Surgical services in low-income and middle-income countries

Division of Orthopedic Surgery, Childrens Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
The Lancet (Impact Factor: 39.21). 10/2007; 370(9592):1013-5. DOI: 10.1016/S0140-6736(07)61457-3
Source: PubMed
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    ABSTRACT: Background It is difficult to measure accurately the out-of-pocket surgical health expenditures in developing countries. The World Health Organization reports that 45% of health costs in the developing world are out-of-pocket expenditures.1 Many households often incur catastrophic costs, pushing them below the poverty line.2, 3, 4, 5, 6, 7 and 8 Methods Ovid MEDLINE literature search on out-of-pocket surgical expenditures, public health, and health systems. Results Various studies have shown that surgical services can sizably reduce premature death or disability in developing countries.9,10 A common misconception is that they are expensive; however, studies show that they are cost-effective public health measures,10 and that surgical conditions are significant public health problems.9,11 In fact, some studies suggest that select surgical interventions may be more cost-effective compared to other health interventions.12, 13 and 14 There are glaring inequalities and inequities in access to surgical services in developing countries, particularly in rural and/or marginalized populations.9,15, 16 and 17 Due to a lack of perceived importance and political advocacy, there is a lack of coverage by health systems which frequently push households below the poverty line due to catastrophic health expenditures. This has wide ranging physical, psychological, financial, and social implications to individuals and households. Surgery could also be the crucial determining factor in the achievement of Millennium Development Goals (MDGs) 4–6.18 Conclusions Surgical interventions are often a neglected public/global health topic as they are, often incorrectly, deemed as high-cost. Health systems strengthening to increase provision and access to surgical interventions are vital to save lives, prevent disability, provide a social safety net, and aid in the achievement of the MDGs.
    01/2013; 2(1):40. DOI:10.1016/S2049-0801(13)70031-1
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    ABSTRACT: Background: Surgical burden is a large and neglected global health problem in low- and middle-income countries. With the increasing trauma burden, the goal of this study was to evaluate the trauma capacity of hospitals in the central plateau of Haiti. Materials and methods: The World Health Organization Emergency and Essential Surgical Care survey was adapted with a focus on trauma capacity. Interviewers along with translators administered the survey to key hospital staff. Results: Seven hospitals in the region were surveyed. Of the hospitals surveyed, 3/7 had functioning surgical facilities. None of the hospitals had trauma registries. 71% of the hospitals had no formal trauma guidelines. 2/7 hospitals had a general surgeon available 100% of the time. All surgical facilities had oxygen cylinders available 100% of the time, but three of the primary level hospitals only had it available 51%-90% of the time. Intubation equipment was available at 57% of the facilities. Ventilators were only available in the operating room. Only the largest hospital had a computed tomography scanner. Other hospitals (66%) had a functioning x-ray machine 76%-90% of the time. Hospitals (57%) had an ultrasound machine. The most common reasons for referral were lack of appropriate facilities and supplies at the primary level care centers or lack of trained personnel at higher-level facilities. Conclusions: Trauma capacity in the central plateau of Haiti is limited. There is a great need for more personnel, trauma training at all staff levels, emergency care guidelines, trauma registries, and imaging equipment and training, specifically in ultrasonography. To accomplish this, coordination is needed between the Haitian government and local and international nongovernmental organizations.
    Journal of Surgical Research 06/2014; 192(1). DOI:10.1016/j.jss.2014.06.009 · 2.12 Impact Factor
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    ABSTRACT: Background: The Alvarado score is the most widely used clinical prediction tool to facilitate decision-making in patients with acute appendicitis, but it has not been validated in the black South African population, which has much wider differential diagnosis than developed world populations. We investigated the applicability of this score to our local population and sought to introduce a checklist for rural doctors to facilitate early referral. Methods: We analyzed patients with proven appendicitis for the period January 2008 to December 2012. Alvarado scores were retrospectively assigned based on patients' admission charts. We generated a clinical probability score (1-4 = low, 5-6 = intermediate, 7-10 = high). Results: We studied 1000 patients (54% male, median age 21 yr). Forty percent had inflamed, nonperforated appendices and 60% had perforated appendices. Alvarado scores were 1-4 in 20.9%, 5-6 in 35.7% and 7-10 in 43.4%, indicating low, intermediate and high clincial probability, respectively. In our subgroup analysis of 510 patients without generalized peritonitis, Alvarado scores were 1-4 in 5.5%, 5-6 in 18.1% and 7-10 in 76.4%, indicating low, intermediate and high clinical probability, respectively. Conclusion: The widespread use of the Alvarado score has its merits, but its applicability in the black South African population is unclear, with a significant proportion of patients with the disease being potentially missed. Further prospective validation of the Alvarado score and possible modification is needed to increase its relevance in our setting.
    Canadian journal of surgery. Journal canadien de chirurgie 08/2014; 57(4):E121-E125. DOI:10.1503/cjs.023013 · 1.27 Impact Factor