183 research outputs found
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Charitable Platforms in Global Surgery: A Systematic Review of their Effectiveness, Cost-Effectiveness, Sustainability, and Role Training
Objective: This study was designed to propose a classification scheme for platforms of surgical delivery in low- and middle-income countries (LMICs) and to review the literature documenting their effectiveness, cost-effectiveness, sustainability, and role in training. Approximately 28 % of the global burden of disease is surgical. In LMICs, much of this burden is borne by a rapidly growing international charitable sector, in fragmented platforms ranging from short-term trips to specialized hospitals. Systematic reviews of these platforms, across regions and across disease conditions, have not been performed. Methods: A systematic review of MEDLINE and EMBASE databases was performed from 1960 to 2013. Inclusion and exclusion criteria were defined a priori. Bibliographies of retrieved studies were searched by hand. Of the 8,854 publications retrieved, 104 were included. Results: Surgery by international charitable organizations is delivered under two, specialized hospitals and temporary platforms. Among the latter, short-term surgical missions were the most common and appeared beneficial when no other option was available. Compared to other platforms, however, worse results and a lack of cost-effectiveness curtailed their role. Self-contained temporary platforms that did not rely on local infrastructure showed promise, based on very few studies. Specialized hospitals provided effective treatment and appeared sustainable; cost-effectiveness evidence was limited. Conclusions: Because the charitable sector delivers surgery in vastly divergent ways, systematic review of these platforms has been difficult. This paper provides a framework from which to study these platforms for surgery in LMICs. Given the available evidence, self-contained temporary platforms and specialized surgical centers appear to provide more effective and cost-effective care than short-term surgical mission trips, except when no other delivery platform exists
Who is pirating medical literature? A bibliometric review of 28 million Sci-Hub downloads.
We aimed to define the proportion of downloads on Sci-Hub that are medical in nature and to consider these data at the national level, evaluating the relation between density of medical literature downloads and scientific output, national income classifications, and indicators of internet penetrance
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Health-system-adapted data envelopment analysis for decision-making in universal health coverage
Abstract Objective: To develop and test a method that allows an objective assessment of the value of any health policy in multiple domains. Methods: We developed a method to assist decision-makers with constrained resources and insufficient knowledge about a society’s preferences to choose between policies with unequal, and at times opposing, effects on multiple outcomes. Our method extends standard data envelopment analysis to address the realities of health policy, such as multiple and adverse outcomes and a lack of information about the population’s preferences over those outcomes. We made four modifications to the standard analysis: (i) treating the policy itself as the object of analysis, (ii) allowing the method to produce a rank-ordering of policies; (iii) allowing any outcome to serve as both an output and input; and (iv) allowing variable return to scale. We tested the method against three previously published analyses of health policies in low-income settings. Results: When applied to previous analyses, our new method performed better than traditional cost–effectiveness analysis and standard data envelopment analysis. The adapted analysis could identify the most efficient policy interventions from among any set of evaluated policies and was able to provide a rank ordering of all interventions. Conclusion: Health-system-adapted data envelopment analysis allows any quantifiable attribute or determinant of health to be included in a calculation. It is easy to perform and, in the absence of evidence about a society’s preferences among multiple policy outcomes, can provide a comprehensive method for health-policy decision-making in the era of sustainable development
Timing and cost of scaling up surgical services in low-income and middle-income countries from 2012 to 2030 : a modelling study
Background: Given the large burden of surgical conditions and the crosscutting nature of surgery, scale-up of basic surgical services is crucial to health-system strengthening. The Lancet Commission on Global Surgery proposed that, to meet populations' needs, countries should achieve 5000 major operations per 100 000 population per year. We modelled the possible scale-up of surgical services in 88 low-income and middle-income countries with a population greater than 1 million from 2012 to 2030 at various rates and quantified the associated costs. Methods: Major surgery includes any intervention within an operating room involving tissue manipulation and anaesthesia. We used estimates for the number of major operations achieved per country annually and the number of operating rooms per region, and data from Mongolia and Mexico for trends in the number of operations. Unit costs included a cost per operation, proxied by caesarean section cost estimates; hospital construction data were used to estimate cost per operating room construction. We determined the year by which each country would achieve the Commission's target. We modelled three scenarios for the scale-up rate: actual rates (5·1% per year) and two "aspirational" rates, the rates achieved by Mongolia (8·9% annual) and Mexico (22·5% annual). We subsequently estimated the associated costs. Findings: About half of the 88 countries would achieve the target by 2030 at actual rates of improvements, with up to two-thirds if the rate were increased to Mongolian rates. We estimate the total costs of achieving scale-up at US$300-420 billion (95% UI 190-600 billion) over 2012-30, which represents 4-8% of total annual health expenditures among low-income and lower middle-income countries and 1% among upper middle-income countries. Interpretation: Scale-up of surgical services will not reach the target of 5000 operations per 100 000 by 2030 in about half of low-income and middle-income countries without increased funding, which countries and the international community must seek to achieve expansion of quality surgical services
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Sustainable Development in Surgery: The Health, Poverty, and Equity Impacts of Charitable Surgery in Uganda
Background. The recently adopted Sustainable Development Goals call for the end of poverty and the equitable provision of healthcare. These goals are often at odds, however: health seeking can lead to catastrophic spending, an outcome for which cancer patients and the poor in resource-limited settings are at particularly high risk. How various health policies affect the additional aims of financial wellbeing and equity is poorly understood. This paper evaluates the health, financial, and equity impacts of governmental and charitable policies for surgical oncology in a resource-limited setting.
Methods. Three charitable platforms for surgical oncology delivery in Uganda were compared to six governmental policies aimed at improving healthcare access. An extended cost-effectiveness analysis using an agent-based simulation model examined the numbers of lives saved, catastrophic expenditure averted, impoverishment averted, costs, and the distribution of benefits across the wealth spectrum.
Findings. Of the nine policies and platforms evaluated, two were able to provide simultaneous health and financial benefits efficiently and equitably: mobile surgical units and governmental policies that simultaneously address surgical scaleup, the cost of surgery, and the cost of transportation. Policies that only remove user fees are dominated, as is the commonly employed short-term “surgical mission trip”. These results are robust to scenario and sensitivity analyses.
Interpretation. The most common platforms for increasing access to surgical care appear unable to provide health and financial risk protection equitably. On the other hand, mobile surgical units, to date an underutilized delivery platform, are able to deliver surgical oncology in a manner that meets sustainable development goals by improving health, financial solvency, and equity. These platforms compare favorably with policies that holistically address surgical delivery and should be considered as countries strengthen health systems
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Facilitating access to surgical care through a decentralised case-finding strategy: experience in Madagascar
Over two-thirds of the world’s population lack access to surgical care. Non-governmental organisation’s providing free surgeries may overcome financial barriers, but other barriers to care still exist. This analysis paper discusses two different case-finding strategies in Madagascar that aimed to increase the proportion of poor patients, women and those for whom multiple barriers to care exist. From October 2014 to June 2015, we used a centralised selection strategy, aiming to find 70% of patients from the port city, Toamasina, and 30% from the national capital and two remote cities. From August 2015 to June 2016, a decentralised strategy was used, aiming to find 30% of patients from Toamasina and 70% from 11 remote locations, including the capital. Demographic information and self-reported barriers to care were collected. Wealth quintile was calculated for each patient using a combination of participant responses to asset-related and demographic questions, and publicly available data. A total of 2971 patients were assessed. The change from centralised to decentralised selection resulted in significantly poorer patients undergoing surgery. All reported barriers to prior care, except for lack of transportation, were significantly more likely to be identified in the decentralised group. Patients who identified multiple barriers to prior surgical care were less likely to be from the richest quintile (p=0.037) and more likely to be in the decentralised group (p=0.046). Our country-specific analysis shows that decentralised patient selection strategies may be used to overcome barriers to care and allow patients in greatest need to access surgical care
Health gains and fi nancial risk protection aff orded by public fi nancing of selected interventions in Ethiopia: an extended cost-eff ectiveness analysis
Background The way in which a government chooses to fi nance a health intervention can aff ect the uptake of health
interventions and consequently the extent of health gains. In addition to health gains, some policies such as public
fi nance can insure against catastrophic health expenditures. We aimed to evaluate the health and fi nancial risk
protection benefi ts of selected interventions that could be publicly fi nanced by the government of Ethiopia.
Methods We used extended cost-eff ectiveness analysis to assess the health gains (deaths averted) and fi nancial risk
protection aff orded (cases of poverty averted) by a bundle of nine (among many other) interventions that the
Government of Ethiopia aims to make universally available. These nine interventions were measles vaccination,
rotavirus vaccination, pneumococcal conjugate vaccination, diarrhoea treatment, malaria treatment, pneumonia
treatment, caesarean section surgery, hypertension treatment, and tuberculosis treatment.
Findings Our analysis shows that, per dollar spent by the Ethiopian Government, the interventions that avert the most
deaths are measles vaccination (367 deaths averted per 100 000 spent), and caesarean section surgery (141 deaths averted per 100 000 spent), tuberculosis
treatment (96 cases averted per 100 000 spent).
Interpretation Our approach incorporates fi nancial risk protection into the economic evaluation of health interventions
and therefore provides information about the effi ciency of attainment of both major objectives of a health system:
improved health and fi nancial risk protection. One intervention might rank higher on one or both metrics than
another, which shows how intervention choice—the selection of a pathway to universal health coverage—might
involve weighing up of sometimes competing objectives. This understanding can help policy makers to select
interventions to target specifi c policy goals (ie, improved health or fi nancial risk protection). It is especially relevant
for the design and sequencing of universal health coverage to meet the needs of poor populations
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
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Assessing the Brazilian surgical system with six surgical indicators: a descriptive and modelling study
Background: Brazil boasts a health scheme that aspires to provide universal coverage, but its surgical system has rarely been analyzed. In an effort to strengthen surgical systems worldwide, the Lancet Commission on Global Surgery proposed collection of six standardized indicators: two-hour access to surgery, surgical workforce density, surgical volume, perioperative mortality rate (POMR), and protection against impoverishing and catastrophic expenditure. This study aims to characterize the Brazilian surgical health system with these newly devised indicators while gaining understanding on the complexity of the indicators themselves.
Methods: Using Brazil’s national healthcare database, commonly reported healthcare variables were used to calculate or simulate the six surgical indicators. Access to surgery was calculated using hospital locations, surgical workforce density was calculated using locations of surgeons, anesthesiologists and obstetricians (SAO), and surgical volume and POMR were identified with surgical procedure codes. The rates of protection against impoverishing and catastrophic expenditure were modelled using cost of inpatient hospitalization and a gamma distribution of incomes based on GINI and GDP/capita.
Findings: In 2014, SAO density is 34·7/100,000 population, surgical volume is 4,433 procedures/100,000 people and POMR is 1·71%. 79·4% of surgical patients are protected against impoverishing expenditure and 84·6% were protected against catastrophic expenditure due to surgery each year. Two-hour access to surgery was not able to be calculated from national health data, but a proxy measure suggested that 97·2% of the population has two-hour access to a hospital that may be able to provide surgery. Geographic disparities were seen in all indicators.
Interpretation: Brazil‘s public surgical system meets several key benchmarks. Geographic disparities, however, are substantial and raise concerns of equity. Policies should focus on stimulating appropriate geographic allocation of the surgical workforce. In some cases, where benchmarks for each indicator are met, supplemental analysis can further inform our understanding of health systems. This measured and systematic evaluation of surgical systems should be encouraged for all nations seeking to better understand their surgical systems.
Funding: There was no funding for this study
Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries
Background: While recommendations for the optimal distribution of surgical services in high-income countries (HICs) exist, it is unclear how these translate to resource-limited settings. Given the significant shortage and maldistribution of surgical workforce and infrastructure in many low- and middle-income countries (LMICs), the optimal role of decentralization versus regionalization (centralization) of surgical care is unknown. The aim of this study is to review evidence around interventions aimed at redistributing surgical services in LMICs, to guide recommendations for the ideal organization of surgical services.Methods: A narrative-based literature review was conducted to answer this question. Studies published in English between 1997 and 2017 in PubMed, describing interventions to decentralize or regionalize a surgical procedure in a LMIC, were included. Procedures were selected using the Disease Control Priorities’ (DCP3) Essential Surgery Package list. Intervention themes and outcomes were analyzed using a narrative, thematic synthesis approach. Primary outcomes included mortality, complications, and patient satisfaction. Secondary outcomes included input measures: workforce and infrastructure, and process measures: facility-based care, surgical volume, and referral rates.Results: Thirty-five studies were included. Nine (33%) of the 27 studies describing decentralization showed an improvement in primary outcomes. The procedures associated with improved outcomes after decentralization included most obstetric, gynecological, and family planning services as well as some minor general surgery procedures. Out of 8 studies on regionalization (centralization), improved outcomes were shown for trauma care in one study and cataract extraction in one study.Conclusion: Interventions aimed at decentralizing obstetric care to the district hospital and health center levels have resulted in mortality benefits in several countries. However, more evidence is needed to link service distribution to patient outcomes in order to provide recommendations for the optimal organization of other surgical procedures in LMICs. Considerations for the optimal distribution of surgical procedures should include the acuity of the condition for which the procedure is indicated, anticipated case volume, and required level of technical skills, resources, and infrastructure. These attributes should be considered within the context of each country
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