To be seen, heard, and valued. Active engagement as the next frontier for global health conference equity: a view from the global South

Dear Editor, “It is the one who lives in the house who knows where the roof leaks” ~African Proverb. As a Global Surgery researcher in Rwanda, I have lived experience of the challenges to conference equity, having spent for example in one instance, 14 hours at an Embassy’s visa processing station to get to the World Health Assembly, and losing two opportunities to present at international Global Health meetings as a result of visa delays in the past one year. [...

Equitable access to quality trauma systems in low-income and middle-income countries: assessing gaps and developing priorities in Ghana, Rwanda and South Africa

Injuries in low-income and middle-income countries are prevalent and their number is expected to increase. Death and disability after injury can be reduced if people reach healthcare facilities in a timely manner. Knowledge of barriers to access to quality injury care is necessary to intervene to improve outcomes. We combined a four-delay framework with WHO Building Blocks and Institution of Medicine Quality Outcomes Frameworks to describe barriers to trauma care in three countries in sub-Saharan Africa: Ghana, South Africa and Rwanda. We used a parallel convergent mixed-methods research design, integrating the results to enable a holistic analysis of the barriers to access to quality injury care. Data were collected using surveys of patient experiences of injury care, interviews and focus group discussions with patients and community leaders, and a survey of policy-makers and healthcare leaders on the governance context for injury care. We identified 121 barriers across all three countries. Of these, 31 (25.6%) were shared across countries. More than half (18/31, 58%) were predominantly related to delay 3 (‘Delays to receiving quality care’). The majority of the barriers were captured using just one of the multiple methods, emphasising the need to use multiple methods to identify all barriers. Given there are many barriers to access to quality care for people who have been injured in Rwanda, Ghana and South Africa, but few of these are shared across countries, solutions to overcome these barriers may also be contextually dependent. This suggests the need for rigorous assessments of contexts using multiple data collection methods before developing interventions to improve access to quality care

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

A Modified Open Primary Laparoscopic Surgery Port Placement through Umbilical Tube

Background: A safe, reliable technique for primary trocar introduction is important for laparoscopic surgery. In resource-constrained settings where there is paucity of needed equipment and cost is prohibitive, a method utilizing fewer instruments will be useful. Aim: This study aims to describe a method of primary trocar introduction that utilizes any available port. Methods: A supra- or infra-umbilical incision is made into an everted tubular umbilicus. The linear alba is incised and the resultant opening bluntly developed, after which any available port is inserted using the trocar as a guide. The trocar is withdrawn while the sleeve is pushed in. Results: One hundred and three successful insertions were affected in 107 patients with age range of 1–75 years, with no significant gas leaks. Conclusion: This modified open approach is a simple and reliable way of primary port insertion. Access is gained easily in different age groups and umbilicus types

Relative frequency and predictors of episiotomy in Ogbomoso, Nigeria

Episiotomy is the commonest obstetric surgical operation performed to increase the diameter of the vulval outlet during the last part of the second stage of labour in order to facilitate vaginal delivery. The rate of episiotomy is on the decline in the developed countries but still remains high in developing countries. The objectives of this study are to determine the rate and risk factors for episiotomies at the Baptist Medical Centre, Ogbomoso, Nigeria. This retrospective study extracted information on age, occupation, parity, type of vaginal delivery, birth weight of the newborn, and episiotomy status from the case notes of 280 patients and analysed it using the Statistical Package for Social Sciences version 13. The episiotomy rate was 34.3% in the present study. The rate of episiotomy decreased with parity, with the nulliparous having the highest rate (62.2%). The rate was higher among those who had assisted delivery (80.0%) than spontaneous vertex delivery. The episiotomy rate at this centre is high (34.3%) in comparison to the recommended 10% by the World Health Organization. Nulliparity and assisted vaginal delivery appear to be the risk factors for episiotomy in this centre

The true costs of cesarean delivery for patients in rural Rwanda : Accounting for post-discharge expenses in estimated health expenditures

Introduction: While it is recognized that there are costs associated with postoperative patient follow-up, risk assessments of catastrophic health expenditures (CHEs) due to surgery in sub-Saharan Africa rarely include expenses after discharge. We describe patient-level costs for cesarean section (c-section) and follow-up care up to postoperative day (POD) 30 and evaluate the contribution of follow-up to CHEs in rural Rwanda. Methods: We interviewed women who delivered via c-section at Kirehe District Hospital between September 2019 and February 2020. Expenditure details were captured on an adapted surgical indicator financial survey tool and extracted from the hospital billing system. CHE was defined as health expenditure of ≥ 10% of annual household expenditure. We report the cost of c-section up to 30 days after discharge, the rate of CHE among c-section patients stratified by in-hospital costs and post-discharge follow-up costs, and the main contributors to c-section follow-up costs. We performed a multivariate logistic regression using a backward stepwise process to determine independent predictors of CHE at POD30 at α ≤ 0.05. Results: Of the 479 participants in this study, 90% were classified as impoverished before surgery and an additional 6.4% were impoverished by the c-section. The median out-of-pocket costs up to POD30 was US$122.16 (IQR:$102.94, $148.11); 63$77.50; IQR: $67.70,$95.60). To afford c-section care, 64.4% borrowed money and 18.4% sold possessions. The CHE rate was 27% when only considering direct and indirect costs up to the time of discharge and 77% when including the reported expenses up to POD30. Transportation and lost household wages were the largest contributors to post-discharge costs. Further, CHE at POD30 was independently predicted by membership in community-based health insurance (aOR = 3.40, 95% CI: 1.21,9.60), being a farmer (aOR = 2.25, 95% CI:1.00,3.03), primary school education (aOR = 2.35, 95% CI:1.91,4.66), and small household sizes had 0.22 lower odds of experiencing CHE compared to large households (aOR = 0.78, 95% CI:0.66,0.91). Conclusion: Costs associated with surgical follow-up are often neglected in financial risk calculations but contribute significantly to the risk of CHE in rural Rwanda. Insurance coverage for direct medical costs is insufficient to protect against CHE. Innovative follow-up solutions to reduce costs of patient transport and compensate for household lost wages need to be considered

Barriers to equitable access to quality trauma care in Rwanda:a qualitative study

Objectives Using the ‘Four Delay’ framework, our study aimed to identify and explore barriers to accessing quality injury care from the injured patients’, caregivers’ and community leaders’ perspectives.Design A qualitative study assessing barriers to trauma care comprising 20 in-depth semistructured interviews and 4 focus group discussions was conducted. The data were analysed thematically.Setting This qualitative study was conducted in Rwanda’s rural Burera District, located in the Northern Province, and in Kigali City, the country’s urban capital, to capture both the rural and urban population’s experiences of being injured.Participants Purposively selected participants were individuals from urban and rural communities who had accessed injury care in the previous 6 months or cared for the injured people, and community leaders. Fifty-one participants, 13 females and 38 males ranging from 21 to 68 years of age participated in interviews and focus group discussions. Thirty-six (71%) were former trauma patients with a wide range of injuries including fractured long bones (9, 45%), other fractures, head injury, polytrauma (3, 15% each), abdominal trauma (1, 5%), and lacerations (1, 5%), while the rest were caregivers and community leaders.Results Multiple barriers were identified cutting across all levels of the ‘Four Delays’ framework, including barriers to seeking, reaching, receiving and remaining in care. Key barriers mentioned by participants in both interviews and focus group discussions were: lack of community health insurance, limited access to ambulances, insufficient number of trauma care specialists and a high volume of trauma patients. The rigid referral process and lack of decentralised rehabilitation services were also identified as significant barriers to accessing quality care for injured patients.Conclusions Future interventions to improve access to injury care in Rwanda must be informed by the identified barriers along the spectrum of care, from the point of injury to receipt of care and rehabilitation

A cross‐sectional survey on surgeon retention in the COSECSA region after specialist training: have things changed?

Background: Increasing surgical specialist workforce density in sub‐Saharan Africa is essential for improving access to surgical care. However, out‐migration creates a significant challenge to attaining provider targets. We aimed to determine the rates and trends of retention of surgeons in the College of Surgeons of East Central and Southern Africa (COSECSA) regions. Methodology: An online, web‐based survey was distributed to COSECSA surgeons who graduated from 2004 to 2020. Current practice and migration patterns were visualized using descriptive analyses and logistic regression models. Results: Response rate was 48% (270/557). Most respondents trained as general surgeons and practiced in Ethiopia, Kenya, Zimbabwe, and Zambia. Majority practiced in public hospitals (74%), and were active in research (81%), teaching (84%) and leadership (55%). Overall country (85%), regional (92%) and Africa retention rates (99%) were high with 100% country retention in Rwanda, Botswana, Lesotho, and Namibia. Tanzania had the lowest retention (61%). Highest inter‐regional migration occurred from East to Southern Africa (26%), and continental out‐migration occurred from Zambia, Zimbabwe, and Kenya. On bivariate analysis, out‐migration from training country and region was associated working with a non‐governmental organization (p = 0.002 and 0.0003) or a specialized hospital (p = 0.046 and 0.011). A multiple regression model with type of institution and leadership was a poor fit (McFadden R2 = 0.055; p = 0.082). Conclusion: Retention rates of surgeons trained by COSECSA in the region remain remarkably high. This can be taken as an indicator of success of the training model to increase surgical workforce density, however, contributory factors need to be qualitatively explored.</p