Nurture the sprouting bud; do not uproot it. Using saving groups to save for maternal and newborn health: lessons from rural Eastern Uganda

Background: Saving groups are increasingly being used to save in many developing countries. However, there is limited literature about how they can be exploited to improve maternal and newborn health. Objectives: This paper describes saving practices, factors that encourage and constrain saving with saving groups, and lessons learnt while supporting communities to save through saving groups. Methods: This qualitative study was done in three districts in Eastern Uganda. Saving groups were identified and provided with support to enhance members’ access to maternal and newborn health. Fifteen focus group discussions (FGDs) and 18 key informant interviews (KIIs) were conducted to elicit members’ views about saving practices. Document review was undertaken to identify key lessons for supporting saving groups. Qualitative data are presented thematically. Results: Awareness of the importance of saving, safe custody of money saved, flexible saving arrangements and easy access to loans for personal needs including transport during obstetric emergencies increased willingness to save with saving groups. Saving groups therefore provided a safety net for the poor during emergencies. Poor management of saving groups and detrimental economic practices like gambling constrained saving. Efficient running of saving groups requires that they have a clear management structure, which is legally registered with relevant authorities and that it is governed by a constitution. Conclusions: Saving groups were considered a useful form of saving that enabled easy access to cash for birth preparedness and transportation during emergencies. They are like ‘a sprouting bud that needs to be nurtured rather than uprooted’, as they appear to have the potential to act as a safety net for poor communities that have no health insurance. Local governments should therefore strengthen the management capacity of saving groups so as to ensure their efficient running through partnerships with non-governmental organizations that can provide support to such groups

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Strategies for sustainability and equity of prepayment health schemes in Uganda

Background: Despite the long existence of community health insurance schemes (CHI) in Uganda, their numbers and coverage levels have remained small with limited accessibility by the poor. Objectives: To examine issues of equity and sustainability in CHI schemes, which are prerequisites to health sector financing. Methods: We carried out a descriptive cross-sectional study employing qualitative techniques. Eight focus group discussions (FGDs) with CHI scheme members and seven FGDs with non-members were held. Twelve Key informant interviews (KIs) were held with scheme managers, officials from Ministry of Health and one health financing organisation. We reviewed relevant documents and records of schemes. Results: Respondents' perceptions of unfairness in schemes were: non-members were treated better in hospital than members; some members pay premiums continuously without falling sick and schemes refused to cover illnesses like diabetes and hypertension. Fairness was related with the very little payment for the services received, members paying less than non-members but both getting the same treatment and no patient discrimination based on gender, age or social status. Schemes are not sustainable because they operate on small budgets, have low enrolment and lack government support. Effect of abolition of user fees on scheme enrolment was minimal.. Conclusion Government should ensure that quality of health care does not deteriorate in the context of increased utilisation after user fees removal, schemes need substantial support to build their sustainability and there is need for technical and policy considerations about whether or not CHI has a role to play in Ugandan health system

Kuluttajabarometri maakunnittain 2000, 2. neljännes

Suomen virallinen tilasto (SVT

Use of failure-to-rescue to identify international variation in postoperative care in low-, middle- and high-income countries: a 7-day cohort study of elective surgery

This was an investigator-initiated study funded by Nestle Health Sciences through an unrestricted research grant and by a National Institute for Health Research (UK) Professorship held by R.P. The study was sponsored by Queen Mary University of London

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

© 2017 British Journal of Anaesthesia Background: The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods: Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results: We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32–0.77); P\u3c0.01], but no difference in complication rates [OR 1.02 (0.88–1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62–0.92); P\u3c0.01; I2=87%] and reduced complication rates [OR 0.73 (0.61–0.88); P\u3c0.01; I2=89%). Conclusions: Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine

Use of failure-to-rescue to identify international variation in postoperative care in low-, middle- and high-income countries: A 7-day cohort study of elective surgery

The incidence and impact of postoperative complications are poorly described. Failure-to-rescue, the rate of death following complications, is an important quality measure for perioperative care but has not been investigated across multiple health care systems. Methods. We analysed data collected during the International Surgical Outcomes Study, an international 7-day cohort study of adults undergoing elective inpatient surgery. Hospitals were ranked by quintiles according to surgical procedural volume (Q1 lowest to Q5 highest). For each quintile we assessed in-hospital complications rates, mortality, and failure-to-rescue. We repeated this analysis ranking hospitals by risk-adjusted complication rates (Q1 lowest to Q5 highest). Results. A total of 44 814 patients from 474 hospitals in 27 low-, middle-, and high-income countries were available for analysis. Of these, 7508 (17%) developed one or more postoperative complication, with 207 deaths in hospital (0.5%), giving an overall failure-to-rescue rate of 2.8%. When hospitals were ranked in quintiles by procedural volume, we identified a threefold variation in mortality (Q1: 0.6% vs Q5: 0.2%) and a two-fold variation in failure-to-rescue (Q1: 3.6% vs Q5: 1.7%). Ranking hospitals in quintiles by risk-adjusted complication rate further confirmed the presence of important variations in failureto- rescue, indicating differences between hospitals in the risk of death among patients after they develop complications. Conclusions. Comparison of failure-to-rescue rates across health care systems suggests the presence of preventable postoperative deaths. Using such metrics, developing nations could benefit from a data-driven approach to quality improvement, which has proved effective in high-income countries

Critical care admission following elective surgery was not associated with survival benefit:prospective analysis of data from 27 countries

Purpose: As global initiatives increase patient access to surgical treatments, there is a need to define optimal levels of perioperative care. Our aim was to describe the relationship between the provision and use of critical care resources and postoperative mortality. Methods: Planned analysis of data collected during an international 7-day cohort study of adults undergoing elective in-patient surgery. We used risk-adjusted mixed-effects logistic regression models to evaluate the association between admission to critical care immediately after surgery and in-hospital mortality. We evaluated hospital-level associations between mortality and critical care admission immediately after surgery, critical care admission to treat life-threatening complications, and hospital provision of critical care beds. We evaluated the effect of national income using interaction tests. Results: 44,814 patients from 474 hospitals in 27 countries were available for analysis. Death was more frequent amongst patients admitted directly to critical care after surgery (critical care: 103/4317 patients [2%], standard ward: 99/39,566 patients [0.3%]; adjusted OR 3.01 [2.10–5.21]; p < 0.001). This association may differ with national income (high income countries OR 2.50 vs. low and middle income countries OR 4.68; p = 0.07). At hospital level, there was no association between mortality and critical care admission directly after surgery (p = 0.26), critical care admission to treat complications (p = 0.33), or provision of critical care beds (p = 0.70). Findings of the hospital-level analyses were not affected by national income status. A sensitivity analysis including only high-risk patients yielded similar findings. Conclusions: We did not identify any survival benefit from critical care admission following surgery