection of endometrium
Abdominal hysteroplasty
Operations for stress incontinence – sling procedures
Vault prolapse repair
Mayovard’s hysterectomy
Transcervical resection of endometrium
Laparoscopic myomectomy
Abdominal hysterectomy
Laparoscopic adhesiolysis
Tubal ligation
Grade 3
Hyseteroscopic cannulation
Internal iliac artery ligation
Laparoscopic metroplasty
Operative laparoscopy hysteroscopy
Laparoscopic appendicectomy
Hysterscopic septal incision
Operative hysteroscopy for mild to moderate ultra uteri adhesions
Tension-free vaginal tape for stress urinary incontinence
Hysterotomy
Ovarian cystectomy (including laparoscopic)
Ovarian wedge resection
Appendicectomy
Pre-sacral neurectomy
Ventrosuspension
Repair of complete perineal tear
Anterior colporrhaphy and posterior colpoperineorrhaphy
Operative laparoscopy for small to moderate ovarian cyst
Operative laparoscopy for small (up to 5 cm.) Sized myoma
Operative laparoscopy for mild to moderate endometriosis
88
Laparoscopic hysterectomy
Operative laparoscopy for ovarian cyst (large)
Operative laparoscopy for dermoid (large)
Fothergill’s operation
Simple vulvectomy
Laparoscopic polycystic ovarian drilling
Laparoscopic salpingo-ovariolysis
Cervical cerclage
Hysterscopic polypectomy
Thermal balloon ablation
Vaginoplasty
Grade 4
Diagnostic laparoscopy & hysteroscopy
Culdoscopy colpotomy
Posterior repair
Fenton’s operation
Excision of bartholin cyst
Trachelorrhaphy
Cone biopsy
Dialation and curettage cervical biopsy and electroconisation or electrocautery of the cervix
Hysteroscopic missed cu-t removal
Microwave ablation
Dilation and curettage
Tubal ligation
Grade 5
Vulva biopsy
Incision of Bartholin’s abscess
89
ONCOLOGY
Supra Major
Total oesophagectomy
Total gastrectomy with node dissection
Whipple’s (total pancreatectomy)
Total exenteration
Craniofacial resection with reconstruction – microvascular
Radical nephrectomy with renal vein or inferior vena cava thrombus removal
Radical cystectomy with ileal conduit or neobladder
Any operative procedure of 6 hours duration or more will be considered as supra major surgery
Microvascular reconstruction
Tracheal reconstruction (major) >4 rings
Total thyroidectomy
Tracheal resection
Grade 1
Radical hysterectomy/ Wertheim’s
Total thyroidectomy
Double flap reconstruction
Partial hepatectomy
Commando operation
Laryngopharyngectomy
Total parotidectomy
Wide field laryngectomy
Pneumonectomy
Ivor lewis
Hepaticojejunostomy
Abdomino perinial repair or subtotal
Low anterior resection
Posterior exenteration
Radical prostatectomy
Pelvic and retroperitoneal node dissection for carcinoma testis or ovaries
Nerve sparing retroperitoneal lymph node dissection
Radical cystectomy with ileal conduit or neobladder
Ovarian debulking – operation (bilateral salphingo opherectomy hysterectomy + omentectomy removal of multiple intra peritoneal
nodules)
Excision large retroperitoneal tumour
Bilateral ilio inguinal node dissection
Removal of adrenal tumour (bilateral)
Thymectomy
Partial nephrectomy
Total nephrectomy
Partial gastrectomy-radical
Maxillectomy
Hemicoloectomy + lymph node dissection
Lobectomy
Partial gastrectomy
Total amputation penis
Removal of adrenal tumour
Radical mastectomy
Grade 2
90
Radical neck dissection
Hemi-mandibulectomy
Superficial parotidectomy
Hemi colectomy
Transuretheral resection multiple bladder tumours
Bilateral salphingo opherectomy hysterectomy + peritoneal lymph node dissection
Trans urethral resection – prostrate
Excision very large tissue and tumour
Grade 3
Hemiglossectomy
Hemi-thyroidectomy
Simple mastectomy
Gastro-jejunostomy
High orchidectomy
Orchidopexy
Partial amputation penis
Cystoscopy + trans urethral resection bladder tumour
Hickmen port insertion
Colostomy
Orchidectomy
Grade 4
Partial glossectomy
Excision breast lump
Excision multiple lipoma
Insertion of hickman’s catheter
Scalene/supra adrenal axillary node
Small node (neck)
Orchidectomy
Grade 5
Biopsy lymph node
Circumcision
Biopsy of mole, wart, or small skin lesion
Excision of lipoma, sebaceous cyst
Direct laryngoscopy
Cystoscopy
Removal of Hickman’s catheter
91
OPHTHALMOLOGY
Grade 2
Keratoplasty
Orbital surgery
Cataract extraction with intraocular lens implant
Vitrectomy
Anti glaucoma surgery
Squint surgery involving 2 muscles or more
Secondary IOL (intra-occular lense) implantation
Intra-occular lense exchange
Retinal detachment surgery
Dacryocystorhinostomy
Ptosis correction
Lid reconstruction with membrane
Trauma repair of global
Retinal membrane surgery
Grade 3
Cataract extraction
Pneumoretinopexy
Entropion correction
Ectropion
Pterygium removal with graft
Tarsorrhaphy
Lensectomy
Grade 4
Silicone oil removal/injection or injection of gas
Dacryocystectomy
Lid repair
Evisceration
Enucleation
Iridectomy
Prophylactic cryopexy
Cyclodestructive surgery
Anterior chamber wash
Encirclage
Paracentesis
Capsulectomy
Synechiotomy
Peritomy or pterygium
Endolaser
Indirect laser
Removal or dislocated nucleus or lens implant
Lensectomy
Retinectomy or subretinal surgery
Intravitreal Anti VEGF (Vascular Endothelial Growth Factor)
Anterior Segment Membranectomy and Capsulectomy
Grade 5
Chalazion removal
Abscess incision & drainage
Eye examination under general anesthesia
92
Suture removal corneal ulcer cauterization punctum occlusion
Probing + syringing
Funduscopy
Needling or capsulotomy
Cauterization of corneal ulcer
93
ORAL AND MAXILLOFACIAL SURGERY
Supra Major
Accessosteotomies for resection of lesions/pathologies
Orthognathic surgeries
Panfacial fractures
Resection of tumours/cysts with reconstruction
Parotid gland tumours
Ankylosis TM (Tempero-mondibular joint)
Bilateral condylectomy with interposition
Grade 1
Mandibular fractures maxillary fractures zygomatico-orbital complex
Submucous fibrosis release
Multiple implants for oral rehabilitation onlay bone grafting procedure, subtotal/partial mandibulectomy/maxillectomy total
extractions with alveoloplasty
Grade 2
Sequestectomy and/or saucerization for chronic osteomyelitis of jaw
Removal of multiple (all 4) molar impactions
Closure of oroantral fistula
Multiple eoisectomies
Neuroectomies
Panfacial infection/drainage
Unilocular cystic lesion of the jaw
Multiple extractions
Grade 3
Dental implants (single)
Management of dentoalveolar fractures
Single tooth apicecotomy
Single arch alveoloplasty
Grade 4
Excision of sinus tract or scar tissue
Clw
Removal of teeth in single quadrant
Frenectomy
Removal of splints and intermaxillary sutures
Grade 5
Biopsies
Secondary suturing
94
ORTHOPAEDIC SURGERY
Supra Major
Revision joint replacement
Complex primary joint replacement requiring use of revision components
Primary joint replacement with add-on procedure
(eg. Total hip replacement with, impaction bone grafting; removal of dynamic hip screw and convert to total hip replacement)
Multiple fracture fixation
Any operative procedure of 6 hours or more
Spinal fusions
Spinal instrumentations
Multilevel discectomy
Multilevel vertebroplasty
Hind quarter/fore quarter amputations
Combination of three grade 2 procedures
Combination of two grade 1 procedures
Grade 1
Primary joint replacement/resurfacing
Bipolar hip replacement
Peri prosthetic fracture fixation
Rotator cuff repair
Meniscal repair
Combination of 2 knee procedures (eg. Anterior cruciate ligament + meniscus)
Fracture fixation with bone grafting
Fixation of more than 1 fracture
Hip arthrodesis/fusion
Single level discectomy
Lumbar spine decompression
2 level vertebroplasty
Combination of two grade 2 procedures
Combination of three grade 3 procedures
Grade 2
Austin Moore prosthesis
Removal of infected joint replacement
Core decompression
Bankart repair
Shoulder stabilizations
Biopsies secondary suturing
Superior labrum from anterior to posterior repair
Subacromial decompression or acromioplaty
Anterior cruciate ligament reconstruction
Posterior cruciate ligament reconstruction
High tibial osteotomy
Single fracture fixation
Fracture plating
External fixation
Open reduction of dislocations
Arthrodesis/fusion of joints
Drainage of deep psoas abscess
Single level vertebroplasty
Above knee amputation/arm amputation
95
Below knee amputation/forearm amputation
Repair of two tendons
Tendon transfer
Carpal tunnel decompression
Tumour curettage/excision
Grade 3
Simple knee arthroscopy
Menisectomy
Arthroscopic knee debridement
Implant removal
Closed reductions and plastering
Toe or finger amputations or amputations on small bones/joints
Single tendon repair
Skin grafting
Major biopsy
Trigger finger release
Dequervains release
Contracture release
Grade 4
Closed reductions/manipulations
Simple plastering
Spinal root canal block
Facet block
Epidural injection
Minor biopsy
Soft tissue suturing
Soft tissue debridement
Incision and drainage of abscess
Grade 5
All other procedures done under local anesthesia
96
PEDIATRIC SURGERY
Supra Major
Tetralogy of Fallot
Diaphragmatic hernia repair
Intestinal atresia surgery
Hepatic lobectomy
Biliary atresia choledochal cyst
Pectus
Ectopic vesicae
One stage severe hypospodios repair
Abdo perineal pull through
Bilateral ureteric implant abdominal tumours
Multiple organ injuries
Grade 1
Hiatus hernia repair
Intestinal strictures
Malrotation
Thoracotomy with decortication with lobectomy
Large cystic hygroma
Large hemangioma
Ureteric implant
Meningomyelocele
Pyeloplasty and renal op
Intestinal resections
Achalasia cardia
Hydatid cysts excision
Grade 2
Pyloromyotomy
Appendicectomy (open + lap)
Ventriculo peritoneal shunt
Cystic hygroma excision
Hemangiornas excision
Herniotomy
Orchiopexy
Incision and drainage (large retropharyngeal abscess + renal abscess + psoas abscess)
Umbilical hernia repair
Exchange blood transfusion
Cleft lip/palate repair
Gynecomastia
Gastrotomy
Colostomy
Intussusception
Brachial and thyroglossal cyst excision
Scopes with procedures
Cystolithotomy
Sacral dermal sinus excision
Grade 3
Circumcision
Incision and drainage under general anesthesia
Confused lacerated wound under general anesthesia
97
Diagnostic scopes
Intercostal drainage under general anesthesia
Liver/kidney biopsies
Rectal polypectomy
Thierch’s operation
Para rectal injection
Tongue tie release
Submucous cysts
Dermoid cysts under general anesthesia
Sebaceous cyst under general anesthesia small haematoma + lymph
Sinuses with skin tags – lymph node biopsies
Grade 4
Urethral dilation
Examination under anesthesia
Incision and drainage under local anesthesia
Intercostal drainage under local anesthesia
Contused lacerated wound under local anesthesia
Anal stretching
Cysts excision under local anesthesia
Grade 5
Umbilical polypectomy
Dressings
Suture removal
Note: Neonatal surgery + surgery on children below 6 months should go one grade higher. Bilateral surgery one grade higher.
98
RECONSTRUCTIVE SURGERY
Supra Major
Craniofacial reconstructions
Head and neck resections with primary reconstruction
Head and neck reconstructions of multiple units of the face
Major reconstructions for full thickness loss of the walls of the trunk
Extensive surgery involving more than one surgical discipline
Limb replantation of multiple units
Limb replantation with a simultaneous free flap cover
Microvascular limb transplantation
Participation of other disciplines to be billed as per the schedule of that discipline
Whole body contouring
Any operative procedures of 6 hours duration or more will be considered as Supra-major surgery
Grade 1
Microvascular flaps
Microvascular limb replantation
Head and neck reconstructions
Primary Reconstructions with local tissue transfers
Secondary cleft deformities: more than two components, lip, alveolar, bone graft, palate, pharynx, septoplaty or rhinoplasty.
Face lift
Penoscrotal hypospadias
Extensive scarring (more than 3 hours surgery)
Bilateral breast reduction
Abdominoplasty
Multiple lipectomies/liposuction – 3 to 4 areas
Grade 2
Localized face-lift
Cleft lip and palate simultaneous repair
Hypospadius – one stage of a staged repair
Perineal hypospadias
Extensive scarring (more than 2 hours of surgery)
Multiple contracture (2 to 3)
Septo-rhinoplasty
Release of two syndactylies
Blepharoplasty (4 lids)
Bilateral mastopexy
Bilateral breast implants
Multiple lipectomies/liposuction – 1 or 2 areas
Grade 3
Cleft lip repair
Cleft palate repair
Scar revision (major)
Hypospadius, a stage of the repair
Epispadias, etc., a stage of the repair
Post-burn contracture (single)
Rhinoplasty
Blepheroplaty (2 lids)
Bed sores
Various distant flaps (transfer)
Temperomandibular joint ankylosis (unilateral)
99
Congenital deformities of hand syndactyly, etc.
Gynecomastia
Local flaps (lasting for more than 2 hours)
Nerve and tendon repair
Skin graft (for extensive defect procedure more than 1.5 hours)
Forehead lift
Eyebrow lift
Grade 4
Scar revision (intermediate)
Blepharoplasty local flap
Skin graft (for small defects procedure less than 1.5 hours)
Dressings under anesthesia
100
UROLOGY
Any operative procedure of 6 hours duration or more will be considered as supra major surgery.
Supra Major
Renal transplant – living
Renal transplant – cadaveric
Grade 1
Donor nephrectomy
Bilateral adrenal surgery
Bench surgery for kidney
Anatropic nephrolithotomy
Reno vascular surgery
Total cystectomy with diversion
Radial prostatectomy
Augmentation cystoplasty
Radical inguinal lymphadenectomy – bilateral
Radial nephrectomy
Nephroureterectomy
Lap nephrectomy
Radical cystectomy
Lab donor nephrectomy
Total cystectomy
Bilateral ureteric reimplantation
Grade 2
Unilateral adrenal surgery
Partial nephrectomy
Percutaneous nephrolithotomy
Uretero renoscopic surgery
Pyeloplasty
Endopyelotomy
Bowel replacement of ureter
Ileal conduit
Urinary unidiversion
Surgery for post prostatectomy incontinence
Total penectomy
Radical inguinal lymphadenectomy – unilateral
Uretero neocystostomy – bilateral
Surgery for retroperitoneal fibrosis – unilateral
Extended pyelolithotomy
V.V.F. repair (vesicovaginal fistula)
Surgery for stress incontinence
Repair of epispadias
Repair of hypospadias – one stage repair
Grade 3
Simple nephrectomy
Simple pyelolithotomy
Uretero lithotomy
Nephrolithotomy
Operations for renal cysts
Stone basketing
Ureterectomy
101
Cutaneous ureterostomy
Ileo ureterostomy
Ureteric reimplantation – unilateral
Surgery for R.P.F. – unilateral
Trans urethral resection bladder tumour
Open prostatectomy
Trans urethral resection – prostate
Partial cystectomy
Partial amputation of penis
Excision of bladder diverticiulum
Staged urethroplasty
Resection of posterior urethral valves
Urethrectomy
Epididymectomy
Orchidectomy
Vasovasotomy
Vaso epididymostomy
Orchiopexy
Cystoscopic teflon injection for reflux
Uretero ureterostomy
Uretero colic anastomosis
Penile prosthesis
Repair of hypospadias – staged
Bilateral varicocelectomy
Release of chordee
Transobturator tape
Grade 4
Arteriovenous fistula
Unilateral varicocelectomy
Percutaneous nephrostomy
Drainage of perinephric abscess
Cystoscopy retrograde pyelography
Double J stenting
Cystoscopy + biopsy
Cystolitholapaxy
Cystolithotomy
Extraction of urethral calculi
Testicular biopsy
Varicocele surgery
Surgery for hydrocele
Vasectomy
Circumcision
Meatoplasty
Optical urethrotomy
Continuous ambulatory peritoneal dialysis catheter insertion/removal
Diagnostic cystoscopy
Cysto visual internal urethrotomy
Renal biopsy
Cystoscopy fulgaration
Grade 5
102
Urethral dilation
Prostatic biopsy
Arteriovenous shunt
Urethral catheterization
Supra pubic cystostomy
Drainage of abscess-scrotal, prostatic
Meatotomy
Cystoscopy
Cystoscopic stent removal
N.B.: All laparoscopic operations to be graded on same scale as their open surgery counterparts.
103
Appendix 2.8: A Novel Web-Based Strategy to Identify Non-Governmental Actors
in Global Surgery.
STUDY METHODOLOGY
JOSHUA S NG-KAMSTRA, SUMEDHA ARYA, TIMOTHY E CHUNG, BRAD WESTON, CLAUDIA
FRANKFURTER, JOHANNA N RIESEL, TINO KREUTZER, JOHN G MEARA
We sought to catalogue and describe all NGOs providing surgical care in low and middle income countries
(LMICs). For this purpose, delivery of surgical care by an NGO was narrowly defined as the manipulation
of tissues taking place within an operating room, and was distinguished from the financial or logistical
support of such care. Non-governmental organizations were defined by the UNROL definition as “not-forprofit group[s], principally independent from government. . .organized on a local, national or international
level to address issues in support of the public good.”1 LMICs were identified by their respective World
Bank lending groups, including upper-middle, lower-middle, and low-income countries.2 Only
organizations with evidence of surgical delivery available on the web (mission statements, reports, trip
schedules, photos, or testimonials) were included. NGOs with one or more national or regional branches
were counted only once. This included the 191 national societies of the IFRC, the 24 national and regional
boards of MSF, and the 15 national branches of Medecins du Monde, each of which may engage in surgical
delivery to varying degrees.3-5
Several strategies were used to identify NGOs, with all searches completed in September 2014. First, an
attempt was made to identify organizations providing surgery during humanitarian disasters. ReliefWeb, an
online service of the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA),
provides an Application Program Interface (API) service listing all organizations reporting data to
UNOCHA.6 These were then screened for inclusion according to the above definition. Next, an attempt was
made to identify organizations providing surgery in non-disaster settings. We used Idealist.org, an online
clearinghouse including data on 92,262 NGOs at the time of review.7 A Boolean search string was
developed to capture all organizations involved in surgical delivery, and the resulting organizations were
similarly screened. Third, we used the method of Casey and McQueen to improve yield, incorporating
organizations from the Society of Pediatric Anesthesia, Operation Giving Back, and US State Department
Private Volunteer Organizations (PVO) registry databases.8-11 Fourth, we included organizations surveyed
by Nguyen, et al, in a study of NGO delivery of pediatric cardiac surgery.12 We completed a PubMed
search using terms related to “nongovernmental organizations”, a variety of surgical specialties and
procedures, and LMIC country names, and extracted organization names from relevant results.
Furthermore, we incorporated a list of organizations provided by a collaborating group resulting from a
search of the GuideStar database.13 Finally, we screened all Twitter followers of the Lancet Commission on
Global Surgery for organizations meeting inclusion criteria.14
104
Once duplicate organizations were eliminated, the resulting screened organizations were then subjected to a
careful review of their websites, extracting data on the location of each organization’s headquarters, its
model of engagement, countries of care delivery, and surgical specialties offered. Short-term missions were
defined as those lasting <30 days, while long-term engagement was defined as permanent presence or
repeated trips to the same sites. Humanitarian surgical care was defined as the provision of surgery during
public health crises or following natural disasters. For organizations providing surgical care in addition to a
broader suite of health and development interventions, we attempted to list only countries in which the
organization provided surgery. Where such information was not available, we assumed surgical delivery in
all of the organization’s country sites.
There were several limitations of this approach. First, our search strategy was biased toward organizations
based in the US and with websites in English. Second, although numerous data sources were employed, it
is difficult to determine whether this review is exhaustive. We did not study surgical volumes or
organizational lifespans, which are critical areas of further research to determine the total and relative
contribution of the charitable sector to global surgical delivery.
REFERENCES
1.
United Nations Rule of Law. Non-governmental organizations. 2014.
http://www.unrol.org/article.aspx?article_id=47 (accessed September 24 2014).
2.
The World Bank Group. Country and Lending Groups. 2014.
http://data.worldbank.org/about/country-and-lending-groups (accessed September 24 2014).
3.
International Federation of Red Cross and Red Crescent Societies. Where we work. 2014.
http://www.ifrc.org/en/what-we-do/where-we-work/ (accessed September 8 2014).
4.
Medecins Sans Frontieres. National and regional boards. 2014. http://association.msf.org/nationalboards (accessed September 8 2014).
5.
Medecins du Monde. Reseau International. 2014. http://www.medecinsdumonde.org/Medecinsdu-Monde/Reseau-international (accessed September 8 2014).
6.
ReliefWeb. ReliefWeb API. 2014. http://reliefweb.int/about (accessed September 24 2014).
7.
Idealist.org. Idealist. 2014. http://www.idealist.org/contact-us (accessed September 24 2014).
8.
McQueen KA, Hyder JA, Taira BR, Semer N, Burkle FM, Jr., Casey KM. The provision of
surgical care by international organizations in developing countries: a preliminary report. World J
Surg 2010; 34(3): 397-402.
9.
Society for Pediatric Anesthesia. Volunteer Medical Services Abroad. 2014.
http://www.pedsanesthesia.org/vmsa_search.iphtml (accessed September 24 2014).
10.
Operation Giving Back. Resources by Specialty. 2014.
http://www.operationgivingback.facs.org/content2342.html (accessed September 24 2014).
11.
US Agency for International Development. Private Voluntary Organizations. 2014.
http://www.pvo.net/usaid/index.html (accessed September 24 2014).
12.
Nguyen N, Jacobs JP, Dearani JA, et al. Survey of nongovernmental organizations providing
pediatric cardiovascular care in low- and middle-income countries. World journal for pediatric &
congenital heart surgery 2014; 5(2): 248-55.
13.
GuideStar. GuideStar Nonprofit Directory. 2014. http://www.guidestar.org/Home.aspx (accessed
September 24 2014).
14.
GSCommission. The Lancet Commission on Global Surgery: official Twitter account. 2014.
https://twitter.com/GSCommission (accessed September 24 2014).
105
Workforce, Training, and Education (WTE)
106
Appendix 3.0: Workforce, Training And Education Key Findings
•
•
•
•
•
The surgical workforce is a diverse network of individuals who collectively contribute to the delivery
of surgical and anaesthesia care
There are over 2 million specialist surgeons, anaesthesiologists, and obstetricians in the world but their
distribution is not commensurate with population size and need; the poorest half of the global
population is served by only a fifth of the global specialist surgical workforce
To meet projected population needs by 2030, today’s surgical workforce would need to double in 15
years. Task sharing in combination with scale-up of specialist surgical and anaesthetic providers may
be an appropriate means of achieving workforce goals
Accreditation, licensing, and continuing professional development, shown to improve quality of the
provision of care, are poorly documented around the world
Rural surgical and anaesthesia care is underemphasized in graduate and post-graduate surgical and
anaesthetic education contributing to the mal-distribution of surgical and anaesthetic providers
worldwide
107
Appendix 3.1: The Surgical Workforce
The health workforce involved in the delivery of surgical care consists of an interdependent network of
clinical and non-clinical professionals involved in healthcare delivery, administration, management,
training, and monitoring.1 A common perception of “surgery” is that of a surgeon and an anaesthetist alone
in a sterile environment. However, a more accurate depiction encompasses an interdependent network of
individuals working in harmony to deliver safe, affordable surgical and anaesthetic care. This includes, but
is not limited to: community health workers (CHWs), hospital managers, theater technicians, a
heterogeneous group of providers, including consultant surgeons, anaesthetists and obstetricians as well as
those still in-training, generalist physicians providing surgical care, associate clinicians providing surgical
and anaesthetic care, educators and educational stakeholders, rehabilitation specialists, technicians and
diagnosticians in laboratory and radiology science (Figure 1). Clinical leadership, monitoring, evaluation,
and care provision are equally important to the necessary delivery of safe, effective surgical and anaesthetic
care. Although workforce considerations for surgical and anaesthetic care extend well beyond the provision
of frontline clinical care, in this section we will focus on issues pertaining primarily to surgical and
anaesthetic providers.
Surgical
Provider
Rehabilitation
Specialists
Trained
Theater Staff
Hospital
Managers
Anaesthetic
Provider
The
Surgical
Workforce
Technical
Support Staff
Perioperative
Nurse
Radiologist/Pat
hologist
Laboratory
Staff
Community
Health Worker
Figure 1 The Surgical Workforce
108
Appendix 3.2: The Global Surgeon, Anaesthesiologist, and Obstetrician Workforce
Thresholds and 2030 Projections
STUDY METHODOLOGY
HAMPUS HOLMER, MARK G. SHRIME, JOHANNA N. RIESEL, JOHN G. MEARA, LARS
HAGANDER
National data on the density of specialist surgeons, anaesthesiologists, and obstetricians per 100 000
population, from Holmer et al 20151, were compared to the most recent national maternal mortality ratio
(per 100 000 live births, modelled estimate; MMR)2. A regression line was fit between provider density and
the logarithm of MMR and the percent change in MMR per 10 unit change in provider density was
expressed with 95% confidence interval. The correlation was explored for an upper and a lower density
threshold. Thresholds were identified as particularly steep improvements were seen from 0 to
approximately 20 providers per 100,000 population, and a flatter gradient above approximately 40
providers per 100,000 population.
The global median in MMR was calculated (67·5 maternal deaths per 100 000 live births). The formula of
the regression line between surgeon, anaesthesiologist and obstetrician density and the logarithm of MMR
was used to derive the approximate MMR level at each threshold (103·5 and 36·3, respectively). The
global median was centred almost exactly between the two thresholds of 20 and 40 providers per 100 000
population.
The thresholds were also symmetrically distributed around the estimated global need of surgical
procedures, as calculated by multiplying the density with the average productivity of surgical procedures
per surgical specialist globally each year3. We calculated the average productivity for surgeons and
obstetricians (with anaesthesiologists analysed separately as they would typically work side by side with
the operating surgeon or obstetrician) to be 196 operations per surgeon and obstetrician per year (or 569
operations per anaesthesiologist). Using the global proportion of anaesthesiologists to surgeons and
obstetricians, we were able to convert the thresholds to represent only surgeons and obstetricians (15 and
30 per 100 000 respectively). By multiplying the average productivity of surgeons and obstetricians with
the corresponding threshold densities, we obtained the number of operations per 100 000 population at each
density level (2917 and 5834 per 100 000, respectively). The global estimate of the number of surgical
operations needed annually presented by Rose et al.3 (4661 per 100 000) was found to be almost exactly
between the two thresholds of 20 and 40 providers per 100,000 population.
Based on imputed and absolute numbers of providers by income category, divided by the total population
of each category, we established that the suggested thresholds roughly corresponded to the current provider
densities in the lower-middle income (16 per 100 000) and upper-middle income countries (38 per
100,000), respectively.
For countries with a provider density below the respective threshold (i.e. excluding all countries with a
density above those levels), we compared the current number of providers with the number needed to reach
each threshold. The number of providers was calculated using absolute or imputed national densities from
Holmer et al.1 multiplied by the population in 2012 by country. By subtracting the needed number with the
current number of providers, we were able to quantify the gap between the current and needed surgical
workforce.
REFERENCES
1. Holmer H; Lantz A; Finlayson S; Hoyler M; Siyam A; Montenegro H; Kelley E.T; Campbell JC, M;
Hagander, L The Global Distribution of Surgeons, Obstetricians and Anaesthesiologists. The Lancet
Global Health in press; 2015.
2. World Bank. Data: Maternal mortality ratio (modeled estimate, per 100,000 live births). 2015.
http://data.worldbank.org/indicator/SH.STA.MMRT (accessed January 25 2015).
3. Rose J, Weiser TG, Hider P, Wilson L, Gruen R, Bickler SW. Estimated need for surgery worldwide
109
based on prevalence of diseases: implications for public health planning of surgical services. The Lancet
Global Health in press; 2015
110
Appendix 3.3: Surgical Volume and The Surgical Workforce
While counting the number of surgical and anaesthetic providers alone cannot guarantee surgical
productivity, they do correlate with surgical volume (Figure 1). While it is not surprising that the higher the
density of the surgical workforce, the higher the number of surgical procedures performed, it is reassuring
that counting the number of surgeons, anaesthetists, and obstetricians per country is not as misleading as
some might suspect. Rather it is a reasonable first step in creating a National Surgical Plan that can later be
expounded with further information once it available.
Average imputed surgical rate (per
100,000; log scale)
100000
10000
1000
r=0.69
2
r =0.47
100
10
0.1
1
10
100
1000
Number of specialist surgical providers (per 100,000; log scale)
Figure 1 Relation between number of major surgeries1 and number of specialist surgeons,
anaesthetists and obstetricians2, logarithmic scale
REFERENCES
1. Weiser TG, Haynes AB, Molina G, Lipsitz SR, Esquivel M, Uribe-Leitz T, Fu R, Azad T, Chao
TE, Berry WR, Gawande AA. The global volume of surgery, cesarean delivery, and life
expectancy in 2012. Currently under review. 2015
2. Holmer H; Lantz A; Finlayson S; Hoyler M; Siyam A; Montenegro H; Kelley E.T; Campbell, J;
Cherian, M; Hagander, L. The Global Distribution of Surgeons, Obstetricians and
Anaesthesiologists. Currently under review. 2014
111
Appendix 3.4: Geospatial Mapping to Estimate Timely Access to Surgical Care in
Nine Low-and-Middle Income Countries
STUDY METHODOLOGY
NAKUL RAYKAR, ALEXIS BOWDER, MARTHA VEGA, JONG KIM, GLORIA BOYE, CHARLES
LIU, SARAH GREENBERG, JOHANNA RIESEL, ROWAN GILLIES, JOHN MEARA, NOBHOJIT
ROY
DATA COLLECTION AND SOURCES
Information detailing surgeon and practice locations within countries was obtained through Ministries of
Health, surgical or medical professional societies, providers or researchers with in-country knowledge of
surgeon distribution, medical school and provider registration databases, and the published literature. Data
for Sierra Leone, for example, referenced in the report, was obtained from the research team led by Hakon
Bolkan (Norwegian University of Science and Technology),1 and consisted of a detailed review of all
hospitals in Sierra Leone and the number of full-time-equivalent (FTE) surgeons operating in each hospital.
ESTABLISHING COVERAGE ZONES ON GOOGLE MAPS ENGINE API
Hospitals locations were identified and geocoded on Google Maps Engine API and thereafter de-identified
and only referenced based on municipal location.2 Google Maps Engine API was used to identify 2-hour
driving distances from each geocoded location based on all major roadways leading into the municipality in
which the hospital resided. Where documented roads were present, 2-hour distances were calculated off of
major roadways into minor roads. Where these were not present, an approximate 10 km distance in each
direction off the major roadway was included in the coverage zone.
CALCULATING COVERAGE ZONE POPULATIONS
The outlined coverage zones in Google Maps Engine API were transposed to NASA’s
Socioeconomic Data and Applications Center (SEDAC) Population Estimation Service to estimate
population sizes residing in coverage zones.3 SEDAC relies on 2005 population data.
DATA ANALYSIS AND PRESENTATION
Populations of coverage zones were compared to full-country populations from comparable SEDAC data to
establish proportions of the country populations with and without access to surgical care.
REFERENCES
1. Hakon Bolkan et al. Hospital Infrastructure and Human Resource Evaluation for Sierra Leone.
Unpublished, 2014.
2. Google Maps Engine API, https://developers.google.com/maps-engine/; accessed January 2015.
3. NASA’s Socioeconomic Data and Applications Center (SEDAC) Population Estimation Service,
http://sedac.ciesin.columbia.edu/tools/population-estimation-mapclient, accessed January 2015.
112
Appendix 3.5: Task Shifting Around the World
STUDY METHODOLOGY
FREDERIK FEDERSPIEL, SWAGOTO MUKHOPADHYAY, PENELOPE MILSOM, JOHN W SCOTT,
JOHANNA N RIESEL, JOHN G MEARA
DATABASE SEARCHES
We followed the 2009 PRISMA guidelines for review without meta-analysis.1 Data for this review were
identified by searches of PubMed on August 17, 2014, yielding 4111 records, and an additional 9 databases
on August 29, 2014: Embase, The Cochrane Library, CINAHL, WHOLIS and 5 regional databases (AIM,
LILACS, IMEMR, IMSEAR and WPRIM), adding a total of 640 records. Our search string consisted of 4
components: 9 database-specific subject heading terms for healthcare personnel (e.g. ”Allied Health
Personnel Statistics”), ”OR”, 50 variations of 15 associate clinician terms (e.g. ”nurse practitioner”),
”AND”, 14 variations of 9 general terms for surgery, anaesthesia, and obstetrics (e.g. anaesthetist), ”AND”,
database-specific subject heading terms for geographic locations in general. All terms within the
components were combined with ”OR”. References of included articles were screened for potential
relevancy.
INCLUSION CRITERIA
Articles published from January 1, 1995 to August 17, 2014 with title or abstract mentioning surgical or
anaesthetic care provision by non-specialist physicians or associate clinicians, where associate clinicians
included physician assistants, nurse practitioners, nurse anaesthetists, medical officers, clinical officers,
surgical technicians, Técnicos de Cirurgia, anaesthesia technicians, anaesthetic care practitioners,
anaesthesia assistants, anaesthetic technical officers and anaesthetic medical assistants.
EXCLUSION CRITERIA
Articles that focused on ophthalmologic or odontologic main topics, task shifting of diagnostic or
outpatient procedures, non-English language, or opinion pieces.
GREY LITERATURE AND REGIONAL SURVEYS:
Grey literature was searched with a hand search of the WHO Global Health Workforce Alliance website
adding 168 records.2 To obtain data on countries not found in our literature searches, and to resolve
conflicts encountered in published data we directly emailed surgical and anaesthetic professionals in these
countries with an un-validated survey consisting of a standard inquiry asking whether or not surgical or
anaesthetic task shifting was currently occurring in these countries and whether it was occurring under
supervision. These countries were: Australia, Bolivia, Brazil, Colombia, Canada, Dominican Republic,
Equator, Egypt, Honduras, Mexico, Mongolia, Myanmar, Nicaragua, New Zealand, Panama, Peru,
Somalia, Sri Lanka and United Kingdom. All professionals contacted responded to our inquiry.
REVIEW PROCESS:
Three reviewers conducted a primary screening of titles and abstracts of all records so that each record was
screened for eligibility by two independent reviewers. Any discrepancies in decisions on eligibility between
the two reviewers were resolved by consensus between all three reviewers. Decision on eligibility for fulltext review was reached by consensus among all three reviewers. To ensure the data would not be
dominated by literature from single countries with large bodies of literature, we introduced a 10-article
limit per country. This showed only to affect USA and UK (61 relevant articles in total). A total of 10
articles from each of these 2 countries published over the recent 10 years were randomly selected for fulltext review, removing 41 additional articles.
113
DATA EXTRACTION AND ANALYSIS:
Data on which health cadres, if any, were performing task shifting in each country, the types of tasks
performed, the presence of a training program for the given profession and whether given tasks were
performed under supervision were extracted where available and the data were compared across regions
and income groups.
REFERENCES
1. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement. Journal of clinical epidemiology. 2009;62(10):1006-12.
2. WHO Global Health Workforce Alliance. Available from: http://www.who.int/workforcealliance/en/
114
Appendix 3.6: Surgical, Anaesthetic, and Obstetric Training Paradigms
STUDY SUMMARY AND METHODOLOGY
FREDRIK OHER AND JOHANNA N RIESEL
There are no comprehensive reports on surgical, anaesthetic, or obstetric training programs around the
world. As we move forward in surgical and anaesthetic training, it is important that we reflect on our
current practices and search for ways to improve them. Learning from other countries can be helpful in this
practice. To better understand the possibilities and variations in training, we endeavoured to obtain
descriptions of surgical and anaesthetic training programs around the world, across all World Bank income
categories and WHO regions.
STUDY DESIGN
This study was designed as a cross-sectional survey. In the fall of 2014, physicians around the world were
contacted and asked to fill out a questionnaire regarding surgical, obstetric, and/or anaesthesia training in
their country. Physicians were identified via relevant papers (often as corresponding authors), personal
contacts, and national and international colleges of surgeons, anaesthetists, and obstetricians (Figure 1). To
minimize the risk of misinterpretation or misunderstanding, data was summarized in a table, and survey
respondents were at a later stage asked to verify the information pertaining to their country. All WHO
member countries were eligible to be part of this survey. However, we prioritized countries with larger
populations and countries where data was readily available.
DATA PRESENTATION AND STATISTICAL ANALYSIS
Data was stratified according to World Bank income categories. Ordinal data was expressed with median
(range) when non-normally distributed, and mean (SD) if normally distributed. Dichotomous data was
expressed with percentages or proportions.
Data was obtained from survey respondents in 40 countries for surgery, 30 countries for anaesthesiology,
and 32 countries for obstetrics. At the deadline for this publication, the survey respondents had verified the
data (for their country) in all but 5 countries for surgery, 2 for anaesthesiology, and 2 for obstetrics.
Figure 1: Survey Respondents by Country.
115
World Bank
Income
Category
N
Median
Minimum Years in
Medical School
(Range)
Median
Minimum years
of post-graduate
pre-residency
years 1 (Range)
Median Minimum
years of primary
residency 2 (Range)
Do trainees receive a
salary or pay tuition
for residency?
Are rural
placements
required during
residency?
Is passing a final
exam required to
practice as a
surgeon, anaesthetist
or obstetrician?
Are work hours
regulated in
residency?
Are residency
programs monitored
for quality by any
national or
international
institution?
Are there any official
Continuing
Professional
Development (CPD)
requirements?
Surgery
LIC/LMIC
40
13
6 (4·5-8)
1 (0-3)
4 (2-5)
Yes 31 %
No 69 %
Yes 92 %
No 8
Yes 8 %
No 92 %
Yes 54 %
No 46 %
Yes 46 %
No 54 %
UMIC
10
6 (4-7)
0 (0-4)
4·5 (2-6)
Salary 69 %
Tuition 23 %
Both 8 % 3
Salary 100 %
Yes 70 %
Optional 30 %
Yes 70 %
No 30 %
17
6 (4-7) 4
0 (0·2)
5 (2-8)
Salary 88 %
Both 6 %3
Variable 6 % 5
Yes 76 %
No 24 %
Yes 40 %
No 50 %
Variable 10 %
Yes 71 %
No 29 %
Yes 60 %
No 40 %
HIC
Yes 20 %
No 60 %
Variable 20 %
Yes 24 %
No 65 %
Variable 12 %
Yes 88 %
No 12 %
Yes 65 %
No 35 %
Anaesthesia
LIC/LMIC
30
12
5·5 (4·5-8)
1 (0-3)
3 (2-4)
Yes 17 %
No 67 %
Variable 17 %
Yes 83 %
No 17 %
Yes 8 %
No 92 %
Yes 50 %
No 50 %
Yes 42 %
No 58 %
UMIC
6
5·5 (5-7)
1 (0-4)
4 (2-5)
Salary 58 %
Tuition 25 %
Both 8 %3
Variable 8 %5
Salary 100 %
No 83 %
Variable 17 %
Yes 83 %
Optional 17 %
Yes 50 %
No 50 %
Yes 67 %
No 33 %
HIC
12
6 (4-7)4
1 (0-2)
5 (2-7)
Salary 100 %
Yes 8 %
No 83 %
Variable 8 %
Yes 75 %
No 25 %
Yes 75 %
No 25 %
Yes 50 %
No 33 %
Variable 17 %
Yes 92 %
No 8 %
Obstetrics
LIC/LMIC
32
11
6 (4·5-7)
1 (0-3)
4 (2-5)
Yes 50 % 6
No 50 %
Yes 91 %
No 9 %
Yes 9 %
No 91 %
Yes 45 %
No 55 %
Yes 50 %6
No 50 %
UMIC
10
6 (4-7)
0·5 (0-4)
4 (2-5)
Salary 64 %
Tuition 27 %
Variable 9 %5
Salary 100 %
6 (4-7)4
1 (0-2)
5 (3-7)
Yes 70 %
No 20 %
Variable 10 %
Yes 91 %
No 9 %
Yes 50 %
No 50 %
11
Yes 70 %
No 20 %
Optional 10 %
Yes 64 %
No 36 %
Yes 40 %
No 60 %
HIC
Yes 10 %
No 80 %
Variable 10 %
Yes 27 %
No 64 %
Variable 9 %
Salary 82 %
Both 18 %3
Yes 82 %
No 18 %
Yes 67 %
No 33 %
Yes 64 %
No 36 %
Table 1. Post-graduate education stratified by income and field
Can include internships, social service, minimum time to prepare for entrance exam, and similar.
Defined as the level of training where after completion you are called a surgeon (or anesthesiologist or obstetrician) and are allowed to practice individually in at least some parts of the country.
Synonymous with specialist or post-graduate or mMed training.
3 Indicates that the trainee receives a salary/stipend but is also required to pay a fee/tuition
4 Includes the United States and Canada where the pre-med years required to enter medical school have not been included
5 Throughout that country, practices of receiving a salary or paying tuition vary between programs
6 Data only available for 10 countries for this question
1
2
116
REFERENCES
1. Pollett, W.G. and B.P. Waxman, Postgraduate surgical education and training in Canada and Australia: each
may benefit from the other's experiences. ANZ J Surg, 2012. 82(9): p. 581-7.
2. Collins, J.P., et al., Surgical education and training in Australia and New Zealand. World J Surg, 2008.
32(10): p. 2138-44.
3. Ferreira, E.A. and S. Rasslan, Surgical education in Brazil. World J Surg, 2010. 34(5): p. 880-3.
4. Wan, Y.C. and Y.I. Wan, Delivering surgical training in the People's Republic of China: Are current
mechanisms adequate? International Journal of Surgery, 2008. 6(6): p. 443-445.
5. Shen, B.Y. and Q. Zhan, Surgical education in China. World J Surg, 2008. 32(10): p. 2145-9.
6. Udwadia, T.E. and G. Sen, Surgical training in India. World J Surg, 2008. 32(10): p. 2150-5.
7. Ito, Y., Surgical education and postgraduate training in Japan. World J Surg, 2008. 32(10): p. 2134-7.
8. Lum, S.K. and A.C. Crisostomo, A comparative study of surgical training in South East Asia, Australia and the
United Kingdom. Asian J Surg, 2009. 32(3): p. 137-42.
9. Itani, K.M., et al., Training of a surgeon: an international perspective. J Am Coll Surg, 2007. 204(3): p. 47885.
10. Cervantes, J., Surgical education in Mexico. World J Surg, 2010. 34(5): p. 875-6.
11. Ojo, E.O., et al., Post-graduate surgical training in Nigeria: The trainees' perspective. Niger Med J, 2014.
55(4): p. 342-7.
12. Bode, C.O., C.C. Nwawolo, and O.F. Giwa-Osagie, Surgical education at the West African College of
Surgeons. World J Surg, 2008. 32(10): p. 2162-6.
13. Talati, J.J. and N.A. Syed, Surgical training programs in Pakistan. World J Surg, 2008. 32(10): p. 2156-61.
14. Kevau, I. and D.A. Watters, Specialist surgical training in Papua New Guinea: the outcomes after 10 years.
ANZ J Surg, 2006. 76(10): p. 937-41.
15. Degiannis, E., et al., Surgical Education in South Africa. World Journal of Surgery, 2009. 33(2): p. 170-173.
16. Galukande, M., et al., Pretraining Experience and Structure of Surgical Training at a Sub-Saharan African
University. World Journal of Surgery, 2013. 37(8): p. 1836-1840.
117
Appendix 3.7: A Systematic Literature Review on Methods for Scaling up the Anaesthesia
Workforce
SWAGOTO MUKHOPADHYAY, MD AND JOHANNA N RIESEL, MD
INTRODUCTION
To fill the current gaps in the global surgical workforce, address the large burden and backlog of surgical conditions,
and meet the demands of a growing and ageing population with increasing surgical needs, a dramatic scale-up in the
availability and accessibility of surgical and anaesthetic providers is required. However, it will not be sufficient to
simply increase the numbers of trainees in each country. Attention must be paid to improving recruitment and
retention, strengthening training and professional development, and developing appropriate regulatory mechanisms
to enhance quality, safety, and responsiveness.
In a comprehensive literature search performed for this Commission, programs that focus on sustainability,
recruitment, retention of providers, and continued access to current educational materials were found the most
effective at scaling up anesthetic training programs and therein anesthetic providers.
METHODS
To assess which methods had been previously successful in scaling up surgical workforce members in LMICs, we
conducted a comprehensive literature search, outlined in the search graphic below. In order to have a more focused
understanding of effective means of scale up, we narrowed our search to examine scale up in the anaesthetic
workforce. Anaesthetists were identified as an essential part of the surgical workforce, and programs effective in
anaesthetic training expansion were presumed generalizable to surgical workforce expansion.
RESULTS
Tools that were useful included video conferencing for teaching sessions to providers not in immediate proximity,
primary textbook donation to anaesthetists, as well as free online journal access provided by the WHO’s Health
118
InterNetwork Access to Research Initiative.4-6 The key issue of recruitment has been successfully addressed through
collaboration with Ministries of Health and accrediting bodies from the initiation of training programs.7-8
Simultaneous training of task-sharers, e.g. nurse anaesthetists, alongside anaesthesia residents has not only expanded
the skilled workforce, but has also addressed both sustainability and retaining of providers.6 Furthermore, programs
with junior and senior residents working in the same training facilities with visiting professors, instead of fully
outsourcing education to foreign nations, is an additional method employed to increase retaining of locally trained
anesthesiologists.9 The American Society of Anaesthesiologists Global Humanitarian Outreach (ASAGHO) has
quadrupled the number of anaesthesia providers in Rwanda by ‘providing a support network and elevating the status
of anaesthesia providers’.10
Barriers to scale up included: shortage of teaching faculty, emigration of junior skilled workers, and varying levels
of infrastructure with no maintenance personnel.7,11 However, overall, data on effective means of and pitfalls of
scale-up are limited. Increased research is needed in these areas to improve efficacy of efforts to increase the
surgical workforce.
REFERENCES
1. World Health O. The world health report: 2006: working together for health. 2006.
2. Holmer H; Lantz A; Finlayson S; Hoyler M; Siyam A; Montenegro H; Kelley E.T; Campbell JC, M; Hagander,
L The Global Distribution of Surgeons, Obstetricians and Anaesthesiologists Under peer review with The
Lancet Global Health; 2014.
3. Weiser TG HA, Molina G, Lipsitz SR, Esquivel M, Uribe-Leitz T, Fu R, Azad T, Chao TE, Berry WR,
Gawande AA. The global volume of surgery, cesarean delivery, and life expectancy in 2012. under review
2015.
4. Higgins NS, Taraporewalla K, Edirippulige S, Ware RS, Steyn M, Watson MO. Educational support for
specialist international medical graduates in anaesthesia. Med J Aust 2013; 199(4): 272-4.
5. Aitken H, O'Sullivan E. The International Relations Committee of the Association of Anaesthetists of Great
Britain and Ireland. Anaesthesia 2007; 62 Suppl 1: 72-4.
6. Enright A. Anesthesia training in Rwanda. Can J Anaesth 2007; 54(11): 935-9.
7. Twagirumugabe T, Carli F. Rwandan anesthesia residency program: a model of north-south educational
partnership. Int Anesthesiol Clin 2010; 48(2): 71-8.
8. Lipnick M, Mijumbi C, Dubowitz G, et al. Surgery and anesthesia capacity-building in resource-poor settings:
description of an ongoing academic partnership in Uganda. World journal of surgery 2013; 37(3): 488-97.
9. Kinnear JA, Bould MD, Ismailova F, Measures E. A new partnership for anesthesia training in Zambia:
reflections on the first year. Can J Anaesth 2013; 60(5): 484-91.
10. Edler AA, Gipp MS. Teaching NonPhysician Anesthesia Providers in Tanzania: a movement toward sustainable
healthcare development. Int Anesthesiol Clin 2010; 48(2): 59-69.
11. Newton M, Bird P. Impact of parallel anesthesia and surgical provider training in sub-Saharan Africa: a model
for a resource-poor setting. World journal of surgery 2010; 34(3): 445-52.
119
Appendix 3.8: The Scale-up of the Surgical Workforce
COUNTRY LEVEL EXAMPLES AND METHODOLOGY
KIMBERLY DANIELS, JOHANNA N. RIESEL, JOHN G MEARA
The Lancet Commission on Global Surgery found that countries with higher densities of providers per 100,000
population have improved maternal survival. In particular, a specialist surgical workforce density of less than 20/100
000 is associated with a significant decrease in maternal survival. Improved maternal survival is noted as countries
approximate a specialist surgical workforce density of 40/100,000. Beyond densities of 40/100,000 gains are still
present but less dramatically so.
Reaching a specialist surgical workforce density of 40/100,000 by 2030 is an optimum. Setting 20/100,000 as a
more realistic interim target may be more feasible. In 2030, countries can re-evaluate their workforce needs and
decide how whether to continue to scale up or diversify their workforce.
STUDY METHODOLOGY
The number of consultant surgical providers needed to reach workforce thresholds of 20/100,000 and 40/100,000 by
2030 was estimated using data on population growth and current workforce numbers. The current number and
density of surgical providers for 194 countries was collected from the WHO Global Surgical Workforce Database.1
Data on the current population size and growth rates over the next fifteen years (medium fertility projection) was
obtained from the UN Department of Economic and Social Affairs for each country.2
It was assumed that the SAO workforce will grow exponentially for countries that have not reached these thresholds
and that the rate of increase of the workforce/country would be constant over the fifteen-year period. For those
countries with current densities less than 20/100K, the current density and the projected 2030 population were used
to generate estimates to determine the number of SAO needed in in 2030 in those countries. The same was done
with a target density of 40/100K. For those countries that have a 2014 density greater than 20/100K or 40/100K,
their current density was assumed to remain constant over the next fifteen years. From these estimates we solved for
the necessary net workforce growth rate using the equation below for population growth where P = future SAO
population needed, and 𝑃𝑃0 = current SAO population and r = net workforce growth rate and t= time.
𝑃𝑃 = 𝑃𝑃0 𝑒𝑒 𝑟𝑟𝑟𝑟
To determine the rate of SAO entering the workforce from 2015-2030, the rates of retirement were added to the net
workforce growth rate in the following equation:
Net growth rate=Workforce Entry rate-Workforce retirement rate
In these calculations we assumed that the global retirement rate for SAO was between 1% and 10% and that SAO
practiced in the country where they were trained for the entirety of their medical careers [retirement rates obtained
from the Australian and New Zealand College of Anaesthetists]. We also assumed that these rates will be constant
over the next fifteen years and therefore the population will grow exponentially.
Using the previous equation, 𝑃𝑃 = 𝑃𝑃0 𝑒𝑒 𝑟𝑟𝑟𝑟 the projected number of total SAO that had to have entered the workforce
by 2030 (P) was calculated by substituting the workforce entry rate in place of the net growth rate. The current
number of SAO in 2014 was subtracted from this projected total trained to determine the total number of SAO
needed to train in the next fifteen years. From this calculation, a model was generated showing the number of SAO
needed to enter the workforce in every country, every year by setting t=1 and using r=the workforce entry rate. This
model assumes that each country can exponentially increase their SAO workforce every year starting now and that
postgraduate training positions and jobs exist to accommodate increased numbers of providers. Separate workforce
growth rates and total SAO needed to train were calculated for a retirement of both 1% and 10% and for a low,
middle, and high rate of population growth. The estimates of providers needed by 2030 were re-calculated to
incorporate surgical and anaesthetic task sharers or associate clinicians in either a 1:2 or a 1:4 Specialist:Associate
Clinicians ratio.
120
The cost to train the necessary providers in order to reach both 20 SAO per 100,000 and 40 SAO per 100,000 was
calculated for each country. Cost data for training consultant SAO in twelve countries spanning low-, middle-, and
high-income levels were found in the literature.3-6 A linear regression was created relating the natural log of each
country’s health care expenditure per capita to the natural log of the cost of medical school and post-graduate
training in that country. Using health care expenditure per capita data and the regression model, estimates for the
cost of training a surgeon, anaesthetist, or obstetrician were calculated for each country. These costs were multiplied
by the total number of SAO needed to be trained in the next fifteen years. Separate costs were calculated for
retirement rates of 1% and 10% and for low, medium, and high population growth projections of the country. The
cost to train a surgical or anaesthetic associate clinician was calculated in the same way as the cost to train a
consultant SAO. Estimates of cost were found from the literature for seven countries spanning all income levels and
a linear regression was created using health care expenditure per capita.3, 6-9 The costs were also calculated for a 1:2
or a 1:4 specialist: associate clinicians ratio. In this model we assumed that the cost to train these providers would
not change over the next fifteen years and future costs were not discounted.
The length of time in person years for each country to train the number of surgical and anaesthetic providers needed
to reach the thresholds of 20/100,000 and 40/100,000 by 2030 was also calculated. In the Lancet Commission on
Global Surgery, they found that it takes approximately 8-10 years following secondary school to train a specialist
SAO, while it usually takes five years following secondary school to train an associate clinician [3, 4, 6-8, 10-12].
The number of SAO needed to train from 2015-2030 in each country was multiplied by ten in order to determine the
number of person-years it will take to train them. A similar calculation was made for scenarios where there is a 1:2
or a 1:4 Consultant: Associate Clinicians ratio.
For all countries to reach a density of 20 surgical, anaesthetic, and obstetric providers per 100,000 by 2030, an
additional 1,272,586 providers will need to be trained. For low-income countries to do this in an SAO only model, it
will cost over 430 million USD on average. For lower-middle-income countries, this will cost over 950 million USD
on average. In the hybrid TS:SAO model, 1,272,586 surgical and anaesthetic providers also need to be trained by
2030 to meet a surgical workforce density of 20/100,000 per country, but it will decrease training costs and time by
40%. This is further illustrated in country level examples in Table 1.
Table 1. SAO Only and TS:SAO Scale-Up Models Demonstrated at the Country Level
Low-Income Countries
Lower-Middle-Income Countries
Model
SAO only
TS:SAO (4:1)
SAO only
Demonstrative Country
Kenya
The Philippines
TS:SAO (4:1)
Upper-Middle-Income Countries
SAO only
Brazil
TS:SAO (4:1)
Time in Person Years
131,448
84,710
182,006
Cost in USD
1.0Billion
361 Million
1.9 Billion
117,292
734 Million
318,685
6.1 Billion
205,375
3.1 Billion
SAO: Specialist Surgeons, Anaesthetists, and Obstetricians
TS: Task Sharers
REFERENCES
1. Holmer H; Lantz A; Finlayson S; Hoyler M; Siyam A; Montenegro H; Kelley E.T; Campbell JC, M; Hagander,
L, The Global Distribution of Surgeons, Obstetricians, and Anaesthesiologists. 2015, Submitted to the Lancet
Global Health.
2. UN World Population Prospects 2012 Total Population-Both Sexes. Accessed from http://esa.un.org/wpp/ on
January 25, 2015
3. Kruk, M.E., et al., Economic evaluation of surgically trained assistant medical officers in performing major
obstetric surgery in Mozambique. BJOG, 2007. 114(10): p. 1253-60.
4. Survey of Resident/Fellow Stipends and Benefits Report. 2013, Association of American Medical Colleges:
Online. p. 2-14.
5. Fresne, J., J. Youngclaus, and M. Shick, Medical Student Education: Debt, Costs, and Loan Repayment Fact
Card, A.o.A.M. Colleges, Editor. 2014, AAMC: Online.
121
6.
MacIntyre, P., et al., Cost of education and earning potential for non-physician anesthesia providers. AANA J,
2014. 82(1): p. 25-31.
7. Mkandawire, N., C. Ngulube, and C. Lavy, Orthopaedic clinical officer program in Malawi: a model for
providing orthopaedic care. Clin Orthop Relat Res, 2008. 466(10): p. 2385-91.
8. Mullan, F. and S. Frehywot, Non-physician clinicians in 47 sub-Saharan African countries. Lancet, 2007.
370(9605): p. 2158-63.
9. Muula, A.S., B. Panulo, and F.C. Maseko, The financial losses from the migration of nurses from Malawi. BMC
Nurs, 2006. 5: p. 9.
10. Hounton, S.H., et al., A cost-effectiveness study of caesarean-section deliveries by clinical officers, general
practitioners and obstetricians in Burkina Faso. Hum Resour Health, 2009. 7: p. 34.
11. Gessessew, A., et al., Task shifting and sharing in Tigray, Ethiopia, to achieve comprehensive emergency
obstetric care. Int J Gynaecol Obstet, 2011. 113(1): p. 28-31.
12. van Amelsfoort, J.J., et al., Surgery in Malawi--the training of clinical officers. Trop Doct, 2010. 40(2): p. 74-6.
122
Appendix 3.9: Increasing Access To Surgical Care Through Task Sharing in Malawi
NYENGO MKANDAWIRE
HEALTH WORKER TRAINING IN MALAWI
Malawi has a longstanding history of associate clinicians in surgery and anaesthesia dating to the colonial and
immediate post-colonial period when Malawian health care workers were trained on the job in government and faith
based institutions as medical assistants. Formal training of associate clinicians started in 1976, while local training
of physicians started in 1991. Malawi has a critical shortage of all cadres of health care workers with an overall
vacancy rate of 49% and needs to increase the number of health care workers from 14,039 to 34,303 to meet the
current demand.1
TASK SHIFTNG: SCOPE OF PRACTICE OF ASSOCIATE CLINICIANS
In Malawi, general clinical officers perform 90% of caesarean sections at the district hospital level, and the
postoperative outcomes of their procedures are comparable to those of medical officers.2 The training of orthopaedic
clinical officers has improved provision of basic orthopaedic care in Malawi and the programme has been reported
as a model of orthopaedic care in resource constrained countries.3
Malawi has 1 specialist ENT surgeon. He has established an ENT clinical officer training programme to increase
access to ENT services which were until recently unavailable. 15 ENT clinical officers have been trained and posted
to district hospitals. 4
To date 118 anaesthetic clinical officers and 7 specialist anaesthesiologists are registered with the medical council.
All physician anaesthesiologists are based at the referral hospitals and clinical officers provide all essential
anaesthesia services that would otherwise be unavailable in the first level hospitals.
LESSONS OF SUCCESS: POLICY AND REGULATION OF TASK SHIFTING PROGRAMS
Currently general clinical officers working in first level hospitals lack continuous supervision and mentorship. Their
training programme is not competence based and their job description has no specific limitations on scope of
practice. This is being addressed by the introduction of bachelor’s degree ‘specialist’ clinical officer who undergoes
a further 3-year training after basic qualification to deepen scientific knowledge and acquire new skills and
competencies. These clinical officers will act as mentors, supervisors and trainers of general clinical officers at the
first level as well as referral hospital level. They will also play a major role in continuing professional development
of general clinical officers. The BSc programme has also opened up the career development paths for clinical
officers which hitherto was seen as having reached a ‘dead-end’. Plans are underway to allow bachelor’s degree
clinical officers to join the medical school and be exempted from some work due to prior knowledge.
At a policy level, all stakeholders in Malawi support associate clinician programmes. As associate clinician training
programmes predate the undergraduate and postgraduate medical programmes and the numbers of doctors is small,
professional protectionism is currently minimal in Malawi. This has been essential to sustaining successful task
shifting programs.
REFERENCES
1. Health CHAICMAMMo. Health Workforce Optimization Analysis: Optimal Health Worker Allocation for Public
Health Facilities across Malawi. 2011.
2. Chilopora G, Pereira C, Kamwendo F, Chimbiri A, Malunga E, Bergstrom S. Postoperative outcome of caesarean
sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi. Human
Resource Health. 2007;5:17.
3. Mkandawire N, Ngulube C, Lavy C. Orthopaedic clinical officer program in Malawi: a model for providing
orthopaedic care. Clinical orthopaedics and related research. 2008;466(10):2385-91.
4. Mulwafu W, Nyirenda TE, Fagan JJ, Bem C, Mlumbe K, Chitule J. Initiating and developing clinical services,
training and research in a low resource setting: the Malawi ENT experience. Trop Doct. 2014;44(3):135-9.
123
Appendix 3.10 Partnering with the NGO sector for Training and Education
An example from Smile Train
ERIN STIEBER, PAMELA SHEERAN, AND ERIC HUBLI
Smile Train has trained local surgeons and medical professionals in cleft care since its founding in 1999. Their
model embodies the proverb “Give a man a fish and you feed him for a day. Teach a man to fish and you feed him
for a lifetime”. They employ simulation, online libraries, hands-on instruction and regular monitoring and evaluation
of quality to enhance the training of local providers. Their scalable model has allowed them to provide more than
1,000,000 cleft lip and palate surgeries in more than 85 countries in 15 years.
EXAMPLES OF SMILE TRAIN’S TRAINING PROGRAMS
• The Virtual Surgery Simulator: To support essential cleft lip and palate surgical training for surgeons,
non-surgeon physicians, residents, medical students and paramedical professionals in the developing
world, Smile Train developed the Virtual Surgery Simulator: a freely available, web-accessible, surgical
simulator providing instruction for cleft lip and palate surgical repair. This technology provides users
anywhere in the world with essential training on cleft lip and palate repair techniques using interactive
animated graphics, clear written and oral instructions, and actual intra-operative surgical video footage.
• Medical Research Library: Smile Train houses the world’s largest online cleft library which allows their
global partners to access information about the latest advances, best practices and research in cleft care at
no cost. This library has been used by medical professionals in more than 60 countries around the world.
• Hands-on Quality Improvement Trainings and Surgical Training Exchange Programs: Hands-on quality
improvement trainings include one-on-one training programs and small group workshops that are
organized by Smile Train to improve surgical outcomes across partner networks. These trainings and
exchange programs are often the result of needs identified through Smile Train’s Quality Assurance
Process, the Smile Train Express medical record database, or observations from Smile Train’s Medical
Advisory Boards and global staff. Many of these trainings are “South-South” collaborations. For
example, surgeons in need of hands-on training may receive a grant to train at a high-volume Smile
Train partner facility in an LMIC.
• Targeted Anesthesia Training Symposia and Courses: Smile Train offers targeted training symposia and
courses. One example is a course that provided basic lessons in safe anesthesia with a specific module
focused on care for children with clefts. All participants also received training on pulse oximetry and a
Lifebox pulse oximeter for use in their hospital.
• Safe Nursing Care Saves Lives Training Program: Smile Train developed a 3-day, train the trainer
program that provides nurses at Smile Train partner facilities with essential skills and information to
increase their competency and confidence in administering nursing care for children undergoing cleft lip
or palate surgery. The workshop has a strong focus on practical and participatory learning, and contains a
train the trainer element that provides nurse participants with information and strategies to teach and
disseminate their skills and learning when they return to their hospitals. This program was started by the
local Smile Train team in East Africa who noted a clear need to improve nursing care, especially postoperatively. Smile Train has scaled this program to support 17 Safe Nursing Care Saves Lives
workshops in 12 countries since 2011. More than 400 nurses have been trained. Upon completing the
workshop, nurses report that they are more confident practitioners who are able to deliver safer and more
effective nursing care to children undergoing cleft surgery.
• Comprehensive Training: Smile Train trains and supports a variety of medical and paramedical
professionals including speech therapists, nutritionists and psychologists to address the psychosocial
elements of cleft lip and palate conditions. Smile Train educates community health workers to address
early feeding challenges and direct patients to treatment. The organization also educates parents to
ensure they understand the implications of surgery and are able to provide optimal post-operative care.
QUALITY AND SAFETY
Smile Train tracks patient outcomes and is committed to offering targeted training and education programs to ensure
safe surgery, anesthesia and nursing care are available. An online patient database tracks patient outcomes and
ensures the quality of Smile Train surgeries around the world. All Smile Train surgeries must be uploaded to this
124
patient record database via a free, web-based program that is mandatory for all Smile Train global partners. Partners
use the database to securely load patient medical records, including clinical photographs, which are reviewed for
accountability and quality. The system allows Smile Train to verify that each record is unique and accurate. It also
allows them to review the surgical outcomes of individual surgeons to ensure quality and to implement education
and training interventions when needed.
If the surgeon meets the minimum threshold score, he or she graduates into a pool of established surgeons from
which a percentage of all cases are reviewed annually. If a surgeon does not meet the minimum threshold score, the
assessment is repeated, and if the threshold is not met after the second round of assessment, training options are
explored. When surgeons do not pass the Quality Assessment Process, Smile Train works with experts to determine
the best training mechanism with appropriate trainers.
125
Appendix 3.11: Tanzanian Tele-Education for Laparoscopic Surgery
LIAM HORGAN AND BRENDA LONGSTAFF
A collaboration has existed between Kilimanjaro Christian Medical Centre (KCMC) in Tanzania and Northumbria
Healthcare NHS Foundation Trust since 1998 to increase service capacity and create sustainable change in
Tanzania. In 2002 the directors of KCMC approached the trust to develop a new laparoscopic surgery service as a
viable solution to overcrowding on the surgical wards where occupancy frequently topped 120%..
In 2003, the first laparoscopic cholecystectomy in Tanzania was performed. As the patient was discharged home the
following day, KCMC Directors were keen to see a laparoscopic service develop at the hospital. By 2005, progress
was evident but hampered by the fact that the UK team could only travel to Tanzania once a year to continue
training. The Tanzanian surgeons had a high conversion rate during laparoscopic procedures (Figure 1). Without
ongoing apprenticeship and training, the Tanzanian surgeons found limited progress and confidence. A new
innovative approach was required to bridge the distance between the surgical teams in the UK and Tanzania.
In 2007 the partners set up a dedicated trans-continental audio-visual link between Hexham General Hospital in the
UK and Theatre 1 at KCMC so that the surgeons in the UK could mentor the Tanzanian surgeons as they were
operating. This enabled training to be fast-tracked by providing support for the Tanzanian surgeons each week and
increasing their confidence and improving their outcomes (Figure 1).
In a relatively short time KCMC was ready to host the first national laparoscopic training course in Tanzania with
the support of the UK team. Since 2008, a course has been held each year, training surgeons and nurses from across
Tanzania. By 2014 more than 500 laparoscopic procedures had been successfully completed.
The UK team has also experienced great gains from this partnership including vital insight into the challenges of
establishing a new service through distance learning. UK surgical registrars, who are part of the team, have gained
vital skills in leadership, faculty participation and project management.
The service is self-sustaining as the Tanzanian surgeons can now provide laparoscopic surgery to the population of
Tanzania as well as train others to do the same. The project was financed through the support of a Northumberland
family who believed in what could be achieved and raised funds so that it could all happen.
Figure 1: Tanzanian Laparoscopic Procedure Characteristics
126
Appendix 3.12: Health Worker Retention in The University of West Indies
JACKY FILS
The University of the West Indies (UWI) was created by the United Kingdom after World War II to serve the
Caribbean region and to promote higher education, learning, and research to address the unique infectious diseases
of the region.1-2 Currently, UWI encompasses 16 different English-speaking islands with 4 main campuses (Mona,
St Augustine, Cave Hill, and Bahamas). In the 1960s, UWI offered an undergraduate MBBS medical training
program. There were no opportunities for postgraduate training, however. Subsequently, as many as 55% trainees
traveled elsewhere for specialist training, and many did not return.3 Today, UWI boasts one of the most impressive
health worker retention rates: nearly 95% of all the surgical graduates are practicing in the region.4-5 Here we will
delineate three critical changes that led to this improvement.
First, a joint committee made of The Caribbean Health Minister’s Committee (CHMC), the UWI, and The Pan
American Health Organization (PAHO) conceived the foundation for post-graduate training as well as an oversight
committee referred to as the “Faculty of Medical Science”. Post-graduate medical education was subsequently
developed in the 1970s and more than 600 doctors have been trained with 89% of them continuing to work in the
region4.
Second, The UWI maintains a close relationship with the Ministries of Health (MOH) of the 16 English-speaking
islands it encompasses. UWI increases enrollment or adds more programs based on the MOH’s recommendation and
needs of the region.5 The CHMC was created to oversee and maintain this relationship. Thus, their contribution to
the success of UWI is critical given the importance of Government allocated facilities, trainee posts, and funding.
Third, The UWI leads by example. In its world health report in 2006 the WHO noted that one prime minister and
four ministers of health in the region are graduates of the Faculty of Medical Sciences demonstrating the virtue in
staying local. Furthermore, seven out of the eight heads of clinical departments and all section heads were trained at
UWI.4,6
Overall, UWI’s success is multi-faceted and may have had other accomplishments that contribute to their high
retention rate. It is hoped that the UWI’s success can be reproduced elsewhere to further build surgical capacity.
REFERENCES
1. Branday JM, Carpenter RA. The evolution of undergraduate medical training at the University of the West Indies,
1948-2008. The West Indian medical journal. 2008;57(6):530-6.
2. Fraser HS. The Faculties and School of Medical Sciences of The University of The West Indies at its diamond
jubilee. The West Indian medical journal. 2008;57(6):537-41.
3. Ragbeer MM. The Faculty of Medical Sciences--notes of a personal odyssey. The West Indian medical journal.
1998;47(1):5-9.
4. Eldemire-Shearer D, Roberts S. Doctor of medicine training--reflections on the UWI (Mona) experience. The
West Indian medical journal. 2008;57(6):634-8.
5. Reid R. The University of the West Indies departmental annual reports 2010-2011. 2011.
6. World Health O. The world health report: 2006: working together for health. 2006.
127
Economics and Financing (EF)
128
Appendix 4.0: Economics and Financing Key Findings
•
•
•
•
•
•
•
There is a strong case for investing in surgical and anaesthesia care within health systems in LMICs
The macroeconomic impact of surgical conditions in LMICs is substantial, and will rise considerably between
2015-2030 without significant and early investment in surgical capacity building
Basic, life-saving surgical and anaesthesia care, delivered at the first level hospital, can be very cost-effective in
LMICs
User fees at the point of care remain a predominant financing mechanism for surgical and anaesthesia care in
many LMICs: this can be impoverishing, and negatively affects equity and access to surgical and anaesthesia
care
Catastrophic health expenditure from the direct medical and non-medical costs of surgery affects a quarter of all
those accessing surgical and anaesthesia care globally, and has the greatest impact on the poorest in all
countries.
Tracking financial flows to surgery through domestic accounts and international development assistance is
currently not possible
From the financial data that is available, domestic and international contributions to surgical and anaesthesia
care are small and are not always well aligned with surgical needs in LMICs
129
Appendix 4.1: Funding Flows to Global Surgery
LILY A GUTNIK, JOSEPH DIELMAN, ANNA J DARE, MARGARITA S RAMOS, ROBERT RIVIELLO, JOHN
G MEARA, GAVIN YAMEY, MARK G SHRIME
Methods:
We identified four major funding channels from which we can estimate resources allocated to surgical efforts in low
resource settings. These include U.S. charitable organizations, foundations, USAID, and the NIH. We defined
charitable organizations as non-profit, non-governmental organizations that serve public interest. The included
organizations represent the spectrum of platforms for surgery including: short-term trips, specialized hospitals, and
self-contained platforms. Although these organizations may receive their funding from a variety of sources including
private donations, grants, government contracts, and user fees, we are only able to track aggregated funds that are
reported on federal tax form 990 (our data source).
Charitable organizations that provide exclusively surgical care were identified from the surgical volunteerism
listings on numerous websites (Table 1). Next, each listed organization website was reviewed to insure adherence to
inclusion criteria of providing exclusively surgical care in LMICs. Tax records (Form 990) provide information on
the organization’s revenue and expenses and were retrieved either from the organization website or from electronic
sources listed in Table 1. Foundations are different from the charitable organizations described above in that the
latter are both funding channels and implementation agents. In contrast, foundations are simply the grant-makers;
they do not implement a service. The Foundation Center Online Directory (FCOD) is a comprehensive digital
library that archives grants made and received by foundations and non-profit organizations. The professional FCOD
subscription was used, which has over three million grants covering the last ten years of their database. Together,
USAID (United States Agency for International Development) and NIH (National Institute of Health) are the biggest
U.S. government investors in global health. Both USAID and the NIH have online searchable databases chronicling
their funded projects, including financial allotment. The NIH has project data from 1990. USAID’s project database
begins in 1992. We constructed a separate database for each funding channel. USAID and NIH databases provided
project-level information on actual disbursed funds. For foundations, grant details including amount, grant recipient,
and specified use of funds were extracted. The grants were categorized for surgical specialty supported and the
specified purpose of the funds (e.g. earmarked dollars). We extracted data on total revenue and the breakdown of
total expenditure from the Forms 990. Due to data limitations, the most current five years of tax forms were
collected for each organization. The charitable organizations were categorized by type of surgical service they
provide. All nominal dollars were adjusted for inflation by converting to 2014 U.S dollars (USD) using the IMF
World Economic Outlook database (downloaded in April 2014). Table 1 summarizes the data sources and detailed
research methods.
Table 1: Summary of Data Source and Research Methods
Funding
Definition
Data Source
Channel
Foundations
Non-governmental entity
Foundation Center Online
that is established as a
Directory
nonprofit corporation or a
charitable trust, with a
principal purpose of
making grants to unrelated
organizations, institutions,
or individuals for
scientific, educational,
cultural, religious, or other
charitable purpose
Methods to Identify Funds towards
Global Surgery
All database keyword search
combinations of the following words:
key word searches with combinations
of “global,” “international,” “low
resource,” “developing
countries/nations” “research” and
“surgery”, “obstetrics and
gynecology,” “obstetric fistula,”
“trauma,” “injury,” “congenital birth
defects,” “cleft lip/palate,”
“cataract,” “ophthalmology,” “burn,”
“reconstructive,” “urology,”
“orthopedics,” “club foot,”
“neurosurgery,” “hydrocephalus,”
“anesthesia,” “cardiac,” and “ENT”;
manual review of results to assure it
was solely related to surgical
130
Charitable
Organizations
USAID
NIH
Non-profit, nongovernmental
organizations that serve
public interest; many of
which qualify for tax
credits. These
organizations may receive
their funding from a
variety of sources
including private
donations, grants,
government contracts, and
user fees.
United States Agency for
International
Development, U.S.
government agency
focusing on foreign
assistance to developing
countries
National Institute of
Health: U.S.- medical
research agency from the
department of health and
human services
Organization Identification:
American College of
Surgeons Operation Giving
Back, the Society of Pediatric
Anesthesiologists,
OmniMed, Foundation
Center Online Directory,
U.S. State Department
Private Volunteer
Organizations registry
Form 990: Guidestar,
ProPublica, Economics
Research Institute,
Citizenaudit.org, National
Center for Charitable
Statistics at the Urban
Institute, and the Foundation
Center Online Directory
USAID website interactive
project mapper
NIH online RePORTER
capacity building, delivery, research,
and training.
Verification of meeting definition
criteria by checking each
organization website that was listed
on the data source websites.
Manual review of each of the 524
projects listed on the online global
health interactive project mapper.
Selection of all fiscal years, selection
of all LMICs from drop down menu,
following keyword searches for all
project descriptions search box:
“surgery”, “obstetrics and
gynecology,” “obstetric fistula,”
“trauma,” “injury,” “congenital birth
defects,” “cleft lip/palate,”
“cataract,” “ophthalmology,” “burn,”
“reconstructive,” “urology,”
“orthopedics,” “club foot,”
“neurosurgery,” “hydrocephalus,”
“anesthesia,” “cardiac,” and “ENT”;
manual review of all
project to assure it was solely related
to surgical capacity building,
delivery, research, and training.
131
Appendix 4.2: Operative Volumes and per capita Government Health Expenditure
Per capita health expenditure ($US)
8000
7000
6000
5000
4000
3000
2000
1000
0
0
5000
10000
15000
Cases per 100,000 population
20000
25000
Figure 1: Operative volumes and per capita health expenditure.
132
Appendix 4.3: Surgical Procedures, Packages, and Platforms
Table 1 Example of platforms for delivery of the core surgical packages, and an outline of their basic
resourcing and staff requirements. These should be tailored to the individual needs and resources of each
country, region or district.
COMMUNITY HEALTH CENTRE
(Primary Care)
Resources
•
Community health center or small rural
hospital
•
May have a small number of inpatient
and maternity beds
•
Capable of performing minor surgical
procedures under local anaesthesia
Staff
•
Paramedical staff, nurses, midwives
•
Visiting doctors
DISTRICT HOSPITAL
(First-referral level hospital)
Resources
•
District or provincial level hospital, with
50–300 beds.
•
1+ major and 1+ minor operating
theaters
•
Recovery room &/or intensive care unit
•
X-Ray, US
•
Basic lab: CBC, U&E, urinalysis, blood
cross-match
Staff
•
Medical staff: Minimum 4 Medical
Officers, 1 General Surgical provider, 1
OBGYN
•
Anaesthetic technicians/nurses: 2
•
Nursing staff: 20
•
Midwives: 6
•
Orderlies: 6
•
Physiotherapists: 2
REGIONAL HOSPITAL
(Second-referral level hospital)
Resources
•
A referral hospital of 200-800 beds
•
Well-equipped 2+ major and minor
operating theaters
•
Supported by imaging, laboratory and
blood bank services, as well as intensive
care facilities
Staff
•
Consultant general surgeons: 2+
•
Consultant obstetrician-gynecologists:
2+
•
Consultant anaesthesiologists: 1+
•
+/- Specialist consultant surgeons
•
Nursing staff: 30+
•
Anaesthetic technicians/nurses: 4+
•
Midwives: 10+
•
Orderlies: 12+
Select Procedures Available May Include:
•
Incision & drainage under local
anaesthetic
•
Treatment of pre-cancerous
cervical lesions
Packages Available May Include:
•
Basic Trauma Surgery Package
•
Basic Emergency Obstetric
Surgical Package:
•
Basic Emergency General Surgery
Package
•
General Surgical Package, Planned
Care
•
Obgyn Surgical Package, Planned
Care
•
Palliative Surgical Package
Packages Available May Include:
•
Basic Trauma Surgery Package:
•
Basic Emergency Obstetric
Surgical Package:
•
Basic Emergency General Surgery
Package
•
General Surgical Package, Planned
Care
•
Obgyn Surgical Package, Planned
Care
•
Specialist Surgical Package,
Planned Care
•
Palliative Surgical Package
133
Information Management
134
Appendix 5.0: Information Management Key Findings
•
•
•
•
•
Comprehensive surgical and anaesthesia data is absent from major global health databases and repositories,
compromising process improvement and research
Validated and uniformly used methods to assess the burden of surgical conditions are lacking
Monitoring surgical services requires attention to the ‘preparedness’ for surgical and anaesthesia care, the
‘delivery’ of surgical and anaesthesia care, and the ‘impact’ of surgical and anaesthesia care
No standard indicators of surgical and anaesthesia care delivery have been adopted globally. Caesarean delivery
rate is the only surgically-relevant indicator commonly used by major international agencies.
There is no standardized, accepted and utilized coding system for surgical conditions or procedures; this limits the
ability to track clinical throughput as well as financial flows linked to surgical and anaesthesia care
135
Appendix 5.1: Surgical Inclusion Household Surveys
STUDY METHODOLOGY
•
•
•
•
•
•
•
•
•
Several publically available websites widely compile household data sets including the International Household
Survey Network (IHSN) and the WHO Central Data Catalog
To assess inclusion of surgical conditions within household surveys, we reviewed four of the most widely used
multinational household surveys: Multiple Indicator Cluster Surveys (MICS), Demographic and Health Surveys
(DHS), the Living Standards Measurement Study (LSMS), and the World Health Survey (WHS).
The most recent version of each survey was used: MICS5, DHS6, and the World Health Survey from 2002-2004.
LSMS versions vary by country. Therefore, LSMS for Malawi 2013 was chosen for review as it was immediately
available.
All components of each survey were queried twice. The first time we used the document’s search function to
search for 12 surgical keywords, which were words pertaining to surgery, or a condition which typically requires
surgical care. The second time we read the documents completely, looking for questions pertaining to surgical
conditions.
The surgical keywords used were: provider = surg*, operat*, inur*, accident, trauma, fall, road, transport, burn,
wound, c-section/caesarean/cesarean/caesarian, cancer/malignancy/tumor/neoplasm
Questions or indicators pertaining to surgery or a condition which typically requires surgical care were documented
Indicators identified by surgical keywords were only included if they directly or indirectly pertained to the
prevention, identification, treatment or monitoring of an actual surgical condition. For example, indicators
identified by the keyword “operat” were only counted if they referred to an operation or procedure. Indicators
referring to non-surgical foci, such as daily management of operations, were not included
Results of this query are within the main report body
The search of these surveys was done between 7.28.14 and 8.3.14
136
Appendix 5.2: Validation of Household Surveys
ALLISON F. LINDEN, REBECCA MAINE, BETHANY L. HEDT-GAUTHIER, EMMANUAL KAMANZI, KEVIN
GAUVEY-KERN, GITA MODY, GEORGES NTAKIYIRUTA, GRACE KANSAYISA, EDMOND NTAGANDA,
FRANCINE NIYONKURU, JOEL MUBILIGI, THARCISSE MPUNGA, JOHN G. MEARA, AND ROBERT
RIVIELLO
STUDY METHODOLOGY
Overview: A structured interview questionnaire to assess for the presence or absence of ten index surgical conditions
was created. Households in Burera District, Rwanda, were randomly sampled. Results from the questionnaire were
compared to the “gold standard” of a physician physical exam of participants included in the survey.
Data collection: The index surgical conditions were chosen based on their high burden of disease (defined by disability
adjusted life years (DALYs)) and/or high prevalence (based on literature reviews of surgical epidemiology in lowincome countries and supplemented by articles from middle- and high-income countries when data was unavailable).
The relevance of these conditions was verified and augmented through a focus groups held with Rwandan surgeons.
The questionnaire was forward and back translated into Kinyarwanda, the local language. Culturally-sensitive pictures
of each index surgical condition were included as part of the survey tool and shown to respondents during questioning.
The tool was pilot tested in March 2012 in Bugesera District, Rwanda, and final edits were made.
Rwandan data collectors surveyed a population cross-section throughout Burera District in March 2012. The
households identified for the study were selected based on a two-stage cluster sampling design. Thirty villages were
randomly chosen with probability proportionate to the village population size. Within a sampled village, 23 households
were selected. The first household in each village was randomly selected, with data collectors continuing to the next
nearest household until 23 households were sampled.
The structured interview, including pictures of the index surgical conditions, was programmed into the mobile data
collection platform iFormBuilder (Version 4.0, Zerion Software, Herndon, VA, USA), which was used on an iPad
(Apple Inc, Cupertino, CA, USA).
In order to validate the structured questionnaire, all surveyed villages were revisited by Rwandan general practice
physicians and surgical postgraduates within two to four weeks after being initially surveyed. The physicians
performed physical exams on all available household members to verify the presence or absence of the ten index
surgical conditions assessed by the questionnaire. This allowed for calculation of sensitivity and specificity of the
structured interview tool against the “gold standard” of the clinician exam.
Analysis: Statistical analyses were performed using Stata v12 (College Station, TX) software.
Ethics: Ethical approval for this study was obtained from: the Rwanda National Ethics Committee; and the institutional
review board of Children’s Hospital Boston, MA, USA. Written consent was obtained for both the structured interview
and the physical exams.
137
Appendix 5.3: Facility Surveys and Surgery
Multiple facility assessments currently exist, including the following surgery-specific tools:
• WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care (SAT)
• Harvard Humanitarian Initiative (HHI) Burden of Surgical Care Survey
• Surgeons OverSeas (SOS) PIPES (Personnel, Infrastructure, Procedure, Equipment and Supplies) tool
• SOS’s PediPIPES (Pediatric Surgery Personnel, Infrastructure, Procedure, Equipment and Supplies)
More broadly-focused facility surveys that also include surgical sub-components include the following:
• WHO Service Availability and Readiness Assessment (SARA)
• WHO Hospital Assessment Tool (HAT)
Additionally, many facility assessments are done using tools that are not formally or widely published, as demonstrated
in table 1 of Appendix 2.2: Infrastructure Literature Review.
138
Appendix 5.4: Registries
THE NIGERIAN TRAUMA REGISTRY
Why it was created: Lack of trauma registries in most LMICs means that comparable, high-quality data on
epidemiology, care and outcome of injury are not available. When obtainable, such data are frequently incomplete,
making them unreliable for injury surveillance, planning, prevention and control. When some form of registry exists in
LMICS, it is often entirely paper-based, making data entry and retrieval cumbersome and time-consuming. Determining
the volume and types of trauma patients treated is important to improve patient care and make data-driven resource
allocation decisions. The Nigerian National Trauma Registry was implemented for hospital performance improvement
and quality improvement purposes, as well as for provision of reliable data for trauma advocacy, resource allocation
and planning of prevention and control measures. The registry was developed as a collaborative project between
epidemiologists at the University of Wisconsin, USA and surgeons in Nigeria. Data entry commenced in April 2010,
starting with two large hospitals, one in a semi-urban area, and one in an urban area.
What is included: The information collected includes data on patient demographics, injury setting, transportation to the
hospital, injury and arrival timings, vital signs, anatomic sites involved, treatment received, mode of departure from the
emergency room, and outcomes. The trauma registry was built using REDCap (Research Electronic Data Capture),
which is a secure, web-based application. The system is password protected and approved users may only enter and
view data from their institutions.
Why it is beneficial: The benefits to Nigeria and perhaps to other parts of Africa are large. This database was the first
means Nigerian surgical providers had to actually count the number of injured patients they treated. Leading causes and
mechanisms of injury can be identified and may influence health policy-making for the country. In addition, resource
allocations for the injured can be better planned and guided by supportive data. The registry is electronic and webbased, making it less cumbersome to use and readily accessible.
Future direction: Other hospitals are gradually being recruited into the registry and expanded coverage is planned for
the entire country. An offline application is also planned to enable data capture for later upload in areas where internet
bandwidth is low.
139
Appendix 5.5: Indicator Search
STUDY METHODOLOGY:
•
•
•
•
•
•
Major global health indicator databanks were searched with 20 surgical keywords to identify indicators with a
potential surgical focus and 7 non-surgical keywords to identify indicators with a primarily non-surgical focus
The number of indictors identified by each surgical keyword were counted and compared to the number of
indicators identified each non-surgical keyword
Each specific indicator was only counted once per databank, even if it was measured by different divisions and
therefore included multiple times within a single databank
Indicators identified by surgical keywords were only included if they directly or indirectly pertained to the
prevention, identification, treatment or monitoring of an actual surgical disease. For example, indicators identified
by the keyword “operat” were only counted if they referred to an operation or procedure. Indicators referring to
non-surgical foci, such as daily management of operations, were not included
The search of these databanks was done between 7.28.14 and 8.3.14
The search included five databases. One database was searched using two search methods.
KEYWORDS
•
Surgical keywords = keywords pertaining to surgery or a disease which typically requires the expertise of a
surgically trained provider = surg*, operat*, inur*, accident, trauma, fall, road, transport, burn, wound, csection/caesarean/cesarean/caesarian, cancer/malignancy/tumor/neoplasm, anaesthe*/anesthe*
o For ease of graphical presentation, key words were grouped under the following single titles:
 Anaesthesia = anaesthesia, anesthesia
 Operation = operat*
 Wound = wound
 Burn = burn
 Surgery = surg*
 Caesarean = c-section, caesarean, cesarean, caesarian
 Injury = trauma, fall, accident, injur*
 Transport = road, transport
 Cancer = cancer, malignancy, tumor, neoplasm
•
Non-surgical keywords = keywords pertaining to diseases or efforts with a primarily non-surgical focus = HIV,
TB/tuberculosis, malaria, child, maternal, mental
o For ease of graphical presentation, key words were grouped under the following single titles:
 HIV = HIV
 TB = TB, tuberculosis
 Malaria = malaria
 Child = child
 Maternal = maternal
 Mental = mental
INDICATOR DATABASES INCLUDED
•
•
WB Data = The World Bank Data Website (indicator search) http://data.worldbank.org
WHO IMR = The World Health Organization Indicator and Measurement Registry (browse indicators)
http://apps.who.int/gho/indicatorregistry/App_Main/browse_indicators.aspx
• WHO GHOi = The World Health Organization Global Health Observatory (search by indicator)
http://apps.who.int/gho/data/?theme=main
• WHO GHOt = The World Health Organization Global Health Observatory (search by topic)
http://apps.who.int/gho/data/?theme=main
• UNICEF = UNICEF Data (quick data search by topic, indicator, keyword)
http://data.unicef.org
ABBREVIATIONS
•
•
GHO = Global Health Observatory (or the WHO)
IMR = Indicators and Measurement Registry (of the WHO)
140
•
•
•
•
•
•
•
•
UN = United Nations
UNICEF = United Nations Children’s Fund
WB = World Bank
WDI = World Development Indicators
WHO = World Health Organization
WHO GHOi = The World Health Organization Global Health Observatory, search by indicator
WHO GHOt = The World Health Organization Global Health Observatory, search by topic
WPRO = Western Pacific Regional Office (of the WHO)
141
Appendix 5.6: Indicator Development
Additional Details Not Discussed within the Text of the Report:
The Commission convened a working group panel charged with forming recommendations for monitoring surgical care
delivery. This panel first met in Boston in January 2014 during the Commission's inaugural meeting. It had members
from six different countries, including low-income, middle-income and high-income groupings. The majority had been
involved with the development or use of indicators in the past, had experience working with the World Health
Organization, and had hands-on experience providing care in low-resource settings.
The panel began by assessing prior use of surgical indicators in LMICs as reported in the academic as well as grey
literature (Appendix 5.6: Indicator Lit Review). They then considered the present state and feasibility of surgical
indicator use globally through review of currently used indicators (Appendix 5.4: Indicator Search); discussions with
the WB, WHO and USAID; deliberations at three international LCoGSs meetings with all of the Commissioners and
participants around the world; conversations with a number of MoHs in LMICs; and new research to assess potential
indicators in the areas of temporal access to surgical care,1,2 surgical volume estimates,3-8 catastrophic expenditure from
out-of-pocket payments,9,10 perioperative mortality,11,12 and surgical workforce.13,14
Using this information and our three group framework, the panel aimed to develop a group of core indicators that were
feasible (based on research done), relevant to the greatest areas of need, and captured components of equity (currently
greatly lacking in global surgery care delivery).
REFERENCES
1. Raykar NB, A.; Vega, M.; Kim, J.; Boye, G.; Liu, C.; Greenberg, S.; Riesel, J.; Gillies, R.; Meara, J.; Roy, N.
Estimating Global Access to Surgical Care with Geospatial Mapping of Surgical Providers (Abstract accepted for
the Academic Surgical Congress conference). 2015.
2. Dare AJ N-KJ, Patra J, Fu SH, Rodriguez PS, Hsiao M, Jotkar RM, Thakur JS, Sheth J, Jha P, for the Million Death
Study Collaborators. Deaths from acute abdominal conditions and geographic access to surgical care in India: a
nationally representative spatial analysis. Submitted to The Lancet Global Health.
3. Weiser TG HA, Molina G, Lipsitz SR, Esquivel M, Uribe-Leitz T, Fu R, Azad T, Chao TE, Berry WR, Gawande
AA. The global volume of surgery, cesarean delivery, and life expectancy in 2012. under review 2015.
4. Molina G WT, Lipsitz SR, Esquivel M, Uribe-Leitz T, Azad T, Shah N, Semrau K, Berry WR, Gawande AA,
Haynes AB. The relationship between cesarean rate and maternal and neonatal mortality: findings suggesting an
updated target for optimal cesarean delivery. UNDER REVIEW 2015.
5. Esquivel MM MG, Uribe-Leitz T, Lipsitz SR, Rose J, Bickler S, Gawande AA, Haynes AB and Weiser TG.
Proposed minimum rates of surgery to support desirable health outcomes: An observational study based on four
strategies. Abstract Submitted to The Lancet 2015.
6. Rose J WT, Hider P, Wilson L, Gruen R, Bickler SW. Estimated need for surgery worldwide based on prevalence of
diseases: implications for public health planning of surgical services. Submitted to The Lancet Global Health 2014.
7. Rose J, Chang DC, Weiser TG, Kassebaum NJ, Bickler SW. The role of surgery in global health: analysis of United
States inpatient procedure frequency by condition using the Global Burden of Disease 2010 framework. PLoS One
2014; 9(2): e89693.
8. Shrime MG DK, Meara JGM. How much surgery is enough? Aligning surgical delivery with best-performing health
systems. Submitted to The Lancet Global Health 2014.
9. Shrime MG, Dare A, Alkire B, O'Neill K, Meara JG. Catastrophic expenditure to pay for surgery: a global estimate.
Submitted to The Lancet Global Health 2014.
10. Jan S, Kimman M, Peters SA, Woodward M. Socioeconomic consequences of surgery for cancer in South-East
Asia: results from the ACTION Study. Surgery (Submitted as part of Lancet Commission on Global Surgery) 2015.
11. Watters DA1 HM, Gruen RL, Maoate K, Perndt H, McDougall RJ, Morriss WW, Tangi V, Casey KM, McQueen
KA. Perioperative Mortality Rate (POMR): A Global Indicator of Access to Safe Surgery and Anaesthesia. World
journal of surgery 2014.
12. Ng-Kamstra JS GS, Kotagal M, Palmqvist CL, Lai FYX, Bollam R, Meara JG, Gruen RL. Utilization definitions of
perioperative mortality rates in low- and midde-income countries: a systematic review. Abstract Submitted to The
Lancet; 2015.
13. Holmer H SM, Riesel JN, Meara JG, Hagander L. . Towards closing the gap of the global surgeon,
anaesthesiologist and obstetrician workforce: thresholds and projections towards 2030. Abstract Submitted to The
Lancet and under peer review; 2014.
142
14. Federspiel FM, S; Mukhopadhyay, S; Milsom, P; Scott, J; Riesel, J.N.; Meara, J.G. Global Surgical and Anaesthetic
Task Shifting: a Systematic Literature Review and Survey. Abstract under peer review at The Lancet; 2014.
143
Appendix 5.7: Literature Review of Utilization Of Metrics For Surgery In Low- And MiddleIncome Countries
STUDY METHODOLOGY
Pubmed was searched for articles related to metrics used for surgery in LMICs. Separate searches to identify articles
related to measures of health systems, surgical care and low- and middle-income countries were done. These searches
were then joined to identify articles common to all three searches (See search terms below).
The total number of articles identified was 10356 (Figure 1). Studies were limited to English and those focused on
humans. This reduced the number to 8290. Titles and abstracts were reviewed to identify candidate articles. The full
text of 484 articles was reviewed, and 238 were included in the final sample.
Articles were included if they described at least one surgical metric that was applied at a system level and measured in a
low- or middle-income country. Systems were defined as an entire hospital, region or larger area. This means that
metrics applied in a case series at a hospital were not included. Further, articles that did not have specific metrics, were
not from LMICs, assessed surgical procedures on a smaller scale, (not at a facility level, case reports, case series), and
metrics from surgical humanitarian missions were excluded. As we focused on surgery, we excluded articles focused on
trauma or obstetric care in general. This was done, in part, because reviews of metrics in these fields have been
undertaken by others.1,2 Advanced and small volume surgeries were also excluded, this included transplantation,
cosmetic surgeries, bariatric procedures, endovascular procedures, and dermatologic procedures. Finally surgical
tourism and metrics related to surgical trainees from HIC operating in LMICs were excluded (Figure 2).
The metrics in each article were recorded and classified according to the following schema:
1: Preparedness for Surgical Care = Includes indicators assessing the degree to which safe surgical care could be
provided universally when needed, and of the absence of barriers to obtaining safe surgical care. Includes availability
and readiness, and accessibility.
2: Delivery of Surgical Care = Includes indicators assessing the degree to which safe surgical care is being provided to
everyone when needed. Includes effective coverage and quality.
3: Impact of Surgical Care = Indicators of the impact of surgical care on the population. Includes human and monetary
impacts.
144
Figure 1: Flow Diagram for Article Selection
Initial match
10356
Not human or not in
English
2066
Titles/Abstracts
Reviewed
8290
Met exclusion
criteria
7806
Full text
Reviewed
484
Met exclusion
criteria
246
Included
238
145
Figure 2. Exclusion Criteria
-
-
Not LMIC
No specific metric
Not assessing surgery at a facility, regional or national level
o Specific procedures at a facility that performs more than just a single type of procedures
Case series
Case reports
Mission surgery
Obstetric care only – Caesarian sections & fistula surgery only considered
Global trauma care - surgery for trauma included
Cosmetic procedure
Endovascular procedures
Abortion
Dermatologic procedures
Bariatric
International rotations for surgical trainees in from HIC
Surgical tourism
- Articles that focused on a specific area of surgery were included if the article discussed coverage across more than
a single institution – at the regional or national level.
146
FIGURE 3: PubMed Query:
Metrics:
((((health status indicators[MeSH Terms]) OR (("manpower" [Subheading]) OR (((((("Health Services Needs and
Demand"[Mesh]) OR "Delivery of Health Care"[Mesh]) OR "Health Resources/supply and distribution"[Mesh]) OR
"Health Services Accessibility"[Mesh])) OR (((quality indicators, health care[MeSH Terms]) OR emergency services,
hospital[MeSH Terms]) OR "quality improvement"[MeSH Terms])))))
AND
Low and Middle Income Countries:
(((("Developing Countries"[Mesh] OR "Africa South of the Sahara"[Mesh] OR "Central America"[Mesh] OR
"Afghanistan"[Mesh] OR "Albania"[Mesh] OR "Algeria"[Mesh] OR "American Samoa"[Mesh] OR "Angola"[Mesh]
OR "Antigua and Barbuda"[Mesh] OR "Argentina"[Mesh] OR "Armenia"[Mesh] OR "Bangladesh"[Mesh] OR "Republic
of Belarus"[Mesh] OR "Belize"[Mesh] OR "Benin"[Mesh] OR "Bhutan"[Mesh] OR "Bolivia"[Mesh] OR "BosniaHerzegovina"[Mesh] OR "Botswana"[Mesh] OR "Brazil"[Mesh] OR "Bulgaria"[Mesh] OR "Burkina Faso"[Mesh] OR
"Burundi"[Mesh] OR "Cape Verde"[Mesh] OR "Cameroon"[Mesh] OR "Cambodia"[Mesh] OR "Central African
Republic"[Mesh] OR "Chad"[Mesh] OR "Chile"[Mesh] OR "China"[Mesh] OR "Colombia"[Mesh] OR
"Comoros"[Mesh] OR "Congo"[Mesh] OR "Democratic Republic of the Congo"[Mesh] OR "Costa Rica"[Mesh] OR
"Cote d'Ivoire"[Mesh] OR "Cuba"[Mesh] OR "Djibouti"[Mesh] OR "Dominica"[Mesh] OR "Dominican Republic"[Mesh]
OR "Ecuador"[Mesh] OR "Egypt"[Mesh] OR "El Salvador"[Mesh] OR "Eritrea"[Mesh] OR "Ethiopia"[Mesh] OR
"Fiji"[Mesh] OR "Gabon"[Mesh] OR "Gambia"[Mesh] OR "Georgia (Republic)"[Mesh] OR "Ghana"[Mesh] OR
"Grenada"[Mesh] OR "Guatemala"[Mesh] OR "Guinea"[Mesh] OR "Equatorial Guinea"[Mesh] OR "GuineaBissau"[Mesh] OR "Guyana"[Mesh] OR "Haiti"[Mesh] OR "Honduras"[Mesh] OR "India"[Mesh] OR "Indonesia"[Mesh]
OR "Iran"[Mesh] OR "Iraq"[Mesh] OR "Jamaica"[Mesh] OR "Jordan"[Mesh] OR "Kazakhstan"[Mesh] OR
"Kenya"[Mesh] OR "Micronesia"[Mesh] OR "Democratic People's Republic of Korea"[Mesh] OR "Yugoslavia"[Mesh]
OR "Kyrgyzstan"[Mesh] OR "Laos"[Mesh] OR "Latvia"[Mesh] OR "Lebanon"[Mesh] OR "Lesotho"[Mesh] OR
"Liberia"[Mesh] OR "Libya"[Mesh] OR "Lithuania"[Mesh] OR "Macedonia (Republic)"[Mesh] OR "Madagascar"[Mesh]
OR "Malawi"[Mesh] OR "Malaysia"[Mesh] OR "Indian Ocean Islands"[Mesh] OR "Mali"[Mesh] OR
"Mauritania"[Mesh] OR "Mexico"[Mesh] OR "Moldova"[Mesh] OR "Mongolia"[Mesh] OR "Montenegro"[Mesh] OR
"Morocco"[Mesh] OR "Mozambique"[Mesh] OR "Myanmar"[Mesh] OR "Namibia"[Mesh] OR "Nepal"[Mesh] OR
"Nicaragua"[Mesh] OR "Niger"[Mesh] OR "Nigeria"[Mesh] OR "Pakistan"[Mesh] OR "Palau"[Mesh] OR
"Panama"[Mesh] OR "Papua New Guinea"[Mesh] OR "Paraguay"[Mesh] OR "Peru"[Mesh] OR "Philippines"[Mesh] OR
"Romania"[Mesh] OR "Siberia"[Mesh] OR "Rwanda"[Mesh] OR "Samoa"[Mesh] OR "Atlantic Islands"[Mesh] OR
"Senegal"[Mesh] OR "Serbia"[Mesh] OR "Seychelles"[Mesh] OR "Sierra Leone"[Mesh] OR "Melanesia"[Mesh] OR
"Somalia"[Mesh] OR "South Africa"[Mesh] OR "Sri Lanka"[Mesh] OR "Saint Lucia"[Mesh] OR "Saint Vincent and the
Grenadines"[Mesh] OR "Sudan"[Mesh] OR "Suriname"[Mesh] OR "Swaziland"[Mesh] OR "Syria"[Mesh] OR
"Tajikistan"[Mesh] OR "Tanzania"[Mesh] OR "Thailand"[Mesh] OR "East Timor"[Mesh] OR "Togo"[Mesh] OR
"Tonga"[Mesh] OR "Tunisia"[Mesh] OR "Turkey"[Mesh] OR "Turkmenistan"[Mesh] OR "Micronesia"[Mesh] OR
"Uganda"[Mesh] OR "Ukraine"[Mesh] OR "Uruguay"[Mesh] OR "Uzbekistan"[Mesh] OR "Vanuatu"[Mesh] OR
"Venezuela"[Mesh] OR "Vietnam"[Mesh] OR "Yemen"[Mesh] OR "Zambia"[Mesh] OR "Zimbabwe"[Mesh])) OR
((("internationality"[MeSH Terms]) OR World health organization[MeSH Terms]) OR united nations[MeSH Terms])) OR
africa[MeSH Terms]))
AND
Surgical Procedure:
((("Surgical Procedures, Operative"[Mesh] OR “surgery department, hospital”[MeSH] OR surgery[Title/Abstract] OR
surgical[Title/Abstract]) NOT "Bone Marrow Transplantation"[Mesh] NOT "Delivery, Obstetric"[Mesh] NOT "Blood
Specimen Collection"[Mesh] NOT "Chorionic Villi Sampling"[Mesh] NOT "Vaginal Smears"[Mesh] NOT "Body
Modification, Non-Therapeutic"[Mesh] NOT "Stem Cell Transplantation"[Mesh]) OR "Cesarean Section"[Mesh] OR
"Specialties, Surgical"[Mesh] OR ("Wounds and Injuries"[Mesh] NOT "Asphyxia"[Mesh] NOT "Athletic Injuries"[Mesh]
NOT "Back Injuries"[Mesh] NOT "Bites and Stings"[Mesh] NOT "Sunburn"[Mesh] NOT "Extravasation of Diagnostic
and Therapeutic Materials"[Mesh] NOT "Heat Stress Disorders"[Mesh] NOT "Occupational Injuries"[Mesh] NOT
"Radiation Injuries"[Mesh] NOT "Self Mutilation"[Mesh] NOT "Sprains and Strains"[Mesh] NOT "Decompression
Sickness"[Mesh] NOT "Drowning"[Mesh] NOT "Tooth Injuries"[Mesh]))
147
RESULTS
Most of the articles covered at least one metric about delivery (205/238, 86.1%), and over half had one metric on
related to preparedness (139/238, 58.4%). Only 13.4% (32/238) of articles had metrics related to the impact of surgical
care.
In the delivery category, the majority of the article had at least one metric focused on met need (152/238, 63.9%) (table
1). Met need metrics included measure of the surgical productivity, including number of surgeries performed and
surgical rates for populations. A total of 105 (44.1%) articles reported on a surgical outcome or process measure
related to safety (either safe or effective metrics).
Table 1. Articles with at least one metric in the category
Preparedness
Percent
Workforce
Infrastructure
Equipment
Access-geographic
Supplies
Medications
Leadership/governance
Access-sociocultural
Access-Financial
Other availability
Access-temporal
Information
84
56
39
39
29
28
28
25
24
12
8
6
35.3%
23.5%
16.4%
16.4%
12.2%
11.8%
11.8%
10.5%
10.1%
5.0%
3.4%
2.5%
Delivery
Number of Articles
Met Need
Total Need
Safety
Effective
Efficient
Timely
Patient-centered
Unmet Need
Equitable
152
105
83
41
38
19
11
10
3
63.9%
44.1%
34.9%
17.2%
16.0%
8.0%
4.6%
4.2%
1.3%
Impact
Metric Category
Financial
Economic
Change in disability
Change in need
Change in death
20
10
6
2
1
8.4%
4.2%
2.5%
0.8%
0.4%
148
Table 2. Number of articles with a metric in each of the major categories – preparedness,
delivery and impact (article number = 238)
CATEGORY
Number of Articles
PREPAREDESS
139
% of all articles
(n= 238)
58.4%
IMPACT
32
13.4%
DELIVERY
205
86.1%
REFERENCES
1.. Paxton A, Bailey P, Lobis S. The United Nations Process Indicators for emergency obstetric care: Reflections based
on a decade of experience. International journal of gynaecology and obstetrics: the official organ of the
International Federation of Gynaecology and Obstetrics. Nov 2006;95(2):192-208.
2.. Stelfox HT, Straus SE, Nathens A, Bobranska-Artiuch B. Evidence for quality indicators to evaluate adult trauma
care: a systematic review. Critical care medicine. Apr 2011;39(4):846-859.
149
Appendix 5.8: Use and Definitions of Perioperative Mortality Rates In Low-Income And
Middle-Income Countries: A Systematic Review
STUDY METHODOLOGY
JOSHUA S NG-KAMSTRA, SARAH L M GREENBERG, MEERA KOTAGAL, CHARLOTTA L PALMQVIST,
FRANCIS Y X LAI, RISHITHA BOLLAM, JOHN G MEARA, RUSSELL L GRUEN
OBJECTIVES
1. To describe reported perioperative mortality rates (POMR) across procedures and diagnoses in low- and
middle-income countries (LMIC).
2. To determine which definition of POMR is most commonly used in the LMIC literature.
3. To determine how POMR has been used in the LMIC literature, describing the types of studies performed and
questions answered using POMR as an indicator.
4. To determine how risk adjustment for case mix, patient age, and disease severity have been undertaken.
BACKGROUND
This project is being undertaken as an investigation for the Lancet Commission on Global Surgery. Following on the
work of Watters, et al, which recommended the global use of Perioperative Mortality Rate (POMR) as an “indicator of
access to and safety of surgery and anesthesia”, the need for a systematic review on the state of POMR as a surgical
indicator was identified1.
SELECTION CRITERIA
Inclusion Criteria:
Any published paper primarily reporting facility-based outcomes or mortality for patients who have undergone surgery
in a low- or middle-income country (LMIC). Any study design (audit, case-control, or cohort) in which such data are
presented is eligible for inclusion. The paper must report perioperative mortality rates within a specified patient
population.
Filters:
• Human subjects
• English
• Publication dates: Jan 1, 2009 to September 1, 2014
For the purposes of this analysis:
•
•
•
“Perioperative” refers to the time period from admission to a health facility to either discharge, or 30 days
following a surgical procedure (whichever comes later). This is extended to 42 days for outcomes following
caesarean section.
“surgery” refers to a procedure performed in an operating theatre
LMIC are defined by World Bank Country and Lending Groups and include upper-middle, lower-middle, and
low-income countries.
EXCLUSION CRITERIA
Interventions: Percutaneous vascular interventions, percutaneous cardiovascular interventions, transplantation, robotic
operations, ECMO, bariatric surgery, trauma sustained during military engagement, surgery performed in temporary
combat hospitals, colonoscopy, HIPEC, cosmetic plastic surgery, short-term medical missions, burr holes without
further surgical intervention
Paper Types: survival analysis for cancer, survival analysis for pericardial effusion, risk factor model assessment
without provision of actual mortality rates, trauma/burn mortality studies without reporting of perioperative mortality,
maternal mortality studies without reporting of perioperative mortality, studies whose denominator is drawn from an
ICU study base, studies of fetal surgery
OUTCOME MEASURES
Primary Outcome: Perioperative mortality rates
Secondary Outcomes:
150
•
•
•
Proportion of studies reporting various definitions of POMR, including intraoperative mortality, 24-hour
mortality, 7-day perioperative mortality, inpatient mortality, and 30-day mortality.
Proportion of studies reporting other perioperative complications
Proportion of studies reporting preoperative risk factors including patient age, comorbidities, ASA status, case
urgency, HIV status, and clinical risk scores.
SEARCH METHODS
Electronic Searches
We will search the following databases:
• PubMed: January 1, 2009 to September 1, 2014 (search string below)
• EMBASE
• LILACS
• Web of Science
• African Index Medicus
• WHO Global Health Library
N.B. The present analysis presents preliminary data from a search of PubMed, with other databases to be included in
subsequent publications.
DATA COLLECTION AND ANALYSIS
Selection of Studies
Two authors will review all titles and abstracts in duplicate to identify studies reporting:
• In-hospital or facility-based mortality or outcomes or results pertaining to surgery or surgically treated diseases
• In-hospital or facility-based mortality pertaining to anesthesia
• In-hospital or facility-based maternal mortality with specific mention of cesarean section
Studies warranting full-text review will be read by one of four authors to evaluate for inclusion or exclusion, with final
oversight by one reviewer.
DATA EXTRACTION
The following data will be extracted from all papers using a piloted Excel form with regular data validation for
consistency:
1. Year of publication
2. Study design
3. Start and end dates of study period
4. Country location of participating hospitals
5. Facility type (academic hospital, community hospital, district hospital, mixed hospital types, other)
6. Description of the patient population
7. Type of anesthesia used
8. Definition of POMR employed (including timeframe, numerator, and denominator).
9. Whether or not the study reports HIV status, case urgency, comorbidities, clinical scoring systems, age, and
whether or not mortality is adjusted for or stratified on these factors.
10. Names of any clinical scoring systems used.
11. Difficulties raised by authors in data collection, including loss to follow up and other such missing data.
12. Planned versus emergent status of operative cases. A planned surgery is one in which the patient is admitted
from his or her place of usual residence at a pre-set date for the purpose of undergoing a surgical procedure.
An emergency surgery is one in which the patient undergoes a surgical procedure after being admitted to
hospital on an unforeseen date with a potentially life- or limb-threatening disease process.
13. Perioperative mortality rate. Where such a rate is not calculated by authors, but a defined numerator and
denominator are reported, it will be imputed as calculated by reviewers. Where studies of operative and nonoperative patients are included, only mortality for patients actually undergoing surgery is reported.
14. Surgical specialty. Where studies are limited to a surgical specialty, the single most appropriate specialty will
be assigned according to the case mix reported.
15. Procedure or diagnosis name. This is imputed where studies are limited to a single diagnosis or a single
procedure.
Planned versus emergent status and perioperative mortality rates will be extracted in duplicate. All other data will
be resampled at regular intervals to ensure consistency across reviewers. Surgical specialty and procedure will be
imputed solely by one reviewer to ensure consistency.
151
Other variables may be collected as deemed appropriate.
RISK OF BIAS
On an individual study level, studies risk selection bias (by failing to represent consecutive cases), or detection bias (by
failing to provide complete follow-up data). All studies will be assessed for both such biases.
On a review level, publication bias may influence results, however the direction of such bias is unclear. Studies may
tend to come from larger centres with more complex patients. This may either overestimate mortality (due to clinical
complexity) or underestimate mortality (due to greater resource availability at such centres). Authors may be reticent to
publish audit data showing high mortality (for professional or political reasons), or they may publish studies of riskier
procedures more frequently (for academic reasons). Such biases will be addressed qualitatively—for example, if studies
are primarily identified from urban, academic centres, results may not be generalizable to smaller rural centres.
DATA SYNTHESIS
The data collected will be analyzed as case-series outcomes (mortality rates), regardless of the underlying study design.
We anticipate significant heterogeneity in mortality rates across clinical groups (specific procedures or diagnoses), and
even within clinical groups. We will therefore simply provide reported ranges of POMR for a variety of procedures or
diagnostic groups, and describe variation by case urgency.
ANALYSIS:
Data analysis will be undertaken using Stata 13/IC
PUBMED SEARCH STRATEGY:
A search strategy was designed in consultation with a medical librarian to retrieve all relevant articles.
Full query:
((("Hospital Mortality"[Mesh] OR "Hospital Mortality"[tiab] OR “Hospital Death”[tiab]) AND ("Surgical Procedures,
Operative"[Mesh] OR “surgery department, hospital”[MeSH] OR “General Surgery”[Mesh] OR “Anesthesia”[Mesh]
OR "Cesarean Section"[Mesh] OR “surgery”[tiab] OR “surgical”[tiab] OR “anesthesia”[tiab] OR “anesthetic”[tiab] OR
“anaesthesia”[tiab] OR “anaesthetic”[tiab] OR "cesarean"[tiab] or "caesarean"[tiab])) OR ("Intraoperative
Care/mortality"[Mesh] OR ("intraoperative"[tiab] AND (“mortality”[tiab] OR “death”[tiab])) OR "Postoperative
Care/mortality"[Mesh] OR "Postoperative Complications/mortality"[Mesh] OR ("postoperative"[tiab] AND
(“mortality”[tiab] OR “death”[tiab])) OR "Perioperative Period/mortality"[Mesh] OR (“perioperative”[tiab] AND
(“mortality”[tiab] OR “death”[tiab])) OR OR ((“cesarean”[tiab] OR “caesarean”[tiab]) AND (“mortality”[tiab] OR
“death”[tiab]))
OR (“surgery”[tiab] AND (“mortality”[tiab] OR “death”[tiab])) OR (“surgical”[tiab] AND (“mortality”[tiab] OR
“death”[tiab])) OR (“operative”[tiab] AND (“mortality”[tiab] OR “death”[tiab])) OR (“operation”[tiab] AND
(“mortality”[tiab] OR “death”[tiab])) OR "Anesthesia/mortality"[Mesh] OR (“anesthesia”[tiab] AND (“mortality”[tiab]
OR “death”[tiab])) OR (“anesthetic”[tiab] AND (“mortality”[tiab] OR “death”[tiab])) OR (“anaesthesia”[tiab] AND
(“mortality”[tiab] OR “death”[tiab])) OR (“anaesthetic”[tiab] AND (“mortality”[tiab] OR “death”[tiab])))) AND
(("Developing Countries"[Mesh] OR "Africa South of the Sahara"[Mesh] OR "Central America"[Mesh] OR
"Afghanistan"[Mesh] OR "Albania"[Mesh] OR "Algeria"[Mesh] OR "American Samoa"[Mesh] OR "Angola"[Mesh]
OR "Antigua and Barbuda"[Mesh] OR "Argentina"[Mesh] OR "Armenia"[Mesh] OR "Bangladesh"[Mesh] OR
"Republic of Belarus"[Mesh] OR "Belize"[Mesh] OR "Benin"[Mesh] OR "Bhutan"[Mesh] OR "Bolivia"[Mesh] OR
"Bosnia-Herzegovina"[Mesh] OR "Botswana"[Mesh] OR "Brazil"[Mesh] OR "Bulgaria"[Mesh] OR "Burkina
Faso"[Mesh] OR "Burundi"[Mesh] OR "Cape Verde"[Mesh] OR "Cameroon"[Mesh] OR "Cambodia"[Mesh] OR
"Central African Republic"[Mesh] OR "Chad"[Mesh] OR "Chile"[Mesh] OR "China"[Mesh] OR "Colombia"[Mesh]
OR "Comoros"[Mesh] OR "Congo"[Mesh] OR "Democratic Republic of the Congo"[Mesh] OR "Costa Rica"[Mesh]
OR "Cote d'Ivoire"[Mesh] OR "Cuba"[Mesh] OR "Djibouti"[Mesh] OR "Dominica"[Mesh] OR "Dominican
Republic"[Mesh] OR "Ecuador"[Mesh] OR "Egypt"[Mesh] OR "El Salvador"[Mesh] OR "Eritrea"[Mesh] OR
"Ethiopia"[Mesh] OR "Fiji"[Mesh] OR "Gabon"[Mesh] OR "Gambia"[Mesh] OR "Georgia (Republic)"[Mesh] OR
"Ghana"[Mesh] OR "Grenada"[Mesh] OR "Guatemala"[Mesh] OR "Guinea"[Mesh] OR "Equatorial Guinea"[Mesh]
OR "Guinea-Bissau"[Mesh] OR "Guyana"[Mesh] OR "Haiti"[Mesh] OR "Honduras"[Mesh] OR "India"[Mesh] OR
"Indonesia"[Mesh] OR "Iran"[Mesh] OR "Iraq"[Mesh] OR "Jamaica"[Mesh] OR "Jordan"[Mesh] OR
"Kazakhstan"[Mesh] OR "Kenya"[Mesh] OR "Micronesia"[Mesh] OR "Democratic People's Republic of
Korea"[Mesh] OR "Yugoslavia"[Mesh] OR "Kyrgyzstan"[Mesh] OR "Laos"[Mesh] OR "Latvia"[Mesh] OR
"Lebanon"[Mesh] OR "Lesotho"[Mesh] OR "Liberia"[Mesh] OR "Libya"[Mesh] OR "Lithuania"[Mesh] OR
"Macedonia (Republic)"[Mesh] OR "Madagascar"[Mesh] OR "Malawi"[Mesh] OR "Malaysia"[Mesh] OR "Indian
Ocean Islands"[Mesh] OR "Mali"[Mesh] OR "Mauritania"[Mesh] OR "Mexico"[Mesh] OR "Moldova"[Mesh] OR
"Mongolia"[Mesh] OR "Montenegro"[Mesh] OR "Morocco"[Mesh] OR "Mozambique"[Mesh] OR "Myanmar"[Mesh]
OR "Namibia"[Mesh] OR "Nepal"[Mesh] OR "Nicaragua"[Mesh] OR "Niger"[Mesh] OR "Nigeria"[Mesh] OR
152
"Pakistan"[Mesh] OR "Palau"[Mesh] OR "Panama"[Mesh] OR "Papua New Guinea"[Mesh] OR "Paraguay"[Mesh] OR
"Peru"[Mesh] OR "Philippines"[Mesh] OR "Romania"[Mesh] OR "Siberia"[Mesh] OR "Rwanda"[Mesh] OR
"Samoa"[Mesh] OR "Atlantic Islands"[Mesh] OR "Senegal"[Mesh] OR "Serbia"[Mesh] OR "Seychelles"[Mesh] OR
"Sierra Leone"[Mesh] OR "Melanesia"[Mesh] OR "Somalia"[Mesh] OR "South Africa"[Mesh] OR "Sri Lanka"[Mesh]
OR "Saint Lucia"[Mesh] OR "Saint Vincent and the Grenadines"[Mesh] OR "Sudan"[Mesh] OR "Suriname"[Mesh]
OR "Swaziland"[Mesh] OR "Syria"[Mesh] OR "Tajikistan"[Mesh] OR "Tanzania"[Mesh] OR "Thailand"[Mesh] OR
"East Timor"[Mesh] OR "Togo"[Mesh] OR "Tonga"[Mesh] OR "Tunisia"[Mesh] OR "Turkey"[Mesh] OR
"Turkmenistan"[Mesh] OR "Micronesia"[Mesh] OR "Uganda"[Mesh] OR "Ukraine"[Mesh] OR "Uruguay"[Mesh] OR
"Uzbekistan"[Mesh] OR "Vanuatu"[Mesh] OR "Venezuela"[Mesh] OR "Vietnam"[Mesh] OR "Yemen"[Mesh] OR
"Zambia"[Mesh] OR "Zimbabwe"[Mesh]) OR ("internationality"[MeSH Terms] OR World health organization[MeSH
Terms] OR united nations[MeSH Terms] OR africa[MeSH Terms]) OR (“low-income”[tiab] OR “middleincome”[tiab] OR “low-resource”[tiab] or “developing country”[tiab] or “Africa”[tiab]) OR ("Central America"[Tiab]
OR "Afghanistan"[Tiab] OR "Albania"[Tiab] OR "Algeria"[Tiab] OR "American Samoa"[Tiab] OR "Angola"[Tiab]
OR "Antigua and Barbuda"[Tiab] OR "Argentina"[Tiab] OR "Armenia"[Tiab] OR "Bangladesh"[Tiab] OR "Republic
of Belarus"[Tiab] OR "Belize"[Tiab] OR "Benin"[Tiab] OR "Bhutan"[Tiab] OR "Bolivia"[Tiab] OR "BosniaHerzegovina"[Tiab] OR "Botswana"[Tiab] OR "Brazil"[Tiab] OR "Bulgaria"[Tiab] OR "Burkina Faso"[Tiab] OR
"Burundi"[Tiab] OR "Cape Verde"[Tiab] OR "Cameroon"[Tiab] OR "Cambodia"[Tiab] OR "Central African
Republic"[Tiab] OR "Chad"[Tiab] OR "Chile"[Tiab] OR "China"[Tiab] OR "Colombia"[Tiab] OR "Comoros"[Tiab]
OR "Congo"[Tiab] OR "Democratic Republic of the Congo"[Tiab] OR "Costa Rica"[Tiab] OR "Cote d'Ivoire"[Tiab]
OR "Cuba"[Tiab] OR "Djibouti"[Tiab] OR "Dominica"[Tiab] OR "Dominican Republic"[Tiab] OR "Ecuador"[Tiab]
OR "Egypt"[Tiab] OR "El Salvador"[Tiab] OR "Eritrea"[Tiab] OR "Ethiopia"[Tiab] OR "Fiji"[Tiab] OR
"Gabon"[Tiab] OR "Gambia"[Tiab] OR "Georgia (Republic)"[Tiab] OR "Ghana"[Tiab] OR "Grenada"[Tiab] OR
"Guatemala"[Tiab] OR "Guinea"[Tiab] OR "Equatorial Guinea"[Tiab] OR "Guinea-Bissau"[Tiab] OR "Guyana"[Tiab]
OR "Haiti"[Tiab] OR "Honduras"[Tiab] OR "India"[Tiab] OR "Indonesia"[Tiab] OR "Iran"[Tiab] OR "Iraq"[Tiab] OR
"Jamaica"[Tiab] OR "Jordan"[Tiab] OR "Kazakhstan"[Tiab] OR "Kenya"[Tiab] OR "Micronesia"[Tiab] OR
"Democratic People's Republic of Korea"[Tiab] OR "Yugoslavia"[Tiab] OR "Kyrgyzstan"[Tiab] OR "Laos"[Tiab] OR
"Latvia"[Tiab] OR "Lebanon"[Tiab] OR "Lesotho"[Tiab] OR "Liberia"[Tiab] OR "Libya"[Tiab] OR "Lithuania"[Tiab]
OR "Macedonia"[Tiab] OR "Madagascar"[Tiab] OR "Malawi"[Tiab] OR "Malaysia"[Tiab] OR "Indian Ocean
Islands"[Tiab] OR "Mali"[Tiab] OR "Mauritania"[Tiab] OR "Mexico"[Tiab] OR "Moldova"[Tiab] OR
"Mongolia"[Tiab] OR "Montenegro"[Tiab] OR "Morocco"[Tiab] OR "Mozambique"[Tiab] OR "Myanmar"[Tiab] OR
"Namibia"[Tiab] OR "Nepal"[Tiab] OR "Nicaragua"[Tiab] OR "Niger"[Tiab] OR "Nigeria"[Tiab] OR "Pakistan"[Tiab]
OR "Palau"[Tiab] OR "Panama"[Tiab] OR "Papua New Guinea"[Tiab] OR "Paraguay"[Tiab] OR "Peru"[Tiab] OR
"Philippines"[Tiab] OR "Romania"[Tiab] OR "Siberia"[Tiab] OR "Rwanda"[Tiab] OR "Samoa"[Tiab] OR "Atlantic
Islands"[Tiab] OR "Senegal"[Tiab] OR "Serbia"[Tiab] OR "Seychelles"[Tiab] OR "Sierra Leone"[Tiab] OR
"Melanesia"[Tiab] OR "Somalia"[Tiab] OR "South Africa"[Tiab] OR "Sri Lanka"[Tiab] OR "Saint Lucia"[Tiab] OR
"Saint Vincent and the Grenadines"[Tiab] OR "Sudan"[Tiab] OR "Suriname"[Tiab] OR "Swaziland"[Tiab] OR
"Syria"[Tiab] OR "Tajikistan"[Tiab] OR "Tanzania"[Tiab] OR "Thailand"[Tiab] OR "East Timor"[Tiab] OR
"Togo"[Tiab] OR "Tonga"[Tiab] OR "Tunisia"[Tiab] OR "Turkey"[Tiab] OR "Turkmenistan"[Tiab] OR
"Micronesia"[Tiab] OR "Uganda"[Tiab] OR "Ukraine"[Tiab] OR "Uruguay"[Tiab] OR "Uzbekistan"[Tiab] OR
"Vanuatu"[Tiab] OR "Venezuela"[Tiab] OR "Vietnam"[Tiab] OR "Yemen"[Tiab] OR "Zambia"[Tiab] OR
"Zimbabwe"[Tiab]))
SEARCH BREAKDOWN
1 AND 2 AND 4
OR
3 AND 4
1. Specify hospital mortality
"Hospital Mortality"[Mesh] OR "Hospital Mortality"[tiab] OR “Hospital Death”[tiab]
2. Delineate by surgery or anesthesia
"Surgical Procedures, Operative"[Mesh] OR “surgery department, hospital”[MeSH] OR “General Surgery”[Mesh] OR
“Anesthesia”[Mesh] OR "Cesarean Section"[Mesh] OR “surgery”[tiab] OR “surgical”[tiab] OR “anesthesia”[tiab] OR
“anesthetic”[tiab] OR “anaesthesia”[tiab] OR “anaesthetic”[tiab] OR "cesarean"[tiab] or "caesarean"[tiab]
3. Delineate by surgery or anesthesia and mortality
"Intraoperative Care/mortality"[Mesh] OR ("intraoperative"[tiab] AND (“mortality”[tiab] OR “death”[tiab])) OR
"Postoperative Care/mortality"[Mesh] OR "Postoperative Complications/mortality"[Mesh] OR ("postoperative"[tiab]
AND (“mortality”[tiab] OR “death”[tiab])) OR "Perioperative Period/mortality"[Mesh] OR (“perioperative”[tiab] AND
(“mortality”[tiab] OR “death”[tiab])) OR (“surgery”[tiab] AND (“mortality”[tiab] OR “death”[tiab])) OR
(“surgical”[tiab] AND (“mortality”[tiab] OR “death”[tiab])) OR (“operative”[tiab] AND (“mortality”[tiab] OR
“death”[tiab])) OR (“operation”[tiab] AND (“mortality”[tiab] OR “death”[tiab])) OR "Anesthesia/mortality"[Mesh] OR
(“anesthesia”[tiab] AND (“mortality”[tiab] OR “death”[tiab])) OR (“anesthetic”[tiab] AND (“mortality”[tiab] OR
153
“death”[tiab])) OR (“anaesthesia”[tiab] AND (“mortality”[tiab] OR “death”[tiab])) OR (“anaesthetic”[tiab] AND
(“mortality”[tiab] OR “death”[tiab])) OR ((“cesarean”[tiab] OR “caesarean”[tiab]) AND (“mortality”[tiab] OR
“death”[tiab]))
4. Delineate by low-resource setting
("Developing Countries"[Mesh] OR "Africa South of the Sahara"[Mesh] OR "Central America"[Mesh] OR
"Afghanistan"[Mesh] OR "Albania"[Mesh] OR "Algeria"[Mesh] OR "American Samoa"[Mesh] OR "Angola"[Mesh]
OR "Antigua and Barbuda"[Mesh] OR "Argentina"[Mesh] OR "Armenia"[Mesh] OR "Bangladesh"[Mesh] OR
"Republic of Belarus"[Mesh] OR "Belize"[Mesh] OR "Benin"[Mesh] OR "Bhutan"[Mesh] OR "Bolivia"[Mesh] OR
"Bosnia-Herzegovina"[Mesh] OR "Botswana"[Mesh] OR "Brazil"[Mesh] OR "Bulgaria"[Mesh] OR "Burkina
Faso"[Mesh] OR "Burundi"[Mesh] OR "Cape Verde"[Mesh] OR "Cameroon"[Mesh] OR "Cambodia"[Mesh] OR
"Central African Republic"[Mesh] OR "Chad"[Mesh] OR "Chile"[Mesh] OR "China"[Mesh] OR "Colombia"[Mesh]
OR "Comoros"[Mesh] OR "Congo"[Mesh] OR "Democratic Republic of the Congo"[Mesh] OR "Costa Rica"[Mesh]
OR "Cote d'Ivoire"[Mesh] OR "Cuba"[Mesh] OR "Djibouti"[Mesh] OR "Dominica"[Mesh] OR "Dominican
Republic"[Mesh] OR "Ecuador"[Mesh] OR "Egypt"[Mesh] OR "El Salvador"[Mesh] OR "Eritrea"[Mesh] OR
"Ethiopia"[Mesh] OR "Fiji"[Mesh] OR "Gabon"[Mesh] OR "Gambia"[Mesh] OR "Georgia (Republic)"[Mesh] OR
"Ghana"[Mesh] OR "Grenada"[Mesh] OR "Guatemala"[Mesh] OR "Guinea"[Mesh] OR "Equatorial Guinea"[Mesh]
OR "Guinea-Bissau"[Mesh] OR "Guyana"[Mesh] OR "Haiti"[Mesh] OR "Honduras"[Mesh] OR "India"[Mesh] OR
"Indonesia"[Mesh] OR "Iran"[Mesh] OR "Iraq"[Mesh] OR "Jamaica"[Mesh] OR "Jordan"[Mesh] OR
"Kazakhstan"[Mesh] OR "Kenya"[Mesh] OR "Micronesia"[Mesh] OR "Democratic People's Republic of
Korea"[Mesh] OR "Yugoslavia"[Mesh] OR "Kyrgyzstan"[Mesh] OR "Laos"[Mesh] OR "Latvia"[Mesh] OR
"Lebanon"[Mesh] OR "Lesotho"[Mesh] OR "Liberia"[Mesh] OR "Libya"[Mesh] OR "Lithuania"[Mesh] OR
"Macedonia (Republic)"[Mesh] OR "Madagascar"[Mesh] OR "Malawi"[Mesh] OR "Malaysia"[Mesh] OR "Indian
Ocean Islands"[Mesh] OR "Mali"[Mesh] OR "Mauritania"[Mesh] OR "Mexico"[Mesh] OR "Moldova"[Mesh] OR
"Mongolia"[Mesh] OR "Montenegro"[Mesh] OR "Morocco"[Mesh] OR "Mozambique"[Mesh] OR "Myanmar"[Mesh]
OR "Namibia"[Mesh] OR "Nepal"[Mesh] OR "Nicaragua"[Mesh] OR "Niger"[Mesh] OR "Nigeria"[Mesh] OR
"Pakistan"[Mesh] OR "Palau"[Mesh] OR "Panama"[Mesh] OR "Papua New Guinea"[Mesh] OR "Paraguay"[Mesh] OR
"Peru"[Mesh] OR "Philippines"[Mesh] OR "Romania"[Mesh] OR "Siberia"[Mesh] OR "Rwanda"[Mesh] OR
"Samoa"[Mesh] OR "Atlantic Islands"[Mesh] OR "Senegal"[Mesh] OR "Serbia"[Mesh] OR "Seychelles"[Mesh] OR
"Sierra Leone"[Mesh] OR "Melanesia"[Mesh] OR "Somalia"[Mesh] OR "South Africa"[Mesh] OR "Sri Lanka"[Mesh]
OR "Saint Lucia"[Mesh] OR "Saint Vincent and the Grenadines"[Mesh] OR "Sudan"[Mesh] OR "Suriname"[Mesh]
OR "Swaziland"[Mesh] OR "Syria"[Mesh] OR "Tajikistan"[Mesh] OR "Tanzania"[Mesh] OR "Thailand"[Mesh] OR
"East Timor"[Mesh] OR "Togo"[Mesh] OR "Tonga"[Mesh] OR "Tunisia"[Mesh] OR "Turkey"[Mesh] OR
"Turkmenistan"[Mesh] OR "Micronesia"[Mesh] OR "Uganda"[Mesh] OR "Ukraine"[Mesh] OR "Uruguay"[Mesh] OR
"Uzbekistan"[Mesh] OR "Vanuatu"[Mesh] OR "Venezuela"[Mesh] OR "Vietnam"[Mesh] OR "Yemen"[Mesh] OR
"Zambia"[Mesh] OR "Zimbabwe"[Mesh]) OR ("internationality"[MeSH Terms] OR World health organization[MeSH
Terms] OR united nations[MeSH Terms] OR africa[MeSH Terms]) OR (“low-income”[tiab] OR “middleincome”[tiab] OR “low-resource”[tiab] or “developing country”[tiab] or “Africa”[tiab]) OR ("Central America"[Tiab]
OR "Afghanistan"[Tiab] OR "Albania"[Tiab] OR "Algeria"[Tiab] OR "American Samoa"[Tiab] OR "Angola"[Tiab]
OR "Antigua and Barbuda"[Tiab] OR "Argentina"[Tiab] OR "Armenia"[Tiab] OR "Bangladesh"[Tiab] OR "Republic
of Belarus"[Tiab] OR "Belize"[Tiab] OR "Benin"[Tiab] OR "Bhutan"[Tiab] OR "Bolivia"[Tiab] OR "BosniaHerzegovina"[Tiab] OR "Botswana"[Tiab] OR "Brazil"[Tiab] OR "Bulgaria"[Tiab] OR "Burkina Faso"[Tiab] OR
"Burundi"[Tiab] OR "Cape Verde"[Tiab] OR "Cameroon"[Tiab] OR "Cambodia"[Tiab] OR "Central African
Republic"[Tiab] OR "Chad"[Tiab] OR "Chile"[Tiab] OR "China"[Tiab] OR "Colombia"[Tiab] OR "Comoros"[Tiab]
OR "Congo"[Tiab] OR "Democratic Republic of the Congo"[Tiab] OR "Costa Rica"[Tiab] OR "Cote d'Ivoire"[Tiab]
OR "Cuba"[Tiab] OR "Djibouti"[Tiab] OR "Dominica"[Tiab] OR "Dominican Republic"[Tiab] OR "Ecuador"[Tiab]
OR "Egypt"[Tiab] OR "El Salvador"[Tiab] OR "Eritrea"[Tiab] OR "Ethiopia"[Tiab] OR "Fiji"[Tiab] OR
"Gabon"[Tiab] OR "Gambia"[Tiab] OR "Georgia (Republic)"[Tiab] OR "Ghana"[Tiab] OR "Grenada"[Tiab] OR
"Guatemala"[Tiab] OR "Guinea"[Tiab] OR "Equatorial Guinea"[Tiab] OR "Guinea-Bissau"[Tiab] OR "Guyana"[Tiab]
OR "Haiti"[Tiab] OR "Honduras"[Tiab] OR "India"[Tiab] OR "Indonesia"[Tiab] OR "Iran"[Tiab] OR "Iraq"[Tiab] OR
"Jamaica"[Tiab] OR "Jordan"[Tiab] OR "Kazakhstan"[Tiab] OR "Kenya"[Tiab] OR "Micronesia"[Tiab] OR
"Democratic People's Republic of Korea"[Tiab] OR "Yugoslavia"[Tiab] OR "Kyrgyzstan"[Tiab] OR "Laos"[Tiab] OR
"Latvia"[Tiab] OR "Lebanon"[Tiab] OR "Lesotho"[Tiab] OR "Liberia"[Tiab] OR "Libya"[Tiab] OR "Lithuania"[Tiab]
OR "Macedonia"[Tiab] OR "Madagascar"[Tiab] OR "Malawi"[Tiab] OR "Malaysia"[Tiab] OR "Indian Ocean
Islands"[Tiab] OR "Mali"[Tiab] OR "Mauritania"[Tiab] OR "Mexico"[Tiab] OR "Moldova"[Tiab] OR
"Mongolia"[Tiab] OR "Montenegro"[Tiab] OR "Morocco"[Tiab] OR "Mozambique"[Tiab] OR "Myanmar"[Tiab] OR
"Namibia"[Tiab] OR "Nepal"[Tiab] OR "Nicaragua"[Tiab] OR "Niger"[Tiab] OR "Nigeria"[Tiab] OR "Pakistan"[Tiab]
OR "Palau"[Tiab] OR "Panama"[Tiab] OR "Papua New Guinea"[Tiab] OR "Paraguay"[Tiab] OR "Peru"[Tiab] OR
"Philippines"[Tiab] OR "Romania"[Tiab] OR "Siberia"[Tiab] OR "Rwanda"[Tiab] OR "Samoa"[Tiab] OR "Atlantic
Islands"[Tiab] OR "Senegal"[Tiab] OR "Serbia"[Tiab] OR "Seychelles"[Tiab] OR "Sierra Leone"[Tiab] OR
"Melanesia"[Tiab] OR "Somalia"[Tiab] OR "South Africa"[Tiab] OR "Sri Lanka"[Tiab] OR "Saint Lucia"[Tiab] OR
154
"Saint Vincent and the Grenadines"[Tiab] OR "Sudan"[Tiab] OR "Suriname"[Tiab] OR "Swaziland"[Tiab] OR
"Syria"[Tiab] OR "Tajikistan"[Tiab] OR "Tanzania"[Tiab] OR "Thailand"[Tiab] OR "East Timor"[Tiab] OR
"Togo"[Tiab] OR "Tonga"[Tiab] OR "Tunisia"[Tiab] OR "Turkey"[Tiab] OR "Turkmenistan"[Tiab] OR
"Micronesia"[Tiab] OR "Uganda"[Tiab] OR "Ukraine"[Tiab] OR "Uruguay"[Tiab] OR "Uzbekistan"[Tiab] OR
"Vanuatu"[Tiab] OR "Venezuela"[Tiab] OR "Vietnam"[Tiab] OR "Yemen"[Tiab] OR "Zambia"[Tiab] OR
"Zimbabwe"[Tiab])
FILTERS
Publication Dates: 1/1/2009 to 9/1/2014
Species: Humans
Languages: English
REFERENCES
1.
Watters DA, Hollands MJ, Gruen RL, et al. Perioperative Mortality Rate (POMR): A Global Indicator of
Access to Safe Surgery and Anaesthesia. World journal of surgery 2014.
155
Research
156
Appendix 6.0: Research Key Findings
•
•
•
•
The majority of surgical research is done in high-income countries by high-income researchers; surgical research
output correlates with country GDP
There are large knowledge gaps across nearly all global surgery research topics
Current surgical research capacity in LMICs is weak with a lack of training, funding and prioritization
Research needs vary by environment, highlighting the need for locally-driven research agendas
157
Appendix 6.1: Bibliometrics; Surgery And Surgical Oncology Research Outputs 2009-2013
SULLIVAN, R AND LEWIS, G.
EXECUTIVE SUMMARY
1. This report updates an earlier report on surgical oncology that was subsequently published in Annals of Surgery.1
This covered the 10 years 1999-2008 and was based on the papers in the Web of Science (WoS) at the intersection of
two filters, for surgery (SURGE) and oncology (ONCOL). Each of these two filters has subsequently been updated to
reflect new technical developments and the wider journal coverage of the WoS: this means that the new combined
filter would have identified 58% more papers in 2007-08 than previously. The new filter (SURON) generated a file of
51,202 papers from the five years 2009-13 whose details were downloaded to a spreadsheet for analysis. In addition,
some analyses were performed on the 274,492 papers in all surgery. Countries were divided into four income groups:
high (HI > $12,746 per caput), upper-middle (UM >$4125 per caput), lower-middle (LM >$1045 per caput) and low
(LO <$1045 per caput) for the purposes of analysis.
2. Surgical oncology research accounts for about 19% of all surgery research, but only 13% of cancer research. The
leading countries, based on integer counts, are the USA, Japan, China, Germany, Italy, South Korea and the UK.
Japan and South Korea show a rather high commitment to SURON relative to their outputs of surgery, and Russia a
notably low commitment relative to both ONCOL and SURGE.
3. Outputs of the countries in the four income groups correlated closely with their total GNPs, and the correlation was
quite good for individual countries.
4. Of the cancer sites, the ones subject to the most surgical research were colorectal, stomach, liver and breast.
The UM country group emphasized research on stomach, liver and cervical cancers. Outputs did not correlate
well with disease burden in DALYs except for the UM country group, which was dominated by China whose
burden was mainly in stomach and liver cancer. India, with a big (14%) burden in mouth cancer, had a high
research output on this site (18%).
1.
INTRODUCTION
1.1
Origins of study
This study was requested by Professor Richard Sullivan on 15 July 2014 as an adjunct to the Lancet Commission on
Global Surgery. The intention was to focus on the relative volumes of output from four groups of countries, defined by
the United Nations in terms of income per head as in Table 1, and international collaboration within and between
groups.
Table 1. Four groups of countries defined by per caput income in 2013
Country group
Code
Countries
Income per caput range in 2013, USD
High
HI
58 – 57
Above $12,746
Upper middle
UM
38 – 54
From $4125 to $12,746
Lower middle
LM
31 – 47
From $1045 to $4125
Low
LO
19 – 35
Below $1045
The first country number is the number with outputs in the WoS, and the second is the number of WHO Member States.
This is usually greater as some countries publish no research, but Taiwan is included in the WoS as a country although
not a UN member.
1.2
Extension of the study to surgery research
This extension was mentioned in the initial commission, and amplified at a meeting on Monday 28 July 2014. The
outputs of the four groups of countries in all surgery research were to be tabulated, together with measures of
collaboration within each of the four groups and between them. In addition, the numbers and percentages of each
country’s papers that involved clinical trials were to be determined.
158
The outputs of the four country groups in surgical oncology were to be compared with the relative disease burden from
different manifestations of cancer, and the relative commitments of the four groups to surgical oncology research on
each selected site were also to be compared with the world norms.
2
METHODOLOGY
2.1
File creation
Since the earlier study, the filters to be applied to the Web of Science (WoS) for both cancer research (ONCOL) and for
surgery (SURGE) have both been updated to reflect the advent of new title words and the coverage of more journals by
the WoS. In particular, the WoS now processes more journals from developing countries than it did in the 1990s and it
also covers more European journals in non-English languages.
Surgical oncology papers were identified from the intersection of the two individual filters, as before, but the new
definitions of both ONCOL and SURGE meant that the new SURON filter retrieved many more papers than the one
used for the earlier study – by 47% in 2005- 06 and by 58% in 2007-08.This means that the results of the new study are
not exactly comparable with those of the earlier one, and that there will be a discontinuity from 2008 to 2009.
2.2
Integer and fractional counts; international collaboration measures
The analysis of the outputs of individual countries and ones in the four income groups (Table 1) can be conducted on
the basis of either integer or fractional country counts, based on their presence in the set of addresses on each paper. For
the SURON analysis, full details of all the papers were downloaded to file, and each paper was marked with the
fractional count of every country involved. However, for the analysis of SURGE papers, this would have been too big a
task (there were almost 275,000 papers in the five years, 2009- 13), and the analysis was performed directly with the
WoS software using integer counts.
The main measure was the amount of international collaboration both within individual groups of countries, and
between the four groups. For the SURON papers, one measure of international collaboration was the difference
between the sum of the group fractional counts and the integer count, expressed as a percentage of the integer count.
Thus for the upper middle income (UM) countries, their fractional count total was 6880 SURON papers and their
integer count total was 7713. The difference is 833, which is 11% of the integer count total, and represents the three
other group fractional contributions to the UM output. However, the number of papers with any UM country presence
was 7629, little short of the integer count of 7713 and differing by only 1.1%. The latter percentage represents the
amount of collaboration between different UM countries, i.e., the “within group” collaboration. There were 1261
collaborative papers with HI countries, 39 with LM countries and 3 with LO countries, total 1303 less the numbers with
both HI and LM countries (28) to leave 1275 papers co-authored with other groups, or 16.7%. Similar calculations can
be made for the other three groups, and also (since they involve only integer counts) for the SURGE papers.
The countries in each of the four income groups are listed in Table 2.
Table 2. Countries (WHO Member States) classified by income group in 2013 – for definitions, see Table 1
High income
Upper middle
Lower middle
Low income
Andorra
Albania
Armenia
Afghanistan
Antigua & Barbuda
Algeria
Bhutan
Bangladesh
Australia
Angola
Bolivia
Benin
Austria
Argentina
Cameroon
Burkina Faso
Bahamas
Azerbaijan
Cape Verde
Burundi
Bahrain
Belarus
Congo
Cambodia
Barbados
Belize
Côte d'Ivoire
C..Afr. Republic
Belgium
Bosnia & Herzegovina
Djibouti
Chad
Brunei
Botswana
Egypt
Comoros
Canada
Brazil
El Salvador
Congo (D. Rep.)
159
Chile
Bulgaria
Georgia
Eritrea
Cook Islands
China
Ghana
Ethiopia
Croatia
Colombia
Guatemala
Gambia
Cyprus
Costa Rica
Guyana
Guinea
Czech Republic
Cuba
Honduras
Guinea-Bissau
Denmark
Dominica
India
Haiti
Equat. Guinea
Dominican Rep.
Indonesia
Kenya
Estonia
Ecuador
Kiribati
Liberia
Finland
Fiji
Kyrgyzstan
Madagascar
France
Gabon
Laos
Malawi
Germany
Grenada
Lesotho
Mali
Greece
Hungary
Mauritania
Mozambique
Iceland
Iran
Micronesia
Myanmar
Ireland
Iraq
Moldova
Nauru
Israel
Jamaica
Mongolia
Nepal
Italy
Jordan
Morocco
Niger
Japan
Kazakhstan
Nicaragua
North Korea
Kuwait
Lebanon
Nigeria
Rwanda
Latvia
Libya
Pakistan
Sierra Leone
Lithuania
Macedonia (FYR)
Papua New Guinea
Somalia
Luxembourg
Malaysia
Paraguay
Tajikistan
Malta
Maldives
Philippines
Tanzania
Monaco
Marshall Islands
Samoa
Togo
Netherlands
Mauritius
S. Tome & Principe
Uganda
New Zealand
Mexico
Senegal
Zimbabwe
Norway
Namibia
Solomon Islands
Oman
Niue
Sri Lanka
160
High income
Upper middle
Lower middle
Poland
Palau
Sudan
Portugal
Panama
Swaziland
Qatar
Peru
Syria
Russia
Romania
Timor-Leste
Saint Kitts & Nevis
Saint Lucia
Ukraine
San Marino
Saint Vincent & Gren’s
Uzbekistan
Saudi Arabia
Serbia & Montenegro
Vanuatu
Singapore
Seychelles
Viet Nam
Slovakia
South Africa
Yemen
Slovenia
Suriname
Zambia
South Korea
Thailand
Spain
Tonga
Sweden
Tunisia
Switzerland
Turkey
Trinidad & Tobago
Turkmenistan
Unit. Arab Emirates
Tuvalu
United Kingdom
Venezuela
Low income
Uruguay
USA
However, not all the countries in this table had an output of papers in surgical oncology research, or indeed in surgery
research. On the other hand, there were also papers from Taiwan (a high income country but not a member of the
WHO or the UN).
161
3
RESULTS
3.1
Outputs of papers from leading countries and from country groups
The numbers of papers, year by year, in cancer and surgery research, and in surgical oncology, are shown in Table 4.
SURON outputs have increased relative to surgery as a whole, but have slightly decreased as a percentage of
cancer research.
Table 4. World outputs of research papers in oncology (ONCOL), surgery (SURGE) and surgical oncology
(SURON) for 2009-13 (articles and reviews only in the WoS).
Year
ONCOL
SURGE
SURON
% of SURGE
% of ONCOL
2009
66012
49878
9007
18.1
13.6
2010
70586
52345
9565
18.3
13.6
2011
74370
54785
10054
18.4
13.5
2012
82666
57683
10979
19.0
13.3
2013
87666
59801
11597
19.4
13.2
Total
381300
274492
51202
18.7
13.4
Table 5. Outputs of papers from 35 leading countries in oncology, surgery and surgical oncology for 2009-13,
integer counts
Country
ONCOL
SURGE
SURON
Country
ONCOL
SURGE
SURON
World
381300
274492
51202
Sweden
7230
3864
630
USA
126603
87393
15751
Belgium
5462
3732
577
China
47883
18178
4195
Poland
5466
3357
539
Japan
32175
20064
5997
Greece
4683
3004
625
Germany
28975
22298
3720
Austria
4285
3273
504
UK
25246
20208
3070
Denmark
4209
2089
299
Italy
24576
14992
3666
Israel
3435
2242
352
France
19893
12357
2400
Iran
3023
2426
245
South Korea
17327
12215
3267
Norway
3528
1667
333
Canada
16499
11395
1922
Finland
2763
1638
207
Netherlands
12058
8106
1467
Czech Republ.
2542
1777
296
Spain
11725
7178
1183
Singapore
2823
1292
228
Australia
10612
6584
1138
Egypt
2049
1363
192
Turkey
6764
9812
1248
Ireland
1909
1453
236
India
9296
5709
880
Russia
1805
1031
82
Taiwan
8902
4538
1050
Romania
1356
1043
246
Brazil
6478
6379
775
New Zealand
1221
1103
131
Switzerland
6609
5698
699
Pakistan
855
1300
188
162
The above table shows the outputs of papers for the five years. They are ordered by their combined output in
oncology and surgery. The next table shows each country's percentage presence relative to the world in each of
the three subjects.
Table 6. Percentage presence of each of 26 countries in cancer research, surgery research, and in surgical
oncology, 2009-13, based on integer counts
Country
ONCOL
SURGE
SURON
Country
ONCOL
SURGE
SURON
World
100.0
100.0
100.0
Sweden
1.90
1.41
1.23
USA
33.2
31.8
30.8
Belgium
1.43
1.36
1.13
China
12.6
6.6
8.2
Poland
1.43
1.22
1.05
Japan
8.4
7.3
11.7
Greece
1.23
1.09
1.22
Germany
7.6
8.1
7.3
Austria
1.12
1.19
0.98
UK
6.6
7.4
6.0
Denmark
1.10
0.76
0.58
Italy
6.4
5.5
7.2
Israel
0.90
0.82
0.69
France
5.2
4.5
4.7
Iran
0.79
0.88
0.48
S. Korea
4.5
4.5
6.4
Norway
0.93
0.61
0.65
Canada
4.3
4.2
3.8
Finland
0.72
0.60
0.40
Netherlands
3.2
3.0
2.9
Czech Rep.
0.67
0.65
0.58
Spain
3.1
2.6
2.3
Singapore
0.74
0.47
0.45
Australia
2.8
2.4
2.2
Egypt
0.54
0.50
0.37
Turkey
1.8
3.6
2.4
Ireland
0.50
0.53
0.46
India
2.4
2.1
1.7
Russia
0.47
0.38
0.16
Taiwan
2.3
1.7
2.1
Romania
0.36
0.38
0.48
Brazil
1.7
2.3
1.5
N. Zealand
0.32
0.40
0.26
Switzerland
1.7
2.1
1.4
Pakistan
0.22
0.47
0.37
3.2
Output of groups and collaboration within and between the groups
As expected, the high-income countries published the largest share of papers followed by the upper middle
countries (led by China), the lower middle countries (led by India) and the low- i n c o m e countries (which no
longer contain Nigeria, now in the lower middle- i n c o m e group. The numbers of papers – the sum of
individual countries’ outputs and the number from the group as a whole – are shown in Tables 7, where the
percentages o f “within-group” collaborations are calculated as a fraction of the group total. Outputs from the
f o u r groups in S URON correlated closely with the g r o u p s ’ total gross domestic products (GDP) see Figure
1, overleaf. For individual countries, the correlation is less good (Figure 2), and it appears that some countries
are publishing relatively more than would be expected (South Korea, Taiwan, Italy) and others rather less (Brazil,
Switzerland, India). The UK, although havinga relatively low commitment to surgical oncology and publishing only
6% of world output (integer count) and 4·7% (fractional count) nevertheless appears to be performing slightly
well than its GDP might suggest.
163
Table 7. Numbers of papers from four income-level country groups in surgery research,
2009-13, integer counts, and percentages of “within-group” collaboration.
Sum of country counts
Group total
Collaboration, %
Year
HI
UM
LM
LO
HI
UM
LM
LO
HI
UM
LM
LO
2009
48977
7229
1656
74
42386
7145
1647
73
15.5
1.2
0.5
1.4
2010
51615
7948
1985
107
44172
7819
1952
98
16.9
1.6
1.7
9.2
2011
53714
8760
2088
113
45909
8602
2061
112
17.0
1.8
1.3
0.9
2012
56866
9911
2003
131
48136
9673
1960
118
18.1
2.5
2.2
11.0
2013
58444
11184
2178
139
48912
10992
2136
134
19.5
1.7
2.0
3.7
Total
269616
45032
9910
564
229515
44231
9756
535
17.5
1.8
1.6
5.4
There is very little “within-group” collaboration except for the high-income country group, which has
increased over the five-year period. In the upper-middle and lower-middle groups, there is slightly less
collaboration in surgical oncology than in surgery overall. The amount of “inter-group” collaboration is shown
in Tables 8 and 9.
Table 8. Numbers of papers from two different income groups of countries in surgery research,
2009-13, and percentages of the output of the lower income group of countries.
Numbers of papers
Inter-group collaboration
Set
UM
LM
LO
% of UM
% of LM
% of LO
HI
8440
1989
302
19.1
20.4
56.4
321
36
3.3
6.7
UM
LM
61
11.4
Most of the inter-group collaboration is between the high-income countries and the others, and such
collaborations account for more than half the low-income group’s papers in surgery research.
It is expected that the smaller countries in scientific output will collaborate internationally more than the
larger companies as it will be less likely that their scientists would find a complementary partner within
their borders. However there are some exceptions, notably the Asian countries (Japan, China and South
Korea; India, Taiwan and Turkey) which remain rather isolated.
REFERENCES
1.
Purushotham AD, Lewison G, Sullivan R. The state of research and development in global cancer
surgery. Annals of surgery 2012; 255(3): 427-32.
164
The Patient Voice
165
Appendix 7: Patient Quotations
Recognizing that the patient is the impetus behind The Lancet Commission on Global Surgery, we ventured
to maintain the perspective of the patient throughout the commission process. What is meaningful to the
patient is too often lost in academic pursuits and publications. Therefore, we attempted to solicit and record
direct quotations from real surgical patients and family members of those undergoing surgical procedures
to represent the “patient voice” throughout The Lancet Commission on Global Surgery. Such quotations
could be used throughout the text to demonstrate key issues and priorities.
Quotations and stories are derived from in-person interviews conducted by Commission partners (The
Right to Heal.org and surgeons from The University of Utah’s Center for Global Surgery) or research
associates affiliated with the Commission. Written or verbal consent was obtained for all patient voice
interviews. An example of our consent form is appended at the end of this document. Quotations are
organized below by country.
166
PATIENTS FROM HAITI 7
33 year old Haitian Man, single, with one child at home, with a large pleural effusion:
“Well, the biggest problem is that there aren’t enough doctors where I live. So, I couldn’t find care
quickly. I had to travel far and wait a long time to see a doctor… I couldn’t breathe… They gave me
oxygen, but they couldn’t give me enough… (They) transferred me to Mirebalais. An ambulance brought
me here. The ambulance didn’t have oxygen. It started to rain as well when we were on our way over.
Eventually I arrived in the emergency department. I couldn’t breathe—I think I passed out, I don’t
remember.”
“They thought that maybe it was a mystical illness. The fact that I was swollen and filled with water, made
them think that it was a mystical illness. It wasn’t until I came to the hospital and they did all these tests
that they believed that it was a hospital illness. That is much better than a mystical illness—once I leave the
hospital, hopefully the illness will go away.”
“The problem with employment is everywhere in Haiti. If there were a hospital like this in every
department, it would help employ people as well—as well as provide an important service. In this hospital,
I feel like I will actually get better. I find care, medications and everything. Pain is at a minimum. The
doctors are nice and they check on you. There are lots of nurses. It is a beautiful thing. For a long time, in
Haiti, you would have to have a ton of money in order to get care like this. But, in Mirebalais, when you
arrive it doesn’t matter who you are—you just get taken care of. And they can save your life. It’s a great
thing. I like it a lot.”
7
Interviews performed and translated by Morgan Mandigo and Katie O’Neill
167
The Mother of an 8 year old girl, 6th of 8 children, badly burned on left side of her body, who has had
multiple skin grafts and debridements:
“I was sick. I had to be in bed all day so my older children were making food for the family that day. The
food was in the fire and when they took it out to transfer it over to the table. They weren’t watching her and
she got too close to the fire. Her clothes caught on fire all of a sudden…[The hospital] was only about 30
minutes away…They gave us lots of medical care. But, it was in a private hospital. We had to pay 20 HD
everyday for the bed and then 100gourdes for each dressing change, which they did about 2 times per day.
Every time we needed another tub of silver sulfadiazine I had to pay 150 gourdes. Then also, there were
medications… I had to sell some things in my home to get more money and I used what I had. [We were
there for] 22 days. After a little while, I couldn’t afford the cost of the hospital anymore. So, they
transferred us ... [Now I live] here with her in this chair… I am a farmer…I could work, but I can’t find any
work here.”
“Well, where I live, when someone needs operations, they often cannot find it. We don’t have a hospital
like this. There is a higher level of care here. There also just aren’t enough doctors. We have Cuban doctors
that come, but if they were not there I don’t know what we would do…there is a group of doctors that come
for trips that do surgeries. A lot of people get their surgery then. But, they don’t stay that long and they
cannot take care of everyone.”
168
65 years old woman, widowed with 7 children. She had completed 6th grade and previously worked
as a farmer but is now unable to work due to illness. She has metastatic breast cancer and goes to the
hospital to receive palliative chemotherapy.
“Well, once I came here I never had any problems. Everyone here has taken care of me. The only problem I
have is that I don’t have money. My husband died and I don’t have money to come back and forth to the
hospital
169
60-year old woman with breast cancer, widowed, receiving chemotherapy. Educated half way
through primary school, then worked selling items in the market until she became ill
“…it was the oldest of my children. She said I had to go see a doctor about the lump in breast. She is
training to be a nurse… [so] another child of mine brought me. They paid for the car to bring me here. I am
not sure how long it took. We left the house around 5am and got here maybe at 2pm. …No I cannot work. I
am sick. Do you think you could give me some money for food? All of my money is completely gone. You
know I come from Cap Haitian. If you could give me some money just so I could buy food…”
170
UNIDENTIFIED LOCATION
A 15 year old girl, who underwent repair for a vesicovaginal fistula which developed after four days
of obstructed labor that ensued after being raped by two of her classmates 8
“… I was 15 years old… and I got pregnant. Those boys in the rural area, you know… they decided to
force me… they were two. I went home and tell my mother… and she tell me… [your home] is not here…
Labor pain started… they take me to the hospital… it took almost 4 days… they operated and they say the
child had already died… after the operation, I stay there for 1 week and I saw the leakage of urine. In
hospital you can stay there for 2 weeks, and you have not eaten anything, you are so stressed, you cannot
walk with your friends… and you’re always scared… because you smell bad… if you are sitting with
people, it is very complicated for you to walk away from them so you wait for the people and they go first
and now you can go. It was so painful, with the loosing of the baby already… It was painful. I was
thinking I was already dead. Now, my life is becoming near. I am just getting well now. I was happy to
hear that I am going back to school. Now I can talk to you people. My mother, she is becoming near to me
now. I want to study hard. And then I will do the work that Dr. Mabaya does. Helping those who have this
problem like I have. My career is to become a nurse.”
8
source: The Right to Heal, Golden Hour Films, LLC
171
MONGOLIA 9
Quotations from Mongolian Patients regarding Barriers to Surgical Care:
- Biggest barrier is emotional. Came to hospital – told us you would have to wait one month for the
surgery. Within this month, told to do investigation, while we are getting our testing, sent to place
A. Place A tells us that they don’t have it, go to place B. Place B tells you to go to C. You get
very discouraged and lose hope. Your sickness can take over you. / If there was a system where
they would just admit you – do investigations, would be much better, better resolutions. Who
knows what will happen within this one month of waiting.
- Had to wait long time before coming to city for surgery (3 years), due to finding time off job.
Stopped work 5 days ago.
- Investigations before surgery take time to collect. Had to wait long time before getting operation.
Initially saw the doctor 5 months ago, with the investigations booked the following week, but I
was too busy and working
- Diagnosing and testing are biggest barriers. Been coming to the hospital every day for about a
month. Many days stand in queue for tests, nothing happens.
- For countryside people, many barriers. Nobody to leave behind to herd animals. If they go to
nearest hospital, doctors not knowledgeable. Transport to city is a problem.
- Surgery healed my pain. Relieved the numbness. But, financially a bit difficult. Lost my job. As
couldn’t get back to work, fired. Still looking, debilitated by disability of reduced bending etc.
Want to receive monetary help from government, but told I don’t qualify.
- Many years ago, thought surgery was dangerous, avoiding at all costs. Now, seeing patient with
surgery who were discharged and repaired, seems like surgical care has improved a lot. Doesn’t
make me feel scared anymore. If I have to have surgery, I won’t be scared.
Chief of surgery at Health Sciences University of Mongolia. Her daughter needed a cholecytectomy.
"Laparoscopic surgery is demanded for the Mongolia. Our people are nomadic, have very little, and cannot
afford to be sick for long times. Laparoscopy that allows patients to return to work faster, recover quicker,
and have less complications is more important for people in poor countries like Mongolia than for people in
wealthier countries!"
9
Quotations Collected in a qualitative research study by Dr. Raymond Price, Dr. Katien Wells, Dr. O.
Sergelen, & Dr. L. Ganbold from the University of Utah Department of Global Surgery (USA) and the
Mongolian Health Sciences University, Mongolia
172
MALAWI
60-year-old man from Malawi, awaiting hernia repair:
“We do not have much money and I was told after the repair I would not be able to work until it am
recovered. I have had to wait for my children to be able to help on our field so we will be able to have a
little money for food while I can not work in the field.”
173
CONSENT FORM FOR INTERVIEW FOR
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174
Acknowledgements
175
Appendix 8: Acknowledgements
The work found in this report was enhanced by the generous financial or in-kind support that we
received from the following organizations:
Association of Anaesthetists of Great Britain and Ireland, Babson College, Bill and Melinda Gates
Foundation, Boston Children's Hospital, Dubai Harvard Foundation for Medical Research, FAPESP
Fundacao de Amparo a Pesquisa de Sao Paolo, Harvard Business School, Harvard Medical School Center
for Global Health Delivery-Dubai, Harvard Medical School Department of Global Health and Social
Medicine, Indian Institute of Management Bangalore, King's College London, Lund University, Melbourne
Business School, National Cancer Institute, Operation Smile, Pershing Square, , Steven C. and Carmella R.
Kletjian Foundation, Inc., Royal College of Surgeons in Ireland, The Royal College of Surgeons of
Edinburgh, The Rockefeller Foundation, University of Virgina Darden School of Business
We are grateful to our core research team without whom this work could not have been feasible. We are
indebted to these participants for their input, dedication, and time:
Geoffrey Anderson, Rishitha Bollam, Alexis Bowder, Gloria Boye, Kimberly Daniels, Samuel Enumah,
Micaela Esquivel, Frederik Federspiel, Jacky Fils, Brigitte Frett, Lily Gutnik, Alex Haynes, Hampus
Holmer, Anton Jarnheimer, Jong Hun Kim, Meera Kotagal, Katie Kralievits, Adam Lantz, Jennifer Leahy,
Charles Liu, Rebecca Maine, Morgan Mandigo, Penelope Milsom, Dimple Mirchandani, George Molina,
Swagoto Mukhopadhay, Shilpa Murthy, EricNagengast, Josh Ng-Kamstra, Kathleen O'Neill, Fredrik Oher,
Charlotta Palmqvist, Sherry Prasad, Jonathan Scott, Alireza Shirazian, Bin Song, Gabriel Toma, Tarsicio
Uribe-Leitz, Martha Vega, Isabeau A Walker, Rachel Yorlets
This report was generated with the tremendous help, wisdom, and counsel of the following individuals:
Our exceptionally experienced peer-reviewers who all shared deep insight and wisdom, pushing us to
improve this report in a multifaceted manner, The Lancet editing team who worked tirelessly to produce
this report and its associated publications, Francis Abantanga, Fizan Abdullah, Leyouget Abebe, Isaac
Adewole, Arnav Agarwal, Larry Akoko, Frank Anderson, Zara Ansari, Paul Arkell, Sumedha Arya,
Genevieve Barnard, Anne Becker, Carol Benoit, Luis Bermudez, Laura Betcherman, Josh Bleicher, Ties
Boerma, Håkon Angell Bolkan, Heather Bougard, Christopher Boyd, Gloria Boye, Susan Briggs, Ruairi
Brugha, Marine Buissonniere, Sule Burger, Yvonne Butler, Josh Butts, James Campbell, Katie Campbell,
Sally Carver, Jorge Cervantes, Elliot Chaikof, Mack Cheney, Meena Cherian, Vicki Chia, Laston Chikoya,
Timothy Chung, Isabel Citron, Mariam Claeson, Ainhoa Costas-Chavarri, Richard Coughlin, Trevor
Crofts, James Cusack, Benedict Darren, Ara Darzi, Nils Daulaire, Haile Debas, Miliard Derbew, Catherine
DeVries, Rochelle Dicker, Chris Doiron, Brian Donley, George Dyer, Bissallah Ekele, Alex Elobu,
Micaela Esquivel, Timothy Evans, Peter Fagenholz, Didi Bertrand Farmer, Alberto Ferreres, Samuel
Finlayson, Paul Firth, Hugo Flores, Esteban Foianini, Claudia Frankfurter, John Freeman, Julio Frenk,
Sehamuddin Galadari, Rafael Galli, Peter George, Ophira Ginsburg, Richard Gliklich, David Golan,
Richard Gosselin, Ramiro Guerrero, Adam Gyedu, Donald Hannan, Hilda Harb, Stephen Hargarten, Alex
Haynes, Ryan Hayton, James Heiby, Jaymie Henry, Bernard Ho, Jamal Hoballah, Michael Hollands, Liam
Horgan, Richard Horton, Sarah Hosein, Marguerite Hoyler, David Hoyt, Renee Hsia, Guoqing Hu, Eric
Hubli, Christopher Hughes, Mautin Hundeyin, Yogesh Jain, Esse Jama, Dean Jamison, Pankaj Jani,
Prabhat Jha, Jorge Jimenez, Oliver Johnson, Haythem Kaafarani, Charles Kabetu, Leonard Kabongo, John
Kachimba, Robert Kaplan, Brima Kargbo, Raman Kataria, Edward T. Kelley, Caitrin Kelly, Oliver P.
Keown, Vanessa Kerry, Monty Khajanchi, Aamir Khan, Abbas Khosravi, Carmella Kletjian, Felicia Knaul,
Adofo Koranteng, Jennifer Kreshak, Catherine Kress, Tino Kreutzer, Francis Lai, Robert Lane, Michael
Lappi, Aiah Lebbie, Abraham Lebenthal, Katherine Lee, Wan Lee, Tonatiuh Liévano, Jerker Liljestrand,
Keith Lillemoe, Allison Linden, Steve Liposky, Brenda Longstaff, Timothy Lu, Laura Luque, William
(Bill) Magee, Zoe Maher, Emmanuel Makasa, Keith Martin, Andrew Marx, Alexi Matousek, Mbololwa
Mbikusita-Lewanika, Craig McClain, Ian McColl, Colin McCord, Kelly McQueen, Nandakumar Menon,
Robert Merrifield, Sam Mills, Charles Mock, Vicki Modest, Gita Mody, Hernan Montenegro, David
Mooney, Allisyn Moran, Saba Morshed, Godfrey Muguti, Miriam Mutebi, Brian Nahed, Devina Nand,
Asad Naveed, David Nicholson, Georges Ntakiyiruta, Rachel Nugent, Cameron Nutt, Benjamin Nwomeh,
Bisola Onajin-Obembe, Elliot Odom, Keith Oldham, Anne Palaia, Dan Palazuelos, Eldryd Parry, Amul
176
Pawaskar, Carlos Pellegrini, Lebei Pi, Michael Porter, CS Pramesh, Raymond Price, Jennifer Puccetti,
Jordan Pyda, Mosiur Rahman, Seyed Mohammad Ali Raisolsadat, Gaboelwe Rammekwa, Margarita
Ramos, Steve Reifenberg, Joe Rhatigan, Robert Riviello, Selwyn Rogers, TT Rogers*, Sakib Rokadaya,
Tapash Roy, Enrique Ruelas, Martin Salia*, Josh Saloman, Lubna Samad, Tom Sato, Sadath Sayeed, Mario
Scheffer, Leonard Schlesinger, Camilo Sepulveda, Amina Shamaki, Bob Shamberger, Pamela Sheeran,
Jeremy Shiffman, Arvydas Skorupskas, Antanas Slivinskas, Martin Smith, Lucas Sobrado, David Spiegel,
Nichole Starr, Michael Steer, Erin Stieber, Mamta Swaroop, Samih Tarabichi, John Tarpley, Robert Taylor,
Carrie Teicher, Suzanne Thomas, Marcelo Torres, Ted Trimble, Maeve Trudeau, Stephen Ttendo, Patricia
Turner, Bilguun Unurbileg, Richard Vanderburg, Jeffrey Vincent, Johan von Schreeb, Melanie Walker,
Waruguru Wanjau, Luther Ward, Benjamin Warf, Andrew Warshaw, Rebecca Weintraub, Brad Weston,
Michelle White, Wendy Williams, Andreas Wladis, Herve Yangni-Angate, Celine Yeung, Kenan YusifZade, Michael Zinner
*Indicates posthumous acknowledgement
An essential team of individuals made substantial contributions to The Lancet Commission on Global
Surgery’s plans for implementation of the report. These individuals, known as The Bellagio
Commissioners are listed here:
Fizan Abdullah, Stephen W. Bickler, Anna J Dare, Justine Davies, Sarah LM Greenberg, Ramiro Guerrero,
Lars Hagander, James Heiby, Jaymie Henry, Pankaj Jani, Jorge Jimenez, Edward T. Kelley, Andy Leather,
Emmanuel Masaka, Mbololwa Mbikusita-Lewanika, John G Meara, Sir David Nicholson, Rachel Nugent,
Bisola Onajin-Obembe, Eldryd Parry, Ray Price, Nakul Raykar, Nobhojit Roy, Tapash Roy, Enrique
Ruelas, Martin Smith, Ted Trimble, Melanie Walker, Herve Yangni-Angate
177