An opportunity for diagonal development in global surgery: cleft lip and palate care in resource-limited settings

Global cleft surgery missions have provided much-needed care to millions of poor patients worldwide. Still, surgical capacity in low- and middle-income countries is generally inadequate. Through surgical missions, global cleft care has largely ascribed to a vertical model of healthcare delivery, which is disease specific, and tends to deliver services parallel to, but not necessarily within, the local healthcare system. The vertical model has been used to address infectious diseases as well as humanitarian emergencies. By contrast, a horizontal model for healthcare delivery tends to focus on long-term investments in public health infrastructure and human capital and has less often been implemented by humanitarian groups for a variety of reasons. As surgical care is an integral component of basic healthcare, the plastic surgery community must challenge itself to address the burden of specific disease entities, such as cleft lip and palate, in a way that sustainably expands and enriches global surgical care as a whole. In this paper, we describe a diagonal care delivery model, whereby cleft missions can enrich surgical capacity through integration into sustainable, local care delivery systems. Furthermore, we examine the applications of diagonal development to cleft care specifically and global surgical care more broadly

Health and Economic Benefits of Improved Injury Prevention and Trauma Care Worldwide

Objectives: Injury is a significant source of morbidity and mortality worldwide, and often disproportionately affects younger, more productive members of society. While many have made the case for improved injury prevention and trauma care, health system development in low- and middle-income countries is often limited by resources. This study aims to determine the economic benefit of improved injury prevention and trauma care in low- and middle-income countries. Methods: This study uses existing data on injury mortality worldwide from the 2010 Global Burden of Disease Study to estimate the number of lives that could be saved if injury mortality rates in low- and middle-income countries could be reduced to rates in high-income countries. Using economic modeling – through the human capital approach and the value of a statistical life approach – the study then demonstrates the associated economic benefit of these lives saved. Results: 88 percent of injury-related deaths occur in low- and middle-income countries. If injury mortality rates in low- and middle-income countries were reduced to rates in high-income countries, 2,117,500 lives could be saved per year. This would result in between 49 million and 52 million disability adjusted life years averted per year, with discounting and age weighting. Using the human capital approach, the associated economic benefit of reducing mortality rates ranges from $245 to$261 billion with discounting and age weighting. Using the value of a statistical life approach, the benefit is between 758 and 786 billion dollars per year. Conclusions: Reducing injury mortality in low- and middle-income countries could save over 2 million lives per year and provide significant economic benefit globally. Further investments in trauma care and injury prevention are needed

Cost-eff ectiveness of surgery and its policy implications for global health: a systematic review and analysis

Background The perception of surgery as expensive and complex might be a barrier to its widespread acceptance in global health eff orts. We did a systematic review and analysis of cost-eff ectiveness studies that assess surgical interventions in low-income and middle-income countries to help quantify the potential value of surgery. Methods We searched Medline for all relevant articles published between Jan 1, 1996 and Jan 31, 2013, and searched the reference lists of retrieved articles. We converted all results to 2012 US$. We extracted cost-eff ectiveness ratios (CERs) and appraised economic assessments for their methodological quality using the 10-point Drummond checklist. Findings Of the 584 identifi ed studies, 26 met full inclusion criteria. Together, these studies gave 121 independent CERs in seven categories of surgical interventions. The median CER of circumcision ($13·78 per disability-adjusted life year [DALY]) was similar to that of standard vaccinations ($12·96–25·93 per DALY) and bednets for malaria prevention ($6·48–22·04 per DALY). Median CERs of cleft lip or palate repair ($47·74 per DALY), general surgery ($82·32 per DALY), hydrocephalus surgery ($108·74 per DALY), and ophthalmic surgery ($136 per DALY) were similar to that of the BCG vaccine ($51·86–220·39 per DALY). Median CERs of caesarean sections ($315·12 per DALY) and orthopaedic surgery ($381·15 per DALY) are more favourable than those of medical treatment for ischaemic heart disease ($500·41–706·54 per DALY) and HIV treatment with multidrug antiretroviral therapy ($453·74–648·20 per DALY). Interpretation Our fi ndings suggest that many essential surgical interventions are cost-eff ective or very cost-eff ective in resource-poor countries. Quantifi cation of the economic value of surgery provides a strong argument for the expansion of global surgery’s role in the global health movement. However, economic value should not be the only argument for resource allocation—other organisational, ethical, and political arguments can also be made for its inclusion

Nasal Glioma: Prenatal Diagnosis and Multidisciplinary Surgical Approach

Nasal gliomas are congenital, nonmalignant rests of neuroglial tissue that typically present as a craniofacial mass. The differential diagnosis of such masses includes lesions that often require the involvement of various surgical subspecialties, including otolaryngology, neurosurgery, plastic surgery, and ophthalmology. Early surgical excision of these masses is advised to minimize nasal and craniofacial distortion. Accordingly, early diagnosis and management planning are paramount, and advances in prenatal imaging are creating a new role for obstetricians and radiologists in the initiation of diagnostic and therapeutic interventions. We describe the case history of a young patient found to have a craniofacial mass on routine prenatal ultrasound and subsequently managed with a multidisciplinary team approach

Assessing the inclusion of children's surgical care in National Surgical, Obstetric and Anaesthesia Plans:a policy content analysis

Objective While National Surgical, Obstetric and Anaesthesia Plans (NSOAPs) have emerged as a strategy to strengthen and scale up surgical healthcare systems in low/middle-income countries (LMICs), the degree to which children's surgery is addressed is not well-known. This study aims to assess the inclusion of children's surgical care among existing NSOAPs, identify practice examples and provide recommendations to guide inclusion of children's surgical care in future policies. Design We performed two qualitative content analyses to assess the inclusion of children's surgical care among NSOAPs. We applied a conventional (inductive) content analysis approach to identify themes and patterns, and developed a framework based on the Global Initiative for Children's Surgery's Optimal Resources for Children's Surgery document. We then used this framework to conduct a directed (deductive) content analysis of the NSOAPs of Ethiopia, Nigeria, Rwanda, Senegal, Tanzania and Zambia. Results Our framework for the inclusion of children's surgical care in NSOAPs included seven domains. We evaluated six NSOAPs with all addressing at least two of the domains. All six NSOAPs addressed € human resources and training' and € infrastructure', four addressed € service delivery', three addressed € governance and financing', two included € research, evaluation and quality improvement', and one NSOAP addressed € equipment and supplies' and € advocacy and awareness'. Conclusions Additional focus must be placed on the development of surgical healthcare systems for children in LMICs. This requires a focus on children's surgical care separate from adult surgical care in the scaling up of surgical healthcare systems, including children-focused needs assessments and the inclusion of children's surgery providers in the process. This study proposes a framework for evaluating NSOAPs, highlights practice examples and suggests recommendations for the development of future policies.</p

Global access to surgical care: a modelling study

Background More than 2 billion people are unable to receive surgical care based on operating theatre density alone. The vision of the Lancet Commission on Global Surgery is universal access to safe, aff ordable surgical and anaesthesia care when needed. We aimed to estimate the number of individuals worldwide without access to surgical services as defi ned by the Commission’s vision. Methods We modelled access to surgical services in 196 countries with respect to four dimensions: timeliness, surgical capacity, safety, and aff ordability. We built a chance tree for each country to model the probability of surgical access with respect to each dimension, and from this we constructed a statistical model to estimate the proportion of the population in each country that does not have access to surgical services. We accounted for uncertainty with oneway sensitivity analyses, multiple imputation for missing data, and probabilistic sensitivity analysis. Findings At least 4·8 billion people (95% posterior credible interval 4·6–5·0 [67%, 64–70]) of the world’s population do not have access to surgery. The proportion of the population without access varied widely when stratifi ed by epidemiological region: greater than 95% of the population in south Asia and central, eastern, and western sub- Saharan Africa do not have access to care, whereas less than 5% of the population in Australasia, high-income North America, and western Europe lack access. Interpretation Most of the world’s population does not have access to surgical care, and access is inequitably distributed. The near absence of access in many low-income and middle-income countries represents a crisis, and as the global health community continues to support the advancement of universal health coverage, increasing access to surgical services will play a central role in ensuring health care for all

Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services

Background The ongoing pandemic is having a collateral health effect on delivery of surgical care to millions of patients. Very little is known about pandemic management and effects on other services, including delivery of surgery. Methods This was a scoping review of all available literature pertaining to COVID‐19 and surgery, using electronic databases, society websites, webinars and preprint repositories. Results Several perioperative guidelines have been issued within a short time. Many suggestions are contradictory and based on anecdotal data at best. As regions with the highest volume of operations per capita are being hit, an unprecedented number of operations are being cancelled or deferred. No major stakeholder seems to have considered how a pandemic deprives patients with a surgical condition of resources, with patients disproportionally affected owing to the nature of treatment (use of anaesthesia, operating rooms, protective equipment, physical invasion and need for perioperative care). No recommendations exist regarding how to reopen surgical delivery. The postpandemic evaluation and future planning should involve surgical services as an essential part to maintain appropriate surgical care for the population during an outbreak. Surgical delivery, owing to its cross‐cutting nature and synergistic effects on health systems at large, needs to be built into the WHO agenda for national health planning. Conclusion Patients are being deprived of surgical access, with uncertain loss of function and risk of adverse prognosis as a collateral effect of the pandemic. Surgical services need a contingency plan for maintaining surgical care in an ongoing or postpandemic phase.publishedVersio

Access and Financial Burden for Patients Seeking Essential Surgical Care in Pakistan

Background: Pakistan is a lower middle-income country in South Asia with a population of over 220 million. With the recent development of national health programs focusing on surgical care, two areas of high priority for research and policy are access and financial risk protection related to surgery. This is the first study in Pakistan to nationally assess geographic access and expenditures for patients undergoing surgery. Methods: This is a cross-sectional study of patients undergoing laparotomy, cesarean section, and surgical management of a fracture at public tertiary care hospitals across the country. A validated financial risk protection tool was adapted for our study to collect data on the socio-economic characteristics of patients, geographic access, and out-of-pocket expenditure. Results: A total of 526 patients were surveyed at 13 public hospitals. 73.8% of patients had 2-hour access to the facility where they underwent their respective surgical procedures. A majority (53%) of patients were poor at baseline, and 79.5% and 70.3% of patients experienced catastrophic health expenditure and impoverishing health expenditure, respectively. Discussion: A substantial number of patients face long travel times to access essential surgical care and face a high percentage of impoverishing health expenditure and catastrophic health expenditure during this process. This study provides valuable baseline data to health policymakers for reform efforts that are underway. Conclusions: Strengthening surgical infrastructure and services in the existing network of public sector first-level facilities has the potential to dramatically improve emergency and essential surgical care across the country