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Impact of Surgical Lighting on Intraoperative Safety in Low-Resource Settings: A Cross-Sectional Survey of Surgical Providers

Authors:

Abstract

Background: Safe surgery requires high-quality, reliable lighting of the surgical field. Little is reported on the quality or potential safety impact of surgical lighting in low-resource settings, where power failures are common and equipment and resources are limited. Methods: Members of the Lifebox Foundation created a novel, non-mandatory, 18-item survey tool using an iterative process. This was distributed to surgical providers practicing in low-resource settings through surgical societies and mailing lists. Results: We received 100 complete responses, representing a range of surgical centres from 39 countries. Poor-quality surgical field lighting was reported by 40% of respondents, with 32% reporting delayed or cancelled operations due to poor lighting and 48% reporting electrical power failures at least once per week. Eighty per cent reported the quality of their surgical lighting presents a patient safety risk with 18% having direct experience of poor-quality lighting leading to negative patient outcomes. When power outages occur, 58% of surgeons rely on a backup generator and 29% operate by mobile phone light. Only 9% of respondents regularly use a surgical headlight, with the most common barriers reported as unaffordability and poor in-country suppliers. Conclusions: In our survey of surgeons working in low-resource settings, a majority report poor surgical lighting as a major risk to patient safety and nearly one-third report delayed or cancelled operations due to poor lighting. Developing and distributing robust, affordable, high-quality surgical headlights could provide an ideal solution to this significant surgical safety issue.
ORIGINAL SCIENTIFIC REPORT
Impact of Surgical Lighting on Intraoperative Safety in Low-
Resource Settings: A Cross-Sectional Survey of Surgical Providers
Jared A. Forrester
1
Nicholas J. Boyd
2
J. Edward F. Fitzgerald
3
Iain H. Wilson
4
Abebe Bekele
5
Thomas G. Weiser
1,6,7
ÓSocie
´te
´Internationale de Chirurgie 2017
Abstract
Background Safe surgery requires high-quality, reliable lighting of the surgical field. Little is reported on the quality
or potential safety impact of surgical lighting in low-resource settings, where power failures are common and
equipment and resources are limited.
Methods Members of the Lifebox Foundation created a novel, non-mandatory, 18-item survey tool using an iterative
process. This was distributed to surgical providers practicing in low-resource settings through surgical societies and
mailing lists.
Results We received 100 complete responses, representing a range of surgical centres from 39 countries. Poor-
quality surgical field lighting was reported by 40% of respondents, with 32% reporting delayed or cancelled oper-
ations due to poor lighting and 48% reporting electrical power failures at least once per week. Eighty per cent
reported the quality of their surgical lighting presents a patient safety risk with 18% having direct experience of poor-
quality lighting leading to negative patient outcomes. When power outages occur, 58% of surgeons rely on a backup
generator and 29% operate by mobile phone light. Only 9% of respondents regularly use a surgical headlight, with
the most common barriers reported as unaffordability and poor in-country suppliers.
Conclusions In our survey of surgeons working in low-resource settings, a majority report poor surgical lighting as a
major risk to patient safety and nearly one-third report delayed or cancelled operations due to poor lighting.
Developing and distributing robust, affordable, high-quality surgical headlights could provide an ideal solution to this
significant surgical safety issue.
Paper will be presented at the 18th COSECSA Scientific Conference
in Maputo, Mozambique, December 4–8.
&Jared A. Forrester
jaredf2@stanford.edu
1
Department of Surgery, Section of Trauma & Critical Care,
Stanford University, 300 Pasteur Drive, S067, Stanford,
CA 94305-5106, USA
2
Great Ormond Street Hospital For Children NHS Trust,
London, UK
3
Kings Centre for Global Health, Kings College London,
London, UK
4
Lifebox Foundation, London, UK
5
Department of Surgery, School of Medicine, Addis Ababa
University, Addis Ababa, Ethiopia
6
Lifebox Foundation, Boston, MA, USA
7
Department of Clinical Surgery, Royal Infirmary of
Edinburgh, University of Edinburgh, Edinburgh, UK
123
World J Surg
DOI 10.1007/s00268-017-4293-z
Introduction
Surgical volume has increased dramatically in the past decade
[1][2], yet there are the estimated 140 million additional
operations required annually to meet the minimum need for
operative care [3]. The Lancet Commission for Global Sur-
gery and the Disease Control Priorities programme evidenced
the need for increasing surgical services and capacity, while
also necessitating assurance for the quality of surgical care
delivered [4,5]. Surgical safety in low- and middle-income
countries (LMICs) is a major, but poorly recognized public
health issue that requires urgent attention.
Along with well-trained healthcare providers, certain fun-
damental equipment and infrastructure requirements are
essential for delivering safe surgical care. High-quality
lighting of the surgical field is one such requirement and is
usually dependent on a reliable electricity supply. The World
Health Organization (WHO) Service Availability and
Readiness Assessment (SARA) classifies essential electrical
equipment into: (1) infrastructure, (2) medical devices, and (3)
support appliances for specific health services [6,7]. Surgical
lighting is part of both the infrastructure and support appli-
ances for health services; therefore, it is a fundamental com-
ponent of safe surgical care.
Electricity outages are common in low-resource settings
and severely impact surgical lighting. In a study of eleven
sub-Saharan African countries, only 28% of health facilities
and 34% of hospitals had reliable access to electricity,
defined as no outages of greater than 2 h in the past week [8].
High-quality theatre lights are nearly universally available in
high-resource settings, yet many surgeons also wear head-
lights specifically designed to improve illumination of the
surgical field. Such headlights are expensive, and their
availability is limited in LMICs. Improving the consistency
of surgical field illumination may have multiple benefits,
such as reducing morbidity and increasing surgical volume
through reduction in delays and cancellations.
Despite known unreliability of electricity in LMICs and the
recognized need for quality lighting to provide surgical care,
there is a paucity of literature on how electricity failures
impact surgical lighting or how operating theatre lighting
affects patient care. This study, through surveying surgical
providers working in LMICs, aimed to assess the current state
of surgical lighting and its perceived impact on surgical care.
Materials and methods
Definitions
For this study, quality of surgical lighting was defined as
the ability to consistently illuminate the surgical field.
LMICs were defined by standard economic criteria [9].
Questionnaire design and distribution
A novel, 18-item questionnaire survey was developed in
English consisting of free text, binomial, and Likert-like
scale responses [Appendix]. The questionnaire was designed
with reference to previously published guidelines on ques-
tionnaire-based research [10,11]. The survey tool was pilot-
tested by surgeon and anaesthesia members of the study team
with experience practicing in LMICs; content validity was
ensured by this iterative process, and the feedback received
was then used to further refine the question items. Individual
question items were compulsory. Identifiable information
collected (e.g. email address) was voluntarily provided. No
incentives were offered for participation.
A link to the online survey (SurveyMonkey.com, LLC,
Palo Alto, California, USA) was distributed to the members of
different surgical societies through the College of Surgeons of
East, Central, and Southern Africa (COSECSA), including the
Surgical Society of Ethiopia, surgical specialty associations,
and local and international surgical mailing lists. Individuals
were also encouraged to share the link with their colleagues in
a ‘‘snowball’’ recruitment strategy. Data collection took place
from 17 December 2016 to 9 May 2017. Due to this snowball
strategy, the survey response rate was not captured. The eth-
ical dimensions of this voluntary evaluation survey were
considered, and no concerns were identified; completion of
the questionnaire was taken as implied consent to participa-
tion in this study; and IRB approval was not pursued.
This study was undertaken by the Lifebox Foundation
(http://www.lifebox.org), a non-profit, charitable organiza-
tion registered in the UK and USA. The Lifebox Founda-
tion works to implement sustainable changes of practice
that will ultimately raise the safety and quality standards of
global surgery and anaesthesia.
Data analysis
Only fully completed questionnaires were included in the
analysis. Mann–Whitney U test was used where appropri-
ate for comparison between groups, and p\0.05 was
considered significant. Microsoft Excel (Microsoft, 2013,
Redmond, Washington, USA) was used to calculate
descriptive statistics. Free-text responses were indepen-
dently categorized by theme into groups for analysis by
four of the authors, with differences resolved by discussion.
Results
Respondent demographics
A total of 100 surveys were fully completed and included
in the analysis. Respondents represented 39 countries, 85%
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being permanent practitioners in LMICs. The remainder
were visiting surgeons who practice in LMICs, responding
for the main LMIC hospital where they practice. A wide
variety of surgical disciplines and surgical practice settings
were represented with the majority practicing in
regional/national referral hospitals (67%) (Table 1).
Current status of surgical lighting
40% of respondents reported the quality of the surgical
lighting in their operating theatre as either poor or very
poor, with no significant difference between surgical set-
ting sizes (41.8% in regional/tertiary centres and 42.9% in
smaller referral centres, p=0.87) (Fig. 1). Electrical
power failures were common. Almost half of respondents
(48%) reported main power failure at least once per week,
with nearly one-third of the respondents (32%) reporting
operation delays or cancellations due to poor lighting. Most
respondents reported their hospitals possess a backup
generator (94%), though of those only 48% noted this
backup to be always available. During power outages and
the resultant failure of surgical field illumination, respon-
dents reported a variety of solutions in the operating the-
atre, most commonly relying on the backup generator
(58%) or the using a mobile phone light (29%). Only 9%
reported using a surgical headlight regularly, with unaf-
fordability (65%) and poor in-country suppliers (43%)
being the most common barriers to headlight use (Table 2).
Table 1 Respondent demographics and practice settings
Demographic Regional/National centres (n=67) Smaller referral centres (n=28) Others (n=5) Total (n=100)
N%N%N%N
Hospital setting
Regional/national referral hospital 67 100 0 0.0 0 0 67
First referral hospital 0 0 9 32.1 0 0 9
District hospital 0 0 8 28.6 0 0 8
Private hospital 0 0 6 21.4 0 0 6
Other 0 0 0 0.0 5 100 5
Rural health clinic/health centre 0 0 3 10.7 0 0 3
Private clinic/health centre 0 0 2 7.1 0 0 2
Surgeon practice location
Permanent 59 88 22 78.6 4 80 85
Visiting 6 9 5 17.9 0 0 11
Other 2 3 1 3.6 1 20 4
Surgical specialty
General 39 58.2 18 64.3 3 60 60
Other 7 10.4 3 10.7 0 0 10
OB/GYN 7 10.4 2 7.1 0 0 9
Orthopaedic 4 6.0 3 10.7 0 0 7
Paediatric surgery 6 9.0 0 0.0 0 0 6
Plastic surgery 2 3.0 0 0.0 1 20 3
Cardiothoracic surgery 1 1.5 1 3.6 1 20 3
Neurosurgery 1 1.5 0 0.0 0 0 1
ENT 0 0.0 1 3.6 0 0 1
Legend. OB/GYN =obstetrician and gynaecologist; ENT =otolaryngologist. Smaller referral centres include first referral hospitals, district
hospitals, private hospitals, rural health clinic/health centres, private clinic/health centres. Note: For categories of ‘‘hospital setting’’ and
‘surgeon practice location’’, respondents instructed that if working at many hospitals, it is the hospital where they work the most. If the
respondent is a visiting surgeon, it is the main hospital where the respondent is visiting
Fig. 1 Quality* of surgical lighting
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Table 2 State of surgical lighting in LMICs
Question Regional/National
centres (n =67)
Smaller referral centres
(n =28)
Others
(n =5)
Total (n =100)
N% NN N%N
How often do you experience main electricity power failures while operating?
Many times per day 6 9.0 5 17.9 1 20 12
Most days 15 22.4 2 7.1 0 0 17
Weekly 11 16.4 7 25.0 1 20 19
Monthly 4 6.0 1 3.6 1 20 6
Less often than monthly 17 25.4 5 17.9 0 0 22
Never 13 19.4 7 25.0 1 20 21
Other 1 1.5 1 3.6 1 20 3
Does your facility have a backup generator?
Yes—always available 29 43.3 15 53.6 4 80 48
Yes—sometimes available 28 41.8 8 28.6 0 0 36
Yes—very unreliable 6 9.0 4 14.3 0 0 10
No 1 1.5 0 0.0 0 0 1
Do not know 2 3.0 0 0.0 0 0 2
Other 1 1.5 1 3.6 1 20 3
What do you do in your operating theatre when there is a main power failure?*
Rely on backup generator 41 61.2 15 53.6 2 40 58
Use mobile phone light 22 32.8 6 21.4 1 20 29
Use torch/other battery-operated light 16 23.9 8 28.6 1 20 25
Use headlight 13 19.4 9 32.1 3 60 25
Stop operating 16 23.9 4 14.3 0 0 20
Not applicable (No power cuts) 9 13.4 6 21.4 1 20 16
Other 2 3.0 2 7.1 0 0 4
Do you ever delay or cancel operations due to poor lighting?
Yes 26 38.8 4 14.3 2 40 32
No 41 61.2 24 85.7 3 60 68
Do you use a surgical headlight for operating?
Yes, always 4 6.0 5 17.9 0 0 9
Yes, occasionally 26 38.8 13 46.4 3 60 42
No 37 55.2 10 35.7 2 40 49
What do you see as the main barrier(s) for having a surgical headlight?*
The cost makes it unaffordable 44 65.7 19 67.9 2 40 65
Poor suppliers in my country 29 43.3 12 42.9 2 40 43
Only poor-quality/unsuitable headlights available to me 13 19.4 6 21.4 1 20 20
Not applicable/there are no barriers/I already own one 10 14.9 4 14.3 0 0 13
Never thought of this as a solution to poor lighting 10 14.9 2 7.1 0 0 12
Uncomfortable to use in my environment 8 11.9 4 14.3 1 20 13
Other 6 9.0 2 7.1 0 0 8
I do not want one 3 4.5 1 3.6 1 20 5
Legend. * =Multiple response question. Smaller referral centres include first referral hospitals, district hospitals, private hospitals, rural health
clinic/health centres, private clinic/health centres
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Impact on patient safety
The majority of respondents (80%) reported the quality of
surgical lighting in their operating theatre presented a
patient safety risk. Eighteen per cent of respondents
reported direct experience of adverse intraoperative events
due to poor surgical lighting (Fig. 2) with two-thirds of
these substantiated in qualitative comments. Of these
responses, qualitative analysis revealed major themes with
issues including unintended blood loss (5), inadvertent
intestinal spillage/injury (4), and inadvertent nerve damage
(1). A representative sample of qualitative comments
received is provided in the text box [Box 1].
Discussion
Despite the known deficiencies of infrastructure in low-
resource settings, this is the first study to investigate the
extent and impact of surgical lighting on surgical capacity
and patient safety and the effect of electrical power outages
on surgical lighting. Surgical practitioners working in low-
resource settings overwhelmingly report that poor-quality
surgical field lighting is a major patient safety issue and
decreases surgical capacity through delayed and cancelled
operations.
Electricity is an essential component of basic hospital
infrastructure [12]. In a study of sub-Saharan African
facilities, less than 65% of all hospitals, and even fewer
clinics, fulfil this basic infrastructural requirement [13]. In
another study, all surveyed hospitals in Uganda reported
frequent power outages [14]. At one centre in Uganda, 13%
of operating days had at least one main operating theatre
power outage, with a mean duration of 6 h and 40 min
[15]. Operating theatre lighting is fundamentally reliant on
a dependable electricity infrastructure [16].
In this survey, 40% of surgeons working in LMICs
reported their operating theatre lighting as poor at best, with
no statistical difference between the different levels of health
facility. For our study, we defined quality of operating the-
atre lighting as the ability to consistently illuminate the
surgical field, which incorporates both power (a represen-
tation of the lighting intensity) and time (consistency of
availability). Poor-quality operating theatre lighting, either
from low intensity or inconsistency, can lead to delays and
cancellations, as reported by a third of the respondents.
The impact of unreliable electricity on patient safety is
recognized, but poorly reported with only a few case
reports highlighting this critical patient safety issue
[17,18]. A global literature review identified only two
papers out of over 1500 linking electricity reliability and
health outcomes [19]. Likewise, a WHO global literature
review identified only a dozen of over 400 titles reporting
the impact of electricity access on health outcomes, with no
studies linking electricity access to health outcomes as a
primary study objective [12].
Fig. 2 Does the quality* of surgical lighting impact the safety for
your patient?
Box 1 Representative qualitative comments from respondents regarding the harm to patients due to poor surgical lighting
Unintended blood loss
‘During a caesarean section, there was excessive haemorrhage following a power cut as the surgeon could not control the bleeder [bleeding
blood vessel] with the torches used. The patient needed a [blood product] transfusion which otherwise was totally unnecessary’
‘We were trying to control bleeding in a case of a trauma due to road traffic accident. [The] patient did not pass, but we could have done
better if there was adequate lighting’
‘The patient had severe haemorrhage, and it was not possible to cauterize due to lack of electricity’’
‘Blood loss from inability to see bleeders [blood vessels]’’
Inadvertent intestinal spillage/injury
‘The patient had an iatrogenic bowel perforation that was missed’’
‘During a Hartman procedure [sigmoidectomy and colostomy], we [were] stuck in total shade, the backup generator was out of gasoline,
and I had a little spillage of the colon [colonic contents] into the abdominal cavity’
‘Injury to the bowel’’
Inadvertent nerve damage
‘While I was ligating a patent ductus arteriosus (PDA), I damaged the recurrent laryngeal nerve of a young girl because of poor visibility
due to lack of good illumination’
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Poor-quality surgical lighting is seen as a patient safety
risk, as reported by 80% of respondents. Nearly one-fifth
reported direct knowledge of an adverse patient outcome
due to poor surgical lighting. Surgeons most commonly
reported uncontrolled haemorrhage or inadvertent bowel
injury, both indicative of lighting failures at crucial times
during surgery. Also of importance, power outages, and
subsequent surgical lighting issues, can affect surgeon
safety. Almost 70% of surgical residents at a large referral
centre in Ethiopia reported a needle-stick injury in the
operating theatre during their training. The lack of appro-
priate operating equipment was cited as the most frequent
cause for injury [20]. Given the low rate of surgeon hep-
atitis B vaccination [21] and the higher prevalence of
human immunodeficiency virus (HIV) and hepatitis B in
patients in LMICs, power cuts impacting surgical lighting
present a substantial occupational work hazard.
Reliance on a backup generator is the most common
solution when surgical lighting is affected by electricity
failures, supporting the previous literature [12,14,22,23].
Despite the overwhelming dependence on backup genera-
tors, over half of respondents reported they are not con-
sistently available. In a previous survey of six sub-Saharan
African countries, less than 29% were functional with fuel
available on the day of the survey [12]. Even when gen-
erators are available, there are financial and time con-
straints. Issues with equipment repair, limitations in fuel
supply, and the high cost of fuel can all impact the relia-
bility of generators [12]. Additionally, there can be delays
between the electricity failure and backup generator func-
tioning, averaging 30 min at one large Ugandan referral
hospital [15].
It is important to note that surgical lighting is more
complex than simply ensuring reliable electricity supply.
Surgical operating theatre lights in low-resource settings
are often of poor quality and may not be present or work at
all. Additionally, many battery-powered portable lights are
of poor design and of little help, even if available. Surgical
infrastructure, including ceiling lights, suction machines,
diathermy, and anaesthesia machines, might be redesigned
in such a way to improve durability and functioning with
the inconsistent electricity supply of LMICs. In lieu of this,
we argue that countries should have a standard when
procuring medical equipment.
Non-generator solutions for illuminating the surgical
field when electricity failures impact surgical lighting
include headlights, cell phone lights, flashlights, and nat-
ural lighting through windows [24]. In our study, surgical
providers were most likely to use mobile phone lights,
followed by using another battery-powered light or a
headlight. Many visiting surgeons working in LMICs bring
battery-powered headlights with which to operate. These
surgical headlights are common practice in high-resource
settings, but affordability, poor in-country suppliers, and
inappropriate design limit their use in low-resource set-
tings. Providers have reported altering or fashioning
camping headlights in order to better illuminate the sur-
gical field [25,26]; however, they are fraught with prob-
lems of poor design, light quality, and battery life. Other
solutions include solar power: We Care Solar is an example
of a non-profit specifically working to improve lighting for
health facilities where power infrastructure is lacking [27].
Surgery requires reliable and high-quality lighting.
Unreliable electricity supplies are common in LMICs with
resultant negative consequences on surgical lighting.
Importantly, poor surgical lighting negatively impacts
patient and surgeon safety. Improving surgical lighting
through more consistent electricity supply is important for
surgical care, yet remains a challenging and complex
infrastructural component to achieve. Dependable surgical
lighting options are critical in order to deliver safe surgical
care. Avenues for further investigation include lighting
options independent of an existing power grid and purpose-
built for functioning in these low-resource settings.
Limitations
There are limitations to the study. First, as with all research
of this nature, the results may reflect an element of
responder bias. Though given the paucity of previous
research on this aspect of essential surgical infrastructure,
these results provide an important baseline and thematic
analysis to guide future work. Second, electrical power
supply for operating theatre lighting is only one aspect of a
much wider set of complex issues that need to be addressed
in order to build surgical capacity in these settings. How-
ever, surgical field lighting has a potentially simple solu-
tion that can be addressed without an infrastructural
overhaul of electricity supply. Third, although the number
of responses received is relatively low, the wide distribu-
tion of the survey responses with representation of all
hospital settings across a range of LMICs helps mitigate
against undue focus on any one subgroup.
Conclusion
In LMICs, the majority of respondents report poor surgical
lighting as a major risk to patient safety and nearly one-
third report delayed or cancelled operations due to poor
lighting. Improving electricity supply is a complex issue to
address, and while most surgeons rely on a backup gen-
erator, they are often unreliable. A purpose-built lighting
element independent of an existing power grid would be a
viable option for operating in these settings. The
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development of robust, affordable, high-quality surgical
headlight could provide an ideal solution to the substantial
surgical safety issue.
Acknowledgments The authors would like to thank the survey
respondents; Luca Koritsanzky, Sibonile Mathe, and Sarah Kessler
for their coordination of efforts within the Lifebox Foundation; and
Rosemary Mugwe, Chief Executive Officer of COSECSA, for help in
the questionnaire distribution.
Compliance with ethical standards
Conflict of interest All authors have been involved in Lifebox
activities. JAF is a current Lifebox fellow; NJB and JEFF were former
fellows; JEFF is currently an honorary clinical fellow; IHW and TGW
are trustees of Lifebox UK and US, respectively; AB is the Ethiopia
Lead for Clean Cut, a Lifebox programme to improve surgical safety.
There was no funding for this project.
Appendix: Lifebox surgical lighting survey
1. Which of these best describes your hospital?
If you work in many hospitals, please complete for the hospital where you work the
most. If you are a visiting surgeon, please complete for the main hospital you visit.
Rural health clinic / health centre
District hospital
First referral hospital
Regional / national referral hospital
Private clinic / health centre
Private hospital
Other (please specify)
Please answer all the following questions based on this hospital
2. Overall, how would you rate the quality of the lighting in your operating theatre?
By quality, we mean the ability to consistently illuminate the surgical field
Very poor
Poor
Good
Excellent
3. How often do you experience main electricity power failures while operating?
Many times each day
Most days
Weekly
Monthly
Less often than monthly
Never
Other (please specify)
4. Does your facility have a backup generator?
Yes - always available
Yes - sometimes available
Yes - very unreliable
No
Do not know
Other (please specify)
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5. What do you do in your operating theatre when there is a main power failure?
(check all that apply)
Use mobile phone light
Use a torch / other battery operated light
Use a headlight
Stop operating
Rely on the backup generator
Not applicable (No powercuts)
Other (please specify)
6. Do you ever delay or cancel operations due to poor lighting?
No
Yes
If yes, how often do you have to do this?
7. Do you use a surgical headlight for operating?
Yes, always
Yes, occasionally
No
If No, please explain why
8. What 5 features would be most important to you for a surgical headlight?
Please select 5 options from the 10 available
Rechargeable battery
Ability to adjust diameter of light focus
Ability to change brightness of the light
Compatibility with eyeglasses and surgical loupes
Separate belt/pocket battery pack
Lightweight on head
Easy to carry around
Durable
Pure white light
Comfortable fit
Other (please specify)
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9. How much would you spend on a high quality headlight with the above features, in USD
($)?
10. What do you see as the main barrier(s) for having a surgical headlight?
(check all that apply)
The cost of specific surgical headlights make it unaffordable for me
Never thought of this as a solution for poor lighting
Poor suppliers in my country
Only poor quality/unsuitable headlights available to me
Uncomfortable to use in my environment
I do not want one
Not applicable (there are no barriers / I already have one)
Other (please specify)
11. In general, does the quality of surgical lighting impact the safety for your patients?
By quality, we mean the ability to consistently illuminate the surgical field
The quality of lighting in my theatre(s) is a significant risk to the safety of my patients
The quality of lighting in my theatre(s) is a small risk to the safety of my patients
The quality of lighting in my theatre(s) is not a risk to the safety of my patients
12. Do you know of a patient who has come to harm because of poor lighting? (eg. during a
power failure)
This can be a patient of yours or a case you heard about
No
Yes
Do not know
If possible, can you describe what happened
13. What country do you work in?
Please complete for the hospital you referred to in question 1
14. Are you permanently based here or a visiting surgeon?
Permanent (or long term resident in this country)
Visiting surgeon
Other (please specify)
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15. What surgical specialty do you practice?
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18. Any other comments you would like to add?
Respondents agree to anonymous use of responses in scoping provision of a Lifebox headlight
device for surgeons, and to presentation and/or publication of the results where appropriate. No
individual will be identified as part of this survey.
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... Nevertheless, opportunities exist to reduce energy use and thus the environmental footprint associated with surgical care by reducing the equipment used, increasing the equipment safely reused, and limiting the size of instrument trays, all of which minimize sterilization requirements [41]. Furthermore, in LMICs, continuous access to electricity has significantly been a significant problem of operating rooms, not infrequently causing power outages and requiring surgeons to operate with headlights (if available) or flashlights [42]. Although this is likely less common in cardiac centers, located in urban centers, it remains a reality of concern. ...
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Background In 2015, the United Nations adopted the Sustainable Development Goals (SDGs) as key priorities to improve the global health and international development agenda in an intersectoral manner, highlighting 17 SDGs. Six billion people lack access to safe, timely, and affordable cardiac surgical care due to capacity, geographic, and financial barriers. Nevertheless, cardiac surgery is largely disregarded on the global health agenda. In this review, we explore the intersection between cardiac surgery and the SDGs to delineate potential policy and advocacy avenues for the cardiothoracic surgical community. Main body A narrative review was performed using the PubMed/MEDLINE, Scopus, and WHO databases with variations of the search terms “cardiac surgery,” “cardiovascular diseases,” and keywords extracted from individual SDGs. All SDGs were manually reviewed to define intersectionality with global cardiac surgery. Out of 17 SDGs, 15 are relevant and require additional attention from the cardiovascular community. SDG3, “Good Health and Well-being,” is the most relevant, although the intersection between global cardiac surgery and other SDGs is apparent. A call for interdisciplinary collaboration through increased preventive mechanisms, rigorous, all-inclusive clinical trials, advocacy with relevant legislators, and mobilizing capacity building mechanisms are made. Conclusion Meeting the SDGs will require recognition of cardiovascular disease management, including cardiac surgical care. Cardiac surgeons are essential stakeholders of multidisciplinary collaborations working to improve access to safe, timely, and affordable cardiac surgery for all. Their role as advocates will be vital to establish local, national, regional, and international partnerships and to ensure progress towards SDG attainment.
... A lack of electricity supply has serious consequences for healthcare provision in lowincome countries. For example, at night in the absence of electric lighting practitioners are forced to perform surgery or child delivery using candles or mobile phone torches, significantly increasing patient risk [33], [34]. The reliability of any supply is of vital importance. ...
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Renewables-based mini-grids have the potential to improve electricity access with lower emissions and better reliability than national grids. However, these systems have a challenging cost to revenue ratio, hindering their implementation. Combining residential loads with an anchor load, a relatively large non-domestic user, can help to improve mini-grid economics. Using measured electricity demand data from India and energy modelling, we assess the cost and emissions advantages of integrating health clinics as anchor loads within domestic solar mini-grids. For comparison, we also assess the ability of the national grid to meet our demand scenarios using monitored grid data. We use a scenario-based approach, using separate domestic and anchor load demand profiles, and both in combination; we test meeting two levels of energy demand, 95% and 100%; and compare systems using PV and batteries, diesel, and hybrid generation. We find that the national grid has poor availability, at just over 50% at the most comparable monitoring site; and that it would meet a lower fraction of energy demand for our anchor load scenarios than the domestic only ones. For the off-grid systems, we find substantial cost and emissions reductions with anchor loads relative to demand scenarios without anchor loads. At 95% of demand met, we find PV and battery systems are 14-22% cheaper than diesel-only systems, with 10 times lower carbon intensity. Our findings illustrate the role off-grid systems can play in the provision of reliable low-carbon electricity and highlight the advantages of incorporating anchor loads like health centres into such systems.
... However, surgical lights are costly for low resource health care settings to acquire. When acquired, it is rather more expensive to replace the surgical light bulbs when they expire as they are not locally available (Forrester et al., 2017). The typical light sources are the incandescent Xenon halogen lamps, quartz and tungsten lamps. ...
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Surgical procedures and patient examination activities have been identified as critical universal health care components by the 2015 world health assembly. These critical tasks often require adequate lighting supply for successful execution. However, surgical lightings are very expensive for rural health care centres in middle and low-income countries. Besides, the epileptic grid power supply has rendered the few available ones underutilized. Technically, most of these lighting designs' control mechanism tends to interfere with the concentration of the surgeon or supporting staff during procedures. Hence, an inexpensive surgical light with footswitch control and battery bank is proposed. The prototype was implemented using 85% locally sourced materials without compromising standards in line with sustainable development goals. The device passed the Chassis leakage test as well as mechanical stability tests. On illumination tests, the device performed seamless control tasks without distraction. It produces a luminosity of 8500lx and correlated colour temperature of 6000k at an average cost of 109 USD.
... The impact of electricity failures threaten the ability for the development and delivery of surgical, anaesthesia, and overall healthcare in LMICs, as seen in Fig 1. Its effects can range from postponing surgery, postponing accurate diagnoses for a needed surgery, permanent disabilities, and even to fatalities during surgery, due to failure of various medical equipment [1,2,6,[23][24][25][26][27]. These effects are additional risks to patients that accompany medical procedures, especially surgeries [28], when electricity fails. ...
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Full-text available
Background Surgery risks increase when electricity is accessible but unreliable. During unreliable electricity events and without data on increased risk to patients, medical professionals base their decisions on anecdotal experience. Decisions should be made based on a cost-benefit analysis, but no methodology exists to quantify these risks, the associated hidden costs, nor risk charts to compare alternatives. Methods Two methodologies were created to quantify these hidden costs. In the first methodology through research literature and/or measurements, the authors obtained and analyzed a year’s worth of hour-by-hour energy failures for four energy healthcare system (EHS) types in four regions (SolarPV in Iraq, Hydroelectric in Ghana, SolarPV+Wind in Bangladesh, and Grid+Diesel in Uganda). In the second methodology, additional patient risks were calculated according to time and duration of electricity failure and medical procedure impact type. Combining these methodologies, the cost from the Value of Statistical Lives lost divided by Energy shortage ($/kWh) is calculated for EHS type and region specifically. The authors define hidden costs due to electricity failure as VSL/E ($/kWh) and compare this to traditional electricity costs (always defined in $/kWh units), including Levelized Cost of Electricity (LCOE also in $/kWh). This is quantified into a fundamentally new energy healthcare system risk chart (EHS-Risk Chart) based on severity of event (probability of deaths) and likelihood of event (probability of electricity failure). Results VSL/E costs were found to be 10 to 10,000 times traditional electricity costs (electric utility or LCOE based). The single power source EHS types have higher risks than hybridized EHS types (especially as power loads increase over time), but all EHS types have additional risks to patients due to electricity failure (between 3 to 105 deaths per 1,000 patients). Conclusions These electricity failure risks and hidden healthcare costs can now be calculated and charted to make medical decisions based on a risk chart instead of anecdotal experience. This risk chart connects public health and electricity failure using this adaptable, scalable, and verifiable model.
... Medical care in low-income countries (LIC) differs a from western medical standards [1]. Compared with civilian trauma in LIC, which is mainly caused by road traffic accidents, the injuries in war zones present different patterns with numerous wounds caused by bullets, mines, and bombs [2,3]. ...
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Purpose: The aim of the study was to identify solution strategies from a non-governmental (NGO) hospital in a war region for violence-related injuries and to show how high-income countries (HIC) might benefit from this expertise. Methods: NGO trauma hospital in Lashkar Gah, Afghanistan. Four hundred eighty-four war victims admitted in a three month period (February 2016-May 2016) were included. Patients´ characteristics were analyzed. Results: The mean age was 23.5 years. Four hundred thirty-four (89.9%) were male, and 50 (10.1%) were female. The most common cause of injury was bullet injuries, shell injuries, and mine injuries. The most common injured body region was the lower extremity, upper extremity, and the chest or the face. Apart from surgical wound care and debridements, which were performed on every wound in the operation theatre, laparotomy was the most common surgical procedure, followed by installation of a chest drainage and amputation. Conclusion: The surgical expertise and clear pathways outweigh modern infrastructure. In case of a mass casualty incident, fast decision-making with basic diagnostic means in order to take rapid measurements for life-saving therapies could make the difference.
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Background The recent data on decision regret of patients undergoing breast cancer surgery are sparse.Methods An electronic cross-sectional survey was distributed to Love Research Army volunteers ages 18–70 years who underwent breast cancer surgery from 2009 to 2020. Decision regret scores were compared among patients who underwent bilateral mastectomy (BM), unilateral mastectomy (UM), breast-conserving surgery (BCS), and BCS first (BCS followed by re-excision or mastectomy) and between procedures during different time periods. Multivariable logistic regression, adjusted for patient and tumor factors, was used to determine whether surgery type was associated with a regret score in the highest quartile range.ResultsThe survey was completed by 2148 women, 1525 (71.0%) of whom reported their surgery choice and answered all questions on the regret scale. The mean age of the participants was 50 years, and the median year of surgery was 2014. The median decision regret score for all the patients was 5 (interquartile range [IQR], 0–20) on a 100-point scale. The regret score of 342 participants (22.4%) was 25 or higher (BCS, 20.2%; BCS first, 31.9%; UM, 30.8%; BM, 15.4%; p < 0.001). In the multivariable analysis, BM was associated with less regret than UM (odds ratio [OR], 0.40 (range, 0.27–0.58); p < 0.001), BCS (OR, 0.56 (range, 0.38–0.83; p = 0.003), or BCS first (OR, 0.32; range, 0.21–0.49; p < 0.001). During the three periods analyzed (2009–2012, 2013–2016, and 2017–2020), the BM and BCS patients had the lowest regret scores of all the surgical types.Conclusions Decision regret was low among the patients undergoing breast cancer surgery but lowest among the BM patients after adjustment for clinical and tumor factors including complications.
Chapter
„Primum nihil nocere“ ist der berufsethische Leitsatz in der Medizin, der sämtliche überlieferten Grundsätze der hippokratischen Tradition in das Zentrum des moralisch geforderten ärztlichen Handelns stellt. Das bedeutet bei allen Heilversuchen in erster Linie zusätzlichen Schaden von dem Patienten abzuwenden. Dennoch ist trotz diesem erklärten Willen und trotz besten Wissens und Gewissens das „Irren“ und „Verfehlen“ in einer getroffenen Entscheidung eine zutiefst menschliche Eigenschaft.
Article
Need. Battery-powered Light Emitting Diode (LED) surgical headlights are necessary for improved intraoperative illumination but may be costly. Technical Solution. The objective of this study was to develop a low-cost surgical headlight using a consumer-grade LED headlight and 3D-printed mount. Proof of Concept. Eighteen surgical residents performed simulation exercises that mimicked suturing in the oral cavity using both a custom prototype headlight and a commercial surgical headlight. The time required to complete the task with each headlight was recorded along with an exit survey. A second device was created based on the critiques of the first device and was tested by ten additional surgical trainees. Surgical residents completed the simulation task in 27 ± 8.6 seconds and 21 ± 5.6 seconds with the commercially available headlight and first prototype, respectively. In the second experiment, the simulation task was completed in 23 ± 11.1 and 23 ± 12.2 seconds with the commercially available headlight and second device, respectively. Survey results showed an overall positive consensus, with critiques about headband security, suggestions for smaller LED chassis, and a more robust mounting bracket. Some preferred the prototype headlight due to the wider field of illumination compared to the commercially available unit (ie, beam spread/beam angle). Next Steps. Future adjustments are required to optimize the location of the headlight and the battery to modify the weight distribution of the device. Conclusion. These findings demonstrate that our prototype models are viable alternatives to conventional surgical headlights and warrant continued optimization for broader adoption by surgeons and trainees for whom higher-cost alternatives are not an option.
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Background: A previous study conducted four years ago among surgeons-in-training at the Addis Ababa University revealed that work-related accidents among surgical trainees were enormous, and there was huge under reporting to the occupational health unit (OHU) of the hospital. The aim of this study was to evaluate the impact of the strengthened OHU of the hospital and what the current status of work-related accidents is like at the same hospital three years later. Methods: A cross-sectional study was conducted to investigate the prevalence and context of all work-related accidents that resulted in contamination with blood and blood products inside the operating theatre, among surgical residents at the Tikur Anbessa teaching specialized referral hospital, in Addis Ababa University, Ethiopia. Data was collected from all 76 surgical residents who were at different stages of their specialty training in 2011. Results: Seventy-two (94.7%) of the residents were males and 26 (34.2%) were in their 3 rd and 4 th year of training. Of the 76 respondents, 53 (69.8%) had sustained a needle-stick injury inside the operating theatre at least once during their residency (Range=1-15 times). For 20 (26.3%), the accidents involved a high risk patient at least once. Cut with a sharp object, contact of blood to an unprotected skin and splash of blood to the eyes and face were reported by 9 (11.7%), 39(51.3%) and 28(36.9%) of the respondents respectively. Information concerning the most recent injuries inside the operating theatre revealed that 46(69.7%) of the residents sustained accidents in the 6 months preceding the survey, 7(9.2%) of which involved a high risk patient. All of the 7 (100%) of the recent high risk injuries and 10(27.7%) of the low-risk injuries were reported to the OHU and all the high risk injury victims were commenced on HIV prophylaxis. Conclusions and Recommendations: Overall, the study revealed that work-related accidents among surgical trainees are still unacceptably high, even though there is a decline in the number of sharp object cut, and blood splash accidents. However, there is a positive trend towards reporting of injuries, particularly those which are high risk. More is expected from the hospital to create a safe working environment and to encourage reporting of all form of injuries.
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Objective To estimate global surgical volume in 2012 and compare it with estimates from 2004. Methods For the 194 Member States of the World Health Organization, we searched PubMed for studies and contacted key informants for reports on surgical volumes between 2005 and 2012. We obtained data on population and total health expenditure per capita for 2012 and categorized Member States as very-low, low, middle and high expenditure. Data on caesarean delivery were obtained from validated statistical reports. For Member States without recorded surgical data, we estimated volumes by multiple imputation using data on total health expenditure. We estimated caesarean deliveries as a proportion of all surgery. Findings We identified 66 Member States reporting surgical data. We estimated that 312.9 million operations (95% confidence interval, CI: 266.2–359.5) took place in 2012, an increase from the 2004 estimate of 226.4 million operations. Only 6.3% (95% CI: 1.7–22.9) and 23.1% (95% CI: 14.8–36.7) of operations took place in very-low- and low-expenditure Member States representing 36.8% (2573 million people) and 34.2% (2393 million people) of the global population of 7001 million people, respectively. Caesarean deliveries comprised 29.6% (5.8/19.6 million operations; 95% CI: 9.7–91.7) of the total surgical volume in very-low-expenditure Member States, but only 2.7% (5.1/187.0 million operations; 95% CI: 2.2–3.4) in high-expenditure Member States. Conclusion Surgical volume is large and growing, with caesarean delivery comprising nearly a third of operations in most resource-poor settings. Nonetheless, there remains disparity in the provision of surgical services globally.
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Surgery is a foundational component of health-care systems. However, previous efforts to integrate surgical services into global health initiatives do not reflect the scope of surgical need and many health systems do not provide essential interventions. We estimate the minimum global volume of surgical need to address prevalent diseases in 21 epidemiological regions from the Global Burden of Disease Study 2010 (GBD). Prevalence data were obtained from GBD 2010 and organised into 119 disease states according to the WHO's Global Health Estimate (GHE). These data, representing 187 countries, were then apportioned into the 21 GBD epidemiological regions. Using previously defined values for the incident need for surgery for each of the 119 GHE disease states, we calculate minimum global need for surgery based on the prevalence of each condition in each region. We estimate that at least 321·5 million surgical procedures would be needed to address the burden of disease for a global population of 6·9 billion in 2010. Minimum rates of surgical need vary across regions, ranging from 3383 operations per 100 000 in central Latin America to 6495 operations per 100 000 in western sub-Saharan Africa. Global surgical need also varied across subcategories of disease, ranging from 131 412 procedures for nutritional deficiencies to 45·8 million procedures for unintentional injuries. The estimated need for surgical procedures worldwide is large and addresses a broad spectrum of disease states. Surgical need varies between regions of the world according to disease prevalence and many countries do not meet the basic needs of their populations. These estimates could be useful for policy makers, funders, and ministries of health as they consider how to incorporate surgical capacity into health systems. US National Institutes of Health. Copyright © 2015 Rose et al. Open access article published under the terms of CC BY-NC-ND. Published by Elsevier Ltd.. All rights reserved.
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Executive summary Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world's poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anaesthesia care in low-income and middle-income countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast and cervical cancer. In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, non-communicable diseases, and injuries. Surgical and anaesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffi c injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anaesthesia care, which should be available, aff ordable, timely, and safe to ensure good coverage, uptake, and outcomes. Despite growing need, the development and delivery of surgical and anaesthesia care in LMICs has been nearly absent from the global health discourse. Little has been written about the human and economic eff ect of surgical conditions, the state of surgical care, or the potential strategies for scale-up of surgical services in LMICs. To begin to address these crucial gaps in knowledge, policy, and action, the Lancet Commission on Global Surgery was launched in January, 2014. The Commission brought together an international, multidisciplinary team of 25 commissioners, supported by advisors and collaborators in more than 110 countries and six continents. We formed four working groups that focused on the domains of health-care delivery and management; workforce, training, and education; economics and fi nance; and information management. Our Commission has fi ve key messages, a set of indicators and recommendations to improve access to safe, aff ordable surgical and anaesthesia care in LMICs, and a template for a national surgical plan. Our fi ve key messages are presented as follows: • 5 billion people do not have access to safe, aff ordable surgical and anaesthesia care when needed. Access is worst in low-income and lower-middle-income countries, where nine of ten people cannot access basic surgical care. • 143 million additional surgical procedures are needed in LMICs each year to save lives and prevent disability. Of the 313 million procedures undertaken worldwide each year, only 6% occur in the poorest countries, where over a third of the world's population lives. Low operative volumes are associated with high case-fatality rates from common, treatable surgical conditions. Unmet need is greatest in eastern, western, and central sub-Saharan Africa, and south Asia. • 33 million individuals face catastrophic health expenditure due to payment for surgery and anaesthesia care each year. An additional 48 million cases of catastrophic expenditure are attributable to the non-medical costs of accessing surgical care. A quarter of people who have a surgical procedure will incur fi nancial catastrophe as a result of seeking care. The burden of catastrophic expenditure for surgery is highest in low-income and lower-middle-income countries and, within any country, lands most heavily on poor people. • Investing in surgical services in LMICs is aff ordable, saves lives, and promotes economic growth. To meet present and projected population demands, urgent investment in human and physical resources for surgical and anaesthesia care is needed. If LMICs were to scale-up surgical services at rates achieved by the present best-performing LMICs, two-thirds of countries would be able to reach a minimum operative volume of 5000 surgical procedures per 100 000 population by 2030. Without urgent and accelerated investment in surgical scale-up, LMICs will continue to have losses in economic productivity, estimated cumulatively at US $12·3 trillion (2010 US$, purchasing power parity) between 2015 and 2030. • Surgery is an " indivisible, indispensable part of health care. " 1 Surgical and anaesthesia care should be an integral component of a national health system in countries at all levels of development. Surgical services are a prerequisite for the full attainment of local and
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Hepatitis B virus (HBV) is a well recognized but under emphasized occupational health hazard in Ethiopia. To assess the vaccination status against Hepatitis B among surgeons practicing in Ethiopia and the reasons for poor adherence to vaccinations. A structured questionnaire was developed using the Qualtrics Survey free software tool and sent to 131 surgeons and surgical residents practicing in 28 hospitals. 98 completed and submitted the online survey. The main outcome measures were vaccination status, recent occupational accidents and reasons for non-vaccination. Ninety-four (95.9%) of the respondents were males, Only 24 (23.5%) were vaccinated against HBV, 18/24 (75%) of whom received the three recommended doses. The main reasons for non vaccination is lack of knowledge about the availability of the vaccine in the country, lack of time and mere negligence. Differences in age, sex, and duration of practice, field of specialty and respondent's institution between vaccinated and unvaccinated were not significant (P > 0.05). Ninety-two (93.9%) believe the vaccination is very useful for the surgeon. 86.4% of the respondents claim they wear double gloves in more than 50% of their operations while 76 (77.6%) had sustained sharp injury over the past one year. 13 (13.25%) of the respondents had taken ART prophylaxis in the past. Despite their strong belief that HBV vaccine is useful, most surgeons are still not vaccinated. As occupational injuries are very common, Hepatitis B vaccination should be a prerequisite for working in the theatre, hence putting the surgeons and surgical patients at reduced risk.
Article
Full-text available
Background: Access to electricity is critical to health care delivery and to the overarching goal of universal health coverage. Data on electricity access in health care facilities are rarely collected and have never been reported systematically in a multi-country study. We conducted a systematic review of available national data on electricity access in health care facilities in sub-Saharan Africa. Methods: We identified publicly-available data from nationally representative facility surveys through a systematic review of articles in PubMed, as well as through websites of development agencies, ministries of health, and national statistics bureaus. To be included in our analysis, data sets had to be collected in or after 2000, be nationally representative of a sub-Saharan African country, cover both public and private health facilities, and include a clear definition of electricity access. Results: We identified 13 health facility surveys from 11 sub-Saharan African countries that met our inclusion criteria. On average, 26% of health facilities in the surveyed countries reported no access to electricity. Only 28% of health care facilities, on average, had reliable electricity among the 8 countries reporting data. Among 9 countries, an average of 7% of facilities relied solely on a generator. Electricity access in health care facilities increased by 1.5% annually in Kenya between 2004 and 2010, and by 4% annually in Rwanda between 2001 and 2007. Conclusions: Energy access for health care facilities in sub-Saharan African countries varies considerably. An urgent need exists to improve the geographic coverage, quality, and frequency of data collection on energy access in health care facilities. Standardized tools should be used to collect data on all sources of power and supply reliability. The United Nations Secretary-General's “Sustainable Energy for All” initiative provides an opportunity to comprehensively monitor energy access in health care facilities. Such evidence about electricity needs and gaps would optimize use of limited resources, which can help to strengthen health systems.
Article
Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anaesthesia care in low-income and middle-income countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast and cervical cancer. In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, non-communicable diseases, and injuries. Surgical and anaesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffic injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anaesthesia care, which should be available, affordable, timely, and safe to ensure good coverage, uptake, and outcomes. Despite growing need, the development and delivery of surgical and anaesthesia care in LMICs has been nearly absent from the global health discourse. Little has been written about the human and economic effect of surgical conditions, the state of surgical care, or the potential strategies for scale-up of surgical services in LMICs. To begin to address these crucial gaps in knowledge, policy, and action, the Lancet Commission on Global Surgery was launched in January, 2014. The Commission brought together an international, multi- disciplinary team of 25 commissioners, supported by advisors and collaborators in more than 110 countries and six continents. We formed four working groups that focused on thedomains of health-care delivery and management; work-force, training, and education; economics and finance; and information management. Our Commission has five key messages, a set of indicators and recommendations to improve access to safe, affordable surgical and anaesthesia care in LMICs, and a template for a national surgical plan.
Article
The World Bank will publish the nine volumes of Disease Control Priorities, 3rd edition, in 2015-16. Volume 1-Essential Surgery-identifies 44 surgical procedures as essential on the basis that they address substantial needs, are cost effective, and are feasible to implement. This report summarises and critically assesses the volume's five key findings. First, provision of essential surgical procedures would avert about 1·5 million deaths a year, or 6-7% of all avertable deaths in low-income and middle-income countries. Second, essential surgical procedures rank among the most cost effective of all health interventions. The surgical platform of the first-level hospital delivers 28 of the 44 essential procedures, making investment in this platform also highly cost effective. Third, measures to expand access to surgery, such as task sharing, have been shown to be safe and effective while countries make long-term investments in building surgical and anaesthesia workforces. Because emergency procedures constitute 23 of the 28 procedures provided at first-level hospitals, expansion of access requires that such facilities be widely geographically diffused. Fourth, substantial disparities remain in the safety of surgical care, driven by high perioperative mortality rates including anaesthesia-related deaths in low-income and middle-income countries. Feasible measures, such as WHO's Surgical Safety Checklist, have led to improvements in safety and quality. Fifth, the large burden of surgical disorders, cost-effectiveness of essential surgery, and strong public demand for surgical services suggest that universal coverage of essential surgery should be financed early on the path to universal health coverage. We point to estimates that full coverage of the component of universal coverage of essential surgery applicable to first-level hospitals would require just over US$3 billion annually of additional spending and yield a benefit-cost ratio of more than 10:1. It would efficiently and equitably provide health benefits, financial protection, and contributions to stronger health systems. Copyright © 2015 Elsevier Ltd. All rights reserved.