95359 VOLUME 1 DISEASE CONTROL PRIORITIES • THIRD EDITION Essential Surgery DISEASE CONTROL PRIORITIES • THIRD EDITION Series Editors Dean T. Jamison Rachel Nugent Hellen Gelband Susan Horton Prabhat Jha Ramanan Laxminarayan Volumes in the Series Essential Surgery Reproductive, Maternal, Newborn, and Child Health Cancer Mental, Neurological, and Substance Use Disorders Cardiovascular, Respiratory, Renal, and Endocrine Disorders HIV/AIDS, STIs, Tuberculosis, and Malaria Injury Prevention and Environmental Health Child and Adolescent Development Disease Control Priorities: Improving Health and Reducing Poverty DISEASE CONTROL PRIORITIES Budgets constrain choices. Policy analysis helps decision makers achieve the greatest value from limited available resources. In 1993, the World Bank published Disease Control Priorities in Developing Countries (DCP1), an attempt to systematically assess the cost-effectiveness (value for money) of interventions that would address the major sources of disease burden in low- and middle-income countries. The World Bank’s 1993 World Development Report on health drew heavily on DCP1’s findings to conclude that specific interventions against noncommunicable diseases were cost-effective, even in environments in which substantial burdens of infection and undernutrition persisted. DCP2, published in 2006, updated and extended DCP1 in several aspects, including explicit consideration of the implications for health systems of expanded intervention coverage. One way that health systems expand intervention coverage is through selected platforms that deliver interventions that require similar logistics but deliver interventions from different packages of conceptually related interventions, for example, against cardiovascular disease. Platforms often provide a more natural unit for investment than do individual interventions. Analysis of the costs of packages and platforms—and of the health improvements they can generate in given epidemiological environments—can help to guide health system investments and development. The third edition of DCP is being completed. DCP3 differs importantly from DCP1 and DCP2 by extending and consolidating the concepts of platforms and packages and by offering explicit consideration of the financial risk protection objective of health systems. In populations lacking access to health insurance or prepaid care, medical expenses that are high relative to income can be impoverishing. Where incomes are low, seemingly inexpensive medical procedures can have catastrophic financial effects. DCP3 offers an approach to explicitly include financial protection as well as the distribution across income groups of financial and health outcomes resulting from policies (for example, public finance) to increase intervention uptake. The task in all of the DCP volumes has been to combine the available science about interventions implemented in very specific locales and under very specific conditions with informed judgment to reach reasonable conclusions about the impact of intervention mixes in diverse environments. DCP3 ’s broad aim is to delineate essential intervention packages and their related delivery platforms to assist decision makers in allocating often tightly constrained budgets so that health system objectives are maximally achieved. DCP3 ’s nine volumes are being published in 2015 and 2016 in an environment in which serious discussion continues about quantifying the sustainable development goal (SDG) for health. DCP3 ’s analyses are well-placed to assist in choosing the means to attain the health SDG and assessing the related costs. Only when these volumes, and the analytic efforts on which they are based, are completed will we be able to explore SDG-related and other broad policy conclusions and generalizations. The final DCP3 volume will report those conclusions. Each individual volume will provide valuable specific policy analyses on the full range of interventions, packages, and policies relevant to its health topic. More than 500 individuals and multiple institutions have contributed to DCP3. We convey our acknowledgments elsewhere in this volume. Here we express our particular gratitude to the Bill & Melinda Gates Foundation for its sustained financial support, to the InterAcademy Medical Panel (and its U.S. affiliate, the Institute of Medicine of the National Academy of Sciences), and to the External and Corporate Relations Publishing and Knowledge division of the World Bank. Each played a critical role in this effort. Dean T. Jamison Rachel Nugent Hellen Gelband Susan Horton Prabhat Jha Ramanan Laxminarayan VOLUME 1 DISEASE CONTROL PRIORITIES • THIRD EDITION Essential Surgery EDITORS Haile T. Debas Peter Donkor Atul Gawande Dean T. Jamison Margaret E. Kruk Charles N. Mock © 2015 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved 1 2 3 4 18 17 16 15 This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Nothing herein shall constitute or be considered to be a limitation upon or waiver of the privileges and immunities of The World Bank, all of which are specifically reserved. Rights and Permissions This work is available under the Creative Commons Attribution 3.0 IGO license (CC BY 3.0 IGO) http://creativecommons.org /licenses/by/3.0/igo. Under the Creative Commons Attribution license, you are free to copy, distribute, transmit, and adapt this work, including for commercial purposes, under the following conditions: Attribution—Please cite the work as follows: Debas, H. T., P. Donkor, A. Gawande, D. T. Jamison, M. E. Kruk, and C. N. Mock, editors. 2015. Essential Surgery. Disease Control Priorities, third edition, volume 1. Washington, DC: World Bank. doi:10.1596 /978-1-4648-0346-8. License: Creative Commons Attribution CC BY 3.0 IGO Translations—If you create a translation of this work, please add the following disclaimer along with the attribution: This translation was not created by The World Bank and should not be considered an official World Bank translation. The World Bank shall not be liable for any content or error in this translation. Adaptations—If you create an adaptation of this work, please add the following disclaimer along with the attribution: This is an adaptation of an original work by The World Bank. Views and opinions expressed in the adaptation are the sole responsibility of the author or authors of the adaptation and are not endorsed by The World Bank. Third-party content—The World Bank does not necessarily own each component of the content contained within the work. The World Bank therefore does not warrant that the use of any third-party-owned individual component or part contained in the work will not infringe on the rights of those third parties. The risk of claims resulting from such infringement rests solely with you. If you wish to re-use a component of the work, it is your responsibility to determine whether permission is needed for that re-use and to obtain permission from the copyright owner. Examples of components can include, but are not limited to, tables, figures, or images. All queries on rights and licenses should be addressed to the Publishing and Knowledge Division, The World Bank, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. ISBN (paper): 978-1-4648-0346-8 ISBN (electronic): 978-1-4648-0367-3 DOI: 10.1596/978-1-4648-0346-8 Cover photo: The 16 Makara hospital in Cambodia’s remote Preah Vihear province is equipped with modern equipment. The maintenance of 16 Makara is supported by the World Bank and other international donors through the Health Sector Support Program and the Cambodia Second Health Sector Support Program. Photo: © Chhor Sokunthea/World Bank. Further permission required for reuse. Cover and interior design: Debra Naylor, Naylor Design, Washington, DC Library of Congress Cataloging-in-Publication Data Essential surgery / volume editors, Haile T. Debas, Peter Donkor, Atul Gawande, Dean T. Jamison, Margaret E. Kruk, Charles N. Mock. p ; cm. — (Disease control priorities ; v. 1) Previously published in: Disease control priorities in developing countries, 2nd ed. c2006. ISBN 978-1-4648-0346-8 (v. 1 : pb) — ISBN 978-1-4648-0097-9 (v. 1 : hc) I. Debas, Haile T., editor. II. Disease control priorities in developing countries. III. Series: Disease control priorities ; v. 1. [DNLM: 1. General Surgery—economics. 2. Developing Countries. WA 395] RD27.42 362.197—dc23 2014037594 Contents Foreword by Paul Farmer xi Preface xv Abbreviations xvii 1. Essential Surgery: Key Messages of This Volume 1 Charles N. Mock, Peter Donkor, Atul Gawande, Dean T. Jamison, Margaret E. Kruk, and Haile T. Debas PART 1: THE GLOBAL BURDEN 2. Global Burden of Surgical Conditions 19 Stephen W. Bickler, Thomas G. Weiser, Nicholas Kassebaum, Hideki Higashi, David C. Chang, Jan J. Barendregt, Emilia V. Noormahomed, and Theo Vos PART 2: SURGICAL INTERVENTIONS 3. Surgery and Trauma Care 41 Richard A. Gosselin, Anthony Charles, Manjul Joshipura, Nyengo Mkandawire, Charles N. Mock, Raymond R. Price, and David Spiegel 4. General Surgical Emergencies 61 Colin McCord, Doruk Ozgediz, Jessica H. Beard, and Haile T. Debas 5. Obstetric Surgery 77 Clark T. Johnson, Timothy R. B. Johnson, and Richard M. K. Adanu 6. Obstetric Fistula 95 Mary Lake Polan, Ambereen Sleemi, Mulu Muleta Bedane, Svjetlana Lozo, and Mark A. Morgan 7. Surgery for Family Planning, Abortion, and Postabortion Care 109 Joseph B. Babigumira, Michael Vlassoff, Asa Ahimbisibwe, and Andy Stergachis 8. Surgical Interventions for Congenital Anomalies 129 Diana Farmer, Nicole Sitkin, Katrine Lofberg, Peter Donkor, and Doruk Ozgediz 9. Hernia and Hydrocele 151 Jessica H. Beard, Michael Ohene-Yeboah, Catherine R. deVries, and William P. Schecter ix 10. Dentistry 173 Richard Niederman, Magda Feres, and Eyitope Ogunbodede 11. Cataract Surgery 197 N. Venkatesh Prajna, Thulasiraj D. Ravilla, and Sathish Srinivasan PART 3: SURGICAL PLATFORMS AND POLICIES 12. Organization of Essential Services and the Role of First-Level Hospitals 213 Colin McCord, Margaret E. Kruk, Charles N. Mock, Meena Cherian, Johan von Schreeb, Sarah Russell, and Mike English 13. Specialized Surgical Platforms 231 Mark G. Shrime, Ambereen Sleemi, and Thulasiraj D. Ravilla 14. Prehospital and Emergency Care 245 Amardeep Thind, Renee Hsia, Jackie Mabweijano, Eduardo Romero Hicks, Ahmed Zakariah, and Charles N. Mock 15. Anesthesia and Perioperative Care 263 Kelly McQueen, Thomas Coonan, Andrew Ottaway, Richard P. Dutton, Florian R. Nuevo, Zipporah Gathuya, and Iain H. Wilson 16. Excess Surgical Mortality: Strategies for Improving Quality of Care 279 Thomas G. Weiser and Atul Gawande 17. Workforce Innovations to Expand the Capacity for Surgical Services 307 Staffan Bergström, Barbara McPake, Caetano Pereira, and Delanyo Dovlo PART 4: THE ECONOMICS OF SURGERY 18. Costs, Effectiveness, and Cost-Effectiveness of Selected Surgical Procedures and Platforms 317 Shankar Prinja, Arindam Nandi, Susan Horton, Carol Levin, and Ramanan Laxminarayan 19. Task-Sharing or Public Finance for Expanding Surgical Access in Rural Ethiopia: An Extended Cost-Effectiveness Analysis 339 Mark G. Shrime, Stéphane Verguet, Kjell Arne Johansson, Dawit Desalegn, Dean T. Jamison, and Margaret E. Kruk 20. Global Surgery and Poverty 353 William P. Schecter and Sweta Adhikari 21. Benefit-Cost Analysis for Selected Surgical Interventions in Low- and Middle-Income Countries 361 Blake C. Alkire, Jeffrey R. Vincent, and John G. Meara DCP3 Series Acknowledgments 381 Series and Volume Editors 383 Contributors 387 Advisory Committee to the Editors 391 Reviewers 393 Index 395 x Contents Foreword The past few decades have seen enormous changes in Ozgediz and others 2009; Bickler and others 2010). Some the global burden of disease. Although many people, illnesses rarely considered to be surgical problems pose especially those living in (or near) poverty and other threats to health if neglected long enough. Some trends privations, are familiar with heavy burdens and much are clear, however. Take the examples offered by Haiti and disease, the term “global burden of disease” emerged in Rwanda, where different types of trauma (intentional public health and in health economics only in recent or the result of crush injuries) account for a majority of decades. It was coined to describe what ails people, young-adult deaths. How many of these deaths are clas- when, and where, and just as reliable quantification is sified as attributable to surgical disease? If someone dies difficult, so too is agreeing on units of analysis. Does this of acute abdomen—and if his or her death is recorded at term truly describe the burden of disease of the globe? all—was it attributed to appendicitis or to enteric fever? Of a nation? A city? Are these infectious complications of surgical disease or We have also learned a thing or two about how to surgical complications of infectious disease? If a child assess this global burden, and how to reveal its sharp with untreated epilepsy falls into a fire and succumbs local variation and transformation with changing condi- from burns, how is this death reported, if it is registered at tions ranging from urbanization to a global rise in obe- all? Clinicians who work in settings far from any pathol- sity (Murray, Lopez, and Jamison 1994; Murray ogy laboratory have seen infected tumors (misdiagnosed and Lopez 1997; Lopez and others 2006; Mathers, Fat, as primary infection) as often as they have discovered that and Boerma 2008; Jamison and others 2013; Lozano and a suspected breast cancer was a long-untreated canalicular others 2013). Measuring illness has never been easy, nor abscess. Brain tumors are revealed to be tuberculomas and has attributing a death—whether premature or at the vice versa. end of fourscore years—to a specific cause (Yarushalmy A sound grasp of the burden of disease is essential to and Palmer 1959; Rothman 1976; Byass 2010; Byass and those seeking data-driven methods to design and evalu- others 2013). Even countries with sound vital registries ate policies aimed at decreasing premature death and generate data of varying quality, given that cause of suffering (Nordberg, Holmberg, and Kiugu 1995; Taira, death is rarely confirmed by autopsy (Mathers and McQueen, and Burkle 2009; Poenaru, Ozgediz, and others 2005; Mahapatra and others 2007). When Gosselin 2014). But surgical disease was not often on the nonlethal or slowly debilitating illness is added to con- agenda. The immensity and complexity of the task of siderations of burden of disease, the challenge of both quantifying the surgical burden of disease has led many measurement and etiologic claims can appear over- to avoid that task, leading to an analytic vacuum with whelming (Kleinman 1995; Arnesen and Nord 1999; adverse consequences. For too long, the global health Salomon and others 2012; Voigt and King 2014). movement has failed to count surgery as an integral The challenges of measuring the burden of disease only part of public health. Prevailing wisdom dictated that get more complex when attempting to use the category the surgical disease burden was too low, surgical of surgical disease. For starters, even experts do not agree expenses too high, and delivery of care too complicated. on definitions of ostensibly simple terms such as “surgical The predecessor to this volume, the second edition disease” (Debas and others 2006; Duba and Hill 2007; of Disease Control Priorities in Developing Countries xi (DCP2; Jamison and others 2006), changed this REFERENCES paradigm. Published in 2006, it included, for the first time in a major global health platform, sustained atten- Arnesen, T., and E. Nord. 1999. “The Value of DALY Life: tion to surgery. The editors sought to marshal the expe- Problems with Ethics and Validity of Disability Adjusted rience of its contributors to help quantify and classify the Life Years.” BMJ 319 (7222): 423–25. burden of surgical disease. Admittedly, this most widely Bickler, S., D. Ozgediz, R. Gosselin, T. Weiser, D. Speigel, and cited estimate of surgical need—11 percent of the global others. 2010. “Key Concepts for Estimating the Burden of Surgical Conditions and the Unmet Need for Surgical burden of disease was surgical—was based on the best Care.” World Journal of Surgery 34 (3): 374–80. educated guesses of a convenience sample of 18 surgeons Byass, P. 2010. “The Imperfect World of Global Health on an online survey. Nonetheless, this figure was later Estimates.” PLOS Medicine 7: e1001006. validated by the common experience of providers and ———, M. de Courten, W. J. Graham, L. Laflamme, A. McCaw- patients alike from the poorest reaches of the world: the Binns, and others. 2013. “Reflections on the Global Burden burden of surgical disease was never trivial. of Disease 2010 Estimates.” PLOS Medicine 10: e1001477. DCP3 builds upon this foundation and substantially Debas, H. T., R. Gosselin, C. McCord, and A. Thind. 2006. improves it. It enhances our understanding of DCP2’s “Surgery.” In Disease Control Priorities in Developing pioneering work with more robust methodology. Over Countries, 2nd edition, edited by D. T. Jamison, J. G. Breman, the years, researchers—led by the editors of and many A. R. Measham, G. Alleyene, M. Claeson, D. B. Evans, P. Jha, of the contributors to this volume—have devoted atten- A. Mills, and P. Musgrove, 1245–59. Washington, DC: World Bank and Oxford University Press. tion to cancers, orthopedic injuries, disfigurements after Duba, R. B., and A. G. Hill. 2007. “Surgery in Developing burns, congenital defects such as cleft lip and palate, Countries: Should Surgery Have a Role in Population- blindness from cataracts, and the many causes of death Based Health Care?” Bulletin of the American College of from acute surgical needs. This volume collates the Surgeons 92 (5): 12–18. knowledge gained through the increased attention to Jamison, D. T., J. G. Breman, A. R. Measham, G. Alleyne, global surgery since 2006. M. Claeson, D. B. Evans, P. Jha, A. Mills, and P. Musgrove, This new volume of DCP underlines the central impor- eds. 2006. Disease Control Priorities in Developing Countries, tance of surgical care because, by these measures, surgical 2nd edition. Washington, DC: World Bank and Oxford disease is thought to account for a significant portion of University Press. the global disease burden. The Essential Surgery volume of Jamison, D. T., L. H. Summers, G. Alleyne, K. J. Arrow, DCP3 helps definitively dispel many of the myths about S. Berkley, and others. 2013. “Global Health 2035: A World Converging within a Generation.” The Lancet 382 (9908): surgery’s role in global health, in part by showing the very 1898–955. large health burden from conditions that are primarily or Kleinman, A. 1995. “A Critique of Objectivity in International extensively treatable by surgery. It dispels the myth that Health.” In Writing at the Margin: Discourse between surgery is too expensive by showing that many essential Anthropology and Medicine, edited by A. Kleinman. surgical services rank among the most cost-effective of Berkeley, CA: University of California Press. all heath interventions. This volume begins to dispel the Lopez, A. D., C. D. Mathers, M. Ezzati, D. T. Jamison, and myth that surgery is not feasible in settings of poverty C. J. L. Murray. 2006. “Global and Regional Burden of by documenting many successful programs that have Disease and Risk Factors, 2001: Systematic Analysis of improved capacity, increased access, and enhanced quality Population Health Data.” The Lancet 367 (9524): 1747–57. of surgical care in countries across the globe. Lozano, R., M. Naghavi, K. Foreman, S. Lim, K. Shibuya, and As argued many times in the past—and worth repeat- others. 2013. “Global and Regional Mortality from 235 Causes of Death for 20 Age Groups in 1990 and 2010: A ing to clinical colleagues, students, trainees, and diverse Systematic Analysis for the Global Burden of Disease Study interlocutors—global surgery is one of the most exciting 2010.” The Lancet 380 (9859): 2095–128. frontiers in the quest for global health equity. Patients Mahapatra, P., K. Shibuya, A. D. Lopez, F. Coullare, F. C. Notzon, and providers, along with those who set and evaluate and others. 2007. “Civil Registration Systems and Vital policies, will want (or need) to join this quest if we are Statistics: Successes and Missed Opportunities.” The Lancet to avert unnecessary suffering. We all have cause to be 370 (9599): 1653–63. grateful for the many individuals whose time and energy Mathers, C., D. M. Fat, and J. T. Boerma. 2008. The Global have been invested in producing the wealth of knowl- Burden of Disease: 2004 Update. Geneva, Switzerland: World edge presented in the Essential Surgery volume of DCP3. Health Organization. Mathers, C. D., M. A. Fat, M. Inoue, C. Rao, and A. D. Lopez. Paul Farmer 2005. “Counting the Dead and What They Died From: Harvard Medical School An Assessment of the Global Status of Cause of Death Brigham and Women’s Hospital Data.” Bulletin of the World Health Organization 83 (3): Partners in Health 161–240. xii Foreword Murray, C. J. L., and A. D. Lopez. 1997. “Global Mortality, Rothman, K. J. 1976. “Causes.” American Journal of Disability, and the Contribution of Risk Factors: Global Epidemiology 104 (6): 587–92. Burden of Disease Study.” The Lancet 349 (9063): 1436–42. Salomon, J. A., T. Vos, D. R. Hogan, M. Gagnon, ———, and D. T. Jamison. 1994. “The Global Burden of M. Naghavi, and others. 2012. “Common Values in Disease in 1990: Summary Results, Sensitivity Analysis Assessing Health Outcomes from Disease and Injury: and Future Directions.” Bulletin of the World Health Disability Weights Measurement Study for the Global Organization 72 (3): 495–509. Burden of Disease Study 2010.” The Lancet 380 (9859): Nordberg, E., S. Holmberg, and S. Kiugu. 1995. “Output 2129–43. of Major Surgery in Developing Countries: Towards a Taira, B. R., K. McQueen, and F. M. Burkle. 2009. “Burden of Quantitative Evaluation and Planning Tool.” Tropical and Surgical Disease: Does the Literature Reflect the Scope of Geographical Medicine 47 (5): 206–11. the International Crisis?” World Journal of Surgery 33 (5): Ozgediz, D., R. Hsia, T. Weiser, R. Gosselin, D. Spiegel, and others. 893–98. 2009. “Population Health Metrics for Surgery: Effective Voigt, K., and N. B. King. 2014. “Disability Weights in the Coverage of Surgical Services in Low-Income and Middle- Global Burden of Disease 2010 Study: Two Steps Forward, Income Countries.” World Journal of Surgery 33 (1): 1–5. One Step Back?” Bulletin of the World Health Organization Poenaru, D., D. Ozgediz, and R. A. Gosselin. 2014. “Burden, 92 (3): 226–28. Need, or Backlog: A Call for Improved Metrics for the Yerushalmy, J., and C. E. Palmer. 1959. “On the Methodology Global Burden of Surgical Disease.” International Journal of of Investigations of Etiologic Factors in Chronic Diseases.” Surgery 12 (5): 483–86. Journal of Chronic Disease 10 (1): 27–40. Foreword xiii Preface Conditions that are treated primarily or frequently by sur- cost-effective of all health interventions. They are gery constitute a significant portion of the global burden eminently feasible to promote globally, and many could of disease. In 2012, injuries killed nearly 5 million people, be delivered at first-level hospitals. and about 270,000 women died from complications of The large burden of surgical conditions, cost- pregnancy. Many of these deaths, as well as deaths from effectiveness of essential surgical procedures, and strong abdominal emergencies, congenital anomalies, and other public demand for those procedures suggest that uni- causes, could be prevented by improved access to quality versal coverage of essential surgery should be imple- surgical care. However, surgical care itself has barely been mented early on the path to universal health coverage. addressed within the field of global health. A growing Implementation would include measures such as using number of people from diverse backgrounds are attempt- public funds to ensure access to essential procedures ing to change this, and to increase access to appropriate, and including them in the packages covered by national safe, surgical care in low- and middle-income countries. health insurance programs. Such measures would also The Essential Surgery volume of Disease Control Priorities, offer financial risk protection against medical impov- third edition (DCP3), contributes to these efforts by erishment from the costs of surgical care. Surgery (1) better defining the health burden from conditions should be considered an indispensable component of a requiring surgery, (2) identifying those surgical proce- properly functioning health system and can be a means dures that are the most cost-effective and cost-beneficial, for strengthening the entire system, thus increasing the and (3) describing the health care policies and platforms return on investment. that can universally deliver these procedures safely and Not covered in this volume are procedures to treat effectively. other surgical conditions, such as transplantation, or Essential Surgery identifies and studies a group of surgery for cancer and vascular disease. Improving “essential” surgical conditions and the procedures access to these procedures will also have benefits. But for needed to treat them. These surgical conditions can be prioritization of the sequencing and use of public funds, defined as those that (1) are primarily or extensively efforts to ensure greater access to the essential surgical treated by surgery, (2) have a large health burden, and services should be undertaken first, relative to increased (3) can be successfully treated by surgical procedures investment in those conditions that are more expensive that are cost-effective and feasible to promote globally. to treat or that have smaller health impacts. To address these conditions, the authors derive a set of The editors and authors of Essential Surgery hope 44 essential surgical procedures. These include proce- that this volume will increase efforts to improve access dures to treat injuries, obstetric complications, abdom- to and quality of essential surgical care in low- and inal emergencies, cataracts, and congenital anomalies, middle-income countries. We especially hope to stim- among others. We estimate that universal access to ulate increased attention to addressing essential surgery this package of essential procedures would prevent on the part of two very different communities: the about 1.5 million deaths per year or 6 to 7 percent global health community and the surgical community. of all preventable deaths in low- and middle-income With the exception of obstetric care, the global health countries. These procedures rank among the most community has largely failed to address the unmet need xv for surgery. The surgical community, in turn, has not Devlan O’Connor, Zach Olson, Rumit Pancholi, tackled broader requirements for incorporating sur- Carlos Rossel, Nopadol Wora-Urai, and The Lancet gery into resource-constrained health systems (with Commission on Global Surgery, especially John Meara, the important exceptions of exploring task-sharing and Sarah Greenberg, Andrew Leather, and Gavin Yamey. improving safety of care). We hope that this volume The authors also thank the reviewers organized by the invigorates the global health community to advocate for Institute of Medicine and the InterAcademy Medical inclusion of essential surgery as part of universal health Panel (listed separately in this volume) and the follow- coverage and as an integral part of a well-functioning ing additional reviewers for their insightful comments: health system. Likewise, we hope that this volume moti- Wame Baravilala, Michael Cotton, Raul Garcia, John S. vates the surgical community to advocate for increased Greenspan, Caris Grimes, Russell Gruen, Jaymie Henry, investment in surgical capabilities in first-level hospitals Robert Lane, Jenny Löfgren, Jane Maraka, Pär Nordin, and for greater access to the basic essential procedures. Ebenezer Anno Nyako, Akinyinka O. Omigbodun, Ensuring that essential surgical services are available to Norgrove Penny, Dan Poenaru, Teri Reynolds, Nitin everyone who needs them when they need them is in Verma, Lee Wallis, Benjamin C. Warf, David Watters, part about improving training in safe surgical care and and Andreas Wladis. We also thank the following pro- techniques, and in part about improving the function- fessional societies that helped to identify reviewers: ing of health systems, including better monitoring and the African Federation for Emergency Medicine; the evaluation and developing appropriate financing mech- American College of Surgeons; the College of Surgeons anisms. It is also about promoting equity, social justice, of East, Central and Southern Africa; the International and human rights. Collaboration for Essential Surgery; the International We thank the following individuals who provided Society of Surgery; the Panamerican Trauma Society; valuable comments and assistance on this effort: Brianne and the West African College of Surgeons. We especially Adderley, Elizabeth Brouwer, Kristen Danforth, Anna thank Rachel Cox for her hard work keeping this large Dare, Mary Fisk, Nancy Lammers, Rachel Nugent, endeavor well organized. Haile T. Debas Peter Donkor Atul Gawande Dean T. Jamison Margaret E. Kruk Charles N. Mock xvi Preface Abbreviations ADLA adenolymphangitis AIDS acquired immune deficiency syndrome ALS advanced life support AMO assistant medical officer ANAC African Network of Associate Clinicians ARM anorectal malformation ASA American Society of Anesthesiologists BC benefit-cost BCA benefit-cost analysis BCVA best-corrected visual acuity BCR benefit-cost ratio BLD banana leaf dressing BLS basic life support bpm beats per minute BPOC Basic Package of Oral Care CC Copenhagen Consensus CEA cost-effectiveness analysis CFR case fatality rate CLP cleft lip and palate CYP couple-year of protection DALY disability-adjusted life year DCP Disease Control Priorities DCP2 Disease Control Priorities in Developing Countries, second edition DCP3 Disease Control Priorities, third edition D&C dilation and curettage ECCE extracapsular cataract extraction ECG electrocardiogram EESC Emergency and Essential Surgical Care EHCP Essential Health Care Program EMLA eutectic mixture of local anesthetics EMRI Emergency Management and Research Institute EMS emergency medical service ETV endoscopic third ventriculostomy EVA electric vacuum aspiration FI fascial interposition FIGO International Federation of Gynecology and Obstetrics xvii GBD Global Burden of Disease study GCCCC Guwahati Comprehensive Cleft Care Center GCS Glasgow Coma Score GDP gross domestic product GHE Global Health Estimates GHS Ghana Hernia Society GIEESC Global Initiative for Emergency and Essential Surgery Care GNI gross national income GPELF Global Programme to Eliminate Lymphatic Filariasis HD Hirschsprung’s disease HDI Human Development Index HIC high-income country HIV human immunodeficiency virus HPV human papilloma virus IA inflammatory arthropathies ICD-9 International Classification of Diseases, Ninth Revision ICER incremental cost-effectiveness ratio IMEESC Integrated Management of Emergency and Essential Surgical Care ISO International Organization for Standardization ISOFS International Society of Obstetric Fistula Surgeons IOL intraocular lens IUD intrauterine device IVD intra vas device LBP low back pain LE life expectancy LF lymphatic filariasis LIC low-income country LMICs low- and middle-income countries LYS life-year saved M&M Morbidity and Mortality Conference MBBHS M&E Matrix Monitoring the Building Blocks of Health Systems Monitoring and Evaluation Matrix MDA mass drug administration MDG Millennium Development Goals MEBO moist exposed burn ointment MIC middle-income country MLP midlevel provider MMR maternal mortality ratio mm millimeter MSICS manual small-incision cataract surgery MSK musculoskeletal system MVA manual vacuum aspiration NGO nongovernmental organization NHANES National Health and Nutrition Examination Survey (U.S.) NHS National Health Service (U.K.) NIS Nationwide Inpatient Sample NPC nonphysician clinician NSAID nonsteroidal anti-inflammatory drug OA osteoarthritis PE phacoemulsification PCO posterior capsule opacification PCR posterior capsular rupture PMMA polymethylmethacrylate xviii Abbreviations POMR perioperative mortality rate PPP purchasing power parity QALY quality-adjusted life year QI quality improvement QOL quality of life RA rheumatoid arthritis RTI road traffic injury RVF recto-vaginal fistula SIA surgically induced astigmatism TBA traditional birth attendant TBSA total body surface area TBI traumatic brain injury TC técnicos de cirurgia (Mozambique) TJR total joint replacement TTO time tradeoff UCVA uncorrected visual acuity UMIC upper-middle-income country UNFPA United Nations Population Fund VA vacuum aspiration VSL value of a statistical life VSLY value of a statistical life year VVF vesico-vaginal fistula WFSA World Federation of Societies of Anaesthesiologists WHA World Health Assembly WHO World Health Organization WTP willingness to pay YLD years lived with disability YLL years of life lost YLS years of life saved Income Classifications World Bank Income Classifications as of July 2014 are as follows, based on estimates of annual gross national income (GNI) per capita for 2013: • Low-income countries (LICs) = US$1,045 or less • Middle-income countries (MICs) are subdivided: a) lower-middle-income = US$1,046 to US$4,125 b) upper-middle-income (UMICs) = US$4,126 to US$12,745 • High-income countries (HICs) = US$12,746 or more. Abbreviations xix Chapter 1 Essential Surgery: Key Messages of This Volume Charles N. Mock, Peter Donkor, Atul Gawande, Dean T. Jamison, Margaret E. Kruk, and Haile T. Debas VOLUME SUMMARY and anesthesia-related deaths in LMICs. Feasible measures, such as the World Health Organization’s Essential Surgery reflects an increased emphasis on (WHO’s) Surgical Safety Checklist (WHO 2008a), health systems relative to previous editions of Disease have led to improvements in safety and quality. Control Priorities. This volume identifies 44 surgical • The large burden of surgical conditions, the cost- procedures as essential on the basis that they address effectiveness of essential surgery, and the strong substantial needs, are cost-effective, and can feasibly be public demand for surgical services suggest that uni- implemented. This chapter summarizes and critically versal coverage of essential surgery (UCES) should assesses the volume’s key findings: be financed early on the path to universal health cov- erage. We point to estimates that full coverage of the • Provision of essential surgical procedures would avert component of UCES applicable to first-level hospitals an estimated 1.5 million deaths a year, or 6 percent would require slightly more than $3 billion annually to 7 percent of all avertable deaths in low- and of additional spending and yield a benefit:cost ratio middle-income countries (LMICs). of better than 10:1. It would efficiently and equitably • Essential surgical procedures rank among the most provide health benefits and financial protection, and cost-effective of all health interventions. The surgical it would contribute to stronger health systems. platform of first-level hospitals delivers 28 of the 44 essential procedures, making investment in this platform also highly cost-effective. • Measures to expand access to surgery, such INTRODUCTION as task-sharing, have been shown to be safe and Conditions that are treated primarily or frequently by sur- effective while countries make long-term invest- gery constitute a significant portion of the global burden ments in building surgical and anesthesia workforces. of disease. In 2011, injuries killed nearly 5 million people; Because emergency procedures constitute 23 of the 270,000 women died from complications of pregnancy 28 procedures provided at first-level hospitals, such (WHO 2014). Many of these injury- and obstetric-related facilities must be widely geographically available. deaths, as well as deaths from other causes such as abdom- • Substantial disparities remain in the safety of surgical inal emergencies and congenital anomalies, could be care, driven by high perioperative mortality rates prevented by improved access to surgical care. 1 Despite this substantial burden, surgical services to define and study a package of essential surgical are not being delivered to many of those who need procedures that would lead to significant improve- them most. An estimated 2 billion people lack access ments in health if they were universally delivered. to even the most basic surgical care (Funk and others This chapter and the volume focus on the situation 2010). This need has not been widely acknowledged, of low-income countries (LICs) and lower-middle- and priorities for investing in health systems’ surgical income countries. capacities have only recently been investigated. Indeed, until the 1990s, health policy in resource-constrained Box 1.1 describes the history, objectives, and contents settings focused sharply on infectious diseases and of DCP3 (Jamison 2015). undernutrition, especially in children. Surgical capacity was developing in urban areas but was often viewed as a secondary priority that principally served those who DEFINITIONS were better off. Health conditions cannot be neatly split between In the 1990s, a number of studies began to ques- conditions that require surgery and those that do not. tion the perception that surgery was costly and low in Different diagnoses range widely in the proportion of effectiveness. Economic evaluations of cataract surgery patients requiring some type of surgical procedure. At found the procedure to be cost-effective, even under the upper end are admissions for musculoskeletal con- resource-constrained circumstances; Javitt pioneered ditions; 84 percent of these patients underwent some cost-effectiveness analysis (CEA) for surgery, including type of surgical procedure in an operating room in the his chapter on cataract in Disease Control Priorities, first United States in 2010. At the lower end are admissions edition (DCP1) in 1993 (Javitt 1993). In 2003, McCord for mental health conditions (0.4 percent) (Rose and and Chowdhury enriched the approach to economic others 2014). evaluation in surgery in a paper looking at the overall The surgical capabilities required are not only those cost-effectiveness of a surgical platform in Bangladesh related to performing operations. Surgical care also (McCord and Chowdhury 2003). By design, DCP2, pub- involves preoperative assessment, including the decision lished in 2006, placed much more emphasis on sur- to operate; provision of safe anesthesia; and postop- gery than had previous health policy documents. DCP2 erative care. Even when patients do not need surgical included a dedicated chapter on surgery that amplified procedures, surgical providers often provide care, such the approach of McCord and Chowdhury and pro- as management of severe head injuries and resuscita- vided an initial estimate of the amount of disease bur- tion for airway compromise and shock in patients with den that could be addressed by surgical intervention in trauma. Such care occurs in contexts in which clinicians LMICs (Debas and others 2006). DCP3 places still greater must be prepared to intervene operatively as complica- emphasis on surgery by dedicating this entire volume tions arise or conditions deteriorate. (out of a total of nine volumes) to the topic. There is also Within the limitations inherent in defining surgical a growing academic literature on surgery’s importance in conditions, DCP3 has outlined, by consensus, a group health system development; for example, Paul Farmer and of essential surgical conditions and the procedures and Jim Kim’s paper observes that “surgery may be thought of other surgical care needed to treat them. Essential sur- as the neglected stepchild of global public health” (Farmer gical conditions can be defined as those that meet the and Kim 2008, 533). The WHO is paying increasing atten- following criteria: tion to surgical care through such vehicles as its Global Initiative for Emergency and Essential Surgical Care. • Are primarily or extensively treated by surgical Finally, the creation of The Lancet Commission on Global procedures and other surgical care Surgery, now well into its work, points to a major change • Have a large health burden in the perceived importance of surgery. • Can be successfully treated by a surgical procedure The chapter seeks to do the following: and other surgical care that is cost-effective and fea- sible to promote globally (Bellagio Essential Surgery • Better define the health burden of conditions requir- Group 2014; Luboga and others 2009; Mock and ing surgery others 2010). • Identify those surgical procedures that are the most cost-effective and cost-beneficial In most situations, procedures to treat these conditions, • Describe the health care policies and platforms for example, cesarean section, can be done at first-level that can universally deliver these procedures at hospital—those that have 50–200 beds, serve 50,000– high quality. In particular, Essential Surgery seeks 200,000 people, and have basic surgical capabilities. 2 Essential Surgery Box 1.1 From the Series Editors of Disease Control Priorities, Third Edition Budgets constrain choices. Policy analysis helps medical procedures can have catastrophic financial decision makers achieve the greatest value from effects. DCP3 offers an approach that explicitly limited available resources. In 1993, the World Bank includes financial protection as well as the distribu- published Disease Control Priorities in Developing tion across income groups of financial and health Countries (DCP1), an attempt to systematically outcomes resulting from policies (for example, pub- assess the cost-effectiveness (value for money) of lic finance) to increase intervention uptake (Verguet, interventions that would address the major sources Laxminarayan, and Jamison 2015). The task in all of disease burden in low- and middle-income coun- the volumes has been to combine the available tries (Jamison and others 1993). The World Bank’s science about interventions implemented in very 1993 World Development Report on health drew specific locales and under very specific conditions heavily on DCP1’s findings to conclude that specific with informed judgment to reach reasonable con- interventions against noncommunicable diseases clusions about the impact of intervention mixes were cost-effective, even in environments in which in diverse environments. DCP3’s broad aim is to substantial burdens of infection and undernutrition delineate essential intervention packages—such as persisted. the essential surgery package in this volume—and DCP2, published in 2006, updated and extended their related delivery platforms. This information DCP1 in several respects, including explicit con- will assist decision makers in allocating often tightly sideration of the implications for health systems constrained budgets so that health system objectives of expanded intervention coverage (Jamison and are maximally achieved. others 2006). One way that health systems expand DCP3’s nine volumes are being published in 2015 intervention coverage is through selected plat- and 2016 in an environment in which serious forms that deliver interventions that require sim- discussion continues about quantifying the sustain- ilar logistics but address heterogeneous health able development goal (SDG) for health (United problems. Platforms often provide a more natural Nations 2015). DCP3’s analyses are well-placed to unit for investment than do individual inter- assist in choosing the means to attain the health ventions, and conventional health economics SDG and assessing the related costs. Only when has offered little understanding of how to make these volumes, and the analytic efforts on which they choices across platforms. Analysis of the costs are based, are completed will we be able to explore of packages and platforms—and of the health SDG-related and other broad policy conclusions improvements they can generate in given epidemi- and generalizations. The final DCP3 volume will ological environments—can help guide health report those conclusions. Each individual volume system investments and development. will provide valuable specific policy analyses on the The third edition of DCP is being completed. DCP3 full range of interventions, packages, and policies differs substantively from DCP1 and DCP2 by relevant to its health topic. extending and consolidating the concepts of plat- forms and packages and by offering explicit con- Dean T. Jamison sideration of the financial risk protection objective Rachel Nugent of health systems. In populations lacking access to Hellen Gelband health insurance or prepaid care, medical expenses Susan Horton that are high relative to income can be impoverish- Prabhat Jha ing. Where incomes are low, seemingly inexpensive Ramanan Laxminarayan Essential Surgery: Key Messages of This Volume 3 However, treatments for some conditions, for example, KEY MESSAGES cataract extraction, are primarily provided at higher level or specialized facilities. Table 1.1 lists the procedures that This chapter synthesizes the main results of the we define to be essential; this chapter addresses those individual chapters of Essential Surgery to provide conditions listed. We acknowledge that the list is not broad directions for policy. The key messages deriving exhaustive, and other procedures might be considered as from our analysis are summarized and explained in essential. For many countries, though, table 1.1 will pro- the following sections and concern five categories of vide a reasonable starting point for an essential surgical results: the surgically avertable disease burden, cost- package, although there will be country-specific varia- effectiveness and economics, improving access, improv- tions. Safe anesthesia and perioperative care are necessary ing quality, and essential surgery in the context of components of all of these procedures. universal health coverage (UHC). Table 1.1 The Essential Surgery Package: Procedures and Platformsa,b Platform for delivery of procedurec Community facility and primary health Second- and third-level Type of procedure center First-level hospital hospitals Dental procedures 1. Extraction 2. Drainage of dental abscess 3. Treatment for cariesd Obstetric, gynecologic, and 4. Normal delivery 1. Cesarean birth 1. Repair obstetric fistula family planning 2. Vacuum extraction/forceps delivery 3. Ectopic pregnancy 4. Manual vacuum aspiration and dilation and curettage 5. Tubal ligation 6. Vasectomy 7. Hysterectomy for uterine rupture or intractable postpartum hemorrhage 8. Visual inspection with acetic acid and cryotherapy for precancerous cervical lesions General surgical 5. Drainage of 9. Repair of perforations: for example, perforated superficial abscess peptic ulcer, typhoid ileal perforation 6. Male circumcision 10. Appendectomy 11. Bowel obstruction 12. Colostomy 13. Gallbladder disease, including emergency surgery 14. Hernia, including incarceration 15. Hydrocelectomy 16. Relief of urinary obstruction: catheterization or suprapubic cystostomy table continues next page 4 Essential Surgery Table 1.1 The Essential Surgery Package: Procedures and Platformsa,b (continued) Platform for delivery of procedurec Community facility and primary health Second- and third-level Type of procedure center First-level hospital hospitals Injurye 7. Resuscitation with 17. Resuscitation with advanced life support basic life support measures, including surgical airway measures 8. Suturing laceration 18. Tube thoracostomy (chest drain) 9. Management of non- 19. Trauma laparotomyf displaced fractures 20. Fracture reduction 21. Irrigation and debridement of open fractures 22. Placement of external fixator; use of traction 23. Escharotomy/fasciotomy (cutting of constricting tissue to relieve pressure from swelling) 24. Trauma-related amputations 25. Skin grafting 26. Burr hole Congenital 2. Repair of cleft lip and palate 3. Repair of club foot 4. Shunt for hydrocephalus 5. Repair of anorectal malformations and Hirschsprung’s Disease Visual impairment 6. Cataract extraction and insertion of intraocular lens 7. Eyelid surgery for trachoma Nontrauma orthopedic 27. Drainage of septic arthritis 28. Debridement of osteomyelitis Sources: This list of essential surgical procedures is based on the authors’ judgment in light of the burden, implementation feasibility, and cost-effectiveness information contained in DCP3 volume 1, Essential Surgery. Earlier assessments of essential surgical interventions also provide useful information (WHO 2015b; Luboga and others 2009; Mock and others 2004, 2010). a. Red type implies emergency procedure or condition. b. All procedures listed in this table are discussed in DCP3, volume 1, Essential Surgery, with three exceptions, which will be covered in other DCP3 volumes: male circumcision, visual inspection and treatment of precancerous cervical lesions, and eyelid surgery for ocular trachoma. c. All of the procedures listed under community health and primary health centers are also frequently provided at first-level and second-level hospitals. All of the procedures under first-level hospitals are also frequently provided at second-level hospitals. The column in which a procedure is listed is the lowest level of the health system in which it would usually be provided. Not included in the table are prehospital interventions, such as first aid, basic life support procedures, or advanced life support procedures done in the prehospital setting. Health systems in different countries are structured differently, and what might be suitable at the various levels of facilities will differ. In this table, community facility implies primarily outpatient capabilities (as would be used to provide the elective procedures such as dental care), whereas primary health center implies a facility with overnight beds and 24-hour staff (as would be needed for procedures such as normal delivery). First-level hospitals imply fairly well-developed surgical capabilities with doctors with surgical expertise; otherwise, many of the procedures would need to be carried out at higher-level facilities. Referral and specialized hospitals (which could also be considered as second- and third-level hospitals) imply facilities that have advanced or subspecialized expertise for treatment of one or more surgical conditions, not usually found at lower-level facilities. d. Treatment for caries can include one or more of the following, depending on local capabilities: silver diamine fluoride application, atraumatic restoration, or fillings. e. Trauma care includes a wide variety of procedures. Not included in the list of essential procedures would be procedures that are more applicable at higher-level facilities: repair of vascular injury, open reduction and internal fixation, drainage of intracranial hematoma other than through burr hole, or exploration of neck or chest. f. Trauma laparotomy applicable at first-level hospitals: exploratory laparotomy for hemoperitoneum, pneumoperitoneum, or bowel injury; specific procedures include splenectomy, splenic repair, packing of hepatic injury, and repair of bowel perforation. Essential Surgery: Key Messages of This Volume 5 Disease Burden Avertable by Essential Surgery conditions often treated by surgery, such as cancer and The conditions treated at least in part by the proce- vascular disease. dures in table 1.1 account for 4.7 million deaths (nearly Obtaining more accurate estimates of the avertable 10 percent of all deaths) in LMICs (table 1.2). This burden from surgically treatable conditions will require figure is likely to be an underestimate; the burden of broad agreement on a definition of the concept of several common surgical conditions listed in table 1.1, avertable burden and the methods for its measurement. for example, bowel obstruction or gallbladder disease, The steps taken in Essential Surgery should be regarded are not estimated as distinct entities in the WHO Global as preliminary. Better estimates of the avertable bur- Health Estimates and hence not included in table 1.2. den will require more systematic data gathering from With UCES in LMICs, 1.5 million deaths per year could hospitals and population-based surveys on the signifi- be averted (table 1.3), representing 6.5 percent of all cant proportion of the world’s people who lack access avertable deaths in LMICs. to surgical care. Such a survey recently conducted in In comparison, DCP2 estimated that 11 percent Sierra Leone indicated that 25 percent of deaths might of the total global burden of death and disability have been prevented with timely surgical care (Groen was from conditions that were very likely to require and others 2012). Similar studies need to be repeated surgery (Debas and others 2006; Laxminarayan and more widely. In addition to individual research studies, others 2006). The current estimates are based on the international community could contribute to devel- a more rigorous estimation method and a more oping and promoting metrics for ongoing monitoring narrowly defined subset of essential surgical condi- of the burden of essential surgical conditions, as is tions (figure 1.1) that excludes other highly prevalent currently done for maternal mortality. Table 1.2 Total Burden of Conditions Addressed by Essential Surgery, Low- and-Middle-Income Countries, 2011 Category Deaths (thousands) DALYS (thousands) Category 1. Communicable, maternal, perinatal, and nutritional Maternal conditions 280 19,000 Birth asphyxia and birth trauma 780 78,000 Category 2. Noncommunicable diseases Cataracts <1 7,000 Peptic ulcer disease 230 7,000 Appendicitis 38 2,000 a Skin diseases 90 16,000 Cleft lip and palate 5 < 1,000 Oral conditionsb <1 13,000 c Category 3. Injuries Road traffic crash 1,160 72,000 Other unintentional injuries 1,550 96,000 Intentional injuries 540 34,000 Burden from these conditions 4,700 340,000 Total burden from all causes 45,000 2,400,000 Share of burden due to conditions addressable by essential surgery (percent) 10.4 14.2 Source: Data are from WHO 2014. Note: DALYs = disability-adjusted life years. a. Skin diseases include abscess and cellulitis. b. Oral conditions include caries, periodontal disease, and edentulism. c . Other unintentional injury includes falls, fires (and heat and hot substances), and exposure to forces of nature; it excludes drowning and poisoning. Intentional injury includes violence and collective violence or legal intervention; it excludes self-harm. 6 Essential Surgery Table 1.3 Disease Burden Avertable by Essential Surgery, Low- and Middle-Income Countries, 2011 Deaths (thousands) DALYs (thousands) 1. Total burdena 45,000 2,400,000 b 2. Total avertable burden 23,000 1,300,000 c 3. Burden from conditions addressable by essential surgery 4,700 340,000 4. Burden avertable by essential surgeryd 1,500 87,000 5. Burden avertable by essential surgery as a % of total burden [(4) ÷ (1)] 3.3% 3.6% 6. Burden avertable by essential surgery as a % of avertable burden [(4) ÷ (2)] 6.5% 6.6% Note: DALYs = disability-adjusted life years. a. Total disease burden from all causes in low- and middle-income countries (WHO 2014). b. Total avertable burden: number of deaths and DALYs that would be averted if all-cause, age-adjusted rates of death and disability in high-income countries pertained in low- and middle-income countries (WHO 2014). c. From table 1.2. d. From Bickler and others 2015. The burden avertable from essential conditions reported in this table is adjusted downward from what is estimated in the chapter; this chapter does not categorize as essential the surgery to address congenital cardiac disease or neural tube defects, while the burden from those conditions is included in the chapter estimates. Furthermore, the total and avertable burden estimates in rows 1 and 2 of this table are slightly higher than those underlying the data in the chapter. This leads to the percentages reported in rows 5 and 6 being very slight underestimates. Economic Evaluation of Essential Surgery Figure 1.1 Deaths, Avertable Deaths, and Surgically Avertable Deaths in Low- and Middle-Income Countries, 2011 Surgical Procedures. At the time of DCP2, a small number of cost-effectiveness analyses had found specific surgical procedures to be very cost-effective. Since then, T the literature has expanded and consistently documented that many of the essential surgical services identified in this chapter rank among health care’s most cost-effective A interventions (figure 1.2). A few examples, all context- specific, include cleft lip repair (US$10–US$110 per disability adjusted life year [DALY] averted), inguinal hernia repair (US$10–US$100 per DALY averted), cata- S2 ract surgery (US$50 per DALY averted), and emergency cesarean section (US$15–US$380 per DALY averted). Many of the widely disseminated public health mea- S1 sures are of similar cost-effectiveness or are not as cost- effective: of vitamin A supplementation (US$10 per DALY averted), oral rehydration solution (more than US$1,000 per DALY averted), and antiretroviral therapy for HIV/ AIDS (US$900 per DALY averted) (Chao and others 2014; Grimes and others 2014). Note: T= total deaths (45 million); A = avertable deaths (23 million); S2 = surgically avertable deaths Benefit-cost analyses have shown similar findings. (estimate not available); S1 = deaths avertable by essential surgery (1.5 million). An analysis of the benefits from cleft lip repair looked Definitions at the costs needed to run a specialized cleft clinic 1. S1 = 2011 deaths in low- and middle-income countries (LMICs) that would have been averted by the universal coverage of essential surgery (UCES). in India and the resulting health benefits, to which a 2. ( S1 / T ) × 100 = percentage of total deaths in 2011 in LMICs that would have been averted by UCES. monetary benefit was ascribed. Cleft surgery had a 3. ( S1 / A ) × 100 = percentage of avertable deaths in 2011 in LMICs that would have been averted by cost of approximately US$300 per DALY averted and UCES. a benefit-cost ratio (BCR) of 12 (Alkire, Vincent, and Meara 2015). These findings put cleft repair within the others 2013). The BCR for cleft surgery is also very BCR range for the key investment priorities for disease high in the range of BCRs across different development control established by the Copenhagen Consensus, an sectors. Box 1.2 provides an overview of approaches organization that asks experts to rank global health to economic evaluation of surgical procedures and an and development interventions (Jamison, Jha, and overview of findings. Essential Surgery: Key Messages of This Volume 7 Figure 1.2 Cost-Effectiveness of Surgical Interventions and national ownership. Specialized hospitals, including those providing surgery for cataract and obstetric fistula, Orthopedic surgery trip appear to be among the most cost-effective of the competing options for specialized platforms (Shrime, Trauma center Sleemi, and Ravilla 2015). Such specialized hospitals Cesarean delivery would be most sustainable if they develop strong Hydrocephalus repair links with local practitioners living and working in that country to promote training and to ensure appropri- Trachoma surgery ate postsurgical care, and if they eventually evolve to Cleft lip and palate repair be led by these local professionals. Since most essen- tial procedures undertaken in specialized hospitals are Hernia repair elective rather than urgent, patients can be scheduled Surgical hospital to achieve high volumes, contain costs, and improve Cataract surgery technical quality. Many people with surgical conditions, especially Obstetric hospital trauma, die in prehospital settings. For example, one study found that 81 percent of trauma deaths were Y LY Y LY AL AL in prehospital settings in Kumasi, Ghana (Mock and DA DA /D /D 0/ 0/ $1 00 others 1998). Most prehospital deaths occur in areas of $1 ,00 $1 $1 Cost/DALY (2012 US$) LMICs where formal emergency medical services are Range rudimentary or absent. Improving the first aid skills of lay first responders can cost less than US$10 per year of Source: Data from Prinja and others 2015. Note: DALY = disability-adjusted life year. This figure summarizes the cost-effectiveness of surgical life gained, making it one of the most cost-effective of all interventions in low- and middle-income countries according to available literature. health interventions. Similarly, basic ambulance services can cost less than US$300 per year of life gained, which is still highly cost-effective (Thind and others 2015). Surgical Platforms. The cost-effectiveness of certain platforms or facility types for providing surgical care Cost of Universal Access. Jamison and colleagues esti- also needs to be considered. Essential Surgery includes a mate that it would cost approximately US$3 billion chapter on CEA (Prinja and others 2015). Basic essential annually to scale up delivery of the component of the procedures are likely to be cost-effective when deliv- essential surgery package shown in table 1.1 that is appli- ered at any level of the health care system. However, cable to first-level hospitals, so that this package would the first-level hospital has been found to be especially be available universally (Jamison, Jha, and others 2013). cost-effective as a surgical delivery platform, with costs This expenditure would have a BCR of 10:1, which is of US$10–US$220 per DALY averted for all surgical broadly consistent with the BCR of other surgical proce- care delivered, across a wide range of LMICs (Gosselin dures as described by Alkire, Vincent, and Meara (2015). and Heitto 2008; Gosselin, Maldonado, and Elder 2010; Gosselin, Thind, and Bellardinelli 2006; McCord and Chowdhury 2003). Most surgery in first-level hospitals Improving Access is emergency surgery. Therefore, health systems need Challenges. The significant avertable burden from to disperse surgical facilities widely in the population, surgical conditions is directly related to the low capac- and surgical teams working in first-level hospital should ity for surgical care in many LMICs, as reflected in the have a broad array of basic emergency skills rather than numbers of surgical procedures performed globally a narrow range of specialized skills. (map 1.1). Most operations (60 percent) take place in Our analysis also considered a range of other surgi- wealthier countries where 15 percent of the world’s cal platforms. Short-term surgical missions by outside people live. Only 3.5 percent of operations take place surgeons appear beneficial only if no other option is in the poorer countries where 35 percent of the world’s available; otherwise, suboptimal outcomes, unfavorable people live (Weiser and others 2008). cost-effectiveness, and lack of sustainability limit their Across 23 LMICs, the ratio of general surgeons per usefulness. Self-contained mobile platforms, such as population ranges from 0.13 to 1.57 per 100,000; the ratio hospital ships, appear to offer good outcomes for peo- of anesthesiologists per population ranges from 0 to 4.9 per ple who can reach them, but there are no data on their 100,000 (Hoyler and others 2014). In contrast, the United cost-effectiveness and obvious limitations for scale-up States has 9 general surgeons and 11.4 anesthesiologists 8 Essential Surgery Box 1.2 Economic Evaluation of Investments in Surgery Economic evaluations aim to inform decision mak- cost (benefit-cost analysis or BCA). BCA enables ing by quantifying the tradeoffs between resource health investments to be compared with invest- inputs required for alternative investments and ments in other sectors. resulting outcomes. Four approaches to economic evaluation in health are particularly salient: CEAs predominate among economic evaluations in surgery and for health interventions more generally. Three recent overviews of CEA findings for surgery • Assessing how much of a specific health out- (one in chapter 18 of this volume) underpin this chap- come, for example, HIV infections averted, can be ter’s conclusion that many essential surgical procedures attained for a given level of resource input. are highly cost-effective even in resource-constrained • Assessing how much of an aggregate measure of environments (Grimes and others 2014; Chao and health—such as deaths or disability or quality others 2014; Prinja and others 2015). This volume’s adjusted life years (DALYs or QALYs)—can be chapter 18 looks as well at the cost-effectiveness of attained from a given level of resource inputs the first-level hospital surgical platform. applied to alternative interventions. This cost- effectiveness analysis (CEA) approach enables the The Lancet Commission on Investing in Health attractiveness of interventions addressing many applied BCA to broad investments in health and different health outcomes to be compared, for found B:C ratios often in excess of 10 (Jamison, example, tuberculosis treatment versus cesarean Summers, and others 2013). This volume contains section. BCA evaluations of selected surgical procedures • Assessing how much health and financial risk reporting similarly high BCAs (Alkire, Vincent, and protection can be attained for a given level of Meara 2015). Earlier, the Copenhagen Consensus public sector finance of a given intervention. This for 2012 used BCA to rank “strengthening surgical approach, extended cost-effectiveness analysis capacity” as number 8 in a list of 30 attractive (ECEA), enables the assessment not only of effi- priorities for investment in development across all ciency in improving the health of a population sectors (Jamison, Jha, and others 2013; Kydland and but also of efficiency in achieving the other major others 2013). goal of a health system, that is, protecting the ECEAs remain a relatively new evaluation population from financial risk. approach. This volume’s chapter 19 applies ECEA • Assessing the economic benefits, measured in to surgical intervention in Ethiopia and finds monetary terms, from investment in a health substantial financial protection benefits (Shrime intervention, and weighing that benefit against its and others 2015). per 100,000 (Stewart and others 2014). Striking differ- these WHO guidelines and tools have shown the consis- ences also exist in the ratio of operating theaters per pop- tent absence of many low-cost pieces of equipment and ulation across countries at different economic levels: 25 supplies, such as chest tubes, oxygen, and equipment for per 100,000 in Eastern Europe, 14–15 in North America airway management and anesthesia, in many locations, and Western Europe, 4–14 in Latin America and the but especially in LICs and at first-level hospitals. In some Caribbean, 4.7 in East Asia, but only 1.3 in South Asia, and cases, items are physically present but nonfunctional, 1–1.2 in Sub-Saharan Africa (Funk and others 2010). such as equipment awaiting repairs. Often, equipment is Two related WHO efforts have defined optimal infra- functional, but it is only available to those who can pay, structure needs for first-level hospitals for surgical care sometimes in advance; many of those who need the ser- in general (the Programme for Emergency and Essential vices are unable to access them (Belle and others 2010; Surgical Care [WHO 2015a]), and for trauma care at all Kushner and others 2010; Mock and others 2004, 2006; levels of the health care system (the Essential Trauma Ologunde and others 2014; Vo and others 2012; WHO Care Project [WHO 2015b]). Surveys conducted using 2003; WHO 2015a; WHO 2015b). Essential Surgery: Key Messages of This Volume 9 Map 1.1 Number of Surgical Procedures per 100,000 Population, 2004 50–499 500–1,499 1,500–4,999 5,000–9,999 Over 10,000 No data Operations were defined as procedures performed in operating theaters that require general or regional anesthesia, or profound sedation to control pain.The map groups countries by number of surgical procedures per 100,000 in the population, based on data from Weiser, T. G., S. E. Regenbogen, K. D. Thompson, A. B. Haynes, S. R. Lipsitz, W. R. Berry, and A. A. Gawande. 2008. "An Estimation of the Global Volume of Surgery: A Modelling Strategy Based on Available Data." The Lancet 372 (9633): 139-44. doi: 10.1016/S0140-6736(08)60878-8. This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. IBRD 41376 | FEBRUARY 2015 Approaches to Improve Access. Some institutions In Mozambique and Tanzania, NPCs perform about and health systems have successfully overcome these 90 percent of major emergency obstetric surgery in rural barriers. For example, the Hanoi Health Department areas where most of the population live (Bergström and steadily improved its physical resources for trauma care others 2015). Challenges continue for many countries, in its network of clinics and hospitals. Such improve- including physicians’ acceptance of NPCs, as well as ments have been stimulated in part by research defining of standardizing their training, supervision, regula- substantial gaps in availability of low-cost items recom- tory mechanisms, continuing skills improvement, and mended in the WHO’s Guidelines for Essential Trauma remuneration and nonfinancial incentives. The long- Care and by advocacy to remedy those gaps (Nguyen range goal is expanding the number of fully trained and Mock 2006). There have also been improvements surgeons. However, general practitioners and NPCs, in the availability of human resources for surgical care. with appropriate support from surgeons, can be an For example, the establishment of the Ghana College important intermediate solution to the problem of of Physicians and Surgeons in 2003 created the first access to basic surgery. in-country credentialing process for surgeons and led Many essential physical resources, such as equip- to an expansion of the workforce of fully trained gen- ment and supplies, are low cost and could be better eral surgeons and obstetricians. As of June 2014, 284 supplied through improved planning and logistics. The specialist surgeons and obstetrician-gynecologists had availability of some of the more expensive items, such graduated from the college and been posted to first- as x-ray machines and ventilators, would be improved and second-level hospitals throughout the country to by research on product development. Such research serve as both providers and trainers. should address improved durability, lower cost of It will likely be impossible to expand access to both purchasing and operating, and increased ease essential surgical services in rural areas of LMICs in of operation. Similarly, the availability of many items the foreseeable future by depending only on fully cer- could be improved by increased capabilities for local tified surgeons and anesthesiologists. Innovative solu- manufacture (WHO 2012). However, international tions to the surgical workforce crisis are imperative. assistance for provision of basic essential equipment Evidence shows that mid-level operators can safely and supplies will be needed for the immediate future perform a number of essential surgical procedures, for the poorest countries. An often overlooked ingredi- provided they are properly trained and supervised and ent is the need to ensure local capacity to maintain and perform the operations frequently (McCord and oth- repair equipment. ers 2009; Pereira and others 2011). In some locations, Population, policy, and implementation research these operators are general practitioners. In other cases, (PPIR) could contribute by identifying more efficient they are nonphysician clinicians (NPCs), such as técnicos and lower-cost delivery methods. The WHO has made de cirurgia (TCs) in Mozambique or assistant medical significant contributions by establishing norms for officers (AMOs) in Tanzania. human and physical resources for surgical and trauma Outcomes such as maternal and neonatal mortality care and by documenting success stories of individual rates after cesarean section and other emergency countries (Mock and others 2004; WHO 2010; WHO obstetric procedures were similar for AMOs, compared 2015b); this is a role for the WHO and other stakeholders with doctors in Tanzania (McCord and others 2009; that should be expanded. Pereira and others 2011). Although cost studies are few, Surgical training has traditionally emphasized deci- preliminary evidence shows the cost-effectiveness of sion making and operative technique for individual task-sharing. For example, in Mozambique, it was three patient care; this is appropriate, given the clinical role times more cost-effective to train and deploy TCs than to that most surgeons play. However, those surgeons who train and deploy physicians to provide obstetric surgery; wish to address the systems-level barriers to achieving the 30-year cost per major operation was US$40 for UCES will need additional skills in management and TCs and US$140 for physicians (Kruk and others 2007). supervision of health care systems, quality improvement Similarly, emergency obstetric care provided by general (QI), and public health. practitioners was found to be more cost-effective than A considerable additional barrier to access to surgical that provided by fully trained obstetricians in Burkina care is financial, especially in situations in which user Faso (Hounton and others 2009). fees are high or where out-of-pocket payments are NPCs are more likely than physicians to stay in under- required. The cost of surgical care is also a significant served rural areas, and they are less likely to emigrate, contributor to medical impoverishment (Schecter and so their deployment significantly increases the avail- Adhikari 2015). Including UCES within universal public ability of surgical services in underserved rural areas. finance would remove financial barriers to access to 12 Essential Surgery essential surgical care and would offer financial risk pro- inpatient complications by 35 percent, from 11 percent tection, as discussed in the conclusions of this chapter. to 7 percent. The checklist improved outcomes in HICs and upper-middle-income countries (UMICs), LMICs, LICs, and in elective and emergency cases. Improving the Safety and Quality of Anesthesia and The safety of anesthesia in HICs has been achieved by Surgery adopting standards of care, such as the continuous pres- Surgical care in all settings is fraught with hazards, ence of a trained anesthesia provider and uninterrupted including risks from the diseases themselves, the oper- monitoring of oxygenation, ventilation, and perfusion ation, and the anesthesia. These hazards translate into (Eichhorn and others 1986). Anesthesia delivery sys- dramatically different risks of death and other compli- tems have been better standardized, with safety features cations in different settings. For example, compared with engineered into the machines. One critical technology Sweden’s rate of 0.04 deaths per 1,000 cesarean sections, is pulse oximetry, an essential standard in HICs, which mortality is at least 2–4 times higher in Latin America allows ongoing monitoring of oxygenation status so and the Caribbean, 6–10 times higher in South Asia, and that problems can be corrected early, before they lead to 100 times higher in Sub-Saharan Africa (Hogberg 1989; serious or lethal consequences. In one study in Moldova, Weiser and Gawande 2015). the introduction of a surgical safety checklist and pulse A large component of the differences in postopera- oximetry led to a significant drop in the number of tive mortality is due to differences in anesthesia-related hypoxic episodes and in the complication rate (Kwok mortality. Major advances have occurred in anesthesia and others 2013). A barrier to pulse oximetry availability safety in high-income countries (HICs), primarily due has been its cost, although a concerted global effort is to improved monitoring and increased standardiza- underway to lower these costs and increase its availabil- tion and professionalization. In wealthier countries ity in LMICs. With lower-cost options now available, the (those with higher scores on the human development cost-effectiveness of introducing pulse oximetry appears index), mortality per million anesthetics has decreased very favorable (Burn and others 2014). from 357 deaths per million anesthetics before 1970 to Improved monitoring and evaluation of surgical 25 deaths per million anesthetics in the 1990s–2000s, but care across institutions, such as through QI programs, high rates of anesthetic deaths remain prevalent in most help to better inform administration and management. LMICs. Deaths solely attributable to anesthesia are esti- QI programs range from very simple outcome assess- mated to occur at a rate of 141 deaths per million anes- ments, such as morbidity and mortality conferences, thetics in poorer countries, that is, those with lower score to more complex monitoring, such as surveillance of on the human development index, in comparison with complications and use of risk-adjusted mortality. Many the noted 25 deaths per million anesthetics in wealthier hospitals in LMICs have some type of basic QI activities. countries (Bainbridge and others 2012). The effectiveness of these activities could be increased by Many of the deaths and complications from surgery simple measures, such as more systematic recording of in LMICs are potentially preventable with three specific proceedings, more purposeful enactment of corrective affordable and sustainable improvements: action, and monitoring of the outcome of corrective action. A WHO review of QI programs for trauma • Use of a surgical safety checklist care shows that most programs led to improvements • Improved monitoring and related safety practices in patient outcomes, including mortality, or process of during anesthesia care; many also reported cost savings (Juillard and others • Improved systems-wide monitoring and evaluation 2009). Although most of the programs were in HICs, of surgical care overall. two were in Thailand, an upper-middle-income country, where a model QI program led to sustained improve- The use of the simple, 19-item WHO Surgical Safety ments in both process of care and mortality rates. Checklist across eight countries was found to dou- Despite their effectiveness, simplicity, and affordability, ble adherence to basic perioperative safety standards QI programs are at a rudimentary level of development (Haynes and others 2009; WHO 2008a), such as con- and implementation in most LMICs (Juillard and others firmation of the procedure and operative site, objective 2009; Mock and others 2006). airway assessment, and completion of instrument and An important role for the international community sponge counts at the end of the procedure. Use of the is to support PPIR that (1) addresses affordable and checklist reduced deaths by 47 percent (the postop- sustainable methods to improve quality of care and erative death rate fell from 1.5 percent before intro- (2) documents and disseminates specific case studies of duction of the checklist to 0.8 percent afterward) and sustaining good practices. The WHO has already made Essential Surgery: Key Messages of This Volume 13 significant contributions by establishing norms, such as of the population. The shading in figure 1.3 depicts the Surgical Safety Checklist (WHO 2008a). This role of this situation, which we have termed UCES. UCES governments, the WHO, and other stakeholders needs to should appear early on the pathway to UHC (Jamison, be expanded, by establishing and promoting standards Summers, and others 2013). for safer, lower-cost anesthesia machines, and norms for Other surgical conditions and procedures merit con- monitoring and evaluation procedures for surgical care. sideration, such as those for cancer; vascular disease; and Definition and tracking of a variety of quality indica- conditions requiring more advanced treatments, such as tors, such as the perioperative mortality rate needs to be transplantation. Improving access to these procedures better globally (McQueen 2013; Weiser and others 2009). will also provide benefits. With regard to sequencing and use of public funds, efforts to ensure greater access to the essential services should be undertaken first, relative to Surgery: A Core Component of Universal Health increased investment in those conditions that are more Coverage expensive to treat or that have smaller health impacts. Our results point to the potential for essential surgery to cost-effectively address a large burden of disease. Moreover, there are several viable short- and longer-term CONCLUSIONS options for improving access to and safety and quality of There is a high burden of avertable death and disability surgical care. Figure 1.3 illustrates alternative uses for from conditions that can be successfully treated by sur- incremental resources in light of these findings. A coun- gery. Many of the surgical procedures and capabilities try’s situation today could be portrayed as a point in needed to treat these conditions are among the most cost- the cube: its position on dimension Q depicts the cur- effective of all health interventions and most in demand rent average quality of care. Its position on dimension from the population. These include procedures to treat A reflects the proportion of the population with access injuries, obstetric complications, abdominal emergencies, to care, and its position on dimension R reflects the cataracts, obstetric fistula, and congenital anomalies. range of services available. Investment choice requires Many of the most needed procedures are affordable and assessment of whether to put incremental money into feasible to deliver, but improving their coverage and qual- improving access, improving average quality, or increas- ity will require a focused effort to strengthen the health ing the range of services to be offered. Our interpretation system, particularly at first-level hospitals. of the results presented is that it will generally prove both With the exception of obstetric care, the global health equitable and efficient to achieve full access to essential community has largely failed to address the unmet need surgery at high quality before committing public resources for surgery. The surgical community, in turn, has not to expanding the range of services for a smaller percentage tackled the broader requirements for incorporating surgery into resource-constrained health systems—with the important exceptions of exploring task-sharing and Figure 1.3 Dimensions of Universal Coverage of Essential Surgery improving quality of care. Ensuring access to essential surgical services for every- Universal surgical coverage (USC) one who needs them, when they need them, is in part about improving training in safe surgical care and tech- nique, and in part about improving the functioning of health systems, including better monitoring and evalua- Universal coverage tion, developing appropriate financing mechanisms, and Complete of essential promoting equity, social justice, and human rights. The surgery (UCES) global system can play an important role in these efforts Range of through informed leadership and advocacy, support for services PPIR, and financial transfers to LICs to assist in attaining covered, R UCES. Universal Improved access to essential surgery should be imple- Minimal Access, A mented early in the path to UHC as part of the overall Minimal essential benefit package advocated by the Commission Low High on Investing in Health (Jamison, Summers, and others Quality, Q 2013). Implementation would include measures such as Note: Access is defined as the extent to which services are available to the population—geographically, using public funds to ensure access to essential surgery socially, and financially, for example, with low or zero out-of-pocket payment at the point of service. and including essential surgery in the packages covered 14 Essential Surgery by national health insurance schemes. Such measures Kelly McQueen, John G. Meara, Nyengo Mkandawire, would also offer financial risk protection against medical Mark A. Morgan, Mulu Muleta Bedane, Arindam Nandi, impoverishment from the costs of surgical care. Surgery Richard Niederman, Emilia V. Noormahomed, Florian should be considered an indispensable component of a R. Nuevo, Eyitope Ogunbodede, Michael Ohene-Yeboah, properly functioning health system and can indeed be Andrew Ottaway, Doruk Ozgediz, Caetano Pereira, Mary a means for strengthening the entire system, thereby Lake Polan, N. Venkatesh Prajna, Raymond R. Price, increasing the return on investment (Jamison, Summers, Shankar Prinja, Thulasiraj D. Ravilla, Eduardo Romero and others 2013; WHO 2008b). Investments to provide Hicks, Sarah Russell, William P. Schecter, Nicole Sitkin, and maintain equipment and to ensure a steady flow of Ambereen Sleemi, David Spiegel, Mark G. Shrime, Sathish supplies required for a functioning surgical service can Srinivasan, Andy Stergachis, Amardeep Thind, Stéphane strengthen the supply chain for an entire facility. Verguet, Jeffrey R. Vincent, Michael Vlassoff, Johan von The nascent literature in this area also suggests pos- Schreeb, Theo Vos, Thomas G. Weiser, Iain H. Wilson, and itive spillovers between surgical investments and the Ahmed Zakariah. functioning of and demand for health care. For exam- ple, upgrading facilities to provide surgery improved the confidence of providers in their facility and in their NOTE own clinical skills in Uganda (Kruk, Rabkin, and others World Bank Income Classifications as of July 2014 are as 2014). Several studies show that availability of surgical follows, based on estimates of gross national income (GNI) services increased demand for health care in potentially per capita for 2013: high-risk conditions, such as labor and delivery or emer- gency care (Kruk, Hermosilla, and others 2014; Yaffee • Low-income countries (LICs) = US$1,045 or less and others 2012). • Middle-income countries (MICs) are subdivided: Commitments by national governments and the • lower-middle-income = US$1,046 to US$4,125 international community to UCES would substantially • upper-middle-income (UMICs) = US$4,126 to US$12,745 reduce the mortality and suffering from treatable sur- • High-income countries (HICs) = US$12,746 or more. gical conditions. Such commitments would also protect populations from financial risk and contribute to the development of the broader health system. REFERENCES Alkire, Blake, Jeffrey Vincent, and John Meara. 2015. “Benefit- Cost Analysis for Selected Surgical Interventions in Low ACKNOWLEDGMENTS and Middle Income Countries.” In Disease Control Priorities The Bill & Melinda Gates Foundation provides finan- (third edition): Volume 1, Essential Surgery, edited by cial support for the Disease Control Priorities Network H. T. Debas, P. Donkor, A. Gawande, D. T. Jamison, project, of which this volume is a part. The following M. E. Kruk, and C. N. Mock. Washington, DC: World Bank. individuals provided valuable comments and assistance Bainbridge, D., J. Martin, M. Arango, D. Cheng, and Evidence- based Peri-operative Clinical Outcomes Research on this chapter: Elizabeth Brouwer, Rachel Cox, Anna (EPiCOR) Group. 2012. “Perioperative and Anaesthetic- Dare, Sarah Greenberg, Andrew Leather, Rachel Nugent, Related Mortality in Developed and Developing Countries: Zachary Olson, and Gavin Yamey. A Systematic Review and Meta-Analysis.” The Lancet Members of the DCP3 Essential Surgery Author 380 (9847): 1075–81. Group wrote the chapters on which this initial chapter Bellagio Essential Surgery Group. 2014. http://essentialsurgery draws. The Group includes Richard M. K. Adanu, Sweta .org/bellagio/. Adhikari, Asa Ahimbisibwe, Blake C. Alkire, Joseph Belle, J., H. Cohen, N. Shindo, M. Lim, A. Velazquez-Berumen, B. Babigumira, Jan J. Barendregt, Jessica H. Beard, and others. 2010. “Influenza Preparedness in Low-Resource Staffan Bergström, Stephen W. Bickler, David Chang, Settings: A Look at Oxygen Delivery in 12 African Countries.” Anthony Charles, Meena Cherian, Thomas Coonan, Journal of Infection in Developing Countries 4: 419–24. Dawit Desalegn, Catherine R. deVries, Delanyo Dovlo, Bergström, S., B. McPake, C. Pereira, and D. Dovlo. 2015. “Workforce Innovations to Expand the Capacity for Surgical Richard P. Dutton, Mike English, Diana Farmer, Magda Services.” In Disease Control Priorities (third edition): Feres, Zipporah Gathuya, Richard A. Gosselin, Hideki Volume 1, Essential Surgery, edited by H. T. Debas, P. Donkor, Higashi, Susan Horton, Renee Hsia, Kjell Arne Johansson, A. Gawande, D. T. Jamison, M. E. Kruk, and C. N. Mock. Clark T. Johnson, Timothy R. B. Johnson, Manjul Washington, DC: World Bank. Joshipura, Nicholas J. Kassebaum, Ramanan Laxmi- Bickler, S., T. Weiser, N. Kassebaum, H. Higashi, D. Chang, narayan, Carol Levin, Katrine Lofberg, Svjetlana Lozo, and others. 2015. “Global Burden of Surgical Conditions.” Jackie Mabweijano, Colin McCord, Barbara McPake, In Disease Control Priorities (third edition): Volume 1, Essential Surgery: Key Messages of This Volume 15 Essential Surgery, edited by H. T. Debas, P. Donkor, Hoyler, M., S. R. Finlayson, C. D. McClain, J. G. Meara, and A. Gawande, D. T. Jamison, M. E. Kruk, and C. N. Mock. L. Hagander. 2014. “Shortage of Doctors, Shortage of Data: Washington, DC: World Bank. A Review of the Global Surgery, Obstetrics, and Anesthesia Burn, S., P. Chilton, A. Gawande, and R. Lilford. 2014. “Peri- Workforce Literature.” World Journal of Surgery 38: 269–80. Operative Pulse Oximetry in Low-Income Countries: Jamison, D. T. 2015. “Disease Control Priorities, 3rd A Cost–Effectiveness Analysis.” Bulletin of the World Health edition: Improving Health and Reducing Poverty.” Organization 14: 137315. The Lancet. February 5. http://dx.doi.org/10.1016 Chao, T. E., K. Sharma, M. Mandigo, L. Hagander, S. C. Resch, /S0140-6736(15)60097-6. and others. 2014. “Cost-Effectiveness of Surgery and Its Jamison, D. T., J. G. Breman, A. R. Measham, G. Alleyne, Policy Implications for Global Health: A Systematic Review M. Claeson, and others. 2006. Disease Control Priorities In and Analysis.” The Lancet Global Health 2: e334–45. Developing Countries, second edition. Washington, DC: Debas, H. T., R. Gosselin, C. McCord, and A. Thind. 2006. Oxford University Press and World Bank. “Surgery.” In Disease Control Priorities in Developing Jamison, D. T., P. Jha, R. Laxminarayan, and T. Ord. 2013. Countries, (second edition): edited by D. T. Jamison, “Infectious Disease, Injury, and Reproductive Health.” In J. Breman, A. Measham, G. Alleyne, M. Claeson, D. B. Evans, Global Problems, Smart Solutions: Costs and Benefits, edited P. Jha, A. Mills, and P. Musgrove, 1245–60. Washington, DC: by Bjørn Lomborg. Cambridge, UK: Cambridge University Oxford University Press and World Bank. Press for Copenhagen Consensus Center. Eichhorn, J. H., J. B. Cooper, D. J. Cullen, W. R. Maier, Jamison, D. T., W. Mosley, A. R. Measham, and J. Bobadilla. J. H. Philip, and others. 1986. “Standards for Patient 1993. Disease Control Priorities in Developing Countries. Monitoring During Anesthesia at Harvard Medical School.” 1st ed. New York: Oxford University Press. Journal of the American Medical Association 256: 1017–20. Jamison, D. T., L. H. Summers, G. Alleyne, K. J. Arrow, Farmer, P. E., and J. Y. Kim. 2008. “Surgery and Global Health: S. Berkley, and others. 2013. “Global Health 2035: A World A View from Beyond the OR.” World Journal of Surgery Converging within a Generation.” The Lancet 382 (9908): 32 (4): 533–36. 1898–955. Funk, L. M., T. G. Weiser, W. R. Berry, S. R. Lipsitz, A. F. Merry, Javitt, J. C. 1993. “The Cost-Effectiveness of Restoring Sight.” and others. 2010. “Global Operating Theatre Distribution Archives of Ophthalmology 111 (12): 1615. and Pulse Oximetry Supply: An Estimation from Reported Juillard, C., C. Mock, J. Goosen, M. Joshipura, and I. Civil. Data.” The Lancet 376: 1055–61. 2009. “Establishing the Evidence Base for Trauma Quality Gosselin, R., and M. Heitto. 2008. “Cost-Effectiveness of Improvement Programs: A Collaborative WHO-IATSIC a District Trauma Hospital in Battambang, Cambodia.” Review.” World Journal of Surgery 33: 1075–86. World Journal of Surgery 32: 2450–53. Kruk, M. E., S. Hermosilla, E. Larson, and G. M. Mbaruku. Gosselin, R., A. Maldonado, and G. Elder. 2010. “Comparative 2014. “Bypassing Primary Clinics for Childbirth: A Cross- Cost-Effectiveness Analysis of Two MSF Surgical Trauma Sectional Study in the Pwani Region, United Republic Centers.” World Journal of Surgery 34: 415–19. of Tanzania.” Bulletin of the World Health Organization Gosselin, R., A. Thind, and A. Bellardinelli. 2006. “Cost/DALY 92: 246–53. Averted in a Small Hospital in Sierra Leone: What Is the Kruk, M. E., C. Pereira, F. Vaz, S. Bergstrom, and S. Galea. Relative Contribution of Different Services?” World Journal 2007. “Economic Evaluation of Surgically Trained Assistant of Surgery 30: 505–11. Medical Officers in Performing Major Obstetric Surgery in Grimes, C. E., J. A. Henry, J. Maraka, N. C. Mkandawire, Mozambique.” BJOG 114: 1253–60. and M. Cotton. 2014. “Cost-Effectiveness of Surgery in Kruk, M. E., M. Rabkin, K. A. Grépin, K. Austin-Evelyn, Low- and Middle-Income Countries: A Systematic Review.” D. Greeson, and others. 2014. “‘Big Push’ to Reduce World Journal of Surgery 38: 252–63. Maternal Mortality in Uganda and Zambia Enhanced Groen, R. S., M. Samai, K. A. Stewart, L. D. Cassidy, T. B. Kamara, Health Systems but Lacked a Sustainability Plan.” Health and others. 2012. “Untreated Surgical Conditions in Affairs (Millwood) 33: 1058–66. Sierra Leone: A Cluster Randomised, Cross-Sectional, Kushner, A., M. N. Cherian, L. Noel, D. A. Spiegel, S. Groth, and Countrywide Survey.” The Lancet 380 (9847): 1082–87. others. 2010. “Addressing the Millennium Development Haynes, A. B., T. G. Weiser, W. R. Berry, S. R. Lipsitz, Goals from a Surgical Perspective: Essential Surgery and A. H. Breizat, and others. 2009. “A Surgical Safety Checklist Anesthesia in 8 Low- and Middle-Income Countries.” to Reduce Morbidity and Mortality in a Global Population.” Archives of Surgery 145: 154–59. New England Journal of Medicine 360: 491–99. Kwok, A. C., L. M. Funk, R. Baltaga, S. R. Lipsitz, Hogberg, U. 1989. “Maternal Deaths Related to Cesarean A. F. Merry, and others. 2013. “Implementation of the Section in Sweden, 1951–1980.” Acta Obstetricia et World Health Organization Surgical Safety Checklist, Gynecologica Scandinavica 68: 351–57. Including Introduction of Pulse Oximetry, in a Resource- Hounton, H., D. Newlands, N. Meda, and V. Brouwere. Limited Setting.” Annals of Surgery 257: 633–39. 2009. “A Cost-Effectiveness Study of Caesarean-Section Kydland, F. E., R. Mundell, T. Schelling, V. Smith, and N. Stokey. Deliveries by Clinical Officers, General Practitioners and 2013. “Expert Panel Ranking.” In Global Problems, Smart Obstetricians in Burkina Faso.” Human Resources for Solutions: Costs and Benefits, edited by B. Lomborg, 701–16. Health 7: 34. Cambridge, UK: Cambridge University Press. 16 Essential Surgery Laxminarayan, R., A. J. Mills, J. G. Breman, A. R. Measham, A. Gawande, D. T. Jamison, M. E. Kruk, and C. N. Mock. G. Alleyne, and others. 2006. “Advancement of Global Washington, DC: World Bank. Health: Key Messages from the Disease Control Priorities Rose, J., D. Chang, T. Weiser, N. Kassebaum, and S. Bickler. Project.” The Lancet 367 (9517): 1193–208. 2014. “The Role of Surgery in Global Health: Analysis Luboga, S., S. B. Macfarlane, J. von Schreeb, M. E. Kruk, of United States Inpatient Procedure Frequency by M. N. Cherian, and others. 2009. “Increasing Access to Condition Using the Global Burden of Disease 2010 Surgical Services in Sub-Saharan Africa: Priorities for Framework.” PLoS One 9 (2): e89693. doi:10.1371/jour- National and International Agencies Recommended by nal.pone.0089693. the Bellagio Essential Surgery Group.” PLoS Med 6 (12): Schecter, W. P., and S. Adhikari. 2015. “Global Surgery and e1000200. Poverty.” In Disease Control Priorities (third edition): McCord, C., and Q. Chowdhury. 2003. “A Cost Effective Small Volume 1, Essential Surgery, edited by H. T. Debas, Hospital in Bangladesh: What It Can Mean for Emergency P. Donkor, A. Gawande, D. T. Jamison, M. E. Kruk, and Obstetric Care.” International Journal of Gynecology and C. N. Mock. Washington, DC: World Bank. Obstetrics 81: 83–92. Shrime, M., A. Sleemi, and T. Ravilla. 2015. “Specialized McCord, C., G. Mbaruku, C. Pereira, C. Nzabuhakwa, and Surgical Platforms.” In Disease Control Priorities (third S. Bergstrom. 2009. “The Quality of Emergency Obstetrical edition): Volume 1, Essential Surgery, edited by H. T. Debas, Surgery by Assistant Medical Officers in Tanzanian District P. Donkkor, A. Gawande, D. T. Jamison, M. E. Kruk, and Hospitals.” Health Affairs (Millwood) 28: w876–85. C. N. Mock. Washington, DC: World Bank. McQueen, K. A. 2013. “Editorial Perspective: Global Surgery: Shrime, M., S. Verguet, K. A. Johansson, D. Desalegne, Measuring the Impact.” World Journal of Surgery 37: D. T. Jamison, and others. 2015. “Task-Sharing or Public 2505–06. Finance for the Expansion of Surgical Access in Rural Mock, C. N., M. Cherian, C. Juillard, P. Donkor, S. Bickler, Ethiopia: An Extended Cost-Effectiveness Analysis.” and others. 2010. “Developing Priorities for Addressing In Disease Control Priorities (third edition): Volume 1, Surgical Conditions Globally: Furthering the Link between Essential Surgery, edited by H. A. Debas, P. Donkor, Surgery and Public Health Policy.” World Journal of Surgery A. Gawande, D. T. Jamison, M. E. Kruk, and C. N. Mock. 34: 381–85. Washington, DC: World Bank. Mock, C. N., G. J. Jurkovich, D. nii-Amon-Kotei, C. Arreola- Stewart, B., P. Khanduri, C. McCord, M. Ohene-Yeboah, Risa, and R. V. Maier. 1998. “Trauma Mortality Patterns in S. Uranues, and others. 2014. “Global Disease Burden of Three Nations at Different Economic Levels: Implications Conditions Requiring Emergency Surgery.” British Journal for Global Trauma System Development.” Journal of of Surgery 101 (1): e9–22. Trauma 44: 804–12. Thind, A., R. Hsia, J. Mabweijano, E. Romero Hicks, A. Zakariah, Mock, C. N., J. D. Lormand, J. Goosen, M. Joshipura, and and C. N. Mock. 2015. “Prehospital and Emergency Care.” M. Peden. 2004. Guidelines for Essential Trauma Care. In Disease Control Priorities (third edition), Volume 1, Geneva: WHO. Essential Surgery, edited by H. T. Debas, P. Donkor, Mock, C. N., S. Nguyen, R. Quansah, C. Arreola-Risa, R. Viradia, A. Gawande, D. T. Jamison, M. E. Kruk, and C. N. Mock. and M. Joshipura. 2006. “Evaluation of Trauma Care Washington, DC: World Bank. Capabilities in Four Countries using the WHO-IATSIC United Nations. 2015. “Sustainable Development Goals.” Guidelines for Essential Trauma Care.” World Journal of http://sustainabledevelopment.un.org/?menu=1300. Surgery 30: 946–56. Verguet, S., R. Laxminarayan, and D. T. Jamison. 2015. Nguyen, S., and C. N. Mock. 2006. “Improvements in Trauma “Universal Public Finance of Tuberculosis Treatment In Care Capabilities in Vietnam through Use of the WHO- India: An Extended Cost-Effectiveness Analysis.” Health IATSIC Guidelines for Essential Trauma Care.” Injury Economics 24 (3): 318–32. Control and Safety Promotion 13 (2): 125–72. Vo, D., M. Cherian, S. Bianchi, L. Noel, G. Lundeg, and others. Ologunde, R., J. P. Vogel, M. N. Cherian, M. Sbaiti, M. Merialdi, 2012. “Anesthesia Capacity in 22 Low- and Middle-Income and others. 2014. “Assessment of Cesarean Delivery Countries.” Journal of Anesthesia and Clinical Research Availability in 26 Low- and Middle-Income Countries: 3: 207. doi:10.4172/2155-6148.1000207. http://omicsonline A Cross-Sectional Study.” American Journal of Obstetrics .org/2155-6148/2155-6148-3-207.pdf. and Gynecology 211 (5): 504. ajog.2014.05.022. Electronic Weiser, T., and A. Gawande. 2015. “Excess Surgical Mortality: publication ahead of print. Strategies for Improving Quality of Care.” In Disease Pereira, C., G. Mbaruku, C. Nzabuhakwa, S. Bergstrom, and Control Priorities (third edition): Volume 1, Essential C. McCord. 2011. “Emergency Obstetric Surgery by Non- Surgery, edited by H. T. Debas, A. Gawande, D. T. Jamison, Physician Clinicians in Tanzania.” International Journal of M. E. Kruk, and C. N. Mock. Washington, DC: World Bank. Gynecology and Obstetrics 114: 180–83. Weiser, T. G., M. A. Makary, A. B. Haynes, G. Dziekan, W. R. Berry, Prinja, S., A. Nandi, S. Horton, C. Levin, and R. Laxminarayan. and others, for the Safe Surgery Saves Lives Measurement 2015. “Costs, Effectiveness, and Cost-Effectiveness of and Study Groups. 2009. “Standardised Metrics for Global Selected Surgical Procedures and Platforms: A Summary.” Surgical Surveillance.” The Lancet 374: 1113–17. In Disease Control Priorities (third edition): Volume 1, Weiser, T. G., S. E. Regenbogen, K. D. Thompson, A. B. Haynes, Essential Surgery, edited by H. T. Debas, P. Donkor, S. R. Lipsitz, and others. 2008. “An Estimation of the Essential Surgery: Key Messages of This Volume 17 Global Volume of Surgery: A Modelling Strategy Based on ———. 2012. Local Production and Technology Transfer to Available Data.” The Lancet 372 (9633): 139–44. Increase Access to Medical Devices. Geneva: WHO. http:// WHO (World Health Organization). 2003. Surgical Care at the www.int/medical_devices/1240EHT_final.pdf. District Hospital. Geneva: WHO. http://www.int/surgery ———. 2014. “Global Health Estimates (2011).” http://www /publications/scdh_manual/en. .who.int/healthinfo/global_burden_disease/en/. ———. 2008a. Surgical Safety Checklist and Implementation ———. 2015a. Essential Trauma Care Project, www.who.int// Manual [Internet]. Geneva: WHO. http://www.who violence_injury_prevention/services/traumacare/en/. .int /patientsafety/safesurgery/tools_resources/SSSL ———. 2015b. Global Initiative for Emergency and Essential _Checklist_finalJun08.pdf?ua=1. Surgical Care, http://www.who.int/surgery/en/. ———. 2008b.World Health Report 2008: Primary Health Care: Yaffee, A. Q., L.Whiteside, R. A. Oteng, P. M. Carter, P. Donkor, Now More Than Ever. Geneva: WHO. and others. 2012. “Bypassing Proximal Health Care Facilities ———. 2010. Strengthening Care for the Injured: Success for Acute Care: A Survey of Patients in a Ghanaian Accident Stories and Lessons Learned from around the World. Geneva: and Emergency Centre.” Tropical Medicine & International WHO. & International Health 17: 775–81. 18 Essential Surgery Chapter 2 Global Burden of Surgical Conditions Stephen W. Bickler, Thomas G. Weiser, Nicholas Kassebaum, Hideki Higashi, David C. Chang, Jan J. Barendregt, Emilia V. Noormahomed, and Theo Vos INTRODUCTION In this chapter, we explore surgery’s multifaceted contribution to global public health. We begin by pro- Approximately 2 billion people lack access to emergency viding an overview of the public health dimensions of and essential surgical care (Funk and others 2010). Most surgical care in LMICs and examine the current chal- of the need is in rural and marginalized populations lenges of making a comprehensive assessment of the living in low- and-middle-income countries (LMICs), global burden of surgical diseases. Next, we estimate where the poorest one-third of the world’s population the public health impact in LMICs if basic and selected receives only 3.5 percent of all surgical procedures subspecialty surgical care could be scaled up to meet (Weiser and others 2008). The lack of surgical care takes standards that currently exist in high-income countries a serious human and economic toll and can lead to (HICs). Finally, we attempt to define where surgical care acute, life-threatening complications. In other instances, fits among other global health priorities and discuss poor-quality care results in chronic disabilities that make areas toward which future research should be focused. productive employment impossible and impose a bur- Our analysis uses the 21 epidemiology regions from the den on family members and society. Global Burden of Diseases, Injuries, and Risk Factors The failure to appreciate the role of surgery in Study 2010. addressing important public health problems is the main cause of disparities in surgical care worldwide. Yet, surgically treatable conditions—such as obstructed ROLE OF SURGERY IN GLOBAL HEALTH labor (Alkire and others 2012; Ndour and others 2013); injuries (Abdur-Rahman, van As, and Rode 2012; Mock Public Health Dimensions and others 2012); intra-abdominal emergencies (Stewart In the second edition of Disease Control Priorities in and others 2014); correctable congenital anomalies, Developing Countries, Debas, McCord, and Thind (2006) such as clubfoot and cleft lip or palate (Mossey and describe four types of surgical interventions that have a Modell 2012; Wu, Poenaru, and Poley 2013); symptom- public health dimension: atic hernias (Beard and others 2013); cataracts (Rao, Khanna, and Payal 2011); osteomyelitis (Bickler and • The provision of competent, initial surgical care to Rode 2002; Stanley and others 2010); and otitis media injury victims to reduce preventable deaths, as well (Monasta and others 2012)—contribute to premature as to decrease the number of survivable injuries that deaths or ill health of populations. result in disability Corresponding author: Stephen W. Bickler, Rady Children’s Hospital and University of California, San Diego, MD, DTM&H, FACS, sbickler@ucsd.edu 19 • The handling of obstetrical complications, such as to 15 percent of pregnancies will require emergency obstructed labor and hemorrhage obstetrical care (Gibbons and others 2010). The expe- • The timely and competent surgical management of rience with controlling HIV infection in LMICs is par- a variety of abdominal and extra-abdominal emer- ticularly germane because programs are most successful gency and life-threatening conditions when screening and prevention strategies are combined • The elective care of simple surgical conditions, such with treatment. Striking a balance between prevention as hernia, clubfoot, cataract, hydroceles, and otitis and clinical programs has proved to be especially chal- media lenging in LMICs, where there is fierce competition for limited resources. Nevertheless, clinical services must be Based on expert opinion, Debas, McCord, and Thind available if the health needs of a population are to be (2006) estimate that 11 percent of the global burden appropriately met. of disease measured in disability-adjusted life years (DALYs) could be treated with surgery. Their estimates range from 7 percent for Sub-Saharan Africa to as high CHALLENGES ESTIMATING A GLOBAL as 15 percent for Europe. Although based on incomplete BURDEN OF SURGICAL DISEASE information and a limited number of surgical proce- dures, the 11 percent estimate is one of the most widely The Global Burden of Diseases, Injuries, and Risk quoted figures in global surgery. Factors Study 2010 (known as GBD 2010) (Murray, Vos, Why surgically treatable conditions are not more and others 2012) reinforces use of the DALY as the pre- widely appreciated as a critical public health problem is ferred metric for determining the relative contribution an important question. Although the answer is complex, of disease categories to the overall burden of disease. it is in part related to the misconception that surgical The DALY is a summary measure of population health care is too costly. Surgical care can, in fact, be remark- that sums up fatal burden and nonfatal burden into ably cost-effective, even in comparison with nonsurgical a single index: years of life lost (YLLs) and years lived interventions that are commonly implemented as public with disability (YLDs). Because the GBD framework is health measures. For example, the cost of emergency increasingly used as a factor to inform resource alloca- obstetric care at a rural hospital in Bangladesh was tion in LMICs, it is extremely important that the impact estimated to be US$11 per DALY averted (McCord and of surgical care be estimated using the DALY metric, Chowdhury 2003). The same measurement for all surgi- if possible. Nevertheless, in the process of trying to cal care services provided by a hospital in Sierra Leone estimate a global burden of surgical disease, we encoun- was just US$33 per DALY averted (Gosselin, Thind, tered several challenges when analyzing surgical care and Bellardinelli 2006). These costs compare favorably using this metric. with many other primary interventions, such as vitamin A distribution (US$9 per DALY averted), acute lower respiratory infection detection and home treatment Challenge 1: Defining Surgical Care (US$20 per DALY averted), or measles immunization Confusion persists about what constitutes surgical care (US$30 per DALY averted) (Grimes and others 2014; and the role surgery should have in settings of limited Ozgediz and Riviello 2008). resources. Surgery is often defined as it relates to spe- cific procedures, but this definition fails to recognize the larger role that surgical care has in clinical practice. Importance of Preventive and Curative Services Our preferred surgical definitions are shown in box 2.1. During the past several decades, public health profes- In addition to the technical execution of an operation, sionals have come to understand that successful health surgical care encompasses the preoperative assessment care depends on both prevention and curative interven- of patients, including deciding whether to operate; intra- tion. Because prevention is rarely 100 percent effective, operative anesthetic management; and postoperative clinical services will always be needed. This principle care—all of which are major determinants of surgical applies to a broad spectrum of health care problems in outcomes. LMICs. Examples include malaria control programs, More important and frequently ignored is that sur- through which bed nets can reduce but not eliminate geons often provide nonoperative care to their patients. the need to treat symptomatic cases, as well as maternal Examples include the airway management of injured health programs, in which cesarean section must be an patients; the use of traction in extremity fractures; the available treatment option for cases of obstructed labor. care of most head injuries; and the nonoperative man- With respect to the latter, approximately 10 percent agement of the majority of blunt abdominal injuries, 20 Essential Surgery provide insight into operative rates in a well-resourced Box 2.1 health system. We compiled all International Classification of Surgical Terminology Diseases, Version 9 (ICD-9) codes from the NIS from 2010 and grouped the NIS primary diagnosis codes Surgically treatable condition: Any condition into GBD 2010 disease categories. The ICD-9 codes in which surgical care can potentially improve used in the GBD 2010 were extracted from table 4 of the outcome the Supplement material of the GBD 10 (annex 2A to this chapter; Lozano and others 2012). We determined the Surgical care: Operative and nonoperative fraction of admitted patients in each GBD cause category interventions directed at reducing the dis- who underwent an operation. Operation was defined as ability or premature death associated with a a surgical procedure performed in an operating room surgically treatable condition; surgical care on inpatients. This definition and corresponding ICD-9 includes the preoperative assessment of patients, procedure codes are standardized and publicly available intraoperative care including anesthesia, and through the Agency for Healthcare Research and Quality postoperative care (AHRQ 2008). The details of our analysis, along with Surgical procedure: The suturing, incision, the AHRQ list of surgical procedures, can be found in excision, or manipulation of tissue; or other annexes 2B and 2C. invasive procedure that usually requires local, In 2010, 10 million inpatient operations were per- regional, or general anesthesia formed in the United States and were associated with Surgical sequelae: Abnormalities that result 28.6 percent of all admissions. Operations were per- from a surgically treatable condition in the formed in every GBD 2010 cause subcategory (frequency absence of surgical care or sometimes as an prevalence ranged from 0.2 percent to 84.0 percent). The adverse event highest frequencies were in the subcategories of mus- culoskeletal (84.0 percent); neoplasm (61.4 percent); Surgical disability: Physical deficit associated and diabetes, urological, blood, and endocrine disease with a surgical sequela. (33.3 percent) (figure 2.1). The GBD 2010 frame- Source: Adapted from Bickler and others 2010. work captured 80.1 percent of inpatient operations; 19.9 percent of operations were performed on patients with a primary diagnosis not included in the GBD 2010 framework. The two most common missed ICD-9 codes were single live birth, both with and without cesarean for example, a spleen injury in a child. Although sur- section. With childbirth being a precarious process in gical care has an important role in the diagnosis and many settings, it illustrates that this important process is treatment of many diseases, it can also have a role in not captured in the GBD framework. prevention, as in the use of circumcision to prevent HIV Surgical care thus cuts across the entire spectrum infection. of GBD 2010 cause categories, calling into question dichotomous traditional classifications of surgical versus nonsurgical disease. There was no disease subcategory Challenge 2: Distinguishing between Surgical and that required an operation 100 percent of the time, nor Nonsurgical Conditions in the GBD 2010 Study was there any that never required an operation. The Efforts to estimate a global burden of surgical disease neoplasm subcategory is an excellent example. In our have been predicated on the idea that GBD causes study, 61.4 percent of patients admitted for treatment must be classified as either surgical or nonsurgical. To of a neoplasm diagnosis underwent a surgical proce- test this assertion, and to gain better insight into the dure. Certainly there is disagreement about whether to role of surgery in a high-functioning health system, classify all patients with a neoplasm as surgical patients. we queried the U. S. National Inpatient Sample (NIS)1 Yet surgical care plays an important role in the diagnosis to determine operative rates for each of the GBD 2010 (biopsy), treatment (resection), and supportive care disease and injury categories (Rose and others 2014). (chronic intravenous access) of patients with tumors. This database is the largest all-payer inpatient care data- Although operative rates vary by country, and our study base in the United States, containing data on more than could not evaluate specific indications or outcomes of 7 million hospital stays each year. This database cannot procedures, the findings illustrate the integrative nature be expected to represent what occurs globally, but it can of surgical care within a health system. Global Burden of Surgical Conditions 21 Figure 2.1 Chance of a Patient Admitted to the Hospital in a Well-Resourced Health System Requiring a Surgical Procedure in the Operating Room GBD 2010 Disease Categories Chance of requiring a procedure in the operating room (%) I. Communicable, Maternal, Neonatal, and Nutritional disorders HIV/AIDS and tuberculosis Diarrhea, lower respiratory infection, meningitis, and other common infectious diseases Neglected tropical diseases and malaria Maternal disorders Neonatal, disorders Nutritional deficiencies Other communicable, maternal, neonatal, and nutritional disorders II. Noncommunicable diseases Neoplasms Cardiovascular and circulatory diseases Chronic respiratory diseases Cirrhosis of the liver Digestive diseases (except cirrhosis) Neurological disorders Mental and behavioral disorders Diabetes, urogenital, blood, and endocrine diseases Musculoskeletal disorders Other noncommunicable diseases III. Injuries Transport injuries Unintentional injuries other than transport injuries Self-harm and interpersonal violence Forces of nature, war, and legal intervention 0 10 20 30 40 50 60 70 80 90 Source: Rose and others 2014, based on the National (Nationwide) Inpatient Sample (NIS), 2010, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, Rockville, MD, http://www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp. Challenge 3: Assigning DALYs Averted Values to Large heart anomalies. The AHRQ list used in the database Numbers of Surgical Procedures analysis includes ICD-9 procedure codes for more than Modern surgical care has an impressive armamentarium 2,500 major operations (annex 2C). To accurately cal- of surgical procedures—everything from the drainage culate DALYs averted by a given surgical procedure, of a simple abscess to the repair of complex congenital one must know the disability weight associated with a 22 Essential Surgery particular condition, the effectiveness of the operation in surgically treatable conditions. The 2012 Copenhagen reducing incidence and mortality, and its ability to affect Consensus reaffirmed the need to strengthen surgical duration or severity of the condition. The effectiveness capacity in the developing world, emphasizing that of an operation varies by the type of operation; resources very low-cost investments could be highly effective available to conduct the operation; operative skills of the (Copenhagen Consensus Center 2012). surgeon; capability and resources of anesthesia person- As funders and national policy makers consider the nel; and patient factors, such as nutritional status and expansion of health systems in LMICs, it is imperative other comorbidities. The large number of surgical pro- that they understand the potential impact that scaling cedures and the variability in operative outcomes make up basic surgical care deliverable at first-level hospitals a comprehensive calculation difficult, if not impossible. could have on population health. Strategy for Assessing the Public Health Impact of Methodology Surgical Care in LICs and MICs Our analysis assumes a basic surgical package with var- Given the complexities and inherent challenges of esti- ious therapeutic interventions that could be provided mating an accurate global burden of surgical disease, we at first-level hospitals. These conditions were selected adopted an alternative strategy for assessing the public based on recommendations and guidelines in the litera- health impact of surgical care in LMICs. Instead of try- ture (Mock and others 2010; WHO 2003); consultation ing to make a comprehensive assessment of all surgical with experts in global surgery; practicality in quanti- care, we focused our efforts on estimating the public fying health outcomes, for example, the existence of health impact of scaling up basic surgical care deliver- clear health outcomes corresponding to specific surgical able at first-level hospitals and selected subspecialty care. procedures; and a corresponding cause in GBD 2010. Our goal was to capture the most important surgical We examined the following: procedures that have the highest impact on improving public health. • Four digestive diseases: Appendicitis, paralytic ileus3 and intestinal obstruction, inguinal and femoral hernia, and gallbladder and bile duct disease BURDEN AVERTED BY SCALING UP BASIC • Four maternal-neonatal conditions: Maternal hem- SURGICAL CARE2 orrhage, obstructed labor, abortion, and neonatal encephalopathy Rationale • Injuries that could be treated with basic interventions: During the past decade, interest in building surgical Resuscitation, surgical airway, peripheral venous capacity at first-level hospitals in LMICs has increased. access, suturing, laceration and wound manage- The rationale for this strategy is that a large per- ment, chest tube or needle decompression, fracture centage of the world’s population receives emergency reduction, escharotomy, fasciotomy, skin grafting, care at first-level facilities. Moreover, many surgical trauma-related amputation, and trauma-related conditions—particularly obstetric emergencies, intra- laparotomy abdominal catastrophes, and life-threatening injuries— require that appropriate care be immediately available if To investigate which surgical procedures would be lives are to be saved. required to treat this group of surgical conditions, we In response to this challenge, the World Health searched Surgical Care for the District Hospital (WHO Organization (WHO) launched two complementary 2003) for procedures that corresponded to the GBD initiatives: the Emergency and Essential Surgical Care causes. Our review showed that almost 50 surgical (EESC) program in 2004 and the Global Initiative for procedures are required to treat these GBD causes, Emergency and Essential Surgical Care (GIEESC) in illustrating that a broad spectrum of procedures are 2005 (Abdullah, Troedsson, and Cherian 2011; Bickler required to treat even a limited list of surgical conditions and Spiegel 2010; Spiegel and others 2013). The goal of (annex 2D). the EESC project was the development and implemen- Our burden estimates were based on data from the tation of training materials to improve care for surgical GBD 2010 (Murray, Vos, and others 2012). Parameters conditions at first-level facilities in LMICs; the objective included population, standard life expectancy, cause- of the GIEESC project was to stimulate collaboration specific mortality, incidence, prevalence, and disabil- among governments, organizations, agencies, and insti- ity weights (Lozano and others 2012; Salomon and tutions involved in reducing death and disability from others 2012; Vos and others 2012). The parameters were Global Burden of Surgical Conditions 23 specific by cause, age, gender, region, and year. The GBD surgically avertable burden and surgically nonavertable 2010 groups countries into 21 epidemiological regions burden. The avertable burden was calculated as follows: (17 of which contain LMICs) and seven superregions (six of which contain LMICs) (table 2.1). Our analysis Avertable burden = DALY Current−DALYcf, (2.1) was conducted at the superregion level by aggregating regional-level parameters. in which DALY Currentdenotes the DALYs reported in GBD Our approach recognized that some conditions, such 2010, and DALYcf the estimated DALYs if the delivery as maternal hemorrhage and neonatal encephalopathy, of surgical care had existed in a counterfactual state in are not fully amenable to surgical care and required which the entire population had access to appropriate adjustments to limit the effect of surgery. Other GBD and safe surgical care appropriate for delivery at the causes (such as drowning, poisoning, self-harm, venom- first-level hospital. The counterfactual level equates to ous animal contact, and injuries not classified elsewhere) the outcome that is achievable across all segments of the were assumed to be not amenable to surgery. When health care system in HICs. questions on the proportions of conditions that could To determine the DALYcf quantity, we estimated be managed by surgical care arose, we referred to the YLLcf and YLDcf for the counterfactual state in separate literature and adjusted the avertable burden accordingly. steps. Such separation in estimating fatal and nonfatal Additional details on the adjustments to account for the burden is consistent with the approach used in generat- burden not amenable to surgical care can be found in ing the GBD 2010 estimates. annex 2E. We first estimated the number of deaths for the coun- The overall concept of the approach was to split the terfactual state in LMIC superregions with the following reported DALYs of surgical conditions in 2010 into equation: gender = Incidence age, gender × superregion superregion DEATHcf age, CFRcf age, gender , Table 2.1 GBD 2010 Epidemiological Regions and Groupings into LMIC Superregions (2.2) GBD 2010 epidemiological regions LMIC superregions superregion in which DEATHcf age , gender is the age- and gender- High-income 1. High-income Asia Pacific specific number of deaths for the counterfactual state superregion countries 2. Western Europe in each superregion, Incidence age , gender the age- and gender-specific number of incident cases from GBD 3. Australasia 2010 in each superregion, and CFRcfage, gender the age- 4. High-income North America and gender-specific case fatality rates for the counter- Low- and 5. Central Europe Eastern Europe and Central factual state. middle- 6. Eastern Europe Asia CFRcfage,gender values would ideally be informed by income complete data on coverage, access, quality, and effective- countries 7. Central Asia ness of surgical care in each region. Although such data 8. Southern Sub-Saharan Africa Sub-Saharan Africa exist for some LMICs and a subset of causes in our anal- 9. Eastern Sub-Saharan Africa ysis, it is very sparse (Choo and others 2010; Galukande 10. Central Sub-Saharan Africa and others 2010; Kushner and others 2010). 11. Western Sub-Saharan Africa We therefore assigned the lowest fatality rates among the 21 epidemiological regions for each age and gender 12. North Africa and Middle East Middle East and North Africa to be representative of CFRcfage, gender. In addition to 13. South Asia South Asia being consistent across conditions, we believe this value 14. Southeast Asia best reflects the situation of the counterfactual state 15. East Asia East Asia and Pacific in which diagnosis is reasonably prompt, treatment is available, and there is access to appropriate and safe 16. Oceania surgical care. Not surprisingly, the majority of lowest 17. Southern Latin America Latin America and the CFRs were from one of the HICs: high-income Asia 18. Tropical Latin America Caribbean Pacific, Western Europe, Australasia, and high-income 19. Central Latin America North America. superregion After calculating DEATHcf age , gender , we multiplied 20. Andean Latin America this quantity by the age-specific standard life expectancy 21. Caribbean used in GBD 2010 to estimate the fatal burden for the 24 Essential Surgery counterfactual state (Lozano and others 2012; Murray, scaled up to match the accessibility and quality of care Ezzati, and others 2012) using the following formula: provided in HICs—the counterfactual rate—either at first-level hospitals or at higher levels of care. gender = superregion superregion YLLcf age, Deathcf age, gender Because surgical care can never completely prevent × Standard life expectancy age, gender . (2.3) or reverse disability, we have also included an estimate of the nonavertable burden. The nonavertable burden refers to the fraction of the burden that is currently not The next step was to estimate the nonfatal burden preventable or reversible with surgical care. Perhaps (YLDcf) for the counterfactual state. Although scaling up the best examples of nonavertable burden occur in surgical coverage would reduce fatal burden (YLL), the injured patients for whom death and disability often averted deaths would still contribute to the nonfatal bur- occur even when the best possible surgical care is avail- den for a shorter—or sometimes longer—duration, as able. Two examples are an amputation for a severely estimated by YLDs. YLDs in GBD 2010 were calculated mangled extremity and a fatality from a severe head by multiplying the prevalent cases by disability weights injury before the patient arrives at the hospital. The that are unique to each health state. However, we did not outcomes are unavoidable and thus nonavertable with know the direct impact of reduced CFRs on prevalence. surgical care. For diseases that had a short duration, defined as less Some may question the value of including data on than one year, we calculated the YLDs for the counter- the nonavertable burden given that we have focused our factual state as follows: efforts on trying to define the role of surgery in reduc- ing death and disability. Nevertheless, we have included superregion YLDcf age ( , gender = Incidenceage , gender − Deathcf age , gender superregion superregion ) these data for two important reasons. First, nonavert- able does not necessarily imply a problem that cannot × Duration × DW , (2.4) be addressed: nonavertable burden can be reduced through nonsurgical means, for example, injury preven- superregion tion, improved delivery of care, or innovation. Second, in which YLDcf age , gender is the nonfatal burden in the without a complete accounting of total burden—the counterfactual state, Duration is the duration of disease avertable and nonavertable burden—it is impossible to calculated by dividing the prevalence by incidence, and appreciate the magnitude of the problem and the limita- DW the disability weight attached to each condition tions of surgical care. from the GBD 2010 study. For injury conditions with long-term sequelae that exceeded a year, we used a slightly different equation: Impact on Population Health Scaling up basic surgical care across all sectors of the , gender = Incidence age , gender superregion superregion YLDcf age health care system in LMICs could prevent 1.4 million (2.5) deaths and 77.2 million DALYs per year. The details of × YLD per incident case lowest from all regions age , gender . these preventable deaths and avertable DALYs, by super- region, are shown in tables 2.2 and 2.3. Overall, scaling The final step was to calculate the avertable bur- up surgical care to treat four gastrointestinal diseases, den, which was accomplished by summing the YLDcf four maternal-neonatal conditions, and injuries treated and YLLcf for each region and then subtracting the with simple interventions could prevent 3.2 and 3.5 total from the total DALYs estimate from GBD 2010, percent of all deaths and DALYs, respectively, that occur and aggregating the results to the superregion level. each year in LMICs. Additional details on how burden calculations were per- The majority of the preventable deaths were due to formed can be found in the four manuscripts included injuries (77 percent), followed by maternal-neonatal in annex 2F. conditions (14 percent) and digestive diseases (9 percent). Results were expressed as the number of deaths and Road injury (292,000 deaths per year) and falls (184,000 burden (DALYs) that would be averted per year by scal- deaths per year) were the two most common causes of ing up care for a group of surgically treatable conditions preventable death. In the maternal-neonatal category, in LMICs. This care would be appropriate for first-level neonatal encephalopathy was the leading cause of pre- hospitals and would include treatment for four digestive ventable death (166,000 deaths per year). The South Asia diseases, four maternal-fetal conditions, and injuries that and Sub-Saharan Africa superregions have the largest could be treated with basic interventions. Our estimates number of preventable deaths per year, 485,000 and are based on the assumption that surgical care could be 327,000 deaths, respectively. Global Burden of Surgical Conditions 25 Table 2.2 Estimated Number of Deaths per Year That Could Be Prevented If Basic Surgical Care Could Be Provided in LMICs Middle Latin Major Eastern Sub- East and East America category Europe and Saharan North South Asia and and the totals Surgical condition Central Asia Africa Africa Asia Pacific Caribbean LMIC total (percent) Digestive Appendicitis 1,773 14,248 1,035 1,712 3,905 3,614 26,286 145,292 diseases Gall bladder and bile duct 3,672 9,123 1,950 2,087 21,605 9,477 47,914 (9.0) disease Hernia 3,810 816 0 4,459 1,279 3,700 14,065 Paralytic ileus and bowel 938 17,637 4,622 23,360 4,525 5,945 57,027 obstruction Maternal- Maternal hemorrhage 63 10,228 703 6,147 2,424 478 20,042 233,658 neonatal Obstructed labor 8 2,248 59 8,284 255 28 10,882 (14.4) Abortion 333 16,756 364 15,179 3,440 862 36,935 Neonatal encephalopathy 1,475 62,271 2,477 91,286 5,871 2,420 165,800 Injuries Road injury 14,342 59,218 19,832 86,610 76,976 34,894 291,872 1,042,292 Other transport injury 405 3,618 633 3,325 2,220 715 10,916 (76.6) Falls 18,731 15,823 3,224 35,239 95,405 15,148 183,570 Drowning 0 0 0 0 0 0 0 Fire, heat, and hot 6,772 44,754 5,016 104,373 7,583 3,922 172,421 substances Poisoning 0 0 0 0 0 0 0 Exposure to mechanical 24,602 25,333 12,094 40,270 24,560 8,370 135,229 forces Adverse effects of 2,305 11,774 1,048 12,789 8,707 6,563 43,186 medical treatment Animal contact 0 0 0 0 0 0 0 (venomous) Animal contact 491 1,508 216 802 1,335 424 4,777 (nonvenomous) Unintentional injuries not 13,342 10,054 1,898 32,828 22,081 11,335 91,537 classified elsewhere Self-harm 0 0 0 0 0 0 0 Interpersonal violence 9,905 21,997 3,261 16,723 12,557 44,342 108,784 Exposure to forces of 0 0 0 0 0 0 0 nature Collective violence and 0 0 0 0 0 0 0 legal intervention Preventable deaths in LMICs 102,966 327,405 58,432 485,472 294,730 152,238 1,421,242 Total deaths in LMICs 4,861,515 8,291,833 2,109,258 12,537,748 12,649,687 3,623,093 44,073,134 Fraction of LMIC deaths (percent) 2.1 3.9 2.8 3.9 2.3 4.2 3.2 Note: LMIC = low- and middle-income countries. The basic surgical care would treat four gastrointestinal diseases, four maternal-fetal conditions, and injuries that require simple interventions. Estimates are based on the assumption that surgical care could be scaled up to match the accessibility and standard of care in high-income countries across all sectors of the health care system. 26 Essential Surgery Table 2.3 Estimated Number of DALYs per Year That Could Be Averted If Basic Surgical Care Could Be Provided in LMICs Eastern Middle Latin Major Europe and Sub- East and East America category Central Saharan North Asia and and the totals Surgical condition Asia Africa Africa South Asia Pacific Caribbean LMIC total (percent) Digestive Appendicitis 52,513 715,487 43,104 91,989 140,253 110,468 1,153,814 4,848,078 diseases Gall bladder and bile 74,813 327,655 48,675 104,648 447,519 188,670 1,191,981 (6.3) duct disease Hernia 68,822 37,015 0 119,929 24,260 75,281 325,308 Paralytic ileus and 50,726 663,486 164,888 975,976 175,431 146,468 2,176,975 bowel obstruction Maternal- Maternal haemorrhage 3,485 577,146 39,034 346,842 132,128 26,409 1,125,044 20,024,726 neonatal Obstructed labor 439 125,618 3,230 462,367 13,636 1,543 606,833 (25.9) Abortion 18,411 953,725 20,397 863,443 189,761 48,443 2,094,180 Neonatal 168,036 5,956,409 292,750 8,744,616 749,316 287,542 16,198,669 encephalopathy Injuries Road injury 779,308 3,507,638 1,093,122 4,692,999 4,336,877 1,691,314 16,101,257 52,316,946 Other transport injury 47,120 270,686 66,709 340,760 309,928 59,125 1,094,328 (67.8) Falls 772,809 934,208 346,824 2,031,692 3,902,220 524,038 8,511,792 Drowning 0 0 0 0 0 0 0 Fire, heat, and hot 270,469 3,010,660 291,629 5,559,069 403,174 173,684 9,708,685 substances Poisoning 0 0 0 0 0 0 0 Exposure to 371,523 721,882 285,019 1,422,803 394,083 147,054 3,342,364 mechanical forces Adverse effects of 97,135 689,029 80,351 688,719 395,255 221,024 2,171,513 medical treatment Animal contact 0 0 0 0 0 0 0 (venomous) Animal contact 15,857 99,707 12,394 49,961 59,451 15,136 252,507 (nonvenomous) Unintentional 557,481 740,551 164,376 1,616,624 1,262,528 560,301 4,901,861 injuries not classified elsewhere Self-harm 0 0 0 0 0 0 0 Interpersonal violence 461,613 1,378,702 206,024 1,043,360 761,912 2,381,028 6,232,639 Exposure to forces of 0 0 0 0 0 0 0 nature Collective violence 0 0 0 0 0 0 0 and legal intervention Avertable DALYs 3,810,561 20,709,604 3,158,526 29,155,798 13,697,732 6,657,528 77,189,749 Total DALYs in LMICs 160,209,494 574,216,660 122,217,565 679,620,290 525,029,717 169,976,643 2,231,270,369 Fraction of LMIC DALYs (percent) 2.4 3.6 2.6 4.3 2.6 3.9 3.5 Note: DALY = disability-adjusted life year; LMIC = low- and middle-income country. The basic surgical care would treat four gastrointestinal diseases, four maternal-fetal conditions, and injuries that require simple interventions. Estimates are based on the assumption that surgical care for these conditions could be scaled up to match the accessibility and standard of care in high-income countries across all sectors of the health care system. Global Burden of Surgical Conditions 27 Figure 2.2 Distribution of Burden Avertable by Scaling Up Basic Surgical proportion (83 percent). Paralytic ileus and intesti- Care Deliverable at First-Level Hospitals in Low- and Middle-Income nal obstruction accounted for the largest portion of Countries avertable burden among the four digestive diseases Percent (2.2 million DALYs per year; 64 percent avertable). The majority of the burden associated with the four Digestive diseases gastrointestinal diseases, four maternal-neonatal condi- 6 tions, and injuries analyzed cannot be averted by surgi- cal care (table 2.4). The nonavertable burden from the group (238.5 million DALYs per year; 10.7 percent of the GBD in LMICs) was 2.5 times greater than the bur- Maternal-neonatal den averted by the basic surgical package. The majority conditions (84 percent) of the total nonavertable burden was due 26 to injuries (200.4 million DALYs per year), followed by maternal-neonatal conditions (34.5 million DALYs per year). Figure 2.3 shows the nonavertable burden by LMIC superregion and its relationship to the avertable burden. South Asia had the largest number of nonavert- able DALYs (75.6 million DALYs per year), while the Latin American and the Caribbean superregion had the Injuries highest fraction of the total regional GBD (17.9 percent). 68 The latter reflects the devastating earthquake in Haiti in January 2010. Source: Data in table 2.3. Note: Percentages are based on a surgical package that could treat four gastrointestinal diseases, four maternal-neonatal conditions, and injuries that could be managed with simple interventions. BURDEN AVERTED BY SCALING UP SELECTED SUBSPECIALTY SURGICAL CARE Injuries also accounted for the largest fraction of avertable DALYs (figure 2.2). Road injury is the Rationale leading cause of injury-related avertable DALYs in Subspecialty surgical care refers to highly specialized LMICs (16.1 million DALYs per year) followed by procedures that require advanced technical skills and fire, heat, and hot substances (9.7 million DALYs per training. Although some third-level referral hospitals year) (table 2.3). Of the total injury burden in LMICs, in LMICs may provide surgical care for these condi- 21 percent is potentially avertable by providing basic tions, the advanced skills required for these proce- trauma care at first-level hospitals and higher levels dures have prevented them being incorporated into of care. Sub-Saharan Africa has the largest propor- the general health care system. Consequently, these tion of potentially avertable DALYs related to injuries conditions have often been managed by establishing (25 percent); South Asia the highest absolute number of vertical, single-procedure-based programs in LMICs, avertable DALYs (17.4 million per year). frequently supported by international funding and Of the burden associated with the maternal-neonatal surgical missions. Nevertheless, because these proce- conditions that we analyzed, 36 percent is potentially dures are relatively common, life changing, and often avertable by full coverage of quality obstetric sur- involve children, they offer a potentially large source of gery in LMICs (20.0 million DALYs). The South Asia avertable DALYs. superregion has the highest total number of avert- able maternal-neonatal DALYs (10.4 million). Neonatal encephalopathy comprises the largest portion of Methodology avertable burden among the five conditions analyzed, We examined five conditions: cataract, clefts (both lip followed by abortion (16.2 and 2.1 million DALYs, and palate), congenital heart anomalies, neural tube respectively). defects, and obstetric fistula. We selected these condi- Of the burden related to the four digestive diseases tions from the GBD 2010 cause list for which clearly (4.8 million DALYs per year), 65 percent is poten- corresponding and well-established surgical programs tially avertable with first-level surgical care in LMICs. exist. Similar to the analysis of surgical burden at first- Sub-Saharan Africa has the largest avertable burden in level hospitals, we obtained demographic and epidemio- absolute DALYs (1.7 million per year) and in avertable logical parameters from the GBD 2010. 28 Essential Surgery Table 2.4 Nonavertable Burden (DALYs) Associated with a Group of Conditions That Can Be Treated with Basic Surgical Care in LMICs Eastern Europe Middle Latin Major and Sub- East and East America category Central Saharan North Asia and and the totals Surgical condition Asia Africa Africa South Asia Pacific Caribbean LMIC total (percent) Digestive Appendicitis 19,536 40,564 21,724 60,541 91,505 30,921 264,791 2,569,667 diseases Gall bladder and bile 84,517 86,298 46,506 171,374 228,275 96,787 713,756 (1.1) duct disease Hernia 24,234 50,564 27,799 101,544 136,906 37,116 378,163 Paralytic ileus and 178,522 178,767 88,595 384,235 302,702 80,136 1,212,957 bowel obstruction Maternal- Maternal hemorrhage 9,551 1,049,909 76,887 701,056 263,167 49,947 2,150,516 35,484,201 neonatal Obstructed labor 100 7,962 1,700 23,261 2,495 1,106 36,624 (14.9) Abortion 4,769 3,068 3,528 5,153 13,647 3,354 33,520 Neonatal 1,439,805 9,159,407 1,345,063 12,856,954 6,364,307 2,098,006 33,263,541 encephalopathy Injuries Road injury 3,595,438 10,438,956 3,705,845 13,102,811 18,456,805 4,236,206 53,536,062 200,495,053 Other transport injury 506,046 863,473 391,651 993,914 1,253,312 334,767 4,343,163 (84.0) Falls 2,100,073 3,087,910 1,247,749 6,769,471 5,823,690 1,345,565 20,374,457 Drowning 1,280,302 3,241,397 699,575 7,152,853 5,518,534 1,234,016 19,126,677 Fire, heat, and hot 499,174 2,811,538 358,772 3,928,508 907,600 303,034 8,808,626 substances Poisoning 817,934 1,502,573 345,178 3,437,583 2,009,199 150,428 8,262,895 Exposure to mechanical 1,184,059 1,496,743 544,190 2,377,539 1,620,976 339,263 7,562,770 forces Adverse effects of 169,265 232,522 135,416 201,614 349,494 280,437 1,368,748 medical treatment Animal contact 41,796 923,985 55,456 1,403,954 179,762 103,217 2,708,170 (venomous) Animal contact 17,706 363,505 15,345 165,198 77,752 16,669 656,174 (nonvenomous) Unintentional injuries 1,332,066 2,079,247 649,305 3,462,963 3,581,777 942,741 12,048,099 not classified elsewhere Self-harm 3,792,899 2,175,157 735,231 14,721,081 8,472,490 1,775,160 31,672,018 Interpersonal violence 1,578,109 3,950,824 683,929 3,034,727 2,980,006 5,590,425 17,818,020 Exposure to forces of 0 5,519 0 0 0 11,373,271 11,378,790 nature Collective violence and 6,228 179,868 61,659 582,628 0 0 830,383 legal intervention Nonavertable DALYs 18,682,128 43,929,755 11,241,103 75,638,960 58,634,402 30,422,573 238,548,921 Total DALYs in LMICs 160,209,494 574,216,660 122,217,565 679,620,290 525,029,717 169,976,643 2,231,270,369 Fraction of LMIC DALYs (percent) 11.7 7.7 9.2 11.1 11.2 17.9 10.7 Note: DALY = disability-adjusted life year; LMIC = low- and middle-income countries. The group includes four digestive diseases, four maternal-fetal conditions, and injuries that can be treated with simple interventions. The nonavertable burden refers to the burden associated with a particular condition that is not preventable or reversible with surgical care. Global Burden of Surgical Conditions 29 Figure 2.3 Burden Associated with a Group of Conditions That Can Be by assuming that the difference in prevalence between a Treated with Basic Surgical Care in Low- and Middle-Income Countries particular age group and the age group immediately fol- lowing that in the high-income superregion reflects the 25 excess mortality for the counterfactual surgical coverage. Percent of total GBD in superregions Beginning with the birth prevalence that varies between 20 LMIC regions, we applied this assumption to age one year and above to follow the prevalence. The resulting 15 prevalence for each gender and age was then multiplied by the disability weights of each condition to derive the 10 YLDs. Next, we estimated the fatal burden attributable to congenital anomalies in the counterfactual situation. We 5 then estimated the YLLs and DALYs for the counterfac- tual state in the same manner as we did in our analysis 0 of basic surgical care in the previous section. Finally, the avertable burden was calculated using equation (2.1). ia a ca sia ific n ric ea As fri hA ac Af ibb A Because it is well known that persons with con- l dP tra ut n th ar ra So an en or dC ha genital anomalies, especially those without access to dN dC ia an Sa As an an b- ica treatment, are at risk for any number of other fatal Su st pe st er Ea Ea ro Am Eu le complications, such as malnutrition or pneumonia, we idd tin rn La ste M performed an additional analysis to more accurately Ea quantify the avertable burden of cleft lip and palate, Superregion congenital heart anomalies, and neural tube defects. Nonavertable Avertable This step was necessary because deaths and YLLs for Source: Data from tables 2.3 and 2.4. congenital anomalies reported in the GBD 2010 are Note: GBD = global burden of disease. The group includes four gastrointestinal diseases, four limited to only those deaths for which the underlying maternal-neonatal conditions, and injuries that can be managed with simple interventions. Results are cause is coded as being due to congenital conditions. expressed as the percentage of the total superregion global burden of disease. Furthermore, natural history modeling of the GBD 2010 data shows a sharp decline in the prevalence of The burden of obstetric fistula and cataract in the non-operated cases compared with those who received GBD 2010 comprised YLDs only. We estimated the bur- operations. The excess number of deaths compared den of fistula in the counterfactual state by adjusting the with the number predicted by the cause-code deaths successful closure rate of surgical repair with the risk of and YLLs clearly illustrate this excess mortality phe- residual urinary incontinence that may take over: nomenon. Accordingly, to avoid underestimating the potential impact of surgical care in treating congenital , gender = Prevalence age , gender × (1 − SuccessRate ) superregion superregion YLDcf age anomalies, we based our avertable DALY estimates on × DW fistula + SuccessRate × UIRate × DW urinary incontinence , the excess mortality related to all causes, not only the DALYs reported for a particular congenital anomaly in (2.6) the GBD study. Additional details on how these burden calculations were performed can be found in manu- in which SuccessRate is the successful closure rate and script B listed in annex 2F. UIRate the risk of urinary incontinence after surgery. The burden of cataract in its counterfactual state was calculated by assuming that the lowest age- and Impact on Population Health sex-specific YLD rates per capita reflect the counterfac- Scaling up selected subspecialty surgical care in LMICs tual situation: could prevent 388,000 deaths and avert 38.9 million DALYs per year. The details of these preventable deaths , gender × YLDRate age , gender superregion lowest from all regions Pop'n age , (2.7) and avertable DALYs, by superregion, are shown in table 2.5. This impact, although smaller than the total where Pop’n is the population in each superregion, and burden averted by scaling up basic surgical care, is still YLDRate the per capita YLD of cataract in each region. substantial and could increase the number of surgically For congenital anomalies, we first estimated the preventable deaths and DALYs by 27.3 and 50.4 percent, nonfatal burden if the counterfactual surgical coverage respectively. Overall, scaling up surgical care to treat could be provided in LMICs. This estimation was made cataract, cleft lip and palate, congenital heart anomalies, 30 Essential Surgery Table 2.5 Estimated Number of Preventable Deaths and Avertable, and Nonavertable DALYs Associated with Scaling Up Selected Subspecialty Surgical Care Eastern Europe Middle Latin and Sub- East and East America Fraction Central Saharan North Asia and and the of total Surgical condition Asia Africa Africa South Asia Pacific Caribbean LMIC total (percent) Preventable Cataract n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. deaths Cleft lip and palate 1,915 16,863 8,330 21,905 13,631 3,004 65,648 16.9 Congenital heart 4,844 89,231 21,742 99,414 32,905 8,045 256,180 66.0 anomalies Neural tube defects 500 18,162 5,395 39,934 1,736 619 66,346 17.1 Obstetric fistula n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. Total preventable 7,259 124,256 35,467 161,253 48,273 11,668 388,174 deaths Total deaths in 4,861,515 8,291,833 2,109,258 12,537,748 12,649,687 3,623,093 44,073,134 LMICs Fraction of LMIC 0.2 1.5 1.7 1.3 0.4 0.3 0.9 deaths (percent) Avertable Cataract 306,592 306,441 288,451 2,043,146 988,834 274,295 4,207,758 10.8 DALYs Cleft lip and palate 147,661 1,447,813 601,006 1,705,359 965,032 209,701 5,076,572 13.0 Congenital heart 442,648 7,726,243 1,898,098 8,938,691 2,893,186 697,631 22,596,497 58.1 anomalies Neural tube defects 46,399 1,602,477 495,807 3,669,764 175,503 57,880 6,047,830 15.5 Obstetric fistula 1,525 415,241 50,472 225,218 298,628 5,471 996,553 2.6 Total avertable 944,823 11,498,214 3,333,834 16,582,177 5,321,183 1,244,978 38,925,209 DALYs Total DALYs in 160,209,494 574,216,660 122,217,565 679,620,290 525,029,717 169,976,643 2,231,270,369 LMICs Fraction of LMIC 0.6 2.0 2.7 2.4 1.0 0.7 1.7 DALYs (percent) Nonavertable Cataract 69,600 41,459 31,647 115,320 222,271 49,772 530,068 1.1 DALYs Cleft lip and palate 54,930 250,262 75,040 311,746 232,878 54,035 978,889 2.1 Congenital heart 1,116,728 14,502,230 3,046,252 15,196,430 5,229,279 1,903,422 40,994,342 88.1 anomalies Neural tube defects 66,776 1,073,060 295,829 1,763,196 611,067 110,549 3,920,477 8.4 Obstetric fistula 191 51,998 6,320 28,202 37,395 685 124,791 0.3 Total nonavertable 1,308,225 15,919,009 3,455,087 17,414,894 6,332,890 2,118,463 46,548,568 DALYs Total DALYs in 160,209,494 574,216,660 122,217,565 679,620,290 525,029,717 169,976,643 2,231,270,369 LMICs Fraction of LMIC 0.8 2.8 2.8 2.6 1.2 1.2 2.1 DALYs (percent) Note: DALY = disability-adjusted life year; LMIC = low- and middle-income countries. Estimates are based on the assumption that care for cataract, cleft lip and palate, congenital heart anomalies, neural tube defects, and obstetric fistula could be scaled up to match the accessibility and standard of care in high-income countries. Estimates for cleft lip and palate, congenital heart anomalies, and neural tube defects account for the excess mortality due to any cause. n.a. = not applicable. Global Burden of Surgical Conditions 31 neural tube defects, and obstetric fistula could pre- 46 percent is avertable with surgical care, compared with vent 0.9 and 1.7 percent of all deaths and DALYs, respec- 24.1 percent of the burden related to the gastrointestinal tively, that occur each year in LMICs. diseases, maternal-neonatal conditions, and injuries we The largest number of preventable deaths occurred analyzed. An advantage of subspecialty surgical care is in the congenital heart anomalies category (66 percent), that it can be planned, is usually reproducible, and can followed by neural tube defects (17 percent). This find- be done on an elective basis. ing may underestimate the actual mortality because not all deaths are necessarily coded to these causes. Figure 2.4 shows the distribution of the burden that LIMITATIONS OF CURRENT ANALYSIS could be averted by scaling up advanced surgical treat- Our methodology relied on the assumption that the ment of cataract, cleft lip and palate, congenital heart lowest fatality and disability estimates for persons with anomalies, neural tube defects, and obstetric fistula. surgically treatable conditions from the 21 epidemiolog- These avertable DALY estimates, which include the ical regions reflect the case of full surgical coverage. The correction for the excess mortality due to other causes, estimates of impact of full coverage on disease burden shows that the majority of avertable burden would were from high-income regions, and whether these fig- result from scaling up surgical care to treat congenital ures are applicable to other settings is not clear. heart anomolies (58 percent) and neural tube defects Even if geographic and financial barriers to surgical (15 percent). The South Asia and Sub-Saharan Africa care are removed, health-seeking behavior may vary sub- superregions have the highest total number of avertable stantially among contexts. The nontrivial variations of DALYs per year, 16.6 million and 11.5 million, respec- fatality rates among HICs suggest that none of the health tively; the Eastern Europe and Central Asia superregion systems truly reflect the counterfactual state, although has the least (945,000 DALYs per year). differences in coding practices and data-gathering mech- The subspecialty surgical care we analyzed is better anisms may contribute to the variations. at addressing burden compared with basic surgical care In addition to full population coverage, the quality of provided at first-level hospitals. Of the burden associ- surgery and anesthesia is a critical precondition of this ated with cataract, cleft lip and palate, congenital heart analysis that, if compromised, could separately add to anomalies, neural tube defects, and obstetric fistula, excess mortality. We may also be overestimating the burden that could be averted with first-level surgical care because our Figure 2.4 Distribution of Burden That Could Be Averted by Scaling analysis is based on the lowest rates of case fatality and Up Selected Subspecialty Surgical Care in Low- and Middle-Income Countries disability in HICs. In HICs, the sickest patients are often Percent transferred to higher levels of care where they benefit from advanced care provided in intensive care units— Obstetric this higher level of care is often not available in LICs, Cataract fistula resulting in higher fatality rates. 11 3 Furthermore, the parameters for our analysis are pri- marily from the GBD 2010. This is a major advantage in Cleft lip that our results are thus directly comparable with those and palate from the GBD 2010, but it also implies that our analysis 13 is fully prone to the GBD 2010’s limitations. Finally, we did not attempt to make any estimates of uncertainty. Uncertainty estimates are reported in the GBD 2010, but to propagate these estimates through to our analysis did not seem practical given that we needed to make numerous assumptions to arrive at our results. Congenital heart Neural tube anomalies WHERE SURGICAL CARE FITS AMONG defects 58 GLOBAL HEALTH PRIORITIES 15 LMICs are increasingly using burden-of-disease data Source: Data from table 2.5. Note: Percentages are based on surgical care that would treat cataracts, cleft lip and palate, to allocate limited resources and to prioritize funding congenital heart anomalies, neural tube defects, and obstetric fistula. for research and treatment programs at the global level. 32 Essential Surgery Table 2.6 Public Health Impact of Scaling Up Surgical Care in Low- and Middle-Income Countries Burden Avertable Nonavertable Fraction of Fraction of Preventable DALYs per year LMIC total GBD DALYs per year LMIC total GBD Type of surgical care deaths (millions) (millions) (percent) (millions) (percent) Basic surgical carea 1.4 77.2 3.5 238.5 10.7 b Subspecialty surgical care 0.4 38.9 1.7 46.5 2.1 Totals 1.8 116.1 5.2 285.0 12.8 Note: DALY = disability-adjusted life year; GBD = global burden of disease; LMIC = low- and middle-income countries. a. Designed to treat four gastrointestinal diseases, four maternal-fetal conditions, and injuries that can be managed with simple interventions. Basic surgical care refers to emergency and essential surgical care that is deliverable with the resources available at first-level hospitals. b. Surgical care for cataract, cleft lip and palate, congenital heart anomalies, neural tube defects, and obstetrical fistula. It is important that our burden estimates be properly Given what seems like the ability to prevent only a represented and interpreted. Table 2.6 summarizes the small fraction of total GBD in LMICs, how then does potential impact on public health in LMICs if surgical surgical care fit among other global health priorities? care could be scaled up to meet the standard of care To address this question, we compared our surgical and accessibility that exists in HICs. Included in the burden estimates to the global burden of tuberculosis, table are our estimates of the number of prevent- HIV/AIDS, malaria, and ischemic heart disease. These able deaths and surgically avertable and nonavertable four conditions were selected because they are currently DALYs and their respective fraction of the total GBD recognized as some of our most important global health in LMICs. Overall, our analysis suggests that scaling problems. Ischemic heart disease (129.8 million DALYs) up basic and selected subspecialty surgical care could ranks first on the GBD 2010 cause list (Murray, Vos, avert 5.2 percent of the total burden of disease in and others 2012). The other three have been the targets LMICs. of the Global Fund to Fight AIDS, Tuberculosis and Care should be exercised in interpreting this 5.2 Malaria since 2002. Because patients with tuberculosis, percent figure because it does not represent the global HIV/AIDS, and ischemic heart disease may sometimes surgical burden or the total burden that could be averted require surgical care, it is important to not interpret this by surgical care in LMICs. To estimate a global surgical simply as a comparison between surgical and nonsur- burden, it would be necessary to extend our analysis to gical conditions; rather, it is intended to illustrate the include surgical care provided in HICs. It would also magnitude of the disease burden amenable to a select be necessary to account for the almost 20 percent of number of surgical interventions. patients in our NIS database analysis whose primary Figure 2.5 illustrates the burden of high-priority diagnoses were not captured by the GBD 2010 cause list. global health problems and compares them with our A more complete assessment of the burden that could be surgical burden estimates. The avertable burden from averted by surgical care in LMICs would need to include scaling up basic surgical care at first-level hospitals the following: and advanced care in specialized clinics in LMICs (116.1 million DALYs per year) exceeds the unad- • Care for other common surgical conditions that dressed global burdens of HIV/AIDS (81.6 million could be or is already being, done at first-level hos- DALYs), tuberculosis (49.4 million DALYs), or malaria pitals, for example, treatment of surgical infections (82.7 million DALYs) individually, but it is less than such as incision and drainage of abscesses, tube tho- the unaddressed burden associated with ischemic heart racostomy for empyema, irrigation of septic joints, disease (130.0 million DALYs per year). Perhaps a better and sequestrectomy for chronic osteomyelitis comparison would be between the burden that could be • Surgical care provided at second- and third-level addressed with surgical care and the burden that could hospitals, for example, complex gastrointestinal be averted by treatment of the other conditions—for surgery, resection of tumors, and major pediatric example, the burden averted by antiretroviral medica- surgical procedures tion to treat HIV—but these data do not exist. Global Burden of Surgical Conditions 33 Figure 2.5 Burden of Important Global Health Problems Burden associated with a group of surgically treatable conditions in LMICs Nonavertable Avertable 401 million DALYs/year Avertable burden = 116 million DALYs/year Nonavertable burden = 285 million DALYs/year Burden targeted by the Global Fund to Fight Burden of ischemic heart disease AIDS, Tuberculosis and Malaria (Number 1 ranking on the GBD 2010 cause list) Tuberculosis 23% Malaria 39% Ischemic heart disease 130 million DALYs/year HIV 38% 214 million DALYs/year Note: DALY = disability-adjusted life year; GBD 2010 = Global Burden of Disease 2010. Area of circles represents the relative number of DALYs per year. The “avertable burden” area depicts the burden that could be averted by scaling up surgical care in low- and middle-income countries (basic surgical care that can be delivered at first-level hospitals and selected subspecialty surgical care). The burden averted from scaling up surgical care (116.1 million DALYs per year) exceeds the global burden of HIV/AIDS (81.6 million DALYs per year) and malaria (82.7 million DALYs per year). The total burden associated with the surgical conditions analyzed is almost twice the burden targeted by the Global Fund to Fight AIDS, Tuberculosis and Malaria. 34 Essential Surgery Just as not all of the HIV (or other disease burden) health care is viewed as a hub of coordination within can be addressed with currently available treatments, the the health system, with the first-level hospital serving magnitude of the nonavertable surgical burden should as one of many components (figure 2.6). The challenge be interpreted as providing crucial direction for devel- for surgery is to integrate the organizational structure of opment of strategies to prevent and more effectively surgical care into the larger health system and to concur- treat these conditions. To place the nonavertable surgical rently develop methods for measuring its performance. burden (285 million DALYs per year) in perspective, Meeting this challenge will require moving beyond the that number is more than twice that associated with reductionist view that surgical care is simply a collection ischemic heart disease; it is more than 1.3 times larger of components that includes infrastructure, human than the total burden targeted by the Global Fund to resources, financing, and supplies. A more comprehen- Fight AIDS, Tuberculosis and Malaria. Given that the sive view is needed, one that recognizes that surgical care largest portion of this nonavertable burden is related to is part of a larger health system in which performance is injuries (200.5 million DALYs per year; 70.3 percent of determined by critical interrelationships. the nonavertable burden), development of injury pre- vention programs and improvement of prehospital care for injured patients in LMICs are critical. To provide the Research and Development Goals best possible care for our patients, we must advocate for The literature on surgical care in LMICs is growing a comprehensive strategy that includes both surgical and rapidly. Nevertheless, major knowledge gaps remain, nonsurgical interventions. especially related to optimal strategies for delivering In conclusion, surgically treatable conditions are surgical care at first-level hospitals and measuring its an important public health problem in LMICs; the impact. Based on the work done in preparing this magnitude of avertable burden exceeds the burden chapter, the following are some of the areas that require of some of the most widely recognized global health investments in research and development. problems. • Improved methodology for assessing the public health impact of surgical care. As noted by Gosselin, Ozgediz, FUTURE DIRECTIONS and Poenaru (2013) and further illustrated by the challenges we encountered in trying to estimate Health Systems and Performance of Surgical Services a global burden of surgical disease, DALY-based Global health initiatives have often struggled to imple- approaches may not be the best metric for global ment changes at scale. It is reasonable to expect that surgery or for measuring the impact of surgical scaling up surgical care in LMICs will face simi- interventions. The ideal metric would be simple to lar problems unless the understanding of the factors measure, oriented toward quantifying outcomes of that determine the performance of surgical services interventions, and easy for policy makers and health is improved. Performance refers to the ability of the planners to interpret. Alternatives include measure- surgical service to deliver safe, effective, accessible, and ment of disease prevalence, backlogs in treatment, cost-efficient care—and ultimately whether that surgi- disability incurred by delays in care, and value of a cal service meets the needs of the population. A health statistical life (Gosselin, Ozgediz, and Poenaru 2013). system encompasses the individuals, organizations, and The value of a statistical life is of particular interest processes—from the national government to the private because it widens the spectrum of tools available sector to community-based organizations—that focus to estimate the cost-effectiveness of surgical care primarily on ensuring health outcomes (WHO 2007). (Corlew 2010). Research is needed to explore these Surgery performance can vary markedly in different and other alternatives and to determine their utility health systems, even at similar levels of health care in HICs as well as LMICs. expenditure. • Better estimates of the avertable and nonavertable The recent focus on strengthening health systems in burden of surgically treatable conditions in LMICs. LMICs (Mills, Rasheed, and Tollman 2006; Palen and Although population-based countrywide surgical others 2012), and, in particular, the role of primary surveys in LMICs have been undertaken (Groen health care, means that this is an opportune time to and others 2013; Petroze and others 2013), these develop strategies for examining the performance of data are not of sufficient detail to be used in GBD surgical services. An evolving theme is that surgical calculations. Data collection needs to be standard- care is an essential component of primary health care ized so that data generated in community-based (WHO 2008). In the new conceptual model, primary surveys can be used in future GBD studies. Global Burden of Surgical Conditions 35 Figure 2.6 Primary Care as a Hub of Coordination: Networking within the Community Served and Outside Partners Specialized care Community Emergency Hospital mental department Tuberculosis health unit Maternity control center Traffic Consultant Surgery Referral for accident Diabetes support Placenta clinic multidrug resistance praevia Referral for Hernia complications Diagnostic services Self-help Diagnostic Primary care team: support group continuous, Training CT scan Training center comprehensive, support person-centered care Social Cytology Liaison services lab Pap smears community health worker Other Other Alcoholism Waste disposel inspection Community Alcoholics Environmental Mammography Gender anonymous health lab violence Cancer Women’s Nongovernmental Specialized screening shelter organizations prevention services center Source: WHO 2008. Note: CT = computed tomography. The emergency, maternity, and surgery departments are included as essential components. Moreover, these data could be used to support the • Tools to assess surgical care within primary health care case for expanding the purview of future GBD systems. Although the development of indicators studies. Because our analysis was based heavily on for monitoring and evaluating project and system methodological assumptions, our estimates need to performance is commonplace within health and be validated. Validation could perhaps be undertaken economic development programs, this process has in prospective pilot studies from a sample of hospitals not been applied in a systematic way to the field or populations, or by comparing appropriately of essential and emergency surgery in LMICs. One matched hospitals in high- and low-income settings. approach might be to adapt the WHO’s Monitoring • Identified strategies to address the nonavertable sur- the Building Blocks of Health Systems Monitoring and gical burden. One of the most important findings Evaluation Matrix (MBBHS M&E Matrix) (WHO in our study was that the majority of the surgical 2010) or similar tool for surgical care. Within the burden is currently nonavertable. Nonavertable does MBBHS M&E Matrix are health system building not necessarily imply a problem that cannot be blocks that represent discrete areas of policy making, addressed; the nonavertable burden can be reduced inputs into the health system, and direct outputs. through nonsurgical means, such as injury pre- Improvements in the health system are measured vention, improved delivery of care, or innovation. in four domains: improved health, responsiveness, Research priorities include a more detailed analysis social and financial risk protection, and improved of the nonavertable burden, ways in which injury efficiency. The MBBHS M&E strategy seeks to create prevention strategies can best be implemented in set- government accountability for progress and perfor- tings of limited resources, and identification of areas mance toward health goals, to facilitate results-based in which surgical innovation might have the greatest financing of health programs, to measure the impact impact in LMICs. of interventions and inputs, and to create sustainable 36 Essential Surgery measurement strategies (WHO 2010). The matrix process and outcomes components. However, under- provides a comprehensive strategy for assessing the standing how the physical and human resources function of primary health care systems, but it has affect processes and outcomes is necessary to gain a not been adapted to monitor and evaluate surgical proper understanding of the factors that determine care. Adapting the MBBSHS M&E Matrix or a sim- quality of care. The link between quality of surgical ilar framework for assessing surgical care in LMICs care and the public’s perception of the health system could help facilitate surgery’s integration into health needs further study. systems and simultaneously provide a mechanism • Initiatives to better align surgical care with other global for measuring its performance. health movements. Surgery has an important role • Models of how surgical care can best be implemented in meeting the 2015 United Nations Millennium in LMICs. Perhaps the most pressing research need Development Goals (PLoS Medicine Editors 2008). in global surgery is to determine how emergency and Scaling up surgical care in LMICs will be required if essential surgical services can best be implemented infectious, child, and maternal mortality rates are to be in countries where the needs are greatest and where brought down to universally low rates by 2035 (Jamison health systems are least developed. At present, far too and others 2013). No detailed studies have been made few examples of well-functioning surgical services of the role surgical care has in meeting the Millennium in LMICs can be found, and little research on what Development Goals and Global Health 2035 targets. factors make them successful has been conducted. Because both initiatives link health improvement to Scaling up surgical care in LMICs requires much economic growth, integrating surgical care into these more than theater personnel, equipment, and infra- important movements could be an important strategy structure; it also requires education and training, for encouraging investment in surgical care in LMICs. functioning methods and processes, data systems, and an enabling environment (Akenroye, Adebona, and ANNEXES Akenroye 2013). Research priorities include the design The annexes to this chapter are as follows. They are available at of a basic surgical package that is flexible enough to be http://www.dcp-3.org/surgery: adapted to local needs, benchmarks to assess what is • Annex 2A. ICD-9 Codes Included in the GBD 2010 Study required for health systems to deliver emergency and • Annex 2B. The Role of Surgery in Global Health: Analysis of essential surgical care at first-level hospitals, strategies United States Inpatient Procedure Frequency by Condition for measuring the impact of the improvements, and Using the Global Burden of Disease 2010 Framework most important, cost estimates. • Annex 2C. AHRQ ICD-9 Procedure Codes • Research to better understand the surgical workforce • Annex 2D. Surgical Procedures Required to Treat the GBD needs in LMICs. One of the greatest challenges of 2010 Causes Included in the Basic Surgical Care Scale-Up scaling up surgical care worldwide lies in deficien- Model cies in the supply, training, and distribution of • Annex 2E. Adjustments to Account For The Burden Not human resources. Training surgeons takes time and Amenable to Surgical Care • Annex 2F. Additional Details on How Burden Calculations is expensive; once qualified, they are reluctant to Were Performed serve in rural first-level hospitals where the needs 1. Higashi, H., J. J. Barendregt, N. J. Kassebaum, T. G. Weiser, are greatest. Nonetheless, various countries have S. W. Bickler, and others. 2014. “Burden of Injuries successfully trained doctors to perform surgical Avertable by a Basic Surgical Package in Low- and care in rural areas (Sani and others 2009); in other Middle-Income Regions: A Systematic Analysis from the cases, countries have introduced nonphysician Global Burden of Disease 2010 Study.” World Journal of cadres specializing in surgery. Mozambique, for Surgery 39 (1):1–9. doi:10.1007/s00268-014-2685-x. example, began training nonphysician surgeons 2. Higashi, H., J. J. Barendregt, N. J. Kassebaum, (técnicos de cirurgia) in 1984, a program involving a T. G. Weiser, S. W. Bickler, and others. 2014. “The Burden three-year degree (Cumbi and others 2007; Pereira of Selected Congenital Anomalies Amenable to Surgery and others 2007; Vaz and others 1999). Important in Low and Middle-Income Regions: Cleft Lip and Palate, Congenital Heart Anomalies and Neural Tube questions remain regarding how surgical providers Defects.” Archives of Disease in Childhood. September 26. in LMICs should be trained, their scope of practice, Electronic publication ahead of print. and how best to assess their surgical skills. 3. Higashi, H., J. J. Barendregt, N. J. Kassebaum, • Studies to define how quality of surgical care affects the T. G. Weiser, S. W. Bickler, and others. 2014. “Surgically- entire health service. Assessment of surgical care in Avertable Burden of Digestive Diseases at First-Level settings of limited resources has typically focused on Hospitals in Low and Middle-Income Regions.” Surgery. physical and human resources and has neglected the October 22. Electronic publication ahead of print. Global Burden of Surgical Conditions 37 4. Higashi, H., J. J. Barendregt, N. J. Kassebaum, AHRQ (Agency for Healthcare Research and Quality). 2008. T. G. Weiser, S. W. Bickler, and T. Vos. 2015. “Surgically- “Appendix A.” In Patient Safety Indicators: Technical Avertable Burden of Obstetric Conditions in Low and Specifications, Version 3.2., A-1—A-20. http://www Middle-Income Regions: A Modelled Analysis.” BJOG .qualityindicators.ahrq.gov/downloads/modules/psi/v32 122 (2): 228–36. /psi_technical_specs_v32.pdf. • Annex 2G. WHO Monitoring the Building Blocks of Health Alkire, B. C., J. R. Vincent, C. T. Burns, I. S. Metzler, P. E. Farmer, Systems and J. G. Meara. 2012. “Obstructed Labor and Caesarean Delivery: The Cost and Benefit of Surgical Intervention.” PLoS One 7 (4): e34595. NOTES Akenroye, O. O., O. T. Adebona, and A. T. Akenroye. 2013. “Surgical This research was supported by grant number R24TW008910 Care in the Developing World—Strategies and Framework for from the Fogarty International Center (Stephen Bickler, David Improvement.” Journal of Public Health in Africa 4: e20. Chang, and Emilia Noormahomed) and the Bill and Melinda Beard, J. H., L. B. Oresanya, M. Ohene-Yeboah, R. A. Dicker, Gates Foundation (Hideki Higashi, Jan Barendregt, and Theo and H. W. Harris. 2013. “Characterizing the Global Burden Vos) under the Disease Control Priorities Network Project. of Surgical Disease: A Method to Estimate Inguinal Hernia The content is solely the responsibility of the authors and Epidemiology in Ghana.” World Journal of Surgery 37 (3): does not necessarily represent the official views of the Fogarty 498–503. International Center, the National Institutes of Health (NIH), Bickler, S., D. Ozgediz, R. Gosselin, T. Weiser, D. Spiegel, and and the Bill and Melinda Gates Foundation. The NIH Common others. 2010. “Key Concepts for Estimating the Burden Fund supports the first award. of Surgical Conditions and the Unmet Need for Surgical The World Bank classifies countries according to four Care.” World Journal of Surgery 34 (3): 374–80. income groupings. Income is measured using gross national Bickler, S. W., and H. Rode. 2002. “Surgical Services for income (GNI) per capita, in U.S. dollars, converted from local Children in Developing Countries.” Bulletin of the World currency using the World Bank Atlas method. Classifications Health Organization 80 (10): 829–35. as of July 2014 are as follows: Bickler, S. W., and D. Spiegel. 2010. “Improving Surgical Care in Low- and Middle-Income Countries: A Pivotal Role for the World Health Organization.” World Journal of Surgery • Low-income countries (LICs) = US$1,045 or less in 2013 34 (3): 386–90. • Middle-income countries (MICs) are subdivided: Choo, S., H. Perry, A. A. Hesse, F. Abantanga, E. Sory, and • Lower-middle-income = US$1,046 to US$4,125 others. 2010. “Assessment of Capacity for Surgery, • Upper-middle-income (UMICs) = US$4,126 to US$12,745 Obstetrics and Anaesthesia in 17 Ghanaian Hospitals • High-income countries (HICs) = US$12,746 or more Using a WHO Assessment Tool.” Tropical Medicine and International Health 15 (9): 1109–15. 1. The National (Nationwide) Inpatient Sample (NIS), Copenhagen Consensus Center. 2012. “Copenhagen 2010, Healthcare Cost and Utilization Project, Agency for Consensus.” http://www.copenhagenconsensus.Com/sites Healthcare Research and Quality, Rockville, MD, http:// /default/files/Outcome_Document_Updated_1105.pdf. www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation Corlew, D. S. 2010. “Estimation of Impact of Surgical Disease .jsp. through Economic Modeling of Cleft Lip and Palate Care.” 2. Basic surgical care refers to emergency and essential surgi- World Journal of Surgery 34 (3): 391–96. cal care that can be provided with the resources available Cumbi, A., C. Pereira, R. Malalane, F. Vaz, C. McCord, and at first-level hospitals. Because emergency and essential others. 2007. “Major Surgery Delegation to Mid-level surgical care is often provided at higher levels of care— Health Practitioners in Mozambique: Health Professionals’ secondary and tertiary hospitals—our estimates are based Perceptions.” Human Resources for Health 5: 27. on the effects of scaling up basic surgical care across all Debas, H. T., C. McCord, and A. Thind. 2006. “Surgery.” In sectors of the health care system. Disease Control Priorities in Developing Countries, 2nd 3. Paralytic ileus is grouped with intestinal obstruction in ed., edited by D. T. Jamison, J. G. Breman, A. R. Measham, GBD 2010. G. Alleyene, M. Claeson, D. B. Evans, P. Jha, A. Mills, and P. Musgrove, 1245–59. Washington, DC: Oxford University Press and World Bank. REFERENCES Funk, L. M., T. G. Weiser, W. R. Berry, S. R. Lipsitz, A. F. Merry, Abdullah, F., H. Troedsson, and M. Cherian. 2011. “The World and others. 2010. “Global Operating Theatre Distribution Health Organization Program for Emergency Surgical, and Pulse Oximetry Supply: An Estimation from Reported Obstetric, and Anesthetic Care: From Mongolia to the Data.” The Lancet 376 (9746): 1055–61. Future.” Archives of Surgery 146 (5): 620–23. Galukande, M., J. von Schreeb, A. Wladis, N. Mbembati, H. de Abdur-Rahman, L. O., A. B. van As, and H. Rode. 2012. Miranda, and others. 2010. “Essential Surgery at the District “Pediatric Trauma Care in Africa: The Evolution and Hospital: A Retrospective Descriptive Analysis in Three Challenges.” Seminars in Pediatric Surgery 21 (2): 111–15. African Countries.” PLoS Med 7 (3): e1000243. 38 Essential Surgery Gibbons, L., J. M. Belizán, J. A. Lauer, A. P. Betrán, M. Merialdi, by Otitis Media: Systematic Review and Global Estimates.” and F. Althabe. 2010. “The Global Numbers and Costs of PLoS One 7 (4): e36226. Additionally Needed and Unnecessary Caesarean Sections Mossey, P. A., and M. B. Modell. 2012 “Epidemiology of Oral Performed per Year: Overuse as a Barrier to Universal Clefts 2012: An International Perspective.” Frontiers of Oral Coverage.” World Health Report Background Paper 30. Biology 16: 1–18. http://www.who.int/healthsystems/topics/financing Murray, C. J., M. Ezzati, A. D. Flaxman, S. Lim, R. Lozano, and /healthreport/30C-sectioncosts.pdf. others. 2012. “GBD 2010: Design, Definitions, and Metrics.” Gosselin R., D. Ozgediz, and D. Poenaru. 2013. “A Square Peg The Lancet 380 (9859): 2063–66. in a Round Hole? Challenges with DALY-Based ‘Burden of Murray, C. J., T. Vos, R. Lozano, M. Naghavi, A. D. Flaxman, Disease’ Calculations in Surgery and a Call for Alternative and others. 2012. “Disability-Adjusted Life Years (DALYs) Metrics.” World Journal of Surgery 37 (11): 2507–11. for 291 Diseases and Injuries in 21 Regions, 1990–2010: Gosselin, R. A., A. Thind, and A. Bellardinelli. 2006. “Cost/ A Systematic Analysis for the Global Burden of Disease DALY Averted in a Small Hospital in Sierra Leone: What Study 2010.” The Lancet 380 (9859): 2197–23. Is the Relative Contribution of Different Services?” World Ndour, C., S. Dossou Gbété, N. Bru, M. Abrahamowicz, Journal of Surgery 30 (4): 505–11. A. Fauconnier, and others. 2013. “Predicting In-Hospital Grimes, C. E., J. A. Henry, J. Maraka, N. C. Mkandawire, and Maternal Mortality in Senegal and Mali.” PLoS One 8(5): M. Cotton. 2014. “Cost-Effectiveness of Surgery in Low- and e64157. Middle-Income Countries: A Systematic Review.” World Journal Ozgediz, D., and R. Riviello. 2008. “The ‘Other’ Neglected of Surgery 38 (1): 252–63. doi: 10.1007/s00268-013-2243-y. Diseases in Global Public Health: Surgical Conditions in Groen, R. S., M. Samai, R. T. Petroze, T. B. Kamara, Sub-Saharan Africa.” PLoS Med 5 (6): e121. L. D. Cassidy, and others. 2013. “Household Survey in Sierra Palen, J., W. El-Sadr, A. Phoya, R. Imtiaz, R. Einterz, and others. Leone Reveals High Prevalence of Surgical Conditions in 2012. “PEPFAR, Health System Strengthening, and Promoting Children.” World Journal of Surgery 37 (6): 1220–26. Sustainability and Country Ownership.” Journal of Acquired Jamison, D. T., L. H. Summers, G. Alleyne, K. J. Arrow, S. Berkley, Immune Deficiency Syndrome 60 (Suppl. 3): S113–19. and others. 2013. “Global Health 2035: A World Converging Pereira, C., A. Cumbi, R. Malalane, F. Vaz, C. McCord, and within a Generation.” The Lancet 382 (9908): 1898–955. others. 2007. “Meeting the Need for Emergency Obstetric Kushner, A. L., M. N. Cherian, L. Noel, D. A. Spiegel, Care in Mozambique: Work Performance and Histories of S. Groth, and C. Etienne. 2010. “Addressing the Millennium Medical Doctors and Assistant Medical Officers Trained for Development Goals from a Surgical Perspective: Essential Surgery.” BJOG 114 (12): 1530–33. Surgery and Anesthesia in 8 Low- and Middle-Income Petroze, R. T., R. S. Groen, F. Niyonkuru, M. Mallory, Countries.” Archives of Surgery 145 (2): 154–59. E. Ntaganda, and others. 2013. “Estimating Operative Lozano, R., M. Naghavi, K. Foreman, S. Lim, K. Shibuya, and Disease Prevalence in a Low-Income Country: Results of a others. 2012. “Global and Regional Mortality from 235 Nationwide Population Survey in Rwanda.” Surgery 153 (4): Causes of Death for 20 Age Groups in 1990 and 2010: 457–64. A Systematic Analysis for the Global Burden of Disease PLoS Medicine Editors. 2008. “A Crucial Role for Surgery in Study 2010.” The Lancet 380 (9859): 2095–128. Reaching the UN Millennium Development Goals.” PLoS McCord, C., and Q. Chowdhury. 2003. “A Cost Effective Small Medicine 5 (8): e182. Hospital in Bangladesh: What It Can Mean for Emergency Rao, G. N., R. Khanna, and A. Payal. 2011. “The Global Burden Obstetric Care.” International Journal of Gynecology and of Cataract.” Current Opinion in Ophthalmology 22 (1): 4–9. Obstetrics 81 (1): 83–92. Rose, J., D. C. Chang, T. G. Weiser, N. J. Kassebaum, and Mills, A., F. Rasheed, and S. Tollman. 2006. “Strengthening S. W. Bickler. 2014. “The Role of Surgery in Global Health: Health Systems.” In Disease Control Priorities in Developing Analysis of United States Inpatient Procedure Frequency Countries, 2nd ed., edited by D. T. Jamison, J. G. Breman, by Condition Using the Global Burden of Disease 2010 A. R. Measham, G. Alleyne, M. Claeson, D. B. Evans, P. Jha, Framework.” PLoS One 9 (2) e89693. A. Mills, and P. Musgrove, 87–102. Washington, DC: World Salomon, J. A., T. Vos, D. R. Hogan, M. Gagnon, M. Naghavi, Bank and Oxford University Press. and others. 2012. “Common Values in Assessing Health Mock, C., M. Cherian, C. Juillard, P. Donkor, S. Bickler, and Outcomes from Disease and Injury: Disability Weights others. 2010. “Developing Priorities for Addressing Surgical Measurement Study for the Global Burden of Disease Study Conditions Globally: Furthering the Link between Surgery 2010.” The Lancet 380 (9859): 2129–43. and Public Health Policy.” World Journal of Surgery 34 (3): Sani, R., B. Nameoua, A. Yahaya, I. Hassane, R. Adamou, and 381–85. others. 2009. “The Impact of Launching Surgery at the Mock, C., M. Joshipura, C. Arreola-Risa, and R. Quansah. 2012. District Level in Niger.” World Journal of Surgery 33 (10): “An Estimate of the Number of Lives That Could Be Saved 2063–68. through Improvements in Trauma Care Globally.” World Spiegel, D. A., F. Abdullah, R. R. Price, R. A. Gosselin and Journal of Surgery 36 (5): 959–63. S. W. Bickler. 2013. “World Health Organization Global Monasta, L., L. Ronfani, F. Marchetti, M. Montico, L. Vecchi Initiative for Emergency and Essential Surgical Care: 2011 Brumatti, and others. 2012. “Burden of Disease Caused and Beyond.” World Journal of Surgery 37 (7): 1462–69. Global Burden of Surgical Conditions 39 Stanley, C. M., G. W. Rutherford, S. Morshed, R. R. Coughlin, Global Volume of Surgery: A Modelling Strategy Based on and T. Beyeza. 2010. “Estimating the Healthcare Burden of Available Data.” The Lancet 372 (9633): 139–44. Osteomyelitis in Uganda.” Transactions of the Royal Society Wu, V. K., D. Poenaru, and M. J. Poley. 2013. “Burden of of Tropical Medicine and Hygiene 104 (2): 139–42. Surgical Congenital Anomalies in Kenya: A Population- Stewart, B., P. Khanduri, C. McCord, M. Ohene-Yeboah, Based Study.” Journal of Tropical Pediatrics 59 (3): S. Uranues, and others. 2014. “Global Disease Burden of 195–202. Conditions Requiring Emergency Surgery.” British Journal WHO (World Health Organization). 2003. Surgical Care at of Surgery 101 (1): e9–22. the District Hospital. Geneva: WHO. http://www.who.int Vaz, F., S. Bergstrom, L. Vaz Mda, J. Langa, and A. Bugalho. /surgery/publications/scdh_manual/en/. 1999. “Training Medical Assistants for Surgery.” Bulletin of ———. 2007. Everybody’s Business: Strengthening Health the World Health Organization 77 (8): 688–91. Systems to Improve Health Outcomes: WHO’s Framework for Vos, T., A. D. Flaxman, M. Naghavi, R. Lozano, C. Michaud, Action. Geneva: WHO. http://www.who.int/healthsystems and others. 2012. “Years Lived with Disability (YLDs) for /strategy/everybodys_business.pdf. 1160 Sequelae of 289 Diseases and Injuries 1990–2010: ———. 2008. World Health Report 2008: Primary Health A Systematic Analysis for the Global Burden of Disease Care—Now More Than Ever. Geneva: WHO. Study 2010.” The Lancet 380 (9859): 2163–96. ———. 2010. Monitoring the Building Blocks of Health Systems: Weiser, T. G., S. E. Regenbogen, K. D. Thompson, A. B. Haynes, A Handbook of Indicators and Their Measurement Strategies. S. R. Lipsitz, and others. 2008. “An Estimation of the Geneva: WHO. 40 Essential Surgery Chapter 3 Surgery and Trauma Care Richard A. Gosselin, Anthony Charles, Manjul Joshipura, Nyengo Mkandawire, Charles N. Mock, Raymond R. Price, and David Spiegel INTRODUCTION This chapter addresses the surgical aspects of care for these conditions. It presents available epidemiological The burden of death and disability attributable to lack data, as well as data on systematic approaches to trauma of access to surgical care for traumatic injuries, as well as and interventions in specific anatomic areas. of nontraumatic chronic conditions and soft tissue and bone infections, falls most heavily on people in low- and middle-income countries (LMICs) (Ozgediz and others International and National Advocacy for Improved 2008; Spiegel and others 2008). Human and technical Trauma Care capacities are insufficient to address the existing burden International and national organizations have begun of injuries in these countries. Selected surgical inter- to recognize and implement strategies for addressing ventions for trauma have proven cost-effective in these the worldwide trauma pandemic. The World Health settings, and innovative low-cost programs and interven- Organization (WHO) has developed guidelines with an tions have improved trauma care outcomes at individual internationally applicable metric for countries to use to hospitals. It is critical that LMICs create or strengthen evaluate and monitor resources for trauma care in their existing trauma systems to improve outcomes. Identifying health care facilities and system-wide parameters. The effective and cost-effective interventions and strategies to creation of the WHO Global Alliance for Care of the inform the future direction of these resource-challenged Injured provides a common platform for greater polit- countries is an essential step in this process. ical advocacy for increased attention and resource allo- The chapter on surgery in the Disease Control cation to trauma care. World Health Assembly (WHA) Priorities in Developing Countries, second edition (DCP2) Resolution 60.22 on trauma and emergency care services (Jamison and others 2006) exposed the scarcity of provides a high-level global political endorsement for relevant evidence on outcomes, effectiveness, and cost- improvements in trauma care. The Ministry of Health effectiveness in the literature from the developing world; in Uganda targeted trauma care and injury prevention unfortunately, this situation has improved only mildly. as one of the nation’s top 10 health care priorities, Although some interventions and strategies have been following the review of data collected from a WHO- identified (Tollefson and Larrabee 2012), deficiencies in supported hospital-based injury surveillance system that both the quantity and the quality of data remain glaring demonstrated the significant burden of disease arising (Vos 2009). from injuries. Corresponding author: Richard A. Gosselin, MD, MPH, MSc, FRCS(C), University of California, San Francisco, froggydoc@gmail.com 41 GLOBAL BURDEN OF TRAUMA Figure 3.1 Case Fatality Rates for Severely Injured People, 1998 One of the findings of the 2013 Global Health Estimates (GHE) study is that the ongoing epidemiological transi- Kumasi, 80 Monterrey, tion is shifting the global disease burden away from pre- Ghana Mexico Fatalities (percent) (ISS ≥ 9) mature deaths (years of life lost, YLLs) and toward years Seattle, Washington lived with disability (YLDs) (WHO 2013b). Worldwide, 60 United States the percentage of deaths due to injury has fallen from 9.4 percent to 9.1 percent. 40 During the same period, deaths due to musculoskel- etal disorders have increased 34 percent (WHO 2013b), 20 as summarized in table 3.1. The WHO report on road safety estimates that 1.25 million people died from road 0 Low Middle High traffic injuries (RTIs) in 2010 (WHO 2013c). More than Country income 75 percent of those were young males in their productive years. More than 50 percent of all deaths in LMICs were Source: Data based on Mock and others (1998). Illustration courtesy of Intermountain pedestrians and cyclists. For every death, it is estimated Healthcare. that 20 people are injured; of these injured, one will expe- Note: ISS = Injury Severity Score. Income classifications are based on status at the rience some form of permanent disability. The burden of time of the study. Ghana is now a lower-middle-income country, and Mexico is an upper-middle-income country. RTIs is already disproportionally shouldered by LMICs (Ameratunga, Hijar, and Norton 2006), and most of the projected increase of this burden will occur in countries one of the main challenges for public health in this cen- with rapid economic growth, in particular, China and tury (ACS 2006; Mock and others 2004). People in LMICs India (Mathew and Hanson 2009; WHO 2013c). have as yet been unable to benefit as significantly from trauma system development as those in high-income countries (HICs) have. Case fatality rates for seriously Epidemiological Burden of Preventable injured patients (Injury Severity Score [ISS] ≥ 9) were Trauma Deaths significantly lower in an HIC (the United States), com- Decreasing the heavy burden imposed on individuals and pared with a middle-income country (MIC) (Mexico), society is the overarching mission of trauma systems and or a low-income country (LIC) (Ghana), as shown in figure 3.1 (Mock and others 1998). Table 3.1 Worldwide Rankings of Injuries and Musculoskeletal Between 1.7 and 1.9 million lives, or 34–38 percent of Conditions for Deaths, YLDs, and DALYs, 2000–11 all injury deaths in LMICs, could be saved if trauma care initiatives could be designed and implemented to reduce Change in rates per the case fatality rates among seriously injured patients to Ranking 100,000 population equal those in HICs (Mock and others 2012). 2000 2011 (percent) All injuries Deaths n.a. n.a. −8.7 Systematic Approach to Trauma Care YLDs n.a. n.a. 8.7 Although this chapter concentrates on the effective- DALYs n.a. n.a. −15.3 ness of individual interventions, such as operations, Road traffic Deaths 11 9 8.9 the overall organizational context within which these injuries interventions are provided needs to be considered as YLDs 16 15 −2.4 an integral part of the health care system. Trauma care DALYs 10 8 +0.9 necessitates the rapid availability of trained personnel Falls Deaths n.a. n.a. 13.7 and readily available and sufficient equipment and YLDs 8 8 12.0 supplies. Improving the availability of these human and physical resources and monitoring the care-provision DALYs n.a. 17 4.0 process can significantly improve the outcomes. Better Musculoskeletal Deaths n.a. n.a. +34.0 system-wide organization and planning for trauma care disorders YLDs n.a. n.a. +7.2 can help achieve these goals. DALYs n.a. n.a. +8.3 A trauma system encompasses the entire spectrum of Source: Data based on Global Health Estimates (WHO 2013b). services that a country or region has in place: prehospital Note: DALYs = disability-adjusted life years; YLDs = years lived with disability; n.a. = not available. care, initial emergency care, definitive hospital care 42 Essential Surgery (care provided after initial resuscitation to definitively EFFECTIVENESS OF TRAUMA CARE SYSTEMS treat injuries), and long-term rehabilitation of injured survivors. It also encompasses the information systems Geographic areas that implement better-organized needed to monitor and ensure quality of care along this trauma systems that include the elements listed in spectrum. In HICs, a variety of elements commonly table 3.2 are able to decrease trauma mortality. Better- constitute a formal and well-organized trauma system organized trauma systems have been consistently (table 3.2). shown to decrease mortality by 15–20 percent among These elements are facilitated by enabling legislation treated patients. The effect is even more pronounced in and oversight by appropriately empowered governmen- lowering medically preventable deaths, that is, deaths tal agencies to achieve the basic goals for trauma systems from causes that should be able to be treated well in (box 3.1). most locations, such as deaths from airway obstruc- tion or splenic lacerations. Such medically prevent- able deaths are typically decreased by 50 percent in Table 3.2 Elements of Trauma Care Systems that better-organized trauma systems. These findings are Coordinate with the Public Health System fairly consistent across multiple states in the United States and provinces in Canada, as well as several other Prevention HICs, including Australia, Israel, the Netherlands, and Prehospital Care the United Kingdom (Siman-Tov, Radomislensky, and Standards for training for paramedics and for equipment on Peleg 2012; Tallon and others 2012). Better-organized ambulances trauma systems have also demonstrated improved func- Triage protocols for prehospital care tional outcomes among survivors of severe injuries Definitive Hospital Care (Gabbe and others 2012). Improvements in the organization of trauma systems Network of facilities with increasing trauma care capabilities have generally been very low cost in comparison with External verification of hospitals and trauma centers with different the overall cost of trauma care. For example, strength- levels of capability for trauma care ening the trauma care system in Quebec Province, Transfer guidelines and interfacility protocols Canada, led to a notable decrease in mortality of all Rehabilitation severely injured persons province-wide from 50 percent in the early 1990s to 10 percent in the early 2000s. The Process Improvement and Patient Safety Initiatives costs of this reduction were low and sustainable. An ini- Research tial expenditure of Can$2 million (US$1.5 million) was Trauma registries invested to elevate the four major trauma centers in the Source: Authors. province to minimum criteria, especially with respect to infrastructure. This expenditure amounted to far less than 1 percent of the provincial health budget for that year. Subsequently, the only ongoing cost has been Box 3.1 for the monitoring, evaluation, and regulatory over- sight provided by the accreditation committee. These Trauma Care System Goals costs have been minimal because the work was mostly done by volunteer academics and trauma care clinicians • Decrease the incidence and severity of trauma (WHO 2010) (box 3.2). • Ensure optimal, equitable, accessible care for The ability to demonstrate systemwide improve- all trauma patients ments in trauma mortality rates requires regionwide • Prevent unnecessary deaths and disabilities trauma registries or other health information systems from trauma to monitor mortality rates among injured persons. Such • Contain costs and enhance efficiency information systems are rudimentary or nonexistent • Implement quality- and performance- in most LMICs. There have been almost no reports improvement processes of effectiveness of systemwide improvements in these • Identify appropriate resources and ensure countries. Many lack designated national lead agencies their availability to oversee trauma-related issues, including policy mak- ing, finance, establishment of trauma systems, training Source: Adapted from U.S. DHHS (2006). of personnel, and accreditation or licensing of trauma care providers (Zong and others 2011). Surgery and Trauma Care 43 Box 3.2 Story of a Successful System-Wide Improvement: The Quebec Trauma System The Problem had allowed the identification of a subset of In 1989, trauma-related mortality was higher in patients with severe injuries, and these patients Quebec than in the rest of Canada and the United were now brought directly to first-level trauma States because of the following deficiencies: centers. • Phase 3 (1997–present): Review, evaluation, and • No prehospital triage system consolidation of the system. New second-level • No communication system among centers to and third-level centers were accredited, and some facilitate the arrival, referral, and transport of older centers lost their accreditation. Protocols patients were reviewed and updated, as necessary; areas of • No prehospital treatment guidelines subspecialty care were made operational. • No province-wide, uniform hospital manage- ment standards The Results • No mechanism for quality control. • Overall mortality fell from 20 percent to 10 percent after accreditation of first-level trauma The Solution centers. The implementation of a province-wide trauma • Mean prehospital time declined from 62 to registry that included all trauma admissions allowed 44 minutes. evidence-based policy decisions to be made and led • Proportion of patients with Injury Severity to the phased implementation of a comprehensive Score > 25 treated at first-level centers went from trauma system: 36 percent to 84 percent. • Mortality for the subset of severely injured • Phase 1 (1993–94): Accreditation of trauma centers patients fell from 52 percent to 10 percent. and initiation of a trauma care network, follow- • The overall costs were very low (Can$2 million to ing American College of Surgeons guidelines start the program) and have remained sustainable. • Phase 2 (1994–97): Creation of prehospital triage and interhospital transfer protocols. The registry Source: WHO 2010. Nevertheless, several countries have made progress interventions studied by DCP3, discussed in more detail in implementing systemwide improvements. Sri Lanka in chapter 14. has put in place a national trauma secretariat that is implementing some of the trauma system elements used in HICs, including a National Injury Surveillance System Definitive Hospital Care to monitor trauma care nationwide. Similarly, the Hanoi Poor infrastructure, limited human resources, unavail- Health Department has documented progressive, sus- ability of acute interventions, and lack of life-saving tainable improvements in the capabilities of its network equipment and essential supplies for resuscitation of hospitals through better organization and planning, plague health care facilities in LMICs trying to pro- with no additional budget allocation to trauma care. vide trauma care for their injured people (Choo and Although data to monitor patient outcomes others 2010; Kushner and others 2010). The WHO systemwide are sparse in most LMICs, documented and the International Association for Trauma Surgery improvements in outcome have been made in some and Intensive Care developed guidelines for essential components of the trauma system, such as in prehospital trauma care services, including the following (Mock and settings. For example, improvements in prehospital care others 2004): capabilities, especially through the provision of wide- spread first aid training for lay first responders, were • Standards for the care of the injured person found to be among the most cost-effective of all surgical • Set of essential trauma care services 44 Essential Surgery • Suggested resources necessary to offer these services Although a network of facilities with increasing • Guidance to promote national efforts to deliver resources and capabilities may provide the best use of resources and services limited resources in LMICs, a variety of systems provide definitive care in different countries and regions of the The Essential Trauma Care Project established a set world. of 11 essential trauma care services that should be made In China, 400,000 people die from trauma-related available to all injured patients in any setting world- deaths each year (Zong and others 2011); trauma is wide. This list can help hospitals, health care providers, the leading cause of death in males ages 18–40 years ministries of health, and other stakeholders develop in China. Although no national guidelines or proto- appropriate trauma care improvement initiatives (Mock cols guide trauma care, China has developed various and others 2006) (box 3.3). types of regionalized trauma systems that have resulted In addition, the Essential Trauma Care Project, in improved patient outcomes. Despite these regional recognizing that every facility cannot have all the improvements, only 1 percent of 19,712 hospitals in the resources and skills of third-level care facilities, cate- country have established trauma departments. gorized resources and skills (essential, desired, irrele- Several LMICs have improved trauma care in the vant, or possibly required) to match the capabilities of rural areas through education and simple infrastruc- different levels of facilities (first level, general practice, ture development (Henry and others 2012; Mock and specialist, or third level) in an attempt to encourage others 2005). A trauma continuing education course appropriate improvements across the entire spectrum of taught in rural Ghana showed improvements in the fixed facilities in the system. initial management of trauma patients with torso and orthopedic injuries, in plastic surgical care, and in radiologic interpretation one year following training. Basic airway maneuvers (93 percent) and proper chest tube insertion (67 percent) increased significantly, while Box 3.3 advanced airway utilization remained low (20 percent). Areas with less improvement appeared to be those Essential Trauma Care Services requiring more advanced training, such as open frac- tures (33 percent), closed fractures (20 percent), and Airway: Appropriately managed diagnosis of intra-abdominal injuries (20 percent) Breathing: Supported until able to breathe (Mock and others 2005). independently Mongolia, using the Global Initiative for Emergency and Essential Surgical Care program, increased the per- Pneumothorax/hemothorax: Diagnosed and centage of rural health facilities with actual emergency treated expeditiously rooms from 25 percent to 83 percent; the emergency Bleeding: Stopped, whether external or internal room supplies availability increased from 5 percent to Shock: Recognized and treated; intravenous 65 percent over a two-year period (Henry and others fluids available 2012). Basic skills in wound debridement (15 percent to 55 percent), resuscitation (5 percent to 15 percent), frac- Brain injuries: Space-occupying lesions decom- ture management (9 percent to 14 percent), and pene- pressed in a timely manner trating injuries (5 percent to 15 percent) all improved. Abdominal injuries: Promptly identified and Interventions to improve prehospital trauma care treated appropriately have proven effective, but this area remains a significant Extremity injuries: Corrected challenge for poorer countries (Jayaraman and others 2009; Nielsen and others 2012). The quality of hospital Unstable spinal cord injuries: Recognized and care varies considerably according to available human managed with appropriate immobilization and material resources (Mock 2011). Facilities that are Rehabilitation services: Provided to minimize integrated into a broader trauma system generally have long-term impairment better outcomes (Gruen and others 2012; O’Reilly and Medications: Made available for these services others 2013). McCord and Chowdhury (2003) were and for pain control. the first to report the cost-effectiveness analysis of a first-level hospital in rural Bangladesh that handled a Source: Mock and others 2004. heavy caseload of obstetrics but also general trauma: US$11 per disability-adjusted life year (DALY) averted. Surgery and Trauma Care 45 A subsequent study in a pure trauma first-level hospital untreated chronic diseases, such as diabetes or vascular in Cambodia found a cost-effectiveness of US$78 per disease, are included. The Jaipur prosthesis, named for DALY averted (Gosselin and Heitto 2008). Another the town where it was designed, is a culturally appro- study comparing two Médecins Sans Frontières trauma priate, socially acceptable, low-cost but high-quality hospitals in Haiti and Nigeria found a cost-effectiveness prosthetic foot that was developed in India through a ratio of US$223 and US$172 per DALY averted, respec- partnership between an orthopedic surgeon (P. D. Sethi) tively, with almost all the difference attributable to and a local craftsman (Ram Chandra Sharma). Using pay scales and employee-benefit schemes (Gosselin, local production methods, the Jaipur foot has been used Maldonado, and Elder 2010). in more than 22 countries, helping more than 900,000 amputees in developing and landmine-affected coun- tries (Price 2013). Transfer Guidelines and Capabilities At its 66th assembly in 2013, the WHA adopted a The guidelines that have been refined over the past 30 resolution that calls for the WHO and member states years in HICs for transferring more severely injured to ensure equal access to health services for people with patients to facilities with increased capabilities rely on disabilities. This resolution, supported by 98 countries, physiologic, anatomic, and mechanistic indicators of serves as a clarion call for improved rehabilitation ser- severe injury (MacKenzie and others 2006). However, vices in LMICs (WHO 2013a). in many LMICs, formal referral systems do not exist or function poorly. In Cambodia, informal systems are used in which patients are transferred by taxi, Research, Quality Improvement, and Patient accompanied by community volunteers (Nakahara and Safety Initiatives others 2010). Referral distances are often long and cost Trauma registries are integral for trauma research that prohibitive for many families. Coordinated transfer of can help monitor and improve trauma care, yet rela- more critically injured patients to regional facilities with tively few trauma registries exist in developing countries adequate human and physical resources could be an (O’Reilly and others 2013). A literature review of trauma important method for more effectively using the limited registries in LMICs identified 84 articles; of these, 76 resources in LMICs. were sourced from 47 registries. Most were from China, the Islamic Republic of Iran, Jamaica, South Africa, and Uganda (O’Reilly and others 2013). There were large Rehabilitation variations in processes and variables collected—some As injury-related disabilities increase, rehabilitation that collecting less than 20 variables. A variety of ISSs were assists with the reintegration of injured patients into used, most commonly the standard ISS. Using informa- functional society has broad implications. Physiotherapy tion obtained from the Injury Control Center in Uganda, and occupational therapy linked with vocational skills the Ministry of Health included injury as one of the top training programs are needed in LMICs to address the 10 health priorities facing the Ugandan people.2 1 billion people who are experiencing disabilities by pro- Quality improvement (QI) programs have been viding the tools needed to help patients attain physical shown to be valuable and inexpensive tools for strength- and socioeconomic independence and remain produc- ening the care of severely injured patients. The Royal tive members of their communities (WHO 2013a). Australasian College of Surgeons convened a meeting LMICs are home to 80 percent of people with disabil- in Melbourne, Australia, in 2012 to explore experiences ities, and they are typically among the very poorest. In with trauma QI activities in LMICs in the East Asia and Haiti, the poorest country in the Western Hemisphere, Pacific region (Stelfox and others 2012). Only 56 percent Healing Hands for Haiti, a nonprofit nongovernmental of the respondents reported having morbidity and mor- organization working closely with the local health care tality conferences, 31 percent monitored complications, community, provides rehabilitation education and train- 25 percent conducted preventable-death studies, and ing, clinical treatment, disability prevention, and public 6 percent used statistical methods for analyzing mor- awareness of disability and rehabilitation.1 bidity and mortality rates. The barriers for instituting Land mines, which are prevalent in many LMICs, QI programs included limited engagement and support are responsible for approximately 26,000 new ampu- from leaders, organizational diversity, heavy clinical tees per year; worldwide, there are more than 250,000 workloads, and medico-legal concerns. One QI program such amputees. Estimates range as high as 10 million implemented successfully at the facility level in Thailand to 25 million amputees worldwide when the effects of is described in box 3.4. 46 Essential Surgery Box 3.4 Success Story: A Quality Improvement Program at Khon Kaen Hospital, Thailand The Problem potential pitfalls, such as delays, errors, and Clinicians at Khon Kaen Hospital in northern systemic inadequacies. Thailand knew that they were seeing increasing trauma cases but lacked ways to document the Examples include the following: increase to inform their recommendations for • Penetrating injuries are explored within one hour better prevention and improved trauma care. of arrival. • Long-bone fractures are fixed within 48 hours of The Solution arrival. The hospital initiated a quality improvement (QI) • All patients with Glasgow Coma Scale <13 receive program based on a trauma registry. a head computed tomography scan. • All patients are seen within four hours of arrival. • Phase 1: Data retrieval, collection, and storage This QI program has been regularly evaluated and using participatory action research, peer review, updated, as necessary. and medical audits. • Phase 2: Data generation to allow the identifi- The Results cation of general problems involving diagnosis, Direct improvements: Mortality rates decreased early management, resuscitation, and monitor- 50 percent, delays in diagnosis decreased 70 percent, ing, as well as specific problems involving rapid and diagnostic or therapeutic errors decreased recognition and management of limb- and 50 percent. life-threatening injuries. Indirect improvements: Improvements were made • Phase 3: Development of key performance in the trauma referral plan, as well as in prehospital indicators for the overall management of care and survival. trauma patients, from prehospital care to reha- bilitation after discharge upon recognition of Source: WHO 2010. Their recommendations on trauma QI and better Head injury is the leading cause of injury death in data were included in the 2007 WHA resolution on many countries (Qureshi and others 2013). An estimated trauma and emergency care (Mock 2007). 10 million people suffer traumatic brain injuries (TBIs) annually, making TBI an important public health problem. TBIs pose especially difficult problems in LICs TRAUMA CARE OF SPECIFIC BODY REGIONS and LMICs, where TBI rates are higher than in HICs, but existing health systems are inadequate to address Head, Neck, Face, and Spine the resulting disabilities (Hyder 2013). Authors in HICs, Traumatic injury epidemiology in LICs and LMICs where resources are much greater, have published remains a relatively neglected subject (Sitsapesan and most of the guidelines for the management of severe others 2013). However, identifying the most commonly brain injuries. injured body regions is important in the design of the In Uganda, minor head injury (12 percent) was most appropriate and cost-effective treatment strategies the third most common cause for trauma admis- (Stewart and others 2013). Health care providers trained in sion in one hospital; more severe injuries, such as neurosurgery, otolaryngology, ophthalmology, plastic sur- intracranial hemorrhage (1.9 percent) and skull frac- gery, or dentistry would be better able to treat face, head, ture (1.5 percent), were much less common (Hulme and neck injuries. Orthopedic and reconstructive surgical 2010). In Sierra Leone, a population survey identified training might be more critical for addressing fractures. injuries to the face, head, and neck combined as the Surgery and Trauma Care 47 second most common cause of injuries reported injuries represent 46.2 percent of all spinal injuries; (16 percent), following extremity injuries (55 percent) the two most common causes of cervical spine injuries (Stewart and others 2013). are RTIs (67 percent) and falls (23 percent) (Solagberu Access to dedicated neurosurgical care is limited 2002). Back injuries represent 12 percent of traumatic in LICs and LMICs (Alexander and others 2009). injuries in Sierra Leone (Stewart and others 2013). General surgeons or even medical officers with lim- In austere environments where specialized rehabilitation ited training care for the vast majority of head injury resources are lacking, conservative management of spine patients. Dedicated neurosurgical units are uncommon. injuries with complete paralysis almost inevitably leads Although TBI is a frequent problem in South Africa to sores, infections, and sepsis (Gosselin and Coppotelli (25 percent of hospital admissions are due to TBI), only 2005). Those patients with no or incomplete spinal cord a small subset of patients actually require specialized injuries generally fare better than those patients with neurosurgical care. complete paralysis, but the recovery time and amount In resource-constrained settings, basic clinical eval- of residual disability are worse than if they had received uation tools such as the Glasgow Coma Score (GCS) surgical treatment. and heart rate can effectively triage head injury patients A study from Pakistan compares costs of operative and identify those most critically ill. In Malawi, a mul- and nonoperative management of spinal injuries with tivariate logistic regression model revealed that GCS complete neurological deficits. The authors find that and heart rate changes correlated closely with mor- outcomes are worse for the patients who had received tality: a drop in heart rate below 60 beats per minute surgery, as evidenced by longer length of stay, longer (bpm) or an increase in heart rate above 100 bpm rehabilitation time, and higher infection rates. The increased the odds of dying by 10.9 and 11.6 times, mean cost of treatment is higher in the operative group respectively (Qureshi and others 2013). Based on the (US$6,500) as compared with the nonoperative group GCS, the odds of mortality for moderate and severe (US$1,490). The researchers conclude that, in their head injury increases by 4- and 88-fold, respectively, setting, patients with complete spinal cord injuries compared with mild head injury. The presence of mul- should be managed nonoperatively, with surgery only tiple injuries exacerbated head trauma; all deaths in if rehabilitation is impeded as the result of pain or the moderate head injury group were associated with deformity (Shamim, Ali, and Enam 2011). multiple trauma. Accordingly, simple methods to improve care for head injuries in LMICs could include the following: Thorax and Abdomen Patients with injuries to the thorax and abdomen may • Immediate measurement should be made of GCS and present with higher ISS scores. Information on injuries vital signs. to these areas is extremely limited in LMICs and may • Triage guidelines should be based on GCS and neuro- be underdiagnosed because of patient deaths in the logic examination. field, the unavailability of diagnostic capability with • Health care personnel treating patients should con- computed tomography scanning, and the scarcity of sider whether injured patients with GCS 3 should comprehensive registries. take up limited beds and resources in intensive care Qureshi and others (2013) suggest that patients units. with moderate head trauma and multiple trauma may • Patients with multiple trauma injuries should receive have died because of the inability to diagnose and higher triage priority and appropriate and accurate treat abdominal injuries. Perforation of abdominal vis- resuscitation to limit mortality and morbidity. cera was only reported in 0.5 percent of trauma cases in a Ugandan hospital, while no chest injuries were Survival rates among the most critical neurotrauma reported (Hulme 2010). Twenty-three cases of isolated patients depend on the development of the trauma small bowel perforation from blunt abdominal trauma system, including access to emergency and neurointen- were identified over a four-year period in a hospital in sive care units and neurosurgeons. Low compensation Cameroon (Chichom Mefire and others 2014). Timely for trauma care and fear of being sued may serve as diagnosis was difficult because of lack of awareness of disincentives to the few neurosurgeons in these areas this injury by clinicians and poor diagnostic capability. from participating fully in integrated neurotrauma care Improved education and clinical awareness, serial exams, (Rubiano and others 2013). and repeated upright chest x-rays are likely to lead to Spinal cord injuries usually result from road traffic earlier diagnosis and improve treatment in low-income accidents, falls, or sports. In Nigeria, cervical spine environments. 48 Essential Surgery Pelvis and Extremities cast or traction in LMICs. The long-term advantages The musculoskeletal (MSK) system is the most com- of surgical management of some tibial shaft fractures mon site of residual disability in trauma survivors over cast treatment are still debated, but not so for hip (Mock and Cherian 2008). If there is one permanently or femur fractures. disabled person for every road traffic death, each year Yet it has been longstanding dogma that, even if RTIs alone would account for 1.25 million newly dis- all necessary resources are available, surgery for MSK abled persons (WHO 2013c). For LMICs, the literature injuries would be too expensive in LMICs. However, contains many more studies on the prevention of inju- the Surgical Implant Generation Network (SIGN) ries than on their treatment (Forjuoh 2003; Norse and intramedullary nailing system was designed specifically Hyder 2009). In many LMICs, particularly in rural areas, for austere environments. SIGN is a nonprofit, nongov- the first, and often only, point of care is the traditional ernmental organization that provides the implants at healer. Although these healers probably do more good no cost to patients. As long as all cases are reported in than harm overall, avoidable sequelae of significant an electronic central database, all implants are replaced injuries are well documented (Dada and others 2009). for free. This user-friendly system has seen remarkable Unfortunately, the preventable burden has never been growth; during a period of approximately 15 years, quantified. more than 110,000 patients were treated by more than Management protocols and techniques for optimal 5,000 surgeons in more than 200 hospitals in 53 LMICs, outcomes of MSK injuries are in general well known with results comparable to those in HICs (Sekimpi and and widely available in HICs. They most often involve others 2011). This system was introduced in Cambodia some form of bone or soft tissue surgical procedure in 2007. A study comparing the first 50 patients who using high-end diagnostic and intraoperative imaging received nails for their femur fractures to the last and monitoring technologies and expensive implants 50 patients who were treated by traction showed that and products. LMICs have severe shortages of well- surgery had better clinical outcomes and was more trained surgeons, anesthesiologists, nurses, rehabilita- cost-effective than traction (US$888 versus US$1,107 tion specialists, and equipment. Providers often have no per DALY averted, respectively) (Gosselin, Heitto, and choice but to use conservative treatment with casts and Zirkle 2009). splints or traction and bed rest, with predictably worse outcomes. Cross-Cutting Issue for Care of Injuries to All Body Most pelvic fractures heal uneventfully with con- Regions: Bleeding servative management; only a minority suffer signifi- cant deformity, shortening, or chronic pain. The upper Tranexamic acid has been found to be effective in low- extremity can tolerate a certain degree of shortening or ering mortality in bleeding trauma patients. It is a low- deformity without affecting function, so conservative cost, generic medication. One cost-effectiveness analysis treatment of fractures of the humerus, forearm, wrist, estimated that the cost per year of life gained by admin- or hand, which are almost routinely treated surgically istering tranexamic acid was US$48–US$$66, depending in HICs, can still yield acceptable functional results. on the geographic location (Guerriero and others 2011). This is not true of displaced intra-articular fractures or neglected dislocations of the shoulder, elbow, or wrist joints. The economic repercussions of a useless BURNS upper extremity in a farmer or manual laborer are self-evident. The lower extremity is not as forgiving Burden of Disease of negative outcomes as the upper one: shortening Burn injuries are among the most devastating of all of more than 2 centimeters, angulation of more than injuries and a major global public health concern 5–10 degrees in any plane, displaced intra- or periar- (Forjuoh 2006). Each year, more than 265,000 people ticular fractures, or nonunions all lead to significant die from fire-related burn injuries. Millions more suffer functional impairment and eventually chronic joint from burn-related disabilities and disfigurements, which pain or low back pain. The superior results of surgical have psychological, social, and economic effects on the treatment over conservative management of hip frac- survivors and their families. Fire-related burns account tures, femur fractures, severe knee ligament injuries, for 17 million DALYs lost worldwide annually (WHO many tibia fractures, and ankle and foot fractures 2013b). Strikingly, fires rank third worldwide for DALYs and dislocations have all been well established in HICs lost because of unintentional injury in Sub-Saharan during the past half century. However, to this day, Africa, second in Eastern Mediterranean and South-East most of these fractures are treated conservatively with Asian countries, and fifth in HICs. Surgery and Trauma Care 49 Burn is a disease of poverty; the burden of burn injury Conte 2009). Furthermore, coordination between first- falls predominantly on the world’s poor, with 95 percent level hospitals and third-level burn centers is limited. of fire-related burn deaths occurring in LMICs. Not only are burn deaths and injuries more common in people of lower socioeconomic status, but the survivors find Cost-Effectiveness of Burn Care that their poverty levels worsen after recovery (Peck, Burn care requires a significant number of dedicated Molnar, and Swart 2009). The high incidence of burns expert personnel and is resource intensive. When choos- in this population is driven by negative impact factors, ing between different treatment options, the available including the influx of people to urban areas, haphazard funds, personnel, and required expertise must be weighed. urban development, inadequate electrification of homes, Reliable information relating costs to clinical outcomes is paraffin used as a primary energy source, and lack of needed. Burn-care costs have been the subject of very few preventive programs. investigations and are among the least studied topics by The worldwide incidence of death from fire-related health services researchers, particularly in LMICs (Atiyeh injuries in 2004 was estimated to be 3.8 per 100,000 and others 2002). In a prospective study by Ahachi and population, with the highest rates in Southeast Asia and others, the direct hospitalization cost of managing major Sub-Saharan Africa. The incidence of burns in LMICs is acute burns in Lagos, Nigeria, was examined to identify 4.4 per 100,000 population, compared with an incidence the factors that influenced cost. The researchers found of 0.84 per 100,000 population in HICs (WHO 2013b). that the average daily cost of treating a burn patient was In Bangladesh, the incidence of nonfatal burn injury is approximately US$6, and that the average overall cost for 166.3 per 100,000 per year (Mashreky and others 2009). a burn admission was approximately US$62; the costs In addition, the epidemiology of burn injuries is of wound dressings, hospital admission, and surgery also different in LMICs, where it is predominantly a constituted 29.5 percent, 25.7 percent, and 19.1 percent, pediatric and geriatric disease (Ahuja and Bhattacharya respectively, of the total amount spent (Ahachi and 2002). Children, especially those under age five, have others 2011). In a similar study in Bangladesh, the aver- been shown to constitute the highest risk group of burn age cost for serious and major burns was US$166 and victims, followed by those ages 20–29. Of the studies that US$58 per burn injury, respectively. For the treatment reported data on childhood burns, children under age of a severe burn, a family spent an average of US$462 four had a disproportionately higher number of burns; (Mashreky and others 2009). they accounted for nearly one-third of the total number Prehospital care of burn victims using simple mea- of burn cases, all age groups considered. In many set- sures, such as irrigation with clean cool water and clean tings, including Brazil, Côte d’Ivoire, India, and Malawi, dressings, is of particular importance where access to this age group accounts for nearly half of all childhood hospital care is commonly delayed. Prehospital care is burns (Forjuoh 2006). discussed at greater length in chapter 14. Burn centers are usually part of large urban hos- pitals and act as referral centers for patients from smaller first-level hospitals and health centers. Burn Cost-Effectiveness of Hospital Management units are dedicated units within hospital structures that Although very little literature exists on the effectiveness manage care for patients of all ages; burn units typi- of burn centers compared with smaller local burn units, cally have dedicated nurses and staff. In LMICs, most data suggest that the early burn excision frequently existing burn centers are situated in large cities and are done in burn centers improves the survival of patients insufficient for the high incidence of injuries. Although (Church and others 2006). Patients with burns exceeding management in these centers is based primarily on 90 percent of total body surface area (TBSA) regularly standard principles, hospitals are ill-equipped with staff survive in the world’s best centers; this rate is in stark and support facilities. In addition to inadequate phys- contrast to the mortality for burns exceeding 40 percent ical structures, these centers are invariably plagued by of TBSA in most LMICs, which approaches 100 percent lack of resources, lack of operating time, and shortages (WHO 2002b). Cost-effective burn treatment to con- of blood. Often, no dedicated burn surgeons are avail- serve scarce resources includes emphasizing early fluid able; general surgeons without formal burn training are resuscitation and ensuring proper compliance with involved in burn care. Burn nursing is also not a recog- established resuscitation protocols, such as the Parkland nized concept. Resuscitation is often delayed because formula. patients have to travel long distances and transport Increasingly aggressive surgical approaches, with facilities are poor. Ambulance and prehospital ser- early tangential excision and wound closure, are stan- vices are practically nonexistent (Atiyeh, Masellis, and dard practice in burn units in HICs. Such approaches 50 Essential Surgery likely represent the most significant change in recent The medicinal properties of honey and other hive years and have led to improvements in mortality products have been well described for a variety of medic- rates of burn victims at substantially lower costs than inal and nutritional purposes, including the treatment of waiting for the eschar—the dead burned skin that burn wounds. The beneficial effects of honey include the forms a scab over the burned area—to peel off. In the cleansing of wounds, absorption of edema fluids, antimi- absence of proper burn-care facilities, blood supply, crobial activity, promotion of granulation tissue, epithe- and other resources such as dressings, and with inad- lialization, and the improvement of nutrition. Another equately trained personnel, such aggressive therapy cost-effective, locally available burn dressing is the in burn victims can induce further trauma and result banana leaf dressing (BLD). Its preparation is very in suboptimal outcomes (Munster, Smith-Meek, and simple: a banana leaf is washed, pasted to bandage cloth Sharkey 1994). Smaller burns over critical areas such with flour paste, dried for 24 hours, rolled, packed into as joints are better suited to this technique (WHO a paper bag, and autoclaved. This process can be easily 2011). However, for a large percentage of patients with taught to previously treated patients, relatives of patients, extensive burns in most LMICs, early excisional sur- and literate as well as illiterate individuals. Banana leaves gery is not available. are readily available in most cities, towns, and villages in LMICs. It is even possible to have a patch of land with a Triage. With the realities of inadequate access to sur- banana plantation within the hospital premises in a busy gical facilities in the LMIC environment, closed burn burn unit. BLD, being totally nonadherent, tends to slip. wound dressing, eschar separation, and delayed skin BLD is 160 times cheaper than Soframycin-impregnated grafting will help to separate patients with less exten- gauze, 1,750 times cheaper than collagen sheet, and sive injuries (less than 40 percent of TBSA) with the 5,200 times cheaper than biosynthetic dressing (Atiyeh, potential to survive from those patients with extensive Masellis, and Conte 2009). More recently, moist exposed wounds exceeding 50 percent of TBSA with poor sur- burn ointment (MEBO), a traditional Chinese burn vival who should be triaged to palliative care (Ahuja and remedy, was reported to provide an adequate moist Bhattacharya 2004). environment for optimal healing without the need for a cumbersome and expensive protective dressing. Its main Wound Care. Local wound care in developing coun- active component is beta-sitosterol in a base of beeswax tries is one of the greatest barriers to effective burn and sesame oil. MEBO has been found to be a useful wound management; wound-care products and dress- alternative in the treatment of partial-thickness burns ing supplies are not easily obtainable or are too expen- because of its convenient method of application; it could sive. Cool running water at a temperature between 10 be a valuable treatment modality in LMICs (Atiyeh and and 15 degrees centigrade for 20–30 minutes is con- others 2003). sidered adequate burn first aid treatment (Skinner and Exposure therapy is often the method of choice Peat 2002). In one study of burn treatment in LMICs because gauze dressings are considered expensive. The that included all countries in Latin America and the exposure method is particularly suitable for the treat- Caribbean, the Middle East and North Africa, and Sub- ment of pediatric burn injuries, especially in a tropical Saharan Africa, plus China, India, and other countries climate where patients are nursed under mosquito nets in Asia and adjoining islands, cool water was applied to keep flies and other insects away from open burn to the burned area as a first aid therapy in one-third of wounds. In an observational study by Gosselin and the cases, a ratio comparable to that observed in some Kuppers comparing open and closed dressing in burn HICs (Forjuoh 2006). Silver-based dressing and oint- wounds, the open method had as good or better early ment should be used, if available. However, the use of outcomes than the closed method, at significantly lower locally available and effective wound-care alternatives, cost; it is the recommended treatment for burns in envi- amniotic membrane in particular, is cost-effective and ronments similar to the one in this study (Gosselin and ideal as a biological dressing. Amniotic membrane Kuppers 2008). remarkably reduces the cost of dressing changes and the periods of stay in hospitals. It also significantly Pain Management. Pain management, particularly in reduces nursing time and thereby nursing costs (Atiyeh, children, is another factor that divides the developed Gunn, and Hayek 2005). It is often in ample supply if from the developing world. Provision of pain relief in the facility has a busy obstetrics department. However, the face of limited resources and a limited spectrum other considerations, such as cultural acceptability or of analgesics, if any are available, is a challenge. In a the risk of HIV or hepatitis infections, also need to be study of the patterns of pediatric analgesic use in Sub- considered. Saharan Africa, paracetamol and ibuprofen were widely Surgery and Trauma Care 51 employed, constituting approximately 60 percent of all Burn prevention strategies are well recognized as analgesics, while morphine was used in only 0.2 percent being very cost-effective, more so than burn treatment of cases. This falls short of the WHO standards (Madadi (see chapter 20). and others 2012). Antibiotic Use. Because of the paucity of studies, Future Developments in the Treatment of Burns whether the use of prophylactic systemic antibiotics Mandatory reporting of burn admissions to a central is effective and cost-effective in preventing infective registry can generate data invaluable for evaluating strat- complications remains unclear; however, the available egies and prevention programs. Optimizing the current evidence does not support its use for prophylaxis (ICHRC information system is achievable by customizing coding 2013). developments already underway; combining data from the various agencies to form a national burn injury data- Adequate Nutrition. Healing a burn injury demands base will provide the best national overview of burns. a great deal of energy from the body. Adequate nour- Large-scale awareness programs aimed at policy mak- ishment, including adequate protein, calories, vitamins, ers, politicians, professionals, the general public, and the and micronutrients, is essential to support healing. media are required to communicate the burden, impact, Some burn units have started to introduce “Plumpy’nut,” and losses due to burn-related injuries. Recognizing that a high-protein and high-energy peanut-based food that burns are a public health problem, and making burn is readily available as a nutritional supplement for prevention and management a national programmatic malnourished children, to the burn nutrition regimen. priority, can ensure that sufficient funds are available for A two-month Plumpy’nut regimen for a child costs such programs. US$60. Telemedicine is an effective tool for accurately evalu- ating the condition of patients with burns. This tool can Rehabilitation. In addition to burn-related mortal- reduce undertriage or overtriage for transport, improve ity, burn-related disabilities have substantial functional resource utilization, and enhance and extend burn center and economic impacts. Functional disability is defined expertise to many rural communities at low cost (Saffle in the Global Burden of Disease report as disability- and others 2009). Data specific to burn assessment and adjusted life years (DALYs), or the number of years lost diagnosis using telemedicine suggest that this is a safe, due to poor health, disability, or early death (Murray reliable, and cost-effective means to attain consultation and Lopez 1996). Worldwide, burns covering more from specialists for patients in underserved areas (Kiser than 20 percent of TBSA rank first among injury and others 2013). As this technology has evolved, it has types causing short- or long-term disability. The WHO become only slightly more expensive than a standard estimates that 116 million people have suffered such computer with a high-speed Internet connection. burns—approximately four times the number of people with HIV/AIDS at 31 million people (WHO 2008). Rehabilitation of burn patients must begin imme- diately after the injury; the delay between inpatient ORTHOPEDICS and outpatient therapy should be minimized to facil- In many HICs, orthopedic surgeons manage acute itate a quick return of functional patients to society MSK injuries and their more chronic sequelae, as well (Takayanagi, Kawai, and Aoki 1999). Part of the reha- as nontrauma-related MSK conditions (“cold” ortho- bilitation process is the prevention and treatment of pedics). Congenital and hereditary MSK conditions postburn scarring, the most common and frustrating are addressed in chapter 8; this section considers only complication because of its aesthetic and functional acquired MSK diseases and conditions. consequences (van den Kerckhove 2001). The lack of The world population is aging: the global life- available personnel significantly limits inpatients and expectancy-adjusted median age will increase from 26.6 outpatient postburn rehabilitation. The ability to train years as of 2014 to 31.1 years by 2050 (Lutz, Sanderson, family members in basic physical and occupational and Scherbov 2008). The burden of age-related con- therapy skills, such as range of motion exercises, is a ditions, such as osteoporosis, will rise accordingly cost-effective way to reduce the extent of disabilities. with the increase in prevalence of known risk factors, Effective rehabilitation can minimize the need for such as menopause, physical inactivity, tobacco and reconstruction. Local surgeons, where available, need to alcohol abuse, nutritional deficiencies such as for cal- be trained in basic plastic surgical techniques, such as cium and vitamin D, and the wider use of medications contracture release (see chapter 13). such as corticosteroids (Lunenfeld and Stratton 2013). 52 Essential Surgery Osteoporosis predisposes people to insufficiency A decade ago, OA was estimated to be the fourth fractures—trauma-related fractures that would not leading cause of disability worldwide, most of it attrib- cause failure of normal bone. Females are affected utable to the involvement of the hip and knee (WHO more than males and suffer more disability than males 2002a). The GHE study estimates it accounts for (Guralnik and others 1997). One study in Thailand approximately 16 percent of all MSK-related DALYs showed that life expectancy at age 60 is 20.3 years for (WHO 2013b); it is strongly associated with aging and males and 23.9 years for females, yet disability-free heavy physical occupational activity. In HICs, end-stage life expectancy is 16.4 and 18.2 years, respectively OA is most commonly treated with total joint replace- (Jitapunkul and others 2003). ment (TJR), a procedure unavailable for the vast major- ity of sufferers in LMICs. It is estimated that the Asian population older than age 65 will double between 2010 Traumatic Injuries and 2040, and the OA burden will increase accordingly It has long been an orthopedic maxim that displaced (Fransen and others 2011). Because surgical treatment fractures, particularly if intra-articular, have a better will remain out of reach for most people, prevention functional outcome if reduced and fixed, surgically if strategies targeting such risk factors as obesity will necessary. The shoulder, wrist, spine, and pelvis are have the greatest impact. In China, for example, each common insufficiency fracture sites; although acutely year only about 50,000 (0.05 percent) of the estimated disabling, most such fractures will heal without signifi- 120 million OA sufferers receive TJRs (Huang, He, and cant long-term disability without surgical treatment, Wang 2012). Although this number has increased by even if displaced. approximately 15 percent every year in the past 10 years, This outcome is not true for fractures of the lower the unmet need will clearly remain enormous for the extremity, in particular the hip. The personal, familial, foreseeable future. and societal burden of hip fractures in elderly patients IAs include rheumatoid arthritis (RA), gout, is well documented in HICs. Such information is sero-negative arthropathies, and a myriad of mono- lacking for most LMICs, but it is estimated that world- or polyarthropathies associated with autoimmune wide, there were 1.7 million hip fractures in 1990. This diseases. According to the GHE, RA and gout account incidence is forecast to grow fourfold to 6 million by for approximately 5 percent of the burden attributable 2050 (WHO 2003). The mortality rate is approximately to MSK disorders (WHO 2013b). Although data on 20 percent, and the lifetime risk for a 50-year-old female the IA burden in LMICs are unavailable, inadequate is estimated to be 40 percent, the same as for coronary rheumatology services suggest that it is likely to be heart disease. quite high. It is estimated that for the more than Early surgery to repair or replace the hip prevents the 4 billion people in LMICs, the prevalence of RA is complications related to prolonged bed rest, including between 8 million and 12 million (Chopra and Abdel- pressure sores, deep vein thrombosis, and urinary or Nasser 2008). The WHO has devised the Community pulmonary infections. It also leads to better functional Oriented Program for the Control of Rheumatic outcomes with less mal-unions or painful nonunions Diseases, which is being implemented in many LMICs than conservative bed treatment. However, even in with the goal of collecting community-based data the best-case scenario, one of every two patients suf- on pain and disability from rheumatic conditions fers some form of permanent disability (WHO 2003). (Chopra and Abdel-Nasser 2008). A study in Singapore reported that overall costs for The need for surgery for IA (synovectomy, tendon surgical care of hip fractures were actually less than for transfers, fusion, or arthroplasty) is less common conservative management (Lee and others 2012). Hip than for OA. Medical management can be quite fractures have doubled or tripled in the past 30 years effective for many years, but depends on early and in Asia. If the same trend persists, the societal and accurate diagnosis and the availability of human and economic burden will be nearly unsustainable by 2050 technological resources, appropriate medications, (Mithal and Kaur 2012). and rehabilitative services (Woolf, Erwin, and March 2012). Many of these resources remain unavailable in LMICs, making educating the public and raising Nontraumatic Conditions awareness of preventive strategies crucial. Such strate- Global aging will also increase acquired chronic MSK gies include weight control, regular exercise, balanced conditions, such as degenerative osteoarthritis (OA), diet, avoidance of tobacco and alcohol use, and mod- inflammatory arthropathies (IA), and neoplasms (pri- ification of the work environment (Mody and Cardiel mary or metastatic). 2008). The higher prevalence of chronic infections, Surgery and Trauma Care 53 such as tuberculosis, HIV/AIDS, and hepatitis B or C, Table 3.3 Change in Rates of Nontraumatic makes the medical management of IA even more Musculoskeletal YLDs and DALYs, 2000–2011 challenging. Change in rates per 100,000 MSK tumors are rare. Primary MSK malignancies are Condition population (percent) not even on the neoplasm list of the GHE framework. Secondary, or metastatic, disease is more common, Osteoarthritis YLDs 14.8 particularly with common primary cancers, such as DALYs 14.8 those of the lung, breast, or prostate. A combination of Rheumatoid arthritis YLDs 7.2 chemotherapy, radiation, and surgery is often standard DALYs 9.2 in HICs. No data are available from LMICs, but late presentation (often pathologic fracture) and lack of Back and neck pain YLDs 5.4 adjuvant therapies preclude any attempt at limb-saving DALYs 5.5 surgery. Palliative amputation is often the only option. Other musculoskeletal YLDs 6.3 When limb-saving surgery is available and indicated, conditions DALYs 9.5 procedures such as autoclaving and then re-implanting Source: Data based on Global Health Estimates (WHO 2013b). diseased bone can be an acceptable alternative to prohib- Note: DALYs = disability-adjusted life years; YLDs = years lost to disability. itively expensive prosthetic replacement (Khattak and others 2006). Although rarely requiring surgery, low back pain (LBP) and neck pain are extremely common. They (Amenu, Belachew, and Araya 2011; Chalya and others encompass a variety of etiologies: mechanical pain, 2012). Independent risk factors for increased noso- perivertebral soft tissue problems, disk disease, degener- comial infections included age greater than 40 years, ative conditions, and even malingering. The worldwide length of hospital stay, and an admitting diagnosis prevalence of LBP is estimated to be 10 percent; even if of trauma. only 1 percent of those cases require surgical treatment, However, geographic variables present important the unmet need is tremendous. Depending on duration barriers to timely access to health services (Spiegel and the presence or absence of leg pain, the disability and others 2011). Delayed presentation, inadequate weight for LBP in the Global Burden of Disease 2010 antibiotic treatment before admission, shock on admis- ranges from 0.269 to 0.374 (profound intellectual dis- sion, compromised immune status with HIV positivity ability has a disability weight of 0.157; severe chronic and low CD4 counts, and malnutrition lead to higher obstructive pulmonary disease has a disability weight morbidity and mortality rates and may be part of the of 0.383), which reflects the significance of perceived underlying increased risk in trauma patients. In obstetric impairment by the survey responders (Salomon and patients, the omission of even one dose of antibiotics others 2012). Personal, societal, and economic burden was associated with increased wound infection rates in are high and well documented in HICs; it is unlikely that Ethiopia (Amenu, Belachew, and Araya 2011). the burden would be substantially different in LMICs, Surveys employing the WHO Tool for Situational although no reliable data exist. Analysis to Assess Emergency and Essential Surgical Table 3.3 summarizes the changes in rates between Care have identified significant gaps in infrastructure, 2000 and 2011 for the above conditions. human resources, life-saving and disability-preventing surgical interventions, and essential equipment in many LMICs (Kushner and others 2010; Spiegel and INFECTIONS others 2011). Incision and drainage capabilities seem to exist in 75–100 percent of first-level facilities (local Soft Tissue Infections dispensaries, first-level health care facilities, and local General surgical cases, including incision and drainage hospitals), and general practitioners and nonphysician of abscesses, represent a high proportion of overall pro- clinicians without significant surgical training perform cedures at hospitals in LMICs (Ivers and others 2008). the majority of procedures. Lack of supplies is the most Surgical site infections are the second most commonly common reason cited when patients are referred to reported nosocomial infections in Sub-Saharan Africa, higher-level facilities for incision and drainage. A coor- following urinary tract infections. In obstetric patients, dinated countrywide initiative to strengthen surgical surgical site infections were higher in LMICs than in services at the first-level hospitals in Mongolia docu- HICs and were the most frequent nosocomial infection mented significantly increased capabilities to perform 54 Essential Surgery incision and drainage of abscesses, wound suturing, Recognizing the complexity, labor intensiveness, com- and wound debridement (Henry and others 2012) plications, and anticipated costs of treating this con- (figure 3.2). Additionally, the development of formal dition when chronic, it is clearly better to prevent the emergency rooms with adequate supplies and the condition by performing a select number of simple and implementation of basic standards and guidelines for cost-effective surgical procedures in the acute phase. emergency care have dramatically improved timely These procedures may be considered to be preventive access to and availability of these basic procedures strategies aimed at reducing the risks of developing a (figure 3.3). chronically infected state; they include drainage of an abscess or debridement of an area of bone destruction, and prompt irrigation, debridement, and stabilization Bone Infections of open fractures. A literature search identified no reli- Osteomyelitis, literally the infection of bone or its mar- able information on cost-effectiveness; we hypothesize row, is most often due to hematogenous (via the blood but cannot prove that a multistage, resource-intensive vessels) seeding in children, or as a complication of open treatment course of chronic osteomyelitis would not be fractures or orthopedic surgical procedures in patients cost-effective. However, preventive surgical strategies of all ages. There is a paucity of information in the lit- are much simpler, can be delivered at the first-level or erature concerning the epidemiology, burden of disease, referral level in most cases, and are likely to be more and cost-effectiveness of treatment for osteomyelitis. cost-effective. Figure 3.2 Surgical Procedures Performed before and after Training at First-Level Facilities 60 50 Number of procedures 40 30 20 10 0 n on se on ion s ti s Am es ctu fting pu ic pr wn nt tin ent Co kin g t my y y infi y ab al en tio se Bl jurie od nc m lea me s m tati rti ri v at do to sto es em em mo na ita nju nb e ra ltr os re ide n t u ins sc eg to c u g ag e gi g p us he lc na ina re r re i s br re un an e cy Fra Res ra mo trac ma de ub fo tic of u S / tra he re ut p ra yro est t es of nd ge / re o rip tu s ne my nt rn t th ou ctu l ec an ng, nc a pe Bu Pe Ch es to v W e/ ra si ido na us Su ptur s dd ic Re e la no dr ub ru ca Ve th g, ap Lo ine on rin ico pr isi er tu Cr Inc Ut su nd ou W Before After Source: Henry and others 2012, figure 6. With permission from Springer Science and Business Media. Note: Before = prior to training; after = two years posttraining, first-level health care workers. Surgery and Trauma Care 55 Figure 3.3 Pilot at First-Level Facilities: Evaluation before and after Two Years Countrywide Training 90 80 70 60 50 Percent 40 30 20 10 0 Establishment Supply of Recording of Instructions on of emergency room emergency kits emergency care cases facility and instrument usage Before After Source: Henry and others 2012, figure 5. With permission from Springer Science and Business Media. Note: Before = prior to training; after = two years posttraining, first-level health care workers. CONCLUSION makers as they make difficult choices in allocating scarce resources. Throughout LMICs, the rates of trauma-related death The international community can assist policy mak- and disability are increasing, a trend that is projected to ers by developing and implementing guidelines and by continue. Timely access to surgical care can play a key regularly monitoring and evaluating them. Appropriate role in improving outcomes; such access has been shown education and training programs, combined with the to be effective and cost-effective. Too often, however, infusion of basic material and technical resources, may the lack of access to surgical care means that medically partially alleviate the brain drain crisis. preventable deaths occur and avoidable disabilities are The creation and strengthening of trauma systems incurred. would also reinforce both the human and the material The toll in human terms is clear and cries out to be resources of existing health care systems. addressed. The toll in economic terms is no less clear: Societies lose the present and future contributions of productive members; poor families suffer increased pov- NOTES erty because of the relatively high costs of medical care as well as the loss or disability of members. Poor families The World Bank classifies countries according to four income are limited in their coping mechanisms, and paying for groupings. Income is measured using gross national income (GNI) per capita, in U.S. dollars, converted from local currency medical care may involve the liquidation of essential using the World Bank Atlas method. Classifications as of July assets or heavy borrowing. Families might not be able 2014 are as follows: to afford to send children to school or must send them to work to replace the contribution of the deceased or • Low-income countries (LICs) = US$1,045 or less in 2013 disabled family member. • Middle-income countries (MICs) are subdivided: Reliable data, particularly data obtained through • Lower-middle-income = US$1,046 to US$4,125 improved surveillance and monitoring systems, • Upper-middle-income (UMICs) = US$4,126 to US$12,745 are needed to better inform the decisions of policy • High-income countries (HICs) = US$12,746 or more 56 Essential Surgery This chapter used the World Health Organization’s geographi- Countries with Limited Health Care Resources cal classification for six regions: African Region, Region of (Part 2).”Annals of Burns and Fire Disasters 22 (4): 189–95. the Americas, South-East Asia Region, European Region, Chalya, P. L., J. B. Mabula, M. Koy, J. B. Kataraihya, H. Jaka, Eastern Mediterranean Region, and Western Pacific and others. 2012. “Typhoid Intestinal Perforations at a Region. University Teaching Hospital in Northwestern Tanzania: 1. Healing Hands for Haiti. http://www.healinghandsforhaiti A Surgical Experience of 104 Cases in a Resource-Limited .org/Home/tabid/38/language/en-US/Default.aspx. Setting.” World Journal of Emergency Surgery 7: 4. 2. WHO and VIP (Violence and Injury Prevention). Chichom Mefire, A., P. E. Weledji, V. S. Verla, and N. M. Lidwine. “Violence and Injury Prevention and Disability (VIP): 2014. “Diagnostic and Therapeutic Challenges of Isolated Uganda.” http://www.who.int/violence_injury_prevention Small Bowel Perforations after Blunt Abdominal Injury in /surveillance/countries/uga/en/index.html. Low Income Settings: Analysis of Twenty-Three New Cases.” Injury 45 (1): 141–45. doi:10.1016/j.injury.2013.02.022. Choo, S., H. Perry, A. A. Hesse, F. Abantanga, E. Sory, and others. 2010. “Assessment of Capacity for Surgery, Obstetrics REFERENCES and Anaesthesia in 17 Ghanaian Hospitals Using a WHO Assessment Tool.” Tropical Medicine and International ACS (American College of Surgeons). 2006. Resources for Health 15 (9): 1109–15. Optimal Care of the Injured Patient. Chicago: American Chopra, A., and A. Abdel-Nasser. 2008. “Epidemiology of College of Surgeons. Rheumatic Musculoskeletal Disorders in the Developing Ahachi, C. N., I. O. Fadeyibi, F. O. Abikoye, M. K. Chira, World.” Best Practice and Research in Clinical Rheumatology A. O. Ugburo, and S. A. Ademiluyi. 2011. “The Direct 22 (4): 583–604. Hospitalization Cost of Care for Acute Burns in Lagos, Church, D., S. Elsayed, O. Reid, B. Winston, and R. Lindsay. Nigeria: A One-Year Prospective Study.” Annals of Burns 2006. “Burn Wound Infections.” Clinical Microbiology and Fire Disasters 24 (2): 94–101. Reviews 19: 403–34. Ahuja, R. B., and S. Bhattacharya. 2002. “An Analysis of Dada, A., S. O. Giwa, W. Yinusa, M. Ugbeye, and S. Gbadegesin. 11,196 Burn Admissions and Evaluation of Conservative 2009. “Complications of Treatment of Musculoskeletal Management Techniques.” Burns 28 (6): 555–61. Injuries by Bone Setters.” West African Journal of Medicine ———. 2004. “Burns in the Developing World and Burn 28 (1): 43–47. Disasters.” British Medical Journal 329: 447–49. Alexander, T., G. Fuller, P. Hargovan, D. L. Clarke, D. J. Muckart, Forjuoh, S. N. 2003. “Traffic-Related Injury Prevention and S. R. Thomson. 2009. “An Audit of the Quality of Care Interventions for Low-Income Countries.” Injury Control of Traumatic Brain Injury at a Busy Regional Hospital and Safety Promotion 10 (1–2): 109–18. in South Africa.” South African Journal of Surgery 47 (4): ———. 2006. “Burns in Low- and Middle-Income Countries: A 120–26. Review of Available Literature on Descriptive Epidemiology, Amenu, D., T. Belachew, and F. Araya. 2011. “Surgical Site Risk Factors, Treatment, and Prevention.” Burns 32 (5): Infection Rate and Risk Factors among Obstetric Cases of 529–37. Jimma University Specialized Hospital, Southwest Ethiopia.” Fransen, M., L. Bridgett, L. March, D. Hoy, E. Penserga, and Ethiopian Journal of Health Sciences 21 (2): 91–100. P. Brooks. 2011. “The Epidemiology of Osteoarthritis in Ameratunga, S., M. Hijar, and R. Norton. 2006. “Road-Traffic Asia.” International Journal of Rheumatic Diseases 14 (2): Injuries: Confronting Disparities to Address a Global 113–21. Health Problem.” The Lancet 367 (9521): 1533–40. Gabbe, B., P. Simpson, A. Sutherland, R. Wolfe, M. C. Fitzgerald, Atiyeh, B. S., R. Dham, M. Kadry, A. F. Abdallah, M. Al-Oteify, and others. 2012. “Improved Functional Outcomes for and others. 2002. “Benefit-Cost Analysis of Moist Exposed Major Trauma Patients in a Regionalized, Inclusive Trauma Burn Ointment.” Burns 28: 659. System.” Annals of Surgery 255 (6): 1009–15. Atiyeh, B. S., S. Gunn, and S. N. Hayek. 2005. “New Technologies Gosselin, R. A., and C. Coppotelli. 2005. “A Follow-Up Study for Burn Wound Closure and Healing: Review of the of Patients with Spinal Cord Injury in Sierra Leone.” Literature.” Burns 31: 944–56. International Orthopedics 29 (5): 330–32. Atiyeh, B. S., J. Ioannovich, G. Magliacani, M. Masellis, Gosselin, R. A., and M. Heitto. 2008. “Cost-Effectiveness of M. Costagliola, and others. 2003. “A New Approach to Local a District Trauma Hospital in Battambang, Cambodia.” Burn Wound Care: Moist Exposed Therapy: A Multiphase, World Journal of Surgery 32 (11): 2450–53. Multicenter Study.” Journal of Surgical Wound Care 2 (1): ———, and L. G. Zirkle. 2009. “Cost-Effectiveness of 18–27. Replacing Skeletal Traction by Interlocked Intramedullary Atiyeh, B. S., A. Masellis, and C. Conte. 2009. “Optimizing Nailing for Femoral Shaft Fractures in a Provincial Trauma Burn Treatment in Developing Low- and Middle-Income Hospital in Cambodia.” International Orthopedics 33 (5): Countries with Limited Health Care Resources (Part 1).” 1445–51. Annals of Burns and Fire Disasters 22 (3): 121–25. Gosselin, R. A., and B. Kuppers. 2008. “Open versus Closed Atiyeh, B., A. Masellis, and C. Conte. 2009. “Optimizing Management of Burn Wounds in a Low-Income Developing Burn Treatment in Developing Low-and Middle-Income Country.” Burns 34 (5): 644–47. Surgery and Trauma Care 57 Gosselin, R. A., A. Maldonado, and G. Elder. 2010. “Comparative Wounds: A Simple Strategy in a Resource-Poor Setting.” Cost-Effectiveness Analysis of Two MSF Surgical Trauma Burns 39 (1): 155–61. Centers.” World Journal of Surgery 34 (3): 415–19. Kushner, A. L., M. N. Cherian, L. Noel, D. A. Spiegel, Gruen, R. L., B. J. Gabbe, H. T. Stelfox, and P. A. Cameron. S. Groth, and C. Etienne. 2010. “Addressing the 2012. “Indicators of the Quality of Trauma Care and the Millennium Development Goals from a Surgical Performance of Trauma Systems.” British Journal of Surgery Perspective: Essential Surgery and Anesthesia in 8 Low- 99 (Suppl1): 97–104. and Middle-Income Countries.” Archives of Surgery Guerriero, C., J. Cairns, P. Perel, H. Shakur, I. Roberts, and 145 (2): 154–59. CRASH-2 trial collaborators. 2011. “Cost-Effectiveness Lee, A. Y., J. Tan, J. Koh, S. M. Fook-Chong, N. N. Lo, and Analysis of Administering Tranexamic Acid to Bleeding T. S. Howe. 2012. “Five-Year Outcome of Individuals with Trauma Patients Using Evidence from the CRASH-2 Hip Fracture Admitted to a Singapore Hospital: Quality Trial.” PLoS One 6 (5): e18987. doi:10.1371/journal of Life and Survival Rates after Treatment.” Journal of the .pone.0018987. American Geriatric Society 60 (5): 994–96. Guralnik, J. M., S. G. Leveille, R. Hirsch, L. Ferrucci, and Lunenfeld, B., and P. Stratton. 2013.“The Clinical Consequences L. P. Fried. 1997. “The Impact of Disability in Older Women.” of an Ageing World and Preventive Strategies.” Best Practice Journal of the American Medical Association 52 (3): 113–20. and Research in Clinical Obstetrics and Gynaecology 27 (5): Henry, J. A., S. Orgoi, S. Govind, R. R. Price, G. Lundeg, and 643–49. doi:10.1016/j.bpobgyn.2013.02.005. B. Kehrer. 2012. “Strengthening Surgical Services at the Lutz, W., W. Sanderson, and S. Scherbov. 2008. “The Coming Soum (First-Referral) Hospital: The WHO Emergency Acceleration of Global Population Ageing.” Nature 451 and Essential Surgical Care (EESC) Program in Mongolia.” (7179): 716–19. World Journal of Surgery 36 (10): 2359–70. MacKenzie, E. J., F. P. Rivara, G. J. Jurkovich, A. B. Nathens, Huang, S. L., X. J. He, and K. Z. Wang. 2012. “Joint Replacement K. P. Frey, and others. 2006. “A National Evaluation of the in China: Progress and Challenges.” Rheumatology 51 (9): Effect of Trauma-Center Care on Mortality.” New England 1525–56. Journal of Medicine 354 (4): 366–78. Hulme, P. 2010. “Mechanisms of Trauma at a Rural Hospital in Madadi, P., E. F. Enato, S. Fulga, C. C. Umeoduagu, Uganda.” Pan African Medical Journal 7: 5. S. M. MacLeod, and others. 2012. “Patterns of Paediatric Hyder, A. A. 2013. “Injuries in Low- and Middle-Income Analgesic Use in Africa: A Systematic Review.” Archives of Countries: A Neglected Disease in Global Public Health.” Diseases in Childhood 97 (12): 1086–91. Injury 44 (5): 579–80. Mashreky, S. R., A. Rahman, S. M. Chowdhury, T. F. Khan, ICHRC (International Child Health Review Collaboration). L. Svanstrom, and F. Rahman. 2009. “Non-fatal Burn 2013. “What Is the Role of Prophylactic Antibiotics in the Is a Major Cause of Illness: Findings from the Largest Management of Burns?” http://www.ichrc.org/sites/www Community-Based National Survey in Bangladesh.” Injury .ichrc.org/files/antibioticburns.pdf. Prevention 15 (6): 397–402. Ivers, L. C., E. S. Garfein, J. Augustin, M. Raymonville, A. T. Yang, Mathew, G., and B. P. Hanson. 2009. “Global Burden of and others. 2008. “Increasing Access to Surgical Services for Trauma: Need for Effective Fracture Therapies.” Indian the Poor in Rural Haiti: Surgery as a Public Good for Public Journal of Orthopedics 43 (2): 111–16. Health.” World Journal of Surgery 32 (4): 537–42. McCord, C., and Q. Chowdhury. 2003. “A Cost Effective Small Jamison, D. T., J. G. Breman, A. R. Measham, G. Alleyne, M. Hospital in Bangladesh: What It Can Mean for Emergency Claeson, D. B. Evans, P. Jha, A. Mills, and P. Musgrove, Obstetric Care.” International Journal of Gynaecology and eds. 2006. Disease Control Priorities in Developing Obstetrics 81 (1): 83–92. Countries. 2nd ed. Washington, DC: World Bank and Mithal, A., and P. Kaur. 2012. “Osteoporosis in Asia: A Call to Oxford University Press. Action.” Current Osteoporosis Reports 10 (4): 245–47. Jayaraman, S., J. R. Mabweijano, M. S. Lipnick, N. Caldwell, Mock, C. N. 2007. “WHA Resolution on Trauma and J. Miyamoto, and others. 2009. “First Things First: Emergency Care Services.” Injury Prevention 13 (4): Effectiveness and Scalability of a Basic Prehospital Trauma 285–56. Care Program for Lay First-Responders in Kampala, ———. 2011. “Strengthening Care of the Injured Globally.” Uganda.” PLoS One 4 (9): e6955. Journal of Trauma 270 (6): 1307–16. Jitapunkul, S., C. Kunanusont, W. Phoolcharoen, ———, and M. N. Cherian. 2008: “The Global Burden of P. Suriyawongpaisal, and S. Ebrahim. 2003. “Disability- Musculoskeletal Injuries: Challenges and Solutions.” Free Life Expectancy of Elderly People in a Population Clinical Orthopedics and Related Research 466 (10): Undergoing Demographic and Epidemiologic Transition.” 2306–16. Age and Ageing 32 (4): 401–05. Mock, C. N., M. Joshipura, C. Arreola-Risa, and R. Quansah. Khattak, M. J., M. Umer, R. Haroon-ur-Rasheed, and M. Umar. 2012. “An Estimate of the Number of Lives That Could Be 2006. “Autoclaved Tumor Bone for Reconstruction: An Saved through Improvements in Trauma Care Globally.” Alternative in Developing Countries.” Clinical Orthopedics World Journal of Surgery 36 (5): 959–63. and Related Research 447: 138–44. Mock, C. N., M. Joshipura, J. Goosen, and R. Maier. 2006. Kiser, M., G. Beijer, S. Mjuweni, A. Muyco, B. Cairns, and “Overview of the Essential Trauma Care Project.” World A. Charles. 2013. “Photographic Assessment of Burn Journal of Surgery 30 (6): 919–29. 58 Essential Surgery Mock, C. N., G. J. Jurkovich, D. nii-Amon-Koti, C. Arreola-Risa, Saffle, J. R., L. Edelman, L. Theurer, S. E. Morris, and and R. V. Maier. 1998. “Trauma Mortality Patterns in Three A. Cochran. 2009. “Telemedicine Evaluation of Acute Nations at Different Economic Levels: Implications for Burns Is Accurate and Cost-Effective.” Journal of Trauma Global Trauma System Development.” Journal of Trauma 44 67 (2): 358–65. (5): 804–12; discussion 812–4. Salomon, J. A., T. Vos, D. R. Hogan, M. Gagnon, M. Naghavi, Mock, C. N., J. D. Lormand, J. Goosen, M. Joshipura, and and others. 2012. “Common Values in Assessing Health M. Peden. 2004. Guidelines for Essential Trauma Care. Outcomes from Disease and Injury: Disability Weights Geneva: World Health Organization. Measurement Study for the Global Burden of Disease Study Mock, C. N., R. Quansah, L. Addae-Mensah, and P. Donkor. 2010.” The Lancet 380 (9859): 2129–43. 2005. “The Development of Continuing Education for Sekimpi, P., K. Okike, L. G. Zirkle, and A. Jawa. 2011. “Femoral Trauma Care in an African Nation.” Injury 36 (6): 725–32. Fracture Fixation in Developing Countries: An Evaluation Mody, G. M., and M. H. Cardiel. 2008. “Challenges in the of the Surgical Implant Generation Network (SIGN) Management of Rheumatoid Arthritis in Developing Intramedullary Nail.” Journal of Bone and Joint Surgery Countries.” Best Practice and Research in Clinical (American) 93(19): 1811–18. Rheumatology 22 (4): 621–41. Shamim, M. S., S. F. Ali, and S. A. Enam. 2011. “Non-operative Munster, A. M., M. Smith-Meek, and P. Sharkey. 1994. “The Management Is Superior to Surgical Stabilization in Spine Effect of Early Surgical Intervention on Mortality and Cost- Injury Patients with Complete Neurological Deficits: A Effectiveness in Burn Care (1978–1991).” Burns 20: 61–64. Perspective Study from a Developing World Country, Murray, C. J. L., and A. D. Lopez, eds. 1996. The Global Burden Pakistan.” Surgical Neurology International 2: 166. of Disease: A Comprehensive Assessment of Mortality and Siman-Tov, M., I. Radomislensky, and K. Peleg. 2012. Disability from Diseases, Injuries, and Risk Factors in 1990 “Reduction in Trauma Mortality in Israel during the and Projected to 2020. Cambridge, MA: Harvard University Last Decade (2000–2010): The Impact of Changes in the Press. Trauma System.” Injury 44 (11): 1448–52. http://www.ncbi Nakahara, S., S. Saint, S. Sann, M. Ichikawa, A. Kimura, .nlm.nih.gov/pubmed/23021368. and others. 2010. “Exploring Referral Systems for Injured Sitsapesan, H. A., T. P. Lawrence, C. Sweasey, and K. Wester. Patients in Low-Income Countries: A Case Study from 2013. “Neurotrauma Outside the High-Income Setting: Cambodia.” Health Policy and Planning 25 (4): 319–27. A Review of Audit and Data-Collection Strategies.” World Nielsen, K., C. N. Mock, M. Joshipura, A. M. Rubiano, Neurosurgery 79 (3–4): 568–75. A. Zakariah, and F. Rivera. 2012. “Assessment of the Status Skinner, A., and B. Peat. 2002. “Burns Treatment for Children of Prehospital Care in 13 Low- and Middle-Income and Adults: A Study of Initial Burns First Aid and Hospital Countries.” Prehospital Emergency Care 16 (3): 381–89. Care.” New Zealand Medical Journal 115: 199. Norse, N. N., and A. A. Hyder. 2009. “Call for More Research Solagberu, B. A. 2002. “Spinal Cord Injuries in Ilorin, Nigeria.” on Injury from the Developing World: Results of a West African Journal of Medicine 21 (3): 230–32. Bibliometric Analysis.” Indian Journal of Medical Research Spiegel, D. A., S. Choo, M. Cherian, S. Orgoi, B. Kehrer, 129 (3): 321–26. and others. 2011. “Quantifying Surgical and Anesthetic O’Reilly, G. M., M. Joshipura, P. A. Cameron, and R. Gruen. Availability at Primary Health Facilities in Mongolia.” 2013. “Trauma Registries in Developing Countries: A World Journal of Surgery 35 (2): 272–79. Review of the Published Experience.” Injury 44 (6): 713–21. Spiegel, D. A., R. A. Gosselin, R. R. Coughlin, M. Joshipura, Ozgediz, D., D. T. Jamison, M. Cherian, and K. McQueen. 2008. B. D. Browner, and J. P. Dormans. 2008. “The Burden “The Burden of Surgical Conditions and Access to Surgical of Musculoskeletal Injury in Low- and Middle-Income Care in Low- and Middle-Income Countries.” Bulletin of the Countries: Challenges and Opportunities.” Journal of Bone World Health Organization 86 (8): 646–47. and Joint Surgery (American) 90 (4): 15–23. Peck, M., J. Molnar, and D. Swart. 2009. “A Global Plan for Stelfox, H. T., M. Joshipura, W. Chadbunchachai, R. N. Ellawala, Burn Prevention and Care.” Bulletin of the World Health G. O’Reilly, and others. 2012. “Trauma Quality Improvement Organization 87 (10): 802–03. in Low and Middle Income Countries of the Asia-Pacific Price, R. R. 2013. “Investigating the Causes of Trauma: Critical Region: A Mixed Methods Study.” World Journal of Surgery Initial Steps to Designing Sustainable Interventions in Sierra 36 (8): 1978–92. Leone: Comment on ‘Traumatic Injuries in Developing Stewart, K. A., R. S. Groen, T. B. Kamara, M. M. Farahzad, Countries.’” Journal of the American Medical Association M. Samai, and others. 2013. “Traumatic Injuries in Surgery 148 (5): 469–70. Developing Countries: Report from a Nationwide Cross- Qureshi, J. S., R. Ohm, H. Rajala, C. Mabedi, O. Sadr-Azodi, Sectional Survey of Sierra Leone.” Journal of the American and others. 2013. “Head Injury Triage in a Sub-Saharan Medical Association Surgery 148 (5): 463–69. African Urban Population.” International Journal of Surgery Takayanagi, K., S. Kawai, and R. Aoki. 1999. “The Cost of 11 (3): 265–69. Burn Care and Implications for Efficient Care.” Clinical Rubiano, A. M., J. C. Puyana, C. N. Mock, M. R. Bullock, and Performance and Quality Health Care 7 (2): 70–73. P. D. Adelson. 2013. “Strengthening Neurotrauma Care Tallon, J. M., S. A. Karim, S. Ackroydstolarz, and D. Petrie. 2012. Systems in Low and Middle Income Countries.” Brain “Influence of a Province-Wide Trauma System on Motor Injury 27 (3): 262–72. Vehicle Collision Process of Trauma Care and Mortality: Surgery and Trauma Care 59 A 10-Year Follow-Up Evaluation.” Canadian Journal of ———. 2008. “Annex Tables.” In Global Burden of Disease: Surgery 55: 8–14. 2004 Update. Geneva. Tollefson, T. T., and W. F. Larrabee, Jr. 2012. “Global Surgical ———. 2010. Strengthening Care for the Injured: Success Initiatives to Reduce the Surgical Burden of Disease.” Stories and Lessons Learned from around the World. Journal of the American Medical Association 307 (7): Geneva: WHO. 667–68. ———. 2011. Burn Prevention: Success Stories, Lessons U.S. DHHS (United States Department of Health and Learned. Geneva: WHO. Human Services). 2006. “Model Trauma System ———. 2013a. Disabilities and Rehabilitation: Better Health Planning and Evaluation.” Health Resources and Services for People with Disabilities. Geneva. http://www.who.int Administration 9, U.S. DHHS. /disabilities/en/. van den Kerckhove, E., K. Stappaerts, W. Boeckx, B. van ———. 2013b. Global Health Estimates for Deaths by Cause, den Hof, S. Monstrey, and others. 2001. “Silicones in the Age, and Sex for Years 2000–2011. Geneva. http://www.who Rehabilitation of Burns: A Review and Overview.” Burns .int/healthinfo/global_burden_disease/en/ 27 (3): 205–14. ———. 2013c. Global Status Report on Road Safety. Geneva: Vos, T. 2009. “Improving the Quantitative Basis of the Surgical WHO. Burden in Low-Income Countries.” PLoS Med 6 (9): Woolf, A. D., J. Erwin, and L. March. 2012. “The Need to e1000149. Address the Burden of Musculoskeletal Conditions.” Best WHO (World Health Organization). 2002a. World Health Practice and Research in Clinical Rheumatology 26 (2): Report 2002. Geneva: WHO. 183–224. ———. 2002b. The Injury Chartbook: A Graphical Overview of Zong, Z. W., N. Li, T. M. Cheng, X. Z. Ran, Y. Shen, and the Global Burden of Injuries. Geneva: WHO. others. 2011. “Current State and Future Perspectives of ———. 2003. Prevention and Management of Osteoporosis. Trauma Care System in Mainland China.” Injury 42 (9): Technical Report Series 921: 1–164, Geneva. 874–78. 60 Essential Surgery Chapter 4 General Surgical Emergencies Colin McCord, Doruk Ozgediz, Jessica H. Beard, and Haile T. Debas INTRODUCTION group how much can be provided and accomplished in very simple facilities, given adequate training and In low- and middle-income countries (LMICs), at least support. 60 percent of the surgical operations performed are for emergencies. Contrary to widespread belief, it has been shown that the provision of treatment, which is often Burden of Disease lifesaving for these patients, can be inexpensive. The The annual death rate from acute abdominal conditions staff and equipment required at first-level facilities for in the United States in 1935 was 38 per 100,000 popu- all categories of surgical emergency, including trauma lation, or 3 percent of all deaths in that year. General (chapter 3) and obstetrics (chapter 5), are essentially the practitioners performed most surgeries; formal surgical same. Accordingly, the treatment of general surgical emer- training did not begin until 1937, when the American gencies requires little additional cost and should be part Board of Surgery was formed. By 1990, the death rate of the services offered at first-level facilities. This chapter for acute abdominal conditions had fallen to 4 per 100,000 (CDC 1990; U.S. Department of Commerce • Describes the common types of general surgical 1935). The 90 percent reduction in mortality was due emergencies that can be treated at first-level hospitals to increased access to operations, made possible by new in LMICs facilities and more skilled staff in combination with the • Provides the best available estimates of disease bur- availability of antibiotics for infection, safer anesthesia, den for the conditions for which these facilities are and blood for transfusions. The operations were not responsible complicated. They are available today in LMICs, as are • Considers the cost and cost-effectiveness of providing low-cost antibiotics, competent anesthesia, and blood; this essential surgical service however, as in the United States in 1935, access to these • Describes the basic systems and the major bottlenecks operations is very limited. In the United States and to access in many other high-income countries (HICs) in 1935, • Discusses the training and distribution of appropri- all general surgical emergencies were responsible for ately skilled staff. 3 percent to 5 percent of deaths. This estimate may be as good as any other estimate of the burden of disease The chapter is written for two primary audiences, from these causes in LMICs, where there is little or no health planners and surgeons in LMICs, to show each available surgical treatment. Corresponding author: Colin McCord, MD, Columbia University (retired), cwm1@columbia.edu 61 The problems that limit access to surgical services in Levels of Hospital Care most LMICs are correctible, although serious and not Definitions of the levels of hospital care were delineated easily overcome. They include the following: in Disease Control Priorities in Developing Countries, sec- ond edition (Jamison and others 2006); as adapted, these • Insufficient number of surgically trained personnel, levels are shown in table 4.1. and the concentration of these personnel in major urban areas • Lack of ongoing training and supervision in peripheral surgical units to supplement and TYPES OF GENERAL SURGICAL upgrade skills EMERGENCIES • Lack of efficient supply systems to ensure the avail- The list of surgically treatable emergencies commonly ability of medications and materials seen in LMIC hospitals is not long, but it includes prob- • Lack of adequate maintenance systems and personnel lems that fall within the purview of several different spe- for diagnostic and therapeutic equipment cialties (Abdullah and others 2011; Curci 2012; Lavy and • Lack of affordable and reliable transport for patients others 2007; McCord and Chowdhury 2003). Fortunately, between facilities so they can receive the appropriate 90 percent of the operations can be mastered by a person level of care in a timely manner without full specialty qualification, so it is not necessary to have fully qualified surgeons, obstetricians, and trau- Despite these handicaps, much can be done and matologists in every first-level hospital. With even a very is being done in very simple facilities with minimal limited ability to refer patients and intermittent supervi- support. This progress is possible because many sion by qualified specialists, a very productive network of the important surgical problems can be resolved for surgical care can be established (box 4.1). with uncomplicated, well-standardized procedures. A fully equipped, modern hospital is not essential to remove an appendix, close a perforated ulcer, drain Acute Abdominal Emergencies an abscess, or even resolve most causes of intestinal Incarcerated and Strangulated Inguinal Hernias. obstruction. Incarcerated hernia, a cause of intestinal obstruction, Table 4.1 Definitions of Levels of Hospital Care Terminology and definitions Alternative terms commonly found in the literature First-level hospital Primary-level hospital Few specialties—mainly internal medicine, obstetrics and gynecology, District hospital pediatrics, and general surgery Rural hospital Often only one general practice physician or a nonphysician clinician Community hospital Limited laboratory services available for general analysis but not for specialized General hospital pathological analysis 50–250 beds Second-level hospital Regional hospital More differentiated by function, with as many as 5 to 10 clinical specialties Provincial (or equivalent administrative area, such as 200–800 beds county) hospital General hospital Third-level hospital National hospital Highly specialized staff and technical equipment—for example, cardiology, Central hospital intensive care unit, and specialized imaging units Academic, teaching, or university hospital Clinical services highly differentiated by function Teaching activities in some facilities 300–1,500 beds Source: Mulligan and others 2003. 62 Essential Surgery is very common in Sub-Saharan Africa (Shillcutt, Clarke, and Kingsnorth 2010). About 4 in 1,000 hernias per year Box 4.1 will become incarcerated, with a segment of intestine trapped inside the hernia sac; if untreated, these hernias General Surgical Emergencies Commonly Seen in can become gangrenous within several days. In 85 percent First- and Second-Level Hospitals of the cases in a large review of incarcerated hernias, the bowel within the hernia sac was viable: it could be Acute abdominal conditions returned to the abdomen and the hernia repaired (van Incarcerated and Strangulated Inguinal Hernias den Heuvel and others 2011). If the intestine is not viable, Appendicitis it must be removed and the divided bowel repaired. This Intestinal obstruction is not a complicated procedure for an adequately trained Complications of peptic ulcer, including perforated surgeon. If bowel resection is not indicated, 99 percent ulcer and bleeding ulcer of patients should survive; if bowel resection is required, Bleeding from esophageal varices 80 percent or more should survive, depending on the Pelvic infections with abscesses experience of the surgeon (Nilsson and others 2007). Perforated typhoid ulcers Amebic liver abscess Appendicitis. This condition is rare in isolated vil- Gall bladder and bile duct disease lages but increasingly common with development and a more “western” diet containing less fiber and more Respiratory obstruction, foreign bodies, and pleural disease meat (Burkitt, Walker, and Painter 1972). Appendicitis Urinary obstruction caused by stricture, stone, or prostatic is common in cities, towns, and more developed rural enlargement areas in many LMICs. Removal of an inflamed appendix Surgical infections of the skin, muscles, bones, and joints is a straightforward procedure. Even in late cases compli- Sources: McConkey 2002; Ohene-Yeboah 2006; WHO 2003; and personal experiences of the cated by perforation and abscess formation, drainage will authors in six hospitals in South Asia and Sub-Saharan Africa. resolve the acute problem unless generalized peritonitis has developed. Overall, including the late-presenting cases with perforation or a gangrenous appendix, 95 percent of Less commonly, the lower end of the large intestine can patients can be expected to survive; this number reaches spontaneously twist on itself (sigmoid volvulus), produc- 99 percent in the hands of experienced surgeons (Mason ing an obstructed bowel. In late cases, the twisted intestine and others 2012; Ohene-Yeboah 2006). can cut off its own blood supply, leading to gangrene and requiring resection and repair. The probability of gan- Intestinal Obstructions Caused by Adhesions, grene cannot be predicted, and early surgery must be the Volvulus, Worm Infection, or Intussusception. The rule. In complicated cases in which no qualified surgeon is most common cause of intestinal obstruction in LMICs available, simple procedures like colostomy (transferring is incarcerated hernia, but if no inguinal hernia is visible, the dead intestine outside of the abdomen by creating then several other conditions should be considered. If a usually temporary artificial anus, without reconstruc- treated early, all cases can be successfully managed with tion of the intestine) will resolve the acute problem, so conservative measures or very simple abdominal opera- that patients can be referred for a second operation that tions; these conditions can become difficult problems if restores normal function. An uncomplicated sigmoid allowed to progress to a later stage. volvulus can be untwisted without opening the abdomen, Twisting (volvulus) of the intestine around an adhe- by gently inserting a well-lubricated large rubber tube sion or scar from a previous operation or infection is through an instrument (a proctoscope) inserted into becoming increasingly common. In many LMICs, it is the rectum. Overall survival should exceed 80 percent the second most common cause of blocked intestine. (Mnguni and others 2012; Nuhu and Jah 2010). Seen early, it will often resolve with tube decompres- Two conditions in children are common causes of sion of the stomach and intravenous fluids. If an oper- intestinal obstruction: ation is necessary, simple division of the adhesion and untwisting of the intestine will resolve the problem at • Heavy infestation with Ascaris worms can lead to balls an early stage; at later stages, the twist can interfere of living worms large enough to obstruct the lumen. with the blood supply, the intestine will die, and only In about 80 percent of cases, this condition will resolve removal of the dead intestine will prevent death of the spontaneously if the intestine is decompressed with a patient (Adesunkanmi and Agbakwuru 1996; Madziga stomach tube. If an operation is needed, the worms and Nuhu 2008). can be removed through a small incision; in rare cases, General Surgical Emergencies 63 the segment of intestine containing the worm ball always successful; if followed by appropriate anti-ulcer may have to be removed. Overall mortality should be medical treatment, it leads to a permanent cure for 1 percent to 2 percent (Wani and others 2010). 95 percent of patients. Delayed operations carry higher • Less commonly, usually in infants under age one, risks, with a possibility of subsequent abscesses. Overall, a segment of intestine can invaginate on itself (intus- 80 percent to 90 percent of patients are likely to survive susception), leading to obstruction. This condition (Chalya and others 2011; Ugochukwu and others 2013). can occur spontaneously and is a relatively rare com- Bleeding ulcers pose more serious problems. Severe plication of the rotavirus vaccine immunization. In a bleeding requires surgery, transfusions, and skilled anes- hospital with a fairly sophisticated radiologist, it will thetic support, which are often unavailable in smaller be treated with a moderately high pressure enema, hospitals. The old standard operation of pyloroplasty, using a dye that can be seen on a fluoroscope as the suture of the bleeding blood vessel, and vagotomy (cut- pressure reduces the invagination. If the skills and ting the vagus nerve that stimulates acid production) is equipment for this are not available, the invagination effective; 90 percent of patients will survive, but usually can be relieved by an operation. The procedure is to only a fully qualified surgeon will be able to perform push on the invaginated segment, never to pull on the procedure. If possible, these patients should be the distal end. Removal of the invaginated segment transferred. If they can go to a third-level center that is rarely needed. Overall mortality in infants should offers endoscopy services, it is likely that they can be be 1 percent to 2 percent or less, given early treat- successfully treated without surgery (Simon and others ment and competent management of anesthesia and 2013). Younger patients with less than massive bleeding fluid replacement. Because of inexperience in infant can usually be managed conservatively and transferred, surgery in many first-level hospitals in LMICs most if necessary, after the bleeding has stopped. patients are referred, but referrals can delay treat- ment and increase mortality (Jiang and others 2013; Bleeding from Esophageal Varices. In HICs, varicose Ngendahayo and others 2014). veins at the lower end of the esophagus are usually complications of alcoholic cirrhosis of the liver. In many Pelvic Infections with Abscesses. Sexually acquired LMICs, they are commonly due to a scarred liver caused infections of the fallopian tubes and adjacent organs are by Schistosoma infestation. The difference is that liver common and can usually be successfully treated with function is very poor in alcoholic cirrhosis patients but is antibiotics and without surgery. If an abscess forms and relatively good in patients with varices due to schistoso- does not respond to medication, simple drainage is usu- miasis. When varices from any cause bleed, they almost ally adequate. In early cases, a trial of antibiotic treatment always bleed massively, requiring multiple transfusions. is the best course; exploratory laparotomy may be nec- Alcoholic cirrhosis patients do not do well with opera- essary for severe, nonresponsive cases. Overall survival tions for varices, but those with schistosomiasis survive should exceed 95 percent. When antibiotic treatment is and do well with operations and with endoscopic treat- late or inadequate, death is rare, but infertility and recur- ments. However, the operations are major undertakings, rent pelvic pain can ensue, as well as increased incidence and the endoscopic treatment requires expensive equip- of subsequent ectopic pregnancy (Soper 2010). ment and skilled personnel. This option is increasingly available in third-level hospitals; these patients are rarely Peptic Ulcer Complications. Three major advances seen in first- or second-level hospitals, probably because have reduced the incidence of and mortality rates for they so often die before they reach any hospital. peptic ulcers: the discovery that Helicobacter, which can be treated with antibiotics, is a primary cause of ulcers; Perforated Typhoid Ulcers. Perforation is a very seri- the development of powerful acid-reducing drugs; and ous complication of advanced typhoid infection that the successful endoscopic control of bleeding from ulcers. causes ulcers of the small intestine. Ulcers can also erode Helicobacter infection is widespread and difficult to blood vessels to produce major bleeding. Diagnosis of prevent, and ulcerogenic medicines like nonsteroidal perforation is often late, even when it occurs in hospi- anti-inflammatory drugs (NSAIDs) are widely available talized patients. These ulcers develop in approximately and overused, with and without prescription. 5 percent of hospitalized patients, and almost always in Perforation of a peptic ulcer allows a flood of gastric patients whose antibiotic treatment started late or had juice to flow into the peritoneal cavity, resulting in diffuse not yet become effective (Chalya and others 2012). peritonitis that is almost always fatal if untreated. Surgery Perforated typhoid ulcer 40 years ago was con- within 24 hours, with closure of the perforation and sidered to have a hopeless outcome. It is gratifying washout of the abdominal cavity, is simple and is almost that several recent reports from Sub-Saharan African 64 Essential Surgery hospitals indicate survival rates of 80 percent to change of position, with or without the insertion of an 90 percent after operative repair of a typhoid perfora- oral airway or a tube into the trachea, may resolve the tion (Chalya and others 2012; Mock and others 1995; problem; often, an incision in the neck is needed to per- Nasir, Abdur-Rahman, and Adeniran 2011). form cricothyroidotomy or tracheostomy. All surgical staff members should be trained to intubate, perform Amebic Liver Abscess. Amebic liver abscess responds these simple operations, and correctly position uncon- so well to antibiotics that it rarely needs surgical treat- scious patients. ment, but surgeons are usually called to examine these patients and so must understand the proper diagnosis Foreign Bodies. If located in the ear, nose, or eye, and treatment. The diagnosis is straightforward if ultra- foreign bodies are usually easy to remove; however, sound or computed tomography (CT) scan is available, the failure to remove them can result in serious infec- but this equipment is usually not available in hospitals tions. In the larynx and trachea, they can obstruct below the third level. respiration and cause death. If a foreign body goes A trial of antibiotics can be a simple way to resolve the beyond the trachea into the bronchial tree, it will pro- question. If pain and fever persist, indicating that rup- duce a pneumonia that is unresponsive to treatment ture into the abdomen is imminent, the best approach unless the foreign body is removed. The removal of is needle drainage or percutaneous catheter drainage, in foreign bodies in the bronchi requires referral for combination with antibiotics. In the absence of ultra- bronchoscopy. Swallowed material in the esophagus sound or other localization, surgery may be necessary to usually passes through or, if stuck at a high level (the ensure proper placement of drainage. cricopharyngeus), can be extracted with a balloon The rupture of such an abscess through the dia- catheter. phragm and into the pleural space requires urgent sur- gical intervention. Simple insertion of a large-bore chest Pneumothorax, Hemothorax, and Empyema. Pneu- tube, combined with appropriate antibiotics, is almost mothorax, hemothorax, and empyema are collections always sufficient. of, respectively, air, blood, or pus in the pleural space In low-income countries (LICs), amebic abscesses that compresses the lungs, leading to respiratory insuf- are more common; in middle-income countries (MICs) ficiency; they often produce scarring with permanent and HICs, about 50 percent of the cases of liver disability. Infected fluid is serious and can lead to death. abscess are bacterial, requiring intensive antibiotics In almost all cases, early drainage with a chest tube, and drainage (Conter and others 1986). Untreated combined with antibiotics as needed, resolves the prob- amebic liver abscesses are often fatal, but even in com- lem. This simple procedure is easily learned (King and plicated cases, 95 percent survival can be expected others 1986; WHO 2003). with appropriate treatment (Chavez-Tapia and others 2009; Jha and others 2012). Urinary Obstructions Gall Bladder and Bile Duct Disease. Acute inflamma- Infection can cause scarring of the urethra, stones in tion of the gall bladder (acute cholecystitis) is very rare the bladder can obstruct the outlet, and an enlarged in rural parts of LICs but increasingly common in cities prostate gland can compress the urethra. In any of and MICs. Experienced surgeons treat most patients these cases, the urethra can be blocked, making urina- with antibiotics and prompt removal of the gall bladder, tion impossible. Often, an instrument can be passed but antibiotics alone will control infection temporarily through the obstruction, followed by a rubber cath- so that an operation can be done later. First-level hos- eter, to relieve the acute problem. However, because pitals choose the second option unless they have a fully the obstruction often recurs, subsequent referral may trained surgeon on staff. Patients with jaundice caused be needed to remove the prostate or the stone or to by gallstones passing into and obstructing the common more radically dilate the urethra. If the urethra cannot bile duct are referred. be dilated, a bladder catheter can be inserted above the pubic bone (suprapubic cystostomy) as an emergency procedure. Removal of bladder stones and cystostomy Respiratory Obstructions, Foreign Bodies, and are practical operations at a first-level hospital, and Pleural Disease prostatectomy can be performed there, if the skills Obstruction has many causes, including head and neck are available. Stones can also form in the kidney itself. infections, bleeding, trauma, tumors, improper position- Small ones will pass without surgical treatment; if they ing of an unconscious person and aspiration. A simple do not pass, referral is necessary. General Surgical Emergencies 65 Infections of the Skin, Muscles, Bones, and Joints Congenital surgical emergencies are covered in detail Antibiotics have changed the course of infections of the in chapter 8. Some of these, especially pyloric stenosis skin, muscles, bones, and joints, which are often associ- and colostomy for imperforate anus, are completely ated with bloodstream infections and were important within the competence of a well-trained general surgeon causes of death and disability before the availability of in a first- or second-level hospital, although it is rare to antibiotics. In HICs, serious infections are often treated find a general surgeon who does these operations. with aspiration of pus, culturing, and intensive use of Almost all of the conditions listed in box 4.1 can be antibiotics. In most LMICs, however, access to bacterial treated in first-level hospitals (see table 4.1), although culturing is not available; antibiotic choice is limited by many of these facilities would refer most or all of these availability and cost; and long-term, high-dose antibiotic patients to a higher level. The public quickly comes to treatment is impractical. know if referral is likely and learns to bypass the closer Fortunately, early treatment with incision and drain- hospital and go directly to a larger center. If bypassing age, in combination with a regimen of antibiotics for is not possible, patients simply stay home. Patients one to two weeks, is generally successful in locations often do not reach the higher-level hospitals to which with limited resources. In late-presenting cases, deaths they are referred, usually for economic reasons (Urassa from sepsis are usually preventable, but bone and and others 2005). The important factor limiting the joint infections, in particular, can require long-term capacity of first-level hospitals is training (Abdullah and treatment and subsequent surgery. Because acute infec- others 2011). The shortage of qualified surgeons and tions are common, often occur in children, and do not anesthetists can be corrected in the short term by train- require complicated surgery, this treatment option is ing general practitioners, nonphysician clinicians, and an important and very cost-effective part of the work nurses to care for most of the common conditions; in of a first-level hospital (King and others 1986; WHO the long term, the shortage can be corrected by training 2003). Surgical infections are covered in more detail appropriate specialists. Approaches to these options are in chapter 3. discussed briefly in this chapter and in more detail in chapters 12 and 17. Other General Surgical Emergencies Although this list of emergency conditions is not DISEASE BURDEN OF GENERAL SURGICAL exhaustive, it covers at least 95 percent of the emergency problems faced in first- and second-level hospitals. EMERGENCIES Staff members who treat these patients must be pre- The World Health Organization’s (WHO’s) Global pared to deal with the common problems, including Health Estimates report global disability-adjusted life the traumatic and obstetric emergencies discussed years (DALYs) lost from 163 specified disease causes in chapters 3 and 5. Facilities should be equipped (WHO 2013a); DALYs are a measure of the years of life and supplied to support this treatment. Referral is lost or seriously impaired by disease, both overall and necessary for less common and more complicated from specified disease entities. conditions, but it should be kept to a minimum The Global Health Estimates do not specifically because of the weakness of existing referral systems. identify general surgical emergencies, but by com- Certain other surgical emergencies common in bining the estimates for three categories (peptic ulcer HICs but not in LMICs are not discussed in this disease, appendicitis, other digestive diseases) out of chapter—notably, diverticulitis, intestinal obstruction the 163, in which death or disability usually results or perforation resulting from colon cancer, and compli- from a general surgical emergency, an estimate of the cations of arteriosclerosis (such as ruptured abdominal worldwide rate of DALYs lost from these conditions aortic aneurism and gangrene of extremities). These can be created. At 596 per 100,000 population, this conditions will undoubtedly become more important constitutes 1.5 percent of DALYs from all causes, in as LMICs progress through the epidemiological tran- all parts of the world (table 4.3). The estimates for sition, in which the complications of a western diet, injuries, maternal, neonatal, and three general surgical arteriosclerosis, and cancer increase. Planners in LMICs emergencies in LMICs were considerably higher than must be aware of these changes in the disease spectrum, those in HICs. which will increase the cost and reduce the potential Diagnoses for cause of death in LMICs are usually benefits of surgical treatment in the future (Stewart and rough estimates, especially for the acute abdominal con- others 2014). ditions lumped together under other digestive diseases. 66 Essential Surgery Not included because they were not listed separately in EFFECTIVENESS OF SURGICAL TREATMENT this DALY calculation are respiratory obstruction, pneu- mothorax, and surgical infections (including empyema, In Germany in 1926, when surgery for acute peritonitis was osteomyelitis, abscesses, pelvic infections, and perforated considered contraindicated, Kirschner (1926) reported a typhoid ulcers). peritonitis hospital mortality rate of 85 percent. Although Debas and others (2006) do not consider general established peritonitis is still a serious condition, mortality surgical emergencies separately, but they estimate that rates of less than 10 percent would be expected today in 11 percent of all lost DALYs worldwide were due to LMICs, with appropriate surgery combined with intrave- surgically correctable conditions. They make it clear that nous fluids and antibiotics. If surgery can be performed this is a very rough estimate, based on “best guesses” by within 24 hours of disease onset, mortality should be 18 surgical experts of the percentage of patients who much lower than 10 percent. could be successfully treated within a list of conditions Meta-analysis of all available operative mortality considered surgically treatable. These estimates were statistics worldwide has shown that the overall decline then applied to the DALY numbers provided by WHO in mortality has been slower in LMICs than in HICs (2002) for each category of potential surgical conditions; (Bainbridge and others 2012). The problems that have the estimates are based on hospital experiences, not on led to this slower rate clearly need to be addressed, population surveys. but the progress that has been achieved in perioper- Vital registers are inaccurate or nonexistent in almost ative mortality is not inconsiderable and seems to be all LMICs. Only three population-based surveys have increasing. Comparing 1970–90 with 1990–2010, the tried to estimate the incidence and mortality rates from same meta-analysis shows a decline in perioperative all surgical emergencies, using family members’ recall mortality in LMICs from 0.73 percent in the first 20-year of disease and death. One set of surveys, conducted in period to 0.25 percent in the second period. a remote, mountainous part of Pakistan, found death The overall survival rates of higher than 95 percent rates from nontraumatic surgical emergencies to be cited for most of the four common categories of emer- only moderately higher than in the United States in gencies in table 4.2 are based on reports from hospitals 1935: 55 and 61 per 100,000, respectively, depending in LICs, primarily in Sub-Saharan Africa. These results on the sample surveyed (Ahmed and others 1999). The have been achieved despite the late arrival of many other two surveys, from rural parts of Sierra Leone patients and the high prevalence of comorbid condi- and Rwanda, calculated much higher death rates for tions, such as malaria and HIV infection. Médecins acute abdominal emergencies (825 per 100,000 per Sans Frontières reported on 16,377 major operations in year for acute abdominal conditions), but the surveys LMICs, most performed for emergencies in the very basic, probably encountered problems with the recall method. first-level hospitals they operated, with a hospital mor- In one, the surveyors calculated a total (all diagnoses) tality rate of 0.2 percent (Chu, Ford, and Trelles 2010). crude death rate of 59.7 per 1,000, which is more than Staff without formal surgical training performed many of three times the total crude death rate estimated for these operations, but trained surgeons were almost always Sub-Saharan Africa by WHO (Groen and others 2012; available for consultation and assistance. A report of 1,976 Petroze and others 2013). Compiling these data can yield a rough estimate of the disease burden from general surgical emergencies Table 4.2 Global DALYs, by Cause, 2011 in LMICs, from 1 percent to 3 percent of all deaths and per 100,000 population all DALYs—more than 10 percent of all surgical DALYs. At that rate, these conditions are not unimportant, and Disease DALYs Percent several factors combine to make them even more so: All causes 39,553 100.0 AIDS and tuberculosis 1,372 3.5 • Reasonably early treatment will achieve good results, Cardiovascular disease 5,461 13.8 usually with complete cures. • Without treatment, mortality rates are high. Injuries 4,278 10.8 • All of the general surgical emergencies are common Maternal 273 0.7 in children and young adults. Neonatal 3,338 8.4 • Human and other resources needed for effective treat- General surgical emergencies a 596 1.5 ment are the same as those needed to treat the other Source: WHO 2013a. important surgically treatable conditions, including Note: DALYs = disability-adjusted life years. trauma and maternal and perinatal mortality. a. Peptic ulcer disease, appendicitis, other digestive diseases. General Surgical Emergencies 67 operations for acute abdominal conditions in a Sub- hospital expenditure. Latin American countries gen- Saharan African public hospital finds a hospital mortality erally spend more, but even there the costs of major rate of less than 10 percent (Ohene-Yeboah 2006). A small surgical procedures are very low, especially in first-level Sub-Saharan African hospital with no trained surgeon hospitals. One review compares the recurrent cost per on staff and very limited capacity for referral reports a major operation in six district hospitals in Mozambique, hospital mortality rate of 10 percent for 173 patients with Tanzania, and Uganda, all three LICs. Results indicate acute abdominal emergencies (McConkey 2002). The that the cost per operation was US$42–US$98 in five of operations were performed by general practitioners. the six. At one low-volume Ugandan hospital, the cost In most cases, if patients are discharged alive, they are was US$308 per operation (Kruk and others 2010). If discharged cured and will need no further treatment. these low-cost estimates were grouped with other esti- Exceptions occur, with late problems requiring addi- mates of DALYs averted by emergency operations (nine tional treatment in fewer than 10 percent of cases. per general surgical operation in box 4.2), the cost per DALY would be very low indeed. The calculation of the marginal cost-benefit of a par- ticular operation is clearly not the first consideration for COST OF SURGICAL TREATMENT health policy makers and planners in LMICs. Political Calculating the cost of individual surgical procedures in considerations will—and should—nearly always lead any setting involves multiple assumptions. The calcula- them to construct general first- and second-level hos- tion becomes even more complicated in LMICs, where pitals that have the ability to manage or refer all hospitals have multiple sources of income, including emergency conditions, whether surgical, medical, or gifts in kind; records are poor; and corruption is com- pediatric. The questions for policy makers and planners monplace. The overall cost per admission or procedure are how much the total cost of such facilities will be; varies greatly between first- and third-level hospitals; what populations they can serve; what services will be third-level hospitals are much more expensive (see most or least cost-effective; and what conditions, if any, chapter 12). can be referred. Within regional income classifications, there is con- The cost and effectiveness of first-level hospitals, the siderable variation between regions in per patient systems to support them, and the role of surgery within Box 4.2 DALYs Averted by Kind of Surgery at Gonoshasthaya Kendra Hospital, Bangladesh, 1995 Table B4.2.1 reports the estimated DALYs averted by outcome without surgery if there was no perforation or surgical treatment in a 50-bed hospital in Bangladesh. gangrene; the risk estimate rose to 95 percent if perfora- In the three-month period studied, 154 operations were tion and peritonitis had occurred. performed; 80 percent were emergencies. A qualified sur- The list of operations is typical for small, first-level geon and an obstetrician were available for most of these hospitals in LICs with trained specialists available. procedures. Anesthesia was provided by a locally trained paramedic with no formal hospital training. All nurses • 27 percent of operations were general surgical; almost and operating room staff were locally trained without for- all of these were emergencies. mal qualifications. One obstetric death and one general • 15 percent of DALYs averted came from general surgical operative death occurred. All other patients were surgical emergencies. discharged well. There were no referrals. • The hospital was rural but adjacent to a major highway. DALY estimates were based on local experience and are The relatively small number of trauma cases reflects the believed to be conservative, for example, acute appendi- absence of any referral system to bring injured patients citis was considered to have a 10 percent risk of a fatal to the hospital. box continues next page 68 Essential Surgery Box 4.2 (continued) Table B4.2.1 DALYs Averted in Three Months, First-Level Hospital, Bangladesh, 1995 Number of operations Total DALYs averted DALYs averted per operation Obstetrics and gynecology Cesarean section 40 1,588 40 Dilation and curettage 24 44 2 Ectopic pregnancy 2 72 36 Extraction of placenta 4 26 7 Cervical tear 1 3 3 Other gynecological 20 149 7 All obstetrics and gynecology 91 1,882 21 General surgery Appendectomy 10 49 5 Cancer 1 13 13 Gall bladder 4 30 8 Hernia 6 47 8 Other acute abdomen 4 64 16 Chest (tube drainage) 3 76 25 Incision and drainage of infection 13 91 7 All general surgery 41 370 9 Trauma Closed fractures 11 43 4 Major wounds and compound fractures 6 81 14 Burns 5 53 11 All trauma 22 177 8 All surgical procedures 154 2,429 16 Source: Data from McCord and Chowdhury 2003. Note: DALY = disabilty-adjusted life year. them is discussed in chapters 12, 18, and 19. First-level BASIC SYSTEMS FOR SURGICAL hospitals have been shown to best serve the needs of the EMERGENCIES population and to be cost-effective. Their surgical ser- vices are usually the most effective component (Debas Although several types of operations can be done in and others 2006; Gosselin, Thind, and Bellardinelli less-than-ideal conditions, the availability of basic 2006; McCord and Chowdhury 2003). At first-level facilities and supporting systems makes procedures facilities, the same staff can provide services for most simpler, safer, and more efficient. Controlling cost general surgical, obstetric, and trauma emergencies. and making optimal use of resources are important With minor adjustments, the same structure, equipment, everywhere, especially in LMICs. Hence, it is essential and supplies can serve all three components at very low to define the basic needs for a functioning surgical cost. At higher referral levels, increasingly specialized system. Fortunately, these essentials do not need to services combined with other inefficiencies can increase be expensive. Some hospitals in LMICs provide good, costs enormously. lifesaving service for a total cost of less than US$50 General Surgical Emergencies 69 per patient day, compared with more than US$1,000 can be managed with inexpensive, long-established per patient day for hospitals in HICs (Kruk and others antibiotics. Guidelines for the appropriate use of 2010). A well-equipped operating theater can be cre- antibiotics should be available at all levels. WHO’s ated in LMICs for less than the cost of a small diner or essential medicine list can be a basis for these guide- restaurant in a HIC. lines (WHO 2013b). Almost all of the surgical emergencies listed in • Referral system: A referral system, with health centers table 4.2 can be managed successfully in a first-level that refer, as well as larger hospitals that receive more hospital, but the basic elements must be in place: complicated cases, should complement the hospital. This model requires some sort of transport system to • Functioning hospital: The hospital should have wards, move patients between these units. an outpatient area, a receiving area for emergency patients, a pharmacy, and a laboratory. Ideally, the Most countries have second-level facilities with fully hospital would also have a blood bank and adequate trained surgeons. Budgetary, staffing, and transport con- staff quarters. Usually, these small facilities will have straints usually require that all hospitals, including at the 50–250 beds. second and third levels, have a first-level function for the • Operating room: The operating room should have local geographic area. appropriate surgical and anesthetic equipment and supplies. • Capacity to administer anesthesia: It is important for Training and Distribution of Staff Members first-level hospitals to have the capability to adminis- Training. Effective training programs for staff members ter anesthesia (see chapter 15). Most general surgical are essential. It is not realistic to expect that all surgical emergencies can be managed with local, spinal, or staff will be fully qualified specialists or certified oper- ketamine anesthesia, but some require general anes- ating room nurses; general practitioners, nonphysician thesia, with induced paralysis and tracheal intubation. clinicians, and nurses can be trained to manage most • Resuscitation: Many of the most severe emergency of the surgical emergencies seen in first-level hospitals. patients arrive at hospitals unconscious, in shock, Variation in surgical capability is an important factor with respiratory obstructions or other urgent prob- that can limit the number of general surgical emer- lems that must be resolved before surgical treatment gencies treated, as well as the quality of the outcomes. can be considered. The essentials of resuscitation are Because first-level facilities need to perform emer- not complicated and are usually very effective: man- gency obstetrical and trauma surgery, training programs aging the airway, controlling bleeding, and providing should create the capacity to manage all three categories adequate fluid replacement. Blood for transfusion can of surgical emergencies: general surgical, traumatic, and be useful but usually is not essential. Resuscitation, obstetric. Programs in Sub-Saharan Africa and elsewhere which is often not managed well, is one of the most have demonstrated that training can be done at low cost important training needs in the hospital systems of and without stationing qualified specialists at every loca- LMICs. Staff members at all levels should be trained tion (Mkandawire, Ngulube, and Lavy 2008; Nyamtema and equipped to provide this service, and areas and others 2011; Sani and others 2009; van Amelsfoort should be set aside where equipment and trained staff and others 2010). are available (see chapters 14 and 15). Surgical societies, such as the West African College of • Supplies: Adequate quantities of basic supplies are Surgeons and the College of Surgeons of East, Central, essential; in addition to gauze and linen, intrave- and Southern Africa, have developed training and edu- nous fluids and antibiotics are the most important. cation programs for surgeons in most LMICs; these pro- Complicated intravenous fluid preparations are not grams are modeled on the programs of similar societies essential, but the basic dextrose with water and in HICs. Most LMICs have a nucleus of well-trained dextrose with saline must be available, along with the surgical specialists; in some countries, large numbers means to add potassium when needed. Appropriate of trained specialists are available. To date, qualified use of high-dose antibiotics can be lifesaving in cases specialists and surgical societies have not had an impor- with established infections that require adequate tant role in the training and supervision of those who drainage and debridement. Prophylactic antibiotics perform surgery in the smaller, first-level hospitals. If can be useful when there has been contamination these surgical societies could take a major interest in the without established infection (as in an operation creation of the surgical networks and in monitoring per- requiring the opening of the intestine) but should not formance, surgical care in LMICs would be significantly be continued beyond 24 hours. Almost all patients improved. 70 Essential Surgery Distribution. The effective distribution of skilled per- for transfers; common conditions must be managed sonnel is an additional challenge. All LMICs have dif- locally to the extent possible. This need to diffuse ser- ficulty inducing qualified medical personnel to work vices to smaller units may change as more specialists outside of major cities, largely because private patients are trained, transportation improves, and economic are few and public facilities that serve poor people pay growth increases the purchasing power of the popula- low salaries. tion. But in most LICs for the next generation or more, Most LMICs partially resolve this problem by send- most people will be treated in public hospitals. General ing recent medical graduates to staff first-level hospi- practitioner or nonphysician clinician surgeons will tals (general practitioner surgeons), training nurses provide much, if not most, of the surgical services or other staff to administer anesthesia, and staffing available, and they will work in small, first-level facili- operating rooms with nurses or others without special ties, serving populations from 50,000 to 250,000. Larger training. A few countries have trained nonphysician urban hospitals also need to provide first-level services clinicians to perform surgery (see chapters 17 and 19). in many cases; ideally, to avoid congestion in facilities Because 90 percent or more of the essential opera- that often serve several million people, networks of tions are within the potential competence of a general district first-level hospitals would be established even practitioner or nonphysician clinician surgeon with a in cities. nonphysician anesthetist, short-course training before assignment and periodic skills improvement courses can greatly improve the quantity and the quality of surgical treatment in these places. Regular visits by NEW TECHNOLOGY supervising specialists will serve to maintain and Two trends in the revolution in operative surgery in expand the skills, as well as to evaluate quality through the past decade are particularly noteworthy. First is audits. Regular supervision of this sort is extremely a general move to more conservative procedures to rare in LMICs. treat infections, malignancies, and biliary, vascular, The shortage of trained staff members results in and other diseases. Second, innovation and new tech- costly inefficiency in facilities that are working at nologies have facilitated this conservative trend. The less than capacity (Kruk and others 2010). Many intensive use of potent antibiotics has reduced the need very poor countries are only beginning to train doc- for surgery. Video-assisted surgery and stapled suturing tors to qualify as surgeons and anesthetists. General have simplified surgical techniques. Ultrasound, com- practitioner and nonphysician clinician surgeons in puterized radiographic technology, magnetic resonance first-level hospitals usually become competent at man- imaging, and endoscopy have improved preoperative aging obstetrical emergencies with nurse-midwives diagnoses; in some cases, they have eliminated the need and nurse-anesthetists. However, they are less confi- for surgery. dent with general surgical emergencies and trauma, Some of these advances, however, are very expen- so that these patients are often referred. Because of sive; all of them increase the demand for technical financial and other barriers, this practice often means expertise to operate and maintain the new equipment. that the patients do not receive the treatment they Surgeons, policy makers, and planners should keep need (Cannoodt, Mock, and Bucagu 2012; Grimes and in mind that most of the improvements in surgical others 2011). outcomes since the 1930s occurred before 1950, before Training programs, supply systems, and supervision any of these new techniques had been developed and should be designed to create and maintain the necessary become available. capacity at each level and to facilitate transfers between It is important to address three limitations on the use facilities as much as is practical. of new technologies in the context of the limited budge- tary and human resources in LMICs: General Surgical Procedures in an Ideal System • Cost: Both the initial costs and the costs of mainte- Table 4.3 presents a list of procedures that should be nance and service should be reasonable. available at different levels of the hospital system. For • Trained personnel: Trained personnel should be avail- this system to function well, efficient patient transfers able to perform the procedures, train assistants, and in and out are important. However, the realities of ensure that the equipment is adequately serviced and available transportation options, as well as the finan- well maintained. cial and other barriers faced by transferred patients • Disposable parts and supplies: Parts and supplies are and their families, make it essential to reduce the need usually expensive, and they put an additional burden General Surgical Emergencies 71 Table 4.3 General Surgical Emergency Capacity in an Ideal System First-level hospitals with Health general practitioner surgeon First- or second-level hospitals with Third-level Capacity center or nonphysician clinician qualified surgeon hospitals Airway management, fluid replacement, Xa X X X bleeding control, antibiotics Blood transfusion Xa X X Tube thoracostomy X a X X Tracheal tube X a X X Local anesthesia X X X X Spinal and general anesthesia X X X Hernia and intestinal obstruction Xa X X Appendicitis X X X Perforated peptic ulcer X a X X Bleeding peptic ulcer X X Bleeding esophageal varices X Pelvic peritonitis X X X Perforated typhoid ulcer Xa X X Colostomy Xa X X Cystostomy Xa X X Cricothyroidostomy X a X X Foreign body removal X X X Damage-control laparotomyb Xa Xa X a. Capacity (i.e., trained staff available 24 hours, with adequate equipment and supplies) should be there, but usually is not. b. This procedure is usually a way to deal with severe trauma, but could be a way to deal with the intestine in a very sick patient, when intestine must be removed, but it is not possible to restore continuity by sewing the ends back together. The ends can simply be tied off and the patient referred for another operation. on supply systems that are sometimes nonexistent depend on a definitive determination that perfora- and always under strain. tion or other complications have not occurred, which requires a CT scan. In LMICs, CT scanners generally It may be possible to overcome these conditions in are not available at first- or second-level hospitals and regional hospitals and in the major referral centers, but are only beginning to be introduced in third-level they are important barriers to the use of new technology hospitals. Nonsurgical treatment of appendicitis is in first- and second-level hospitals. Virtually no data are not likely to be practical for most people in LICs in available to enable cost-effectiveness analysis. the foreseeable future. Examples illustrating some of the complexities intro- • Bleeding peptic ulcer can almost always be controlled duced by technical advances include the following: without surgery using endoscopy. In one Indian hos- pital where mortality was very low, only 3 percent • Appendicitis that has not progressed to perforation, of patients required operations (Simon and others abscess, gangrene, or generalized peritonitis can be 2013). However, endoscopes and the skill to use them successfully treated with high-dose, intensive anti- are rarely available at first-level hospitals, and the biotics, but the condition will recur in 10 percent to surgery to control a bleeding ulcer is considerably 20 percent of patients who are treated without opera- more complicated than that for an appendectomy. tion. Randomized controlled trials of antibiotic treat- These patients should be referred, if possible. ment for nonperforated, nongangrenous appendicitis are underway in HICs (Mason and others 2012); One technological advance that can easily be made even if these trials favor nonsurgical treatment, they available in all hospital operating rooms is pulse oximetry. 72 Essential Surgery The pulse oximeter, a simple, sturdy, and inexpensive FUTURE DIRECTIONS device that continuously monitors oxygen levels in the blood, has increased the safety of general anesthesia. Research has underscored the magnitude of the burden WHO has launched the Patient Safety Pulse Oximetry of surgical disease in LMICs and the extent of the unmet project to improve the safety of surgical anesthesia need for surgical care. Although the estimates available care in LMICs, testing the effect on patient outcome are imprecise, most LMICs clearly have a substantial of providing a bundle consisting of the Surgical Safety burden of surgically treatable disease, and the available Checklist, pulse oximeters, and training in a number of surgical treatments reach only a fraction of the popula- pilot hospitals globally. WHO, with the World Federation tion in need. It is also clear that the needed services can of Societies of Anaesthesiologists, the Association of be provided at remarkably low cost and that surgery in Anaesthetists of Great Britain and Ireland, and others, very simple settings can be effective. has developed a training tool kit consisting of a manual, a video, and slide sets to improve provider responses to • The urgent need today is to know more about the cost hypoxemia. and cost-effectiveness of programs to expand services The results of “old-fashioned” surgery are generally as well as to improve training, supervision, logistical comparable to those obtained with modern technology, support, and the referral system. This knowledge will so health policy makers and planners in LMICs may be best acquired in the context of active programs want to devote resources to other priorities. The first to increase coverage, improve service delivery, and priority should be to provide the basic services that are provide better support for service delivery in existing the most cost-effective. Unfortunately, those patients facilities, especially first-level hospitals. who can pay often demand high technology, even in • The standards for training and certification of all the poorest countries, which can influence the planning staff members providing surgical care need to be process. There is a real risk that basic surgery in first- developed. These standards and certifications include and second-level hospitals will be considered second specialists, but also general practitioner surgeons, class and that qualified surgeons in private practice nonphysician clinician surgeons, anesthetists, and will encourage that opinion. That mindset needs to be operating theater staff. avoided, or it could set back progress considerably. • Monitored guidelines and checklists to organize and supervise treatment are needed. The active involvement of national and regional professional associations in these programs and investigations is essential. BARRIERS TO EFFECTIVE SERVICE DELIVERY • Monitoring and evaluating progress requires hospi- Hospital and community surveys in LICs show that tals that provide surgical services to have databases. the proportion of patients with surgical emergencies The databases need to be improved, but this improve- who receive effective treatment is very low (Ahmed and ment must acknowledge that too much paperwork others 1999; Grimes and others 2011; Kruk and others can detract from service delivery. Nursing staff, in 2010; Mock and others 1998) and that many of those particular, already have a heavy recordkeeping bur- who are untreated die. Multiple barriers to delivery of den. Improvements should be designed to reduce this surgical services exist in these countries. By far the most burden, improve quality, and ensure that the data important are inadequate training of existing staff, lack collected are used to improve service. of a referral system that can bring patients to referral hospitals from health centers and dispensaries, and the With commitment by the surgical leadership, prog- financial burden of a hospital stay for poor families (see ress could be rapid in coming years. The number of chapter 12). qualified surgeons and anesthetists in the poorest coun- The financial burden for patients and families is tries is growing exponentially, and ways can be found to very important. Even when services are free, a major persuade them to locate in or near first-level hospitals. operation can create a debt burden from which a In the interim, most of these conditions can be treated family may not recover (Afsana 2004). Lost income; with relatively simple surgery, which means that general travel and maintenance costs for patients and those practitioners, nonphysician clinicians, and nurses can who accompany them; food, medications, and supplies upgrade their skills with relatively short training aimed at not available in the hospital; and “informal charges” to those who will be assigned to first-level hospitals. Ideally, obtain minimal services can add up to large sums. This this training will be conducted in larger, high-volume reality is an important reason to avoid referrals as much hospitals by qualified surgeons who will follow up with as possible. in-service training and supervision conducted in the General Surgical Emergencies 73 first-level hospitals where these short-course surgeons Chalya, P. L., J. B. Mabula, M. Koy, J. B. Kataraihya, H. Jaka, practice. Models exist for this sort of upgrading program and others. 2012. “Typhoid Intestinal Perforations at a in Malawi, Niger, and Tanzania (Mkandawire, Ngulube, University Teaching Hospital in Northwestern Tanzania: and Lavy 2008; Nyamtema and others 2011; Sani and A Surgical Experience of 104 Cases in a Resource- Limited Setting.” World Journal of Emergency Surgery 7: 4. others 2009; van Amelsfoort and others 2010). doi:10.1186/1749-7922-7-4. Chalya, P. L., J. B. Mabula, M. Koy, M. D. McHembe, H. Jaka, and others. 2011. “Clinical Profile and NOTE Outcome of Surgical Treatment of Perforated Peptic Ulcers in Northwestern Tanzania: A Tertiary Hospital The World Bank classifies countries according to four income Experience.” World Journal of Emergency Surgery 6: 31. groupings. Income is measured using gross national income doi:10.1186/1749-7922-6-31. (GNI) per capita, in U.S. dollars, converted from local currency Chavez-Tapia, N. C., J. Hernandez-Calleros, F. I. Tellez-Avila, using the World Bank Atlas method. Classifications as of July A. Torre, and M. Uribe. 2009. “Image-Guided Percutaneous 2014 are as follows: Procedure Plus Metronidazole versus Metronidazole Alone for Uncomplicated Amoebic Liver Abscess.” • Low-income countries (LICs) = US$1,045 or less in 2013 Cochrane Database of Systematic Reviews 1: Cd004886. • Middle-income countries (MICs) are subdivided: doi:10.1002/14651858.CD004886.pub2. • Lower-middle-income = US$1,046 to US$4,125 Chu, K. M., N. Ford, and M. Trelles. 2010. “Operative Mortality • Upper-middle-income (UMICs) = US$4,126 to US$12,745 in Resource-Limited Settings: The Experience of Médecins • High-income countries (HICs) = US$12,746 or more Sans Frontiéres in 13 Countries.” Archives of Surgery 145 (8): 721–25. doi:10.1001/archsurg.2010.137. Conter, R. L., H. A. Pitt, R. K. Tompkins, and W. P. Longmire Jr. 1986. “Differentiation of Pyogenic from Amebic Hepatic REFERENCES Abscesses.” Surgery, Gynecology, and Obstetrics 162 (2): Abdullah, F., S. Choo, A. A. Hesse, F. Abantanga, E. Sory, and 114–20. others. 2011. “Assessment of Surgical and Obstetrical Care Curci, M. 2012. “Task Shifting Overcomes the Limitations at 10 District Hospitals in Ghana Using On-Site Interviews.” of Volunteerism in Developing Nations.” Bulletin of the Journal of Surgical Research 171 (2): 461–66. doi:10.1016/j American College of Surgeons 97 (10): 9–14. .jss.2010.04.016. Debas, H. T., R. Gosselin, C. McCord, and A. Thind. 2006. Adesunkanmi, A. R., and E. A. Agbakwuru. 1996. “Changing “Surgery.” In Disease Control Priorities in Developing Pattern of Acute Intestinal Obstruction in a Tropical Countries, 2nd ed., edited by D. T. Jamison, J. G. Breman, African Population.” East African Medical Journal 73 (11): A. R. Measham, G. Alleyne, M. Claeson, D. B. Evans, P. Jha, 727–31. A. Mills, and P. Musgrove, 1245–59. Washington, DC: Afsana, K. 2004. “The Tremendous Cost of Seeking Hospital World Bank and Oxford University Press. Obstetric Care in Bangladesh.” Reproductive Health Matters Grimes, C. E., K. G. Bowman, C. M. Dodgion, and C. B. Lavy. 12 (24): 171–80. 2011. “Systematic Review of Barriers to Surgical Care Ahmed, M., M. Shah, S. Luby, P. Drago-Johnson, and S. Wali. in Low-Income and Middle-Income Countries.” World 1999. “Survey of Surgical Emergencies in a Rural Population Journal of Surgery 35 (5): 941–50. in the Northern Areas of Pakistan.” Tropical Medicine and Gosselin, R. A., A. Thind, and A. Bellardinelli. 2006. “Cost/ International Health 4 (12): 846–57. DALY Averted in a Small Hospital in Sierra Leone: What Bainbridge, D., J. Martin, M. Arango, and D. Cheng. 2012. Is the Relative Contribution of Different Services?” “Perioperative and Anaesthetic-Related Mortality in World Journal of Surgery 30 (4): 505–11. doi:10.1007 Developed and Developing Countries: A Systematic /s00268-005-0609-5. Review and Meta-Analysis.” The Lancet 380 (9847): 1075–81. Groen, R. S., M. Samai, K. A. Stewart, L. D. Cassidy, doi:10.1016/s0140-6736(12)60990-8. T. B. Kamara, and others. 2012. “Untreated Surgical Burkitt, D. P., A. R. Walker, and N. S. Painter. 1972. “Effect Conditions in Sierra Leone: A Cluster Randomised, of Dietary Fibre on Stools and the Transit-Times, and Its Cross-Sectional, Countrywide Survey.” The Lancet 380 Role in the Causation of Disease.” The Lancet 2 (7792): (9847): 1082–87. doi:10.1016/s0140-6736(12)61081-2. 1408–12. Jamison, D. T., J. G. Breman, A. R. Measham, G. Alleyne, Cannoodt, L., C. Mock, and M. Bucagu. 2012. “Identifying M. Claeson, D. B. Evans, P. Jha, A. Mills, and P. Musgrove, Barriers to Emergency Care Services.” International Journal eds. 2006. Disease Control Priorities in Developing Countries, of Health Planning and Management 27 (2): e104–20. 2nd ed. Washington, DC: World Bank and Oxford doi:10.1002/hpm.1098. University Press. CDC (Centers for Disease Control). 1990. Vital Statistics of the Jha, A. K., G. Das, S. Maitra, T. K. Sengupta, and S. Sen. United States, Vol. 2, Mortality, Part B. http://www.cdc.gov 2012. “Management of Large Amoebic Liver Abscess— /nchs/data/vsus/mort90_2b.pdf. A Comparative Study of Needle Aspiration and 74 Essential Surgery Catheter Drainage.” Journal of the Indian Medical Association Decrease Mortality from Typhoid Ileal Perforation.” 110 (1): 13–15. Tropical Doctor 25 (3): 115–17. Jiang, J., B. Jiang, U. Parashar, T. Nguyen, J. Bines, and others. Mulligan, J., J. Fox-Rushby, T. Adams, B. Johns, and A. Mills. 2013. “Childhood Intussusception: A Literature Review.” 2003. “Unit Costs of Health Care Inputs in Low and PLoS One 8 (7): e68482. doi:10.1371/journal.pone.0068482. Middle Income Regions.” Working Paper 9, Disease Control King, M., P. Bewes, J. Cairns, and J. Thornton, eds. 1986. Priorities. Fogarty International Center, National Institutes Chapters 5, 6, and 7. In Non-Trauma. Vol. 1 of Primary of Health, Bethesda, MD. Surgery, 52–103. Oxford: Oxford University Press. Nasir, A. A., L. O. Abdur-Rahman, and J. O. Adeniran. 2011. Kirschner, M. 1926. “Die behandlung der akutren eitrigen freien “Predictor of Mortality in Children with Typhoid Intestinal Bauchfellentzundung.” Archivus Klinikum Chirurgicum Perforation in a Tertiary Hospital in Nigeria.” Pediatric 142: 253. Surgery International 27 (12): 1317–21. doi:10.1007 Kruk, M. E., A. Wladis, N. Mbembati, S. K. Ndao-Brumblay, /s00383-011-2924-2. R. Y. Hsia, and others. 2010. “Human Resource and Ngendahayo, E., A. Bonane, G. Ntakiyiruta, Funding Constraints for Essential Surgery in District A. Munyanshongore, N. Muganga, and others. 2014. Hospitals in Africa: A Retrospective Cross-Sectional “Preparing for Safety Monitoring after Rotavirus Survey.” PLoS Med 7 (3): e1000242. doi:10.1371/journal Vaccine Implementation: A Retrospective Review of .pmed.1000242. Intussusception Cases among Children at a Large Teaching Lavy, C., A. Tindall, C. Steinlechner, N. Mkandawire, and Hospital in Rwanda, 2009–2012.” Pediatric Infectious S. Chimangeni. 2007. “Surgery in Malawi: A National Disease Journal 33 (Suppl 1): S99–103. doi:10.1097 Survey of Activity in Rural and Urban Hospitals.” Annals /inf.0000000000000093. of the Royal College of Surgeons of England 89 (7): 722–24. Nilsson, H., G. Stylianidis, M. Haapamaki, E. Nilsson, and doi:10.1308/003588407x209329. P. Nordin. 2007. “Mortality after Groin Hernia Surgery.” Madziga, A. G., and A. I. Nuhu. 2008. “Causes and Treatment Annals of Surgery 245 (4): 656–60. Outcome of Mechanical Bowel Obstruction in North Nuhu, A., and A. Jah. 2010. “Acute Sigmoid Volvulus in a West Eastern Nigeria.” West African Journal of Medicine 27 (2): African Population.” West African Journal of Medicine 29 (2): 101–05. 109–12. Mason, R. J., A. Moazzez, H. Sohn, and N. Katkhouda. Nyamtema, A. S., S. K. Pemba, G. Mbaruku, F. D. Rutasha, 2012. “Meta-Analysis of Randomized Trials Comparing and J. van Roosmalen. 2011. “Tanzanian Lessons Antibiotic Therapy with Appendectomy for Acute in Using Non-physician Clinicians to Scale up Uncomplicated (No Abscess or Phlegmon) Appendicitis.” Comprehensive Emergency Obstetric Care in Remote Surgical Infections (Larchmt) 13 (2): 74–84. doi:10.1089/ and Rural Areas.” Human Resources for Health 9: 28. sur.2011.058. doi:10.1186/1478-4491-9-28. McConkey, S. J. 2002. “Case Series of Acute Abdominal Surgery Ohene-Yeboah, M. 2006. “Acute Surgical Admissions for in Rural Sierra Leone.” World Journal of Surgery 26 (4): Abdominal Pain in Adults in Kumasi, Ghana.” ANZ 509–13. doi:10.1007/s00268-001-0258-2. Journal of Surgery 76 (10): 898–903. doi:10.1111/j.1445 McCord, C., and Q. Chowdhury. 2003. “A Cost Effective Small -2197.2006.03905.x. Hospital in Bangladesh: What It Can Mean for Emergency Petroze, R. T., R. S. Groen, F. Niyonkuru, M. Mallory, Obstetric Care.” International Journal of Gynaecology and E. Ntaganda, and others. 2013. “Estimating Operative Obstetrics 81 (1): 83–92. Disease Prevalence in a Low-Income Country: Results of a Mkandawire, N., C. Ngulube, and C. Lavy. 2008. “Orthopaedic Nationwide Population Survey in Rwanda.” Surgery 153 (4): Clinical Officer Program in Malawi: A Model for 457–64. doi:10.1016/j.surg.2012.10.001. Providing Orthopaedic Care.” Clinical Orthopaedics Sani, R., B. Nameoua, A. Yahaya, I. Hassane, R. Adamou, and and Related Research 466 (10): 2385–91. doi:10.1007 others. 2009. “The Impact of Launching Surgery at the /s11999-008-0366-5. District Level in Niger.” World Journal of Surgery 33 (10): Mnguni, M. N., J. Islam, V. Manzini, V. Govindasamy, 2063–68. doi:10.1007/s00268-009-0160-x. B. M. Zulu, and others. 2012. “How Far Has the Pendulum Shillcutt, S. D., M. G. Clarke, and A. N. Kingsnorth. 2010. Swung in the Surgical Management of Sigmoid Volvulus? “Cost-Effectiveness of Groin Hernia Surgery in the Western Experience from the KwaZulu-Natal Teaching Hospitals Region of Ghana.” Archives of Surgery 145 (10): 954–61. and Review of the Literature.” Colorectal Disease 14 (12): doi:10.1001/archsurg.2010.208. 1531–37. doi:10.1111/j.1463-1318.2012.03046.x. Simon, E. G., A. Chacko, A. K. Dutta, A. J. Joseph, and Mock, C. N., G. J. Jurkovich, D. nii-Amon-Kotei, C. Arreola- B. George. 2013. “Acute Nonvariceal Upper Gastrointestinal Risa, and R. V. Maier. 1998. “Trauma Mortality Patterns in Bleeding: Experience of a Tertiary Care Center in Southern Three Nations at Different Economic Levels: Implications India.” Indian Journal of Gastroenterology 32 (4): 236–41. for Global Trauma System Development.” Journal of doi:10.1007/s12664-013-0305-6. Trauma 44 (5): 804–12; discussion 812–4. Soper, D. E. 2010. “Pelvic Inflammatory Disease.” Obstetrics Mock, C. N., L. Visser, D. Denno, and R. Maier. 1995. “Aggressive and Gynecology 116 (2 Pt 1): 419–28. doi:10.1097/AOG Fluid Resuscitation and Broad Spectrum Antibiotics .0b013e3181e92c54. General Surgical Emergencies 75 Stewart, B., P. Khanduri, C. McCord, M. Ohene-Yeboah, Clinical Officers.” Tropical Doctor 40 (2): 74–76. doi:10.1258 S. Uranues, and others. 2014. “Global Disease Burden of /td.2009.090068. Conditions Requiring Emergency Surgery.” British Journal van den Heuvel, B., B. J. Dwars, D. R. Klassen, and H. J. Bonjer. of Surgery 101 (1): e9–22. doi:10.1002/bjs.9329. 2011. “Is Surgical Repair of an Asymptomatic Groin Hernia Ugochukwu, A. I., O. C. Amu, M. A. Nzegwu, and U. C. Dilibe. Appropriate? A Review.” Hernia 15 (3): 251–59. doi:10.1007 2013. “Acute Perforated Peptic Ulcer: On Clinical Experience /s10029-011-0796-y. in an Urban Tertiary Hospital in South East Nigeria.” Wani, I., M. Rather, G. Naikoo, A. Amin, S. Mushtaq, International Journal of Surgery 11 (3): 223–27. doi:10.1016 and others. 2010. “Intestinal Ascariasis in Children.” /j.ijsu.2013.01.015. World Journal of Surgery 34 (5): 963–68. doi:10.1007 Urassa, D. P., A. Carlstedt, L. Nystrom, S. N. Massawe, and /s00268-010-0450-3. G. Lindmark. 2005. “Are Process Indicators Adequate to WHO (World Health Organization). 2002. World Health Assess Essential Obstetric Care at District Level? A Case Report 2002: Reducing Risks, Promoting Healthy Life. Study from Rufiji District, Tanzania.” African Journal of Geneva: WHO. Reproductive Health 9 (3): 100–11. ———. 2003. Surgical Care at the District Hospital. Geneva: U.S. Department of Commerce, Bureau of the Census. 1935. WHO. Mortality Statistics 1935: Thirty-Sixth Annual Report. ———. 2013a. “Global Health Estimates (GHE).” http://www http://www.cdc.gov/nchs/data/vsushistorical/mortstatsh .who.int/healthinfo/global_burden_disease/en/. _1935.pdf/. ———. 2013b.“WHO Model List of Essential Medicines.”http:// van Amelsfoort, J. J., P. A. van Leeuwen, P. Jiskoot, and www.who.int/medicines/publications/essentialmedicines Y. E. Ratsma. 2010. “Surgery in Malawi: The Training of /18th_EML_Final_web_8Jul13.pdf. 76 Essential Surgery Chapter 5 Obstetric Surgery Clark T. Johnson, Timothy R. B. Johnson, and Richard M. K. Adanu GLOBAL BURDEN OF SURGICALLY This chapter uses the World Health Organization’s TREATABLE OBSTETRIC CONDITIONS (WHO’s) six geographical regions: African Region, Region of the Americas, South-East Asia Region, Surgically Preventable or Treatable Conditions European Region, Eastern Mediterranean Region, and Pregnancy is not a disease but a condition undertaken by Western Pacific Region. most women during their reproductive lives. Pregnancy, however, is a time when health can be threatened. Any pregnancy carries the risk for hemorrhage, obstructed Burden of Maternal Mortality labor, or the need for a cesarean delivery. The sheer In 2000, total maternal mortality was 421,010; by volume of maternal morbidity and mortality worldwide 2011, worldwide maternal mortality had decreased sig- indicates that every pregnant woman is at risk for surgi- nificantly to 279,000. The maternal mortality ratio cally preventable obstetric complications that can lead to (MMR)—maternal deaths per 100,000 live births— death or disability. improved from 321 in 2000 to 207 in 2011. In high- Maternal morbidity and mortality are significantly income countries (HICs), a small increase was noted, increased by conditions that can be prevented by access from 12 to 14; LMICs saw a marked improvement, from to safe obstetric surgery. Obstructed labor, which can lead 352 to 227 (WHO 2013). This risk is much higher in to fistula formation, uterine perforation, hemorrhage, adolescent pregnancies, which account for an increasing sepsis, or death, can be avoided by observing labor for proportion of maternal mortality in LMICs (Patton and deviations from normal and providing access to nearby others 2009). safe cesarean delivery. Most low- and middle-income In LMICs, a woman has a 1:150 lifetime risk, on countries (LMICs) do not have birth attendants present average, of dying from complications of pregnancy and at deliveries to monitor for abnormalities; most of these childbirth (WHO 2012). In some areas of Sub-Saharan countries also lack the capacity to provide access to nearby Africa, this risk is as high as 1:16; a woman who sur- hospitals, where safe and timely cesarean deliveries can vives until childbearing years has a 6.25 percent chance be undertaken. Hemorrhage during pregnancy and the that her life will be ended prematurely from the com- postpartum period can be catastrophic; the occurrence of plications of pregnancy. These burdens are even higher hemorrhage remote from access to surgical services, such in the underdeveloped regions of countries with high as uterine curettage or lifesaving hysterectomy, drives maternal morbidity and mortality rates (Liang and avoidable maternal mortality rates worldwide. others 2011). Corresponding author: Clark T. Johnson, MD, MPH, Johns Hopkins Medical Institutions, ctj@jhu.edu 77 The reduction of maternal mortality during preg- such assessments is that efforts to drive down MMRs nancy and up to six weeks postpartum was estab- succeed in part by creating permanent disabilities lished as Millennium Development Goal (MDG) 5 in lieu of maternal death. The societal costs of these (UN 2013). Although the world has yet to approach DALYs can be significant, and a full assessment of the MDG 5 goal of a 75 percent reduction in the the burden of disease should include an evaluation MMR, there are reasons for optimism (Hogan and of DALYs. others 2010). Worldwide efforts to meet this goal have In 2010, the collective disability for all measured yielded dramatic improvements. Overall success has maternal disorders reached 16 million DALYs (Murray been attributed to improvements in the total fertility and others 2012). Of this number, 3.3 million DALYs rate, per capita income, maternal education level, and were attributed to maternal hemorrhage, 1.8 million presence of skilled birth attendants. However, the HIV to complications of obstructed labor, and 1.3 million epidemic has significantly added to MMRs; areas that to maternal sepsis. These numbers are indicative of the could have been expected to see a reduction in maternal tremendous morbidity associated with surgically pre- mortality have instead not seen significant differences. ventable obstetric complications that can be targeted The tremendous disparity in MMRs between HICs on worldwide. the one hand and LMICs on the other indicates the As table 5.1 demonstrates, dramatic improve- potential to reduce maternal morbidity and mortality ments in reducing MMRs have been made in the past on a worldwide scale. 20 years. However, obstructed labor has lagged behind the other major maternal disorders (Murray and oth- ers 2012). This lag is partly due to the challenges in Disability Burden the treatment of this condition. Simply having access Assessments of disability-adjusted life years (DALYs) to safe and timely cesarean delivery can prevent the have been made for major obstetric complications sequelae of obstructed labor. This simple procedure worldwide (table 5.1). A DALY is a metric of the num- has been more difficult to implement in LMICs than ber of years lost due to ill health, disability, or early have the medical treatments that can reduce morbid- death for one individual. When summed for a popula- ity from hemorrhage or hypertensive diseases, in large tion, it can assess the burden of a disease in a way that part because of the associated up-front infrastructural mortality assessments may miss. The significance of and systems costs of developing the environments Table 5.1 The Global Disability Burden of Obstetric Disease in Terms of Disability-Adjusted Life Years, 1990–2010 All ages DALYs (thousands) DALYs (per 100,000 total population) 1990 2010 Difference (%) 1990 2010 Difference (%) Maternal disorders 21,582 16,104 −25.4 407 (340–485) 234 (188–274) −42.6 (18,000–25,720) (12,972–18,912) Maternal 4,784 3,289 −31.2 90 (74–108) 48 (38–56) −47.1 hemorrhage (3,923–5,713) (2,619–3,860) Maternal sepsis 2,043 1,309 −35.9 39 (32–47) 19 (15–23) −50.7 (1,701–2,508) (1,059–1,585) Hypertensive 4,108 2,797 −31.9 77 (64–94) 41 (33–49) −47.6 disorders of (3,406–4,986) (2,254–3,357) pregnancy Obstructed labor 1,891 1,792 −5.2 36 (27–50) 26 (18–41) −27.1 (1,451–2,625) (1,249–2,806) Abortion 3,218 2,138 −33.6 61 (50–74) 31 (25–38) −48.9 (2,668–3,945) (1,731–2,592) Other maternal 5,538 4,778 −13.7 104 (86–123) 69 (55–80) −33.6 disorders (4,576–6,538) (3,819–5,512) Source: Adapted from Murray and others 2012. Note: 95 percent confident interval in parentheses. 78 Essential Surgery in which patients can be referred and safe cesarean OVERVIEW OF SURGICAL OBSTETRICAL delivery performed. PROCEDURES The successful management of labor and delivery Societal Impact of Maternal Mortality requires a balanced use of medical and surgical prac- A valid assessment of the health burden of obstetric tices. Most pregnancies end with uncomplicated vaginal complications should not be limited to maternal mor- deliveries. Pregnant women in labor have the right to bidity and mortality, but should also consider the attendants who can manage obstetric complications as effect of the morbidity and mortality rates in LMICs. they arise and who can transfer patients to a higher level Such assessments have included the effects that a mater- of care as needed. nal death can have on societies as well as on families The presence of skilled birth attendants at all deliv- (Yamin and others 2013). Children who are orphaned eries facilitates normal deliveries and the identification as the result of a maternal death suffer from hindered and referral of complications, but their effectiveness is access to health care, poorer nutrition, and worse edu- limited by available referral resources. Although birth cation. Female orphans particularly suffer because they attendants may be able to accommodate minor com- are often expected to perform the household chores that plications, the benefit of their ability to identify major their mothers would have performed. Their educational morbidity is limited if patients lack timely access to and economic opportunities become limited, and high- higher levels of care. risk sexual behavior or early marriage can result. These A majority of obstetric complications that require developments, in turn, can lead to early pregnancies, surgical intervention occurs peridelivery. Obstructed putting daughters at risk for the same complications labor from a number of causes, including malpresenta- that led to their mothers’ deaths. tion and large fetal size, can necessitate one of a number In addition to the negative impacts on orphan chil- of procedures to facilitate fetal delivery. Following deliv- dren, maternal deaths affect the entire family structure ery, hemorrhage from a number of etiologies, including (Yamin and others 2013). Economically, the loss of a lacerations and uterine atony, can similarly require one mother is a loss of help around the house, a loss of a of a number of lifesaving procedures to help stop ongo- potentially important secondary income, and the loss ing bleeding. of a caregiver. In these environments with high mater- nal mortality, high societal mortality rates often lead to women having multiple children with different fathers. Operative Vaginal Delivery It is uncommon for surviving fathers to care for non- Operative vaginal delivery, such as delivery assisted biological children, potentially abandoning orphaned with forceps or a vacuum, requires trained providers children without living fathers. The loss of mothers as well as available instruments (Hale and Dennen frequently can lead to the dissolution and permanent 2001); its use in LMICs is often limited to the hospital fragmentation of families, with children going to dif- setting. Vacuums require a fundamental level of train- ferent homes or family members. Support structures ing before routine use, and forceps require potentially for families that have lost mothers are uncommon and more training, in addition to provision of the actual not well developed in countries where maternal death devices. The WHO is developing variations on a vac- rates are high. uum to provide a low-cost and easy-to-use device that In sum, the global health burden of obstetric dis- can be widely implemented by birth attendants to ease is tremendous, with essentially all women of reduce morbidity and mortality (FIGO 2012). Some reproductive age at risk for obstetric complications. devices are reusable; after the initial investment in the Some percentage of pregnancies require some form of device, the subsequent cost largely consists of training operative delivery; an estimated 15 percent of all deliv- providers to effectively and safely use it. The use of eries require cesarean delivery to optimize maternal operative vaginal delivery techniques in the appropri- and neonatal outcomes (Gibbons and others 2012). ate clinical circumstance might prevent the need for an Worldwide, 50 percent of countries have cesarean inaccessible but otherwise necessary cesarean delivery. delivery rates that are less than 15 percent; 25 percent Additionally, manual or digital rotation of the fetal of countries have cesarean delivery rates of less than head without the use of forceps can help to guide the 5 percent. The WHO estimates that in LMICs, the head through the pelvis to facilitate vaginal delivery cesarean rate should be at least 5 percent to 10 percent (Le Ray and others 2007), but it requires a similar of deliveries to optimize maternal and neonatal out- level of training. In sum, the minimal costs associated comes (Gibbons and others 2012). with providing the devices, as well as training for Obstetric Surgery 79 management of the second stage of labor, can help Similarly, hematomas can occur; even without visible reduce morbidity and mortality without requiring the bleeding, large volumes of blood can accumulate in use of an operating theater. the pelvis following vaginal delivery. Depending on their location, prompt identification and treatment can be life saving. Shoulder Dystocia Shoulder dystocia and its association with poor fetal outcomes and brachial plexus injuries make it a Abnormal Fetal Presentation feared obstetrical complication (Baskett, Calder, and Breech Presentation. In most pregnancies, the fetus Arulkumaran 2007; O’Grady and others 2008). Shoulder moves into the safest position of head down at approx- dystocia results from delivery of the fetal head, with a imately 36 weeks. However, this movement does not dystocia at the level of the shoulder that obstructs deliv- occur in 4 percent of cases, resulting in breech presen- ery. It is more common with large infants, particularly tation (Baskett, Calder, and Arulkumaran 2007), and its with relatively large shoulder widths born to mothers incidence rises dramatically with prematurity. Breech with diabetes. Attempts at delivery may cause permanent presentation is associated with inferior fetal outcomes, nerve injury, and delay in delivery may cause hypoxic as a result of both the antenatal risk factors and the per- injury or death. inatal risk of birth injury at delivery. Several maneuvers have been described for delivery. Ideally, a breech presentation is identified before Most techniques involve rotation of the fetal shoulder delivery so that consideration can be given to attempt- from the anterior-posterior orientation to a more ing the external turning of the fetus. This technique is oblique position, where the more generous dimen- optimally performed near 36 weeks, when the success sions of the pelvis might permit shoulder delivery. rate is generally better than 50 percent. Although exter- Specific surgical instruments may be needed for oper- nal version can effectively make a mother a candidate ative management without successful resolution of the for vaginal delivery and decrease morbidity, it carries dystocia. Successful management of a shoulder dysto- the risk of manually traumatizing the placenta or the cia depends primarily on the training of the attending fetus, necessitating immediate delivery. It should only providers. take place when the fetal status can be confirmed, and Intentional pubic symphysiotomy, where the pubic intervention, including cesarean delivery, is immedi- bone is broken to facilitate fetal delivery, is controver- ately available. Unfortunately, in LMICs where ante- sial because it can cause significant maternal morbidity natal care is scant, breech presentation may not be and chronic pain. Its implementation should be per- identified until labor, and delivery has to be facilitated formed only by experienced providers when all other either by emergent cesarean or by unanticipated vagi- options have failed and cesarean delivery is not available. nal breech delivery. Significantly, it is only necessary without timely access to Large studies have demonstrated improved fetal out- safe cesarean delivery. comes in breech presentation with cesarean delivery (Hannah and others 2000; Hannah and others 2002); safe cesarean delivery is preferred, when available, unless Genital Tract Lacerations practitioners are trained to manage breech labor and Lacerations of the genital tract, which can occur spon- its complications. Birth attendants should be trained in taneously or result from an episiotomy, are the second the maneuvers to assist intact delivery in cases in which most common cause of postpartum hemorrhage. breech delivery is inevitable or advisable. Particularly in They can occur at any level, including the perineum, the absence of antenatal care, a possible clinical scenario sulci, cervix, or the broad ligament in the abdomen; is a vaginal breech delivery in progress, and fetal out- without spontaneous hemostasis, they will require come will depend on a present provider who can safely repair. The use of routine episiotomy in obstetrics deliver the fetus. has evolved, with studies demonstrating the cost- effectiveness of its selective rather than routine use Other Presentation. Malpresentation, in which neither (Borghi and others 2002). An attendant with available the fetal vertex nor the breech is the presenting part, as suture can repair a majority of perineal lacerations with a transverse presenting fetus (where the fetus is without referral, but severe lacerations can threaten sideways), is a universal indication for cesarean delivery. or end a mother’s life. Complicated lacerations can Without a safe and timely cesarean delivery, the preg- bleed profusely; ongoing bleeding can exhaust clot- nancy can end with obstructed labor and its sequelae, ting factors, resulting in an inability to clot and death. or fetal demise. 80 Essential Surgery Multiple Gestation bimanual massage is optimized when two parties coor- Delivery of more than one fetus is inherently more dinate to help compress the atonic uterus and stop complicated (Baskett, Calder, and Arulkumaran 2007). maternal hemorrhage (Andreatta, Perosky, and Johnson Contraindications to vaginal delivery include three or 2012). Active management of the delivery of the placenta more fetuses, an exceedingly uncommon event in the itself can significantly help prevent atonic hemorrhage absence of assisted reproductive technology. Fortunately, and limit the need for additional uterotonics (Stanton the presenting fetus will usually be head down in the and others 2009). pelvis and can be managed essentially as a singleton If hemorrhage continues despite these maneuvers, labor. Following delivery of the first twin, and if the surgical management should be considered. Surgical second twin does not present vertex, attempts can be management can include blunt or sharp curettage of made to externally rotate the fetus to vertex and proceed the uterus, particularly with a large curette to minimize with vaginal delivery. Otherwise, breech extraction of the risk of perforating the fragile peripartum uterus and the second twin can be considered. In multifetal deliver- necessitating abdominal surgery. Otherwise, laparotomy ies, vaginal delivery has lower maternal morbidity than can be used to access the uterus and perform maneuvers cesarean delivery, but a combined vaginal delivery and such as compression sutures, ligation of uterine vessels, cesarean delivery is more morbid than either. If vaginal or ultimately hysterectomy for definitive management. delivery of a second twin is doubtful, particularly in the Delays in or the unavailability of surgical interventions absence of a provider comfortable with breech extrac- can lead to uncontrolled hemorrhage, disseminated tion, cesarean delivery may be considered primarily. intravascular coagulopathy, and death. For persistent hemorrhage, the uterus can be packed to tamponade and temporize the bleeding. This procedure can be Postpartum Hemorrhage done either with packing or with a balloon catheter to help drain the uterine cavity while providing tampon- Postpartum hemorrhage is a dreaded complication ade. Surgical management may still be fundamentally akin to the most severe surgical trauma. The average needed, but maternal survival may depend on the ability blood losses for a routine vaginal delivery and a cesar- to transport to provide abdominal surgery. ean delivery are commonly accepted to be 500 mls and 1,000 mls, respectively; blood loss in excess of these Retained Placenta. Following delivery of the placenta, values is considered to be hemorrhage. The causes of any remnant of the products of conception can con- postpartum hemorrhage are as follows, in the order of tribute to uterine atony and ongoing vaginal bleed- frequency, with optimal management based on underly- ing. Retained products may be suspected with difficult ing etiology (O’Grady and others 2008): extrusion of the placental membranes. In any scenario in which retained products of conception are suspected, • Uterine atony consideration should be given to the possibility of • Lacerations placenta accreta because further placental bed manip- • Retained placenta, including abnormal placentation ulation could contribute to catastrophic hemorrhage • Uterine rupture and death. Surgical curettage may be needed to remove • Uterine inversion persistent retained products and arrest hemorrhage if • Coagulopathy placental abnormalities are not present. Uterine Atony. Uterine atony accounts for approx- Uterine Inversion. Inversion of the uterus can occur imately 80 percent of all postpartum hemorrhage as a result of overzealous traction on a placenta or from (O’Grady and others 2008). Risk factors include uterine fundal pressure in the third stage of labor. With inver- overdistension, prolonged labor, multiparity, infection, sion, on examination, the fundus may be noted to have and use of uterine relaxants. Medical uterotonics, where descended or prolapsed into the vagina. A skilled atten- available, can be administered to assist uterine tone, dant can use gentle manual replacement of the fundus including pitocin, misoprostol, and ergots or pros- back to its appropriate station, and effort may be needed taglandins. Consideration may also be given to draining to avoid relapse of the prolapse. Without successful the bladder, given that a distended bladder can contrib- manual replacement, other techniques may be urgently ute to uterine atony. Mechanically, bimanual massage needed in the face of ongoing hemorrhage or mater- can at least temporize uterine atony. Without medical nal shock (Baskett, Calder, and Arulkumaran 2007). or surgical interventions, effective bimanual massage Nonsurgically, intravaginal pressure can be increased can be life saving. Research has suggested that effective with infusion of intravenous fluids while the introitus Obstetric Surgery 81 is blocked, which may reduce the inversion. Surgically, thromboembolism during routine cesarean delivery the abdomen can be entered with a Pfannenstiel inci- is low in the absence of other risk factors, and routine sion or otherwise to gain exposure to the uterus. In the medical thrombolytic prophylaxis is not recommended Huntington procedure, the round ligaments are elevated (Dahlke and others 2013). and followed medially, eventually restoring the inverted fundus. Alternatively, with the Haultian procedure, the Incision. The Pfannenstiel incision, transversely in inversion is incised vertically, permitting appropriate the lower abdomen, has classically been described for reapproximation of the fundus. cesarean delivery. A midline vertical incision may be considered for better exposure. Alternatives to the Blood Transfusion. The WHO considers access to Pfannenstiel or midline vertical incisions include the safe blood transfusion be a key lifesaving interven- Joel-Cohen technique and the Misgav-Ladach method tion (WHO 2008). The availability of blood transfu- in which blunt dissection is used and may decrease sions at the time of obstetric emergency can be life blood loss and operative time, although studies have not saving. Accordingly, blood transfusion services should shown significant decreases in morbidity or mortality be considered part of emergency obstetric management (CORONIS 2013). capacity. Blood transfusion availability is severely lim- The uterus is incised in the lower nonmuscular ited in LICs and LMICs, and efforts to make it available portion to facilitate fetal delivery. Occasionally, a con- locally can save lives. traction ring or “Bandl’s ring” can be seen in prolonged obstructed labor at the time of cesarean delivery. Its treatment requires perpendicular incision, through Cesarean Delivery the ring and muscle of the uterus, to relax the tension Prolonged labor can lead to uterine rupture, which can and permit delivery, with significant future morbidity lead to rapid fetal or maternal exsanguination. In set- associated with the incision. Notably, any uterine inci- tings of prolonged and obstructed labor, eventual cesar- sion that extends up into the thick muscle significantly ean section has a significantly increased risk of maternal compromises the uterus and increases the risk of uter- morbidity or potentially death, compared with timely ine rupture in a future pregnancy. It is considered a cesarean delivery. contraindication to a future trial of labor, sentencing the patient to indicated cesarean deliveries for all future Indications. The indications for cesarean delivery are pregnancies. numerous, and its potential to reduce associated mor- bidity is significant. The decision to proceed is influ- Delivery. The fetus is delivered through the uterine enced by a number of factors, including the training of incision, with morbidity associated with cesarean deliv- the operator, the operative and clinical resources, and ery increasing if the fetal head has engaged in the pelvis the variables of the clinical presentation. The caveat and labor has taken longer, as with obstructed labor. is that cesarean delivery is a more morbid procedure: Techniques to facilitate a challenging cesarean deliv- blood loss is increased, recovery time is lengthened, ery may include breech extraction, use of the vacuum and potentially inferior fetal outcomes can occur. In extractor, or use of one or two forceps blades to facilitate certain scenarios, however, a cesarean is necessary delivery through the hysterotomy. Morbidity includes and inevitable to save a life or lives. Efforts to develop hemorrhage, infection, or uterine excision extension evidence-based best practices for cesarean delivery are into the nearby anatomy of either the major vasculature ongoing (Berghella, Baxter, and Chauhan 2005; Dahlke or the urinary tract. and others 2013). If the placenta does not easily separate, occult pla- centa accreta may be considered. If accreta is suspected, Preoperative Preparation. Once the decision is made manual removal should be avoided; if spontaneous to proceed, the patient is moved to the operating the- delivery does not occur, then hysterectomy should be ater, and the appropriate anesthesia, whether regional considered. The uterus may be exteriorized to facilitate or general, is administered. The abdomen is prepared exposure for closure, although this may increase patient in a sterile manner. A Foley catheter may be placed discomfort and nausea, as well as risk of avulsion of to help minimize the presence of the bladder in the adhesions to the uterus, if present. operative field and to provide an accurate assessment Uterine closure then takes place quickly in the face of urine output. A single dose of antibiotic prophy- of bleeding from the hysterotomy edges and from the laxis within 30 minutes before incision is associated uterus. Atony should be addressed while surgery con- with decreased risk of infection. The risk of venous tinues with bimanual massage used as needed. If the 82 Essential Surgery patient desires an intrauterine device for contraception, The term placenta accreta encompasses placenta increta it can be placed at this time directly at the level of the (where placenta grows into the uterine wall) and percreta fundus, with the strings trimmed and introduced near (where placenta grows into nearby tissue including or through the cervix. bowel and bladder). Risk factors include previous uter- ine scarring from surgical procedures, including previ- Obstetric Hemorrhage at Time of Cesarean Delivery. ous cesarean section. Hemorrhage following cesarean differs from that fol- Antenatal diagnosis can be achieved with ultrasound lowing vaginal delivery in that there is already access to imaging in combination with clinical history. With the abdominal cavity, improving the odds of successful antenatal diagnosis, preparations should be made at the definitive management. Conservative measures can onset of labor to plan for delivery in a scheduled set- also be taken, including medicines and bimanual mas- ting, ready for the probability of cesarean hysterectomy sage. Without quick resolution, a stitch can be placed and the need for blood products, if available. Even in bilaterally around the large uterine vessels to decrease settings with full obstetric resources, placenta accreta active hemorrhage from the uterus. Hypogastric artery can lead to poor maternal outcomes. The aggressive ligation can similarly decrease the blood flow and rate hemorrhage associated with incomplete placental sep- of blood loss, although its dissection is technically chal- aration can quickly lead to disseminated coagulopathy lenging and should only be undertaken by an operator and require massive blood transfusions to maintain sufficiently trained in and comfortable with the proce- maternal life. dure. Tamponade and packing can be performed and left Suspicion of placenta percreta before delivery calls in place to arrest bleeding as well. for the coordination of a team of surgeons in a facil- If atony is the underlying issue and the outlined steps ity with resources to maximize the likelihood of safe have not stopped the bleeding, compression sutures may delivery. Cesarean delivery should be undertaken, with be helpful in the scenario in which bimanual massage is consideration for a midline vertical incision to facilitate effective, but as soon as the hands are removed uterine a potential hysterectomy. Following exposure of the tone is lost. gravid uterus, a uterine incision may be made to avoid When ongoing hemorrhage is significant and not disruption of the placental bed if its location is known. easily abated, definitive management with hysterectomy In cases of diagnostic certainty, cesarean hysterectomy should be strongly considered because delay will only can be accomplished without attempting placental deliv- increase morbidity. The B-Lynch suture is described as ery, decreasing the risk of morbidity associated with passing a stitch on a large needle across the hysterotomy hemorrhage. In cases in which accreta is not identified about halfway toward the side (El-Hamamy, Wright, and until the time of delivery, a balloon catheter can be used Lynch 2009). The stitch is then taken to the posterior to tamponade the uterine cavity, potentially avoiding of the uterus, where it is passed transversely at approxi- further surgical morbidity. mately the level of the anterior low uterine segment hys- Following delivery, the hysterectomy is performed; in terotomy. It is brought back anterior, where it is thrown these cases, the caliber of the vasculature is significantly vertically across the hysterotomy on the other side. The generous and the anatomy can be distorted. Care must two ends of the suture are tied down while an assistant be taken to skeletonize the engorged uterine vessels while has maximally compressed and folded the uterus on ensuring safe distance from the ureters to prevent their itself, so that when the stitch is tied down, the uterus injury. is as compressed as possible because any relaxation There is no definitive answer for when to deliver sus- will contribute to bleeding from atony. Other types of pected placenta accreta, although it is frequently done compression sutures are described as passing anterior between 34 weeks and 36 weeks to balance neonatal sur- to posterior in the body of the uterus to tamponade vival against risk of onset of labor and emergent delivery sequential pockets throughout the cavity. If compres- in the setting of acute hemorrhage (ACOG 2013). sion sutures are performed, care should be taken not to obstruct cavity outflow given that hematometra or pyometra can result. EFFECTIVENESS AND COST-EFFECTIVENESS Abnormal Placentation and Cesarean Hysterectomy OF OBSTETRIC SURGERY When the placenta grows into tissue beyond its nor- The need to prove the cost-effectiveness of operative mal boundaries, it can embed in that tissue and cause obstetrics to decrease the tragedy of preventable mater- catastrophic hemorrhage with attempted removal. nal mortality or morbidity may be offensive to some. Obstetric Surgery 83 Regardless, the provision of safe cesarean delivery to pre- the importance of providing emergency obstetric vent obstructed labor in LMICs has been demonstrated services during humanitarian crises; it further dem- to be cost-effective, with a positive net economic return onstrates that financial investments can significantly to those societies. improve maternal and neonatal mortality (Deboutte and others 2013). One of the major sequelae of not having access Safe Cesarean Delivery to safe cesarean delivery is obstetric fistula resulting Numerous studies have demonstrated the significant from obstructed labor (see chapter 6). An estimated cost-effective benefits of providing access to safe cesarean 3 million women suffer from obstetric fistula world- delivery in countries where it is not currently available wide. Obstetric fistula can result in societal marginal- (table 5.2) (Grimes and others 2014). Separate analysis ization, in addition to significant medical morbidities finds that the provision of cesarean for obstructed labor, that are frequently permanent (Wall 2006). One anal- malpresentation, or fetal distress in these countries ysis that examines only the impact of obstructed labor would cost US$73 for each DALY averted in Sub-Saharan sequelae finds that the provision of safe cesarean deliv- Africa, and US$2,638 in South-East Asia (Adam and ery where not available would avert 16,800 maternal others 2005). deaths in one year (Alkire and others 2012). This study, A study in Guinea finds that the provision of which analyzes countries where the number of cesarean cesarean delivery for obstructed labor was very cost- deliveries provided is inadequate to meet demand, finds effective at US$18 per year of life saved (Jha, Bangoura, that approximately 1 million DALYs would be saved and Ranson 1998). A study in the Democratic by providing accessible cesarean delivery to 90 percent Republic of Congo reinforces the challenges and of the pregnancies complicated by obstructed labor Table 5.2 Overview of Studies Evaluating the Cost-Effectiveness of Cesarean Delivery Study Country or region Details of intervention analyzed Cost-effectiveness Measurement Alkire and 49 countries with Evaluation of the unmet need for cesarean Median US$304 Cost per DALY others 2012 unmet demand for delivery indicated for obstructed labor Range $251–$3,462 averted cesarean delivery Adam and High-risk areas of Evaluation of the unmet need for cesarean Sub-Saharan Africa: Cost per DALY others 2005 Sub-Saharan Africa delivery indicated for a composite of obstructed US$1,576 averted and South-East Asia labor, malpresentation, and nonreassuring fetal South-East Asia: status US$1,449 Jha, Bangoura, Guinea Evaluation of the unmet need for multiple surgical US$18 Cost per YLS and Ranson services, including cesarean delivery indicated for 1998 obstructed labor Hu and others Mexico Upgrading current obstetric practice to meet the US$550 Cost per YLS 2007 WHO mother-baby standard of care package US$390 Cost per DALY Erim, Resch, Nigeria Stepwise improvement in family planning; US$3,930–US$4,481 Cost per maternal and Goldie safe abortion provision; and intrapartum care, death averted 2012 including cesarean delivery Goldie and India Stepwise improvement in family planning; safe US$300 in rural India Cost per YLS others 2010 abortion provision; and intrapartum care, including US$350 in urban India cesarean delivery Carvalho, Afghanistan Stepwise improvement in family planning; safe US$178 Cost per YLS Salehi, and abortion provision; and intrapartum care, including Goldie 2013 cesarean delivery Deboutte and Congo, Dem. Rep. Investment in an NGO hospital in the postconflict US$9.2 Cost per health- others 2013 environment to provide emergency obstetric care adjusted YLS Source: Adapted from Grimes and others 2014. Note: NGO = nongovernmental organization; WHO = World Health Organization; YLS = year of life saved. 84 Essential Surgery (Alkire and others 2012). The cost-effectiveness asso- saves costs of US$900,000 per 100,000 women compared ciated with providing cesarean delivery services at with the current practice (Hu and others 2007). this level varies widely by country, from US$251 for The cost-effectiveness of safe cesarean delivery and each DALY averted in countries with higher maternal emergency obstetric care can be significantly enhanced morbidity risks to US$3,462 per DALY averted in other by effective family planning programs involving contra- countries analyzed. ception and safe abortion (see chapter 7). An analysis in India suggests that combining the cost savings of effec- tive family planning with the cost savings of providing Free or Subsidized Surgical Care emergency obstetric care could amount to savings of The provision of safe cesarean delivery services implies US$1.5 billion dollars per year and would help to reduce inherent costs to individuals without subsidized cesar- maternal mortality by as much as 75 percent (Goldie ean delivery that prevent implementation of indicated and others 2010). A similar analysis in Afghanistan finds cesarean deliveries. This provision of free intrapartum that providing access to effective family planning ser- services that include cesarean delivery is associated with vices results in significant cost savings and reductions in increased rates of supervised labor and increased uti- maternal mortality (Carvalho, Salehi, and Goldie 2013). lization of needed cesarean delivery (Lawn and others Additional reductions in maternal mortality depend on 2009). This scenario has been evaluated in Senegal, access to safe cesarean delivery and emergency obstetric where the provision of free cesarean delivery helped to care; in combination with family planning services, such increase the rate to greater than 5 percent (Witter and access could help reduce maternal mortality by as much Diadhiou 2008; Witter and others 2010). The US$461 as 80 percent. In Nigeria, a similar analysis using a step- cost associated with each additional cesarean delivery wise improvement package of family planning, abortion was judged to be beneficial, given that it represents services, and emergency obstetric care demonstrates a cesarean delivery that would otherwise not be pro- cost-effective improvements in public health (Erim, vided. Similarly, in Ghana, a policy removing patient Resch, and Goldie 2012). responsibility for costs at birth and postpartum was It is clear from these and other studies that the associated with an increase in attended births and cost-effectiveness of cesarean delivery has synergy with institutional delivery (Lawn and others 2009; Witter other public health interventions involving family plan- and others 2007). ning and abortion care (Souza and others 2013). The In India, Janani Suraksha Yojana, a cash incentive combination of these interventions will be far more program to promote attended obstetric delivery, encour- effective than any single intervention in achieving the aged the practice, but it also raised concerns regarding goals of substantial improvements in maternal mortality, the targeting of funding to the poorest in the population as in MDG 5 (UN 2013). (Lim and others 2010). Subsidizing and encouraging An overview of studies evaluating the cost- safe obstetric delivery and free cesarean delivery in areas effectiveness of obstetric interventions in different where the infrastructure exists to provide the services countries or areas is limited by the ability of the risks exacerbating disparities between areas where access results from one setting to be generalized to another. to safe and timely cesarean delivery is available and areas The countries and areas in table 5.2 are widely vari- where it is not available regardless of cost (Witter and able, limiting this generalizability. A consistent theme, others 2010). however, is that the provision of these fundamental In addition, care must be taken in auditing cesar- obstetric packages is profoundly cost-effective or cost ean delivery rates in areas where costs are subsidized saving. The concept of areas where interventions can to ensure that the system does not develop a supra- save a year of maternal life for less than US$20 or save therapeutic cesarean rate. Overall, however, the evi- the life of a reproductive-age woman for less than dence clearly indicates that the provision of financial US$5,000 argues for the implementation of such pro- incentives, or the removal of disincentives, can help grams to help save lives. improve access to emergency obstetric care (Briand and others 2012). Other Obstetric Surgical Procedures Little research has been conducted to justify the Synergy of Providing Obstetric Care with Family cost-effectiveness of other obstetric surgical proce- Planning Services dures, in part because safe childbirth and prevention of An analysis demonstrates that in Mexico, coupling effec- unnecessary maternal and neonatal death may be con- tive family planning with emergency obstetric services sidered goals without the need for cost justification. Obstetric Surgery 85 Additional shared costs are involved when consid- curriculum; upon completion, they have provided ering use of the techniques discussed in addition to a majority of the emergency obstetric care in the cesarean delivery. Cost-effectiveness analysis of other area (Pereira and others 2011). The evaluation found operative obstetric techniques—including operative no significant differences in the obstetric outcomes vaginal delivery and surgical treatment of postpartum between the nonphysician clinicians and the physician hemorrhage—is limited in part by the difficulty of providers (McCord and others 2009). Despite the associating the costs and benefits of a single inter- implementation of these nonphysician clinician teams, vention. Although procedures may employ reusable most emergency obstetrical care needs remain unmet. equipment or sutures, these costs are relatively minor Further gains appear to depend on access to hospital when compared with the cost of provider training to care centers rather than additional qualified obstetric perform these procedures. Given the significant costs providers. of developing a surgical center with providers trained The cost-effectiveness of using different providers has to perform safe cesarean delivery, these same providers been evaluated in Burkina Faso (Hounton and others at these facilities—or elsewhere in the field—can be 2009). Clinical officers are trained nurses who undergo readily trained to perform the other obstetric surgical two additional years of surgical training; general practi- procedures. tioners in rural areas are trained in basic surgical tech- Although the WHO estimates that the cesarean rate niques, including cesarean delivery. Obstetricians and should be at least 5 percent to 10 percent of deliveries general practitioners had significantly better maternal in LMICs to optimize maternal and neonatal outcomes, and neonatal outcomes compared with clinical officers. studies suggest that cesarean delivery rates higher than Obstetricians overall had moderately better neonatal 15 percent to 20 percent in these countries may have outcomes than the general practitioners, but at sig- greater associated maternal and neonatal surgical mor- nificantly higher costs; the cost per cesarean delivery bidity rates, compared with those for vaginal delivery, was twice as high with obstetricians compared with without providing significant health benefits (Gibbons task-shifted providers. The benefit of using the trained and others 2012). The cost of excess cesarean rates in general practitioners rather than clinical officers was HICs has been estimated to be well over US$2 billion associated with a cost of US$200 for each neonatal life annually, suggesting the cost-saving utility of operative saved. vaginal delivery to reduce the rate of unnecessary cesar- A review in Ethiopia finds that more than 63 percent ean delivery in HICs (Gibbons and others 2012). The of obstetric procedures and cesarean deliveries are costs of both supplies and obstetric training must be performed by nonphysician clinicians (Gessessew and considered in evaluating operative vaginal techniques, others 2011). The study finds similar postoperative out- but both are likely to be cost saving compared with a comes in the two groups. The review suggests that the cesarean delivery. This modeling has limitations when nonphysician clinicians were more likely to remain in safe alternatives to vaginal delivery, including safe cesar- rural areas, providing a potential solution to the migra- ean delivery, are not available. tion of more trained providers. Unfortunately, the analysis of these clinical officers who perform emergency obstetric procedures in Malawi, Task-Shifting to Increase Skilled Providers Mozambique, and Tanzania finds that these officers are As countries attempt to meet the goal of providing apt to leave their positions after training (McAuliffe and safe cesarean delivery, expanding the pool of those others 2013). Specifically, negative predictors of reten- who provide surgical services to providers other than tion include an absence of oversight or supervision of obstetricians becomes an option. Mullan and Frehywot the clinical providers in their roles, suggesting that for- (2007) in an assessment of Sub-Saharan countries find mal supervision is correlated with job satisfaction and, that more than 50 percent use nonphysician clinicians in in effect, with provider retention. Given the significant lieu of medical doctors to provide health care for com- costs of training these individuals, attention to main- munities. Task-shifting has been evaluated with non- taining cohorts of trainees is important to maximize obstetrician physicians, or even clinical officers, trained their benefit. to perform cesarean deliveries. Diminishing returns were observed on investments In Tanzania, nonphysician clinicians have been an in training providers to provide cesarean delivery in important asset in helping overcome the unmet need, Burkina Faso (Hounton and others 2009) and Tanzania which exceeds 70 percent, of emergency obstetric care (Nyamtema and others 2011). Although these types of (Nyamtema and others 2011). These nonphysician studies are difficult to perform and have limitations clinicians were given an effective three-month training related to data collection, it is clearly more cost-effective 86 Essential Surgery to train lower-level providers to provide cesarean deliv- As with obstetric fistula, obstetric morbidity has eries than fully trained obstetricians. In Sub-Saharan frequently been associated with social ostracism, the Africa, a small minority of countries (Ethiopia, Ghana, cost of which is difficult to measure (Wall 2006). Malawi, Mozambique, and Tanzania) allow nonphysi- The loss of a maternal life has far-reaching effects, cian providers to perform emergency obstetric surgery including the impact on her family structure and (Pereira and others 2011). In other areas, these nonphy- downstream effects on that family and on society as a sician clinicians provide obstetric care but not cesarean whole (Yamin and others 2013). This reality suggests delivery, limiting their utility. that most assessments involving the cost of maternal Overall, clinical outcomes may be improved when a deaths are likely to underestimate those costs. The trained obstetrician performs the cesarean deliveries, but cost of basic obstetric interventions widely used in with significant cost. It is worth considering that trained HICs that can significantly reduce maternal mor- obstetricians have the ability to train those around them bidity in LMICs can be difficult to measure. Given and elevate the skills of other members of the team the significant benefits to health that they offer, their (Anderson and others 2014). Having supervisory forces potential implementation cost would have to be dra- for the nonphysician teams may assist in the retention of matic if they were to be not cost-effective in their trained providers. Because of their lower up-front cost, lifesaving employment. Although cost-effectiveness however, task-shifted providers may solve short-term data are lacking for some of these interventions, such workforce problems. as vaginal laceration repair to prevent hemorrhage, When training a workforce, consideration needs implementation costs are so minimal and health ben- to be given to training obstetric providers rather than efits are so significant that these data may not ever be medical practitioners to provide cesarean deliveries, produced. depending on the resources and short- and long-term The analyses examining the benefits of cesarean goals. It would be unreasonable in an HIC with an delivery focus on maternal morbidity and mortality, adequate supply of trained obstetric providers to fully although neonatal morbidity and mortality are also revert to nonobstetricians to provide cesarean services directly related. The provision of cesarean delivery for and emergency obstetric care, because doing so would obstructed labor, malpresentation, or intrauterine fetal exacerbate negative maternal and neonatal outcomes. distress often means the difference between neonatal In LMICs attempting to establish fundamental obstetric intact survival, on the one hand, and fetal demise or care, task-shifting provides a short-term solution to permanent and significant injury, neurologic or oth- unbearable circumstances (Hounton and others 2009). erwise, on the other hand (Hofmeyr and others 2009). Given the tremendous burden of unmet need, however, The provision of neonatal resuscitation by birth implementation of task-shifting appears to be a reason- attendants has been demonstrated to be cost-effective, able step while infrastructure is developed (McCord and at US$208 per neonatal life year saved and US$5 per others 2009). neonatal DALY averted (Wall and others 2010). Full implementation of trained birth attendants to pro- vide immediate neonatal care would avert 100 million Challenges in Assessing the True Costs and Benefits DALYs at a cost of US$1.8 billion (Lawn and others of Obstetric Surgery 2009). In this analysis, the additional provision of Cost analysis becomes difficult because of the wide emergency obstetric care to cover 90 percent of number of variables across nations. In the long term, the perceived need would cost US$2.8 billion and avert common goal of reducing morbidity and mortality will 150 million DALYs. Synergy was noted by bundling be accomplished by establishing universally accessible birth attendance, emergency obstetric care including first-level hospitals with mechanisms to refer to second- cesarean delivery, and neonatal resuscitation, with and third-level hospitals with fully trained providers to resulting improved costs and cost-effectiveness of all optimize maternal and neonatal outcomes. However, in the interventions. Overall, the universal provision of the short term, in areas with limited resources for train- emergency obstetric services to 90 percent of women ing an obstetric force, training task-shifted individuals in need could avert approximately 500,000 neonatal can help mitigate maternal and neonatal morbidity and deaths annually (Lawn and others 2009). mortality rates. Beyond the provision of cesarean delivery, little Similar to the difficulty of assessing the cost- evidence is available to guide cost-effective techniques, effectiveness of a single intervention, the difficulties but common sense suggests that the provision of fun- of assessing the true costs associated with mater- damental obstetrical services is a reproductive right. The nal morbidity or mortality hinder valid assessment. fact that adolescent women in LMICs can have a higher Obstetric Surgery 87 risk of dying from pregnancy than other factors is not Even when other factors are not an issue, transporta- something that should be tolerated. The cost of birth tion of patients can be limited because of poor roads and attendants can vary, but their provision is accepted other impediments (Mehtsun and others 2012). These as fundamental to the amelioration of the status of factors illustrate how a focus on relatively simple efforts women’s health worldwide. in rural areas can have significant impacts on public health (You and others 2012). OBSTETRIC SURGICAL IMPLEMENTATION IN Approaches to Improving Access to Surgical Care LOW- AND MIDDLE-INCOME COUNTRIES More Widespread Technology. More widespread dis- Challenges to Provision of Safe Cesarean Delivery tribution of technology to access remote areas and link them to centers for emergency obstetric care will facil- Although access to safe and timely cesarean delivery itate significant improvements to maternal health. The should be a fundamental right guaranteed to all preg- increasing availability of cell phones has the potential nant women, cesarean rates vary widely. The general to improve women’s health services networks while consensus is that cesarean rates of less than 10 percent overcoming traditional obstacles to establishing effec- are low and inadequate to meet the obstetric needs of the tive health care systems (Fiander and Vanneste 2012). population (Gibbons and others 2012). Cesarean rates of Low-cost cellular technology can connect birth atten- less than 5 percent, as throughout much of Sub-Saharan dants with regional obstetric officers, helping to guide Africa, are considered extremely low. In these settings, management of intrapartum complications remotely, most cesarean deliveries are undertaken intrapartum, outside of health care centers, averting potential mor- frequently following failed labor. bidity, and to coordinate access to emergency services. A different problem has developed in countries New methods of transferring funds using cell phones with widely accessible cesarean delivery. Although have been used to finance transport for patients to many countries have rates well in excess of 20 percent, regional centers for advanced levels of care (Fiander these higher rates are not associated with improve- and Vanneste 2012). ments in maternal or fetal outcomes (Gibbons and others 2012). Moreover, higher rates of cesarean deliv- ery are associated with higher incidence of placenta Improved Infrastructure. Infrastructural shortcom- accreta and surgical morbidity. Many factors influence ings and lack of provider motivation can prevent the increased cesarean delivery rates, including societal full implementation of available obstetric resources to factors; some countries in South America have rates benefit maternal and child health in LMICs (Koblinsky as high as 45 percent. Active discouragement of such and others 2006), as can societal reluctance to access high rates of cesarean delivery has not been successful. available obstetric resources. Factors influencing this As further data are produced regarding the long-term reluctance include financial costs and an unwelcome morbidity and societal burden from these suprather- environment resulting from discriminatory or cul- apeutic cesarean rates, it is likely that the populations turally insensitive practices. Any hesitation can delay will start to respond. presentation to permit the timely diagnosis and treat- Fundamental to the provision of safe cesarean deliv- ment of potential complications. Fundamentally, the ery is an adequate triage system. In countries with the establishment or development of first-level hospitals lowest rates of cesarean delivery, the many challenges that can support safe cesarean delivery and obstetric faced in implementing skilled obstetric care include the care will be necessary to employ the trained providers following: and receive referred patients who require emergency obstetric care. • The pervasive lack of trained obstetric providers— midwives, obstetricians, and anesthetists—especially Increased Supply of Trained Providers. The education in rural areas (Darmstadt and others 2009; Mavalankar and training of obstetric providers need to be expanded and others 2009) to meet the needs of the populations in LMICs (Evans • The ineffective distribution of the available skilled and others 2009; Hofmeyr and others 2009). Efforts to providers, as well as difficulty retaining those who train large numbers of providers, which have been chal- are dispersed lenging without an established training infrastructure, • The lack of support staff, infrastructure, equipment, must persist. An essential complement to initiatives to and supplies (Koblinsky and others 2006). increase the numbers of skilled obstetric providers is 88 Essential Surgery the provision and maintenance of first-level hospitals providers will require additional training to acquire a or centers where the providers can perform cesarean more sophisticated skill set than that possessed by birth deliveries and administer anesthesia (Anderson and attendants. Societal and economic investments in suc- others 2007). cessful outcomes will be critical, both in training and in retaining these providers. The effective retention of Improved Patient Transport and Local Facilities. In trained providers will require satisfactory facilities and HICs, the time to prepare to perform an indicated resources to utilize their training. The provision of the cesarean providing obstetric surgery is expected to be resources for emergency obstetric care at local levels will 30 minutes to optimize outcomes (ACOG 2009; Soltanifar dramatically improve worldwide maternal health in the and Russell 2012). This standard is ambitious for LMICs, coming decades. but a realistic and reliable expectation of timely transport to such facilities would substantially reduce the burden of disease from obstructed labor (Spangler 2012). Quality Care and Improvement Initiatives The development of these locally accessible first-level Achieving the goal of universal provision of evidence- hospitals would effectively make a network of these based obstetric care will take time and resources. hospitals that would be universally accessible where Programs have examined established practice improve- cesarean deliveries could be performed. Such first-level ment techniques using educational outreach and obstetric institutions would require the availability morbidity and mortality reviews, as in the QUARITE of obstetric providers to perform the surgery and the (QUAlity of care, RIsk management and TEchnology in capacity to administer anesthesia safely. Contributing obstetrics) trial taking place in Senegal and Mali. The to these structures would be the local network of skilled establishment of infrastructure to monitor outcomes birth attendants at the bedside with mothers in labor— will help improve care at local levels by focusing on attendants with the ability to manage minor compli- unsatisfactory outcomes that can be improved in those cations and successfully transfer patients in a timely areas (Dumont and others 2013; Pirkle and others manner when major complications arise or cesarean 2013). Practice-based learning and morbidity and mor- delivery is needed. tality reviews are established methods of improving In developing these units, providing fully trained care and maternal outcomes, and their application anesthesiologists and obstetricians for all deliveries will to nations working to establish or build up obstetric be a challenge (Evans and others 2009; Mavalankar and services will be significant (Choo and others 2013). others 2009). Countries have examined the implementa- Partnerships between programs in LMICs and HICs tion of teams of nonspecialists trained to provide emer- will help the former to develop the training infrastruc- gency obstetric care. Studies in Tanzania examining such ture to cultivate and maintain an obstetric workforce nonphysician clinicians show good results (Nyamtema (Klufio and others 2003). and others 2011; Pereira and others 2011). Despite the availability of trained nonspecialists, too many signifi- cant obstetric complications, particularly those requir- Lessons from Ghana ing cesarean delivery, remained untreated. Ghana has been a model for improvement in women’s reproductive health. In 1989, a grant from the Carnegie Foundation established university-based training pro- grams to help train obstetric providers; its goal was to CONCLUSION: FUTURE DIRECTIONS maintain trained obstetricians in practice after they com- Future efforts to reduce the global disease burden of pleted their training (Anderson and others 2014). Before obstetric complications requiring surgery will depend on this program, Ghana had significant difficulty retaining interventions that have demonstrated equal effectiveness trained providers (Clinton, Anderson, and Kwawukume on small scales, and will implement those interventions 2010); the retention rate of trained obstetric providers on a universal scale. had been 10 percent. Since establishment of the program in 1989, over 95 percent of the trained obstetric provid- ers have remained in country to practice (Anderson and Numbers of Skilled Birth Attendants others 2014). Significant progress has been seen with the provision With the exponential increase in obstetric providers of birth attendants; the next step is the universal pro- in the country, the ability to train later generations of vision of emergency obstetric providers who can per- providers each year has increased; the country had 20 form safe cesarean delivery. These emergency obstetric certified practicing obstetricians in 2000 and 85 in 2010. Obstetric Surgery 89 With the increase in providers, some individuals have will help coordinate that front line with first-level located to different periurban and more rural first- hospitals that have essential emergency care capabilities, level hospitals, expanding the areas where safe emer- including cesarean delivery. Once cesarean delivery is gency obstetric services are available. Although this available at the regional level, a wide variety of surgical program did not produce dedicated birth attendants, interventions will be available to improve public health, it produced certified obstetrical and gynecological pro- using synergistic capabilities and therapies. These quan- viders who have the skills to manage a wide variety of tum units of referral and emergency care centers will women’s health issues. Their wide variety of expertise become more widespread, making safe cesarean delivery encompasses contraception and obstetric care, including a universally accessible reproductive right, available to definitive delivery and management of obstetric com- women throughout all HICs and LMICs alike. plications. The influence of this program is difficult to Regional and academic centers will assist in training assess because of the implementation of other programs and retaining the necessary workforces to provide care to improve obstetric care. At one rural institution, how- in these nations, and they will serve as referral centers ever, the implementation of certified obstetrical and for complicated cases beyond the first-level hospitals to gynecological capacity reduced maternal mortality by second- and third-level hospitals where appropriate. 74 percent (Anderson and others 2014). The common goal will be the prevention of unneces- The establishment of this training program resulted sary pregnancy-related morbidity and death through the from a concerted effort by the American College provision of universal access to standard and emergency of Obstetrics and Gynecology and the Royal College of obstetric care that is safe and effective—with benefits to Obstetrics and Gynecology, in combination with the the mothers, their families, and their societies as a whole. obstetrics and gynecology departments at The Johns Hopkins University and the University of Michigan (Anderson and others 2014). With the assistance of Consideration of Essential Obstetric Interventions to these institutions, Ghana was able to design the five- Improve Obstetric Outcomes year program that has produced so many trained Surgical obstetric interventions—including operative providers. The ongoing relationship between the vaginal delivery, cesarean delivery, and emergency university-based training programs in Ghana and obstetric care—are clearly effective at reducing mor- the University of Michigan has caused the evolu- bidity and death. Sufficient evidence demonstrates tion of evidence-based obstetric training within the that access to these services can improve the health country. Practice-based learning and maternal mortal- of societies. As with any intervention, the costs must ity and morbidity reviews have guided improvements be weighed against the potential benefits. Whether in obstetric training and management that have spread these costs warrant investment is not easily answered across the country as providers complete their training with scientific study. We reviewed a number of studies (Choo and others 2013). The provision of funding to that have evaluated a broad range of obstetric surgi- establish this type of academic partnership, and the cal interventions to improve the health of societies. establishment of in-country training programs, will These interventions appear universally cost-effective, contribute significantly to the goal of providing uni- albeit to different degrees, across different LMICs. We versal access to emergency obstetric care services and implore interested parties to consider the relatively cesarean delivery. small cost per individual of these interventions to save maternal and neonatal lives. We recommend consideration of the following goals to improve the Future Goals of Global Operative Obstetrics health of reproductive-age women and their children Future efforts to improve maternal mortality and mor- worldwide. bidity will expand successful programs to areas where they have yet to be implemented, will scale up estab- Birth Attendants. Universal access to birth atten- lished programs to provide health care to a wider popu- dants who can help address obstetric emergencies that lation, and will develop new methods to improve access require emergent attention should be a goal. Training to care and standards of care in LMICs. Self-reflection will ultimately include the management of postpartum and evidence-based medicine will help identify pro- hemorrhage, operative vaginal delivery, and facilitated grams that work and those that need to improve. emergency vaginal breech delivery. Most important, The numbers of skilled birth attendants, who consti- training will facilitate the identification of obstetric tute the front line in the ability to provide safe childbirth complications that require transfers to higher levels care, will continue to increase. Technological advances of care. 90 Essential Surgery Hospital Units. Approximately 10 percent to 15 percent these fundamental surgical services. Societal expecta- of deliveries need operative interventions that require tions will include the provision of obstetric care as a access to a nearby hospital or center to provide these fundamental reproductive and human right. With this surgical services, including cesarean delivery. In the long effective valuation of maternal health and consider- term, transport to such centers within two hours for any ation of obstetric and reproductive rights, maternal woman in labor is desirable. In the short term, access outcomes in particular and societal outcomes in to such centers within six hours would be a significant general will improve. improvement. These centers require the ability to perform safe cesarean delivery. An operating theater with anesthetic availability should be part of that center. Blood trans- NOTE fusion services could help improve maternal outcomes. The World Bank classifies countries according to four income These centers require staffing by individuals trained in groupings. Income is measured using gross national income cesarean delivery and management of obstetric emer- (GNI) per capita, in U.S. dollars, converted from local currency gencies, with the ability to transfer to higher levels of using the World Bank Atlas method. Classifications as of July care, if needed. 2014 are as follows: • Low-income countries (LICs) = US$1,045 or less in 2013 Trained Obstetric Providers. Effectively trained • Middle-income countries (MICs) are subdivided: obstetric providers could help train other providers, • Lower-middle-income = US$1,046 to US$4,125 as well as the birth attendants present at time of • Upper-middle-income (UMICs) = US$4,126 to US$12,745 delivery who may be in the best position to timely • High-income countries (HICs) = US$12,746 or more manage obstetric emergencies. Obstetric training partnerships, as in Ghana, can successfully train providers who can rapidly grow a nation’s obstetric workforce to staff local centers for the management REFERENCES of obstetric emergencies and cesarean delivery. In the ACOG (American Congress of Obstetricians and short term, nonphysician clinicians can participate Gynecologists). 2009. “Optimal Goals for Anesthesia in obstetric care to help quickly meet improvement Care in Obstetrics.” Committee Opinion No. 433, goals. Involving these clinicians in all aspects of emer- Committee on Obstetric Practice. Obstetrics and Gynecology 113: 1197–99. gency obstetric care can help meet immediate health ———. 2013. “Medically Indicated Late-Preterm and Early- needs, depending on the population. Partnerships to Term Deliveries.” Committee Opinion No. 560, Committee train obstetric providers, along with financial sup- on Obstetric Practice. Obstetrics and Gynecology 121 (4): port, will grow, as the obstetric workforce in Ghana 908–10. has grown, thereby improving the worldwide supply Adam, T., S. S. Lim, S. Mehta, Z. A. Bhutta, H. Fogstad, and of obstetric providers in local settings. These trainees others. 2005. “Cost Effectiveness Analysis of Strategies for can then help train other physician and nonphysi- Maternal and Neonatal Health in Developing Countries.” cian providers and provide ongoing supervision to British Medical Journal 331 (7525): 1107. help retention efforts. The training of these obstetric Alkire, B. C., J. R. Vincent, C. T. Burns, I. S. Metzler, P. E. Farmer, providers will affect all levels of obstetric care and and others. 2012. “Obstructed Labor and Caesarean improve overall reproductive health care in their indi- Delivery: The Cost and Benefit of Surgical Intervention.” PloS One 7 (4): e34595. vidual nations. Anderson, F. W., I. Mutchnick, E. Y. Kwawukume, K. A. Danso, C. A. Klufio, and others. 2007. “Who Will Be There Valuation of Maternal Health and Reproductive Rights When Women Deliver? Assuring Retention of Obstetric “When women thrive, all of society benefits, and suc- Providers.” Obstetrics and Gynecology 110 (5): 1012–16. ceeding generations are given a better start in life.” Anderson, F. W., S. A. Obed, E. L. Boothman, and H. Opare-Ado. 2014. “The Public Health Impact of Training –Kofi Annan Physicians to Become Obstetricians and Gynecologists in Ghana.” American Journal of Public Health 104 (Suppl 1): Death or morbidity in childbirth is a preventable trag- S159–65. edy. As societies develop and improve maternal health, Andreatta, P., J. Perosky, and T. R. Johnson. 2012. “Two- all levels of society will benefit. Future obstetric inter- Provider Technique for Bimanual Uterine Compression to ventions will fully consider the value of these mater- Control Postpartum Hemorrhage.” Journal of Midwifery nal lives and the societal costs of failing to provide and Women’s Health 57 (4): 371–75. Obstetric Surgery 91 Baskett, T. F., A. A. Calder, and S. Arulkumaran. 2007. Munro A Decade of Experience and Outcome.” Journal of the Kerr’s Operative Obstetrics. 11th ed. Philadelphia, PA: Institute of Obstetrics and Gynaecology 29 (4): 278–83. Saunders Elsevier. Erim, D. O., S. C. Resch, and S. J. Goldie. 2012. “Assessing Berghella, V., J. K. Baxter, and S. P. Chauhan. 2005. “Evidence- Health and Economic Outcomes of Interventions to Based Surgery for Cesarean Delivery.” American Journal of Reduce Pregnancy-Related Mortality in Nigeria.” BMC Obstetrics and Gynecology 193 (5): 1607–17. Public Health 12 (786): 1–11. Borghi, J., J. Fox-Rushby, E. Bergel, E. Abalos, G. Hutton, and Evans, C. L., D. Maine, L. McCloskey, F. G. Feeley, and others. 2002. “The Cost-Effectiveness of Routine versus H. Sanghvi. 2009. “Where There Is No Obstetrician: Restrictive Episiotomy in Argentina.” American Journal of Increasing Capacity for Emergency Obstetric Care in Obstetrics and Gynecology 186 (2): 221–28. Rural India: An Evaluation of a Pilot Program to Train Briand, V., A. Dumont, M. Abrahamowicz, M. Traore, General Doctors.” International Journal of Gynaecology and L. Watier, and others. 2012. “Individual and Institutional Obstetrics 107 (3): 277–82. Determinants of Caesarean Section in Referral Hospitals Fiander, A. N., and T. Vanneste. 2012. “TransportMYpatient: in Senegal and Mali: A Cross-Sectional Epidemiological An Initiative to Overcome the Barrier of Transport Costs Survey.” BMC Pregnancy and Childbirth 12: 114. for Patients Accessing Treatment for Obstetric Fistulae and doi:10.1186/1471-2393-12-114. Cleft Lip in Tanzania.” Tropical Doctor 42 (2): 77–79. Carvalho, N., A. S. Salehi, and S. J. Goldie. 2013. “National and FIGO (International Federation of Gynecology and Obstetrics). Sub-national Analysis of the Health Benefits and Cost- 2012. “Management of the Second Stage of Labor.” Safe Effectiveness of Strategies to Reduce Maternal Mortality Motherhood and Newborn Health (SMNH) Committee. in Afghanistan.” Health Policy and Planning 28 (1): 62–74. International Journal of Gynaecology and Obstetrics 119 (2): Choo, S., D. Papandria, S. D. Goldstein, H. Perry, A. A. Hesse, 111–16. and others. 2013. “Quality Improvement Activities for Gessessew, A., G. A. Barnabas, N. Prata, and K. Weidert. Surgical Services at District Hospitals in Developing 2011. “Task Shifting and Sharing in Tigray, Ethiopia, to Countries and Perceived Barriers to Quality Improvement: Achieve Comprehensive Emergency Obstetric Care.” Findings from Ghana and the Scientific Literature.” World International Journal of Gynaecology and Obstetrics 113 Journal of Surgery 37 (11): 2512–29. (1): 28–31. Clinton, Y., F. W. Anderson, and E. Y. Kwawukume. 2010. Gibbons, L., J. M. Belizan, J. A. Lauer, A. P. Betran, M. Merialdi, “Factors Related to Retention of Postgraduate Trainees in and others. 2012. “Inequities in the Use of Cesarean Section Obstetrics-Gynecology at the Korle-Bu Teaching Hospital Deliveries in the World.” American Journal of Obstetrics and in Ghana.” Academic Medicine: Journal of the Association of Gynecology 206 (4): 331.e1, 331.19. American Medical Colleges 85 (10): 1564–70. Goldie, S. J., S. Sweet, N. Carvalho, U. C. Natchu, and D. Hu. CORONIS Collaborative Group, E. Abalos, V. Addo, 2010. “Alternative Strategies to Reduce Maternal Mortality P. Brocklehurst, M. E. Sheikh, and others. 2013. “Caesarean in India: A Cost-Effectiveness Analysis.” PLoS Medicine Section Surgical Techniques (CORONIS): A Fractional, 7 (4): e1000264. Factorial, Unmasked, Randomised Controlled Trial.” The Grimes, C. E., J. A. Henry, J. Maraka, N. C. Mkandawire, and Lancet 382 (9888): 234–48. C. Cotton. 2014. “Cost-Effectiveness of Surgery in Low- and Dahlke, J. D., H. Mendez-Figueroa, D. J. Rouse, V. Berghella, Middle-Income Countries: A Systematic Review.” World J. K. Baxter, and others. 2013. “Evidence-Based Surgery for Journal of Surgery 38 (1): 252–63. Cesarean Delivery: An Updated Systematic Review.” American Hale, R. W., and E. H. Dennen. 2001. Dennen’s Forceps Journal of Obstetrics and Gynecology 209 (4): 294–306. Deliveries. 4th ed. Washington, DC: American College of Darmstadt, G. L., A. C. Lee, S. Cousens, L. Sibley, Z. A. Bhutta, Obstetricians and Gynecologists. and others. 2009. “60 Million Non-facility Births: Who Can Hannah, M. E., W. J. Hannah, S. A. Hewson, E. D. Hodnett, Deliver in Community Settings to Reduce Intrapartum- S. Saigal, and others. 2000. “Planned Caesarean Section Related Deaths?” International Journal of Gynaecology and versus Planned Vaginal Birth for Breech Presentation at Obstetrics 107 (Suppl 1): S89–112. Term: A Randomised Multicentre Trial: Term Breech Trial Deboutte, D., T. O’Dempsey, G. Mann, and B. Faragher. 2013. Collaborative Group.” The Lancet 356 (9239): 1375–83. “Cost-Effectiveness of Caesarean Sections in a Post-conflict Hannah, M. E., W. J. Hannah, E. D. Hodnett, B. Chalmers, Environment: A Case Study of Bunia, Democratic Republic R. Kung, and others. 2002. “Outcomes at 3 Months after of the Congo.” Disasters 37 (Suppl 1): S105–20. Planned Cesarean vs Planned Vaginal Delivery for Breech Dumont, A., P. Fournier, M. Abrahamowicz, M. Traore, Presentation at Term: The International Randomized Term S. Haddad, and others. 2013. “Quality of Care, Risk Breech Trial.” Journal of the American Medical Association Management, and Technology in Obstetrics to Reduce 287 (14): 1822–31. Hospital-Based Maternal Mortality in Senegal and Mali Hofmeyr, G. J., R. A. Haws, S. Bergstrom, A. C. Lee, P. Okong, (QUARITE): A Cluster-Randomised Trial.” The Lancet 382 and others. 2009. “Obstetric Care in Low-Resource Settings: (9887): 146–57. What, Who, and How to Overcome Challenges to Scale El-Hamamy, E., A. Wright, and C. B. Lynch. 2009. “The Up?” International Journal of Gynaecology and Obstetrics B-Lynch Suture Technique for Postpartum Haemorrhage: 107 (Suppl 1): S21, 44, 44–45. 92 Essential Surgery Hogan, M. C., K. J. Foreman, M. Naghavi, S. Y. Ahn, M. Wang, and Mehtsun, W. T., K. Weatherspoon, L. McElrath, A. Chima, others. 2010. “Maternal Mortality for 181 Countries, 1980– V. E. Torsu, and others. 2012. “Assessing the Surgical 2008: A Systematic Analysis of Progress towards Millennium and Obstetrics-Gynecology Workload of Medical Officers: Development Goal 5.” The Lancet 375 (9726): 1609–23. Findings from 10 District Hospitals in Ghana.” Archives of Hounton, S. H., D. Newlands, N. Meda, and V. De Brouwere. 2009. Surgery 147 (6): 542–48. “A Cost-Effectiveness Study of Caesarean-Section Deliveries Mullan, F., and S. Frehywot. 2007. “Non-physician Clinicians in by Clinical Officers, General Practitioners and Obstetricians 47 Sub-Saharan African Countries.” The Lancet 370 (9605): in Burkina Faso.” Human Resources for Health 7 (34): 1–12. 2158–63. Hu, D., S. M. Bertozzi, E. Gakidou, S. Sweet, and S. J. Goldie. Murray, C. J., T. Vos, R. Lozano, M. Naghavi, A. D. Flaxman, 2007. “The Costs, Benefits, and Cost-Effectiveness of and others. 2012. “Disability-Adjusted Life Years (DALYs) Interventions to Reduce Maternal Morbidity and Mortality for 291 Diseases and Injuries in 21 Regions, 1990–2010: in Mexico.” PloS One 2 (8): e750. A Systematic Analysis for the Global Burden of Disease Jha, P., O. Bangoura, and K. Ranson. 1998. “The Cost- Study 2010.” The Lancet 380 (9859): 2197–223. Effectiveness of Forty Health Interventions in Guinea.” Nyamtema, A. S., S. K. Pemba, G. Mbaruku, F. D. Rutasha, Health Policy and Planning 13 (3): 249–62. and J. van Roosmalen. 2011. “Tanzanian Lessons in Using Klufio, C. A., E. Y. Kwawukume, K. A. Danso, J. J. Sciarra, Non-physician Clinicians to Scale Up Comprehensive and T. Johnson. 2003. “Ghana Postgraduate Obstetrics/ Emergency Obstetric Care in Remote and Rural Areas.” Gynecology Collaborative Residency Training Program: Human Resources for Health 9 (28): 1–8. Success Story and Model for Africa.” American Journal of O’Grady, J. P., M. L. Gimovsky, L. A. Bayer-Zwirello, and Obstetrics and Gynecology 189 (3): 692–96. K. Giordano. 2008. Operative Obstetrics. Baltimore: Williams Koblinsky, M., Z. Matthews, J. Hussein, D. Mavalankar, & Wilkins. M. K. Mridha, and others. 2006. “Going to Scale with Patton, G. C., C. Coffey, S. M. Sawyer, R. M. Viner, D. M. Haller, Professional Skilled Care.” The Lancet 368 (9544): 1377–86. and others. 2009. “Global Patterns of Mortality in Young Lawn, J. E., M. Kinney, A. C. Lee, M. Chopra, F. Donnay, and People: A Systematic Analysis of Population Health Data.” others. 2009. “Reducing Intrapartum-Related Deaths and The Lancet 374: 881–92. Disability: Can the Health System Deliver?” International Pereira, C., G. Mbaruku, C. Nzabuhakwa, S. Bergstrom, and Journal of Gynaecology and Obstetrics 107 (Suppl 1): C. McCord. 2011. “Emergency Obstetric Surgery by Non- S123–40, S140–42. physician Clinicians in Tanzania.” International Journal of Le Ray, C., P. Serres, T. Schmitz, D. Cabrol, and F. Goffinet. Gynaecology and Obstetrics 114 (2): 180–83. 2007. “Manual Rotation in Occiput Posterior or Pirkle, C. M., A. Dumont, M. Traore, and M. V. Zunzunegui. Transverse Positions: Risk Factors and Consequences 2013. “Effect of a Facility-Based Multifaceted Intervention on the Cesarean Delivery Rate.” Obstetrics and Gynecology on the Quality of Obstetrical Care: A Cluster Randomized 110 (4): 873–79. Controlled Trial in Mali and Senegal.” BMC Pregnancy and Liang, J., L. Dai, J. Zhu, X. Li, W. Zeng, and others. 2011. Childbirth 13 (24): 1–13. “Preventable Maternal Mortality: Geographic/Rural-Urban Soltanifar, S., and R. Russell. 2012. “The National Institute Differences and Associated Factors from the Population- for Health and Clinical Excellence (NICE) Guidelines Based Maternal Mortality Surveillance System in China.” for Caesarean Section, 2011 Update: Implications for the BMC Public Health 11 (243): 1–9. Anaesthetist.” International Journal of Obstetric Anesthesia Lim, S. S., L. Dandona, J. A. Hoisington, S. L. James, 21 (3): 264–72. M. C. Hogan, and others. 2010. “India’s Janani Suraksha Souza, J. P., A. M. Gulmezoglu, J. Vogel, G. Carroli, Yojana, a Conditional Cash Transfer Programme to Increase P. Lumbiganon, and others. 2013. “Moving beyond Births in Health Facilities: An Impact Evaluation.” The Essential Interventions for Reduction of Maternal Lancet 375 (9730): 2009–23. Mortality (The WHO Multicountry Survey on Maternal Mavalankar, D., K. Callahan, V. Sriram, P. Singh, and and Newborn Health): A Cross-Sectional Study.” The A. Desai. 2009. “Where There Is No Anesthetist: Increasing Lancet 381 (9879): 1747–55. Capacity for Emergency Obstetric Care in Rural India: An Spangler, S. A. 2012. “Assessing Skilled Birth Attendants Evaluation of a Pilot Program to Train General Doctors.” and Emergency Obstetric Care in Rural Tanzania: The International Journal of Gynaecology and Obstetrics 107 (3): Inadequacy of Using Global Standards and Indicators 283–88. to Measure Local Realities.” Reproductive Health Matters McAuliffe, E., M. Daly, F. Kamwendo, H. Masanja, M. Sidat, and 20 (39): 133–41. others. 2013. “The Critical Role of Supervision in Retaining Stanton, C., D. Armbruster, R. Knight, I. Ariawan, Staff in Obstetric Services: A Three Country Study.” PloS S. Gbangbade, and others. 2009. “Use of Active One 8 (3): e58415. Management of the Third Stage of Labour in Seven McCord, C., G. Mbaruku, C. Pereira, C. Nzabuhakwa, and Developing Countries.” Bulletin of the World Health S. Bergstrom. 2009. “The Quality of Emergency Obstetrical Organization 87 (3): 207–15. Surgery by Assistant Medical Officers in Tanzanian District UN (United Nations). 2013. The Millennium Development Hospitals.” Health Affairs 28 (5): w876–85. Goals Report 2013. New York: United Nations. Obstetric Surgery 93 Wall, L. L. 2006. “Obstetric Vesicovaginal Fistula as an International Fee Exemption Policy to Provide Free Delivery Care.” Public-Health Problem.” The Lancet 368 (9542): 1201–19. Reproductive Health Matters (30): 61–71. Wall, S. N., A. C. Lee, W. Carlo, R. Goldenberg, S. Niermeyer, Witter, S., and M. Diadhiou. 2008. “Key Informant Views of and others. 2010. “Reducing Intrapartum-Related Neonatal a Free Delivery and Caesarean Policy in Senegal.” African Deaths in Low- and Middle-Income Countries: What Journal of Reproductive Health 12 (3): 93–111. Works?” Seminars in Perinatology 34 (6): 395–407. Witter, S., T. Dieng, D. Mbengue, I. Moreira, and V. De Brouwere. WHO (World Health Organization). 2008. “Universal Access to 2010. “The National Free Delivery and Caesarean Policy in Safe Blood Transfusion.” WHO, Geneva. Senegal: Evaluating Process and Outcomes.” Health Policy ———. 2012. Trends in Maternal Mortality: 1990–2010— and Planning 25 (5): 384–92. Estimates Developed by WHO, UNICEF, UNFPA, and the Yamin, A. E., V. M. Boulanger, K. L. Falb, J. Shuma, and World Bank. Geneva: WHO. J. Leaning. 2013. “Costs of Inaction on Maternal Mortality: ———. 2013. “Global Health Estimates for Deaths by Cause, Qualitative Evidence of the Impacts of Maternal Deaths on Age, and Sex for Years 2000–2011.” WHO, Geneva. http:// Living Children in Tanzania.” PloS One 8 (8): e71674. www.who.int/healthinfo/global_health_estimates/en/. You, F., K. Huo, R. Wang, D. Xu, J. Deng, and others. 2012. Witter, S., D. K. Arhinful, A. Kusi, and S. Zakariah-Akoto. “Maternal Mortality in Henan Province, China: Changes 2007. “The Experience of Ghana in Implementing a User between 1996 and 2009.” PLoS One 7 (10): e47153. 94 Essential Surgery Chapter 6 Obstetric Fistula Mary Lake Polan, Ambereen Sleemi, Mulu Muleta Bedane, Svjetlana Lozo, and Mark A. Morgan INTRODUCTION attendant and far from medical care capable of pro- viding surgical intervention. In the absence of ade- Obstetric fistula is a serious and debilitating compli- quate communication or transportation services, labor cation of childbirth affecting millions of women in continues for several days; if delivery does not follow, the developing world. A gynecologic fistula refers to the baby dies and the mother often endures the long- an abnormal communication between the urinary term complications of an obstetric fistula (IMPAC tract or the gastrointestinal tract and the genital tract, 2006). Figure 6.1 describes the clinical implications of produced by obstetric causes, usually prolonged and obstetric fistula. obstructed labor. The advent of anesthesia and safe, effective surgical The earliest example of obstetric fistula was found in procedures for cesarean sections have made the occur- 2050 BC in Egypt, where an Eleventh Dynasty mummy, rence of obstetric fistula a rare event in the developed Henhenit, appears to have had a vesico-vaginal fistula world; when they do occur, they are typically due to a (VVF). The relationship between obstructed labor and congenital anomaly, surgical complication, malignancy, fistula development was recognized and described by or radiation damage. the Persian physician, Avicenna, in 1037 AD (Zacharin However, in the low- and middle-income regions 2000). Before the twentieth century, both urinary of Asia and Sub-Saharan Africa, the overwhelm- and rectal fistulas were a common result of deliveries ing cause of fistulas between the bladder and the throughout the world. vagina (vesico-vaginal fistula, VVF) and between the The unfortunate women who endure such rectum and vagina (recto-vaginal fistula, RVF) is pro- obstructed labors and resulting incontinence are often longed and obstructed labor. This is also the situation, young, undernourished, uneducated, and married although less well documented, in Latin America and early (Wall and others 2004). They are usually from the Caribbean. In prolonged labor, which frequently rural, poor areas, often with an early first pregnancy. results in delivery of a stillborn, the bladder and/or However, a Tanzanian survey by the Women’s Dignity rectal tissue is compressed between the pelvic bones Project and Engender Health (2006) has shown that and the fetal head, cutting off blood flow and causing fewer than half of the fistulas in that country resulted ischemic pressure necrosis (Husain and others 2005). from a first birth, suggesting that many fistulas occur In the hours or days following such a prolonged in subsequent pregnancies as well. The woman labors labor, the fistula forms and leakage of urine, stool, or at home, without the benefit of a trained birth both appears. Corresponding author: Mary Lake Polan, MD, PhD, MPH, Columbia University, polan@stanford.edu 95 Figure 6.1 Worldwide Fistula Fund’s Obstetric Fistula Pathway Low socioeconomic status of women Malnutrition Limited social roles Illiteracy and lack of formal education Early marriage Childbearing before pelvic growth is complete Relatively large foetus or malpresentation Cephalopelvic disproportion Lack of emergency obstetric services Obstructed labor Harmful traditional practices “Obstructed labor injury complex” Fetal death Fecal incontinence Fistula formation U ri n a r y i n c o n ti n e n c e Complex urologic injury Vaginal scarring and stenosis Secondary infertility Musculoskeletal injury Foot drop Chronic skin irritation Offensive odor Stigmatization Isolation and loss of social support Divorce or separation Worsening poverty Worsening malnutrition Suffering, illness, and premature death Source: “The Obstetric Fistula Pathway: Origins and Consequences” (Wall and others 2005), copyright Worldwide Fistula Fund. Used by permission. Additional Complications Hamlin, and Wall 1996); and renal damage, resulting Additional major complications can include repro- in decreased kidney function. Women also report ductive organ damage, such as uterine rupture, amen- genital soreness; painful intercourse; constipation; and orrhea, and uterine scarring resulting in secondary unpleasant odor, despite frequent washing and pad infertility; dermatological conditions, resulting in exco- changes (Turan, Johnson, and Polan 2007). riations and infections; neurological damage, resulting As devastating as the physical outcomes of obstructed in weakness in the leg and foot drop (Arrowsmith, labor are, the emotional and social implications are 96 Essential Surgery equally tragic. A stillborn child is the most frequent Finally, we offer comments on future directions and result of such a delivery, and the woman may be educational and surgical innovations to both prevent abandoned by her husband and family to live as a social and treat the occurrence of obstructed labor and the outcast without the ability to earn a living (Wall and resulting fistula. others 2002). In many cultures, the woman either blames herself or is blamed by the community for the fistula, which is seen as a mark of punishment for some wrong- BURDEN OF DISEASE DUE TO doing (Johnson and others 2010). She endures social OBSTETRIC FISTULA isolation, economic deprivation, and depression (Turan, Johnson, and Polan 2007; Weston and others 2011). Beyond the actual physical and anatomic burdens of unrelenting urinary and fecal incontinence, the burden of disease encompasses many other physical and psy- Surgical Initiatives chological consequences. Obstructed labor is a leading Numerous surgical initiatives during the past 40 years cause of maternal mortality and morbidity in LMICs. have attempted to repair this obstetric damage and to In these countries in the Middle East and North Africa, rehabilitate these women. Among the first such initia- East Asia and Pacific, South Asia, and Sub-Saharan tives was the establishment of the Addis Ababa Fistula Africa, it is estimated that fistulas occur in one to three Hospital in 1974 by Reginald and Catherine Hamlin. of every 1,000 deliveries (Wall 1998). An estimated This hospital has cared for thousands of women and 50,000 to 100,000 women worldwide develop obstetric trained many surgeons in the techniques of fistula repair. fistula annually, 60,000 to 90,000 annually in Sub- Multiple surgical teams throughout Southeast Asia and Saharan Africa alone; more than 2 million women in Sub-Saharan Africa have reported successful closure of Asia and Sub-Saharan Africa are living with an untreated more than 80 percent of fistulas (Wall and others 2005). obstetric fistula and the resulting urinary and/or rectal However, successful closure of anatomic defects does incontinence (UNFPA 2003). not necessarily result in the absence of incontinence, Although obstetric fistulas in themselves rarely lead which is an equally important criterion for a successful to immediate death, patients suffering with this disease surgical outcome. The United Nations Population Fund have been referred to as the walking dead (Ahmed and (UNFPA) launched its Campaign to End Fistula in 2003. others 2007). The women can also sustain long-term Awareness of the issues highlighted by this campaign, renal damage and eventually succumb to renal failure. along with discussion of strategies to prevent and treat In the words of expert fistula surgeon Dr. Kees Waaldijk obstetric fistula, have resulted in increased interest in of Katsina, Nigeria, “The poor woman survives the and knowledge of obstetric fistula, as well as the training labor, and then the real problems begin” (personal of more fistula surgeons and additional reporting of the communication). The physical disabilities include blad- results of fistula surgeries (Husain and others 2005). der and urethral damage, renal failure, and gynecologic and neurologic complications. The ischemic injury can lead to the damage and sloughing of bladder, urethral, Chapter Goals rectal, and vaginal tissue, as well as tissue loss to the This chapter describes the present state of fistula surgery pelvic musculature and reproductive organs. and the burden of death and disability, including the social and economic effects on women and their fami- lies. Although there is scant literature on both the cost of Reproductive Organ Damage fistula surgeries and the quantitative impact on women’s Vaginal, bladder, and rectal damage result from earnings in low- and middle-income countries (LMICs), compression of the maternal tissue by the fetus dur- we present what information is known. We describe cur- ing repeated uterine contractions that restrict blood rent surgical procedures, as well as the skills and types flow, resulting in ischemia and tissue death. Vaginal of trained health workers necessary to perform these strictures were noted in 17 percent of patients in one procedures. Clinical follow-up is complicated because study (Raassen, Verdaasdonk, and Vierhout 2008), and a most women return to their rural homes, making it small Nigerian study reported vaginal scarring in up to difficult to contact them to assess long-term surgical 68 percent (Adetiloye and Dare 2000). Only 26.4 percent outcomes. However, using the imperfect follow-up of women admitted for fistula repair surgery in this data available, we attempt to draw conclusions on the study were married, and these were the only women who surgical outcomes and cost-effectiveness of the multi- reported regular sexual intercourse. Few studies to date ple surgical procedures used to repair obstetric fistula. have looked at sexual functioning in women who have Obstetric Fistula 97 such tissue damage or those who have had attempts such be caused by compression injury or ischemic damage to as vaginoplasty to repair the damage. the peroneal nerve, leading to the inability to dorsiflex The widespread damage to the pelvis can lead to the foot. The involvement of the L5 root is often noted, cervical and uterine scarring from both ischemia and sub- and severe pelvic ischemia can lead to postdelivery sequent infection, resulting in postpartum amenorrhea. paraplegia that will recover (Hancock 2009a). Affected Amenorrhea may also be caused by hypothalamic- women tend to drag one or both legs, needing a stick pituitary dysfunction secondary to intra- or postpartum or walls for support. Originally called “obstetric palsy,” hemorrhage (Sheehan’s syndrome). A study from Ethiopia this lower extremity nerve damage has been associated reported amenorrhea in 63.1 percent of women with with labor for hundreds of years. A prospective study of obstetric fistula (Arrowsmith, Hamlin, and Wall 1996). 947 Nigerian women with obstetric fistula found that One high-volume expert surgeon in Nigeria reports approximately 27 percent had signs of peroneal nerve amenorrhea rates of 12 percent to 15 percent if the fistula weakness, and approximately 38 percent had a history duration exceeds one year (Waaldijk 2008). of relevant symptoms such as foot drop (Waaldijk and Although no long-term studies have examined the Elkins 1994). fecundity and birth rates of women with unrepaired In an East African study, unilateral or bilateral per- fistulas, several papers have examined the reproductive oneal nerve damage was observed in 43.7 percent performance in women who have had obstetric fistula of first-time obstetrical fistula patients. On a scale of surgery. No conclusive reproductive rates have been 0 (paralyzed) to 5 (normal strength), 7.1 percent had a reported after repair; however, it is known from expe- score of ≤ 2 in one or both legs. When comparing routes riences at multiple sites that patients with repaired of delivery, there was no statistically significant difference fistulas can conceive and subsequently deliver healthy in peroneal paralysis frequency between women who infants, although the rates are presumed to be markedly eventually delivered vaginally (43.9 percent) and those diminished because of pelvic adhesions. The long-term who were delivered by cesarean section (43.5 percent) social impact of infertility for young women in a poor (Raassen, Verdaasdonk, and Vierhout 2008). Waaldijk country, where fistulas are endemic, includes the nega- and Elkins (1994) report that most women regain tive economic effect of not having offspring in societies function after two years. Despite this, 13 percent remain in which government welfare programs are nonexis- with some residual nerve damage. tent and security in old age is directly linked to having children (Wall and others 2002). Renal Damage The proximity of the ureters to the area where most Dermatological Conditions obstetric fistulas occur puts them at risk of damage Skin excoriations and ulcerations due to urinary from obstructed labor. A radiology study in Nigeria ammonia deposition on the skin are a common com- looked at the incidence of renal and ureteric injury in plication of fistula. The chronic moisture and acidity of 216 Nigerian women with obstetric fistula. Intravenous urine can cause the formation of uric acid crystals, and urographic studies found 48.6 percent of the patients the skin may become infected. A review of 639 patients evaluated had evidence of renal damage; 34 percent in East Africa found that almost 50 percent had evidence had evidence of unilateral or bilateral hydroureter with of excoriations of the labia and medial aspects of the significant ureteral dilation. The most extreme damage thigh (Raassen, Verdaasdonk, and Vierhout 2008). Other was found in 4.6 percent of patients who had nonfunc- studies report lower rates (20 percent) for similar skin tioning bilateral kidneys (Lagundoye and others 1976). damage (Gharoro and Agholor 2009). This skin con- Long-term follow-up was not performed on these dition is painful, and the constant contact with urine women. allows little relief from the discomfort. The ideal regimen for skin care remains to be determined; however, several salves and creams, including steroids and estrogens, have Stillbirths been proposed. In cases in which the woman survives the obstruction, most of the pregnancies result in the birth of a still- born fetus. After the traumatic ordeal of prolonged Neurological Disabilities labor with associated pain and fear, this tragic outcome The extensive ischemic damage that leads to an obstetric enhances the despair. In one study, 85 percent of women fistula can also result in nerve damage. Foot drop may incurred fetal loss from deliveries resulting in fistula 98 Essential Surgery (Raassen, Verdaasdonk, and Vierhout 2008). In another the smell of urine was the reason many felt unable series of 899 fistula cases, fetal mortality was 92 percent; to participate in routine activities that were a cor- of the 75 infants who were live-born, an additional 14 nerstone of their social lives. The women would not died within the neonatal period (Wall and others 2004). go to church or be able to pray because of feeling “unclean” (ongoing survey of the quality of life of fistula patients, Eritrean MOH, personal communi- Mental and Emotional Issues cation, 2012). Obstetric fistula patients have been called the most From the social standpoint, the most traumatic dispossessed, outcast, powerless group of women in the aspects of VVF result from incontinence, distorted world. For women in many cultures in which fistula is self-image, and childlessness. These factors can lead to prevalent, the obstetrical problems that result in VVF are divorce, depression, and exclusion from families and not only considered physiological events, they can also society. A review of 899 women with obstetrical fistula profoundly affect personal relationships with families in central Nigeria found that approximately 50 percent and entire communities. Goh and others (2005) ques- of patients had been divorced as the result of fistula- tioned women with obstetric fistula from Bangladesh related problems (Wall and others 2004). In a study and Ethiopia using a psychiatric disorders screening from Bangladesh, 61.4 percent of women reported tool. They found that 97 percent of women screened embarrassment in their social lives, 39.4 percent reported positive for potential mental health dysfunctions. They feeling constantly ill, and 33.3 percent reported difficulty estimated between 23 percent and 39 percent of women in maintaining sexual relations. In addition, 67.4 percent with fistula had major depression. reported the inability to perform their prayers, and This finding is in contrast to controls surveyed during 62 percent reported unhappiness in their married lives the same study in Bangladesh and Ethiopia, where only (Islam and Begum 1992). 32 percent screened positive with the same question- naire, equating to a major depression prevalence of 8 percent to 13 percent (Goh and others 2005). A study Economic Burden of 70 women with fistula from Kenya reported depres- The obstetric fistula is an affliction of reproductive-age sion in 72.9 percent, with 25.7 percent meeting the women who are primiparous in 31 percent to criteria for severe depression. Risk factors for depression 66.7 percent of documented studies. The economic appeared to be age older than 20 years, unemployment, burden includes the patients’ loss of the ability to work lack of social support after fistula development, and and perhaps the loss of a society’s future workforce living with fistula for more than three months (Weston due to high rates of stillbirth and subsequent infertility and others 2011). Even though studies have suggested (Tebeu and others 2012; Waaldijk 2008). In Nigeria, a that some women commit suicide, no data have been study reported that women with fistula were 50 percent published about the risk of murder or “honor killing.” more economically impoverished by job loss. In many There is, however, anecdotal evidence of increased instances, such as in a study of women in Tanzania, domestic violence. they were farmers and were unable to perform hard One study found high levels of mental distress manual labor after sustaining a fistula (Pope, Bangser, in women living with fistula resulting from long-time and Requejo 2011). All of the women had some form social isolation. The greatest distress and frustra- of occupation when the fistula developed; 92 percent tion appears to come from the inability to establish were farmers, 5 percent were domestic workers, and and maintain healthy social relationships. This same one (3 percent) was a potter. While living with a fistula, study reported that 14 percent of women attempted 22 percent stopped working and remained at home. suicide while living with fistula (Nielsen and others Following surgery, 75 percent of these women returned 2009). Nearly all women suffered from isolation, to their former occupations (Nielson and others 2009). shame, and stigma. Avoidance of public places due Long hours of field labor may be difficult with injuries to the risk of being insulted or simply ignored was such as foot drop or pelvic trauma, and many women common. Patients have had community members hold wait years before seeking help. their noses publicly and humiliate them with words Research in Addis Ababa found that women affected of abuse. by fistula and rejected by their husbands often had to In a survey of Eritrean fistula patients, self-imposed depend on relatives for their food; some of the women isolation during meal times and religious ceremonies were reduced to begging and lived on donations (Kelly was almost universal. A small cohort revealed that 1995). A large number of women reported not having Obstetric Fistula 99 the means to afford soaps and clothes to stay clean and agricultural labor, was the most important factor in their remain a productive part of working society. Most of the reintegration process. Those who experienced difficul- injured women were not able to continue employment ties resuming their expected social roles after treatment and lost their ability to be contributing members of the mentioned that they were afraid that they would develop household (Women’s Dignity Project and Engender another fistula from physical exertion or sexual activity Health 2006). Families affected by fistula experience and/or experience a lot of pain and weakness while significant economic burdens that can be a factor in working (Pope, Bangser, and Requejo 2011). reducing families to poverty levels. Browning, Fentahun, and Goh (2007) report on the impact of surgical treatment on mental health. Closure of the fistula markedly improved mental health SURGICAL REPAIR AS EFFECTIVE scores, despite the lack of any formal psychological or TREATMENT psychiatric input. Surgery improved quality of life and facilitated social reintegration to a level comparable to The surgical closure of an obstetric fistula is the most that experienced before fistula development for both effective way to treat this condition. Evidence indicates women who were continent and those with residual that life improves dramatically for the majority of incontinence. It was not surprising that no change was women after successful fistula repair. Women are able seen in those women still suffering from fistula (Nielson to return to their normal lives; interact freely with their and others 2009). families, friends, and communities; and play active roles in economic pursuits (Women’s Dignity Project and Engender Health 2006). COST-EFFECTIVENESS OF SURGERY A cross-sectional, prospective study sought to assess the quality of life of women with surgical repair of their The cost-effectiveness of obstetric fistula repair is under- VVF. Of the 150 women studied, only 20 percent felt studied, leading to a paucity of literature on this issue. satisfied with their general state of health and quality of Current research indicates that “[A]t the world’s current life before the repair; this figure increased to 90 percent capacity to repair fistula, it would take at least 400 years following successful repair. In the physical health domain, to clear the backlog of patients, provided that there the mean quality of life score was significantly improved; are no more new cases” and that less than 1 percent of this improvement was also seen in the mental health surgical needs for this disease is met (Browning and domain. In the social health domain, the mean score was Patel 2004, 321). Prevention of the fistula is the ultimate 20.2 ± 2.7 before and 69.7 ± 2.3 after successful repair goal. The mental, physical, and economic burden to (p < 0.001). The conclusions suggest that successful women with obstetric fistula has been well documented. repair of VVF is associated with significant improvement However, for those currently living with, and those in the multidimensional quality of life among affected who will develop, a fistula, the demonstrable benefit in women (Umoiyoho and others 2011). economic terms must be studied further. An Eritrea-based study of patients’ postoperative experiences notes that patients described improvements in their conditions, but many continued to have problems Estimated Costs with incontinence and sexual health (Turan, Johnson, The UNFPA estimates that the average cost of fistula and Polan 2007). The majority of women in another surgery is approximately US$400 (UNFPA 2012). study were able to resume their household and farming According to the Fistula Foundation, costs vary depend- responsibilities postrepair (Pope, Bangser, and Requejo ing on the sociopolitical situation in countries where 2011). By one year postrepair, 68 percent of the women wars, conflict, and political instability have significantly who perceived themselves healed or mostly healed increased the cost of fistula repair; the estimated aver- reported feeling “themselves again.” Looking toward the age cost of fistula surgery was US$1,000 (Church and future, most hoped that they could continue working in Grant 2012). A Kenyan paper reports that the heavily the fields, engage in small trade, bring their children to subsidized cost of fistula repair is about 30,000 Kenya school, and “maybe build a home.” Most treated women shillings (US$375) at the main referral center in Kenyatta (99 percent) did not link their physical condition to National Hospital in Nairobi; the cost in a private economic problems. As one woman explained, “Life is hospital can be at least five times that amount. However, tough, but that does not affect anything economically.” in Kenya, only 7.5 percent of women have access to However, 60 percent of the women reported that treatment, and the majority cannot afford to travel to being able to work again, principally in the fields doing the fistula center.1 100 Essential Surgery Disability-Adjusted Life Years Once women develop fistulas, transportation to a med- Research in Ethiopia finds that the average age of women ical facility is extremely difficult because of the cost at the time of fistula appearance is 22 years, and surgical of transportation and also because of the inadequate treatment is initiated eight years later (Muleta 2009). hygiene and leaking that women with fistulas exhibit. The Fistula Foundation’s Shaun Church and Kate Grant A 2001 UNFPA survey of fistula patients in Tanzania report that the life expectancy of women in Ethiopia is reports that some women travel as far as 500 kilometers 58.8 years.2 Therefore, it can be estimated that fistula to reach the nearest fistula center (UNFPA 2001). The surgery savings could be 28.8 disability-adjusted life survey notes that of 32 fistula centers, only 3 provide years (DALYs). Using Ethiopia as an example and free surgery. estimating the cost of fistula surgery to be US$1,163, Education of the medical profession has been a dividing that cost by the estimated 28.8 DALYs results in challenge in LMICs, limiting access to doctors who are a conservative savings of about US$40 per DALY averted able to provide successful fistula repair. Sub-Saharan with surgery. This suggests fistula surgery is a highly Africa, which accounts for about 24 percent of the global cost-effective intervention. disease burden, has only 3 percent of the global health workforce (Anyangwe and Mtonga 2007). Insufficient numbers of medical schools, inadequate salaries, and Prevention Strategies and Costs poor working conditions account for this situation. There are an estimated 0.25 trained surgeons per 100,000 The prevention of fistula requires significant social persons in East Africa, compared with 5.60 per 100,000 and economic attention. Investing in medical facilities in the United States. that are able to provide adequate prenatal care as well “Brain drain” exacerbates the shortage of trained as healthy deliveries needs to be a priority. Prenatal medical personnel. Uganda’s government spends an care, with early identification of at-risk pregnancies estimated US$21,000 and South Africa spends about coupled with early referral to delivery centers capable US$59,000 to subsidize each medical doctor’s training of operative delivery, is essential for prevention. The (Mills and others 2011). Sub-Saharan African countries cost of prenatal care varies by country, as well as by spent about US$2 billion dollars to train doctors who government-provided insurance plan, but all costs for later migrated to more stable, richer countries. Mills these preventive strategies are significantly lower than and others (2011) estimate that the United Kingdom the cost of later treatment. benefited by about US$2.7 billion and the United States Access to medical care in most of the countries by about US$846 million from the immigration of where obstetric fistula is endemic is extremely limited. Africa-trained physicians. Based on the impact of this The economic cost of obtaining medical care at hos- loss of medical expertise, those countries that benefit pitals is beyond the budget of all but the wealthiest the most from this drain of intellectual and surgical families. The costs of travel and accommodations for resources might consider investing in the source coun- patients and family members are extremely high. Studies tries and strengthening their training systems. involving obstetrical costs in Benin, Ghana, and Pakistan concluded that vaginal delivery and cesarean sections in medical facilities were beyond the limits of what PRESURGICAL PROCEDURES IN OBSTETRIC 75 percent of residents could afford (Lewis and de Bernis 2006). FISTULA REPAIR Cesarean sections need to be more widely available as Women with bladder fistulas can sometimes be treated an option for the treatment of obstructed labor. A study conservatively if the injury is recent and the hole is in Kenya found that the cost of one cesarean section small. Continuous bladder drainage with Foley cath- is about 3,000 Kenya shillings, or US$35 to US$40, in eters for four to six weeks has been reported to result government hospitals; in rural Tanzania, the average in the spontaneous closure of small fistulas with fresh cost is US$135.40 (Kowalewski, Mujinja, and Jahn 2002; edges in 15 percent to 20 percent of cases (Waaldijk Wanzala 2011). The patient population also needs to 1994). However, the majority of VVFs require surgical be educated about the natural progress of labor and to treatment. have the ability to be transported to the hospital when General principles in obstetric fistula surgery include obstructed labor occurs. patient evaluation and preoperative care, maximum One key factor in LMICs is the lack of transportation exposure of the repair site, adequate tissue mobilization, to medical facilities; women in prolonged labor often do gentle tissue management, closure of the defect without not have adequate resources to reach medical facilities. tension, and meticulous postoperative care. Obstetric Fistula 101 PATIENT SELECTION AND PREOPERATIVE vaginal skin (epithelium). Lateral extension of the CARE incision, at the 3:00 and 9:00 o’clock positions, is made bilaterally. These incisions over the vaginal A standard classification of obstetric fistula has not been mucosa should be just deep enough to cut only the agreed upon. However, urethral involvement, extent of vaginal mucosa. The bladder (rectum in RVF) should scar, defect size, bladder capacity, and history of prior be mobilized adequately to avoid tension on the clo- repair attempts are generally acknowledged as predictors sure of the defect. of posttreatment continence (Nardos, Browning, and Bladder or rectal muscle should be approximated, Chen 2009). The first attempt at fistula repair is likely to avoiding the bladder or rectal mucosa. The closure of be the most successful; therefore, the woman should be bladder fistulas can be in either a single or a double provided the best available care and skill during the first layer based on individual preference. Closure of rectal surgery (Angioli and others 2003). fistula is preferable in two layers, to avoid rectal mucosal The timing of surgery after injury is controversial, interposition between the sutures. In patients who had but it should be delayed until the quality of the tissue had a diverting colostomy and repair of an RVF, a dye needed for repair improves. This can take up to three test must be done to confirm success of repair before months, although some surgeons advocate immediate planning for colostomy closure. repair and claim comparable results (Waaldijk 1994). Early repair might minimize the social neglect of the affected women; however, the evidence for this Postoperative Care approach is limited. Physiotherapy and psychological The main concern in VVF patients in the postopera- counseling should begin preoperatively and should tive period is the maintenance of free and continuous continue postoperatively. Malnutrition and anemia, bladder drainage. High fluid intake is widely advised; ammonia dermatitis, and genital infections should be women should be encouraged to drink four to five treated before surgery. liters a day (Hancock 2009b) and the color of the urine should be watched as the indicator of the adequacy of hydration. A blocked catheter signals an emergency. SURGICAL REPAIR Transurethral drainage catheters are generally kept for an average of 14 days (up to 21 days following Repair Procedure new urethral reconstruction) and should be removed The surgical approach can be vaginal, abdominal, or without clamping. Some suggest that postoperative combined, based on the location of the fistula and the catheterization for 10 days may be sufficient for less preference and experience of the surgeon. The vaginal complicated cases of VVF repair (Nardos, Browning, route seems to be associated with less blood loss and and Member 2008). Women are advised not to resume pain (Chigbu and others 2006). However, the evidence sexual contact for three months to give adequate time on the difference in operative complications and speed for the tissues to heal. of recovery is limited. In some cases, the damage to The most challenging situation in obstetric fistula the urethra and bladder is so severe that conventional management is post-VVF-repair incontinence. Although repair methods are not successful. In specialized centers, failure of fistula repair must be ruled out, incontinence these patients are sometimes offered urinary diversion is often due to stress incontinence or combined stress in which the ureters are implanted in the lower bowel and urge incontinence (Murray and others 2002). (Morgan and others 2009). Urodynamic studies of bladder and urethral func- Maximizing the exposure of the defect is necessary tion can be helpful, but the equipment is most often to identify the location and size of the fistula, the extent unavailable in settings where fistulas are frequently of the tissue loss, the involved organs and tissues, and encountered. the amount of scar tissue in the vagina. The patient should be positioned in exaggerated lithotomy with a Trendelenburg tilt and the buttocks protruding on POSTOPERATIVE TRAINING AND an adjustable operating table, if available. The use of REINTEGRATION bright and well-focused light over the field of surgery is essential. For women who have lived with fistula for many years, An incision is made over the vaginal mucosa all reintegration into society involves redefinition of self around the fistula about 3 millimeters away from and transition from being identified as filthy, dependent, the junction of the bladder (rectum in RVF) and and unworthy to being seen as clean, feminine, and active 102 Essential Surgery in family and community life. Thus, reintegration into and fistulas. More than 50 percent of the reporting family and community life is a major adjustment and fistula treatment centers in the world provide surgery goal after surgery. This need for reintegration requires in fewer than 50 cases a year; only five centers report that surgical programs dedicated to fistula repair con- doing more than 500 a year (United Nations General sider and implement counseling for social integration Assembly 2012). and training in life skills to help these women return to gainful employment after repair. Models of Treatment Most women live an agrarian lifestyle, and returning to farming is important to them. One paper identifies According to the World Health Organization (WHO), the most important factor helping them feel normal several models of treatment are currently in practice, again is the ability to return to farming after surgical but no convincing evidence is available with respect to repair (Pope, Bangser, and Requejo 2011). However, which approach is superior. Many are supported by non- most women felt that they needed more time after governmental organizations and charitable donations; surgery to fully recover their strength; the authors rec- others are integrated into the country’s reproductive ommend having an alternate non-labor-intensive form health programs and are supported by the government, of income for the first year after repair before most often with help from international organizations like the women return to their routine work. The full reinte- UNFPA. gration of a patient postrepair should also include her The most famous standalone fistula center program is sexual and reproductive health needs (Mselle and others at Addis Ababa Fistula Hospital. The Women and Health 2012). Preoperative and postoperative counseling for Alliance International has integrated fistula repair cen- 47 Eritrean fistula patients was shown to increase their ters into three university hospitals in Ethiopia, Somalia, self-esteem (Johnson and others 2010). and the Republic of the Sudan that are similar to centers After postsurgery counseling, women were signifi- in Eritrea (box 6.1), Niger, and Nigeria. Some centers cantly more likely to practice positive health behaviors, are integrated into gynecology or urology departments to use family planning, and to improve their nutritional in academic centers; others are satellite units that refer intake. Following counseling, 91 percent of women complicated cases to regional independent or national expressed intentions to talk with family members fistula centers. and 77 percent intended to talk to other community Finally, there are “fistula camps” that are managed members about fistula and fistula prevention, com- by national and international teams. International pared with 26 percent and 34 percent, respectively, training centers are being selected and developed to before counseling. Counseling seems to have a marked serve as training sites for future fistula surgeons, using impact on women’s ability to resume their roles in their a Global Competency-Based Fistula Surgery Training communities. Manual developed by the International Federation of One Nigerian study calculated the cost of surgical Gynecology and Obstetrics (FIGO), the International treatment and rehabilitation to be US$2,300 per patient Society of Obstetric Fistula Surgeons (ISOFS), and other for a 10-month stay, and an additional US$340 for international partners. The UNFPA funded develop- 12-month follow-up and reintegration (Mohammed ment of the manual. 2007). To validate the long-term impact and sustainabil- The WHO recommends that each country set up ity of these programs, studies need to be performed in an obstetric fistula strategy committee as part of a the community settings where patients settle after repair national maternal-newborn health program. This pro- and after rehabilitation. gram should include a needs assessment that is both facility and community based. It is important that the community understand the context in which fistulas HEALTH SYSTEM CONSIDERATIONS develop so that cultural and logistical issues (for exam- Obstetric fistula, a problem seen primarily in women ple, transportation) can be addressed. The program from resource-poor countries, results from financial, should include strategies for preventing fistula; for cultural, political, and logistical obstacles. Although providing facilities for fistula repair and rehabilitation; international efforts, such as the UNFPA’s Campaign and for training surgeons, nurses, and other health to End Fistula, have made some improvements in the care personnel. The program should also include number of fistulas treated, overall only a very small provisions for oversight and advocacy to ensure that fraction of cases are ever repaired. The number of the program continues to be funded and that the fistula treatment centers is especially low in countries results are acceptable (Lewis and de Bernis 2006). that have the highest levels of maternal mortality Setting up this kind of model, however, is difficult in Obstetric Fistula 103 Box 6.1 Case Study: Eritrean Women’s Project 2000−13 Eritrea, a country of 5 million people, is located • 2013: The 40-bed Fistula Waiting Home at along the coast of the Red Sea and is bordered by Mendefera Referral Hospital opened. Djibouti, Ethiopia, and the Republic of Sudan. Eritrea’s population is 20 percent urban and 80 per- Supportive Government Actions cent rural; 55 percent of the people are farmers, The government of Eritrea and the Ministry of and 30 percent are pastoralists who move across Health supported and amplified the project’s goals borders with their animals. There are nine main for improving reproductive health by instituting a ethnic groups and religions, including Islam, Eastern national campaign to promote the use of condoms, Orthodoxy, and Catholicism. raising the legal age of marriage to 18, and prohib- The original goals of the Eritrean Women’s Project, iting female genital mutilation. Most important, the founded by Mary Lake Polan, MD, included repair Ministry of Health set a goal of ending fistula in of fistulas, training of Eritrean surgeons, implemen- Eritrea by 2013. tation of interventions to educate women about the causes and treatment of fistulas, and establishment Outcomes of the Fistulae Treatment Center for comprehensive care, education, and rehabilitation of women with • More than 600 surgical procedures over 12 years fistulas. were performed by the U.S. surgeons, with a continence rate of approximately 70 percent. • More than 303 urinary and 49 recto-vaginal Program Milestones: fistulas were repaired. • 2001−13: A small group of surgeons traveled • More than 1,000 surgical procedures were per- to Eritrea two to three times a year for two formed by Eritrean and U.S. surgeons. weeks each time, scheduled by the Ministry of • Approximately 8 percent of patients required Health and UNFPA, to operate on women with urinary diversion procedures because of irrep- fistulas. The trips were funded by the United arable fistulas; follow-up of one to nine years Nations Population Fund (UNFPA) and private resulted in live births for five diversion patients donations. and no perioperative mortality. • 2005: The first class of medical students enrolled • Six articles on fistula issues were published in in Orotta School of Medicine in Asmara and was peer-reviewed journals. subsequently taught by the visiting surgeons. • Three Eritrean residents’ abstracts were accepted • 2006: The project organized the perioperative to attend the 2012 meeting of the International counseling program. Federation of Gynecology and Obstetrics (FIGO) • 2007: The community-based study of reproduc- in Rome. tive outcomes sponsored by the project showed • Trained Eritrean surgeons now perform that inclusion of the entire community in a fistula 80 percent of fistula repairs and treat more than education program improved prenatal care. 100 cases a year. • 2008: The Eritrean government established the • The National Fistula Center now has dedicated National Fistula Center at Mendefera Referral and trained nursing staff. Hospital. • The 40-bed Fistula Waiting Home serving pre- • Two Eritrean fistula surgeons have been trained operative and postoperative patients and women at the National Fistula Center since its opening in with high-risk pregnancies in their third trimester 2008 as part of the project. was constructed on the grounds of the Mendefera • 2012: The first five residents in obstetrics and Referral Hospital, with donations from Friends of gynecology were trained in Eritrea. UNFPA, and opened in April 2013. box continues next page 104 Essential Surgery Box 6.1 (continued) Building a Sustainable Fistula Program: Health and staff members was an essential element, Lessons Learned as was the support of the UNFPA and the Eritrean The considerable progress achieved in a relatively staff. The financial assistance of private donations to short time is the result of the widespread support Friends of UNFPA in the United States supported the and commitment of key organizations and part- travel expenses of physicians, fellows, residents, and nerships, including the trained surgeons who treat medical students. Moreover, the in-kind corporate patients and teach medical students and residents in donations of ultrasound equipment, sutures, retrac- obstetrics and gynecology, as well as the visiting phy- tors, catheters, and antibiotics allowed the surgeons sicians, nurses, physical therapists, and students from to more effectively care for women with fistula. the United States who have donated their time and skills. The strong relationship with the Minister of Source: Data collected by Drs. Ambereen Sleemi and Mark Morgan. many resource-poor countries, particularly in those Good nursing care for patients with fistula is essential with internal or external conflicts. to the surgical outcome. Nurses often receive special training onsite; the training includes presurgery and postsurgery care, psychological support, and counseling Health Workforce Requirements and communication skills. The main obstacle in fistula care is the lack of trained medical personnel in surgery. The fistula surgeon must have basic surgical skills in abdominal, pelvic, FUTURE DIRECTIONS and vaginal surgery. Training for this type of com- plex surgery is highly specialized and, until recently, Centers providing obstetric fistula treatment are few, was organized differently in different institutions. and patients must often undertake long and difficult Recently, however, FIGO, ISOFS, and other partners journeys to access care. Many of these services operate developed a consensus-derived document that focuses outside the government health sector as part of cam- on competency-based training in fistula surgery to paigns involving surgeons who come for short visits. three levels: standard, advanced, and expert (FIGO A complete fistula treatment center includes surgical and Partners 2011). services (operating theaters, postoperative wards, and Local gynecologists, urologists, general surgeons, and anesthetic services), investigation services (laboratory, other professionals with basic surgical skills can be radiology, and blood bank), and physiotherapy and trained in fistula repair. Having a maximum number social-reintegration services. The largest financial chal- of trained local staff increases the number of locally lenge of most fistula centers is the cost of consumables managed fistula operations. A preferable strategy is and salaries, renewal of equipment, and maintenance of to integrate fistula care and training into the services the infrastructure. The less-than-optimal training and provided by local governmental institutions so that an supervision of health workers and the very low wages for adequate number of gynecology, urology, surgery, and fistula surgeons have resulted in the uneven distribution other students with basic surgical skills are systematically of specialized health care providers. The long-term sus- trained to manage fistula cases. This approach is a tainability of such services depends on the strong com- sustainable way to dramatically increase the number mitment of health professionals, health management of operations available in regions with the heaviest bur- teams, governments, and local authorities (Donnay and den of fistula, and it offers a greater number of women Ramsey 2006). the opportunity to return to normal and dignified lives. Training facilities should be developed in districts Good prenatal care, adequate transportation of patients with large numbers of untreated patients. The size of in labor, and delivery facilities able to intervene with the health facility is determined by the magnitude of the cesarean section for operative delivery would reduce the problem in the area. Being part of a larger health insti- incidence of fistulas and, thereby, the specific need for tution provides access to and use of essential facilities, fistula surgeons and specialized surgical care. such as pharmacies, laboratories, laundries, sterilization Obstetric Fistula 105 services, and kitchens. Being part of a hospital offers Angioli, R., M. Penalver, L. Muzii, L. Mendez, R. Mirhashemi, other advantages as well, such as access to other aspects and others. 2003. “Guidelines of How to Manage of health care, including prenatal health care services Vesicovaginal Fistula.” Critical Reviews in Oncology and and emergency obstetric services. Hematology 48 (3): 295–304. Anyangwe, S. C., and C. Mtonga. 2007. “Inequities in the A global consensus exists on the need for improved Global Health Workforce: The Greatest Impediment to access to quality and sustainable fistula care and Health in Sub-Saharan Africa.” International Journal of training services, as well as postoperative social- Environmental Research in Public Health 4 (2): 93–100. reintegration services. This goal can be attained by Arrowsmith, S., E. C. Hamlin, and L. L. Wall. 1996. “Obstetric integrating fistula treatment and training into existing Labor Injury Complex: Obstetric Fistula Formation and the government health services (PMNCH 2006). Fistula Multifaceted Morbidity of Maternal Birth Trauma in the centers do not need to be sophisticated, however, if Developing World.” Obstetrical and Gynecological Survey they provide human resources with basic skills, facil- 51 (9): 568. ities, and equipment to provide fistula-management Browning, A., W. Fentahun, and J. Goh. 2007. “The Impact of services. Surgical Treatment on the Mental Health of Women with The UNFPA released a fistula map in 2013 to Obstetric Fistula.” BJOG 114 (11): 1439–41. Browning, A., and T. L. Patel. 2004. “FIGO Initiative for the track fistula services internationally (http://www Prevention and Treatment of Vaginal Fistula.” International .globalfistulamap.org). It is hoped that these efforts Journal of Gynecology and Obstetrics 86 (2): 317–22. will have a significant effect on the worldwide burden Chigbu, C. O., E. E. Nwogu-Ikojo, and H. E. Onah. 2006. of obstetric fistula by combining prevention with treat- “Juxta Cervical Vesicovaginal Fistulae: Outcome by ment and rehabilitation services. Intensive advocacy Route of Repair.” Journal of Obstetrics and Gynaecology for increased resource allocation to strengthen health 26 (8): 795–97. systems to ensure prevention and treatment of obstetric Church, S., and K. Grant. 2012. “Fistula Foundation: Fistula fistula is equally important. Foundation Letter.” February. http://www.givewell.org /files/DWDA%202009/Fistula%20Foundation/Fistula%20 Foundation%20Letter%2002-09-12.pdf. NOTES Donnay, F., and K. Ramsey. 2006. “Eliminating Obstetric Fistula: Progress in Partnerships.” International Journal The World Bank classifies countries according to four income of Gynaecology and Obstetrics 94 (3): 256–61. groupings. Income is measured using gross national income FIGO (International Federation of Gynecology and Obstetrics) (GNI) per capita, in U.S. dollars, converted from local currency and Partners. 2011. Global Competency-Based Fistula Surgery using the World Bank Atlas method. Classifications as of July Training Manual. London: FIGO. http:/www.figo.org 2014 are as follows: /projects/fistula_initiative. Gharoro, E. P., and K. N. Agholor. 2009. “Aspects of Psychosocial • Low-income countries (LICs) = US$1,045 or less in 2013 Problems of Patients with Vesico-Vaginal Fistula.” Journal of • Middle-income countries (MICs) are subdivided: Obstetrics and Gynaecology 29 (7): 644–47. • Lower-middle-income = US$1,046 to US$4,125 Goh, J. T. W., K. M. Sloane, H. G. Krause, A. Browning, and • Upper-middle-income (UMICs) = US$4,126 to US$12,745 S. Akhter. 2005. “Mental Health Screening in Women with • High-income countries (HICs) = US$12,746 or more Genital Tract Fistulae.” British Journal of Obstetrics and Gynaecology 112 (9): 1328–30. 1. Irin News. 2010. “Kenya Focus on Fistula,” July. http://www Hancock, B. 2009a. “Obstetric Fistulae: Cause and Nature; .irinnews.org/Report/89886/KENYA-Focus-on-fistula. The Obstetric Fistula Complex; Classification.” In 2. Shaun Church and Kate Grant. 2012. “Fistula Foundation: Practical Obstetric Fistula Surgery, edited by B. Hancock Fistula Foundation Letter.”February. http://www.givewell.org and A. Browning, 3–8. London: Royal Society of /files/DWDA%202009/Fistula%20Foundation/Fistula%20 Medicine Ltd. Foundation%20Letter%2002-09-12.pdf. ———. 2009b. “Post-operative Nursing Care of the Fistula Patient.” In Practical Obstetric Fistula Surgery, edited by B. Hancock and A. Browning, 133–47. London: Royal REFERENCES Society of Medicine Ltd. Adetiloye, V. A., and F. O. Dare. 2000. “Obstetric Fistula: Husain, A., K. Johnson, C. A. Glowacki, J. Osias, C. R. Wheeless, Evaluation with Ultrasonography.” Journal of Ultrasound and others. 2005. “Surgical Management of Complex Medicine 19 (4): 243–49. Obstetric Fistula in Eritrea.” Journal of Women’s Health Ahmed, S., R. Genadry, C. Stanton, and A. B. Lalonde. 2007. 14 (9): 839–44. “Dead Women Walking: Neglected Millions with Obstetric IMPAC (Integrated Management of Pregnancy and Childbirth). Fistula.” International Journal of Gynaecology and Obstetrics 2006. “Obstetric Fistula: Guiding Principles for Clinical 99 (Suppl 1): S1–3. Management of Programme Development.” Department 106 Essential Surgery of Making Pregnancy Safer, World Health Organization, Long-Term Follow Up of Women Undergoing Obstetric Geneva. Fistula Repair in Rural Ethiopia.” British Journal of Obstetrics Islam, A. I., and A. Begum. 1992. “A Psycho-Social Study and Gynaecology 116 (9): 1258–64. on Genito-Urinary Fistula.” Bangladesh Medical Research PMNCH (Partnership for Maternal, Newborn, and Child Council Bulletin 18 (2): 82–94. Health). 2006. Conceptual Institutional Framework. Johnson, K. A., J. M. Turan, L. Hailemariam, E. Mengsteab, Geneva: Partnership for Maternal, Newborn, and Child D. Jena, and M. L. Polan. 2010. “The Role of Counseling for Health. Obstetric Fistula Patients: Lessons Learned from Eritrea.” Pope, R., M. Bangser, and J. H. Requejo. 2011. “Restoring Patient Education and Counseling 80 (2): 262–65. Dignity: Social Reintegration after Obstetric Fistula Kelly J. 1995. “Ethiopia: An Epidemiological Study of Vesico- Repair in Ukerewe, Tanzania.” Global Public Health: Vaginal Fistula in Addis Ababa.” World Health Statistics International Journal for Research, Policy and Practice Quarterly 48 (1): 15–17. 6 (8): 859–73. Kowalewski, M., P. Mujinja, and A. Jahn. 2002. “Can Mothers Raassen, T. J., E. G. Verdaasdonk, and M. E. Vierhout. Afford Maternal Health Care Costs? User Costs of Maternity 2008. “Prospective Results after First-Time Surgery for Services in Rural Tanzania.” African Journal of Reproductive Obstetric Fistulas in East African Women.” International Health 6 (1): 65–73. Urogynecology Journal 19 (1): 73–79. Lagundoye, S. B., D. Bell, G. Gill, and O. Ogunbode. 1976. Tebeu, P. M., J. N. Fomulu, S. Khaddaj, L. de Bernis, T. Delvaux, “Urinary Tract Changes in Obstetric Vesico-Vaginal and C. H. Rochat. 2012. “Risk Factors for Obstetric Fistula: Fistulae: A Report of 216 Cases Studied by Intravenous A Clinical Review.” International Urogynecology Journal Urography.” Clinical Radiology 27 (4): 531–39. 23 (4): 387–94. Lewis, G., and L. de Bernis. 2006. Obstetric Fistula: Guiding Turan, J. M., K. Johnson, and M. L. Polan. 2007. “Experiences Principles for Clinical Management and Programme of Women Seeking Medical Care for Obstetric Fistula in Development. Geneva: World Health Organization. Eritrea: Implications for Prevention, Treatment and Social Mills, E., S. Kanters, A. Hagopian, N. Bansback, J. Nachega, and Reintegration.” Global Public Health 2 (1): 64–77. others. 2011. “The Financial Cost of Doctors Emigrating Umoiyoho, A. J., E. C. Inyang-Etoh, G. M. Abah, from Sub-Saharan Africa: Human Capital Analysis.” British A. M. Abasiattaim, and O. E. Akaiso. 2011. “Quality of Life Medical Journal 343: d7031. Following Successful Repair of Vesicovaginal Fistula in Mohammed, R. H. 2007. “A Community Program for Women’s Nigeria.” Rural Remote Health 11 (3): 1734. Health and Development: Implications for the Long-Term UNFPA (United Nations Population Fund). 2001. “Tanzania: Care of Women with Fistulas.” International Journal of Campaign to End Fistula; Tanzania Fistula Survey Gynaecology and Obstetrics 99: S137–42. 2001.” New York. http://www.endfistula.org/webdav Morgan, M. A., M. L. Polan, H. H. Melecot, B. Debru, /site/endfistula/shared/documents/needs%20assessments A. Sleemi, and others. 2009. “Experience with a Low- /Tanzania%20OF%20Needs%20Assessment.pdf. Pressure Colonic Pouch (Mainz II) Urinary Diversion for ———. 2003. Second Meeting of the Working Group for Irreparable Vesicovaginal Fistula and Bladder Extrophy in the Prevention and Treatment of Obstetric Fistula. Addis East Africa.” International Urogynecology Journal 20 (10): Ababa, 30 October–1 November, 2002. New York: UNFPA. 1163–68. ———. 2012. “When Childbirth Harms: Obstetric Fistula.” Murray, C., J. T. Goh, M. Fynes, and M. P. Carey. 2002. “Urinary New York. https://www.unfpa.org/webdav/site/global/shared and Faecal Incontinence Following Delayed Primary Repair /factsheets/srh/EN-SRH%20fact%20sheet-Fistula.pdf. of Obstetric Genital Fistula.” BJOG 109 (7): 828–32. United Nations General Assembly. 2012. “Supporting Efforts Mselle, L. T., B. Evjen-Olsen, K. M. Moland, A. Mvungi, to End Obstetric Fistula: Report of the Secretary-General.” and T. W. Kohi. 2012. “Hoping for a Normal Life Again: New York. Reintegration after Fistula Repair in Rural Tanzania.” Waaldijk, K. 1994. “The Immediate Surgical Management Journal of Obstetetrics and Gynaecology 34 (10): 927–38. of Fresh Obstetric Fistulas with Catheter and/or Early Muleta, Mulu. 2009. “Obstetric Fistula: Prevalence, Causes, Closure.” International Journal of Gynaecology and Consequences and Associated Factors.” University of Obstetrics 45 (1): 11–16. Bergen. ———. 2008. Obstetric Fistula Surgery, Art and Science: Nardos, R., A. Browning, and C. C. Chen. 2009. “Risk Factors Basics. Katsina, Nigeria: Babbar Ruga Fistula Teaching that Predict Failure after Vaginal Repair of Obstetric Hospital. Vesico-Vaginal Fistulae.” American Journal of Obstetrics and Waaldijk, K., and T. E. Elkins. 1994. “The Obstetric Gynecology 200 (5): 578. Fistula and Peroneal Nerve Injury: An Analysis of Nardos, R., A. Browning, and B. Member. 2008. “Duration of 947 Consecutive Patients.” International Urogynecology Bladder Catheterization after Surgery for Obstetric Fistula.” Journal 5 (1): 12–14. International Journal of Gynaecology and Obstetrics 103 (1): Wall, L. L. 1998. “Dead Mothers and Injured Wives: The Social 30–32. Context of Maternal Morbidity and Mortality among the Nielsen, H. S., L. Lindberg, U. Nygaard, H. Aytenfisu, Hausa of Northern Nigeria.” Studies in Family Planning O. L. Johnston, and others. 2009. “A Community-Based 19 (4): 341–59. Obstetric Fistula 107 Wall, L. L., S. D. Arrowsmith, N. D. Briggs, and A. Lassey. Wanzala, Ouma. 2011. “Thousands of Women Are Suffering 2002. “Urinary Incontinence in the Developing World: The in Silence.” All Africa News, July 26. http://allafrica.com Obstetric Fistula.” In Incontinence, second edition, edited /stories/201107270191.html. by P. Abrams, L. Cardozo, S. Khoury, and A. Wein, 893–935. Weston, K., S. Mutiso, J. W. Mwangi, Z. Qureshi, J. Beard, and Plymouth, UK: Health Publications, Ltd. P. Venkat. 2011. “Depression among Women with Obstetric Wall, L. L., S. D. Arrowsmith, N. D. Briggs, A. Browning, and Fistula in Kenya.” International Journal of Gynaecology and A. Lassey. 2005. “The Obstetric Vesicovaginal Fistula in Obstetrics 115 (1): 31–33. the Developing World.” Obstetric and Gynecologic Survey Women’s Dignity Project and Engender Health. 2006. Risk and 60 (7): S3–51. Resilience: Obstetrical Fistula in Tanzania. Dar es Salaam, Wall, L. L., J. A. Karshim, C. Kirschner, and S. D. Arrowsmith. Tanzania: Women’s Dignity Project; New York: Engender 2004. “The Obstetric Vesicovaginal Fistula: Characteristics Health. of 899 Patients from Jos, Nigeria.” American Journal of Zacharin, R. F. 2000. “A History of Obstetric Vesico-Vaginal Obstetrics and Gynecology 190 (4): 1011–19. Fistula.” Australian and New Zealand Journal of Surgery 70: 851. 108 Essential Surgery Chapter 7 Surgery for Family Planning, Abortion, and Postabortion Care Joseph B. Babigumira, Michael Vlassoff, Asa Ahimbisibwe, and Andy Stergachis INTRODUCTION complications from clandestine, unsafe procedures (Grimes and others 2006; Shah and Ahman 2009; Singh This chapter discusses two related but conceptually and others 2006; Singh 2010). Therefore, postabortion distinct health concerns in low- and middle-income care is a significant health issue in LMICs. Timely, safe countries (LMICs): (a) voluntary family planning, and surgical interventions can reduce the morbidity and (b) abortion, including postabortion care. In the first mortality associated with unsafe abortions. section, on family planning, the health condition of The same surgical procedures used for abortion are interest is unmet need: the percentage of women who also used to manage incomplete abortion, which is one would like to either stop or delay childbearing but of the most common postabortion complications and who are not using any contraceptive method to pre- is often accompanied by other complications such as vent pregnancy. The unmet need for family planning bleeding, sepsis, and genital injury. The surgical pro- (to either limit family size or determine the intervals cedures used to manage such complications include between children) results in unintended and unwanted laparotomy for sepsis and uterine injury and a wide pregnancies, which in turn lead to a broad range of range of minor procedures to repair injuries to the prox- maternal and child conditions that increase morbidity imal birth canal. and mortality. Surgical procedures for family planning Both sections discuss the burden of reproductive can help reduce this unmet need, particularly the need health conditions, including morbidity, mortality, and to limit childbirth. other effects. We discuss surgical procedures (their The second section concerns surgery for induced performance, inputs, and implementation) and the abortion (as opposed to spontaneous abortion, or mis- health workforce implications of scaling up those pro- carriage) and the surgical management of the compli- cedures in LMICs. We also explore evidence on the cations of induced, mostly unsafe, abortion.1 Unsafe procedures’ effectiveness in reducing morbidity and abortion is defined as abortion performed outside of mortality and improving quality of life as well as evi- health facilities (or any other place legally recognized dence on their cost-effectiveness. Finally, we outline for the procedure) or by an unskilled person (WHO future directions—including implementation challenges 1992). The demand for abortion is high in many and considerations for increasing access to these surgical LMICs, and the illegality of the procedure in most of interventions—and conclude by summarizing the find- these countries increases the likelihood of postabortion ings and recommendations. Corresponding author: Joseph B. Babigumira, PhD, MS, MBChB, University of Washington, babijo@uw.edu 109 SURGERY FOR FAMILY PLANNING schooling and body mass indexes (Canning and Schultz 2012). At the macroeconomic level, it reduces Importance of Family Planning youth dependency and increases labor force participa- Family planning is a pillar of reproductive and overall tion by women, thereby enhancing economic growth health in several ways: (Canning and Schultz 2012). Increasing access to family planning will slow population growth, convey- • Reducing maternal mortality by reducing the number ing environmental benefits such as substantial reduc- of times women are pregnant, including high-risk tions in global carbon dioxide emissions (O’Neill and pregnancies associated with very young or older others 2012). women (Ahmed and others 2012) Conversely, when LMICs lack affordable, acces- • Preventing high parity (among the potential factors sible, acceptable, and sustainable family planning meth- leading to anemia in pregnancy)2 ods, tangible economic development becomes more • Lengthening the intervals between pregnancies, difficult: without low fertility, countries cannot attain which also improves perinatal outcomes and reduces the well-documented “demographic dividend” that child mortality (Cleland and others 2012) has benefited several formerly low-income countries • Decreasing the number of pregnancies that would (Bloom, Canning, and Sevilla 2003).4 have ended in induced, mostly unsafe, abortions in LMICs. Family Planning Methods Recent data illustrate how high the stakes can be, Family planning comprises both traditional and mod- although some trends have improved during the past ern methods of contraception. Traditional methods, two decades. The Global Burden of Disease (GBD) including withdrawal and fertility awareness, have low Study 2010 estimated that almost 254,700 deaths (4 per efficacy; up to 24 percent of women who use them will 100,000) globally were attributable to maternal condi- have unintended pregnancies within one year (Trussell tions in 2010, a 29 percent decrease from 1990, when 2011a). Modern methods—including sterilization, there were 358,600 maternal deaths (7 per 100,000) intrauterine devices (IUDs), injections, implants, pills, (Lozano and others 2013). Almost 1.8 million years and mechanical methods such as condoms—have higher lived with disability (YLDs) globally were attributable to effectiveness, resulting in lower rates of unintended maternal conditions in 2010, a 28 percent increase from pregnancies (Trussell 2011a). 1990, when there were nearly 1.4 million YLDs (Vos and Sterilization is the most common method of per- others 2013).3 manent family planning; most other methods are tem- Family planning is one of the most effective, and porary. Permanent methods are indicated for couples cost-effective, interventions against maternal mortality who consider their families to be complete and would and disability. Increasing contraceptive coverage was pri- like to stop childbirth (limit the number of children). marily responsible for a substantial reduction in global Temporary methods are indicated for couples who fertility rates (from 3.63 births per woman in 1990 to would like to delay childbirth to space children further 2.83 in 2005), also averting 1.2 million deaths (Stover and apart or for other reasons. Ross 2010). Despite a 42 percent increase in the number Contraception can also be divided into surgical meth- of women of reproductive age (15–49 years old) between ods, methods that employ minor surgery (for insertion 1990 and 2008, the number of births per year remained and removal), and nonsurgical methods (table 7.1). constant, and the mortality risk per birth decreased (Ross Methods involving surgery or minor surgery are generally and Blanc 2012). Meeting the need for family planning more effective than the nonsurgical methods. Surgery is globally would further reduce maternal mortality by an employed primarily for sterilization. The most common estimated 29 percent, a reduction of more than 100,000 male sterilization procedure is vasectomy, and the most deaths annually (Ahmed and others 2012). common female sterilization procedure is tubal ligation. Moreover, family planning has both household and Vasectomy and tubal ligation are among the most macroeconomic benefits. At the household level, it effective of the modern contraceptive methods, having reduces fertility—an important attribute given that first-year failure rates of 0.15 percent and 0.5 percent, women in LMICs increasingly desire better-planned respectively (Trussell 2011b). Although some nonsurgi- and better-spaced families (Darroch 2013; Darroch cal forms of female sterilization exist, they are either not and Singh 2013). Family planning not only improves available or not practicable for LMICs in the foreseeable birth spacing but also increases women’s earnings, future.5 Therefore, this chapter focuses on tubal ligation assets, and body mass indexes, and improves children’s and vasectomy. 110 Essential Surgery Table 7.1 Primary Contraceptive Methods by Degree of Surgical Involvement Surgery Minor surgery Nonsurgical Female sterilization: tubal ligation Intrauterine device (IUD) Fertility awareness • Copper IUD • Standard days methoda • Hormonal IUD (for example, Mirena) • Symptothermalb • Ovulationc Male sterilization: vasectomy Subdermal implant (for example, Implanon, Jadelle) Barrier • Spermicide • Sponge • Male condom • Female condom • Diaphragm Hormonal • Injection (for example, Depo-Provera) • Birth control pill • Vaginal ring (for example, NuvaRing) • Transdermal patch (for example, Ortho Evra) Other • Lactational amenorrhead • Withdrawal a. In the “standard days” method, a calendar (using colored beads, for example) is used to track the menstrual cycle as an aid to abstinence from unprotected vaginal intercourse during peak fertility periods. b. The symptothermal method usually combines a number of fertility awareness methods, including observation of primary fertility signs (such as basal body temperature and cervical mucus) and the calendar-based methods. c. The ovulation method identifies patterns of relative fertility and infertility during the menstrual cycle based on vulvar sensation and the appearance of vaginal discharge. d. Lactational amenorrhea is the temporary postnatal infertility that occurs when women are actively breastfeeding. Contraceptive Prevalence and Unmet Need or female sterilization: 10 percent in Sub-Saharan Africa, Contraceptive Prevalence. Globally, total contracep- 64 percent in South and Central Asia, and 13 percent in tive prevalence is 63 percent, defined as the percentage Southeast Asia (Darroch, Sedgh, and Ball 2011; Singh and of women of reproductive age who report that they or Darroch 2012). their partners use at least one traditional or modern Many factors, besides inadequate knowledge and contraceptive method. Countries vary widely in this esti- poor-quality family planning services that are difficult to mate by development status: contraceptive prevalence access, contribute to non-use of contraception: is 72 percent in developed countries and 54 percent in developing countries (excluding China). In Africa, it is • Ambivalence about pregnancy (Frost, Singh, and even lower, at 31 percent; some countries, such as Chad, Finer 2007) Mali, Sierra Leone, and Republic of South Sudan, have a • Underestimation of the risk of pregnancy at the time contraceptive prevalence of less than 10 percent (Alkema of sexual intercourse (Nettleman and others 2007) and others 2013). • Historical, cultural, and religious beliefs (Schuler, In LMICs, more than 25 percent of almost 820 million Choque, and Rance 1994; Thorburn and Bogart 2005; sexually active women of reproductive age use low-efficacy Wickstrom and Jacobstein 2011) traditional methods or no method at all. This percentage • Low levels of education (Ali and Okud 2013; Frost, rises to 38 percent in Sub-Saharan Africa, South and Singh, and Finer 2007; Muyindike and others 2012; Central Asia, and Southeast Asia. Among women in LMICs Tawiah 1997) who use modern contraceptive methods, a substantial • Low income or poverty (Asiimwe, Ndugga, and proportion report that they or their partners use male Mushomi 2013; Muyindike and others 2012) Surgery for Family Planning, Abortion, and Postabortion Care 111 Other variables affecting contraceptive use or 1990, 55 percent in 2000, and 55 percent in 2009. Among non-use include the number of children already born women in the poorest countries, use of modern contra- (Muyindike and others 2012), age (Muyindike and ception increased marginally, from 39 percent in 2008 to others 2012), and race (Frost, Singh, and Finer 2007). 40 percent in 2012. In LMICs overall, however, it is the most disadvantaged Meanwhile, the unmet need for modern contracep- members of society who use contraceptives less often tive methods in developing countries decreased from and have a higher unmet need for them. 29 percent in 2003 to 26 percent in 2012 (Darroch and Singh 2013). Although the unmet need decreased during Unmet Need for Contraception. Globally, at least this period in all LMICs, it remained far higher in Africa 150 million women ages 15–49 years in a marriage or (despite a reduction from 60 percent to 53 percent), par- union have an unmet need for contraception, mean- ticularly in Sub-Saharan Africa, where it decreased from ing that they want to either stop or delay childbearing 68 percent to 60 percent (Darroch and Singh 2013). but are using no contraceptive method to prevent Moreover, modern contraceptive users in develop- pregnancy. This corresponds to 11–14 percent of these ing countries shifted away from surgical contraception partnered women, varying widely by income status. In (sterilization) to other forms. The proportion using high-income countries (HICs), the unmet need is 9 per- sterilization declined, on average, from 47 percent to cent and in developing countries, 13 percent (16 percent 38 percent. In Africa overall, where sterilization use if China is excluded). In Africa, the unmet need is 23 was already extremely low, it declined from 9 percent percent, exceeding 35 percent in some countries, includ- to 8 percent of modern contraceptive use, and in Sub- ing Kenya, Rwanda, and Togo (Alkema and others 2013). Saharan Africa, from 12 percent to 10 percent (Darroch Among all women of childbearing age in devel- and Singh 2013). This decline is, however, relative: oping countries who want to avoid pregnancy, more sterilization use is increasing in absolute terms, but than 200 million, or 26 percent, have an unmet need use of other modern methods is increasing at an even for modern contraceptive methods. This unmet need faster rate. varies widely by region: it is much higher in Africa In addition to unwanted pregnancies, an unmet need (53 percent; 60 percent in Sub-Saharan Africa) than in for accessible, modern contraception has a variety of Latin America and the Caribbean (22 percent) and Asia other consequences: (21 percent) (Darroch and Singh 2013). Among all women of reproductive age who want to • Poorly timed and closely spaced pregnancies increase either stop or delay childbearing but use no contracep- child mortality. tion, the proportion of those who want to have no (or no • Maternal deaths during childbirth also increase child more) children is a crude indicator of potential demand mortality. for permanent contraception, that is, sterilization. • Unwanted pregnancies lead to increased pregnancy This proportion varies substantially by geography: it is complications, abortions (including unsafe, ille- 32 percent in Sub-Saharan Africa, 41 percent in North gal abortions), childhood illnesses, and the overall Africa, 50 percent in Central America, 57 percent in the disease burden. Caribbean, 63 percent in Asia (excluding China), and • Excess fertility has negative economic and social 64 percent in Southeast Asia (Clifton and Kaneda 2013). results. Despite substantial variation, many women would like to avoid all (or further) childbirth and could benefit from expanded access to sterilization methods, which are pre- Surgical Contraception dominantly surgical. Advantages of Sterilization. Sterilization is highly effec- tive and offers permanent protection from unwanted Trends in Prevalence and Unmet Need. During the pregnancy with none of the potential side effects of tem- period 1990–2010, global contraceptive prevalence porary contraceptive methods. Sterilization, whether of increased by 8 percentage points, from 55 percent to males or of females, eliminates the need for continuous 63 percent. During the same period, unmet need for involvement in family planning activities. It also spares contraception decreased by 3 percentage points, from couples and individuals some of the common worries 15 percent to 12 percent (Alkema and others 2013). associated with temporary methods, including partner However, prevalence has plateaued since 2000, espe- compliance, domestic violence (arising from disagree- cially in the use of modern contraceptives (Singh and ments between partners about fertility goals), inconve- Darroch 2012): Among all women of reproductive age nience, side effects, supply needs, and the consequences in LMICs, 57 percent used modern contraceptives in of forgetfulness (WHO 1999). 112 Essential Surgery Convenience and the longer duration of effective other contraceptive methods. The reasons for choosing action are often the overriding factors in choosing sterilization should be clear, and potential recipients contraceptives, and sterilization provides both of these should understand that the procedures are meant to be advantages (Steiner and others 2006). These positive permanent methods of family planning, to be chosen factors may be even more attractive to couples in the only if they are certain they do not want more children. lowest-income countries, where supplies may be irregu- Clients should also receive information on the potential lar and health facilities may be substandard or far away for reversal and chances of success. The most common from their homes. However, surgical contraception reasons for sterilization regret—such as young age or and other nonbarrier methods also have an important marital instability—should be assessed and addressed limitation: they do not protect against human immuno- before surgery. deficiency virus (HIV) and other sexually transmitted The details of surgery, including the risks of infections. anesthesia (particularly for tubal ligation), should be clearly communicated and informed consent obtained. Barriers to Access. LMIC populations face a vari- Prospective tubal ligation recipients should under- ety of demand- and supply-side barriers to access stand the chance of procedure failure and the risk of to surgical methods of family planning. Among the ectopic pregnancy (estimated at 7.3 per 1,000 proce- most important are individual attitudes and motiva- dures [Peterson and others 1997]), which is quadruple tions: Some women want to have many children as a the risk for women using oral contraceptives and triple defense against high child mortality or as a source of the risk for women using barrier methods (Holt and future farm labor. Interpersonal factors may play a others 1991). Women should be prepared for potential role—for example, women often reject long-acting postsurgical physiological changes such as menstrual or permanent surgical contraceptive methods in def- disorders, which may increase the chance of postpro- erence to their spouses’ (or the community’s) desire cedure hospitalization (Shy and others 1992). Potential for fertility. Cultural and religious norms also impede recipients should also know that sterilization does not access to surgical contraception. Some cultures value protect against sexually transmitted infections, includ- high fertility, and some religions prohibit any form of ing HIV and acquired immune deficiency syndrome contraception. (AIDS). Medical personnel and other providers should In addition, lack of information leads to misunder- offer an opportunity to ask further questions regarding standing, misconceptions, and myths about tubal liga- the procedure and its associated risks. tion and vasectomy. Generally, information on surgical contraception is limited, particularly among unmarried Female Sterilization: Tubal Ligation. Female steril- individuals. Myths about surgical methods of contra- ization (tubal ligation) prevents pregnancy by blocking ception are also common. For instance, in Uganda, some the fallopian tubes so that the egg and sperm cannot men equate vasectomy to castration or loss of manhood, unite. It involves surgery to (a) isolate the tubes and and some women associate tubal ligation with laziness, (b) achieve tubal occlusion (blockage) through a choice disinterest in sex, loss of menstrual regularity, and of methods. weight gain (Kasedde 2000). Other barriers include fear of surgery, poverty and Timing. The surgery can be performed postpartum, other economic barriers, geographic impediments such postabortion, or during time periods unrelated to preg- as living in remote rural areas, and poor health services nancy (interval tubal ligation). This timing affects the and facilities (Gaym 2012; Kasedde 2000). Studies also type of counseling, the type of surgery, and the method of suggest that providers often have insufficient knowl- tubal occlusion used, as described below (ACOG 1996): edge or motivation to provide surgical contraception Postpartum procedures. Postpartum tubal ligation (Gaym 2012). may follow either (a) a cesarean section with the abdo- men still open, or (b) a vaginal birth using minilapar- Surgical Procedures. Surgical procedures for family otomy under local anesthesia with sedation, regional planning include tubal ligation for female sterilization anesthesia, or general anesthesia. A postpartum mini- and vasectomy for male sterilization. Before either laparotomy is conducted before full uterine involution are performed, potential recipients should be care- but after a full assessment of mother and child. It uses fully selected and counseled (ACOG 1996; Pollack a subumbilical incision, which allows easy access to and Soderstrom 1994). As part of the comprehensive the abdomen because the wall is thin at this point just consent process, clients should be informed about ster- above the uterine fundus. Laparoscopy should not be ilization options (male or female sterilization) as well as performed postpartum because of the nonoptimal Surgery for Family Planning, Abortion, and Postabortion Care 113 orientation and the technical difficulty that may arise and under local anesthesia and conscious sedation. from the size and vascular nature of the postpartum Complications from female sterilization are rare and uterus (WHO 1999). include immediate complications such as anesthetic Postabortion procedures. Following a first-trimester issues, uterine injury and perforation, and organ injury. abortion, tubal ligation may be performed by either There is an increased chance of ectopic pregnancy laparoscopy or minilaparotomy using a suprapubic (Holt and others 1991; Peterson and others 1996), incision. Following a second-trimester abortion, a min- which can be lethal, particularly in LMICs (Goyaux and ilaparotomy using a small vertical midline incision is others 2003). preferred. The risk of perforating the soft uterus with On balance, minilaparotomy may be better suited the laparoscopic trocar may warrant either the use of to LMICs because it is simple and inexpensive, uses open laparoscopy using the Hasson cannula or wait- basic surgical equipment, may be performed by general ing for uterine inversion and performing an interval practitioners and paramedics in maternity and health procedure. centers, and is recommended for both postpartum Interval procedures. Interval sterilization proce- and interval procedures (WHO 1999). In contrast, dures may be performed at any time during the laparoscopy—despite its smaller incision, lesser pain, menstrual cycle, preferably during the follicular phase smaller probability of complications, shorter recovery to reduce the risk of a luteal-phase pregnancy (a preg- time, and smaller scar—requires specially trained sur- nancy in which conception occurs before sterilization). geons; equipment that is sophisticated, expensive, and However, because of nonoptimal uterine and tube difficult to maintain; and fully equipped tertiary hos- positioning, tubal ligation should be avoided during pitals with sterile equipment and a surgical theater to pregnancy or between days 8 and 41 after delivery; it reduce the risk of infections (WHO 1999). should be performed only with special care between days 3 and 7 postpartum (WHO 1999). On the day of Tubal occlusion methods. During female sterilization, the interval procedure, it is good practice to confirm tubal occlusion is achieved through electrical methods, that a woman is using contraception and to perform a mechanical methods, or ligation and excision as follows: pregnancy test. Interval procedures may be performed transvaginally (Kondo and others 2009) through poste- • Monopolar and bipolar electrocoagulation are the most rior colpotomy (Ayhan, Boynukalin, and Salman 2006) commonly used tubal occlusion methods during or transcervically using hysteroscopy (Castano and laparoscopic procedures. Adekunle 2010). • Tubal clips or rings may be used to mechanically block the tubes. Similarly, in the Pomeroy method, a loop Laparoscopy versus minilaparotomy. Laparoscopy of tube is “strangled” with a suture, a cut, and the emerged in the 1960s and 1970s; by 1990, one-third of cauterization of the ends. Reversal of sterilization is all tubal ligations were performed using this method. easier with clips and rings than with electrocoagu- Laparoscopic sterilization can be closed or open. In lation because clips destroy a smaller portion of the the closed procedure, the laparoscopic incision is made fallopian tube. just below the umbilicus, through which the trocar is • Ligation and excision, severing of the tubes followed inserted into the peritoneum. In the open procedure, the by ligation using a variety of techniques, is the most incision goes through all abdominal wall layers, and the common procedure for tubal occlusion during lapar- peritoneum is entered directly. otomy or at cesarean section. The advantages of laparoscopic sterilization include a • Fimbriectomy, which removes the part of the tube quick recovery and minimal blood loss and postopera- closest to the ovary, involves the modified Irving pro- tive pain; small, barely visible scars; and the opportunity cedure in which ligatures are placed at two points on to inspect internal organs. The disadvantage is that the the tube, the segment between them is removed, and trocar could injure organs. the ends are attached to the back of the uterus and Minilaparotomy became another option after its connective tissue. development in the 1970s, and most tubal ligations • The Essure method, a newer method, places small use this method. In minilaparotomy, an incision of 2–3 metal and fiber coils in the tubes to induce scarring centimeters is placed in relation to the uterine fundus. and block the fallopian tubes.6 For interval sterilization, a uterine manipulator is used to bring the uterine fundus close to the incision. During interval sterilizations, ligation and mechan- Both minilaparotomy and laparoscopy are safe and ical devices can be used, but in the immediate post- effective and can be performed in outpatient facilities partum period, ligation using clips, rings, or bands is 114 Essential Surgery preferred (WHO 1999). In the postabortion period, FI is commonly performed during vasectomy to both blocking methods are acceptable (with special prevent recanalization, a common cause of vasectomy care when using mechanical devices to avoid injuring failure. This procedure, which significantly increases enlarged tubes) (WHO 1999). the success rate of vasectomy, positions the prostatic end of the vas outside the fascial sheath of the scrotal Male Sterilization: Vasectomy. Vasectomy includes sac, leaving the testicular side inside the fascia (Sokal three steps: anesthesia, delivery and isolation of the vas and others 2004). Irrigation of the distal vas with sterile deferens from the scrotal sac, and vas occlusion. water or the spermicide euflavine is sometimes used to Anesthesia. The most common anesthesia is a local reduce time to achieve azoospermia (lack of measurable vasal block using lidocaine without epinephrine (Li and sperm in the semen). others 1992). Other techniques to improve anesthetic Vas occlusive contraception also includes some newer, quality and comfort include the use of eutectic mixture nontraditional methods. One of them—the use of clips of local anesthetics (EMLA) creams as an adjunct to without vas severance—has shown unacceptably high the vasal block, buffered anesthesia, the spermatic cord failure rates despite the procedure’s higher potential for block, the no-needle injector, and the mini-needle tech- reversal (Levine, Abern, and Lux 2006). Another new, nique (Shih, Turok, and Parker 2011; Weiss and Li 2005). nonocclusive method involves insertion of a soft silicone Vasectomy may be performed under general anesthesia or urethane intra vas device (IVD) that contains a set in exceptional circumstances such as previous adverse of tiny implants to block the flow of sperm, enabling reactions to local anesthesia, scarring or deformity that the vas to remain intact and easing reversal. Although make local anesthesia difficult, current anticoagulation human clinical trials of the IVD have been conducted therapy (which increases the chance of hematoma for- (for example, Song and others 2006), it has been neither mation), and when vasectomy is part of a series of pro- marketed nor approved for general use as of this writing. cedures to be performed on the same day. Isolation of vas deferens. In the traditional vasec- Safety and Effectiveness of Tubal Ligation and tomy, following anesthesia, two small incisions are made Vasectomy. Vasectomy is generally more effective and on each side of the scrotum with a scalpel, and both vas safer than tubal ligation (table 7.2). In addition, follow- deferens are isolated for excision, followed by vassal ing attempted reversal, both procedures have similar occlusion (Cook, Pun, and others 2007). Alternatively, success rates as measured by pregnancy after reversal the no-scalpel method, or keyhole vasectomy, uses a (Cos and others 1983; Fox 1994; Henderson 1984; sharp pair of forceps in lieu of a scalpel to puncture Lee 1986; Rock and others 1982; Spivak, Librach, and the scrotum. The no-scalpel method reduces bleeding Rosenthal 1986). Tubal ligation is comparatively riskier, and hematoma formation, reduces the probability of at least in part because either method (laparoscopy or infection, removes the need for stitches, and increases minilaparotomy) could proceed to an open laparotomy healing time (Cook, Pun, and others 2007). The open- if internal organs, especially major vessels, are injured, ended vasectomy leaves the testicular end of the vas resulting in life-threatening hemorrhage (Hendrix, open to allow a continuous stream of sperm into the Chauhan, and Morrison 1999). scrotum. This procedure reduces the risk of postva- The vasectomy procedure is almost always performed sectomy pain syndrome and congestive epididymitis under a local anesthetic and does not require as much (Christiansen and Sandlow 2003; Moss 1992; Shapiro technical expertise as tubal ligation does. Nurses in and Silber 1979). LMICs who are knowledgeable about anatomy can be Vas occlusion. The most common, but relatively trained to perform vasectomies because of their rela- less effective, method of vas occlusion is ligation and tively less severe complications. excision. (Vasectomy failure rates are estimated at less than 3 percent, but some studies suggest the rate is higher for ligation and excision [Aradhya, Best, and Costs and Cost-Effectiveness of Surgical versus Sokal 2005]).7 Other methods include electrical and Nonsurgical Contraception thermal cautery, fascial interposition (FI), and vas irri- Along with a higher success rate, surgical contraception gation (Shih, Turok, and Parker 2011). Both FI and vas generally costs more than nonsurgical interventions. In irrigation are highly effective but rarely used (Cook, this section we evaluate evidence of the costs and cost- van Vliet, and others 2007). Reviews suggest that effectiveness of surgical versus nonsurgical methods of cautery combined with FI is the superior occlusion contraception. We also attempt to assess whether the method (Cook, van Vliet, and others 2007; Labrecque added costs would represent value for money if scaled and others 2004). up in LMICs. Surgery for Family Planning, Abortion, and Postabortion Care 115 Table 7.2 Safety and Effectiveness of Surgical Sterilization, by Procedure Tubal ligation Vasectomy Failure rate (%)a Year 1 0.55 0.15 Year 2 0.29 0.01 Year 3 0.15 0.01 Year 4 0.19 0.01 Year 5 0.13 0.01 Cumulative probability of postprocedure failure (number per 1,000 procedures)b Year 1 7.4 5.5 Year 5 11.3 13.1 c Pregnancy rate after reversal (%) 40.0–60.0 42.0–74.0 Reversal requests after five years (%)d 6.0 6.0 d Timing of efficacy Immediate Delayed until azoospermiae Relative rate of complicationsf High (20 times that of vasectomy) Low (1/20 that of tubal ligation) Relative rate of mortalityf 12 times that of vasectomy 1/12 that of tubal ligation Sources: a. Trussell 2011b. b. Jamieson and others 2004; Peterson and others 1996. c. Cos and others 1983; Fox 1994; Henderson 1984; Lee 1986; Spivak, Librach, and Rosenthal 1986. d. Shih, Turok, and Parker 2011. e. Azoospermia is lack of measurable sperm in the semen. f. Hendrix, Chauhan, and Morrison 1999. Note: The “failure rate” refers to the probability of pregnancy. Costs. Surgical sterilization methods generally carry Weissman, and Stover 2009). However, direct cost com- higher up-front or unit costs than nonsurgical meth- parisons on this basis are difficult because contracep- ods. Notably, however, a single surgical set can be tive methods vary widely in duration of effectiveness. used for many years if well used and maintained, thus The cost per couple-year of protection (CYP), is gen- offsetting the up-front costs. However, the cost of con- erally lower for surgical methods than for nonsurgical tinuously sterilizing and maintaining equipment is also methods (the exception being IUDs, which have the important. lowest cost per CYP of all methods). Table 7.3 compares Among the surgical procedures, vasectomy, in addi- the total annual direct and indirect costs of contracep- tion to being more effective and safer, costs less than tive methods in four Sub-Saharan African countries: tubal ligation by either laparoscopy or laparotomy Burkina Faso, Cameroon, Ethiopia, and Uganda. (Smith, Taylor, and Smith 1985). Increasing the number of vasectomies relative to tubal ligations would sub- Cost-Effectiveness. Modern contraception as evalu- stantially reduce overall procedural costs and the costs ated in program settings is highly cost-effective by of managing adverse events (Hendrix, Chauhan, and various metrics including cost per life year and cost per Morrison 1999). disability-adjusted life year (DALY): Looking solely at per use commodity costs, the drugs and supplies for female sterilization cost • In India, intensive efforts to improve family planning, $9.09 (in 2009 U.S. dollars) and, for male steriliza- control fertility, and provide safe abortions would tion, $4.95. By comparison, oral contraceptives cost save nearly 150,000 lives and save $1.5 billion over $0.21 per use; IUDs, $0.37; and injectable hormonal five years (Goldie and others 2010). contraceptives, $0.87 (Ross, Weissman, and Stover • In Uganda, universal access to contraception would 2009). However, some proprietary implants such as reduce the average number of pregnancies per Implanon (an etonogestrel implant effective for three woman (15–50 years of age) by 1.6, reduce the years) cost more ($24.09) than surgical methods (Ross, fertility rate by 1.1 children per woman, improve 116 Essential Surgery Table 7.3 Annual Cost per CYP of Contraceptive Methods in Selected African Countries U.S. dollars per CYP Method Ethiopia (2008) Uganda (2008) Burkina Faso (2009) Cameroon (2013) Female sterilization 8.65 7.50 17.16 3.23 Male sterilization 8.26 7.24 3.07 2.42 Pill 31.43 23.66 28.51 17.00 IUD 5.24 4.14 6.51 23.35 a Injectable or implant 33.74 27.28 58.54 19.84 Condom 22.15 17.12 19.20 15.51 Other modern methodb 23.14 18.05 18.66 16.26 Periodic abstinence 0.00 0.00 0.00 0.00 Withdrawal 0.00 0.00 0.00 0.00 c Other traditional 0.00 0.00 0.00 0.00 Sources: Vlassoff, Walker, and others 2009; Vlassoff and others 2011; Vlassoff and others 2012; Vlassoff, Jerman, and others 2014. Note: CYP = couple-year of protection; IUD = intrauterine device. a. Costs of injectables and implants were combined in the four studies. b. The “other modern method” category includes other barrier methods such as spermicides, sponges, and diaphragms, as well as other hormonal methods such as the vaginal ring or transdermal patch. c. The “other traditional” category includes fertility awareness methods that track the menstrual cycle or fertility signs and patterns. maternal and child health outcomes, and save Future Directions almost $40 per woman in societal costs (Babigumira Goals, Trends, and Challenges. As noted at the outset and others 2012).8 of this section, family planning is important to the devel- • Satisfying unmet need for modern contraception opment aspirations of LMICs. Specifically, increasing through increased family planning that reduces access to the highly efficacious and convenient surgi- mother and newborn care costs would save a net cal methods of contraception can enhance important $112 million per year in Uganda (Vlassoff and others health, social welfare, educational, and other benefits 2009). Similar studies found annual net savings (Canning and Schultz 2012). of $35 million in Ethiopia (Sundaram and others To that end, universal access to reproductive 2010) and $32 million in Burkina Faso (Vlassoff and health by 2015 is a target of the United Nations–led others 2011). Millennium Development Goals (MDGs): MDG 5 is “to improve maternal health.”9 Increased access to repro- In the United States, one cost simulation found that ductive health and family planning would also help to the three most cost-effective contraceptive methods are achieve most of the other MDGs: MDG 1 (“eradicate vasectomy, the copper-T IUD, and a hormonal IUD extreme poverty and hunger”); MDG 2 (“achieve uni- (specifically, levonorgestrel [LNG]-20, marketed under versal primary education”); MDG 3 (“promote gender brand names including Mirena). All other methods, equality and empower women”); MDG 4 (“reduce child including tubal ligation, were found to be less effective mortality”); MDG 6 (“combat HIV/AIDS, malaria and and more costly than the copper-T IUD (Trussell and other diseases”); and MDG 7 (“ensure environmental others 2009). sustainability”). A comprehensive review of the health economics Is access to family planning in the developing world of contraception supported the data presented above, expanding fast enough to contribute to those goals? finding that male and female sterilization and long- Worldwide, sterilization is the most common form of acting reversible methods such as IUDs and subdermal modern family planning: 38 percent of women who implants were the most cost-effective contraceptive used modern methods in 2012 chose sterilization. options, followed by other hormonal methods such However, the reverse is true in LMICs, particularly as oral contraceptives; the least cost-effective options in Africa, where contraceptive injections and pills were barrier and traditional behavioral methods dominate (Darroch and Singh 2013). Only 8 percent (Mavranezouli 2009). of women in Africa who use modern methods chose Surgery for Family Planning, Abortion, and Postabortion Care 117 sterilization; among the four main groups of mod- (such as sterilizations) competently will such efforts ern methods (sterilization, barriers, hormones, and substantially increase access to contraception including IUDs), sterilization is the least common (Darroch and surgical contraception (Janowitz, Stanback, and Boyer Singh 2013). 2012; WHO 2012). In Africa, a variety of factors have constrained expan- sion of sterilization: lack of planning tools; technical and Agenda for Action. LMICs can increase access to sur- programmatic difficulty; relatively high commodity and gical contraceptive methods to the extent that they provision costs; health system constraints; overemphasis achieve these goals (Wickstrom and Jacobstein 2011): on short-term, commodity-based contraceptive meth- ods instead of services; and social and cultural barriers • Improve quality of services (Wickstrom and Jacobstein 2011). • Increase public-policy advocacy as well as provider and population awareness of surgical contraception The Malawi Model. In contrast to the general pattern • Increase financing to procure theater equipment; in Africa, the use of female sterilization (as a percentage strengthen human resources; and ensure adequate of all modern contraceptive use) doubled in Malawi supply of surgical contraceptive equipment, instru- in the decade from 2000 to 2010. Sterilization use was ments, and national essential drugs and equipment relatively equitable, as measured by rural-urban or • Implement service-oriented instead of only com- education status, although disparities existed by income modity-oriented programs status (wealthy women used sterilization more than • Expand and update resources and tools to support poor women). Jacobstein (2013) attributed the overall contraceptive security (for example, by including sur- increase to several factors: gical contraception methods in health care logistics training)10 • Increased demand due to increased knowledge of • Clarify definitions, goals, and success indicators for female sterilization contraceptive security promotion • Increased desire to limit childbearing • Improved service delivery due to expanded ser- LMICs also need to change how their health workers vice access within a supportive and enabling health and service providers promote contraception to people. care system characterized by strong public-private Instead of stating, “You need to use family planning to partnerships reduce your fertility,” they might ask the client, “What • Provision of free and widespread outreach services by are your fertility desires, and how can we help you to dedicated providers have the number of children you can afford while also maintaining a productive lifestyle?” If LMIC popu- This evidence suggests that LMICs with conditions lations receive enough information, education, and such as Malawi’s have great potential to scale up access communication about the benefits of family planning to surgical sterilization. However, almost all steriliza- and the available contraceptive methods, the planning tions in Malawi are female sterilizations (about 150 of childbearing will begin to be their idea and they will tubal ligations for every vasectomy), so efficacy and start demanding family planning from their leaders as a savings could increase further if this gender gap could basic need. be closed. Moreover, ethical concerns about coerced steril- To overcome human resource constraints such as ization have been raised, especially regarding women severe physician shortages—an important collective with HIV/AIDS (Mallet and Kalambi 2008). LMICs barrier to increased access to surgical contraception need to step up education and communication efforts in LMICs—programs in Malawi have developed dedi- to ensure that surgical contraceptive services are cated nonphysician cadres (clinical officers) to provide scaled up ethically to avoid coercion, particularly in mobile contraceptive services including tubal ligation countries with high HIV prevalence (Delvaux and (Jacobstein 2013). To succeed, the programs depend Nostlinger 2007). on task shifting (delegating or shifting some tasks to less-specialized health workers [WHO 2007]) and task sharing (in which providers of different levels do Conclusions and Recommendations similar work, rather than leaving all provision of a ser- In this section, we have discussed the unmet need vice to less-credentialed workers [Janowitz, Stanback, for modern surgical methods of contraception; the and Boyer 2012]). Only if less-specialized health work- potential benefits of increasing access to contracep- ers can be trained to perform selected clinical tasks tion (particularly male and female sterilization); and 118 Essential Surgery both the effectiveness and cost-effectiveness of such an is, performed outside of health facilities or other places increase. Based on our findings, we offer the following legally recognized for the procedure, or by an unskilled conclusions and recommendations: person (WHO 1992). • The surgical methods of male and female steriliza- tion (vasectomy and tubal ligation, respectively) Incomplete Abortion are highly effective, cost-effective, and convenient. Incomplete abortion is one of the most common com- Although they constitute the most widely used plications of induced abortion, particularly in the case contraceptive category worldwide, many LMICs, of illegal induced abortion. It occurs when the products particularly in Sub-Saharan Africa, have not of conception have not been fully expelled through the adopted them widely. We recommend that pol- cervix (Bottomley and Bourne 2009). The symptoms icy makers adopt policies to promote and ensure and signs of abortion complications—vaginal bleed- widespread access to surgical methods of family ing, abdominal pain, fever, purulent or foul-smelling planning. vaginal discharge, and shock—are usually present with • As LMICs add, and expand access to, surgical facilities, incomplete abortion. In one study, even after clini- equipment, and human resources, they should make cal assessments had suggested that no products were increased access to surgical contraception a repro- retained (in this case, following first-trimester spontane- ductive priority. Health workers should be trained to ous abortions, or miscarriages), ultrasounds showed that provide surgical family planning and, given the acute 45 percent of the women had retained tissue (Alcázar, shortage of physicians, task shifting of surgical family Baldonado, and Laparte 1995). planning to nurses and medical assistants should be Studies in Rwanda and Uganda (where abortion encouraged. is legally restricted) showed that 65–75 percent of all • Contraception advocacy in LMICs needs to change postabortion complications involved incomplete abor- such that the populations begin to own the idea of tions (Vlassoff and others 2014; Vlassoff and others planning families and realize their ability to control 2009). Sepsis and hypovolemic shock were among the their own fertility. common complications, together making up about a • Policy makers should advocate surgical methods quarter of all postabortion complications in these two of family planning because they provide value for countries. money; despite relatively high up-front costs, they are among the most cost-effective contraceptive methods for LMICs in the long term. Global Demand for Abortion • Policy dialogues on expansion of family planning pro- Globally, almost 44 million induced abortions were grams should emphasize the greater effectiveness and performed in 2008—86 percent of them in developing cost-effectiveness of male sterilization (vasectomy) countries (Sedgh and others 2012). Although the world- relative to female sterilization (tubal ligation). wide total declined from about 46 million in 1995 to • Policy makers and advocates in LMICs should 44 million in 2008 (a 4 percent drop), the proportion encourage more qualitative and quantitative research of abortions that were unsafe increased by 4 percentage on how to increase the quality, uptake, and impact points during the same period, from 44 percent to of—and access to—surgical contraception. 49 percent (Sedgh and others 2012). Moreover, almost all abortions performed in Africa (97 percent) were unsafe in 2008, only a slight decline from 99 percent in SURGERY FOR ABORTION AND 1995 (Sedgh and others 2012). Of the 185 million pregnancies that occurred in POSTABORTION CARE developing countries in 2008, 40 percent were unin- Induced abortion is common in LMICs, particularly tended (Singh, Sedgh, and Hussain 2010). Most unin- in those countries where the unmet need for family tended pregnancies (82 percent) occur among couples planning is high. Wherever abortion is legal, it can be using either no method or traditional methods of performed safely in the first and second trimesters either contraception (Darroch, Sedgh, and Ball 2011; Singh medically or surgically. But in countries where abortion and Darroch 2012). Many unintended pregnancies is legally restricted, most abortions are performed by result in induced abortions. In 2008, 37.8 million poorly trained practitioners in clandestine locations induced abortions were performed in developing using a variety of methods. Such abortions are, by the countries, 6.4 million of them in Africa, almost all being World Health Organization’s definition, unsafe—that unsafe (Sedgh and others 2012). Surgery for Family Planning, Abortion, and Postabortion Care 119 Driving the demand for induced abortion, particu- The GBD Study 2010 tells the global story in hard larly in low-income settings, are both individual factors numbers, estimating that more than 37,000 abortion- (such as educational level, marital status, family size and related deaths occurred in 2010, a 39 percent decrease composition, fertility expectations, and contraceptive from 1990 and corresponding to almost 0.5 deaths per use) and systemic factors (such as service availability and 100,000 women (Lozano and others 2013). Almost quality, social conditions, economic pressures, religious 32,000 YLDs, corresponding to 1 YLD per 100,000 and cultural beliefs, and societal norms and values) women, were attributable to abortion in 2010, a (Warriner and Shah 2006). 20 percent increase from 1990 and corresponding to fewer than 0.5 YLD per 100,000 women (Vos and others 2013).11 During the same period, in a welcome Consequences of Unsafe Abortion downward trend, the burden of disease due to abortion Abortions performed correctly by trained practitioners declined by 33 percent (Murray and others 2013).12 are safe, with minimal risk of complications (Bartlett and others 2004; Grimes and others 2006; Henshaw 1993). The occurrence of complications following Barriers to Access to Surgical Procedures for induced abortion depends on both the type of pro- Abortion and Postabortion Care cedure and the type of provider. In Uganda in 2003, Legal prohibition of abortion is the main barrier to for example, at least one complication occurred in access to surgical abortion and postabortion care in 25 percent of abortions induced by doctors, 45 percent LMICs. Many countries have one or more legal barriers induced by clinical officers, 50 percent induced by to abortion, ranging from complete criminalization to pharmacy workers, 66 percent induced by traditional limitation of services to specific periods during preg- healers or lay practitioners, and 73 percent that were nancy. Other legal barriers include requirements that self-induced (Henshaw 1993; Prada and others 2005; abortions be provided by more than one physician, Singh and others 2006). that abortion be provided only at licensed facilities, that The rates of unsafe abortion and abortion complica- parents consent (for young girls), that women receive tions as well as the demand for postabortion care also preabortion counseling, or that abortions be delayed by vary remarkably by geographic region. The hospitaliza- mandated preabortion “reflection” periods. tion rate for abortion complications per 1,000 women Social and cultural norms constitute another impor- in 2005 was 8.8 in Africa, 4.1 in Asia, and 5.7 in Latin tant barrier to access to surgical abortion and postabor- America and the Caribbean (Singh 2006). In that year tion care. In many LMICs, the culture so disapproves alone, more than 5 million unsafe abortions in develop- of sexual activity by young women that, when they ing countries resulted in hospital admission, 1.7 million get pregnant, they often travel long distances to ensure of them in Africa (Singh 2006). confidentiality. They are stigmatized for getting preg- That LMICs exhibit the world’s highest demand for nant, seeking abortions, and seeking postabortion care. postabortion care is understandable given that, in most Pregnancy or abortion may also be associated with gen- of them, induced abortion is either completely illegal, der-based violence in some areas. legal only to save the mother’s life or after rape or incest, Low-quality health services present yet another bar- or legal but with limited access by women who need it. rier to access to surgical services for abortion and posta- In such settings, the only option for women wishing to bortion care. In LMICs that lack good health systems or end their pregnancies is to procure clandestine, usu- quality of service, surgical methods are often unavailable ally unsafe, abortions—with substantial negative conse- as choices, health workers are rude or judgmental toward quences for themselves, their families, and their societies women who seek abortion or postabortion care, confi- (Singh 2010): dentiality is limited, and health workers are absent or poorly trained. Moreover, the health systems in many • Increased death and disability (Murray and others LMICs are unaffordable, limited in number and distri- 2013; Okonofua 2006) bution, and lacking drugs and equipment. • Increased health care costs (Babigumira and others 2011; Benson and others 2012; Shearer, Walker, and Vlassoff 2010; Vlassoff and others 2009) Surgical Procedures • Decreased quality of life and social support (Lubinga The long-standing standard for safe induced abortion and others 2013) is surgery through either dilation and curettage (D&C) • Reduced economic productivity (Singh 2010; or vacuum aspiration (VA). However, medical abortion Sundaram and others 2010). (which induces abortion nonsurgically, using medicines) 120 Essential Surgery is now considered a safe and viable alternative (Neilson adhesions (Asherman’s syndrome), the latter of which and others 2010, 2013; Ngo and others 2011). increases the risks of future ectopic pregnancy, miscar- In low-income settings, postabortion surgical inter- riage, or abnormal placentation (placenta previa and vention is most commonly a result of incomplete acreta) (Dalton and others 2006). abortion, which presents with sepsis and hemorrhage. Management of incomplete abortion comprises three Vacuum Aspiration. VA uses suction to remove types: retained products of conception through the cervix. Generally performed in an outpatient setting under • Expectant management, which allows products of local anesthesia or with analgesics, VA has been doc- conception to be spontaneously evacuated umented in multiple studies to be safe (Greenslade • Medical management, which uses medications to and others 1993), although complications can include induce evacuation hemorrhage, infection, cervical and uterine injury, and • Surgical management, which uses either sharp metal adhesions (Dalton and others 2006). curettage (with or without cervical dilation) or The procedure was pioneered in 1958 by Chinese VA (manual vacuum aspiration [MVA] or electric physicians Wu Yuantai and Wu Xianzhen (Wu and Wu vacuum aspiration [EVA]). 1958). Improvements in the West over the years led to the development of a soft, flexible device, the Karman Other surgical procedures are necessary to manage cannula, which removed the need for cervical dilation the complications of induced abortions, particularly and reduced uterine injury. MVA uses a manual vacuum those that are clandestine and unsafe. These include syringe and cannula, and EVA uses an electric pump. In surgery to repair tears and perforations in the genital both methods, the pump mechanism creates a vacuum tract, laparotomy for reasons such as repairs and sepsis that empties the uterus. management, and hysterectomy. Dilation and Curettage. Sharp metal curettage involves Effectiveness of Methods evacuation of the retained products of conception using To avoid anesthesia and surgery, some women prefer forceps and a sharp metal curette. In most cases follow- medical (drug-induced) abortion. However, medical ing incomplete abortion, the cervix is already open and abortion is associated with more pain and bleeding, no dilation is needed. If the cervix is open, curettage is more distress after the procedure, and more side preceded by evacuation. effects in general than surgical abortion (Grimes, Sharp metal curettage is usually performed in an Smith, and Witham 2004; Grossman, Blanchard, and operating room under general anesthesia, but in some Blumenthal 2008; Grossman and others 2011; Kelly countries it is performed under mild sedation with and others 2010; Lohr, Hayes, and Gemzell-Danielsson analgesics and in minor theaters. Some practitioners 2008). In the first trimester, medical abortion is more administer medications for presurgical preparation of painful, is associated with more negative experiences the cervix, using prostaglandin gels or pessaries to and complications after the procedure, and is both reduce trauma to the cervix and uterus. Pessaries and less effective and less acceptable than surgical abor- gels also reduce the technical difficulties of performing tion (Robson and others 2009; Say and others 2005). the procedure, thereby reducing the procedure time and In the second trimester, surgical abortion is similar postprocedural pain and discomfort. in efficacy to medical abortion (Grossman and others The curette has a handle at one end and a sharp loop 2011; Grossman, Blanchard, and Blumenthal 2008; at the other. After administering anesthesia, if the cer- Lohr, Hayes, and Gemzell-Danielsson 2008; Kelly and vix is still closed, it is gently dilated by inserting serial others 2010). Hegar’s dilators until an appropriately sized curette Regarding the three methods for management can be introduced safely without force to avoid lacer- of incomplete abortion—expectant, medical, and ating or tearing the cervix (which would create a false surgical—a 2005 meta-analysis found that surgical passage into the cervix and risk torrential bleeding and management was more likely to complete uterine evac- severe uterine perforation). The curette is then used to uation than medical management, which in turn was gently scrape the uterine wall and remove tissue in the more effective than expectant management (Sotiriadis uterus, which is examined to ensure the procedure is and others 2005). However, studies report mixed results complete. regarding the overall advantages and disadvantages In addition to the complications of anesthesia, of medical versus surgical management of incom- D&C may result in uterine perforation, infection, and plete abortion or miscarriage. One study reported Surgery for Family Planning, Abortion, and Postabortion Care 121 that surgical management resulted in more infections Second-trimester abortion. D&C is less expensive but less pain, a lower chance of retained products, and more effective than medical induction for second- and greater satisfaction than medical management trimester abortion (Cowett, Golub, and Grobman 2006). (Niinimaki and others 2006; Niinimaki and others Others suggest that medical management is less pref- 2009). A Cochrane review found that, compared with erable economically because its higher probability of expectant management, surgical management reduced abortion failure and bleeding increases costs (Xia, She, the risk of incomplete abortion or miscarriage, need and Lam 2011). for additional surgery, bleeding, and transfusion despite Miscarriage. Medical management of miscarriage being less costly; however, the two methods carried sim- using the labor-induction medication misoprostol is ilar risks of infection and psychological issues (Nanda less costly than expectant management, which in and others 2012). turn is less costly than surgical management of first- Specifically comparing surgical methods, a 2010 trimester miscarriage (You and Chung 2005). However, Cochrane review found that VA was safer, quicker, and to treat first-trimester miscarriage or incomplete less painful than sharp metal curettage and also led to abortion, medical management is more efficacious less blood loss. However, differences were nonsignifi- and cost-effective (Tasnim and others 2011). Some cant in the incidence of sepsis postprocedure, uterine studies indicate no clear preference concerning the perforation, or the need for reevacuation (Forna and cost-effectiveness of medical versus surgical manage- Gulmezoglu 2001; Tuncalp, Gulmezoglu, and Souza ment but cite other advantages associated with both 2010). MVA and EVA do not appear to differ substan- (Niinimaki and others 2009). Others suggest that either tially in efficacy (Mittal and others 2011). expectant or medical management of first-trimester Additionally, VA can be performed in the absence miscarriage would be more cost-effective than tradi- of a fully equipped facility and at secondary health tional surgical management (Petrou and others 2006). facilities, with or without electricity, and without the For first-trimester pregnancy loss, surgical manage- capacity for general anesthesia. It is better suited for ment is more cost-effective and more efficacious than low-income settings because it is more accessible and medical management when performed in the outpa- reduces the consequences of blood loss and worsening tient setting (Rausch and others 2012). For incom- infection associated with transportation to tertiary plete or inevitable abortion, medical management is health facilities. cost-effective and more efficacious (Rausch and others Despite its advantages over sharp metal curettage, 2012). Among the surgical procedures, MVA is more VA has not been adopted in many LMICs, particularly cost-effective than EVA because it costs less, does not in Sub-Saharan Africa, because practitioners generally require general anesthesia, and is more suited to LMICs lack the knowledge and training to perform it, lack the (Tasnim and others 2011). necessary equipment, or remain unconvinced of its effectiveness and safety. Future Directions Surgical methods for safe abortion are unlikely to be Cost-Effectiveness of Methods used in most LMICs because prevailing legal restrictions Relative to unsafe abortion, provision of safe abortion force women to seek clandestine, usually unsafe, abor- is highly cost-effective in LMICs (Hu and others 2009; tions. Therefore, surgical methods will likely play a more Hu and others 2010). Studies that compare the cost- significant role in the management of abortion compli- effectiveness of safe procedures break down their find- cations, particularly incomplete abortion. ings by trimester of the procedure, usually finding Although medical management will probably con- surgical management to be the most cost-effective stitute a substantial proportion of management of method. The conclusions are far more mixed, however, incomplete abortion in LMICs in the future, surgery will concerning the distinct circumstances of spontaneous continue to be important as long as medical manage- abortion (miscarriage). ment remains inaccessible to many, if not most, women First-trimester abortion. Clinic-based MVA is the in need. To date, the use of medical management is lim- most effective and most cost-effective method in Mexico, ited because of high drug costs and health systems that Nigeria, and the United States, far surpassing D&C and lack adequate ability to provide careful follow-up and medical abortion (Hu and others 2009; Hu and others continuous access to medical care (Ballagh, Harris, and 2010; Rocconi and others 2005). In Ghana, however, Demasio 1998). medical abortion was found to be more cost-effective Ultimately, comprehensive family planning would than clinic-based MVA (Hu and others 2010).13 reduce unintended pregnancies and therefore the 122 Essential Surgery incidence of unsafe abortions. For example, universal NOTES access to contraceptives by women who express the The World Bank classifies countries according to four income need for them would reduce unintended pregnancies in groupings. Income is measured using gross national income developing countries by more than two-thirds—from (GNI) per capita, in U.S. dollars, converted from local currency 80 million to 26 million (Singh and Darroch 2012). Such using the World Bank Atlas method. Classifications as of July a massive decline would reduce the number of induced 2014 are as follows: abortions by an estimated 26 million, unsafe abortions by 14.5 million (from 20 million to 5.5 million), and • Low-income countries (LICs) = US$1,045 or less in 2013 unsafe-abortion-related deaths by more than four-fifths, • Middle-income countries (MICs) are subdivided: from 46,000 to 8,000 (Guttmacher Institute 2010; Singh • Lower-middle-income = US$1,046 to US$4,125 and Darroch 2012). • Upper-middle-income (UMICs) = US$4,126 to US$12,745 • High-income countries (HICs) = US$12,746 or more Conclusions and Recommendations 1. This section considers surgery for induced abortion only. We do not consider induced abortion to be a method of In this section, we discuss the burden of unintended family planning (although some people use it as such). In pregnancy and the demand for both abortion and this regard, we follow the global policy community, which postabortion care in LMICs, the potential benefits has considered family planning and induced abortion to of increased access to surgical services for abor- be separate concerns. tion and postabortion care, and the potential health 2. There is no consensus on the definition of “high parity”: and economic results of such an increase. Based on some authors suggest a threshold of more than five viable our findings, we offer the following conclusions and pregnancies, and others suggest a threshold of more than recommendations: eight births (Aliyu and others 2005). 3. Increased population and aging drove the seemingly • Surgical methods for abortion and the management paradoxical increase in YLDs during a decrease in the YLD rate. Although the absolute number of YLDs of incomplete abortion are more effective and more increased by 28 percent from 1990 through 2010, the cost-effective than medical management, particularly number of YLDs per 100,000 declined by 1.2 percent in LMICs where access to medical interventions (Vos and others 2013). might be limited. They are associated with fewer side 4. The “demographic dividend” refers to the increased eco- effects such as pain and bleeding—a critical advan- nomic growth that changes in the age structure of a coun- tage in LMICs, where health facilities might be distant try’s population can generate as it transitions from high and transportation difficult. birth and death rates to low ones. • Access to VA and D&C should be increased by train- 5. Nonsurgical female sterilization techniques include tran- ing more health workers and investing in surgical scervical tubal occlusion, which emerged in 2003 (Bartz equipment in secondary health care settings. and Greenberg 2008; Zite and Borrero 2011), and chemical • Although surgical management of incomplete abor- sterilization using the cytotoxic agent quinacrine sulfate, which has been proposed but not approved by the U.S. tion predominates where such services are available Food and Drug Administration (Zipper and Kessel 2003). in LMICs, increased access should be a priority to Transcervical tubal occlusion is not feasible for LMICs improve postabortion care and reduce abortion- in the near future because it requires high-technology related morbidity and mortality. (hysteroscopic) equipment, highly skilled surgeons, and • Safe surgical abortion is not a current option in high equipment maintenance costs. most LMICs, given their legal restrictions; expand- 6. A similar method, the Adiana method, which used silicone ing access to it will be impossible for the fore- to induce scarring, was removed from the market for seeable future. That these restrictions encourage infringing on the Essure patent. women to seek unsafe abortions, with their higher 7. The “failure rate” of vasectomy is defined as the presence complication rates, only heightens the need to of motile sperm in the postvasectomy ejaculate. Early fail- expand access to surgical management of incom- ure occurs within three to six months after the vasectomy, and late failure occurs if motile sperm appear in the ejacu- plete abortion. late after documented azoospermia in two postvasectomy • Increased investment in family planning will help semen analyses. satisfy the large unmet need for contraception in 8. “Societal costs” refers to an all-inclusive set of costs includ- LMICs and, by reducing the number of unintended ing direct medical costs, direct nonmedical costs (such as pregnancies, dramatically lower maternal mortal- transportation to receive health services), indirect costs ity and morbidity as well as the number of unsafe (such as lost productivity while seeking health services), abortions. and program-related costs. Surgery for Family Planning, Abortion, and Postabortion Care 123 9. For more information about the eight MDGs, see the United Ayhan, A., K. Boynukalin, and M. C. Salman. 2006. “Tubal Nations website: http://www.un.org/millenniumgoals/. Ligation via Posterior Colpotomy.” International Journal of 10. “Contraceptive security” refers to individuals’ ability to Gynecology and Obstetrics 93 (3): 254–55. choose, obtain, and use reliable, high-quality contracep- Babigumira, J. B., A. Stergachis, D. L. Veenstra, J. S. Gardner, tives for family planning when they want them. J. Ngonzi, and others. 2011. “Estimating the Costs of 11. Increased population and aging drove the seemingly Induced Abortion in Uganda: A Model-Based Analysis.” paradoxical 20 percent increase in YLDs from 1990 BMC Public Health 11: 904. through 2010, even though, during the same 20-year Babigumira, J. B., A. Stergachis, D. L. Veenstra, J. S. Gardner, period, the number of abortion-related deaths decreased by J. Ngonzi, P. Mukasa-Kivunike, and L. P. Garrison. 2012. 39 percent (Vos and others 2013) and the burden of disease “Potential Cost-Effectiveness of Universal Access to Modern decreased by 33 percent (Murray and others 2013). Contraceptives in Uganda.” PLoS One 7 (2): e30735. 12. The World Health Organization (WHO) “burden of dis- Ballagh, S. A., H. A. Harris, and K. Demasio. 1998. “Is Curettage ease” refers to a time-based measure that combines the Needed for Uncomplicated Incomplete Spontaneous years of life lost from premature mortality and the years Abortion?” American Journal of Obstetrics and Gynecology of life lost from being in less than full health (http://www 179 (5): 1279–82. .who.int/topics /global_burden_of_disease/en/). It is mea- Bartlett, L. A., C. J. Berg, H. B. Shulman, S. B. Zane, C. A. Green, sured by disability-adjusted life years (DALYs). and others. 2004. “Risk Factors for Legal Induced Abortion- 13. The differences in the rank order of cost-effectiveness Related Mortality in the United States.” Obstetrics and of medical abortion and MVA in the study by Hu and Gynecology 103 (4): 729–37. others (2010) were due to the country-specific and Bartz, D., and J. A. Greenberg. 2008. “Sterilization in the sector-specific variations in the baseline cost of service United States.” Reviews in Obstetrics and Gynecology 1 (1): provision. 23–32. Benson, J., M. Okoh, K. KrennHrubec, M. A. Lazzarino, and H. B. Johnston. 2012. “Public Hospital Costs of Treatment of Abortion Complications in Nigeria.” International Journal REFERENCES of Gynaecology and Obstetrics 118 (Suppl 2): S134–40. ACOG (American College of Obstetricians and Gynecologists). Bloom, D. E., D. Canning, and J. Sevilla. 2003. “The 1996. “Technical Bulletin: Sterilization.” International Demographic Dividend: A New Perspective on the Economic Journal of Gynecology and Obstetrics 53 (3): 281–88. Consequences of Population Change.” Population Matters Ahmed, S., Q. Li, L. Liu, and A. O. Tsui. 2012. “Maternal Monograph MR-1274, RAND, Santa Monica, CA. Deaths Averted by Contraceptive Use: An Analysis of 172 Bottomley, C., and T. Bourne. 2009. “Diagnosing Miscarriage.” Countries.” The Lancet 380 (9837): 111–25. Best Practice and Research Clinical Obstetrics and Alcázar, J. L., C. Baldonado, and C. Laparte. 1995. “The Gynaecology 23 (4): 463–77. Reliability of Transvaginal Ultrasonography to Detect Canning, D., and T. P. Schultz. 2012. “The Economic Retained Tissue after Spontaneous First-Trimester Consequences of Reproductive Health and Family Abortion, Clinically Thought to Be Complete.” Ultrasound Planning.” The Lancet 380 (9837): 165–71. in Obstetrics and Gynecology 6 (2): 126–29. Castano, P. M., and L. Adekunle. 2010. “Transcervical Ali, A. A., and A. Okud. 2013. “Factors Affecting Unmet Need Sterilization.” Seminars in Reproductive Medicine 28 (2): for Family Planning in Eastern Sudan.” BMC Public Health 103–09. 13 (1): 102. Christiansen, C. G., and J. I. Sandlow. 2003. “Testicular Pain Aliyu, M. H., P. E. Jolly, J. E. Ehiri, and H. M. Salihu. 2005. Following Vasectomy: A Review of Postvasectomy Pain “High Parity and Adverse Birth Outcomes: Exploring the Syndrome.” Journal of Andrology 24 (3): 293–98. Maze.” Birth 32 (1): 45–59. Cleland, J., A. Conde-Agudelo, H. Peterson, J. Ross, and A. Tsui. Alkema, L., V. Kantorova, C. Menozzi, and A. Biddlecom. 2012. “Contraception and Health.” The Lancet 380 (9837): 2013. “National, Regional, and Global Rates and Trends 149–56. doi:10.1016/s0140-6736(12)60609-6. in Contraceptive Prevalence and Unmet Need for Family Clifton, D., and T. Kaneda. 2013. “Family Planning Worldwide Planning between 1990 and 2015: A Systematic and 2013 Data Sheet.” Population Reference Bureau, Comprehensive Analysis.” The Lancet 381 (9878): 1642–52. Washington, DC. Aradhya, K. W., K. Best, and D. C. Sokal. 2005. Cook, L. A., A. Pun, H. van Vliet, M. F. Gallo, and L. M. Lopez. “Recent Developments in Vasectomy.” BMJ 330 (7486): 2007. “Scalpel versus No-Scalpel Incision for Vasectomy.” 296–99. Cochrane Database of Systematic Reviews 18 (2): CD004112. Asiimwe, J. B., P. Ndugga, and J. Mushomi. 2013. “Socio- Cook, L. A., H. van Vliet, L. M. Lopez, A. Pun, and M. F. Gallo. Demographic Factors Associated with Contraceptive 2007. “Vasectomy Occlusion Techniques for Male Use among Young Women in Comparison with Older Sterilization.” Cochrane Database of Systematic Reviews Women in Uganda.” DHS (Demographic and Health 18 (2): CD003991. Surveys) Working Paper 95, ICF International (for the Cos, L. R., J. R. Valvo, R. S. Davis, and A. T. Cockett. 1983. United States Agency for International Development), “Vasovasostomy: Current State of the Art.” Urology 22 (6): Calverton, MD. 567–75. 124 Essential Surgery Cowett, A. A., R. M. Golub, and W. A. Grobman. 2006. Grossman, D., D. Constant, N. Lince, M. Alblas, K. Blanchard, “Cost-Effectiveness of Dilation and Evacuation versus and others. 2011. “Surgical and Medical Second Trimester the Induction of Labor for Second-Trimester Pregnancy Abortion in South Africa: A Cross-Sectional Study.” BMC Termination.” American Journal of Obstetrics and Gynecology Health Services Research 11: 224. 194 (3): 768–73. Guttmacher Institute. 2010. “Facts on Investing in Family Dalton, V. K., N. A. Saunders, L. H. Harris, J. A. Williams, and Planning and Maternal and Newborn Health.” In Brief D. I. Lebovic. 2006. “Intrauterine Adhesions after Manual update, November. Vacuum Aspiration for Early Pregnancy Failure.” Fertility Henderson, S. R. 1984. “The Reversibility of Female Sterilization and Sterility 85 (6): 1823.e1–1823.e3. with the Use of Microsurgery: A Report on 102 Patients with Darroch, J. E. 2013. “Trends in Contraceptive Use.” More than One Year of Follow-Up.” American Journal of Contraception 87 (3): 259–63. Obstetrics and Gynecology 149 (1): 57–65. Darroch, J. E., G. Sedgh, and H. Ball. 2011. Contraceptive Hendrix, N. W., S. P. Chauhan, and J. C. Morrison. 1999. Technologies: Responding to Women’s Needs. New York: “Sterilization and Its Consequences.” Obstetrical and Guttmacher Institute. Gynecological Survey 54 (12): 766–77. Darroch, J. E., and S. Singh. 2013. “Trends in Contraceptive Henshaw, S. K. 1993. “How Safe Is Therapeutic Abortion?” Need and Use in Developing Countries in 2003, 2008, and In The Current Status of Gynaecology and Obstetrics 2012: An Analysis of National Surveys.” The Lancet 381 Series, Vol. 5, edited by E. S. Teoh, S. S. Ratnam, and (9879): 1756–62. M. Macnaughton, 31–41. Carnforth, U.K.: Parthenon Delvaux, T., and C. Nostlinger. 2007. “Reproductive Choice Publishing Group. for Women and Men Living with HIV: Contraception, Holt, V. L., J. Chu, J. R. Daling, A. S. Stergachis, and Abortion and Fertility.” Reproductive Health Matters N. S. Weiss. 1991. “Tubal Sterilization and Subsequent 15 (29 Suppl): 46–66. Ectopic Pregnancy. A Case-Control Study.” JAMA 266 (2): Forna, F., and A. M. Gulmezoglu. 2001. “Surgical Procedures 242–46. to Evacuate Incomplete Abortion.” Cochrane Database of Hu, D., D. Grossman, C. Levin, K. Blanchard, R. Adanu, Systematic Reviews 1 (1): CD001993. and others. 2010. “Cost-Effectiveness Analysis of Unsafe Fox, M. 1994. “Vasectomy Reversal—Microsurgery for Best Abortion and Alternative First-Trimester Pregnancy Results.” British Journal of Urology 73 (4): 449–53. Termination Strategies in Nigeria and Ghana.” African Frost, J. J., S. Singh, and L. B. Finer. 2007. “Factors Associated Journal of Reproductive Health 14 (2): 85–103. with Contraceptive Use and Nonuse, United States, 2004.” Hu, D., D. Grossman, C. Levin, K. Blanchard, and S. J. Goldie. Perspectives on Sexual and Reproductive Health 39 (2): 2009. “Cost-Effectiveness Analysis of Alternative First- 90–99. Trimester Pregnancy Termination Strategies in Mexico Gaym, A. 2012. “Current and Future Role of Voluntary Surgical City.” BJOG: An International Journal of Obstetrics and Contraception in Increasing Access to and Utilization of Gynaecology 116 (6): 768–79. Family Planning Services in Africa.” Ethiopian Medical Jacobstein, R. 2013. “Lessons from the Recent Rise in Use of Journal 50 (4): 363–70. Female Sterilization in Malawi.” Studies in Family Planning Goldie, S. J., S. Sweet, N. Carvalho, U. C. Natchu, and D. Hu. 44 (1): 85–95. 2010. “Alternative Strategies to Reduce Maternal Mortality Jamieson, D. J., C. Costello, J. Trussell, S. D. Hillis, in India: A Cost-Effectiveness Analysis.” PLoS Med 7 (4): P. A. Marchbanks, and H. B. Peterson. 2004. “The Risk e1000264. of Pregnancy after Vasectomy.” Obstetrics and Gynecology Goyaux, N., R. Leke, N. Keita, and P. Thonneau. 2003. 103 (5 Pt 1): 848–50. “Ectopic Pregnancy in African Developing Countries.” Acta Janowitz, B., J. Stanback, and B. Boyer. 2012. “Task Sharing in Obstetricia et Gynecologica Scandinavica 82 (4): 305–12. Family Planning.” Studies in Family Planning 43 (1): 57–62. Greenslade, F. C., A. L. Leonard, J. Benson, J. Wunkler, and Kasedde, S. 2000. “Long-Term and Permanent Family Planning V. L. Henderson. 1993. Manual Vacuum Aspiration: Methods in Uganda: A Literature Review.”Unpublished paper A Summary of Clinical and Programmatic Experience (USAID Cooperative Agreement 617-00-00-00001-00). Worldwide. Chapel Hill, NC: Ipas. http://www.ugandadish.org/best.shtml. Grimes, D. A., J. Benson, S. Singh, M. Romero, B. Ganatra, and Kelly, T., J. Suddes, D. Howel, J. Hewison, and S. Robson. others. 2006. “Unsafe Abortion: The Preventable Pandemic.” 2010. “Comparing Medical versus Surgical Termination The Lancet 368 (9550): 1908–19. of Pregnancy at 13–20 Weeks of Gestation: A Randomised Grimes, D. A., M. S. Smith, and A. D. Witham. 2004. Controlled Trial.” BJOG: An International Journal of “Mifepristone and Misoprostol versus Dilation and Obstetrics and Gynaecology 117 (12): 1512–20. Evacuation for Midtrimester Abortion: A Pilot Randomised Kondo, W., R. W. Noda, A. W. Branco, M. Rangel, and Controlled Trial.” BJOG: An International Journal of A. J. Branco Filho. 2009. “Transvaginal Endoscopic Tubal Obstetrics and Gynaecology 111 (2): 148–53. Sterilization.” Journal of Laparoendoscopic and Advanced Grossman, D., K. Blanchard, and P. Blumenthal. 2008. Surgical Techniques Part A 19 (1): 59–61. “Complications after Second Trimester Surgical and Medical Labrecque, M., C. Dufresne, M. A. Barone, and K. St.-Hilaire. Abortion.” Reproductive Health Matters 16 (31 Suppl): 2004. “Vasectomy Surgical Techniques: A Systematic 173–82. Review.” BMC Medicine 2 (21): 21. Surgery for Family Planning, Abortion, and Postabortion Care 125 Lee, H. Y. 1986. “A 20-Year Experience with Vasovasostomy.” Nettleman, M. D., H. Chung, J. Brewer, A. Ayoola, and Journal of Urology 136 (2): 413–15. P. L. Reed. 2007. “Reasons for Unprotected Intercourse: Levine, L. A., M. R. Abern, and M. M. Lux. 2006. “Persistent Analysis of the PRAMS Survey.” Contraception 75 (5): Motile Sperm after Ligation Band Vasectomy.” Journal of 361–66. Urology 176 (5): 2146–48. Ngo, T. D., M. H. Park, H. Shakur, and C. Free. 2011. Li, P. S., S. Q. Li, P. N. Schlegel, and M. Goldstein. 1992. “Comparative Effectiveness, Safety and Acceptability of “External Spermatic Sheath Injection for Vasal Nerve Medical Abortion at Home and in a Clinic: A Systematic Block.” Urology 39 (2): 173–76. Review.” Bulletin of the World Health Organization 89 (5): Lohr, P. A., J. L. Hayes, and K. Gemzell-Danielsson. 2008. 360–70. “Surgical versus Medical Methods for Second Trimester Niinimaki, M., P. Jouppila, H. Martikainen, and A. Talvensaari- Induced Abortion.” Cochrane Database of Systematic Mattila. 2006. “A Randomized Study Comparing Efficacy Reviews 23 (1): CD006714. and Patient Satisfaction in Medical or Surgical Treatment of Lozano, R., M. Naghavi, K. Foreman, S. Lim, K. Shibuya, and Miscarriage.” Fertility and Sterility 86 (2): 367–72. others. 2013. “Global and Regional Mortality from 235 Niinimaki, M., P. Karinen, A. L. Hartikainen, and A. Pouta. Causes of Death for 20 Age Groups in 1990 and 2010: 2009. “Treating Miscarriages: A Randomised Study of Cost- A Systematic Analysis for the Global Burden of Disease Effectiveness in Medical or Surgical Choice.” BJOG: An Study 2010.” The Lancet 380 (9859): 2095–128. International Journal of Obstetrics and Gynaecology 116 (7): Lubinga, S. J., G. A. Levine, A. M. Jenny, J. Ngonzi, P. Mukasa- 984–90. Kivunike, and others. 2013. “Health-Related Quality of Life O’Neill, B. C., B. Liddle, L. Jiang, K. R. Smith, S. Pachauri, and and Social Support among Women Treated for Abortion others. 2012. “Demographic Change and Carbon Dioxide Complications in Western Uganda.” Health and Quality of Emissions.” Lancet 380 (9837): 157–64. Life Outcomes 11: 118. Okonofua, F. 2006. “Abortion and Maternal Mortality in the Mallet, J., and V. Kalambi. 2008. “Coerced and Forced Developing World.” Journal of Obstetrics and Gynaecology Sterilization of HIV-Positive Women in Namibia.” Canada 28 (11): 974–79. HIV/AIDS Policy and Law Review 13 (2–3): 77–78. Peterson, H. B., Z. Xia, J. M. Hughes, L. S. Wilcox, L. R. Tylor, Mavranezouli, I. 2009. “Health Economics of Contraception.” and others. 1996. “The Risk of Pregnancy after Tubal Best Practice and Research Clinical Obstetrics and Sterilization: Findings from the U.S. Collaborative Review Gynaecology 23 (2): 187–98. of Sterilization.” American Journal of Obstetrics and Mittal, S., R. Sehgal, S. Aggarwal, J. Aruna, A. Bahadur, and Gynecology 174 (4): 1161–68; discussion 1168–70. G. Kumar. 2011. “Cervical Priming with Misoprostol ———. 1997. “The Risk of Ectopic Pregnancy after Tubal before Manual Vacuum Aspiration versus Electric Sterilization.” U.S. Collaborative Review of Sterilization Vacuum Aspiration for First-Trimester Surgical Abortion.” Working Group. New England Journal of Medicine 336 (11): International Journal of Gynaecology and Obstetrics 112 762–67. (1): 34–39. Petrou, S., J. Trinder, P. Brocklehurst, and L. Smith. 2006. Moss, W. M. 1992. “A Comparison of Open-End versus Closed- “Economic Evaluation of Alternative Management End Vasectomies: A Report on 6,220 Cases.” Contraception Methods of First-Trimester Miscarriage Based on Results 46 (6): 521–25. from the MIST Trial.” BJOG: An International Journal of Murray, C. J., T. Vos, R. Lozano, M. Naghavi, A. D. Flaxman, Obstetrics and Gynaecology 113 (8): 879–89. and others. 2013. “Disability-Adjusted Life Years (DALYs) Pollack, A. E., and R. M. Soderstrom. 1994. “Female Tubal for 291 Diseases and Injuries in 21 Regions, 1990–2010: Sterilization.” In Fertility Control, 2nd ed., edited by A Systematic Analysis for the Global Burden of Disease S. L. Corson, R. J. Derman, and L. B. Tyrer, 293–318. Study 2010.” The Lancet 380 (9859): 2197–223. London, ON: Goldin Publishers. Muyindike, W., R. Fatch, R. Steinfield, L. T. Matthews, Prada, E., E. T. Mirembe, F. Ahmed, R. Nalwadda, and N. Musinguzi, and others. 2012. “Contraceptive Use and C. Kiggundu. 2005. Abortion and Postabortion Care in Associated Factors among Women Enrolling into HIV Care Uganda: A Report from Health Care Professionals and Health in Southwestern Uganda.” Infectious Diseases in Obstetrics Facilities. Occasional Report No. 17. New York: The Alan and Gynecology 2012: 340782. Guttmacher Institute. Nanda, K., L. M. Lopez, D. A. Grimes, A. Peloggia, and Rausch, M., S. Lorch, K. Chung, M. Frederick, J. Zhang, and G. Nanda. 2012. “Expectant Care versus Surgical Treatment others. 2012. “A Cost-Effectiveness Analysis of Surgical ver- for Miscarriage.” Cochrane Database of Systematic Reviews sus Medical Management of Early Pregnancy Loss.” Fertility 3 (14): CD003518. and Sterility 97 (2): 355–60. Neilson, J. P., G. M. Gyte, M. Hickey, J. C. Vazquez, and L. Dou. Robson, S. C., T. Kelly, D. Howel, M. Deverill, J. Hewison, and 2010. “Medical Treatments for Incomplete Miscarriage others. 2009. “Randomised Preference Trial of Medical ver- (Less than 24 Weeks).” Cochrane Database of Systematic sus Surgical Termination of Pregnancy Less than 14 Weeks’ Reviews 20 (1): CD007223. Gestation (TOPS).” Health Technology Assessment 13 (53): ———. 2013. “Medical Treatments for Incomplete 1–124, iii–iv. Miscarriage.” Cochrane Database of Systematic Reviews Rocconi, R. P., S. Chiang, H. E. Richter, and J. M. Straughn 3 (28): CD007223. Jr. 2005. “Management Strategies for Abnormal Early 126 Essential Surgery Pregnancy: A Cost-Effectiveness Analysis.” Journal of Smith, G. L., G. P. Taylor, and K. F. Smith. 1985. “Comparative Reproductive Medicine 50 (7): 486–90. Risks and Costs of Male and Female Sterilization.” American Rock, J. A., C. A. Bergquist, H. A. Zacur, T. H. Parmley, Journal of Public Health 75 (4): 370–74. D. S. Guzick, and others. 1982. “Tubal Anastomosis Following Sokal, D., B. Irsula, M. Hays, M. Chen-Mok, and M. A. Barone. Unipolar Cautery.” Fertility and Sterility 37 (5): 613–18. 2004. “Vasectomy by Ligation and Excision, with or with- Ross, J. A., and A. K. Blanc. 2012. “Why Aren’t There More out Fascial Interposition: A Randomized Controlled Trial.” Maternal Deaths? A Decomposition Analysis.” Maternal BMC Medicine 2 (6): 6. and Child Health Journal 16 (2): 456–63. Song, L., Y. Gu, W. Lu, X. Liang, and Z. Chen. 2006. “A Phase II Ross, J., E. Weissman, and J. Stover. 2009. Contraceptive Randomized Controlled Trial of a Novel Male Contraception, Projections and the Donor Gap: Meeting the Challenge. an Intra-Vas Device.” International Journal of Andrology 29 Brussels: Reproductive Health Supplies Coalition. (4): 489-95. doi:10.1111/j.1365-2605.2006.00686.x. Say, L., R. Kulier, M. Gulmezoglu, and A. Campana. 2005. Sotiriadis, A., G. Makrydimas, S. Papatheodorou, and “Medical versus Surgical Methods for First Trimester J. P. Ioannidis. 2005. “Expectant, Medical, or Surgical Termination of Pregnancy.” Cochrane Database of Systematic Management of First-Trimester Miscarriage: A Meta- Reviews 25 (1): CD003037. Analysis.” Obstetrics and Gynecology 105 (5 Pt 1): 1104–13. Schuler, S. R., M. E. Choque, and S. Rance. 1994. Spivak, M. M., C. L. Librach, and D. M. Rosenthal. 1986. “Misinformation, Mistrust, and Mistreatment: Family “Microsurgical Reversal of Sterilization: A Six-Year Study.” Planning among Bolivian Market Women.” Studies in American Journal of Obstetrics and Gynecology 154 (2): Family Planning 25 (4): 211–21. 355–61. Sedgh, G., S. Singh, I. H. Shah, E. Ahman, S. K. Henshaw, Steiner, M. J., J. Trussell, N. Mehta, S. Condon, S. Subramaniam, and A. Bankole. 2012. “Induced Abortion: Incidence and and others. 2006. “Communicating Contraceptive Trends Worldwide from 1995 to 2008.” Lancet 379 (9816): Effectiveness: A Randomized Controlled Trial to Inform a 625–32. World Health Organization Family Planning Handbook.” Shah, I., and E. Ahman. 2009. “Unsafe Abortion: Global American Journal of Obstetrics and Gynecology 195 (1): and Regional Incidence, Trends, Consequences, and 85–91. Challenges.” Journal of Obstetrics and Gynaecology Canada Stover, J., and J. Ross. 2010. “How Increased Contraceptive 31 (12): 1149–58. Use Has Reduced Maternal Mortality.” Maternal and Child Shapiro, E. I., and S. J. Silber. 1979. “Open-Ended Vasectomy, Health Journal 14 (5): 687–95. Sperm Granuloma, and Postvasectomy Orchialgia.” Fertility Sundaram, A., M. Vlassoff, A. Bankole, L. Remez, and and Sterility 32 (5): 546–50. Y. Gebrehiwot. 2010. “Benefits of Meeting the Contraceptive Shearer, J. C., D. G. Walker, and M. Vlassoff. 2010. “Costs of Needs of Ethiopian Women.” Issues Brief (Alan Guttmacher Post-Abortion Care in Low- and Middle-Income Countries.” Institute) 1: 1–8. International Journal of Gynaecology and Obstetrics 108 (2): Tasnim, N., G. Mahmud, S. Fatima, and M. Sultana. 2011. 165–69. “Manual Vacuum Aspiration: A Safe and Cost-Effective Shih, G., D. K. Turok, and W. J. Parker. 2011. “Vasectomy: The Substitute of Electric Vacuum Aspiration for the Surgical Other (Better) Form of Sterilization.” Contraception 83 (4): Management of Early Pregnancy Loss.” Journal of Pakistan 310–15. Medical Association 61 (2): 149–53. Shy, K. K., A. Stergachis, L. G. Grothaus, E. H. Wagner, Tawiah, E. O. 1997. “Factors Affecting Contraceptive Use in J. Hecht, and others. 1992. “Tubal Sterilization and Ghana.” Journal of Biosocial Science 29 (2): 141–49. Risk of Subsequent Hospital Admission for Menstrual Thorburn, S., and L. M. Bogart. 2005. “Conspiracy Beliefs Disorders.” American Journal of Obstetrics and Gynecology about Birth Control: Barriers to Pregnancy Prevention 166 (6 Pt 1):1698–1705; discussion 1705–06. among African Americans of Reproductive Age.” Health Singh, S. 2006. “Hospital Admissions Resulting from Unsafe Education and Behavior 32 (4): 474–87. Abortion: Estimates from 13 Developing Countries.” Lancet Trussell, J. 2011a. “Contraceptive Efficacy.” In Contraceptive 368 (9550): 1887–92. Technology: Twentieth Revised Edition, edited by ———. 2010. “Global Consequences of Unsafe Abortion.” R. A. Hatcher, J. Trussell, A. L. Nelson, W. Cates, D. Kowal, Womens Health (London, England) 6 (6): 849–60. and others. New York: Ardent Media. Singh, S., and J. E. Darroch. 2012. “Adding It Up: Costs and ———. 2011b. “Contraceptive Failure in the United States.” Benefits of Contraceptive Services—Estimates for 2012.” Contraception 83 (5): 397–404. Guttmacher Institute and United Nations Population Fund Trussell, J., A. M. Lalla, Q. V. Doan, E. Reyes, L. Pinto, and (UNFPA), New York. others. 2009. “Cost Effectiveness of Contraceptives in the Singh, S., A. M. Moore, A. Bankole, F. Mirembe, D. Wulf, United States.” Contraception 79 (1): 5–14. and E. Prada. 2006. Unintended Pregnancy and Induced Tuncalp, O., A. M. Gulmezoglu, and J. P. Souza. 2010. Abortion in Uganda: Causes and Consequences. New York: “Surgical Procedures for Evacuating Incomplete Guttmacher Institute. Miscarriage.” Cochrane Database of Systematic Reviews 8 Singh, S., G. Sedgh, and R. Hussain. 2010. “Unintended (9): CD001993. Pregnancy: Worldwide Levels, Trends, and Outcomes.” Vlassoff, M., G. Beninguisse, F. Kamgaing, F. Zinvi-Dossou, Studies in Family Planning 41 (4): 241–50. J. Jerman, and others. 2014. “Benefits of Meeting the Surgery for Family Planning, Abortion, and Postabortion Care 127 Contraceptive Needs of Cameroonian Women.” In Brief, Weiss, R. S., and P. S. Li. 2005. “No-Needle Jet Anesthetic Guttmacher Institute, No. 1. Technique for No-Scalpel Vasectomy.” Journal of Urology Vlassoff, M., T. Fetters, S. Kumbi, and S. Singh. 2012. “The 173 (5): 1677–80. Health System Cost of Postabortion Care in Ethiopia.” WHO (World Health Organization). 1992. The Prevention International Journal of Gynaecology and Obstetrics 118 and Management of Unsafe Abortion. Report of a Technical (Suppl 2): S127–33. Working Group (WHO/MSM/92.5). Geneva: WHO. Vlassoff, M., S. Furere, I. R. Kalisa, F. Ngabo, F. Sayinzoga, and ———. 1999. Female Sterilization: What Health Workers Need others. 2014. “The Health System Cost of Post-abortion to Know. Geneva: WHO. Care in Rwanda.” Health Policy and Planning (advance ———. 2007. “Task Shifting to Tackle Health Worker online access). doi:10.1093/heapol/czu006. Shortages.” WHO, Geneva. Vlassoff, M., J. Jerman, G. Beninguisse, F. Kamgaing, and ———. 2012. Optimizing Health Worker Roles for Maternal F. Zinvi-Dossou. 2014. “Benefits of Meeting the and Newborn Health Interventions through Task Shifting. Contraceptive Needs of Cameroonian Women.” Issues Brief Geneva: WHO. (Alan Guttmacher Institute) 1: 1–13. Wickstrom, J., and R. Jacobstein. 2011. “Contraceptive Security: Vlassoff, M., A. Sundaram, A. Bankole, L. Remez, and Incomplete without Long-Acting and Permanent Methods D. Belemsaga-Yugbare. 2011. “Benefits of Meeting Women’s of Family Planning.” Studies in Family Planning 42 (4): Contraceptive Needs in Burkina Faso.” Issues Brief (Alan 291–98. Guttmacher Institute) 1: 1–33. Wu, Y., and X. Wu. 1958. “A Report of 300 Cases Using Vacuum Vlassoff, M., A. Sundaram, A. Bankole, L. Remez, and Aspiration for the Termination of Pregnancy.” Chinese F. Mugisha. 2009. “Benefits of Meeting the Contraceptive Journal of Obstetrics and Gynaecology (in English transla- Needs of Ugandan Women.” Issues Brief (Alan Guttmacher tion from BMJ): 447–49. Institute) 4 (4): 1–8. Xia, W., S. She, and T. H. Lam. 2011. “Medical versus Surgical Vlassoff, M., D. Walker, J. Shearer, D. Newlands, and S. Singh. Abortion Methods for Pregnancy in China: A Cost- 2009. “Estimates of Health Care System Costs of Unsafe Minimization Analysis.” Gynecologic and Obstetric Abortion in Africa and Latin America.” International Investigation 72 (4): 257–63. Perspectives on Sexual and Reproductive Health 35 (3): You, J. H., and T. K. Chung. 2005. “Expectant, Medical 114–21. or Surgical Treatment for Spontaneous Abortion in Vos, T., A. D. Flaxman, M. Naghavi, R. Lozano, C. Michaud, First Trimester of Pregnancy: A Cost Analysis.” Human and others. 2013. “Years Lived with Disability (YLDs) for Reproduction 20 (10): 2873–78. 1,160 Sequelae of 289 Diseases and Injuries 1990–2010: Zipper, J., and E. Kessel. 2003. “Quinacrine Sterilization: A Systematic Analysis for the Global Burden of Disease A Retrospective.” International Journal of Gynaecology and Study 2010.” Lancet 380 (9859): 2163–96. Obstetrics 83 (Suppl 2): S7–11. Warriner, I. K., and I. H. Shah. 2006. Preventing Unsafe Zite, N., and S. Borrero. 2011. “Female Sterilisation in the Abortion and Its Consequences: Priorities for Research and United States.” European Journal of Contraception and Action. New York: Guttmacher Institute. Reproductive Health Care 16 (5): 336–40. 128 Essential Surgery Chapter 8 Surgical Interventions for Congenital Anomalies Diana Farmer, Nicole Sitkin, Katrine Lofberg, Peter Donkor, and Doruk Ozgediz INTRODUCTION unrealized promise of pediatric surgery, and concludes with crucial future steps to reduce the burden of disease. Great strides have been made during the past 50 years Chapter 21 addresses economic evaluation of cleft lip in the diagnosis and management of congenital anom- and palate repair. alies, once referred to as birth defects. Formally fatal conditions can now be treated with success rates exceeding 90 percent. Yet improvements in care have MORBIDITY, MORTALITY, AND ADDITIONAL been largely limited to high-income countries (HICs), ADVERSE CONSEQUENCES even though many anomalies can be cured with sim- ple operations (Chirdan, Ngiloi, and Elhalaby 2012). Congenital anomalies are one of the leading causes of If surgery is the neglected stepchild of global health global disease, responsible for a staggering 57.7 million (Farmer and Kim 2008), then pediatric surgery is the disability-adjusted life years (DALYs) lost worldwide child not yet born. (WHO 2013b). DALYs—a measure of the number of Improving the accessibility and quality of pediatric healthy life years lost to premature death or disability— surgical care in low-income (LICs) and lower-middle- are an established metric for the burden of disease. income countries (LMICs) has the potential to substan- Current estimates of the surgical burden of disease tially reduce childhood mortality and lifelong disability. are acknowledged to be a “best educated guess,” given the Data on congenital anomalies in these countries are sparse, “near total lack of pertinent data” (Jamison and others including on the incidence (conservatively estimated at 2006, 1246). Even less is known about pediatric surgical 3 percent to 6 percent [CDC 2012; Christianson, Howson, disease (Bickler and Rode 2002). The studies that have and Modell 2006]), country-specific differences in disease begun to fill this knowledge gap paint a brutal picture. burden, and cost-effective interventions. These areas of The burden of congenital anomalies falls most heavily on knowledge must be developed to identify implemen- LICs and LMICs, where 94 percent of anomalies occur tation and surveillance priorities, and to advocate for (WHO 2012). Higher fertility rates translate to higher resources. birth rates and more children born with anomalies. This chapter briefly summarizes the growing body of Disease incidence (or frequency of disease occurring in knowledge on surgical congenital anomalies in LICs and the population) is also higher, a phenomenon attributed LMICs, highlights prevalent anomalies that exemplify the to higher micronutrient and macronutrient deficiencies, Corresponding author: Diana Farmer, MD, University of California, Davis, diana.farmer@ucdmc.ucdavis.edu 129 exposure to teratogens, prevalence of intrauterine infec- approach to addressing this challenge (Wu, Poenaru, and tion, and self-medication with unsupervised drugs or Poley 2013). traditional remedies (Christianson, Howson, and Modell 2006; Penchaszadeh 2002). Though decreased fertility may reduce incidence of anomalies, most are not oth- Mortality Rate Estimation Challenges erwise preventable and are treated through surgical The burden of disease associated with congenital anom- interventions. alies in LICs and LMICs is most often calculated as the Some anomalies are “quick fixes” that can be easily mortality rate, including neither measures of morbidity repaired; others require staged, or multioperation, sur- nor the cost of ongoing illness (table 8.1). Analysis gical interventions, and delays in treatment may result of mortality data in these countries can be challeng- in lifelong illness, disability, and poor quality of life. The ing; for example, autopsies were performed in only paucity of surgical resources in LICs and LMICs means 0.8 percent of nearly 1,100 neonatal deaths in Benin. that anomalies attributed to the former category in HICs In all examined cases, autopsies provided additional often fall into the latter in LICs and LMICs. Anomalies information on the cause of death (Ugiagbe and Osifo resulting in visible deformity—such as clubfoot and cleft 2012). Furthermore, a high proportion of children with lip—cause stigma, which can trigger abandonment or surgical diseases do not reach a health facility and die at infanticide. Invisible deformities that result in chronic home or in transit, suggesting a sizable hidden mortality disability can lead to similar outcomes. A long-term, (Mo Suwan and others 2009; Ozgediz and others 2008). “incurable” anomaly may also endanger families’ well- Nonfatal anomalies can result in extensive, ongoing being because key resources are allocated to care for the morbidity. The burden of disease is grossly underesti- afflicted child. Families may fracture, with one or both mated if this measure of impairment is not included. parents leaving the child with other family members. Extant calculations do, however, highlight marked dis- Improving the pediatric surgical capabilities of LICs parities in outcomes between HICs, on the one hand, and LMICs will dramatically reduce this burden. Because and LICs and LMICs, on the other hand. children are the future economic engine powering the development of these countries, the value of investing in surgical care for children extends beyond DALYs averted to encompass the future socioeconomic well-being of CHALLENGES TO PROVIDING CARE FOR LICs and LMICs themselves. It is critical to address the gaps in knowledge that impede the development of CONGENITAL ANOMALIES effective care systems. Despite the higher incidence of congenital anomalies in LICs and LMICs, lower population prevalence is seen compared with HICS, most likely indicating a high Data Collection Challenges infant and child mortality rate (Christianson, Howson, Many LICs and LMICs lack rigorous congenital anomaly and Modell 2006). In LICs and LMICs, up to 10 percent surveillance programs, making calculations of incidence of infants die during the neonatal period (Zupan 2005); and prevalence (the total number of individuals in the a considerable portion of this mortality can reasonably population with a given disease) difficult (Penchaszadeh be attributed to congenital anomalies. 2002). Estimates, which range from 4 to 12 cases per 1,000 births, likely undervalue the problem because of stigma and exclusion (Bickler and others 2010; Goksan and Treatment Delays others 2006; Wu and Poenaru 2013). LICs and LMICs Heightened mortality rates stem from delays in treat- often report incidence in cases over time, as opposed to ment caused by the paucity of health profession- using standard metrics, such as incidence per 10,000 live als trained to identify and treat anomalies and by births. Incidence and prevalence data are also skewed by pejorative cultural beliefs surrounding anomalies. the survivability of the anomaly under consideration. In LICs and LMICs, many births occur at home, either Because children with anomalies that are not immedi- with no assistance or with traditional birth atten- ately life threatening are more likely to reach medical dants (TBAs), and patients must often travel great centers, the relative incidence and prevalence of imme- distances to reach medical facilities. Hypothermia—a diately life-threatening impairments appears compara- dangerous drop in body temperature—is com- tively lower in hospital-based data (Nandi, Mungongo, mon following medically unsupervised transport and Lakhoo 2008). Population-based surveys—which over long distances, with severe repercussions directly collect data from noncentralized sites—are one on patient outcomes (Agarwala and others 1996; 130 Essential Surgery Table 8.1 Prevalence and Mortality of Selected Congenital Anomalies in Selected Countries High-income countries Selected countries Congenital Reference Reference mortality Country of reporting Prevalence at reporting anomalies prevalence (percent) institution institution Mortality (percent) Anorectal 1 per 5,000 live <5a Iran, Islamic Rep.b 22 (1993–96) 27.3 (1993–96) malformations birthsa 106 (2002–05) 13.2 (2002–05) Nigeria c 88 over 17 years 30.2 Indiad 125 over 2 years 22.0 Nigeriae 81 over 8 years 32.0 (38 percent of neonatal obstructions) Nigeriaf 54 over 10 years 20.4 Ethiopia g 27 over 5 years 33.0 Indiah 948 over 14 years 15.0–20.0 (staged repair) 4.5 (primary repair) Nigeriai 55 over 10 years 20.0 Hirschsprung’s 1 per 5,000 live Less than 5–10 j, k Iran, Islamic Rep. b 8 (1993–96) 25.0 (1993–96) disease birthsa 50 (2002–05) 4.0 (2002–05) Nigeriae 30 over 8 years 20.0 (14 percent of neonatal obstructions) Nigeriai 24 over 10 years 20.8 (18.7 percent of neonatal obstructions) Bangladeshl 1,273 over 5.5 years 14.3 Burkina Fasom 52 over 7 years 16.0 Eritrean 11 over 5 years 9.1 Nigeria o 78 over 10 years 22.6 Congenital heart 8.2 per 1,000 3–7q Guatemalar 1,215 over 8 years 10.7 (overall) 32.1 (highest- disease live births risk patients) (Europe)p Indias 330 over 8 years 21.4 (1999–2001) 6.9 per 1,000 4.3 (2002–06) live births (North America)p Nepalt 5.8 per 1,000 children 20.2 Sri Lanka u 102 over 1 year 18.6 Esophageal atresia One per 3,500 live 5–15 a Indiav 50 over 2 years 30.0 birthsa Barbadosw 2.06 per 10,000 live births 30.8 Saudi Arabia x 48 over 20 years 25.0 Bangladesh y 21 over 2 years 47.6 Chinaz 15 over 10 years 46.7 following surgery Malaysiaaa 52 over 10 years 23.0 table continues next page Surgical Interventions for Congenital Anomalies 131 Table 8.1 Prevalence and Mortality of Selected Congenital Anomalies in Selected Countries (continued) High-income countries Selected countries Congenital Reference Reference mortality Country of reporting Prevalence at reporting anomalies prevalence (percent) institution institution Mortality (percent) Pakistanab 80 over 1 year, excluding 58.0 isolated esophageal atresia patients Saudi Arabiaac 94 over 15 years 30.8 Iran, Islamic Rep.b 22 (1993–96) 75.0 (1993–96) 106 (2002–05) 58.8 (2002–05) Ethiopia g 12 over 5 years 91.7 Gastroschisis 3.3 to 5 per 10,000 1 (30-day mortality)af Ghana; Nigeria; Over four years: 23.0 (30-day mortality) live birthsa, ad, ae South Africaaf 2 (Ghana) 5 (Nigeria) 19 (South Africa) Iran, Islamic Rep. b 2 (1993–96) 100 (1993–96) 7 (2002–05) 85.7 (2002–05) Iran, Islamic Rep.ag 0.65 per 1,000 births 80.0 (2005–07) 10 per 15,321 live births (2005–07) Nigeriaah 14 over 10 years 71.4 Nigeriaai 12 over 11 years 33.0 Colombia aj 32 over 9 years 18.8 South Africa ak 106 over 6 years; 43.0 (total) 6 neonatal surgical 68.0 patients with admissions (2003); staged, silo-assisted closure 15 neonatal surgical admissions (2007) Thailandal 49 over 3 years 14.0 Nigeriaam 7 of 2,381 patients treated at 57.1 the pediatric surgery unit over eight years Omphalocele 2.18–5 per 10,000 5a Iran, Islamic Rep.b 12 (1993–96) 75.0 (1993–96) live birthsa, ad, ae 68 (2002–05) 58.8 (2002–05) Iran, Islamic Rep. ag 2.1 per 1,000 births 20.0 (2005–07) 42 of 15,321 live newborn births (2005–07) Nigeriaai 42 over 11 years 43.0 Colombia aj 23 over 9 years 43.5 Nigeriaam 49 over 8 years 32.4 (patients with omphalocele major) table continues next page 132 Essential Surgery Table 8.1 Prevalence and Mortality of Selected Congenital Anomalies in Selected Countries (continued) High-income countries Selected countries Congenital Reference Reference mortality Country of reporting Prevalence at reporting anomalies prevalence (percent) institution institution Mortality (percent) Congenital 1 per 2,000 to 1 per ≤ 10an Turkeyao 10 over 4 years 50.0 diaphragmatic 5,000 live birthsa Tunisia ap 28 over 13 years 39.0 hernia Nigeria aq 64 over 24 years 35.5 (overall) 60.0 in patients born in hospital 28.5 in patients born outside hospital who survive until presentation Nigeriaar 7 over 6 years 43.0 Malaysia as 21 over 6 years 47.6 Sources: Anorectal malformations, Ethiopia: Anorectal malformations, India: Anorectal malformations, Iran, Islamic Rep.: Anorectal malformations, Nigeria: a. Coran and others 2012. b. Peyvasteh and others 2011. c. Adejuyigbe and others 2004. d. Chalapathi and others 2004. e. Adeyemi 1989. f. Archibong and Idika 2004. g. Tefera, Teka, and Derbew 2007. h. Gangopadhyay and others 2005. i. Ekenze, Ibeziako, and Ezomike 2007. j. Rescorla and others 1992. k. Swenson 2002. l. Banu and others 2009. m. Bandre and others 2010. n. Calisti and others 2011. o. Chirdan and Uba 2006. p. van der Linde and others 2011.q. Bernier and others 2010. r. Larrazabal and others 2007. s. Bakshi and others 2007. t. Shah and others 2008. u. Wickramasinghe, Lambabadusuriya, and Narenthiran 2001. v. Upadhyaya and others 2007. w. Singh and others 2012. x. Rayes 2010, y. Islam and Aziz 2011. z. Yang and others 2006. aa. Narasimman, Nallusamy, and Hassan 2013. ab. Anwar-ul-Haq and others 2009. ac. Al-Salem and others 2006. ad. Sadler 2010. ae. Canfield and others 2006. af. Manson and others 2012. ag. Askarpour and others 2012. ah. Ameh and Chirdan 2000b. ai. Uba and Chirdan 2003. aj. Toro, Rave, and Gomez 2010. ak. Sekabira and Hadley 2009. al. Saranrittichai 2008. am. Abdur-Rahman, Abdulrasheed, and Adeniran 2011. an. Chiu and Hedrick 2008. ao. Ozdogan and others 2010. ap. Khemakhem and others 2012. aq. Adegboye and others 2002. ar. Abubakar and others 2011. as. Rohana, Boo, and Thambidorai 2008. Sekabira and Hadley 2009; Uba and Chirdan 2003). surgeons and surgery teams must be a fundamental goal The misdiagnosis of anomalies as better-known of ongoing and future programs to address the pediatric infectious diseases, and added delays for invisible surgical burden of disease. anomalies, may further hinder the provision of timely, appropriate services. These multifactorial delays are a crucial hurdle in treating both immediately and non-immediately life-threatening anomalies. While ESTIMATING THE IMPACT OF PEDIATRIC non-immediately life-threatening anomalies often SURGERY ON THE GLOBAL BURDEN require emergency interventions, the period before OF DISEASE these conditions become emergencies can be better used to dramatically improve outcomes. In the World Health Organization’s (WHO’s) most recent Global Health Estimates, congenital anomalies constitute 2.1 percent of the total disease burden and rank eleventh Scarcity of Skilled Surgeons in the causes of disease burden (WHO 2013b). Although The scarcity of trained surgeons in LICs and LMICs also impressive, these figures are likely to be underestimates significantly contributes to the burden: one pediatric because of the limited number of anomalies included in general surgeon may serve millions of children (Chirdan the analysis and the difficulties in evaluating incidence, and others 2010), and physicians performing pediatric morbidity, and mortality. Only six congenital surgical surgery may have little or no pediatric surgery training conditions had disability weights in the 2004 estimates, (Ekenze, Ibeziako, and Ezomike 2007; Mhando, Young, and congenital anomalies were not among the new dis- and Lakhoo 2008). Whereas North America has an ability weights estimated in 2012 (Saloman and others estimated one pediatric cardiac surgeon per 3 million 2012; WHO 2008). people, Sub-Saharan Africa has one per 38 million peo- Some researchers have tried to fill the gap with ple (Bernier and others 2010); 75 percent of the world’s evidence-based estimates of selected disability weights population is estimated to have no access to cardiac sur- (Poenaru and others 2013). Of the conditions measured gery (Hoffman 2013). Similarly, 33 percent of the world’s in the Global Health Estimates, cardiac anomalies rep- population is covered by 5 percent of its neurosurgeons resent the greatest overall burden (table 8.2), and, along (Warf 2013). Expanding the pool of specially trained with neural tube anomalies and cleft lip and palate, cause Surgical Interventions for Congenital Anomalies 133 32 million DALYs. Some 57 percent, or 18 million, of averted or cost-effectiveness. Yet, these foundational stud- these DALYs are estimated to be surgically preventable if ies have provided compelling evidence that pediatric sur- outcomes in HICs could be achieved in LICs and LMICs gery is a cost-effective intervention with the potential to (Higashi, Barendregt, and Vos 2013). These anoma- avert more than 67 percent of the DALYs associated with lies typify the reservoir of unmet need that congenital congenital anomalies (Corlew 2010; Higashi, Barendregt, anomalies in LICs and LMICs create (table 8.3). and Vos 2013; Ozgediz and Poenaru 2012; Poenaru 2013; Only a small body of literature evaluates the poten- Wu and Poenaru 2013; Wu, Poenaru, and Poley 2013). tial of surgery to reduce this burden in terms of DALYs Favorable outcomes have been reported in HICs for such conditions as anorectal malformations (ARMs) and con- Table 8.2 Burden of Disease due to Congenital genital diaphragmatic hernia (Poley and others 2008). Anomalies In LICs and LMICs, the human capital approach to cleft lip and palate repair (see chapter 21) has provided very Anomaly DALYs (thousand) YLDs favorable cost-effectiveness analysis estimates. An exten- Cardiac 20,760 565 sion of this methodology to treatment for congenital Neural tube 10,075 759 swelling of the brain in Uganda has also yielded favorable results, at a cost of US$59 to US$126 per DALY averted Down syndrome 2,939 1,225 (Warf and others 2011). Surgical repair of congenital Cleft lip 709 254 inguinal hernias in Uganda has been estimated to have Other chromosomal 2,941 694 an incremental cost-effectiveness of US$12 per DALY Other congenital 20,272 1,835 averted (Eason and others 2012). Another report from Total 57,696 5,332 Cambodia estimates a cost-effectiveness of US$99 per DALY averted over three months for reconstructive sur- Source: WHO 2013b. Note: DALYs = disability-adjusted life years; YLDs = years living with disability. gery for an array of anomalies (Rattray and others 2013). Table 8.3 Prevalent Congenital Anomalies and Avertable Disease Burden Congenital anomaly Brief description Treatment opportunities Cardiac anomalies Most prevalent anomalies Backlog of 1 million to 2 million children need congenital cardiac surgery Incidence: Approximately 8 per 1,000 in India. births Requires relatively resource-intensive treatment compared with other Most common: Ventricular septal defect anomalies; estimated US$2,500 per operation in some programs (hole between the lower chambers of (Hoffman 2013). the heart) Cost containment and capacity-building strategies have been described (Rao 2007). Neural tube defects Incidence: Nearly 1 per 1,000 births Preventable through folate supplementation, a major public health strategy Most common: Spina bifida in many LICs and LMICs. ETV is an innovative, sustainable strategy to treat associated hydrocephalus, or swelling of the brain, with favorable results compared with traditional treatment. Longer-term follow-up confirms the feasibility and effectiveness of community-based strategies for ETV (Warf and others 2011; Warf 2011). Cleft lip and palate Incidence: 1 per 700 live births; slightly Global backlog of unrepaired cleft cases is between 400,000 and 2 million higher in some regions, like Sub- cases. Saharan Africa (Poenaru 2013) Guidelines suggest that cleft lip should be repaired in the first six months Approximately 25 percent of cases of life; cleft palate, in the first year to 18 months. Average age at time of associated with other anomalies repair is nearly age 10 years in Sub-Saharan Africa (Poenaru 2013). Cleft lip may require a single corrective operation. Approximately 20 percent of palate repair cases may require subsequent surgery; postoperative speech therapy is essential (Semer 2001). Sources: Hoffman 2013; Poenaru 2013; Rao 2007; Semer 2001; Warf and others 2011; Warf 2011. Note: ETV = endoscopic third ventriculostomy; LICs = low-income countries; LMICs = lower-middle-income countries. 134 Essential Surgery The benefits of improved pediatric surgical services Africa and constitute a significant clinical load (Calisti in averted morbidity and cost extend across the lifespan. and others 2011; Moore and others 2008). HD has been Treating congenital disease at its inception may result in associated with a number of congenital syndromes and a significantly greater reduction in the burden of disease. anomalies, and may have various genetic causes (Amiel The following sections present examples of anoma- and others 2008). The incidence of HD is comparable to lies that are prime targets for intervention. Because of that of ARMs (Coran and others 2012) and is one of the the lack of cost-effectiveness data, these anomalies are leading causes of pediatric intestinal obstruction in LICs presented as case studies that highlight the preventable and LMICs (Adeyemi 1989; Ameh and Chirdan 2000a; burden of disease and the potential of low-cost mea- Saha and others 2012). Hidden mortality and traditional sures adapted to low-resource settings (i.e., low-income health practices (for example, enemas) mask prevalence countries [LICs] and LMICs) to substantially improve (Bandre and others 2010), suggesting that the burden of outcomes. Further research is urgently needed to develop disease may be significantly underestimated. and evaluate cost-effective treatment programs to take advantage of the substantial DALY upside of treating Diagnosis and Treatment in LICs and LMICs. ARMs congenital anomalies. Congenital heart conditions are are usually diagnosed on physical examination. HD is discussed in more detail in volume 5, Cardiovascular, not visually identifiable, so must be diagnosed based on Respiratory, Renal, and Endocrine Disorders. the symptoms—feeding intolerance, vomiting, abdom- inal distension, delayed passage of the meconium (the first stool passed by a newborn) and severe neonatal Case Study 1: Congenital Colorectal Disease— intestinal infection, or enterocolitis (Amiel and others Anorectal Malformations and Hirschprung’s Disease 2008). Meconium passage may serve as a valuable screen- Description. ARMs and Hirschsprung’s disease (HD) ing tool for HD in HICs, LICs, and LMICs; 95 percent of are two of the most prevalent congenital anomalies. children with HD do not pass the meconium within the first 24 hours of life, while only 1 percent of children • ARMs are physical anomalies that prevent the passage without HD experience a comparable delay. of fecal matter through a distinct anus. Examples HD is definitively diagnosed via rectal biopsy1 (Amiel include absence of an anus or fusion of the anus to and others 2008), but diagnostic ability may be limited other openings in the body (for example, the urethra). in LICs and LMICs because of the cost of biopsy anal- • HD is a functional obstruction of the bowel caused ysis and the scarcity of pathology services (Bandre and by the absence of the nerve cells needed to stimulate others 2010). Many practitioners are forced to provide normal contractile movement of the bowel. If food definitive treatment without confirmation of the HD matter cannot move through the bowel, material diagnosis. Analytic protocols for biopsy specimens can, collects in the preceding bowel and dilates it, causing however, be adapted to the resources of medical lab- megacolon. The intestinal tract may perforate, caus- oratories in LICs and LMICs (Babu and others 2003; ing widespread infection and death. Poenaru and others 2010), and inexpensive radiography can replace costly endoscopic technologies in preopera- HD and some ARMs are not immediately life threat- tive planning (Pratap and others 2007). ening when partial passage of fecal material is possible. In LICs and LMICs, late presentation for nonemer- For example, female children in LICs and LMICs with gency congenital colorectal disease is the norm. More the most common female ARM—vestibular fistula, than 60 percent of patients with HD present late, as chil- whereby the rectum opens into the vagina—often dren, adolescents, and even adults (Ameh and Chirdan remain undiagnosed until much later in life. Untreated, 2000a; Poenaru and others 2010; Sharma and Gupta however, non-immediately life-threatening conditions 2012; Vincent and Jackman 2009). Delayed diagnosis can lead to substantial morbidity and eventual mortality results from a web of interacting societal, cultural, and due to intestinal rupture. socioeconomic factors that delay the diagnosis of other The etiology of ARMs is unclear, but both genetic anomalies detailed in this chapter. Presentation and diag- and environmental factors have been implicated (Davies, nosis are delayed by geographical and financial barriers Creighton, and Wilcox 2004). The incidence of ARMs is to care, social taboo, cultural norms (for example, routine cited as one per 3,000 to 5,000 live births (Chalapathi and traditional enemas), lack of awareness among medical others 2004; Chowdhary and others 2004; Eltayeb 2010), personnel in first- and second-level facilities, inaccu- but this incidence varies with ethnicity and geography rate medical advice, and failed or unwarranted proce- (Moore and others 2008; van Heurn and others 2002). dures at other medical facilities (Al-Jazaeri and others ARMs are reportedly more common in Sub-Saharan 2012; Bandre and others 2010; Ekenze, Ngaikedi, and Surgical Interventions for Congenital Anomalies 135 Obasi 2011; Sharma and Gupta 2012; Sinha and others caring for children with long-term colostomies has not 2008; Vincent and Jackman 2009). Delayed diagnosis of yet been well captured. ARMs leads to severe morbidities and elevated mortality, Primary repair reduces the number of surgeries, which are further heightened for infants in rural areas minimizing treatment costs and averting colostomy- where delayed diagnosis is coupled with subsequent related morbidity and mortality. Good outcomes in LICs transport to distant medical facilities (Adejuyigbe and and LMICs have been reported (Adeniran and Abdur- others 2004; Chalapathi and others 2004; Eltayeb 2010; Rahman 2005; Elhalaby 2006; Ibrahim 2007; Osifo and Turowski, Dingemann, and Giilick 2010). Okolo 2009; Pratap and others 2007), with mortality Delayed presentation of HD is characterized by rates rivaling those in HICs (Ibrahim 2007; Osifo and chronic constipation, abdominal distension, bowel Okolo 2009). However, the prevalence of delayed diag- loops visible through the abdominal wall, failure to nosis and treatment render routine primary repair thrive, anemia, malnutrition, and fecal impaction risky. Reducing delays is key to relieving the preventable (Al-Jazaeri and others 2012; Coran and Teitelbaum burden of congenital colorectal disease. Suggestions 2000; Ekenze, Ngaikedi, and Obasi 2011; Frykman and include the following (Adeniran and Abdur-Rahman Short 2012; Prato and others 2011; Sharma and Gupta 2005; Al-Jazaeri and others 2012; Ameh and others 2006; 2012). Some patients present with bloody diarrhea due Ekenze, Ngaikedi, and Obasi 2011; Olivieri and others to HD-associated enterocolitis, the leading cause of 2012; Peyvestah 2011; Poenaru and others 2010): HD-related morbidity. In HICs, mortality for ARMs is negligible. In LICs • Increase the number of third-level facilities (major and LMICs, mortality reaches 20 percent to 30 percent hospitals offering a full spectrum of services) (Adejuyigbe and others 2004; Adeyemi 1989; Archibong • Increase participation of existing third-level facilities and Idika 2004; Chalapathi and others 2004; Ekenze, in the training of community health centers in diag- Ibeziako, and Ezomike 2007; Peyvasteh and others 2011; nosis and preoperative management Tefera, Teka, and Derbew 2007). The mortality rate for HD • Improve training at the level of the TBA, primary care is less than 5 percent to 10 percent in HICs (Rescorla and provider, and community health worker others 1992; Swenson 2002) but jumps to 20 percent to • Modify medical education curricula to encompass 43 percent in LICs and LMICs (Adeyemi 1989; Ameh and ARMs and HD Chirdan 2000a; Bandre and others 2010; Ekenze, Ibeziako, • Target surgeons at first-level hospitals to perform and Ezomike 2007). These disparities are linked to delayed colostomies with available resources diagnosis and treatment, sepsis,2 and the absence of crit- • Institute low-cost modifications to standard repair ical care when patients present with advanced complica- procedures tions (Adeniran and Abdur-Rahman 2005; Chalapathi and others 2004; Chowdhary and others 2004). Substantial loss to follow-up after colostomy for- Both ARMs and HD can be treated with either pri- mation in LICs and LMICs remains a challenge, and mary (one-step) or staged (multistep) surgical repair innovative approaches to ensuring patient return or (Coran and others 2012). These operations generally local follow-up in home regions must be developed to do not require intensive postoperative care, but they overcome barriers to continuity of care. do require general anesthesia. Delays in diagnosis often preclude primary repair because these repairs cannot be performed when the bowel is grossly distended. In such Case Study 2: Abdominal Wall Defects—Omphalocele cases, a colostomy3 is a life-saving first step in staged and Gastroschisis repair. Colostomy complications, however, are common Description. Omphalocele and gastroschisis are abdom- in HICs, LICs, and LMICs (Chalya and others 2011; inal wall defects in which the internal organs, or viscera, Chandramouli and others 2004; Patwardhan and others protrude through the abdominal wall. In omphalocele, 2001). The risks are compounded in LICs and LMICs by the gut and other abdominal organs, such as the liver, the prohibitive cost of colostomy bags, cultural preju- spleen, and gonads, protrude through the abdominal wall dice, and limited parental understanding (Adeniran and into a membranous sac. In gastroschisis, no sac is present Abdur-Rahman 2005; Chandramouli and others 2004; and usually only the gut protrudes from the abdomen Olivieri and others 2012). Although simple, inexpensive (Coran and others 2012). Patients with omphalocele can treatments may ameliorate some of these challenges be fed if the sac is intact; those with gastroschisis cannot (Chalya and others 2011), a significant burden remains. be fed and quickly perish without treatment. Many children live for years with colostomies without The incidence of omphalocele is approximately 2.18 receiving definitive repair. The burden on families of to 5 per 10,000 live births; that of gastroschisis is 3.3 to 136 Essential Surgery 5 per 10,000 live births (Canfield and others 2006; Coran necessitating the use of intravenous nutrition, often and others 2012; Sadler 2010; Stoll and others 2001). The not available in poorer countries. It has been suggested incidence of gastroschisis is on the rise and varies geo- that in-house birth at centers equipped to medically graphically (Andrew, Holland, and Badawi 2010; Arnold manage patients with abdominal wall defects is essential 2004; Benjamin and others 2010; Castilla, Mastroiacovo, to improving outcomes, as is improving training for and Orioli 2008; Laughon and others 2003; Loane, Dolk, transport personnel, obstetricians, and primary care and Bradbury 2007; Vu and others 2008). physicians (Sekabira and Hadley 2009). Training TBAs Risk factors for omphalocele include chromosomal to recognize omphalocele and gastroschisis, and to place anomalies, very young and very advanced maternal children from the shoulder down in clean polyethylene age, lack of multivitamin and folic acid supplementa- bags to protect the bowels during transport, is another tion during pregnancy, and maternal history of fevered viable option for reducing complications associated with illness (Botto and others 2002; Botto, Mulinare, and delayed presentation (Ameh and Chirdan 2000b). Erickson 2002; Frolov, Alali, and Klein 2010; Mills and Surgical procedures commonly used in HICs may others 2012). Gastroschisis has not yet been associated increase mortality in LICs and LMICs, largely as a result with any particular genes. Risk factors for gastroschisis of infection and sepsis (Ameh and Chirdan 2000b; include young maternal age, low socioeconomic status, Uba and Chirdan 2003); nonsurgical or altered sur- poor nutrition, and lack of vitamin supplementation gical procedures may be preferable. Uba and Chirdan during pregnancy (Coran and others 2012). Mothers in (2003) report the successful treatment of unruptured LICs and LMICs are more likely to have children at both omphalocele using daily application of scab-inducing younger and more advanced ages, to have limited family topical ointments, leading to eventual skin growth over planning knowledge and resources, and to suffer nutri- the defect. Bedside placement of a silo bag followed by tional deficiencies. Accordingly, their children are likely gradual reduction of the viscera into the abdomen and to be at greater risk for omphalocele and gastroschisis. sutureless repair is a potentially cost-effective treatment strategy worthy of additional evaluation in LICs and Diagnosis and Treatment in LICs and LMICs. Ultra- LMICs. Several studies have investigated low-cost alter- sonography, a low-cost technology once in place, can detect natives to silos, including transfusion bags and female omphalocele and gastroschisis before birth with high suc- condoms (Bustorff-Silva and others 2008; Miranda cess (Richmond and Atkins 2005). This technology can and others 1999). The female condom is particularly inform decisions about pregnancy termination and mode intriguing because its use requires no sutures, surgery, of delivery, facilitating improvements in outcomes. or anesthesia; allows for easy preoperative observation; Several effective surgical strategies for omphalocele and allows gravity to gradually move the viscera into the have been described. Gastroschisis necessitates greater abdomen (Bustorff-Silva and others 2008). attention to heat loss and moisture preservation because Once infants with omphalocele or gastroschisis sur- a larger surface area of viscera is exposed. Historically, vive the neonatal period, there is little to no associated primary closure has been the treatment of choice in that disability or mortality. These anomalies are highly treat- it limits damage incurred by exposure. Recent studies able and thus potentially highly DALY averting. have shown that using a silo (a moisture-retaining bag that holds the viscera before they are returned to the abdomen) and postponing closure for hours to days can Case Study 3: Clubfoot be equally effective (Coran and others 2012). Description. Talipes equinovarus, or clubfoot, is a com- Treatment is highly effective in HICs; multiple series plex congenital anomaly in which the entire foot is rotated report survival rates of 70 percent to 95 percent for inward (van Bosse 2011). Clubfoot may be idiopathic— omphalocele and 90 percent or greater for gastroschisis without an identifiable cause—or associated with other (Coran and others 2012). In comparison, the mortality congenital anomalies. The etiology is unknown but likely associated with omphalocele and gastroschisis in LICs involves genetic and environmental factors (Dobbs and and LMICs is shockingly elevated, with survival falling Gurnett 2009). According to estimates from HICs, the to less than 20 percent in some studies (Askarpour incidence is approximately 1 per 1,000 live births (Coran and others 2012; Richmond and Atkins 2005). Delayed and others 2012). However, incidence varies widely with presentation plays a key role because hypothermia and ethnicity, and reports from LICs and LMICs have shown gangrenous bowel may develop in the interim (Ameh that incidence may be about 1 per 500 live births (Dobbs and Chirdan 2000b; Sekabira and Hadley 2009; Uba and Gurnett 2009; Mkandawire and Kaunda 2002); and Chirdan 2003). An additional challenge with gastro- 80 percent of children with untreated clubfoot are born schisis is that bowel function can be impaired initially, in LICs and LMICs (WHO 2013a). Untreated clubfoot Surgical Interventions for Congenital Anomalies 137 leads to lifelong disability, social stigmatization, and performed by health and allied health professionals4 decreased economic self-sufficiency in adulthood (Alavi (Janicki and others 2009; Lavy and others 2007; Mayo and others 2012; Lourenço and Morcuende 2007). and others, n.d.), an advantageous attribute in contexts with few orthopedic surgeons. It requires no specialized Diagnosis and Treatment in LICs and LMICs. The surgical facilities and produces a functional foot (Gupta most effective treatment for idiopathic clubfoot, and others 2008). the Ponseti method, is largely nonsurgical. We have Treatment programs using the Ponseti method have included this anomaly for analysis because it exempli- been set up in many LICs and LMICs, with success rates fies the importance of holistically approaching surgical that regularly approximate those seen in HICs (Goksan disease to use both low-cost surgical and nonsurgical and others 2006; Gupta and others 2008; Jawadi 2010; interventions to reduce the burden of disease. Makhdoom and others 2011; Mendez-Tompson and The Ponseti method, in which a series of casts are others 2012; Panjavi and others 2012; Sarrafan and applied between incremental manipulations of the foot others 2012). The Ponseti method is also successful in by trained practitioners, is successful in up to 98 percent treating neglected clubfoot in LICs and LMICs, yielding of patients (WHO 2013a). The Achilles tendon is often superior outcomes and incurring significantly lower cut through the skin to correct lingering deformity, and costs than purely surgical interventions (Adegbehingbe corrective braces are worn for several years to prevent and others 2010; Hegazy, Nasef, and Abdel-Ghani 2009; relapse (Dobbs and others 2000). The Ponseti method is Spiegel and others 2009). also successful in treating neglected idiopathic clubfoot, The success of national clubfoot programs (box 8.1) in which the anomaly is not treated before walking age provides strong evidence for the utility of task-shifting, (Lourenço and Morcuende 2007). If surgery alone is that is, training paramedical practitioners to perform used to correct this aggravated form of the deformity, select health care tasks. Nonphysician practitioners functionality is low and may degrade into crippling pain trained in orthopedics and the Ponseti method can and weakness in adolescence and adulthood (Gupta and achieve results comparable to those of surgeons in others 2008). HICs (Tindall and others 2005). Collaborations among The Ponseti procedure is well suited to use in LICs diverse partners, including nongovernmental organiza- and LMICs; it is a low-cost intervention that can be tions, ministries of health, and academic institutions, Box 8.1 The Uganda Sustainable Clubfoot Care Project Clubfoot, the most common cause of locomotor in serial casting in rural hospitals and medical disability in low-income countries leads to pro- officers in tenotomy found impairments in activities of daily life, social • Development and distribution of locally made exclusion, and abandonment. After several years of orthoses, or mechanical devices (for example, pilot intervention, the Uganda Sustainable Clubfoot braces) to provide support and correct alignment Care Project was implemented in 2000. Essential of the clubfoot. elements include the following: • Development of a national strategic plan address- In 2006 and 2007, 872 children were treated, nearly ing all levels of the health system 800 providers were trained, and services were made • Endorsement by the Ministry of Health and available in 21 hospitals. Using this experience in incorporation into the National Health Policy Uganda and a similar program in Malawi as a basis, • Community awareness campaigns interventions have been implemented in 10 other • Sensitization of maternity units via education countries; early two-year follow-up data suggest • Training: Ponseti method trainers at the national similarly successful results. hospital to train nonphysician orthopedic officers Source: Pirani and others 2009; Tindall and others 2005. 138 Essential Surgery are instrumental for increasing the number of trained The strengths and weaknesses of these strategies are paramedical practitioners, and thereby the availability summarized in table 8.4. It is critical that local exper- of treatment (Owen and others 2012). To achieve these tise and buy-in be integrated into all efforts to increase goals, it is critical to implement a coordinated, standard- the accessibility of pediatric surgery so as to create ized program to decentralize care, and to integrate edu- sustainable systems that increase long-term capacity and cation, awareness, and service delivery into the public take advantage of the substantial potential intellectual, health sector. creative, and personnel resources in LICs and LMICs. Strategy 1. Cultivating Treatment Centers in LICs and IMPLEMENTATION AND SURVEILLANCE LMICs PRIORITIES Recent humanitarian efforts have favored establishing sustainable surgical centers in LICs and LMICs, staffed Addressing the Burden of Disease of Congenital by either local or foreign personnel. This approach max- Anomalies imizes the number of children treated and enables local Strategies to increase the accessibility of surgical care for trainees to learn to practice in their future professional children with congenital anomalies include development environments, preventing later struggles to adapt pro- of treatment centers for specific conditions (niche hospi- tocols learned abroad to local resources (Larrazabal and tals), short-term surgical missions, partnerships to train others 2007). The entire surgical team can be concur- local providers, and the transporting of patients to other rently trained, prepping both the surgeon and the center countries for care. Interventions at the policy level may to operate independently (Larrazabal and others 2007; also play a role, as may novel tools such as telemedicine. Loisance 2012). Table 8.4 Increasing the Accessibility of Pediatric Surgery Strategy Advantages Disadvantages Treatment centers in Creates infrastructure and expertise to broadly affect Streamlined centers often not integrated with local training LICs and LMICs the burden of disease caused by congenital anomalies programs and public health care systems Streamlines care if center focuses on one pathology or organ system Provides treatment in home countries Surgical missions Minimizes costs and culture shock for patients Episodic Streamlines care if missions focus on one condition Limited time window restricts number of patients treated Offers opportunity to train local personnel Pressure to deliver care in limited period may restrict training Are well suited for nonemergency conditions with efforts backlogs Follow-up limited Integration with existing services may be limited Not designed to treat emergency life-threatening conditions Academic partnerships Provides coordinated interface for students and Not as focused on delivery of care professionals from HICs, LICs, and LMICs to learn from Research may not be truly collaborative and collaborate with each other Potential for medical tourism by HIC practitioners, especially Opportunity for training and resource sharing if training not provided to LIC and LMIC partners Facilitates scholarly approach to intervention and Financial sustainability may be limited by availability of evaluation institutional funding Human resources Task-shifting increases health care access Necessitates rigorous regulation and standardization and policy changes Telemedicine table continues next page Surgical Interventions for Congenital Anomalies 139 Table 8.4 Increasing the Accessibility of Pediatric Surgery (continued) Strategy Advantages Disadvantages Potentially reduces transport risks and costs No opportunity for hands-on training Builds local capacity through consultation Improves communication between different points of health care access Health care delivery Increases level of care compared with local systems Costly outside of LICs and Benefits only a few patients LMICs Does not contribute to developing capacity in LICs and LMICs Note: HICs = high-income countries; LICs = low-income countries; LMICs = lower-middle-income countries. Successful centers have developed from inter- Strategy 2. Surgical Missions national partnerships, foreign humanitarian initia- The short-term surgical mission, also commonly referred tives, and home-grown efforts in LICs and LMICs to as humanitarian assistance or a volunteer trip, is an (Bode-Thomas 2012), with evidence that continuous established health care delivery model that is becoming support through development programs can build increasingly popular. Individual providers or organized pediatric surgery capacity. Networks of faith-based teams travel from HICs to deliver surgical care in LICs hospitals also provide specialized surgical services, and LMICs (Martiniuk and others 2012). Smile Train such as the CURE network, which focuses primarily and Operation Smile, the two largest global cleft lip and on neurosurgery and orthopedics; CBM International, palate charities, exemplify two different models of suc- which supports an array of surgical services; and the cessful, long-running surgical missions. Operation Smile Pan-African Academy of Christian Surgeons network, primarily funds teams from HICs to provide short-term which has developed training programs in association health care delivery and training in LICs and LMICs; with BethanyKids, a faith-based pediatric surgical Smile Train5 funds local providers to offer outreach and organization. Surgical mission–oriented organiza- training (Poenaru 2013). In some regions, these teams tions may also develop treatment centers, as has been provide the only surgical services for children (Walker done by Operation Smile, a mission program special- and others 2010). In recent years, Operation Smile has izing in cleft lip and palate repairs (Patel and others also developed treatment centers as a more sustainable 2013). approach (Magee and others 2012). Treatment at these centers can be tailored to available Sustainability, follow-up for postsurgical compli- resources. Less-expensive, but effective, diagnostic and cations, and integration with existing health systems therapeutic modalities can be used. Simple, palliative are significant challenges for the inherently episodic surgeries may predominate in the neonatal period if surgical mission model. Perhaps most important, sur- early definitive repair is too risky. Cheaper surgical gical missions are better suited for “prevalent” rather materials are produced by countries like Brazil and than “incident” conditions. Prevalent conditions incur China; medical equipment companies may be persuaded increasing morbidity, whereas incident conditions are to make donations; and some disposable surgical materi- surgical emergencies. A greater proportion of the burden als can be sterilized and reused (Rao 2007; Senga and of disease may be averted by targeting emergency con- others 2013). ditions, but emergency treatment cannot be improved The few cost-effectiveness analyses that have been without improving capacity at the systems level (Bickler published support the feasibility of developing local and others 2010). treatment centers. For example, at the CURE Children’s Hospital in Mbale, Uganda, children with hydrocephalus are treated at an estimated cost of US$59 to US$126 per Strategy 3. Partnerships between Academic DALY averted, with US$3 million to US$5 million saved Organizations and Development Programs to Uganda, and US$5 million to US$188 million saved Academic organizations have increasingly focused based on statistical calculations of the value of a life on augmenting surgical capacity in LICs and LMICs (Warf and others 2011). through partnerships (Calland and others 2013; Qureshi 140 Essential Surgery and others 2011). Some organizations subsidize aca- pediatric surgical conditions has not been specifically demic surgeons, who then deliver care, train providers, analyzed. and conduct research in LICs and LMICs. Partnerships also provide mechanisms by which practitioners from LICs can obtain foreign training in middle-income Strategy 5. Telemedicine countries (MICs) (for example, a Sub-Saharan African Telemedicine6 may increase the accessibility of limited practitioner training in India) or HICs. Training outside surgical specialists to large populations requiring care. of the home environment has the disadvantage that the Chaotic roads and a lack of medical transport compli- trainee may not return for practice. Funding the training cate the great distances that patients in LICs and LMICs of local practitioners by underwriting the presence of must travel to reach care. Children seeking treatment visiting surgeons in partnered development programs may present in critical and sometimes unsalvageable may be an effective alternative. For example, during condition following such physiologically stressful transit the course of a four-year project funded by the Italian (Rao 2007). With telemedicine, physicians at local or Cooperation in Eritrea, local Eritrean surgeons achieved regional medical centers can interact with experts at independence and favorable outcomes in the treatment centralized third-level facilities to guide patient treat- of a wide range of congenital anomalies (Calisti and ment, potentially circumventing the need for patients to others 2011). Overall, the scope of activities undertaken undergo life-threatening journeys. The cost burden of by academic organizations in these partnerships varies travel and treatment for families is decreased, and unspe- widely, and outcomes of many permutations of partner- cialized providers can receive training from specialized ship are not yet well characterized. peers (Sekar and Vilvanathan 2007). Telemedicine can also link medical centers for educational or research purposes (Hadley and Mars 2008). This developing Strategy 4. Human Resources and Policy Changes technology has the potential to beneficially decentralize Policy changes, such as the provision of free health care specialized care and education in LICs and LMICs. to children, may increase access to pediatric surgery (Groen and others 2013). The expansion of training pro- grams is key to ensuring that children with anomalies are Strategy 6. Health Services Delivery Outside of diagnosed in a timely manner and can access appropri- Local Systems ate surgical services. Regional professional societies offer Families may seek care in foreign treatment centers, a limited number of training spots and scholarships, and funded out of pocket, through community fund- training programs need support (Elhalaby and others raising, or by humanitarian organizations. Increased 2012). More training positions are required to meet the access to advanced treatment methods saves lives need for trained pediatric surgeons and the interest level that would otherwise be lost. However, transport- of general surgery trainees. To date, only limited analy- ing children to foreign centers limits the number of ses of the cost-effectiveness of such programs have been children treated. Because the cost of surgery abroad conducted. often surpasses a family’s annual income in LICs and Specially trained paramedical practitioners may be a LMICs, even the highest-earning families must rely on viable solution to the scarcity of providers, as demon- limited governmental and nongovernmental agency strated by the success of clubfoot programs; however, funds (Sadoh, Nwaneri, and Owobu 2011). If patients the scope of treatment may be limited to select condi- require multiple surgeries, financial sponsors must tions (Mayo and others, n.d.; Pirani and others 2009; decide whether to perform the surgery at all, abstain Tindall and others 2005). The scope of practice for a from follow-up surgeries, or fly the patient back for pediatric general surgeon includes congenital anoma- additional surgeries. If patients die abroad, the fami- lies, acquired surgical diseases, and a high proportion lies must wrestle with substantial financial and emo- of emergencies. This breadth has made it challenging to tional challenges in coordinating burial arrangements design and implement intervention packages in hospitals (Bode-Thomas 2012). Furthermore, this approach does and health care systems. Other surgical providers may do not build local surgical capacity. The social and eco- their best to meet the need, but the shortfall is tremen- nomic costs for patients and families who seek care dous. Pediatric anesthesia providers are similarly few, as abroad are likely significant but have not been esti- are trained pediatric neurosurgeons, cardiac surgeons, mated; an estimate may provide incentives for govern- orthopedic surgeons, and other surgical subspecialists. ments and funders to invest in local care. Although task-shifting has been promoted to meet the These strategies are not mutually exclusive; they may need for essential surgery in adults, its applicability to coexist or evolve into different models. Surgical Interventions for Congenital Anomalies 141 Although the development of health care capacity (table 8.5). Robust data from LICs and LMICs are sparse; within LICs and LMICs is crucial to the long-term therefore, the following recommendations—based on reduction of the burden of disease associated with con- the available literature—should be understood as the best genital anomalies, other intervention strategies provide available at this time. Future research will undoubtedly additional and immediate opportunities to improve lead to more precise, substantiated recommendations. pediatric surgical care and outcomes. • The village health center should have health pro- viders trained to identify anomalies. In Tanzania, ACTION PLAN educating TBAs and using a birth card to register and record birth data are being evaluated as tools Clinical Intervention at Every Level for improving identification of treatable anomalies Given that platforms for delivery vary by setting, we (Norgrove Penny, personal communication) and may propose only general guidelines for congenital anomalies be useful in other practice settings. Public education Table 8.5 Pediatric Surgery Capacity in an Ideal System Village health First-level Second-level Third-level Capacity center hospital hospital hospital Airway management, fluid replacement, bleeding control, Xa X X X antibiotic therapy Blood transfusion Xa X X Tracheal tube X a X X Local anesthesia X X X X Spinal and general anesthesia X X X Pediatric hernia X X X Pediatric hernia (infant) Xa X Umbilical hernia X X X Pyloric stenosis Xa X Colostomy Xa X X Neonatal bowel obstruction (atresia, stenosis, malrotation) X Tracheoesophageal fistula repair Xa Clubfoot X X X Cleft lip X X X Anorectal malformations or Hirschsprung’s disease (first stage; X X X often colostomy) Anorectal malformations or Hirschsprung’s disease (definitive X X treatment) Abdominal wall defects Xa X Hydrocephalus Xa X Congenital cardiac anomalies Xa X Spina bifida X Bladder extrophy X Undescended testicles X X Hypospadias X Note: “Capacity” is defined as trained staff available 24 hours, seven days a week, with adequate equipment and supplies. a. Capacity should already be there but usually is not. 142 Essential Surgery is important for raising awareness that congenital the mechanisms to strengthen systems for pediatric anomalies are treatable and not a death sentence; this surgery. vital information prompts families to seek care. • The first-level hospital should have the ability to Metric Optimization. The quantitative metrics of stabilize pediatric patients with surgical emergencies disease burden should be optimized. Although DALYs and to definitively treat conditions for which the are an accepted metric, they are difficult to apply capacity exists. In-depth guidelines have been sug- practically. Surgical backlogs can be calculated for gested for first-level hospitals but have not yet been congenital anomalies and can be a useful advocacy tool tested or validated (Bickler and Ameh 2011). for estimating the resources needed to treat prevalent, • The second-level hospital should provide life-saving nonfatal anomalies. Improved measurements of the surgical treatments, especially those that are part of burden imposed by delayed access to care have not yet staged repair procedures, and should house at least been developed. In middle- and high-income countries, one specialist surgeon with training in pediatric gen- many prevalent congenital anomalies are treated in the eral surgery. first year of life; in LICs, they are never treated or are • The third-level hospital must be able to provide treat- treated years later, after children have suffered unnec- ment for a broader range of neonatal emergencies and essary complications. Many diseases with 100 percent more complex urgent conditions. The availability of survivability in HICs result in death or permanent specialist pediatric surgeons and anesthesia providers disability in LICs and LMICs. Improved measurement with expertise in infants and children is critical. of disparities must be highlighted as an advocacy tool for health equity. Research Priorities Integration Model Evaluation. Models for the integra- Improved data collection and identification of dispari- tion of pediatric surgical services within existing child ties will fuel advocacy and inform targeted intervention health initiatives should be evaluated. Large-scale child programs for congenital anomalies. Research priorities health initiatives exist (such as the WHO’s Integrated include the following: Management of Childhood Illness but have not his- torically included surgical care. Providers of children’s Data Expansion for Further Evaluation. Epidemiology, surgical services share a general concern that if the par- prevalence, and incidence of disease in various health ticular needs of children are not specifically addressed, contexts need further evaluation. Epidemiology may then they are often neglected. Although congenital vary locally, but additional data are needed (Bickler anomalies are sometimes considered noncommunicable 2000). Registries for selected anomalies may assist in diseases (as in the Global Burden of Disease study), the improving surveillance (for example, via participation agenda of the noncommunicable disease movement has in the International Clearinghouse for Birth Defects not addressed them. Furthermore, greater planning is Surveillance and Research). The evaluation of hidden needed between networks of specialty organizations and mortality and morbidity will better approximate the true providers treating a broad range of congenital anomalies burden of disease. to collaborate where possible. Capacity Assessment and Guideline Development. Cost-Effectiveness Data Generation. Cost-effectiveness The capacity for pediatric surgical care at various levels data should be generated to evaluate and select models of the health system must be assessed, and guidelines to improve access to care. Although cost-effectiveness for minimum human resources and infrastructure for has been estimated for adult general surgery wards in countries at different stages of development should selected hospitals (Gosselin, Thind, and Bellardinelli be created. The WHO Tool for Situational Analysis to 2006), only one attempt has been made for pediatric Assess Emergency and Essential Surgical Care includes surgical wards (Rattray and others 2013). Low-cost only two items pertaining to pediatric surgical care, technological innovations and modification of surgical and an alternative capacity tool has been proposed procedures hold great promise to improve periopera- (Nacul and others 2013). This tool could be refined tive care (Hadley 2008). Cost-effectiveness analysis of and further evaluated as it is piloted in different coun- training programs could also aid advocacy for greater tries. Although surgical outreach programs can tackle resources for training. the backlog of nonemergency conditions, emergency conditions require development of the whole health Marketing and Advocacy Alignment. Marketing and system. More work is needed to define and develop advocacy should become more aligned. Congenital Surgical Interventions for Congenital Anomalies 143 anomalies vary greatly in scope and severity. Some REFERENCES treatable visible anomalies have received greater empha- Abdur-Rahman, L. O., N. A. Abdulrasheed, and J. O. Adeniran. sis than those invisible anomalies for which it has been 2011. “Challenges and Outcomes of Management of more difficult to engage donor programs for targeted Anterior Abdominal Wall Defects in a Nigerian Tertiary support. Improved multidimensional measurements of Hospital.” African Journal of Paediatric Surgery 8 (2): the burden may help to make children and families suf- 159–63. fering from all treatable anomalies more visible to the Abubakar, A. M., M. A. Bello, D. Y. Chinda, K. Danladi, and public health community. Development of innovative I. M. Umar. 2011. “Challenges in the Management of Early strategies for this process is needed. versus Late Presenting Congenital Diaphragmatic Hernia in a Poor Resource Setting.” African Journal of Paediatric Surgery 8 (1): 29–33. Adegbehingbe, O. O., L. M. Oginni, O. J. Ogundele, A. L. Ariyibi, P. O. Abiola, and O. D. Ojo. 2010. “Ponseti CONCLUSIONS Clubfoot Management: Changing Surgical Trends in Nigeria.” Iowa Orthopaedic Journal 30: 7–14. This chapter highlights the considerable burden of Adegboye, V., S. Omokhodion, O. Ogunkunle, M. Obajimi, disease associated with congenital anomalies and A. Brimmo, and O. Adebo. 2002. “Experience with the outlines key strategies for intervention. The conse- Management of Congenital Diaphragmatic Hernia at the quences of nonintervention are readily apparent. It University College Hospital, Ibadan.” Nigerian Journal of is both an economic and a moral imperative that Paediatrics 29 (2): 40–46. global partners invest in pediatric surgery as a vital Adejuyigbe, O., A. M. Abubakar, O. A. Sowande, component of reducing the burden of disease and O. S. Olayinka, and A. F. Uba. 2004. “Experience with improving the public health and economic fortunes Anorectal Malformations in Ile-Ife, Nigeria.” Pediatric of LICs and LMICs. Surgery International 20 (11–12): 855–58. Adeniran, J. O., and L. Abdur-Rahman. 2005. “Late-Stage Correction of Intermediate Imperforate Anus in Males.” Pediatric Surgery International 21 (2): 88–90. NOTES Adeyemi, D. 1989. “Neonatal Intestinal Obstruction in a Developing Tropical Country: Patterns, Problems, and The World Bank classifies countries according to four income Prognosis.” Journal of Tropical Pediatrics 35 (2): 66–70. groupings. Income is measured using gross national income Agarwala, S., V. Bhatnagar, M. Bajpai, D. Gupta, and D. Mitra. (GNI) per capita, in U.S. dollars, converted from local currency 1996. “Factors Contributing to Poor Results of Treatment using the World Bank Atlas method. Classifications as of July of Esophageal Atresia in Developing Countries.” Pediatric 2014 are as follows: Surgery International 11 (5–6): 312–15. Alavi, Y., V. Jumbe, S. Hartley, S. Smith, D. Lamping, and others. • Low-income countries (LICs) = US$1,045 or less in 2013 2012. “Indignity, Exclusion, Pain and Hunger: The Impact • Middle-income countries (MICs) are subdivided: of Musculoskeletal Impairments in the Lives of Children • Lower-middle-income (LMICs) = US$1,046 to US$4,125 in Malawi.” Disability and Rehabilitation 34 (20): 1736–46. • Upper-middle-income (UMICs) = US$4,126 to US$12,745 Al-Jazaeri, A., S. Al-Shanafey, M. Zamakhshary, W. Al-Jarbou, • High-income countries (HICs) = US$12,746 or more E. Hajr, and others. 2012. “The Impact of Variation in Access to Care on the Management of Hirschsprung 1. Rectal biopsy: A surgeon removes small samples of tissue Disease.” Journal of Pediatric Surgery 47 (5): 952–55. from the patient’s rectum. These samples are subjected to Al-Salem, A. H., M. Tayeb, S. Khogair, A. Roy, N. Al-Jishi, laboratory tests that lead to a diagnosis. and others. 2006. “Esophageal Atresia with or without 2. Sepsis: Severe widespread infection within the body that Tracheoesophageal Fistula: Success and Failure in 94 Cases.” can lead to death. Annals of Saudi Medicine 26 (2): 116–19. 3. Colostomy: Temporary creation of an opening in the Ameh, E. A., and L. B. Chirdan. 2000a. “Neonatal Intestinal abdomen that is connected to the intestine; fecal material Obstruction in Zaria, Nigeria.” East African Medical Journal exits the opening into a colostomy bag. 77 (9): 510–13. 4. Allied health or paramedical practitioners: Nonphysician ———. 2000b. “Ruptured Exomphalos and Gastroschisis: health professionals who provide supplementary or emer- A Retrospective Analysis of Morbidity and Mortality gency health services. in Nigerian Children.” Pediatric Surgery International 5. Smile Train. “Smile Train Report Card.” http://www 16 (1–2): 23–25. .smiletrain.org/our-model/. Ameh, E. A., P. M. Mshelbwala, L. Sabiu, and L. B. Chirdan. 2006. 6. Telemedicine: Using technology to exchange informa- “Colostomy in Children—An Evaluation of Acceptance tion between different locations to improve training or among Mothers and Caregivers in a Developing Country.” clinical care. South African Journal of Surgery 44 (4): 138–39. 144 Essential Surgery Amiel, J., E. Sproat-Emison, M. Garcia-Barcelo, F. Lantieri, Bickler, S. W., and H. Rode. 2002. “Surgical Services for G. Burzynski, and others. 2008. “Hirschsprung Disease, Children in Developing Countries.” Bulletin of the World Associated Syndromes, and Genetics: A Review.” Journal of Health Organization 80 (10): 829–35. Medical Genetics 45 (1): 1–14. Bode-Thomas, F. 2012. “Challenges in the Management Andrew, J. A., K. W. Holland, and N. Badawi. 2011. of Congenital Heart Disease in Developing Countries.” “Gastroschisis: An Update.” Pediatric Surgery International In Congenital Heart Disease: Selected Aspects, edited by 26 (9): 871–78. P. Syamasundar Rao, 263–72. Rijeka, Croatia: Intech. http:// Anwar-ul-Haq, N. Akhter, Ubaidullah, Javeria, Samiullah, www.intechopen.com/books/congenital-heart-disease and others. 2009. “Factors Affecting Survival in Patients -selectedaspects/challenges-in-the-management-of with Oesophageal Atresia and Tracheo-Oesophageal Fistula.” -congenital-heart-disease-in-developing-countries. Journal of Ayub Medical College Abbottabad 21 (4): 129–33. Botto, L. D., J. D. Erickson, J. Mulinare, M. C. Lynberg, Archibong, A. E., and I. M. Idika. 2004. “Results of Treatment and Y. Liu. 2002. “Maternal Fever, Multivitamin Use, in Children with Anorectal Malformations in Calabar, and Selected Birth Defects: Evidence of Interaction?” Nigeria.” South African Journal of Surgery 42 (3): 88–90. Epidemiology 13 (4): 485–88. Arnold, M. 2004. “Is the Incidence of Gastroschisis Rising in Botto, L. D., J. Mulinare, and J. D. Erickson. 2002. “Occurrence South Africa in Accordance with International Trends? A of Omphalocele in Relation to Maternal Multivitamin Retrospective Analysis at Pretoria Academic and Kalafong Use: A Population-Based Study.” Pediatrics 109 (5): Hospitals, 1981–2001.” South African Journal of Surgery 904–08. 42 (3): 86–88. Bustorff-Silva, J. M., A. F. S. Schmidt, A. Goncalves, S. Marba, Askarpour, S., N. Ostadian, H. Javaherizadeh, and S. Chabi. and L. Sbragia. 2008. “The Female Condom as a Temporary 2012. “Omphalocele, Gastroschisis: Epidemiology, Survival, Silo: A Simple and Inexpensive Tool in the Initial and Mortality in Imam Khomeini Hospital, Ahvaz-Iran.” Management of the Newborn with Gastroschisis.” Journal Polski Przeglad Chirurgiczny 84 (2): 82–85. of Maternal-Fetal and Neonatal Medicine 21 (9): 648–51. Babu, M. K., U. Kini, K. Das, A. Alladi, and A. D’Cruz. 2003. Calisti, A., K. Belay, G. Mazzoni, G. Fiocca, G. Retrosi, and “A Modified Technique for the Diagnosis of Hirschsprung others. 2011. “Promoting Major Pediatric Surgical Care in Disease from Rectal Biopsies.” National Medical Journal of a Low-Income Country: A 4-Year Experience in Eritrea.” India 16 (5): 245–48. World Journal of Surgery 35 (4): 760–66. Bakshi, K. D., B. Vaidyanathan, K. R. Sundaram, S. J. Roth, Calland, J. F., R. T. Petroze, J. Abelson, and E. Kraus. 2013. K. Shivaprakasha, and others. 2007. “Determinants of Early “Engaging Academic Surgery in Global Health: Challenges Outcome after Neontal Cardiac Surgery in a Developing and Opportunities in the Development of an Academic Country.” Journal of Thoracic and Cardiovascular Surgery Track in Global Surgery.” Surgery 153 (3): 316–20. 134 (3): 765–71. Canfield, M. A., M. A. Honein, N. Yuskiv, J. Xing, C. T. Mai, and Bandre, E., R. A. Kabore, I. Ouedraogo, O. Sore, T. Tapsoba, others. 2006. “National Estimates and Race/Ethnic-Specific and others. 2010. “Hirschsprung’s Disease: Management Variation of Selected Birth Defects in the United States, Problem in a Developing Country.” African Journal of 1999–2001.” Birth Defects Research Part A: Clinical and Paediatric Surgery 7 (3): 166–68. Molecular Teratology 76 (11): 747–56. Banu, T., M. Hoque, K. Laila, H. Ashraf Ul, and A. Hanif. 2009. Castilla, E. E., P. Mastroiacovo, and I. M. Orioli. 2008. “Management of Male H-Type Anorectal Malformations.” “Gastroschisis: International Epidemiology and Public Pediatric Surgery International 25 (10): 857–61. Health Perspectives.” American Journal of Medical Genetics Benjamin, B. G., M. K. Ethen, C. L. Van Hook, C. A. Myers, and Part C: Seminars in Medical Genetics 148C (3): 162–79. M. A. Canfield. 2010. “Gastroschisis Prevalence in Texas CDC (Centers for Disease Control). 2012. Birth defects. 1999–2003.” Birth Defects Research Part A: Clinical and Chalapathi, G., S. K. Chowdhary, K. L. Rao, R. Samujh, Molecular Teratology 88 (3): 178–85. K. L. Narasimhan, and others. 2004. “Risk Factors in Bernier, P. L., A. Stefanescu, G. Samoukovic, and the Primary Management of Anorectal Malformations in C. Tchervenkov. 2010. “The Challenge of Congenital Heart Northern India.” Pediatric Surgery International 20 (6): Disease Worldwide: Epidemiologic and Demographic 408–11. Facts.” Pediatric Cardiac Surgery Annual of the Seminars in Chalya, P. L., J. B. Mabula, E. S. Kanumba, G. Giit, A. B. Thoracic and Cardiovascular Surgery 13 (1): 26–34. Chandika, and others. 2011. “Experiences with Childhood Bickler, S. W. 2000. “Non-Communicable Diseases: Is Their Colostomy at a Tertiary Hospital in Mwanza, Tanzania.” Emergence in Industrialized Societies Related to Changes Tanzania Journal of Health Research 13 (3): 1–12. in Neuroendocrine Function?” Medical Hypotheses 54 (5): Chandramouli, B., K. Srinivasan, J. Jagdish, and 825–28. N. Ananthakrishnan. 2004. “Morbidity and Mortality of Bickler, S. W., and E. Ameh. 2011. Surgical Care for Children: A Colostomy and Its Closure in Children.” Journal of Pediatric Guide for Primary Referral Hospitals. London: Macmillan. Surgery 39 (4): 596–99. Bickler, S., D. Ozgediz, R. Gosselin, T. Weiser, D. Spiegel, and Chirdan, L. B., E. A. Ameh, F. A. Abantanga, D. Sidler, and others. 2010. “Key Concepts for Estimating the Burden E. A. Elhalaby. 2010. “Challenges of Training and Delivery of Surgical Conditions and the Unmet Need for Surgical of Pediatric Surgical Services in Africa.” Journal of Pediatric Care.” World Journal of Surgery 34 (3): 374–80. Surgery 45 (3): 610–18. Surgical Interventions for Congenital Anomalies 145 Chirdan, L. B., P. J. Ngiloi, and E. A. Elhalaby. 2012. “Neonatal Eltayeb, A. A. 2010. “Delayed Presentation of Anorectal Surgery in Africa.” Seminars in Pediatric Surgery 21 (2): Malformations: The Possible Associated Morbidity and 151–59. Mortality.” Pediatric Surgery International 26 (8): 801–06. Chirdan, L. B., and A. F. Uba. 2006. “Hirschsprung’s Disease Farmer, P., and J. Kim. 2008. “Surgery and Global Health: Presenting in the Neonatal Period in Jos, Nigeria.” Nigerian A View from beyond the OR.” World Journal of Surgery Journal of Surgical Research 8 (1–2): 62–64. 32 (4): 533–36. Chiu, P., and H. L. Hedrick. 2008. “Postnatal Management Frolov, P., J. Alali, and M. D. Klein. 2010. “Clinical Risk Factors for and Long-Term Outcome for Survivors with Congenital Gastroschisis and Omphalocele in Humans: A Review of the Diaphragmatic Hernia.” Prenatal Diagnosis 28 (7): Literature.” Pediatric Surgery International 26 (12): 1135–48. 592–603. Frykman, P. K., and S. S. Short. 2012. “Hirschsprung-Associated Chowdhary, S. K., G. Chalapathi, K. L. Narasimhan, Enterocolitis: Prevention and Therapy.” Seminars in R. Samujh, J. K. Mahajan, and others. 2004. “An Audit of Pediatric Surgery 21 (4): 328–35. Neonatal Colostomy for High Anorectal Malformation: Gangopadhyay, A. N., S. Shilpa, T. V. Mohan, and S. C. Gopal. The Developing World Perspective.” Pediatric Surgery 2005. “Single-Stage Management of All Pouch Colon International 20 (2): 111–13. (Anorectal Malformation) in Newborns.” Journal of Christianson, A. L., C. P. Howson, and B. Modell. 2006. Global Pediatric Surgery 40 (7): 1151–55. Report on Birth Defects: The Hidden Toll of Dying and Goksan, S. B., A. Bursali, F. Bilgili, S. Sivacioglu, and S. Ayanoglu. Disabled Children. White Plains, NY: March of Dimes Birth 2006. “Ponseti Technique for the Correction of Idiopathic Defects Foundation. Clubfeet Presenting up to 1 Year of Age: A Preliminary Coran, A. G., A. Caldamone, N. S. Adzick, T. M. Krummel, J.-M. Study in Children with Untreated or Complex Deformities.” Laberge, and others. 2012. Pediatric Surgery: Expert Consult Archives of Orthopedic Trauma Surgery 126 (1): 15–21. (2 volumes). 7th ed. London: Elsevier Health Sciences. Gosselin, R. A., A. Thind, and A. Bellardinelli. 2006. “Cost/ Coran, A. G., and D. H. Teitelbaum. 2000. “Recent Advances DALY Averted in a Small Hospital in Sierra Leone: What in the Management of Hirschsprung’s Disease.” American Is the Relative Contribution of Different Services?” World Journal of Surgery 180 (5): 382–87. Journal of Surgery 30 (4): 505–11. Corlew, D. S. 2010. “Estimation of Impact of Surgical Disease Groen, R. S., M. Samai, R. T. Petroze, T. B. Kamara, L. D. Cassidy, through Economic Modeling of Cleft Lip and Palate Care.” and others. 2013. “Household Survey in Sierra Leone Reveals World Journal of Surgery 34 (3): 391–96. High Prevalence of Surgical Conditions in Children.” World Davies, M. C., S. M. Creighton, and D. T. Wilcox. 2004. “Long- Journal of Surgery 37 (6): 1220–26. Term Outcomes of Anorectal Malformations.” Pediatric Gupta, A., S. Singh, P. Patel, J. Patel, and M. K. Varshney. Surgery International 20 (8): 567–72. 2008. “Evaluation of the Utility of the Ponseti Method of Dobbs, M. B., and C. A. Gurnett. 2009. “Update on Clubfoot: Correction of Clubfoot Deformity in a Developing Nation.” Etiology and Treatment.” Clinical Orthopaedics and Related International Orthopaedics 32 (1): 75–79. Research 467 (5): 1146–53. Hadley, G. P. 2008. “Perspectives on Congenital Abnormalities Dobbs, M. B., J. A. Morcuende, C. A. Gurnett, and I. V. Ponseti. in the Third World.” African Journal of Paediatric Surgery 2000. “Treatment of Idiopathic Clubfoot: An Historical 5 (1): 1–2. Review.” Iowa Orthopedic Journal 20: 59–64. ———, and M. Mars. 2008. “Postgraduate Medical Education Eason, G., M. Langer, D. Birabwa-Male, E. Reimer, in Paediatric Surgery: Videoconferencing—A Possible M. Pennington, and others. 2012. “Costs and Cost- Solution for Africa?” Pediatric Surgery International 24 (2): Effectiveness of Pediatric Inguinal Hernia Repair in 223–26. Uganda.” Abstract presented at the European Paediatric Hegazy, M., N. M. Nasef, and H. Abdel-Ghani. 2009. “Results Surgeons Association and British Association of Paediatric of Treatment of Idiopathic Clubfoot in Older Infants Using Surgeons Joint Congress, Rome, June. the Ponseti Method: A Preliminary Report.” Journal of Ekenze, S. O., S. N. Ibeziako, and U. O. Ezomike. 2007. Pediatric Orthopaedics. Part B 18 (2): 76–78. “Trends in Neonatal Intestinal Obstruction in a Developing Higashi, H., J. J. Barendregt, and T. Vos. 2013. “The Burden Country, 1996–2005.” World Journal of Surgery 31 (12): of Congenital Anomalies Amenable to Surgeries in Low- 2405–09. Income and Middle-Income Countries: A Modeled Ekenze, S. O., C. Ngaikedi, and A. A. Obasi. 2011. “Problems Analysis.” The Lancet 381: S62. and Outcome of Hirschsprung’s Disease Presenting after Hoffman, J. 2013. “The Global Burden of Congenital Heart 1 Year of Age in a Developing Country.” World Journal of Disease.” Cardiovascular Journal of Africa 24 (4): 141–45. Surgery 35 (1): 22–26. Ibrahim, A. I. 2007. “One Stage Posterior Sagittal Anorectoplasty Elhalaby, E.A. 2006. “Primary Repair of High and Intermediate for Treatment of High and Intermediate Anorectal Anomalies Anorectal Malformations in the Neonates.” Annals of at Birth.” Annals of Pediatric Surgery 3 (3–4): 11–124. Pediatric Surgery 2 (2): 117–22. Islam, M., and M. A. Aziz. 2011. “Esophageal Atresia: Outcome Elhalaby, E. A., F. A. Uba, E. S. Borgstein, H. Rode, and in 21 Cases.” Bangladesh Armed Forces Medical Journal A. J. Millar. 2012. “Training and Practice of Pediatric 44 (1): 47–50. Surgery in Africa: Past, Present, and Future.” Seminars in Jamison, D. T., J. G. Breman, A. R. Measham, G. Alleyne, Pediatric Surgery 21 (2): 103–10. M. Claeson, D. B. Evans, P. Jha. A. Mills, and P. Musgrove, 146 Essential Surgery eds. 2006. Disease Control Priorities in Developing Countries, Mendez-Tompson, M., O. Olivares-Becerril, M. Preciado- 2nd ed. Washington, DC: World Bank and Oxford Salgado, I. Quezada-Daniel, and J. G. Vega-Sanchez. 2012. University Press. “Management of Congenital Adduct Clubfoot with the Janicki, J. A., U. G. Narayanan, B. J. Harvey, A. Roy, S. Weir, and Ponseti Technique. Experience at La Perla General Hospital.” others. 2009. “Comparison of Surgeon and Physiotherapist- Acta Ortopedica Mexicana 26 (4): 228–30. Directed Ponseti Treatment of Idiopathic Clubfoot.” Journal Mhando, S., B. Young, and K. Lakhoo. 2008. “The Scope of Bone and Joint Surgery 91 (5): 1101–08. of Emergency Paediatric Surgery in Tanzania.” Pediatric Jawadi, A. H. 2010. “Clubfoot Management by the Ponseti Surgery International 24 (2): 219–22. Technique in Saudi Patients.” Saudi Medical Journal 31 (1): Mills, J. L., T. C. Carter, D. M. Kay, M. L. Browne, L. C. Brody, 49–52. and others. 2012. “Folate and Vitamin B12–Related Genes Khemakhem, R., B. Haggui, H. Rahay, F. Nouira, A. Charieg, and Risk for Oomphalocele.” Human Genetics 131 (5): and others. 2012. “Congenital Diaphragmatic Hernia in 739–46. Neonate: A Retrospective Study about 28 Observations.” Miranda, M. E., E. D. Tatsuo, J. T. Guimaraes, R. M. Paixao, and African Journal of Paediatric Surgery 9 (3): 217–22. J. C. B. D. Lanna. 1999. “Use of a Plastic Hemoderivative Larrazabal, L. A., K. J. Jenkins, K. Gauvreau, V. L. Vida, Bag in the Treatment of Gastroschisis.” Pediatric Surgery O. J. Benavidez, and others. 2007. “Improvement in International 15 (5–6): 442–44. Congenital Heart Surgery in a Developing Country: The Mkandawire, M., and E. Kaunda. 2002. “An Audit of Congenital Guatemalan Experience.” Circulation 116 (17): 1882–87. Anomalies in the Neonatal Unit of Queen Elizabeth Central Laughon, M., R. Meyer, C. Bose, A. Wall, E. Otero, and others. Hospital. One-Year Study Period: 1st November 2000 2003. “Rising Birth Prevalence of Gastroschisis.” Journal to 31st October 2001.” East and Central African Journal of of Perinatology: Official Journal of the California Perinatal Surgery 7 (1): 29–33. Association 23 (4): 291–93. Mo Suwan, L., S. Isaranurug, P. Chanvitan, W. Techasena, Lavy, C. B. D., S. J. Mannion, N. C. Mkandawire, A. Tindall, S. Sutra, and others. 2009. “Perinatal Death Pattern in the C. Steinlechner, and others. 2007. “Club Foot Treatment Four Districts of Thailand: Findings from the Prospective in Malawi: A Public Health Approach.” Disability and Cohort Study of Thai Children.” Journal of the Medical Rehabilitation 29 (11–12): 857–62. Association of Thailand 92 (5): 660–66. Loane, M., H. Dolk, and I. Bradbury. 2007. “Increasing Moore, S. W., A. Alexander, D. Sidler, J. Alves, G. P. Hadley, and Prevalence of Gastroschisis in Europe 1980–2002: A others. 2008. “The Spectrum of Anorectal Malformations Phenomenon Restricted to Younger Mothers?” Paediatric in Africa.” Pediatric Surgery International 24 (6): 677–83. and Perinatal Epidemiology 21 (4): 363–69. Nacul, L. C., A. Stewart, C. Alberg, S. Chowdhury, Loisance, D. Y. 2012. “Training Young Cardiac Surgeons in M. W. Darlison, and others. 2013. “A Toolkit to Assess Developing Countries.” Asian Cardiovascular and Thoracic Health Needs for Congenital Disorders in Low- and Annals 20 (4): 384–86. Middle-Income Countries: An Instrument for Public Lourenço, A., and J. Morcuende. 2007. “Correction of Neglected Health Action.” Journal of Public Health. Advance online Idiopathic Club Foot by the Ponseti Method.” Journal of publication. doi:10.1093/pubmed/fdt048. Bone and Joint Surgery. British Volume 89 (3): 378–81. Nandi, B., C. Mungongo, and K. Lakhoo. 2008. “A Comparison Magee, W., H. M. Raimondi, M. Beers, and M. C. Koech. 2012. of Neonatal Surgical Admissions between Two Linked “Effectiveness of International Surgical Program Model Surgical Departments in Africa and Europe.” Pediatric to Build Local Sustainability.” Plastic Surgery International Surgery International 24 (8): 939–42. 2012: 185725. doi:10.1155/2012/185725. Narasimman, S., M. Nallusamy, and S. Hassan. 2013. “Review Makhdoom, A., M. A. Laghari, M. K. Pahore, P. A. L. Qureshi, of Oesophageal Atresia and Tracheoesophageal Fistula I. A. Bhutto, and others. 2011. “Clubfoot Treatment by in Hospital Sultanah Bahiyah, Alor Star. Malaysia from Ponseti Method.” Journal of the Liaquat University of January 2000 to December 2009.” Medical Journal of Medical and Health Sciences 10 (2): 71–74. Malaysia 68 (1): 48–51. Manson, J., E. Ameh, N. Canvassar, T. Chen, A. V. den Hoeve, Olivieri, C., K. Belay, R. Coletta, G. Retrosi, P. Molle, and A. Calisti. and others. 2012. “Gastroschisis: A Multi-centre Comparison 2012. “Preventing Posterior Sagittal Anoplasty ‘Cripples’ in of Management and Outcome.” African Journal of Paediatric Areas with Limited Medical Resources: A Few Modifications Surgery 9 (1): 17–21. to Surgical Approach in Anorectal Malformations.” African Martiniuk, A. L. C., M. Manouchehiran, J. A. Negin, and Journal of Paediatric Surgery 9 (3): 223–26. A. B. Zwi. 2012. “Brain Gains: A Literature Review of Osifo, O. D., and C. J. Okolo. 2009. “Outcome of Trans-anal Medical Missions to Low and Middle-Income Countries.” Posterior Anorectal Myectomy for the Ultrashort Segment BMC Health Services Research 12: 134. Hirschprung’s Disease—Benin City Experience in 5 Years.” Mayo, E., A. Cuthel, J. Macharia, C. Lavy, and T. Mead. Nigerian Postgraduate Medical Journal 16 (3): 213–17. n.d. “Creating a Countrywide Program Model for Owen, R. M., J. N. Penny, A. Mayo, J. Morcuende, and Implementation of a Ponseti Method Clubfoot Treatment C. B. Lavy. 2012. “A Collaborative Public Health Approach Program in Developing Countries.” Unpublished. http:// to Clubfoot Intervention in 10 Low-Income and Middle- cure.org/downloads/site/clubfoot/ccw-creating_a Income Countries: 2-Year Outcomes and Lessons Learnt.” _countrywide_program_model.pdf. Journal of Pediatric Orthopaedics. Part B 21 (4): 361–65. Surgical Interventions for Congenital Anomalies 147 Ozdogan, T., C. Durakbasa, M. Mutus, and M. Iscen. 2010. Initiative as a Model for Sustainable Collaboration.” World “Congenital Diaphragmatic Hernia: A 4-Year Experience in Journal of Surgery 35 (1): 17–21. a Single Centre.” African Journal of Paediatric Surgery 7 (2): Rao, S. G. 2007. “Pediatric Cardiac Surgery in Developing 105–06. Countries.” Pediatric Cardiology 28 (2): 144–48. Ozgediz, D., D. T. Jamison, M. Cherian, and K. McQueen. 2008. Rattray, K. W., T. C. Harrop, J. Aird, M. Beveridge, J. G. Gollogly, “The Burden of Surgical Conditions and Access to Surgical and others. 2013. “The Cost Effectiveness of Reconstructive Care in Low- and Middle-Income Countries.” Bulletin of the Surgery in Cambodia.” Asian Biomedicine 7 (3): 319–24. World Health Organization 86 (8): 646–47. Rayes, O. M. 2010. “Congenital Tracheoesophageal Fistula Ozgediz, D., and D. Poenaru. 2012. “The Burden of Pediatric with or without Esophageal Atresia, King Abdulaziz Surgical Conditions in Low and Middle Income Countries: A University Hospital Experience over 15 Years.” Journal of Call to Action.” Journal of Pediatric Surgery 47 (12): 2305–11. King Abdulaziz University-Medical Sciences 17 (4): 59–72. Panjavi, B., A. Sharafatvaziri, R. H. Zargarbashi, and S. Mehrpour. Rescorla, F. J., A. M. Morrison, D. Engles, J. W. West, and 2012. “Use of the Ponseti Method in the Iranian Population.” J. L. Grosfeld. 1992. “Hirschsprung’s Disease: Evaluation of Journal of Pediatric Orthopaedics 32 (3): e11–14. Mortality and Long-Term Function in 260 Cases.” Archives Patel, A., J. E. Clune, D. M. Steinbacher, and J. A. Persing. 2013. of Surgery 127 (8): 934. “Comprehensive Cleft Center: A Paradigm Shift in Cleft Richmond, S., and J. Atkins. 2005. “A Population-Based Study Care.” Plastic and Reconstructive Surgery 131 (2): 312e–13e. of the Prenatal Diagnosis of Congenital Malformation over Patwardhan, N., E. Kiely, D. P. Drake, L. Spitz, and A. Pierro. 16 Years.” BJOG: An International Journal of Obstetrics and 2001. “Colostomy for Anorectal Anomalies: High Incidence Gynaecology 112 (10): 1349–57. of Complications.” Journal of Pediatric Surgery 36 (5): 795–98. Rohana, J., N. Y. Boo, and C. R. Thambidorai. 2008. “Early Penchaszadeh, V. B. 2002. “Preventing Congenital Anomalies in Outcome of Congenital Diaphragmatic Hernia in a Developing Countries.” Community Genetics 5 (1): 61–69. Malaysian Tertiary Centre.” Singapore Medical Journal Peyvasteh, M., S. Askarpour, H. Javaherizadeh, and 49 (2): 142–44. T. Fatahian. 2011. “Evaluation of Epidemiologic Indices Sadler, T. W. 2010. “The Embryologic Origin of Ventral Body of Neonate’s Diseases in the Pediatric Surgery Ward of the Wall Defects.” Seminars in Pediatric Surgery 19 (3): 209–14. Ahvaz Jundishapur University Hospitals during the Period Sadoh, W. E., D. U. Nwaneri, and A. C. Owobu. 2011. “The Cost 1993–1996 and 2002–2005.” Annals of Pediatric Surgery of Out-Patient Management of Chronic Heart Failure in 7 (1): 7–9. Children with Congenital Heart Disease.” Nigerian Journal Pirani, S., E. Naddumba, R. Mathias, J. Konde-Lule, J. N. Penny, of Clinical Practice 14 (1): 65–69. and others. 2009. “Towards Effective Ponseti Clubfoot Care: Saha, A. K., M. B. Ali, S. K. Biswas, H. M. Z. Sharif, and The Uganda Sustainable Clubfoot Care Project.” Clinical A. Azim. 2012. “Neonatal Intestinal Obstruction: Patterns, Orthopaedics and Related Research 467 (5): 1154–63. Problems and Outcomes.” Bangladesh Medical Journal Poenaru, D. 2013. “Getting the Job Done: Analysis of the (Kulna) 45 (1-2): 6–10. Impact and Effectiveness of the Smile Train Program in Salomon, J. A., T. Vos, D. R. Hogan, M. Gagnon, M. Naghavi, Alleviating the Global Burden of Cleft Disease.” World and others. 2012. “Common Values in Assessing Health Journal of Surgery 37 (7): 1562–70. Outcomes from Disease and Injury: Disability Weights Poenaru, D., E. Borgstein, A. Numanoglu, and G. Azzie. Measurement Study for the Global Burden of Disease Study 2010. “Caring for Children with Colorectal Disease in 2010.” The Lancet 380 (9859): 2129–43. the Context of Limited Resources.” Seminars in Pediatric Saranrittichai, S. 2008. “Gastroschisis: Delivery and Immediate Surgery 19 (2): 118–27. Repair in the Operating Room.” Journal of the Medical Poenaru, D., J. Pemberton, C. Frankfurter, and B. Cameron. 2013. Association of Thailand 91 (5): 686–92. “Establishing Disability Weights for Congenital Pediatric Sarrafan, N., S. A. M. Nasab, M. Fakoor, and A. Zakeri. 2012. Surgical Disease: A Multi-modal Study.” The Lancet 381: “Short Term Outcome of Congenital Clubfoot Treated S3115. by Ponseti Method.” Pakistan Journal of Medical Sciences Poley, M. J., W. F. B. Brouwer, J. J. V. Busschbach, 28 (3): 459–62. F. W. J. Hazebroek, D. Tibboel, and others. 2008. “Cost- Sekabira, J., and G. P. Hadley. 2009. “Gastroschisis: A Third Effectiveness of Neonatal Surgery: First Greeted with World Perspective.” Pediatric Surgery International 25 (4): Skepticism, Now Increasingly Accepted.” Pediatric Surgery 327–29. International 24 (2): 119–27. Sekar, P., and V. Vilvanathan. 2007. “Telecardiology: Effective Pratap, A., D. K. Gupta, A. Tiwari, A. Sinha, N. Bhatta, and Means of Delivering Cardiac Care to Rural Children.” Asian others. 2007. “Application of a Plain Abdominal Radiograph Cardiovascular and Thoracic Annals 15 (4): 320–23. Transition Zone (PARTZ) in Hirschsprung’s Disease.” BMC Semer, N. 2001. Practical Plastic Surgery for Nonsurgeons. Pediatrics 7: 5. Philadelphia, PA: Hanley and Belfus. Prato, A. P., V. Rossi, S. Avanzini, G. Mattioli, N. Disma, Senga, J., E. Rusingiza, J. Mucumbitsi, A. Binagwaho, B. Suys, and others. 2011. “Hirschsprung’s Disease: What about and others. 2013. “Catheter Interventions in Congenital Mortality?” Pediatric Surgery International 27 (5): 473–78. Heart Disease without Regular Catheterization Laboratory Qureshi, J. S., J. Samuel, C. Lee, B. Cairns, C. Shores, and others. Equipment: The Chain of Hope Experience in Rwanda.” 2011. “Surgery and Global Public Health: The UNC-Malawi Pediatric Cardiology 34 (1): 39–45. 148 Essential Surgery Shah, G., M. Singh, T. Pandey, B. Kalakheti, and G. Bhandari. van Bosse, H. J. 2011. “Ponseti Treatment for Clubfeet, An 2008. “Incidence of Congenital Heart Disease in a Tertiary International Perspective.” Current Opinion in Pediatrics Care Hospital.” Kathmandu University Medical Journal 23 (1): 41–45. 6 (1): 33–36. van der Linde, D., E. E. M. Konings, M. A. Slager, M. Witsenburg, Sharma, S., and D. K. Gupta. 2012. “Hirschsprung’s Disease W.A. Helbing, and others. 2011. “Birth Prevalanece of Presenting beyond Infancy: Surgical Options and Postoperative Congenital Heart Disease Worldwide.” Journal of the Outcome.” Pediatric Surgery International 28 (1): 5–8. American College of Cardiology 58 (21): 2241–47. Singh, K., C. Greaves, L. Mohammed, and A. Kumar. 2012. van Heurn, L. W. E., W. Cheng, B. de Vries, H. Saing, “Epidemiology of Treacheoesophageal Fistula and Other N. J. G. Jansen, and others. 2002. “Anomolies Associated Major Congenital Malformations of the Digestive System with Oesophageal Atresia in Asians and Europeans.” among Newborns in an English Speaking Caribbean Pediatric Surgery International 18 (4): 241–43. Country: A Population Based Study.” British Journal of Vincent, M. V., and S. U. Jackman. 2009. “Hirschsprung’s Medical Sciences 1 (3): 16–25. Disease in Barbados—A 16-Year Review.” West Indian Sinha, S. K., R. P. Kanojia, A. Wakhlu, J. D. Rawat, S. N. Kureel, Medical Journal 58 (4): 347–51. and others. 2008. “Delayed Presentation of Anorectal Vu, L. T., K. K. Nobuhara, C. Laurent, and G. M. Shaw. 2008. Malformations.” Journal of the Indian Association of “Increasing Prevalence of Gastroschisis: Population- Pediatric Surgery 13 (2): 64–68. Based Study in California.” Journal of Pediatrics 152 (6): Spiegel, D. A., O. P. Shrestha, P. Sitoula, T. Rajbhandary, 807–11. B. Bijukachhe, and others. 2009. “Ponseti Method for Walker, I. A., A. D. Obua, F. Mouton, S. Ttendo, and Untreated Idiopathic Clubfeet in Nepalese Patients from I. H. Wilson. 2010. “Paediatric Surgery and Anaesthesia in 1 to 6 Years of Age.” Clinical Orthopaedics and Related South-Western Uganda: A Cross-Sectional Survey.” Bulletin Research 467 (5): 1164–70. of the World Health Organization 88 (12): 897–906. Stoll, C., Y. Alembik, B. Dott, and M. P. Roth. 2001. “Risk Factors Warf, B. C. 2011. “Hydrocephalus Associated with Neural in Congenital Abdominal Wall Defects (Omphalocele and Tube Defects: Characteristics, Management, and Outcomes Gastroschisi): A Study in a Series of 265,858 Consecutive in Sub-Saharan Africa.” Child’s Nervous System 27 (10): Births.” Annales De Genetique 44 (4): 201–08. 1589–94. Swenson, O. 2002. “Hirschsprung’s Disease: A Review.” ———. 2013. “Educate One to Save A Few. Educate Few to Pediatrics 109 (5): 914–18. Save Many.” World Neurosurgery 79 (2 Suppl.): e15–8. Tefera, E., T. Teka, and M. Derbew. 2007. “Neonatal Warf, B. C., B. C. Alkire, S. Bhai, C. Hughes, S. J. Schiff, Gastrointestinal Surgical Emergencies: A 5-Year Review in and others. 2011. “Costs and Benefits of Neurosurgical a Teaching Hospital in Addis Ababa, Ethiopia.” Ethiopian Intervention for Infant Hydrocephalus in Sub-Saharan Medical Journal 45 (3): 251–56. Africa.” Journal of Neurosurgical Pediatrics 8 (5): 509–21. Tindall, A. J., C. W. E. Steinlechner, C. B. D. Lavy, S. Mannion, WHO (World Health Organization). 2008. “Global Burden of and N. Mkandawire. 2005. “Results of Manipulation of Disease 2004 Update: Disability Weights for Diseases and Idiopathic Clubfoot Deformity in Malawi by Orthopaedic Conditions.” WHO, Geneva. Clinical Officers Using the Ponseti Method: A Realistic ———. 2012. “Congenital Anomalies,” Fact Sheet No. 370, Alternative for the Developing World?” Journal of Pediatric WHO, Geneva. http://www.who.int/mediacentre/factsheets Orthopaedics 25 (5): 627–29. /fs370/en/. Toro, M. N. H., M. E. A. Rave, and P. M. J. Gomez. 2010. ———. 2013a. “Emergency and Essential Surgical Care: “Management of Abdominal Wall Defects (Gastroschisis Congenital Anomalies.” http://www.who.int/surgery and Omphalocele) at Hospital Universitario San Vicente de /challenges/esc_congenital_nomalies/en/. Paúl, in Medellín, Colombia, 1998–2006.” [Spanish]. Iatreia ———. 2013b. “Global Health Estimates for Deaths by Cause, 23 (3): 220–26. Age, and Sex for Years 2000–2011.” WHO, Geneva. Turowski, C., J. Dingemann, and J. Giilick. 2010. “Delayed Wickramasinghe, P., S. P. Lambabadusuriya, and S. Narenthiran. Diagnosis of Imperforate Anus: An Unacceptable 2001. “Prospective Study of Congenital Heart Disease in Morbidity.” Pediatric Surgery International 26 (11): 1083–86. Children.” Ceylon Medical Journal 46 (3): 96–98. Uba, A. F., and L. B. Chirdan. 2003. “Omphalocoele and Wu, V., and D. Poenaru. 2013. “Burden of Surgically Correctable Gastroschisis: Management in a Developing Country.” Disabilities among Children in the Dadaab Refugee Camp.” Nigerian Journal of Surgical Research 5 (1): 57–61. World Journal of Surgery 37 (7): 1536–43. Ugiagbe, E. E., and O. D. Osifo. 2012. “Postmortem Wu, V., D. Poenaru, and M. J. Poley. 2013. “Burden of Surgical Examinations on Deceased Neonates: A Rarely Utilized Congenital Anomalies in Kenya: A Population-Based Procedure in an African Referral Center.” Pediatric and Study.” Journal of Tropical Pediatrics 59 (3): 195–220. Developmental Pathology 15 (1): 1–4. Yang, C. F., W. J. Soong, M. J. Jeng, S. J. Chen, Y. S. Lee, and Upadhyaya, V. D., A. N. Gangopadhyaya, D. K. Gupta, others. 2006. “Esophageal Atresia with Tracheoesophageal S. P. Sharma, V. Kumar, and others. 2007. “Prognosis of Fistula: Ten Years of Experience in an Institute.” Journal of Congenital Tracheoesophageal Fistula with Esophageal the Chinese Medical Association 69 (7): 317–21. Atresia on the Basis of Gap Length.” Pediatric Surgery Zupan, J. 2005. “Perinantal Mortality in Developing Countries.” International 23 (8): 767–71. New England Journal of Medicine 352 (20): 2047–48. Surgical Interventions for Congenital Anomalies 149 Chapter 9 Hernia and Hydrocele Jessica H. Beard, Michael Ohene-Yeboah, Catherine R. deVries, and William P. Schecter INTRODUCTION first-level hospitals. Training programs to improve the skills of surgical-care providers in LMICs, in combina- Groin hernia and hydrocele are two of the most common tion with infrastructure investment to build hospital surgical conditions globally. This chapter summarizes capacity, are urgently needed to increase access to these the literature on the pathogenesis, clinical presentation, essential surgical procedures. and treatment for groin hernia and hydrocele, focusing on unique clinical characteristics and management strat- egies for these conditions in low- and middle-income GROIN HERNIA countries (LMICs). We present our estimate of the global and regional Definitions of Groin Hernia burden of disease from groin hernia, the first of its kind A hernia is a protrusion of a body part through a defect in the literature. In addition, we highlight the existing in the anatomic structure that normally contains it. data on the cost-effectiveness of surgical treatment for A groin hernia is a specific type of hernia involving the groin hernia and hydrocele. We document the success- bulging of abdominal contents through the inguinal or ful global efforts of Operation Hernia and the Global femoral canal. The inguinal canal is a “corridor” in the Programme to Eliminate Lymphatic Filariasis (GPELF) abdominal wall that, in men, houses the spermatic cord in combating hernia and lymphatic filariasis, a common as it passes on its way to the testicle. Inguinal hernias cause of hydrocele in LMICs. may be caused either by a failure in the normal closure Groin hernia repair and hydrocelectomy are cost- of the abdominal wall lining in the inguinal canal dur- effective curative therapies that can improve the ing fetal development, or by an acquired weakening of quality of life. In addition, herniorrhaphy can prevent the abdominal wall, often later in life. In either case, the life-threatening complications associated with groin hernia sac, a pouch made of the membrane lining the hernia. Unfortunately, many people do not have access abdomen and containing fat, ovary, bowel, or bladder, to safe and effective surgical care for these common protrudes into the inguinal canal. conditions. A scrotal hernia is a type of inguinal hernia in which The treatment of groin hernia and hydrocele should the hernia sac, often containing bowel, follows the be a high priority on any global surgery agenda. Basic path of the spermatic cord into the scrotum. Femoral surgical care for these conditions is a crucial part hernias occur rarely and involve the protrusion of of health care services that should be available at abdominal contents through the femoral canal, a space Corresponding author: Jessica H. Beard, MD, MPH, University of California, San Francisco, Jessica.Beard@ucsfmedctr.org 151 adjacent to the femoral vein in the upper thigh. This The key question in determining the natural history type of hernia occurs most commonly in women of hernia centers on the identification of the annual (Nilsson and others 2007). risk of hernia accident (that is, bowel obstruction, Groin hernias may be further classified as reducible, incarceration, or strangulation) without hernia repair. incarcerated, or strangulated. To address this question, Neuhauser (1977) examined data in two settings in which herniorrhaphy was gen- • A reducible hernia is one in which the hernia contents erally not practiced: Paul Berger’s Paris truss clinic can be gently pushed back into the abdominal cavity. (circa 1880) and Cali, Colombia (circa 1970). He • An incarcerated hernia is irreducible, meaning found that the probabilities of hernia accident per year that the hernia sac contents are “stuck” outside the were 0.0037 and 0.00291 in the Berger and Colombia abdomen. data, respectively. • A strangulated hernia refers to an incarcerated hernia Using Neuhauser’s figures and U.S. life-table analysis, in which the entrance to the hernia sac or “neck” is Turaga, Fitzgibbons, and Puri (2008) calculated a hernia constricted, limiting blood supply to the sac con- accident lifetime incidence of 19.4 percent in 18-year- tents and ultimately resulting in tissue necrosis, old men with inguinal hernia in the United States. They bowel infarction, and perforation. This condition is found only a 4.4 percent lifetime incidence of hernia a life-threatening emergency requiring immediate accident in 72-year-old men with hernia. These calcu- surgery. lations suggest that hernia accident is a relatively com- mon lifetime event in younger patients with unrepaired Scrotal and femoral hernias are more likely to become inguinal hernia. incarcerated and cause complications. Clinical Features of Groin Hernia in LMICs Risk Factors and Natural History of Groin Hernia Patients with inguinal hernia generally present with a In a study of hernias in adults (5,316 men and 8,136 bulge in the groin, which may have associated symp- women) in the United States participating in the First toms. Limited access to surgical care in LMICs leads to a National Health and Nutrition Examination Survey clinical picture of groin hernia that is distinct from that (NHANES) between 1971−75 and followed up in 1993, in high-income countries (HICs). In fact, most cases of male gender and increasing age were identified as impor- inguinal hernia in LMICs go untreated, resulting in large tant groin hernia risk factors. Black race and obesity painful hernias that often limit physical activity (Herszage were independently associated with a lower incidence of 2004; Sanders and others 2008; Shillcutt, Clarke, and inguinal hernia in the cohort (Ruhl and Everhart 2007). Kingsnorth 2010). In a prospective study from Ghana, Increased intra-abdominal pressure has long been 67 percent of patients presenting for repair had scrotal implicated in the pathogenesis of inguinal hernia; how- hernias, placing them at increased risk of hernia compli- ever, data on physical activity as a risk factor for groin cations. When the Ghanaian cohort was compared with hernia are inconclusive. NHANES found no evidence a similar group of patients from the United Kingdom, of association between physical activity and hernia risk, the Ghanaians were found to be younger and have larger but two case-control studies from Spain suggest that hernias (Sanders and others 2008). strenuous activity may play a role in hernia development Groin hernias are often longstanding in LMICs. In (Carbonell and others 1993; Flich and others 1992; Ruhl Tanzania, nearly 50 percent of hernia patients in one and Everhart 2007). It is likely that different types of study presented for repair more than five years after dis- physical activity are associated with different levels of ease onset (Mabula and Chalya 2012). Groin hernias also risk, and further study is needed. Other risk factors for have negative effects on patients’ well-being and pro- groin hernia include a family history of hernia and the ductivity in LMICs. For example, in another Ghanaian presence of a hiatal hernia (Ruhl and Everhart 2007). hernia cohort, 16 percent of hernia patients were unable Prematurity is an important risk factor in children (Lau to work, and 64 percent reported limited daily activity and others 2007). (Sanders and others 2008). The natural history of inguinal hernia is poorly under- Most symptomatic groin hernias in HICs are treated stood. Population-based studies of inguinal hernia’s with elective surgery before complications such as natural history are nearly impossible today because obstruction or strangulation occur. In a prospective inguinal hernia repair is at least somewhat available in study of 6,895 patients in the Swedish Hernia Register, most settings. The little contemporary data that exist only 5 percent of groin herniorrhaphies in men were are limited by selection bias (Gallegos and others 1991). classified as emergencies (Koch and others 2005). 152 Essential Surgery In contrast, patients with groin hernias in LMICs inguinal hernia repairs are performed annually in the often present for medical care with complications. United States. More than two-thirds of inguinal hernia repairs at a The annual inguinal hernia repair rate in the United third-level center in Kumasi, Ghana, were emergency Kingdom (130 per 100,000 population) is lower than operations (Ohene-Yeboah and others 2009). In a the rate of repair in the United States (Primatesta and study from Bugando Medical Center in Tanzania, more Goldacre 1996). Differing practice patterns among sur- than half of presenting groin hernias were incarcer- geons and referring primary care physicians may explain ated, while 18.6 percent and 11.1 percent of patients, regional differences in the incidence of inguinal hernior- respectively, had obstructed and strangulated hernias rhaphy in HICs (Hair and others 2001). (Mabula and Chalya 2012). The unique clinical features of groin hernias in LMICs, including large size, longer Epidemiology of Inguinal Hernia in LICs and disease duration, physical limitations, and compli- MICs. Published information on inguinal hernia epi- cated hospital presentation, result in high morbidity demiology in low-resource settings is limited to two and mortality rates. studies of hernia prevalence in Sub-Saharan Africa from the 1960s and 1970s (Belcher, Nyame, and Wurapa 1978; Yardov and Stoyanov 1969). Inguinal hernia prev- Epidemiology and Burden of Disease alence in men in these studies ranged from 7.7 percent Prevalence and Incidence of Inguinal Hernia in HICs. in rural Ghana to 25 percent on the island of Pemba in Inguinal hernia is one of the most common surgical East Africa. Given poor access to surgical care in LMICs, conditions globally. An estimated 20 million groin it makes sense that inguinal hernia prevalence would be hernias are repaired annually worldwide (Bay-Nielsen higher in LMICs than in HICs. However, only limited and others 2001). Despite the high disease preva- evidence supports this thesis. lence, relatively few studies of inguinal hernia epi- A rigorous population-based investigation of groin demiology have been undertaken, even in HICs. hernia prevalence has been recently conducted in eastern Data from World War II cohorts demonstrate an Uganda (Löfgren and others 2014). This study demon- inguinal hernia prevalence of between 6.5 percent strated a prevalence of untreated hernia of 6.6 percent and 8.0 percent in American soldiers (Everhart 1994). in men, with an overall hernia prevalence (including A study from the United Kingdom found a 27 percent repaired hernias) of 9.4 percent. Although this study is lifetime risk for inguinal hernia repair in men and an important contribution to the literature on hernia 3 percent in women (Primatesta and Goldacre 1996). epidemiology, contemporary data on the incidence of A rigorous community-based survey demonstrated inguinal hernia in LMICs is notably lacking. an inguinal hernia prevalence of 18.3 percent among To fill this gap in knowledge, Beard and colleagues men in an ethnically diverse Jerusalem neighborhood created a method to estimate inguinal hernia incidence (Abramson and others 1978). Of note, 7.6 percent of and prevalence in LMICs, carrying out their analysis men had “obvious” groin hernias in this study, while in both the Ghanaian and Tanzanian contexts (Beard, the remaining 10.7 percent had hernia diagnosed as Oresanya, Akoko, and others 2013; Beard, Oresanya, a palpable impulse at the external inguinal canal by Ohene-Yeboah, and others 2013). In their Tanzanian physician examination. These data suggest that the analysis, they adjusted incidence data from the NHANES actual hernia prevalence in Jerusalem may be less than study for the population age and gender structure of 18.3 percent. the country, and calculated an annual incidence of new Studies of groin hernia incidence are particularly hernias in Tanzanian adults of 244 per 100,000 popu- limited. Data from the NHANES study have been used lation. This number is lower than the inguinal hernia to make the most reliable assessment of inguinal hernia incidence of 315 per 100,000 person-years calculated incidence in the United States. In their analysis of the in the NHANES study (Ruhl and Everhart 2007). The NHANES cohort, Ruhl and Everhart (2007) found an authors attribute the lower incidence of inguinal hernia annual incidence of inguinal hernia of 315 per 100,000 in Tanzania to the relative youth of the population com- population in adults in the United States. pared with that of the United States. Not surprisingly, the incidence of inguinal hernia Despite demonstrating a lower incidence of inguinal repair is lower than disease incidence. A retrospective hernia, Beard and others estimated a relatively high review of all inguinal hernia repairs in Minnesota during prevalence of inguinal hernia in Tanzanian men at a 20-year period found an incidence of hernia repair 12.1 percent (Beard, Oresanya, Akoko, and others 2013). of 217 per 100,000 person-years (Zendejas and others Because heavy labor and racial factors have not been 2013). This finding means that approximately 670,000 clearly substantiated as significant inguinal hernia risk Hernia and Hydrocele 153 factors in the literature, the authors attribute the higher Organization (WHO) regions.1 We then calculated inci- prevalence of hernia in Sub-Saharan Africa to lack of dence and prevalence accordingly. Deaths were esti- access to surgery in the region (Lau and others 2007; mated by using Neuhauser’s figure of 0.0037 probability Ruhl and Everhart 2007). of hernia accident per year, along with our own esti- mates of death from hernia complications in the various WHO regions (Neuhauser 1977). Global Burden of Inguinal Hernia For our DALY calculation, we assumed that hernia Estimates of the global burden of inguinal hernia are patients in the Sub-Saharan African region present rough at best. Yang and others (2011) calculated that for surgical treatment at an average age of 45 years, 58.7 million disability-adjusted life years (DALYs) would whereas patients in other regions present at an older be averted by repair of all adult hernias in Sub-Saharan age (60 years in North and South America, the Eastern Africa. This figure is more than double the estimates of Mediterranean, Southeast Asia, and the Western Pacific; the total surgical disease burden for Sub-Saharan Africa 70 years in Europe) (Mabula and Chalya 2012; Nilsson calculated by Debas and others (2006). The discrepancy and others 2007). We used the GBD 2010 inguinal hernia could be caused either by a previous underestimation of disability weight of 0.012 to calculate years of life lost the burden of surgical disease or, more likely, by different due to disability. methods used to calculate surgical DALYs. A standard The results of our epidemiologic analysis are pre- metric for measuring the surgical burden of disease is sented in table 9.1. We estimate that inguinal her- urgently needed to accurately identify global surgical nia prevalence in the general population ranges from priorities and guide resource allocation and advocacy 4.06 percent in Europe to 6.05 percent in the Western efforts. Pacific. Prevalence differences across regions are likely In the 2010 Global Burden of Disease study (referred to be caused by variations in population age structure, to as GBD 2010), Murray and others (2012) found that access to surgical care, and risk of death from hernia 11 DALYs per 100,000 population per year were attrib- accident. We estimate a global inguinal hernia preva- utable to groin hernia worldwide. This figure is less lence of 5.85 percent, meaning that about 223 million than their estimates for non-life-threatening conditions people globally have hernias. The global mortality from like premenstrual syndrome (18 DALYs per 100,000 inguinal hernia is significant; according to our calcula- population) and scabies (23 per 100,000 population). tions, nearly 44,000 people die from hernia each year. We believe that GBD 2010 underestimated the disease Our analysis indicates that hernia prevalence is burden of groin hernia, and we present our estimates highest in the Sub-Saharan African and Western Pacific of inguinal hernia epidemiology and global disease regions. Although the literature on hernia epidemiology burden. in Africa is relatively well developed, studies of hernia To test our hypothesis, we recalculated the DALYs disease burden and treatment in the Western Pacific are attributable to inguinal hernia using the method notably quite limited. More research on the burden of described by Beard, Oresanya, Akoko, and others (2013). hernia in this region is needed in light of these findings. We adjusted the NHANES incidence figures to the Table 9.2 presents our estimate of global and regional population age structures of the six World Health inguinal hernia disease burden. The figures suggest that Table 9.1 Estimated Global and Regional Inguinal Hernia Epidemiologic Figures Yearly incidence Number of people with Estimated deaths Region Prevalence (%) (per 100,000 people) inguinal hernia (million) per year World 5.85 293 223 43,689 Africa 5.35 250 22.7 8,396 Americas 4.36 307 28.2 4,173 Eastern Mediterranean 4.70 251 15.4 2,857 Europe 4.06 336 27.1 3,010 Southeast Asia 4.88 278 54.9 10,159 Western Pacific 6.05 310 81.6 15,094 Sources: Authors’ estimates based on Beard, Oresanya, Akoko, and others (2013) and United States Census Bureau International Database (http://www.census.gov/population /international/data/idb/region.php). 154 Essential Surgery Table 9.2 Estimated Burden of Inguinal Hernia by Region Estimated inguinal Estimated inguinal Estimated inguinal hernia DALYs as hernia DALYs per Total DALYs Estimated surgical hernia DALYs a percentage of 100,000 population Region (100,000) DALYs (100,000) (100,000) surgical DALYs per year World 1,5230 1,640 38.4 2.3 85 Africa 3,770 250 5.8 2.3 136 Americas 1,430 180 4.3 2.4 67 Eastern Mediterranean 1,420 150 2.5 1.7 76 Europe 1,510 220 3.7 1.7 55 Southeast Asia 4,430 480 8.9 1.9 79 Western Pacific 2,650 370 13.2 3.6 98 Sources: Authors’ estimates based on Beard, Oresanya, Akoko, and others (2013); Debas and others (2006); and United States Census Bureau International Database (http://www .census.gov/population/international/data/idb/region.php). Note: DALY = disability-adjusted life year. inguinal hernia accounts for a small but measureable performs only 30 hernia repairs per 100,000 population proportion of the surgical DALYs, as estimated by Debas per year, illustrating the vast unmet need for herniorrha- and others (2006). Most important, we demonstrate phy in the region. that the disease burden of hernia is likely to be higher Beard and colleagues in an unpublished study than the GBD 2010 calculations suggest. According to investigated surgical activity at all seven first-level our method, inguinal hernia accounts for an average hospitals in the Pwani Region of Tanzania. Despite of 85 DALYs per 100,000 population per year, almost its proximity to Dar es Salaam, Pwani is one of the eight times the disease burden calculated by GBD 2010 poorest regions in Tanzania. According to estimates (Murray and others 2012). This finding places the dis- by the Tanzanian government, Pwani ranks fourteenth ease burden of hernia on par with that of other surgi- out of 21 regions in measures of GDP per capita cal diseases such as benign prostatic hypertrophy and (National Bureau of Statistics and Coast Regional ovarian cancer. Notably, the burden of inguinal hernia is Commissioners Office 2007). highest in the most impoverished regions of the world, Table 9.3 presents data from this study, specifically where access to surgical care and surgical outcomes are focusing on rates of both elective and emergency repairs likely to be the poorest. in each of the Pwani districts. Our analysis found that first-level hospitals in Pwani performed a popula- tion-weighted average of 34.5 elective and emergency Met and Unmet Need for Inguinal Hernia Repair herniorrhaphies per 100,000 population, a number in LMICs similar to the hernia repair rate calculated by Grimes Mock and others (2010) have identified improved access and others (2012). These findings further document to safe inguinal hernia repair as a high global health pri- the surgical capacity crisis in first-level hospitals in Sub- ority. Studies indicate that inguinal herniorrhaphy is the Saharan Africa. most frequently performed general surgical procedure There also appears to be a significant disparity in at many first-level hospitals throughout Sub-Saharan the number of inguinal hernia repairs by district in Africa (Galukande and others 2010; Nordberg 1984). the Pwani region. In Kibaha, only 10.5 inguinal hernia There is general consensus that the unmet need repairs were performed per 100,000 population in 2012, for inguinal herniorrhaphy in LMICs is significant. compared with nearly 67 repairs per 100,000 population Estimates of need range from 163 to 357 hernia repairs in Kisarawe. Additional operations are possibly per- per 100,000 population per year, depending on whether formed in other health dispensaries, which may account incident only or incident and prevalent cases are to be for variations in hernia repair rates. Patients from addressed (Beard, Oresanya, Akoko, and others 2013; one district may also be seeking care in a neighboring Beard, Oresanya, Ohene-Yeboah, and others 2013; district. Further research is needed to more accurately Nordberg 1984). Grimes and others (2012) reported characterize surgical capacity and the need for essential that the average first-level hospital in Sub-Saharan Africa surgical services in low-resource settings. Hernia and Hydrocele 155 Table 9.3 Rates of Elective and Emergency Inguinal Hernia Repair in the Pwani Region, Tanzania, 2012 Elective hernia repair Emergency hernia repair Performed by nonphysicians, Performed by surgeons, District per 100,000 population per 100,000 population number (percent) number (percent) Bagamoyo 18.5 12.1 76 (100) 0 (0) Kibaha 7.8 2.7 8 (29.6) 11 (40.7) Kisarawe 46.2 20.7 38 (55.9) 0 (0) Mafia 23.3 0 4 (40.0) 6 (60.0) Mkuranga 23.8 6.7 58 (98.3) 0 (0) Rufiji 47.9 9.6 73 (57.9) 6 (4.8) Weighted average 25.8 8.7 Management of Inguinal Hernia to reconstruct the posterior wall of the inguinal canal, is Nonsurgical Management. Nonsurgical management an example of a tension-free tissue repair. This technique is appropriate for small, minimally symptomatic or has been shown to have rates of recurrence and postop- asymptomatic inguinal hernias in HICs. In a random- erative pain similar to that of the Lichtenstein technique ized controlled trial comparing a “watchful waiting” (Szopinski and others 2012). approach with routine herniorrhaphy for minimally Laparoscopic approaches to inguinal herniorrha- symptomatic inguinal hernias, the risk of hernia acci- phy were introduced in the 1990s. Although the risk dent was low (1.8 accidents per 1,000 patient-years of postoperative complications is slightly higher after during the 2- to 4.5-year follow-up period); outcomes laparoscopic repair, laparoscopy is associated with were similar between groups (Fitzgibbons and others decreased recovery time and less postoperative pain 2006). In LMICs, this watchful waiting approach to than open mesh techniques (McCormack and others inguinal hernia may not be safe (and is generally not 2003; Neumayer and others 2004). Cost-effectiveness practiced) because patients have limited access to rou- studies comparing laparoscopic with open inguinal her- tine follow-up and emergency surgery. nia repair techniques have been inconclusive (Heikkinen and others 1997; Schneider and others 2003). Surgical Management. Various techniques are avail- Although the tension-free repair has become the able for surgical reconstruction of the posterior wall gold standard in HICs, most inguinal hernias are still of the inguinal canal. The most common procedures repaired with the Bassini method in LMICs because of are the Bassini, McVay, and Shouldice repairs, all of the high cost of prosthetic mesh and the lack of train- which involve different methods of suturing together ing in mesh repair (Ohene-Yeboah and Abantanga components of the abdominal wall through an inguinal 2011). However, a report from Nigeria found that incision. The problem with these repairs is that groin the mesh repair was well tolerated, with few compli- tissues are sutured together under tension. The tension cations at one-year follow-up (Arowolo and others results in a relatively high risk of postoperative hernia 2011). In India, mesh repairs are more common than recurrence, in the range of 10 percent to 30 percent in other LMICs, and laparoscopic inguinal hernia (RAND Corporation 1983). repair is becoming more widely practiced (Krishna In 1986, Lichtenstein introduced a tension-free repair and others 2012; Swadia 2011). Nevertheless, the technique, using prosthetic mesh to reinforce weakness cost of the prosthetic mesh remains prohibitive for in the posterior wall of the inguinal canal. A randomized most patients in LMICs. A study from Uganda com- trial demonstrated a recurrence rate of only 1 percent to paring patients randomized to receive the Desarda 2 percent with the Lichtenstein technique (Fitzgibbons tension-free tissue hernia repair and the Lichtenstein and others 2006). Although some studies suggest that mesh repair demonstrated similar short-term clinical the mesh technique may increase the risk of chronic outcomes. Of note, the operating time for the Desarda postoperative groin pain, the results of the Lichtenstein repair was shorter in this study (Manyilirah and others repair represent a significant improvement over tradi- 2012). The Desarda technique is a promising and tional tissue repair (Hakeem and Shanmugam 2011). potentially effective low-cost method to repair hernias First described in 2001, the Desarda repair, which in LMICs, and its applicability in this context merits uses an undetached strip of external oblique aponeurosis further investigation. 156 Essential Surgery Anesthesia Considerations. Open inguinal hernia mesh compared with commercial hernia prosthetics. repair may be performed using local, spinal, or gen- In one study, Sanders and others (2013) inoculated eral anesthesia, depending on both patient status and polyethylene mosquito-net and industry meshes with surgeon preference. All three anesthetic techniques staphylococcus epidermidis and staphylococcus aureus. are safe in healthy young patients when administered They found no difference in the mean number of adher- by skilled practitioners in HICs. However, spinal and ent bacteria to mosquito-net mesh when compared with general anesthesia are associated with higher rates of commercial polypropylene-based meshes. These results myocardial infarction and urinary retention, respec- suggest that implantation of mosquito-net mesh should tively, in patients older than age 65 years (Bay-Nielsen not increase the risk of surgical site infection. Sanders, and Kehlet 2008). Kingsnorth, and Stephenson (2013) investigated the A meta-analysis demonstrated the incredible dispar- macromolecular structure of polyethylene mosquito-net ity in anesthesia-related mortality in LMICs when com- mesh using electron microscopy and spectroscopy, pared with HICs (Bainbridge and others 2012). Factors demonstrating that the material and mechanical prop- associated with this disparity included few qualified erties of mosquito net, including tensile strength, are anesthetists, lack of appropriate training of anesthesia equivalent to those of common lightweight commercial practitioners, and limited supplies for safe monitor- meshes. ing and administration of anesthesia in many LMICs Although the results of these studies are promising, (Walker and Wilson 2008). No pulse oximeters were sample sizes are small and follow-up is limited. Further found in any of the 14 government hospitals surveyed in investigation into the efficacy and safety of mosquito-net a study from Uganda (Linden and others 2012). Given mesh for inguinal hernia repair is needed before wide- these limitations in anesthesia care and the inherently spread implementation. The United Kingdom’s nonprofit higher risk associated with a general anesthetic, we rec- organization Operation Hernia (see box 9.1) is planning ommend that groin hernia repairs in LMICs be carried an audit of outcomes of copolymer mosquito-net mesh out under local or spinal anesthesia whenever possible. purchased from India for use during humanitarian sur- gical repair camps (Stephenson and Kingsnorth 2011). Mosquito-Net Mesh Hernia Repair. Mosquito netting (See box 9.2 for a description of a successful local has been introduced as a prosthesis for inguinal her- initiative.) nia repair to address the high cost of industry mesh. If the safety of mosquito-net mesh is demonstrated, In the 1990s, sterilized mosquito-net mesh was first steps should be taken to make it more widely available used to repair inguinal hernias in India. Tongaonkar for hernia repair in LMICs. Potential challenges to wide- and others (2003) reported a series of 359 hernias that spread implementation include inadequate training in were repaired with a copolymer mosquito-net mesh the mesh technique, barriers to acceptance of mosquito (polyethylene and polypropylene) in multiple hospitals netting as a surgical tool by care providers, and complex- throughout India. On short-term follow-up, the minor ities of acquisition and distribution of the mosquito- wound infection rate was less than 5 percent; there were net mesh. A comprehensive program that addresses no mesh infections and one hernia recurrence. these issues is needed to ensure equitable access to mesh These promising preliminary findings in India have inguinal hernia repair in LMICs. prompted further investigation into the use of non- insecticide-treated mosquito-net mesh for inguinal hernia repair in other low-resource settings, specifically, Africa. Complications Associated with Groin Hernia Repair The feasibility and safety of this technique have been Repair Complications in HICs. Complications after demonstrated for nylon and polyester mosquito-net mesh elective herniorrhaphy in HICs include wound hema- in Burkina Faso, Ghana, and India (Clarke and others toma (6.1 percent), scrotal hematoma (4.5 percent), 2009; Freudenberg and others 2006; Gundre, Iyer, and urinary tract infection (2.1 percent), wound infection Subramaniyan 2012). In addition, experimental research (1.8 percent), and testicular swelling (1.6 percent) in goats has shown that nylon mesh leads to a similar (Fitzgibbons and others 2006). Another important and amount of tissue fibrosis when compared with standard increasingly recognized complication is chronic post- polypropylene industry mesh (Wilhelm and others 2007). operative groin pain. Postoperative pain syndrome may Effective sterilization techniques have been described occur in up to 53 percent of patients and is often diffi- for both copolymer and polyester mosquito-net meshes cult to prevent and treat (Poobalan and others 2003). (Stephenson and Kingsnorth 2011). Mortality following groin herniorrhaphy is difficult Newer studies have investigated the molecular char- to measure. Primatesta and Goldacre (1996) observed acteristics and associated infection risk of mosquito-net the rate of postoperative deaths following elective and Hernia and Hydrocele 157 Box 9.1 Effective Global Health Program: Operation Hernia Operation Hernia, a nonprofit organization based in the of groin hernia. In addition, leaders of the organiza- United Kingdom, is an effective program aimed at com- tion have spearheaded much of the research on hernia bating inguinal hernia in low- and middle-income coun- epidemiology in LMICs, along with safety and efficacy tries (LMICs). Years before Operation Hernia began, a studies of mosquito net mesh repair. Much of the lit- “sister city” relationship was established between Takoradi, erature on cost-effectiveness of groin hernia repair in Ghana, and Plymouth, United Kingdom. In 2005, Andrew low-resource settings was funded and carried out by Kingsnorth and Chris Oppong, surgeons from Plymouth Operation Hernia. Hospital, initiated the first Operation Hernia mission to One of Operation Hernia’s stated goals is to teach Ghana. With support from the British High Commissioner mesh hernia repair techniques to local surgical care and the European Hernia Society, the team of surgeons providers (Kingsnorth and others 2006). If this aspect repaired 130 hernias during their first one-week mission of the mission were to be systemized and expanded, it (Kingsnorth and others 2006). Since then, Operation would make the humanitarian model for the delivery Hernia has established a Hernia Treatment Center in of hernia surgical care more sustainable. Although Takoradi and expanded its services to 10 countries in Africa, some might criticize Operation Hernia for being a Asia, Eastern Europe, and Latin America. This organization disease-focused vertical intervention, this organiza- has supported more than 85 humanitarian missions and tion has demonstrated that its model is scalable and treated more than 9,000 patients with hernias worldwide.a effective. Operation Hernia has been instrumental in advocacy for recognition of the global public health significance a. Operation Hernia Website 2013. http://www.operationhernia.org.uk. Box 9.2 Local Solutions: The Ghana Hernia Society’s Comprehensive Approach to Groin Hernia Care During the past decade, local surgeons have become GHS has held two teaching workshops on groin anat- increasingly interested in improving hernia care and omy and mesh hernia repair techniques in Kumasi and increasing access to groin hernia repair throughout Tamale. Ghana. Initially, a core group of surgeons engaged inde- Figure B9.2.1 demonstrates the current structure of pendently in surgical outreach programs focused on hernia activities of the GHS. The GHS employs a comprehensive care, working with the Apridec Medical Outreach Group, public health approach to the treatment of groin hernia in a Ghanaian nongovernmental organization whose mission Ghana, partnering with key actors in the Ghanaian gov- is to provide free specialist care in northern Ghana. ernment, the Ghana Health Service, and local hospitals to To better coordinate their individual hernia treatment address hernia at multiple levels. The GHS coordinates efforts, Michael Ohene-Yeboah and F. A. Abantanga groin hernia community education programs, advocacy (professors at Kwame Nkrumah University of Science efforts for the prioritization of hernia care, surgical skills and Technology in Kumasi, Ghana) along with Stephen training in mesh techniques, and hernia epidemiology Tabiri (Department of Surgery, Tamale Teaching Hospital research. The GHS’s ultimate goals include the develop- in Tamale, Ghana) and others founded the Ghana Hernia ment of a Pan-African Hernia Society and partnership Society (GHS) in February 2013. Since its inception, the with other international hernia organizations. box continues next page 158 Essential Surgery Box 9.2 (continued) Figure B9.2.1 Activity Flowchart of the Ghana Hernia Society Institutions Members Association Ghana Hernia Society 4 Teaching hospitals 37 Surgeons 10 Regional hospitals Repair Awareness Advocacy Research Aims and Surgical skills Create awareness of IH Advocacy for IH as Public Health Data management objectives Training as a serious DX Priority Prevalence/repair rates Mesh repair of IH Collaborators Government MDAs Hospitals Ministry of Health: Public Health Division Directorate of Health Information Services Regional hospital Ghana Health Service District hospital National Health Insurance Scheme District Medical Officers National Farmers Day Secretariat Outreach services Community health educational Lobbying activities Mesh repair of IH Data analysis Actions programmes on IH similar to Policy change Seminars on IH Audit Tuberculosis, Malaria Mesh repair Update on IH Evaluation of performance Outcome measurement Report from collaborators, reports on prevalence and repair rates Source: Correspondence to authors from S. Tabiri and M. Ohene-Yeboah of the Ghana Hernia Society, 2013. Note: IH = inguinal hernia; MDA = ministries, departments, and agencies. The GHS’s plan could easily be adapted for use in the as a model for the development of local solutions for other establishment of hernia societies with similar goals in common surgical conditions such as hydrocele, traumatic other low-resource settings. In addition, this four-pronged injury, and obstetric fistula. Although in its early stages, approach including community education, advocacy, sur- the GHS is an excellent example of a local public health gical intervention and education, and research could serve solution to a common and important surgical issue. emergency inguinal hernia repairs during a 10-year this condition in the United Kingdom (Primatesta and period in the United Kingdom. They found a signifi- Goldacre 1996). cantly increased risk of death after emergency com- A study of the mortality rate after groin hernia sur- pared with elective herniorrhaphy (1.6 percent and gery in Sweden found similar results. The mortality rate 0.1 percent, respectively). Inguinal hernia was listed as after elective hernia repair was similar to that of the the cause of death in only 17 percent of cases of early background population, but it increased 7-fold after postoperative mortality after emergency hernia repair, emergency operations and 20-fold if bowel resection was suggesting underestimation of the risk of death from required (Nilsson and others 2007). Hernia and Hydrocele 159 Repair Complications in LMICs. Although the lit- of postoperative morbidity and mortality in LMICs is erature on the subject is sparse, complications after likely due to delayed presentation of large scrotal hernias; groin hernia repair in LMICs appear to be higher than inadequate training of surgical, anesthetic, and nursing in HICs. In Senegal, Fall and others (2005) reported a staff; and limitations in preoperative and postoperative complication rate of more than 20 percent after elective care, hospital infrastructure, and supplies. groin herniorrhaphy. Some of the most serious post- operative complications found in this study, such as bladder injury and immediate hernia recurrence, were Task-Shifting in Hernia Surgery: A Targeted Way to likely to be related to surgical technique. In Jos, Nigeria, Improve Quality of Care rates of wound infections after elective inguinal hernia LMICs face a severe shortage of skilled health care repair approach 8 percent, significantly higher than the providers. The global workforce crisis is especially pro- rate of less than 2 percent reported in the United States nounced in the fields of surgery and anesthesia. In their (Ramyil and others 2000). Reliable data on the rate of analysis of surgical care provided at the hospitals in hernia recurrence are not available in LMICs. Pwani, Tanzania, Beard and others (2014) found only two A review of the literature on inguinal hernia epi- staff general surgeons providing care in the region with a demiology and management in Africa found in-hospital population of more than 1.1 million people (table 9.3). inguinal hernia–related mortality rates ranging from At Bagamoyo and Mkuranga District Hospitals, nearly 0.48 percent to 40.0 percent in six studies (Ohene- all hernia repairs in 2012 were done by nonphysician Yeboah and Abantanga 2011). A retrospective investiga- clinicians (NPCs). Mafia District Hospital, located on a tion of morbidity and mortality associated with inguinal remote island off the coast of southern Tanzania, has no hernia in Nigeria demonstrated an overall hernia mor- surgical specialist on staff; surgeons performing hernia tality rate of 5.3 percent (Mbah 2007). Of note, although repairs at this hospital during the study period were there were no deaths among patients with hernias flown in by the nonprofit organization African Medical treated electively in the Nigerian study, the mortality rate and Research Foundation. In Kibaha, the presence of a of patients with obstructed or strangulated hernias was general surgeon did not increase surgical output in the greater than 21 percent (Mbah 2007). In Niger, mortal- district in 2012. ity from hernia strangulation with small bowel necrosis NPCs and nonsurgeon physicians clearly play a key may be as high as 40 percent (Harouna and others 2000). role in the delivery of surgical care for inguinal hernia Figure 9.1 demonstrates the pronounced disparity in in Tanzania. Reports from other countries in Africa, outcomes after inguinal hernia repair in HICs and LMICs including Malawi, Mozambique, and Niger, indicate a found in our review of the literature. This increased risk similar function for NPCs in the provision of surgical care (Kruk and others 2010; Sani and others 2009; Wilhelm and others 2011). Several studies document Figure 9.1 Disparity in Outcomes in Inguinal Hernia Repair in HICs and the safety of task-shifting of emergency obstetric pro- LICs and MICs cedures to nonphysicians in Ethiopia, Mozambique, and Tanzania (Gessessew and others 2011; McCord and others 2009; Pereira and others 1996). 21.0 Studies on outcomes after general surgical proce- 21.0 dures performed by nonsurgeons, specifically hernia, Postoperative mortality rate (%) 18.0 are notably lacking in the literature. Wilhelm and 15.0 others (2011) found similar outcomes after repair 12.0 of strangulated inguinal hernia with bowel resection performed by surgeons and clinical officers at Zomba 9.0 Central Hospital, a large teaching center in Malawi. 6.0 5.3 Although promising, these results may not be gener- alizable to other LMICs. At Zomba Central Hospital, 3.0 1.6 0.1 clinical officers were often directly proctored by fully 0.0 qualified surgeons, which may explain the good results. Elective repair Emergency repair In other Sub-Saharan African countries, NPCs and HICs LICs and MICs nonsurgeon physicians often operate independently with no oversight from a surgical specialist. Although Sources: Mbah 2007; Primatesta and Goldacre 1996. one retrospective study showed similar outcomes after Note: HICs = high-income countries; LICs = low- income countries; MICs = middle-income countries. major surgery performed by NPCs and physicians in 160 Essential Surgery Tanzania, more studies on outcomes after nonobstetric low-cost mesh in Ghana is as cost-effective as a vaccine general surgical procedures performed by NPCs are and 10 times as cost-effective as HIV treatment (Ozgidez urgently needed to guide policy and program planning and Riviello 2008). Of note, approximately 70 percent of (Beard and others 2014). hernias in the Shillcutt, Clarke, and Kingsnorth (2010) First-level hospitals in LMICs offer few continuing study were repaired under local anesthesia, a technique education programs in surgical care. This would be an that likely increased the cost-effectiveness of hernia ideal level at which to intervene with an inguinal hernia repair in this patient cohort. educational program targeted to nonsurgeons providing In India, low-cost polyethylene mesh has been shown surgical care. Tension-free mesh repair techniques with not only to be safe and effective for use in inguinal mosquito net could be taught through short courses hernia repair but also 2,808 times cheaper than com- at first-level hospitals. The introduction of these edu- mercially available polypropylene mesh (Gundre, Iyer, cational programs and tension-free techniques should and Subramaniyan 2012). Mosquito-net mesh is the improve outcomes. ultimate in surgical cost savings: one polyester mosquito net can repair approximately 3,000 hernias (Shillcutt, Clarke, and Kingsnorth 2010), and all symptomatic Cost-Effectiveness of Groin Hernia Repair hernias in Ghana could be repaired today using an Inguinal hernia repair is one of the most cost-effective estimated US$15,000 worth of mesh (Beard, Oresanya, general surgical procedures performed in HICs. Data Ohene-Yeboa, and others 2013). from a randomized trial of laparoscopic repair versus Shillcutt and others (2013) also demonstrated the open-mesh inguinal hernia repair conducted in the cost-effectiveness of mosquito-net mesh hernia repair United States indicate that both types of herniorrhaphy in Ecuador, a middle-income country. The mean cost- are cost-effective (Hynes and others 2006). In this study, effectiveness for herniorrhaphy in this study is US$78.18 investigators used the generally accepted threshold of per DALY, a good buy considering Ecuador’s gross cost-effectiveness in the United States of US$50,000 per national income of US$3,850. These data are strong quality-adjusted life year (QALY). evidence of the cost-effectiveness of hernia repair with In an analysis of inguinal hernia repair using nation- low-cost mesh in LMIC contexts and of the need to ally collected, patient-reported outcome measures prioritize surgery for inguinal hernia when allocating from the National Health Service (NHS) in the United scarce resources. Kingdom, Coronini-Cronberg and others (2013) cal- The findings of Shillcutt’s Ghana and Ecuador studies culated the cost per QALY of open and laparoscopic should be interpreted with some caution because the inguinal herniorrhaphy to be £1,746 ($2,970) and £1,540 DALYs averted per hernia repair were based on expert ($2,620), respectively. The United Kingdom’s National opinion and may be overestimated (Shillcutt, Clarke, and Institute for Health and Clinical Excellence committee Kingsnorth 2010; Shillcutt and others 2013). In addition, routinely uses a cutoff of £20,000 to £30,000 ($34,000 both studies included hernias repaired on Operation to $51,000) per QALY to determine treatment cost- Hernia missions, which may not represent the typical sce- effectiveness and define the scope of NHS therapies. nario in a low-resource setting. Further research is needed These findings suggest that inguinal hernia repair is to characterize the cost-effectiveness of inguinal hernia especially cost-effective in the United Kingdom. repair performed by local practitioners using both low- In Sweden, Nordin and others (2007) found that cost mesh and traditional tissue techniques to get a clearer inguinal hernia repair performed under local anesthesia picture of herniorrhaphy cost-effectiveness in LMICs. has significant cost advantages when compared with the use of spinal and general anesthesia techniques. This result has important implications for inguinal hernior- HYDROCELE rhaphy in LMICs, where the use of local anesthesia may be an important cost-saving strategy for hernia repair. Definitions of Hydrocele Inguinal hernia repair with mosquito-net mesh has A hydrocele is an abnormal accumulation of fluid most been demonstrated to be cost-effective in LMICs even commonly occurring in the scrotum in men or the labia when compared with more traditional public health majora in women: interventions. In a study using Operation Hernia data from Ghana, Shillcutt, Clarke, and Kingsnorth (2010) • A communicating hydrocele is similar to a hernia found that inguinal hernia repair with mosquito-net except that the sac connecting the abdomen to the mesh costs approximately US$12.88 per DALY averted. scrotum or labia majora contains only fluid rather This figure means that inguinal hernia repair with than abdominal contents. Hernia and Hydrocele 161 • A noncommunicating hydrocele is a collection of the filarial origin of the hydrocele and can be useful in scrotal fluid that is isolated from the abdomen. distinguishing actively evolving disease from residual This type of hydrocele is caused by an imbalance scrotal disease after medical treatment. between secretion, absorption, and drainage of fluid Filarial hydroceles can be either acute or chronic. in the scrotal sac. Increased scrotal fluid secretion Acute hydroceles are associated with painful, inflamma- may be caused by local inflammation from bacte- tory nodules caused by the death of adult worms (Dreyer ria or viruses, whereas poor absorption commonly and others 2002; Figueredo-Silva and others 2002). They results from thickening of the sac or lymphatic are often seen after medical treatment for LF but can malfunction. Noncommunicating hydroceles are the also be unrelated to treatment. In these cases, they are a most common type of hydrocele globally, affecting response to acute lymphatic inflammation or infection more than 30 million men and boys (WHO 2013a). known as acute adenolymphangitis (ADLA). Chronic hydroceles are thought to correlate with chronic dysfunction of the lymphatic drainage system Risk Factors for Hydrocele in Adults of the testicular cord, the sac, or both, and this pathol- Obstruction of the testicular venous or lymphatic vessels ogy may be a result of intermittent attacks of ADLA is associated with acute hydrocele development. Venous over a number of years. Hydrocele patients suffer two or lymphatic obstruction can be caused by torsion of episodes of ADLA per year, on average, resulting in the testicle, lymphoma, or the death of parasitic filarial scrotal nodules (Chu and others 2010); Dreyer and worms. In the temperate climates of Europe, North others 2002; Norões and Dreyer 2010). Chronic filarial and South America, and China, most primary hydro- hydroceles are associated with dilation and malfunction celes in adult males are idiopathic. In tropical regions, of the lymphatics (known as lymphangiectasia), rather mainly in LMICs, lymphatic filariasis (LF) is the most than chronic lymphatic obstruction; lymphangiectasia significant risk factor for the development of noncom- can be identified by ultrasound and direct observation. municating hydrocele. LF is caused by infection with the The ultrasound may have a similar appearance to a mosquito-borne worm Wuchereria bancrofti (Michael, varicocele. Hydrocele fluid in these patients contains Bundy, and Grenfell 1996; WHO 2005). lymphatic fluid leaked from damaged lymphatic vessels LF is a complex disease affecting several parts of (Dreyer and others 2000; Pani and Dhanda 1994). the male genital anatomy. The biological predilection of adult filarial worms to live and reproduce in the lymphatic channels of the scrotum means that more Epidemiology and Burden of Disease of Lymphatic than 50 percent of infected men will, with age, develop Filariasis and Hydrocele chronic hydrocele (Addiss and others 1995; Eigege and In many LMICs, including India and countries in Africa, others 2002; Mathieu and others 2008). Hydroceles LF accounts for a significant portion of the total burden caused by LF are sometimes called filariceles. of disease. Approximately 1.3 billion people—more In tropical or subtropical zones, the Culex, Aedes, and than one-seventh of the world’s population—are at risk Anopheles mosquitoes carry the filarial parasite. The cycle for LF in 83 countries (Chu and others 2010; Michael, of infection requires that mosquitoes deposit larvae on Bundy, and Grenfell 1996; WHO 2013a). The Southeast the host skin; the larvae migrate through the puncture site Asia region is home to 65 percent of LF cases, and to the venous system and lymphatics, where they mature 30 percent of patients live in Sub-Saharan Africa. into adults. Nests of the male and female adults are most Some 40 million people are estimated to have symp- commonly identified in the male scrotal lymphatics, tomatic manifestations of filariasis; one-third of these where they produce the first-stage larvae (microfilariae) people live in India. In tropical regions, an estimated that are subsequently consumed by mosquitoes. 25 million to 27 million men have filarial hydroceles (Pani, Kumaraswami and Das 2005; WHO 2013a). In many communities, the majority of men with LF even- Clinical Features of Filarial Hydrocele tually develop symptomatic hydroceles (Addiss 2013; Studies have identified living adult worms within the scro- Babu, Mishra, and Nayak 2009; Dreyer, Norões, and tal lymphatics in a large cohort of patients with hydrocele Addiss 1997; Wijers 1977; Zeldenryk and others 2011). in northern Brazil (Dreyer and others 2002; Norões and In a summary by Haddix and Kestler (2000), a high others 1996; Norões and others 2003). Filarial parasites prevalence of hydrocele was demonstrated in several can be identified by ultrasound (the filarial dance sign) LMICs. On the coasts of Tanzania and Kenya, 90 percent or by visual examination during surgery. In practice, clin- and 60 percent of men, respectively, were found to have ical demonstration of the living adult parasite confirms hydrocele at age 70. In Pondicherry, India, 45 percent 162 Essential Surgery of men have hydroceles by age 60 (Haddix and Kestler approximately one-half the estimate in the WHO Global 2000). Hydrocele is also common in young men and has Burden of Disease study of 2004, which found a total of been identified in a large number of military recruits in 5.9 million DALYs associated with the disease (Murray northern Brazil (Norões and others 1996). and others 2012; Vos and others 2012; WHO 2005). Studies indicate that population-based and house- Clearly these estimates are significantly different, though hold surveys consistently underestimate the true preva- the reasons for this variation in disease burden are not lence of hydrocele and disability from the disease (Eigege yet understood. and others 2002; Mathieu and others 2008). Personal Although GBD 2010 acknowledged that the world’s modesty often impedes accurate reporting of hydroce- population is aging, and therefore years lived with dis- les in household surveys. Clinical mapping by patient ability is increasing, it did not consider that the burden examination is the only precise method of hydro- of filarial hydrocele may actually increase in many cele prevalence measurement (Eigege and others 2002; regions, or that other diseases such as depression may be Mathieu and others 2008; Pani, Kumaraswami, and directly attributable to hydrocele (Vos and others 2012). Das 2005). Spot mapping of children for LF may pro- In addition, the previous edition of Disease Control duce imprecise estimates of hydrocele disease burden; Priorities in Developing Countries (Jamison and others spot maps of men with hydrocele generally correlate 2006) did not consider the burden of filarial hydroceles highly with local LF prevalence. in its calculation of global surgical DALYs (Debas and others 2006). Global Burden of Lymphatic Filariasis and Hydrocele. Map 9.1 illustrates that the global DALYs Economic Burden of Lymphatic Filariasis and attributable to LF in 2004 were concentrated in tropical Hydrocele in LMICs. A number of studies have regions in Sub-Saharan Africa and Southeast Asia, some attempted to estimate the economic burden of LF. It is of the poorest areas in the world. GBD 2010 ranks dis- clear that the disease not only predominantly affects the ability from LF at 105.2; in men, the disease has a slightly world’s poor, but it also perpetuates poverty (Haddix higher disability ranking of 87. According to GBD 2010, and Kestler 2000). The burden can be measured as direct the number of DALYs attributable to LF (2.8 million) is disease-related costs to individuals and households, lost Map 9.1 Global Disability-Adjusted Life Years Attributable to Lymphatic Filariasis (per 100,000 population), 2004 IBRD 41377 | FEBRUARY 2015 Global Disability-Adjusted Life Years Attributable to Lymphatic Filariasis (per 100,000 population), 2004 More than 500 400–500 200–300 80–90 Fewer than 10 No data Source: Lokal_Profil. 2009. “Lymphatic Filariasis World Map–DALY–WHO2004.svg. ”Wikipedia Commons (http://commons.wikimedia.org/wiki/File: Lymphatic_filariasis_world_map_-_DALY). This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank GSDPM Group, any judgment on the legal status of any territory, or any Map Design Unit endorsement or acceptance of such boundaries. Hernia and Hydrocele 163 productivity of individuals, reduced productivity due to hydroceles on communities also has been grossly under- changes in the economies of affected communities, and estimated, especially when the psychosocial impacts of costs to government-funded health care systems. disfiguring hydroceles are considered; the preventive In 2000, more than 10 million people in India sought role of hydrocele surgery for the human and monetary medical care for symptoms associated with LF (Haddix costs of DALYs attributable to depression is potentially and Kestler 2000; Ramaiah and others 2000). However, huge (Wynd and others 2007). the number of people who seek treatment varies from community to community, depending on availability of care and other factors. The economic loss due to dis- Global Efforts to Combat Lymphatic Filariasis and ability from LF in India alone is estimated to be US$1 Hydrocele billion to US$1.5 billion per year, with another US$1 LF is categorized as a neglected tropical disease. In billion attributable to LF in Sub-Saharan Africa. In Sub- 1997, the WHO listed it among the six communicable Saharan Africa, 83 percent of this economic loss is due diseases that could potentially be eliminated worldwide. to hydrocele (Gyapong and others 1996; Haddix and Recognizing this, World Health Assembly Resolution Kestler 2000; Pani, Kumaraswami, and Das 2005). Entire 50.29 identified LF as a significant source of global communities have had to adapt their economic structure disease burden and called for its elimination. In 2000, from fishing to agriculture on the eastern coast of Sub- the GPELF launched a program for LF elimination by Saharan Africa because of the high prevalence of LF in 2020 (Ottesen 2000). The GPELF set the parallel goals this region (Muhondwa 1983). of alleviating disability from LF, including hydrocele, Industry both suffers from, and in some cases is lymphedema, and ADLA, and interrupting transmission responsible for, the perpetuation of conditions condu- of the disease with mass drug administration (MDA). cive to LF. For example, workers in large irrigation proj- Although MDA, mosquito control, and bednets have ects in Ghana and in coco fiber processing in Sri Lanka effectively eliminated LF in some countries, MDA has are at increased risk of LF because of environmental been less successful in others, for social, economic, exposure to mosquitoes carrying the filarial parasite. and geographic reasons (WHO 2011). Moreover, even Migration of infected individuals and crowded living when transmission has been effectively prevented at a arrangements complicate disease eradication efforts. population level, large numbers of people will still suffer disability from filarial hydrocele because of cumulative Social Burden of Filarial Hydrocele in LMICs. The damage to scrotal lymphatics. social burden of filarial hydroceles has been explored in Orissa, India, by Babu, Mishra, and Nayak (2009). Economic Effects of Global Elimination Efforts. In In their ethnographic study, the authors interviewed the first eight years of MDA supported by the GPELF, hydrocele patients, their wives, and the general pub- more than 570 million at-risk individuals were treated lic to understand how hydroceles impact sexual and for four to six years. More than 1.9 billion treatments married life. A high rate of depression accompanied were given in 48 of the 83 endemic countries (map 9.2). the loss of a satisfactory sexual life in these patients Economic benefits have been measurable. This effort has and their spouses. An unmarried man with a hydro- rendered an estimated US$21.8 billion of economic ben- cele seeking a wife was seen as a last-choice marriage efit for affected individuals and US$2.2 billion in health prospect. Because of the severity of the psychological systems savings. Approximately 6.6 million newborns impact on patients, Addiss (2013) has argued for an have been protected from 1.4 million symptomatic “uprising of compassion” for people disabled with hydroceles. Among those already affected with LF and LF. He noted that the 1997 World Health Assembly subclinical disease, MDA is expected to prevent its pro- resolution charged the GPELF with two missions: the gression (Chu and others 2010). elimination of filarial transmission and the alleviation In individual terms, the cost of preventing one case of infection-related disability. of hydrocele, ADLA, or lymphedema in India has been Stories of suffering due to the consequences of calculated to be US$8.41, which would save 58.35 work- LF, including hydrocele, from Brazil, the Dominican ing days per year and improve wages by US$39.39. The Republic, Ghana, Haiti, and India highlight the very cost-benefit ratio has been calculated to be 52.6, which human cost of these disabilities. These disabilities have is among the most cost-effective of any disease control largely not received international attention to the extent program (Remme and others 2006). that some other disabilities, yet they affect at least The potential economic benefit of hydrocelectomy 15 times as many people (Addiss 2013; Addiss and has not yet been calculated but may be similar to that of others 1995; Zeldenryk and others 2011). The impact of hernia surgery, scaled to the known number of cases of 164 Essential Surgery Map 9.2 Mass Drug Administration (MDA) Elimination Programs for Lymphatic Filariasis, 2012 IBRD 41378 | FEBRUARY 2015 Mass Drug Administration (MDA) Elimination Programs for Lymphatic Filariasis, 2012 Endemic countries and territories Endemic countries implementing MDA Endemic countries and territories where the target was achieved and the MDA stopped Not applicable Non-endemic countries and territories Source: WHO 2012 This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank GSDPM Group, any judgment on the legal status of any territory, or any Map Design Unit endorsement or acceptance of such boundaries. existing disease. Unfortunately, access to hydrocelectomy concluded that subtotal excision of the sac is superior to in LMICs is limited. The waitlists for hydrocele repair complete excision. However, the generalizability of this in government-sponsored health programs annually study is limited because there was no standardization exceed 2,000 to 5,000 in endemic Sub-Saharan African of perioperative care or surgical technique. countries. The need for hydrocelectomy in these areas clearly exceeds the surgical capacity (Odoom, personal Filarial Hydrocele. Surgical management of filarial communication, 2013). hydrocele is especially critical. In LMICs, patients may present with massive, disfiguring hydroceles requiring more specialized care. Scrotal skin and lymphatics are Surgical Management of Hydrocele damaged by the parasitic infection, leading to increased Idiopathic Hydrocele. The surgical management of inflammation in the operative field and poor wound benign idiopathic hydroceles can be complex. Although healing. Given this situation, complications after repair the technical drainage of hydrocele via a scrotal incision of filarial hydroceles, including infection, recurrence, appears to be straightforward, the complexity of vascu- and hematoma, have been shown to be even higher than lar and lymphatic anatomy is often underappreciated those after surgical repair of benign idiopathic hydro- (Gottesman 1976; Ku and others 2001; Rodriguez, celes (deVries 2002; Fasana 1982; Thambugala 1971; Rodriguez, and Fortuño 1981). Complication rates Thomas and others 2009; WHO 2002). after hydrocelectomy are high, even in HICs. In a ret- In Brazil, postoperative infection rates after filarial rospective series during the period 1998−2004 in the hydrocelectomy have been reported to be as high as United States, a posthydrocelectomy complication rate 30 percent; recurrence was as high as 19 percent in of 20 percent was found (Swartz, Morgan, and Krieger a large series of patients who underwent sac-sparing 2007), including recurrences of hydrocele, hematoma, surgery for LF (Norões and Dreyer 2010). In this series, infection, and testicular infarction. The surgical tech- a total of 1,128 surgical patients with hydroceles received niques used in this series included sac partial excision complete excision of the hydrocele sac. Postoperative and eversion (47 percent), sac eversion alone (22 per- outcomes in these patients were compared with those cent), and excision alone (18 percent). The authors of a group of 218 patients with “sac-sparing” subtotal Hernia and Hydrocele 165 excision of the sac, done elsewhere. With a mean fol- Programs to expand the capacity for inguinal hernia low-up of 8.6 years, recurrence rates for complete repair and hydrocelectomy at first-level hospitals should excision were 0.3 percent compared with 19 percent use existing human resources and focus on skills training in sac-sparing surgery. Although resection of the sac is for surgeons, physicians, and NPCs already performing more challenging and requires special care for hemosta- these repairs. Local organizations such as the Ghana sis, it has become the standard of care in Brazil, Haiti, Hernia Society could be instrumental in spearheading and the West African Filariasis Program (Mante 2012; training efforts. Infrastructure investment to build hos- Mante and Seim 2007). pital capacity for essential surgeries like herniorrhaphy Particular care must be taken when the skin of and hydrocelectomy is needed to ensure access to these the scrotum is thickened, especially when dripping procedures. with lymphatic fluid—a condition known as “lymph Addressing inguinal hernia and filarial hydrocele scrotum.” These cases require reconstructive surgery. should be a high priority on any global surgery agenda. Simple hydrocelectomy is contraindicated. Successful Basic surgical care, specifically, essential procedures like lymphovenous shunts for hydroceles and lymphedema groin herniorrhaphy and hydrocelectomy, is a crucial secondary to LF have also been reported in the Indian part of health care services that should be available at literature (Manokaran 2005). first-level hospitals. Working toward equitable provision The surgical management of filarial hydroceles in of hernia repair and hydrocelectomy in LMICs has the LMICs is largely not standardized. In our experience, potential to strengthen health systems and ultimately protocols for LF hydrocelectomy appear to improve out- increase much-needed hospital capacity. comes by standardizing the use of antibiotics, surgical techniques, dressings, and perioperative management, although little published data on this topic are available. NOTES The World Bank classifies countries according to four income CONCLUSIONS groupings. Income is measured using gross national income (GNI) per capita, in U.S. dollars, converted from local currency The global burden of groin hernia and hydrocele is using the World Bank Atlas method. Classifications as of July significant. We estimate that 223 million people in the 2014 are as follows: world, equivalent to about two-thirds of the popula- tion of the United States, have inguinal hernia, while • Low-income countries (LICs) = US$1,045 or less in 2013 nearly 30 million men suffer from filarial hydrocele. • Middle-income countries (MICs) are subdivided: Elective hernia repair and hydrocelectomy are curative • Lower-middle-income = US$1,046 to US$4,125 public health interventions. Herniorrhaphy prevents • Upper-middle-income (UMICs) = US$4,126 to US$12,745 life-threatening complications from hernia accidents, • High-income countries (HICs) = US$12,746 or more and both procedures improve quality of life. Hernia repair is also cost-effective, even when compared with 1. International Database, 2013, United States Census Bureau, more traditional public health interventions. Washington, DC. http://www.census.gov /population Many people in the world do not have access to safe /international/data/idb/region.php. groin hernia surgery or hydrocelectomy. This dispar- ity results in higher levels of morbidity and mortality from hernia in LMICs. Limited access to hydrocelec- tomy in LMICs perpetuates the continuing suffering REFERENCES of the world’s poorest people from disfiguring filarial Abramson, J. H., J. Gofin, C. Hopp, A. Makler, and L. M. Epstein. hydroceles. Although tension-free mesh repair is the 1978. “The Epidemiology of Inguinal Hernia: A Survey in standard of care for groin hernia in HICs, it is unavail- Western Jerusalem.” Journal of Epidemiology & Community able to most patients in LMICs. Mosquito-net mesh Health 32 (1): 59–67. Addiss, D. G. 2013. “Global Elimination of Lymphatic Filariasis: may be a safe and cost-effective way to correct this A ‘Mass Uprising of Compassion’.” PLoS Neglected Tropical disparity. However, pending widespread availability Diseases 7 (8): e2264. doi:10.1371/journal.pntd.0002264. of a proven safe option for mesh, increased access to Addiss, D. G., K. A. Dimock, M. L. Eberhard, and P. J. Lammie. well-established tissue techniques of groin hernia repair 1995. “Clinical, Parasitologic and Immunologic Observations should be promoted. of Patients with Hydrocele and Elephantiasis in an Area Task-shifting of herniorrhaphy to NPCs and non- with Endemic Lymphatic Filariasis.” Journal of Infectious surgeon physicians is occurring throughout Africa. Diseases 171 (3): 755–58. 166 Essential Surgery Arowolo, O. A., E. A. Agbakwuru, A. O. Adisa, O. O. Lawal, (PROMs) Data to Estimate Cost-Effectiveness of Hernia M. H. Ibrahim, and others. 2011. “Evaluation of Surgery in England.” Journal of the Royal Society of Medicine Tension-Free Mesh Inguinal Hernia Repair in Nigeria: 106 (7): 278–87. doi:10.1177/0141076813489679. A Preliminary Report.” West African Journal of Medicine Debas, H. T., R. Gosselin, C. McCord, and A. Thind. 2006. 30 (2): 110–13. “Surgery.” In Disease Control Priorities in Developing Babu, B. V., S. Mishra, and A. N. Nayak. 2009. “Marriage, Countries, edited by D. T. Jamison, J. G. Breman, Sex, and Hydrocele: An Ethnographic Study on the A. R. Measham, G. Alleyne, M. Claeson, D. B. Evans, P. Jha, Effect of Filarial Hydrocele on Conjugal Life and A. Mills, and P. Musgrove, 2nd ed., 1245–60. Washington, Marriageability from Orissa, India.” PLoS Neglected DC: World Bank and Oxford University Press. Tropical Diseases 3 (4): e414. deVries, C. R. 2002. “The Role of the Urologist in the Treatment Bainbridge, D., J. Martin, M. Arango, and D. Cheng. 2012. and Elimination of Lymphatic Filariasis Worldwide.” BJU “Perioperative and Anaesthetic-Related Mortality in International 89 (suppl 1): 37–43. Developed and Developing Countries: A Systematic Review Dreyer, G., D. Addiss, J. Roberts, and J. Norões. 2002. and Meta-Analysis.” The Lancet 380 (9847): 1075–81. “Progression of Lymphatic Vessel Dilatation in the Presence Bay-Nielsen, M., and H. Kehlet. 2008. “Anesthesia and of Living Adult Wuchereria bancrofti.” Transactions of the Postoperative Morbidity after Elective Groin Hernia Repair: Royal Society of Tropical Medicine and Hygiene 96 (2): A Nationwide Study.” Acta Anaesthesiologica Scandinavica 157–61. 52 (2): 169–74. Dreyer, G., J. Norões, and D. Addiss. 1997. “The Silent Burden Bay-Nielsen, M., L. Strand, J. Malmstrom, F. H. Anderson, of Sexual Disability Associated with Lymphatic Filariasis.” and others. 2001. “Quality Assessment of 26,304 Acta Tropica 63 (1): 57–60. Herniorrhaphies in Denmark: A Prospective Nationwide Dreyer, G., J. Norões, J. Figueredo-Silva, and W. F. Piessens. Study.” The Lancet 358 (9288): 1124–28. 2000. “Pathogenesis of Lymphatic Disease in Bancroftian Beard, J. H., L. B. Oresanya, L. Akoko, A. Mwanga, R. A. Dicker, Filariasis: A Clinical Perspective.” Parasitology Today and H. W. Harris. 2013. “An Estimation of Inguinal Hernia 16 (12): 544–48. Epidemiology Adjusted for Population Age Structure in Eigege, A., F. O. Richards, D. D. Blaney, E. S. Miri, I. Gontor, Tanzania.” Hernia 18 (2): 289–95. doi:10.1007/s10029 and others. 2002. “Rapid Assessment for Lymphatic -013-1177-5. Filariasis in Central Nigeria: A Comparison of the Beard, J. H., L. B. Oresanya, L. Akoko, A. Mwanga, C. A. Mkony, Immunochromaticographic Card Test and Hydrocele Rates and R. A. Dicker. 2014. “Surgical Task-Shifting in a Low- in an Area of High Endemicity.” American Journal of Resource Setting: Outcomes after Major Surgery Performed Tropical Medicine and Hygiene 68 (6): 643–46. by Non-physician Clinicians in Tanzania.” World Journal of Everhart, J. E. 1994. “Abdominal Wall Hernia.” In Digestive Surgery 38 (6): 1398–404. Diseases in the United States: Epidemiology and Impact, ———. Not dated. “Hernia Repair Capacity in Pwanu Region, edited by J. E. Everhart, 471–507. Bethesda, MD: Tanzania, 2014.” Unpublished. National Institute of Diabetes and Digestive and Kidney Beard, J. H., L. B. Oresanya, M. Ohene-Yeboah, R. A. Dicker, Diseases. and H. W. Harris. 2013. “Characterizing the Global Burden Fall, B., M. E. Betel, O. Diarra, M. Ba, A. Dia, and A. Diop. 2005. of Surgical Disease: A Method to Estimate Inguinal Hernia “Complications of Treatment of Adult’s Groin Hernia: Epidemiology in Ghana.” World Journal of Surgery 37 (3): A Report of 100 Cases Comparative Study between Bassini 498–503. and McVay’s Techniques.” Dakar Médical 50 (1): 37–40. Belcher, D. W., P. K. Nyame, and F. K. Wurapa. 1978. “The Fasana, F. 1982. “Treatment of Tropical Hydrocele: A Study of Prevalence of Inguinal Hernia in Adult Ghanaian Males.” 273 Cases.” Medicom 4 (3): 73–75. Tropical Geographical Medicine 30 (1): 39–43. Figueredo-Silva, J., J. Norões, A. Cedenho, and G. Dreyer. 2002. Carbonell, J. F., J. L. Sanchez, R. T. Peris, J. C. Ivorra, “The Histopathology of Bancroftian Filariasis Revisited: M. J. Del Baño, and others. 1993. “Risk Factors Associated The Role of the Adult Worm in the Lymphatic-Vessel with Inguinal Hernias: A Case Control Study.” European Disease.” Annals of Tropical Medicine and Parasitology Journal of Surgery 159 (9): 481–86. 96 (6): 531–41. Chu, B. K., P. J. Hooper, M. H. Bradley, D. A. McFarland, and Fitzgibbons, R. J., Jr., A. Giobbie-Hurder, J. O. Gibbs, E. A. Ottesen. 2010. “The Economic Benefits Resulting from D. D. Dunlop, D. J. Reda, and others. 2006. “Watchful the First 8 Years of the Global Programme to Eliminate Waiting vs. Repair of Inguinal Hernia in Minimally Lymphatic Filariasis (2000–2007).” PLoS Neglected Tropical Symptomatic Men: A Randomized Clinical Trial.” Journal Diseases 4 (6): e708. of the American Medical Association 295 (3): 285–92. Clarke, M. G., C. Oppong, R. Simmermacher, K. Park, Flich, J., J. L. Alfonso, F. Delgado, M. J. Prado, and P. Cortina. M. Kurzer, and others. 2009. “The Use of Sterilised Polyester 1992. “Inguinal Hernia and Certain Risk Factors.” European Mosquito Net Mesh for Inguinal Hernia Repair in Ghana.” Journal of Epidemiology 8 (2): 277–82. Hernia 13 (2): 155–59. Freudenberg, S., D. Sano, E. Ouangre, C. Weiss, and Coronini-Cronberg, S., J. Appleby, and J. Thompson. 2013. T. J. Wilhelm. 2006. “Commercial Mesh versus Nylon “Application of Patient-Reported Outcome Measures Mosquito Net for Hernia Repair: A Randomized Hernia and Hydrocele 167 Double-Blind Study in Burkina Faso.” World Journal of Jamison, D. T., J. G. Brennan, A. R. Measham, G. Alleyne, Surgery 30 (10): 1784–89. M. Claesen, and others, eds. 2006. Disease Control Priorities Gallegos, N. C., J. Dawson, M. Jarvis, and M. Hibsely. 1991. in Developing Countries, 2nd ed. New York: Oxford “Risk of Strangulation in Groin Hernias.” British Journal of University Press. Surgery 78 (10): 1171–73. Kingsnorth, A. N., C. Oppong, J. Akoh, B. Stephenson, and Galukande, M., J. von Schreeb, A. Wladis, N. Mbembati, R. Simmermacher. 2006. “Operation Hernia to Ghana.” H. de Miranda, and others. 2010. “Essential Surgery at the Hernia 10 (5): 376–79. District Hospital: A Retrospective Descriptive Analysis in Koch, A., A. Edwards, S. Haapaniemi, P. Nordin, and A. Three African Countries.” PLoS Medicine 7 (3): e1000243. Kald. 2005. “Prospective Evaluation of 6895 Groin Hernia doi:10.1371/journal.pmed.1000243. Repairs in Women.” British Journal of Surgery 92 (12): Gessessew, A., G. A. Barnabas, N. Prata, and K. Weidert. 1553–58. 2011. “Task Shifting and Sharing in Tigray, Ethiopia, Krishna, A., M. C. Misra, V. K. Bansal, S. Kumar, S. Rajeshwari, to Achieve Comprehensive Emergency Obstetric Care.” and others. 2012. “Laparoscopic Inguinal Hernia Repair: International Journal of Gynaecology and Obstetrics Transabdominal Preperitoneal (TAPP) versus Totally 113 (1): 28–31. Extraperitoneal (TEP) Approach: A Prospective Randomized Gottesman, J. E. 1976. “Hydrocelectomy: Evaluation of Controlled Trial.” Surgical Endoscopy 26 (3): 639–49. Technique.” Urology 7 (4): 386–87. Kruk, M. E., A. Wladis, N. Mbembati, S. K. Ndao-Brumblay, Grimes, C. E., R. S. Law, E. S. Borgstein, N. C. Mkandawire, R. Y. Hsia, and others. 2010. “Human Resource and Funding C. B. Lavy, and others. 2012. “Systematic Review of Met Constraints for Essential Surgery in District Hospitals and Unmet Need of Surgical Disease in Rural Sub-Saharan in Africa: A Retrospective Cross-Sectional Survey.” PLoS Africa.” World Journal of Surgery 36 (1): 8–23. Medicine 7 (3): e1000242. Gundre, N. P., S. P. Iyer, and P. Subramaniyan. 2012. “Prospective Ku, J. H., M. E. Kim, N. K. Lee, and Y. H. Park. 2001. “The Randomized Controlled Study Using Polyethylene Mesh Excisional, Plication and Internal Drainage Techniques: for Inguinal Hernia Meshplasty as a Safe and Cost-Effective A Comparison of the Results for Idiopathic Hydrocele.” Alternative to Polypropylene Mesh.” Updates in Surgery BJU International 87 (1): 82–84. 64 (1): 37–42. Lau, H., C. Fang, W. K. Yuen, and N. G. Patil. 2007. “Risk Gyapong, J. O., M. Gyapong, D. B. Evans, M. K. Aikins, Factors for Inguinal Hernia in Adult Males: A Case-Control and S. Adjei. 1996. “The Economic Burden of Lymphatic Study.” Surgery 141 (2): 262–66. Filariasis in Northern Ghana.” Annals of Tropical Medicine Linden, A. F., F. S. Sekidde, M. Galukande, L. M. Knowlton, and Parasitology 90 (1): 39–48. S. Chackungal, and K. A. McQueen. 2012. “Challenges of Haddix, A. C., and A. Kestler. 2000. “Lymphatic Filariasis: Surgery in Developing Countries: A Survey of Surgical and Economic Aspects of the Disease and Programmes for Its Anesthesia Capacity in Uganda’s Public Hospitals.” World Elimination.” Transactions of the Royal Society of Tropical Journal of Surgery 36 (5): 1056–65. Medicine and Hygiene 94 (6): 592–93. Löfgren, J., F. Makumbi, E. Galliwango, P. Nordin, C. Ibingira, Hair, A., C. Paterson, D. Wright, J. N. Baxter, and P. J. O’Dwyer. and others. 2014. “Prevalence of Treated and Untreated 2001. “What Effect Does the Duration of an Inguinal Hernia Groin Hernia in Eastern Uganda.” British Journal of Surgery Have on Patient Symptoms?” Journal of the American 101 (6): 728–34. College of Surgeons 193 (2): 125–29. Mabula, J. B., and P. L. Chalya. 2012. “Surgical Management Hakeem, A., and V. Shanmugam. 2011. “Inguinodynia of Inguinal Hernias at Bugando Medical Center in Following Lichtenstein Tension-Free Hernia Repair: A Northwestern Tanzania: Our Experiences in a Resource- Review.” World Journal of Gastroenterology 17 (14): 1791–96. Limited Setting.” BMC Research Notes 5: 585. Harouna, Y., H. Yaya, I. Abdou, and L. Bazira. 2000. “Prognosis Manokaran, G. 2005. “Management of Genitourinary of Strangulated Hernia in Adult with Necrosis of Small Manifestations of Lymphatic Filariasis.” Indian Journal of Bowel: A 34 Cases Report.” Bulletin de la Société de Pathologie Urology 21 (1): 39–43. Exotique 93: 317–20. Mante, S. D. 2012. “The African Filariasis Morbidity Project: Heikkinen, T., K. Haukipuro, J. Leppälä, and A. Hulkko. 1997. The Past, the Present, and the Future.” http://filariasis.org “Total Costs of Laparoscopic and Lichtenstein Inguinal /documents/4.TheAfricanMorbidityProject.pdf. Hernia Repairs: A Prospective Study.” Surgical Laparoscopy, Mante, S. D., and A. R. Seim. 2007. West African Lymphatic Endoscopy, and Percutaneous Techniques 7 (1): 1. Filariasis Morbidity Project Surgical Handbook: An Aid to Herszage, L. 2004. “Hernia Surgery in the South American District Hospital Surgeons. 2nd ed. Fjellstrand, Norway: Woodlands: A Surgical Adventure in Argentina.” Hernia Health and Development International. http://hdi.no/pdfs 8 (4): 306–10. /LF/lymphatic-filariasis-guide.pdf. Hynes, D. M., K. T. Stroupe, P. Luo, A. Giobbie-Hurder, D. Reda, Manyilirah, W., S. Kijambu, A. Upoki, and J. Kiryabwire. and others. 2006. “Cost Effectiveness of Laparoscopic versus 2012. “Comparison of Non-mesh (Desarda) and Mesh Open Mesh Hernia Operation: Results of a Department of (Lichtenstein) Methods for Inguinal Hernia Repair among Veterans Affairs Randomized Clinical Trial.” Journal of the Black African Patients: A Short-Term Double-Blind RCT.” American College of Surgeons 203 (4): 447–57. Hernia 16 (2): 134–44. 168 Essential Surgery Mathieu, E., J. Amann, A. Eigege, F. Richards, and Y. Sodahhlon. Norões, J., D. Addiss, F. Amaral, A. Coutinho, Z. Medeiros, 2008. “Collecting Baseline Information for National and others. 1996. “Occurrence of Living Adult Wuchereria Morbidity Alleviation Programs: Different Methods to bancrofti in the Scrotal Area of Men with Microfilaraemia.” Estimate Lymphatic Filariasis Morbidity Prevalence.” Transactions of the Royal Society of Tropical Medicine and American Journal of Tropical Medicine and Hygiene 78: (1): Hygiene 90 (1): 55–56. 153–58. Norões, J., D. Addiss, A. Cedenho, J. Figueredo-Silva, G. Lima, Mbah, N. 2007. “Morbidity and Mortality Associated with and G. Dreyer. 2003. “Pathogenesis of Filarial Hydrocele: Inguinal Hernia in Northwestern Nigeria.” West African Risk Associated with Intrascrotal Nodules Caused by Journal of Medicine 26 (4): 288–92. Death of Adult Wuchereria bancrofti.” Transactions of the McCord, C., G. Mbaruku, C. Pereira, C. Nzabuhakwa, and Royal Society of Tropical Medicine and Hygiene 97 (5): S. Bergstrom. 2009. “The Quality of Emergency Obstetrical 561–66. Surgery by Assistant Medical Officers in Tanzanian District Norões, J., D. Addiss, A. Santos, Z. Medeiros, A. Coutinho, and Hospitals.” Health Affairs 28 (5): w876–85. G. Dreyer. 1996. “Ultrasonographic Evidence of Abnormal McCormack, K., N. W. Scott, P. M. Go, S. Ross, A. M. Grant, Lymphatic Vessels in Young Men with Adult Wuchereria and others. 2003. “Laparoscopic Techniques versus Open bancrofti Infection in the Scrotal Area.” Journal of Urology Techniques for Inguinal Hernia Repair.” Cochrane Database 156 (2 Pt 1): 409–12. of Systematic Reviews 1: Cd001785. doi:10.1002/14651858. Noro¸ es, J., and G. Dreyer. 2010. “A Mechanism for Chronic CD001785. Filarial Hydrocele with Implications for Its Surgical Repair.” Michael, E., D. A. Bundy, and B. T. Grenfell. 1996. “Re-Assessing PLoS Neglected Tropical Diseases 4 (6): e695. the Global Prevalence and Distribution of Lymphatic Ohene-Yeboah, M., and F. A. Abantanga. 2011. “Inguinal Filariasis.” Parasitology 112 (4): 409–28. Hernia Disease in Africa: A Common but Neglected Mock, C., M. Cherian, C. Julliard, P. Donkor, S. Bickler, and Surgical Problem.” West African Journal of Medicine 30 others. 2010. “Developing Priorities for Addressing Surgical (2): 77–83. Conditions Globally: Furthering the Link between Surgery Ohene-Yeboah, M., J. Oppong, B. Togbe, B. Nimako, and and Public Health Policy.” World Journal of Surgery 34 (3): others. 2009. “Some Aspects of the Epidemiology of 381–85. External Hernia in Kumasi, Ghana.” Hernia 13 (5): Muhondwa, E. P. Y. 1983. “Community Participation in 529–32. Filariasis Control: The Tanzania Experiment.” TDR/SER Ottesen, E. A. 2000. “The Global Programme to Eliminate /SWG (4)/WP/83.13, WHO, Geneva. Lymphatic Filariasis.” Tropical Medicine and International Murray, C. J. L., T. Vos, R. Lozano, M. Naghavi, A. D. Flaxman, Health 5 (9): 591–94. and others. 2012. “Disability-Adjusted Life Years (DALYs) Ozgediz, D., and R. Riviello. 2008. “The ‘Other’ Neglected for 291 Diseases and Injuries in 21 Regions, 1990–2010: Diseases in Global Public Health: Surgical Conditions in A Systematic Analysis for the Global Burden of Disease Sub-Saharan Africa.” PLoS Medicine 5 (6): 850–54. Study 2010.” The Lancet 380 (9859): 2197–223. Pani, S. P., and V. Dhanda. 1994. “Natural History and Dynamics National Bureau of Statistics and Coast Regional Commissioners of Progression of Clinical Manifestations of Filariasis.” In Office. 2007. “United Republic of Tanzania Coast Region Tropical Disease: Molecular Biology and Control Strategies, Socioeconomic Profile.” edited by Sushil Kumar, A. K. Sen, G. P. Dutta, and Neuhauser, D. 1977. “Elective Inguinal Herniorrhaphy versus R. N. Sharma. New Delhi: Publications and Information Truss in the Elderly.” In Costs, Risks, and Benefits of Surgery, Directorate. edited by J. P. Bunker, B. A. Barnes, and F. Mosteller, 223–39. Pani, S. P., V. Kumaraswami, and L. K. Das. 2005. “Epidemiology New York: Oxford University Press. of Lymphatic Filariasis with Special Reference to Urogenital- Neumayer, L., A. Giobbie-Hurder, O. Jonasson, R. Fitzgibbons, Manifestations.” Indian Journal of Urology 21 (1): 44–49. Jr., D. Dunlop, and others. 2004. “Open Mesh versus Pereira, C., A. Bugalho, S. Bergstrom, F. Vaz, and M. Cotiro. 1996. Laparoscopic Mesh Repair of Inguinal Hernia.” New “A Comparative Study of Cesarean Deliveries by Assistant England Journal of Medicine 350: 1819. Medical Officers and Obstetricians in Mozambique.” British Nilsson, H., G. Stylianidis, M. Haapamaki, E. Nilsson, and Journal of Obstetrics and Gynaecology 103 (6): 508–12. P. Nordin. 2007. “Mortality after Groin Hernia Surgery.” Poobalan, A. S., J. Bruce, W. C. Smith, P. M. King, Annals of Surgery 245 (4): 656–60. Z. H. Krukowski, and others. 2003. “A Review of Chronic Nordberg, E. 1984. “Incidence and Estimated Need of Pain after Inguinal Herniorrhaphy.” Clinical Journal of Cesarean Section, Inguinal Hernia Repair, and Operation Pain 19 (1): 48. for Strangulated Hernia in Rural Africa.” British Medical Primatesta, P., and M. J. Goldacre. 1996. “Inguinal Hernia Journal (Clinical Research Edition) 289 (6437): 92–93. Repair: Incidence of Elective and Emergency Surgery, Nordin, P., H. Zetterstrom, P. Carlsson, and E. Nilsson. 2007. Readmission and Mortality.” International Journal of “Cost-Effectiveness Analysis of Local, Regional and General Epidemiology 25 (4): 835–39. Anaesthesia for Inguinal Hernia Repair Using Data from a Ramaiah, K. D., P. K. Das, E. Michael, and H. Guyatt. 2000. Randomized Controlled Trial.” British Journal of Surgery “The Economic Burden of Lymphatic Filariasis in India.” 94 (4): 500–05. Parasitology Today 16 (6): 251–23. Hernia and Hydrocele 169 Ramyil, V. M., D. Iya, B. C. Ogbonna, and M. K. Dakum. 2000. Swartz, M., T. M. Morgan, and J. N. Krieger. 2007. “Safety of Daycare Hernia Repair in Jos, Nigeria.” East “Complications of Scrotal Surgery for Benign Conditions.” African Medical Journal 77 (6): 326–28. Urology 69 (4): 616–19. RAND Corporation. 1983. Conceptualization and Measurement Szopinski, J., S. Dabrowiecki, S. Pierscinski, M. Jackowski, of Physiologic Health of Adults. Santa Monica, CA: RAND M. Jaworski, and Z. Szuflet. 2012. “Desarda versus Corporation. Lichtenstein Technique for Primary Inguinal Hernia Remme, J. H. F., P. Feenstra, P. R. Lever, A. C. Medici, Treatment: 3-Year Results of a Randomized Clinical Trial.” C. M. Morel, and others. 2006. “Tropical Diseases Targeted World Journal of Surgery 36 (5): 984–92. for Elimination: Chagas Disease, Lymphatic Filariasis, Thambugala, R. L. 1971. “The Radical Cure of Hydrocele of Onchocerciasis, and Leprosy.” In Disease Control Priorities in the Tunica Vaginalis: The Technique of Excision of the Sac.” Developing Countries, edited by D. T. Jamison, J. G. Brennan, British Journal of Surgery 58 (7): 517–51. A. R. Measham, G. Alleyne, S. Claesen, and others, 2nd ed., Thomas, G., F. O. Richards, Jr., A. Eigege, N. K. Dakum, 433–44. New York: Oxford University Press. M. P. Azzuwut, and others. 2009. “A Pilot Program of Rodriguez, W. C., D. D. Rodriguez, and R. F. Fortuño. 1981. Mass Surgery Weeks for Treatment of Hydrocele Due to “The Operative Treatment of Hydrocele: A Comparison Lymphatic Filariasis in Central Nigeria.” American Journal of 4 Basic Techniques.” Journal of Urology 125 (6): of Tropical Medicine and Hygiene 80 (3): 447–51. 804–05. Tongaonkar, R. R., B. V. Reddy, V. K. Mehta, N. S. Singh, and Ruhl, C. E., and J. E. Everhart. 2007. “Risk Factors for Inguinal S. Shivade. 2003. “Preliminary Multicentric Trial of Cheap Hernia among Adults in the US Population.” American Indigenous Mosquito-Net Cloth for Tension-Free Hernia Journal of Epidemiology 165 (10): 1154–61. Repair.” Indian Journal of Surgery 65 (1): 89–95. Sanders, D. L., A. N. Kingsnorth, R. Moate, and J. A. Steer. 2013. Turaga, K., R. J. Fitzgibbons, and V. Puri. 2008. “Inguinal “An In Vitro Study Assessing the Infection Risk of Low-Cost Hernias: Should We Repair?” Surgical Clinics of North Polyethylene Mosquito Net Compared with Commercial America 88 (1): 127–38. Hernia Prosthetics.” Journal of Surgical Research 183 (2): Vos, T., A. D. Flaxman, M. Naghavi, R. Lozano, C. Michaud, e31–37. and others. 2012. “Years Lived with Disability (YLDs) for Sanders, D. L., A. N. Kingsnorth, and B. M. Stephenson. 1,160 Sequelae of 289 Diseases and Injuries, 1990–2010: 2013. “Mosquito Net Mesh for Abdominal Wall A Systematic Analysis for the Global Burden of Disease Hernioplasty: A Comparison of Material Characteristics Study 2010.” The Lancet 380 (9859): 2163–96. with Commercial Prosthetics.” World Journal of Surgery Walker, I. A., and I. H. Wilson. 2008. “Anaesthesia in 37 (4): 737–45. Developing Countries—A Risk for Patients.” The Lancet Sanders, D. L., C. S. Porter, C. D. Mitchell, and A. N. Kingsnorth. 371 (9617): 968–69. 2008. “A Prospective Cohort Study Comparing the African WHO (World Health Organization). 2002. Surgical Approaches and European Hernia.” Hernia 12 (5): 527–29. to the Urogenital Manifestations of Lymphatic Filariasis. Sani, R., B Nameoua, A. Yahaya, I. Hassane, R. Adamou, and Geneva: WHO. http://whqlibdoc.who.int/hq/2002/WHO others. 2009. “The Impact of Launching Surgery at the _CDS_CPE_CEE_2002.33.pdf. District Level in Niger.” World Journal of Surgery 33 (10): ———. 2005. “Global Programme to Eliminate Lymphatic 2063–68. Filariasis: Progress Report for 2004.” Weekly Epidemiological Schneider, B. E., J. M. Castillo, L. Villegas, D. J. Scott, and Record 80: 202–12. http://www.who.int/wer/2005/wer8023 D. B. Jones. 2003. “Laparoscopic Totally Extraperitoneal .pdf. versus Lichtenstein Herniorrhaphy: Cost Comparison at ———. 2011. Accelerating Work to Overcome the Global Teaching Hospitals.” Surgical Laparoscopy, Endoscopy, and Impact of Neglected Tropical Diseases: A Roadmap for Percutaneous Techniques 13 (4): 261–67. Implementation. Geneva: WHO. http://www.who.int Shillcutt, S. D., M. G. Clarke, and A. N. Kingsnorth. 2010. /neglected_diseases/NTD_RoadMap_2012_Fullversion.pdf. “Cost-Effectiveness of Groin Hernia Surgery in the ———. 2012. “Global Programme to Eliminate Lymphatic Western Region of Ghana.” Archives of Surgery 145 (10): Filariasis: Progress Report, 2011.” Weekly Epidemiological 954–61. Record 87: 345–56. http://www.who.int/wer/2012/REH Shillcutt, S. D., D. L. Sanders, M. T. Butron-Vila, and _37.pdf. A. N. Kingsnorth. 2013. “Cost-Effectiveness of Inguinal ———. 2013a. “Lymphatic Filariasis.” Factsheet No. 102, Hernia Surgery in Northwestern Ecuador.” World Journal of WHO, Geneva. http://www.who.int/mediacentre/factsheets Surgery 37 (1): 32–41. /fs102/en/. Stephenson, B. M., and A. N. Kingsnorth. 2011. “Safety and ———. 2013b. “World Health Organization Media Center: Sterilization of Mosquito Net Mesh for Humanitarian Maternal Mortality.” Factsheet No. 348, WHO, Geneva. Inguinal Hernioplasty.” World Journal of Surgery 35 (9): http://www.who.int/mediacentre/factsheets/fs348/en/. 1957–60. Wijers, D. J. B. 1977. “Bancroftian Filariasis in Kenya Swadia, N. D. 2011. “Laparoscopic Totally Extra-Peritoneal I. Prevalence Survey among Adult Males in the Coast Inguinal Hernia Repair: 9 Year’s Experience.” Hernia 15 (3): Province.” Annals of Tropical Medicine and Parasitology 273–79. 71 (3): 313–33. 170 Essential Surgery Wilhelm, T. J., S. Freudenberg, E. Jonas, R. Gobholz, S. Post, Yang, J., D. Papandria, D. Rhee, H. Perry, and F. Abdullah. 2011. and P. Kyamanywa. 2007. “Sterilized Mosquito Net versus “Low-Cost Mesh for Inguinal Hernia Repair in Resource- Commercial Mesh for Hernia Repair: An Experimental Limited Settings.” Hernia 15 (5): 485–89. Study in Goats in Mbarara/Uganda.” European Surgical Yardov, Y. S., and S. K. Stoyanov. 1969. “The Incidence of Research 39 (5): 312–17. Hernia on the Island of Pemba.” East African Medical Wilhelm, T. J., I. Thawe, B. Mwatabu, H. Mothes, and S. Post. Journal 46 (12): 687–91. 2011. “Efficacy of Major General Surgery Performed by Zeldenryk, L. M., M. Gray, R. Speare, S. Gordon, and Non-physician Clinicians at a Central Hospital in Malawi.” W. Melrose. 2011. “The Emerging Story of Disability Tropical Doctor 41 (2): 71–75. Associated with Lymphatic Filariasis: A Critical Review.” Wynd, S., W. D. Melrose, D. N. Durrheim, J. Carron, and PLoS Neglected Tropical Diseases 5 (12): e1366. M. Gyapong. 2007. “Understanding the Community Zendejas, B., T. Ramirez, T. Jones, A. Kuchena, S. M. Ali, and Impact of Lymphatic Filariasis: A Review of the others. 2013. “Incidence of Inguinal Hernia Repairs in Sociocultural Literature.” Bulletin of the World Health Olmsted County, MN: A Population-Based Study.” Annals Organization 85 (6): 493–98. of Surgery 257 (3): 520–26. Hernia and Hydrocele 171 Chapter 10 Dentistry Richard Niederman, Magda Feres, and Eyitope Ogunbodede INTRODUCTION This chapter addresses the first category—the largely preventable bacterial infections of caries, periodontitis, The oral health chapter in Disease Control Priorities and noma. It does not specifically address oral-systemic in Developing Countries, second edition, focused on interactions or associations. The other maladies in noncommunicable disease models for health systems the remaining three categories are addressed in other (Bratthall and others 2006). The current chapter pro- chapters and volumes in this series. vides a complementary approach based on the defini- We identify evidence-based, cost-effective, preven- tion of health care delivery as the “effective provision of tive interventions that community health care work- services to people with diseases for which proven ther- ers can deliver at the community level. These same apies exist” (Kim, Farmer, and Porter 2013, 1060–61). workers provide better sanitation and clean water, These complementary approaches—top down and as well as treat a range of diseases, such as diabe- bottom up, respectively—are both necessary; neither tes, helminthiasis, HIV/AIDS, malaria, malnutrition, alone is sufficient to improve oral health. More specif- and tuberculosis. These community-based preventive ically, we focus on the effective provision of preventive interventions for oral health will increase access to services and the implications of this goal for global care, improve health, and reduce the burden of disease policy changes, and the upstream value and economic and the costs of care, compared with traditional surgi- choices that must be made to effect these positive cal approaches to care. changes. However, in low- and middle-income countries Oral health maladies can be divided into four (LMICs), access to the identified services, as well as the categories: financial resources and infrastructure to deliver them, vary. Accordingly, in the initial stages, stakeholders need • Largely preventable bacterial or viral infections, for to be very selective in the starting points. example, caries, periodontitis, noma, as well as oral We specifically selected caries and periodontitis for manifestations of HIV/AIDS the following reasons (Marcenes and others 2013): • Largely preventable cellular transformations, for example, oral cancer • They are the first and sixth most prevalent global • Congenital defects, for example, cleft lip and cleft diseases. palate • They are increasing in prevalence because of popula- • Trauma. tion growth and aging. Corresponding author: Richard Niederman, DMD, New York University, rniederman@nyu.edu. 173 • They are largely preventable bacterial infections of reflection of social determinants of health and disease epidemic proportions. (Lee and Divaris 2014; Watt 2012; Watt and Sheiham 2012). Other factors include the following: Additional considerations include the following: • Tobacco use (Benedetti and others 2013; Fiorini and • Preventing and controlling these maladies will others 2014; Walter and others 2012) address the goals of the World Health Organization’s • Nutrition (Moynihan and Kelly 2014; Palacios, (WHO’s) Basic Package of Oral Care (Frencken and Joshipura, and Willett 2009; Ritchie and others 2002; others 2002). Touger-Decker, Mobley, and American Dietetic • Cost-effective preventive measures can be imple- Association 2007) mented globally (Benzian and others 2012). • Bidirectional impacts of oral and systemic health • Multiple effective training, workforce, and care mod- (Cullinan and Seymour 2013; Friedewald and els are available to support global implementation others 2009a; Linden, Lyons, and Scannapieco 2013; (Mathu-Muju, Friedman, and Nash 2013; Nash and Lockhart and others 2012). others 2012). However, cross-cultural applications will need to be validated. EPIDEMIOLOGY OF CARIES, PERIODONTITIS, Like caries and periodontitis, noma is a pre- ventable infection. Unlike caries and periodontitis, AND NOMA which have high prevalence but low morbidity and According to assessments of the WHO and World Bank’s low mortality, noma has a low prevalence (approxi- Global Burden of Disease (Marcenes and others 2013), mately 0.0005 percent; 0.5 per 100,000), but very high untreated caries, or tooth decay, is the most common of morbidity and mortality (approximately 80 percent) all 291 diseases and injuries assessed, affecting 35 percent (Marck 2003). of the global population. If periodontitis is added to car- We focus on the critical few preventive measures with ies, untreated oral maladies affect almost 50 percent of the demonstrated benefit based on the following: global population, or 4 billion people. When people with untreated oral maladies are added to those with a history • Multiple systematic reviews of human trials (caries of treatment, oral diseases affect nearly 100 percent of the and periodontitis) global population (Marcenes and others 2013). • Multiple human trials exhibiting similar quantitative Caries and periodontitis have the highest preva- and qualitative directionality (caries, periodontitis, lence among oral diseases, but other oral diseases add and noma). significant morbidity and mortality, including noma, oral manifestations of HIV/AIDs, oral cancer, genetic For clarity of purpose, we do not address the other defects, and orofacial trauma. prevention and treatment modalities for which there are Of particular concern is the 11 percent increase of oral no systematic reviews or for which results from human diseases between 2000 and 2011, despite the 4 percent trials differ from one another. decrease in the global burden of other diseases in this Although we address specific effective preventive period (table 10.1). Quantitatively, and as measured by measures for oral maladies, these maladies are but one disability-adjusted life years (DALYs), 15,152,000 years of Table 10.1 Changes in All Global Burden of Disease Causes and Oral Health, 2000–11 2011 DALYs Percent change, 2011 DALYs Percent change, (thousands) 2000–11 (per 100,000 population) 2000–11 All GBD causes 2,744,322 −4 39,553 −16 All oral conditions 15,152 11 218 −3 Untreated caries in primary teeth 5,031 15 73 1 Periodontitis 5,501 27 79 11 Tooth loss 4,620 −7 67 −19 Source: WHO 2013. Note: DALYs = disability-adjusted life year (years of life lost + years lived with disability); GBD = Global Burden of Disease. 174 Essential Surgery healthy life were lost because of oral conditions in 2011. MICROBIOLOGY OF CARIES, PERIODONTITIS, This loss was almost evenly divided between untreated AND NOMA caries, severe periodontitis, and severe tooth loss. The largest increases in oral disease occurred in Caries, periodontitis, and noma are largely preventable, Sub-Saharan Africa (24 percent) and South Asia mixed, bacterial infections. The specific causative agents (19 percent) (table 10.2). Although thought to be due for each disease are as follows: primarily to population growth and aging, increases in caries and periodontitis occurred in almost all LMICs • Caries is a microaerophilic Gram-positive mixture and high-income countries (HICs). Tables 10.3 through of Lactobacillus and several Streptococci including 10.5 provide details by region for untreated caries mutans, sanguis, mitis, and salivarius (Gibbons and (table 10.3), periodontitis (table 10.4), and tooth loss van Houte 1975). (table 10.5) (Marcenes and others 2013). • Periodontitis is an anaerobic Gram-negative mix- Figure 10.1 illustrates the burden of disease for caries ture of Actinobacillus actinomycetemcomitans, by income level, demonstrating the substantial differ- Porphyromonas gingivalis, Campylobacter rectus, ences in needs. These differences, in turn, suggest that Prevotella intermedia, Prevotella nigrescens, and different approaches to care are required by income level Fusobacterium nucleatum (Haffajee and Socransky and need, both among and within countries. 1994; Socransky and Haffajee 1994), and the more Table 10.2 Changes in Oral Health, by Region, 2000–11 2011 DALYs Percent change, 2011 DALYs Percent change, (thousands) 2000–11 (per 100,000 population) 2000–11 World 15,152 11 218 −3 High income 2,467 −2 225 −9 East Asia and Pacific 4,308 14 217 5 Europe and Central Asia 1,242 −6 305 −7 Latin America and the Caribbean 1,502 11 255 −3 Middle East and North Africa 627 14 189 −6 South Asia 3,614 19 219 0 Sub-Saharan Africa 1,392 24 159 −5 Source: WHO 2013. Note: DALYs = disability-adjusted life years (years of life lost + years lived with disability); GBD = Global Burden of Disease. Table 10.3 Untreated Caries, 2000–11 2011 DALYs Percent change, 2011 DALYs Percent change, (thousands) 2000–11 (per 100,000 population) 2000–11 World 5,031 15 73 1 High income 338 9 31 1 East Asia and Pacific 1,561 10 79 1 Europe and Central Asia 362 1 89 −1 Latin America and Caribbean 349 16 59 2 Middle East and North Africa 245 24 74 2 South Asia 1,581 20 96 1 Sub-Saharan Africa 594 33 68 1 Source: WHO 2013. Note: DALY = disability-adjusted life year; GBD = Global Burden of Disease. Dentistry 175 Table 10.4 Periodontitis, 2000–11 2011 DALYs Percent change, 2011 DALYs Percent change, (thousands) 2000–11 (per 100,000 population) 2000–11 World 5,501 27 79 11 High income 915 14 84 6 East Asia and Pacific 1,817 29 91 19 Europe and Central Asia 449 10 110 8 Latin America and Caribbean 635 31 108 14 Middle East and North Africa 177 42 53 17 South Asia 990 34 60 13 Sub-Saharan Africa 518 37 59 5 Source: WHO 2013. Note: DALY = disability-adjusted life year; GBD = Global Burden of Disease. Table 10.5 Tooth Loss, 2000–11 2011 DALYs Percent change, 2011 DALYs Percent change, (thousands) 2000–11 (per 100,000 population) 2000–11 World 4,620 −7 67 −19 High income 1,214 −13 111 −20 East Asia and Pacific 930 −4 47 −11 Europe and Central Asia 432 −22 106 −23 Latin America and the Caribbean 518 −8 88 −20 Middle East and North Africa 205 −10 62 −25 South Asia 1,043 6 63 −10 Sub-Saharan Africa 279 −7 32 −29 Source: WHO 2013. Note: DALY = disability-adjusted life year; GBD = Global Burden of Disease. recently identified or renamed Aggregatibacter is termed extension for prevention, or comprehensive actinomycetemcomitans, Tannerella forsythia, and treatment (Webster 1908). The clinical principle was Treponema denticola. that, to ensure success, all decay and all areas of potential • Noma exhibits an altered oral microbiota with an decay had to be removed. Once this was done, additional increase in Prevotella and Peptostreptococcus genus tooth structure was removed to provide undercuts that exacerbated by poor nutrition, poverty, and prior mechanically hold the “permanent” fillings (usually infections (Huyghe and others 2013; Paster and silver amalgam) in place. These permanent fillings, how- others 2002). ever, have a limited life span of approximately 10 years and then require replacement (Burke and Lucarotti 2009; Chadwick and others 2001; Downer and others 1999). CARIES The traditional surgical approach to care is office based; patients travel to dental offices multiple times for Traditional Surgical Treatment comprehensive care. Additionally, systematic reviews For more than 100 years, dentists have successfully demonstrate that traditional fillings, with extensive treated dental cavities with surgery, consisting of local excision of tooth structure, lead to a significant increase anesthesia, followed by surgical excision of the decay, in risk of adverse events, when compared with sealing followed by filling. To ensure success, surgical excision early caries lesions or providing atraumatic restora- normally extended beyond the lesion itself as a pre- tions (Ricketts and others 2013; Schwendicke, Dörfer, ventive measure against further decay. This approach and Paris 2013). 176 Essential Surgery There exist little or no data to demonstrate that tradi- Figure 10.1 Proportion of Decayed, Missing, and Filled Teeth in Children, tional surgical care followed by fillings reduces or prevents by Income Level, 1990–2004 the underlying causative infection from instigating fur- ther tooth destruction. Accordingly, the identification of a. Ages 4–9 years causative bacterial agents, together with the identification of a number of preventive and treatment agents, led to 100 the twenty-first-century concept, and first clinical demon- 90 stration, of minimal intervention dentistry (Frencken and 80 others 1994). 70 Finally, this chapter’s focus on prevention precludes 60 discussion of surgical care (such as fillings and extrac- Percent tions). We recognize that fillings for treating cavities have 50 an established history (Webster 1908); extractions for 40 acute problems are essential components of the WHO’s 30 Basic Package of Oral Care (Frencken and others 2002), 20 and extractions are an integral part of emergency and trauma care. However, work on both the longevity and 10 the cost of fillings, compared with prevention, indi- 0 cates that investments in prevention outweigh invest- Low income Middle income High income (n = 9) (n = 21) (n = 13) ments in fillings (Mickenautsch and Yengopal 2012; Mickenautsch, Yengopal, and Banerjee 2010; Ricketts b. Ages 11–14 years and others 2013; Schwendicke and others 2013). 100 90 Preventive Approaches 80 Multiple systematic reviews of human randomized 70 controlled trials from multiple LMICs and HICs have identified a number of effective caries prevention agents 60 Percent (table 10.6). In all cases, preventive care can be commu- 50 nity based, in addition to office or clinic based, allow- 40 ing care to be brought to patients rather than patients 30 brought to care. Furthermore, because the biology of caries is identical globally and across the life span, the 20 mode of action and efficacy of these agents are also 10 similar. However, because of training deficiencies, tar- 0 iffs, local regulations, and social infrastructure, the Low income Middle income High income delivery of these evidence-based, cost-effective preven- (n = 9) (n = 21) (n = 13) tive therapeutics varies substantially among countries Decayed Filled Missing and within countries. Systematic reviews with formal comparative com- Source: Yee 2008. prehensive economic evaluations of all caries preven- tion methods are modest in both number and quality (Källestål and others 2003; Mariño, Khan, and Morgan indicate reductions in caries greater than 20 percent 2013). The available work indicates that for specific to 50 percent for approximately US$0.50 per year countries, and for specific populations, prevention per person (Campain and others 2010; Doessel 1979; is cost-effective. However, many of these evaluations Griffin, Jones, and Tomar 2001; Johnson and others fall short of current economic evaluation standards. 2014). A caution is warranted because these studies use Accordingly, only estimated efficacy and costs are pro- differing methodologies and may not relate to LMICs vided in table 10.6 to facilitate local assessments. (Mariño, Khan, and Morgan 2013). Studies of water fluoridation have been carried out Water Fluoridation. High-quality economic evalua- in LMICs. Two examples of import provide object tions of water fluoridation conducted in Australia and lessons on its benefits. In Brazil, a 25-year longitu- the United States for the general and aging populations dinal assessment of caries demonstrates a significant Dentistry 177 Table 10.6 Summary of Current Systematic Reviews: Identifying Effective Caries Preventive and Therapeutic Agents Material costa Estimated efficacy Agent Frequency (percent) US$ US$ per year Delivery agent Water fluoridation Continuous 20–401 $0.502 Piped water 3 4 Salt fluoride Daily 20 $0.03 Cooked food b 5 6 Fluoride toothpaste Twice a day 25 < $0.05 per dose $0.50–36.50 Individual or school Fluoride milk More than >207 n.a. n.a.8 Individual twice a day Silver fluoride Twice a year 809 $0.10 per dose $0.20 Community health care worker Fluoride varnish More than 4010 $3.00 per dose $6.0011 Community health care worker twice a year Sealant Once for 8012 $3.00 per application Community health care worker posterior tooth on multiple teeth Atraumatic restoration As needed 8013 $3.00 per application Community health care worker (therapeutic sealant) on multiple teeth14 Filling As needed 8013 $2.00 per anesthesia Community health care worker and filling per tooth or dentist Extraction As needed 100 $1.00 per tooth for Community health care worker anesthesia or dentist Sources: 1. Griffin and others 2007; Johnson and others 2014; McDonagh and others 2000; Parnell, Whelton, and O’Mullane 2009. 2. Kroon and van Wyk 2012b; Mariño, Fajardo, and Morgan 2012; van Wyk, Kroon, and Holtshousen 2001. 3. Yengopal and others 2010. 4. Gillespie and Marthaler 2005; Mariño, Fajardo, and Morgan 2012; Marino and others 2011. 5. Dos Santos, Nadanovsky, and de Oliveira 2012; Wong and others 2011. 6. Benzian 2012; Davies and others 2003; Splieth and Flessa 2008; Yee, McDonald, and Walker 2004. 7. Cagetti and others 2013; Espelid 2009. 8. Mariño, Fajardo, and Morgan 2012. 9. Liu and others 2012; Rosenblatt, Stamford, and Niederman 2009; Zhi, Lo, and Lin 2012. 10. Marinho and others 2013. 11. Hendrix and others 2013; Quiñonez and others 2006; Sköld and others 2008. 12. Ahovuo-Saloranta and others 2013; Mickenautsch and Yengopal 2011; Yengopal and others 2009. 13. de Amorim, Leal, and Frencken 2012; Mickenautsch and Yengopal 2011; Ricketts and others 2013; Schwendicke, Dörfer, and Paris 2013. 14. da Mata and others 2014; Schwendicke and others 2013. Note: n.a. = not available. a. Only includes actual material cost for active agent, not ancillary material costs (for example, toothbrush, applicators, sterile instruments, gloves, and barriers to deliver active agents), or indirect costs (for example, transportation and rent). b. Systematic reviews support an international standard level of 1,000 parts per million fluoride for younger children and up to 1,500 parts per million for older children and adults (Wong and others 2011). 25 percent reduction in caries over five years fol- a cost of approximately US$0.36 per year per person lowing water fluoridation (Lauris, da Silva Bastos, and is cost-effective (Kroon and van Wyk 2012a, 2012b; and de Magalhaes Bastos 2012) at a cost of approxi- van Wyk, Kroon, and Holtshousen 2001). mately US$0.03 per year per person (Frias and others Water fluoridation depends on the availability of 2006). Routine assessments of water fluoride levels potable piped water. However, even when fluori- were needed to ensure success (Buzalaf and others dated water is available, it is not 100 percent effective. 2013; Moimaz and others 2012; Moimaz and others Implementation of complementary effective fluoride 2013). In South Africa, a Commission of Inquiry delivery systems and preventive measures need to be recommended community water fluoridation with considered to control and prevent caries. Efficacy studies regulations compelling water fluoridation. However, have been carried out in LMICs for all of these fluo- the water remains unfluoridated, despite multiple ride delivery systems and preventive interventions (table economic analyses demonstrating that water fluorida- 10.6); they are likely to be effective at local levels if tion can reduce caries by approximately 15 percent at affordable high-quality products are available. 178 Essential Surgery Modeling and subsequent testing of the projected and mouthwashes, and professionally prescribed anti- economic costs to achieve these health benefits need microbials (Teles and Teles 2009). Gingivitis is gen- to be locally determined. Some examples from LMICs, erally considered to be a precursor to periodontitis, UMICs, and HICs are relevant (Mariño, Khan, and and patient-applied oral use of specific mouthwashes Morgan 2013; Morgan and others 2012). Focused stud- and toothpaste can potentially reduce risk of subse- ies of salt fluoridation in Peru (Marino and others quent periodontitis. The agents that provide a clinically 2011), toothpaste in Nepal and Brazil (Frazao 2012; Yee, significant benefit in reducing gingivitis are triclosan McDonald, and Helderman 2006; Yee, McDonald, and copolymer toothpaste and chlorhexidine mouthwash Walker 2004), and comparative studies in Chile (Mariño, (Gunsolley 2006; Osso and Kanani 2013; Riley and Fajardo, and Morgan 2012) differ in methodology; how- Lamont 2013; Van Strydonck and others 2012). ever, all demonstrate the tangible clinical and economic benefits of salt, water, toothpaste, and milk fluoridation. Seminal Clinical Trials Three seminal trials provide key turning points and offer an alternate approach to periodontal mechanical PERIODONTITIS therapy—the use of combination therapy with metro- Periodontitis is an inflammatory reaction to an over- nidazole and amoxicillin (250–500 milligrams of each growth of a mixed, anaerobic bacterial infection col- agent, three times a day, for seven days). The first trial onizing the subgingival crevices around the teeth. If was a case series of 118 patients who, having failed all untreated, this infection leads to bleeding gingiva, loose forms of traditional mechanical therapy, received met- teeth, and ultimately, tooth loss. In addition, this inflam- ronidazole and amoxicillin and scaling (van Winkelhoff, matory reaction is associated with adverse effects on Tijhof, and de Graaff 1992). The second trial was a systemic health (Han and others 2014). These include, masked randomized controlled trial of 46 patients that for example, cardiovascular disease (Friedewald and compared metronidazole and amoxicillin to placebo others 2009b; Tonetti, van Dyke, and Working Group 1 (López and Gamonal 1998). Perhaps the most surprising 2013), diabetic control (Borgnakke and others 2013), of all the studies, but with multiple threats to validity, and adverse pregnancy outcomes (Ide and Papapanou was the paradigm-breaking solitary study comparing 2013; Sanz, Kornman, and Working Group 3 2013). a seven-day regimen of metronidazole plus amoxicil- Paradoxically, most of the bacterial species present lin alone to scaling or root planing alone (López and in the oral biofilm are host-compatible or beneficial others 2006). At 12 months, the clinical and microbial (Socransky and others 1988; Socransky and others outcomes of care for patients receiving antimicrobial 1998). These bacteria not only inhabit the subgingival therapy alone were similar to those of patients receiv- crevice; they are also found on the supragingival tissue, ing only mechanical therapy. In sum, in all three cases, tongue, cheek, and palate (Faveri and others 2006; Mager seven days of metronidazole and amoxicillin shifted the and others 2003). Thus, health or disease is a result of the oral ecology from disease-related to health-related and balance or imbalance in the oral microbiome (Socransky improved clinical health, compared with prior or con- and Haffajee 2002; Teles, Haffajee, and Socransky 2006). current mechanical therapy. Current data support the concept that clinical improvement is attained when there is a change from a disease-related to a health-related oral ecology (Feres Systematic Reviews 2008; Socransky and Haffajee 2002; Teles, Haffajee, and Three systematic reviews of human randomized con- Socransky 2006). To achieve this shift, effective therapy trolled trials examined combined short-term metroni- needs to address all the oral ecological environments. dazole plus amoxicillin for treating periodontitis. The Similar to dental caries, periodontitis has been suc- results of all three reviews found significant statistical cessfully treated with mechanical therapy for more than and clinical benefit of short-term (7–14 days) 250–500 100 years, including scaling and root planing with or milligram metronidazole and amoxicillin three times without subsequent surgery. Furthermore, successful a day (Sgolastra, Gatto, and others 2012; Sgolastra, therapy requires quarterly maintenance therapy. It is of Petrucci, and others 2012; Zandbergen and others 2013). interest to note that we were unable to identify studies demonstrating beneficial long-term impact on the oral microbiome following mechanical therapy. Recent Clinical Trials Two levels of care are potentially effective in the Human randomized clinical trials, published after the treatment of gingivitis: patient-applied toothpastes inclusion dates of these systematic reviews, support the Dentistry 179 use of short-term metronidazole and amoxicillin (Feres • Acquired resistance. Resistance to metronidazole has and others 2012; Goodson and others 2012; Mestnik and rarely been reported (Soares and others 2012). others 2010). Although these studies differed from each • Allergic reactions. Assessments vary, but current data other in important ways, they reached similar conclu- suggest a prevalence of approximately 37 percent for sions: antibiotic therapy shifts the oral microbiome from nonsteroidal anti-inflammatory drugs and 5 percent disease related to health related, with substantial clinical to 29.4 percent for beta-lactam antibiotics (Bigby and improvement. Feres and others (2012) treated high-risk others 1986; Dona and others 2012). Clindamycin patients, Mestnik and others (2010) treated patients with and azithromycin are alternatives (Herrera and others aggressive disease, and Goodson and others (2012) treated 2008). patients with moderate to high disease levels. These trials • Global increase in antibiotic resistance. The dra- demonstrate that short-term treatment with metroni- matic and effective use of metronidazole plus dazole and amoxicillin achieved the following outcomes: amoxicillin for treating Helicobacter pylori and the global increase in resistance provides a use- • The combination therapy moved 66 percent of ful object lesson. In Latin America, amoxicillin patients from high-risk levels to low-risk levels one resistance is approximately 4 percent, and met- year after therapy; in contrast, mechanical therapy ronidazole resistance is approximately 53 percent only moved 22 percent of patients from high-risk (Camargo and others 2014). Early short courses levels to low-risk levels (Feres and others 2012). of combination therapy with the two antibiotics • The combination therapy was more clinically effec- prevent the emergence of resistant strains (D’Agata tive than mechanical therapy in patients with aggres- and others 2008). sive periodontitis (Mestnik and others 2010). • Relative balance (known and unknown) of direct • The combination therapy resulted in better microbial benefits and risks. Preliminary data suggest that anti- and clinical outcomes two years after therapy, com- microbial use changes the human microbiome in pared with other treatments, for example, scaling and the direction of increasing the risk of obesity, type 1 root planing, surgery, scaling and root planing plus diabetes, inflammatory bowel disease, allergies, and surgery, and local antibiotic delivery (Goodson and asthma (Blaser 2011). Conversely, data also indi- others 2012). cate that treating periodontitis with metronidazole plus amoxicillin facilitates oral recolonization by the health-compatible oral microbiome (Matarazzo and others 2008; Silva and others 2011). The potential Concerns with Antimicrobial Use benefits of effectively treating periodontal infections The studies described all support the demonstrated sus- include reductions in the negative impacts that the tained clinical and statistical improvements in periodon- inflammatory response has on cardiovascular disease, tal health in subjects receiving short-term metronidazole diabetes, and pregnancy outcomes (Borgnakke and in combination with amoxicillin. However, antibiotic others 2013; Friedewald and others 2009b; Ide and use in a public health context raises concerns about sev- Papapanou 2013; Sanz, Kornman, and Working eral issues: the quality, affordability, and availability of Group 3 2013; Tonetti, van Dyke, and Working Group the antibiotics; resistance to the antibiotics as well as the 1 2013). emergence of resistant-strains of bacteria; and changes or reequilibration of the oral (and gastrointestinal) In sum, the most effective approach to control- microbiome. ling and preventing periodontitis appears to be Multiple perspectives merit consideration: short-term metronidazole and amoxicillin, with or without concordant mechanical therapy. However, in • Risks versus benefits. The benefits need to clearly offset countries without access to professional treatment, the risks. The benefits of short-term metronidazole metronidazole and amoxicillin alone may be the plus amoxicillin in treating periodontitis must secure only effective and efficient option. This assumption benefits that would be much more difficult, costly, will need rigorous testing under local conditions inaccessible, or risky by other means, such as surgery for widespread validation. The additional potential with quarterly cleaning. benefits of local testing will be the secondary bene- • Recolonization. Treating periodontitis with metroni- fits of improved systemic health. The alternative to dazole plus amoxicillin facilitates oral recolonization testing is the absence of care or the implementation by a health-compatible oral microbiome (Matarazzo of mechanical therapy, which is more expensive and and others 2008; Silva and others 2011). less effective. 180 Essential Surgery Additional Considerations regions of Nigeria, the incidence is estimated to reach Two additional points relevant to systemic health are 6.4 per 1,000 children, which extrapolates to a global noteworthy with respect to the available data. incidence of 30,000 to 40,000 (Fieger and others 2003). First, we were unable to identify any human trials However, these estimates are based on cases and projec- supporting the concept that a single round of mechani- tions and may overestimate or underestimate the preva- cal therapy alone (for example, scaling and root planing, lence and incidence. with or without surgery) will prevent or control peri- odontal infections or improve oral health in the long Contributing Factors term (Loesche and Grossman 2001; Sampaio, Araújo, and Oliveira 2011; Worthington and others 2013). This The precipitating events are unclear. The most recent lack of support was not unexpected. Mechanical therapy and best studies are a matched and powered case control targets specific tooth surfaces but does not comprehen- and a parallel microbial analysis. They indicate three sively address other areas of microbial residence, such contributing factors: as tongue and oral mucosal; nor is mechanical therapy capable of removing residual disease-related microbial • An altered oral flora, specifically an increase in the colonies from the treated tooth surfaces. percentage of Prevotella and Peptostreptococcus genus, Second, only a few studies address the economics of and a decrease in the percentage of Fusobacterium, mechanical periodontal therapy, and these indicate that Capnocytophaga, Neisseria, and Spirochaeta scaling and root planing do not confer an economic ben- • Malnutrition efit (Braegger 2005; Gaunt and others 2008). In light of • Recent illness of respiratory or intestinal origin or the enhanced clinical benefit of antimicrobial interven- compromised immune response, for example, the tion (with or without scaling and root planing), the wider presence of HIV/AIDS (Baratti-Mayer, Pittet, and opportunity for intervention and access to care provided Montandon 2004; Bolivar and others 2012; Feller by nondental personnel, the broader potential beneficial and others 2014). impact of antimicrobials on systemic disease, and the broader potential negative impact on antimicrobial resis- Treatment tance, we await demonstration programs examining the clinical and economic impact of antimicrobial therapy. When detected early, noma responds to antibi- otic treatment with metronidazole plus amoxicillin. Recommended doses vary with age and body weight; they range from 100 milligrams to 500 milligrams of NOMA each agent three times per day for seven days. When Noma (cancrum oris, necrotizing ulcerative gingivitis, antibiotics are used in conjunction with nutritional stomatitis gangrenosa) is a destructive ulceration of the rehabilitation, the mortality rate drops from more than gingival-oral mucosa that spreads extraorally, degrading 80 percent to less than 10 percent (Baratti-Mayer, Pittet, the tissues of the face and bone (Ogbureke and Ogbureke and Montandon 2004; Bolivar and others 2012; Tempest 2010). The disease leads to severe destruction of the 1966). These findings support a bacterial and nutritional midface—the lips, cheek, maxilla, mandible, nose, and etiology. orbital floor—with unsightly facial disfigurement, impaired For survivors, postinfection surgical reconstruction, self-nutrition, impaired speech, trismus, and social when available, is extensive. No standardized approach alienation (Marck 2003; Ogbureke and Ogbureke 2010). can be advocated because of the variety of anatomical manifestations (Marck and others 2010). The current consensus is that surgical techniques will largely depend Prevalence and Incidence on the extent and location of the lesions, the availabil- Noma is most commonly found in Sub-Saharan Africa, ity of technical facilities, the competence of the sur- where extreme poverty, malnutrition, and childhood gical teams, and the timing of surgery (Ogbureke and infections are common (Feller and others 2014). Noma Ogbureke 2010). is commonly described as the “face of poverty” because Treatment normally consists of excising all scar tissue, of its facial location and prevalence among children ages correcting the trismus, raising and transposing local one to four years in LMICs (Marck 2003). Estimates and distant soft tissue flaps, and bone grafting in cases suggest a global prevalence of 500,000 people; an annual of considerable loss of facial bone or jawbone. Multiple incidence of 140,000; and a mortality rate of 80 percent flap, transposition, and closure designs have been imple- to 90 percent (Bourgeois and Leclercq 1999). In local mented, often paralleling oncologic reconstruction. Dentistry 181 Reconstruction for noma, however, differs from oncologic surgical model of oral care, these preventive measures reconstruction in several ways (Huijing and others 2011): can be delivered outside of clinical settings by commu- nity health workers (Benzian and others 2012; Monse • Compound tissue losses are common. and others 2010; Nash and others 2012). • The bony defect and soft-tissue scar affect facial skele- ton and dental development, producing gross asymme- try, with loss of normal anatomical reference points. Delivery Models for Prevention • Patients usually suffer nutritional deficiencies and The widespread incidence and increasing prevalence; the extreme deprivation. attendant long-term detrimental educational, medical, • Postoperative complications, such as poor healing and social effects; the absolute and relative inequalities in and infection, are common. care for HICs as well as LMICs (and within coun- tries); and the collocation of these diseases with other Even in the most advanced medical environments, noncommunicable diseases combine to suggest that however, the results of surgical repair are less than it is appropriate to consider alternative approaches to perfect (Bisseling and others 2010; Bouman and others traditional surgical care delivered by dentists. 2010), but preoperative planning, multiple staged sur- geries, and a multidisciplinary team approach have been Prevention Choices. Nationally, regionally, and locally, found to be useful in reducing postoperative complica- the preventive choices and modes of delivery will vary. tions (Huijing and others 2011; Marck and others 2010). These variations will depend on local needs, values, These include the following precautions: circumstances, and infrastructure, as well as on prod- uct availability and cost (box 10.1). Furthermore, if • Postponement of surgical treatment until the acute the goal is sustainable, long-term improvements in phase has abated oral health, then systemic changes will be required at • Routine presurgical clinical workup, including dental all stakeholder levels: patients, care providers, orga- care, hyperalimentation, multivitamin and anthel- nizations, and governments. These evidence-based, minthic treatment, and general hygiene measures effective, preventive methods will need to be culturally • Multidisciplinary team approach of plastic and max- integrated into the social systems of personal care, illofacial surgeons, orthodontists, pedodontists, prost- care-provider training, and workforce models, as well hodontists, physical therapists, and psychologists. as into community-based care delivery, compensation, and incentive systems. Additional studies demonstrate the benefits of anesthesiologists who can provide special airway and Elements of a High-Value Program. An effective ventilation techniques needed for the limited openings population- and patient-centered delivery framework is (Coupe and others 2013), as well as psychiatric support hypothesized to have four elements essential to deliver- and societal reintegration (Yunusa and Obembe 2012). ing and optimizing value (Kim, Farmer, and Porter 2013; Economic analysis of this care is unavailable, possi- Porter 2010; Porter, Pabo, and Lee 2013): bly because of the low prevalence, high morbidity, and variability and complexity of care. • Integration of care for every individual condition over the cycle of care • Shared delivery infrastructure across medical conditions IMPLICATIONS FOR GLOBAL HEALTH POLICY • Implemented knowledge of local patient and com- The oral diseases discussed in this chapter are preventable munity constraints global epidemics that affect more than 50 percent of the • Maximized equitable economic and community population and have increasing prevalence (Marcenes development to improve value. and others 2013). The systematic reviews and clinical studies cited indicate that effective preventive mea- sures are available. However, effective dissemination and Delivery Choices. Oral prevention could be delivered implementation that improve oral health depend on two in three ways, depending on local values, circumstances, complementary approaches: a top-down noncommu- infrastructure, and product availability: nicable disease model (Bratthall and others 2006), and a bottom-up health care delivery model (Kim, Farmer, • By patients themselves, for example, by the use of and Porter 2013). In marked contrast to the traditional affordable fluoridated toothpaste and fluoride salt 182 Essential Surgery Box 10.1 Guidelines for Selecting and Implementing the Basic Package of Oral Care Guidelines for selecting and implementing the Implementation precepts: Basic Package of Oral Care (BPOC) in LMICs follow. The selection of interventions will be determined • Safe: Care should be as safe for patients in health locally, regionally, and nationally. care facilities as in their homes. Examples of partial implementation of the BPOC: • Effective: The science and evidence behind health care should serve as the standard in the delivery • Cambodia: Training of rural nurses to provide of care and be applied. simple extractions, draining of abscess under • Efficient: Both process and outcomes of care local anesthesia, and atraumatic restorative treat- should achieve maximum outcome with minimal ment (Chher and others 2009). time, effort, or expense. • Nepal: Implementation of affordable toothpaste • Timely: Patients should not experience excessive resulted in 27 percent decrease in caries preva- delays in receiving care and service. lence and 10 percent decrease in oral pain (Yee, • Patient centered: The system of care should be McDonald, and Helderman 2006). patient centered, respect patient preferences, and • The Philippines: Training of teachers and educa- put patients in control. tion staff members to implement hand washing, • Equitable: Disparities in care should be fluoride tooth brushing, and school deworming eliminated. programs (Monse and others 2013). • Feasible: The initiating clinical, organizational, • Tanzania: Training of primary health care work- or governmental stakeholders should have the ers in the provision of simple extractions and financial, organizational, technical, capacity, and atraumatic restorative treatment, resulting in collaborative commitments to implement the improved oral health and quality of life (Kikwilu, programs. Frencken, and Mulder 2009; Mashoto and others • Sustainable: The delivery system must be 2010). financially, organizationally, and technically sustainable. Barriers to Implementing the BPOC: • Improvement: Process and outcome measures should be systematically implemented and the results evaluated to reduce waste and variation. • An absence of knowledge of the BPOC among • Regulatory compliance: Compliance with all government entities, nongovernmental organi- local and national regulations should be ensured. zations, and clinicians collaborating to improve • Communicated outcomes: Outcomes must oral health be disseminated to overcome implementation • Knowledge of the BPOC, but failure to accept barriers. its utility based on the perceived absence of evi- dence, advantage, simplicity, compatibility with Implementation Steps values, and trust in concept • Acceptance of BPOC, but an absence of meth- Step 1. Ask three questions: odological knowledge of implementation and improvement, or determination of how BPOC • What is to be improved at the local, regional, or might be integrated into existing health or edu- national level? cational structures • What change will be made? • A reluctance on the part of the dental profession to • How will we know that the change effected accept oral care provision by ancillary personnel. improvement? box continues next page Dentistry 183 Box 10.1 (continued) Step 2. Determine local, regional, or national needs • Evaluation of impact (for example, Reach mul- and capacities: tiplied by Effectiveness for patient-centered outcomes) • Oral health needs (to see if implementation is • Identification and reduction of waste and needed) variations • Costs and availability of funding • Availability of necessary supplies, personnel, and Step 4. Develop improvement plan to accomplish collaborating health groups the following: • Quality of supplies • Scale up effective pilot programs • Evaluate wider impact validity Step 3. Develop improvement plan to accomplish • Evaluate fidelity of adoption and maintenance the following: Sources: Chher and others 2009; Glasgow and others 2005; Greenhalgh and others 2004; IHI 2014; IOM 2001; Kikwilu, Frencken, and Mulder 2009; Langley and others • A pilot program manual of procedures 2009; Mashoto and others 2010; Monse and others 2013; Rogers 2002; Yee, • Carrying out of pilot McDonald, and Helderman 2006. • By nondentist community health workers and school indicate that community health care workers can increase systems, for example, by the provision of fluoride access to care, improve health, and reduce costs by elim- toothpaste, silver fluoride, fluoride varnish, sealants, inating the proximal need for dentists. Much of the data atraumatic restorations, antibiotics, and improved in table 10.6 come from studies employing community nutrition health workers. Local values and circumstances will • By community-wide programs and capacities, for guide decisions, and local pilot and scaling programs will example, the provision of water fluoridation and be required to quantitatively validate local process and fluoride salt. outcome effectiveness. One example of the beneficial and significant impact Of the three ways, the modest training of com- of an integrated community-based care program using a munity health workers and school system staff, and noncommunicable disease model is the award-winning the expansion of their current services, may provide Fit for School program in the Philippines. This pro- the most immediate opportunity for oral health care gram marries once-a-year school-based deworming with improvement. Community water fluoridation is perhaps school-based tooth brushing with fluoridated toothpaste the most cost-effective preventive measure for caries, (box 10.2) (Benzian 2012; Benzian and others 2012; but it requires the most significant prior systematic Monse and others 2010). infrastructure—piped potable water. Until such infra- Fit for School parallels numerous improvement structure exists, mobile clinics that bring dental services initiatives in LMICs (see box 10.1 for oral health to rural communities may be cost-effective solutions for examples). These initiatives include agriculture, edu- secondary prevention, such as restorative care, as demon- cation, environment, finance, governance, labor, and strated in South Africa and Thailand (Holtshousen and health. Many of these effective programs are chronicled Smit 2007; Tianviwat, Chongsuvivatwong, and Birch in Banerjee and Duflo (2011). This work ranges from 2009). For individual community-based care, affordable evaluating effectiveness, building capacity, and changing fluoridated toothpaste needs to be locally available for policies for deworming, bed nets, and chlorine in Kenya; home use. to water disinfectants in Zambia; to hand washing with At least two narrative and two systematic reviews soap in India and Pakistan.1 support the community-based delivery of preventive oral health care by nondentists (Calache and Hopcraft Fees. Among the key counterintuitive policy findings is 2012; Mathu-Muju, Friedman, and Nash 2013; Nash that the evidence does not support the practice of charg- and others 2012; Wright and others 2013). These studies ing small fees to poor people for health products and 184 Essential Surgery Box 10.2 The Fit for School Approach The Philippine Department of Education, sup- • Biannual deworming according to the WHO ported by the German Enterprise for International guidelines Cooperation, the Philippine Fit for School Inc., and other partners, initiated the Essential Health Care These evidence-based interventions are comple- Program (EHCP) in public elementary schools. The mented by the construction of facilities for group program is based on the Fit for School Approach hand washing and sanitation and the provision of and integrates three evidence-based prevention clean water to schools without access to it. The EHCP measures for the most prevalent childhood dis- currently reaches more than 2.5 million Filipino eases: soil-transmitted intestinal worm infections, children and is also implemented in Cambodia, hygiene-related diseases such as diarrhea and respi- Indonesia, and the Lao People’s Democratic ratory infections, and rampant tooth decay. Republic. Material costs average US$0.50 per child The program implements the following activities per year. Affordability increases the probability that run by teachers: this program can be integrated into the regular gov- ernment budgets, even in resource-poor countries, thereby ensuring sustainability beyond the initial • Daily group hand washing with soap start-up costs. • Daily group tooth brushing with fluoride toothpaste Sources: Benzian 2012; Monse and others 2013. services, a policy promoted to help reduce waste. Even overuse, underuse, and misuse of services (NHS 2005; small fees for prevention services substantially reduce Steele 2009). use. This finding suggests that prevention programs In the United States, the Healthy People initiative should be provided at no charge to patients and should reports that, from 1990 to 2010, the percentage of stud- be sustained by governmental funding.2 ied children with untreated decay remained virtually unchanged at almost 30 percent.3 For underserved, Examples, Principles, and Guidelines. Box 10.1 provides rural, and minority populations, the percentage is sig- examples of programs implementing the Basic Package nificantly higher, reaching almost 50 percent (Dye and of Oral Care, as well as the principles and guidelines for Thornton-Evans 2010). During the same period, yearly selecting and implementing prevention programs. governmental dental expenditures for children increased from US$1 billion to US$7 billion. Spending is expected to reach US$15 billion by 2020 (CMS 2011b). In parallel, Lessons Learned from Current Care Delivery Models national spending for oral health care reached US$105 in High-Income Countries billion in 2010 (CMS 2011b). This level is second only The unchanging high oral health needs in the United to that of cardiac care (AHRQ 2007) and is expected to Kingdom and the United States provide the counter- be US$170 billion by 2020 (CMS 2011b). Yet, data from factual to focusing on traditional surgical rather than the national Healthy People initiative indicate that oral preventive care. health is not improving in concert with spending.4 As a In the United Kingdom, 33 percent of children age result, the need for a change to prevention-focused care is five years have active decay, and 2.3 percent have sepsis chronicled in multiple government and foundation pub- (NHS 2007). The need for care extends to adults: 31 per- lications (CMS 2011a; HHS 2010; IOM 2011a, 2011b). cent have untreated cavities, 22 percent have urgent conditions, and 9 percent have dental pain (NHS 2009). The reviews of National Health Service dental care dur- Dental Workforce ing the past 30 years repeatedly call for increases in both The immediate need for considering alternatives to the prevention and access to care, and for reductions in both current surgical-mechanical model of care is also clear the inequality of service distribution and waste through when the current dental workforce is taken into account. Dentistry 185 The 188 countries for which there are data have, on • It is not timely in that multiple appointments, travel, average, 0.3 (plus or minus 0.4 standard deviation) and missed work or school are required to treat mul- dentists per 1,000 residents (WHO 2006). The United tiple teeth. States, which has five times the global average, has not • It is not efficient in that surgical care requires a dental been able to improve oral health during the past 20 years.4 office, and preventive care can be delivered in loca- These findings suggest that new education, training, tions where people learn, work, play, or pray. and workforce models are needed (Bhutta and others • It is not equitable in that care is available only to peo- 2010; Frenk and others 2010; Mathu-Muju, Friedman, ple who are geographically near clinics, have a means and Nash 2013; Nash and others 2012). The current of transportation, and can pay for care. surgical-mechanical care model will not solve the global oral health problem. Countries need two com- The surgical approach provides an example of plementary prevention frameworks for improving oral the overuse of ineffective treatment and the under- health care: use of effective prevention (Kohn, Corrigan, and Donaldson 2000). • A community-based health care provider model for providing services to people with diseases for which proven therapies exist (Kim, Farmer, and Porter INCREASING CLINICAL VALUE WITH 2013) • A noncommunicable disease model (Bratthall and COMMUNITY-BASED PREVENTION others 2006). A conceptual strategic starting point for thinking about alternative care models is value-based oral health To succeed, the community-based health care worker care. Value for global health care delivery is defined model will need to consider the following: as the aggregate health outcomes per aggregate costs (value = outcomes divided by costs) (Kim, Farmer, and • Preventive care delivered by nondentists Porter 2013; Porter 2010; Porter, Pabo, and Lee 2013). • Triage prevention, extractions, and complex surgical Outcomes depend on patient results rather than process care measures such as numbers of patients seen and proce- • Innovative methods to increase access to care at all dures completed. levels, such as focused prevention integrated with Work from multiple groups (IOM 2013; Kaplan and other health initiatives, and focused mobile extrac- Porter 2011; Porter 2010; Schoen and others 2013), an tion service, to overcome the many barriers to access international comparison of 12 countries (Soderlund to safe oral health care. and others 2012), and assessments of oral health care (Glassman 2011) all indicate that focusing on values can be a key driver for health improvement. The goal is to simultaneously address a set of interrelated patient Quality of Care circumstances for a distinct population with distinct The Institute of Medicine’s report Crossing the Quality prevention and care challenges using an integrated and Chasm identified six quality aims for clinical care (IOM shared delivery infrastructure to improve health and 2001). From this perspective, using surgery rather than reduce costs. prevention as the primary mode of dental care seems Value can be increased in two ways: by continually to violate five of the six quality aims. This is not to implementing the current best evidence to improve out- say that surgery is unsafe or unwarranted; clearly, it is comes, and by reducing the costs accruing from waste critical for treatment of acute abscesses, extractions, and variation. In short, value can be improved by imple- and noma. menting safe, effective, patient-centered, timely, efficient, However, for the most common infections—caries and equitable care (Kohn, Corrigan, and Donaldson and periodontitis—surgical care appears to have the 2000). following limitations: • It is not effective in treating the underlying causative Outcomes infection. With the exception of noma, for which only case • It is not patient centered in that clinicians are well series are available, the data cited all derive primarily compensated to intervene surgically but patients are from systematic reviews of studies done in LMICs; better served by prevention. the reviews indicate that the success rates for 186 Essential Surgery prevention are equivalent to or exceed those for traditional thought regarding the efficacy of fillings surgery. For noma, the available data indicate that (Mickenautsch and Yengopal 2012), complete caries population-based and immediate prevention is more removal is contraindicated for effective comprehen- effective than surgery. sive prevention (Frencken and others 2012; Ricketts These comments are independent of the geographic and others 2013). location, the patient age, and the longevity of the study. The data for periodontitis and noma are less The findings for caries and periodontitis contradict the extensive but nonetheless informative. For periodon- conventional clinical thinking and training, which tend tal health, current thinking recommends quarterly to focus on the individual clinical techniques of com- mechanical scaling. In marked contrast, clinical trials prehensive surgical treatment and overlook community- indicate that one round of a week-long regimen of based comprehensive prevention. metronidazole and amoxicillin shifts the oral ecology from disease related to health related, improves clinical health, and remains stable for up to five years without Short-Term Costs further intervention. For noma, the week-long costs In the traditional clinical setting, short-term costs accrue for a regimen of metronidazole and amoxicillin directly and indirectly. Surgically related direct costs for and hyperalimentation are significantly less than personnel, equipment, and supplies are all substantially extensive, repetitive, hospital-based surgeries. Further, higher than those associated with preventive care deliv- with preventive care the patient is left with far fewer ered by community health workers, plus prevention functional, esthetic, and emotional challenges. supplies, and antibiotics. Similarly, the indirect costs for In sum, the following approaches increase health care surgery (for example, office space rent; utilities; patients’ value: travel to dental offices or hospitals; and time away from work, school, and family, and for multiple visits) are • Effectively providing preventive services to people all substantially higher than prevention delivered in with diseases for which proven therapies exist community locations. Although the absolute costs may • Implementing integrated care delivery across multi- vary among LMICs, we suspect that the relative cost ple disease conditions differentials are similar. This assumption calls for local • Implementing local knowledge to ensure quality and validation. equity. Long-Term Costs Benefits of Focus on Prevention The impact of long-term costs may be even more The efficacy trials distilled in the multiple systematic substantial than short-term costs because of sur- reviews cited here indicate that prevention offers several gical longevity. Caries, periodontitis, and noma theoretical and actual benefits: typically require cycles of surgical treatment and retreatment. • Moving oral health toward achieving health care’s In the case of filling for the treatment of den- triple aim of increasing access, improving health, and tal caries, the standard of care—excavating poten- reducing costs tial carious lesions and placing undercuts to • Facilitating the prevention and treatment of disease mechanically secure the fillings (Webster 1908)— earlier in life and earlier in the disease progress, obvi- undermines the long-term structural integrity of ating the multitude of negative biological and social the tooth. Consequently, the “permanent” fillings downstream consequences have an average lifespan of about 10 years (Burke • Improving health for both the well served and and Lucarotti 2009; Chadwick and others 2001; underserved, reducing one aspect of the social Downer and others 1999); the net result is the initi- gradients. ation of a rerestoration cycle. Estimates indicate that 70 percent of the replacement restorations are The indicated benefits require vigorous testing in larger than the original fillings (Brantley and oth- country- and region-specific effectiveness trials to ers 1995; Elderton 1990). With sequential restora- demonstrate the universality of the findings (Banerjee tions, the ultimate outcome in some cases is tooth and Duflo 2011; Glasgow and others 2005). These trials loss and the need for bridges or implants. The need to be supported by a noncommunicable disease attendant cost implications are significant (Shugars system infrastructure to ensure care delivery across and Bader 1996). Therefore, in marked contrast to multiple systems. Dentistry 187 Barriers and Challenges to Prevention Programs evidence that is more easily understood by policy mak- Significant challenges to comprehensive prevention can ers, specifically, advantage, simplicity, values, trust, be expected from governments, organizations, pro- and choice (Backer and Rogers 1998; Rogers 2002). fessional schools, clinicians, and regulatory agencies These will be significant undertakings (Sheiham and (Benzian and others 2011) (box 10.1). The reasons are others 2011; Williams 2011). relatively simple. First, these evidence-based, effective, preventive measures violate many of the oral health profession’s closely held assumptions and clinical prin- NOTES ciples that focus on surgical treatment of dental diseases. The World Bank classifies countries according to four income Second, the current predominant stakeholders support groupings. Income is measured using gross national income an infrastructure, value system, and economy of train- (GNI) per capita, in U.S. dollars, converted from local currency ing, licensing, boarding, and compensation that was using the World Bank Atlas method. Classifications as of July created more than 100 years ago. This established social 2014 are as follows: architecture will be difficult to change. • Low-income countries (LICs) = US$1,045 or less in 2013 • Middle-income countries (MICs) are subdivided: CONCLUSIONS • Lower-middle-income = US$1,046 to US$4,125 • Upper-middle-income (UMICs) = US$4,126 to US$12,745 The challenge to achieving Alma-Ata’s promise of • High-income countries (HICs) = US$12,746 or more “health care for all” (WHO 1978) and health care’s tri- ple aim will be to coordinate and integrate a top-down, 1. Abdul Latif Jameel Poverty Action Lab (http://www noncommunicable disease policy change and a prag- .povertyactionlab.org/). matic bottom-up innovation approach (Christensen 2. Abdul Latif Jameel Poverty Action Lab (http://www and others 2009; Frenk 2009). It seems unlikely that a .povertyactionlab.org/health). top-down policy change will occur rapidly (Benzian and 3. “2020 Topics and Objectives Oral Health.” http://www others 2011). It is much more likely that a bottom-up, .healthypeople.gov/2020/topicsobjectives2020/ebr .aspx?topicId=32. pragmatic innovation approach to oral health care 4. “2020 Topics and Objectives Oral Health.” http://www improvement will be successful in the short- and long- .healthypeople.gov/2020/topicsobjectives2020/ebr terms. Data-driven measures of bottom-up success will .aspx?topicId=32. demonstrate the plausibility of and necessity for policy change. Functionally, the challenge for pragmatic innovative REFERENCES programs will be to quantitatively improve health and document value, using methods of health improve- Ahovuo-Saloranta, A., H. Forss, T. Walsh, A. Hiiri, A. Nordblad, ment (IHI 2014; Langley and others 2009). Successful and others. 2013. “Sealants for Preventing Dental Decay in the Permanent Teeth.” Cochrane Database of Systematic examples using local improvement initiatives with Reviews 3: CD001830. accompanying data are emerging (Banerjee and Duflo AHRQ (Agency for Healthcare Research and Quality). 2007. 2011; Monse and others 2013), but more are needed. “Medical Expenditure Panel Survey 2007.” Rockville, MD: Additionally, the incremental cost for delivering com- Agency for Healthcare Research and Quality. prehensive prevention is likely to provide significantly Backer, T. E., and E. M. Rogers. 1998. “Diffusion of Innovations greater benefit and value than incremental prevention. Theory and Work-Site AIDS Programs.” Journal of Health However, this economic assumption will require local Communication 3 (1): 17–28. validation. The effective preventive interventions identi- Banerjee, A. V., and E. Duflo. 2011. Poor Economics: A Radical fied in this chapter provide starting points. Rethinking of the Way to Fight Global Poverty. 1st edition. If the multiple local and regional pilot oral health New York: Public Affairs. improvement initiatives simultaneously implement Baratti-Mayer, D., B. Pittet, and D. Montandon. 2004. “[GESNOMA (Geneva Study Group on Noma): the multiple preventive interventions identified here, State-of-the-Art Medical Research for Humanitarian use community health workers to deliver care, and Purposes].” Annales de chirurgie plastique et esthétique 49 quantitatively assess outcomes and value, they are (3): 302–05. doi:10.1016/j.anplas.2004.04.005. more likely to organically change policy and ensure Benedetti, G., G. Campus, L. Strohmenger, and P. Lingstrom. sustainability than approaches that start with policy 2013. “Tobacco and Dental Caries: A Systematic Review.” change. Finally, to effect this sea change, stakeholder Acta Odontologica Scandinavica 71 (3–4): 363–71. advocates will need to consider actively providing doi:10.3109/00016357.2012.734409. 188 Essential Surgery Benzian, H. 2012. Keeping Children ‘Fit for School’: Simple, Burke, F. J. T., and P. S. K. Lucarotti. 2009. “How Long Do Scalable and Sustainable School Health in the Philippines. Direct Restorations Placed within the General Dental German Health Practice Collection. Bonn: Deutsche Services in England and Wales Survive?” British Dental Gesellschaft für Internationale Zusammenarbeit (GIZ). Journal 206 (1): E2; discussion 26–7. ———, M. Hobdell, C. Holmgren, R. Yee, B. Monse, and Buzalaf, M. A., C. M. Moraes, K. P. Olympio, J. P. Pessan, others. 2011. “Political Priority of Global Oral Health: An L. T. Grizzo, and others. 2013. “Seven Years of External Analysis of Reasons for International Neglect.” International Control of Fluoride Levels in the Public Water Supply in Dental Journal 61 (3): 124–30. Bauru, São Paulo, Brazil.” Journal of Applied Oral Science Benzian, H., B. Monse, V. Belizario, A. Schratz, M. Sahin, 21 (1): 92–98. and W. van Palenstein Helderman. 2012. “Public Health Cagetti, M. G., G. Campus, E. Milia, and P. Lingström. 2013. in Action: Effective School Health Needs Renewed “A Systematic Review on Fluoridated Food in Caries International Attention.” Global Health Action 5: 14870. Prevention.” Acta Odontologica Scandinavica 71 (3–4): Bhutta, Z. A., L. Chen, J. Cohen, N. Crisp, T. Evans, and others. 381–87. 2010. “Education of Health Professionals for the 21st Calache, H., and M. Hopcraft. 2012. “The Role of the Oral Century: A Global Independent Commission.” The Lancet Health Therapist in the Provision of Oral Health Care to 375 (9721): 1137–38. doi:10.1016/S0140-6736(10)60450-3. Patients of All Ages.” In Oral Health Care: Prosthodontics, Bigby, M., S. Jick, H. Jick, and K. Arndt. 1986. “Drug- Periodontology, Biology, Research and Systemic Conditions, Induced Cutaneous Reactions: A Report from the Boston edited by M. Virdi, 249–68. Rijeka, Croatia: InTech Collaborative Drug Surveillance Program on 15,438 Europe. Consecutive Inpatients, 1975 to 1982.” Journal of the Camargo, M. C., A. Garcia, A. Riquelme, W. Otero, C. A. Camargo, American Medical Association 256 (24): 3358–63. and others. 2014. “The Problem of Helicobacter pylori Bisseling, P., J. Bruhn, T. Erdsach, A. M. Ettema, R. Sautter, Resistance to Antibiotics: A Systematic Review in Latin and others. 2010. “Long-Term Results of Trismus Release America.” American Journal of Gastroenterology 109 (4): in Noma Patients.” International Journal of Oral and 485–95. doi:10.1038/ajg.2014.24. Maxillofacial Surgery 39 (9): 873–77. Campain, A. C., R. J. Marino, F. A. Wright, D. Harrison, D. L. Bailey, Blaser, M. 2011. “Antibiotic Overuse: Stop the Killing of and others. 2010. “The Impact of Changing Dental Needs on Beneficial Bacteria.” Nature 476 (7361): 393–94. Cost Savings from Fluoridation.” Australian Dental Journal doi:10.1038/476393a. 55 (1): 37–44. doi:10.1111/j.1834-7819.2010.01173.x. Bolivar, I., K. Whiteson, B. Stadelmann, D. Baratti-Mayer, Chadwick, B., E. Treasure, P. Dummer, F. Dunstan, A. Gilmour, Y. Gizard, and others. 2012. “Bacterial Diversity in Oral and others. 2001. “Challenges with Studies Investigating Samples of Children in Niger with Acute Noma, Acute Longevity of Dental Restorations: A Critique of a Systematic Necrotizing Gingivitis, and Healthy Controls.” PLoS Review.” Journal of Dentistry 29 (3): 155–61. Neglected Tropical Diseases 6 (3): e1556. Chher, T., S. Hak, F. Courtel, and C. Durward. 2009. “Improving Borgnakke, W. S., P. V. Ylostalo, G. W. Taylor, and R. J. Genco. the Provision of the Basic Package of Oral Care (BPOC) in 2013. “Effect of Periodontal Disease on Diabetes: Systematic Cambodia.” International Dental Journal 59 (1): 47–52. Review of Epidemiologic Observational Evidence.” Journal Christensen, C. M., J. H. Grossman, J. Hwang, and N. Y. York. of Periodontology 84 (Suppl 4): S135–52. doi:10.1902/jop 2009. The Innovator’s Prescription: A Disruptive Solution for .2013.1340013. Health Care. New York: McGraw-Hill. Bouman, M. A., K. W. Marck, J. E. M. Griep, R. E. Marck, CMS (Centers for Medicare and Medicaid Services). 2011a. M. A. Huijing, and others. 2010. “Early Outcome of Noma “Improving Access to and Utilization of Oral Health Surgery.” Journal of Plastic, Reconstructive and Aesthetic Services for Children in Medicaid and CHIP Programs.” Surgery: JPRAS 63 (12): 2052–56. CMS, Washington, DC. Bourgeois, D. M., and M. H. Leclercq. 1999. “The World Health ———. 2011b. “National Health Expenditure Projections Organization Initiative on Noma.” Oral Diseases 5 (2): 172–74. 2011–2021.” U.S. Department of Health and Human Braegger, U. J. 2005. “Cost-Benefit, Cost-Effectiveness and Services, Washington, DC. Cost-Utility Analyses of Periodontitis Prevention.” Coupe, M. H., D. Johnson, P. Seigne, and B. Hamlin. 2013. Periodontology 32 (Suppl.6): 301–13. “Special Article: Airway Management in Reconstructive Brantley, C. F., J. D. Bader, D. A. Shugars, and S. P. Nesbit. Surgery for Noma (Cancrum Oris).” Anesthesia and 1995. “Does the Cycle of Rerestoration Lead to Larger Analgesia 117 (1): 211–18. Restorations?” Journal of the American Dental Association Cullinan, M. P., and G. J. Seymour. 2013. “Periodontal Disease (1939) 126 (10): 1407–13. and Systemic Illness: Will the Evidence Ever Be Enough?” Bratthall, D., P. E. Petersen, J. R. Stjernsward, and L. J. Brown. Periodontology 2000 62 (1): 271–86. doi:10.1111/prd.12007. 2006. “Oral and Craniofacial Diseases and Disorders.” In D’Agata, E. M., M. Dupont-Rouzeyrol, P. Magal, D. Olivier, Disease Control Priorities in Developing Countries, edited and S. Ruan. 2008. “The Impact of Different Antibiotic by D. T. Jamison, J. G. Breman, A. R. Measham, G. Alleyne, Regimens on the Emergence of Antimicrobial-Resistant M. Claeson, D. B. Evans, P. Jha, A. Mills, and P. Musgrove Bacteria.” PLoS One 3 (12): e4036. doi:10.1371/journal 723–36. 2nd ed. Washington, DC: World Bank. .pone.0004036. Dentistry 189 da Mata, C., P. F. Allen, M. Cronin, D. O’Mahony, G. McKenna, Fieger, A., K. W. Marck, R. Busch, and A. Schmidt. 2003. and others. 2014. “Cost-Effectiveness of ART Restorations “An Estimation of the Incidence of Noma in North-West in Elderly Adults: A Randomized Clinical Trial.” Community Nigeria.” Tropical Medicine and International Health 8 (5): Dentistry and Oral Epidemiology 42 (1): 79–87. 402–07. Davies, G. M., H. V. Worthington, R. P. Ellwood, A. S. Blinkhorn, Fiorini, T., M. L. Musskopf, R. V. Oppermann, and C. Susin. G. O. Taylor, and others. 2003. “An Assessment of the Cost 2014. “Is There a Positive Effect of Smoking Cessation Effectiveness of a Postal Toothpaste Programme to Prevent on Periodontal Health? A Systematic Review.” Journal of Caries among Five-Year-Old Children in the North West of Periodontology 85 (1): 83–91. doi:10.1902/jop.2013.130047. England.” Community Dental Health 20 (4): 207–10. Frazao, P. 2012. “[Cost-Effectiveness of Conventional and de Amorim, R. G., S. C. Leal, and J. E. Frencken. 2012. “Survival Modified Supervised Toothbrushing in Preventing Caries in of Atraumatic Restorative Treatment (ART) Sealants and Permanent Molars among 5-Year-Old Children].” Cadernos Restorations: A Meta-Analysis.” Clinical Oral Investigations de Saúde Pública 28 (2): 281–90. 16 (2): 429–41. Frencken, J. E., C. Holmgren, W. Helderman, and WHO. 2002. Doessel, D. P. 1979. Cost-Benefit Analysis and Water “Van Palenstein Basic Package of Oral Care (BPOC).” Fluoridation: An Australian Study. Canberra: Australian Centre for Oral Health Care Planning and Future Scenarios, National University Press. University of Nijmegen, Nijmegen, Netherlands. Dona, I., N. Blanca-Lopez, M. J. Torres, J. Garcia-Campos, Frencken, J. E., M. C. Peters, D. J. Manton, S. C. Leal, I. Garcia-Nunez, and others. 2012. “Drug Hypersensitivity V. V. Gordan, and E. Eden. 2012. “Minimal Intervention Reactions: Response Patterns, Drug Involved, and Temporal Dentistry for Managing Dental Caries: A Review: Report Variations in a Large Series of Patients.” Journal of Investigative of a FDI Task Group.” International Dental Journal 62 (5): Allergology and Clinical Immunology 22 (5): 363–71. 223–43. Dos Santos, A. P., P. Nadanovsky, and B. H. de Oliveira. 2012. Frencken, J. E., Y. Songpaisan, P. Phantumvanit, and T. Pilot. “A Systematic Review and Meta-Analysis of the Effects 1994. “An Atraumatic Restorative Treatment (ART) of Fluoride Toothpastes on the Prevention of Dental Technique: Evaluation after One Year.” International Dental Caries in the Primary Dentition of Preschool Children.” Journal 44 (5): 460–64. Community Dentistry and Oral Epidemiology 41 (1): 1–12. Frenk, J. 2009. “Reinventing Primary Health Care: The Need doi:10.1111/j.1600-0528.2012.00708.x. for Systems Integration.” The Lancet 374 (9684): 170–73. Downer, M. C., N. A. Azli, R. Bedi, D. R. Moles, and doi:10.1016/S0140-6736(09)60693-0. D. J. Setchell. 1999. “How Long Do Routine Dental Frenk, J., L. Chen, Z. A. Bhutta, J. Cohen, N. Crisp, and Restorations Last? A Systematic Review.” British Dental others. 2010. “Health Professionals for a New Century: Journal 187 (8): 432–39. Transforming Education to Strengthen Health Systems in Dye, B. A., and G. Thornton-Evans. 2010. “Trends in Oral an Interdependent World.” The Lancet 376 (9756): 1923–58. Health by Poverty Status as Measured by Healthy People doi:10.1016/S0140-6736(10)61854-5. 2010 Objectives.” Public Health 125 (6): 817–30. Frias, A. C., P. C. Narvai, M. E. Araujo, C. Zilbovicius, and Elderton, R. J. 1990. “Clinical Studies Concerning Re-restoration J. L. Antunes. 2006. “[Cost of Fluoridating the Public Water of Teeth.” Advances in Dental Research 4: 4–9. Supply: A Study Case in the City of São Paulo, Brazil, Espelid, I. 2009. “Caries Preventive Effect of Fluoride in Milk, 1985–2003].” Cadernos de Saude Publica 22 (6): 1237–46. Salt and Tablets: A Literature Review.” European Archives of doi:S0102-311X2006000600013. Paediatric Dentistry 10 (3): 149–56. Friedewald, V. E., K. S. Kornman, J. D. Beck, R. Genco, Faveri, M., M. Feres, J. A. Shibli, R. F. Hayacibara, M. M. Hayacibara, A. Goldfine, and others. 2009a. “The American and others. 2006. “Microbiota of the Dorsum of the Tongue Journal of Cardiology and Journal of Periodontology after Plaque Accumulation: An Experimental Study in Editors’ Consensus: Periodontitis and Atherosclerotic Humans.” Journal of Periodontology 77 (9): 1539–46. Cardiovascular Disease.” American Journal of Cardiology Feller, L., M. Altini, R. Chandran, R. A. Khammissa, J. N. Masipa, 104 (1): 59–68. doi:10.1016/j.amjcard.2009.05.002. and others. 2014. “Noma (Cancrum Oris) in the South ———. 2009b. “The American Journal of Cardiology African Context.” Journal of Oral Pathology and Medicine and Journal of Periodontology Editors’ Consensus: 43 (1): 1–6. doi:10.1111/jop.12079. Periodontitis and Atherosclerotic Cardiovascular Disease.” Feres, M. 2008. “Antibiotics in the Treatment of Periodontal Journal of Periodontology 80 (7): 1021–32. doi:10.1902 Diseases: Microbiological Basis and Clinical Applications.” /jop.2009.097001. Annals of the Royal Australasian College of Dental Surgeons Gaunt, F., M. Devine, M. Pennington, C. Vernazza, E. Gwynnett, 19: 37–44. and others. 2008. “The Cost-Effectiveness of Supportive Feres, M., G. M. S. Soares, J. A. V. Mendes, M. P. Silva, Periodontal Care for Patients with Chronic Periodontitis.” M. Faveri, and others. 2012. “Metronidazole Alone or with Journal of Clinical Periodontology 35 (8 Suppl): 67–82. Amoxicillin as Adjuncts to Non-surgical Treatment of Gibbons, R. J., and J. van Houte. 1975. “Dental Caries.” Annual Chronic Periodontitis: A 1-Year Double-Blinded, Placebo- Review of Medicine 26: 121–36. Controlled, Randomized Clinical Trial.” Journal of Clinical Gillespie, G. M., and T. M. Marthaler. 2005. “Cost Periodontology 39 (12): 1149–58. Aspects of Salt Fluoridation.” Schweizer Monatsschrift 190 Essential Surgery fur Zahnmedizin=Revue mensuelle suisse d’odonto- Huijing, M. A., K. W. Marck, J. Combes, K. D. Mizen, L. Fourie, stomatologie=Rivista mensile svizzera di odontologia e and others. 2011. “Facial Reconstruction in the Developing stomatologia. SSO 115 (9): 778–84. World: A Complicated Matter.” British Journal of Oral and Glasgow, R. E., D. J. Magid, A. Beck, D. Ritzwoller, and Maxillofacial Surgery 49 (4): 292–96. P. A. Estabrooks. 2005. “Practical Clinical Trials for Huyghe, A., P. François, A. Mombelli, M. Tangomo, M. Girard, Translating Research to Practice: Design and Measurement and others. 2013. “Microarray Analysis of Microbiota of Recommendations.” Medical Care 43 (6): 551–57. Gingival Lesions in Noma Patients.” PLoS Neglected Tropical Glassman, P. 2011. Oral Health Quality Improvement Diseases 7 (9): e2453. in the Era of Accountability. Report prepared for the Ide, M., and P. N. Papapanou. 2013. “Epidemiology of Association W. K. Kellogg Foundation, Battle Creek, MI. https://www between Maternal Periodontal Disease and Adverse Pregnancy .dentaquestinstitute.org/sites/default/files/reports/2011/12 Outcomes: Systematic Review.” Journal of Periodontology 84 /Pacific_Center_for_Special_Care_Report.pdf. (Suppl. 4): S181–94. doi:10.1902/jop.2013.134009. Goodson, J. M., A. D. Haffajee, S. S. Socransky, R. Kent, R. Teles, IHI (Institute for Healthcare Improvement). 2014. “How and others. 2012. “Control of Periodontal Infections: to Improve.” IHI, Cambridge, MA. http://www.ihi.org A Randomized Controlled Trial I. The Primary Outcome /resources/Pages/HowtoImprove/default.aspx. Attachment Gain and Pocket Depth Reduction at Treated IOM (Institute of Medicine). 2001. Crossing the Quality Chasm: Sites.” Journal of Clinical Periodontology 39 (6): 526–36. A New Health System for the 21st Century. Washington, DC: doi:10.1111/j.1600-051X.2012.01870.x. National Academies Press. Greenhalgh, T., G. Robert, F. Macfarlane, P. Bate, and ———. 2011a. Advancing Oral Health in America. Washington, O. Kyriakidou. 2004. “Diffusion of Innovations in Service DC: National Academies Press. Organizations: Systematic Review and Recommendations.” ———. 2011b. Children and Adolescent Health and Health Milbank Quarterly 82 (4): 581–629. doi:10.1111/j.0887 Care Quality: Measuring What Matters. Washington, DC: -378X.2004.00325.x. National Academies Press. Griffin, S. O., K. Jones, and S. L. Tomar. 2001. “An Economic ———. 2013. “Roundtable on Value & Science-Driven Health Evaluation of Community Water Fluoridation.” Journal of Care.” Institute of Medicine, Washington, DC. http://www Public Health Dentistry 61 (2): 78–86. .iom.edu/~/media/Files/Activity%20Files/Quality/VSRT Griffin, S. O., E. Regnier, P. M. Griffin, and V. Huntley. 2007. /Core%20Documents/Background.pdf. “Effectiveness of Fluoride in Preventing Caries in Adults.” Johnson, N., R. Lalloo, J. Kroon, S. Fernando, and O. Tut. Journal of Dental Research 86 (5): 410–15. 2014. “Effectiveness of Water Fluoridation in Caries Gunsolley, J. C. 2006. “A Meta-Analysis of Six-Month Studies Reduction in a Remote Indigenous Community in Far of Antiplaque and Antigingivitis Agents.” Journal of the North Queensland.” Australian Dental Journal. Online in American Dental Association 137 (12): 1649–57. advance of print. doi:10.1111/adj.12190. Haffajee, A. D., and S. S. Socransky. 1994. “Microbial Etiological Källestål, C., A. Norlund, B. Söder, G. Nordenram, H. Dahlgren, Agents of Destructive Periodontal Diseases.” Periodontology and others. 2003. “Economic Evaluation of Dental Caries 2000 5: 78–111. Prevention: A Systematic Review.” Acta Odontologica Han, Y. W., W. Houcken, B. G. Loos, H. A. Schenkein, and Scandinavica 61 (6): 341–46. M. Tezal. 2014. “Periodontal Disease, Atherosclerosis, Kaplan, R. S., and M. E. Porter. 2011. “How to Solve the Cost Adverse Pregnancy Outcomes, and Head-and-Neck Crisis in Health Care.” Harvard Business Review 89 (9): Cancer.” Advances in Dental Research 26 (1): 47–55. 46–52, 54, 56. doi:10.1177/0022034514528334. Kikwilu, E. N., J. Frencken, and J. Mulder. 2009. “Impact Hendrix, K. S., S. M. Downs, G. Brophy, C. C. Doebbeling, and of Atraumatic Restorative Treatment (ART) on the N. L. Swigonski. 2013. “Threshold Analysis of Reimbursing Treatment Profile in Pilot Government Dental Clinics Physicians for the Application of Fluoride Varnish in Young in Tanzania.” BMC Oral Health 9: 14. doi:10.1186/1472 Children.” Journal of Public Health Dentistry 73 (4): 297–303. -6831-9-14. Herrera, D., B. Alonso, R. Leon, S. Roldan, and M. Sanz. Kim, J. Y., P. Farmer, and M. E. Porter. 2013. “Redefining Global 2008. “Antimicrobial Therapy in Periodontitis: The Use of Health-Care Delivery.” The Lancet 382 (9897): 1060–69. Systemic Antimicrobials against the Subgingival Biofilm.” doi:10.1016/S0140-6736(13)61047-8. Journal of Clinical Periodontology 35 (Suppl. 8): 45–66. Kohn, L. T., J. Corrigan, and M. S. Donaldson. 2000. To Err Is doi:10.1111/j.1600-051X.2008.01260.x. Human: Building a Safer Health System. Washington, DC: HHS (Health and Human Services). 2010. “Promoting National Academies Press. and Enhancing the Oral Health of the Public.” HHS, Kroon, J., and P. J. van Wyk. 2012a. “A Retrospective View on the Washington, DC. http://www.hrsa.gov/publichealth/clinical Viability of Water Fluoridation in South Africa to Prevent /oralhealth/hhsinitiative.pdf. Dental Caries.” Community Dentistry and Oral Epidemiology Holtshousen, W. S., and A. Smit. 2007. “A Cost-Efficiency 40 (5): 441–50. doi:10.1111/j.1600-0528.2012.00681.x. Analysis of a Mobile Dental Clinic in the Public Services.” ———. 2012b. “A Model to Determine the Economic Viability SADJ [Journal of the South African Dental Association] of Water Fluoridation.” Journal of Public Health Dentistry 62 (8): 334, 336–38, 340. 72 (4): 327–33. Dentistry 191 Langley, G. L., R. Moen, K. M. Nolan, T. W. Nolan, C. L. Norman, Fluoridation Program in Peru.” Journal of Public Health and others. 2009. The Improvement Guide: A Practical Dentistry 71 (2): 125–30. Approach to Enhancing Organizational Performance. 2nd Mariño, R., J. Fajardo, and M. Morgan. 2012. “Cost-Effectiveness edition. San Francisco, CA: Jossey-Bass. Models for Dental Caries Prevention Programmes among Lauris, J. R., R. da Silva Bastos, and J. R. de Magalhaes Chilean Schoolchildren.” Community Dental Health 29 (4): Bastos. 2012. “Decline in Dental Caries among 12-Year-Old 302–08. Children in Brazil, 1980–2005.” International Dental Journal Mariño, R. J., A. R. Khan, and M. Morgan. 2013. “Systematic 62 (6): 308–14. doi:10.1111/j.1875-595x.2012.00124.x. Review of Publications on Economic Evaluations of Lee, J. Y., and K. Divaris. 2014. “The Ethical Imperative of Caries Prevention Programs.” Caries Research 47 (4): Addressing Oral Health Disparities: A Unifying Framework.” 265–72. Journal of Dental Research 93 (3): 224–30. doi:10.1177 Mashoto, K. O., A. N. Astrom, M. S. Skeie, and J. R. Masalu. /0022034513511821. 2010. “Changes in the Quality of Life of Tanzanian School Linden, G. J., A. Lyons, and F. A. Scannapieco. 2013. “Periodontal Children after Treatment Interventions Using the Child- Systemic Associations: Review of the Evidence.” Journal OIDP.” European Journal of Oral Sciences 118 (6): 626–34. of Periodontology 84 (Suppl. 4): S8–19. doi:10.1902 doi:10.1111/j.1600-0722.2010.00776.x. /jop.2013.1340010. Matarazzo, F., L. C. Figueiredo, S. E. B. Cruz, M. Faveri, and Liu, B. Y., E. C. M. Lo, C. H. Chu, and H. C. Lin. 2012. M. Feres. 2008. “Clinical and Microbiological Benefits of “Randomized Trial on Fluorides and Sealants for Fissure Systemic Metronidazole and Amoxicillin in the Treatment Caries Prevention.” Journal of Dental Research 91 (8): 753–58. of Smokers with Chronic Periodontitis: A Randomized Lockhart, P. B., A. F. Bolger, P. N. Papapanou, O. Osinbowale, Placebo-Controlled Study.” Journal of Clinical Periodontology M. Trevisan, and others. 2012. “Periodontal Disease and 35 (10): 885–96. Atherosclerotic Vascular Disease: Does the Evidence Support Mathu-Muju, K. R., J. W. Friedman, and D. A. Nash. 2013. an Independent Association? A Scientific Statement from “Oral Health Care for Children in Countries Using Dental the American Heart Association.” Circulation 125 (20): Therapists in Public, School-Based Programs, Contrasted 2520–44. doi:10.1161/CIR.0b013e31825719f3. with That of the United States, Using Dentists in a Private Loesche, W. J., and N. S. Grossman. 2001. “Periodontal Disease Practice Model.” American Journal of Public Health 103 (9): as a Specific, Albeit Chronic, Infection: Diagnosis and e7–e13. doi:10.2105/AJPH.2013.301251. Treatment.” Clinical Microbiology Reviews 14 (4): 727–52. McDonagh, M. S., P. F. Whiting, P. M. Wilson, A. J. Sutton, López, N. J., and J. A. Gamonal. 1998. “Effects of Metronidazole I. Chestnutt, and others. 2000. “Systematic Review of Water Plus Amoxicillin in Progressive Untreated Adult Fluoridation.” BMJ (Clinical research ed.) 321 (7265): Periodontitis: Results of a Single 1-Week Course after 2 855–59. and 4 Months.” Journal of Periodontology 69 (11): 1291–98. Mestnik, M. J., M. Feres, L. C. Figueiredo, P. M. Duarte, López, N. J., S. S. Socransky, I. Da Silva, M. R. Japlit, and E. A. G. Lira, and others. 2010. “Short-Term Benefits of A. D. Haffajee. 2006. “Effects of Metronidazole Plus the Adjunctive Use of Metronidazole Plus Amoxicillin in Amoxicillin as the Only Therapy on the Microbiological and the Microbial Profile and in the Clinical Parameters of Clinical Parameters of Untreated Chronic Periodontitis.” Subjects with Generalized Aggressive Periodontitis.” Journal Journal of Clinical Periodontology 33 (9): 648–60. of Clinical Periodontology 37 (4): 353–65. Mager, D. L., L. A. Ximenez-Fyvie, A. D. Haffajee, and Mickenautsch, S., and V. Yengopal. 2011. “Caries-Preventive S. S. Socransky. 2003. “Distribution of Selected Bacterial Effect of Glass Ionomer and Resin-Based Fissure Sealants Species on Intraoral Surfaces.” Journal of Clinical on Permanent Teeth: An Update of Systematic Review Periodontology 30 (7): 644–54. Evidence.” BMC Research Notes 4: 22. Marcenes, W., N. J. Kassebaum, E. Bernabé, A. Flaxman, ———. 2012. “Failure Rate of High-Viscosity GIC Based M. Naghavi, and others. 2013. “Global Burden of Oral ART Compared with That of Conventional Amalgam Conditions in 1990–2010: A Systematic Analysis.” Journal Restorations: Evidence from an Update of a Systematic of Dental Research 92 (7): 592–97. Review.” SADJ [Journal of the South African Dental Marck, K. W. 2003. Noma, the Face of Poverty. Hannover, Association] 67 (7): 329–31. Germany: MIT-Verlag GmbH. Mickenautsch, S., V. Yengopal, and A. Banerjee. 2010. Marck, R., M. Huijing, D. Vest, M. Eshete, K. Marck, and others. “Atraumatic Restorative Treatment versus Amalgam 2010. “Early Outcome of Facial Reconstructive Surgery Restoration Longevity: A Systematic Review.” Clinical Oral Abroad: A Comparative Study.” European Journal of Plastic Investigations 14 (3): 233–40. Surgery 33 (4): 193–97. Moimaz, S. A., O. Saliba, F. Y. Chiba, and N. A. Saliba. Marinho, V. C. C., H. V. Worthington, T. Walsh, and 2012. “External Control of the Public Water Supply in 29 J. E. Clarkson. 2013. “Fluoride Varnishes for Preventing Brazilian Cities.” Brazilian Oral Research 26 (1): 12–18. Dental Caries in Children and Adolescents.” Cochrane Moimaz, S. A., N. A. Saliba, O. Saliba, D. H. Sumida, N. P. Souza, Database of Systematic Reviews 7: CD002279. F. Y. Chiba, and C. A. Garbin. 2013. “Water Fluoridation in Marino, R. J., J. Fajardo, A. Arana, C. Garcia, and F. Pachas. 40 Brazilian cities: 7 Year Analysis.” Journal of Applied Oral 2011. “Modeling an Economic Evaluation of a Salt Science 21 (1): 92–98. 192 Essential Surgery Monse, B., H. Benzian, E. Naliponguit, V. Belizario, A. Schratz, by Organizing around Patients’ Needs.” Health Affairs and W. van Palenstein Helderman. 2013. “The Fit for (Millwood) 32 (3): 516–25. doi:10.1377/hlthaff.2012.0961. School Health Outcome Study: A Longitudinal Survey Quiñonez, R. B., S. C. Stearns, B. S. Talekar, R. G. Rozier, and to Assess Health Impacts of an Integrated School Health S. M. Downs. 2006. “Simulating Cost-Effectiveness of Programme in the Philippines.” BMC Public Health 13: 256. Fluoride Varnish during Well-Child Visits for Medicaid- doi:10.1186/1471-2458-13-256. Enrolled Children.” Archives of Pediatrics and Adolescent Monse, B., E. Naliponguit, V. Belizario, H. Benzian, and Medicine 160 (2): 164–70. W. Palenstein van Helderman. 2010. “Essential Health Ricketts, D., T. Lamont, N. P. T. Innes, E. Kidd, and Care Package for Children: The ‘Fit for School’ Program J. E. Clarkson. 2013. “Operative Caries Management in in the Philippines.” International Dental Journal 60 (2): Adults and Children.” Cochrane Database of Systematic 85–93. Reviews 3: CD003808. Morgan, M., R. Marino, C. Wright, D. Bailey, and Riley, P., and T. Lamont. 2013. “Triclosan/Copolymer M. Hopcraft. 2012. “Economic Evaluation of Preventive Containing Toothpastes for Oral Health.” Cochrane Database Dental Programs: What Can They Tell Us?” Community of Systematic Reviews 12: CD010514. doi:10.1002/14651858 Dentistry and Oral Epidemiology 40 (Suppl 2): 117–21. .CD010514.pub2. doi:10.1111/j.1600-0528.2012.00730.x. Ritchie, C. S., K. Joshipura, H. C. Hung, and C. W. Douglass. Moynihan, P. J., and S. A. Kelly. 2014. “Effect on Caries of 2002. “Nutrition as a Mediator in the Relation between Restricting Sugars Intake: Systematic Review to Inform Oral and Systemic Disease: Associations between Specific WHO Guidelines.” Journal of Dental Research 93 (1): 8–18. Measures of Adult Oral Health and Nutrition Outcomes.” doi:10.1177/0022034513508954. Critical Reviews in Oral Biology and Medicine 13 (3): 291–300. Nash, D. A., J. W. Friedman, K. R. Mathu-Muju, P. G. Robinson, Rogers, E. M. 2002. “Diffusion of Preventive Innovations.” J. Satur, and others. 2012. A Review of the Global Literature Addictive Behaviors 27 (6): 989–93. on Dental Therapists. Battle Creek, MI: W. K. Kellogg Rosenblatt, A., T. C. M. Stamford, and R. Niederman. 2009. Foundation. “Silver Diamine Fluoride: A Caries ‘Silver-Fluoride Bullet.’” NHS (National Health Service). 2005. Choosing Better Oral Journal of Dental Research 88 (2): 116–25. Health: An Oral Health Plan for England. Edited by Sampaio, A. L. L., M. F. S. Araújo, and C. A. C. P. Oliveira. 2011. Department of Health: Dental and Ophthalmic Services “New Criteria of Indication and Selection of Patients to Division, London. http://webarchive.nationalarchives.gov Cochlear Implant.” International Journal of Otolaryngology .uk/20130107105354/http://www.dh.gov.uk/prod_consum 2011: 573968. _dh/groups/dh_digitalassets/@dh/@en/documents Sanz, M., K. Kornman, and EFP/AAP Workshop Working /digitalasset/dh_4123253.pdf. Group 3. 2013. “Periodontitis and Adverse Pregnancy ———. 2007. “Oral Health Survey of 5 Year Old Children Outcomes: Consensus Report of the Joint EFP/AAP 2007/2008.” London. http://www.nwph.net/dentalhealth (European Federation of Periodontology and American /reports/NHS_DEP_for_England_OH_Survey_5yr_2007 Academy of Peridontology) Workshop on Periodontitis and -08_Report.pdf. Systemic Diseases.” Journal of Periodontology 84 (Suppl. 4): ———. 2009. “Adult Dental Health Survey 2009.” London. S164–69. doi:10.1902/jop.2013.1340016. http://www.hscic.gov.uk/pubs/dentalsurveyfullreport09. Schoen, C., S. Guterman, M. Zezza, and M. Abrams. 2013. Ogbureke, K. U. E., and E. I. Ogbureke. 2010. “Noma: “Confronting Costs: Stabilizing U.S. Health Spending While A Preventable ‘Scourge’ of African Children.” Open Moving toward a High Performance Health Care System.” Dentistry Journal 4: 201–06. Publication 1653, The Commonwealth Fund Commission Osso, D., and N. Kanani. 2013. “Antiseptic Mouth Rinses: on a High Performance Health System, Washington, DC. An Update on Comparative Effectiveness, Risks and Schwendicke, F., C. E. Dörfer, and S. Paris. 2013. “Incomplete Recommendations.” Journal of Dental Hygiene 87 (1): 10–18. Caries Removal: A Systematic Review and Meta-Analysis.” Palacios, C., K. Joshipura, and W. Willett. 2009. “Nutrition and Journal of Dental Research 92 (4): 306–14. Health: Guidelines for Dental Practitioners.” Oral Diseases Schwendicke, F., M. Stolpe, H. Meyer-Lueckel, S. Paris, and 15 (6): 369–81. doi:10.1111/j.1601-0825.2009.01571.x. C. E. Dörfer. 2013. “Cost-Effectiveness of One- and Two- Parnell, C., H. Whelton, and D. O’Mullane. 2009. “Water Step Incomplete and Complete Excavations.” Journal of Fluoridation.” European Archives of Paediatric Dentistry 10 Dental Research 92 (10): 880–87. (3): 141–48. Sgolastra, F., R. Gatto, A. Petrucci, and A. Monaco. 2012. Paster, B. J., W. A. Falkler Jr., C. O. Enwonwu, E. O. Idigbe, “Effectiveness of Systemic Amoxicillin/Metronidazole as K. O. Savage, and others. 2002. “Prevalent Bacterial Species Adjunctive Therapy to Scaling and Root Planing in the and Novel Phylotypes in Advanced Noma Lesions.” Journal Treatment of Chronic Periodontitis: A Systematic Review of Clinical Microbiology 40 (6): 2187–91. and Meta-Analysis.” Journal of Periodontology 83 (10): Porter, M. E. 2010. “What Is Value in Health Care?” New 1257–69. England Journal of Medicine 363 (26): 2477–81. Sgolastra, F., A. Petrucci, R. Gatto, and A. Monaco. 2012. Porter, M. E., E. A. Pabo, and T. H. Lee. 2013. “Redesigning “Effectiveness of Systemic Amoxicillin/Metronidazole as an Primary Care: A Strategic Vision to Improve Value Adjunctive Therapy to Full-Mouth Scaling and Root Planing Dentistry 193 in the Treatment of Aggressive Periodontitis: A Systematic Institutional and Community-Based Settings in Southern Review and Meta-Analysis.” Journal of Periodontology 83 Thailand.” Asia Pacific Journal of Public Health 21 (1): (6): 731–43. 84–93. doi:10.1177/ 1010539508327246. Sheiham, A., D. Alexander, L. Cohen, V. Marinho, S. Moysés, Tonetti, M. S., T. E. Van Dyke, and EFP/AAP (European and others. 2011. “Global Oral Health Inequalities: Task Federation of Periodontology and American Academy of Group: Implementation and Delivery of Oral Health Peridontology) Working Group 1. 2013. “Periodontitis and Strategies.” Advances in Dental Research 23 (2): 259–67. Atherosclerotic Cardiovascular Disease: Consensus Report Shugars, D. A., and J. D. Bader. 1996. “Cost Implications of of the Joint EFP/AAP Workshop on Periodontitis and Differences in Dentists’ Restorative Treatment Decisions.” Systemic Diseases.” Journal of Periodontology 84 (Suppl. 4): Journal of Public Health Dentistry 56 (4): 219–22. S24–9. doi:10.1902/jop.2013.1340019. Silva, M. P., M. Feres, T. A. Sirotto, G. M. Soares, J. A. Mendes, Touger-Decker, R., C. C. Mobley, and American Dietetic and others. 2011. “Clinical and Microbiological Benefits of Association. 2007. “Position of the American Dietetic Metronidazole Alone or with Amoxicillin as Adjuncts in the Association: Oral Health and Nutrition.” Journal of the Treatment of Chronic Periodontitis: A Randomized Placebo- American Dietetic Association 107 (8): 1418–28. Controlled Clinical Trial.” Journal of Clinical Periodontology Van Strydonck, D. A., D. E. Slot, U. van der Velden, and 38 (9): 828–37. doi:10.1111/j.1600-051X.2011.01763.x. F. Van der Weijden. 2012. “Effect of a Chlorhexidine Sköld, U. M., L. G. Petersson, D. Birkhed, and A. Norlund. Mouthrinse on Plaque, Gingival Inflammation and 2008. “Cost-Analysis of School-Based Fluoride Varnish Staining in Gingivitis Patients: A Systematic Review.” and Fluoride Rinsing Programs.” Acta Odontologica Journal of Clinical Periodontology 39 (11): 1042–55. Scandinavica 66 (5): 286–92. doi:10.1111/j.1600-051X.2012.01883.x. Soares, G. M., L. C. Figueiredo, M. Faveri, S. C. Cortelli, van Winkelhoff, A. J., C. J. Tijhof, and J. de Graaff. P. M. Duarte, and M. Feres. 2012. “Mechanisms of Action 1992. “Microbiological and Clinical Results of of Systemic Antibiotics Used in Periodontal Treatment Metronidazole Plus Amoxicillin Therapy in Actinobacillus and Mechanisms of Bacterial Resistance to These Drugs.” actinomycetemcomitans–Associated Periodontitis.” Journal Journal of Applied Oral Science 20 (3): 295–309. of Periodontology 63 (1): 52–57. Socransky, S. S., and A. D. Haffajee. 1994. “Evidence of Bacterial van Wyk, P. J., J. Kroon, and W. S. Holtshousen. 2001. “Cost Etiology: A Historical Perspective.” Periodontology 2000 5: Evaluation for the Implementation of Water Fluoridation 7–25. in Gauteng.” SADJ [Journal of the South African Dental ———. 2002. “Dental Biofilms: Difficult Therapeutic Targets.” Association] 56 (2): 71–76. Periodontology 2000 28: 12–55. Walter, C., F. R. Rodriguez, B. Taner, H. Hecker, and R. Weiger. ———, M. A. Cugini, C. Smith, and R. L. Kent. 1998. 2012. “Association of Tobacco Use and Periapical Pathosis: “Microbial Complexes in Subgingival Plaque.” Journal of A Systematic Review.” International Endodontic Journal 45 Clinical Periodontology 25 (2): 134–44. (12): 1065–73. doi:10.1111/j.1365-2591.2012.02072.x. Socransky, S. S., A. D. Haffajee, J. L. Dzink, and J. D. Hillman. Watt, R. G. 2012. “Social Determinants of Oral Health 1988. “Associations between Microbial Species in Inequalities: Implications for Action.” Community Subgingival Plaque Samples.” Oral Microbiology and Dental and Oral Epidemiology 40 (Suppl 2): 44–48. Immunology 3 (1): 1–7. doi:10.1111/j.1600-0528.2012.00719.x. Soderlund, N., J. Kent, P. Lawyer, and S. Larsson. 2012. “Progress Watt, R. G., and A. Sheiham. 2012. “Integrating the Common toward Value-Based Health Care: Lessons Learned from Risk Factor Approach into a Social Determinants 12 Countries.” Boston Consulting Group. Framework.” Community Dental and Oral Epidemiology 40 Splieth, C. H., and S. Flessa. 2008. “Modelling Lifelong Costs of (4): 289–96. doi:10.1111/j.1600-0528.2012.00680.x. Caries with and without Fluoride Use.” European Journal of Webster, A. E. 1908. “Preparation of Cavities for Fillings.” In Oral Sciences 116 (2): 164–69. A Textbook of Operative Dentistry, edited by C. N. Johnson, Steele, J. 2009. “NHS Dental Services in England: An 161–214. Philadelphia, PA: P. Blakiston’s Son & Co. Independent Review Led by Professor Jimmy Steele.” NHS WHO (World Health Organization). 1978. “Declaration of Department of Health, London. http://www.sigwales.org Alma-Ata.” International Conference on Primary Health /wp-content/uploads/dh_101180.pdf. Care, Alma-Ata, Kazakhstan, September 6–12. Teles, R. P., A. D. Haffajee, and S. S. Socransky. 2006. ———. 2006. The World Health Report 2006: Working Together “Microbiological Goals of Periodontal Therapy.” for Health. Geneva: WHO. http://www.who.int/whr/2006 Periodontology 2000 42: 180–218. /whr06_en.pdf. Teles, R. P., and F. R. Teles. 2009. “Antimicrobial Agents Used ———. 2013. “Global Health Estimates for Deaths by Cause, in the Control of Periodontal Biofilms: Effective Adjuncts Age, and Sex for Years 2000–2011.” WHO, Geneva. http:// to Mechanical Plaque Control?” Brazilian Oral Research 23 www.who.int/healthinfo/global_health_estimates/en/. (Suppl. 1): 39–48. Williams, D. M. 2011. “Global Oral Health Inequalities: The Tempest, M. N. 1966. “Cancrum Oris.” British Journal of Research Agenda.” Journal of Dental Research 90 (5): Surgery 53 (11): 949–69. 549–51. doi:10.1177/0022034511402210. Tianviwat, S., V. Chongsuvivatwong, and S. Birch. 2009. Wong, M. C. M., J. Clarkson, A. M. Glenny, E. C. M. Lo, “Estimating Unit Costs for Dental Service Delivery in V. C. C. Marinho, and others. 2011. “Cochrane Reviews 194 Essential Surgery on the Benefits/Risks of Fluoride Toothpastes.” Journal of Yengopal, V., U. M. E. Chikte, S. Mickenautsch, L. B. Oliveira, Dental Research 90 (5): 573–79. and A. Bhayat. 2010. “Salt Fluoridation: A Meta-analysis Worthington, H. V., J. E. Clarkson, G. Bryan, and P. V. Beirne. of Its Efficacy for Caries Prevention.” SADJ [Journal of the 2013. “Routine Scale and Polish for Periodontal Health South African Dental Association] 65 (2): 60–4, 66. in Adults.” Cochrane Database of Systematic Reviews 11: Yengopal, V., S. Mickenautsch, A. C. Bezerra, and S. C. Leal. CD004625. 2009. “Caries-Preventive Effect of Glass Ionomer and Wright, J. Timothy, F. Graham, C. Hayes, A. I. Ismail, Resin-Based Fissure Sealants on Permanent Teeth: A Meta K. W. Noraian, and others. 2013. “A Systematic Review Analysis.” Journal of Oral Science 51 (3): 373–82. of Oral Health Outcomes Produced by Dental Teams Yunusa, M., and A. Obembe. 2012. “Prevalence of Psychiatric Incorporating Midlevel Providers.” Journal of the American Morbidity and Its Associated Factors among Patients Facially Dental Association (1939) 144 (1): 75–91. Disfigured by Cancrum Oris in Nigeria: A Controlled Yee, R. 2008. “Healthy Choices, Healthy Smiles: Appropriate Study.” Nigerian Journal of Medicine: Journal of the National and Affordable Fluorides in Nepal.” Dissertation. Radboud Association of Resident Doctors of Nigeria 21 (3): 277–81. University of Nijmegen. Zandbergen, D., D. E. Slot, C. M. Cobb, and F. A. Van der ———, N. McDonald, and W. H. Helderman. 2006. “Gains in Weijden. 2013. “The Clinical Effect of Scaling and Root Oral Health and Improved Quality of Life of 12-13-Year- Planing and the Concomitant Administration of Systemic Old Nepali Schoolchildren: Outcomes of an Advocacy Amoxicillin and Metronidazole: A Systematic Review.” Project to Fluoridate Toothpaste.” International Dental Journal of Periodontology 84 (3): 332–51. Journal 56 (4): 196–202. Zhi, Q. H., E. C. Lo, and H. C. Lin. 2012. “Randomized Clinical Yee, R., N. McDonald, and D. Walker. 2004. “A Cost-Benefit Trial on Effectiveness of Silver Diamine Fluoride and Analysis of an Advocacy Project to Fluoridate Toothpastes Glass Ionomer in Arresting Dentine Caries in Preschool in Nepal.” Community Dental Health 21 (4): 265–70. Children.” Journal of Dentistry 40 (11): 962–67. Dentistry 195 Chapter 11 Cataract Surgery N. Venkatesh Prajna, Thulasiraj D. Ravilla, and Sathish Srinivasan THE GLOBAL CHALLENGE OF BLINDNESS in Asia and Sub-Saharan Africa (Pascolini and Mariotti 2012). Even in high-income countries (HICs), the prev- Prevalence alence is more common among the economically poorer The worldwide estimate of blindness (defined as best segments of the population. corrected visual acuity [BCVA] of 3/60 [recognizing at Other major risk factors for blindness include 3 meters what a person with normal acuity can recognize advancing age, illiteracy, and rural residence (Abdull at 60 meters] and less in the better eye) is 39 million and others 2009; Huang and others 2009; Li and others people (Pascolini and Mariotti 2012). This figure is just 2008; Li and others 2009; Murthy and others 2010; the tip of the iceberg; a significantly larger proportion Salomão and others 2008; Woldeyes and Adamu 2008). of people suffer from low vision (defined as BCVA in Conflicting data have been reported with respect to the range of 6/18 to 3/60), which reduces their levels of potential gender-based risks. Although some studies independence, safety, and productivity (Thylefors and conducted in Sub-Saharan Africa (Komolafe and others others 1995). The World Health Organization (WHO) 2010; Lewallen and others 2009; Rabiu and Muhammed has expanded the scope of the definition of blindness 2008), China (Li and others 2008; Li and others 2009), by using presenting visual acuity instead of BCVA. and India (Neena and others 2008) report that the prev- Table 11.1 provides a classification of severity of visual alence of blindness is more common in women, other impairment as recommended by the International studies conducted in Brazil (Salomão and others 2008), Council of Ophthalmology (2002) and the recommen- China (Huang and others 2009), India (Murthy and dations of the WHO (2003). others 2010), and Nepal (Sherchan and others 2010) have not established an association. Risk Factors The distribution of the burden of disease is disparate; Costs 90 percent of all blind and visually impaired people The estimation of the cost of blindness has been a sub- live in low- and middle-income countries (LMICs) ject of considerable interest. One 1996 study estimates (Cunningham 2001; Thylefors 1998). A study performed the annual worldwide productivity cost of blindness in 2010 indicates that visual impairment is unequally to be US$168 billion, using the data on prevalence distributed among the WHO regions (Stevens and rates, GDP, and populations (Smith and Smith 1996). others 2013). The bulk of the blind population resides This estimate is based on an assumption that all blind Corresponding author: N. Venkatesh Prajna, DNB, FRCOphth, Aravind Eye Hospital, prajna@aravind.org 197 Table 11.1 Visual Acuity Scale individuals are completely unproductive, while all other adults and children are assumed to be productive. Presenting visual acuity Category Worse than Equal to or better than A subsequent study, using data from 2000 and based on a more conservative estimate of personal productivity Mild or no visual impairment n.a. 6/18 losses associated with blindness, estimates the economic 0 3/10 (0.3) productivity loss to be US$19 billion (Frick and Foster 20/70 2003). Another study estimates the direct investment Moderate visual impairment 6/18 6/60 required to treat the backlog of avoidable blindness and visual impairment over 10 years, to 2020, to be US$23.1 1 3/10 (0.3) 1/10 (0.1) billion (PwC 2012). 20/70 20/200 Severe visual impairment 6/60 3/60 2 1/10 (0.1) 1/20 (0.05) CATARACT DISEASE 20/200 20/400 Description and Prevalence a Blindness 3/60 1/60 Cataract is defined as a significant opacity in the crystal- 3 1/20 (0.05) 1/50 (0.02) line lens that obstructs or distorts light entering the eye. 20/400 5/300 (20/1200) The WHO in 2004 estimated that cataract was responsi- a ble for blindness in 17.7 million people, or 47.8 percent Blindness 1/60 Light perception of all blindness (Resnikoff and others 2004). A more 4 1/50 (0.02) recent estimate from Pascolini and Mariotti (2012) finds 5/300 (20/1200) cataract the leading cause of avoidable blindness, respon- Blindness No light perception sible for 51 percent of cases (figure 11.1). The prevalence of cataract as a proportion of the blind population shows 5 large variations across countries. The figure is as low as 9 Undetermined or unspecified 5 percent in developed countries such as Australia, the Source: WHO 2008. United Kingdom, and the United States; it is more than Note: Three visual acuity measurements are included for each category because countries express visual acuity in different ways. The first notation is given in metric form and is expressed as meters. The second 55 percent in countries such as Peru and some parts of notation is expressed in decimal form. The third notation is given in imperial form and expressed as feet. Sub-Saharan Africa (Resnikoff and others 2004). An esti- Note: n.a. = not applicable. mate based on the number of cataract surgery procedures a. Or counts fingers at 1 meter. Figure 11.1 Global Burden of Cataract Percent a. Cataract and uncorrected refractive errors b. Unoperated cataract and glaucoma are the are the leading causes of avoidable visual impairment leading causes of avoidable blindness Corneal Diabetic Cataract, opacities, 33 retinopathy, 1 Age-related 1 Cataract, macular degeneration, 51 5 Uncorrected Diabetic refractive error, retinopathy, Uncorrected 3 1 refractive error, 42 Childhood Other causes, blindness, 21 1 Other causes, Corneal Trachoma, Trachoma, 18 opacities, 3 1 Childhood Age-related 4 Glaucoma, blindness, macular Glaucoma, 2 4 degeneration, 8 1 Source: Pascolini and Mariotti 2012. 198 Essential Surgery per million population shows interesting variations. Even importance of this examination; 33 percent of patients among high-income countries (HICs), annual cataract surveyed had a secondary ophthalmic diagnosis, indi- surgical rates per million population vary dramatically; cating that they may receive a reduced benefit from the for example, there are 1,200 in the United Arab Emirates surgery. Systemic conditions such as diabetes mellitus, versus 8,000 in Australia (WHO 2010). hypertension, and compromised cardiac status should The burden of visual loss due to cataract can markedly be evaluated before the decision is made to subject reduce the quality of life (QOL) of the affected elderly patients to surgery. population because routine activities like reading, driv- The power of the IOL to be placed inside the eye should ing, walking, and remaining independent are severely be customized for each individual. Ultrasonography is affected (Salive and others 1994; Stuck and others 1999; performed to estimate the axial length of the eye; this West and others 1997). Impaired vision may be associated estimate is used to determine the power of the IOL. It with an increased risk of falls, which can cause broken might be argued that the vast majority of patients may hips and associated increased morbidity (Patino and oth- benefit from receiving a standard 20-diopter IOL, which ers 2010). Studies have suggested that this visual disability would eliminate the high cost of obtaining an ultra- may pose an increased risk for mental depression and sound, but the advantage of having a customized power suicide (Lam and others 2008; Zheng and others 2012). IOL is far greater. Cataract has no proven preventive or medical therapy. The amount of preoperative testing performed for Surgery, the only option, consists of removing the cloudy healthy patients undergoing cataract surgery may vary natural lens and replacing it with an artificial, transpar- significantly, which might influence the ultimate cost ent intraocular lens (IOL). Studies have clearly estab- of the intervention. A national survey in the United lished that this surgery with the implantation of IOL States assessed variations in preoperative medical tests significantly improves vision-related QOL (Fletcher and ordered by physicians (Bass and others 1995). Results others 1998). Although economic conditions play a sig- indicate that 50 percent of ophthalmologists, 40 percent nificant role, the availability of adequate and appropriate of internists, and 33 percent of anesthesiologists fre- surgical resources and patients’ perceptions of the ben- quently or always obtained chest x-rays; in contrast, efits could be significant factors in increasing the utility 20 percent of ophthalmologists, 27 percent of internists, of cataract surgery. and 37 percent of anesthesiologists never obtained x-rays. A visual acuity measurement can serve as a guid- Similar significant differences were also seen with respect ing factor, but the timing of surgery should be based to the ordering of routine blood tests. Many respondents on the visual needs of individual patients. In general, (32 percent to 80 percent) believed that these tests may patients in developed countries are more likely to seek be unnecessary, but they cited medico-legal reasons or and obtain cataract surgery early in the course of the institutional requirements for ordering them (Bass and disease because of the widespread availability and easy others 1995). accessibility of quality eye care services and probably because of government-provided or -subsidized health care, to an extent. Anecdotal experiences in India suggest that this phenomenon of early cataract surgery interven- SURGICAL INTERVENTIONS tion has increased in recent years, probably due to the Surgery is the only treatment choice for visually dis- country’s improving economy and access to affordable abling cataract. If surgery is delayed, the following quality interventions. Early surgery also helps the indi- sequelae may occur: vidual make informed decisions before loss of social independence. 1. Cataract may become denser (hard or brunescent, which implies a browner color) or whiter (mature cataract). Preoperative Evaluation 2. If still untreated, it may proceed to the following A comprehensive ocular examination evaluates the stages: cornea, anterior chamber, pupil, lens status, retina, and • Phacolytic glaucoma: A hypermature cataract can optic nerve; this examination is the first step in deter- leak, causing increased intraocular pressure. mining the need for a surgical procedure. This exami- • Phacomorphic glaucoma: A mature cataract nation is useful for identifying associated comorbidities, can sometimes cause crowding of the anterior such as glaucoma or retinal and optic nerve disorders, chamber, leading to increased intraocular pres- given that their presence may contribute to a poor final sure. Surgery at these stages has to be undertaken visual outcome. Räsänen and others (2006) highlight the as an emergency to prevent irreversible blindness. Cataract Surgery 199 Surgical Types and Procedures (which is foldable), and MSICS and ECCE use a rigid lens There are three basic types of cataract surgery: of polymethylmethacrylate (PMMA) (which is rigid). PE is the most commonly performed cataract surgery Phacoemulsification (PE) in HICs. However, in LMICs, most surgeries are done Manual small-incision cataract surgery (MSICS) using the MSICS and ECCE techniques. There are valid Extracapsular cataract extraction (ECCE) reasons for these different approaches. Patients seek The basic steps in all three surgical procedures are the cataract surgery much later than in developed coun- following: making an entry wound into the eye, remov- tries. The surgery is often postponed until the disease ing the cloudy natural lens, and replacing the lens with progresses, by which time the cataract may have become an artificial IOL. advanced and mature. It is not uncommon to see phaco- lytic and phacomorphic glaucoma, the sequelae of long- standing cataract. Even though PE can be performed for Incision. In PE, a small incision of approximately hard cataract, MSICS is easier and more cost-effective 2.5 millimeters (mm) is made, either in the sclera or the in this situation. MSICS has been reported to be safer cornea. This wound is triplanar, which provides a self- in situations such as brunescent cataract (Gogate and sealing trapdoor incision. The configuration of the inci- others 2003; Venkatesh and others 2009), white mature sion is more important than the size, with respect to the cataract (Venkatesh, Das, and others 2005; Venkatesh maintenance of the self-sealing property. In most cases, and others 2010), and cataract causing phacolytic and no sutures are used that could distort the corneal edge, phacomorphic glaucomas (Ramakrishanan and others any resultant induced astigmatism is negligible, and the 2010; Venkatesh and others 2007), which are more prev- visual rehabilitation is very quick. alent in LMICs. In MSICS, a triplanar incision, similar in configura- Another deterrent for large-scale adoption of the tion to that in PE but considerably wider (8 to 9 mm), is PE procedure in LMICs is the high cost of the instru- made in the sclera. This incision is large enough to let the ments and the consumables, which include tubings, lens be delivered through it, but it is self-sealing because cassettes, and the surgical tips of the machine, and the of the triplanar configuration. Hence, the entry wounds need for trained technical personnel to maintain these for PE and MSICS are superior to those of ECCE in sophisticated instruments. In contrast, MSICS does not ensuring quick visual rehabilitation. require sophisticated equipment, except for an operating In ECCE, the entry wound is biplanar, placed at the microscope, which is an essential requirement for all limbus, and is 10 to 12 mm in length. Because this inci- intraocular procedures. sion is biplanar, it requires meticulous suturing. These The scarcest resource for an effective intervention is sutures may have many inherent problems, the most the availability of a trained ophthalmic surgeon; this can important of which is suture-induced astigmatism, be an important rate-limiting step in eye care service which prolongs visual rehabilitation. Occasionally, the delivery in LMICs. Effective use of surgeons’ time by sutures may cause significant irritation and may serve as using well-organized and efficient supporting teams is a locus for potential intraocular infection. a prerequisite to improving cost-effectiveness. Surgeries that take less time mean that more surgeries can be Removal of the Cloudy Natural Lens. In PE, the performed in a given period. In general, PE takes signifi- nucleus is fragmented and emulsified using ultrasound cantly more time than MSICS; Ruit and others (2007) within the eye. Hence, this surgery requires a smaller and Gogate and others (2005) report mean surgical incision, only wide enough to allow the ultrasound time of 15.5 minutes for PE and 9 minutes for MSICS. probe to enter the eye and access the lens. In ECCE and In high-volume settings, the mean surgical time can be MSICS, the nuclear and corneal material is manually reduced to as low as 4.5 minutes for MSICS, making it delivered, which requires a wide incision to allow the an extremely fast procedure (Balent and others 2001; lens to be retrieved. Venkatesh and others 2005). Replacement with an Artificial Lens. Following the cataract extraction, an IOL of a customized dioptric COMPARATIVE SAFETY OF SURGICAL power is placed in the posterior chamber of the eye. The power is determined preoperatively using a formula INTERVENTIONS based on keratometry and the axial length measurement. Many studies have compared the incidence of intraop- These posterior chamber IOLs are manufactured from erative and postoperative complications of these proce- one of two types of material: PE uses an acrylic lens dures (Ruit and others 2007; Venkatesh and others 2010). 200 Essential Surgery Posterior Capsular Rupture requires an additional surgical intervention called During cataract surgery, the anterior capsule, the nucleus, yttrium-aluminum garnet laser capsulotomy. Ruit and and the cortex of the cataractous lens are removed, while others (2007) report an incidence of grade-one PCO the posterior capsule is retained. The integrity of the (defined as a non-vision-threatening, mild peripheral posterior capsule acts as a scaffold for keeping the artifi- PCO) of 26.1 percent of MSICS patients, compared cial IOL in place. Posterior capsular rupture (PCR) with with 14.6 percent in PE patients. The incidence of or without vitreous loss is one of the important intraop- grade-two PCO was 17.4 percent in the MSICS group, erative complications during cataract surgery and may and none in the PE group. However, in this study, lead to suboptimal visual outcomes. IOLs made of different materials were used for these The occurrence of PCR is often used as a surrogate two interventions. The design of the IOL also matters. for estimation of safety in cataract surgeries. Ruit and Square-edged IOLs are known to cause less PCO than others (2007) report a 1.85 percent PCR rate in the PE round-edged IOLs. group, versus none in the MSICS group. Venkatesh and others (2010) report that PCR occurred in 2.2 percent of PE cases, compared with 1.4 percent in MSICS cases. COMPARATIVE EFFICACY OF SURGICAL Gogate and others (2005) report a higher incidence of INTERVENTIONS PCR in both groups: 6 percent in the MSICS group Visual Acuity versus 3.5 percent in the PE group. These studies show that the incidence of PCR is comparable between the The visual outcomes following cataract surgery are often groups; anecdotal experience among high-volume sur- reported either as uncorrected visual acuity (UCVA) or geons suggests that the incidence of PCR declines with BCVA. UCVA, which is the visual acuity of the operated increasing surgical experience. eye without the aid of additional refractive tools like spectacles, often reflects the real-life situation in LMICs, in which patients often do not have easy access to spec- tacles. BCVA represents the best possible visual potential Endophthalmitis of the operated eye, usually with the aid of spectacles. Endophthalmitis is a serious postoperative compli- The WHO recommends that 88 percent of surgically cation that can cause significant ocular morbidity. operated patients should have a UCVA of 6/18 and better Infection within the eye is more difficult to treat (WHO 1998). because antibiotics are not able to cross the blood- The three randomized trials mentioned compare ocular barrier with ease. Hence, the results are very the visual outcomes between PE and MSICS. Venkatesh often devastating and all efforts should be made to and others (2010) randomize 270 consecutive patients, prevent this complication. A retrospective observa- who presented with white mature cataract (a common tional study reported the comparative incidence for PE occurrence in many LMICs), to receive either PE or and MSICS (Ravindran and others 2009). This study MSICS. At six weeks’ follow-up, 87.6 percent of the was performed at Aravind Eye Hospital, a large eye eyes in the PE group and 82.0 percent in the MSICS care facility in India that offers services to two distinct group had a UCVA of 6/18 and better. The BCVA com- subsets of patients: private patients who come from parison revealed that 99.0 percent of the eyes in the comparatively good economic backgrounds; and poor PE group and 98.2 percent of the eyes in the MSICS patients who come from distant areas, where outreach group had vision of 6/18 and better. Gogate and others screening eye examinations are conducted. This study (2005), who compare PE with MSICS in a prospec- reports lower incidence of endophthalmitis in private tive randomized trial of 400 eyes, report that UCVA patients, who had a better standard of living, than in of 6/18 or better was achieved by 81.1 percent of the patients from eye camps. PE eyes, versus 71.1 percent of the MSICS eyes, at six weeks. The BCVA was 6/18 or better in 98.4 percent of the PE group and 98.4 percent of the MSICS group at Posterior Capsule Opacification six weeks. Ruit and others (2007) report longer-term Posterior capsule opacification (PCO) is one of visual outcomes in a prospective trial of 108 eyes in the significant postoperative occurrences following Nepal. The patients were randomized to PE or MSICS, cataract surgery, and the incidence increases over with each type of surgery performed by an acknowl- longer follow-up periods. Although a minimal PCO edged expert in that technique. They report compa- does not warrant any treatment, a significant PCO rable rates of 98 percent achieving BCVA of 6/18 or may cause a substantial reduction in visual acuity and better at six months. Cataract Surgery 201 Surgically Induced Astigmatism • The treatment is often a one-time surgical interven- The main determinant in the difference between UCVA tion with excellent visual rehabilitation. This is one and BCVA is the amount of surgically induced astigma- of the few age-related conditions for which surgical tism (SIA). SIA is the most important reason for patients intervention will result in near-normal functional to have a suboptimal UCVA, while their BCVA may be levels. Because there is no need for routine systemic normal. The lower the SIA created, the closer UCVA and antibiotics, the cost of postoperative medications BCVA will be to each other, an ideal situation. Hence, is lower. one of the main strategies for optimizing the visual acu- • Visual acuity becomes normal after the initial con- ity of the patient is to keep the incidence of SIA as low valescent period of one month, and patients are as possible. able to resume their occupations with near-normal The size and location of the incision play key roles in productivity. the occurrence of SIA; larger incisions cause more SIA. A prospective Japanese study compares the SIA between Despite these factors and the availability of time- two sizes of surgical incision in MSICS, 3.2 mm and 5.5 tested surgical options, cataract continues to constitute mm, and finds a reduction of SIA by 0.3 diopter when a major global health care burden, not because of the the smaller incision size is used (Kimura and others lack of a clinical solution, but because of the challeng- 1999). Surgical incisions created in the temporal side of ing issues in effective program implementation. These the corneo-scleral junction are known to cause less SIA challenges include identifying patients in need, making than the traditional superior incisions (Gokhale and services available, creating supportive infrastructures, Sawhney 2005; Reddy, Raj, and Singh 2007). ensuring quality, and developing sustainable service Studies have also looked at the SIA created by PE delivery systems. and MSICS. At six months’ follow-up, Ruit and others (2007) report a mean astigmatism of 0.7 diopter for the Identifying Patients in Need PE group and 0.88 for the MSICS group. This difference of astigmatism was not statistically significant. At six The first strategy for a successful cataract surgery pro- weeks postoperatively, Gogate and others (2005) report gram is to ensure a high throughput of patients into an mean astigmatism of 1.1 diopters for PE and 1.2 diopters efficient, quality-conscious, and cost-effective service for MSICS, which were also comparable. Other authors, delivery system. Emerging evidence indicates that the however, report that PE causes significantly less SIA incidence of blinding cataract varies among regions. than MSICS at six weeks postoperatively (George and Studies have suggested that the burden of cataract dis- others 2005; Venkatesh and others 2010). Astigmatism ease may be lower in Sub-Saharan Africa than in India caused by MSICS is greater when a superior incision is (Mathenge and others 2007; Neena and others 2008; Oye used; accordingly, it can be lessened to a great extent by and Kuper 2007; Oye and others 2006). The proportion using a temporal incision, thereby improving the UCVA of people in India who are older than age 50 years is of MSICS (Gokhale and Sawhney 2005; Kimura and about 16 percent of the total population, which is twice others 1999). that of some Sub-Saharan African countries (Lewallen and Thulasiraj 2010). Given that advancing age is a significant risk factor for the development of cataract, it may be prudent to assume that the incidence in these FACTORS AFFECTING THE EFFICACY OF Sub-Saharan African countries may be lower than that SURGICAL INTERVENTIONS in India. In addition, physical access to patients in remote locations such as the mountainous regions of Advantages of Interventions Nepal and in some Sub-Saharan African countries with Cataract surgery has several advantages over other low population density may be considerably more dif- ophthalmic conditions, including the following: ficult than in a country such as India, which has high population density. • Because cataract causes visual disability early in the disease course, patients become symptomatic and seek medical care, which is in contrast to other Increasing Access to Care ocular morbidities, such as diabetic retinopathy and It is often difficult to provide continuous ophthalmic glaucoma, in which patients may be asymptomatic services to sparsely populated areas. However, evi- and may not seek care until the disease is more dence exists that even when such services are provided, advanced. they are underutilized (Brilliant and Brilliant 1985; 202 Essential Surgery Brilliant and others 1991; Courtright, Kanjaloti, Aravind Eye Hospital operating room staff supports and Lewallen 1995; Gupta and Murthy 1995; a single surgeon; the staff includes three scrub nurses, Venkataswamy and Brilliant 1981). In India, screening one orderly, one circulating nurse, and one nurse to eye camps have been available for decades to identify clean and sterilize instruments. To minimize the sur- and advise surgery to people affected by cataract. gical turnaround time, the ophthalmologist alternates A study conducted by the Aravind Eye Hospital inves- between two adjacent operating tables. A centrally tigated service uptake in rural Indian populations placed operating microscope can rotate between the served by regular outreach camps and tried to identify two tables. While the surgeon is operating on one the barriers (Fletcher and others 1999). The authors patient, the paramedical team positions and prepares found that, of the people with eye problems, only the next patient on an adjacent table. The average sur- 7 percent attended the eye camps. The major barriers gical time is about 3.5 minutes, with 16 to 18 surgeries were lack of resources such as money, transportation, performed by a single surgeon per hour. The compli- and attendants. cation rate and the visual results are comparable to the The cost of getting cataract patients to hospitals best global standards (Venkatesh, Muralikrishnan, and can also vary significantly between geographic settings. others 2005). Whereas it costs about US$4.50 to transport one patient for cataract surgery to Aravind Eye Hospital in south- ern India, the same effort is estimated to cost US$40 Ensuring Quality to US$60 in the much less densely populated areas The WHO recommends that 80 percent of eyes should of eastern Africa (Lewallen, Eliah, and Gilbert 2006). have presenting visual acuity better than 6/18 after Innovative programs, such as the creation of low-cost surgery, and fewer than 5 percent should be worse than permanent facilities staffed by ophthalmic assistants 6/60 (Lewallen and Thulasiraj 2010). However, several connected with an ophthalmologist in a central location population-based studies have reported poor visual through telemedicine connectivity, may positively influ- outcome of less than 6/60, which would be defined as ence eye care–seeking behavior. blind in most countries (Courtright and others 2004; Habiyakire and others 2010; Kimani and others 2008; Oye and Kuper 2007; Oye and others 2006). These pop- Optimizing Productivity ulation-based studies may have encompassed patients The lack of availability of ophthalmologists and their operated over a large time span; hence, the results disproportional distribution is a major issue. There may reflect services offered both in the past and in the are approximately 200,000 ophthalmologists world- present. Nevertheless, these data clearly indicate sig- wide. Although this number is growing annually by nificant room for improvement. Poor outcomes start a 1.2 percent, the population older than age 60 years, vicious cycle that will result in lower demand and lower which is more at risk of developing cataract, is growing patient volumes. by 2.9 percent. Sub-Saharan Africa has three ophthal- mologists per 1 million population in contrast to 79 ophthalmologists per 1 million population in HICs Building Sustainable Service Delivery Systems (Resnikoff and others 2012). Excellent programs are not able to continue without Although the presence of skilled ophthalmologists sustainable strategies. Although philanthropy can be is a key factor, this alone may not solve the issue of an initial source of support, programs need to devise optimal productivity. Good infrastructure with optimal ways to become self-sustaining to continue to be effi- paramedical support is crucial for the productivity of cient. Eye care service providers can allow patients to ophthalmologists. In a study in Sub-Saharan Africa, choose the type of surgical procedure and the IOL Courtright and others (2007) show that the creation of from a menu of options. For example, Aravind Eye an enabling environment improves the productivity of a Hospitals have developed a tiered service system. cataract surgeon by four- to five-fold, from a low of 100 Using this system, it offers free surgery to patients to a high of nearly 500 surgeries per year. from eye camps, subsidized by fees paid by wealthier The establishment of such a system has produced a patients who choose to pay for special services such successful high-volume, high-quality eye care service as PE procedures with costlier IOLs or for private model in India (Natchiar and others 1994). Maximizing rooms. Paying customers also have high standards operating room efficiency is extremely important for quality care, and these standards are used as the in achieving high-volume productivity. Venkatesh, benchmark for nonpaying customers as well (Rangan Muralikrishnan, and others (2005) describe how the and Thulasiraj 2007). Cataract Surgery 203 MEASURING COSTS OF SURGICAL Cost-Effectiveness Analysis PROGRAMS Cost-effectiveness analysis looks beyond the concepts of cost minimization and cost-benefit analysis to mea- There are different ways of analyzing the economic sure the costs expended upon an intervention and implications of cataract surgical procedures. compares them for a single outcome (Brown and others 2003). These outcomes can be analyzed as measured Cost-Minimization Analysis by life-years gained, vision-years gained, or disability- adjusted life years (DALYs) averted, and expressed in Cost-minimization analysis compares events that have cost per output unit (Lansingh, Carter, and Martens similar outcomes and determines which procedures 2007). The first Global Burden of Disease study quan- are less costly (Brown and others 2003). The results are tified health effects by employing DALYs (Murray and expressed in units of currency expended for each out- Lopez 1996). This metric integrates parameters such as come. Various studies report the cost of providing PE morbidity, mortality, and disability information, and and MSICS services (table 11.2). arrives at a single unit. In essence, this unit aims to mea- The data in table 11.2 show, in the three studies, sure the difference between the current health status of that provider costs for MSICS are consistently less than individuals and ideal situations in which people would those for PE. Provider costs for PE show a wide vari- live to old age without disease or disability. ation, ranging from US$25.50 to US$70 even though Data from the WHO’s Global Health Estimates these studies were in similar geographic locations with study indicate that the global burden of eye disease comparable socioeconomic dynamics. The cost differ- was an estimated 25 million DALYs, accounting for ence was mainly attributable to the different types of 1 percent of total DALYs (WHO 2013). The highest IOLs used. For example, in the Nepal study (Ruit and number of DALYs was found in South Asia (including others 2007), the provider cost was US$70, of which India), and East Asia and the Pacific (including China), US$52 was due to the more expensive, imported, followed by Sub-Saharan Africa and the other LMICs. foldable acrylic IOL. In comparison, the cost of an Among the ocular noncommunicable diseases, cata- indigenous IOL made of PMMA would be US$3. If ract was most unevenly distributed across the globe, a PMMA lens had been used instead of a foldable with increased presence in LMICs, and contributed acrylic IOL, the provider cost would have been reduced to 7 million DALYs. In HICs such as Australia and dramatically and would have been similar to the costs the United States, cataract surgery is offered to people reported in the other studies (Gogate and others 2005; with early lens changes and not delayed until cases Muralikrishnan and others 2004). Muralikrishnan and are severe, probably because of market demand (Ono, others (2004) study the societal costs (obtained by Hiratsuka, and Murakami 2010). summing the provider costs and the patient costs) of Cost-effectiveness can vary among countries and also the two procedures and arrive at US$29.40 for MSICS among providers in the same country. Singh, Garner, and US$37.92 for PE. Even though rigid PMMA IOLs and Floyd (2000) compare the cost-effectiveness of cata- were used in both arms of this study, PE procedures ract surgery in southern India in three types of facilities: were more expensive because of the capital costs of the government camps, a nongovernment hospital, and a machine and the costs of the consumables. Compared state medical college functioning as a first-level hospi- with PE, MSICS clearly reduces the costs for the tal. This study reports that even though camps were a health care delivery system (Gogate, Deshpande, and low-cost option, the poor outcomes experienced there Nirmalan 2007). reduced their cost-effectiveness to US$97 per patient. The state medical college hospital was least cost-effective at US$176 per patient; the nongovernmental hospital Table 11.2 Providers’ Cost of PE and MSICS was the most cost-effective at US$54 per patient. A study from Nepal reports that under a best-estimate scenario, US$ per procedure cataract surgery had a cost of US$5.06 per DALY, which Study PE MSICS places it among the most cost-effective public health Muralikrishnan and others 2004 25.55 17.03 interventions (Marseille 1996). Gogate and others 2005 42.10 15.34 Ruit and others 2007 70 15 Cost Utility Analysis Source: Venkatesh and others 2012. Cost utility analysis is more exhaustive than sim- Note: MSICS = manual small-incision cataract surgery; PE = phacoemulsification. ple cost-effectiveness in that it includes evaluation 204 Essential Surgery of both QOL as perceived by the patient and lon- on investment to society over 13 years (Brown and gevity (Brown and Brown 2005; Brown, Brown, and others 2013). Sharma 2004; Lansingh, Carter, and Martens 2007). Improvement in visual outcome following an inter- Surgery on the First Eye. The results of the cost utility vention is often used as the indicator of success after analysis are expressed using cost per quality-adjusted life the procedure. However, this result does not effectively year ($/QALY) gained. Vision improvement after cata- illuminate the intrinsic value of the intervention from ract surgery has been shown to positively affect utility patients’ perspectives. values and, in most instances, to correlate positively with Utility value is a quantifiable measure of data health-related QOL instruments or utility measuring derived from patient-preference-based value, clini- methods (Brown, Brown, Sharma, Busbee, and Brown cian, and community (Groot 2000). The time tradeoff 2001; Gafni 1994; Lee and others 2000; Rosen, Kaplan, (TTO) method is a major tool for measuring utility and David 2005). Studies have been performed on cost value; subjects are asked what proportion of their lives utility following cataract surgery; the results have been they would be willing to trade in return for guaranteed depicted in the form of QALY per unit of currency perfect vision in each eye (Brown, Brown, Sharma, (table 11.3). Busbee, and Brown 2001; Brown, Brown, Sharma, and A Swedish study that analyzes the cost utility of Garrett 1999; Brown, Brown, Sharma, and Shah 1999; cataract surgery based on cost data and vision and Brown, Sharma, Brown, and Garrett 1999; Wakker disability scores estimates the cost utility in 2006 to be and Stiggelbout 1995). TTO utility values were signifi- US$4,800 per QALY, using the common benefit dis- cantly higher in patients with ocular disease and good count of 3 percent (Kobelt, Lundström, and Stenevi bilateral visual acuity than in those with good uni- 2002). In HICs such as the United States, interventions lateral visual acuity (Brown, Brown, Sharma, Busbee, costing less than US$100,000 per QALY gained have been and Brown 2001). Patients who had undergone cat- considered cost-effective (Laupacis and others 1992). aract surgery in both eyes had a better QOL than Cost-effectiveness is accentuated when the cost is less those who had surgery in only one eye (Castells and than US$20,000. others 1999; Desai and others 1996; Javitt, Brenner, The benefit of any surgery is increased if the dura- and others 1993; Javitt, Steinberg, and others 1995). tion of the benefit is extended. One study tries to deter- A 2012 cataract surgery cost utility study finds that mine the duration of the visual improvement following cataract surgery yielded a remarkable 36.2 percent cataract surgery (Lundstrom and Wendel 2005). This gain in QOL for surgery in both eyes. Additionally, study, performed in Sweden on 615 patients, assesses the it was highly cost-effective, being 34.4 percent less patients preoperatively, at one year, and at eight years expensive than in 2000 and 85 percent less expensive after the surgery, using clinical data and the Catquest than in 1985. Initial cataract surgery was estimated to questionnaire. The results indicate that 80 percent yield an extraordinary 4.57 percent financial return of patients reported improved visual function at the Table 11.3 Studies Reporting Cost Utility of Cataract Surgery Using Intraocular Implants for the First Eye, Unless Otherwise Stated Cost utility Method used to Study Year published Country (US$/QALY) measure utility Remarks Aribaba 2004 Nigeria 1,928–2,875 TTO Cost utility for four scenarios Busbee and others 2002 United States 2,020 TTO Cost/QALYs discounted 3 percent over 12 years (life expectancy) Busbee and others 2003 United States 2,727 TTO Cost utility of surgery for second eye Kobelt, Lundström, 2002 Sweden 4,900 EQ-5D and Undiscounted costs; QALYs discounted and Stenevi Catquest* 3 percent over 5 years (life expectancy); correlation of Catquest and EQ-5D Räsänen and others 2006 Finland 13,018 15D QALYs discounted 3 percent; costs not discounted; life expectancy unknown Source: Lansingh, Carter, and Martens 2007. Note: EQ-5D = Euro quality of life measure on five dimensions; QALY = quality-adjusted life year; TTO = time tradeoff; 15D = 15 dimensions of the health-related quality of life. *Catquest = a disease-specific, health-related quality-of-life instrument measuring the benefit of surgery as a function of a patient’s specifics at baseline. Cataract Surgery 205 latest follow-up, implying that the cost utility benefit amount of per capita spending on health alone does not of cataract surgery may continue throughout indi- translate into an efficient health system. It is imperative viduals’ life spans. As life expectancy increases, higher to find more effective, sustainable, and equitable solu- numbers of QALYs can be expected. The costs will tions to meet the needs of the world’s population. also be discounted over the longer period. Brown and others (2013) find that cataract surgery is very effective Changing Demographics at $2,222 per QALY, from the third-party insurer cost perspective. Demographic projections suggest that there will be a significant increase in the general population and in Surgery on the Second Eye. Cost utility studies have the proportion of the population that is older (Lutz, demonstrated the benefit of surgery on the second eye Sanderson, and Scherbov 1997). Without new inter- in cases of bilateral cataract. Busbee and others (2003) ventions, the global number of blind individuals is analyze the cost utility of cataract surgery in the second likely to increase from 44 million in 2000 to 76 million eye of the same patient in the outcomes research team in 2020 (Frick and Foster 2003). Providing quality eye study cohort; they find that patients gained 0.92 QALYs. care, with its projected increase in costs, is going to be This figure is similar to the cost utility for the first eye an increasing challenge for both LMICs and HICs. The reported by the same authors (Busbee and others 2002). government of the United Kingdom had to increase its These studies indicate that the cost utilities for surgeries eye care budget by £730 million between 2003 and 2009, on both eyes are similar when calculated using the same a 60 percent increase (figure 11.2) (Malik and others methodology. 2013). In this era of financial austerity, such increased Utility values can also be used to compare the expenditures cannot be sustained. cost-effectiveness analyses of medical interventions across different specialties. One study compares the cost-effectiveness of cataract surgery and other sur- Current Scenario gical options; results indicate that cataract surgery is Realizing the need for an increasing thrust to combat more cost-effective than knee arthroplasty, epileptic avoidable blindness, the WHO, in partnership with the surgery, or implantation of a defibrillator, but it may International Agency for the Prevention of Blindness, be less cost-effective than hip arthroplasty (Lansingh, launched the VISION 2020 Right to Sight initiative in Carter, and Martens 2007). Another study states that 1999. At that time, it was envisaged that if successfully when total benefits are compared with total costs implemented, this initiative would lower the projected (estimated to eliminate avoidable blindness and visual number of people who are blind to 24 million in 2020 impairment), the result shows a 2:1 benefit-to-cost and lead to 429 million blind person-years avoided. ratio (PwC 2012). Recent studies done across the world have shown encouraging trends in the reduction of vision loss. In Southeast Asia, blindness decreased significantly from CONCLUSIONS Figure 11.2 Gross Expenditure on Vision Program, 2003–09 Rising Costs Health care expenditures are rising throughout the 2.5 world and hence must be considered in any health care delivery intervention. In 1970, total health care expen- Gross expenditure (£billion) 2.0 diture in the United States was US$73.1 billion, which was 7 percent of GDP. By 2001, this figure had risen to 1.5 US$1,425 billion or 14.1 percent of GDP (Brown and others 2003). In 2000, the WHO published a health system per- 1.0 formance assessment of its 191 member states that measured how efficiently health systems translate expen- 0.5 ditures into health care (Brown and others 2003; WHO 2000). The United States, which incurred the highest 0 health care expenditures per capita, adjusted for cost 2003 2004 2005 2006 2007 2008 2009 of living differences in 1997, achieved a ranking of 72, between Argentina and Bhutan. Clearly, increasing the Source: Malik and others 2013. 206 Essential Surgery 1.4 percent in 1990 to 0.8 percent in 2010, a 43 percent NOTE decrease (Keeffe and others 2014). Similarly, in Central The World Bank classifies countries according to four income Asia, the estimated age-standardized prevalence of blind- groupings. Income is measured using gross national income ness decreased from 0.4 percent in 1990 to 0.2 percent (GNI) per capita, in U.S. dollars, converted from local currency in 2010, while in South Asia, blindness has decreased using the World Bank Atlas method. Classifications as of July from 1.7 percent to 1.1 percent in the same period 2014 are as follows: (Jonas and others 2014). East Asia was no different, and the blindness prevalence dropped from 0.7 percent in • Low-income countries (LICs) = US$1,045 or less in 2013 1990 to 0.4 percent in 2010 (Wong and others 2014). The • Middle-income countries (MICs) are subdivided: change in these figures can be linked to major cataract • Lower-middle-income = US$1,046 to US$4,125 programs that have been conducted in the most popu- • Upper-middle-income (UMICs) = US$4,126 to US$12,745 lous countries, such as India, which now has a cataract • High-income countries (HICs) = US$12,746 or more surgery rate of 4,000 per 1 million population (Keeffe and others 2014). However, in absolute numbers, the number of blind people remains constant because of the rapid increase in the older adult population (Stevens and REFERENCES others 2013). Abdull, M. M., S. Sivasubramaniam, G. V. S. Murthy, C. Gilbert, T. Abubakar, and others. 2009. “Causes of Blindness and Visual Impairment in Nigeria: The Nigeria Demand and Supply Strategies National Blindness and Visual Impairment Survey.” In an early study, cataract surgery was identified by the Investigative Ophthalmology and Visual Science 50 (4): World Bank as one of the most cost-effective interven- 4114–20. tions that can be offered in LMICs (Javitt, Venkataswamy, Aribaba, O. T. “Cost Effectiveness Analysis of Cataract Services and Somme 1983). Programs need to put effective teams in Lagos University Teaching Hospital [LUTH], Lagos, Nigeria.” Master’s thesis summary. http://www.iceh.org.uk and processes in place to create an environment that can /alumni/more/aribaba04.htm. address both the demand and the supply sides of the Balent, L. C., K. Narendran, S. Patel, S. Kar, and D. A. Patterson. equation. Strategies on demand creation would ensure 2001. “High Volume Sutureless Intraocular Lens Surgery in that all those who can benefit from cataract surgery a Rural Eye Camp in India.” Ophthalmic Surgery, Lasers, and will actively seek it; such strategies also need to facili- Imaging 32 (6): 446–55. tate the efficient delivery of cataract services with good Bass, E. B., E. P. Steinberg, R. Luthra, O. D. Schein, J. M. Tielsch, visual outcomes. The scenario of increasing backlogs of and others. 1995. “Do Ophthalmologists, Anesthesiologists, patients, low surgical productivity, and poor visual out- and Internists Agree about Preoperative Testing in comes indicates that this demand-supply equation needs Healthy Patients Undergoing Cataract Surgery?” Archives of to be refined, evaluated, and monitored. Although the Ophthalmology 113 (10): 1248–56. resource bases such as infrastructure, equipment, oph- Brilliant, G. E., and L. B. Brilliant. 1985. “Using Social Epidemiology to Understand Who Stays Blind and Who thalmologists, and paramedical staff should be strength- Gets Operated for Cataract in a Rural Setting.” Social ened, an equal emphasis is needed on management Science and Medicine 21 (5): 553–58. aspects and competencies (Lewallen and Thulasiraj Brilliant, G. E., J. M. Lepkowski, B. Zurita, and R. D. Thulasiraj. 2010) to build the effective processes and organizational 1991. “Social Determinants of Cataract Surgery Utilization capabilities to use resources optimally. in South India: The Operations Research Group.” Archives LMICs have to use their economic resources even of Ophthalmology 109 (4): 584–89. more judiciously in light of competing and compelling Brown, M. M., and G. C. Brown. 2005. “How to Interpret health care needs, such as maternal and child health a Healthcare Economic Analysis.” Current Opinion in programs and immunizations. Resources are neither Ophthalmology 16 (3): 191–94. infinite nor indefinite. The law of diminishing returns Brown, G. C., M. M. Brown, A. Menezes, B. G. Busbee, states that for a certain period, the benefits to patients H. B. Lieske, and P. A. Lieske. 2013. “Cataract Surgery Cost Utility Revisited in 2012: A New Economic Paradigm.” increase when health care resources are increased. After Ophthalmology 120 (12): 2367–76. a certain point, however, additional resources may lead Brown, G. C., M. M. Brown, and S. Sharma. 2004. “Health Care to a reduction in net benefits to patients (Malik and Economic Analyses.” Retina 24 (1): 139–46. others 2013). Supporting literature indicates that PE and Brown, M. M., G. C. Brown, S. Sharma, B. Busbee, and MSICS procedures are comparable with respect to safety H. Brown. 2001. “Quality of Life Associated with Unilateral and efficacy, and MSICS is more cost-effective and more and Bilateral Good Vision.” Ophthalmology 108 (4): 643–47; appropriate in these settings. discussion 647–48. Cataract Surgery 207 Brown, M. M., G. C. Brown, S. Sharma, and S. Garrett. 1999. Loss and Surgically Induced Astigmatism Following “Evidence-Based Medicine, Utilities, and Quality of Life.” Conventional Extracapsular Cataract Surgery, Manual Current Opinion in Ophthalmology 10 (3): 221–26. Small-Incision Surgery and Phacoemulsification.” Brown, M. M., G. C. Brown, S. Sharma, H. Hollands, and Ophthalmic Epidemiology 12 (5): 293–97. A. F. Smith. 2001. “Physician Manpower and Health Gogate, P., M. Deshpande, and P. K. Nirmalan. 2007. “Why Care Expenditures in the United States: A Thirty-Year Do Phacoemulsification? Manual Small-Incision Cataract Perspective.” Journal of Health Care Finance 27 (4): 55–64. Surgery Is Almost as Effective, but Less Expensive.” Brown, M. M., G. C. Brown, S. Sharma, and J. Landy. 2003. Ophthalmology 114 (5): 965–68. “Health Care Economic Analyses and Value-Based Gogate, P. M., M. Deshpande, R. P. Wormald, R. Deshpande, Medicine.” Survey of Ophthalmology 48 (2): 204–23. and S. R. Kulkarni. 2003. “Extracapsular Cataract Brown, M. M., G. C. Brown, S. Sharma, and G. Shah. 1999. Surgery Compared with Manual Small Incision Cataract “Utility Values and Diabetic Retinopathy.” American Journal Surgery in Community Eye Care Setting in Western of Ophthalmology 128 (3): 324–30. India: A Randomised Controlled Trial.” British Journal of Brown, G. C., S. Sharma, M. M. Brown, and S. Garrett. 1999. Ophthalmology 87 (6): 667–72. “Evidence-Based Medicine and Cost-Effectiveness.” Journal Gogate, P. M., S. R. Kulkarni, S. Krishnaiah, R. D. Deshpande, of Health Care Finance 26 (2): 14–23. S. A. Joshi, and others. 2005. “Safety and Efficacy of Busbee, B. G., M. M. Brown, G. C. Brown, and S. Sharma. 2002. Phacoemulsification Compared with Manual Small-Incision “Incremental Cost-Effectiveness of Initial Cataract Surgery.” Cataract Surgery by a Randomized Controlled Clinical Trial: Ophthalmology 109 (3): 606–12; discussion 612–13. Six-Week Results.” Ophthalmology 112 (5): 869–74. ———. 2003. “Cost-Utility Analysis of Cataract Surgery in the Gokhale, N. S., and S. Sawhney. 2005. “Reduction in Astigmatism Second Eye.” Ophthalmology 110 (12): 2310–17. in Manual Small Incision Cataract Surgery through Change Castells, X., J. Alonso, C. Ribó, A. Casado, J. A. Buil, and others. of Incision Site.” Indian Journal of Ophthalmology 53 (3): 1999. “Comparison of the Results of First and Second 201–03. Cataract Eye Surgery.” Ophthalmology 106 (4): 676–82. Groot, W. 2000. “Adaptation and Scale of Reference Bias in Courtright, P., S. Kanjaloti, and S. Lewallen. 1995. “Barriers to Self-Assessments of Quality of Life.” Journal of Health Acceptance of Cataract Surgery among Patients Presenting Economics 19 (3): 403–20. to District Hospitals in Rural Malawi.” Tropical Geographical Gupta, S. K., and G. V. Murthy. 1995. “Where Do Persons with Medicine 47 (1): 15–18. Blindness Caused by Cataracts in Rural Areas of India Seek Courtright, P., N. Metcalfe, A. Hoechsmann, M. Chirambo, Treatment and Why?” Archives of Ophthalmology 113 (10): S. Lewallen, and others. 2004. “Cataract Surgical Coverage 1337–40. and Outcome of Cataract Surgery in a Rural District in Habiyakire, C., G. Kabona, P. Courtright, and S. Lewallen. 2010. Malawi.” Canadian Journal of Ophthalmology 39 (1): 25–30. “Rapid Assessment of Avoidable Blindness and Cataract Courtright, P., L. Ndegwa, J. Msosa, and J. Banzi. 2007. “Use of Surgical Services in Kilimanjaro Region, Tanzania.” Our Existing Eye Care Human Resources: Assessment of Ophthalmic Epidemiology 17 (2): 90–94. the Productivity of Cataract Surgeons Trained in Eastern Huang, S., Y. Zheng, P. J. Foster, W. Huang, and M. He. Africa.” Archives of Ophthalmology 125 (5): 684–87. 2009. “Prevalence and Causes of Visual Impairment in Cunningham, E. T., Jr. 2001. “World Blindness—No End in Chinese Adults in Urban Southern China.” Archives of Sight.” British Journal of Ophthalmology 85 (3): 253. Ophthalmology 127 (10): 1362–67. Desai, P., A. Reidy, D. C. Minassian, G. Vafidis, and J. Bolger. 1996. International Council of Ophthalmology. 2002. “Visual “Gains from Cataract Surgery: Visual Function and Quality Standards—Aspects and Range of Vision Loss, with of Life.” British Journal of Ophthalmology 80 (10): 868–73. Emphasis on Population Surveys.” A report at the 29th Fletcher, A., M. Donoghue, J. Devavaram, R. D. Thulasiraj, International Congress of Ophthalmology, Sydney, S. Scott, and others. 1999. “Low Uptake of Eye Services Australia. in Rural India: A Challenge for Programs of Blindness Javitt, J. C., M. H. Brenner, B. Curbow, M. W. Legro, and Prevention.” Archives of Ophthalmology 117 (10): 1393–99. D. A. Street. 1993. “Outcomes of Cataract Surgery: Fletcher, A., V. Vijaykumar, S. Selvaraj, R. D. Thulasiraj, and Improvement in Visual Acuity and Subjective Visual L. B. Ellwein. 1998. “The Madurai Intraocular Lens Study. Function after Surgery in the First, Second, and Both Eyes.” III: Visual Functioning and Quality of Life Outcomes.” Archives of Ophthalmology 111 (5): 686–91. American Journal of Ophthalmology 125 (1): 26–35. Javitt, J. C., E. P. Steinberg, P. Sharkey, O. D. Schein, Frick, K. D., and A. Foster. 2003. “The Magnitude and Cost J. M. Tielsch, and others. 1995. “Cataract Surgery in of Global Blindness: An Increasing Problem That Can Be One Eye or Both: A Billion Dollar per Year Issue.” Alleviated.” American Journal of Ophthalmology 135 (4): Ophthalmology 102 (11): 1583–92; discussion 1592–93. 471–76. Javitt, J., G. Venkataswamy, and A. Somme. 1983. “The Gafni, A. 1994. “The Standard Gamble Method: What Is Being Economic and Social Aspects of Restoring Sight.” In ACTA: Measured and How It Is Interpreted.” Health Services 24th International Congress of Ophthalmology, edited by Research 29 (2): 207–24. P. Henkind, 1308–12. New York: J. B. Lippincott. George, R., P. Rupauliha, A. V. Sripriya, P. S. Rajesh, P. V. Vahan, Jonas, J. B., R. George, R. Asokan, S. R. Flaxman, J. Keeffe, and S. Praveen. 2005. “Comparison of Endothelial Cell and others. 2014. “Prevalence and Causes of Vision Loss 208 Essential Surgery in Central and South Asia: 1990–2010.” British Journal of Lutz, W., W. Sanderson, and S. Scherbov. 1997. “Doubling of Ophthalmology 98 (5): 592–98. World Population Unlikely.” Nature 387 (6635): 803–05. Keeffe, J., H. R. Taylor, K. Fotis, K. Pesudovs, S. R. Fkaxnab, Malik, A. N. J., A. Cassels-Brown, R. Wormald, and J. A. M. Gray. and others. 2014. “Prevalence and Causes of Vision Loss in 2013. “Better Value Eye Care for the 21st Century: The Southeast Asia and Oceania: 1990–2010.” British Journal of Population Approach.” British Journal of Ophthalmology Ophthalmology 98 (5): 586–91. 97 (5): 553–57. Kimani, K., W. Mathenge, M. Sheila, O. Oscar, W. Wachira, and Marseille, E. 1996. “Cost-Effectiveness of Cataract Surgery in others. 2008. “Cataract Surgical Services, Outcomes and a Public Health Eye Care Programme in Nepal.” Bulletin of Barriers in Kericho, Bureti and Bomet Districts, Kenya.” the World Health Organization 74 (3): 319–24. East African Journal of Ophthalmology 13: 36–41. Mathenge, W., J. Nkurikiye, H. Limburg, and H. Kuper. 2007. Kimura, H., S. Kuroda, N. Mizoguchi, H. Terauchi, M. Matsumura, “Rapid Assessment of Avoidable Blindness in Western and M. Nagata. 1999. “Extracapsular Cataract Extraction Rwanda: Blindness in a Postconflict Setting.” PLoS Medicine with a Sutureless Incision for Dense Cataracts.” Journal of 4: e217. Cataract and Refractive Surgery 25 (9): 1275–79. Muralikrishnan, R., R. Venkatesh, N. V. Prajna, and K. J. D. Frick. Kobelt, G., M. Lundström, and U. Stenevi. 2002. “Cost- 2004. “Economic Cost of Cataract Surgery Procedures in an Effectiveness of Cataract Surgery: Method to Assess Cost- Established Eye Care Centre in Southern India.” Ophthalmic Effectiveness Using Registry Data.” Journal of Cataract and Epidemiology 11 (5): 369–80. Refractive Surgery 28 (10): 1742–49. Murray, C. J. L., and A. D. Lopez, eds. 1996. The Global Burden Komolafe, O. O., A. O. Ashaye, B. G. K. Ajayi, and of Disease: A Comprehensive Assessment of Mortality and C. O. Bekibele. 2010. “Visual Impairment from Age-Related Disability from Diseases, Injuries, and Risk Factors in 1990 Cataract among an Indigenous African Population.” Eye 24 and Projected to 2020. Cambridge, MA: Harvard University (1): 53–58. Press. Lam, B. L., S. L. Christ, D. J. Lee, D. D. Zheng, and K. L. Arheart. Murthy, G. V. S., P. Vashist, N. John, G. Pokharel, and 2008. “Reported Visual Impairment and Risk of Suicide: The L. B. Ellwein. 2010. “Prevalence and Causes of Visual 1986–1996 National Health Interview Surveys.” Archives of Impairment and Blindness in Older Adults in an Area of Ophthalmology 126 (7): 975–80. India with a High Cataract Surgical Rate.” Ophthalmic Lansingh, V. C., M. J. Carter, and M. Martens. 2007. “Global Epidemiology 17 (4): 185–95. Cost-Effectiveness of Cataract Surgery.” Ophthalmology 114 Natchiar, G., A. L. Robin, R. D. Thulasiraj, and S. Krishnaswamy. (9): 1670–78. 1994. “Attacking the Backlog of India’s Curable Blind: The Laupacis, A., D. Feeny, A. S. Detsky, and P. X. Tugwell. 1992. Aravind Eye Hospital Model.” Archives of Ophthalmology “How Attractive Does a New Technology Have to Be to 112 (7): 987–93. Warrant Adoption and Utilization? Tentative Guidelines Neena, J., J. Rachel, V. Praveen, and G. V. S. Murthy. 2008. for Using Clinical and Economic Evaluations.” Canadian “Rapid Assessment of Avoidable Blindness in India.” PLoS Medical Association Journal 146 (4): 473–81. One 3: e2867. Lee, J. E., P. J. Fos, M. A. Zuniga, P. R. Kastl, and J. H. Sung. Ono, K., Y. Hiratsuka, and A. Murakami. 2010. “Global 2000. “Assessing Health-Related Quality of Life in Cataract Inequality in Eye Health: Country-Level Analysis from the Patients: The Relationship between Utility and Health- Global Burden of Disease Study.” American Journal of Public Related Quality of Life Measurement.” Quality of Life Health 100 (9): 1784–88. Research 9 (10): 1127–35. Oye, J. E., B. Dineen, R. Befidi-Mengue, and A. Foster. 2006. Lewallen, S., E. Eliah, and S. Gilbert. 2006. “The Cost of “Prevalence and Causes of Blindness and Visual Impairment Outreach Services in Eastern Africa.” IAPB (International in Muyuka: A Rural Health District in South West Agency for the Prevention of Blindness) News 50: 16–17. Province, Cameroon.” British Journal of Ophthalmology Lewallen, S., A. Mousa, K. Bassett, and P. Courtright. 2009. 90 (5): 538–42. “Cataract Surgical Coverage Remains Lower in Women.” Oye, J. E., and H. Kuper. 2007. “Prevalence and Causes British Journal of Ophthalmology 93 (3): 295–98. of Blindness and Visual Impairment in Limbe Urban Lewallen, S., and R. D. Thulasiraj. 2010. “Eliminating Area, South West Province, Cameroon.” British Journal of Cataract Blindness: How Do We Apply Lessons from Ophthalmology 91 (11): 1435–39. Asia to Sub-Saharan Africa”? Global Public Health 5 (6): Pascolini, D., and S. P. Mariotti. 2012. “Global Estimates of 639–48. Visual Impairment: 2010.” British Journal of Ophthalmology Li, L., H. Guan, P. Xun, J. Zhou, and H. Gu. 2008. “Prevalence 96 (5): 614–18. and Causes of Visual Impairment among the Elderly in Patino, C. M., R. McKean-Cowdin, S. P. Azen, J. C. Allison, Nantong, China.” Eye 22 (8): 1069–75. F. Choudhury, and R. Varma. 2010. “Central and Peripheral Li, Z., H. Cui, L. Zhang, P. Liu, and H. Yang. 2009. “Cataract Visual Impairment and the Risk of Falls and Falls with Blindness and Surgery among the Elderly in Rural Southern Injury.” Ophthalmology 117 (2): 199–206.e1. Harbin, China.” Ophthalmic Epidemiology 16 (2): 78–83. PwC (PricewaterhouseCoopers). 2012. The Price of Sight: The Lundstrom, M., and E. Wendel. 2005. “Duration of Self Global Cost of Eliminating Avoidable Blindness. Final report Assessed Benefit of Cataract Extraction: A Long Term for the Fred Hollows Foundation. Melbourne, Australia: Study.” British Journal of Ophthalmology 89 (8): 1017–20. PricewaterhouseCoopers. Cataract Surgery 209 Rabiu, M. M., and N. Muhammed. 2008. “Rapid Assessment Brazil: The São Paulo Eye Study.” Ophthalmic Epidemiology of Cataract Surgical Services in Birnin-Kebbi Local 15 (3): 167–75. Government Area of Kebbi State, Nigeria.” Ophthalmic Sherchan, A., R. P. Kandel, M. K. Sharma, Y. D. Sapkota, Epidemiology 15 (6): 359–65. J. Aghajanian, and K. L. Bassett. 2010. “Blindness Prevalence Ramakrishanan, R., D. Maheshwari, M. A. Kader, R. Singh, and Cataract Surgical Coverage in Lumbini Zone and N. Pawar, and M. J. Bharathi. 2010. “Visual Prognosis, Chetwan District of Nepal.” British Journal of Ophthalmology Intraocular Pressure Control and Complications in 94 (2): 161–66. Phacomorphic Glaucoma Following Manual Small Incision Singh, A. J., P. Garner, and K. Floyd. 2000. “Cost-Effectiveness Cataract Surgery.” Indian Journal of Ophthalmology 58 (4): of Public-Funded Options for Cataract Surgery in Mysore, 303–6. India.” The Lancet 355 (9199): 180–84. Rangan, V. K., and R. D. Thulasiraj. 2007. “Making Sight Smith, A. F., and J. G. Smith. 1996. “The Economic Burden Affordable.” Innovations 2 (4): 35–49. of Global Blindness: A Price Too High.” British Journal of Räsänen, P., K. Krootila, H. Sintonen, T. Leivo, A.-M. Koivisto, Ophthalmology 80 (4): 276–77. and others. 2006. “Cost-Utility of Routine Cataract Surgery.” Stevens, G. A., R. A. White, S. R. Flaxman, H. Price, J. B. Jonas, Health Quality of Life Outcomes 4: 74. and others, for the Vision Loss Expert Group. 2013. “Global Ravindran, R. D., R. Venkatesh, D. F. Chang, S. Sengupta, Prevalence of Vision Impairment and Blindness: Magnitude J. Gyatsho, and B. Talwar. 2009. “Incidence of Post-cataract and Temporal Trends, 1990–2010.” Ophthalmology 120 Endophthalmitis at Aravind Eye Hospital: Outcomes of (12): 2377–84. More than 42,000 Consecutive Cases Using Standardized Stuck, A. E., J. M. Walthert, T. Nikolaus, C. J. Büla, C. Hohmann, Sterilization and Prophylaxis Protocols.” Journal of Cataract and J. C. Beck. 1999. “Risk Factors for Functional Status and Refractive Surgery 35 (4): 629–36. Decline in Community-Living Elderly People: A Systematic Reddy, B., A. Raj, and V. P. Singh. 2007. “Site of Incision Literature Review.” Social Science and Medicine 48 (4): and Corneal Astigmatism in Conventional SICS versus 445–69. Phacoemulsification.” Annals of Ophthalmology (Skokie) Thylefors, B. 1998. “A Global Initiative for the Elimination of 39 (3): 209–16. Avoidable Blindness.” American Journal of Ophthalmology Resnikoff, S., W. Felch, T. M. Gauthier, and B. Spivey. 2012. “The 125 (1): 90–93. Number of Ophthalmologists in Practice and Training Thylefors, B., A. D. Négrel, R. Pararajasegaram, and Worldwide: A Growing Gap Despite More than 200,000 K. Y. Dadzie. 1995. “Global Data on Blindness.” Bulletin of Practitioners.” British Journal of Ophthalmology 96 (6): the World Health Organization 73 (1): 115–21. 783–87. Venkataswamy, G., and G. Brilliant. 1981. “Social and Economic Resnikoff, S., D. Pascolini, D. Etya’ale, I. Kocur, Barriers to Cataract Surgery in Rural South India: A R. Pararajasegaram, and others. 2004. “Global Data on Preliminary Report.” Journal of Visual Impairment and Visual Impairment in the Year 2002.” Bulletin of the World Blindness 405–08. Health Organization 82 (11): 844–51. Venkatesh, R., D. F. Chang, R. Muralikrishnan, K. Hemal, Rosen, P. N., R. M. Kaplan, and K. David. 2005. “Measuring P. Gogate, and S. Sengupta. 2012. “Manual Small Incision Outcomes of Cataract Surgery Using the Quality of Well- Cataract Surgery: A Review.” Asia Pacific Journal of Being Scale and VF-14 Visual Function Index.” Journal of Ophthalmology 1 (2): 113–19. Cataract and Refractive Surgery 31 (2): 369–78. Venkatesh, R., M. Das, S. Prashanth, and R. Muralikrishnan. Rubin, G. S., S. K. West, B. Muñoz, K. Bandeen-Roche, 2005. “Manual Small Incision Cataract Surgery in Eyes S. Zeger, and others.1997. “A Comprehensive Assessment with White Cataracts.” Indian Journal of Ophthalmology of Visual Impairment in a Population of Older 53: 173–76. Americans. The SEE Study. Salisbury Eye Evaluation Venkatesh, R., R. Muralikrishnan, L. C. Balent, S. K. Prakash, Project.” Investigative Ophthalmology and Visual Science and N. V. Prajna. 2005. “Outcomes of High Volume 38 (3): 557–68. Cataract Surgeries in a Developing Country.” British Journal Ruit, S., G. Tabin, D. Chang, L. Bajracharya, D. C. Kline, and of Ophthalmology 89 (9): 1079–83. others. 2007. “A Prospective Randomized Clinical Trial of Venkatesh, R., C. S. H. Tan, T. T. Kumar, and R. D. Ravindran. Phacoemulsification vs Manual Sutureless Small-Incision 2007. “Safety and Efficacy of Manual Small Incision Extracapsular Cataract Surgery in Nepal.” American Journal Cataract Surgery for Phacolytic Glaucoma.” British Journal of Ophthalmology 143 (1): 32–38. of Ophthalmology 91 (3): 279–81. Salive, M. E., J. Guralnik, R. J. Glynn, W. Christen, R. B. Wallace, Venkatesh, R., C. S. H. Tan, S. Sengupta, R. D. Ravindran, and A. M. Ostfeld. 1994. “Association of Visual Impairment K. T. Krishnan, and D. F. Chang. 2010. “Phacoemulsification with Mobility and Physical Function.” Journal of the versus Manual Small-Incision Cataract Surgery for White American Geriatric Society 42 (3): 287–92. Cataract.” Journal of Cataract and Refractive Surgery 36 (11): Salomão, S. R., R. W. Cinoto, A. Berezovsky, A. Araújo-Filho, 1849–54. M. R. Mitsuhiro, and others. 2008. “Prevalence and Causes Venkatesh, R., C. S. H. Tan, G. P. Singh, K. Veena, K. T. Krishnan, of Vision Impairment and Blindness in Older Adults in and R. D. Ravindran. 2009. “Safety and Efficacy of Manual 210 Essential Surgery Small Incision Cataract Surgery for Brunescent and Black ———. 2008. “Change the Definition of Blindness.” WHO, Cataracts.” Eye 23 (5): 1155–57. Geneva. http://www.who.int/blindness/Change%20the%20 Wakker, P., and A. Stiggelbout. 1995. “Explaining Distortions Definition%20of%20Blindness.pdf. in Utility Elicitation through the Rank-Dependent Model ———. 2013. “Global Health Estimates for Deaths by Cause, for Risky Choices.” Medical Decision Making 15 (2): Age, and Sex for Years 2000–2011.” WHO, Geneva. http:// 180–86. www.who.int/healthinfo/global_health_estimates/en/. West, S. K., B. Munoz, G. S. Rubin, O. D. Schein, K. Bandeen- Woldeyes, A., and Y. Adamu. 2008. “Gender Differences Roche, and others. 1997. “Function and Visual Impairment in Adult Blindness and Low Vision, Central Ethiopia.” in a Population-Based Study of Older Adults: The Ethiopian Medical Journal 46 (3): 211–18. SEE Project. Salisbury Eye Evaluation.” Investigative Wong, T. Y., Y. Zheng, J. B. Jonas, S. R. Flaxman, J. Keeffe, and oth- Ophthalmology and Visual Science 38 (1): 72–82. ers. 2014. “Prevalence and Causes of Vision Loss in East Asia: WHO (World Health Organization). 1998. “Informal 1990–2010.” British Journal of Ophthalmology 98 (5): 599–604. Consultation on Analysis of Blindness Prevention World Bank. 2001. World Development Indicators 2001. Outcomes.” WHO/PBL/98.68, Geneva, WHO. CD-ROM. Washington, DC: World Bank. ———. 2000. World Health Report 2000—Health Systems: ———. 2009. “World Bank List of Economies.” World Bank, Improving Performance. Geneva: WHO. Washington, DC. http://siteresources.worldbank.org ———. 2003. “Consultation on Development of Standards for /DATASTATISTICS/Resources/CIASS.xls. Characterization of Vision Loss and Visual Functioning.” Zheng, D. D., S. L. Christ, B. L. Lam, K. L. Arheart, A. Galor, WHO/PUBL/03.91, WHO, Geneva. and D. J. Lee. 2012. “Increased Mortality Risk among the ———. 2010.“Prevention of Blindness and Visual Impairment.” Visually Impaired: The Roles of Mental Well-Being and WHO/NMH/PBD/12.01. WHO, Geneva. http://www.who Preventive Care Practices.” Investigative Ophthalmology and .int/blindness/GLOBALDATAFINALforweb.pdf Visual Science 53 (6): 2685–92. Cataract Surgery 211 Chapter 12 Organization of Essential Services and the Role of First-Level Hospitals Colin McCord, Margaret E. Kruk, Charles N. Mock, Meena Cherian, Johan von Schreeb, Sarah Russell, and Mike English INTRODUCTION facilities, and how such systems could function (Debas and others 2006; WHO 1992, 2003, 2010). The WHO Every country has some sort of system to provide surgical has assisted countries in analyzing their current systems and other health services at various levels, with a progres- and asked them to make realistic plans to get from where sive increase in the capacity to treat more complicated they are to a point closer to the ideal. Chapter 67 in problems. Reliable evidence indicates that properly Disease Control Priorities in Developing Countries, sec- functioning small hospitals and health centers can deliver ond edition (DCP2), presents a detailed outline of what effective basic surgical services at very low cost; these skills, services, and infrastructure would be available in surgical services can be one of the most cost-effective an ideal district hospital and calculates the cost in 2004 components of the public health system in low- and U.S. dollars (Debas and others 2006). middle-income countries (LMICs) (Alkire and others This chapter considers, and generally follows, the 2012; Debas and others 2006; Gosselin, Maldonado, recommendations of DCP2 and the WHO, discusses and Elder 2010; Gosselin, Thind, and Bellardinelli 2006; what is actually available in LMICs, and considers how McCord and Chowdhury 2003). Properly functioning to move from the current situation to an achievable is a key phrase; a hospital lacking personnel trained in improvement. The emphasis is on first-level hospitals— surgery and in the administration of anesthesia cannot the lowest level hospital that provides major surgery— provide major surgical procedures. Even minor surgery and the systems to support them. requires trained personnel. More than 50 percent of the disability-adjusted life years (DALYs) averted in a small hospital can derive from surgical treatment, (McCord Referral Systems and Chowdhury 2003) so the cost-effectiveness of these Referrals of surgical patients from lower levels such as units is drastically reduced if this treatment is not avail- clinics to first-level hospitals, as well as from first-level able. Box 12.1 defines the three levels of hospital care. facilities to second- and third-level facilities, is an essen- tial part of any system; however, in LMICs, the transport of referred patients is a major problem for families Recommended Skills and Services with low incomes. If surgical care is not available at The World Health Organization (WHO) and others have an accessible first-level hospital, it is effectively beyond provided descriptions of what services would be available the reach of at least 1 billion people (Weiser and others at properly functioning first-, second-, and third-level 2008). This group includes 80 percent of the population Corresponding author: Colin McCord, MD, Columbia University (retired), cwm1@columbia.edu 213 Box 12.1 Levels of Hospital Care in Low- and Middle-Income Countries Crucial treatment for surgical conditions can be available Important differences exist among regions: in clinics and dispensaries, especially treatment for surgical infections and simple trauma. However, the lack of trained • In Sub-Saharan Africa, first-level hospitals are usually staff, limited supplies, and unavailability of anesthesia small facilities, serving populations of fewer than seriously restrict the services that can be offered in these 500,000. They rarely have specialized physicians on facilities, so most patients with important problems need staff. Surgical services are provided by general practi- to find hospitals (table B12.1.1). tioners, often recent medical school graduates. In some The principal function of second- and third-level countries (notably Malawi, Mozambique, Tanzania, and hospitals is to provide more complex clinical care Zambia), nonphysician clinicians (NPCs) have been to patients referred from lower levels; however, no trained to do major surgery. agreed-on international definition determines which • In South Asia, first-level hospitals are larger and com- specific services should be provided at hospitals at the monly serve much larger populations of 1 million to three levels in these settings. The range of services offered 2 million or more. They usually have several specialists tends to vary substantially, even between third-level on staff. Nonphysicians rarely perform major surgery. hospitals within the same country, as much because of • In Latin America and the Caribbean, small hospitals historical accident as deliberate design. Also, almost all often provide first-level surgical services to populations second- and third-level hospitals provide emergency of fewer than 100,000. They usually have a surgeon and services for local areas and thereby function as first-level an obstetrician, and nonphysicians do not perform hospitals to varying degrees. major surgery. Table B12.1.1 Definitions of Levels of Hospital Care Level of care Alternative terms commonly found in the literature First-level hospitals: Few specialties—mainly internal medicine, obstetrics and Primary-level hospital gynecology, pediatrics, and general surgery; often only one general practice District hospital physician or a nonphysician practitioner; limited laboratory services available for general but not specialized pathological analysis; from 50 to 250 beds. Rural hospital Community hospital General hospital Second-level hospitals: More differentiated by function with as many as 5 to 10 Regional hospital clinical specialties; from 200 to 800 beds. Provincial hospital (or equivalent administrative area such as county) General hospital Third-level hospitals: Highly specialized staff and technical equipment—for National hospital example, cardiology, intensive care unit, and specialized imaging units; clinical Central hospital services highly differentiated by function; could have teaching activities; from 300 to 1,500 beds. Academic or teaching or university hospital Source: Adapted from Mulligan and others 2003. of Sub-Saharan Africa and 60 percent of the population Transportation can generally be found, but the cost of South Asia, as well as large parts of the populations of usually falls on the patient. Additional high costs include Latin America and the Caribbean and middle-income transportation of and accommodations for family mem- countries (MICs) in other regions. bers to accompany patients, the opportunity costs of Distance and lack of transportation restrict patient family members taken away from work, medical supplies travel outside of local areas, but the real barrier is cost. not provided by hospitals, and often “informal payments” 214 Essential Surgery to hospital staff. Moreover, many patients are not in any refer patients to a fairly extensive network of second- condition to withstand a long trip, even if they can and third-level hospitals (Lebrun and others 2012; afford it. Solis and others 2013). The need for first-level hospitals is not limited to However the pyramid is structured, the constraints rural areas. In cities, population growth can overwhelm listed previously seriously limit the way it can function. the third-level central hospitals; smaller urban hospitals The two most important and difficult of these con- are too often unable to provide 24-hour emergency straints are the shortage of trained staff, which limits services, except in private facilities that are too costly for the services that can be provided, especially in first- most urban residents in LMICs. level hospitals, and the weakness of the referral system, which often makes it impossible to send patients to a higher level, where more highly trained staff may be Capacity Constraints available. Clearly, the two problems work against each These issues place first-level hospitals at the center of any other. If trained staff are not available, patients should system to provide surgery in LMICs (Kushner and oth- be referred. If they cannot be referred, they often do not ers 2010). Major constraints limit their capacity. These receive appropriate treatment, which can lead to death constraints reflect the extremely low budgets within or serious disability. Although the emphasis today needs which these hospitals must function—usually less than to be on initiatives to increase the capacity of peripheral US$30 per day per patient in Sub-Saharan Africa (Kruk first-level hospitals, access to transportation and referral and others 2010)—and include the following: can reduce the need for this expansion of capacity and lead to a more efficient system. • Lack of trained staff In DCP2, Debas and others (2006) list the resource • Inadequate supplies requirements for surgical services in ideal LMIC clinics • Inadequate maintenance of basic equipment and hospitals, based on their own estimates and those of • Poor condition of buildings and intermittent or the WHO (table 12.1). absent water and electricity • Transportation challenges that restrict the effective- ness of a functioning referral system The Reality Table 12.2 presents the actual situation in 3 first- level hospitals in Tanzania, as well as the averages for FIRST-LEVEL HOSPITALS: POTENTIAL 11 hospitals in Bolivia and 7 in Bangladesh. VERSUS REALITY • The Kasulu District Hospital is typical of the The Ideal second-level hospitals in Tanzania and most other Although most health systems are organized as a pyra- Sub-Saharan African countries, except that the popu- mid, with primary care facilities at the base and national lation served is more than twice the national average. third-level hospitals at the apex, the specifics vary among The one physician also serves as the district medical countries (Chatterjee, Levin, and Laxminarayan 2013; officer, an administrative job that occupies most of Galukande and others 2010; Lebrun and others 2013; the physician’s time. No specialists and no one fully Zafar and McQueen 2011). In most of Sub-Saharan qualified in surgery or obstetrics is on staff. Assistant Africa, dispensaries and health centers provide primary medical officers (NPCs with six months of formal care, deliver newborns, and usually perform minor sur- surgical and obstetrical training) perform the surgery. gery. When patients need major surgery, they are meant • The Maweni Regional Hospital serves as the first-level to be referred to a district (first-level) hospital, usually hospital for two districts and receives few patients as with 100 to 200 beds, serving a population of 100,000 referrals for higher-level care, a common situation in to 500,000 (Galukande and others 2010). In Bangladesh, Tanzania. There are six physicians, including one aca- India, and Pakistan, the smallest unit regularly providing demically qualified pediatrician, but no qualified sur- major surgery is also called a district hospital, but the geon or obstetrician. NPCs perform all of the surgery. districts are much bigger, usually with a population of • The St. Francis Designated District Hospital is a large, 2 million or more (Chatterjee, Levin, and Laxminarayan faith-based hospital that serves as a designated first- 2013; Lebrun and others 2013; Zafar and McQueen level hospital for two districts. Although it has been 2011). In Latin America and the Caribbean, many named a regional referral hospital, it still serves a quite small “basic hospitals” provide first-level surgical first-level function because a new first-level hospital functions for populations of fewer than 100,000, and has not yet been created. The six qualified specialists Organization of Essential Services and the Role of First-Level Hospitals 215 Table 12.1 Resource Requirements for Surgical Services by Level of Care: The Ideal Category of 100-bed district (second-level) requirement Community clinic hospital Third-level hospital Infrastructure Weatherproof building Inpatient facility of 100 beds, including A major facility providing (100 square meters) several wards and an isolation ward • Full emergency services with advanced Storage space Outpatient facility including an emergency diagnostic services Clean water supply room; operating rooms (at least two: one • Inpatient wards for complex general clean, one contaminated) medical and surgical care Power supply Labor and delivery rooms • Various types of specialty services Recovery room or intensive care unit • Several delivery rooms and operating rooms Blood bank • One or more recovery rooms and intensive Pharmacy care units Clinical laboratory • Rehabilitation and occupational therapy Radiology and ultrasonography suite facilities Equipment Furniture Anesthetic machines and inhalation gases Equipment and supplies as for the 100-bed and supplies Refrigerator Monitors (electrocardiogram, blood (first-level) hospital, plus all required equipment pressure, pulse oximetry) and supplies to undertake the range of routine Blood pressure machine and complex services provided Minor surgical trays Fully equipped operating room Sterile and burn dressings Fully equipped delivery Autoclave room Intravenous sets and solutions Fully equipped recovery room or intensive care unit Bandages and splints Respirators and oxygen supply Drugs: local anesthetics, nonsteroidal anti-inflammatory Blood products and intravenous fluids drugs, antibiotics, tetanus Basic microbiology equipment toxoid, silver nitrate ointment, Pharmaceuticals, (anesthetics, analgesics, oxytocin, magnesium sulfate antibiotics) Wireless communication Surgical materials (drapes, gowns, equipment dressings, gloves), and other consumables Materials for recordkeeping (disposable equipment and devices) Human Nurse or nurse equivalent Nurses (50+) Nurses (100+) resourcesa Skilled birth attendant Midwives (5+) Midwives (20+) Orderly Anesthetists (2–3) Anesthetists (5) Anesthesiologist (1)b Anesthesiologists (3) Primary care physicians (4)c Primary care physicians (10) Obstetrician/gynecologist (1 or 2) Obstetricians and gynecologists (5) General surgeons (2) General surgeons (5) Pharmacy assistants (2) Orthopedic surgeon (1) Pharmacist (1)b Pharmacy assistants Radiology technician (1) (2) Radiologist (1) Pharmacist (1) Physiotherapist (1) Radiology technicians (5) table continues next page 216 Essential Surgery Table 12.1 Resource Requirements for Surgical Services by Level of Care: The Ideal (continued) Category of 100-bed district (second-level) requirement Community clinic hospital Third-level hospital Radiologists (2) Physiotherapists (5) Neurosurgeon (1)b Cardiac surgeonb Reconstructive surgeonb Source: Debas and others 2006. a. The variability in the size and the complexity of services provided by third-level hospitals makes it difficult to describe a standard third-level hospital; the human resource needs given in the table represent what is thought to be minimally adequate. b. Desirable but not absolutely necessary. c. May be a general internist, general practitioner, or general pediatrician. Table 12.2 Human Resources and Infrastructure at Selected First-Level Hospitals in Three Regions: The Reality St. Francis 11 “basic” 7 district (first- Kasulu District Maweni Regional Designated (first-level) level) hospitals, Hospital, Hospital, District Hospital, hospitals Bangladesh,a Tanzania, 2010 Tanzania, 2013 Tanzania, 2013 Bolivia,a 2012 2013 Population served 677,000 850,000 500,000+ 134,000 1,879,000 Beds 200 256 372 54 140 Admissions per year 12,900 25,800 18,140 3,644 20,000 Operating rooms 3 3 3 2.1 2.4 Physicians 1 6 14 29.4 29.3 General surgeons 0 0 2 3.4 1.6 Obstetricians and gynecologists 0 0 3 3.5 1.4 Orthopedic surgeons 0 0 1 1.4 1.1 Anesthesiologists 0 0 2 3 1 Nurses 61 57 126 24.5 50.5 Beds per nurse 3.3 4.5 3.0 2.2 2.8 Nonphysician clinicians 23 29 8 0 0 Physicians and nonphysician 12 14 6 54 21 clinicians per 100 beds Sources: Kruk and others 2010; Lebrun and others 2012, 2013. a. Average for all hospitals reviewed. provide approximately 50 percent of the surgery, and Data are not available from these hospitals to permit NPCs provide the remainder. a calculation of nursing hours per patient-day. One staff • Bolivia, a lower-middle-income country with a large, nurse per bed is normally required to achieve the usually very poor population, has trained enough physicians recommended five to six hours per patient per day for to be able to staff its first-level hospitals with qualified an average hospital (Coffman, Seago, and Spetz 2002; specialists. McHugh, Berez, and Small 2013; Needleman and others • In Bangladesh, as in India, Pakistan, and Sri Lanka, 2011). The number of beds per nurse far exceeds this districts are much larger (usually 2 million people level in all of these hospitals. or more); first-level surgery is rarely available below Surgical and obstetrical specialists are rarely avail- the level of the district hospital. Qualified surgeons, able in Sub-Saharan African first-level hospitals, obstetricians, and orthopedists are usually present. which typically have one or two general practitioners Organization of Essential Services and the Role of First-Level Hospitals 217 (often a recently graduated doctor) for whom surgery in lower-middle-income countries such as Bolivia and is one of many clinical and administrative responsibil- Nicaragua, have specialists (Lebrun and others 2012; ities. Tanzania is one of several Sub-Saharan African Solis and others 2013). countries that have trained NPCs to provide basic sur- In many Sub-Saharan African countries, mission gery at this level, especially for obstetrical emergencies. hospitals (faith-based) can offer to serve as the district In Mozambique, this training is a three-year program (first-level) hospital for a specified area. In Tanzania, for focused on all types of basic emergency surgery; but in example, if accepted as a “designated district hospital,” most countries with these cadres, surgery and obstetrics these faith-based hospitals receive government support are part of a course designed to produce general practi- for salaries and supplies, and the government does not tioners (see chapter 17). provide another first-level hospital for that area. Virtually every country has a private health sector, Everywhere, almost all of the second- and third-level which is often divided into charitable facilities (usually hospitals act as first-level hospitals for local emergencies. faith based) and for-profit facilities. In much of Latin Table 12.3 presents the surgical volume and pro- America and the Caribbean, multiple systems work in cedures in the same hospitals described in table 12.2. parallel: a public system for the poorest; a system serv- The detailed information presented in these tables is ing those with insurance usually derived from salaried not available on a national scale for any of these coun- employment; and a private sector for the more affluent tries, but the selected hospitals are probably typical segment of the population (Lebrun and others 2012; for Latin America and the Caribbean, South Asia, and Solis and others 2013). Sub-Saharan Africa. In Tanzania, private (usually faith- In India, where the private sector accounts for based) hospitals that have become designated district 78 percent of health expenditure (Kumar and others hospitals often have several surgical specialists on staff, 2011), the supply of medical school graduates is large, and some of them have a larger number of nurses. and in some places, excessive. In Sub-Saharan Africa Second-level hospitals are meant to be referral hospitals, the private health sector is much smaller but is growing but many in Sub-Saharan Africa have few or no surgical rapidly, as is the supply of graduate doctors. In both specialists and primarily function as larger first-level South Asia and Sub-Saharan Africa, no matter how hospitals (Sanders and others 1998; Siddiqi and others large the supply of doctors, persuading physicians, espe- 2001). South Asia has more physicians and specialists for cially specialists, to work in rural areas or to serve the a given population than Sub-Saharan Africa and Latin poor majority in the cities has been difficult. In Latin America and the Caribbean countries usually have many America and the Caribbean, the number of physicians more than other LMIC regions. In Latin America and is much higher, and many first-level hospitals, even the Caribbean, this larger professional force is reflected Table 12.3 Current Surgical Volume and Major Procedures Performed at Selected First-Level Hospitals in Three Regions Maweni St. Francis 7 “district” (first- Kasula District Regional Designated 11 “basic” (first- level) hospitals, Hospital, Tanzania, Hospital, District Hospital, level) hospitals, Bangladesh,a 2010 Tanzania, 2013 Tanzania, 2013 Bolivia,a 2012 2013 Total operations per year 893 915 2,034c 730 3,215 General surgery 99 (11%) 119 (13%) 252 (12%) 284 (39%) 845 (26%) b Obstetrics and gynecology 635 (71%) 499 (55%) 1,386 (68%) 311 (43%) 1,077 (33%) Other 159 (18%) 297 (32%) 396 (19%) 135 (18%) 1,293 (40%)c Population served 677,000 850,000 500,000 134,000 1,879,000 Operations per specialist n.a. n.a. 339 88 784 Operations per 100,000 132 108 407 545 171 population Sources: Kruk and others 2010; Lebrun and others 2012, 2013. Note: % = percentage of total annual operations that fall within a category; n.a. = not applicable (no specialist surgeons). a. Average for all hospitals reviewed. b. Average for hospitals in towns with no maternity hospital. c. Includes 717 orthopedic operations; 349 ocular operations; and 199 ear, nose, and throat operations. 218 Essential Surgery in adequate (even excessive) numbers of physicians and operations can prevent maternal, fetal, and newborn specialists in small first-level hospitals (Lebrun and death. The demand for emergency obstetrical surgery others 2012; Solis and others 2013). is limited primarily by persistent restricted access to In Bangladesh as well as Pakistan, Sri Lanka, and hospitals that can provide surgical care. Because the much of India, most major surgery is provided at operations are common, relatively safe, and uncompli- the district level or above. District hospitals in these cated, general practitioners and NPCs have been trained countries serve populations of 1 million to 2 million to perform them with considerable success (McCord people. These hospitals have specialists available, but and others 2009; Pereira and others 1996). Still, met the populations served are so large that the numbers need for obstetrical surgery is 25 percent or less in most of major operations per 100,000 people is comparable of Sub-Saharan Africa and much of South Asia (Paxton, to those in Sub-Saharan Africa (Chatterjee, Levin, and Bailey, and Lobis 2006; Pearson and Shoo 2005). Latin Laxminarayan 2013; Lebrun and others 2013; Zafar and America and the Caribbean have a much larger supply of McQueen 2011). obstetrical specialists working in first-level hospitals and The “population served” by these five hospital groups a correspondingly higher met need and lower maternal is an approximation given that patients often move in mortality, even in very poor countries (Bailey 2005; and out of an area to seek hospital care. In some places, Hogan and others 2010). such as Kasulu in tables 12.2 and 12.3, transportation is More general surgical operations (including trauma, so difficult that practically no movement of patients to acute abdomen, and other surgical emergencies) are other districts occurs, so the population cited is the true performed in hospitals that have specialists available, catchment area. but estimates indicate that in all regions, the met need In all three regions, operations for obstetrical emer- for these emergencies is even lower than the met need gencies are the largest single component of surgical activ- for obstetrical care (chapters 5 and 6). The list of oper- ity; in Tanzania they are by far the most common kind of ations actually performed in one year in eight first-level surgery. All over the world women are aware that these hospitals in Sub-Saharan Africa (table 12.4) shows Table 12.4 Annual Major Operations at Eight First-Level Hospitals in Sub-Saharan Africa Percent, except as noted Tanzania, 2007 Mozambique, 2007 Uganda, 2006 Procedure Bagamoyo Kasulu Chokwe Catandica Mityana Kiryandongo Buluba Iganga Major nonobstetric (number) 428 242 171 133 456 80 125 711 Amputation 0 3 2 8 0 1 10 1 Appendectomy 11 2 6 2 2 0 1 4 Circumcision 0 1 13 18 1 68 1 0 Excision 0 10 0 5 0 0 0 0 Herniorrhaphy 22 24 17 20 41 16 24 29 Hydrocelectomy 13 8 4 20 2 1 4 0 Hysterectomy (elective) 6 2 9 0 5 1 2 17 Laparotomy 6 26 20 10 3 5 10 43 Open fracture reduction 3 0 2 0 31 0 0 0 Other 9 24 29 17 15 8 48 5 Obstetric (number) 431 883 377 110 754 35 100 915 Tubal ligation 6 11 7 4 10 14 0 0 Cesarean 61 62 80 73 63 74 88 88 Evacuation of uterus 30 22 0 1 19 0 0 0 Other 3 5 13 23 8 11 12 12 Source: Galukande and others 2010. Note: Data are based on annual aggregate hospital statistics extracted from hospital information systems. Organization of Essential Services and the Role of First-Level Hospitals 219 Table 12.5 Surgical Procedures That Could Be Managed at First- and Second-Level Hospitals First-level hospitals with general practitioner surgeon or Second-level hospitals with qualified specialist available nonphysician clinician surgeon (all first-level operations, as well as the following) Emergency obstetrical surgery (including repair of ruptured uterus and Elective major gynecological surgery emergency hysterectomy) Salpingectomy for ruptured ectopic pregnancy Evacuation of the uterus Appendectomy Gall bladder and biliary tract Herniorrhaphy (elective repair and emergency) Intestinal resection and repair Intestinal obstruction Suture of intestinal perforation Plication of perforated ulcer Operation for bleeding peptic ulcer Colostomy Tube thoracostomy Cricothyroidotomy Closed fracture reduction and stabilization Open fracture management Amputation Minor burn care Major burn care Conservative management of head injury Drainage of epidural and subdural hematoma Wound care and repair Surgical infections that many of the problems in table 12.5 that could be could be mastered by the staff available at this level, few addressed in these facilities were not treated at all. Wide patients would need to be referred. The ideal will be variations exist among hospitals; in some cases, there to put fully qualified surgeons and obstetricians in all was complete omission of operations that are urgently hospitals, but better training of the general practitioners needed, not complicated, and within the competence and NPCs now serving as the only surgeons in many of general practitioners with brief surgical training (for first-level hospitals could bring these facilities closer to example, open reduction of compound fractures). Such the ideal. omissions can lead to a major loss of cost-effectiveness in these hospitals. Closed fracture treatment and some uterine evac- HEALTH CENTERS AS A SURGICAL uations may not have been recorded in the operating room logbooks (the source of data for this study) PLATFORM because they are not always carried out in the main Health centers (clinics, usually without inpatient beds operating rooms. Trauma is not listed separately, except for normal deliveries) deliver babies, suture small but the very small number of open fracture reduc- lacerations, and drain small abscesses, but very few pro- tions (with the exception of Kiryandongo) indicates vide more comprehensive services. The primary reason that major trauma either is not being seen or is being for the limited range of services is the limited training referred elsewhere. available to health care personnel; another reason is the If general anesthesia and a qualified surgeon are shortage of medical personnel of all kinds, which results available in a first-level hospital, all of the procedures in heavy workloads and makes additional responsibili- in table 12.5 can be done at this level, which would be ties and skill acquisition a problem. ideal, since referral often is not possible or practical. If As these issues are resolved, it will be important to all of the procedures in the first-level hospitals column ensure that basic surgical training is provided. The list of 220 Essential Surgery services that could be provided at the health center level unquestionably high; for trauma, the estimated burden is substantial and includes the following: is much higher than that due to obstetrical emergencies, even though trauma has been found to be a relatively • Treatment of simple fractures, burns, and other injuries small part of surgical activities in hospitals in LMICs • Resuscitation of major trauma patients: control of (Canoodt and others 2012; Mock and others 2012; Mock bleeding, airway maintenance, fluid replacement, and and others 1998). The reason for this discrepancy in met shock prevention and treatment need between traumatic and obstetrical emergencies • Tubectomy, intrauterine device insertion, and other seems clear: childbirth is a predictable event; when contraceptive procedures emergencies occur, there is usually enough time to bring • Early management of postpartum bleeding, eclamp- patients to hospitals, even distant ones. That the unmet sia, and prolonged labor; suture of perineal lacera- need for emergency obstetrical care is still greater than tions; extraction of retained placentas 80 percent in most of Sub-Saharan Africa is a measure • Uterine curettage for incomplete abortion of the very serious deficiencies in the health systems • Circumcision in the region. That the unmet need has been less than • Removal of foreign bodies in eyes, ears, and noses 25 percent in Sri Lanka for more than 20 years shows that these deficiencies can be corrected, even in LMICs. A functioning referral system with patient access to Most of the causes of the unmet need for trauma transportation will increase the efficiency and the effec- care lie outside of the hospitals. Immediate emergency tiveness of these services. assistance and prompt transfer for definitive care are often needed and rarely available in LMICs; 21 percent BURDEN OF SURGICALLY TREATABLE of serious vehicle accident victims die before reaching a DISEASE AND THE UNMET NEED hospital in the United States compared with 51 percent in Ghana (Henry and Reingold 2012; Mock and others This volume has shown that universal provision of a 1998). Emergency resuscitation is usually not well orga- package of essential surgical services would avert an nized in LMICs, neither before nor after arrival at hos- estimated 1.5 million deaths per year, or 6–7 percent of pitals. Furthermore, the general practitioners or NPCs all avertable deaths in LMICs (Debas and others 2006; available for emergencies at most first-level hospitals are Mock and others 2015). For many of the conditions not well trained for trauma care after resuscitation. treated by this package, surgical care is the only option. There are no preventive strategies for many pregnancy- related complications or for most general surgical emer- Surgery for Disabling Conditions gencies. Similarly, road traffic crashes and other injuries Most LMICs have a high burden of surgically treatable are increasing in LMICs, and there is a substantial and disabling conditions (Beard and others 2013; Petroze and growing burden of chronic, congenital, and acquired others 2013; Wu, Poenaru, and Poley 2013). Specialists conditions that can be treated surgically. visiting first-level hospitals can effectively treat cataracts, complicated fractures, burn contractures, congenital Surgery for Obstetrical Emergencies anomalies, vesico-vaginal fistulas, and many other The need for emergency obstetrical surgery is relatively easy conditions that are beyond the capacity and skills of the to calculate because the birth rate is almost always known, permanent staff of first-level hospitals; during the same and it is generally accepted that 10 percent to 15 percent visit, the specialists can provide in-service training and of births are likely to have complications, most of them supervision. Many successful programs bring specialists requiring surgical treatment, that threaten the lives of the to these hospitals, but too often the visits are sporadic and mothers or newborns. There are important exceptions: uncoordinated. Regular visits to provide continuity and El Salvador, Honduras, and Sri Lanka, for example, have follow-up can greatly increase the effectiveness of these reduced the unmet obstetrical need to 25 percent or lower, programs (see chapter 13). with a corresponding drop in the maternal mortality ratio to well below 100 per 100,000 births (AMDD Working Group 2003; Paxton and others 2005). SURGICAL OUTCOMES AT FIRST-LEVEL HOSPITALS Surgery for Trauma and General Surgical Emergencies Of the surgical patients seen in first-level hospitals, The surgical burdens due to trauma and general surgical 50 percent to 80 percent present with emergencies. emergencies are harder to estimate, but the burdens are Problems with transportation to a higher-level facility Organization of Essential Services and the Role of First-Level Hospitals 221 and the attendant costs of families’ travel place a very not have a positive outcome without follow-up basic high premium on managing these cases at first-level physiotherapy; and patients with emergency relief of facilities. Fortunately, the surgical treatment needed for sigmoid volvulus will need resection of the sigmoid these emergencies is usually straightforward, relatively intestine to prevent recurrence, which is common. simple, and well standardized. Outcomes are remark- Serious operative complications are also relatively ably good, given reasonable training to manage a rare. Infections are usually minor, and the proper use of relatively short list of problems, even when a fully quali- anesthetics for these short operations is safe and effec- fied surgeon is not available. tive. This surgical capacity relies on medical personnel, usually nurses, who have been trained to administer anesthesia, and surgeons who know when to take simple Surgery for Obstetrical Emergencies measures to prevent major infections, such as leaving Obstetrical emergency surgery is the most common the skin open with subsequent secondary closure in surgical problem presenting in first-level hospitals. The heavily contaminated operations, and using antibiotics standard established in the United Nations process appropriately. indicators (Paxton, Bailey, and Lobis 2006) calls for case fatality rates of 1 percent or less for mothers with obstetrical complications requiring hospital treatment. SURGICAL COST AND COST-EFFECTIVENESS Many hospitals in LMICs, including those in which this When DALYs averted were calculated for all patients work is usually done by NPCs, come close to this target, discharged from a first-level nongovernmental hospital with mortality rates less than 2 percent (McCord and in Bangladesh, surgical and obstetrical patients con- others 2009; Pereira and others 1996). tributed the largest share by far: 80 percent of 3,309 DALYs averted in three months. The cost per DALY averted for the whole hospital was US$11, which was Surgery for General Emergencies comparable to the cost per DALY of many public health General surgical emergencies, including acute abdomi- interventions at that time (McCord and Chowdhury nal conditions, surgical infections, thoracic emergencies, 2003). and airway obstruction, can almost always be managed Debas and others (2006) estimate a cost per DALY at first-level hospitals, with overall mortality rates of less averted of the surgical services in the ideal first-level than 5 percent (see chapter 4). hospital described in table 12.1 at US$33 in Sub- Saharan Africa, US$38 in South Asia, and US$95 in Latin America and the Caribbean. Gosselin, Thind, Surgery for Trauma Emergencies and Bellardinelli (2006); Gosselin and Heitto (2008); Trauma can lead to very serious and complicated prob- and Gosselin, Maldonado, and Elder (2010) calculate lems. Unfortunately, most seriously injured patients die US$32.78 per DALY averted for surgical services in a before arrival, leaving first-level hospitals with patients nongovernmental hospital in Sierra Leone, and US$172, who usually have treatable problems and a smaller US$223, and US$77 in nongovernmental trauma cen- group that can be stabilized and transferred. Because the ters in Cambodia, Haiti, and Nigeria, respectively. These number of accident victims is so high, caring for patients directly observed cost-per-DALY averted estimates, all with manageable problems and treating them with of them in nongovernmental facilities (and three of the straightforward procedures to prevent death and dis- four were hospitals that did not provide obstetrical care), ability should be the most important surgical activity in need to be supplemented by other studies in LMICs, with first-level surgical systems. This potential is not realized a focus on government hospitals, local private hospitals, in most LMICs, primarily because transportation sys- and hospitals unable to provide major surgical services. tems to bring injured patients to hospitals safely are so It is likely that small, Sub-Saharan African government poorly developed. hospitals with active surgical services will have costs per DALY averted comparable to the Bangladesh hospital, given that hospital costs in these government hospitals Postsurgical Treatment Needs are comparable (table 12.6). Government third-level Successful operations will cure most patients requiring hospitals and private hospitals are more costly and prob- emergency surgery at first-level hospitals, and these ably will be less cost-effective (Barnum and Kutzin 1993; patients usually will not need further treatment. A few Chatterjee, Levin, and Laxminarayan 2013). exceptions exist: patients with peptic ulcers will need Conducting cost analysis in hospitals in LMICs, medical treatment for ulcer disease; many fractures will especially in public hospitals, is difficult, and not many 222 Essential Surgery Table 12.6 Hospital Costs and Surgical Services Costs at Hospitals in Sub-Saharan Africa (2010) and India (2012) U.S. dollars Bagamoyo Kasulu District Chokwe District Hospital Mityana Kiryandongo Private District Private Third-level District Hospital, Hospital, Hospital, Catandica, Hospital, Hospital, Hospital, Hospital, Teaching Hospital, Tanzania Tanzania Mozambique Mozambique Uganda Uganda India India hospital, India India Total annual 329,716 800,662 286,593 155,908 251,448 369,419 13,758,650 2,315,165 4,606,788 10,152,380 expenditures Surgery annual 31,700 84,492 19,358 11,376 33,980 33,470 1,158,319 181,468 915,350 517,657 expenditures (9.6%) (10.6%) (6.7%) (7.3%) (13.5%) (9.1%) (8.4%) (7.8%) (19.9%) (5.1%) Beds 125 135 214 91 100 100 200 400 655 778 Admissions 6,545 10,296 8,089 3,861 9,106 5,713 5,925 25,871 19,139 205,949 Expenditure per bed 2,640 5,933 1,341 1,714 2,510 3,690 68,795 5,788 7,034 13,049 Expenditure per 53.02 85.24 43.33 42.11 39.96 68.81 134.54 7.58 6.63 11.81 admission Expenditure per day 17.70 26.84 10.79 18.16 11.22 22.05 n.a. n.a. n.a. n.a. Operations 980 2,045 601 256 1,484 248 2,508 3,623 2,768 3,219 Expenditure per 56.41 98.82 41.54 49.03 55.34 304.28 461.85 50.10 330.69 160.81 operation Source: Chatterjee, Levin, and Laxminarayan 2013; Galukande and others 2010; Kruk and others 2010. Note: % = annual surgical expenditure as a percentage of total annual expenditure; n.a. = data not available. Organization of Essential Services and the Role of First-Level Hospitals 223 comprehensive cost reports dealing with LMIC hospitals worth the cost in time, money, and discomfort. Very are available. Government funds come from different few patients with cancer select first-level hospitals for sources; there are nongovernmental gifts, grants, and treatment in LMICs, but many women experiencing programs; supplies and equipment may be provided pregnancy-related complications will seek compe- in kind; the contribution of “cost recovery” (patient tent obstetrical care, if available. If the outcomes are payments to the hospital) is often not well documented; suboptimal at a particular facility, patients will find and “informal payments” are usually not documented at better ones (Kruk and others 2009). The end result all. Table 12.6 summarizes some of the findings in three is a patient population that has self-selected itself so analyses of annual recurrent cost, including depreciation that individuals who seek treatment can be effectively of buildings and equipment, for several hospitals in treated. India and Sub-Saharan Africa. No estimates of DALYs • Effective, inexpensive technology: Operating rooms averted were available. Cost per surgical operation for are not expensive; affordable antibiotics, anesthesia, most of the second-level hospitals in both regions was and other supplies are usually effective. Training and low and comparable. In the one Sub-Saharan African mobilizing staff members is the largest expense. The second-level hospital with high cost per operation, total hospital cost in a first-level hospital is usually surgical activity was very low. The cost per operation less than US$30 per patient-day (Kruk and others in the single Indian third-level hospital was three times 2010), compared with US$1,000 per day or more in higher than the average for the six low-cost second-level high-income countries (HICs), and surgical services hospitals; in the Indian private hospitals, it was seven cost is a fraction of total hospital costs (table 12.6). times higher. There are some inconsistencies in these • Resource-limited hospitals: Hospital budgets, even reports; the very high number of admissions to the though they are a major part of total health budgets Indian third-level hospital probably includes both inpa- in LMICs, are low by any international standard. tient admissions and outpatient visits. Despite this limitation, these hospitals are able to In all public hospitals, personnel costs were consider- achieve good results in patient care. Undoubtedly, ably higher than those of any other cost centers within they could do better with more resources, but this the hospital. Salaries were low, and staff shortages were relative starvation keeps costs down. One of the most pervasive, so relatively high personnel costs probably important reasons for further analysis of the cost- reflect inadequate funding for supplies, maintenance, effectiveness of different levels of hospitals in differ- and transportation, and certainly not large numbers of ent places is to determine the most efficient ways to staff or excessive salaries. More analysis of this kind is improve and expand services delivery with minimum urgently needed and could be combined with estimates increases in cost. of DALYs averted to better define the true cost and cost effectiveness of properly functioning hospital systems in LMICs. OBSTACLES TO LOW COST AND HIGH COST-EFFECTIVENESS Not every hospital is cost-effective. The third-level Reasons for the Cost-Effectiveness of First-Level hospitals and the private hospitals in table 12.6 are much Hospitals more expensive than the smaller, first- and second-level The high cost-effectiveness of surgery in a small first- government or nongovernmental facilities. Anything that level hospital is due to three factors: self-selection, diverts patients from low-cost hospitals to higher-cost, effective and inexpensive technology, and efficient use of third-level ones increases the costs of the whole system limited resources. Furthermore, the most common oper- and lowers the effectiveness of the first- and second-level ations performed in first-level hospitals are very effective hospitals. and low-cost procedures, including cesarean sections, Fixed expenses, notably for personnel, are the major acute abdominal emergencies, and herniorrhaphies. component of hospital costs, so the cost per unit of service delivery rises when utilization is low. • Self-selection: Few people want to be in a hospital, but the resource-starved hospitals in LMICs can be especially unpleasant places. People quickly come Training to know what services a hospital can and cannot Less-than-optimal training may be the most impor- provide, and they generally make intelligent choices tant contributor to a reduction in cost-effectiveness. with respect to the places where service provided is First-level hospitals in LMICs usually do not have 224 Essential Surgery a fully qualified surgeon, obstetrician, or orthopedist on The second component is outright corruption in the staff. General practitioners or NPCs generally learn to form of payments to staff for presumably better service; treat obstetric emergencies, but they often refer serious in some areas this abuse can more than double the trauma and acute abdominal emergencies to higher-level costs to patients (Lewis 2007). Increased costs plus the facilities. If patient transfer could be made efficient and associated loss of confidence in hospital staff can lead inexpensive, this process might work well. However, in to further reductions in utilization and increase the cost many places, most transferred patients never arrive at per unit of service. the referral hospitals (Urassa and others 2005); death en route is common. Moreover, the receiving hospitals may be no better able to provide care than the hospitals Epidemiological Transition from which the patients were sent (Grimes and others The epidemiological transition (from infectious to 2011; Siddiqi and others 2001). Patients bypass hospi- noninfectious, degenerative disease) is in full swing in tals known to refer often, reducing surgical volume to MICs and among the upper classes in many low-income inefficient levels. The operations and surgical conditions countries, with consequent increases in the incidence listed for first-level hospitals in table 12.5 are all within of cancer, diabetes, and complications from arterio- the competence of general practitioners or NPCs, given sclerosis. Surgery for these conditions is generally more appropriate training. A six-month program in a busy complicated and often will not be curative; the underly- second-level facility could provide substantial bene- ing disease remains and complications of the disease can fits. If this training could be combined with follow-up recur. Costs are higher and cost-effectiveness is lower. in-service training and supervision, the capacity and Universal health coverage is increasing, and treatment outcomes could be further improved. for degenerative diseases certainly cannot be excluded, but health budgets in LMICs will not support, for example, the universal availability of cardiac surgery for Anesthesia coronary artery disease. Fortunately, diabetes, arterio- Major surgery usually requires general or spinal anesthe- sclerosis, and many cancers are preventable. Energetic sia. Doctors, nurses, and NPCs are not routinely trained efforts at primary and secondary prevention will pay off to administer anesthesia. Many first-level hospitals do in lower hospital costs. The elimination of tobacco use not perform surgery or perform very limited surgery and better management of hypertension could be the simply because they lack trained staff to administer most important activities. anesthesia. This relatively simple staff deficiency can be readily addressed. A one- or two-year course for nurses or NPCs can produce a sufficient level of competence New Technology for the safe administration of general and spinal anes- New diagnostic and therapeutic technologies are usually thesia; a six-month course can be enough for hospitals expensive and have the further disadvantage of imposing to make spinal and Ketamine anesthesia available.1 The an additional training burden to teach staff to use and same short course can produce competency in the resus- maintain equipment. There are exceptions: citation of patients with severe trauma, blood loss, or respiratory insufficiency. • Replacement lenses for cataract operations are made in India and Nepal at very low cost. • The mesh for hernia repair greatly improves long- Poor Quality of Service and Low Utilization term results; mosquito netting seems to work well, Poor quality of patient care reduces the number of but factories in LMICs could produce a standardized, positive outcomes and is a common reason for low uti- sterile product at low cost. lization. Low utilization, in turn, reduces the experience • The pulse oximeter is a simple, sturdy, and relatively of hospital staff and can lead to even poorer outcomes. inexpensive electronic instrument that can greatly improve the safety of anesthesia and the control of respiration and circulation during resuscitation of Informal Payments severely injured patients. The issue of informal payments has two components. • Flexible gastroscopes are expensive, but they can The first is that hospitals with inadequate inventories control bleeding from stomach and duodenal ulcers ask patients to purchase medicine and other needed so well as to virtually eliminate the need for surgery supplies, which adds considerably to patients’ costs. for bleeding ulcers. Organization of Essential Services and the Role of First-Level Hospitals 225 Careful evaluation, including cost analysis, of each and to those services that can give the greatest public example of new technology should be able to control health outcome, for example, obstetrics, trauma, a technological cost spiral, at least in the public sector. emergency surgery, and neonatal care. However, However, little is being done to make this increasingly equitable utilization of “free surgery” is by no means important evaluation. The National Institute for Health guaranteed; poor people continue to face high costs and Care Excellence of the British National Health for transportation, supplies, food, and informal Service provides a model of how such an evaluation can charges (El-Khoury, Hatt, and Gandaho 2012). be conducted (http://www.nice.org.uk). Financing of surgical care is further complicated by the large number of first-level surgical procedures FINANCING SURGICAL CARE that are emergencies. The need for out-of-pocket user fees (especially fees required before treatment can be Financial support for surgical services delivery is dis- provided) has been found to be a major barrier to the cussed in chapter 18. The reality is that no matter how provision of emergency care in many places (Canoodt, cost-effective it is, most people in low-income countries Mock, and Bucagu 2012). (LICS) and many in lower-middle-income countries, cannot afford surgery unless it is available without charge at the point of care. Although El Salvador, Honduras, STRENGTHENING FIRST-LEVEL SURGICAL and Sri Lanka, for example, have shown that free service can be made available within very low budget public FACILITIES health systems, most lower-middle-income countries, The first-level hospitals and the clinics below them and many upper-middle-income countries, have hospi- described in table 12.1 are an ideal, achieved in a few tal systems that reach only a fraction of the population, LMICs but far from a reality in most. Although existing largely because of the cost barrier. Economic growth and first-level hospitals are cost-effective, and their surgical increased government budgets for health are reducing this services seem to be especially so, they could be doing disparity, but progress is slow. In many LMICs, availability much more, especially for trauma, general surgical of trained staff and other resources has not improved at emergencies, and the backlog of treatable disabling all in the past 20 years, especially in the first-level hospital conditions. The successful development more than network. Efforts to mobilize nongovernmental funds to 20 years ago of effective hospital systems in countries support health care have had limited success. such as Sri Lanka has shown that this is possible even with low budgets for health. The number of available • Although the private health sector is growing rapidly trained health personnel is increasing rapidly in almost everywhere, it reaches only a fraction of the popu- all countries, and health budgets are rising, so that it lation. In India, 78 percent of health expenditures should be possible for all LMICs to achieve a much bet- occur in the private sector, but in most Indian states, ter level of care in the next 20 years. The question is how only a fraction of the population has access to private to accomplish this rapidly and efficiently, so that the hospital care (Kumar and others 2011). poor majorities in these countries are not left behind. • Cost-sharing (fees for service) in public hospitals has been shown to reduce utilization, but it contributes very little to covering hospital costs (Lagarde and Removing Roadblocks Palmer 2011; Robert and Ridde 2013). The following are three major roadblocks to better care: • Government-run insurance systems that provide direct government financing of essential services • Access to well-functioning health centers and first- have been shown to be possible on a large scale (Kruk level hospitals is critical: These clinics and hospitals 2013; Kumar and others 2011). The most common must have better patient transport available, and example is free emergency obstetrical care. If such the financial barriers to travel should be removed to plans can be successfully implemented, they will have the extent possible. All of the financial barriers for a double benefit: they reduce the financial barrier to families cannot be eliminated, but the cost of trans- the use of clinical services, and they give purchasing port and the cost of the hospital’s or clinic’s services power to patients, thereby directing income to the are the two most important. Not enough is known hospitals and clinics that provide the most popular, about how much free transport would cost, but it and it is to be hoped the best, services. The key is would probably not be an unbearable burden. The to direct the benefits to those who need them most creation and analysis of real-life models will facilitate 226 Essential Surgery the raising of funds for this purpose. Hospitals with Evaluation can include the evaluation of the popula- limited budgets will not be able to pay for all of this, tion impact as well as of the costs and benefits. Training, so outside funding sources will need to be found. especially to increase the availability of surgical skills in • Staffing is inadequate, both in numbers and in training. first-level hospitals, will be an essential element of these Many years will pass before fully trained staff can programs. National professional societies could play a be available at all levels; therefore, it is important crucial role in this process, and qualified surgeons from to identify intermediate solutions. These solutions HICs could provide important assistance, improving the include training general physicians and NPCs to availability of trained staff in the first- and second-level perform basic surgery; training nurses to administer hospitals that will be the principal venues for this training. anesthesia; and providing in-service training of staff at all levels in such skills as better management of nonsurgical obstetric emergencies, patient resuscita- Finance tion on arrival at the clinic or hospital, and appro- Hospitals and the systems to support them are terribly priate care during transport for referral. Functioning underfunded in most LMICs, as are all of the health models with cost analysis are needed. services for the poor segments of the population in these • Logistical systems to provide supplies and maintain places. For most people in these countries, a generation equipment are usually underfunded and inadequate. or more will pass before incomes rise sufficiently to pro- Closer consideration of areas in which such systems vide purchasing power for basic surgical services. LMICs seem to be working better, such as Sri Lanka, will are increasingly embracing universal health coverage, help solutions for widespread implementation to be primarily funded through taxes, as a means of improv- developed. ing access to services and ensuring that medical bills do not force families into poverty. Essential and life-saving surgeries are likely to be core components of these insur- Expanding Capacity ance programs. If the roadblocks are removed, utilization will increase and it will be necessary to expand facilities, eliminate the Epidemiological Transition gross inadequacies in such fundamentals as water and electricity supply, and, in some cases, create new clinics Controlling the inevitable increase in cost and decrease and hospitals. Upgrading health centers to provide more in effectiveness associated with surgery for compli- surgical services will help ease the burden for hospitals. cations of arteriosclerosis, cancer, and diabetes is an As the medical workload increases, paying attention important issue. The best approach is probably through to staff morale in health centers and hospitals will be primary and secondary prevention. Investments to essential. Adequate pay, decent housing, sufficient staff control tobacco use and improve the medical manage- numbers, and professional satisfaction from supportive ment of hypertension could produce significant benefits supervision and recognition are all important. to individual health, as well as reduce inefficient hospital use. Nevertheless, surgeons still need to be prepared to address the sequelae of chronic diseases. FUTURE DIRECTIONS FOR SURGICAL SERVICES Technological Advances Research and Training Although new technology can improve treatment and, Better determination of the burden of surgical disease in some cases, reduce costs, it initially increases costs is needed, but retrospective population surveys produce for equipment, materials, and training. The demand for incomplete and imprecise information, and prospective video-assisted surgery, computerized tomography scan- surveys are expensive. Prospective studies in places with ning, and coronary artery stenting is likely to increase. ongoing demographic surveillance could produce more These advances should be carefully evaluated before they useful information. are incorporated into public programs. However, enough is known to begin the implementa- tion of programs to improve services and increase access to services. Monitoring and evaluating the effectiveness Referral Systems and cost of these improvements as they are implemented Patient transportation is generally available, but paying will be important. Monitoring can provide ongoing evi- for it is difficult. The most practical approach may be to dence of the effect on utilization and outcomes. provide ambulances to hospitals and health centers, with Organization of Essential Services and the Role of First-Level Hospitals 227 adequate budgets for fuel and maintenance. A realistic in their countries; they have taken too little interest in evaluation of the cost for provision of adequate trans- first-level hospitals to date. Professional societies could port is needed; the costs may be less than expected if take responsibility for equitable delivery of services; work corruption and misuse can be controlled. Monitoring with communities and government to develop the needed by community and district government councils could political will; and provide guidance in the development of help. For example, second-level health teams in Uganda programs for training, supervision, and logistical support. have established local transport committees to manage Traditionally, advancement and recognition within dispatch, communications, and repair and maintenance the surgical community and within surgical organizations of donated vehicles. are based on factors such as the skills of individual sur- There should be a tradeoff between more referral geons; training of residents to become fully trained sur- and less need for surgical facilities, but how important geons, and especially subspecialists; and research on basic this tradeoff will be remains unknown. It is likely that science or operative surgical issues. Surgeons who develop the combination of more and better trained staff in and master the most difficult, complicated procedures first-level units, with better transport between units, will are usually those who are most highly regarded. However, improve service, as well as pay for itself by reducing the most of the burden of surgical disease could be lowered need for multiple hospitals delivering service. by improved access to fairly simple procedures that are both very cost-effective and very suitable to being per- formed in first-level hospitals. The surgical community Supervision Systems and surgical organizations need to develop a focus on First-level hospital surgeons and other surgeons in the wider population. Surgeons who choose to devote LMICs generally work without effective supervision, themselves to improving access to the most-needed pro- oversight, and in-service training. These shortcomings cedures (whether through their own labor or through can only be corrected if enough qualified specialists can the training and research activities they conduct) need to be made available to provide training and supervision, be better recognized for these contributions. Professional as well as direct service. In the long term, most countries organizations need to develop their own mechanisms for will have adequate numbers of specialists, but ways need supporting and encouraging such work. to be found to make service provision in first-level hos- pitals and clinics an important part of their work. NOTES One of the authors of this chapter is a WHO staff member. The Logistical Systems authors alone are responsible for the views expressed in this Logistical systems need to be decentralized, adequately publication and they do not necessarily represent the decisions or policies of the World Health Organization. funded, simplified, and controlled. At all hospital levels The World Bank classifies countries according to four in the public system, the cost of personnel is the largest income groupings. Income is measured using gross national budgetary component. It makes no sense to pay for income (GNI) per capita, in U.S. dollars, converted from local trained staff and deny them the relatively small funds currency using the World Bank Atlas method. Classifications as needed for basic supplies that make it possible to do of July 2014 are as follows: what they are trained to do. • Low-income countries (LICs) = US$1,045 or less in 2013 • Middle-income countries (MICs) are subdivided: Health Policy and National Health Plans • Lower-middle-income = US$1,046 to US$4,125 • Upper-middle-income (UMICs) = US$4,126 to US$12,745 Service delivery in almost all LMIC public hospitals is • High-income countries (HICs)= US$12,746 or more a government responsibility, but delivery of emergency and essential surgical services is usually not mentioned 1. Ketamine is a relatively new and safe anesthetic agent in health plans at either the central or the local level. that can induce general anesthesia without paralysis of respiration and the need for artificial respiration or a Attention to surgical services in these plans would help tracheal tube. focus attention on its importance (Hedges, Mock, and Cherian 2010). REFERENCES Alkire, B. C., J. R. Vincent, C. T. Burns, I. S. Metzler, P. E. Farmer, Professional Societies and others. 2012. “Obstructed Labor and Caesarean Delivery: National professional societies need to play a more active The Cost and Benefit of Surgical Intervention.” PLoS One 7 role in the development of robust first-level surgical care (4): e34595. doi:10.1371/journal.pone.0034595. 228 Essential Surgery AMDD Working Group (Averting Maternal Death and Is the Relative Contribution of Different Services?” Disability Working Group). 2003. “Using UN Process World Journal of Surgery 30 (4): 505–11. doi:10.1007 Indicators to Assess Needs in Emergency Obstetric /s00268-005-0609-5. Services: Morocco, Nicaragua and Sri Lanka.” Program Grimes, C. E., K. G. Bowman, C. M. Dodgion, and C. B. Lavy. note. International Journal of Gynaecology and Obstetrics 2011. “Systematic Review of Barriers to Surgical Care in 80 (2): 222–30. Low-Income and Middle-Income Countries.” World Journal Bailey, P. 2005. “Using UN Process Indicators to Assess Needs of Surgery 35 (5): 941–50. doi:10.1007/s00268-011-1010-1. in Emergency Obstetric Services: Bolivia, El Salvador Hedges, J. P., C. Mock, and M. N. Cherian. 2010. “The Political and Honduras.” Program note. International Journal of Economy of Emergency and Essential Surgery in Global Gynaecology and Obstetrics 89 (2): 221–30. doi:10.1016 Health.” World Journal of Surgery 34 (9): 2003–06. /j.ijgo.2004.12.045. Henry, J. A., and A. L. Reingold. 2012. “Prehospital Trauma Barnum, B., and B. H. Kutzin. 1993. Public Hospitals in Systems Reduce Mortality in Developing Countries: A Developing Countries. Baltimore, MD: Johns Hopkins Systematic Review and Meta-Analysis.” Journal of Trauma University Press. and Acute Care Surgery 73 (1): 261–68. doi:10.1097 Beard, J. H., L. B. Oresanya, M. Ohene-Yeboah, R. A. Dicker, /TA.0b013e31824bde1e. and H. W. Harris. 2013. “Characterizing the Global Burden Hogan, M. C., K. J. Foreman, M. Naghavi, S. Y. Ahn, M. Wan, of Surgical Disease: A Method to Estimate Inguinal Hernia and others. 2010. “Maternal Mortality for 181 Countries, Epidemiology in Ghana.” World Journal of Surgery 37 (3): 1980–2008: A Systematic Analysis of Progress towards 498–503. doi:10.1007/s00268-012-1864-x. Millennium Development Goal 5.” The Lancet 375 (9726): Cannoodt, L., C. Mock, and M. Bucagu. 2012. “Identifying 1609–23. doi:10.1016/s0140-6736(10)60518-1. Barriers to Emergency Care Services.” International Journal Kruk, M. E. 2013. “Universal Health Coverage: A Policy Whose of Health Planning and Management 27 (2): e104–20. Time Has Come.” British Medical Journal 347: f6360. doi:10.1002/hpm.1098. doi:10.1136/bmj.f6360. Chatterjee, S., and R. Laxminarayan. 2013. “Costs of Surgical Kruk, M. E., G. Mbaruku, C. W. McCord, M. Moran, Procedures in Indian Hospitals.” British Medical Journal P. C. Rockers, and others. 2009. “Bypassing Primary Care Open 3 (6). doi:10.1136/bmjopen-2013-002844. Facilities for Childbirth: A Population-Based Study in Chatterjee, S., C. Levin, and R. Laxminarayan. 2013. “Unit Cost Rural Tanzania.” Health Policy and Planning 24 (4): 279–88. of Medical Services at Different Hospitals in India.” PLoS doi:10.1093/heapol/czp011. One 8 (7): e69728. doi:10.1371/journal.pone.0069728. Kruk, M. E., A. Wladis, N. Mbembati, S. K. Ndao-Brumblay, Coffman, J. M., J. S. Seago, and J. Spetz. 2002. “Minimum Nurse- R. Y. Hsia, and others. 2010. “Human Resource and to-Patient Ratios in Acute Care Hospitals in California.” Funding Constraints for Essential Surgery in District Health Affairs (Millwood) 21 (5): 53–64. Hospitals in Africa: A Retrospective Cross-Sectional Debas, H. T., R. Gosselin, C. McCord, and A. Thind. 2006. Survey.” PLoS Medicine 7 (3): e1000242. doi:10.1371/ “Surgery.” In Disease Control Priorities in Developing Countries, journal.pmed.1000242. 2nd ed. edited by D. T. Jamison, J. G. Breman, A. R. Measham, Kumar, A. K., L. C. Chen, M. Choudhury, S. Ganju, V. Mahajan, G. Alleyne, M. Claeson, D. B. Evans, P. Jha, A. Mills, and and others. 2011. “Financing Health Care for All: Challenges P. Musgrove, 1245–60. Washington, DC: World Bank and and Opportunities.” The Lancet 377 (9766): 668–79. Oxford University Press. doi:10.1016/s0140-6736(10)61884-3. El-Khoury, M., L. Hatt, and T. Gandaho. 2012. “User Kushner, A. L., M. N. Cherian, L. Noel, D. A. Spiegel, Fee Exemptions and Equity in Access to Caesarean S. Groth, and others. 2010. “Addressing the Millennium Sections: An Analysis of Patient Survey Data in Mali.” Development Goals from a Surgical Perspective: Essential International Journal of Equity in Health 11 (49). Surgery and Anesthesia in 8 Low- and Middle-Income doi:10.1186/1475-9276-11-49. Countries.” Archives of Surgery 145 (2): 154–59. doi:10.1001/ Galukande, M., J. von Schreeb, A. Wladis, N. Mbembati, archsurg.2009.263. H. de Miranda, and others. 2010. “Essential Surgery at the Lagarde, M., and N. Palmer. 2011. “The Impact of User Fees District Hospital: A Retrospective Descriptive Analysis in on Access to Health Services in Low- and Middle-Income Three African Countries.” PLoS Medicine 7 (3): e1000243. Countries.” Cochrane Database of Systematic Reviews (4): doi:10.1371/journal.pmed.1000243. Cd009094. doi:10.1002/14651858.cd009094. Gosselin, R. A., and M. Heitto. 2008. “Cost-Effectiveness of Lebrun, D. G., D. Dhar, M. I. Sarkar, T. M. Imran, S. N. Kazi, a District Trauma Hospital in Battambang, Cambodia.” and others. 2013. “Measuring Global Surgical Disparities: World Journal of Surgery 32 (11): 2450–53. doi:10.1007 A Survey of Surgical and Anesthesia Infrastructure in /s00268-008-9708-4. Bangladesh.” World Journal of Surgery 37 (1): 24–31. Gosselin, R. A., A. Maldonado, and G. Elder. 2010. doi:10.1007/s00268-012-1806-7. “Comparative Cost-Effectiveness Analysis of Two MSF Lebrun, D. G., I. Saavedra-Pozo, F. Agreda-Flores, M. L. Burdic, Surgical Trauma Centers.” World Journal of Surgery 34 (3): M. R. Notrica, and others. 2012. “Surgical and Anesthesia 415–19. doi:10.1007/s00268-009-0230-0. Capacity in Bolivian Public Hospitals: Results from a Gosselin, R. A., A. Thind, and A. Bellardinelli. 2006. “Cost/ National Hospital Survey.” World Journal of Surgery 36 (11): DALY Averted in a Small Hospital in Sierra Leone: What 2559–66. doi:10.1007/s00268-012-1722-x. Organization of Essential Services and the Role of First-Level Hospitals 229 Lewis, M. 2007. “Informal Payments and the Financing of Health Southern Sudan, and Uganda.” International Journal of Care in Developing and Transition Countries.” Health Affairs Gynaecology and Obstetrics 88 (2): 208–15. doi:10.1016 (Millwood) 26 (4): 984–97. doi:10.1377/hlthaff.26.4.984. /j.ijgo.2004.09.027. McCord, C., and Q. Chowdhury. 2003. “A Cost Effective Small Pereira, C., A. Bugalho, S. Bergstrom, F. Vaz, and M. Cotiro. Hospital in Bangladesh: What It Can Mean for Emergency 1996. “A Comparative Study of Caesarean Deliveries by Obstetric Care.” International Journal of Gynaecology and Assistant Medical Officers and Obstetricians in Mozambique.” Obstetrics 81 (1): 83–92. British Journal of Obstetrics and Gynaecology 103 (6): 508–12. McCord, C., G. Mbaruku, C. Pereira, C. Nzabuhakwa, and Petroze, R. T., R. S. Groen, F. Niyonkuru, M. Mallory, S. Bergstrom. 2009. “The Quality of Emergency Obstetrical E. Ntaganda, and others. 2013. “Estimating Operative Surgery by Assistant Medical Officers in Tanzanian District Disease Prevalence in a Low-Income Country: Results Hospitals.” Health Affairs (Millwood) 28 (5): w876–85. of a Nationwide Population Survey in Rwanda.” Surgery doi:10.1377/hlthaff.28.5.w876. 153 (4): 457–64. doi:10.1016/j.surg.2012.10.001. McHugh, M. D., J. Berez, and D. S. Small. 2013. “Hospitals with Robert, E., and V. Ridde. 2013. “Global Health Actors No Higher Nurse Staffing Had Lower Odds of Readmissions Longer in Favor of User Fees: A Documentary Study.” Penalties than Hospitals with Lower Staffing.” Health Global Health 9 (1): 29. doi:10.1186/1744-8603-9-29. Affairs (Millwood) 32 (10): 1740–47. doi:10.1377 Sanders, D., J. Kravitz, S. Lewin, and M. McKee. 1998. /hlthaff.2013.0613. “Zimbabwe’s Hospital Referral System: Does It Work?” Mock, C. N., P. Donkor, A. Gawande, D. T. Jamison, M. E. Kruk, Health Policy and Planning 13 (4): 359–70. and H. T. Debas. 2015. “Essential Surgery: Key Messages Siddiqi, S., A. Kielmann, M. Khan, N. Ali, A. Ghaffar, and of This Volume.” In Disease Control Priorities (third others. 2001. “The Effectiveness of Patient Referral in edition): Volume 1, Essential Surgery, edited by H. T. Debas, Pakistan.” Health Policy and Planning 16 (2): 193–98. P. Donkor, A. Gawande, D. T. Jamison, M. E. Kruk, and Solis, C., P. Leon, N. Sanchez, M. Burdic, L. Johnson, and C. N. Mock. Washington, DC: World Bank. others. 2013. “Nicaraguan Surgical and Anesthesia Mock, C. N., M. Joshipura, C. Arreola-Risa, and R. Quansah. Infrastructure: Survey of Ministry of Health Hospitals.” 2012. “An Estimate of the Number of Lives That Could Be World Journal of Surgery 37 (9): 2109–21. doi:10.1007 Saved through Improvements in Trauma Care Globally.” /s00268-013-2112-8. World Journal of Surgery 36 (5): 959–63. doi:10.1007 Urassa, D. P., A. Carlstedt, L. Nystrom, S. N. Massawe, and /s00268-012-1459-6. G. Lindmark. 2005. “Are Process Indicators Adequate to Mock, C. N., G. J. Jurkovich, D. nii-Amon-Kotei, C. Arreola- Assess Essential Obstetric Care at District Level? A Case Risa, and R. V. Maier. 1998. “Trauma Mortality Patterns in Study from Rufiji District, Tanzania.” African Journal of Three Nations at Different Economic Levels: Implications Reproductive Health 9 (3): 100–11. for Global Trauma System Development.” Journal of Weiser, T. G., S. E. Regenbogen, K. D. Thompson, A. B. Haynes, Trauma 44 (5): 804–12; discussion 812–04. S. R. Lipsitz, and others. 2008. “An Estimation of the Mulligan, J., J. Fox-Rushby, T. Adams, B. Johns, and A. Mills. Global Volume of Surgery: A Modeling Strategy Based on 2003. “Unit Costs of Health Care Inputs in Low and Available Data.” The Lancet 372 (9633): 139–44. doi:10.1016 Middle Income Regions.” Working Paper 9, Disease Control /s0140-6736(08)60878-8. Priorities Project, Fogarty International Center, National WHO (World Health Organization). 1992. “The Hospital in Institutes of Health, Bethesda, MD. Rural and Urban Districts. Report of a WHO Study Group Needleman, J., P. Buerhaus, V. S. Pankratz, C. L. Leibson, on the Functions of Hospitals at the First Referral Level.” S. R. Stevens, and others. 2011. “Nurse Staffing and Inpatient World Health Organization Technical Report 819, WHO, Hospital Mortality.” New England Journal of Medicine 364 Geneva. (11): 1037–45. doi:10.1056/NEJMsa1001025. ———. 2003. Surgical Care at the District Hospital. Geneva: Paxton, A., P. Bailey, and S. Lobis. 2006. “The United Nations WHO. Process Indicators for Emergency Obstetric Care: ———. 2010. “Planning Tool for Emergency and Essential Reflections Based on a Decade of Experience.” International Care Surgical Services.” WHO, Geneva. http://www.who Journal of Gynaecology and Obstetrics 95 (2): 192–208. .int/surgery/publications/Planning_toolEESC.pdf. doi:10.1016/j.ijgo.2006.08.009. Wu, V. K., D. Poenaru, and M. J. Poley. 2013. “Burden of Paxton, A., D. Maine, L. Freedman, D. Fry, and S. Lobis. 2005. Surgical Congenital Anomalies in Kenya: A Population- “The Evidence for Emergency Obstetric Care.” International Based Study.” Journal of Tropical Pediatrics 59 (3): 195–202. Journal of Gynaecology and Obstetrics 88 (2): 181–93. doi:10.1093/tropej/fmt001. doi:10.1016/j.ijgo.2004.11.026. Zafar, S. N., and K. A. McQueen. 2011. “Surgery, Public Health, Pearson, L., and R. Shoo. 2005. “Availability and Use of and Pakistan.” World Journal of Surgery 35 (12): 2625–34. Emergency Obstetric Services: Kenya, Rwanda, doi:10.1007/s00268-011-1304-3. 230 Essential Surgery Chapter 13 Specialized Surgical Platforms Mark G. Shrime, Ambereen Sleemi, and Thulasiraj D. Ravilla INTRODUCTION private funders (McCoy, Chand, and Sridhar 2010). This review focuses specifically on the charitable sector’s A large fraction of the burden of disease comprises role in the delivery of surgical care in LMICs. conditions that are potentially amenable to surgical This chapter uses the World Health Organization’s intervention (chapters 1 and 2) (Bickler and others (WHO’s) six geographical regions: African Region, 2015; Mock and others 2015). The proportion is higher Region of the Americas, South-East Asia Region, in low- and middle-income countries (LMICs) (Shrime, European Region, Eastern Mediterranean Region, and Sleemi, and Ravilla 2014). Because of difficulties in Western Pacific Region. access to surgical care—often due to issues of cost, transportation, infrastructure, and a lack of providers (Chao and others 2012; Ilbawi, Einterz, and Nkusu Challenges to Defining Platforms for Service Delivery 2013; Knowlton and others 2013; Linden and others Any attempt to examine the specialized platforms that 2012)—this surgical burden is sometimes borne by the nongovernmental organizations (NGOs) establish for international charitable sector. surgical delivery must necessarily define these plat- Historically, first-level hospitals in LMICs have tended forms. This is a daunting task—an entire galaxy of primarily to treat conditions associated with a low NGOs provide surgical care, few of which easily fit into disability-adjusted life year (DALY) burden. These hos- any single category, and many of which overlap. Fully pitals have done so with a high loss to follow-up; patients 50 percent of international surgical organizations scheduled for surgeries often do not return for their operate in Southeast Asia, with another 46 percent each operations (Ilbawi, Einterz, and Nkusu 2013), especially in Central and South America and 43 percent in as the complexity and up-front costs of the surger- Sub-Saharan Africa. Only 20 percent of the organiza- ies increase. Meanwhile, charitable sector involvement tions provide services in East Asia and the Pacific, the has grown rapidly: the charitable sector in the United Middle East and North Africa, Europe, or North States, which includes many international charitable America (McQueen and others 2010). Organizations surgical organizations, has grown at a pace exceeding vary broadly in surgical scope: 70 percent provide gen- the growth of gross domestic product by 20 percent eral surgery, 60 percent provide plastic and reconstruc- and is currently larger than its counterpart agricul- tive surgery or gynecologic surgery, 50 percent provide ture, construction, transportation, and utilities sectors ophthalmology services. A minority of surveyed (Casey 2007). Médecins Sans Frontières (also known as organizations provide other services, including ortho- Doctors Without Borders) alone has an annual budget of pedics; ear, nose, and throat; burns; cardiac; and more than US$700 million, much of which comes from transplant surgeries (McQueen and others 2010). Corresponding author: Mark G. Shrime, MD, MPH, FACS, Harvard University, shrime@mail.harvard.edu 231 Most of the literature evaluating these organizations (Surgical Procedures, Operative[MeSH Terms] OR sur- focuses on breaking down NGOs by the conditions that gery[tiab] OR surgeries[tiab] OR surgical[tiab] OR each treats. This approach is not, however, informative; operative[tiab] OR operating room[tiab] OR opera- it masks salient similarities and differences between tion[tiab] OR cleft lip[tiab] OR cleft palate[tiab] OR platforms, and, in doing so, may actually promote eye[tiab] OR congenital[tiab] OR heart[tiab] OR car- fragmentation in delivery. diac[tiab] OR vesicovaginal[tiab] OR obstetric fistula- [tiab] OR genital fistula[tiab] OR trauma[tiab]) New Classification by Delivery Platform AND This chapter proposes a novel classification scheme by (Medical Missions, Official[MeSH Terms] OR Missions delivery platform. Focusing on the platform of care, and Missionaries[MeSH Terms] OR Mobile Health rather than on disease-specific organizations themselves, Units[MeSH Terms] OR Relief Work[MeSH Terms] OR allows for a discussion of the costs and effectiveness of Voluntary Workers[MeSH Terms] OR humanitarian[tiab] the platforms and for benefit patterns common to the OR surgical mission*[tiab] OR missionary[tiab] OR respective platforms to emerge, distinct from the dis- resource limited[tiab] OR low income countr*[tiab] eases treated and the organizations providing treatment. OR middle income countr*[tiab] OR developing Using this new framework, nongovernmental surgical countr*[tiab] OR LMIC[tiab]) platforms are compared along metrics of effectiveness, cost-effectiveness, sustainability, and training. NOT “case reports”[publication type] It should be noted that although the vast majority of Bibliographies of the retrieved studies were searched providers of specialized surgical care in low- and middle- for other relevant publications. Inclusion and exclu- income countries are NGOs, not all are, and that the con- sion criteria were determined a priori. Only published, centration of NGOs varies by region. At least one of the peer-reviewed articles were included. The search was not organizations discussed—Babbar Ruga Fistula Teaching limited to articles in English. Data were extracted using Hospital—is better described as a public-private (or piloted forms and performed by all three authors. Because public-charitable) partnership. Other organizations, of a high risk of heterogeneity in studies across multiple such as Médecins Sans Frontières and the International disease conditions, countries, and platforms of delivery, Committee of the Red Cross, provide primarily human- no mathematical summary measure was calculated. itarian emergency services, although both have been Of 8,854 records retrieved, 6,741 were screened by title involved in training and capacity building (Chu, Ford, and abstract; one additional article was found on bibli- and Trelles 2010, 2011; Chu, Trelles, and Ford 2011). ographic review, and the full texts of 322 were screened. Therefore, although the focus of this chapter is the From these, 104 articles were selected for inclusion. The charitable sector, it is not the only model for delivering review process, as well as the previously determined inclu- surgical care; when other platforms are discussed, they sion and exclusion criteria, is described in figure 13.1. are highlighted as such. Other methods of delivering surgery by external organizations are not discussed: CHARITABLE SURGICAL DELIVERY • Telemedicine (Bai and others 2007), in which surgeons PLATFORMS from high-income countries (HICs) diagnose condi- Charitable surgical delivery platforms can be divided tions or guide surgeons in LMICs, is not considered a into two basic types: temporary surgical delivery plat- platform for the actual delivery of surgery. forms and specialty surgical hospitals. • Cancer screening (Bailie 1996), despite the surgical nature of many cancers, is not included for similar reasons. Temporary Surgical Delivery Platforms These platforms are, by definition, temporary, and do not establish hospitals in-country. Although they are METHODOLOGY almost exclusively run by NGOs, they are different A systematic review of the literature was performed to enough to warrant subclassification into short-term sur- assess the cost, effectiveness, sustainability, and training gical trips and self-contained mobile surgical platforms. role of various surgical platforms. The following search strategy was used to query the MEDLINE database, with Short-Term Surgical Trips. Short-term surgical trips similar strategies for EMBASE and Google Scholar: are by far the most common model for surgical delivery 232 Essential Surgery by the charitable sector in LMICs; these platforms send Figure 13.1 Search Strategy Results, Inclusion Criteria, Exclusion surgeons, anesthesiologists, nurses, and support- Criteria, and Final Records Included in Qualitative Systematic Review ing staff—along with, at times, surgical instruments and technology—into hospitals in LMICs for short, MEDLINE search EMBASE search time-limited periods. Often, these NGOs perform a 8,384 results 4,666 results restricted set of surgeries, using existing local infrastruc- ture for surgical delivery, and relying on local physicians for follow-up. Operation Smile (Bermudez, Trost, and 8,854 1,272 records excluded: Ayala 2013; Bermudez and others 2010; Magee 2010; nonduplicate nonhuman subjects Magee, Vander Burg, and Hatcher 2010; Magee and records others 2012), the Kenya Orthopedic Program (Cousins and others 2012), and many others fit this model. 7,582 records 841 records excluded: with human abstract not available subjects Self-Contained Mobile Surgical Platforms. A signifi- cantly rarer model for surgical delivery, NGOs function- ing as self-contained mobile surgical platforms spend 6,741 records screened longer periods (months to years) in-country than the short-term trips and, an important distinction, they carry their entire infrastructure with them. Contained on 322 records 219 records excluded: airplanes, ships, and other modes of transportation, these selected for • Case reports organizations tend not to leave behind any physical struc- full-text review • Prevalence-only studies or lack of ture. Organizations such as Mercy Ships (Cheng, McColl, outcome and Parker 2012; Harris 2013), CinterAndes, and, in • Nonsurgical some settings, Médecins Sans Frontières fit this model. • Non-LMIC 1 nonduplicate • Acute record found on emergencies manual • Noncharitable or bibliography Specialty Surgical Hospitals review nonmilitary • Screening Another common model for surgical delivery by the • LIC and LMIC 104 records patients brought charitable sector, specialty surgical hospitals establish an to HICs included in entire physical plant, either completely new or within an qualitative existing structure, dedicated to the treatment of one or review a few related surgical conditions. Unlike the temporary platforms, specialized surgical hospitals tend to be a mix- Note: HICs = high-income countries; LMICs = low- and middle-income countries. ture of charitable organizations and government insti- tutions. Organizations such as the Addis Ababa Fistula Hospital and the Aravind Eye Hospital fit this model. Short-term surgical platforms have been used for the following: TEMPORARY SURGICAL DELIVERY • Eye camps in India (Balent and others 2001; Civerchia and others 1993, 1996; Kapoor and others 1999; van PLATFORMS der Hoek 1997; Venkataswamy 1975) Temporary surgical platforms are legion and span the • Ear camps in Namibia (Lehnerdt, van Delden, and spectrum from one-week mission trips, through recur- Lautermann 2005) ring mission trips, to mobile platforms that remain on • Surgery for facial clefts (Bermudez, Trost, and Ayala a near-permanent basis in a region. Short-term surgical 2013; Bermudez and others 2010; Magee 2010; trips and self-contained mobile platforms are evaluated Magee, Vander Burg, and Hatcher 2010; Magee and separately. others 2012) • Surgery for hernias in Ghana (Sanders and Kingsnorth 2007) Short-Term Surgical Missions • Cardiac surgery in Papua New Guinea (Tefuarani and Short-term, disease-specific surgical missions are myriad others 2007) (McQueen and others 2010), and services rendered, • Surgery on endemic goiter in Burkina Faso (Rumstadt lengths of surgical trips, and resultant efficacy vary. and others 2008) Specialized Surgical Platforms 233 Underpinning these diverse platforms, however, is a Simpler procedures, like tonsillectomy, appear safe when uniting model: surgeons and other specialists are flown performed by short-term surgical missions (Sykes and into regions with high burdens of specific surgical others 2012). Others are less so: Maine and others (2012) diseases, where they operate for short periods, often report a rate of fistulization between the mouth and the one to two weeks (Gosselin, Gialamas, and Atkin 2011) nose after cleft palate repair more than 20 times higher and often in partnership with in-country physicians, to in surgical missions than in HICs. In this study, opera- whom is left all but the most immediate follow-up care. tions performed by experienced Ecuadorean and North These missions, which have alternately been called surgi- American cleft surgeons on a mission in Ecuador were cal safaris (Frampton 1993) or surgical blitzes (Nthumba compared with cases performed by similar surgeons at a 2010), not infrequently carry their own equipment to third-level referral hospital in the United States. Notably, local hospitals in which they work (Gosselin, Gialamas, all surgeons showed this 20-fold increase in complica- and Atkin 2011; Hodges and Hodges 2000). Often, they tion rates, and no statistically significant difference was return to the same region in subsequent years (Cousins found between surgeries performed by U.S. surgeons on and others 2012; de Buys Roessingh and others 2012; short-term surgical missions and those performed by Haskell and others 2002; Ruiz-Razura, Cronin, and Ecuadorean surgeons on the same mission. Although Navarro 2000) and strive toward close partnership with patient-level factors obviously confound this increased local hospitals and ministries of health (Wright, Walker, complication rate, the finding lends further credence and Yacoub 2007; Yeow and others 2002). to an assertion that mission volume potentially has a Despite the plethora of organizations that adopt the greater impact than surgeon experience (Maine and short-term surgical model, evaluations of its effective- others 2012). De Buys Roessingh and others (2012) simi- ness and cost-effectiveness are few, in part because of larly report relatively poor functional results in the repair the difficulty with follow-up. Of 4,100 operations for of cleft palates on short-term surgical missions; the lack cleft lip and palate by one organization in 40 simulta- of a multidisciplinary approach to the repair of these neous sites, for example, only 703 patients returned for conditions, inherent in short-term surgical blitzes, may a six- to nine-month postoperative visit (Bermudez and contribute to worse outcomes (Furr and others 2011). others 2010). Results from cataract surgeries performed in eye camps are equally variable. Some (Kapoor and others Effectiveness of Short-Term Surgical Missions. In 1999) report good vision outcomes, while others (Singh, a survey of 99 international organizations providing Garner, and Floyd 2000) report poor outcomes. Similar surgeries, nearly two-thirds provided fewer than 500 variability is also seen in studies on otologic surgery. operative interventions per year (McQueen and others In surgical camps in Greenland, Homøe, Siim, and 2010). Strong evidence indicates an association between Bretlau (2008) and Homøe and others (2008) find low surgical volume and outcomes in Canada and the United complication rates and good results in patients with States (Birkmeyer and others 2002). More specifically, chronic ear disease; mobile surgical units in Thailand evidence also points to a stronger impact on outcomes have similarly high success rates. Other authors, how- by hospital volume than by surgeon volume, especially ever, report success rates tied very strongly to either for more complex procedures (Birkmeyer and others pathologic diagnosis (Horlbeck and others 2009) or the 2003; Eskander and others 2014). age of the surgical mission, with better results occurring Despite myriad organizations using the short-term a few years after the mission’s establishment (Barrs and model, surgeries performed by these missions tend to others 2000). Finally, in cardiac surgery, Adams and suffer from higher mortality and complication rates others (2012) find relatively acceptable results in patients and to produce mixed results, especially for more operated on for rheumatic, congenital, and ischemic complex pathologies. In an evaluation of more than heart disease during two surgical missions to Peru, but 17,000 operations performed in Sub-Saharan Africa these results come from a survey of very few patients. during 114 surgical missions in two decades, overall Overall, a solid pattern emerges in a review of the mortality was 3.3 percent (Poilleux and Lobry 1991). The effectiveness of surgical missions: the more complex vast majority of these operations were for hernias, for the surgery, the more unsatisfactory the results. Both which a mortality as high as 1 percent was observed—20 Marck and others (2010) and Huijing and others (2011) times higher than the observed mortality for similar find this pattern in complex reconstructions, which, procedures in HICs (Rodgers and others 2000). combined with the findings of Maine and others (2012), Both the success of an operative mission and its leads them to recommend against short-term surgical complication rates, however, vary by surgical procedure. missions for all but the simplest conditions. 234 Essential Surgery Cost-Effectiveness of Short-Term Surgical Missions. surgeries performed at specialized eye camps, at NGO With a significant caveat to be discussed below, the few hospitals, and at the state medical college. Although not cost-effectiveness analyses that have been performed on the worst value—that distinction fell to the state medical surgical missions point, in general, to a beneficial ratio college—cataract surgery performed at short-term eye of costs to effectiveness. The cost of a short-term surgi- camps was much less cost-effective than that performed cal mission is difficult to calculate and very sensitive to in permanent, nongovernmental hospitals. assumptions made regarding discounting, analysis per- spective, the inclusion of nonmedical patient costs, and Sustainability and Training Role of Short-Term the inclusion of opportunity costs for the volunteering Surgical Missions. Many authors laud the salutary staff (Corlew 2013). Cleft missions have been estimated role that short-term surgical missions can have in to range from approximately US$40 per case to US$335 the education of HIC surgical trainees. Alterman and per case (Hodges and Hodges 2000; Moon, Perry, and Goldman (2008); Aziz, Ziccardi, and Chuang (2012); Baek 2012), and up to US$65,500 per mission (Magee, Belyansky and others (2011); Boyd and Cruz (2011); Vander Burg, and Hatcher 2010). Orthopedic missions Cameron and others (2010); Campbell, Sherman, and cost more than US$170,000 each (Gosselin, Gialamas, Magee (2010); Campbell and others (2011); Haskell and Atkin 2011), and short-term cataract camps cost and others (2002); Henry and others (2013); Hughes $50 per case (Singh, Garner, and Floyd 2000). and others (2010); Jarman, Cogbill, and Kitowski (2009); These estimates translate to cost-effectiveness ratios Lee and Weinstein (2009); and Matar and others (2012) comparable with other global health interventions: Cleft are among many who have written about this beneficial lip and palate repair costs anywhere from US$52/DALY impact on surgical trainees and the surgeons with whom averted (up to US$97 per DALY averted when costs of they travel. Although this role is not to be discounted, lost income to the physician are included) (Moon, Perry, the benefits to surgical residents in HICs clearly cannot and Baek 2012) to US$1,827 per DALY averted (Magee, come at the cost of delivery of unsatisfactory care in Vander Burg, and Hatcher 2010). Orthopedic surgeries LMICs (Wall 2011). are slightly more expensive; elective and emergency No published evidence was found for the role that operative procedures cost between US$340 and US$360 short-term missions play in training within LMICs per DALY averted in Haiti (the emergency figures, nota- themselves. Short-term surgical missions have, however, bly, come from efforts surrounding the 2010 earthquake, been put forward as a method to alleviate the disease and their generalizability may be limited) (Gosselin, burden—especially given that these NGOs frequently Gialamas, and Atkin 2011). offer surgery for free. Unfortunately, with higher compli- These findings, however, must be interpreted cation rates and unsatisfactory results in more complex with extreme caution, especially because they do not operations, the sustainable role of the surgical mission square with the assessment that surgical results of is unclear. It is not altogether unlikely, for example, that short-term surgical missions tend toward the unsat- these surgical missions treat the same conditions that isfactory. The apparent cost-effectiveness of surgical would be treated otherwise in first-level hospitals, and missions is, in fact, very likely simply an artifact of that fragmentation in delivery (Butler 2010) contributes the way in which the cost-effectiveness analyses were to poor coordination and often a frank inability to meet conducted. All of the cited studies compared interven- the large burden of unmet need by the short-term mis- tion with no intervention—as opposed, for example, sion (Cam and others 2010). to surgery by a surgical mission versus surgery by the The structure of the short-term medical mission local infrastructure. This analytic method will frequently itself may also be detrimental to sustainability. Patients result in a misleadingly small cost-effectiveness ratio, are usually identified before the surgical team’s arrival which must, in turn, be interpreted very narrowly: only by local medical staff (Nthumba 2010). While the team when no other platform exists to deliver care for the con- is there, a large volume of cases are performed, often dition treated by the mission do these results imply that overwhelming the local infrastructure during and after a surgical mission is cost-effective. If the condition can the team’s visit (Nthumba 2010). be treated by other platforms, including first-level hos- Finally, it should also be noted that, in the commu- pitals, these cost-effectiveness results cannot be applied. nities they serve, these platforms create an awareness of One cost-effectiveness analysis was found that actu- a given surgical condition and the potential to address ally compares the surgical mission with other platforms it surgically. This awareness can often have counterin- for the delivery of identical surgeries. Singh, Garner, and tuitively detrimental effects on health care utilization Floyd (2000) examine the cost-effectiveness of cataract among the population. When outcomes are consistently Specialized Surgical Platforms 235 good, increased awareness influences positive health- Military organizations adopt a similar model. The seeking behavior in potential patients. Even the most United States Navy maintains two hospital ships sporadic of bad outcomes, however, seem to discourage that report mortality and complication rates that are care-seeking outright (Fletcher and others 1999). equivalent to, if not better than, those found in hospi- Despite its ubiquity, then, the short-term surgical tals in HICs (Troup 2007; Walk and others 2011, 2012). mission appears to have a relatively limited role in the There have been, as yet, no cost evaluations and no delivery of surgical care. In settings in which surgical cost-effectiveness evaluations of these self-contained conditions cannot otherwise be treated, the short-term surgical platforms. mission is cost-effective and appears to have a role in the amelioration of the surgical burden. However, in settings in which other platforms exist for surgical deliv- SPECIALTY SURGICAL HOSPITALS ery, the short-term mission is unlikely to be either the most effective or the most cost-effective method with Demand and Supply Constraints which to alleviate the large burden of surgical disease Specialized surgical hospitals are myriad (table 13.1). in LMICs. Given potentially unsatisfactory results with Many have evolved from temporary surgical platforms. complex surgeries, potentially detrimental effects on Cataract surgeries in India, for example, were initially health-seeking behavior, and stress on the local surgical performed in makeshift surgical facilities, schools, or infrastructure, the short-term stand-alone surgical mis- community halls, before their care made the transition sion, when other options exist, is likely to be inefficient to specialized hospitals. Technologies were very basic, (Browning and Patel 2004). limited essentially to surgical instruments and the skills of the surgeons. Although this sort of outreach—with improved technology—continues to be common, a Self-Contained Mobile Surgical Platforms population-based study estimates that those accessing The fact that complex procedures performed by short- these outreach eye camps represent a mere 7 percent of term missions yield unsatisfactory results, (Huijing and those in need of eye care (Fletcher and others 1998). others 2011; Marck and others 2010), combined with Similarly, current global estimates put resource the fact that most first-level hospitals are also unable utilization of eye care facilities at 25 percent of to provide this care consistently (Hsia and others 2012; incident cases of blindness (WHO 2005). Research by Ilbawi, Einterz, and Nkusu 2013; Linden and others 2012), leads to an obvious question. Many LMICs are Table 13.1 Examples of Surgical Specialty Hospitals in committed to improving their surgical capacity; while LMICs they do so, how can the interim unmet need be best met, Cardiac if not with short-term missions? Are specialized surgical Salam Centre for Cardiac Surgery, Khartoum, Sudan hospitals the best way to provide adequate complex care that the local health infrastructure cannot yet provide— Narayana Hrudayalaya Hospitals, Bangalore, India and to do so cost-effectively? Or can a different tem- Innova Children’s Heart Hospital, Hyderabad, India porary model, better structured than the short-term Ophthalmic mission, provide this level of care? ORBIS Few examples of such an intermediate model for Aravind Eye Hospitals, Tamilnadu, India surgical delivery exist, but those that do are prom- ising. Mercy Ships, for example, maintains hospital LRBT Eye Hospitals, Pakistan ships that provide specialized surgical care in West Obstetric Fistula Africa. They carry their entire infrastructure with them, Babbar Ruga Fistula Teaching Hospital, Katsina, Nigeria including pathology and radiology (Harris 2013), and Addis Ababa Fistula Hospital, Addis Ababa, Ethiopia they are able to provide ophthalmologic, reconstruc- tive, general, orthopedic, and obstetric fistula surgeries Danja Fistula Center, Danja, Niger (Cheng, McColl, and Parker 2012; Lewis and de Bernis Maternity Services 2006). The limited studies on the effectiveness of surgi- Life Spring Hospitals, India cal procedures performed using this platform indicate a Cancer complication rate that is comparable with complication rates for cases performed in centers in HICs (Cheng, Adayar Cancer Institute, Chennai, India McColl, and Parker 2012). No literature on similar plat- Tata Memorial Hospital, Mumbai, India forms, such as Floating Doctors, was found. Note: LMICs = low- and middle-income countries. 236 Essential Surgery Browning and Patel (2004, 321) in the obstetric fistula Figure 13.2 Demand and Supply Levers in Delivering Surgical Care setting indicates that “at the world’s current capacity in LMICs to repair fistula, it would take at least 400 years to clear the backlog of patients, provided that there are Equipment and Facility Awareness no more new cases.” At present, less than 1 percent of technology Staff and Retention and creation the surgical need for fistula repair is met (Browning compliance skills and Patel 2004). In Ethiopia alone, it is estimated that Quality of the 2.9 million women who give birth annually, Barriers Supply almost 9,000 will develop an obstetric fistula (Hamlin, Operating Access Demand Muleta, and Kennedy 2002; Muleta, Rasmussen, and systems Kiserud 2010). Similar statements can be made about Ownership of Cost the unmet need for cardiac surgery, maternity services, Attitude and the issue Remote Partnerships and cancer care. diagnosis perspective for referrals In addition to constituting a large unmet need, many surgical conditions—especially those treated Note: LMICs = low- and middle-income countries. by specialized hospitals—are chronic, allowing (with notable exceptions) these surgeries to be performed electively. Because at least some of these conditions (cat- Evidence for the effectiveness of ophthalmologic aracts, hernias, and cardiac conditions, for example) also centers has already been presented: specialized NGO tend to be age related, and because these interventions hospitals are more cost-effective than other platforms can dramatically enhance activities of daily living and in the provision of cataract surgery (Singh, Garner, and the quality of life (Fletcher and others 1998), an aging Floyd 2000). population will make it crucial that such services are Repair of obstetric fistula is complex. Fistula surgeons provided in a sustainable manner. are not considered expert until they have performed at Demand is, however, constrained by a number of least 300 cases (FIGO and Partners 2011); even expert factors: a large, underserved, and dispersed population; surgeons deliver, on average, closure and continence to scarce capital and human resources; poor in-country only 85 percent of patients. The volume of surgeries logistics; and patient-level characteristics—barriers to required to qualify as an expert and competent fistula market entry, fluctuating incomes with little disposable surgeon may not be met in short-term missions, or at a surplus, unfamiliarity with surgical procedures, and first-level hospital, for years (FIGO and Partners 2011). multiple domestic necessities (figure 13.2) (Prahalad Published studies, however, document good results for 2009). Finally, many complex conditions cannot be specialized fistula hospitals: the Addis Ababa Fistula treated by a single surgical procedure and require treat- Hospital (a charitable organization) and Babbar Ruga ment of specialized preoperative and postoperative Fistula Teaching Hospital (an initiative sponsored by the needs—including physiotherapy, economic rehabilita- Nigerian government with reliance on external funding) tion, preoperative nourishment, social counseling, and do well, reporting rates of successful fistula closure and physical environments that are geared toward specific return to continence of greater than 90 percent (Muleta surgical conditions—for which the specialized hospital 1997; Waaldijk 2008). may be well suited. In addition to issues of volume and success rates, complex surgical conditions, such as obstetric fistula and cleft palate, place specific demands on the design of Effectiveness of Specialty Surgical Hospitals the physical facility, often not feasible on a short-term The challenge for specialized surgical hospitals is not mission. For instance, Hamlin, Muleta, and Kennedy one of discovering novel clinical solutions to these (2002) highlight needs unique to the vulnerable fistula conditions—time-tested surgical interventions for population: traditional multistoried hospitals are not in many of the conditions treated by long-term surgical sympathy with the poor communities from which these platforms exist (Ruit and others 2007)—but of effec- women come, while grassy areas can absorb leaking tive long-term implementation in permanent centers urine, and wide, open walkways and corridors allow located in resource-limited settings. Effectiveness data the “pervasive smell of urine … to escape more readily” for specialized surgical hospitals are, however, limited (Hamlin, Muleta, and Kennedy 2002, 51), both of which and come primarily from ophthalmologic and fistula improve morale. Finally, specialized long-term platforms centers. We found no evidence from specialty hospitals can provide physical therapy services and rehabilitation treating other conditions. and reintegration services, all deemed to be important Specialized Surgical Platforms 237 to an effective fistula program. Similar rehabilitative Browning and Patel’s 2004 estimates, the experience of considerations—including speech and swallowing one of this review’s authors (A. Sleemi) with short-term therapy—are required for the repair of cleft palate. surgical missions for obstetric fistula demonstrates the Temporary surgical platforms—especially those level of sustainability required for education: the train- espousing a short-term model—are unlikely to be able ing of two Eritrean fistula surgeons required at least to meet these needs; and while first-level hospitals five years before competency levels and adequate case may meet some of them, they often cannot priori- numbers were met. tize such additional services and facilities over more Finally, from an academic standpoint, the bulk of the life-threatening surgical conditions, further preventing literature comes from such specialized training centers: the delivery of complex surgery (Wall 2007). In keeping both Addis Ababa and Babbar Ruga Fistula Hospitals with these findings, an expert elicitation study also con- have provided key data and landmark papers on the cludes that outcomes for complicated obstetric fistula management of obstetric fistula. Specialized surgical cases are most likely best at the high-volume, specialized centers, because of their high volumes, may have a role surgical hospitals as opposed to first-level hospitals in filling the void of an evidence base in global surgery. (Colson and others 2013). Cost-Effectiveness of Specialty Surgical Hospitals DISCUSSION The single comparison of cataract care across platforms Surgical conditions constitute up to 26 percent of demonstrates the superior cost-effectiveness of perma- the global burden of disease, and the current surgical nent NGO hospitals (Singh, Garner, and Floyd 2000). infrastructure in many LMICs meets very little of that Compared with US$50 per case at short-term cataract need. Access to surgical care is low (Brilliant and others hospitals, NGO hospitals treat cataracts at US$46 per case, 1985; Browning and Patel 2004; WHO 2005), and most with nearly double the patient satisfaction (Singh, Garner, hospitals in LMICs are themselves unable to meet the and Floyd 2000). No adequate data, unfortunately, exist demand of high-DALY surgical conditions (Ilbawi, to assess the cost-effectiveness of fistula repair centers, Einterz, and Nkusu 2013). Simultaneously, a rich, rap- cardiac centers, or other specialized surgical hospitals. idly growing, and often fragmented charitable sector has stepped in to meet surgical need—a sector that, despite its growth, has not been systematically evaluated (Butler Sustainability and Training Role of Specialty 2010). This review summarizes the known evidence on Surgical Hospitals the impact of the charitable sector in delivering surgical Whether a hospital is run for profit or as a nonprofit, care in LMICs. it must be sustainable across the several dimensions Unfortunately, what evaluations have been done may of financial stability, clinical services, leadership, and actually promote fragmentation—examining surgical community support. Financial stability is addressed by missions in isolation, as most studies have, prevents developing sustainable sources of income, as well as by informative similarities and differences among these ensuring high efficiency, appropriate pricing, and effec- missions from becoming explicit. We propose, instead, to tive cost control measures that do not adversely affect structure evaluations around platforms for the delivery quality or productivity. Standard protocols, processes of care, rather than around disease types or individual for continuous improvement, and succession planning missions. Doing so highlights the relative effectiveness also contribute to stability and sustainability. The ability or ineffectiveness of models that underpin charitable to continue to provide clinical services once they have surgical delivery. departed is difficult for short-term surgical platforms— Accordingly, we have broken down the galaxy of most teams take the technical skills, support, and equip- surgical NGOs into two types: temporary surgical ment with them when they leave. platforms—including short-term, surgical missions and The high volume of specialized centers, however, self-contained mobile surgical programs—and free- allows for sustainable surgical training programs. The standing specialized surgical centers. The overall findings Babbar Ruga Fistula Teaching Hospital has trained more from this systematic review are presented in table 13.2. than 315 fistula surgeons and 320 nurses worldwide (Waaldijk 2008); to meet ophthalmic training needs, internal training programs at the Aravind Eye Hospital Short-Term Surgical Missions now graduate about 400 mid-level ophthalmic person- The available evidence suggests that, despite its ubiquity nel and 33 ophthalmologists each year. Consistent with and benefit to HIC medical resident training, the role 238 Essential Surgery Table 13.2 Summary of Results Platform Domain Temporary, short-term mission Temporary, self-containeda Surgical specialty hospital Effectiveness Poor results for complex procedures; Potentially equivalent to outcomes Equivalent to outcomes in HICs effective for simple procedures in HICs Cost-effectiveness Yes if serving as the only platform for No data available Most cost-effective of the surgery; unlikely otherwise competing choices Sustainability Unlikely; may have a detrimental impact on No data available Platform suitable for sustainability health-seeking behavior Training Effective for HIC surgeons; limited data on Available for training Definite role in LMICs surgeons in LMICs Note: HICs = high-income countries; LMICs = low- and middle-income countries. a. Sparse data on this platform limit the certainty of these conclusions. of short-term temporary surgical missions should be specialty hospital. They offer services, such as radiology, limited to areas and conditions for which no other sur- that are usually not found in the short-term mission gical delivery platform is available. In these settings, this (Harris 2013) and are able to deliver care comparable to platform delivers care very cost-effectively. that found in HICs (Cheng, McColl, and Parker 2012). In settings in which alternative delivery systems exist, Studies on this platform are few, and cost-effectiveness the short-term mission appears to be an inefficient way studies are nonexistent; in the interim, while surgical to meet the global burden of high-DALY surgical disease infrastructure develops, a scale-up of this model should (Cam and others 2010). These missions may not be be considered, given that it might meet the burden of effective at reaching the patients with unmet need, given surgical disease in a more effective and efficient way than that they treat conditions that first-level hospitals may its short-term counterpart. already be treating (Browning and Patel 2004; Butler 2010) and may risk delivering unsatisfactory results, especially for complex reconstructions (Huijing and Specialty Surgical Hospitals others 2011; Maine and others 2012; Marck and others Finally, the literature suggests that specialized surgical 2010). Although some conditions are amenable to surgi- centers might be effective in providing a high volume cal blitzes (Sykes and others 2012), the blitzes themselves of care with good outcomes (Muleta 1997; Waaldijk often stress the underlying local surgical infrastructure 2008). These long-term platforms are also able to (Nthumba 2010) and may discourage health-seeking provide for some of the unique needs faced by patients behavior (Fletcher and others 1999), which undermines with more complex conditions (Hamlin, Muleta, and this platform’s sustainability. Kennedy 2002; Wall 2007; Wall and others 2006). One For conditions for which cost-effectiveness evidence cost-effectiveness analysis that makes comparisons exists (facial clefting and orthopedic care), these sur- across platforms does demonstrate the superiority of gical missions provide cost-effective service—but they these specialized surgical hospitals to short-term mis- do so only, again, in comparison with settings that sions (Singh, Garner, and Floyd 2000), but further do not provide any surgery (Gosselin, Gialamas, and analyses are necessary. Atkin 2011; Hodges and Hodges 2000; Magee, Vander This review is the first to attempt a broad, sys- Burg, and Hatcher 2010; Moon, Perry, and Baek 2012). tematic evaluation of charitable surgical delivery in In analyses in which they are compared with other LMICs, distinct from the conditions treated and the platforms in delivering identical services, surgical mis- individual organizations that treat them. As such, it sions become less cost-effective (Singh, Garner, and has certain limitations. It should be noted, for exam- Floyd 2000). ple, that any taxonomy is leaky. Some organizations that establish hospitals also send short-term missions to other countries; some of the self-contained orga- Self-Contained Mobile Surgical Platforms nizations have themselves established hospitals. That Self-contained mobile platforms are rare, but they fit in no classification system can adequately characterize the negative space between the surgical mission and the any NGO does not, however, mean that research into Specialized Surgical Platforms 239 these organizations must remain fragmented. This • Short-term surgical missions are useful when access taxonomy, incomplete though it may be, proposes a to surgical services is nonexistent. This recommenda- structure for future research into a large sector of the tion must, however, be made with caution because, health system. although any surgical access is better than none, poor The peer-reviewed literature in this area is small, outcomes may have a chilling effect on health-seeking all outcomes studies are case series, and nearly all the behavior. cost-effectiveness studies are predicated on heroic • Consideration should be given to expansion of assumptions. In addition, although some studies do self-contained mobile platforms instead of short- show less-than-optimal results, publication bias very term surgical trips to meet the unmet surgi- likely exists. More important, a lack of evidence does cal need in countries developing their surgical not imply evidence of a lack. Many surgeons in LMICs, infrastructure. in addition to surgeons who work with these charitable • Rigorous evaluations of the cost-effectiveness and organizations, have little time to devote to produc- sustainability of various charitable delivery platforms ing peer-reviewed publications. As such, a dearth of should be undertaken. evidence exists as to the comparative effectiveness • Because training already occurs within the confines of NGO platforms and first-level hospitals within of some NGOs, further evaluations of the effec- the same setting. This evidence void highlights the tiveness of this training should be undertaken— need for further investigation into the effectiveness with respect to the retention of surgical skills, to of surgery as delivered in these settings, as well as the improvements in outcomes, and to the retention of potential role for other research methods—such as in-country providers. realist synthesis—in the study of surgical delivery by charities in LMICs. Although the paucity of data implies a measure of Finally, of the domains along which delivery platforms uncertainty in these recommendations, this literature were evaluated (cost-effectiveness, effectiveness, sustain- review suggests that following them may help in decreas- ability, and training role), the first is especially contro- ing the fragmentation found in the nongovernmental versial, especially given the various platforms used. Some sector, to the ultimate benefit of surgical patients (Ilbawi, organizations, for example, work entirely with volunteer Einterz, and Nkusu 2013). staff; others pay. Therefore, cost-effectiveness claims must be interpreted with caution. ACKNOWLEDGMENTS CONCLUSIONS AND RECOMMENDATIONS The authors are indebted to Dr. Peggy Lai, Sweta Adhikari, and Vittoria Lutje for help in the literature Limitations in the literature highlight the clear need search. for more, and larger, evaluations of the effectiveness and cost-effectiveness of the charitable sector’s role in the delivery of surgical care in LMICs. This sector is large and spends a significant amount of donor money NOTES (Casey 2007). Determining the most effective platform This chapter uses the World Health Organization’s for the delivery of care stands to benefit patients, for (WHO’s) six geographical regions: African Region, whom this is often the only affordable avenue of care; Region of the Americas, South-East Asia Region, European determining the most cost-effective platform stands also Region, Eastern Mediterranean Region, and Western to align donor interests with those of the patients they Pacific Region. seek to help. The World Bank classifies countries according to four The available literature allows the following recom- income groupings. Income is measured using gross national income (GNI) per capita, in U.S. dollars, converted from local mendations to be made: currency using the World Bank Atlas method. Classifications as of July 2014 are as follows: • Evaluations of charitable surgery should be under- taken from the perspective of the care-delivery • Low-income countries (LICs) = US$1,045 or less in 2013 platform—short-term surgical trips, self-contained • Middle-income countries (MICs) are subdivided: mobile platforms, and specialty hospitals—instead • lower-middle-income = US$1,046 to US$4,125 of by the disease condition addressed by individual • upper-middle-income (UMICs) = US$4,126 to US$12,745 organizations. • High-income countries (HICs) = US$12,746 or more 240 Essential Surgery REFERENCES Boyd, N. H., and R. M. Cruz. 2011. “The Importance of International Medical Rotations in Selection of an Adams, C., P. Kiefer, K. Ryan, D. Smith, G. McCabe, and Otolaryngology Residency.” Journal of Graduate Medical others. 2012. “Humanitarian Cardiac Care in Arequipa, Education 3 (3): 414–16. doi:10.4300/jgme-d-10-00185.1. Peru: Experiences of a Multidisciplinary Canadian Brilliant, L. B., R. P. Pokrel, N. C. Grasset, J. M. Lepkowski, Cardiovascular Team.” Canadian Journal of Surgery 55 (3): A. Kolstad, and others. 1985. “Epidemiology of Blindness 171–76. doi:10.1503/cjs.029910. in Nepal.” Bulletin of the World Health Organization 63 (2): Alterman, D. M., and M. H. Goldman. 2008. “International 375–86. Volunteerism during General Surgical Residency: A Browning, A., and T. L. Patel. 2004. “FIGO Initiative for the Resident’s Experience.” Journal of Surgical Education 65 (5): Prevention and Treatment of Vaginal Fistula.” International 378–83. doi:10.1016/j.jsurg.2008.07.009. Journal of Gynecology and Obstetrics 86 (2): 317–22. Aziz, S. R., V. B. Ziccardi, and S. K. Chuang. 2012. “Survey of Butler, M. W. 2010. “Fragmented International Volunteerism: Residents Who Have Participated in Humanitarian Medical Need for a Global Pediatric Surgery Network.” Journal of Missions.” Journal of Oral and Maxillofacial Surgery 70 (2): Pediatric Surgery 45 (2): 303–09. doi:10.1016/j.jpedsurg e147–57. doi:10.1016/j.joms.2011.10.007. .2009.10.064. Bai, V. T., V. Murali, R. Kim, and S. K. Srivatsa. 2007. Cam, C., A. Karateke, A. Ozdemir, C. Gunes, C. Celik, and “Teleophthalmology-Based Rural Eye Care in India.” others. 2010. “Fistula Campaigns—Are They of Any Telemedicine Journal and e-Health 13 (3): 313–21. Benefit?” Taiwanese Journal of Obstetrics and Gynecology doi:10.1089/tmj.2006.0048. 49 (3): 291–96. doi:10.1016/s1028-4559(10)60063-0. Bailie, R. 1996. “An Economic Appraisal of a Mobile Cervical Cameron, B. H., M. Rambaran, D. P. Sharma, and R. H. Taylor. Cytology Screening Service.” South African Medical Journal 2010. “International Surgery: The Development of Post- 86 (9 Suppl): 1179–84. graduate Surgical Training in Guyana.” Canadian Journal of Balent, L. C., K. Narendrum, S. Patel, S. Kar, and D. A. Patterson. Surgery 53 (1): 11–16. 2001. “High Volume Sutureless Intraocular Lens Surgery in Campbell, A., R. Sherman, and W. P. Magee. 2010. “The Role a Rural Eye Camp in India.” Ophthalmic Surgery and Lasers of Humanitarian Missions in Modern Surgical Training.” 32 (6): 446–55. Plastic and Reconstructive Surgery 126 (1): 295–302. Barrs, D. M., S. P. Muller, D. B. Worrndell, and E. W. Weidmann. doi:10.1097/PRS.0b013e3181dab618. 2000. “Results of a Humanitarian Otologic and Audiologic Campbell, A., M. Sullivan, R. Sherman, and W. P. Magee. 2011. Project Performed outside of the United States: Lessons “The Medical Mission and Modern Cultural Competency Learned from the Oye, Amigos! Project.” Otolaryngology— Training.” Journal of the American College of Surgeons Head and Neck Surgery 123 (6): 722–27. doi:10.1067 212 (1): 124–19. doi:10.1016/j.jamcollsurg.2010.08.019. /mhn.2000.110959. Casey, K. M. 2007. “The Global Impact of Surgical Belyansky, I., K. B. Williams, M. Gashti, and R. F. Heitmiller. Volunteerism.” Surgical Clinics of North America 87 (4): 2011. “Surgical Relief Work in Haiti: A Practical Resident 949–60, ix. doi:10.1016/j.suc.2007.07.018. Learning Experience.” Journal of Surgical Education 68 (3): Chao, T. E., M. Burdic, K. Ganjawalla, M. Derbew, C. Keshian, 213–17. doi:10.1016/j.jsurg.2010.12.003. and others. 2012. “Survey of Surgery and Anesthesia Bermudez, L., V. Carter, W. Magee, Jr., R. Sherman, and Infrastructure in Ethiopia.” World Journal of Surgery 36 R. Ayala. 2010. “Surgical Outcomes Auditing Systems in (11): 2545–53. doi:10.1007/s00268-012-1729-3. Humanitarian Organizations.” World Journal of Surgery 34 Cheng, L. H., L. McColl, and G. Parker. 2012. “Thyroid (3): 403–10. doi:10.1007/s00268-009-0253-6. Surgery in the UK and on Board the Mercy Ships.” British Bermudez, L., K. Trost, and R. Ayala. 2013. “Investing in Journal of Oral and Maxillofacial Surgery 50 (7): 592–96. a Surgical Outcomes Auditing System.” Plastic Surgery doi:10.1016/j.bjoms.2011.10.009. International 2013: 671786. doi:10.1155/2013/671786. Chu, K. M., N. Ford, and M. Trelles. 2010. “Operative Mortality Bickler, S. W., T. G. Weiser, N. Kassebaum, H. Higashi, in Resource-Limited Settings: The Experience of Médecins D. C. Chang, and others. 2015. “Global Burden of Surgical Sans Frontières in 13 Countries.” Archives of Surgery 145 (8): Conditions.” In Disease Control Priorities (third edition): 721–25. Volume 1, Essential Surgery, edited by H. T. Debas, ———. 2011. “Providing Surgical Care in Somalia: A Model of P. Donkor, A. Gawande, D. T. Jamison, M. E. Kruk, and Task-Shifting.” Conflict and Health 5: 12. C. N. Mock. Washington, DC: World Bank. Chu, K. M., M. Trelles, and N. Ford. 2011. “Quality of Care in Birkmeyer, J. D., A. E. Siewers, E. V. Finlayson, T. A. Stukel, Humanitarian Surgery.” World Journal of Surgery 35 (6): F. L. Lucas, and others. 2002. “Hospital Volume and Surgical 1169–72; discussion 1173–74. Mortality in the United States.” New England Journal of Civerchia, L., S. W. Apoorvananda, G. Natchiar, A. Balent, Medicine 346 (15): 1128–37. R. Ramakrishnan, and others. 1993. “Intraocular Lens Birkmeyer, J. D., T. A. Stukel, A. E. Siewers, P. P. Goodney, and Implantation in Rural India.” Ophthalmic Surgery 24 (10): D. E. Wennberg. 2003. “Surgeon Volume and Operative 648–52; discussion 652–53. Mortality in the United States.” New England Journal of Civerchia, L., R. D. Ravindran, S. W. Apoorvananda, Medicine 349 (22): 2117–27. R. Ramakrishnan, A. Balent, and others. 1996.“High-Volume Specialized Surgical Platforms 241 Intraocular Lens Surgery in a Rural Eye Camp in India.” Haskell, A., D. Rovinsky, H. K. Brown, and R. R. Coughlin. Ophthalmic Surgery Lasers 27 (3): 200–08. 2002. “The University of California at San Francisco Colson, A., S. Adhikari, A. Sleemi, and R. Laxminarayan. 2013. International Orthopaedic Elective.” Clinical Orthopaedics “Quantifying Uncertainty in Intervention Effectiveness: and Related Research (396): 12–18. An Application in Obstetric Fistula.” DCP3 Working Henry, J. A., R. S. Groen, R. R. Price, B. C. Nwomeh, T. P. Kingham, Paper No. 7. and others. 2013. “The Benefits of International Rotations Corlew, D. S. 2013. “Economic Modeling of Surgical Disease: to Resource-Limited Settings for U.S. Surgery Residents.” A Measure of Public Health Interventions.” World Journal Surgery 153 (4): 445–54. doi:10.1016/j.surg.2012.10.018. of Surgery 37 (7): 1478–85. Hodges, A. M., and S. C. Hodges. 2000. “A Rural Cleft Project Cousins, G. R., L. Obolensky, C. McAllen, V. Acharya, and in Uganda.” British Journal of Plastic Surgery 53 (1): 7–11. A. Beebeejaun. 2012. “The Kenya Orthopaedic Project: doi:10.1054/bjps.1999.3238. Surgical Outcomes of a Travelling Multidisciplinary Team.” Homøe, P., G. Nikoghosyan, C. Siim, and P. Bretlau. 2008. Journal of Bone and Joint Surgery British Volume 94 (12): “Hearing Outcomes after Mobile Ear Surgery for Chronic 1591–94. doi:10.1302/0301-620x.94b12.29920. Otitis Media in Greenland.” International Journal of de Buys Roessingh, A. S., M. Dolci, C. Zbinden-Trichet, Circumpolar Health 67 (5): 452–60. R. Bossou, B. J. Meyrat, and others. 2012. “Success and Homøe, P., C. Siim, and P. Bretlau. 2008. “Outcome of Mobile Failure for Children Born with Facial Clefts in Africa: Ear Surgery for Chronic Otitis Media in Remote Areas.” A 15-Year Follow-Up.” World Journal of Surgery 36 (8): Otolaryngology—Head and Neck Surgery 139 (1): 55–61. 1963–69. doi:10.1007/s00268-012-1607-z. doi:10.1016/j.otohns.2008.03.014. Eskander, A., J. Irish, P. A. Groome, J. Freeman, P. Gullane, Horlbeck, D., M. Boston, B. Balough, B. Sierra, G. Saenz, and others. 2014. “Volume-Outcome Relationships in the and others. 2009. “Humanitarian Otologic Missions: Surgical Management of Head and Neck Cancer in a Long-Term Surgical Results.” Otolaryngology—Head Universal Health Care System.” Laryngoscope. Advance and Neck Surgery 140 (4): 559–65. doi:10.1016/j online publication. doi:10.1002/lary.24704. .otohns.2008.12.033. FIGO (International Federation of Gynecology and Hsia, R. Y., N. A. Mbembati, S. Macfarlane, and M. E. Kruk. Obstetrics) and Partners. 2011. “Global Competency- 2012. “Access to Emergency and Surgical Care in Sub- Based Fistula Surgery Training Manual.” London: Saharan Africa: The Infrastructure Gap.” Health Policy and FIGO. http://www .figo.org/files/figo-corp/FIGO Planning 27 (3): 234–44. doi:10.1093/heapol/czr023. _Global_Competency -Based_Fistula_Surgery_Training Hughes, C., S. Zani, B. O’Connell, and I. Daoud. 2010. _Manual_0.pdf. “International Surgery and the University of Connecticut Fletcher, A., M. Donoghue, J. Devavaram, R. D. Thulasiraj, Experience: Lessons from a Short-Term Surgical Mission.” S. Scott, and others. 1999. “Low Uptake of Eye Services Connecticut Medicine 74 (3): 157–60. in Rural India: A Challenge for Programs of Blindness Huijing, M. A., K. W. Marck, J. Combes, K. D. Mizen, L. Fourie, Prevention.” Archives of Ophthalmology 117 (10): and others. 2011. “Facial Reconstruction in the Developing 1393–99. World: A Complicated Matter.” British Journal of Oral Fletcher, A., V. Vijaykumar, S. Selvaraj, R. D. Thulasiraj, and and Maxillofacial Surgery 49 (4): 292–96. doi:10.1016/j L. B. Ellwein. 1998. “The Madurai Intraocular Lens Study. .bjoms.2009.08.044. III: Visual Functioning and Quality of Life Outcomes.” Ilbawi, A. M., E. M. Einterz, and D. Nkusu. 2013. “Obstacles to American Journal of Ophthalmology 125 (1): 26–35. Surgical Services in a Rural Cameroonian District Hospital.” Frampton, M. C. 1993. “Otological Relief Work in Romania.” World Journal of Surgery 37 (6): 1208–15. doi:10.1007 Journal of Laryngology and Otology 107 (12): 1185–89. /s00268-013-1977-x. Furr, M. C., E. Larkin, R. Blakeley, T. W. Albert, L. Tsugawa, and Jarman, B. T., T. H. Cogbill, and N. J. Kitowski. 2009. others. 2011. “Extending Multidisciplinary Management “Development of an International Elective in a General of Cleft Palate to the Developing World.” Journal of Oral Surgery Residency.” Journal of Surgical Education 66 (4): and Maxillofacial Surgery 69 (1): 237–41. doi:10.1016/j 222–24. doi:10.1016/j.jsurg.2009.07.003. .joms.2010.06.214. Kapoor, H., A. Chatterjee, R. Daniel, and A. Foster. 1999. Gosselin, R. A., G. Gialamas, and D. M. Atkin. 2011. “Comparing “Evaluation of Visual Outcome of Cataract Surgery in an the Cost-Effectiveness of Short Orthopedic Missions in Indian Eye Camp.” British Journal of Ophthalmology 83 (3): Elective and Relief Situations in Developing Countries.” 343–46. World Journal of Surgery 35 (5): 951–55. doi:10.1007 Knowlton, L. M., S. Chackungal, B. Dahn, D. LeBrun, /s00268-010-0947-9. J. Nickerson, and others. 2013. “Liberian Surgical and Hamlin, E. C., M. Muleta, and R. C. Kennedy. 2002. “Providing Anesthesia Infrastructure: A Survey of County Hospitals.” an Obstetric Fistula Service.” British Journal of Urology World Journal of Surgery 37 (4): 721–29. doi:10.1007 International 89 (S1): 50–53. /s00268-013-1903-2. Harris, R. D. 2013. “Radiology on the Africa Mercy, the Largest Lee, D. K., and S. Weinstein. 2009. “International Public Health Private Floating Hospital Ship in the World.” American in Third World Country Medical Missions: When Small Journal of Roentgenology 200 (2): W124–29. doi:10.2214 Legs Walk, We All Stand a Little Taller.” Journal of the /ajr.12.9087. American Podiatric Medical Association 99 (4): 371–76. 242 Essential Surgery Lehnerdt, G., A. van Delden, and J. Lautermann. 2005. East Asia.” World Journal of Surgery 36 (12): 2819–30. “Management of an ‘Ear Camp’ for Children in Namibia.” doi:10.1007/s00268-012-1761-3. International Journal of Pediatric Otorhinolaryngology 69 Muleta, M. 1997. “Obstetric Fistulae: A Retrospective Study of (5): 663–68. doi:10.1016/j.ijporl.2004.12.007. 1210 Cases at the Addis Ababa Fistula Hospital.” Journal of Lewis, G., and L. de Bernis. 2006. Obstetric Fistula: Guiding Obstetrics and Gynecology 17 (1): 68–70. Principles for Clinical Management and Programme Muleta, M., S. Rasmussen, and T. Kiserud. 2010. “Obstetric Development. Geneva: World Health Organization. Fistula in 14,928 Ethiopian Women.” Acta Obstetrica et http://www.endfistula.org/webdav/site/endfistula/shared Gynecologica Scandinavica 89 (7): 945–51. doi:10.3109 /documents/publications/who_obstetric_fistula.pdf. /00016341003801698. Linden, A. F., F. S. Sekidde, M. Galukande, L. M. Knowlton, Nthumba, P. M. 2010. “‘Blitz Surgery’: Redefining Surgical S. Chackungal, and others. 2012. “Challenges of Surgery in Needs, Training, and Practice in Sub-Saharan Africa.” Developing Countries: A Survey of Surgical and Anesthesia World Journal of Surgery 34 (3): 433–37. doi:10.1007 Capacity in Uganda’s Public Hospitals.” World Journal of /s00268-009-0256-3. Surgery 36 (5): 1056–65. doi:10.1007/s00268-012-1482-7. Poilleux, J., and P. Lobry. 1991. “Surgical Humanitarian Magee, W. P., Jr. 2010. “Evolution of a Sustainable Surgical Missions: An Experience over 18 Years.” Chirurgie 117 (8): Delivery Model.” Journal of Craniofacial Surgery 21 (5): 602–06. 1321–26. doi:10.1097/SCS.0b013e3181ef2a6c. Prahalad, C. K. 2009. The Fortune at the Bottom of the Pyramid: ———, H. M. Raimondi, M. Beers, and M. C. Koech. 2012. Eradicating Poverty through Profits. 5th ed. Upper Saddle “Effectiveness of International Surgical Program Model River, NJ: Prentice Hall. to Build Local Sustainability.” Plastic Surgery International Rodgers, A., N. Walker, S. Schug, A. McKee, H. Kehlet, and 2012: 185725. doi:10.1155/2012/185725. others. 2000. “Reduction of Postoperative Mortality and Magee, W. P., Jr., R. Vander Burg, and K. W. Hatcher. 2010. Morbidity with Epidural or Spinal Anaesthesia: Results “Cleft Lip and Palate as a Cost-Effective Health Care from Overview of Randomised Trials.” British Medical Treatment in the Developing World.” World Journal of Journal 321 (7275): 1493. Surgery 34 (3): 420–27. doi:10.1007/s00268-009-0333-7. Ruit, S., G. Tabin, D. Chang, L. Bajracharya, D. C. Kline, and Maine, R. G., W. Y. Hoffman, J. H. Palacios-Martinez, D. S. others. 2007. “A Prospective Randomized Clinical Trial of Corlew, and G. A. Gregory. 2012. “Comparison of Fistula Phacoemulsification vs Manual Sutureless Small-Incision Rates after Palatoplasty for International and Local Surgeons Extracapsular Cataract Surgery in Nepal.” American Journal on Surgical Missions in Ecuador with Rates at a Craniofacial of Ophthalmology 143 (1): 32–38. Center in the United States.” Plastic and Reconstructive Surgery Ruiz-Razura, A., E. D. Cronin, and C. E. Navarro. 2000. 129 (2): 319e–26e. doi:10.1097/PRS.0b013e31823aea7e. “Creating Long-Term Benefits in Cleft Lip and Palate Marck, R., M. Huijing, D. Vest, M. Eshete, K. Marck, and Volunteer Missions.” Plastic and Reconstructive Surgery others. 2010. “Early Outcome of Facial Reconstructive 105 (1): 195–201. Surgery Abroad: A Comparative Study.” European Rumstadt, B., B. Klein, H. Kirr, N. Kaltenbach, W. Homenu, Journal of Plastic Surgery 33 (4): 193–97. doi:10.1007 and others. 2008. “Thyroid Surgery in Burkina Faso, /s00238-010-0409-5. West Africa: Experience from a Surgical Help Program.” Matar, W. Y., D. C. Trottier, F. Balaa, R. Fairful-Smith, World Journal of Surgery 32 (12): 2627–30. doi:10.1007 and P. Moroz. 2012. “Surgical Residency Training and /s00268-008-9775-6. International Volunteerism: A National Survey of Residents Sanders, D. L., and A. N. Kingsnorth. 2007. “Operation Hernia: from 2 Surgical Specialties.” Canadian Journal of Surgery Humanitarian Hernia Repairs in Ghana.” Hernia 11 (5): 55 (4): S191–99. doi:10.1503/cjs.005411. 389–91. doi:10.1007/s10029-007-0238-z. McCoy, D., S. Chand, and D. Sridhar. 2010. “Global Health Shrime, M. G., A. Sleemi, and T. D. Ravilla. 2014. “Charitable Funding: How Much, Where It Comes from, and Where It Platforms in Global Surgery: A Systematic Review of Their Goes.” Health Policy and Planning 24 (6): 407–17. Effectiveness, Cost-Effectiveness, Sustainability, and Role in McQueen, K. A., J. A. Hyder, B. R. Taira, N. Semer, F. M. Burkle, Training.” World Journal of Surgery, March 29. doi: 10.1007 Jr., and others. 2010. “The Provision of Surgical Care by /s00268-014-2516-0. International Organizations in Developing Countries: A Singh, A. J., P. Garner, and K. Floyd. 2000. “Cost-Effectiveness Preliminary Report.” World Journal of Surgery 34 (3): of Public-Funded Options for Cataract Surgery in Mysore, 397–402. doi:10.1007/s00268-009-0181-5. India.” The Lancet 355 (9199): 180–84. Mock, C. N., P. Donkor, A. Gawande, D. T. Jamison, M. E. Kruk, Sykes, K. J., P. T. Le, K. A. Sale, and P. J. Nicklaus. 2012. “A and H. T. Debas. 2015. “Essential Surgery: Key Messages of 7-Year Review of the Safety of Tonsillectomy during This Volume.” In Disease Control Priorities (third edition): Short-Term Medical Mission Trips.” Otolaryngology— Volume 1, Essential Surgery, edited by H. T. Debas, P. Donkor, Head and Neck Surgery 146 (5): 752–56. doi:10.1177 A. Gawande, D. T. Jamison, M. E. Kruk, and C. N. Mock. /0194599812437317. Washington, DC: World Bank. Tefuarani, N., J. Vince, R. Hawker, G. Nunn, R. Lee, and Moon, W., H. Perry, and R. M. Baek. 2012. “Is International others. 2007. “Operation Open Heart in PNG, 1993–2006.” Volunteer Surgery for Cleft Lip and Cleft Palate a Cost- Heart, Lung and Circulation 16 (5): 373–77. doi:10.1016/j Effective and Justifiable Intervention? A Case Study from .hlc.2007.05.013. Specialized Surgical Platforms 243 Troup, L. 2007. “The USNS Mercy’s Southeast Asia ———. 2011. “Ethical Concerns Regarding Operations by Humanitarian Cruise: The Perioperative Experience.” AORN Volunteer Surgeons on Vulnerable Patient Groups: The Journal 86 (5): 781–90. doi:10.1016/j.aorn.2007.10.004. Case of Women with Obstetric Fistulas.” HEC Forum van der Hoek, J. 1997. “Three Months Follow Up of IOL 23 (2): 115–27. doi:10.1007/s10730-011-9153-x. Implantation in Remote Eye Camps in Nepal.” International ———, S. D. Arrowsmith, A. T. Lassey, and K. Danso. 2006. Ophthalmology 21 (4): 195–97. “Humanitarian Ventures or ‘Fistula Tourism?’: The Venkataswamy, G. 1975. “Massive Eye Relief Project in India.” Ethical Perils of Pelvic Surgery in the Developing World.” American Journal of Ophthalmology 79 (1): 135–40. International Urogynecology Journal and Pelvic Floor Waaldijk, K. 2008. Obstetric Fistula Surgery: Art and Science: Dysfunction 17 (6): 559–62. doi:10.1007/s00192-005-0056-8. The Basics. Katsina, Nigeria: Babbar Ruga Fistula Teaching WHO (World Health Organization). 2005. State of the Hospital. World’s Sight: VISION 2020: The Right to Sight 1999–2005. Walk, R. M., T. F. Donahue, R. P. Sharpe, and S. D. Safford. Geneva: WHO. http://apps.who.int/iris/bitstream/10665 2011. “Three Phases of Disaster Relief in Haiti: Pediatric /43300/1/9241593458_eng.pdf?ua=1. Surgical Care on Board the United States Naval Ship ———. 2013. “Global Health Estimates for Deaths by Cause, Comfort.” Journal of Pediatric Surgery 46 (10): 1978–84. Age, and Sex for Years 2000–2011.” WHO, Geneva. http:// Walk, R. M., J. Glaser, L. M. Marmon, T. F. Donahue, J. Bastien, www.who.int/healthinfo/global_health_estimates/en/. and others. 2012. “Continuing Promise 2009: Assessment Wright, I. G., I. A. Walker, and M. H. Yacoub. 2007. of a Recent Pediatric Surgical Humanitarian Mission.” “Specialist Surgery in the Developing World: Luxury Journal of Pediatric Surgery 47 (4): 652–57. or Necessity?” Anaesthesia 62 (Suppl 1): 84–89. Wall, L. L. 2007. “Where Should Obstetric Vesico-Vaginal doi:10.1111/j.1365-2044.2007.05308.x. Fistulas Be Repaired: At the District General Hospital Yeow, V. K., S. T. Lee, T. J. Lambrecht, J. Barnett, M. Gorney, and or a Specialized Fistula Center?” International Journal of others. 2002. “International Task Force on Volunteer Cleft Gynecology and Obstetrics 99 (S1): S28–31. Missions.” Journal of Craniofacial Surgery 13 (1): 18–25. 244 Essential Surgery Chapter 14 Prehospital and Emergency Care Amardeep Thind, Renee Hsia, Jackie Mabweijano, Eduardo Romero Hicks, Ahmed Zakariah, and Charles N. Mock INTRODUCTION cost-effective in LMICs (Kobusingye and others 2005), leading to policies that allocate the bulk of scarce health Disease or illness can strike at any time. If the condition care resources elsewhere. is acute, or if the injury is life-threatening or limb- This chapter identifies the scale of the challenge by threatening, immediate care is needed. These time- presenting data on the burden of disease that prehospital dependent conditions that affect both adults and children and emergency care systems in LMICs could potentially may be due to medical, surgical, or obstetric conditions. address. It then describes the common health care They may result from acute injuries or illnesses or from delivery structures in these countries and assesses the exacerbations of chronic disease. literature on costs and effectiveness of such mechanisms. In low- and middle-income countries (LMICs), It closes with a discussion of future directions in research patients with such conditions may face delays of hours and policy. or even days before reaching the nearest medical facility or provider. Transportation may be provided by ambu- lance, but more often it is provided by laypersons using BURDEN OF DISEASE the handiest mode of transport available (Arellano, Mello, and Clark 2010; Khorasani-Zavareh and others The burden of disease that can potentially be addressed by 2009; Nguyen and others 2008; Ramanujam and prehospital and emergency care in LMICs (figure 14.1) Aschkenasy 2007). Health care before arrival at heath was derived from the diseases and disease conditions facilities may be provided by trained paramedics or by used by Kobusingye and others in their chapter on laypersons; quite often, however, no health care is pro- emergency medical services in Disease Control Priorities vided (Bavonratanavech 2003; Khorasani-Zavareh and in Developing Countries, second edition (Jamison and others 2009; Nguyen and others 2008; Solagberu and others 2006). The latest data for these conditions others 2009). were extracted from the World Health Organization’s In contrast to systems in high-income countries (WHO’s) Global Health Estimates (WHO 2013). Data (HICs), the prehospital and emergency medical systems for the diseases and conditions are clustered into three of LMICs are often rudimentary. Justifiably, health groups: systems in LMICs have focused on increasing access to health care by building facility-based health care • Communicable and maternal conditions systems. Such thinking is abetted by a perception that • Chronic conditions the provision of prehospital and emergency care is not • Injuries Corresponding author: Amardeep Thind, MD, PhD, University of Western Ontario, athind2@uwo.ca 245 Figure 14.1 Burden of Disease Potentially Addressable by Prehospital and Emergency Care in LMICs 200 Total addressable deaths = 24.3 million 180 Total addressable DALYs lost = 1,023 million Total addressable YLL = 932 million 160 Total addressable YLD = 91.4 million 140 120 Millions 100 80 60 40 20 0 l s ns s s ria s se e e ma es l na na e on iti ion s as as tio ea ea et ala tio ing th tio iti ise dit ab ise dis dis ec As en nd M en en td on Di nf ld int co Int rt lar M ar yi lc ea ea Un od cu he or na ch rh as ho at er ive ar mi pir ov ild at Di ns he br M es Ch rte re Isc rr Ce pe we Hy Lo Communicable and maternal conditions Chronic conditions Injuries Deaths DALYs YLL YLD Source: Data from WHO 2013. Note: DALYs = disability-adjusted life years; LMICs = low- and middle-income countries; YLD = years lived with disability; YLL = years of life lost. The communicable and maternal conditions group The injuries group includes the following: includes the following: • Unintentional: transport and nontransport injuries, • Diarrheal diseases: cholera, other salmonella infec- and forces of nature tions, shigellosis, E. coli, campylobacter, amoebiasis, • Intentional: self-harm, interpersonal violence, war, cryptosporidiosis, rotavirus, typhoid and paraty- and legal intervention phoid fevers • Lower respiratory infections: influenza, pneumococ- Our estimates suggest that out of the approximately cal pneumonia, haemophilus influenzae pneumonia, 45 million deaths in LMICs each year, 54 percent, or respiratory syncytial virus pneumonia, other lower 24.3 million, are due to conditions that are potentially respiratory infections addressable by prehospital and emergency care. This • Childhood conditions: diphtheria, whooping cough, loss translates into a staggering 1,023 million DALYs, or tetanus, measles 932 million years of life lost (YLL) to premature mor- • Meningitis tality. From a morbidity perspective, this disease burden • Malaria translates into 91.4 million years lived with disability • Maternal conditions: hemorrhage, sepsis, hyperten- (YLD). While ischemic heart disease and cerebrovas- sive disorders of pregnancy, obstructed labor, and cular disease contribute the largest number of deaths, abortion unintentional injuries are the single largest contribu- tor to the DALYs. The largest contributors to YLL are The chronic conditions group includes the following: unintentional injuries, lower respiratory infections, and ischemic heart disease. • Ischemic heart disease In this array of disease burden, maternal condi- • Cerebrovascular disease tions (hemorrhage, sepsis, obstructed labor, and abor- • Hypertensive heart disease tion) and injuries may require surgical intervention. • Asthma Nearly 19 percent (or 4.7 million) of these 24.3 million • Diabetes deaths in LMICs are surgically treatable. This number 246 Essential Surgery corresponds to nearly 28 percent—285 million—of the Figure 14.2 Regional Distribution of Deaths Addressable by Prehospital DALYs, or 25 percent—286 million—of the YLL. From and Emergency Care in LMICs a morbidity perspective, surgically treatable conditions Percent account for 38 million YLD, or 41 percent of the condi- tions that are potentially addressable by prehospital and Sub-Saharan Africa, emergency care. East Asia and 21 Figures 14.2–14.5 depict the regional variations in the Pacific, mortality, DALYs, YLL, and YLD. By virtue of their 29 large populations, South Asia and East Asia and the Pacific account for 56 percent of the addressable deaths (figure 14.2). South Asia and Sub-Saharan Africa account for 61 percent of the DALYs (figure 14.3), and Sub-Saharan Africa contributes 33 percent of the YLL Europe and (figure 14.4). Morbidity is the highest in East Asia and South Asia, Central Asia, 27 12 the Pacific, which accounts for 31 percent of the YLD (figure 14.5). Latin America and Middle East and North Africa, the Caribbean, 4 7 CURRENT DELIVERY SYSTEMS Total addressable deaths in LMICs = 24.3 million To develop and enhance the capacity to provide effective Source: Data from WHO 2013. emergency care, it is essential to view such care in the Note: LMICs = low- and middle-income countries. context of the overall health system rather than as a discrete and independent unit. Emergency care covers a range of services, from the care provided by laypersons at Figure 14.3 Regional Distribution of DALYs Potentially Addressable by the scene to that provided in a dedicated trauma facility. Prehospital and Emergency Care in LMICs Between these two phases lie the transportation systems, Percent health centers, and first-level hospitals. Patient survival depends on how well each component functions. Sub-Saharan East Asia and The organization and operation of the prehospital Africa, the Pacific, care system vary by country, but should be linked to 32 21 the local hospitals or facilities to which patients are to be transported. When prehospital transportation is poor or absent, deaths occur that could have been prevented by inexpensive procedures (Mock and others Europe and 1998). Most maternal deaths may fall into this category. Central Asia, Poor quality of care at hospitals will lead to in-hospital 8 deaths and may eventually discourage communities that might have the capacity to promptly transfer patients Latin America and to such facilities (Leigh and others 1997). Skilled and the Caribbean, motivated personnel, appropriate supplies, pharma- South Asia, 6 29 Middle East and ceuticals, equipment, coordination, and management North Africa, oriented to the needs of the critically ill all contribute 4 to making emergency care effective in reducing death and disability. Total addressable DALYs in LMICs = 1,023 million Source: Data from the WHO Global Health Estimates (WHO 2013). Note: DALY = disability-adjusted life year; LMICs = low- and middle-income countries. Tiers of Care Tier One. Prehospital care encompasses the care pro- appropriate personnel, equipment, and supplies needed vided by the community—from the scene of injury, to assess, prioritize, and institute interventions to min- home, school, or other location—until the patient imize the probability of death or disability. The most- arrives at a formal health care facility. This care should effective strategies are basic and inexpensive; the lack of comprise basic and proven strategies and the most high-technology interventions should not deter efforts Prehospital and Emergency Care 247 Figure 14.4 Regional Distribution of YLL Potentially Addressable by improve patient outcomes (Liberman and others 2003; Prehospital and Emergency Care in LMICs Sampalis and others 1994, 1995, 1997). Percent Prehospital care should be simple, sustainable, and efficient. Because resource availability varies greatly Sub-Saharan East Asia and across and within countries, different tiers of care are Africa, the Pacific, recognized. Where no formal prehospital system exists, 33 20 the first tier of care may be composed of laypersons in the community who have been taught basic first aid techniques. Recruiting and training particularly motivated citizens who often confront emergencies to Europe and function as prehospital care providers can expand this Central Asia, resource (Geduld and Wallis 2011). 8 Latin America and Tier Two. The second tier comprises paramedical per- the Caribbean, sonnel who use dedicated vehicles and equipment and 6 are usually able to get to patients and take them to hospi- Middle East and tals quickly. This second tier may involve the performance South Asia, North Africa, of advanced procedures or the administration of intrave- 29 4 nous and other medications by physician or nonphysi- cian providers, or both. This care is not always available Total addressable YLL in LMICs = 932 million in LMICs; few trained personnel and inadequate funding Source: Data from WHO 2013. make around-the-clock coverage infeasible. Note: LMICs = low- and middle-income countries; YLL = years of life lost. Although providing advanced life-saving measures in the prehospital environment may be beneficial in Figure 14.5 Regional Distribution of YLD Potentially Addressable by Prehospital and Emergency Care in LMICs some cases, these benefits may be negated if such mea- Percent sures divert scarce resources from more basic interven- tions that can benefit far larger numbers of patients (Hauswald and Yeoh 1997). In most LMICs in East Asia Sub-Saharan East Asia and Africa, and the Pacific, Latin America and the Caribbean, South the Pacific, 16 31 Asia, and Sub-Saharan Africa, high maternal and child mortality are linked to inadequate emergency care, espe- cially poor access to quality hospital care. In these set- tings, it is essential to integrate resources rather than to segregate systems for injuries and obstetric emergencies. Personnel South Asia, Most of the world’s population do not have access to 26 formal prehospital care. In LMICs, personnel are not Europe and employed for the sole purpose of dealing with medical Central Asia, 9 emergencies outside of hospitals, and transportation is Middle East and not dedicated to the task of getting patients in need of North Africa, 7 Latin America and emergency care to hospitals. the Caribbean, The following discussion introduces a scenario in 11 which mortality rate reduction could be achieved in a Total addressable YLD in LMICs = 91.4 million health system in an LIC or LMIC by a small group of para- Source: Data from WHO 2013. medics working together with a large group of trained lay Note: LMICs = low- and middle-income countries; YLD = years lived with disability. responders. The scenario uses only emergencies caused by trauma, although it is expected that both paramedics to provide good care. Even where resources allow them, and lay first responders would also save lives in medical the more invasive procedures performed by physicians or obstetric emergencies. Existing studies have not been in some prehospital settings, such as intravenous access large enough to document these effects, and they are not and fluid infusion or intubations, do not appear to included in the estimates of cost-effectiveness. 248 Essential Surgery Lay First Responders. The most basic tier of a pre- hospital system depends upon interested community Box 14.1 members who serve as volunteers to learn simple, yet effective, first aid techniques. These laypersons Critical Tasks for First Responders should also ideally be able to recognize life-threatening conditions—whether obstetric, traumatic, or medical. The World Health Organization lists six critical tasks for Examples may range from traditional birth attendants first responders: or similar persons in the community who respond to obstetric emergencies to commercial taxi and minibus • Get involved drivers who encounter traumatic injuries. Other exam- • Call for help ples include students or workers who receive training • Assess the scene for safety so that they can call for help and provide basic emer- • Assess the victim for life-threatening injuries gency care, such as cleansing wounds, stopping external • Provide immediate assistance bleeding with direct pressure, and splinting suspected • Secure essential equipment and supplies fractures or necks in suspected cervical injuries. See box 14.1. Each of these components requires training and education— Materials to train laypersons with low rates of lit- most bystanders fear getting involved, whether because eracy are available, including When Someone Is Hurt: of lack of knowledge or skills, or fear of exposure to body A First Aid Guide for Lay Persons and Community fluids, or other cultural and social barriers. Even something Workers (Varghese and Mohan 1998) and the British Red as simple as calling for help requires knowledge of available Cross’s Anyone Can Save a Life: Road Accidents and First local resources, for example, taxi or ambulance services, Aid (Fiander 2001). Context-specific first aid training private practitioners, and local police or fire departments. materials have been developed, for example, in Ghana Scene safety includes ensuring that victims do not sustain (Tiska and others 2004) and Uganda (Jayaraman and additional injuries; this component could include managing others 2009a, 2009b). These materials contain many crowds and traffic. illustrations so that learners can better understand the basic skills needed for first aid. Depending on the level of Source: Kobusingye and others 2005. interest and availability of first responders, training can last for as little as one day or can extend to several weeks. It is important that refresher training be incorpo- rated into the program to allow learners to maintain and upgrade their skills; knowledge retention should It is important to incorporate local needs so that be reassessed as well, as shown in previous studies of the local training curricula, if they exist or are to be layperson training (Jayaraman and others 2009a, 2009b; developed, can be adapted to address and meet specific Sangowawa and Owoaje 2012). An ongoing moni- considerations. For example, in a township outside Cape toring system, such as providing feedback on first aid Town, South Africa, one study shows that the content provided, should be a major component of the system. of the course was adapted to specific township needs, The WHO provides a matrix of essential knowledge, including how to handle scene safety; penetrating inju- skills, equipment, and supplies for prehospital providers ries from violence; and medical issues, including drug (Kobusingye and others 2005). Emerging evidence indi- overdose and alcohol abuse. This responsiveness to com- cates that even children as young as ages five to six years munity needs seems to have enhanced the integration of can be given basic first aid training and that their knowl- the system into the community. This system was run by a edge retention is good at six months (Bollig, Wahl, and community governing board and administered by com- Svendsen 2009; Bollig, Myklebust, and Ostringen 2011). munity organizations already involved in the township Husum and others (2003) and Husum, Gilbert, and (Sun, Shing, and others 2012; Sun, Twomey, and others Wisborg (2003) demonstrate that laypersons who are 2012; Sun and Wallis 2011). given first aid skills can effectively respond to emer- A study of midwives and traditional birth atten- gencies in communities with high trauma burdens. In dants in rural Cambodia also finds that a prehospital Ghana, it was demonstrated that taxi and minibus driv- training course could significantly improve knowledge, ers trained in first aid could provide effective prehospital compared with precourse levels, of interventions such care (box 14.2) (Mock and others 2002). This experience as uterine packing to control hemorrhage and suturing has been replicated in other settings (Geduld and Wallis tears (Chandy, Steinholt, and Husum 2007). A study 2011; Jayaraman and others 2009a, 2009b). from northern Iraq also shows a mortality benefit of Prehospital and Emergency Care 249 Box 14.2 Improving Trauma Care in the Absence of a Formal Ambulance System in Ghana Background: The efficacy of a program that builds on the aid in comparison to what was reported before the course existing, although informal, system of prehospital trans- (table B14.2.1): portation in Ghana was assessed. In Ghana, the majority of injured persons are transported to the hospital by some Table B14.2.1 Provision of First Aid before and after type of commercial vehicle, such as a taxi or bus. Training Methods: A total of 335 commercial drivers were trained Percent of respondents using a six-hour basic first aid course. The efficacy of this Component of first aid Before After course was assessed by comparing the process of prehos- Crash scene management 7 35 pital trauma care provided before and after the course, as determined by self-reporting from the drivers. Airway management 2 35 The course was conducted with moderate amounts of Bleeding control 4 42 volunteer labor and gifts in kind, such as transportation Splint application 1 16 to the course. The actual cost of the course amounted to Triage 7 21 US$3 per participant. Conclusions: Even in the absence of a formal emergency Results: Follow-up interviews were conducted on 71 of medical system, prehospital trauma care can be improved the drivers a mean of 10.6 months after the course. In the by building on existing, although informal, prehospital interviews, 61 percent indicated that they had provided transportation. first aid since taking the course. There was considerable improvement in the provision of the components of first Source: Mock and others 2002. first responder training (Murad and Husum 2010). Lay • Systems-level developments, such as a complex responders are likely to have an impact when the burden regional call management center and an integrated of emergencies from injuries and other causes is high. communication network (Sasser and others 2005). Attrition of both the responders and the skills is a con- cern unless they are frequently used. Transportation and Communication Paramedical Personnel. In most middle-income After basic first aid has been provided and para- countries (MICs) and some cities in low-income coun- medical personnel have been deployed to the scene, tries (LICs), trained paramedical personnel provide transportation to the nearest and most appropriate prehospital care (Mock and others 1998; Tannebaum health facility is critical. Efficient communication and others 2001). These basic and advanced person- is vital to ensure that contact can be made between nel are often paid ambulance personnel or, in some those who know that patients need help and the med- cases, specially designated cohorts of fire or police ical personnel who provide it. Although most LMICs personnel who desire to acquire more medical skills. have poor telecommunications infrastructure, cellular They receive professional instruction in both theory mobile phones are rapidly being adopted by individ- and practice, ranging from 100 to 400 hours (Sasser uals and offer an opportunity to bypass the need for and others 2005). These personnel can be further traditional communications services (Kobusingye and categorized as follows: others 2005). In most of East Asia and the Pacific, South Asia, and • Those who are able to offer basic prehospital trauma Sub-Saharan Africa, where commercial ambulances care, including scene management, rescue, stabiliza- may not be available, a range of options exists and can tion, and the transport of injured patients be further developed. These options include private • Those who can provide more advanced care, includ- motorized or nonmotorized vehicles (Joshipura and ing services such as invasive airway techniques, as others 2003; Kobusingye and others 2002). In Malawi, well as transportation has even been achieved with bicycle 250 Essential Surgery ambulances (Lungu and others 2001). The establish- With close attention to keeping costs sustainably ment of rudimentary ambulance systems has been low, paramedical personnel could be introduced in successful even in low-resource settings such as Niger, large urban areas where they do not function at including an intervention using solar-panel-powered present. They could be stationed at dispatch sites with radios to connect health centers with the second-level dedicated vehicles, fast communications with area hospital (Bossyns and others 2005). hospitals, and links with other emergency services, When ambulance services do exist in East Asia and such as fire and police departments. The communities the Pacific, South Asia, and Sub-Saharan Africa, they served by the system should have a well-known and are often limited to transferring patients between health rapid method of calling the paramedical teams when facilities rather than from the scenes of injury or from an emergency arises. Both lay and paramedical teams homes (Joshipura and others 2003). In MICs, however, require ongoing refresher courses so that their skills do ambulance services are a major component of existing not deteriorate. emergency care systems (Arreola-Risa and others 2000; Where paramedical personnel have already been inte- Mock and others 2002). Their presence reduces the grated into the emergency care system, their numbers interval between the recognition of an emergency and and organization—location, training, deployment, and the arrival of patients at the hospital (Ali and others monitoring—should be enhanced to improve response 1993, 1997; Arreola-Risa and others 2000). times and patient outcomes, especially for cardiac and The effectiveness of well-placed dispatch sites has obstetric emergencies. It is essential that such systems be also been demonstrated in urban populations, where the evaluated, not only with metrics that assess the availabil- vehicles and personnel can be optimized. Shorter pre- ity of services, for example, the number of units on duty hospital times, in general, are considered an important or number of sites of ambulance dispatch, but also their parameter of the quality of prehospital care. These times cost-effectiveness. have the following components: The recommended ratio of one ambulance unit for every 50,000 people suggested by McSwain (1991) results • Notification time is the time elapsed from the occur- in response times as low as four to six minutes. The ratio rence of the injury or the recognition of severe illness does not distinguish between basic and advanced life- until the prehospital or ambulance system is notified. support capabilities. Traffic congestion, poor maps, and • Response time is the time elapsed from notification poor road signs may all increase the response time in cit- until arrival of an ambulance to the site of the ill or ies with poor infrastructure. In Monterrey, Mexico, one injured person. unit per 100,000 people manages an average response • Scene time is the time elapsed from the arrival of pre- time of 10 minutes. Hanoi, Vietnam, with one unit for hospital providers on the scene until departure. every 3 million people, has an average response time of • Transport time is the time elapsed from departure 30 minutes (Mock and others 1998). from the scene until arrival at the hospital or other Where paramedical services exist in parallel to lay treatment facility. responder services, the two could be integrated under the same organizational unit. The paramedical staff Notification time is influenced by the availability of will be more successful in urban areas, where distances telecommunications. Response time is influenced by the between dispatch sites, communities served, and hospi- capabilities of a dispatch center to handle emergency tals are short. Other enabling factors are good telecom- calls, and especially by the geographic distribution of munications; rapid and dedicated transportation; and sites of ambulance dispatch. The greater the number of coordinating capacity among the community, hospitals, ambulance stations and the wider their distribution, the and other emergency services. shorter are the response times. Geographic distribution and associated response times can be improved in some circumstances by using Equipment and Supplies a tiered or layered response system. This system requires The provision of appropriate equipment and supplies a relatively larger number of basically trained and is essential; previous studies have shown that educa- equipped first responders with wider geographic distri- tional interventions to paramedics are less effective if bution, and a smaller number of centrally located and equipment availability limits the ability of these trained more highly trained and equipped second responders. personnel to implement their knowledge (Arreola-Risa This approach allows the first responders to respond and others 2007; McClure and others 2007). The WHO more rapidly and involves second responders only provides a comprehensive list of equipment and supplies if needed. needed for prehospital providers, which is shown in Prehospital and Emergency Care 251 annex 14A (Sasser and others 2005). Despite adequate Life Support training (Ali and others 1993). Life-saving provision, the utilization of appropriate equipment obstetric skills training contributed to a reduction in in LMICs is variable; a study from Malaysia finds that maternal deaths. In Kebbi state in Nigeria, training led oxygen delivery devices were used in 45 percent of to a reduction in case-fatality rates to 5 percent from ambulance runs, the scoop stretcher in 29 percent, and 22 percent among women with obstetric complications wound dressings in only 23 percent (Ismail and others (Oyesola and others 1997). 2012). Similar trends were observed in other sites at which the intervention was implemented (Oyesola and others 1997). Emergency Triage Assessment and Treatment has HEALTH FACILITY–BASED SUBSYSTEMS been used in many countries to improve pediatric emer- gency care (WHO and UNICEF 2000). Other examples Health facility–based subsystems refer to the level within are Primary Trauma Care, which is a trauma manage- the health care system at which appropriate definitive ment course to train doctors and other health workers care is delivered. Formal health facilities vary immensely in first-level hospitals and remote locations (Wilkinson across and within countries. In some countries, this sub- and Skinner 2000), and Advanced Life Support in system may be a regional or second-level hospital with Obstetrics (http://www.aafp.org/also). These courses specialists; in others, a district or first-level hospital with have been beneficial in standardizing protocol-based general practitioners or nonspecialist doctors; and in emergency care, but their outcome evaluations are still still others, a health center with nonphysician clinicians. awaited. Box 14.3 describes public and private initiatives In some LMICs, some types of emergency medical care, to facilitate training in India. for conditions such as acute diarrhea or severe malaria, may be effectively delivered at a health center staffed by nonphysician clinicians. However, such a facility will Equipment and Supplies be inadequate for the management of severe multiple A list of resources for emergency care required at dif- injuries or obstructed labor. The triage process in the ferent levels is available in annex 14B. This template is prehospital subsystem should determine which patients flexible; countries can customize it to suit local con- receive transportation to which facility rather than ditions such as existing facility levels and prevailing merely transportation to the nearest facility. Precious burden of emergency disease conditions. Equipment time and lives may be lost when patients are taken to and supplies at each level should match the knowledge facilities where the desired care is not available. and skills of the personnel available to use them. The goal of an effective emergency medical system is One study provides sobering evidence that one of the the provision of emergency care to all who need it. This key barriers to the provision of emergency and surgical section presents guidelines on the necessary inputs. Two of care in Sub-Saharan Africa is lack of basic infrastruc- the components in hospital emergency care are discussed ture; in an assessment of five countries (Ghana, Kenya, in more detail: training, and equipment and supplies. Rwanda, Tanzania, and Uganda), for example, only 22 percent to 46 percent of hospitals at all levels had Training dependable running water and electricity. Not one sur- veyed hospital met the minimum WHO standards for Most in-service training for emergency care profes- the provision of emergency and surgical care, suggesting sionals working in hospitals is designed to address a that these infrastructure investments must be made in particular problem, such as severe injuries, emergency conjunction with investments in the human workforce pediatrics, or obstetric emergencies. Yet because of the (Hsia and others 2012). resource constraints in LMICs, the same personnel will be confronted with all of these problems. Few courses in emergency care have been rigor- COSTS AND EFFECTIVENESS ously evaluated (Black and Brocklehurst 2003). The Advanced Trauma Life Support course for physicians Costs has resulted in improved patient outcomes in some set- There is a paucity of literature delineating the costs of tings, although it may be too expensive for most LMICs providing prehospital and emergency care, especially in and inappropriate in settings in which the majority LMICs. A few studies examine the costs of specific com- of patients are not seen by physicians. In a third-level ponents of this system, but none evaluates the actual cost hospital in Trinidad and Tobago, injury mortality was of the entire system. Reporting on the 10-year results reduced by 50 percent following Advanced Trauma of the implementation and expansion of a trauma 252 Essential Surgery Box 14.3 Emergency Care Training in India The training of personnel working in emergency medical GVK Emergency Management and Research Institute services is crucial to the success of the efficient delivery (EMRI) in Hyderabad. The first internationally affiliated of care. Evidence exists to support the usefulness of life- paramedic program, the Post-Graduate Program in support training for emergency caregivers in low- and Emergency Care, began in 2007 to develop advanced clin- middle-income countries. Courses such as Advanced ical educators, who are essentially paramedic-instructors, Trauma Life Support are available and well established with 15 two-week modules that include simulation, inter- in some high-income countries and middle-income active case-based studies, and distance learning. countries. In most low-income countries, however, such training is not available, mainly because of prohibitive Prehospital Research Center costs. The three-day Advanced Trauma Life Support In 2008, the Post-Graduate Program in Emergency Care course costs, on average, US$700 per trainee and is taught also began a prehospital research center at the GVK EMRI to 6 to 20 trainees at a time. campus in Hyderabad, India, and conducts research on obstetric emergencies, chest pain, vehicular trauma, gas- National Trauma Management Course trointestinal emergencies, seizures, poisoning and suicide The National Trauma Management Course is a two-day attempts, burns, shortness of breath, and nonvehicular course developed in India by the Academy of Traumatology trauma. The program was turned over to GVK EMRI in with the help of international peers. The curriculum takes July 2009 and continues to train Indian paramedics. In into account local conditions and capabilities. The cost is May 2013, more than 5,700 ambulances were providing US$50 per trainee; local trainers teach 100 trainees at a prehospital care to more than 750 million Indians, includ- time. Animal specimens, instead of expensive commercially ing 2,121,000 medical emergencies a day, making it the produced mannequins, are used to teach life-saving proce- largest ambulance system in the world. dures. More than 2,000 health professionals were trained in less than three years. The course has become a national Prehospital Emergency Care Protocol training standard for immediate trauma care in India. Another output from the Stanford-Apollo EMT Intermediate Training has been a Prehospital Emergency Care Protocol, published in 2012, for physicians, emer- Private Initiatives gency medical technicians, and educators. These proto- In addition, several private initiatives have increased cols did not exist before March 2011. The goals of these the number of formally trained prehospital paramed- unique protocols are to ensure countrywide uniformity ics who have graduated to become Advanced Cardiac and consistency of prehospital care and to espouse Life Support/Basic Life Support instructors. One exam- evidence-based practice related to ambulance systems ple is the Stanford-Apollo EMT [Emergency Medical (when this evidence is available). More than 5,000 proto- Technician]-Intermediate Training program at Apollo col manuals have been printed and placed in ambulances Hospital in Hyderabad and Chennai, in conjunction with and call centers throughout India. the Stanford School of Medicine (Stanford, California). A second, also in conjunction with Stanford, is the Sources: Mahadevan and others 2009; Mantha and others 2009. system (consisting of trained laypersons, paramedics, In their modeling exercise, they estimate system costs of and two trauma referral centers) in north and central establishing and running two types of prehospital and Iraq, Murad, Larsen, and Husum (2012) note that the emergency care systems: per patient treatment costs—medical treatment, evacu- ation, data gathering, and quality control—ranged from • One in which trained lay responders and paramedics US$130 to US$180. provide care Perhaps the best exercise to date in estimating • One in which staffed community ambulances provide system-level costs is Kobusingye and others (2006). care Prehospital and Emergency Care 253 For a population of 1 million, they assume that reduced significantly after trauma system implementa- the trained laypersons and paramedics system will tion (Kane and others 1992; Mullins and others 1994; require 7,500 lay responders, with 2,500 trained on a Rutledge and others 1992). Similar evidence is emerging rolling basis. The system would also require 50 trained from Iraq, where the implementation and expansion of a paramedics annually. Training costs would include a trauma system in north and central Iraq reduced trauma classroom, copies of curricula, time costs, and remu- mortality over a 10-year period to 4 percent from neration of trainees and trainers. The training (and its 17 percent (Murad, Larsen, and others 2012). A study costs) would be repeated every three years to maintain from Portugal shows a reduction in mortality of approx- skill levels. Paramedics would be equipped with basic imately 50 percent in trauma patients who received some kits consisting of a stethoscope, gloves, bandages, and form of treatment in the prehospital phase (Gomes and splint materials. Trained laypersons and paramedics others 2010). Work done in Cambodia and northern would volunteer their services after training. Given Iraq demonstrates a 9 percent reduction in mortality these assumptions, Kobusingye and others’ (2006) best among trauma victims after the institution of a system estimate of cost was US$62,923 or US$0.06 per capita comprising first-level responders and trained paramed- (ranging between US$30,254 and US$126,475). ics (Husum and others 2003); this study forms the basis Jayaraman and others (2009b) build on this frame- of the cost-effectiveness analysis of trained laypersons work to estimate the costs of scaling up their layperson and paramedics by Kobusingye and others (2006). first aid training pilot to cover Kampala, Uganda. They Experience from the northern Iraq system suggests assume that 9,000 trainees (a range of 6,000 to 12,000) an even greater impact of providing prehospital care to are required to cover the city’s 1.2 million residents. trauma patients. Murad and others (2012) report a mor- Using Kobusingye and others’ (2006) costs and costing tality rate of 8 percent in road traffic accident patients assumptions, their base case scenario (of training 9,000 managed onsite and evacuated by trained first responders trainees over three years) results in an annual cost of and paramedics; the mortality rate is 40 percent in the US$47,854 or US$0.12 per capita; these costs increase patients admitted without any prehospital care. Similarly, to US$143,854 annually or US$0.36 per capita when the a review of eight studies on prehospital care in LMICs to first aid kit and its restocking (US$16 each) are factored attempt to determine aggregate risk reduction for mortal- in (Jayaraman and others 2009b). ity, injury severity, and transport time found a 25 percent For a system that relies on staffed ambulances, reduction in the risk of mortality with the implementation Kobusingye and others (2006) assume that an ambu- of a prehospital system; treatment effects were enhanced lance unit serves 30,000 people and has a staff of in rural settings. In addition, response times were reduced seven paramedic-drivers. Accordingly, 33 such units are 66 minutes overall in rural settings, and 6 minutes in required for a population of 1 million; in addition, a urban settings (Henry and Reingold 2012) (box 14.4). supervisor will oversee three ambulance units per year. An ambulance-based system can potentially save Ambulances can be purchased and retrofitted locally; 700 lives annually: 200 from ischemic heart disease, they are assumed to have a useful life of nine years 200 from obstetric emergencies, and 300 from trauma and to be driven 20,000 kilometers every year. Under (Kobusingye and others 2006). these assumptions, the authors estimate the yearly cost Evidence from LMICs suggests that providing basic of such a system in an urban area to be approximately life support (BLS) training to ambulance personnel can US$1.27 million or US$1.27 per capita (a range of reduce trauma mortality, as evidenced by a decrease in US$0.79 million to US$2.15 million), with a rural ambu- mortality to 10.6 percent from 15.7 percent in Trinidad lance system costing three times as much. when such a system was established (Ali and others 1993). However, other LMICs are gravitating toward providing advanced life support (ALS) training to these personnel, Effectiveness rather than BLS training. This shift is, in part, due to Although a prehospital and emergency care system can evidence from HICs that attributes a reduction in trauma respond to a wide range of conditions, most studies in mortality to ALS training (Kirsch 1998; Reines and others the literature report outcomes pertaining to trauma, 1988). A meta-analysis of 18 studies finds that provision with a small but growing body of literature on the effec- of ALS care to nontraumatic cardiac arrest patients could tiveness of first responders and paramedics. increase their survival; it also finds no difference in sur- Increasing evidence indicates the benefits of a well- vival in trauma patients who received ALS versus those functioning prehospital care system. Literature from receiving BLS (Bakalos and others 2011). Similarly, a high-income countries (HICs) suggests that for patients Cochrane review did not find any differences in mortality with serious injuries, preventable trauma deaths are among trauma victims cared for by BLS-trained versus 254 Essential Surgery Box 14.4 Training Community Paramedics and First Responders: Experiences from Iraq and Cambodia In northern Iraq (Sulaymaniyah Governorate) and north- A study has documented the benefits of the first responder west Cambodia (Battambang Province), two conflict program separately from the paramedic program, show- areas with extensive minefields, the estimated mortality ing that mortality rates were 9.8 percent in those seen rates for mine casualties were approximately 40 percent. by first responders, and 15.6 percent in those with only Based on the concept of the Village University, layper- paramedic contact (difference of 6 percent, 95 percent sons recommended by their village leaders were trained confidence interval of 2 percent to 10 percent). Of those by outside trainers in basic prehospital life-support and with an injury severity score greater than 15, mortality life-saving skills—for example, keeping airways open and was lower (38 percent) in those treated by first responders, stopping bleeding. In 1997−99, a core group of 44 trainees compared with 51 percent in those only seen by para- received 150 hours of training in basic airway, breathing, medics (95 percent confidence interval on the difference and circulation techniques; each trainee subsequently of 1 percent to 24 percent). In addition, those seen by trained 50 village first helpers in two-day training sessions only first responders had lower mortality rates than those 6 to 12 months after the initial training. seen by first responders and then paramedics (4.7 percent versus 13.4 percent, 95 percent confidence interval of By the end of the fifth year of the program, 135 com- 3 percent to 15 percent). This is likely because shorter munity paramedics and 5,200 first responders had been travel times allow for direct handoff from first responder trained. Refresher courses were also provided for the to facility, rather than longer transit times that allow for paramedics and first responders. a handoff to a paramedic who then brings the patient to Care had been provided to 1,061 trauma victims, with a treating facility. In other words, these studies show that a reduction in the mean response time from 2.9 hours mortality can be lower if the injured person is treated (1997) to 1.8 hours (2001) from time of injury to initially by a first responder before a paramedic arrives first medical contact, although there was no change when travel times are long. in mean prehospital transit time. Mortality for these Finally, the effect of this two-tier prehospital rural trauma trauma patients was reduced from a pre-intervention system with first responders and rural paramedics has level of 40 percent to 8 percent postintervention at the been shown to have benefits for patients in road traffic final stage. accidents with long transport times, with a mortality rate Further studies have shown that the time from injury to of 8 percent in the intervention areas, compared with first medical help decreased even more, to 0.6 hours, and 44 percent in the control areas. time of injury to hospital decreased to 2.8 hours from 9.6 Source: Husum and others 2003; Murad and Husum 2010; Murad and others 2012; WHO during the period 1997−2004. These studies have shown a 2010; Wisborg, Murad, Edvardsen, and Brinchmann 2008; Wisborg, Murad, Edvardsen, high retention of paramedics (72 percent) over the period. and Husum 2008. ALS-trained ambulance personnel (Jayaraman and Sethi analysis of ALS-level interventions in Monterrey and 2010). On the contrary, some evidence suggests that care San Pedro, Mexico, showed no significant improvements provided by ALS-trained personnel might have worse in the mortality rates of transported patients, versus a outcomes (Stiell and others 2008). BLS training project, which did reduce mortality from This evidence suggests that an advanced prehospital 8.7 percent to 4.7 percent (Arreola-Risa and others 2004, emergency medical system should never be developed at 2007; Hauswald and Yeoh 1997). Another disadvantage the expense of a broad base of basic prehospital care. ALS of ALS training for lay personnel is that the Mexican interventions benefit a small subset of critically ill patients study showed low pass rates for students in the advanced who may require a large investment of resources that may cardiac life support course; only 29 percent passed, be less cost-effective. Some experts recommend that the compared with more than 80 percent who passed the development of these more advanced systems be delayed BLS courses. This result could have been due to the rela- until additional evidence demonstrates that improved tively low levels of schooling for the majority of medics outcomes can be gained by such systems. Indeed, an (Arreola-Risa and others 2007). Prehospital and Emergency Care 255 Cost-Effectiveness communications equipment for the prehospital and Table 14.1 summarizes the cost-effectiveness estimates emergency care system. of Kobusingye and others (2006). In a population of From a methodological perspective, certain assump- 1 million, a system of trained laypersons and paramed- tions are also important. Kobusingye and others (2006) ics is highly cost-effective at US$170 to avert one death; assume that the trained laypersons and paramedics an ambulance-based system in an urban area costs would offer their services on a volunteer basis. Both US$1,818 to achieve a similar result. A different metric studies apply the outcome on a global basis, without (cost per life year gained) yields similar results; the taking into account regional variations. Systemic costs, trained layperson and paramedic system costs US$7 per or the additional burden to the health care system from year of life gained; the urban ambulance–based system additional visits, are not factored into their calcula- costs approximately 13 times as much. tions. The ambulance system is assumed to have the Table 14.2 is a similar synopsis of an analysis of same effectiveness in both rural and urban areas; the the cost-effectiveness of scaling up a pilot layperson authors caution that “substantial uncertainty remains first aid training program to cover all of Kampala over actual effectiveness of the interventions in emer- (Jayaraman and others 2009b). Mortality reductions gency medicine” (Kobusingye and others 2006, 1271). resulting from this training program were assumed to be 15 percent (based on Husum and others 2003); the authors repeat the calculations using a more conser- FUTURE DIRECTIONS vative 7.5 percent reduction to perform a sensitivity This section summarizes considerations for LMICs as analysis. they develop their prehospital and emergency systems However, there are caveats. The inputs in Kobusingye and highlights the gaps in evidence that hamper effective and others (2006) were based on 2001 data; the results policy making. are reported in 2001 U.S. dollars and may not be reflec- tive of today’s economic environment. For example, the wide availability of cellular phones has revolutionized Systems Organization both the availability and the cost of communications Effective emergency medical systems require careful plan- in many LMICs, decreasing the need to have dedicated ning, implementation, coordination, and communication Table 14.1 Summary of Cost and Effectiveness of Interventions U.S. dollars Intervention Trained lay first responders and Staffed community Staffed community paramedic responders ambulance, urban ambulance, rural Cost per 1 million population 62,923 1,272,705 3,827,376 Cost per death averted per 1 million population 170 1,818 5,468 Cost per life year gained per 1 million population 7 94 284 Source: Kobusingye and others 2006. Note: Figures are unweighted averages. Table 14.2 Cost-Effectiveness of Scaling Up Lay Person First Aid Training in Kampala U.S. dollars Estimated 240 deaths averted (15 percent) Estimated 120 deaths averted (7.5 percent) Cost per life year Cost per life year Cost per death averted saved Cost per death averted saved Base case 598 25 1,196 50 Base case + US$32 supplies 1,798 75 3,596 150 Source: Jayaraman and others 2009b. 256 Essential Surgery with local communities. The respective components audits or other processes to ensure quality need to be should be linked to ensure that the entire system operates incorporated to maintain and improve patient care. as a unit. A coordinator should be responsible for mon- The emergency medical system should include a quality itoring and coordinating all emergency medical care in management component that is simple and continuous the community or district; this coordinator should work and that allows for rapid changes. with a central committee that reflects and represents the Expensive technology and equipment and specialists components. should not be advocated for the urban privileged at the Coordination costs are important and should not expense of the majority of the rural poor. The most dif- be overlooked in the development of a new emergency ficult decisions concern balancing funds invested in the management system. Such costs include the salary of the emergency care capacity of first-level and second-level coordinator, an efficient telephone or communication centers against support for referral and transportation system, vehicle and fuel costs, and a budget to organize networks to feed third-level centers. These decisions are meetings of stakeholders at least twice a year (Bazzoli, too variable and too system specific to allow uniform Harmata, and Chan 1998; Nurok 2001). policy prescriptions. Two principles can help inform these difficult decisions: Financing • Collect data on costs, capacities, and outcomes. To optimize outcomes, emergency care systems in LMICs • Enhance the integration of the emergency care to should require explicit consideration of how poor peo- improve its functioning and lead to wiser investment ple interact with these services and how barriers to acute allocations. care can be overcome. Issues of access become critical because the lack of money often keeps people from Legislation using emergency services. Direct payment of costs for The issues discussed in this chapter form the rationale transportation, medical treatment, and medications may for countries to enact specific legislation addressing well constitute a major barrier for poor people in every the provision of emergency care. This area requires country. Emergencies frequently cripple individuals and major cooperation between public health and the law, families financially in these communities, often for many which together provide the legal framework for ensur- years. At the same time, evidence indicates that when ing that all individuals who need emergency care can services such as ambulance transport are provided, fam- receive it, irrespective of their personal characteristics ilies are willing to pay (Bose and others 2012). or their ability to pay. Having laws that protect trained Financial protection for emergency health care in individuals and laypersons as they provide such care is LMICs is a necessity that has not received adequate also important. Box 14.5 provides an example of how attention. The goal of such protection is to ensure that legislative action can help the coordination and creation individuals and families do not spiral down the pathway of emergency care, from prehospital to hospital settings. to abject poverty as a result of obtaining needed health care. Such financial protection may be achieved by a number of different means, including community financ- Research and Development Agenda ing (Ande and others 1997; Desmet, Chowdhury, and The research and development priorities for emergency Islam 1999; Macintyre and Hotchkiss 1999). Community care are challenging to define because emergency care loan funds to cover transportation and other require- is a neglected area of research in LMICs, and the needs ments for emergencies, especially for obstetrics, have are great. As a neglected topic, emergency care is part of been explored with mixed results (Essien and others the “10–90” gap of health research: less than 10 percent 1997; Shehu, Ikeh, and Kuna 1997). It is plausible that of global research investments are for problems affect- these approaches can help overcome barriers to accessing ing 90 percent of the world’s population (GFHR and emergency medical services and should be considered. WHO 2002). Research and Development Approach. The spectrum Documentation and Quality Assurance of research required is diverse and may be more easily Ensuring the quality of emergency care for all people understood with the help of the schematic in table 14.3. is critical. Lack of funds, lower-paying jobs, social class distinctions, ethnicity, and other affiliations make the • The rectangle is a schematic representation of the already vulnerable poor susceptible to receiving sub- totality of the global burden of disease that can standard care. Systematic documentation and periodic potentially be addressed by emergency care systems. Prehospital and Emergency Care 257 Box 14.5 Emergency Medical Services Coordination and Legislative Efforts in Colombia Because of the heavy burden of trauma in Colombia, hospitals; ACAPH advocated that prehospital care and numerous cities had separate emergency medical systems, training be included in the national guidelines. with varying protocols, training, and personnel. Some These efforts ultimately resulted in the creation of the cities had volunteer systems; others had publicly funded Prehospital Trauma Life Support and Basic Trauma firefighters or other civil employees. This lack of central- Life Support course as well as the National Medical ized organizational structure made it almost impossible Prehospital Guidelines in 2005, which ACAPH devel- to coordinate mass-casualty events across cities, such as oped in conjunction with the Health Sciences Institute in 1985 with the eruption of the Nevado del Ruiz volcano, (Instituto de Ciencias de la Salud) and the Ministry of which was responsible for the deaths of more than 22,000 Social Protection. Integration of prehospital and emer- individuals. gency medical services into national legislation contin- This challenge prompted a response to standardize ued in different resolutions to include various levels of training. Legislation mandated additional funds for the ambulance services, which evolved into a separate decree coordination of and authority over prehospital systems. for auditing the quality of care and accreditation of To standardize processes nationwide, the Colombian ambulance services. Prehospital Care Association (ACAPH, Asociación The results of this national legislation have prompted six Colombiana de Atención Prehospitalaria) was consti- national universities to create formal prehospital career tuted from stakeholders, including physicians; private training programs, such as the National Emergency and public ambulance services; hospital administrators; Medical Services Technologist Curriculum. In addi- university researchers; and volunteer groups, such as the tion, coordination across emergency medical units has civil defense, Red Cross, firefighters, and volunteer rescue improved, as evidenced in the response to the 2008 agencies. The ACAPH developed standardized curricula Nevado del Huila volcano eruption. Although it is dif- for nurse assistants, emergency technicians, and emer- ficult to completely attribute the decline in mortality to gency technologists. In addition, the ACAPH secured these programs and legislation, injury deaths decreased increased governmental legislation. At the time, there was from 44,000 in 2002 to 28,000 in 2007. already a quality plan with standardized protocols for hospital-based health care staff and coordination across Source: WHO 2010. • A portion of this potential burden is being addressed The schematic representation in table 14.3 is useful or reduced by existing interventions, defined by box A. for demonstrating two critical needs: • If the efficiency of current interventions were enhanced and their coverage increased, then another portion of • Essential research on emergency care in LMICs the burden defined by box B could be addressed; this • A diverse set of research studies and approaches to increase in efficiency will require operations research, reduce the burden that emergency care systems can policy research, and social science research. address • If existing interventions that have not been imple- mented because of their high costs were made more cost-effective, then another portion of the burden Priority Setting defined by box C could be reduced. This process of Setting priorities for the research and development of making interventions more cost-effective will require emergency care systems needs to be a region-specific, economic analysis and clinical research in many rather than a country-specific, process. No current list instances. exists of global research and development priorities, • Finally, some portion of the burden has no existing reflecting the need for more attention and investment in interventions; basic and clinical research are required this area. This chapter does not prescribe a list of issues to develop and pilot interventions that can address or topics for global research and development efforts, other determinants of the emergency care–related but rather highlights the gap in global research and burden in the future. development and suggests possible issues and topics 258 Essential Surgery Table 14.3 Burden of Disease Potentially Addressed by Emergency Medical Services D: No emergency care interventions currently available to address this burden A: Currently implemented emergency care B: Existing emergency care interventions C: Potential emergency care interventions that interventions that are addressing this that are able to address existing burden if could address this burden if they were made burden efficiency enhanced cost-effective Source: Kobusingye and others 2006. that may be broadly relevant to LMICs for these efforts This chapter highlights not only the urgent need for in the short to medium term. more attention to emergency care in LMICs, but also Methods for setting research priorities in the points out an opportunity for these countries to define health sector are available, such as the Combined better emergency care systems for their needs. In pro- Approach Matrix promoted by the Global Forum for moting the systematic development of evidence-based Health Research (GFHR and WHO 2002), and the emergency care systems, LMICs could help define more Essential National Health Research process promoted effective and more cost-effective emergency systems by the Council on Health Research for Development. than currently exist in HICs. This opportunity should Countries and regions can use these approaches not be lost as a result of political inattention or lack of to help develop their individual emergency care funds; international and national stakeholders should research agendas. move forward to stem the preventable loss of life from The review of evidence available in the field of the lack of emergency care. emergency care as applicable to LMICs reveals many Too little is known about the true extent of the gaps in global knowledge. Following from the presen- need for emergency care, the design that would work tation in table 14.3 is the need to better understand well for different communities and populations, and the the epidemiology of those conditions that can be costs and benefits of delivering emergency care. These addressed by emergency care systems in LMICs and gaps call for more investment in the research, develop- which interventions in place address them. There is ment, and implementation of emergency care, especially little knowledge of how to enhance the efficiency of in LMICs. Universal emergency care is consistent with these existing interventions and reduce their costs. the right to health care; by definition, emergency care Most important, the lack of intervention trials in is a matter of life and death. It is essential to endeavor LMICs creates a major research priority for the field to ensure that prompt, appropriate care is available in of emergency care. Well-designed, locally appropri- critical moments when delays in care—or the delivery ate interventions that establish their effectiveness are of inappropriate care—could mean the loss of lives. urgently needed and should include both interven- tions that may be available in HICs as well as new ANNEXES interventions. Economic analysis is another area for major research input in the field of emergency care, The annexes to this chapter are as follows. They are available at where cost and cost-effectiveness information from http://www.dcp-3.org/surgery: LMICs is scant. These gaps reflect the need for a more • Annex 14A. Matrix of Essential Knowledge, Skills, Equipment, and Supplies for Prehospital Providers systematic analysis of where emergency care research • Annex 14B. Essential Resources for the Delivery of investments should be directed for optimal results Emergency Care in Hospitals in the future. NOTE CONCLUSIONS: PROMISES AND PITFALLS The World Bank classifies countries according to four income Emergency care is a critical and integral component groupings. Income is measured using gross national income of national health systems in LMICs. Governments (GNI) per capita, in U.S. dollars, converted from local currency and ministries of health in these countries need to pay using the World Bank Atlas method. Classifications as of July specific attention to the development of emergency 2014 are as follows: care and to ensure that their evolution is both evi- • Low-income countries (LICs) = US$1,045 or less in 2013 dence based and appropriate to their national needs. • Middle-income countries (MICs) are subdivided: More important, the context and implementation of • Lower-middle-income = US$1,046 to US$4,125 emergency care should improve health equity and not • Upper-middle-income (UMICs) = US$4,126 to US$12,745 widen existing health disparities. • High-income countries (HICs) = US$12,746 or more Prehospital and Emergency Care 259 REFERENCES Bossyns, P., R. Abache, M. S. Abdoulaye, and W. V. Lerberghe. 2005. “Unaffordable or Cost-Effective?: Introducing an Ali, J., R. Adam, A. K. Butler, H. Chang, M. Howard, and others. Emergency Referral System in Rural Niger.” Tropical 1993. “Trauma Outcome Improves Following the Advanced Medicine and International Health 10 (9): 879–87. Trauma Life Support Program in a Developing Country.” Chandy, H., M. Steinholt, and H. Husum. 2007. “Delivery Life Journal of Trauma 34 (6): 890–98; discussion 898–99. Support: A Preliminary Report on the Chain of Survival for Ali, J., R. U. Adam, T. J. Gana, and J. I. Williams. 1997. “Trauma Complicated Deliveries in Rural Cambodia.” Nursing and Patient Outcome after the Prehospital Trauma Life Support Health Sciences 9 (4): 263–69. Program.” Journal of Trauma 42 (6): 1018–21; discussion Desmet, M., A. Q. Chowdhury, and M. K. Islam. 1999. 1021–12. “The Potential for Social Mobilisation in Bangladesh: The Ande, B., J. Chiwuzie, W. Akpala, A. Oronsaye, O. Okojie, and Organisation and Functioning of Two Health Insurance others. 1997. “Improving Obstetric Care at the District Schemes.” Social Science and Medicine 48 (7): 925–38. Hospital, Ekpoma, Nigeria: The Benin PMM Team.” Essien, E., D. Ifenne, K. Sabitu, A. Musa, M. Alti-Mu’azu, and International Journal of Gynaecology and Obstetrics 59 others. 1997. “Community Loan Funds and Transport (Suppl 2): S47–53. Services for Obstetric Emergencies in Northern Nigeria.” Arellano, N., M. J. Mello, and M. A. Clark. 2010. “The Role of International Journal of Gynaecology and Obstetrics 59 Motorcycle Taxi Drivers in the Pre-hospital Care of Road (Suppl 2): S237–44. Traffic Injury Victims in Rural Dominican Republic.” Injury Fiander, S. 2001. Anyone Can Save a Life: Road Accidents and Prevention 16 (4): 272–74. First Aid. London: British Red Cross. Arreola-Risa, C., C. N. Mock, A. J. Herrera-Escamilla, I. Contreras, Geduld, H., and L. Wallis. 2011. “Taxi Driver Training in and J. Vargas. 2004. “Cost-Effectiveness and Benefit of Madagascar: The First Step in Developing a Functioning Alternatives to Improve Training for Prehospital Trauma Prehospital Emergency Care System.” Emergency Medicine Care in Mexico.” Prehospital Disaster Medicine 19 (4): 318–25. Journal 28 (9): 794–96. Arreola-Risa, C., C. N. Mock, L. Lojero-Wheatly, O. de la Cruz, GFHR (Global Forum for Health Research) and WHO (World C. Garcia, and others. 2000. “Low-Cost Improvements in Health Organization). 2002. The 10/90 Report on Health Prehospital Trauma Care in a Latin American City.” Journal Research 2001–2002. Geneva: Global Forum for Health of Trauma 48 (1): 119–24. Research. Arreola-Risa, C., J. Vargas, I. Contreras, and C. N. Mock. 2007. Gomes, E., R. Araujo, A. Carneiro, C. Dias, A. Costa-Pereira, “Effect of Emergency Medical Technician Certification for and others. 2010. “The Importance of Pre-trauma Centre All Prehospital Personnel in a Latin American City.” Journal Treatment of Life-Threatening Events on the Mortality of of Trauma 63 (4): 914–19. Patients Transferred with Severe Trauma.” Resuscitation 81 Bakalos, G., M. Mamali, C. Komninos, E. Koukou, A. Tsantilas, (4): 440–45. and others. 2011. “Advanced Life Support versus Basic Hauswald, M., and E. Yeoh. 1997. “Designing a Prehospital Life Support in the Pre-hospital Setting: A Meta-Analysis.” System for a Developing Country: Estimated Cost and Resuscitation 82 (9): 1130–37. Benefits.” American Journal of Emergency Medicine 15 (6): Bavonratanavech, S. 2003. “Trauma Care Systems in Thailand.” 600–03. Injury 34 (9): 720–21. Henry, J. A., and A. L. Reingold. 2012. “Prehospital Trauma Bazzoli, G. J., R. Harmata, and C. Chan. 1998. “Community- Systems Reduce Mortality in Developing Countries: A Based Trauma Systems in the United States: An Examination Systematic Review and Meta-Analysis.” Journal of Trauma of Structural Development.” Social Science and Medicine 46 and Acute Care Surgery 73 (1): 261–68. (9): 1137–49. Hsia, R. Y., N. A. Mbembati, S. MacFarlane, and M. E. Kruk. Black, R. S., and P. Brocklehurst. 2003. “A Systematic Review 2012. “Access to Emergency and Surgical Care in Sub- of Training in Acute Obstetric Emergencies.” BJOG: An Saharan Africa: The Infrastructure Gap.” Health Policy and International Journal of Obstetrics and Gynaecology 110 (9): Planning 27 (3): 234–44. 837–41. Husum, H., M. Gilbert, and T. Wisborg. 2003. “Training Pre- Bollig, G., A. G. Myklebust, and K. Ostringen. 2011. “Effects Hospital Trauma Care in Low-Income Countries: The of First Aid Training in the Kindergarten: A Pilot Study.” ‘Village University’ Experience.” Medical Teacher 25 (2): Scandinavian Journal of Trauma, Resuscitation and 142–48. Emergency Medicine 19 (1): 13. Husum, H., M. Gilbert, T. Wisborg, Y. Van Heng, and M. Murad. Bollig, G., H. A. Wahl, and M. V. Svendsen. 2009. “Primary 2003. “Rural Prehospital Trauma Systems Improve Trauma School Children Are Able to Perform Basic Life-Saving First Outcome in Low-Income Countries: A Prospective Study Aid Measures.” Resuscitation 80 (6): 689–92. from North Iraq and Cambodia.” Journal of Trauma 54 (6): Bose, S. K., K. D. Bream, F. K. Barg, and R. A. Band. 2012. 1188–96. “Willingness to Pay for Emergency Referral Transport Ismail, M. S., A. B. Hasinah, M. N. Syaiful, H. B. Murshidah, in a Developing Setting: A Geographically Randomized T. J. Thong, and others. 2012. “Study on Advanced Life Study.” Academic Emergency Medicine 19 (7): 793–800. Support Devices in the Ambulances for Emergency Cases in doi:10.1111/j.1553-2712.2012.01382.x. Klang Valley, Malaysia.” La Clinica Terapeutica 163 (2): 115–22. 260 Essential Surgery Jamison, D. T., J. G. Bremen, A. R. Measham, G. Alleyne, Lungu, K., V. Kamfose, J. Hussein, and H. Ashwood-Smith. M. Claeson, D. B. Evans, P. Jha, A. Mills, and P. Musgrove, 2001. “Are Bicycle Ambulances and Community Transport eds. 2006. Disease Control Priorities in Developing Countries. Plans Effective in Strengthening Obstetric Referral Systems 2nd ed. Washington, DC: World Bank and Oxford in Southern Malawi?” Malawi Medical Journal 12: 16–18. University Press. Macintyre, K., and D. R. Hotchkiss. 1999. “Referral Revisited: Jayaraman, S., J. R. Mabweijano, M. S. Lipnick, N. Caldwell, Community Financing Schemes and Emergency Transport J. Miyamoto, and others. 2009a. “Current Patterns of in Rural Africa.” Social Science and Medicine 49 (11): Prehospital Trauma Care in Kampala, Uganda and the 1473–87. Feasibility of a Lay-First-Responder Training Program.” Mahadevan, S., M. Strehlow, A. Chiao, G. Ramana Rao, World Journal of Surgery 33 (12): 2512–21. D. Shelke, and others. 2009. Development of a Self-Sustaining ———. 2009b. “First Things First: Effectiveness and Paramedic Educational Program in India. Guwahati, India: Scalability of a Basic Prehospital Trauma Care Program EMCON. for Lay First-Responders in Kampala, Uganda.” PLoS One Mantha, A., A. Gupta, M. Strehlow, and S. Mahadevan. 2009. 4 (9): e6955. Development of a Focused Leadership Curriculum for Jayaraman, S., and D. Sethi. 2010. “Advanced Trauma Life Paramedic Students in India. Guwahati, India: EMCON. Support Training for Ambulance Crews.” Cochrane Database McClure, E. M., W. A. Carlo, L. L. Wright, E. Chomba, F. Uxa, of Systematic Reviews 1: CD003109. doi:10.1002/14651858 and others. 2007. “Evaluation of the Educational Impact of .CD003109.pub2. the WHO Essential Newborn Care Course in Zambia.” Acta Joshipura, M. K., H. S. Shah, P. R. Patel, P. A. Divatia, and Paediatrica 96 (8): 1135–38. P. M. Desai. 2003. “Trauma Care Systems in India.” Injury McSwain, N. 1991. “Prehospital Emergency Medical Systems 34 (9): 686–92. and Cardiopulmonary Resuscitation.” In Trauma, edited Kane, G., N. C. Wheeler, S. Cook, R. Englehardt, B. Pavey, and by E. Moore, K. Mattox, and D. Feliciano. Norwalk, CT: others. 1992. “Impact of the Los Angeles County Trauma Appleton and Lange. System on the Survival of Seriously Injured Patients.” Mock, C. N., G. J. Jurkovich, D. nii-Amon-Kotei, C. Arreola- Journal of Trauma 32 (5): 576–83. Risa, and R. V. Maier. 1998. “Trauma Mortality Patterns in Khorasani-Zavareh, D., B. J. Haglund, R. Mohammadi, Three Nations at Different Economic Levels: Implications M. Naghavi, and L. Laflamme. 2009. “Traffic Injury Deaths for Global Trauma System Development.” Journal of in West Azarbaijan Province of Iran: A Cross-Sectional Trauma 44 (5): 804–12; discussion 812–14. Interview-Based Study on Victims’ Characteristics and Pre- Mock, C. N., M. Tiska, M. Adu-Ampofo, and G. Boakye. 2002. hospital Care.” International Journal of Injury Control and “Improvements in Prehospital Trauma Care in an African Safety Promotion 16 (3): 119–26. Country with No Formal Emergency Medical Services.” Kirsch, T. D. 1998. “Emergency Medicine around the World.” Journal of Trauma 53 (1): 90–97. Annals of Emergency Medicine 32 (2): 237–38. Mullins, R. J., J. Veum-Stone, M. Helfand, M. Zimmer- Kobusingye, O. C., D. Guwatudde, G. Owor, and R. R. Lett. Gembeck, J. R. Hedges, and others. 1994. “Outcome of 2002. “Citywide Trauma Experience in Kampala, Uganda: Hospitalized Injured Patients after Institution of a Trauma A Call for Intervention.” Injury Prevention 8 (2): 133–36. System in an Urban Area.” Journal of the American Medical Kobusingye, O. C., A. A. Hyder, D. Bishai, E. R. Hicks, C. Mock, Association 271 (24): 1919–24. and others. 2005. “Emergency Medical Systems in Low- Murad, M. K., and H. Husum. 2010. “Trained Lay First and Middle-Income Countries: Recommendations for Responders Reduce Trauma Mortality: A Controlled Study Action.” Bulletin of the World Health Organization 83 of Rural Trauma in Iraq.” Prehospital and Disaster Medicine (8): 626–31. http://www.ncbi.nlm.nih.gov/pmc/articles 25 (6): 533–39. /PMC2626309/. Murad, M. K., D. B. Issa, F. M. Mustafa, H. O. Hassan, and Kobusingye, O. C., A. A. Hyder, D. Bishai, M. Joshipura, H. Husum. 2012. “Prehospital Trauma System Reduces E. R. Hicks, and others. 2006. “Emergency Medical Services.” Mortality in Severe Trauma: A Controlled Study of Road In Disease Control Priorities in Developing Countries, edited Traffic Casualties in Iraq.” Prehospital and Disaster Medicine by D. T. Jamison, J. G. Bremen, A. R. Measham, G. Alleyne, 27 (1): 36–41. M. Claeson, D. B. Evans, P. Jha, A. Mills, and P. Musgrove, Murad, M. K., S. Larsen, and H. Husum. 2012. “Prehospital 2nd ed. 1261–80. Washington, DC: World Bank and Oxford Trauma Care Reduces Mortality. Ten-Year Results University Press. from a Time-Cohort and Trauma Audit Study in Iraq.” Leigh, B., H. B. Kandeh, M. S. Kanu, M. Kuteh, I. S. Palmer, Scandinavian Journal of Trauma, Resuscitation and and others. 1997. “Improving Emergency Obstetric Care at Emergency Medicine 20: 13. a District Hospital, Makeni, Sierra Leone: The Freetown/ Nguyen, T. L., T. H. Nguyen, S. Morita, and J. Sakamoto. 2008. Makeni PMM Team.” International Journal of Gynaecology “Injury and Pre-hospital Trauma Care in Hanoi, Vietnam.” and Obstetrics 59 (Suppl 2): S55–65. Injury 39 (9): 1026–33. Liberman, M., D. Mulder, A. Lavoie, R. Denis, and J. S. Sampalis. Nurok, M. 2001. “The Death of a Princess and the Formulation 2003. “Multicenter Canadian Study of Prehospital Trauma of Medical Competence.” Social Science and Medicine 53 Care.” Annals of Surgery 237 (2): 153–60. (11): 1427–38. Prehospital and Emergency Care 261 Oyesola, R., D. Shehu, A. T. Ikeh, and I. Maru. 1997. “Improving Canadian Medical Association Journal 178 (9): 1141–52. Emergency Obstetric Care at a State Referral Hospital, doi:10.1503/cmaj.071154. Kebbi State, Nigeria: The Sokoto PMM Team.” International Sun, J. H., R. Shing, M. Twomey, and L. A. Wallis. 2012. “A Journal of Gynaecology and Obstetrics 59 (Suppl 2): S75–81. Strategy to Implement and Support Pre-hospital Emergency Ramanujam, P., and M. Aschkenasy. 2007. “Identifying Medical Systems in Developing, Resource-Constrained the Need for Pre-hospital and Emergency Care in the Areas of South Africa.” Injury 45 (1): 31–38. Developing World: A Case Study in Chennai, India.” Journal Sun, J. H., M. Twomey, J. Tran, and L. A. Wallis. 2012. “The of the Association of Physicians of India 55: 491–95. Need for a Usable Assessment Tool to Analyse the Efficacy Reines, H. D., R. L. Bartlett, N. E. Chudy, K. R. Kiragu, of Emergency Care Systems in Developing Countries: and M. A. McKnew. 1988. “Is Advanced Life Support Proposal to Use the TEWS Methodology.” Emergency Appropriate for Victims of Motor Vehicle Accidents: The Medicine 29 (11): 882–86. South Carolina Highway Trauma Project.” Journal of Sun, J. H., and L. Wallis. 2011. “The Psychological Effects of Trauma 28 (5): 563–70. Widespread Emergencies and a First Responder Training Rutledge, R., J. Messick, C. C. Baker, S. Rhyne, J. Butts, A. Meyer, Course on a Violent, Developing Community.” African and others. 1992. “Multivariate Population-Based Analysis Journal of Emergency Medicine 1 (4): 166–73. of the Association of County Trauma Centers with per Tannebaum, R. D., J. L. Arnold, A. De Negri Filho, and Capita County Trauma Death Rates.” Journal of Trauma 33 V. S. Spadoni. 2001. “Emergency Medicine in Southern (1): 29–37; discussion 37–28. Brazil.” Annals of Emergency Medicine 37 (2): 223–28. Sampalis, J. S., S. Boukas, A. Lavoie, A. Nikolis, P. Frechette, Tiska, M. A., M. Adu-Ampofo, G. Boakye, L. Tuuli, and and others. 1995. “Preventable Death Evaluation of the C. N. Mock. 2004. “A Model of Prehospital Trauma Training Appropriateness of the On-Site Trauma Care Provided for Lay Persons Devised in Africa.” Emergency Medicine 21 by Urgences-Sante Physicians.” Journal of Trauma 39 (6): (2): 237–39. 1029–35. Varghese, M., and P. Mohan. 1998. When Someone Is Hurt: Sampalis, J. S., A. Lavoie, M. Salas, A. Nikolis, and J. I. Williams. A First Aid Guide for Laypersons and Community Workers. 1994. “Determinants of On-Scene Time in Injured Patients New Delhi: The Other Media Communications. Treated by Physicians at the Site.” Prehospital and Disaster WHO (World Health Organization). 2010. Strengthening Care Medicine 9 (3): 178–88; discussion 189. for the Injured: Success Stories and Lessons Learned from Sampalis, J. S., H. Tamim, R. Denis, S. Boukas, S. A. Ruest, and around the World. Geneva: WHO. others. 1997. “Ineffectiveness of On-Site Intravenous Lines: ———. 2013. “Global Health Estimates for Deaths by Cause, Is Prehospital Time the Culprit?” Journal of Trauma 43 (4): Age, and Sex for Years 2000–2011.” WHO, Geneva. http:// 608–15; discussion 615–07. www.who.int/healthinfo/global_burden_disease/en/. Sangowawa, A. O., and E. T. Owoaje. 2012. “Building Capacity WHO and UNICEF (United Nations International Children’s of Drivers in Nigeria to Provide First Aid for Road Crash Emergency Fund). 2000. Management of the Child with a Victims.” Injury Prevention 18 (1): 62–65. Serious Infection or Severe Malnutrition: Guidelines for Care Sasser, S., M. Varghese, A. Kellerman, and J.-D. Lormand, eds. at the First-Referral Level in Developing Countries. Geneva: 2005. Prehospital Trauma Care Systems. Geneva: World WHO. Health Organization. Wilkinson, D., and M. Skinner. 2000. Primary Trauma Care Shehu, D., A. T. Ikeh, and M. J. Kuna. 1997. “Mobilizing Manual: A Manual for Trauma Management in District Transport for Obstetric Emergencies in Northwestern and Remote Locations. Oxford: Primary Trauma Care Nigeria. The Sokoto PMM Team.” International Journal of Foundation. http://www.primarytraumacare.org/wp-content Gynaecology and Obstetrics 59 (Suppl 2): S173–80. /uploads/2011/09/PTC_ENG.pdf. Solagberu, B. A., C. K. Ofoegbu, L. O. Abdur-Rahman, Wisborg, T., M. K. Murad, O. Edvardsen, and B. S. Brinchmann. A. O. Adekanye, U. S. Udoffa, and others. 2009. “Pre-hospital 2008. “Life or Death: The Social Impact of Paramedics Care in Nigeria: A Country without Emergency Medical and First Responders in Landmine-Infested Villages in Services.” Nigerian Journal of Clinical Practice 12 (1): Northern Iraq.” Rural and Remote Health 8 (1): 816. 29–33. Wisborg, T., M. K. Murad, O. Edvardsen, and H. Husum. 2008. Stiell, I. G., L. P. Nesbitt, W. Pickett, D. Munkley, D. W. Spaite, “Prehospital Trauma System in a Low-Income Country: and others. 2008. “The OPALS Major Trauma Study: Impact System Maturation and Adaptation During 8 Years.” Journal of Advanced Life-Support on Survival and Morbidity.” of Trauma 64 (5): 1342–48. 262 Essential Surgery Chapter 15 Anesthesia and Perioperative Care Kelly McQueen, Thomas Coonan, Andrew Ottaway, Richard P. Dutton, Florian R. Nuevo, Zipporah Gathuya, and Iain H. Wilson INTRODUCTION resources, education, and outcomes. Finally, this chap- ter proposes effective and responsible policy and fund- In the not-so-distant past, the impact of safe anesthesia ing solutions for the anesthesia crisis in most of these on surgical outcomes often went unrecognized. countries. Beginning in the 1950s, as surgical techniques advanced, strategies to improve patient safety and surgical out- comes were emphasized; physician anesthesia provid- ANESTHESIA AND THE GLOBAL ers were recognized as essential members of surgical BURDEN OF DISEASE teams in high-income countries (HICs). Most low- and middle-income countries (LMICs), which have the Global Burden of Disease Averted by Safe Anesthesia greatest unmet surgical need, have not been able to apply for Surgical Interventions the anesthesia advances in patient care and monitoring The anesthesia crisis significantly affects the global that have proven so successful in HICs. The availability gap between the surgical burden of disease and access of anesthesia providers is limited in LMICs, and many to surgical services. The World Health Organization’s lack requisite training and supervision. (WHO’s) Global Health Estimates documented sub- Although many of the advances that improved out- stantial premature death and disability from trauma, comes in anesthesia and surgery are technology based cancer, and pregnancy and childbirth worldwide and expensive, several early interventions are feasible in (WHO 2013a) and the inadequate surgical resources all settings. As surgical intervention expands in LMICs to meet these burgeoning surgical needs (Notrica and to fill the growing and largely unmet treatment needs, others 2011; Penoyar and others 2012). The unmet an anesthesia crisis looms. anesthesia and patient safety needs are generally cor- This chapter reviews the historical, remote, and related with the level of a country’s development, with recent global data that reveal the contributions of the greatest needs in South Asia and Sub-Saharan anesthesia to surgical and perioperative outcomes, as Africa (map 15.1). well as the anesthesia-associated morbidity and mor- Noncommunicable diseases are eclipsing infectious tality rates, where available. It emphasizes the role of diseases as the leading global health issue and are pro- outcomes analysis and quality improvement, and it jected to be the most important cause of mortality by discusses the global cost and cost-effectiveness data, 2020. Many of these conditions are potentially amenable as well as the limited data from LMICs on human to surgical treatment. Although providing adequate Corresponding author: Kelly McQueen, MD, MPH, Vanderbilt University Medical Center, kelly.mcqueen@vanderbilt.edu 263 264 Map 15.1 Global Development and Surgical Need IBRD 41379 | FEBRUARY 2015 The World by Income Low ($1,035 or less) Lower middle ($1,036–$4,085) Upper middle ($4,086–$12,615) High ($12,616 or more) No data Source: World Bank 2014 This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank GSDPM Group, any judgment on the legal status of any territory, or any Map Design Unit endorsement or acceptance of such boundaries. resources is a daunting task, it is no more impossible with a tracheal tube is often not an option, even during than addressing the HIV/AIDS crisis in the past 25 years. general anesthesia, because of a lack of provider skills Cost-effective and attainable surgical solutions exist and the absence of a laryngoscope required for intu- (WHO 2008) but will only be valuable if safe anesthe- bation. Equipment is antiquated, broken, or absent. sia is simultaneously supported. The contribution of Frequently there are no pressurized gasses, no anes- anesthesia to the burden of surgical disease is difficult to thesia circuitry or other requisite disposables, and no measure, but it is integral to surgery and an equal con- medications for hemodynamic rescue. tributor to disability and death. Without safe anesthesia, current anesthesia practice will contribute to additional Causes of the Crisis. Many factors contribute to the disability and death, even when surgery is provided. crisis (McQueen 2010). Inadequate numbers of trained Definitions essential to understanding the contribu- anesthesiologists and the brain drain to other specialties tions that anesthesia makes to patient safety and out- or higher resource countries are important contributors.1 comes include the following: Understandably, available resources—human, capital, and pharmaceutical—were diverted away from surgically • Anesthesia machine: A machine specifically designed treatable diseases and toward HIV/AIDS. for the delivery of anesthesia that includes the ability A correlation exists between surgical access, to provide oxygen and ventilation. anesthesia capacity, and patient safety on the one hand • Patient safety: A phrase that describes processes in and mortality on the other hand. Few studies speak place in hospitals and operating rooms to ensure the directly to this correlation. Several studies strikingly best possible outcomes for patients; these processes reveal specific risks of anesthesia in LMICs. Anesthesia- include policies and monitors that focus on prevent- related mortality is unacceptably high in these countries ing adverse outcomes and on alerting personnel to and is amplified in the maternal and pediatric popula- situations requiring urgent attention. tions (Bosenberg 2007; Fenton, Whitty, and Reynolds • Precordial stethoscope: A modified stethoscope for 2003; Hodges and Hodges 2000; Hodges and others the purpose of listening to heart and breath sounds; 2007; Jochberger and others 2008; Kushner and it may be modified to become an esophageal stetho- others 2010; Walker and Wilson 2008; Walker and oth- scope that amplifies sounds. ers 2010). Globally, 2 billion people lack access to • Perioperative period: The days and weeks imme- surgical treatment (Funk and others 2010), and diately preceding and following a surgical interven- 85 percent of children in LMICs are likely to require tion. In this period, optimization of the patient’s treatment for a surgical condition by age 15 years health may occur preoperatively, and complications (Bickler, Telfer, and Sanno-Duanda 2003). In Uganda in are observed. In HICs, the postoperative period at 2010, 17 percent of anesthesia providers had no formal 24 hours and at 30 days is specifically noted for criti- training (Walker and others 2010). The absence of cal events, including death. trained providers for children is a matter of particular • Perioperative Mortality Rates (POMRs): The mor- concern. tality rates in the operating room or within 24 hours of a surgical intervention and anesthesia. In HICs, Barriers to Safe Anesthesia Services. The greatest bar- these rates are reported and followed as indicators of riers to access to safe anesthesia are the lack of adequate safety. training and supervision for providers, safety monitor- • Vigilance: The continuous presence of and monitor- ing capacity, sustainable organizational structure, and a ing by providers, without distraction or time lapses. modern system of quality review. The state of the crisis has been largely underestimated as a result of the lack of out- comes measurement, including perioperative mortality, Global Anesthesia Crisis and the overall absence of patient follow-up. Assessments In LMICs, poor perioperative care has several causes: few of anesthesia-related mortality rates, when available, are trained providers; unreliable access to essential medica- indicative of poor patient care and safety (Bosenberg 2007; tions, including oxygen; limited safety monitoring; and Fenton, Whitty, and Reynolds 2003; Hodges and Hodges limited options for postoperative care, including pain 2000; Hodges and others 2007; Jochberger and others management. 2008; Kushner and others 2010; Walker and Wilson 2008; In these truly austere situations, most anesthetics Walker and others 2010). are administered with intravenous or intramuscular The shortage in the number of anesthesiologists ketamine, with no safety monitoring and no oxygen, is exacerbated by the fact that the available anesthe- by attendants with limited training. Airway protection sia providers spend only 60 percent of their time in Anesthesia and Perioperative Care 265 clinical care. The remainder is spent dealing with including halothane, cause more myocardial depres- broken equipment and the bureaucracy necessary sion than more modern agents. Unfortunately, in these to improve conditions for providers and patients same settings, standard rescue medications, including (Dubowitz, Detlefs, and McQueen 2010). epinephrine, are not routinely available to treat these predictable side effects. One major study found that in HICs approxi- SAFE ANESTHESIA FOR SURGICAL mately 5 percent of patients have perioperative myo- INTERVENTIONS cardial infarctions following major noncardiac surgery (Devereaux and others 2011). This event was associated Patient Safety with a fivefold increase in 30-day mortality. Evidence Successful initiatives directed at patient safety and suggests that changes in the perioperative management improved outcomes include airway management, car- initiated by anesthetists at the time of surgery can sig- diac outcomes, and perioperative care. nificantly reduce mortality related to these anticipated cardiac events (Canty and others 2012). Airway Management. Safe anesthesia requires the skills to maintain an open airway and to provide breathing Perioperative Care. The perioperative period— and oxygenation. The lack of such skills is at the core of extending from the initial preoperative evaluation of patient safety issues in LMICs. the patient’s general health and comorbidities to Pulse oximetry and continuous capnography have 30 days postoperatively—is an important window undoubtedly improved results in HICs, although ethical for patient evaluation and significantly affects patient practice has forestalled a true scientific study compar- outcomes. Perioperative evaluation provides valuable ing anesthesia safety with and without these monitors. information to providers planning optimal anesthesia Pulse oximetry, a noninvasive monitoring of oxygen management. An inexpensive screening test, such as saturation, has been in use since 1981. Capnography hemoglobin measurement, contributes to improved is the monitoring of carbon dioxide in the respiratory outcomes. gases. Anesthesia-related mortality rates declined in HICs with the mandatory use of both of these moni- Comorbidities. Ideally, the perioperative period should tors. Both pulse oximetry and capnography require the be used to alter or improve comorbidities and to continuous vigilance of an anesthesia provider with improve perioperative health status. The current situa- appropriate skills to respond to deviations. Such pro- tion in most LMICs does not often allow for this advance viders are more important than the monitors (Beecher preparation; as surgical systems evolve, planning for and Todd 1954; Merry and others 2010; Pedersen and perioperative evaluation will become necessary. others 2014). The contributory role of neuromuscular blocking Pain Management. Pain management is not only agents administered to facilitate intubation or surgery basic to the right to health (MacIntyre and Scott in poor outcomes related to airway management is 2010; Morriss and Goucke 2011; Size, Soyannwo, and well known. In a seminal examination of perioperative Justins 2007), but inadequately treated pain contrib- mortality in a cohort of American hospitals, Beecher utes to morbidity and, in some rare cases, to mortality. and Todd (1954) document a twofold increase in death Uncontrolled acute pain also increases the incidence of when these agents were used. Neuromuscular blocking chronic pain (MacIntyre and Scott 2010), potentially agents are included in the WHO Model List of Essential imposing a degree of suffering and disability that may Medicines (WHO 2013b) but are often unavailable in last for years. The tragic reality in LMICs is that pain LMICs, which is perhaps fortunate for patient safety. medicines, opioids, or nonsteroidal anti-inflamma- However, as surgical interventions become increas- tory medications are often unavailable, even though ingly available and surgical techniques advance, these they are included on the WHO Model List of Essential medications have the potential to contribute to poor Medicines (WHO 2013b) and are inexpensive and outcomes. effective. In HICs, the initial postoperative care of patients is Cardiac Perturbations. Myocardial depression is a provided by anesthesia providers and thereafter by sur- common side effect of anesthesia medications and geons and other physicians; this approach has improved can prove lethal in patients with underlying disease or outcomes. In LMICs, postoperative care is often admin- those with hemorrhage or hemodynamic instability. The istered by family members, even in the immediate post- older anesthetics still commonly in use in most LMICs, operative period. Although the impact of the absence 266 Essential Surgery of professional care in the postoperative period is in HICs, as a result of aggressive implementation unknown, it is likely to be associated with increased of clinical adjuvants, monitoring capacity, and the POMRs. imprint of a culture of safety (Eichorn 1989; Merry and others 2010). For example, 50 years of intense commitment in Australia has reduced avoidable Perioperative- and Anesthesia-Related Mortality anesthesia-related mortality from 1 in 5,000 to 1 in Systematic review of perioperative and anesthesia- 100,000—and 1 in 180,000 in cases in which anes- related mortality demonstrates global improvements thesia is the sole cause of mortality and morbidity in outcomes during the past five decades, primarily in (Mackay and Cousins 2006). Unfortunately, LMICs lag HICs (Bainbridge and others 2012). Overall mortality far behind; mortality rates solely related to anesthesia from anesthesia fell from 357 per million before the are 100 to 1,000 times higher than in HICs, espe- 1970s to 34 per million during 1990–2010, despite the cially in obstetric and pediatric populations (Hansen, growing number of patients with increased anesthetic Gausi, and Merikebu 2000; Heywood, Wilson, and risks. Analysis demonstrated not only an increased risk Sinclair 1989; Kushner and others 2010; McKenzie of anesthesia in higher-risk patients but also a correla- 1996; Ouro-Bang’na Maman and others 2005; Vasdev tion between anesthesia risk, mortality, and the human and others 2008). Information related to periopera- development index (HDI), an index related to life tive morbidity is more difficult to obtain because of expectancy, education, and income (Bainbridge and the lack of postoperative care units and postsurgical others 2012). In countries with high HDIs, anesthesia patient follow-up. Solutions to this information gap mortality has fallen from 357 per million to 25 per are possible based on HIC models, but the feasibility million. In low-HDI countries, no figure from before of these solutions may be decades away. the 1970s is available; in recent decades, the estimate As the anesthesia and surgical resources of a of 141 per million has been reported (Bainbridge and country improve, gains in absolute perioperative others 2012). mortality are likely to be reinvested in operating on Studies of perioperative mortality are difficult to patients with more serious conditions and comor- conduct and infrequent in LMICs. However, a series bidities. Figure 15.1 provides a graphic represen- of small anesthesia outcome studies in Sub-Saharan tation of this hypothesis. Low-HDI countries with Africa from the 1980s to the 2000s has reported con- high POMRs today might be expected to make rapid sistent and shocking rates of mortality in otherwise progress in the short term, perhaps based on a few healthy patients in countries with similar HDIs. In highly cost-effective interventions. In time, however, 1988, a study from a hospital in Zambia reported an the improvements in mortality will plateau. Further anesthesia mortality rate of 1 in 1,925; in Malawi in gains will require exponentially greater investments, 2000, a rate of 1 in 504; in Zimbabwe in 2005, a rate of and progress might be more apparent in the increased 1 in 482; in Togo in 2005, a rate of 1 in 133; in Nigeria acuity of patients taken to the operating room rather in 2006, a rate of 1 in 387 in mothers undergoing than in improved overall survival. cesarean section; and in Benin in 2010, a rate of 1 in 97 in pediatric anesthesia patients (Enohuman and Imarengiaye 2006; Glenshaw and Madzimbamuto 2005; Hansen, Gausi, and Merikebu 2000; Heywood, Wilson, Figure 15.1 Perioperative Mortality versus National and Sinclair 1989; Ouro-Bang’na Maman and others Resources 2005; Zoumenou and others 2010). In comparison, the perioperative mortality in the United States in the 1950s was 1 in 1,500 (Beecher and Todd 1954). In each study, deaths from anesthesia were most commonly due to undetected hypoxia or hypovolemia. Inadequate equip- ment, training and supervision, and safety monitoring— particularly pulse oximetry—were cited as contributors Mortality to these poor outcomes. Several of these studies shared a similar methodology; despite being relatively small, they are important because of the consistently high rates of mortality reported. During the past 30 years, anesthesia mortality Human development index and morbidity have decreased significantly, primarily Anesthesia and Perioperative Care 267 Reporting POMRs and benchmarking outcomes in table 15.1 suggest that these improvements and will be essential to improving patient safety and to interventions have been effective. The determination of better anesthesia and surgical outcomes in LMICs. cost-effectiveness is more arduous. Even in HICs, cost- Preventable, anesthesia-specific mortality rates will only effectiveness analyses have not been applied to the stan- be affected when common inciting events are docu- dard monitoring of patients undergoing anesthesia. mented and stratified using the American Society of Anesthesiologists (ASA) physical status, age, and the Absolute Costs. The absolute cost of providing safe social determinants of health related to living in LMICs anesthesia is a complex equation that varies by country (Doorley and others 2013). and is affected by market variables such as the required use of medical-grade equipment, nongeneric medica- tions, and changing technology. Every variable, from the COST, EFFECTIVENESS, AND COST- cost of training a physician anesthesiologist to provid- EFFECTIVENESS OF SAFE ANESTHESIA ing oxygen, is affected by local access, government, and regional availability of resources. Table 15.2 illustrates Improvements in monitoring, and the increased avail- the spectrum of costs in HICs for necessary infrastruc- ability of medications and screened blood products, ture and the required safety equipment to provide con- have elevated the effectiveness and safety of anesthesia. tinuous information on patients’ vital functions. These improvements have occurred in the context of a The comprehensive list of medications, solutions, platform of professional education and training, clinical and blood products for anesthesia are included in the excellence, and professionalism. Safety innovation has WHO Model List of Essential Medicines (WHO 2013b); not always occurred under circumstances of rigorous the World Federation of Societies of Anaesthesiologists validation of efficacy and cost-effectiveness. The pulse (WFSA) considers these to be the minimum for the oximeter, for instance, was rapidly embraced as man- safe administration of anesthesia (Merry and others datory safety technology and included as a required 2010). The WHO’s selection process for essential med- monitor for sedation and anesthesia by organizations icines ensures cost-effectiveness and promotes quality and societies throughout the world; to date, however, it (Manikandan and Gitanjali 2012), but it requires appro- has not been evaluated for cost-effectiveness (Pedersen priate resourcing and procurement by governments. The and others 2014). The most compelling argument for medicines for anesthesia and pain management included the effectiveness of anesthesia safety initiatives is evi- on the WHO Model List of Essential Medicines identifies dent in a comparison of the mortality rates over time inexpensive and cost-effective choices, agreed upon by in HICs (table 15.1), and between countries that com- international experts for local, regional, and general monly use standard safety measures and those that do anesthesia as well as for acute and chronic pain manage- not (Bainbridge and others 2012; Fenton, Whitty, and ment (table 15.3).2 Reynolds 2003; Hodges and Hodges 2000; Hodges and others 2007). Efficacy and Cost-Effectiveness An evolving library of literature is evaluating anesthe- Costs of Adequate Resources and Patient Safety sia efficacy and cost-effectiveness, applicable mostly Safety measures since 1970 include the required vigi- to upper-middle-income countries and HICs (Nakada lance of anesthesia providers, improved pharmacology and others 2010; Rando and others 2011). Some of to support hemodynamic stability, and safety monitor- these studies will have applicability for LMICs when ing to provide early warning of the common risks of trained providers and advanced pharmacology are anesthesia—hypoxemia, inadvertent esophageal intu- available and adequate monitoring is in place. Until bation, and cardiac depression. The mortality rates then, the most compelling analyses are those com- paring general, regional, and local anesthesia for specific procedures (Borendal Wodlin and others Table 15.1 Global Perioperative Mortality, per 1 Million 2011; Doberneck 1980; Duh and others 1999; Gonano Population and others 2009; Schuster and others 2005; Shillcutt, Before 1970 Since 1990 Clarke, and Kingsnorth 2010; Shillcutt and others 2013; Song and others 2000; Wilhelm and others Anesthesia-related mortality 357 34 2006). Much of this research was undertaken in HICs, Perioperative mortality 10,600 1,170 and more research specific to LMICs is needed. Local Source: Bainbridge and others 2012. and regional techniques provide nearly equivalent 268 Essential Surgery Table 15.2 Required Patient Safety Monitors and Medications in High-Resource Settings Improvement or intervention Year introduced Cost (US$) Professionalism in anesthesiology 1950s $1,000–$148,000a Sphygmomanometer 1881 Less than $20 Electrocardiogram (three-lead machine) 1901 More than $1,000 Smartphone monitor (AliveCor) $199 + phone Precordial stethoscope 1950s Less than $20 Capnography 1990 $1,600–$2,500 Pulse oximetry 1980 Durable, portable unit (Lifebox) $250 Smartphone monitor (Masimo) $100 + phone Anesthetic agent monitoring 1980s $350 to $2,500 Oxygen: 1903 $40/6,000 liters + $100 flowmeter + more than $10,000 per 20 beds Cylinders $500–$1,500 b Hospital piping system Concentratorc Rescue medicines 1902 Less than $1 a. Estimated training costs per anesthesiologist based on country of training. b. Initial capital costs for systems and equipment. c. Electricity must be available and energy costs must be considered for operating a concentrator. Table 15.3 World Health Organization’s List of Essential Glenshaw and Madzimbamuto 2005; Hansen, Gausi, Medicines for Anesthesia and Pain Management, 2013 and Merikebu 2000; Heywood, Wilson, and Sinclair 1989; McKenzie 1996; Ouro-Bang’na Maman and Medication class Specific medication listed others 2005; Vasdev and others 2008; Walker and oth- Inhaled gas Oxygen, halothane, isoflurane, nitrous oxide ers 2010; Zoumenou and others 2010). Muscle relaxant Suxamethonium, atracurium Both local and regional anesthetic techniques are Sedative/hypnotic Ketamine, propofol or thiopental, low cost and low technology; they offer achievable proficiency and have a good safety record when basic midazolam, diazepam sterile techniques are employed and key safety steps Narcotic Morphine, codeine are observed. Few direct comparisons of local anes- Local anesthetic Lidocaine, bupivacaine thesia versus neuroaxial anesthesia, such as spinal Anti-inflammatory Ibuprofen, paracetamol anesthesia, have been performed in LMICs; however, Vaz and others (2010) report no increase in operative Antiemetic Ondansetron time, and significant reductions in recovery room Chronic pain relief Amitriptyline time and immediate postoperative pain, in a group Reversal agent Neostigmine, naloxone receiving local anesthesia and intravenous sedation Rescue medicines Epinephrine, atropine, ephedrine for loop colostomy. This technique was cost saving Source: WHO 2013b. when compared with spinal anesthesia for the same procedure. Comparisons between local anesthetic classes (amide vs. ester) reveal no difference in efficacy in surgical conditions, hemodynamics, and patient com- endodontic treatment and a statistically significant cost fort, compared with general anesthesia (Faisy and savings when the amide lidocaine is used (Li and oth- others 1996). Where providers have limited training ers 2000; Maniglia-Ferreira and others 2009). The risk and rescue medicines are often unavailable, the safety profiles of local anesthetics vary significantly, as do the profile for these approaches is greater (Edomwonyi costs of treating toxicity for an accidental intravascu- and others 2000; Fenton, Whitty, and Reynolds 2003; lar injection of an amide or an ester (Harmatz 2009). Anesthesia and Perioperative Care 269 Intralipid, the treatment for intravascular injection However, in LMICs, the skill of providers and the lack of of bupivacaine (Mirtallo and others 2010) is approx- safety monitors contribute to the overall greater risk for imately US$100–US$300 per dose and not routinely complications. The quality and type of anesthesia pro- available in LMICs; for this reason alone, lidocaine is vided for the surgical intervention, particularly regional cost saving in LMICs. versus general, and the adequacy of postoperative anal- Literature from HICs compares regional, local, and gesia have a major impact on the incidence of compli- general anesthesia safety and outcomes; on balance, cations, and thereby the overall cost-effectiveness of the there is no consensus that regional and local anesthesia technique (Duggan and Kavanagh 2010; MacIntyre and are superior to general anesthesia (Lin and others Scott 2010). The relationship between general anesthesia 2013). However, there is no evidence that regional and complication incidence is one reason that ketamine and local anesthesia are inferior. Studies conducted in is ubiquitously and uniquely used in LMICs. Ketamine, HICs have consistently shown lower costs and at least which can be used alone or as an adjuvant therapy for equal efficacy with regional anesthesia compared with postoperative or chronic pain management, can be safely general anesthesia (Neuman and others 2012). used for general anesthesia for many surgical interven- The situation is quite different in LMICs. Reliable tions without the additional infrastructure required for equipment for general anesthesia, including airway general anesthesia secondary to inhaled gases (Green, equipment and the medications necessary to manage Clem, and Rothrock 1996). circulatory challenges, is limited and frequently not Developing markets in LMICs are driving the available. Regional and especially local anesthesia are availability of cost-appropriate equipment, anesthesia therefore preferable, when feasible (Schnittger 2007; machines, and safety monitors. The nearly ubiquitous Wilhelm and others 2006). availability of smartphones has encouraged manufac- The systematic literature review of anesthesia cost- turers to produce pulse oximetry and electrocardiogram effectiveness revealed no cost-effectiveness analysis (ECG) attachments and apps for use wherever smart- of general anesthesia, and no comparisons between phones are functional (Dawson and others 2013).3 These general anesthesia and regional anesthesia in LMICs. solutions have yet to be tested and compared with stan- Logical conclusions can be drawn from the compara- dard monitors, but the trend is encouraging for patient tive costs of general anesthesia and regional anesthesia, safety in LMICs (McCormick and Eltringham 2007). It especially when the costs are inclusive of an anesthe- is timely that an initiative is underway for the creation sia machine specific for this purpose (Beringer and of an International Organization for Standardization Eltringham 2008; Read and Taylor 2012). Anesthesia (ISO) standard for equipment being marketed to LMICs machines for general anesthesia deliver anesthetic gases (Walker and others 2010). and frequently have a ventilator component, essen- The best evidence of the cost-effectiveness of tial to providing oxygenation and ventilation when successful interventions is likely to be the prevention of pharmaceutical paralytics are used for some types of ASA category 1 or 2 perioperative deaths or permanent surgical intervention. However, if based only on known disability secondary to hypoxemia or sustained hypoten- mortality rates related to anesthesia in adults, children, sion. Modeling has shown that overall risk is reduced and parturients, the cost-effectiveness of local and by a checklist (WHO 2006) that includes the use of a regional anesthesia exceeds that of general anesthesia pulse oximeter and the ability to identify risks related to (Bosenberg, Jöhr, and Wolf 2011; Fecho and others surgery, anesthesia, and the presence of patient allergies. 2008; Luger and others 2010; Wilhelm and others 2006). General anesthesia is uniquely related to malignant hyperthermia, a genetic condition for which anesthesia Cost of Training Anesthesia Providers gases are the trigger, requiring prompt treatment with Until trained and credentialed providers are pres- dantrolene for survival. Dantrolene is expensive and ent and vigilant for every surgical intervention, it is not available in most LMICs, and this rare but reported unlikely that the addition of technology, machines, event is uniformly fatal in these countries. or advanced medications will significantly affect Although the general anesthesia medications on the outcomes in the short term; even the addition of WHO Model List of Essential Medicines (WHO 2013b) cost-appropriate monitors and equipment must be are cost-effective, the overall costs are substantially carefully balanced with the simultaneous addition of affected by the additional supplies, delivery systems, education and training. Investments in training and and related complications. When general anesthesia evaluating existing providers will have the greatest is indicated, it is possible to deliver a cost-responsible impact on patient safety and outcomes in LMICs. The option with available medications and other resources. costs of training vary, and the effectiveness of training 270 Essential Surgery in anesthesia is likely to be revealed by the anesthesia- hospital level. Countries that provide training outside related mortality rates. of physician training programs usually offer two tiers The shortage of physician anesthesiologists has of training (Cherian, Merry, and Wilson 2007; Collins led to task-shifting to nurses and technicians as the 2011; Dubowitz, Detlefs, and McQueen 2010; Dubowitz most feasible workforce alternative in many LMICs and Evans 2012; Hodges and others 2007; Notrica and (Hoyler and others 2014; Rosseel and others 2010). others 2011; Rosseel and others 2010). At a basic level, This practical measure can mitigate the crisis but anesthesia officers often originate from a nursing or does not replace the long-term need for physician medical background and train for 6 to 24 months. anesthesia providers for leadership, oversight, and Graduates of these programs commonly provide basic education. The critical need and dangerous situation anesthesia in second- and third-level hospitals, under require accepting a functional model for the provision varying degrees of supervision, and frequently without of anesthesia that specifically addresses barriers to supervision. Several LMICs offer a higher level of train- patient safety and unacceptable outcomes. Building on ing to medical practitioners for two to four years; these existing in-country models will facilitate the transition providers function in third-level referral hospitals pro- to safe patient care if education and credentialing are viding complex anesthesia and supervision of anesthesia provided at all levels. officers at all levels (Dubowitz, Detlefs, and McQueen Comprehensive information on types of and costs of 2010; Dubowitz and Evans 2012; Newton and Bird 2010; training for anesthesia providers in LMICs is still widely Notrica and others 2011). unavailable. Increasingly, however, reports are available Anesthesia training in HICs is evidence based and from surveys (Hoyler and others 2014) and from several includes theoretical knowledge and clinical, practical training programs in East Asia and the Pacific and in experience. At its most basic level, four practical skills are Sub-Saharan Africa (table 15.4). The training required, required of anesthesia providers: costs incurred, and external support received vary con- siderably across countries and regions; the absence of a • Intravenous cannulation related metric or indicator limits comparison of effec- • Bag-mask ventilation tiveness and resulting patient safety. • Tracheal intubation Many countries train their own anesthesia providers, • Initiation of neuroaxial (spinal or epidural) or even if only in the form of on-the-job training at the peripheral nerve block anesthesia. Table 15.4 Training and Education Levels, Time Commitment, and Costs in Selected Countries, 2013 Physician anesthetists Anesthesia officers External support Cost of tuition Cost of tuition Teaching Duration of (US$ per Duration of (US$ per Resident salary Financial (months per Country training year) training year) (per year) (per year) year) Rwanda 4 years $0 2 years — $8,400 $500,000 18 Zambia — — 2 years — $9,700 $24,000 — Uganda — $2,000 18–24 months $400 Variable, may $2,000+ — be $0 Kenya 4 years $2,500 18–24 months $2,500 $0 — — Lao PDR 3 years $0 6–12 months $0 $0 $2,500 3 Mongolia 2 years $1,000 — — $0 $0 4 Fiji 4 years for a $0 1 year for a $0 — — 18 master’s diploma Canada 5 years $0 — — $60,000–$80,000 — — Sources: Personal communications with local professionals providing and administering education: Dr. Paulin Ruhato, Rwanda; Dr. Sarah Hodges, Zambia; Dr. Gerald Dubowitz, Uganda; Dr. Mark Newton, Kenya; Dr. Simon Hendle, Fiji, the Lao People’s Democratic Republic, and Mongolia; and Dr. Tom Coonan, Canada. Note: — = not available. Anesthesia and Perioperative Care 271 All providers must also understand basic physiology FUTURE DIRECTIONS FOR MITIGATING and a few interventions to improve life-threatening THE GLOBAL ANESTHESIA CRISIS alterations in physiology, including hypoxemia and hypotension. An intricate knowledge of patient phys- Patient Safety iology, pharmacology, and therapeutics is essential, of Improving patient safety and access to surgery course, for physicians and nurses with advanced train- requires an investment across health care systems, ing. Access to leaders with this knowledge is important especially outside of the second- and third-level to the implementation of a system of safe anesthesia care hospitals in urban areas. Strategies for patient safety and patient safety. will need to be tailored and sufficiently flexible to The costs of theoretical and clinical teaching vary. meet diverse training needs. However, the goal of Ideally, anesthesia education is provided by physicians vigilance must be uniform, even where safety mon- with years of clinical experience. In some LMICs, such as itors vary. This systemic approach has the potential Kenya and Rwanda, senior nurses and technicians have to improve the entire health system through access to become effective clinical teachers. However, the impor- appropriate technology and diagnostics required for tance of physicians in ensuring the quality and accuracy surgery and safe anesthesia with dual purposes for of the information imparted cannot be discounted. other disease states. Costs are a consideration for the teaching model chosen; any system must be benchmarked and monitored for acceptable patient outcomes, including perioperative Education and Training mortality. Investments in education, training, and credentialing for Administrative costs are incurred when providing anesthesia providers are essential to improving patient educational materials, as well as when examinations or safety and surgical outcomes. Anesthesia-specific edu- assessment processes are conducted. In LMICs, living cation in LMICs will involve the training of future expenses are often required to enable trainees to par- anesthesia providers as well as the ongoing education ticipate in the program; these expenses may include and support of those already providing services. food, accommodation, and travel. The estimated costs Task-shifting or task-sharing is often applied to the of providing safe anesthesia in LMICs must include global surgical and anesthesia crises as a means to the investment in training. These specific costs are pro- expand the workforce responsibly and more rapidly gram and country specific, and are attainable through than traditional educational tracks allow. This prac- several models (table 15.4). Similarly the costs of tice is already widespread in LMICs out of necessity accreditation will vary by country, and this important (table 15.5). Ensuring that providers at all levels have component of a system of trained providers is unlikely education, training, and credentials will be important to add significant costs to the required education and to ensuring patient safety and creating a culture of training described. vigilance and best practice. Table 15.5 Surgical and Anesthesia Tasks for Task-Sharing Health workers Level of care Procedures performed Surgeon-anesthesiologist Third-level hospital Complex airway procedures, neurosurgery, thoracic and vascular surgery, pediatric surgery, complex orthopedic surgery, reconstruction surgery, endocrine surgery, critical care General doctor; nonphysician clinician Second-level hospital Cesarean section (elective and emergency), emergency airway with surgical or anesthesia skills (nurse management, abscess drainage, wound debridement, circumcision, or technician anesthesia provider) hernia repair, dilation and curettage, exploratory laparotomy— bowel resection, ectopic pregnancy, ovarian torsion, hysterectomy, appendectomy, limb amputation, skin grafts, skeletal traction, acute burn care Community health worker First-level hospital Prehospital transport of trauma patients, basic wound care, resuscitation, emergency cesarean section Source: Adapted from Chu and others 2009. 272 Essential Surgery The WFSA regards anesthesia as a medical spe- patients with greater comorbidity, confirms the pivotal cialty to be provided by medically trained and accred- role of the quality process. ited physicians. Where this is not possible—and it One approach is to pursue quality management met- often is not—the WFSA recommends that medically rics for perioperative care that are attainable for LMICs qualified anesthetists supervise nonmedical anes- as a tiered process. The most fundamental outcomes to thesia providers (Merry and others 2010). Although pursue would be simple recording of the surgical pro- the pros and cons of this position have been debated cedure performed and the short-term survival of the (Dubowitz, Detlefs, and McQueen 2010; Jacob 2009; patient in every setting in which surgical procedures are Walker 2009), the reality remains that medical anes- provided. When possible, additional collection of data, thetists are often rare in LMICs. What is needed is the including patient demographics such as age, gender, development of a coordinated anesthesia workforce illness, and the acuity of the planned procedure, will led by fully trained physician anesthesiologists who augment the value of the quality metric. Additional train, supervise, and monitor nonphysician anesthesia stratification of the fundamental outcomes, through providers. capture of the ASA Physical Status, is internationally There is no central, international classification of defined and of value in every setting when outcomes anesthesia providers. Many countries, even at the level are analyzed (box 15.1). The ASA’s five-point scale is of the Ministry of Health, have incomplete knowledge of intended to capture multiple objective and subjective the anesthesia providers functioning in remote settings. assessments of patients’ states of health before surgery Planning for a spectrum of training and credentialing and correlates strongly with perioperative mortality. is recommended, and providing practical guidelines for anesthesia safety will empower even the providers func- Perioperative Mortality Rate. A nonspecific indicator tioning with the fewest resources without compromising of patient safety during anesthesia and surgery amena- progress. ble to the tiered process and of value to LMICs is the A focus on the ongoing education and training of POMR at 24 hours. This rate, defined as unexpected anesthesia providers will generate benefits, including death within 24 hours of surgery, is often captured even increased surgical capacity within LMICs, improved in the most austere circumstances for two reasons: the patient outcomes, respect for the specialty of anesthesia existence of an operative log book, and the fact that most among other health care providers, and the potential surgical patients in LMICs remain in the hospital for for better staff retention. Creating high levels of patient 24 hours. Consistent with the tiered quality-management safety and access to quality anesthesia in the context process described above, the fundamental outcomes are of the current crisis will require a comprehensive approach: • Developing and implementing national training pro- Box 15.1 grams for anesthesia providers at all levels supported by the national health care system and the Ministries of Health American Society of Anesthesiologists’ Physical • Credentialing of trained anesthesia providers that Status allows for the tracking of providers and ensures a minimum qualification level 1 = A normal, healthy patient • Creating national and global professionalism within 2 = A patient with a stable chronic disease, for example, the anesthesia community through continuing medi- diabetes or asthma cal education and the support of national societies for 3 = A patient with an active disease process, for example, representation and growth. new onset angina or shortness of breath 4 = A patient with a severe medical condition that is life Quality Improvement threatening, for example, liver failure Efforts to improve anesthesia and perioperative care 5 = A patient not expected to survive the surgical will be influenced by measurement of the outcomes in procedure LMICs similar to the influence of quality improvement programs in Europe and the United States. The observa- Source: American Society of Anesthesiologists (https://www.asahq.org/For-Members /Clinical-Information/ASA-Physical-Status-Classification-System.aspx). tion that surgical outcomes are substantially better in the high HDI world, despite a generally older population of Anesthesia and Perioperative Care 273 uniformly available for capture. Although the data cap- independent groups have suggested the POMR as a tured in the first step of the process are minimal, similar low-technology option (McQueen 2013; Watters 2014). to the maternal mortality rate the POMR is a benchmark Initially nonspecific, the POMR at 24 hours could be of surgical and anesthesia safety, and an initial indicator stratified and expanded to 30 days as the surgical system that is easy to track and report (McQueen 2013; Watters grows. and others 2014). Stratification and Data Capture. As the data collec- CONCLUSIONS tion capabilities of the hospital or nation advance, Safe anesthesia is effective, beneficial, and inexpensive more information should be collected and reported when essential medicines are routinely available, appro- related to the outcomes of surgery and anesthesia and priate technology is used, and sustained investments are the population of patients treated. Anesthesia-related made in training and credentialing. disability or morbidity includes the occurrence of any The scope of global mortality that would be modified permanent injury, such as renal failure, myocardial by enhanced surgical capacity is staggering. Safe anes- infarction, stroke, or peripheral neurologic injury. Also thesia is critical to improving access to surgery, achieving included at this level of data capture should be the acceptable outcomes for the spectrum of surgical inter- occurrence of perioperative events that carry a high risk ventions, and mitigating the global burden of disease. of death or major morbidity: malignant hyperthermia, The scale of the global burden of surgical disease in anaphylaxis, intraoperative cardiac arrest, major trans- LMICs and the critical role of safe anesthesia in averting fusion reaction, and wrong-site or wrong-side surgery. disability and death through surgical intervention has On the preoperative side, more detailed coding of led to the following recommendations: patient comorbidities (for example, the International Classification of Diseases [ICD] codes) and patient • Prioritize patient safety and safe anesthesia to secure physical examination (for example, body mass index a foundation of quality anesthesia and monitor the and airway) will allow for improved risk adjustment of impact of surgical intervention on the rates of prema- quality-management results. ture death from surgically treatable diseases • Maintain functional workforces through patient safety Research education, training, and credentialing for existing and future anesthesia providers, including technicians, Capturing surgical and anesthesia complications and nurses, and physicians related mortality rates is not yet a global health priority. • Create a culture committed to vigilance, and provide As noncommunicable diseases increasingly contribute appropriate safety monitoring to the global burden of disease, the need for access • Ensure that oxygen and rescue medicines are reliably to surgical services and safe anesthesia will increase. available Related mortality rates are important to benchmark • Collect and report POMRs for benchmarking patient progress and document improved patient safety in safety and quality improvement LMICs. The only perioperative complication currently • Recommend universal reporting of POMRs by the recorded on a routine basis is intraoperative death; after WHO as part of the initiative for global patient safety. the event is recorded in the operating theater log book, it is rarely reviewed. Perioperative mortality in the operating theater and NOTES within 24 hours is reemphasized here because of the ease of data collection and existence of an example of The World Bank classifies countries according to four income similar reporting—the maternal mortality rate, which is groupings. Income is measured using gross national income (GNI) per capita, in U.S. dollars, converted from local currency required by the WHO and performed by every member using the World Bank Atlas method. Classifications as of July nation on an annual basis. 2014 are as follows: Finding solutions for collecting meaningful data in LMICs is an important prerequisite to addressing • Low-income countries (LICs) = US$1,045 or less in 2013 the global anesthesia crisis. Acknowledging that find- • Middle-income countries (MICs) are subdivided: ing solutions may be a stepwise process, and agreeing • Lower-middle-income = US$1,046 to US$4,125 on an initial indicator that is logistically possible • Upper-middle-income (UMICs) = US$4,126 to US$12,745 and ultimately meaningful, are the first steps. Several • High-income countries (HICs) = US$12,746 or more. 274 Essential Surgery 1. World Federation of Societies of Anaesthesiologists, http:// Dawson, J. A., A. Saraswat, L. Simionato, M. Thio, C. O. Kamlin, www.wfsahq.org/. and others. 2013. “Comparison of Heart Rate and Oxygen 2. The process by which medicines are added to or Saturation Measurements from Masimo and Nellcor Pulse deleted from the model list, and the related applica- Oximeters in Newly Born Term Infants.” Acta Paediatrica tions, is available at http://www.who.int/features/2013 102 (10): 955–60. /essential_medicines_list/en/. Devereaux, P. J., D. Xavier, J. Pogue, G. Guyatt, A. Sigamani, and 3. “Masimo Launches iPhone-Compatible Pulse Oximeter,” others. 2011. “Characteristics and Short-Term Prognosis of Damian Garde, December 13, 2012. http://www Perioperative Myocardial Infarction in Patients Undergoing .fiercemedicaldevices.com/story/masimo-launches-iphone Noncardiac Surgery: A Cohort Study.” Annals of Internal -compatible-pulse-oximeter/2012-12-13. Medicine 154 (8): 523–28. Doberneck, R. C. 1980. “Breast Biopsy: A Study of Cost- Effectiveness.” Annals of Surgery 192 (2): 152–56. REFERENCES Doorley, S. L., N. C. Doohan, S. Kodali, and K. McQueen. 2013. “Social Determinants of the Impact of Surgical Disease on Bainbridge, D., J. Martin, M. Arango, D. Cheng, and Evidence- Health.” Tropical Medicine and Surgery 1: 113–18. based Peri-operative Clinical Outcomes Research. 2012. Dubowitz, G., S. Detlefs, and K. A. McQueen. 2010. “Global “Perioperative and Anaesthetic-Related Mortality in Anesthesia Workforce Crisis: A Preliminary Survey Revealing Developed and Developing Countries: A Systematic Review Shortages Contributing to Undesirable Outcomes and and Meta-Analysis.” Lancet 380 (9847): 1075–81. Unsafe Practices.” World Journal of Surgery 34 (3): 438–44. Beecher, H. K., and D. P. Todd. 1954. “A Study of the Deaths Dubowitz, G., and F. M. Evans. 2012. “Developing a Associated with Anesthesia and Surgery: Based on a Study Curriculum for Anaesthesia Training in Low- and Middle- of 599,548 Anesthesias in Ten Institutions 1948–1952, Income Countries.” Best Practice and Research Clinical Inclusive.” Annals of Surgery 140 (1): 2–35. Anaesthesiology 26 (1): 17–21. Beringer, R. M., and R. J. Eltringham. 2008. “The Glostavent: Duggan, M., and B. P. Kavanagh. 2010. “Perioperative Evolution of an Anaesthetic Machine for Developing Modifications of Respiratory Function.” Best Practice and Countries.” Anaesthesia and Intensive Care 36 (3): 442–48. Research Clinical Anaesthesiology 24 (2): 145–55. Bickler, S. W., M. L. Telfer, and B. Sanno-Duanda. 2003. “Need Duh, Q. Y., A. L. Senokozlieff-Englehart, Y. S. Choe, for Paediatric Surgery Care in an Urban Area of The A. E. Siperstein, K. Rowland, and others. 1999. “Laparoscopic Gambia.” Tropical Doctor 33 (2): 91–94. Gastrostomy and Jejunostomy: Safety and Cost with Local Borendal Wodlin, N., L. Nilsson, P. Carlsson, and P. Kjolhede. vs General Anesthesia.” Archives of Surgery 134 (2): 151–56. 2011. “Cost-Effectiveness of General Anesthesia vs Spinal Edomwonyi, N. P., M. O. Obiaya, S. O. Imasuen, and Anesthesia in Fast-Track Abdominal Benign Hysterectomy.” A. S. Weerasinghe. 2000. “A Study of Co-induction of American Journal of Obstetrics and Gynecology 205 (4): Anaesthesia U.B.T.H. Experience.” West African Journal of e321–27. Medicine 19 (2): 132–36. Bosenberg, A. T. 2007. “Pediatric Anesthesia in Developing Eichorn, J. H. 1989. “Prevention of Intraoperative Anesthesia Countries.” Current Opinion in Anaesthesiology 20 (3): Accidents and Related Severe Injury through Safety 204–10. Monitoring.” Anesthesiology 70 (4): 572–77. Bosenberg, A. T., M. Jöhr, and A. R. Wolf. 2011. “Pro Con Debate: The Use of Regional vs Systemic Analgesia for Enohumah, K. O., and C. O. Imarengiaye. 2006. “Factors Neonatal Surgery.” Paediatric Anaesthesia 21 (12): 1247–58. Associated with Anaesthesia-Related Maternal Mortality Canty, D. J., C. F. Royse, D. Kilpatrick, A. Bowyer, and in a Tertiary Hospital in Nigeria.” Acta Anaesthesiologica A. G. Royse. 2012. “The Impact on Cardiac Diagnosis Scandinavica 50 (2): 206–10. and Mortality of Focused Transthoracic Echocardiography Faisy, C., G. Gueguen, M. Lanteri-Minet, A. Blatt, and in Hip Fracture Surgery Patients with Increased Risk of J. Iloumbou. 1996. “Cost Effectiveness of Local Regional Cardiac Disease: A Retrospective Cohort Study.” Anaesthesia Anesthesia in a Remote Area.” Médecine Tropicale (Mars) 67 (11): 1202–09. 56 (4): 367–72. Cherian, M. N., A. F. Merry, and I. H. Wilson. 2007. “The Fecho, K., A. T. Lunney, P. G. Boysen, P. Rock, and E. A. Norfleet. World Health Organization and Anaesthesia.” Anaesthesia 2008. “Postoperative Mortality after Inpatient Surgery: 62 (Suppl 1): 65–66. Incidence and Risk Factors.” Therapeutics and Clinical Risk Chu, K., P. Rosseel, P. Gielis, and N. Ford. 2009. “Surgical Management 4 (4): 681–88. Task Shifting in Sub-Saharan Africa.” PLoS Medicine 6 Fenton, P. M., C. J. Whitty, and F. Reynolds. 2003. “Caesarean (5): e1000078. doi:10.1371/journal.pmed.1000078. http:// Section in Malawi: Prospective Study of Early Maternal and www.plosmedicine.org/article/info:doi/10.1371/journal Perinatal Mortality.” BMJ 327 (7415): 587. .pmed.1000078. Funk, L. M., T. G. Weiser, W. R. Berry, S. R. Lipsitz, A. F. Merry, Collins, S. B. 2011. “Model for a Reproducible Curriculum and others. 2010. “Global Operating Theatre Distribution Infrastructure to Provide International Nurse Anesthesia and Pulse Oximetry Supply: An Estimation from Reported Continuing Education.” AANA Journal 79 (6): 491–96. Data.” Lancet 376 (9746): 1055–61. Anesthesia and Perioperative Care 275 Glenshaw, M., and F. D. Madzimbamuto. 2005. “Anaesthesia Fracture Surgery: Does It Matter?” Osteoporosis International Associated Mortality in a District Hospital in Zimbabwe: 21 (Suppl 4): S555–72. 1994 to 2001.” Central African Journal of Medicine 51 (3–4): MacIntyre, P. E., and D. A. Scott, eds. 2010. Acute Pain 39–44. Management: Scientific Evidence. 3rd ed. Sydney: Australian Gonano, C., S. C. Kettner, M. Ernstbrunner, K. Schebesta, and New Zealand College of Anaesthetists and Faculty of A. Chiari, and others. 2009. “Comparison of Economical Pain Medicine. http://www.anzca.edu.au. Aspects of Interscalene Brachial Plexus Blockade and Mackay, P., and M. Cousins. 2006. “Safety in Anaesthesia.” General Anaesthesia for Arthroscopic Shoulder Surgery.” Anaesthesia and Intensive Care 34 (3): 303–04. British Journal of Anaesthesia 103 (3): 428–33. Maniglia-Ferreira, C., F. Almeida-Gomes, B. Carvalho-Sousa, Green, S. M., K. J. Clem, and S. G. Rothrock. 1996. A. V. Barbosa, C. C. Lins, and others. 2009. “Clinical “Ketamine Safety Profile in the Developing World: Survey Evaluation of the Use of Three Anesthetics in Endodontics.” of Practitioners.” Academic Emergency Medicine 3 (6): Acta Odontológica Latinoamericana 22 (1): 21–26. 598–604. Manikandan, S., and B. Gitanjali. 2012. “National List of Hansen, D., S. C. Gausi, and M. Merikebu. 2000. “Anaesthesia Essential Medicines of India: The Way Forward.” Journal of in Malawi: Complications and Deaths.” Tropical Doctor Postgraduate Medicine 58 (1): 68–72. 30 (3): 146–49. McCormick, B. A., and R. J. Eltringham. 2007. “Anaesthesia Harmatz, A. 2009. “Local Anesthetics: Uses and Toxicities.” Equipment for Resource-Poor Environments.” Anaesthesia Surgical Clinics of North America 89 (3): 587–98. 62 (Suppl 1): 54–60. Heywood, A. J., I. H. Wilson, and J. R. Sinclair. 1989. McKenzie, A. G. 1996. “Mortality Associated with Anaesthesia “Perioperative Mortality in Zambia.” Annals of the Royal at Zimbabwean Teaching Hospitals.” South African Medical College of Surgeons of England 71 (6): 354–58. Journal 86 (4): 338–42. Hodges, S. C., and A. M. Hodges. 2000. “A Protocol for Safe McQueen, K. A. 2010. “Anesthesia and the Global Burden Anasthesia for Cleft Lip and Palate Surgery in Developing of Surgical Disease.” International Anesthesiology Clinics Countries.” Anaesthesia 55 (5): 436–41. 48 (2): 91–107. Hodges, S. C., C. Mijumbi, M. Okello, B. A. McCormick, ———. 2013. “Global Surgery: Measuring the Impact.” I. A. Walker, and others. 2007. “Anaesthesia Services in World Journal of Surgery 37 (11): 2505–6. doi:10.1007 Developing Countries: Defining the Problems.” Anaesthesia /s00268-013-2198-z. 62 (1): 4–11. Merry, A. F., J. B. Cooper, O. Soyannwo, I. H. Wilson, and Hoyler, M., S. R. Finlayson, C. D. McClain, J. G. Meara, and J. H. Eichhorn. 2010. “International Standards for a Safe L. Hagander. 2014. “Shortage of Doctors, Shortage of Data: Practice of Anesthesia 2010.” Canadian Journal of Anesthesia A Review of the Global Surgery, Obstetrics, and Anesthesia 57 (11): 1027–34. Workforce Literature.” World Journal of Surgery 38 (2): Mirtallo, J. M., J. F. Dasta, K. C. Kleinschmidt, and J. Varon. 2010. 269–80. “State of the Art Review: Intravenous Fat Emulsions: Current Jacob, R. 2009. “Pro: Anesthesia for Children in the Developing Applications, Safety Profile, and Clinical Implications.” World Should Be Delivered by Medical Anesthetists.” Annals of Pharmacotherapy 44 (4): 688–700. Paediatric Anaesthesia 19 (1): 35–38. Morriss, W., and R. Goucke. 2011. “Essential Pain Management: Jochberger, S., F. Ismailova, W. Lederer, V. D. Mayr, G. Luckner, A Workshop for Health Workers.” Sydney: Australian and and others. 2008. “Anesthesia and Its Allied Disciplines New Zealand College of Anaesthetists and Faculty of Pain in the Developing World: A Nationwide Survey of the Medicine. http://www.fpm.anzca.edu.au/fellows/essential Republic of Zambia.” Anesthesia and Analgesia 106 (3): -pain-management/pdfs/EPM-Manual-2012-04-19.pdf. 942–48. Nakada, T., D. Ikeda, M. Yokota, and K. Kawahara. 2010. Kushner, A. L., M. N. Cherian, L. Noel, D. A. Spiegel, “Analysis of the Cost-Effectiveness of Remifentanil-Based S. Groth, and C. Etienne. 2010. “Addressing the Millennium General Anesthesia: A Survey of Clinical Economics under Development Goals from a Surgical Perspective: Essential the Japanese Health Care System.” Journal of Anesthesia Surgery and Anesthesia in 8 Low- and Middle-Income 24 (6): 832–37. Countries.” Archives of Surgery 145 (2): 154–59. Neuman, M. D., J. H. Silber, N. M. Elkassabany, J. M. Ludwig, Li, S., M. Coloma, P. F. White, M. F. Watcha, J. W. Chiu, and and L. A. Fleisher. 2012. “Comparative Effectiveness of others. 2000. “Comparison of the Costs and Recovery Regional versus General Anesthesia for Hip Fracture Profiles of Three Anesthetic Techniques for Ambulatory Surgery in Adults.” Anesthesiology 117 (1): 72–92. Anorectal Surgery.” Anesthesiology 93 (5): 1225–30. Newton, M., and P. Bird. 2010. “Impact of Parallel Anesthesia Lin, R., A. Hingorani, N. Marks, E. Ascher, R. Jimenez, and and Surgical Provider Training in Sub-Saharan Africa: others. 2013. “Effects of Anesthesia versus Regional Nerve A Model for a Resource-Poor Setting.” World Journal of Block on Major Leg Amputation Mortality Rate.” Vascular Surgery 34 (3): 445–52. 21 (2): 83–86. Notrica, M. R., F. M. Evans, L. M. Knowlton, and Luger, T. J., C. Kammerlander, M. Gosch, M. F. Luger, K. A. Kelly McQueen. 2011. “Rwandan Surgical and U. Kammerlander-Knauer, and others. 2010. “Neuroaxial Anesthesia Infrastructure: A Survey of District Hospitals.” versus General Anaesthesia in Geriatric Patients for Hip World Journal of Surgery 35 (8): 1770–80. 276 Essential Surgery Ouro-Bang’na Maman, A. F., K. Tomta, S. Ahouangbevi, and in Obstetric Anesthesia.” Journal of Anesthesia 22 (1): M. Chobli. 2005. “Deaths Associated with Anaesthesia in 38–48. Togo, West Africa.” Tropical Doctor 35 (4): 220–22. Vaz, F. A., R. A. Abreu, P. C. Soarez, M. B. Speranzini, Pedersen, T., A. Nicholson, K. Hovhannisyan, A. M. Moller, L. C. Fernandes, and others. 2010. “Cost-Effectiveness A. F. Smith, and others. 2014. “Pulse Oximetry for Analysis on Spinal Anesthesia versus Local Anesthesia Perioperative Monitoring.” Cochrane Database of Systematic Plus Sedation for Loop Colostomy Closure.” Arquivos de Reviews 3: CD002013. Gastroenterologia 47 (2): 159–64. Penoyar, T., H. Cohen, P. Kibatala, A. Magoda, G. Saguti, and Walker, I. A. 2009. “Con: Pediatric Anesthesia Training in others. 2012. “Emergency and Surgery Services of Primary Developing Countries Is Best Achieved by Out of Country Hospitals in the United Republic of Tanzania.” BMJ Open Scholarships.” Paediatric Anaesthesia 19 (1): 45–49. 2 (1): e000369. ———, A. D. Obua, F. Mouton, S. Ttendo, and I. H. Wilson. Rando, K., C. U. Niemann, P. Taura, and J. Klinck. 2011. 2010. “Paediatric Surgery and Anaesthesia in South- “Optimizing Cost-Effectiveness in Perioperative Care for Western Uganda: A Cross-Sectional Survey.” Bulletin of the Liver Transplantation: A Model for Low- to Medium- World Health Organization 88 (12): 897–906. Income Countries.” Liver Transplantation 17 (11): Walker, I. A., and I. H. Wilson. 2008. “Anaesthesia in 1247–78. Developing Countries: A Risk for Patients.” Lancet 371 Read, E., and E. Taylor. 2012. “Portable Diamedica Glostavent: (9617): 968–69. An Anaesthetic Machine for the Itinerant Anaesthetist.” Watters D. A., M. J. Hollands, R. L. Gruen, K. Maoate, H. Perndt, British Journal of Anaesthesia 109 (4): 648–49. and others. 2014. “Perioperative Mortality Rate: A Global Rosseel, P., M. Trelles, S. Guilavogui, N. Ford, and K. Chu. Indicator of Access to Safe Surgery and Anesthesia.” World 2010. “Ten Years of Experience Training Non-physician Journal of Surgery. Electronic publication ahead of print. Anesthesia Providers in Haiti.” World Journal of Surgery 34 doi:10.1007/s00268-014-2638-4. (3): 453–58. WHO (World Health Organization). 2006. “Surgical Schnittger, T. 2007. “Regional Anaesthesia in Developing Safety Checklist.” WHO, Geneva. http://www.who.int Countries.” Anaesthesia 62 (Suppl 1): 44–47. /patientsafety/safesurgery/ss_checklist/en. Schuster, M., A. Gottschalk, J. Berger, and T. Standl. 2005. ———. 2008. World Health Report 2008. Geneva: WHO. “A Retrospective Comparison of Costs for Regional and http://www.who.int/whr/2008/en. General Anesthesia Techniques.” Anesthesia and Analgesia ———. 2013a. “Global Health Estimates for Deaths by Cause, 100 (3): 786–94. Age, and Sex for Years 2000–2011.” WHO, Geneva. http:// Shillcutt, S. D., M. G. Clarke, and A. N. Kingsnorth. 2010. www.who.int/healthinfo/global_health_estimates/en/. “Cost-Effectiveness of Groin Hernia Surgery in the Western ———. 2013b. WHO Model List of Essential Medicines. Region of Ghana.” Archives of Surgery 145 (10): 954–61. 18th List (April 2013) Final Amendments—October 2013. Shillcutt, S. D., D. L. Sanders, M. Teresa Butron-Vila, and http://www.int/medicines/publications/essentialmedicines A. N. Kingsnorth. 2013. “Cost-Effectiveness of Inguinal /en/index.html. Hernia Surgery in Northwestern Ecuador.” World Journal of Wilhelm, T. J., S. Anemana, P. Kyamanywa, J. Rennie, S. Post, Surgery 37 (1): 32–41. and others. 2006. “Anaesthesia for Elective Inguinal Hernia Size, M., O. A. Soyannwo, and D. M. Justins. 2007. “Pain Repair in Rural Ghana: Appeal for Local Anaesthesia in Management in Developing Countries.” Anaesthesia 62 Resource-Poor Countries.” Tropical Doctor 36 (3): 147–49. (Suppl 1): 38–43. World Bank. 2014. World Development Indicators. Washington, Song, D., N. B. Greilich, P. F. White, M. F. Watcha, and W. K. Tongier. DC: World Bank. 2000. “Recovery Profiles and Costs of Anesthesia for Zoumenou, E., S. Gbenou, P. Assouto, A. F. Ouro-Bang’na Outpatient Unilateral Inguinal Herniorrhaphy.” Anesthesia Maman, T. Lokossou, and others. 2010. “Pediatric Anesthesia and Analgesia 91 (4): 876–81. in Developing Countries: Experience in the Two Main Vasdev, G. M., B. A. Harrison, M. T. Keegan, and C. M. Burkle. University Hospitals of Benin in West Africa.” Paediatric 2008. “Management of the Difficult and Failed Airway Anaesthesia 20 (8): 741–47. Anesthesia and Perioperative Care 277 Chapter 16 Excess Surgical Mortality: Strategies for Improving Quality of Care Thomas G. Weiser and Atul Gawande GLOBAL VOLUME AND SAFETY OF Mortality Following Surgery SURGICAL CARE The annual volume of surgery is almost twice that of obstetrical deliveries, and surgical death rates far surpass The World Health Organization (WHO) has estimated maternal mortality rates. Global estimates suggest that that 234 million operations are performed worldwide at least 7 million people suffer complications following each year (Weiser and others 2008). The WHO’s analysis surgery each year, including at least 1 million deaths, establishes three significant findings: a magnitude that exceeds both maternal and AIDS- related mortality. As many as 50 percent of these deaths • Surgical interventions take place on a massive and and complications are preventable (Weiser and others previously unrecognized scale in all countries and 2008). Surgical care is fraught with hazards in every resource settings. setting; patients face immediate danger from both the • The inequity in service provision among countries technical risks of the procedures themselves and the and settings is dramatic. anesthesia needed to induce insensibility and sedation. • Little is known about the indications for, and the Studies from high-income countries (HICs) con- quality, safety, and outcomes of, surgical care. firm high rates of postoperative mortality and high variability in those rates. In the Netherlands, a review of Much has since been done to investigate these issues. 3.7 million inpatient surgical procedures at 102 hospitals The WHO has provided guidance for measuring surgical over 15 years reveals a perioperative mortality rate of services and capacity through a set of standardized met- 1.85 percent (Noordzij and others 2010). A similar rics for surgical surveillance (Weiser and others 2009). inpatient surgical death rate has been noted in the In addition, a situational analysis tool has been con- United States, with all-cause postoperative mortality structed and deployed in a number of countries to help in 2006 estimated to be 1.14 percent to 1.32 percent assess surgical capacity (WHO 2010). Yet the logistics of (Semel and others 2012; Weiser and others 2011). Pearse performing surgery are complex and demand standard- and others (2012) studied the outcomes of one week ization. Surgical services must also continuously mea- of inpatient surgery (excluding cardiac, neurosurgical, sure patient outcomes to identify shortcomings, inform radiological, and obstetric procedures) in 498 hospi- improvements, and maintain high levels of quality care. tals in 28 European countries. The in-hospital crude Corresponding author: Thomas G. Weiser, MD, Stanford University Medical Center, tweiser@stanford.edu 279 postoperative mortality ranged from 1.2 percent in The extent of unmet need in resource-poor settings Iceland to 21.5 percent in Latvia. After adjusting for remains unclear, but basic surgical services are increas- patient age, the American Society of Anesthesiologists’s ingly recognized as essential for relieving suffering score of patient fitness for surgery, the urgency of and sustaining health. Surgery is critical for obstetrical surgery, the extent of surgery (minor, intermediate, or emergencies; common congenital conditions, such as major), the specialty, and the presence of metastatic clubfoot; traumatic injuries, including orthopedic inju- disease or cirrhosis, the odds ratios for death following ries; and treatment of abscesses, cancers, hernias, and surgery—using the United Kingdom as reference— cataracts. Maternal health advocates estimate that an ranged from a low of 0.44 in Finland to a high of 6.92 optimum rate of cesarean section is at least 5 percent in Poland (figure 16.1). Overall, the researchers noted a of all births to avert high rates of death of mothers and 4 percent in-hospital crude mortality rate in this sample children (Dumont and others 2001), but similar mini- of more than 46,000 surgical cases, a previously unre- mum criteria have not been proposed for basic surgical ported and unexpectedly high number. services to address the disease burden in a population. It has, however, become clear that surgical care is an Disparity of Service Provision essential component of effective health delivery systems and vital for enabling long and healthy life. In a popu- Nearly 60 percent of all operations take place in HICs, lation-based survey in Sierra Leone, one of the poorest where 15 percent of the world’s population lives countries in the world, one in every four respondents (table 16.1). Low-income countries (LICs) account reported needs that might benefit from surgical consul- for nearly 35 percent of the global population, yet tation (Groen and others 2012). In addition, almost one only 3.5 percent of all surgical interventions (Weiser in three households had experienced a death within the and others 2008). This lack of equity in access to past year; of these households, one in four had a condi- surgical interventions demands further investigation. tion within the week preceding death that likely could Figure 16.1 Adjusted Odds Ratio for In-Hospital Mortality Following have been treated surgically: abdominal distention, Surgery in 28 European Countries, 2011 bleeding or complications following childbirth, an acute or chronic wound, a mass, or an acquired or congenital Finland deformity. This survey indicates a tremendous unad- Iceland dressed disease burden that might be mitigated with Norway improved access to surgical care. Sweden Estonia Netherlands Cyprus Limitations in the Scope of Practice in LMICs Germany Surgical interventions are performed at much lower Switzerland United Kingdom (reference) frequency in the resource-poor settings of low- and Serbia middle-income countries (LMICs) and under more Slovenia limited circumstances. Typically, rural first-level hospi- Denmark tals and even third-level public hospitals have a high- Greece Lithuania percentage of urgent cases; these facilities focus on Hungary a limited set of interventions, given their resource Czech Republic constraints. For example, studies from LMICs have France Spain shown very high ratios of cesarean section compared Portugal with other types of surgical procedures. Cesarean sec- Belgium tion has been found to represent a substantially higher Italy proportion of all surgical interventions in Sierra Leone Croatia Slovak Republic (42 percent), Zambia (40 percent), Uganda (34 percent), Ireland Niger (26 percent), Malawi (23 percent), and Haiti Romania (12 percent) than in Organisation for Economic Latvia Co-operation and Development countries (3 percent) Poland (Bowman 2013; Hughes and others 2012; Kushner, 0.01 0.1 1 10 100 Groen, and Kingham 2010). At least one study sug- Adjusted odds ratios (95% confidence interval) gests that the higher the surgical capacity, the lower the observed proportion of cesarean section, indicating Source: Pearse and others 2012. that improved skills, materials, and capacity allow the 280 Essential Surgery Table 16.1 Average National Rate of Surgery for Countries by Category of Health Expenditure, and Total Surgical Volume by Category, 2004 Mean estimated surgical rate per Estimated volume of 100,000 population (standard errors surgery in millions (%; 95% Share of global in parentheses) confidence interval) population (%) Expenditure Poor-expenditure countries (N = 47) 295 (53) 8.1 (3.5; 3.4–12.8) 34.8 Low-expenditure countries (N = 60) 2,255 (342) 53.8 (23.0; 9.8–97.4) 35.0 Middle-expenditure countries (N = 47) 4,248 (524) 34.3 (14.6; 23.6–43.3) 14.6 High-expenditure countries (N = 38) 11,110 (1,300) 138.0 (58.9; 132.5–143.9) 15.6 Overall Total global volume of surgery n.a. 234.2 (187.2–281.2) n.a. Average surgical rate 4,016 (431) n.a. n.a. Source: Weiser and others 2008. Note: Expenditures are adjusted to 2004 U.S. dollars. Poor-expenditure countries = per capita total expenditure on health US$100 or less; low-expenditure countries = US$101 to US$400; middle-expenditure countries = US$401 to US$1,000; high-expenditure countries > US$1,000. n.a. = not applicable. p < 0.0001 for difference between expenditure groups. provision of a more comprehensive range of surgical However, improvements in appropriateness, safety, and services (Petroze, Mehtsun, and others 2012). quality must accompany any increase in surgical volume The WHO has identified a set of emergency and in LMICs to minimize harm and secure patient trust in essential surgical interventions that all first-level hos- care. Currently, resource-poor settings place little empha- pitals with surgical capacity should be able to perform. sis on safety or quality, effectively constraining the value Besides cesarean section, these procedures encompass of improving access to surgical care. Earlier chapters of uterine evacuation, circumcision, wound care, chest this volume focus on the lack of services and the unmet drainage, basic laparotomy, amputation, hernia repair, need for surgical care; this chapter assesses the magni- tubal ligation, closed or temporary reduction of frac- tude of harm from surgical interventions under these tures, cataract surgery, removal of foreign bodies, and circumstances and evaluates strategies to mitigate it. emergency airway management and ventilation. This The analysis was performed in three phases. We guideline for essential surgical services is based on the first evaluated the unmet surgical volume using data typical capacity of health facilities in remote, resource- previously gathered for a study assessing the global constrained settings. These conditions involve relatively volume of surgery (Weiser and others 2008). We then straightforward interventions, requiring less complex sought to estimate potential excess harm by ascertain- skills, resources, and postoperative management. Surgical ing postsurgical mortality rates for three procedures providers at first-level hospitals appear to refer patients common in LMICs: cesarean section, appendectomy, to higher-level facilities due to lack of training and expe- and inguinal hernia repair. Finally, we combined these rience rather than lack of resources (Bowman and others two analyses to estimate the theoretical risks if surgical 2013; Petroze, Nzayisenga, and others 2012). The WHO capacity were increased to meet minimum estimates of recommends that referral facilities ensure capacity to delivery without concurrent improvements in mortality provide facial and intracranial surgery, complex bowel rates. By quantifying excess mortality across countries surgery, pediatric and neonatal surgery, thoracic surgery, and settings, we demonstrate large gaps in safety and major ophthalmic surgery, and complex gynecologic the impact these have on outcomes and postoperative surgery (WHO 2009c). mortality. Methodology MORTALITY FOLLOWING SURGERY IN LMICs Estimates of Minimum Surgical Rates. Using previ- As explained in chapter 2, increasing basic surgical ously estimated national surgical rates for 192 countries capacity at first-level hospitals could potentially avert loss (Weiser and others 2008), we performed an incremental of 77.2 million disability-adjusted life years every year. surgical effectiveness analysis comparing surgical rates Excess Surgical Mortality: Strategies for Improving Quality of Care 281 with average life expectancy (Goldie 2003). We elimi- adjacent, higher-rate country (that is, one in which nated “strongly dominated” nations—those that either the incremental gain in life expectancy per increase in provided more operations for equal or lesser life expec- surgery was less than its comparator) was considered tancy or provided the same amount as a nation with “weakly dominated” and was discarded, leaving only greater life expectancy—and then arrayed the remaining countries with maximally “efficient” systems, that is, nations in ascending order by surgical rate. Incremental those with the lowest surgical rate for the highest life surgical rates and life expectancy, and the incremental expectancy (table 16.2). We estimated the minimum per surgical system effectiveness ratio were then calculated capita surgical rates from an “efficiency frontier” line by comparing the surgical rates and life expectancy of plotted from these countries (figure 16.2). each country with the one above it. Countries whose We then created a regression model for these maxi- surgical system effectiveness ratio was greater than an mally efficient countries and extrapolated a provisional minimum surgical rate based on life expectancies of 70, 75, and 80 years. We estimated the surgical gap by Table 16.2 Countries with the Lowest Surgical Rates and Highest determining the deficit of surgery for countries whose Life Expectancies Based on an Incremental Cost-Effectiveness rates were below these minimum surgical rates at each Selection Strategy life expectancy. Confidence intervals for the surgical def- icit were calculated taking into account the error of the Life expectancy Surgical rate (per imputed country-specific rates. (years) 100,000 people) Tajikistan 63 181 Estimates of Surgical Mortality in LMICs. We reviewed Korea, Dem. People’s Rep. 66 303 the published literature from LMICs that reported death and complication rates following three operations Panama 76 1,637 commonly performed in first-level hospitals: cesarean New Zealand 80 4,547 section, appendectomy, and hernia repair. Our inclusion Italy 81 7,768 criteria were articles published since 2000 from countries Japan 82 11,741 classified by the World Bank as LICs or middle-income countries in either 2005 or 2012 that reported either morbidity or mortality following one of these interven- tions, regardless of preoperative status, indication for Figure 16.2 Surgical Efficiency Curve Based on Countries Whose intervention, or cause of death. We reviewed SCOPUS, Health Systems Provide the Lowest Surgical Rates and the Highest MedLine, and PubMed, as well as other studies identified Life Expectancies by their references or bibliographies (see annex 16A for search terms and identified references). We discarded studies that appeared to be duplicate analyses of the Ne same data. We aggregated studies by country to create w Ja ly 85 Ze pa Ita ala n larger data samples for analysis. Pa nd 80 na ma Ko ople kista re ´s Pe Taji 75 Estimates of Theoretical Death Following Increased a, R n De ep Life expectancy (years) m. . 70 Surgical Service Delivery. We applied our estimates 65 of surgical mortality to the volume of surgery needed 60 to close the gap in surgical care and bring all countries falling below our minimum surgical rate up to the cal- 55 culated minimum. We assumed a conservative midrange 50 mortality rate estimate, even though we presumed that 45 this low surgical volume continues to reflect a similar 40 proportion of urgent cases with a correspondingly high mortality rate. 35 100 1,000 10,000 100,000 Surgical rate (log scale, per 100,000 people) Results Minimal Annual Surgical Rates. Six countries defined Note: Any particular life expectancy can be associated with a minimum estimated surgical rate based on this efficiency frontier. In this example, a life expectancy of 75 years is associated with a surgical the efficiency frontier with a combination of the lowest rate of at least 1,504 per 100,000 people. rates of surgery and the highest life expectancies 282 Essential Surgery (table 16.2 and figure 16.2). Using this surgical efficiency identified 131 articles that met the inclusion criteria calculation, minimum annual surgical rates observed at and evaluated either mortality or morbidity from cesar- life expectancies of 70, 75, and 80 years were 836, 1,504, ean section, appendectomy, and inguinal hernia repair and 4,547 operations per 100,000 people, respectively. in LMICs. We summarize these results in tables 16.3, In 2004, 49 countries had rates of less than 836 per 16.4, and 16.5. Crude mortality rates following cesarean 100,000, and 65 had rates of less than 1,504 per 100,000; section ranged from 0.5 per 1,000 operations to 51.3 per the vast majority of countries with rates of less than 836 1,000. For appendectomy, the rates of death were 0 to 88.6 were LICs. Most countries with rates higher than 4,547 per 1,000 operations; and for inguinal hernia repair, rates per 100,000 were upper-middle-income (UMICs) or of death ranged from 0 to 411.8 per 1,000 operations. high-income countries (HICs). For LMICs to deliver at For comparison, historical death rates following cesarean least 836 operations per 100,000 people, an additional section in Sweden and the Netherlands are 0.4 and 0.53 10.9 million operations per year (95 percent confidence per 1,000, respectively (Hogberg 1989; Schuitemaker and interval of 3.9 million to 30.7 million) would need to others 1997); for appendectomy they are 2.4 and 3.0 per be performed in these settings. To achieve a rate of 1,000 (Blomqvist and others 2001; Noordzij and others 1,504 operations per 100,000 people would require an 2010). The mortality rate for elective inguinal hernia additional 28.4 million (95 percent confidence interval repair in Sweden is 1.1 per 1,000, but the rate rises to 29.5 of 11.3 million to 71.2 million) operations annually in for emergency operations; overall mortality following these countries. inguinal hernia repair is 2.4 per 1,000 in Sweden (Nilsson and others 2007). The death rate following elective Variable Mortality Rates. Based on the results of our inguinal hernia repair in Denmark is calculated to be estimates of surgical mortality, however, increased sur- 2.2 per 1,000; however, for urgent cases it is substantially gical capacity will exact a substantial toll in postsurgical higher at 70.1, with an overall mortality rate of 5.2 per harm and risk for adverse events. The literature search 1,000 operations (Bay-Nielsen and others 2001). Table 16.3 Published Mortality and Morbidity Rates in Selected Countries Following Cesarean Section Crude Cesarean Total number Total Crude mortality morbidity per section rate of cesarean number of Total number of per 1,000 cesarean 1,000 cesarean Country (percent) sections deaths complications sections sections Afghanistan 1.0 565 29 — 51.3 — Brazil 45.9 371,981 202 — 0.5 — Burkina Faso 0.7 15,279 58 206 3.8 56.0 Chad 0.4 275 11 — 40.0 — Ethiopia 1.0 267 2 20 7.5 88.9 India 8.5 8,893 25 35 2.8 18.7 Malawi 3.1 10,201 108 151 10.6 70.9 Morocco 5.4 3231 9 165 2.8 51.1 Nigeria 1.8 4215 41 11 9.7 67.1 a Pakistan 7.3 14,257 39 — 2.7 — Rwanda 2.9 896 9 — 10.0 — Senegal 3.3 370 7 — 18.9 — South Africa 20.6 904 1 — 1.1 — Tanzania 3.2 6,765 7 — 1.0 — Thailand 17.4 187 0 7 0 37.4 Uganda 3.1 500 7 77 14.0 154.0 Zimbabwe 4.8 3,147 25 — 7.9 — table continues next page Excess Surgical Mortality: Strategies for Improving Quality of Care 283 Table 16.3 Published Mortality and Morbidity Rates in Selected Countries Following Cesarean Section (continued) Crude Cesarean Total number Total Crude mortality morbidity per section rate of cesarean number of Total number of per 1,000 cesarean 1,000 cesarean Country (percent) sections deaths complications sections sections Bangladesh, China, Indonesia, Mongolia, 0.4 7,390 14 1,137 1.9 153.9 Myanmar, Nepal, Thailand, Sri Lanka, and Vietnam Cambodia, China, India, Japan, Nepal, 0.3 29,428 35 2,895 1.2 98.4 Philippines, Sri Lanka, Thailand, and Vietnam Congo, Dem. Rep.; Burundi; and — 1,276 7 93 5.5 72.9 Sierra Leone Côte d’Ivoire, Mali, Niger, Mauritania, — 335 13 — 38.8 — Burkina Faso, and Senegal Senegal and Mali 0.1 11,255 157 536 13.9 47.6 Argentina, Brazil, Cuba, Ecuador, 0.3 31,803 16 984 0.5 30.9 Nicaragua, Mexico, Paraguay, and Peru Source: Authors’ calculations based on Abbassi and others 2000; Bano and others 2011; Basak and others 2011; Bouvier-Colle and others 2001; Briand and others 2012; Chilopora and others 2007; Chongsuvivatwong and others 2010; Chu and others 2012; Fauveau 2007; Fenton and others 2003; Fesseha and others 2011; Glenshaw and Madzimbamuto 2005; Imbert and others 2003; Kaboro and others 2012; Kambo and others 2002; Kandasamy and others 2009; Kelly and others 2010; Kilsztajn and others 2007; Kim and others 2012; Kor-Anantakul and others 2008; Lumbiganon and others 2010; Ministère de la Santé Burkina Faso 2013; Okafor and Okezie 2005; Okafor and others 2009; Okezie and others 2007; Oladapo and others 2007; Ozumba and Anya 2002; Rahlenbeck and Hakizimana 2002; Rutgers and van Eygen 2008; Seal and others 2010; Sekirime and Lule 2008; Sorbye and others 2011; Tshibangu and others 2002; and Villar and others 2007. Cesarean section rates for Afghanistan and The Gambia are from Kim and others 2012 and Fauveau 2007, respectively. All other cesarean section rates are from Gibbons and others 2010. Note: Denominators of mortality and morbidity may differ due to different studies from the same country using separate patient populations. — = not available. a. Total number of cesarean sections in Pakistan obtained from Naheed Bano, Rawalpindi Medical College, and Holy Family Hospital, Rawalpindi, Pakistan. Table 16.4 Published Mortality and Morbidity Rates in Selected Countries Following Appendectomy Total number of Total number Total number of Crude mortality per Crude morbidity per Country appendectomies of deaths complications 1,000 appendectomies 1,000 appendectomies Bangladesh 30 0 7 0 233.3 Bolivia 55 1 4 18.2 72.7 Burkina Faso 789 0 — 0 — Cameroon 323 2 33 6.2 102.2 Central African Republic 158 14 19 88.6 188.1 China 1,269 3 143 2.4 112.7 Congo, Rep. 56 1 4 17.9 71.4 Ethiopia 200 8 64 40.0 320.0 Ghana 789 13 114 16.5 178.7 India 749 0 39 0 52.1 Iran, Islamic Rep. 450 0 17 0 37.8 Kenya 301 0 43 0 142.9 Nepal 536 3 38 5.6 102.2 Nigeria 2,220 14 492 6.3 222.8 Pakistan 516 1 58 1.9 112.4 Peru 104 0 23 0 221.2 table continues next page 284 Essential Surgery Table 16.4 Published Mortality and Morbidity Rates in Selected Countries Following Appendectomy (continued) Total number of Total number Total number of Crude mortality per Crude morbidity per Country appendectomies of deaths complications 1,000 appendectomies 1,000 appendectomies Senegal 100 0 — 0 — South Africa 960 12 96 12.5 183.2 Thailand 2,139 0 26 0 12.2 Turkey 183 10 36 54.6 235.0 Source: Authors’ calculations, based on Abantanga and others 2009; Adisa and others 2012; Ali and Aliyu 2012; Asefa 2002; Ayoade and others 2006; Batajoo and Hazra 2012; Chamisa 2009; Chavda and others 2005; Chung and others 2000; Cunnigaiper and others 2010; Ekenze and others 2010; Fahim and Shirjeel 2005; Farthouat and others 2005; Fashina and others 2009; Gavilan-Yodu 2010; Gurleyik and Gurleyik 2003; Ibis and others 2010; Kargar and others 2011; Kasatpibal and others 2006; Khalil and others 2011; Khan and others 2012; Khiria and others 2011; Kong and others 2012; Kumar and Jain 2004; Liu and others 2007; Mabiala-Babela and others 2006; Malik and others 2009; Mehrabi Bahar and others 2010; Ming and others 2009; Ministère de la Santé Burkina Faso 2013; Ngowe Ngowe and others 2008; Ohene-Yeboah and Togbe 2006; Okafor and others 2003; Osifo and Ogiemwonyi 2009; Paudel and others 2003; Peralta Vargas and others 2004; Pokharel and others 2011; Rogers and others 2008; Saha and others 2010; Salahuddin and others 2012; Séréngbé and others 2002; Shaikh and others 2009; Terzi and others 2010; Utpal 2005; Willmore and Hill 2001; H. S. Wu and others 2011; S. C. Wu and others 2011; and Zoguereh and others 2001. See annex 16A for a list of citations by country. Note: Denominators of mortality and morbidity may differ due to multiple different studies from the same country using separate patient populations. — = not available. LICs and lower-middle-income countries have rates within countries; it is not surprising that this variability of death that are orders of magnitude greater than is more pronounced in LICs and lower-middle-income those of HICs and UMICs. Compared with Sweden, countries. However, the extreme rates of death and a country with historically low death rates following disability are so dramatic that health systems in these these three operations, cesarean section mortality is settings need to adopt strategies to improve survival and at least 2 to 4 times higher in Latin America and the reduce complications if surgical interventions are to be Caribbean, 6 to 10 times higher in South Asia, and 100 acceptable and have a meaningful health impact. times higher in Sub-Saharan Africa. The ranges of mor- tality rates following both appendectomy and inguinal hernia repair are much narrower, but there is frequently CHALLENGES TO SURGICAL SERVICES a 40-fold mortality increase in Sub-Saharan Africa, and in some cases more than a 100-fold increased risk of IN LICS AND LMICs death for the same intervention. If LICs and lower- The causes of the disparities in mortality described in middle-income countries closed the gap in surgical the previous section are multifactorial and include access rates to attain a minimum rate of 836 operations per to care, transportation options, behaviors, and attitudes. 100,000 people, but surgical mortality remained at Financial barriers in particular are substantial, especially 4 percent—a number well within the range of that in for the poor and near poor. Catastrophic health expendi- Europe—436,000 people would die annually following ture is a major cause of impoverishment, and surgical care surgery in these settings. With rates of surgery reaching can quickly deplete a family’s financial resources (Kruk, 1,504 per 100,000 people in LICs and lower-middle- Goldmann, and Galea 2009; Nguyen and others 2013; Van income countries, a postoperative mortality rate of Minh and others 2013; Xu and others 2007). Geographic 4 percent would increase this number to 1.14 million and transportation barriers present a challenge for pop- deaths per year. Reducing variability in mortality and ulations who live at distances from health centers and bringing postoperative mortality to 1.5 percent would first-level hospitals. Delays in care-seeking behaviors are prevent more than 200,000 and 700,000 deaths, respec- exacerbated when populations lack knowledge of health tively, for these two surgical rates. risks or when poor care has led to severe mistrust in health Although these estimates do not control for comor- systems (Gauthier and Wane 2011; Kahabuka and others bidities or other demographic, patient, or facility fac- 2011; Kruk and others 2009; Yaffee and others 2012). tors, they suggest tremendous excess mortality following These factors pose difficult challenges when evaluat- surgical interventions. The excessively high death rates ing outcomes of surgical care. Delays in presentation for following essential surgical interventions such as cesarean care translate into higher morbidity and mortality, par- section, appendectomy, and hernia repair indicate that ticularly for surgically treatable conditions. Patients may safety concerns are justified and demand attention. The arrive septic, malnourished, physiologically stressed, variability in mortality in HICs in Europe and North dehydrated, and anemic; many may arrive moribund. America has been well established, both among and Yet those with life- or limb-threatening conditions tend Excess Surgical Mortality: Strategies for Improving Quality of Care 285 Table 16.5 Published Mortality and Morbidity Rates in LMICs Following Inguinal Hernia Repair Total number of patients Total number Total number of Crude mortality per Crude morbidity per Country undergoing hernia repair of deaths complications 1,000 hernia repairs 1,000 hernia repairs Burkina Faso 7,421 36 0 4.9 0 Cameroon and Mali 524 0 5 0 9.5 China 4,072 0 13 0 3.2 Colombia 13 0 0 0 0 Côte d’Ivoire 128 1 1 7.8 7.8 Dominican Republic 239 0 0 0 0 Ecuador 102 0 0 0 0 Ghana 973 9 29 9.2 33.1 Haiti 17 0 1 0 58.8 India 358 0 31 0 86.6 Jamaica 314 0 — 0 — Nepal 61 0 5 0 82.0 Nicaragua 10 0 0 0 0 Niger 34 14 16 411.8 470.6 Nigeria 5,451 26 275 4.8 50.5 Pakistan 605 8 25 13.2 41.3 Sierra Leone 45 5 — 111.1 — Sudan 64 4 7 62.5 109.4 Tanzania 452 44 24 97.3 53.1 Thailand 24 0 1 0 41.7 Tunisia 595 4 — 6.7 — Turkey 970 11 31 11.3 37.7 Source: Authors’ calculations; based on Abantanga 2003; Aderounmu and others 2008; Adesunkanmi and others 2000; Akcakaya and others 2000; Akinci and others 2010; Ameh 2002; Awojobi and Ayantunde 2004; Chauhan and others 2007; Cingi and others 2005; Clarke and others 2009; Diarra and others 2001; ElRashied and others 2007; Freudenberg and others 2006; Gao and others 2009; Gil and others 2012; Harouna and others 2001; Huang and others 2005; Jani 2005; Kingsnorth and others 2006; Lagoo and others 2012; Lau and others 2002; Lohsiriwat and others 2007; Mabula and Chalya 2012; Malik and others 2010; Mbah 2007; McConkey 2002; Memon and others 2013; Ministère de la Santé Burkina Faso 2013; Mungadi 2005; Obalum and others 2008; Ohene-Yeboah 2003; Osifo and Irowa 2008; Pradhan and others 2011; Ramyil and others 2000; Samaali and others 2012; Sanders and Kingsnorth 2007; Scarlett and others 2007; Shaikh and others 2012; Shi and others 2010; Shillcutt and others 2010; Shillcutt and others 2013; Taqvi and others 2006; Turaga and others 2006; Usang and others 2008; Walk and others 2012; Wu and others 2008; Yeung and others 2002; and Zhou 2013. See annex 16A for a list of citations by country. Note: Denominators of mortality and morbidity may differ due to multiple different studies from the same country using separate patient populations. — = not available. to derive the greatest benefit from interventions, but at a work under less-than-ideal circumstances and operate cost of poorer overall outcomes. The physiologic insults on patients with more severe, life-threatening comorbid of surgery and anesthesia are substantial, and patients conditions are important. that arrive with only minimal physiological reserves As demonstrated throughout this volume, LMICs do fare poorly. Thus, even situations that might be consid- not meet the basic surgical needs of their populations. ered low risk from a population perspective—such as Estimating minimum surgical rates using a surgical cesarean section in otherwise young, healthy women or rate efficiency methodology indicates that most LMICs appendectomy in healthy young children—demonstrate fall far short of minimum need. In addition, death high levels of complications and mortality compared rates following common operations are substantial and with similar conditions in HICs. When addressing issues exceed what would be considered acceptable in HICs. If of harm from surgery, providing constructive improve- health systems in LMICs improve their surgical num- ment strategies to health systems and providers who bers without concurrently improving the safety, quality, 286 Essential Surgery and transparency of their services, they jeopardize the Figure 16.3 Relationship of Barriers to Care and Delays in Obtaining Care health of patients seeking care and risk exacerbating mistrust. Barriers to care Phases of delay Acceptability Phase I: • Fear, mistrust Deciding to seek Barriers to Surgical Care • Quality of services, “return on investment” care • Social and family roles and hierarchy Multiple factors contribute to the risks that surgical • Understanding and perceptions of condition patients face in resource-constrained environments. Patients, particularly those whose conditions require Affordability Phase II: urgent surgical interventions, encounter significant bar- • Direct costs: fees, transport, food, lodging, Identifying and riers to effective and timely care. These conditions can informal payments reaching care rapidly become fatal, and delays in care are associated • Indirect costs: loss of income with significantly worse outcomes. Emergency surgery carries an added risk of mortality due to the extenuating Availability Phase III: • Geographic distribution Receiving adequate, circumstances of the condition, the inability to ade- • Transportation appropriate, and quately plan or prepare for the procedure, the inability • Hours of service timely care to control or modify patient-specific risk factors, the • Durable and consumable goods and resources logistical difficulties rallying appropriate human or infra- • Human skills and resources structure resources, and the challenge of intervening • Range of services with incomplete information. Accordingly, outcomes are worse for emergency interventions compared with Source: Adapted from Thaddeus and Maine 1994. elective or semielective procedures. Emergency oper- • The range, quantity, and quality of services provided ations constitute a higher proportion of operations in and the nature and extent of the health needs of resource-limited settings, and any barrier that delays people seeking care presentation imposes a tremendous burden on patients and the health system. A tremendous obstacle to early presentation is the Delays in care have been categorized into three geographic distribution of health facilities with the phases: delays in deciding to seek care; delays in reach- capacity to recognize and deal with surgical issues (Dye ing adequate health facilities; and delays in receiving and others 2010; Hang and Byass 2009; Macharia and adequate, appropriate, and timely care (Thaddeus and others 2009; Mock, nii-Amon-Kotei, and Maier 1997; Maine 1994). Because access to and delivery of surgical Parkhurst, Rahman, and Ssengooba 2006). Health centers care presents particular challenges in LICs and LMICs, with the sophistication to provide surgical care tend to it is especially important to understand the barriers be located in more populous areas, and LMICs with that contribute to delays in definitive interventional the lowest surgical volumes frequently have large rural care. These barriers can generally be divided into three populations. Timely transport to surgical care is critical, dimensions: availability, affordability, and acceptabil- yet road and transportation infrastructure can be lack- ity (Grimes and others 2011; McIntyre, Thiede, and ing or intermittent (Macharia and others 2009; Mock, Birch 2009). Each of these dimensions causes delays nii-Amon-Kotei, and Maier 1997; Seljeskog, Sundby, and experienced by patients in need of surgical care Chimango 2006). Finally, social norms can prevent early (figure 16.3). presentation; consultation with traditional healers, vil- lage elders, or heads of family may delay access to the for- Availability of Care. Availability refers to the following: mal health care system (Briesen and others 2010; Hang and Byass 2009; Mock, nii-Amon-Kotei, and Maier 1997; • The relationship between the location of health care Parkhurst, Rahman, and Ssengooba 2006; Seljeskog, facilities with the capacity to provide appropriate Sundby, and Chimango 2006). services, the location of the population needing them, Once patients do arrive at facilities, the requisite and the transport opportunities available durable and consumable supplies and equipment are • The ability and willingness of care providers to serve often inadequate (Lebrun, Chackungal, and others 2013; the population in accordance with the type and sever- Lebrun, Dhar, and others 2014; Macharia and others ity of the presenting condition 2009). The availability of personnel and services is often • The timing and hours of available services and the intermittent, particularly at night. Above all, the human times patients seek care resources for health are frequently lacking. Surgical skill Excess Surgical Mortality: Strategies for Improving Quality of Care 287 requires education, training, and experience; trained Many of these domains interact in ways that magnify clinicians are not always available or capable of per- delays. Concerns about financial commitments, com- forming specific surgical tasks; the status of anesthe- pounded by mistrust of the health care system, a lack sia services, as discussed in chapter 15, is even more of transparency, and poor quality, lead to long delays in dire. Providers’ confidence in their skills is particularly treatment-seeking behavior. People in many LMICs may important for the provision of surgical care; recent justifiably perceive surgical care to be a poor investment research has indicated that lack of confidence—due to of resources. lack of training, experience, or surgical assistance— may be a primary cause of triage and transfer, as well as a major barrier preventing immediate intervention Anesthesia Safety (Bowman and others 2013; Petroze, Nzayisenga, and The safe provision of anesthesia is a critical consider- others 2012). ation in establishing and expanding the capacity for surgical care. Improvements in anesthetic monitoring Affordability of Care. Affordability, the match between and techniques have led to dramatic improvements costs of services and the ability of individuals to pay, in its safety profile in HICs and UMICs. In many presents a major challenge because of the following settings with low levels of human resources, however, factors: anesthesia is provided by nonphysician clinicians or technicians, or even by the operating surgeons. Poor • Price of services at the point of delivery training, supervision, and monitoring standards all • Direct costs associated with transportation, food, and contribute to high mortality from the administration lodging of anesthesia. • Indirect costs, such as lost income or productivity Although the rate of overall deaths due to anesthesia is estimated to be 34 per 1 million anesthetics adminis- The ability of individuals to pay also relates to their tered, profound differences exist among countries and personal wealth and assets, eligibility for financial settings. Bainbridge and others (2012) report that in support from financing mechanisms, and amount of low human development index countries, deaths solely indirect costs incurred. Transportation costs can be attributable to anesthesia are estimated to be 141 per unaffordable, and, when combined with prohibitive million, compared with 25 per million in high human out-of-pocket expenses, frequently delays early con- development index countries. Critically, anesthesia sultation (Afsana 2004; Mock, nii-Amon-Kotei, and mortality in LMICs continues to be a major problem, Maier 1997; Nwameme, Phillips, and Adongo 2013). with death rates as high as one per 500 (Walker and In addition, affordability refers not just to the ability Wilson 2008). Anesthesia in HICs and UMICs has of an individual or family to pay for care but also the improved only relatively recently, with changes in potential impact of that payment on the household, monitoring and increased standardization responsible and the manner and timing of payment. For example, for a 100-fold reduction in mortality over the past up-front charges may prevent early assessment and 40 years—34 deaths per million instances of anesthet- definitive management as families seek to secure neces- ics administered in the 1990s and 2000s, down from sary funds for payment for services (Kruk, Goldmann, 357 deaths per million before 1970 (figure 16.4). Low and Galea 2009). professional standing, inadequate basic monitoring equipment, and a lack of professional standards all Acceptability of Care. Acceptability refers to the expec- contribute to the current disparity between HICs and tations, behaviors, perceptions, and attitudes inherent other countries. in medical encounters. Providers’ attitudes are affected by stereotypes, chief complaints, and the manner of presentation. Patients’ attitudes are similarly affected Perioperative Safety by stereotypes, as well as by perceptions of respect, effi- Surgical intervention, by its nature, involves risks. High- ciency of care, and trust in the integrity of the system. quality and high-resource systems still fail to provide Of particular concern with surgical intervention is the proven interventions every time for every patient. personal security of clinicians; deaths following surgery In the United States, the failure to adhere to basic may be blamed directly on surgical providers, and family WHO standards occurs in 6 percent to 20 percent of and community members may seek retribution, regard- operations, indicating substantial room for improvement less of premorbid conditions or cause of demise (Burch (Stulberg and others 2010). Individual care standards and others 2011; Malik and others 2010). are being used in pay-for-performance initiatives to 288 Essential Surgery help improve quality by linking it to reimbursement. Figure 16.4 Meta-Regression for Risk of Death due Solely to Anesthesia, When individual standards are evaluated in isolation, 1939–2009 however, they frequently fail to demonstrate improve- ments in outcomes with improving levels of compliance –6.64 (table 16.6) (Stulberg and others 2010). Multiple care –7.28 Log-odds event rate standards need to be evaluated as a composite whole; –7.93 –8.57 partial completion of tasks does not always deliver a –9.22 partial benefit, and improvements often require total –9.86 compliance to result in improved outcomes (Nolan and –10.51 –11.15 Berwick 2006). –11.79 This all-or-none compliance likely indicates that –12.44 systems able to achieve high compliance rates with mul- –13.08 tiple standards-of-care processes are highly organized 1939 1946 1953 1960 1967 1974 1981 1988 1995 2002 2009 and functioning efficiently; accordingly, they are able Study year to deliver on difficult-to-measure but essential compo- Source: Bainbridge and others 2012. nents of care, such as communication and information Note: Every circle represents a study; the circle size is representative of the weight of that study in the transfer (Weiser 2010). In LMICs, lack of compliance analysis. The relationship between mortality and year of study was significant, with a significant decline may be especially germane—poorly used or misallocated over the decades (slope −0.053; 95 percent confidence interval of −0.058 to −0.049; p = 0.000001). Table 16.6 Surgical Care Improvement Project: Infection-Prevention Process Measures Nonadherent discharges Adherent discharges Postoperative Postoperative Adjusted odds infections Discharges infections Discharges ratio (95% CI) Individual SCIP measures Prophylactic antibiotic 251 18,147 1,394 190,925 0.89 (0.75–1.06) received within 1 hour prior to surgical incision Prophylactic antibiotic 266 12,670 1,486 198,002 0.83 (0.69–1.00) selection for surgical patients Prophylactic antibiotics 310 26,499 1,024 173,228 0.94 (0.78–1.13) discontinued within 24 hours after surgery end time Cardiac surgery patients 65 4,168 362 31,512 0.93 (0.68–1.27) with controlled postoperative morning blood glucose Surgery patients with 194 21,308 3,539 360,111 1.00 (0.85–1.19) appropriate hair removal Colorectal surgery patients 181 4,564 676 18,101 1.00 (0.81–1.23) with immediate postoperative normothermia Composite measures SCIP Antibiotic Measures 511 44,417 816 154,963 0.86 (0.74–1.01) (1st three above) performed At least 2 of the above SCIP 843 59,356 1,070 158,304 0.85 (0.76–0.95) 0.50 1.00 2.00 measures recorded in a single Adjusted odds ratio (95% CI) visit Source: Stulberg and others 2010. Note: Each estimate accounts for the surgical procedure performed, patient characteristics, and hospital characteristics. CI = confidence interval; SCIP = Surgical Care Improvement Project. Excess Surgical Mortality: Strategies for Improving Quality of Care 289 resources constitute a drain on an already stressed health no formal medical education to fully licensed physician, system. only a small difference was observed in adherence to care Compliance with care standards in LMICs is fre- standards; no difference was observed in arriving at the quently poor. In a study in India, Das and others (2012) correct diagnosis or providing the correct treatment. selected a random sample of health care providers in Such studies point to troubling discrepancies between rural Madhya Pradesh and urban Delhi to receive a visit what is known and taught about care standards, on the from a “standardized patient” trained to present one of one hand, and actual practice patterns, on the other three scenarios: unstable angina, asthma, or a parent hand. Adherence to known practice standards is a hall- describing dysentery in a child at home. These stan- mark of high-quality health organizations; yet, similar dardized patients were then debriefed following their to what is found in primary care and general practice clinic visit to assess the quality of care and compliance settings, surgical delivery in HICs and LMICs alike with care checklists and best practices. Providers in both frequently fails to follow standards of care, despite well- locations did poorly in asking appropriate questions described strategies and techniques for improvement. and performing appropriate examinations (33.7 percent and 31.8 percent in Madhya Pradesh and Delhi, respec- tively); making the correct diagnosis (12.2 percent and Postoperative Care and Safety 21.8 percent in Madhya Pradesh and Delhi, respec- In addition to the risks during surgery, patients are tively); and identifying pertinent clinical issues and mak- at high risk during postoperative recovery. The two ing appropriate recommendations for treatment (30.4 most common causes of complications within the first percent and 45.6 percent in Madhya Pradesh and Delhi, week of surgery are bleeding and infections. Additional respectively) (figure 16.5). The rate of unnecessary or causes of delayed morbidities include blood clots, harmful treatments exceeded 40 percent in Madhya heart attacks, pneumonia, and stroke. Anticipating Pradesh. Despite the range of provider education, from potential complications, and either preventing them (for example, by prophylaxis for venous thromboem- bolism) or identifying the signs and symptoms and Figure 16.5 Adherence to Checklist of Questions and Examinations for intervening early and aggressively, are essential to Unstable Angina, Madhya Pradesh, 2010 reduce these risks. An important study established the prominent role of Temperature attempt a mature system of postoperative care in managing com- EKG plications and preventing them from resulting in death Blood pressure (E) Pulse (E) (also known as failure to rescue). Ghaferi, Birkmeyer, and Checklist of questions and exams Auscultation front or back Dimick (2009a, 2009b) found that although baseline Family history complications rates were strikingly similar in institu- Bidi-cigarette habit tions across the United States, mortality rates following Activity when pain started these complications varied dramatically (figure 16.6 and Shortness of breath (E) Pain quality (E) table 16.7). These findings confirm earlier research sug- Pain radiation (E) gesting that the primary difference in outcomes among When pain first experienced hospitals is not due to differences in complication rates Pain severity but to differences in the rates of failure to rescue (Silber Nausea and others 1992). Sweating Further research has demonstrated that higher-volume Pain previously Pain start time hospitals appear to have a better ability to recognize, Pain location (E) intervene, and save patients undergoing high-risk pro- 0 10 20 30 40 50 60 70 80 cedures from death and complications following surgery Percent of interactions (Ghaferi, Birkmeyer, and Dimick 2011). Complications must be anticipated following high-risk procedures; the Mean value 95 percent confidence interval ability to recognize, diagnose, and treat complications separates the high performers from the poor performers. Source: Das and others 2012. The quality of communication and the systems of care, Note: All items listed are recommended; those marked (E) are essential. “Temperature attempt” refers to and the skills and capacity of ancillary services—such as checking temperature either by touch or with a thermometer. EKG = electrocardiogram and refers to availability of intensive care and the presence and expe- either an electrocardiogram performed by practitioners or referrals for electrocardiograms. “Bidi-cigarette habit” indicates whether the doctor asked about tobacco use; a bidi is an Indian cigarette rience of specialized services—appear to be important consisting of tobacco wrapped in a leaf. “Pain start time” is asked to ascertain a specific time of day. factors for improving outcomes following complications. 290 Essential Surgery STRATEGIES FOR IMPROVING SURGICAL Figure 16.6 Rates of All Postsurgical Complications, Major Complications, and Deaths after Major Complications, According to CARE Hospital Quintile of Mortality Several effective strategies have been identified for 35 improving surgical outcomes in LMICs. These strate- gies include the adoption and use of basic technologies, 30 27.6 26.9 26.9 24.6 23.5 the development of monitoring standards, and the 25 21.4 Patients (%) use of surgical safety checklists. Organizational and 18.4 19.3 20 18.0 18.2 17.5 16.2 management strategies also appear to be important. 14.9 14.7 15 12.5 Essential to all of these interventions is a mandate to 10 measure the delivery of care and its impact on health. These low-cost interventions, which can dramatically 5 lower postsurgical mortality rates, demand prioritiza- 0 tion by health systems seeking to improve access and All Major Death after major complications complications complications surgical service provision. Very low Low Medium High Very high Anesthetic Monitoring and Safety Source: Ghaferi and others 2009b. Note: Although rates of all complications and major complications did not vary significantly across One of the most important contributions to improved hospital mortality quintiles, the rate of death in patients with major complications was almost twice as surgical safety has been the development of basic stan- high in hospitals with very high overall mortality as in those with very low overall mortality (21.4 percent dards of anesthetic monitoring. The Harvard monitoring versus 12.5 percent, p < 0.001). Table 16.7 Rates of Deaths, Complications, and Death after Major Complications for Five Operations with the Highest Number of Deaths, According to Hospital Quintile of Mortality, 2005–07 Odds ratio for very high Very low mortality Very high mortality versus very low mortality Type of surgery (percent of patients) (percent of patients) (95% confidence interval) Colectomy Overall mortality 2.5 5.6 2.29 (1.76–2.98) All complications 24.7 28.1 1.19 (0.95–1.50) Major complications 15.4 17.6 1.17 (0.94–1.46) Mortality after major complications 11.4 20.5 2.08 (1.54–2.82) Abdominal-aortic-aneurysm repair Overall mortality 3.1 7.3 2.49 (1.63–3.81) All complications 17.4 19.3 1.13 (0.87–1.46) Major complications 13.6 15.5 1.26 (0.86–1.56) Mortality after major complications 15.6 26.3 1.94 (1.04–3.62) Above-knee amputation Overall mortality 10.0 15.0 1.59 (1.00–2.53) All complications 25.7 26.6 1.05 (0.75–1.47) Major complications 18.9 18.6 0.98 (0.67–1.43) Mortality after major complications 20.8 35.2 2.08 (0.94–4.60) Lower-extremity bypass Overall mortality 1.9 2.9 1.55 (0.92–2.60) All complications 24.0 23.6 0.97 (0.81–1.17) Major complications 11.5 11.1 0.95 (0.75–1.22) Mortality after major complications 8.2 12.7 1.63 (0.76–3.53) table continues next page Excess Surgical Mortality: Strategies for Improving Quality of Care 291 Table 16.7 Rates of Deaths, Complications, and Death after Major Complications for Five Operations with the Highest Number of Deaths, According to Hospital Quintile of Mortality, 2005–07 (continued) Odds ratio for very high Very low mortality Very high mortality versus very low mortality Type of surgery (percent of patients) (percent of patients) (95% confidence interval) Below-knee amputation Overall mortality 4.2 8.4 2.07 (1.18–3.63) All complications 23.7 25.4 1.09 (0.82–1.46) Major complications 15.5 17.3 1.14 (0.81–1.60) Mortality after major complications 14.5 29.7 2.49 (1.10–5.63) Source: Ghaferi, Birkmeyer, and Dimick 2009b. standards for intraoperative anesthesia care formalized a with the cost per DALY averted from anesthetic mis- set of medical standards of practice that have become haps due to improved monitoring at US$374 for a stan- de facto international standards endorsed by the World dard commercial oximeter and US$115 for a smaller Federation of Societies of Anaesthesiologists (Eichhorn hand held device (Burn and others 2014). A concerted and others 1986; WFSA 2008). The standards include the effort is underway through the Lifebox Foundation to continuous presence of trained anesthesia providers and provide pulse oximetry monitoring capabilities to every the uninterrupted monitoring of oxygenation, ventila- operating theater in the world (http://www.lifebox.org). tion, and perfusion. Today, adherence to these standards in HICs is essentially universal; however, this was not the case a mere three decades ago, and it is far from standard Surgical Checklists practice in many LMICs. Standardization of care is essential because of the In addition to continuous monitoring techniques, tremendous magnitude of interactions and care pro- anesthesia delivery systems have been standardized, cesses that occur during even simple surgical procedures. with safety engineered into the instruments themselves. Complex patient characteristics, therapeutic options, Inhalational anesthetic machines are now engineered to technical demands, and team dynamics require specific be redundant; safety features, such as auto-lock mecha- strategies for organizing care protocols and service nisms, prevent lethal hypoxic gas mixtures. Despite the delivery. The effective use of checklists by teams during 100-fold plunge in anesthetic-related mortality rates in surgery has cut mortality rates by up to 50 percent. HICs and UMICs during the past 40 years, anesthetic In 2008, the WHO codified a set of basic surgical mortality in LMICs is a major problem due to lack of standards into guidelines for safe surgery. Researchers professional stature, training, and credentialing of anes- transformed these guidelines into a simple, 19-item thesia providers; deficiencies in basic monitoring equip- checklist to be used during the perioperative period and ment; and failure to adhere to strict standards of care. conducted a multicenter trial assessing the efficacy of One critical mechanism for anesthesia monitoring this safety tool on postoperative morbidity and mortality is the use of pulse oximetry. Although the continuous (figure 16.7). In a pre- and postanalysis of nearly 8,000 monitoring of blood oxygen levels using a pulse surgical patients, use of this checklist nearly doubled oximeter is considered an essential standard, more adherence to basic perioperative safety standards, includ- than 77,000 operating rooms worldwide do not have ing confirmation of the procedure and operative site, this basic monitoring device (Funk and others 2010). administration of antibiotics, use of pulse oximetry for Pulse oximetry can alert anesthesia personnel to drops monitoring, objective airway assessment, and comple- in oxygenation before clinical signs become apparent, tion of instrument and sponge counts at the conclusion allowing for corrective actions before hemodynamic of the operation. Use of the checklist reduced deaths by instability or lethal arrhythmias occur. In Moldova, an more than 47 percent and cut complication rates by 35 implementation program supplying pulse oximetry percent (Haynes and others 2009). This beneficial effect equipment in conjunction with provider training on was maintained in a subanalysis of urgent and emer- the use of a surgical safety checklist reduced postopera- gency cases (Weiser, Haynes, Dziekan, and others 2010). tive deaths and complications (Kwok and others 2013). Several other large, well-designed studies have con- Use of pulse oximetry is highly cost-effective as well, firmed the substantial enhancements to surgical safety 292 Essential Surgery Figure 16.7 World Health Organization Surgical Safety Checklist Before induction of anesthesia Before skin incision Before patient leaves operating room (with at least nurse and anesthetist) (with nurse, anesthetist, and surgeon) (with nurse, anesthetist, and surgeon) Has the patient confirmed his/her Confirm all team members have Nurse verbally confirms: identity, site, procedure, and consent? introduced themselves by name and role. Yes The name of the procedure Confirm the patient’s name, procedure, Is the site marked? and where the incision will be made. Completion of instrument, sponge, and needle counts Yes Has antibiotic prophylaxis been given within Not applicable the last 60 minutes? Specimen labeling (read specimen labels Yes aloud, including patient name) Is the anesthesia machine and medication check complete? Not applicable Whether there are any equipment problems to be addressed Yes Anticipated critical events Is the pulse oximeter on the patient and To surgeon: To surgeon, anesthetist, and nurse: functioning? What are the critical or nonroutine steps? Yes How long will the case take? What are the key concerns for recovery and management of this patient? Does patient have a: What is the anticipated blood loss? Known allergy? To anesthetist: No Are there any patient-specific concerns? Yes To nursing team: Difficult airway or aspiration risk? Has sterility (including indicator results) been confirmed? No Yes, and equipment/assistance available Are there equipment issues or any concerns? Risk of >500ml blood loss (7ml/kg in children)? Is essential imaging displayed? No Yes Yes, and two IVs/central access and fluids Not applicable planned Source: WHO 2009b. Note: This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged. IV = intravenous therapy; kg = kilogram; ml = milliliter. that checklists provide. Following the introduction of a organizations and sectors in which high reliability and comprehensive perioperative checklist in six hospitals in fidelity are paramount, such as aviation and nuclear the Netherlands, postoperative complications and deaths power. This method has been extended to surgical dropped by 30 percent and 47 percent, respectively; teams; it has been observed, for example, that cardiac in five control hospitals, no improvements were noted surgery teams that consistently work together are more during the same period (de Vries and others 2010). efficient and have better outcomes than those with A second study in the Netherlands virtually repeated rotating members (Carthey, de Leval, and Reason 2001; the original multinational WHO investigation, demon- de Leval and others 2000). Because this method is often strating improvements in postoperative mortality that not possible in urgent circumstances or when human strongly correlated with checklist compliance (van Klei resources are limited, checklists can play an essential role and others 2012). in promoting consistent processes of care. A study con- Just as a pilot’s checklist does not instruct a pilot ducted at 74 Veterans Administration hospitals in the how to fly a plane, surgical checklists do not dictate United States demonstrated significant improvements how clinicians should deliver care; instead, checklists in mortality compared to controls following a full-day help confirm critical steps, prompt consideration of team training program that included implementation extenuating or unusual factors, and stimulate or facil- and training in the use of checklist-guided briefings and itate team communication. These processes are partic- debriefings (Neily and others 2010). ularly important in the complex and multidisciplinary Checklists have become an established standard of environment of surgery. Checklists are often a critical surgical care globally (Birkmeyer 2010). Their effec- part of crew resource management, a method of team tiveness has demonstrated the accuracy of previous training that promotes shared mental models for care estimates suggesting that at least 50 percent of existing and conduct that has been implemented in many surgical mortality is preventable. Checklists are most Excess Surgical Mortality: Strategies for Improving Quality of Care 293 effective when they are implemented, not as a tickbox lower overall productivity. Although economic envi- exercise, but as a means to reinforce communication, ronments and organizational factors played a role prompt genuine dialogue and discussion of critical (Bloom, Sadun, and van Reenen 2012), introducing information, and facilitate prospective feedback and management practices through an intensive consulting quality improvement (Weiser, Haynes, Lashoher, and process resulted in massive improvements in efficiency others 2010). Large-scale regulatory mandates alone and productivity (Bloom and others 2010; Bloom and appear not to be effective in fostering effective adoption others 2013). (Urbach and others 2014). Implementation has been In health care, the management practices evaluated found to require local champions from all disciplines, by Bloom and van Reenen (2010) roughly translate to support from leadership, monitoring of progress, and operations management, quality evaluation, goal-setting, involvement of frontline clinicians (such as through and talent management. Their scoring mechanism has team training) and not just administrators. Such an been used to evaluate hospital management practices and approach has been followed in Scotland, leading to a its subsequent correlation with patient outcomes across statistically significant drop in inpatient surgical death Brazil, Europe, India, and the United States. They find rates from 2011 after three years of flat mortality tremendous variability in management practices within rates. The Scottish government has documented more countries, as well as a particularly large proportion of than 9,000 lives saved (Leitch 2012). poorly managed hospitals in LMICs. A McKinsey study The challenge of conducting multidisciplinary looking at hospitals in the United Kingdom and the implementation programs in LMICs raises legitimate United States determined that an increase of 1 point on concerns about ability to scale up such programs glob- Bloom’s management practice survey scale is associated ally. However, a follow-up WHO study in Honduras, with a decrease of 6 percent to 7 percent in 30-day mor- Moldova, and Zambia confirms the ability to implement tality following acute myocardial infarction, an increase and replicate large improvements in safety and outcomes in hospital earnings of 14 percent to 33 percent, and an (Kim and others 2012). overall improvement in patient satisfaction (Bury and others 2007). Although there is a paucity of research in the area of Management Practices hospital management in LMICs, it is reasonable to infer Effective and efficient management strategies are an that management practices affect the organizational essential component in the smooth functioning of health structure, efficiency, and even safety of the health sys- facilities. Numerous econometric studies have looked at tem. In one of the first studies of this kind, Funk and management practices in industry and business and others (2013) suggest that more robust management identified characteristics that affect productivity. Two practices are associated with enhanced surgical produc- economists from Stanford University and the London tivity. Unfortunately, many first-level rural and urban School of Economics conducted a series of interviews referral hospitals in LMICS are likely to be plagued by with midlevel managers from a range of medium-sized poor management practices similar to their business manufacturing firms in France, Germany, the United and manufacturing counterparts. Such problems lead Kingdom, and the United States, using a survey to assess to waste and poor resource allocation, and potentially four domains of management: operations, monitoring, even to fraud and abuse. It remains to be seen whether targets, and incentives (Bloom and van Reenen 2007). improvements in management translate into improved High scores in these domains were strongly related to surgical productivity in these settings and, if so, the higher productivity and profitability, as well as to the mechanisms by which such improvements occur. longevity of the company. One essential mechanism that management uses to In LMICs, however, multiple factors affect the enhance the quality of care is the implementation of performance of industry, particularly for the worse. surveillance and evaluation practices, allowing quality Management practices are suboptimal for various rea- improvement (QI) programs to be targeted to identi- sons, including lack of knowledge of optimal manage- fied weaknesses. These practices range from very simple ment practices, reduced competition, high proportion outcome assessments, such as Morbidity and Mortality of family ownership, lack of delegation of decision Conferences (M&M), to more complex monitoring, making because of fear or mistrust, reduced incen- such as ongoing surveillance of complications, adverse tives, and poorly allocated financing. Bloom and van events, and errors, and use of risk-adjusted mortality. Reenen (2010) and Bloom and others (2010) note that Many hospitals in LMICs have some type of QI activity, similarly sized local firms in LMICs were severely lack- even if limited to periodic M&M conferences. Often, ing in management practices, with correspondingly the effectiveness of these efforts could be increased by 294 Essential Surgery simple measures, such as better recording of problems are used efficiently, effectively, and with the least harm discussed, more purposeful enactment of corrective to patients. Practitioners, facilities, and health systems action, and monitoring of the outcome of the corrective require information on surgical capacity, throughput, action. A WHO review of the effectiveness of QI pro- and results to determine how such service lines perform. grams for trauma care identifies 36 studies, 34 of which Other notable public health successes, such as improve- report improvements in patient outcomes (including ments in maternal and neonatal health, HIV care, and mortality) or process of care after a new QI program control of poliomyelitis and malaria, have been depen- or method is introduced (Juillard and others 2009). dent on surveillance (Ceesay and others 2008; Ronsmans Two articles report no change, and no articles report a and Graham 2006; WHO 2000, 2005, 2007). Surveillance worsening of any outcome; five articles also report cost is equally essential in optimizing access to and the safety savings. Most of the articles were from HICs; two were of surgical care; the absence of data on surgical delivery from Thailand. A summary of the model QI program in and outcomes perpetuates the neglect such therapy Thailand is provided in chapter 3 on trauma care in this receives in resource-constrained settings (Weiser and volume. The WHO has outlined a multimodal approach others 2008, 2009). to QI processes for trauma systems through the use The WHO has proposed a set of standardized metrics of morbidity and mortality, preventable death panel for surgical surveillance at the national level that have reviews, audit filters, and the establishment of trauma been tested and validated (WHO 2009d), and is included data bases and surveillance systems (WHO 2009a). in annex 16B. These metrics include the number of operating rooms in each country, the numbers of trained surgeons and trained anesthetists in each country, the Measurement Strategies number of procedures performed in operating rooms in The measurement of outcomes of intervention, regard- each country, the number of deaths on the day of sur- less of the service provided, is essential to ensure that the gery, and the number of in-hospital deaths after surgery effects of care are aligned with intent and that resources (Weiser and others 2009) (table 16.8). Although each Table 16.8 Standardized Statistics for Surgery: Definitions, Rationale, and Data Sources Definition Rationale for use Data sources Comments Number of Operating rooms are rooms The number of operating Administrative records Minor procedure rooms that are operating rooms used specifically for surgical rooms available to a based on reported not suitable for invasive operations procedures and equipped to population is a structural data by inpatient and and are not equipped to deliver deliver anesthesia indicator of the ability outpatient facilities; anesthesia should not be included to provide surgical censuses of health in the total number of operating interventions. facilities rooms. Number of Accredited surgeons are The availability and Facility surveys, Each country can define the accredited physicians who have achieved composition of human labor force surveys, acceptable national standards surgeons and certification in a surgical resources for health is and records from for accreditation of surgeons number of specialty as recognized by the an important indicator of professional and and anesthesia professionals. accredited accepted national standards the strength of the health administrative sources The word professional in anesthesia of the state or national system. anesthesia professional recognizes professionals professional organizations. the important contribution Accredited anesthesia nonphysician anesthesia professionals are physicians, practitioners provide in all nurses, and other countries. practitioners who have Individuals who perform surgery or achieved certification in the administer anesthesia but are not provision of anesthesia as accredited, including those still in recognized by the accepted training, should not be included in national standards of the this measure. state or national professional organizations table continues next page Excess Surgical Mortality: Strategies for Improving Quality of Care 295 Table 16.8 Standardized Statistics for Surgery: Definitions, Rationale, and Data Sources (continued) Definition Rationale for use Data sources Comments Number The absolute number of all Surgical volume is an Hospital records and Invasive procedures that meet the of surgical surgical procedures, defined indication of the access routine health service definition but that are done in a procedures done as the incision, excision, or to and use of health statistics procedure room not suitable for in an operating manipulation of tissue that care, particularly surgical more extensive operations should room per year requires regional or general services. not be considered in the total anesthesia, or profound number of surgical procedures. sedation to control pain, If, however, they are done in the undertaken in an operating operating room, they should be room counted. Day-of-surgery Number of deaths on the day Day-of-surgery death Administrative and Death on the day of surgery often death ratio of surgery, irrespective of ratios allow the health hospital records based reflects the comorbidities and cause, divided by the number system to assess its on health service physiological disorders of the of surgical procedures in a performance and the statistics patient, the quality and complexity given year or period, reported state of health of the of surgical care, or the risks of as a percentage population. anesthesia. This measure cannot be used to compare one site, facility, or country with another without appropriate, validated, and time- consuming risk adjustment. Postoperative Number of deaths in the The in-hospital death ratio Administrative and Patients who undergo surgery and in-hospital death hospital following surgery, after surgery provides hospital records based die outside a health facility or ratio irrespective of cause and insight into the risks on health service after readmission to the same or a limited to 30 days, divided associated with surgical statistics different facility are important to by the number of surgical intervention. record in postoperative mortality procedures done in a given assessments. year or period, reported as a Facilities should be encouraged to percentage gather such information. Neither circumstance is included in this statistic, however. Source: Weiser and others 2009. of these metrics has important weaknesses that must • Process metrics, such as hours of operation, duration be acknowledged, all can be obtained and reported in a of operations, number of operations per operating straightforward manner. room, appropriate administration of antibiotics, and National-level metrics nonetheless require the inter- use of and compliance with checklists est, investment, and commitment of the central govern- • Outcome metrics beyond mortality, such as surgical ment or agency responsible for collecting, analyzing, infections and reoperation, and other perioperative and disseminating such information. Local efforts at QI complications such as pneumonia, renal failure, heart should not be limited to crude, population-level data attack, or stroke collected to measure health system performance. Several basic metrics must be adopted by facilities and health One of the issues of greatest concern is the misuse systems to improve the quality and delivery of care of such metrics to deny care to the most frail and vul- (table 16.9). These could include the following: nerable populations. Health systems that manipulate their outcomes by increasing inappropriate services, • Structural metrics, such as the availability of essential failing to intervene, and underreporting mortality monitors like pulse oximetry; equipment, such as succumb to perverse, negative incentives that divert anesthetic machines and autoclaves; and consumable essential resources and inhibit care for the sickest and reusable materials, such as surgical equipment, patients. Under ideal circumstances, surgical statis- devices, and antibiotics tics should help health systems improve the delivery 296 Essential Surgery Table 16.9 Proposed Facility-Level Metrics for Quality Improvement, in Addition to the Standardized Statistics Described in Table 16.8 Structural metrics Process metrics Outcome metrics Number of pulse oximeters per Number of cases performed with pulse oximetry in place for entirety of Surgical-site infection rates operating room operation Percentage of cases requiring Number of functional anesthetic Number of cases delayed because of lack of equipment or supplies reoperation machines Number of cases delayed because of lack of personnel Other complication rates, for Number of functioning Percentage of cases in full checklist compliance example, transfusion or renal autoclaves insufficiency Percentage of cases with appropriate antibiotic administration Percentage of essential surgical procedures transferred to another facility and safety of surgical care by creating benchmarks management practices, and instituting measurement for improvement rather than being used for pun- and surveillance techniques could dramatically improve ishment or comparison across fundamentally differ- care within existing health systems. However, designing, ent organizations, environments, and populations implementing, and scaling these interventions in LMICs (WHO 2009b). Attempts at comparisons across sys- will take considerable resources because each strategy for tems, countries, and health settings ignore variations improvement requires training, infrastructure, an infor- in patient condition and complexity of procedure. mation management system, and political will. Even Hospitals and health systems that wish to evaluate though little is currently known about the actual invest- differences between facilities and practitioners must ment and recurrent costs of introducing and scaling up account for the characteristics of the patients, case these strategies, they are likely to be highly cost-effective. mix, and urgency—all of which require robust and sophisticated data collection that is frequently beyond the capacity of overworked or underfinanced health CONCLUSIONS systems. However, countries and health systems in LMICs that are able to collect such metrics will have To avoid premature death, disability, and suffering from a foundation of information upon which they can the time of birth through adulthood, most human improve and sustain surgical care to the betterment of beings require surgical care at some point in their their nation’s health. lives. Strategies to increase access to surgical care, how- Any complete discussion of quality clearly encom- ever, must also increase the safety and quality of care. passes more than simple measures of mortality and Profound consequences, including massively high rates complications. Important outcomes also include, among of disability and death, ensue when health systems others, the nuanced measures of functional recovery, neglect to use strategies known to improve surgical control of pain, and satisfaction with care. While mean- safety. Profound indirect consequences also follow that ingful, these issues are beyond the scope of this chapter, are harder to measure but that are also extremely impor- as are the potentially important strategies for improving tant, including loss of confidence in the health system, surgical capacity through the use of physician extenders late patient presentation, and cost inefficiencies that add and task sharing, and the aggregation and centraliza- to an overburdened and underfunded health system. tion of cases to take advantage of volume-outcome Well-established interventions have proven effective in relationships. reducing surgical risk and provide promising strategies Much work is needed to strengthen surgical systems to further reduce harm from surgical care. of care, and the investments are likely to be considerable. Given the barriers to access and delivery of needed surgi- cal services, investments are necessary at the facility and ACKNOWLEDGMENTS institutional level, as well as for the progressive financing of health protection and communication and transpor- The authors would like to thank Charles N. Mock, tation infrastructure. Improving anesthetic monitoring University of Washington, for his help and guidance and safety, implementing surgical checklists, refining with this chapter; Pablo Uribe Leitz, Lydia Maurer, Excess Surgical Mortality: Strategies for Improving Quality of Care 297 and Joshua Jaramillo, Stanford University, for help Casablanca University Hospital, Morocco.” [In French.] with data extraction and analysis; and Marissa Wagner, Santé 10 (6): 419–23. University of Texas, Houston, and Kimberly Brayton, Aderounmu, A. O., S. A. Afolayan, T. A. Nasiru, J. A. Olaore, Stanford University, for their assistance with the initial M. L. Adeoti, and M. Adelasoye. 2008. “Rotational Rural Surgery for the Poor in Developing Countries.” Tropical creation and structuring of the database. They also Doctor 38 (3): 141–44. would like to extend appreciation to Rebecca Kim and Adesunkanmi, A. R., T. A. Badmos, and A. A. Salako. 2000. Lyen Huang, Stanford University Medical Center; Luke “Groin Hernias in Patients 50 Years of Age and Above Funk, University of Wisconsin Medical Center; and Pattern and Outcome of Management in 250 Consecutive Kendra Bowman, Brigham and Women’s Hospital, for Patients.” West African Journal of Medicine 19 (2): 142–47. their willingness to share preliminary data. Kristan Adisa, A. O., O. I. Alatise, O. A. Arowolo, and O. O Lawal. Staudenmayer, Stanford University, helped review and 2012. “Laparoscopic Appendectomy in a Nigerian Teaching proof drafts. Riti Shimkhada and John Peabody, Qure Hospital.” Journal of the Society of Laparoendoscopic Surgeons Healthcare, provided insightful feedback on metrics for 16 (4): 576–80. measurement; and Nick Bloom, Stanford University, Afsana, K. 2004. “The Tremendous Cost of Seeking Hospital offered invaluable insights regarding his work on Obstetric Care in Bangladesh.” Reproductive Health Matters 12 (24): 171–80. management practices. Akcakaya, A., et al. 2000. “Mechanical Intestinal Obstruction Caused by Abdominal Wall Hernias.” [In Turkish.] Ulusal Travma Dergisi [Turkish journal of trauma and emergency ANNEXES surgery] 6 (4): 260–265. The annexes to this chapter are as follows. They are available at Akinci, M., Z. Ergül, B. Kulah, K. B. Yilmaz, and H. Kulacog ˘ lu. http://www.dcp-3.org/surgery. 2010. “Risk Factors Related with Unfavorable Outcomes in • Annex 16A. Search Terms and Bibliographic References per Groin Hernia Repairs.” Hernia 14 (5): 489–93. Country Ali, N., and S. Aliyu 2012. “Appendicitis and Its Surgical • Annex 16B. WHP Guidelines for Safe Surgery 2009, Management Experience at the University of Maiduguri Objective 10: Hospitals and Public Health Systems Will Teaching Hospital Nigeria.” Nigerian Journal of Medicine Establish Routine Surveillance of Surgical Capacity, 21 (2): 223–26. Volume, and Results Ameh, E. A. 2002. “Morbidity and Mortality of Inguinal Hernia in the Newborn.” Nigerian Postgraduate Medical Journal 9 (4): 233–34. Asefa, Z. 2002. “Acute Appendicitis in Yirgalem Hospital, NOTE Southern Ethiopia.” Ethiopian Medical Journal 40 (2): The World Bank classifies countries according to four income 155–62. groupings. Income is measured using gross national income Awojobi, O. A., and A. A. Ayantunde 2004. “Inguinal Hernia in (GNI) per capita, in U.S. dollars, converted from local currency Nigeria.” Tropical Doctor 34(3): 180–81. using the World Bank Atlas method. Classifications as of July Ayoade, B. A., O. A. Olawoye, B. A. Salami, and A. A. Banjo. 2014 are as follows: 2006. “Acute Appendicitis in Olabisi Onabanjo University Teaching Hospital Sagamu: A Three-Year Review.” Nigerian • Low-income countries (LICs) = US$1,045 or less in 2013 Journal of Clinical Practice 9 (1): 52–56. • Middle-income countries (MICs) are subdivided: Bainbridge, D., J. Martin, M. Arango, and D. Cheng. 2012. • Lower-middle-income = US$1,046 to US$4,125 “Perioperative and Anaesthetic-Related Mortality in • Upper-middle-income (UMICs) = US$4,126 to US$12,745 Developed and Developing Countries: A Systematic Review • High-income countries (HICs)= US$12,746 or more and Meta-Analysis.” The Lancet 380 (9847): 1075–81. Bano, N., R. Chaudhri, L. Yasmeen, F. Shafi, and L. Ejaz. 2011. “A Study of Maternal Mortality in 8 Principal Hospitals in Pakistan in 2009.” International Journal of Gynecology and REFERENCES Obstetrics 114 (3): 255–59. Abantanga, F. A. 2003. “Groin and Scrotal Swellings in Children Basak, S., S. Kanungo, and C. Majhi. 2011. “Symphysiotomy: Is Aged 5 Years and Below: A Review of 535 Cases.” Pediatric It Obsolete?” Journal of Obstetrics and Gynaecology Research Surgery International 19 (6): 446–50. 37 (7): 770–74. Abantanga, F. A., B. Nimako, and M Amoah. 2009. “The Range Batajoo, H., and N. K. Hazra 2012. “Laparoscopic versus Open of Abdominal Surgical Emergencies in Children Older Appendectomy in Acute Appendicitis.” Journal of Nepal Than 1 Year at the Komfo Anokye Teaching Hospital, Health Research Council 10 (22): 239–42. Kumasi, Ghana.” Annals of African Medicine 8 (4): 236–42. Bay-Nielsen, M., H. Kehlet, L. Strand, J. Malmstrom, Abbassi, H., A. Aboulfalah, F. Morsad, N. Matar, A. Himmi, and F. H. Andersen, and others. 2001. “Quality Assessment A. E. Mansouri. 2000. “Maternal Complications of Cesarean of 26,304 Herniorrhaphies in Denmark: A Prospective Section: Retrospective Analysis of 3,231 Interventions at the Nationwide Study.” The Lancet 358 (9288): 1124–28. 298 Essential Surgery Birkmeyer, J. D. 2010. “Strategies for Improving Surgical Ceesay, S. J., C. Casals-Pascual, J. Erskine, S. E. Anya, N. O. Duah, Quality: Checklists and Beyond.” New England Journal of and others. 2008. “Changes in Malaria Indices between Medicine 363 (20): 1963–65. 1999 and 2007 in The Gambia: A Retrospective Analysis.” Blomqvist, P. G., R. E. Andersson, F. Granath, M. P. Lambe, The Lancet 372 (9649): 1545–54. and A. R. Ekbom. 2001. “Mortality after Appendectomy Chauhan, A., S. Tiwari, and A. Gupta. 2007. “Study of Efficacy in Sweden, 1987–1996.” Annals of Surgery 233 (4): of Bilayer Mesh Device versus Conventional Polypropelene 455–60. Hernia System in Inguinal Hernia Repair: Early Results.” Bloom, N., B. Eifert, A. Mahajan, D. McKenzie, and J. Roberts. World Journal of Surgery 31 (6): 1356–59; discussion 2013. “Does Management Matter? Evidence from India.” 1360–61. Quarterly Journal of Economics 128 (1): 1–51. Chamisa, I. 2009. “A Clinicopathological Review of 324 Bloom, N., A. Mahajan, D. McKenzie, and J. Roberts. 2010. Appendices Removed for Acute Appendicitis in Durban, “Why Do Firms in Developing Countries Have Low South Africa: A Retrospective Analysis.” Annals of the Royal Productivity?” American Economic Review: Papers and College of Surgeons of England 91 (8): 688–92. Proceedings 100 (2): 619–23. Chavda, S. K., S. Hassan, and G. A. Magoha. 2000. “Appendicitis Bloom, N., R. Sadun, and J. van Reenen. 2012. “The at Kenyatta National Hospital, Nairobi.” East African Organization of Firms across Countries.” Quarterly Journal Medical Journal 82 (10): 526–30. of Economics 127 (4): 1663–705. Chilopora, G., C. Pereira, F. Kamwendo, A. Chimbiri, Bloom, N., and J. van Reenen. 2007. “Measuring and Explaining E. Malunga, and S. Bergström. 2007. “Postoperative Management Practices across Firms and Countries.” Outcome of Caesarean Sections and Other Major Emergency Quarterly Journal of Economics 122 (4): 1351–408. Obstetric Surgery by Clinical Officers and Medical Officers ———. 2010. “Why Do Management Practices Differ across in Malawi.” Human Resources for Health 5: 17. Firms and Countries?” Journal of Economic Perspectives 24 Chongsuvivatwong, V., H. Bachtiar, M. E. Chowdhury, (1): 203–24. S. Fernando, C. Suwanrath, O. Kor-Anantakul, A. Tuan le, Bouvier-Colle, M. H., C. Ouedraogo, A. Dumont, A. Lim, P. Lumbiganon, B. Manandhar, M. Muchtar, C. Vangeenderhuysen, B. Salanave, and C. Decam. 2001. L. Nahar, N. T. Hieu, P. X. Fang, W. Prasertcharoensuk, “Maternal Mortality in West Africa: Rates, Causes, and E. Radnaabarzar, D. Sibuea, K. K. Than, P. Tharnpaisan, Substandard Care from a Prospective Survey.” Acta T. S. Thach, and P. Rowe. 2010. “Maternal and Fetal Obstetricia et Gynecologica Scandinavica 80 (2): 113–19. Mortality and Complications Associated with Cesarean Bowman, K. G., G. Jovic, S. Rangel, W. R. Berry, and Section Deliveries in Teaching Hospitals in Asia.” Journal of A. A. Gawande. 2013. “Pediatric Emergency and Essential Obstetrics and Gynaecology Research 36 (1): 45–51. Surgical Care in Zambian Hospitals: A Nationwide Study.” Chu, K., H. Cortier, F. Maldonado, T. Mashant, N. Ford, and Journal of Pediatric Surgery 48 (6): 1363–70. M. Trelles. 2012. “Cesarean Section Rates and Indications in Briand, V., A. Dumont, M. Abrahamowicz, A. Sow, M. Traore, Sub-Saharan Africa: A Multi-Country Study from Medecins P. Rozenberg, L. Watier, and P. Fournier. 2012. “Maternal sans Frontieres.” PLoS One 7 (9): e44484. and Perinatal Outcomes by Mode of Delivery in Senegal Chung, C. H., et al. 2000. “Delays by Patients, Emergency and Mali: A Cross-Sectional Epidemiological Survey.” PLoS Physicians, and Surgeons in the Management of Acute One 7 (10): e47352. Appendicitis: Retrospective Study.” Hong Kong Medical Briesen, S., R. Geneau, H. Roberts, J. Opiyo, and P. Courtright. Journal 6 (3): 254–59. 2010. “Understanding Why Patients with Cataract Refuse Cingi, A., et al. 2005. “Use of Resterilized Polypropylene Mesh Free Surgery: The Influence of Rumours in Kenya.” Tropical in Inguinal Hernia Repair: A Prospective, Randomized Study.” Medicine and International Health 15 (5): 534–39. Journal of the American College of Surgeons 201 (6): 834–40. Burch, V. C., D. McKinley, J. van Wyk, S. Kiguli-Walube, Clarke, M. G., et al. 2009. “The Use of Sterilised Polyester D. Cameron, and others. 2011. “Career Intentions of Mosquito Net Mesh for Inguinal Hernia Repair in Ghana.” Medical Students Trained in Six Sub-Saharan African Hernia 13 (2): 155–59. Countries.” Education for Health (Abingdon) 24 (3): 614. Cunnigaiper, N. D., et al. 2010. “Does Ochsner-Sherren Regimen Burn S., P. Chilton, A. Gawande, and R. Lilford. 2014. “Peri- Still Hold True in the Management of Appendicular Mass?” operative Pulse Oximetry in Low-Income Countries: A Ulusal Travma Ve Acil Cerrahi Dergisi-Turkish Journal of Cost-Effectiveness Analysis.” Bulletin of the World Health Trauma & Emergency Surgery 16 (1): 43–46. Organization 92: 858–67. Das, J., A. Holla, V. Das, M. Mohanan, D. Tabak, and others. Bury, E., K. Carter, M. Feigelman, and J. Grant. 2007. 2012. “In Urban and Rural India, a Standardized Patient “How Service-Line Management Can Improve Hospital Study Showed Low Levels of Provider Training and Huge Performance.” Health International 7: 54–65. http://www Quality Gaps.” Health Affairs (Millwood) 31 (12): 2774–84. .mckinsey.it/storage/first/uploadfile/attach/140188/file de Leval, M. R., J. Carthey, D. J. Wright, V. T. Farewell, and /hi08_5slm_final.pdf. R. T. Reason. 2000. “Human Factors and Cardiac Surgery: Carthey, J., M. R. de Leval, and J. T. Reason. 2001. “The Human A Multicenter Study.” Journal of Thoracic and Cardiovascular Factor in Cardiac Surgery: Errors and Near Misses in a Surgery 119 (4 Pt 1): 661–72. High Technology Medical Domain.” Annals of Thoracic de Vries, E. N., H. A. Prins, R. M. Crolla, A. J. den Outer, Surgery 72 (1): 300–05. G. van Andel, and others. 2010. “Effect of a Comprehensive Excess Surgical Mortality: Strategies for Improving Quality of Care 299 Surgical Safety System on Patient Outcomes.” New England and Pulse Oximetry Supply: An Estimation from Reported Journal of Medicine 363 (20): 1928–37. Data.” The Lancet 376 (9746): 1055–61. Diarra, B., et al. 2001. “Experience with Preperitoneal Gao, J. S., Z. J. Wang, B. Zhao, S. Z. Ma, G. Y. Pang, and Hernioplasty Using Stoppa’s Procedures in the Ivory Coast.” others. 2009. “Inguinal Hernia Repair with Tension-Free [In French.] Annales de Chirurgie 126 (4): 325–29. Hernioplasty under Local Anesthesia.” Saudi Medical Dumont, A., L. de Bernis, M. H. Bouvier-Colle, and G. Breart. Journal 30 (4): 534–36. 2001. “Caesarean Section Rate for Maternal Indication in Gauthier, B., and W. Wane. 2011. “Bypassing Health Providers: Sub-Saharan Africa: A Systematic Review.” The Lancet 358 The Quest for Better Price and Quality of Health Care in (9290): 1328–33. Chad.” Social Science and Medicine 73 (4): 540–49. Dye, T. D., S. Bogale, C. Hobden, Y. Tilahun, V. Hechter, Gavilan-Yodu, R. L. 2010. “Morbilidad y mortalidad por apen- and others. 2010. “Complex Care Systems in Developing dicitis aguda en el hospital integral comunitario del munic- Countries: Breast Cancer Patient Navigation in Ethiopia.” ipio Monteagudo (2006–2008).” MEDISAN 14: 2010–2016. Cancer 116 (3): 577–85. Ghaferi, A. A., J. D. Birkmeyer, and J. B. Dimick. 2009a. Eichhorn, J. H., J. B. Cooper, D. J. Cullen, W. R. Maier, J. H. Philip, “Complications, Failure to Rescue, and Mortality with and others. 1986. “Standards for Patient Monitoring during Major Inpatient Surgery in Medicare Patients.” Annals of Anesthesia at Harvard Medical School.” Journal of the Surgery 250 (6): 1029–34. American Medical Association 256 (8): 1017–20. ———. 2009b. “Variation in Hospital Mortality Associated Ekenze, S. O., P. A. Anyanwu, U. O. Ezomike, and T. Oguonu. with Inpatient Surgery.” New England Journal of Medicine 2010. “Profile of Pediatric Abdominal Surgical Emergencies in 361 (14): 1368–75. a Developing Country.” International Surgery 95 (4): 319–24. ———. 2011. “Hospital Volume and Failure to Rescue with ElRashied, M., A. H. Widatalla, and M. E. Ahmed. 2007. High-Risk Surgery.” Medical Care 49 (12): 1076–81. “External Strangulated Hernia in Khartoum, Sudan.” East Gibbons, L., J. M. Belizán, J. A. Lauer, A. P. Betrán, M. Merialdi, African Medical Journal 84 (8): 379–82. and others. 2010. “The Global Numbers and Costs of Fahim, F., and S. Shirjeel. 2005. “A Comparison between Additionally Needed and Unnecessary Caesarean Sections Presenatation Time and Delay in Surgery in Simple and Performed per Year: Overuse as a Barrier to Universal Advanced Appendicitis.” Journal of Ayub Medical College Coverage.” World Health Report Background Paper 30, Abbottabad 17 (2): 37–39. World Health Organization, Geneva. Farthouat, P., O. Fall, M. Ogougbemy, A. Sow, A. Millon, and Gil, J., J. M. Rodríguez, Q. Hernández, E. Gil, M. D. Balsalobre, others. 2005. “Appendicectomy in the tropics: Prospective and others. 2012. “Do Hernia Operations in African study at Hopital Principal in Dakar.” [In French.] Médecine International Cooperation Programmes Provide Good tropicale (Mars) 65 (6): 549–53. Quality?” World Journal of Surgery 36 (12): 2795–801. Fashina, I. B., A. A. Adesanya, O. A. Atoyebi, O. O. Osinowo, Glenshaw, M., and F. D. Madzimbamuto. 2005. “Anaesthesia- and C. J. Atimomo. 2009. “Acute Appendicitis in Lagos: A Associated Mortality in a District Hospital in Zimbabwe: Review of 250 Cases.” Nigerian Postgraduate Medical Journal 1994 to 2001.” Central African Journal of Medicine 51 16 (4): 268–73. (3–4): 39–44. Fauveau, V. 2007. “Using UN Process Indicators to Assess Needs Goldie, S. J. 2003. “Chapter 15: Public Health Policy and in Emergency Obstetric Services: Gabon, Guinea-Bissau, Cost-Effectiveness Analysis.” Journal of the National Cancer and The Gambia.” International Journal of Gynaecology and Institute Monograph 31: 102–10. Obstetrics 96 (3): 233–40. Grimes, C. E., K. G. Bowman, C. M. Dodgion, and C. B. Lavy. Fenton, P. M., C. J. Whitty, and F. Reynolds. 2003. “Caesarean 2011. “Systematic Review of Barriers to Surgical Care Section in Malawi: Prospective Study of Early Maternal and in Low-Income and Middle-Income Countries.” World Perinatal Mortality.” BMJ 327 (7415): 587. Journal of Surgery 35 (5): 941–50. Fesseha, N., A. Getachew, M. Hiluf, Y. Gebrehiwot, and Groen, R. S., M. Samai, K. A. Stewart, L. D. Cassidy, P. Bailey. 2011. “A National Review of Cesarean Delivery T. B. Kamara, and others. 2012. “Untreated Surgical in Ethiopia.” International Journal of Gynecology and Conditions in Sierra Leone: A Cluster Randomised, Cross- Obstetrics 115 (1): 106–11. Sectional, Countrywide Survey.” The Lancet 380 (9847): Freudenberg, S., D. Sano, E. Ouangré, C. Weiss, and 1082–87. T. J. Wilhelm. 2006. “Commercial Mesh versus Nylon Gurleyik, G., and E. Gurleyik. 2003. “Age-Related Clinical Mosquito Net for Hernia Repair. A Randomized Double- Features in Older Patients with Acute Appendicitis.” Blind Study in Burkina Faso.” World Journal of Surgery European Journal of Emergency Medicine 10 (3): 200–03. 30 (10): 1784–89; discussion 1790. Hang, H. M., and P. Byass. 2009. “Difficulties in Getting Funk, L. M., D. M. Conley, W. R. Berry, and A. A. Gawande. Treatment for Injuries in Rural Vietnam.” Public Health 123 2013. “Hospital Management Practices and Availability (1): 58–65. of Surgery in Sub-Saharan Africa: A Pilot Study of Three Harouna, Y., H. Yaya, I. Abdou, and L. Bazira. 2001. “Prognosis Hospitals.” World Journal of Surgery 37 (11): 2520–28. of Strangulated Hernia in Adult With Necrosis of Small Funk, L. M., T. G. Weiser, W. R. Berry, S. R. Lipsitz, A. F. Merry, Bowel: A 34 Cases Report.” Bulletin de la Societe de Pathologie and others. 2010. “Global Operating Theatre Distribution Exotique 93 (5): 317–20. 300 Essential Surgery Haynes, A. B., T. G. Weiser, W. R. Berry, S. R. Lipsitz, Randomized Comparison.” Acta Medica Iranica 49 (6): A. H. Breizat, and others. 2009. “A Surgical Safety Checklist 352–56. to Reduce Morbidity and Mortality in a Global Population.” Kasatpibal, N., M. Nørgaard, H. T. Sørensen, H. C. Schønheyder, New England Journal of Medicine 360 (5): 491–99. S. Jamulitrat, and V. Chongsuvivatwong. 2006. “Risk Hogberg, U. 1989. “Maternal Deaths Related to Cesarean of Surgical Site Infection and Efficacy of Antibiotic Section in Sweden, 1951–1980.” Acta Obstetricia et Prophylaxis: A Cohort Study of Appendectomy Patients in Gynecologica Scandinavica 68 (4): 351–57. Thailand.” BMC Infectious Diseases 6: 111. Huang, C. S., C. C. Huang, and H. H. Lien. 2005. “Prolene Kelly, J., E. Kohls, P. Poovan, R. Schiffer, A. Redito, H. Winter, Hernia System Compared with Mesh Plug Technique: and C. MacArthur. 2010. “The Role of a Maternity A Prospective Study of Short- to Mid-term Outcomes in Waiting Area (MWA) in Reducing Maternal Mortality and Primary Groin Hernia Repair.” Hernia 9 (2): 167–71. Stillbirths in High-Risk Women in Rural Ethiopia.” BJOG: Hughes, C. D., C. D. McClain, L. Hagander, J. H. Pierre, An International Journal of Obstetrics and Gynaecology R. S. Groen, and others. 2012. “Ratio of Cesarean Deliveries 117 (11): 1377–83. to Total Operations and Surgeon Nationality Are Khalil, J., R. Muqim, M. Rafique, and M. Khan. 2011. Potential Proxies for Surgical Capacity in Central Haiti.” “Laparoscopic versus Open Appendectomy: A Comparison World Journal of Surgery 37 (7): 1526–29. doi:10.1007 of Primary Outcome Measures.” Saudi Journal of /s00268-012-1794-7. Gastroenterology 17 (4): 236–40. Ibis, C., D. Albayrak, A. R. Hatipoglu, and N. Turan. 2010. Khan, K. I., S. Mahmood, M. Akmal, and A. Waqas. 2012. “The Amount of Comorbidities as a Single Parameter “Comparison of Rate of Surgical Wound Infection, Length Has No Effect in Predicting the Outcome in Appendicitis of Hospital Stay and Patient Convenience in Complicated Patients Older Than 60 Years.” Southern Medical Journal Appendicitis between Primary Closure and Delayed Primary 103 (3): 202–06. Closure.” Journal of the Pakistan Medical Association 62 (6): Imbert, P., F. Berger, N. S. Diallo, C. Cellier, M. Goumbala, 596–98. A. S. Ka, and R. Petrognani. 2003. “Maternal and Infant Khiria, L. S., R. Ardhnari, N. Mohan, P. Kumar, and R. Nambiar. Prognosis of Emergency Cesarean Section: Prospective 2011. “Laparoscopic Appendicectomy for Complicated Study of the Principal Hospital in Dakar, Senegal.” [In Appendicitis: Is It Safe and Justified? A Retrospective French.]” Médecine tropicale: Revue du Corps de santé colo- Analysis.” Surgical Laparoscopy, Endoscopy, and Percutaneous nial 63 (4–5): 351–57. Techniques 21 (3): 142–45. Jani, K. 2005. “Prospective Randomized Study of Internal Kilsztajn, S., M. S. Carmo, L. C. Machado Jr., E. S. Lopes, Oblique Aponeurotic Flap Repair for Tension-Free and L. Z. Lima. 2007. “Caesarean Sections and Maternal Reinforcement of the Posterior Inguinal Wall: A New Mortality in São Paulo.” European Journal of Obstetrics and Technique.” International Surgery 90 (3): 155–59. Gynecology and Reproductive Biology 132 (1): 64–69. Juillard, C. J., C. Mock, J. Goosen, M. Joshipura, and I. Civil. Kim, Y. M., H. Tappis, P. Zainullah, N. Ansara, C. Evans, 2009. “Establishing the Evidence Base for Trauma Quality and others. 2012. “Quality of Caesarean Delivery Services Improvement: A Collaborative WHO-IAtypesetterIC and Documentation in First-Line Referral Facilities Review.” World Journal of Surgery 33 (5): 1075–86. in Afghanistan: A Chart Review.” BMC Pregnancy and Kaboro, M., M. A. Djibril, E. Zoumendou, P. Assouto, Childbirth 12: 14. doi:10.1186/1471-2393-12-14. T. Lokossou, and M. Chobli. 2012. “L’anesthésie en urgence Kingsnorth, A. N., C. Oppong, J. Akoh, B. Stephenson, and à la maternité de l’hôpital général de réfence national R. Simmermacher. 2006. “Operation Hernia to Ghana.” de N’Djaména (Tchad).” Médecine-afrique-noire 4 (59): Hernia 10 (5): 376–79. 211–20. Kong, V. Y., B. Bulajic, N. L. Allorto, J. Handley, and D. L. Clarke. Kahabuka, C., G. Kvale, K. M. Moland, and S. G. Hinderaker. 2012. “Acute Appendicitis in a Developing Country.” World 2011. “Why Caretakers Bypass Primary Health Care Journal of Surgery 36 (9): 2068–73. Facilities for Child Care: A Case from Rural Tanzania.” Kor-Anantakul, O., C. Suwanrath, A. Lim, and BMC Health Services Research 11: 315. V. Chongsuviwatwon. 2008. “Comparing Complications Kambo, I., N. Bedi, B. S. Dhillon, and N. C. Saxena. 2002. in Intended Vaginal and Caesarean Deliveries.” Journal of “A Critical Appraisal of Cesarean Section Rates at Teaching Obstetrics and Gynaecology Research 28 (1): 64–68. Hospitals in India.” International Journal of Gynecology and Kruk, M. E., E. Goldmann, and S. Galea. 2009. “Borrowing and Obstetrics 79 (2): 151–58. Selling to Pay for Health Care in Low- and Middle-Income Kandasamy, T., M. Merialdi, R. J. Guidotti, A. P. Betran, Countries.” Health Affairs (Millwood) 28 (4): 1056–66. J. Harris-Requejo, F. Hakimi, P. F. van Look, and F. Kakar. Kruk, M. E., G. Mbaruku, C. W. McCord, M. Moran, 2009. “Cesarean Delivery Surveillance System at a Maternity P. C. Rockers, and others. 2009. “Bypassing Primary Care Hospital in Kabul, Afghanistan.” International Journal of Facilities for Childbirth: A Population-Based Study in Rural Gynecology and Obstetrics 104 (1): 14–17. Tanzania.” Health Policy and Planning 24 (4): 279–88. Kargar, S., M. H. Mirshamsi, M. Zare, S. Arefanian, E. Shadman Kumar, S. and S. Jain. 2004. “Treatment of Appendiceal Mass: Yazdi, and A. Aref. 2011. “Laparoscopic versus Open Prospective, Randomized Clinical Trial.” Indian Journal of Appendectomy; Which Method to Choose? A Prospective Gastroenterology 23 (5): 165–67. Excess Surgical Mortality: Strategies for Improving Quality of Care 301 Kushner, A. L., R. S. Groen, and T. P. Kingham. 2010. “Percentage Mabula, J. B. and P. L. Chalya. 2012. “Surgical Management of Cesarean Sections among Total Surgical Procedures of Inguinal Hernias at Bugando Medical Centre in in Sub-Saharan Africa: Possible Indicator of the Overall Northwestern Tanzania: Our Experiences in a Resource- Adequacy of Surgical Care.” World Journal of Surgery 34 (9): Limited Setting.” BMC Research Notes 5: 585. 2007–08. Macharia, W. M., E. K. Njeru, F. Muli-Musiime, and V. Nantulya. Kwok, A. C., L. M. Funk, R. Baltaga, S. R. Lipsitz, A. F. Merry, 2009. “Severe Road Traffic Injuries in Kenya, Quality of and others. 2013. “Implementation of the World Health Care and Access.” African Health Sciences 9 (2): 118–24. Organization Surgical Safety Checklist, Including Malik, A. A., S. S. Yamamoto, A. Souares, Z. Malik, and Introduction of Pulse Oximetry, in a Resource-Limited R. Sauerborn. 2010. “Motivational Determinants among Setting.” Annals of Surgery 257 (4): 633–39. Physicians in Lahore, Pakistan.” BMC Health Services Lagoo, J., J. Wilkinson, J. Thacker, M. Deshmukh, S. Khorgade, Research 10: 201. and R. Bang. 2012. “Impact of Anemia on Surgical Malik, A.M., A.H. Talpur, and A.A. Laghari. 2009. “Video- Outcomes: Innovative Interventions in Resource-Poor Assisted Laparoscopic Extracorporeal Appendectomy Settings.” World Journal of Surgery 36 (9): 2080–89. versus Open Appendectomy.” Journal of Laparoendoscopic Lau, H., C. Wong, L. C. Goh, N. G. Patil, and F. Lee. 2002. and Advanced Surgical Techniques 19 (3): 355–59. “Prospective Randomized Trial of Pre-emptive Analgesics Malik, A. M., A. Khan, K. A. Talpur, and A. A. Laghari. 2010. Following Ambulatory Inguinal Hernia Repair: Intravenous “Factors Influencing Morbidity and Mortality in Elderly Ketorolac versus Diclofenac Suppository.” ANZ Journal of Population Undergoing Inguinal Hernia Surgery.” Journal Surgery 72 (10): 704–07. of the Pakistan Medical Association 60 (1): 45–47. Lebrun, D. G., S. Chackungal, T. E. Chao, L. M. Knowlton, Mbah, N. 2007. “Morbidity and Mortality Associated with A. F. Linden, and others. 2014. “Prioritizing Essential Surgery Inguinal Hernia in Northwestern Nigeria.” West African and Safe Anesthesia for the Post-2015 Development Agenda: Journal of Medicine 26 (4): 288–92. Operative Capacities of 78 District Hospitals in 7 Low- and McConkey, S. J. 2002. “Case Series of Acute Abdominal Surgery Middle-Income Countries.” Surgery 155 (3): 365–73. in Rural Sierra Leone.” World Journal of Surgery 26 (4): Lebrun, D. G., D. Dhar, M. I. Sarkar, T. M. Imran, S. N. Kazi, 509–13. and others. 2013. “Measuring Global Surgical Disparities: McIntyre, D., M. Thiede, and S. Birch. 2009. “Access as a Policy- A Survey of Surgical and Anesthesia Infrastructure in Relevant Concept in Low- and Middle-Income Countries.” Bangladesh.” World Journal of Surgery 37 (1): 24–31. Health Economics, Policy and Law 4 (Pt 2): 179–93. Leitch, J. 2012. “Measuring Outcomes across a Nation: The Mehrabi Bahar, M., A. Jangjoo, A. Amouzeshi, and K. Kavianifar. Scottish Experience.” Presentation to the International 2010. “Wound Infection Incidence in Patients with Simple Society for Quality in Healthcare International Conference, and Gangrenous or Perforated Appendicitis.” Archives of Geneva, October 21–24, 2012. http://www.isqua.org/docs Iranian Medicine 13 (1): 13–16. /geneva-presentations/b16-jason-leitch.pdf. Memon, A. A., F. G. Siddiqui, A. H. Abro, A. H. Agha, Levy, S. M., C. E. Senter, R. B. Hawkins, J. Y. Zhao, K. Doody, S. Lubna, and A. S.Memon. 2013. “Management of and others. 2012. “Implementing a Surgical Checklist: More Recurrent Inguinal Hernia at a Tertiary Care Hospital of Than Checking a Box.” Surgery 152 (3): 331–36. Southern Sindh, Pakistan.” World Journal of Surgery 37 Liu, Z. F., J. C. Yu, H. F. Hsieh, and C. H. Lin. 2007. “Perforated (3): 510–15. Appendicitis: Urgency or Interval Surgery?” Zentralblatt für Ming, P. C., T. Y. Yan, and L. H. Tat. 2009. “Risk Factors Chirurgie 132 (6): 539–41 of Postoperative Infections in Adults with Complicated Lohsiriwat, V., W. Sridermma, T. Akaraviputh, W. Boonnuch, Appendicitis.” Surgical Laparoscopy, Endoscopy, and V. Chinsawangwatthanakol, and others. 2007. “Surgical Percutaneous Techniques 19 (3): 244–48. Outcomes of Lichtenstein Tension-Free Hernioplasty Ministère de la Santé Burkina Faso. 2013. “Annuaire statistique for Acutely Incarcerated Inguinal Hernia.” Surgery Today 2012.” http://www.sante.gov.bf/index.php/publications 37 (3): 212–14. -statistiques/file/338-annuaire-statistique-2012. (Accessed Lumbiganon, P., M. Laopaiboon, A. M. Gulmezoglu, J. P. Souza, March 5, 2014.) S. Taneepanichskul, P. Ruyan, D. E. Attygalle, N. Shrestha, Mock, C. N., D. nii-Amon-Kotei, and R. V. Maier. 1997. “Low R. Mori, D. H. Nguyen, T. B. Hoang, T. Rathavy, K. Chuyun, Utilization of Formal Medical Services by Injured Persons K. Cheang, M. Festin, V. Udomprasertgul, M. J. Germar, in a Developing Nation: Health Service Data Underestimate G. Yanqiu, M. Roy, G. Carroli, K. Ba-Thike, E. Filatova, and J. the Importance of Trauma.” Journal of Trauma 42 (3): Villar. 2010. “Method of Delivery and Pregnancy Outcomes 504–11. in Asia: the WHO Global Survey on Maternal and Perinatal Mungadi, I. A. 2005. “Quality Surgical Care for Rural Dwellers: Health 2007–08.” The Lancet 375 (9713): 490–99. The Visiting Option.” Tropical Doctor 35 (3): 151–53. Mabiala-Babela, J. R., N. Pandzou, E. Koutaba, S. Ganga- Neily, J., P. D. Mills, Y. Young-Xu, B. T. Carney, P. West, and Zandzou, and P. Senga. 2006. “Retrospective Study of others. 2010. “Association between Implementation of a Visceral Surgical Emergencies in Children at the University Medical Team Training Program and Surgical Mortality.” Hospital Center of Brazzaville (Congo).” [In French.] Journal of the American Medical Association 304 (15): Médecine tropicale (Mars) 66 (2): 172–76. 1693–700. 302 Essential Surgery Ngowe Ngowe, M., J. Bissou Mahop, R. Atangana, V. C. Eyenga, Osifo, O. D., and S. O. Ogiemwonyi. 2009. “Appendicitis in C. Pisoh-Tangnym, and A. M. Sosso. 2008. “Current Clinical Children: An Increasing Health Scourge in a Developing Features of Acute Appendicitis in Adults in Yaounde, Country.” Pakistan Journal of Medical Sciences 25 (3): Cameroon.” [In French.] Bulletin de la Société de pathologie 490–95. exotique 101 (5): 398–99. Ozumba, B. C., and S. E. Anya. 2002. “Maternal Deaths Nguyen, H., R. Ivers, S. Jan, A. Martiniuk, and C. Pham. 2013. Associated with Cesarean Section in Enugu, Nigeria.” “Catastrophic Household Costs Due to Injury in Vietnam.” International Journal of Gynecology and Obstetrics 76 (3): Injury 44 (5): 684–90. 307–9. Nilsson, H., G. Stylianidis, M. Haapamaki, E. Nilsson, and Parkhurst, J. O., S. A. Rahman, and F. Ssengooba. 2006. P. Nordin. 2007. “Mortality after Groin Hernia Surgery.” “Overcoming Access Barriers for Facility-Based Delivery Annals of Surgery 245 (4): 656–60. in Low-Income Settings: Insights from Bangladesh and Nolan, T., and D. M. Berwick. 2006. “All-or-None Measurement Uganda.” Journal of Health, Population and Nutrition 24 (4): Raises the Bar on Performance.” Journal of the American 438–45. Medical Association 295 (10): 1168–70. Paudel, R. K., B. K. Jain, S. Rani, S. K. Gupta, and S. R. Niraula. Noordzij, P. G., D. Poldermans, O. Schouten, J. J. Bax, 2003. “Acute Appendicitis: A Quality Assurance Study.” F. A. Schreiner, and others. 2010. “Postoperative Mortality in Tropical Gastroenterology 24 (2): 83–86. the Netherlands: A Population-Based Analysis of Surgery- Pearse, R. M., R. P. Moreno, P. Bauer, P. Pelosi, P. Metnitz, and Specific Risk in Adults.” Anesthesiology 112 (5): 1105–15. others. 2012. “Mortality after Surgery in Europe: A 7 Day Nwameme, A. U., J. F. Phillips, and P. B. Adongo. 2013. Cohort Study.” The Lancet 380 (9847): 1059–65. “Compliance with Emergency Obstetric Care Referrals Peralta Vargas, C. E., A. López, J. R. Díaz Gil, R. M. Rodríguez among Pregnant Women in an Urban Informal Settlement of Montoya, and W. R. Angulo Guzmán. 2004. “Surgical Accra, Ghana.” Maternal and Child Health Journal. Advance Wound Infection in Appendectomized Patients in the online publication. doi:10.1007/s10995-013-1380-0. Surgical Service of Hospital III Essalud-Chimbote.” [In Obalum, D. C., S. U. Eyesan, C. N. Ogo, and O. A. Atoyebi. Spanish.] Revista de gastroenterología del Perú 24 (1): 2008. “Day-Case Surgery for Inguinal Hernia: A Multi- 43–49. Specialist Private Hospital Experience in Nigeria.” Nigerian Petroze, R. T., W. Mehtsun, A. Nzayisenga, G. Ntakiyiruta, Quarterly Journal of Hospital Medicine 18 (1): 42–44. R. G. Sawyer, and others. 2012. “Ratio of Cesarean Sections Ohene-Yeboah, M. 2003. “Strangulated External Hernias in to Total Procedures as a Marker of District Hospital Trauma Kumasi.” West African Journal of Medicine 22 (4): 310–13. Capacity.” World Journal of Surgery 36 (9): 2074–79. Ohene-Yeboah, M., and B. Togbe. 2006. “An Audit of Petroze, R. T., A. Nzayisenga, V. Rusanganwa, G. Ntakiyiruta, Appendicitis and Appendicectomy in Kumasi, Ghana.” West and J. F. Calland. 2012. “Comprehensive National Analysis African Journal of Medicine 25 (2): 138–43. of Emergency and Essential Surgical Capacity in Rwanda.” Okafor, P. I., J. C. Orakwe, and G. U. Chianakwana. 2003. British Journal of Surgery 99 (3): 436–43. “Management of Appendiceal Masses in a Peripheral Pokharel, N., P. Sapkota, B. Kc, S. Rimal, S. Thapa, and Hospital in Nigeria: Review of Thirty Cases.” World Journal R. Shakya. 2011. “Acute appendicitis in Elderly Patients: of Surgery 27 (7): 800–803. A Challenge for Surgeons.” Nepal Medical College Journal Okafor, U. V., H. U. Ezegwui, and K. Ekwazi. 2009. “Trends 13 (4): 285–88. of Different Forms of Anaesthesia for Caesarean Section Pradhan, G. B., D. Shrestha, S. Shrestha, and C. L. Bhattachan. in South-Eastern Nigeria.” Journal of Obstetrics and 2011. “Inguinal Herniotomy in Children: A One Year Gynaecology Research 29 (5): 392–95. Survey at Nepal Medical College Teaching Hospital.” Nepal Okafor, U. V. and O. Okezie 2005. “Maternal and Fetal Outcome Medical College Journal 13 (4): 301–2. of Anaesthesia for Caesarean Delivery in Preeclampsia/ Ramyil, V. M., D. Iya, B. C. Ogbonna, and N. K. Dakum. 2000. Eclampsia in Enugu, Nigeria: A Retrospective Observational “Safety of Daycare Hernia Repair in Jos, Nigeria.” East Study.” International Journal of Obstetric Anesthesia 14 (2): African Medical Journal 77 (6): 326–28. 108–13. Rahlenbeck, S., and C. Hakizimana. 2002. “Deliveries at a Okezie, A. O., B. Oyefara, and C. O. Chigbu. 2007. “A 4-year District Hospital in Rwanda, 1997–2000.” International Analysis of Caesarean Delivery in a Nigerian Teaching Journal of Gynecology and Obstetrics 76(3): 325–28. Hospital: One-Quarter of Babies Born Surgically.” Journal Rogers, A. D., M. I. Hampton, M. Bunting, and A. K. Atherstone. of Obstetrics and Gynaecology 27 (5): 470–74. 2008. “Audit of Appendicectomies at Frere Hospital, Eastern Oladapo, O. T., M. A. Lamina, and A. O. Sule-Odu. 2007. Cape.” South African Journal of Surgery 46 (3): 74–77. “Maternal Morbidity and Mortality Associated with Ronsmans, C., and W. J. Graham. 2006. “Maternal Mortality: Elective Caesarean Delivery at a University Hospital in Who, When, Where, and Why.” The Lancet 368 (9542): Nigeria.” Australian and New Zealand Journal of Obstetrics 1189–200. and Gynaecology 47 (2): 110–14. Rutgers, R. A., and L. van Eygen. 2008. “Mortality Related to Osifo, O. D., and O. O. Irowa. 2008. “Indirect Inguinal Caesarean Section in Rural Matebeleland North Province, Hernia in Nigerian Older Children and Young Adults: Is Zimbabwe.” Central African Journal of Medicine 54 (5–8): Herniorrhaphy Necessary?” Hernia 12 (6): 635–39. 24–27. Excess Surgical Mortality: Strategies for Improving Quality of Care 303 Saha, N., D. K. Saha, M. A. Rahman, M. K. Islam, and M. A. Aziz. Shillcutt, S. D., M. G. Clarke, and A. N. Kingsnorth. 2010. 2010. “Comparison of Post Operative Morbidity between “Cost-Effectiveness of Groin Hernia Surgery in the Western Laparoscopic and Open Appendectomy in Children.” Region of Ghana.” Archives of Surgery 145 (10): 954–61. Mymensingh Medical Journal: MMJ 19 (3): 348–52. Shillcutt, S. D., D. L. Sanders, M. Teresa Butrón-Vila, and Salahuddin, O., M. A. Malik, M. A. Sajid, M. Azhar, O. Dilawar, A. N. Kingsnorth. 2013. “Cost-Effectiveness of Inguinal and A. Salahuddin. 2012. “Acute Appendicitis in the Hernia Surgery in Northwestern Ecuador.” World Journal of Elderly; Pakistan Ordnance Factories Hospital, Wah Cantt. Surgery 37 (1): 32–41. Experience.” Journal of the Pakistan Medical Association 62 Silber, J. H., S. V. Williams, H. Krakauer, and J. S. Schwartz. (9): 946–49. 1992. “Hospital and Patient Characteristics Associated with Samaali, I., S. Ben Osman, R. Bedoui, I. Bouasker, Y. Chaker, and Death after Surgery: A Study of Adverse Occurrence and others. 2012. “Spinal Anesthesia versus General Anesthesia Failure to Rescue.” Medical Care 30 (7): 615–29. for Inguinal Hernia Repair: Propensity Score Analysis.” Sorbye, I. K., S. Vangen, O. Oneko, J. Sundby, and P. Bergsjo. [In French.] Tunisie Médicale 90 (10): 686–91. 2011. “Caesarean Section among Referred and Self-Referred Sanders, D. L., and A. N. Kingsnorth. 2007. “Operation Hernia: Birthing Women: A Cohort Study from a Tertiary Hospital, Humanitarian Hernia Repairs in Ghana.” Hernia 11 (5): Northeastern Tanzania.” BMC Pregnancy and Childbirth 389–91. 11 (55). Scarlett, M., A. Crawford-Sykes, M. Thomas, and N. D. Duncan. Stulberg, J. J., C. P. Delaney, D. V. Neuhauser, D. C. Aron, 2007. “Paediatric Day Surgery: Revisiting the University P. Fu, and S. M. Koroukian. 2010. “Adherence to Surgical Hospital of the West Indies Experience.” West Indian Care Improvement Project Measures and the Association Medical Journal 56 (4): 320–25. with Postoperative Infections.” Journal of the American Schuitemaker, N., J. van Roosmalen, G. Dekker, P. van Dongen, Medical Association 303 (24): 2479–85. H. van Geijn, and J. B. Gravenhorst. 1997. “Maternal Taqvi, S. R., J. Akhtar, T. Batool, R. Tabassum, and F. Mirza. Mortality after Cesarean Section in the Netherlands.”Acta 2006. ”Complications of Inguinal Hernia Surgery in Obstetricia et Gynecologica Scandinavica 76 (4): 332–34. Children.” Journal of the College of Physicians and Surgeons, Seal, S. L., G. Kamilya, J. Mukherji, S. K. Bhattacharyya, A. De, Pakistan 16 (8): 532–35. and A. Hazra. 2010. “Outcome in Second- versus First-Stage Terzi, A., F. Yildiz, M. Vural, S. Coban, H. Cece, and Cesarean Delivery in a Teaching Institution in Eastern M. Kaya. 2010. “A Case Series of 46 Appendectomies India.” American Journal of Perinatology 27 (6): 507–12. during Pregnancy.” Wien Klin Wochenschr 122 (23–24): Sekirime, W. K., and J. C. Lule. 2008. “Maternal Morbidity 686–690. Following Emergency Caesarean Section in Asymptomatic Thaddeus, S., and D. Maine. 1994. “Too Far to Walk: Maternal HIV-1 Infected Patients in Mulago Hospital Kampala, Mortality in Context.” Social Science and Medicine 38 (8): Uganda.” Journal of Obstetrics and Gynaecology Research 1091–110. 28 (7): 703–9. Tshibangu, K. C., M. A. de Jongh, D. J. de Villiers, J. J. du Toit, Seljeskog, L., J. Sundby, and J. Chimango. 2006. “Factors and S. M. Shah. 2002. “Incidence and Outcome of Caesarean Influencing Women’s Choice of Place of Delivery in Section in the Private Sector--3-Year Experience at Pretoria Rural Malawi: An Explorative Study.” African Journal of Gynaecological Hospital.” South African Medical Journal 92 Reproductive Health 10 (3): 66–75. (12): 956–59. Semel, M. E., S. R. Lipsitz, L. M. Funk, A. M. Bader, T. G. Weiser, Turaga, K. K., N. Garg, M. Coeling, K. Smith, B. Amirlak, and and others. 2012. “Rates and Patterns of Death after Surgery others. 2006. “Inguinal Hernia Repair in a Developing in the United States, 1996 and 2006.” Surgery 151 (2): 171–82. Country.” Hernia 10 (4): 294–98. Séréngbé, B. G., A. Gaudeuille, A. Soumouk, J. C. Gody, Urbach, D. R., A. Govindarajan, R. Saskin, A. S. Wilton, S. Yassibanda, and J. L. Mandaba. 2002. “Acute Abdominal and N. N. Baxter. 2014. “Introduction of Surgical Safety Pain in Children at the Pediatric Hospital in Bangui (Central Checklists in Ontario, Canada.” New England Journal of African Republic). Epidemiological, Clinical, Paraclinical, Medicine 370 (11): 1029–38. Therapeutic and Evolutive Aspects.” [In French.] Archives Usang, U. E., O. A. Sowande, O. Adejuyigbe, T. I. Bakare, des pédiatrie 9 (2): 136–41. and O. A. Ademuyiwa. 2008. “The Role of Preoperative Shaikh, A. R., A. M. Rao, and A. Muneer. 2012. “Inguinal Mesh Antibiotics in the Prevention of Wound Infection after Hernioplasty under Local Anaesthesia.” Journal of the Day Case Surgery for Inguinal Hernia in Children in Ile Ife, Pakistan Medical Association 62 (6): 566–69. Nigeria.” Pediatric Surgery International 24 (10): 1181–85. Shaikh, A. R., A. K. Sangrasi, and G. A. Shaikh. 2009. “Clinical Utpal, D. 2005. “Laparoscopic versus Open Appendectomy in Outcomes of Laparoscopic versus Open Appendectomy.” West Bengal, India.” Chinese Journal of Digestive Diseases Journal of the Society of Laparoendoscopic Surgeons 13 (4): 6 (4): 165–69. 574–80. van Klei, W. A., R. G. Hoff, E. E. van Aarnhem, Shi, Y., Z. Su, L. Li, H. Liu, and C. Jing. 2010. “Comparing the R. K. Simmermacher, L. P. Regli, and others. 2012. “Effects Effects of Bassini versus Tension-Free Hernioplasty: Three of the Introduction of the WHO Surgical Safety Checklist Years’ Follow-Up.” Frontiers of Medicine in China 4 (4): on In-Hospital Mortality: A Cohort Study.” Annals of 463–68. Surgery 255 (1): 44–9. 304 Essential Surgery Van Minh, H., N. T. Kim Phuong, P. Saksena, C. D. James, ———. 2009a. “Guidelines for Trauma Quality Improvement and K. Xu. 2013. “Financial Burden of Household Out-of Programmes.” WHO, Geneva. Pocket Health Expenditure in Viet Nam: Findings from the ———. 2009b. Implementation Manual: Surgical Safety National Living Standard Survey 2002–2010.” Social Science Checklist, edited by A. A. Gawande and T. G. Weiser, first and Medicine 96: 258–63. edition. Geneva: WHO. Villar, J., G. Carroli, N. Zavaleta, A. Donner, D. Wojdyla, ———. 2009c. “Integrated Management of Essential and A. Faundes, A. Velazco, V. Bataglia, A. Langer, A. Narvaez, Emergency Surgical Care (IMEESC) Tool Kit.” Geneva: WHO. E. Valladares, A. Shah, L. Campodonico, M. Romero, http://www.who.int/surgery/publications/imeesc/en/. S. Reynoso, K. S. de Padua, D. Giordano, M. Kublickas, and ———. 2009d. WHO Guidelines for Safe Surgery: Safe Surgery A. Acosta. 2007. “Maternal and Neonatal Individual Risks Saves Lives, edited by A. A. Gawande and T. G. Weiser. and Benefits Associated with Caesarean Delivery: Multicentre Geneva: WHO. http://whqlibdoc.who.int/publications Prospective Study.” BMJ 335 (7628): 1025. /2009/9789241598552_eng.pdf. Walk, R. M., J. Glaser, L. M. Marmon, T. F. Donahue, J. Bastien, and ———. 2010. “Tool for Situational Analysis to Assess S. D. Safford. 2012. “Continuing Promise 2009-Assessment Emergency and Essential Surgical Care.” Geneva: of a Recent Pediatric Surgical Humanitarian Mission.” WHO. http://www .who .int/surgery/publications Journal of Pediatric Surgery 47 (4): 652–57. /QuickSitAnalysisEESCsurvey.pdf. Walker, I. A., and I. H. Wilson. 2008. “Anaesthesia in Willmore, W. S., and A. G. Hill. 2001. “Acute Appendicitis in Developing Countries: A Risk for Patients.” The Lancet 371 a Kenyan Rural Hospital.” East African Medical Journal 78 (9617): 968–69. (7): 355–57. Weiser, T. G. 2010. “Health Policy: All-or-None Compliance is Wu, H. S., H. W. Lai, S. J. Kuo, Y. T. Lee, D. R. Chen, and others. the Best Determinant of Quality of Care.” Nature Reviews 2011. “Competitive Edge of Laparoscopic Appendectomy Urology 7 (10): 541–42. versus Open Appendectomy: A Subgroup Comparison Weiser, T. G., A. B. Haynes, G. Dziekan, W. R. Berry, S. R. Lipsitz, Analysis.” Journal of Laparoendoscopic and Advanced Surgical and others. 2010. “Effect of a 19-Item Surgical Safety Techniques, Part A 21 (3): 197–202. Checklist during Urgent Operations in a Global Patient Wu, S. C., C. C. Wang, and C. C. Yong. 2008. “Quadrapod Population.” Annals of Surgery 251 (5): 976–80. Mesh for Posterior Wall Reconstruction in Adult Inguinal Weiser, T. G., A. B. Haynes, A. Lashoher, G. Dziekan, Hernias.” ANZ Journal of Surgery 78 (3): 182–84. D. J. Boorman, and others. 2010. “Perspectives in Quality: Wu, S. C., Y. C. Wang, C. Y. Fu, R. J. Chen, H. C. Huang, and Designing the WHO Surgical Safety Checklist.” International others. 2011. “Laparoscopic Appendectomy Provides Better Journal for Quality in Health Care 22 (5): 365–70. Outcomes Than Open Appendectomy in Elderly Patients.” Weiser, T. G., M. A. Makary, A. B. Haynes, G. Dziekan, American Surgeon 77 (4): 466–70. W. R. Berry, and others. 2009. “Standardised Metrics for Xu, K., D. B. Evans, G. Carrin, A. M. Aguilar-Rivera, Global Surgical Surveillance.” The Lancet 374 (9695): P. Musgrove, and others. 2007. “Protecting Households 1113–17. from Catastrophic Health Spending.” Health Affairs Weiser, T. G., S. E. Regenbogen, K. D. Thompson, A. B. Haynes, (Millwood) 26 (4): 972–83. S. R. Lipsitz, and others. 2008. “An Estimation of the Yaffee, A. Q., L. K. Whiteside, R. A. Oteng, P. M. Carter, Global Volume of Surgery: A Modelling Strategy Based on P. Donkor, and others. 2012. “Bypassing Proximal Health Available Data.” The Lancet 372 (9633): 139–44. Care Facilities for Acute Care: A Survey of Patients in Weiser, T. G., M. E. Semel, A. E. Simon, S. R. Lipsitz, A. B. Haynes, a Ghanaian Accident and Emergency Centre.” Tropical and others. 2011. “In-Hospital Death Following Inpatient Medicine and International Health 17 (6): 775–81. Surgical Procedures in the United States, 1996–2006.” World Yeung, Y. P., M. S. Cheng, K. L. Ho, and A. W. Yip. 2002. “Day-Case Journal of Surgery 35 (9): 1950–56. Inguinal Herniotomy in Chinese Children: Retrospective WFSA (World Federation of Societies of Anesthesiologists). Study.” Hong Kong Medical Journal 8 (4): 245–48. 2008. “2008 International Standards for Safe Practice of Zhou, X. L. 2013. “Comparison of the Posterior Approach Anaesthesia.”WFSA, London. http://www.anaesthesiologists and Anterior Approach for a Kugel Repair of Treatment of .org. Inguinal Hernias.” Surgery Today 43 (4): 403–7. WHO (World Health Organization). 2000. “Millennium Zoguereh, D. D., X. Lemaître, J. F. Ikoli, J. Delmont, A. Chamlian, Development Goals.” WHO, Geneva. and others. 2001. “Acute Appendicitis at the National ———. 2005. Make Every Mother and Child Count: The World University Hospital in Bangui, Central African Republic: Health Report 2005. Geneva: WHO. Epidemiologic, Clinical, Paraclinical and Therapeutic ———. 2007. World Health Statistics 2007. Geneva: WHO. Aspects.” [In French.] Santé 11 (2): 117–25. Excess Surgical Mortality: Strategies for Improving Quality of Care 305 Chapter 17 Workforce Innovations to Expand the Capacity for Surgical Services Staffan Bergström, Barbara McPake, Caetano Pereira, and Delanyo Dovlo INTRODUCTION • Staff attrition due to retirement, death, or resignation, and the consequences of brain drain Surgical interventions are often considered complex procedures to be undertaken by highly trained surgeons, The reluctance of governments to invest in human but such specialists are rare in many low-income coun- resources compounds the effects of these factors. Current tries (LICs). However, many common surgical problems financial constraints, such as those in Tanzania, for in resource-limited settings do not require the inter- example, have forced governments to announce freezes vention of specialized staff. Significant documentation in employing new human resources for health. demonstrates that cost-effective surgical interventions Sub-Saharan Africa is most affected by the global can be undertaken in LICs with the innovative use and shortage of human resources for health (Chankova, deployment of trained staff, including emergency care Muchiri, and Kombe 2009; Mills and others 2008; for trauma and obstetrical needs. Despite this docu- WHO 2006). Two countries profiled in this chapter, mentation, surgical workforce innovations that use Mozambique and Tanzania, experienced this crisis some nonspecialized cadres often meet with resistance from years ago (Liese and Dussault 2004; Mills and others established surgeons and their professional associations. 2008; Smith and Henderson-Andrade 2006). In other The most important barrier to the safe provision of countries, despite years of interventions to overcome preoperative, intraoperative, and postoperative surgical the scarcity of doctors, the shortage has worsened as and anesthesia services in LICs is the shortage of trained the result of population growth, presenting a major staff. The well-documented reasons for this scarcity challenge to the ability of these countries to achieve the include the following (Chu and others 2009; FAIMER health-related Millennium Development Goals (MDGs) Institute 2008): (Anand and Barnighausen 2004; Liese and Dussault 2004) (box 17.1). Available doctors tend to concentrate • Low number of medical school graduates and work in urban areas and in regional or even national • Inadequate initial and ongoing training hospitals, limiting access for rural populations, who • Poor salaries and working conditions often constitute up to 75 percent of national populations. • Inability to motivate and retain staff in remote and A major reason for Sub-Saharan Africa’s high mater- rural areas nal mortality is that few infants are born in the presence Corresponding author: Staffan Bergström, MD, PhD, Karolinska Institutet, staffan.bergstrom@ki.se 307 global burden of disease; yet it has 3 percent of the global Box 17.1 health workforce (Chen and others 2004), only a small percentage of whom are qualified surgeons. Sub-Saharan Millennium Development Goals (MDGs) for Health Africa has less than 1 percent of the number of surgeons that the United States has, despite having a population Goal 4: Reduce the under-five mortality rate by two-thirds that is three times as large (Ozgediz, Riviello, and Rogers between 1990 and 2015. 2008). Expanding the human workforce is clearly essen- tial to improving the performance of health systems (de Goal 5: Reduce the maternal mortality ratio by three- Bertodano 2003; Chankova, Muchiri, and Kombe 2009; quarters; achieve universal access to reproductive health. Liese and Dussault 2004; WHO 2000; World Bank 2004) Goal 6: Have halted and begun to reverse the spread of and improving outcomes, even under difficult circum- HIV/AIDS by 2015; achieve universal access to treatment stances (Chu and others 2009; EQUINET 2007; FAIMER for HIV/AIDS by 2010 for all those who need it; have halted Institute 2008; Mills and others 2008). and begun to reverse by 2015 the incidence of malaria and In Mozambique, the scarcity of human resources other major diseases. for health 30 years ago was alarming; the country had A review of progress on the MDGs is available at http:// fewer than 5 physicians per 100,000 population. Our www.hrh-observatory.afro.who.int/en/data-and-statistics research estimated that there are 33 registered nurses /hrh-statistics.html. and midwives per 100,000 population (Pereira 2010). In Tanzania, the health workforce shortage was disastrous, Source: United Nations, http://www.un.org/millenniumgoals. according to the report of the Joint Learning Initiative (Chen and others 2004). A study by the London School of Hygiene and Tropical Medicine suggests that the number of health care providers would need to increase of skilled attendants. The lack of skilled birth atten- by more than 58,000 to provide necessary interven- dants contributes to the 5 million to 6 million maternal tions to meet the health-related MDGs for Tanzania deaths, stillbirths, and newborn deaths each year world- (Anyangwe and Mtonga 2007). wide. In 19 of the 52 Sub-Saharan African countries In most countries in Sub-Saharan Africa, the scarcity of that reported data, fewer than 50 percent of births were human resources for health existed before independence, attended by skilled health personnel. The World Health as a result of colonial training policies and, in some cases, Organization (WHO) estimates that 80 percent of births the massive exodus of colonial professionals after indepen- need to be attended by an adequately equipped and dence (Ministry of Health, Mozambique 2008; Ozgediz skilled birth attendant to reach the fifth MDG target of and others 2008). In Mozambique, a civil war provoked by reducing maternal mortality by three-quarters (UNECA, neighboring South Africa in the early 1980s worsened the African Commission, African Development Bank, and situation. Both Mozambique and Tanzania suffered from UNDP n.d.). the consequences of the brain drain, either externally as One colleague in Tanzania expressed his frustrations health professionals moved to high-income countries in the following way: (HICs) or internally as they migrated from rural to urban areas (Dodani and LaPorte 2005; McKinsey and … [We] are fed up with the government’s commitments Company 2006; Mullan and Frehywot 2007). and the politicians’ alleged devotion to the problem of maternal deaths in Tanzania. Our work burden is increasing tremendously, but there are no signs of real support. Imagine: If I am up during the night to make NONPHYSICIAN CLINICIANS one to two cesarean sections, I have to work the full day The literature uses a number of terms to describe cate- the morning after. We are entitled to a symbolic call gories of health professionals who may serve as substi- allowance of US$6 (six!) per night, but we do not receive tutes for physicians in providing health care. The most even that! The government says “there is no money.” common are nonphysician clinicians (NPCs)—nowadays This is not true. referred to as associate clinicians—and midlevel providers The AIDS epidemic in Sub-Saharan Africa may have (MLPs), although others such as substitute health work- aggravated this crisis by depriving health systems of a ers have been used (Dovlo 2005). significant proportion of their trained staff (Chen and The terms appear to be used interchangeably, although others 2004). Sub-Saharan Africa has 11 percent of the there is inconsistency across the literature in the ways in world’s population and 24 percent of the total estimated which the terms are used. In the Sub-Saharan African 308 Essential Surgery literature, the characteristics of the nontraditional cadres network—the African Network of Associate Clinicians of health professionals are generally as follows: (ANAC)—has developed and is based at the Chainama College of Health Sciences in Lusaka, Zambia, • They have been created as a response to physician a lower-middle-income country. The ANAC is signifi- scarcity. cant; for the first time, differently titled MLPs from a • They have a lower initial level of education. large number of Sub-Saharan African countries have • They receive a shorter period of preservice training formed a major international association. This develop- than physicians, with the training often limited to a ment will facilitate the recognition of this category of key specific set of clinical skills. health staff for advanced care, including surgery, in rural settings that lack access to physicians. These cadres include the Tanzanian assistant medical officers (AMOs) and the Mozambican técnicos de cirurgia (TCs), whose experiences particularly inform this TASK-SHIFTING AND TASK-SHARING chapter. Other countries use the terms medical assis- tants (Ghana) or clinical officers (Kenya and Uganda) to The literature indicates that informal or formal delegation denote similar cadres. of tasks from one cadre to another is not a new concept. Studies and commentators differ in their inclusion Task-shifting implies the delegation of certain medi- or exclusion of traditional health professional cadres, cal responsibilities to less specialized health workers including nurses, midwives, pharmacists, and other (McCord and others 2009). This is the direct substitution allied health professionals, who have distinct and com- of new and different cadres for an existing traditional plementary clinical roles to play. For example, Warriner profession (Pereira and others 2007; Pereira and others and others (2006, 1) define MLPs as “health care pro- 2011). In surgery, such health workers may provide many viders who are not doctors, such as nurses, midwives, of the diagnostic and clinical functions usually per- and doctor-assistants” in their review of the options formed by physicians. However, opinions have diverged; for providing induced abortion services in South Africa some experts suggest that task-sharing may be a more and Vietnam. Similarly, the American Osteopathic appropriate concept. These two expressions, however, Association, Division of State Government Affairs seem to signify two different realities. Where no physi- (2003), based in the United States, counts both new and cians are available, the tasks of physicians must be shifted traditional health professional cadres in the definition to nonphysicians. Where a few physicians are available, of the term NPC. In contrast, Bradley and McAuliffe their range of tasks may be shared with nonphysicians. (2009, n.p.) define MLPs as “cadres of health workers who undertake roles and tasks that are more usually the province of internationally recognized cadres, such Training for Safe and Effective Care as doctors and nurses,” implying that nurses are not In most Sub-Saharan countries, the use of substitute included among MLPs. This definition is similar to that health workers started as a temporary measure until of NPCs according to Mullan and Frehywot (2007), who more doctors could be trained. However, in the face list health officers, clinical officers, physician assistants, of the persisting human resources crisis, this strategy nurse practitioners, and nurse clinicians as the labels by has become permanent. More of these countries have which NPCs are known. embarked on the expanded training of midlevel health This chapter focuses on the role of NPCs or MLPs— professionals and nonphysician cadres to promote access AMOs and TCs in particular—in surgical services to care and to contain costs (Dovlo 2004; Ministry of in Sub-Saharan Africa in situations characterized by Health, Mozambique 2008; Pereira and others 2011). physician shortages. These cadres have been central to This trend to delegate procedures to lower cadres the debate about ensuring adequate staffing for essen- has often met with resistance for various reasons. tial surgery and other physician-delivered services in Surgery is considered a highly specialized field that such environments, although growing interest has been requires several years of training; hence, it is impor- expressed in the greater use of midwives and nurse- tant to define the boundaries of surgical task-shifting midwives in obstetric surgery, and countries have been considered essential to ensure quality of care. The building on their experiences in such expanded uses WHO has established a list of surgical procedures per- (Berer 2009; Warriner and others 2006). formed at first-level hospitals that facilitates the classi- In recent years, a welcome terminological shift has fication of various interventions and can help training occurred, from the NPC concept (which actually is a schools establish which essential interventions could negation) to the concept of associate clinician. A growing be safely shifted to NPCs (Lehmann, Dieleman, and Workforce Innovations to Expand the Capacity for Surgical Services 309 Martineau 2008; McCord and others 2009). A district Well-Being in Kintampo, a move is underway to change or first-level hospital is usually the most remote, rurally the procedures and allow these cadres to perform situated hospital with inpatient care and a theater for life-saving surgery and obstetric procedures. limited major surgery interventions, such as cesarean In both Mozambique and Tanzania, the real challenge sections, open fractures, and bowel resections for stran- in providing quality care is not primarily in the prac- gulated hernias (Chilopora and others 2007). tical skills in the operating room. The difficult aspect In Mozambique, the training of NPCs in surgery is of emergency obstetrics and surgery is rather in the well structured and is followed by a formal internship. decision-making process, specifically, whether and how The recruitment focus is on candidates with previous to intervene. It is easy to solve most emergency problems job experience in peripheral health units or first-level in obstetrics by resorting to cesarean section, a simple hospitals (Pereira 2010). Studies have shown that NPCs technique that is easy to learn. Any health worker, NPC in Mozambique are well appreciated by other profes- (assistant medical officer, clinical officer, or other cate- sionals, doctors, nurses, and midwives (Cumbi and gory of midlevel health worker), or physician who has others 2007). Approximately 90 percent of physicians not been trained in properly assisting vaginal delivery and other health staff gave positive ratings to the strong in general and in vacuum extraction in particular would practical skills and the critical roles played by NPCs in tend to solve many obstetric problems by performing a saving the lives of mothers and newborns at first-level cesarean section—whether justified or not. hospitals. With accumulated surgical experience among Most often—in practice—no one would blame a these NPCs, young doctors deployed in rural areas health care provider for having performed a cesarean are increasingly trained in surgery by TCs (Hounton section; however, health care providers would be blamed and others 2009). An assessment of the outcomes of for not having performed a cesarean section if the mother cesarean sections between TCs and physicians at the or the baby died or suffered a serious complication. This Maputo Central Hospital showed no clinically signifi- reality increases the number of medically unnecessary cant differences between the two cadres (Cherian and cesarean sections. This problem has one solution: the others 2004). careful auditing of cesarean section decision making. In Tanzania, AMOs are selected from among the This auditing practice is already routine in efforts in clinical officers who have a minimum of three years of Tanzania to reduce maternal mortality rates. Cesarean working experience in peripheral health units or first- section auditing has proven to be a necessary corollary level hospitals. Their subsequent training is for two to the task-shifting of major obstetric surgery. The audit years and includes three months each of surgery and scrutinizes the circumstances leading to the cesarean obstetrics. Studies show no significant differences in section; it then questions each step by examining the the clinical outcomes, risk indicators, or quality of care details of the partogram to determine whether oxytocin indicators for major obstetric operations performed augmentation of labor should have been undertaken, or by AMOs and nonspecialized physicians (McKinsey if assisted vaginal delivery should have been considered and Company 2006). For example, despite logistic and to be the preferred option. material resource problems in all the hospitals, the aggregate maternal case fatality rate was acceptable at 1 percent to 2 percent. Treatment Areas for Task-Sharing or Task-Shifting Ghana, a lower-middle-income country, initiated its Our studies and other literature show that midlevel program for training medical assistants, consisting of health professionals carry out the majority of surgical one year of postnursing qualification training, in 1969. procedures outside urban areas in a number of Sub- In 2007, this program was converted into a physician Saharan African countries and can be indispensable assistants program, consisting of four years of direct when physicians are scarce (Chankova and others training after high school. The students were trained 2009; Cumbi and others 2007; Dovlo 2004; McCord to perform only limited surgical procedures and tasks. and others 2009). The studies indicate that TCs in A nurse anesthetist (now called anesthetist physician Mozambique perform 92 percent of cesarean sections assistant) program has become the backbone of surgical in first-level hospitals (Pereira 2010; Pereira and others procedures, even in regional third-level hospitals. The 2007); in Tanzania, AMOs perform 85 percent of surgical tasks of these cadres remain limited to perform- cesarean sections, 94 percent of repairs of ruptured ing incisions, draining abscesses, suturing wounds, and uterus, 86 percent of removals of ectopic pregnancy, immobilizing fractures. Most obstetric tasks beyond and 70 percent of hysterectomies in the Mwanza and normal delivery are not part of their responsibilities. Kigoma regions in Tanzania (McCord and others 2009; According to the director of the College of Health and Pereira 2010). 310 Essential Surgery ACCEPTANCE OF MIDLEVEL PROVIDERS especially in LICs and lower-middle-income countries FOR MAJOR SURGERY (Mills and others 2008; Pereira and others 1996). Both motivation and retention are directly influenced by poor The literature highlights the problem of reluctance and remuneration and working conditions, suboptimal man- even resistance among doctors and other professionals agement of human resources, and limited opportunities to consider task-shifting in surgery (Lehman, Dieleman, for career progression (Pereira 2010). These challenges and Martineau 2008; McCord and others 2009). Since are issues for both physicians and NPCs. the inception in 1984 of training of TCs in Mozambique, In Mozambique, the same factors resulting in poor this reluctance has gradually disappeared; members of motivation also prevail (Cumbi and others 2007). A key this cadre are now well accepted and recognized among issue behind the dissatisfaction that TCs express is the physicians. They are also acknowledged to be important heavy workload; they can rarely leave the workplace to for the training and support of recently graduated and attend training in referral hospitals or attend specific inexperienced physicians assigned to first-level hospitals seminars to enhance their knowledge. In addition, the (Cumbi and others 2007). One physician in our research scarcity of surgical specialists at the provincial level lim- in Mozambique expressed his opinion as follows: its the capacity to provide and receive adequate supervi- … [O]ur TC is good, because without him I don’t know sion (Hounton and others 2009). what would be in terms of the rural hospital [where] The NPCs in Ghana and Tanzania face a similar he is the surgeon; here in the provincial hospital he situation, with motivation reportedly weak (Hongoro works in shifts in equal terms with the other specialists and McPake 2004). AMOs are overworked, face poor [surgeon, obstetrician, and orthopedist]; when one working conditions, and experience a lack of supervi- specialist goes on vacation, she or he is replaced by sion. Unlike nurses and midwives, they are rarely invited the TC. At rural hospital level, they [TCs] provide all to attend professional meetings and workshops, despite [types of] care and they decrease the provincial hospital their crucial roles. They are seldom moved to referral workload, [can you] imagine without their presence hospitals for job training to improve their skills and per- [in the districts], what would be the workload at the formance. Limited career prospects and opportunities provincial hospital? for upward mobility increase their levels of dissatisfac- tion (Pereira 2010). The TCs have been trained and deployed for a quar- ter of a century, and the young physicians are taught in school to respect these cadres, given that new phy- Financial Incentives sicians themselves have limited exposure to surgical In Mozambique, the lower salary level for TCs than for interventions. other midlevel professionals has been a significant cause In Tanzania, this issue has not yet been studied scien- of dissatisfaction. The training of TCs was initially con- tifically. Forthcoming research into attitudinal problems troversial, largely due to physician resistance, resulting related to perceived threats to conventional areas of in the unclear definition of career paths by the Ministry professional competence in surgical practice by task- of Health, since TCs were considered midlevel profes- shifting will be useful. In Ghana, physician assistants sionals without specialization. This designation affects were, until recently, not under any regulatory authority, their position on the salary scale, which has a significant which may have contributed to their lack of acceptance impact on their motivation (Pereira 2010). During the by physicians and the reluctance to shift certain tasks to past decade, the salaries of TCs have improved. them. Associate physicians in Ghana are now registered and regulated by the Medical and Dental Council and may soon be permitted to perform life-saving surgical Nonfinancial Incentives procedures. Improving Supervision. Initiatives to improve the capacity to provide adequate supervision and manage- ment can improve work satisfaction, performance, and IMPROVING WORKING CONDITIONS AND quality of work in remote settings (Maestad 2006; Pang, PROMOTING RETENTION OF MIDLEVEL Lansang, and Haines 2002; Pereira and others 2007). Our studies did not specifically address supervision, PROVIDERS but the literature reviewed indicates that supervision The need to develop policies and programs to improve is irregular or nonexistent in most districts in the two health worker motivation and retention in rural locations countries (Anyangwe and Mtonga 2007; Dovlo 2005). is a crucial area in addressing the health resource crisis, In Ghana, annual meetings have become popular and Workforce Innovations to Expand the Capacity for Surgical Services 311 important sources for updating skills and providing and depreciating circumstances—such as access or lack forums for professional networking.1 of access to housing, positive or negative working con- ditions, an enabling or disabling work environment, and Improving Working and Living Conditions. Working the availability or lack of availability of further training and living conditions are important determinants of are the decisive factors in whether to stay in or leave motivation and retention in HICs, lower-middle-income remote areas. countries, and LICs (Douglas 1991; Lavy and others 2007; Our results in Mozambique show that 88 percent Pereira and others 2007; Stringhini and others 2009). of TCs remained in rural areas seven years after grad- Our studies did not address these issues further, because uation, while none of the physicians remained after in the majority of districts, the housing for TCs had been graduation (the first assignment always being in a rural assessed beforehand, a prerequisite to deployment of area) (Pereira 2010; Pereira and others 2007). Another these cadres at first-level hospitals. In Mozambique, the study indicates that retention may be related to the government is implementing a decentralization program recruitment system. If candidates are selected from each to partner with local authorities and communities to region of the country, are mainly from rural areas, and better respond to the health resource problems in remote are integrated into scholarship schemes at the provincial areas. This consultative process is expected to generate level with the commitment to return after completion better accommodations for staff, more electricity, better of training, then the distribution of cadres and their roads, and improvements to health and educational retention may be improved.2 facilities (Loevinsohn and others 1995). The impact of Retention is also a major issue in Tanzania (Anyangwa this program has not yet been evaluated. and Mtonga 2007; Ministry of Health, Tanzania 2007), In Tanzania, the health sector reform strategy, which with migratory flows from rural to urban areas and aims to influence changes in the health system to from the public to the private sectors. Most of the skilled improve the health status of all citizens, has focused health workforce, particularly physicians and specialists, on district decentralization, improvement of the health are concentrated in urban areas, where only 20 percent system, health management, and financing and human of the population lives. As early as 1982, Tanzania started resource development (Cavanagh and Coffin 1992; a decentralization reform that was designed to empower Kunaviktikul and others 2001). An evaluation reveals local authorities to recruit health workers. Decentralized that the impact on the general health status of the pop- recruitment was supposed to be effective in improv- ulation was unsatisfactory (Lambert and Lambert 2001). ing retention because the responsibility for hiring was transferred to the local governments. The assessment of Improving Staff Satisfaction. Staff satisfaction has a the potential impact of this decentralization program large influence on motivation, which affects the perfor- is underway, but the initial findings reveal that decen- mance and retention of health workers (Ministério da tralization enhanced the retention of the lower-cadre Administração Estatal 2001). Training, study leave, the health workers in the districts.3 In Ghana, approximately opportunity to work in a team, support from supervisors, 75 percent of medical assistants and physician assistants and provision of housing and transport increase staff work in rural areas.4 satisfaction and consequently motivation (Dominick and Kurowski 2005; Munishi 2003). In both Mozambique and Tanzania, a widespread opinion among health work- COST-EFFECTIVENESS OF SURGICAL ers is that the situation is difficult because their salaries do not adequately cover the cost of living. Health work- TRAINING OF MIDLEVEL PROVIDERS ers consider administrative management to be weak Few studies have addressed the issue of the cost- (Anyangwe and Mtonga 2007; Dovlo 2005; Ministry of effectiveness of training NPCs, associate clinicians, Health, Tanzania 2007). general practitioners, and specialists (Dovlo 2004). In Burkina Faso, NPCs are trained for two years in surgery Improving Retention. According to the literature, the (attachés de santé), and general practitioners receive retention of human resources for health, particularly six months of training to perform emergency surgery in rural areas, is a major and complex problem in most in rural areas. These personnel are cost-effective com- LICs (Pereira and others 2007; Stilwell and others 2001; pared with specialists (Hounton and others 2009). In WHO 2004; Wilbulpolprasert 1999), and no single Mozambique, the cost-effectiveness of general practi- solution applies in all settings. Comparatively low sala- tioners was not addressed in our studies, given that this ries are the primary source of dissatisfaction. However, cadre does not receive additional training in surgery. socioeconomic status—implying a set of appreciating Such a scheme would increase the training of general 312 Essential Surgery practitioners to a total of nine years after secondary major emergency obstetric surgery, and the concept of school, which the Ministry of Health did not deem teamwork. The Ministry of Health expects that more advisable. A comparison of the cost-effectiveness of TCs effective teamwork and, consequently, improvement of in relation to physicians demonstrates that the former the quality of work can be achieved because TCs will are significantly more cost-effective if the costs of train- be relieved of much of the workload of obstetrical and ing and deployment are considered (Kruk and others gynecological emergency surgery. 2007). In Mozambique, most physicians, after initial Emergency obstetrics and gynecology constitutes the rural assignments of a few years, move to urban areas predominant work burden for TCs. The task-shifting to meet administrative commitments or to start their scenario, however, is changing; NPCs, in all likelihood, specialization at teaching hospitals (Pereira 2010). In will handle more elective surgery in general surgery, as Tanzania, the literature review shows that training AMOs well as in obstetrics and gynecology. Two examples are is less expensive than training physicians (Anyangwe and bilateral tubal ligation and a growing number of planned Mtonga 2007). cesarean sections, whether clinically indicated or not. In middle-class Sub-Saharan Africa, the trend to request cesarean sections is, unfortunately, clearly on the rise. In Mozambique, the government plan for 2005−09 ESTABLISHING ENABLING ENVIRONMENTS focused on capacity building, including the rehabilita- The governments of Mozambique and Tanzania have tion of infrastructure and theaters in the whole health made strong commitments in recent decades to address system; the timely supply and deployment of human the crisis in human resources for health. Solving the resources in general, and in peripheral areas in par- problem of inadequate numbers of health profession- ticular; the development of norms and guidelines for als, however, is not the solution to improving access to obstetric emergency care and essential care to newborns; health care. Other problems have to be addressed simul- the implementation of a formative system of supervi- taneously. An environment conducive to quality surgical sion; and the strengthening of the ability to commu- care, as perceived by the health workers, requires that nicate with radios and to transport patients (ISCISA trained NPCs be able to execute their skills in settings 2003). The plan from 2010 onward aims to strengthen that foster and value their professional services. This the system and the previously existing plan (Ministry of environment, which is required for well-trained health Health, Mozambique 2008). workers in sufficient numbers to perform optimally, is The human resources plan approved by the Ministry needed both at the central level of the Ministry of Health of Health for implementation incorporates four main and at the provincial and district levels. strategic areas: • Organization of services and a functioning system Mozambique of rules In Mozambique, the Instituto Superior de Ciências de • Expanded capacity of management at different levels Saúde (Higher Institute of Health Sciences) was created • Improved distribution and retention of human to clarify the career path for TCs (ISCISA 2003). The resources for health initiation of the national human resources program is • Expansion of the institutional capacity to provide a positive step in counteracting the human resources training and continuous education crisis (Pereira 2010). In Ghana, a similar school is under the medical faculty of a university and the program has been upgraded, measures that have improved the envi- Tanzania ronment for task enhancement.5 In Tanzania, facilitating the establishment of an enabling To begin to reduce TCs’ heavy workload in environment has received increasing attention (Munga Mozambique, a program to train midwives to perform and others 2009; Nyamtema and others 2011). The major obstetric surgery has been initiated (Enfermeiras government recognizes the importance of improv- de Saùde Materna) to strengthen teamwork at first- ing health care and expanding the supply of human level hospitals.6 This new training, which results in a resources. It has made a commitment to address the licentiate degree, comprises three-and-a-half years of shortage of human resources for health, particularly the theoretical and practical training, in addition to six skilled workforce. Tanzania has established relationships months of internship in first- or second-level hospitals. with other governments, donors, and agencies that are The training is grounded in nursing but empha- potential partners in these approaches (Anyangwe and sizes diagnostic and treatment skills, the practice of Mtonga 2007). Workforce Innovations to Expand the Capacity for Surgical Services 313 CONCLUSIONS • High-income countries (HICs) = US$12,746 or more 1. Delanyo Dovlo, personal communication. The shortage of skilled human resources in surgical health 2. Caetano Pereira, personal communication. care is a major health system problem in Mozambique and 3. Caetano Pereira, personal communication. Tanzania, as well as in other LICs. Innovative and multi- 4. Delanyo Dovlo, personal communication. faceted workforce solutions offer viable options for allevi- 5. Delanyo Dovlo, personal communication. ating the consequences of the shortage and building the 6. Caetano Pereira and Staffan Bergström, personal capacity of countries to provide skilled surgical care. Task- communication. shifting and task-sharing are feasible strategies and should be seriously considered to address the human resources crisis in Mozambique and Tanzania, as well as in other REFERENCES countries facing the same human resources problems. American Osteopathic Association. 2003. “Support Needed for NPCs perform approximately 90 percent of major Clinical Faculty in Osteopathic Emergency Residencies.” emergency obstetric surgeries in rural areas where 103 (12): 575–76. http://www.jaoa.org/content/103/12/575 most of the population live in both Mozambique and .full.pdf. Tanzania. A comparison of the quality of care provided Anand, S., and T. Barnighausen. 2004. “Human Resources by medical doctors and that provided by TCs and AMOs and Health Outcomes: Cross-Country Econometric demonstrates no clinically significant differences in Study.” The Lancet 364 (9445): 1603–09. outcomes in major obstetric surgery. In Mozambique, Anyangwe, S. C., and C. Mtonga. 2007. “Inequities in the Global Health Workforce: The Greatest Impediment to physicians (general practitioners and specialists), nurses, Health in Sub-Saharan Africa.” International Journal of and midwives rate TCs and AMOs positively. Environmental Research and Public Health 4 (2): 93–100. In Mozambique, NPCs have a high retention rate Berer, M. 2009. “Provision of Abortion by Mid-level Providers: in rural areas. NPCs are cost-effective, and the training International Policy, Practice and Perspectives.” Bulletin of and deployment of TCs is three times more cost-effective the World Health Organization 97: 1. than the training and deployment of medical doctors. Bradley, S., and E. McAuliffe. 2009. “Mid-Level Providers Motivation is a problem among NPCs in general and in Emergency Obstetric and Newborn Health Care: among TCs in particular, for multiple reasons, and pro- Factors Affecting Their Performance and Retention grams are being developed to address some of the causes. within the Malawian Health System.” Human Resources Challenges continue for many countries in physi- for Health 7: 14. cian acceptance of midlevel clinicians; the develop- Cavanagh, S. J., and D. A. Coffin. 1992. “Staff Turnover among Hospital Nurses.” Journal of Advanced Nursing 17 (11): ment and implementation of training and regulatory 1369–76. mechanisms; the expansion of the capacity for skills Chankova, S., S. Muchiri, and G. Kombe. 2009. “Health development and improvement, as well as supervision; Workforce Attrition in the Public Sector in Kenya: A Look and better financial and nonfinancial compensation. at the Reasons.” Human Resources for Health 7: 58. Initiatives to improve accuracy in decision making Chen, L., T. Evans, S. Anand, J. B. Ivey, H. Brown, and others. in obstetric cases by different professional categories 2004. “Human Resources for Health: Overcoming the deserve a more specific approach. Crisis.” The Lancet 364 (9449): 1984–90. Cherian, M. N., L. Noel, Y. B. Jargan, and G. Salil. 2004. “Essential Emergency Surgical Procedures in Resource- Limited Facilities: A WHO Workshop in Mongolia.” World NOTES Hospital Health Services 40 (4): 24–29. One of the authors of this chapter is a WHO staff member. The Chilopora, G., F. Kamwendo, E. Malunga, C. Pereira, authors alone are responsible for the views expressed in this S. Bergström, and others. 2007. “Postoperative Outcome of publication and they do not necessarily represent the decisions Caesarean Sections and Other Major Emergency Obstetric or policies of the World Health Organization. Surgery by Clinical Officers and Medical Officers in Malawi.” The World Bank classifies countries according to four Human Resources for Health 5: 17. income groupings. Income is measured using gross national Chu, K., P. Rosseel, P. Gielis, and N. Ford. 2009. “Surgical Task income (GNI) per capita, in U.S. dollars, converted from local Shifting in Sub-Saharan Africa.” PLoS Med 6 (5): e1000078. currency using the World Bank Atlas method. Classifications as Cumbi, A., C. Pereira, R. Malalane, F. Vaz, C. McCord, and of July 2014 are as follows: others. 2007. “Major Surgery Delegation to Mid-level Health Practitioners in Mozambique: Health Professionals’ • Low-income countries (LICs) = US$1,045 or less in 2013 Perceptions.” Human Resources for Health 5: 27. • Middle-income countries (MICs) are subdivided: de Bertodano, I. 2003. “The Costa Rican Health System: Low • Lower-middle-income = US$1,046 to US$4,125 Cost, High Value.” Bulletin of the World Health Organization • Upper-middle-income (UMICs) = US$4,126 to US$12,745 81 (8): 626–27. 314 Essential Surgery Dodani, S., and R. E. LaPorte. 2005. “Brain Drain from and Analysis of Contributing Factors.” Africa Region Developing Countries: How Can Brain Drain Be Converted Human Development Working Paper 32804, World Bank, into Wisdom Gain?” Journal of the Royal Society of Medicine Washington, DC. 98 (11): 487–91. Loevinsohn, B., P. Erlinda, T. Guerrero, and S. P. Gregorio. Dominick, A., and C. Kurowski. 2005. “Human Resources 1995. “Improving Primary Health Care through Systematic for Health: An Appraisal of the Status Quo in Tanzania Supervision: A Controlled Field Trial.” Health Policy and Mainland.” Working Paper, Ifakara Health Research and Planning 10 (2): 144–53. Development Centre and World Bank, Washington, DC. Maestad, O. 2006. “Human Resources for Health in Tanzania: Douglas, M. 1991. “Supervision of Rural Health Centres in Challenges, Policy Options and Knowledge Gaps.” CMI Papua New Guinea: Consolidation of the Delivery of Health Report, CHR Michelsen Institute, Bergen, Norway. Services.” Papua New Guinea Medical Journal 34 (2): 144–48. McCord, C., G. Mbaruku, C. Pereira, C. Nzabuhakwam, Dovlo, D. 2004. “Using Mid-level Cadres as Substitutes for and S. Bergström. 2009. “The Quality of Emergency Internationally Mobile Health Professionals in Africa: Obstetrical Surgery by Assistant Medical Officers in A Desk Review.” Human Resources for Health 2 (1): 7. Tanzanian District Hospitals.” Health Affairs (Millwood) ———. 2005. “Wastage in the Health Workforce: Some 28 (5): w876–85. Perspectives from African Countries.” Human Resources for McKinsey and Company. 2006. “Investing in Tanzanian Human Health 3: 6. Resources for Health.” Human Resources for Health Report, EQUINET. 2007. “Health Worker Retention and Migration TOUCH Foundation, New York. in East and Southern Africa.” Regional meeting report Mills, E. J., W. A. Schabas, J. Volmink, R. Walker, N. Ford, from the Regional Network for Equity in Health in East and others. 2008. “Should Active Recruitment of Health and Southern Africa (EQUINET/ECSA-CH), Training and Workers from Sub-Saharan Africa Be Viewed as a Crime?” Research Support Center, Arusha, March 17–19. http:// The Lancet 371 (9613): 685–88. www.equinetafrica.org/bibl/docs/REPMTG0307HRH.pdf. Ministério da Administração Estatal. 2001. “Documento: FAIMER (Foundation for Advancement of International Medical Estrategia Global da Reforma Sector Publico 2001–2011.” Education and Research) Institute. 2008. “International http://www.Portaldogoverno.gov.mz. Medical Directory.” FAIMER Institute, New York. Ministry of Health, Tanzania. 2007. “Joint External Evaluation Hongoro, C., and B. McPake. 2004. “How to Bridge the Gap of the Health Sector in Tanzania.” Inception Report 13–18. in Human Resources for Health.” The Lancet 364 (9443): Dar es Salaam, Tanzania: Ministry of Health. 451–56. Ministry of Health, Mozambique. 2008. “Plano Nacional Hounton, S. H., D. Newlands, N. Meda, and V. D. Brouwere. 2009. de Desenvolvimento dos Recursos Humanos da Saúde.” “A Cost-Effectiveness Study of Caesarean-Section Deliveries PNRHS 2008–2015. National Directorate of Human by Clinical Officers, General Practitioners and Obstetricians Resources, Maputo, Mozambique. in Burkina Faso.” Human Resources for Health 7: 34. Mullan, F., and S. Frehywot. 2007. “Non-physician Clinicians in ISCISA. 2003. Estatuto Orgânico do Instituto Superior de 47 Sub-Saharan African Countries.” The Lancet 370 (9605): Ciências de Saúde. Instituto Superior de Ciências de Saúde, 2158–63. Maputo, Mozambique. Munga, M. A., N. G. Songstad, A. Blystad, and O. Mæstad. Kruk, M., C. Pereira, F. Vaz, S. Bergström, and S. Galeae. 2009. “The Decentralisation-Centralisation Dilemma: 2007. “Economic Evaluation of Surgically Trained Assistant Recruitment and Distribution of Health Workers in Remote Medical Officers in Performing Major Obstetric Surgery in Districts of Tanzania.” BioMed Central International Health Mozambique.” BJOG: An International Journal of Obstetrics and Human Rights 9 (1): 9. and Gynaecology 1 (14): 1253–60. Munishi, G. K. 2003. “Intervening to Address Constraints Kunaviktikul, W., R. Anders, W. Srisuphan, R. Chontawan, through Health Sector Reforms in Tanzania: Some Gains R. Nuntasupawat, and others. 2001. “Development of and the Unfinished Business.” Journal of International Quality of Nursing Care in Thailand.” Journal of Advanced Development 15 (1): 115–31. Nursing 36 (6): 776–84. Nyamtema, A. S., S. K. Pemba, G. Mbaruku, F. D. Rutasha, Lambert, V. A., and C. E. Lambert. 2001. “Literature Review of and J. van Roosmalen. 2011. “Tanzanian Lessons in Using Role Stress/Strain on Nurses: An International Perspective.” Non-physician Clinicians to Scale Up Comprehensive Nursing and Health Sciences 3 (3): 161–72. Emergency Obstetric Care in Remote and Rural Areas.” Lavy, C., A. Tindall, C. Steinlechner, N. Mkandawire, and Human Resources for Health 9: 28. S. Chimageni. 2007. “Surgery in Malawi: A National Survey Ozgediz, D., R. Riviello, and S. O. Rogers. 2008. “The Surgical of Activity in Rural and Urban Hospitals.” Annals of the Royal Workforce Crisis in Africa: A Call to Action.” Bulletin of the College of Surgeons 89 (7): 722–24. American College of Surgeons 93 (8): 10–16. Lehmann, U., M. Dieleman, and T. Martineau. 2008. “Staffing Pang, T., M. A. Lansang, and A. Haines. 2002. “Brain Drain and Remote Rural Areas in Middle- and Low-Income Countries: Health Professionals.” British Medical Journal 324 (7336): A Literature Review of Attraction and Retention.” Biomed 499–500. Central Health Services Research 8: 19. Pereira, C. 2010. “Task-Shifting of Major Surgery to Midlevel Liese, B., and G. Dussault. 2004. “The State of the Health Providers of Health Care in Mozambique and Tanzania: Workforce in Sub-Saharan Africa: Evidence of Crisis A Solution to the Crisis in Human Resources to Enhance Workforce Innovations to Expand the Capacity for Surgical Services 315 Maternal and Neonatal Survival.” PhD thesis, Karolinska UNECA (United Nations Economic Commission for Africa), Institutet, Stockholm. African Union, African Development Bank Group, and Pereira, C., A. Bugalho, F. Vaz, M. Cotiro, and S. Bergström. 1996. UNDP (United Nations Development Programme). n.d. “A Comparative Study of Caesarean Deliveries by Assistant Executive Summary, MDG Report 2013, Assessing Progress Medical Officers and Obstetricians in Mozambique.” BJOG: in Africa toward the Millennium Development Goals— An International Journal of Obstetrics and Gynaecology 103 Food Security in Africa: Issues, Challenges and Lessons. (6): 508–12. Addis Ababa, Ethiopia: United Nations Economic Pereira, C., A. Cumbi, R. Malalane, F. Vaz, C. McCord, and others. Commission for Africa. http://www.undp.org/content 2007. “Meeting the Need for Emergency Obstetric Care in /dam/undp/library/MDG/english/MDG%20Regional%20 Mozambique: Work Performance and Histories of Medical Reports/Africa/MDG%20report%202013%20summary Doctors and Assistant Medical Officers Trained for Surgery.” _EN.pdf. BJOG: An International Journal of Obstetrics and Gynaecology Warriner, I. K., O. Meirik, M. Hoffman, C. Morroni, J. Harries, 114 (12): 1530–33. and others. 2006. “Rates of Complication in First-Trimester Pereira, C., G. Mbaruku, C. Nzabuhakwa, S. Bergström, and Manual Vacuum Aspiration Abortion Done by Doctors C. McCord. 2011. “Emergency Obstetric Surgery by Non- and Mid-level Providers in South Africa and Vietnam: physician Clinicians in Tanzania.” International Journal of A Randomized Controlled Equivalence Trial.” The Lancet Gynecology and Obstetrics 114 (2): 180–83. 368 (9551): 1965–72. Smith, M. K., and N. Henderson-Andrade. 2006. “Facing the WHO (World Health Organization). 2000. World Health Report Health Worker Crisis in Developing Countries: A Call for 2000: Health Systems—Improving Performance.Geneva:WHO. Global Solidarity.” Bulletin of the World Health Organization ———. 2004. “Migration of Health-Care Workers from 84 (6): 426–27. Developing Countries: Strategic Approaches to Its Stilwell, B., K. Diallo, P. Zurn, M. Vujicic, O. Adams, and others. Management.” Bulletin of the World Health Organization 2001. “Health Worker Motivation in Zimbabwe.” Internal 82 (8): 595–600. Report for the Department of Organization of Health Care ———. 2006. The World Health Report 2006: Working Together Delivery, World Health Organization, Geneva. for Health. Geneva: WHO. Stringhini, S., S. Thomas, P. Bidwell, T. Mtui, and A. Mwisongo. Wilbulpolprasert, S. 1999. “Inequitable Distribution of 2009. “Understanding Informal Payments in Health Care: Doctors: Can It Be Solved?” Human Resources for Health Motivation of Health Workers in Tanzania.” Human 3: 2–22. Resources for Health 7: 53. World Bank. 2004. World Development Report 2004: Making UN (United Nations). “Millennium Development Goals.” Services Work for Poor People. Washington, DC: Oxford http://www.un.org/millenniumgoals. University Press and World Bank. 316 Essential Surgery Chapter 18 Costs, Effectiveness, and Cost-Effectiveness of Selected Surgical Procedures and Platforms Shankar Prinja, Arindam Nandi, Susan Horton, Carol Levin, and Ramanan Laxminarayan INTRODUCTION government health budget. Feasibility is important, particularly in low-income countries (LICs), which This volume has shown that universal provision of a lack many health systems resources. Some deficiencies package of essential surgical services would avert an can be remedied if cost and cost-effectiveness consid- estimated 1.5 million deaths per year, or 6–7 percent erations identify additional investments that provide of all avertable deaths in LMICs (Debas and others good value. For example, purchasing more radiotherapy 2006; Mock and others 2015). Although approximately equipment or training additional personnel may make 234 million surgeries are performed worldwide each a substantial difference. Other deficiencies are harder to year, the distribution is very inequitable (Funk and remedy. LMICs typically have limited ability to manage others 2010). Nearly two billion people live in areas with resources, which restricts how referral or organized a density of less than one operating room per 100,000 screening systems work. population (Funk and others 2010); in high-income In this chapter, we discuss evidence showing that countries (HICs), the density is 14 per 100,000. With this some types of surgery can be both highly cost-effective— scarcity of surgical services in low- and middle-income saving lives or improving the quality of life—and afford- countries (LMICs), the need for scaling up is imperative. able. We focus on a set of surgical interventions that can Challenges to the implementation of surgical services be undertaken at first-level hospitals, or in some cases, in resource-limited environments are substantial and in clinics or mobile facilities. These interventions include include limited human resources, transportation sys- selected emergency surgeries, surgeries associated with tems, and access to electricity and water (Hsia and others reproductive functions, and nonemergency surgeries. 2012; Kruk and others 2010). Moreover, evidence on the We do not cover other types of surgery that also may be different attributes of scaling up is insufficient. Scaling cost-effective and even modest in cost but that are more up requires increasing the share of current income suited to referral hospitals in LMICs, namely, surgery devoted to spending on health, as well as major invest- for cardiovascular disease, cancer, organ transplantation, ments in facilities and human resources. and neurosurgery. Priority interventions in LMICs are those that are Surgical interventions for cardiovascular disease, such cost-effective and reasonable in cost; reasonable is defined as left main coronary artery bypass graft surgery and relative to the prevalence of the condition and size of the percutaneous transluminal coronary angioplasty, have Corresponding author: Shankar Prinja, MD, Post Graduate Institute of Medical Education and Research, shankarprinja@gmail.com 317 been very cost-effective in certain population groups in of the global number—taking into account the propor- HICs, compared with medical management (Tengs and tion for which treatment can be expected to be success- others 1995); this outcome is likely to apply to some ful. An additional 0.9 percent of deaths could be averted population groups in LMICs. Basic surgical interven- by advanced surgical care delivered at specialized clinics tions for cancer treatment are likely to be cost-effective to treat nonemergency conditions, such as cataracts, cleft and, in some cases, feasible at the first-level hospital, for lip and palate, congenital heart anomalies, neural tube example, oophorectomy, simple hysterectomy, radical defects, and obstetric fistula. In addition, surgery could mastectomy, and colectomy. Very few cost-effectiveness reduce the substantial burden of disabilities. results are available on these interventions, surveyed in Cost-effectiveness data can provide important sup- Horton and Gauvreau (2015) and not discussed further port for additional investments in surgical facilities at here. Kidney transplants, although relatively costly, may first-level hospitals. The data can help identify high- be cost-effective (Tengs and others 1995). We do not priority procedures from a cost-effectiveness perspec- cover neurosurgery, such as surgery to treat epilepsy or tive, leading to an analysis of the resources required to to treat infant hydrocephalus, although Warf and others expand their availability. (2011) show that such surgeries can be cost-effective The cost-effectiveness data have limitations. In the in Sub-Saharan Africa. Cost-effectiveness of reproduc- United States, a major expansion of access to surgical tive surgery is considered in volume 2, Reproductive, facilities occurred after the 1930s (chapter 4), while Maternal, Newborn, and Child Health (Black and others cost-effectiveness analysis in health became widespread forthcoming). Dental surgery is not covered because of only during the 1970s. By the 1970s, it was not easy a lack of studies using quality-adjusted life year (QALY), to conduct cost-effectiveness studies of many basic disability-adjusted life year (DALY), life year saved (LYS), and nonelective surgical techniques because they had and death-averted outcome measures. become “usual care.” Much of the more recent cost- The set of conditions covered in the chapter is listed effectiveness literature for HICs focuses on refinements, in annex 18A and includes interventions discussed such as minimally invasive techniques, for example, in other chapters in this volume; chapter 1 provides laparoscopic surgery; new types of surgery that become a more comprehensive list of the detailed procedures more relevant in aging populations, for example, joint considered. These are surgery types that can feasibly be arthroplasty; or new, and often disposable, technologies, undertaken at first-level hospitals, although they may such as mesh or stents, and compares these newer inter- also be undertaken at second-level hospitals, often when ventions with more basic forms of surgery. This literature urgent cases arrive at these emergency units. Some can is of less immediate interest to policy makers in LMICs. be undertaken in specialized facilities, for example, a cat- Cost-effectiveness data are more feasibly obtained in aract hospital, a specialized mobile facility, a short-term LMICs as services expand, given that “usual care” can surgical mission focused on specific surgical conditions, mean “no intervention” in areas with little or no access or a trauma center. to surgery. In LMICs, however, there are fewer studies of We briefly summarize the literature on the cost- emergency procedures and a greater number of studies effectiveness of different ways of organizing facilities of elective procedures and nonurgent procedures. Much for surgery. Equity and affordability are important of the evidence is from surgical missions or nongovern- considerations when prioritizing care. We review ment surgical facilities, and this evidence has limitations. both of these issues before discussing data limitations Mission data tend to underestimate costs, because the and presenting conclusions. This chapter uses World costs of facilities and follow-up care tend not to be Health Organization (WHO) geographical regions: included; nongovernment facilities often have foreign Africa, the Americas, South-East Asia, Europe, Eastern support or foreign personnel, and their costs are not Mediterranean, and Western Pacific. representative. The organization of surgical services affects cost- effectiveness; in particular, the cost effectiveness of WHY ARE COST-EFFECTIVENESS DATA first-level hospitals differs from that of second-level hospitals, specialty hospitals, and surgical missions. USEFUL FOR SURGERY? Cost-effectiveness of government hospitals may dif- Conditions potentially treatable by surgery constitute a fer from that in hospitals operated by charitable significant proportion of the global burden of disease. organizations. We briefly summarize some compar- Bickler and others (chapter 2) estimate that scaling up the ative cost-effectiveness data for surgical missions recommended list of procedures at first-level hospitals compared with first-level hospitals, specialized could prevent 1.4 million deaths annually—3.2 percent hospitals compared with first-level hospitals, and one 318 Essential Surgery example of a government-run hospital compared with converted all published cost data if expressed in another a nongovernment-run hospital. Shrime and others currency into U.S. dollars, using the market exchange (chapter 13) discuss in more detail the cost-effectiveness rate of the year the data were collected. We have also of surgical missions compared with first-level hospitals. converted costs to 2012 U.S. dollars to allow compari- sons, first inflating local currency units to 2012 using the consumer price index of the relevant country, and then COST-EFFECTIVENESS OF SURGICAL converting using the average exchange rate for 2012. INTERVENTIONS Throughout the discussion, we refer to the costs and cost-effectiveness in 2012 U.S. dollars. Methods There is a large literature on methodology (see, Several different metrics can be used to measure the for example, Drummond and others 2005), and the cost-effectiveness of surgical interventions. For LMICs, debates continue. For example, many of the studies the cost per DALY averted is often used, as are older surveyed use discounting to weight costs and benefits variants, such as cost per life year saved (LYS) or cost occurring further in the future, commonly using the per death averted. For HICs, the cost per QALY gained 3 percent social discount rate. More recently, some have is often used. The DALY and QALY measures allow argued that discounting is not appropriate (Murray comparisons to be made between interventions that do and others, 2012). Past efforts applied different pref- not necessarily save lives but may substantially improve erence weights at different ages, weighting deaths of the quality of life or reduce disabilities; deaths averted prime-age working adults more heavily than those of or LYS only allow comparisons to be made between children or the elderly, but this is no longer common life-saving interventions. Some studies do not assess practice. Differences in methodology can change the disability and measure only LYS. We have to be cautious cost-effectiveness ranking of different procedures; for because studies do not use the same outcome measures; example, the decision as to whether, and by how much, the underlying methodologies and assumptions also to discount the future has major impacts on interven- vary. Accordingly, we use such data to illustrate broad tions affecting children. tendencies. The data in tables 18.1 through 18.4 come from The studies cited mainly use DALYs averted or QALYs various sources. A systematic search of the literature on gained. Although DALYs and QALYs are not identical all surgical costs was undertaken from March through (the weights attached to different conditions are not the July 2013, with a supplemental search in 2014 in same), we treat them as roughly equivalent. We have PubMed since 2000 in English. The search combined Table 18.1 Cost-Effectiveness of Trauma and Emergency Surgery, Excluding Obstetric Emergencies Cost per Cost per outcome outcome, Source Condition Country US$ Unit of outcome Currency, US$ 2012 US$ Gosselin and Heitto Trauma Cambodia $77 DALY averted 2006 87 2008a Gosselin, Trauma Haiti $223 DALY averted 2008 302 Maldonado, and Trauma including Nigeria $172 DALY averted 2008 218 Elder 2010b burns Gosselin, Gialamas, Acute orthopedic Haiti $343 DALY averted 2010 362 and Atkin 2011c conditions Kong and others Acute appendicitis South Africa $1,714 LYS 2011 1,611 2013d Note: DALY = disability-adjusted life year; LYS = life year saved; n.a. = not applicable. a. Modeled based on costs and estimated DALYs saved for all admissions during a three-month period for a trauma hospital, excluding outpatients. b. Modeled based on costs and estimated DALYs saved associated with all admissions for a trauma hospital during a three-month period. A higher proportion in Nigeria was life-saving surgery; Haiti includes burns. c . Included 93 patients during 5 one-week relief missions following earthquake, all acute conditions (debridements, amputation, stump revision, few fixations). d. Microcosting of appendicitis surgery, combined with estimate from Jha, Bangoura, and Ranson (1998) that appendectomy saves 1.86 life years, based on mortality risks for complicated appendicitis. In South Africa, 36 percent were uncomplicated, 57 percent had perforation, 8 percent had other pathologies and were excluded. Costs, Effectiveness, and Cost-Effectiveness of Selected Surgical Procedures and Platforms 319 terms for specific surgical interventions listed in The focus was on identifying a base set of candidate annex 18A with economic terms as well as with names interventions that are cost-effective at first-level hos- of all LMICs and regions containing groups of LMICs. pitals and another set that are not cost-effective. In Items determined to be relevant included outcomes HICs, where surgical capacity is much more broadly such as cost per LYS, per QALY gained, or per DALY available and the interventions described have become averted. From the 124 articles found on all surgeries, usual care, the focus of recent literature has shifted we included 29 cost studies that were for essential to comparisons between different surgical interven- surgeries covered in this chapter. The search for LMICs tions for the same condition or sometimes surgical identified 36 cost-effectiveness studies, of which 17 interventions in comparison with other treatment, were also captured in a systematic survey by Grimes for example, a surgical versus a medical approach to and others (2014) that used slightly different search cardiovascular disease, or surgery for a musculoskele- criteria. We augmented our search with another sys- tal condition versus a corrective device. We reference tematic survey by Chao and others (2014), which added some of these studies in the text but do not include three articles not obtained from either of the searches. them in the tables. Of these, we omitted 16 studies that were not related We use the term cost-effectiveness. Unless otherwise to essential surgeries, or that focused on circumcision, specified, we use incremental cost-effectiveness ratios which is treated in volume 2 of this series. The result (ICERs); when comparing surgical treatment to “no was a total of 25 cost-effectiveness studies included in intervention,” this can readily be described as cost- this review. Databases other than PubMed were not effectiveness. When we start comparing two different included and would have potentially yielded additional interventions, we need to be more precise. The cost- studies. Additional articles published between the time effectiveness ratios presented are point estimates, but of the original search and the publication date of this individual studies often conduct sensitivity analysis and chapter were not included. provide ranges for their estimates. This systematic search was augmented by selective How can we compare cost-effectiveness results across searches of the literature for HICs using more limited a range of countries? How transferable are these results search terms for potentially important interventions for across different environments? Care must be taken in which little or no literature turned up for LMICs, such extrapolating results. Costs of interventions vary consid- as trauma centers. Results for HICs are discussed in the erably across countries. The same intervention may have text but not included in the tables. Other useful pub- different effectiveness when implemented in different lished systematic searches, including studies of HICs, environments. Disease prevalence differs, comorbidities include Brauer and others (2005) and Dougherty and differ, and usual care may be vastly different. Howard (2013), both for orthopedic surgery in HICs, The approach suggested by the Commission and Lansingh, Carter, and Martens (2007) for cataracts on Macroeconomics and Health (WHO 2001) is in LMICs and HICs. Annex 18B provides the search that interventions costing less than the per capita statistics. gross domestic product (GDP) in LMICs are “very Articles included were also graded using the cost-effective,” and those costing less than triple the Drummond and others (2005) checklist, as used by per capita GDP are “cost-effective.” Although this Chao and others (2014), to provide a quality score for approach has not typically been applied to HICs, each article (annex 18c). The quality score data are a major study of Australia (Vos and others 2010) cate- included in the tables. Most of the studies were graded gorized a cost per QALY gained of less than $A 50,000 as 7 or above out of 10, with the one exception of none- as cost-effective, and less than $A 10,000 as very mergency surgery, where three of the seven articles were cost-effective. Studies of the United States have used graded lower than 7 out of 10. The checklist is similar a similar yardstick for cost-effectiveness; a threshold but not identical to the Consolidated Health Economic of £20,000–£30,000 has sometimes been used for the Evaluation Reporting Standards checklist (Husereau United Kingdom (NICE 2008). and others 2013). Some variations occurred across the studies with regard to methodology. For example, although many adopt a societal perspective for the anal- Trauma and Emergency Surgery ysis, others use the health system perspective. Trauma Care Articles chosen for inclusion typically compare a Trauma care saves lives; 77 percent of the deaths surgical intervention with usual care, that is, no sur- preventable by surgery are from injuries, representing gical intervention. Comparisons of two different sur- 1.04 million deaths annually (chapter 2). Every year, gical interventions were generally not included. 20–50 million injury survivors are left permanently 320 Essential Surgery disabled, most often because of musculoskeletal injuries others, chapter 2 of this volume). The major conditions (Debas and others 2006). included are maternal hemorrhage, obstructed labor, Trauma care can be very cost-effective (table 18.1). abortion, and neonatal encephalopathy. Table 18.2 sum- Gosselin and Heitto (2008) show that at US$87 per marizes some of the cost-effectiveness results for repro- DALY averted, pure trauma hospitals in Cambodia ductive surgery. could be very cost-effective. Gosselin, Maldonado, and Elder (2010) evaluate two trauma hospitals in Haiti Abortion and Early Pregnancy Loss and Nigeria to find cost-effectiveness ratios of US$302 Early pregnancy failure is a common occurrence that and US$218 per DALY averted, respectively. The differ- affects one-third of early pregnancies (Wilcox and oth- ences in cost-effectiveness were mainly due to different ers 1988) and one-fourth of all women (Warburton and labor cost structures, as well as differences in case mix: Fraser 1964). Although the traditional treatment option the hospital in Haiti includes a burn unit, whereas the for such pregnancies has been surgical evacuation of the one in Nigeria does not. A study of five short relief uterus, medical treatment with misoprostol has been missions to Haiti following the 2010 earthquake sug- gaining popularity as a noninvasive alternative. Both gested that the cost per DALY averted was US$362 for surgical and nonsurgical treatments are acceptable in acute orthopedic conditions (Gosselin, Gialamas, and practice (Chen and Creinin 2008), but determining the Atkin 2011). best regimen to use in a given clinical scenario is not always clear. With regard to the cost-effectiveness of Emergency Surgery different methods, four strategies have been evaluated: Although emergency surgery is life saving, it is more difficult to find cost-effectiveness estimates • Hospital-based dilatation and curettage (D&C) for interventions such as obstructed airway, bowel • Hospital-based manual vacuum aspiration (MVA) obstruction, perforation, and cholecystectomy. • Clinic-based MVA Appendectomy may be emergency surgery, depend- • Medical abortion using misoprostol. ing on whether there are complications and sepsis. Kong and others (2013; see table 18.1) estimate that The World Health Organization (WHO) recom- appendectomy costs were US$1,611 per LYS for South mends vacuum aspiration (manual or electric) and Africa. A study for Guinea by Jha, Bangoura, and medical abortion as the preferred methods for first- Ranson (1998) finds appendectomy to be very cost- trimester abortion (Grimes and others 2006; WHO effective for emergency cases. 2003a). Findings from economic evaluations gen- erally support these recommendations and suggest clinic-based MVA is the most cost-effective option for Reproductive Surgery safe, first-trimester induced abortion. In Mexico and Selected maternal and neonatal conditions avertable by Nigeria, clinic-based MVA was found to be least costly surgery account for 234,000 deaths annually (Bickler and and most effective, compared with D&C; in Ghana, Table 18.2 Cost-Effectiveness of Reproductive Surgery Unit of Currency (unless Cost per outcome Source Condition Country Cost per outcome outcome noted otherwise) 2012 US$ First trimester pregnancy termination Hu and others First trimester Mexico n.a. Clinic-based MVA n.a. 2009a pregnancy dominated termination Hu and others First trimester Nigeria n.a. Clinic-based MVA is n.a. 2010b pregnancy most cost-effective termination and cost saving Ghana n.a. Medical abortion is n.a. most cost-effective and cost saving table continues next page Costs, Effectiveness, and Cost-Effectiveness of Selected Surgical Procedures and Platforms 321 Table 18.2 Cost-Effectiveness of Reproductive Surgery (continued) Unit of Currency (unless Cost per outcome Source Condition Country Cost per outcome outcome noted otherwise) 2012 US$ Intrapartum care Hu and others Intrapartum care Mexico $300 DALY 2001 US$ $308 2007c averted Goldie and others Intrapartum care India $150–$350 LYS 2010 US$ $211–$492 2010d Erim, Resch, and Intrapartum care Nigeria < $550 LYS 2008 US$ < $696 Goldie 2012d Carvalho, Salehi, Intrapartum care Afghanistan $143–$178 (national LYS 2006 US$ $215–$268 and Goldie 2013d model) (national model) $100–$400 $151–$602 (subnational model) (subnational model) Obstructed labor or cesarean section Adam and others Management of Southeast $38 DALY 2000 US$ $72 2005e obstructed labor Asia averted Sub-Saharan $28 $82 Africa Hounton and Surgically trained Burkina Faso Obstetrician: Newborn 2006 I$ Obstetrician: others 2009 medical officers $11,757 life saved $5,080 for cesarean Clinical officer: section Clinical officer: $3,235 $1,398 General practitioner: General $200 practitioner: $86 Alkire and others Cesarean section 49 LMICs $304 (median) DALY 2008 US$ $384 2012f for obstructed $251–$3,462 (range) averted labor McCord and Emergency Bangladesh $11 DALY 1995 US$ $15 Chowdhury 2013g obstetric care averted Note: DALY = disability-adjusted life year; D&C = dilation and curettage; I$ = international dollar; LMIC = low- to middle-income country; LYS = life year saved; MVA = manual vacuum aspiration; n.a. = not applicable. a. Model-based comparative analysis of three methods for first-trimester pregnancy termination: D&C, MVA, and medical abortion using a regimen of vaginal misoprostol. b. Computer-based decision analytic model of induced abortion and its complications comparing unsafe abortion and three methods for safe, first trimester pregnancy: D&C, MVA, and medical abortion using misoprostol. c . Maternal health policy model used to evaluate a package of care that includes safe abortion and surgical treatment of emergency obstetric care. d. Maternal health policy model. e. WHO-CHOICE cost-effectiveness analysis of a package of interventions that includes treatment of emergency obstetric care. Skilled attendance to allow appropriate early recognition and treatment of complications and timely referral to hospitals for more complex care require considerably more resources than community-based and antenatal care packages, but are effective in reducing maternal and neonatal morbidity and mortality and are highly cost-effective. f . Modeling study. g. Includes all emergency care at a hospital in Bangladesh for three months: obstetric emergencies are a large proportion and have higher cost-effectiveness than other emergency surgeries. medical abortion using misoprostol was most cost- have additional benefits by increasing access to safe effective. In addition to being cost-effective, similar to abortion services, given the challenges of providing studies in the United States, shifting to MVA outpatient surgical services in many low-resource settings, and services has been found to be cost saving (Levin and reducing overall costs of care. It also frees up surgical others 2009; Rausch and others 2012; Rocconi and resources for other essential services for which there others 2005). The promotion of medical abortion may may be no nonsurgical options. 322 Essential Surgery The overall implications of these findings from services are central to reducing the maternal mortality economic evaluations of the management of early preg- rate in Afghanistan, India, and Nigeria (Carvalho, Salehi, nancy loss can be summarized as follows: and Goldie 2013; Erim, Resch, and Goldie 2012; Goldie and others 2010). However, these studies consistently • The provision of safe abortion is the single most find that further reductions would not occur without influential factor on health and economic outcomes. increasing access to high-quality intrapartum and emer- • All else equal, shifting services from D&C to clinic- gency obstetrical care. based MVA will provide equivalent or greater benefits For example, in India, attainment of the fifth and will result in fewer complications and lower costs. Millennium Development Goal of a 75 percent reduc- tion in maternal mortality by 2015 would require invest- ments targeting the intrapartum period, in addition to Institutional Delivery: Emergency Obstetric Care family planning and safer abortion. Including surgery Overall, achievement of the Millennium Development in a package of maternal care also includes family Goals for the reduction of maternal mortality hinges on planning, safe abortion facilities, facility-based basic the extent of the provision of institutional care during emergency obstetric care, and quality comprehensive the intrapartum period. Evidence shows that the best emergency obstetric care. The ICERs for increased cov- intrapartum care strategy is likely to be one in which erage were in the range of US$211–US$492 per LYS, that women routinely choose to deliver in health centers, is, 14 percent to 33 percent of GDP per capita in India with midwives as the main providers but with other and hence very cost-effective (Goldie and others 2010; attendants working with them. Such care is variously table 18.2). The same package of care costs less than referred to as basic, primary, routine, basic essential US$696 per LYS in Nigeria (Erim, Resch, and Goldie obstetric care, and most recently, skilled care at the first 2012) and less than US$268 in Afghanistan (Carvalho, level (WHO 2005). Two cost-effectiveness analyses of Salehi, and Goldie 2013). maternal and neonatal care packages and means of Adam and others (2005) find skilled care at birth con- distribution emphasize the potential of close-to-client sisting of basic emergency obstetric care and compre- care for normal and complicated cases—essentially hensive emergency obstetric care to be cost-effective in encompassing basic essential obstetric care and basic LMICs, such as those in South and Southeast Asia and emergency obstetric care, finding them among the most Sub-Saharan Africa. In 2000, a package of care consisting cost-effective options (Adam and others 2005; Bale and of basic antenatal care and skilled attendance at birth others 2003). More widespread availability of proximate had an incremental cost of US$21.72 in Sub-Saharan services would increase the likelihood that women Africa and US$36.64 in South and Southeast Asia, would have access if the need for emergency care were to compared with the option of antenatal care without arise in the antenatal or postpartum period (Campbell skilled attendance at birth. This package amounted to an and Wendy 2006). additional US$67.3 million and US$96.2 million, respec- Moreover, because health centers are part of the health tively, in the entire Sub-Saharan African and Southeast system, the affordability and sustainability of a health cen- Asian regions, including South Asia, for universal access ter intrapartum-care strategy are likely to surpass those of (Adam and others 2005). strategies distributed outside of the health system, such Two studies explore increasing access through task- as traditional birth attendants or volunteer community shifting and the training of lower-level general prac- workers. Accordingly, it is likely that a health center titioners to overcome staff shortages of physicians for intrapartum-care strategy would be adequate to deal performing emergency care and surgical services. Kruk with most births and that this level fits well with the dis- and others (2007) show that lower-level cadres can trict approach to health systems. Minor variations on the provide surgical services at a reasonable cost in rural strategy might be needed in some contexts. These varia- Mozambique. Hounton and others (2009) look at the tions relate to the cadre of skilled attendants—midwives cost-effectiveness of training different cadres of health or doctors—and the case for a hospital intrapartum-care workers to perform cesarean sections, finding that strategy (Campbell and Wendy 2006). training of general practitioners appeared effective and Safe motherhood strategies, such as intrapartum care cost-effective. consisting of normal or assisted delivery, or compre- hensive emergency obstetric care, are usually delivered as a package of services. The literature evaluates the Nonemergency Surgery cost-effectiveness of such strategies using packages of Nonemergency surgery, although less often life saving, care. Family planning interventions and safe abortion can still alleviate a considerable proportion of the Costs, Effectiveness, and Cost-Effectiveness of Selected Surgical Procedures and Platforms 323 global burden of disease. Cost-effectiveness data are in early childhood. Data from surgical missions for cleft summarized in table 18.3, panels a (congenital defects, lip/palate surgery in four countries (Magee, Vander hernia, and nonemergency orthopedic conditions) and Burg, and Hatcher 2010; Moon, Perry, and Baek 2012) b (selected types of eye surgery). suggest that this surgery is very cost-effective. Moon, Perry, and Baek (2012) estimate the average cost for a Congenital Defects mission in Vietnam was US$86/DALY averted; Magee, Cleft lip/palate is one of the more common birth defects, Vander Burg, and Hatcher (2010) estimate that the cost occurring in 1 out of 500–700 births (Magee, Vander over eight missions to four countries ranged from US$9 Burg, and Hatcher 2010). If untreated, it can lead to to US$108 per DALY averted. Surgical mission data do problems with eating, language development, and hear- not typically account for the costs of the surgeon’s time ing; in severe cases, it is associated with higher mortality or the facilities. Table 18.3 Cost-Effectiveness of Nonemergency Surgeries a. Selected surgeries Unit of Cost per outcome, Source Condition Country Cost per outcome outcome Currency 2012 US$ Congenital defects Corlew 2010a Cleft lip, cleft Nepal $29 DALY averted 2005 US$ $40 palate Magee, Vander Burg, Cleft lip, cleft 8 missions $7–$96 DALY averted 2008 US$ $9–$108 and Hatcher 2010b palate (5 Vietnam, 1 each Nicaragua, Kenya, Russian Federation) Moon, Perry, and Cleft lip, cleft Vietnam $68 ($87 imputing DALY averted 2003 US$ $67 ($86 imputing Baek 2012c palate volunteer time) volunteer time) Hernia Shillcutt, Clarke, and Inguinal hernia Ghana $13 DALY averted 2008 US$ $11 Kingsnorth 2010d Shillcutt and others Inguinal Ecuador $96 DALY averted 2011 US$ $101 2013e hernia Nonemergency orthopedic surgery Gosselin, Gialamas, Various Dominican Republic, $362 DALY averted 2009/10 $359 and Atkin 2011f Nicaragua US$ Chen and others Various Nicaragua $476 DALY averted 2011 US$ $540 2012g Source: Note: DALY = disability-adjusted life year. a. Calculated from one center in Kathmandu specializing in cleft lip (402 cases) and palate (166 cases) in one year. b. Only includes mission costs, not local hospital costs. c . Based on costs of 16 missions from Korea to Vietnam during 1996–2010. Excludes cost of hospital space and depreciation of hospital facilities. d. Based on five-day mission to four first-level hospitals in Ghana. Used Liechtenstein repair, day surgery. e. Based on 2 two-week missions. Used Liechtenstein repair, day surgery. f . Volunteer surgical mission of one week, 30 patients (knee osteoarthritis, fractures, dislocations, amputations, injured nerves); excludes building costs, maintenance, utilities. Cost-effectiveness from Nicaraguan provider perspective. g. Some 117 patients over three missions 2009–10; less than 10 percent were acute conditions; congenital malformations (club foot, developmental dysplasia of hip) were 32 percent. No salary cost for surgical volunteers, but travel and lodging cost is included. 324 Essential Surgery b. Cataract Surgery and Similar Eye Surgeries Unit of Cost per outcome, Source Condition Country Cost per outcome outcome Currency 2012 US$ Baltussen and others Trachoma Seven WHO $13–$78 DALY averted 2000 I$ $7–$28 2005a subregions AFR-E (lowest cost per DALY averted) to EMRO-D Lansingh, Carter, and Cataracts Nine LMICs $4–$253 QALY gained 2004 US$ $6–$423 Martens 2007b Wittenborn and Rein Laser surgery Barbados $1,528 DALY averted 2005 US$ $2,314 2011c for glaucoma Ghana $1,771 $1,989 Baltussen and Smith Trachoma Sub-Saharan Africa $71–$90 AFR-E DALY averted 2005 I$ $31–$40 AFR-E 2012d (trichiasis (AFR-E); South Asia $285–$374 SEA-D $106–$140 SEA-D surgery) (SEA-D) (80–95% coverage) Cataracts $116 DALY averted 2005 I$ $36 AFR-E AFR-E $97 SEA-D $51 SEA-D Note: AFR-E = the WHO subregion in Africa with the highest mortality rates; DALY = disability-adjusted life year; EMRO-B = the WHO subregion in the Eastern Mediterranean with the highest mortality rates; I$ = international dollar; n.a. = not applicable; QALY = quality-adjusted life year; SEA-D = the WHO subregion in Southeast Asia (including South Asia) with the highest mortality rates. a. WHO-CHOICE model; extracapsular cataract extraction for cataracts. b. Literature survey 1996–2006. The authors find 5 studies with calculated cost-effectiveness for first eye (4 countries), and use cost data from another 11 countries to calculate cost-effectiveness. c . Laser surgery only for syndromic referral; treatment with full American Academy of Ophthalmology guidelines is more costly, as is treatment on incidence, and screen and treat. d. Newer version of model in Baltussen and others (2005). An estimate by Corlew (2010) for a nongovernment- 175 people per 100,000 need this operation each supported program at Katmandu Model Hospital, year (Shillcutt, Clarke, and Kingsnorth 2010). The using local physicians, was US$40 per DALY averted for lack of access to timely care leads to complications Nepal; these DALYs were age weighted. The program and ultimately more expensive emergency surgery, also provides orthodontic services and speech therapy, and it increases mortality and morbidity. Estimates which are not included in the short-term missions. from surgical missions suggest that the repair was Cost data from a permanent facility are likely to be a very cost-effective in Ecuador at US$101 per DALY better guide for ongoing programs than cost data from averted (Shillcutt and others 2013) and Ghana at missions. All of these estimates are in the very cost- US$11 per DALY averted (Shillcutt, Clarke, and effective range. Kingsnorth 2010). Clubfoot is a less common condition, and can be Estimates from HICs confirm the findings that treated nonsurgically as well as surgically. One estimate surgery for abdominal, inguinal, umbilical, and fem- of surgical cost for New Zealand (Halanski and others oral hernia is very cost-effective (Coronini-Cronberg, 2009) yielded an estimated cost per DALY averted Appleby, and Thompson 2013). A comparative study that would fall in the very cost-effective range for of three different options for inguinal hernia repair for New Zealand; however, no cost-effectiveness results were the United States (Stylopoulos, Gazelle, and Rattner found for LMICs. 2003) suggests that laparoscopic repair was more cost- effective than open methods, each compared with no Hernia intervention, largely because the greater effectiveness Repair of inguinal hernia is one of the most com- possibly offset the higher cost. However, laparoscopic monly performed operations in the Americas methods are not widely available in LMICs at first-level (Shillcutt and others 2013). In Sub-Saharan Africa, hospitals. One study for the United States (Stroupe and Costs, Effectiveness, and Cost-Effectiveness of Selected Surgical Procedures and Platforms 325 others 2006) points out that cost-effectiveness depends similar surgeries are grouped together. Nonspecialized on the population considered; repair is much less hospitals could conceivably try to do similar grouping, cost-effective for men with asymptomatic or minimally for example, perform orthopedic surgery on one specific symptomatic hernia. day of the week, but doing so requires managerial capac- Recent literature in HICs examines the cost- ity that is scarce in many of these settings. effectiveness of devices and technologies that may require Data from HICs confirm that there are cost- expensive purchased inputs. Most LMICs cannot afford effective, nonemergency orthopedic procedures. Hip these inputs. In India, Gundre, Iyer, and Subramaniyan arthroplasty is very cost-effective in the United States (2012) have shown that using polyethylene mesh for (Chang, Pellissier, and Hazen 1996), although some of inguinal hernia meshplasty is equally safe and effective the assumptions, such as the cost savings anticipated in but 2,808 times cheaper compared with the use of com- the United States from custodial care in the absence of mercially available polypropylene mesh. surgery, are unlikely to apply in LMICs. Dougherty and Howard (2013) show similar findings for the United Nonemergency Orthopedic Procedures Kingdom, but the costs per QALY gained are higher In 1990, an estimated 1.7 million people worldwide than for the United States; James, St Leger, and Rowsell had hip fractures, a number that is expected to increase (1996) find that hip arthroplasty is very cost-effective in to 6 million annually by 2050 (chapter 3). Estimates the United Kingdom. This operation is likely to become for 2002 were that osteoarthritis was the fourth most increasingly common in LMICs as populations age. important source of disability, mainly due to osteoar- Knee arthroplasty costs at least twice as much as thritis of the hip and knee (chapter 3). As populations hip arthroplasty per DALY averted in both the United in large LMICs age, the demand for nonemergency Kingdom and the United States, but it may also be orthopedic procedures is expected to grow dramatically. cost-effective (Chang, Pellissier, and Hazen 1996; James, Estimates of the cost per DALY averted for nonemer- St Leger, and Rowsell 1996; Lavernia, Guzman, and gency surgical missions are similar to those for trauma Gachupin-Garcia 1997). However, Dougherty and surgery. One study of 30 patients (Chen and others 2012, Howard (2013) find that hip arthroplasty in the United table 18.3A) estimates the cost of a mission to Nicaragua Kingdom is twice as costly as knee arthroplasty, although to be US$540 per DALY averted; another study of their work is a literature survey and the underly- 117 patients and three missions estimates the costs for ing studies may not all use the same methodology. the Dominican Republic and Nicaragua to be US$359 James, St Leger, and Rowsell (1996) suggest that other per DALY averted (Gosselin, Gialamas, and Atkin 2011). interventions in the United Kingdom, including those Both studies likely underestimate the costs of such treat- for spinal discectomy, carpal tunnel syndrome, and ment on an ongoing basis. The former study does not Dupuytren’s contracture, were also very cost-effective, include costs for space, maintenance, and utilities; the but that flexor tenosynovectomy costs more per DALY latter does not include salary costs, although it includes averted, and some operations had negative cost- travel costs for the volunteers. These costs per DALY effectiveness. The sample numbers in this study for averted are similar to those of the emergency surgery interventions other than knee and hip arthroscopy were missions and likely suffer from similar methodological fairly small. Dougherty and Howard (2013) also provide issues in costing. However, the costs per DALY averted cost-effectiveness results for other orthopedic proce- are so modest that even if all costs are included these dures for the United States. interventions are likely to remain very cost-effective. Mission data in general are likely to be somewhat arti- Cataracts ficial. To take maximum advantage of the availability The number of blind persons globally increased from of surgeons, it is likely that a significant amount of 38 million in 1990 to 124 million in 2002 (Resnikoff organization has to occur before the mission to line up a and others 2004; Thylefors and others 1995). Cataract suitable number of surgical appointments. Similarly, fol- disease is the cause of approximately 48 percent of the lowing the mission, follow-up is likely to be required by cases of total blindness worldwide (Resnikoff and others the local hospitals and health facilities. Neither of these 2004); a rapidly aging population in many countries will inputs is generally included in the mission cost. The continue to exacerbate the prevalence of visual impair- caseload and case mix for missions is not representative ment as a result of cataract disease. The WHO and the of that seen in a regular hospital. Missions may aim not International Agency for the Prevention of Blindness to have downtime, while ongoing surgical facilities in joined forces in 1999 to respond to the problem, result- LMICs may have more downtime. Missions have the ing in the launch of VISION 2020: The Right to Sight advantage of economies of scale, that is, a number of global initiative (Pizzarello and others 2004). The chief 326 Essential Surgery goal of this program is to eliminate avoidable blindness both Barbados and Ghana; screening and using the full by 2020; if the planned interventions succeed, an esti- United States guideline treatment was not cost-effective mated 52 million persons will have their sight saved, in Ghana. with the concurrent avoidance of 429 million blind person-years and an economic gain of US$102 billion (Frick and Foster 2003). To achieve this lofty target, one Organization of Surgical Services of VISION 2020’s specific objectives is to increase the The volume of surgeries undertaken is important. availability of cataract surgery globally by raising output Effectiveness is higher and mortality rates are lower and training ophthalmic surgeons, especially in LMICs. for surgeons who undertake the same operation many Cataract surgery is a routine intervention, and times in a year or in their careers; the same holds true demand is expected to increase substantially as popula- for facilities and hospitals. In most cases, costs will likely tions age. Knowledge of the cost-effectiveness of cataract be lower per operation at higher volumes because stan- surgery is essential if decisions on health care spending dardization typically reduces costs and allows the cost are to be as objective as possible. of any specialized equipment to be spread over a larger Baltussen and Smith (2012, table 18.3B) estimate the volume of patients. cost-effectiveness of cataract surgery via extracapsular For nonemergency surgery, specialized units that cataract extraction (ECCE) with posterior chamber focus on specific types of surgery can be considered. intraocular lens implantation compared with no inter- These include specialized units performing cataract vention, and find it to be very cost-effective in various surgery, such as the Lumbini Zone eye hospital in Nepal WHO subregions, as is trichiasis surgery for trachoma. (Marseille 1996); cleft lip and palate surgery, such as the Another review (Lansingh, Carter, and Martens 2007) one in Nepal (Corlew 2010); and fistula repair, such as finds that cataract surgery, irrespective of country, is very centers in Ethiopia, Ghana, Nigeria, and Rwanda. To cost-effective in all 15 countries considered (including increase access, specialized units can be brought to local 9 LMICs). The study also shows that cataract surgery is areas periodically, for example, through camps. cheaper in an outpatient setting than with an overnight Cataract camps occur in South Asia with some stay, and the phacoemulsification technique is costlier regularity. Singh and others (2000) review the cost- than either ECCE or manual small-incision cataract effectiveness of three different types of facility offering surgery. This review assesses the affordability of cata- cataract surgery in Karnataka state, India. They com- ract surgery, defined as cost compared with per capita pare government camps, which were the least expensive income, and finds that it is more affordable in Western for patients; nongovernment facilities, in which costs to Europe than in the United States; India is one country patients were double that of the camps; and a govern- where it is most affordable among the LMICs of Asia ment medical college hospital, in which costs to patients (Lansingh, Carter, and Martens 2007). were three times that of the camps. The total costs of A study in Nepal (Marseille 1996) confirms that the camps and the nongovernment facility were similar; cataract surgery is very cost-effective, although this par- the cost of the medical college hospital was more than ticular study may not have fully incorporated all costs. twice that of the others. The most cost-effective facility Several issues affect the cost-effectiveness of cata- was the nongovernment one because of higher quality; ract surgery. Cost-effectiveness tends to be higher in the camps were intermediate, and the medical college the first eye treated than in the second, and the worse the least cost-effective. eye is usually prioritized. Most of the studies include a Specialized facilities bring tradeoffs. The facilities short follow-up period. Lundström and Wendel (2005) may offer greater effectiveness due to the specialized find that in Sweden, 80 percent of patients still enjoyed team and facilities, possibly even a lower cost due to improved visual function seven years after surgery. This economies of scale, but they may be more distant and finding implies that a lifetime study horizon would be hence be more costly to patients. To address the acces- most appropriate for evaluating economic impact. With sibility issue, it may be possible to bring specialized the rising life expectancy of populations, patients who teams closer to more decentralized populations by offer- receive the surgery are likely to live longer and enjoy ing a mobile camp, or by bringing specialized teams to a better quality of life with better vision for a longer first-level hospitals one day a week or one week every few period. This finding implies that the ICERs for cataract months; however, doing so requires additional organiza- surgery are likely to be lower in the future, and cataract tional capacity. surgery will become even more cost-effective. Finally, international surgical missions are a particular Wittenborn and Rein (2011) find that one-time sur- version of increasing access by bringing in specialized gery for self-referring patients was very cost-effective for resources. Surgical missions occur in all areas: trauma Costs, Effectiveness, and Cost-Effectiveness of Selected Surgical Procedures and Platforms 327 (Gosselin and Heitto 2008, table 18.1; Gosselin, Heitto, patients treated at 69 trauma centers and nontrauma and Zirkle 2009); congenital defects (Magee, Vander centers in 14 states of the United States (MacKenzie and Burg, and Hatcher 2010; Moon, Perry, and Baek 2012; others 2010). hernia (Shillcutt, Clarke, and Kingsnorth 2010; Shillcutt and others 2013); cataract surgery (Marseille 1996); and WHO BENEFITS FROM SURGICAL SERVICES? nonemergency orthopedic surgery (Chen and others 2012; Gosselin, Gialamas, and Atkin 2011). Missions can Major health shocks often lead to large out-of-pocket increase capacity, and many surgical missions assist in medical expenditures, induced borrowing, or the forced building local capacity by helping train local surgical teams. selling of assets and resulting in impoverishment in Shrime and others (chapter 13) examine the cost- LMICs. Using data from 89 countries, Xu and others effectiveness of surgical missions, as well as that of spe- (2007) estimate that annually 150 million households cialty hospitals supported by charitable organizations. across the world experience catastrophic health spending, Their conclusion is that short-term missions should defined as 40 percent or more of their nonfood expendi- be used only if no other option is available because ture on health care. Leive and Xu (2008) analyze house- evidence suggests that effectiveness is not as high as hold health care financing in 15 Sub-Saharan African in more fixed facilities. This result is not surprising countries; they find that in Burkina Faso, as many as given that preoperative care and follow-up after surgery 68 percent of households that had out-of-pocket health are not to the usual standard because of the logistics. spending had borrowed money or sold assets to finance They also examine the limited cost-effectiveness data medical expenditures in the past year. In a larger study, on specialty hospitals, identifying the same study of Kruk, Goldmann, and Galea (2009) use data from cataract surgery (Singh, Garner, and Floyd 2000) dis- 40 LMICs and find that more than 25 percent of house- cussed in this chapter, which shows that the charitable holds were forced to borrow money or sell assets to pay hospital had the most cost-effective outcomes of the for health care costs. Other multicountry studies report three modalities considered. Cost-effectiveness data are similar large household financial costs associated with available for other such facilities (Corlew 2010) for cleft major health shocks (van Doorslaer and others 2007; palate, but no comparison is made to other facilities in Xu and others 2007). the same country. Additional factors—such as access to care, willingness Trauma care is different from other surgical inter- to pay, and the ability to pay—are important. As Weiser ventions. The emergency nature of this care, which and others (2008) estimate, LMICs account for about also applies to obstetric emergencies, makes specialized 70 percent of the world’s population but only perform trauma care facilities more difficult to establish. Urban about 26 percent of the 234 million annual surgeries. areas in HICs can support trauma centers, provided that The large and often prohibitive costs of surgery are likely adequate rapid transportation is available. Trauma cen- to be the greatest deterrent to obtaining care (Malhotra ters do exist in LMICS, for example, the ones analyzed and others 2005). Accordingly, the majority of the by Gosselin, Maldonado, and Elder (2010) in Nigeria literature on surgery in LMICs focuses on the barriers and Haiti. to access. Several studies for the United States have documented A few studies have examined the economic benefits the effectiveness of a regionalized approach to trauma of providing access to surgical care, particularly for care, where critically injured patients are treated in a poor people. For example, poverty and blindness are limited number of designated trauma centers (Durham often found to be highly correlated (Gilbert and others and others 2006; MacKenzie and others 2010; Nathens 2008; Zimmer 2008). Accordingly, cataract surgery that and others 2000). Risk of death is 25 percent lower when prevents blindness may also prevent impoverishment. care is provided in a regional, third-level trauma center Kuper and others (2010) conducted a case-control than when it is provided in a nontrauma center hospital study of cataract surgery in Bangladesh, Kenya, and the (MacKenzie and others 2010). Philippines. The authors find that cataract surgery suc- MacKenzie and others (2010) find that the cost- cessfully increased the standard of living, as measured effectiveness ratio for treatment in a trauma center by monthly per capita expenditure, in the intervention versus a nontrauma center in the United States fell in group. The average increase in monthly per capita the cost-effective range. It is more cost-effective to treat expenditure among patients who received the surgery more severely injured patients and those patients younger was 36 percent in Kenya, 44 percent in Bangladesh, and than age 55 years in a trauma center. This study uses 88 percent in the Philippines, compared with the control comprehensive data available on both the effectiveness group, whose income did not change in Kenya and the and the costs incurred in the year after injury for 5,043 Philippines and fell slightly in Bangladesh. Although the 328 Essential Surgery economic benefits reached patients in all socioeconomic including US$295,556 in a 60-bed charitable hospital; groups, the positive effect of blindness prevention was US$321,887 in a 400-bed first-level public hospital; the greatest among the poorest participants. US$1,314,935 in a private teaching hospital with Finger and others (2012), in a similar study in south 655 beds; and US$2,019,260 in a public third-level care India, find that cataract surgery was associated with hospital with 778 beds (Chatterjee and Laxminarayan higher standards of living and gainful economic activ- 2013). In Ghana, a first-level hospital with 117 beds ities. At least 45 percent of the participants receiving had annual surgical costs of US$66,492, which was cataract surgery reported higher income levels after sur- two-and-a-half times less than a 200-bed mission gery, and the share of participants engaged in economic hospital and four times less than a 110-bed third-level activities increased from 44 percent to 77 percent. The hospital (Aboagye, Degboe, and Obuobi 2010). These authors also found that the surgery improved the social surgical program costs in India and Ghana vary con- status of widowed participants by increasing the rates of siderably from previous regional estimates attributable remarriage. to surgical patients, based on a standardized first-level Two studies have modeled the economic benefits hospital of 100 beds, which was US$1,124,728 for from cleft lip and palate surgery but without using South Asia and US$1,471,575 for Sub-Saharan Africa household data on actual effects. Corlew (2010) for (Debas and others 2006). Nepal and Alkire and others (2011) for Sub-Saharan In LMICs, nongovernment surgical hospitals are Africa estimate that considerable potential economic a popular strategy for providing specialty care for benefits were realized. trauma and orthopedics, especially among the urban poor who have limited access to surgical services. Nongovernmental hospitals are often characterized by SURGICAL INTERVENTION COSTS1 higher costs because expatriate surgeons are working The unit cost data in LMICs are not robust, but they closely with national counterparts in a well-staffed and have grown since the publication of Disease Control supplied facility, and the throughput of patients and Priorities in Developing Countries, second edition, surgical procedures performed throughout the year in 2006. Noting the paucity of literature on surgical is higher. Two nongovernment surgical hospitals with costs and cost-effectiveness, Debas and others (2006) 70 beds in Sierra Leone and 106 beds in Cambodia estimate costs of surgical services offered by first-level had annual operating budgets of US$214,113 and hospitals and community clinics that were not spe- US$118,228, respectively (Gosselin, Thind, and cific to interventions. The number of studies present- Bellardinelli 2006; Gosselin and Heitto 2008). Labor ing economic information on surgical services and costs constituted the major share of total surgical costs, intervention-specific surgeries has increased since 2000; with expatriate staff alone accounting for 30 percent the majority of articles were published after 2006, and of total costs in Cambodia. Medical surgical trauma more than two-thirds were published after 2009. Most centers operated by Médecins Sans Frontières cost studies were conducted in South Asia and Sub-Saharan US$1,112,665 per year in Nigeria’s 70-bed urban hos- Africa, with the greatest body of literature emerging pital and US$1,864,822 per year in two surgical sites from India, followed by Bangladesh and Pakistan. in Haiti, with one urban hospital with 60 beds and a Box 18.1 summarizes results for one such study, for second facility with 48 beds (Gosselin, Maldonado, Nepal. Much of the recent literature captures costs from and Elder 2010). Surgical unit costs are also available third-level hospitals and focuses on specific diseases, for platforms that deliver specialized services for cat- surgical procedures, or platforms, with fewer studies aract, cleft palate, or orthopedics through short-term providing estimates of surgical facility or ward costs outreach or medical missions; costs for these services from first-level hospitals. are typically provided on a per trip or per person basis, and the services reach between 30 and 2,000 patients per year through time-limited medical missions (Chen Surgical Costs, by Type of Hospital and others 2012; Kandel and others 2010; Moon, Perry, Total program costs for surgical care are driven by and Baek 2012). several factors, including the type and size of the hospital; whether it is public or privately owned and operated; and the surgical platform for delivering ser- Surgical Unit Costs, by Condition vices, bed occupancy, and differences in salary struc- Recently published studies provide costs for disease- tures. A study of five hospitals in India finds a range of specific surgeries rather than surgical programs, adding annual program costs for different types of hospitals, an additional layer of variability depending on the Costs, Effectiveness, and Cost-Effectiveness of Selected Surgical Procedures and Platforms 329 Box 18.1 Financial Sustainability of Scaling Up Surgical Services in a First-Level Facility: Case Study of Bayalpata Hospital in Nepal Bayalpata Hospital in Nepal offers a unique case to perform surgery, and visiting senior surgeons, study for understanding the financial issues of scal- both national and international, provided ongoing ing up (Maru and others 2011). This hospital serves training. as the referral hospital for the Achham district’s pri- The list of essential surgical services to be provided mary health care centers, as well as for populations under IMEESC-Plus includes the following: from two adjacent districts. It has three sources of funding: • Amputation of distal or proximal limbs • Appendectomy • The government of Nepal (25 percent) • Cesarean section • Individual donors via the U.S.-based parent • Cholecystectomy organization, Nyaya Health (approximately 50 • Exploratory laparotomy percent) • Hernia repair • Foundation grants (25 percent). • Hydrocele reduction • Surgical correction of head, chest, and abdominal The hospital includes outpatient and inpatient ser- trauma vices and 24-hour emergency and delivery services, • Surgical management of acute closed and open as well as laboratory and radiological (x-ray and fractures ultrasound) diagnostic services. It has an onsite • Surgical management of wounds and burns. pharmacy and ambulance, and it implements com- munity health programs. Its staff performs minor surgeries, such as repair of lacerations, abscess A financial costing of this basic package of surgi- drainage, closed reductions, casting, and man- cal services was undertaken. Based on Bayalpata ual vacuum aspiration. It has two physicians and Hospital’s costing model, it was proposed that a nursing and midwifery staff but no surgeon. the overall construction and two-year operating Without an operating room, there is no capacity for costs of implementing the IMEESC-Plus model major surgeries. would be US$0.50 per capita in the district, which has a population of 266,000 (Maru and others The WHO developed an Integrated Management of 2011). The reported per capita health expendi- Emergency and Essential Surgical Care (IMEESC) ture in Nepal in 2008–09 was US$24.8. Nearly program in LMICs (WHO 2006). Bayalpata Hospital 24 percent of this expenditure, or US$6, was borne by in Nepal upgraded its services under the IMEESC- the government. If this incremental cost of US$0.50 Plus program (Maru and others 2011). This upgrade were entirely publicly financed and scaled up across included the list of essential services proposed under the country, it would amount to an 8.4 percent IMEESC and two other components: community increase in the government’s health budget. follow-up of surgical cases and quality improvement of hospital care. A general physician was trained Source: Maru and others 2011. disease condition treated, the number and frequency of because of research and advocacy interest in increasing surgeries performed for a particular condition during a access to reproductive and maternal health services, given period, and the surgical technique used. Table 18.4 including access to safe surgical abortion. In addition, provides a summary for four reproductive surgeries, two obstetric and gynecological services typically constitute types of nonemergency surgeries, and cardiothoracic a large share of total inpatient activity at hospitals. surgery. Although variations across studies are typical, several Information is available on the costs of specific studies have shown variations in the cost of procedures, conditions for obstetric and gynecological services such as cesarean section, within the same study (Levin 330 Essential Surgery Table 18.4 Variations in Cost of Selected Surgical Procedures Type of surgery Location Range of costs (2012 US$) Source Reproductive surgery Cesarean section Africa $41–$202 Honda, Randaoharison, and Matsui 2011; Hounton and others 2009; Kruk and others 2007; Levin and others 2003 East Asia and Pacific $548 Quayyum and others 2010 South Asia $121–$195 Khan and Zaman 2010; Sarowar and others 2010 Emergency obstetric Africa $158–$202 Kruk and others 2007; Richard and others surgery 2007 Surgical abortion Various countries, types of $8–$158 (D&C) Banerjee, Andersen, and Warvadekar 2012; hospital (public, private), and $8–$103 (MVA) Benson and others 2012; Henshaw and procedures others 2008; Hu and others 2010; Koontz and others 2003; Levin and others 2009; PATH and M. O. H. Reproductive Health Department 2006; Sarowar and others 2010; Xia, She, and Lam 2011 Postabortion Various countries; various $58 (median) Asante, Avotri, and d’Almeida 2004; Erim, complications procedures (cervical or vaginal $18–$2,368 Resch, and Goldie 2012; Hu and others 2010; lacerations less costly than Levin and others 2003; Levin and others vaginal perforations) 2009; Rehan 2011; Vlassoff and others 2012; Vlassoff and others 2014 Nonemergency surgery Cataract surgery India, various techniques $30–$47 Muralikrishnan and others 2004 Nepal, different camps $63–$94 Kandel and others 2010 Hernia repair Lichtenstein tension-free $114 (Ghana), US$1,212 (China) Gong and others 2011; Shillcutt, Clarke, and repair, various countries Kingsnorth 2010 India, different hospitals and $270 (first-level)–$1,047 (third-level Bansal and others 2012; Chatterjee and techniques hospital, laparoscopic method) Laxminarayan 2013; Krishna and others 2012 Cardiothoracic surgery India, public hospital $3,315 Chatterjee and Laxminarayan 2013 and others 2003; Quayyum and others 2010). Some and costs are generally lower in countries with lower per differences could be explained by differences in cost capita incomes. components. In general, labor was the single largest component of LIMITATIONS IN THE EVIDENCE BASE total direct costs for all public hospital types, and indi- rect costs were the largest driver of costs for charitable As this review suggests, cost-effectiveness data for and private hospitals. For some procedures, such as LMICs are scarce and may be affected by reporting hernia repair and external fixations, drugs and materials bias. The data that do exist are heavily dominated constituted the largest share of direct costs. In general, by studies of surgical missions and nongovernment costs tend to be lower at first-level hospitals than at facilities. The data for missions likely understate the second-level hospitals, probably because the more costly costs of ongoing services, and the effectiveness of gov- and specialized facilities are not available at the first- ernment hospitals may be lower than that of hospitals level hospital; private hospitals may be more costly than run by charitable foundations. We have used data from public; more specialized procedures and procedures HICs to supplement that from LMICs and to fill gaps. using additional medical technologies are more costly; Cost-effectiveness findings depend on the context, Costs, Effectiveness, and Cost-Effectiveness of Selected Surgical Procedures and Platforms 331 methodology, and assumptions made. However, there is the minimum standards for medical economic reason to believe that a range of surgical interventions analysis. Kruper, Kurichi, and Sonnad (2007) searched are cost-effective for LMICs. MEDLINE for 1995 to 2004 to identify articles that The data limitations include the following: included economic analyses of surgical procedures. Their review indicates that published economic evalu- • First, despite the increase in the number of economic ations of surgical procedures in general do not follow evaluations, cost estimations, especially of unit cost accepted methodological standards, with fewer than data from first-level hospitals covering some or all of half of the basic principles met by any given analysis. the recommended essential surgeries, are deficient. A comparison of nonsurgical versus surgical journals Specifically, most cost estimations have been disease demonstrates a significant difference in compliance specific and typically do not provide the costs of sur- with methodological criteria, with much lower com- gical wards. In addition, whatever cost estimates are pliance in surgical journals. The average proportion available pertain to localized geographic areas and of criteria met in the nonsurgical journals was slightly are typically derived from one or several hospitals, more than half, whereas in the surgery journals it was but they are not representative of the national health less than one-third. The surgical journals were also care system. In addition to heterogeneity in costs due consistently lower in compliance with each individual to geography or conditions treated, inconsistency in criterion as compared with the nonsurgical journals, data-collection methods and reporting formats limit with less than 20 percent compliance for five criteria. the comparability of the data. To defend the use of surgical interventions and treat- • Second, limited availability of empirical disability ment strategies in an environment that is becoming weights for various conditions in international health progressively more cost conscious, quality data become is an issue, mentioned, for example, in Shillcutt, increasingly important. Those performing analyses in Clarke, and Kingsnorth (2010) and Shillcutt and surgical areas need to increase their awareness of meth- others (2013). odological standards so that the quality of surgical • Third, reliable information is critical if any attempt economic evaluations can improve, especially those is to be made to base medical decisions on health evaluations in surgical journals. Wider promulgation and monetary considerations. The value of economic of the methodological criteria in surgical journals or at analysis is compromised if the quality of the data is surgical meetings may significantly improve the quality poor. Methodologies for economic analyses appeared of economic analysis published in surgical journals or in the medical literature as early as the 1970s, with concerning surgical interventions. refinements over time (Blackmore and Smith 1998; Evidence gaps exist in the literature. No studies for Detsky and Naglie 1990; Jefferson, Demicheli, and Vale LMICs were found for several conditions relevant for 2002). Although these methods are intended to reduce cancer, including mastectomy, hysterectomy, and block- bias and improve the validity of economic analyses, ages of the colon, or for obstetric fistula, despite the these methodological principles are used infrequently existence of some specialized units providing surgery for (Blackmore and Smith 1998; Doubilet, Weinstein, and this condition in LMICs. McNeil 1986). Calls have been made to standardize economic analysis methodology and for adherence to CONCLUSIONS these principles in the medical literature (Doubilet, Weinstein and McNeil 1986; Drummond and Jefferson Disease Control Priorities in Developing Countries, second 1996; Jefferson, Demicheli, and Vale 2002). edition (DCP2), drew attention to the importance of surgical interventions in LMICs (Debas and others Research that assesses the quality of cost- 2006). The authors showed that particular examples effectiveness data in specialties is available, including of surgical packages and platforms, such as providing for gynecologic oncology (Manuel and others 2004), cataract surgery, training lower-level medical staff for pharmacoeconomics (Iskedjian and others 1997), emergency obstetric surgery, and delivering surgery at pediatrics (Ungar and Santos 2005), and nuclear first-level hospitals, were very cost-effective in many medicine (Gambhir and Schwimmer 2000). These countries in South Asia and Sub-Saharan Africa. assessments, along with more generalized ones, systematically review studies to verify compliance with methodological criteria. Studies use various Inclusion in Primary Health Care scoring methods; however, many check compliance Many countries are considering including surgical care with methodological principles thought to represent in comprehensive primary health care. This primary 332 Essential Surgery care initiative, described in World Health Report (WHO This chapter has shown the potential for these inter- 2008), focuses on strengthening health systems through ventions to be cost-effective and reasonable in cost. More a series of reforms under the umbrella of primary work needs to be done to determine how best to organize health care. It is increasingly recognized that the provi- these services to use economies of scale to reduce costs sion and maintenance of a quality surgical service can and increase effectiveness when specialized surgical inter- strengthen the capacity to deliver other health services. ventions are consolidated. More work also needs to be Surgery is an essential component of efforts to reduce done to estimate the investment costs of setting up these maternal mortality in childbirth, and it is of growing facilities, including training surgeons, providing specialty importance as the burden of noncommunicable dis- training, and equipping facilities appropriately. eases increases. ANNEXES Global Initiatives The annexes to this chapter are as follows. They are available at In response to the deficiencies in the capacity to deliver http://www.dcp-3.org/surgery: basic surgical services in LMICs, the WHO launched the • Annex 18A. Search Terms Used to Identify Relevant Emergency and Essential Surgical Care (EESC) Project Literature. in 2004 (Bickler and Spiegel 2010). The IMEESC toolkit, • Annex 18B. Flow Chart of Identification, Screening, and supplemented by the text Surgical Care at the District Eligibility of Included Cost Studies: Surgery. • Annex 18C. List of Studies, Results, and Quality Scores Hospital (WHO 2003b), was developed to provide a basic training package. These teaching materials are based on the WHO’s minimum standards and technol- ogies for emergency and essential surgical care, and they NOTES are designed to strengthen the delivery of surgical and The World Bank classifies countries according to four income anesthetic services at primary health facilities. groupings. Income is measured using gross national income The Global Initiative for Emergency and Essential (GNI) per capita, in U.S. dollars, converted from local currency Surgery Care (GIEESC) was established in 2005 to pro- using the World Bank Atlas method. Classifications as of July mote the EESC program and to address deficiencies in 2014 are as follows: capacity for surgical care at the primary referral level in • Low-income countries (LICs) = US$1,045 or less in 2013 • Middle-income countries (MICs) are subdivided: LMICs. The overall objective of the GIEESC is to stim- • Lower-middle-income = US$1,046 to US$4,125 ulate collaboration among organizations, agencies, and • Upper-middle-income (UMICs) = US$4,126 to US$12,745 institutions involved in reducing death and disability • High-income countries (HICs)= US$12,746 or more from surgically treatable conditions. 1. All intervention costs in this section have been converted into 2012 U.S. dollars using the World Bank consumer Future Priorities price index or regional inflation rates, unless otherwise noted. Future priorities include development of appropriate surgical care models for all levels of care, based on local and regional characteristics and surgical needs. Cost- effectiveness and cost-benefit analyses of health systems REFERENCES implementation need to be undertaken. Further research Aboagye, A. Q. Q., A. N. K. Degboe, and A. A. D. Obuobi. on different modalities for provision of surgery, for 2010. “Estimating the Cost of Healthcare Delivery in Three example, the use of mobile clinics to reach underserviced Hospitals in Southern Ghana.” Ghana Medical Journal areas, as well as the possibilities of task-shifting to reduce 44 (3): 82. costs and increase affordability, would be useful. The Adam, T., S. S. Lim, S. Mehta, Z. A. Bhutta, H. Fogstad, and evaluation of surgery as a prevention strategy in public others. 2005. “Cost Effectiveness Analysis of Strategies for Maternal and Neonatal Health in Developing Countries.” health should include cost-effectiveness analysis of ade- British Medical Journal 331 (7525): 1107. quate, prompt, initial surgical treatment of injuries to Alkire, B., C. D. Hughes, K. Nash, J. R. Vincent, and J. G. Meara. prevent chronic disability from poorly diagnosed and 2011. “Potential Economic Benefit of Cleft Lip and Palate treated survivable injuries, as well as elective treatment Repair in Sub-Saharan Africa.” World Journal of Surgery of hernia, hydrocele, otitis media, cataract, clubfoot, and 35 (6): 1194–201. nonemergency orthopedic conditions to prevent com- Alkire, B., J. R. Vincent, C. T. Burns, I. S. Metzler, P. E. Farmer, plications and disabilities. and others. 2012. “Obstructed Labor and Caesarean Costs, Effectiveness, and Cost-Effectiveness of Selected Surgical Procedures and Platforms 333 Delivery: The Cost and Benefit of Surgical Intervention.” Chang, R. W., J. M. Pellissier, and G. B. Hazen. 1996. PLoS One 7 (4): e34595. doi:10.1371/journal.pone.0034595. “A Cost-Effectiveness Analysis of Total Hip Arthroplasty for Asante, F. A., T. S. Avotri, and S. A. d’Almeida. 2004. “Costing Osteoarthritis of the Hip.” Journal of the American Medical of Safe Motherhood (Making Pregnancy Safer) Initiative Association 275 (11): 858–65. in Ghana: A Case Study of Wassa West District.” WHO Chao, T. E., K. Sharma, M. Mandigo, L. Hagander, S. C. Resch, Regional Office for Africa, Harare, Zimbabwe. and others. 2014. “Cost-Effectiveness of Surgery and Its Bale, J., B. Stoll, A. Mack, and A. Lucas. 2003. Improving Policy Implications for Global Health: A Systematic Review Birth Outcomes: Meeting the Challenges in the Developing and Analysis.” The Lancet Global Health 2: e334–45. World. Washington, DC: National Academy of Sciences and Chatterjee, S., and R. Laxminarayan. 2013. “Costs of Surgical Institute of Medicine. Procedures in Indian Hospitals.” BMJ Open 3 (6). Baltussen, R., and A. Smith. 2012. “Cost Effectiveness of Chen, A. T., A. Pedtke, J. K. Kobs, G. S. Edwards, R. R. Coughlin, Strategies to Combat Vision and Hearing Loss in Sub- and R. A. Gosselin. 2012. “Volunteer Orthopedic Surgical Saharan Africa and South East Asia: Mathematical Trips in Nicaragua: A Cost-Effectiveness Evaluation.” World Modelling Study.” British Medical Journal 344: E615. Journal of Surgery 35 (12): 951–55. Baltussen, R., M. Sylla, K. D. Frick, and S. P. Mariotti. 2005. Chen, B., and M. Creinin. 2008. “Medical Management of “Cost-Effectiveness of Trachoma Control in Seven World Early Pregnancy Failure: Efficacy.” Seminars in Reproductive Regions.” Ophthalmic Epidemiology 12 (2): 91–101. Medicine 26 (5): 411–22. Banerjee, S. K., K. L. Andersen, and J. Warvadekar. 2012. Corlew, D. 2010. “Estimation of Impact of Surgical Disease “Pathways and Consequences of Unsafe Abortion: through Economic Modeling of Cleft Lip and Palate Care.” A Comparison among Women with Complications after World Journal of Surgery 34 (3): 391–96. Induced and Spontaneous Abortions in Madhya Pradesh, Coronini-Cronberg, S., J. Appleby, and J. Thompson. 2013. India.” International Journal of Gynecology and Obstetrics “Application of Patient-Reported Outcome Measures 118: S113–20. (PROMs) Data to Estimate Cost-Effectiveness of Hernia Bansal, V. K., M. C. Misra, D. Babu, P. Singhal, K. Rao, and Surgery in England.” Journal of the Royal Society of Medicine others. 2012. “Comparison of Long-Term Outcome and 106 (7): 278–87. Quality of Life after Laparoscopic Repair of Incisional Debas, H., R. Gosselin, C. McCord, and A. Thind. 2006. and Ventral Hernias with Suture Fixation with and with- “Surgery.” In Disease Control Priorities in Developing out Tacks: A Prospective, Randomized, Controlled Study.” Countries, 2nd edition, edited by D. T. Jamison, Surgical Endoscopy 26 (12): 3476–85. J. G. Breman, A. R. Measham, G. Alleyne, M. Claeson, and Benson, J., M. Okoh, K. Krennhrubec, M. A. Lazzarino, and others, 1245–59. Washington, DC: World Bank and Oxford H. B. Johnston. 2012 “Public Hospital Costs of Treatment of University Press. Abortion Complications in Nigeria.” International Journal Detsky, A. S., and I. G. Naglie. 1990. “A Clinician’s Guide to of Gynecology and Obstetrics 118: S134–40. Cost-Effectiveness Analysis.” Annals of Internal Medicine Bickler, S. W., and D. Spiegel. 2010. “Improving Surgical Care 113 (2): 147–54. in Low- and Middle-Income Countries: A Pivotal Role for Doubilet, P., M. C. Weinstein, and B. J. McNeil. 1986. “Use the World Health Organization.” World Journal of Surgery and Misuse of the Term ‘Cost Effective’ in Medicine.” 34 (3): 386–90. New England Journal of Medicine 314 (4): 253–56. Black, R., R. Laxminarayan, M. Temmerman, and N. Walker, Dougherty, C., and T. Howard. 2013. “Cost-Effectiveness in eds. Forthcoming. Reproductive, Maternal, Newborn, Orthopedics: Providing Essential Information to Both and Child Health. Vol. 2 in Disease Control Priorities in Physicians and Health Care Policy Makers for Appropriate Developing Countries, third edition, edited by D. T. Jamison, Allocation of Medical Resources.” Sports Medicine and H. Gelband, S. Horton, P. Jha, R. Laxminarayan, and Arthroscopy Review 21 (3): 166–68. R. Nugent. Washington, DC: World Bank. Drummond, M. F., and T. O. Jefferson. 1996. “Guidelines for Blackmore, C. C., and W. J. Smith. 1998. “Economic Analyses Authors and Peer Reviewers of Economic Submissions to of Radiological Procedures: A Methodological Evaluation the BMJ: The BMJ Economic Evaluation Working Party.” of the Medical Literature.” European Journal of Radiology British Medical Journal 313 (7052): 275–83. 27 (2): 123–30. Drummond, M. F., M. J. Schulpher, G. W. Torrance, Brauer, C. A., A. B. Rosen, N. V. Olchanski, and P. J. Neumann. D. J. O’Brien, and G. L. Stoddart. 2005. Methods for 2005. “Cost-Utility Analyses in Orthopaedic Surgery.” the Economic Evaluation of Health Care Programmes, 3rd Journal of Bone and Joint Surgery 87-A (6): 1253–59. edition. New York: Oxford University Press. Campbell, O., and J. Wendy. 2006. “Strategies for Reducing Durham, R., E. Pracht, B. Orban, L. Lottenburg, J. Tepas, and Maternal Mortality: Getting on with What Works.” The others. 2006. “Evaluation of a Mature Trauma System.” Lancet 368 (9543): 1284–99. Annals of Surgery 243 (6): 775–83; discussion 83–5. Carvalho, N., A. S. Salehi, and S. J. Goldie. 2013. “National Erim, D. O., S. C. Resch, and S. G. Goldie. 2012. and Sub-National Analysis of the Health Benefits and “Assessing Health and Economic Outcomes of Cost-Effectiveness of Strategies to Reduce Maternal Interventions to Reduce Pregnancy-Related Mortality Mortality in Afghanistan.” Health Policy and Planning in Nigeria.” BMC Public Health, September 14. doi: 28: 62–74. 10.1186/1471-2458-12-786. 334 Essential Surgery Finger, R. P., D. G. Kupitz, E. Fenwick, B. Balasubramaniam, Gundre, N. P., S. P. Iyer, and P. Subramaniyan. 2012. “Prospective R. V. Ramani, and others. 2012. “The Impact of Successful Randomized Controlled Study Using Polyethylene Mesh Cataract Surgery on Quality of Life, Household Income for Inguinal Hernia Meshplasty as a Safe and Cost-Effective and Social Status in South India.” PloS One 7 (8): E44268. Alternative to Polypropylene Mesh.” Updates in Surgery Frick, K. D., and A. Foster. 2003. “The Magnitude and Cost 64 (1): 37–42. of Global Blindness: An Increasing Problem That Can Be Halanski, M. A., J.-C. Huang, S. J. Walsh, and H. A. Crawford. Alleviated.” American Journal of Ophthalmology 135 (4): 2009. “Resource Utilization in Clubfoot Management.” 471–76. Clinical Orthopaedics and Related Research 467 (5): 1171–79. Funk, L. M., T. G. Weiser, W. R. Berry, S. R. Lipsitz, A. F. Merry, Henshaw, S. K., I. Adewole, S. Singh, A. Bankole, B. Oye- and others. 2010. “Global Operating Theatre Distribution Adeniran, and others. 2008. “Severity and Cost of Unsafe and Pulse Oximetry Supply: An Estimation from Reported Abortion Complications Treated in Nigerian Hospitals.” Data.” The Lancet 376 (9746): 1055–61. International Family Planning Perspectives 34 (1): 40–50. Gambhir, S. S., and J. Schwimmer. 2000. “Economic Evaluation Honda, A., P. G. Randaoharison, and M. Matsui. 2011. Studies in Nuclear Medicine: A Methodological Review “Affordability of Emergency Obstetric and Neonatal Care of the Literature.” Quarterly Journal of Nuclear Medicine at Public Hospitals in Madagascar.” Reproductive Health 44 (2): 121–37. Matters 19 (37): 10–20. Gilbert, C. E., S. P. Shah, M. Z. Jadoon, R. Bourne, B. Dineen, Horton, S., and C. Gauvreau. 2015. “Economic Overview: and others. 2008. “Poverty and Blindness in Pakistan: Cancer in Low and Middle-Income Countries.” In Disease Results from the Pakistan National Blindness and Visual Control Priorities in Developing Countries (third edi- Impairment Survey.” British Medical Journal 336 (7634): tion): Volume 3, Cancer, edited by H. Gelband, P. Jha, 29–32. R. Sankaranarayanan, and S. Horton. Washington, DC: Goldie, S. J., S. Sweet, N. Carvalho, U. C. Natchu, and D. Hu. World Bank. 2010. “Alternative Strategies to Reduce Maternal Mortality Hounton, S. H., D. Newlands, N. Meda, and V. De Brouwere. in India: A Cost-Effectiveness Analysis.” PloS Medicine 2009. “A Cost-Effectiveness Study of Caesarean-Section 7 (4): e1000264. Deliveries by Clinical Officers, General Practitioners and Gong, K., N. Zhang, Y. Lu, B. Zhu, Z. Zhang, and others. Obstetricians in Burkina Faso.” Human Resources for Health 2011. “Comparison of the Open Tension-Free Mesh- 7: 34–45. Plug, Transabdominal Preperitoneal (TAPP), and Totally Hsia, R., N. Mbembate, S. Macfarlane, and M. Kruk. 2012. Extraperitoneal (TEP) Laparoscopic Techniques for “Access to Emergency and Surgical Care in Sub-Saharan Primary Unilateral Inguinal Hernia Repair: A Prospective Africa: The Infrastructure Gap.” Health Policy and Planning Randomized Controlled Trial.” Surgical Endoscopy 25 (1): 27 (3): 234–44. 234–39. doi:10.1007/s00464-010-1165-0. Hu, D., S. M. Bertozzi, E. Gakidou, S. Sweet, and S. Goldie. Gosselin, R. A., G. Gialamas, and D. M. Atkin. 2011. “Comparing 2007. “The Costs, Benefits, and Cost-Effectiveness the Cost-Effectiveness of Short Orthopedic Missions in of Interventions to Reduce Maternal Morbidity and Elective and Relief Situations in Developing Countries.” Mortality in Mexico.” PLoS One: e750. doi:10.1371/Journal. World Journal of Surgery 35 (5): 951–55. Pone.0000750. Gosselin, R. A., and M. Heitto. 2008. “Cost-Effectiveness of Hu, D., D. Grossman, C. Levin, K. Blanchard, and S. J. Goldie. a District Trauma Hospital in Battambang, Cambodia.” 2009. “Cost-Effectiveness Analysis of Alternative First- World Journal of Surgery 32 (11): 2450–53. Trimester Pregnancy Termination Strategies in Mexico ———, and L. Zirkle. 2009. “Cost-Effectiveness of Replacing City.” British Journal of Obstetrics and Gynaecology 116 (6): Skeletal Traction by Interlocked Intramedullary Nailing for 768–79. Femoral Shaft Fractures in a Provincial Trauma Hospital Hu, D., D. Grossman, C. Levin, K. Blanchard, R. Adanu, in Cambodia.” International Orthopaedics 33 (5): 1445–58. and others. 2010. “Cost-Effectiveness Analysis of Unsafe Gosselin, R. A., A. Maldonado, and G. Elder. 2010. Abortion and Alternative First-Trimester Pregnancy “Comparative Cost-Effectiveness Analysis of Two MSF Termination Strategies in Nigeria and Ghana.” African Surgical Trauma Centers.” World Journal of Surgery 34 (3): Journal of Reproductive Health 14 (2): 85–103. 415–19. Husereau, D., M. Drummond, S. Petrou, C. Carswell, Gosselin, R. A., A. Thind, and A. Bellardinelli. 2006. “Cost/ D. Moher, and others. 2013. “Consolidated Health Economic DALY Averted in a Small Hospital in Sierra Leone: What Evaluation Reporting Standards (CHEERS)–Explanation Is the Relative Contribution of Different Services?” World and Elaboration: An ISPOR Task Force Report.” ISPOR Journal of Surgery 30 (4): 505–11. Health Economic Evaluation Publication Guidelines: Grimes, C. E., J. A. Henry, J. Maraka, N. C. Mkandawire, and CHEERS Good Reporting Practices Task Force. Value in others. 2014. “Cost-Effectiveness of Surgery in Low- and Health 16 (2): 231–50. Middle-Income Countries: A Systematic Review.” World IHME (Institute for Health Metrics and Evaluation). 2013. Journal of Surgery 38 (1): 252–63. The Global Burden of Disease: Generating Evidence, Guiding Grimes, D., J. Benson, S. Singh, M. Romero, B. Ganatra, and Policy. Seattle, WA: IHME. others. 2006. “Unsafe Abortion: The Preventable Pandemic.” Iskedjian, M., K. Trakas, C. A. Bradley, A. Addis, K. Lanctot, and The Lancet 368 (9550): 1908–19. others. 1997. “Quality Assessment of Economic Evaluations Costs, Effectiveness, and Cost-Effectiveness of Selected Surgical Procedures and Platforms 335 Published in Pharmacoeconomics. The First Four Years Lansingh, V. C., M. J. Carter, and M. Martens. 2007. “Global (1992 to 1995).” Pharmacoeconomics 12 (6): 685–94. Cost-Effectiveness of Cataract Surgery.” Ophthalmology 114 James, M., S. St Leger, and K. V. Rowsell. 1996. “Prioritising (9): 1670–78. Elective Care: A Cost Utility Analysis of Orthopaedics in Lavernia, C. J., J. F. Guzman, and A. Gachupin-Garcia. the North West of England.” Journal of Epidemiology and 1997. “Cost Effectiveness and Quality of Life in Knee Community Health 50 (2): 182–89. Arthroplasty.” Clinical Orthopaedics and Related Research Jefferson, T., V. Demicheli, and L. Vale. 2002. “Quality of Dec (345): 134–9. Systematic Reviews of Economic Evaluations in Health Leive, A., and K. Xu. 2008. “Coping with Out-of-Pocket Care.” Journal of the American Medical Association 287 (21): Health Payments: Empirical Evidence from 15 African 2809–12. Countries.” Bulletin of the World Health Organization 86 Jha, P., O. Bangoura, and K. Ranson. 1998. “The Cost- (11): 849–56. Effectiveness of Forty Health Interventions in Guinea.” Levin, A., T. Dmytraczenko, M. McEuen, F. Ssengooba, Health Policy and Planning 13 (3): 249–62. R. Mangani, and others. 2003. “Costs of Maternal Health Kandel, R. P., S. R. Rajashekaran, M. Gautam, and K. L. Bassett. Care Services in Three Anglophone African Countries.” 2010. “Evaluation of Alternate Outreach Models for International Journal of Health Planning and Management Cataract Services in Rural Nepal.” BMC Ophthalmology 18 (1): 3–22. 10: 9. Levin, C., D. Grossman, K. Berdichesvsky, C. Diaz, Khan, A., and S. Zaman. 2010. “Costs of Vaginal Delivery and B. Aracena, and others. 2009. “Exploring the Costs and Caesarean Section at a Tertiary Level Public Hospital in Economic Consequences of Unsafe Abortion in Mexico Islamabad, Pakistan.” BMC Pregnancy and Childbirth 10: 2. City before Legislation.” Reproductive Health Matters 17 Kong, V., C. Aldous, J. Handley, and D. Clarke. 2013. “The Cost (33): 120–32. Effectiveness of Early Management of Acute Appendicitis Lundström, M., and E. Wendel. 2005. “Duration of Self Underlies the Importance of Curative Surgical Services Assessed Benefit of Cataract Extraction: A Long Term to a Primary Healthcare Programme.”Annals of the Royal Study.” British Journal of Ophthalmology 89 (8): 1017–20. College of Surgery England 95 (4): 280–84. MacKenzie, E. J., S. Weir, F. P. Rivara, G. J. Jurkovich, Koontz, S. L., O. Molina de Perez, K. Leon, and A. Foster-Rosales. A. B. Nathens, and others. 2010. “The Value of Trauma 2003. “Treating Incomplete Abortion in El Salvador: Cost Center Care.” Journal of Trauma 69 (1): 1–10. Savings with Manual Vacuum Aspiration.” Contraception Magee, W. P. Jr., R. Vander Burg, and K. W. Hatcher. 2010. 68 (5): 345–51. “Cleft Lip and Palate as a Cost-Effective Health Care Krishna, A., M. C. Misra, V. K. Bansal, S. Kumar, S. Rajeshwari, Treatment in the Developing World.” World Journal of and others. 2012. “Laparoscopic Inguinal Hernia Surgery 34 (3): 420–27. Repair: Transabdominal Preperitoneal (TAPP) versus Malhotra, R., Y. Uppal, A. Misra, D. K. Taneja, V. K. Gupta, and Totally Extraperitoneal (TEP) Approach: A Prospective others. 2005. “Increasing Access to Cataract Surgery in a Randomized Controlled Trial.” Surgical Endoscopy 26 (3): Rural Area: A Support Strategy.” Indian Journal of Public 639–49. Health 49 (2): 63–67. Kruk, M. E., E. Goldmann, and S. Galea. 2009. “Borrowing and Manuel, M. R., L. M. Chen, A. B. Caughey, and L. L. Subak. 2004. Selling to Pay for Health Care in Low- and Middle-Income “Cost-Effectiveness Analyses in Gynecologic Oncology: Countries.” Health Affairs (Millwood) 28 (4): 1056–66. Methodological Quality and Trends.” Gynecologic Oncology Kruk, M. E., C. Pereira, F. Vaz, S. Bergstrom, and S. Galea. 93 (1): 1–8. 2007. “Economic Evaluation of Surgically Trained Assistant Marseille, E. 1996. “Cost-Effectiveness of Cataract Surgery in Medical Officers in Performing Major Obstetric Surgery in a Public Health Eye Care Programme in Nepal.” Bulletin of Mozambique.” British Journal of Obstetrics and Gynaecology the World Health Organization 74 (3): 319–24. 114 (10): 1253–60. Maru, D. S., R. Schwarz, D. Schwarz, J. Andrews, M. T. Panizales, Kruk, M. E., A. Wladis, N. Mbembati, S. K. Ndao-Brumblay, and others. 2011. “Implementing Surgical Services in a R. Y. Hsia, and others. 2010. “Human Resource and Funding Rural, Resource-Limited Setting: A Study Protocol.” British Constraints for Essential Surgery in District Hospitals Medical Journal Open 1 (1): e000166. in Africa: A Retrospective Cross-Sectional Survey.” PLoS McCord, C., and Q. Chowdhury. 2003. “A Cost-Effective Small Medicine 7(3): e1000242. Hospital in Bangladesh: What It Can Mean for Emergency Kruper, L., J. E. Kurichi, and S. S. Sonnad. 2007. “Methodologic Obstetric Care.” International Journal of Gynecology and Quality of Cost-Effectiveness Analyses of Surgical Obstetrics 81 (1): 83–92. Procedures.” Annals of Surgery 245 (1): 147–51. Mock, C. N., P. Donkor, A. Gawande, D. T. Jamison, M. E. Kruk, Kuper, H., S. Polack, W. Mathenge, C. Eusebio, Z. Wadud, and H. T. Debas. 2015. “Essential Surgery: Key Messages of and others. 2010. “Does Cataract Surgery Alleviate This Volume.” In Disease Control Priorities (third edition): Poverty? Evidence from a Multi-centre Intervention Study Volume 1, Essential Surgery, edited by H. T. Debas, P. Donkor, Conducted in Kenya, the Philippines and Bangladesh.” A. Gawande, D. T. Jamison, M. E. Kruk, and C. N. Mock. PLoS One 5 (11): e15431. Washington, DC: World Bank. 336 Essential Surgery Moon, W., H. Perry, and R. M. Baek. 2012. “Is International Sarowar, M. G., E. Medin, R. Gazi, T. P. Koehlmoos, C. Rehnberg, Volunteer Surgery for Cleft Lip and Cleft Palate a Cost- and others. 2010. “Calculation of Costs of Pregnancy- and Effective and Justifiable Intervention? A Case Study Puerperium-Related Care: Experience from a Hospital in a from East Asia.” World Journal of Surgery 36 (12): Low-Income Country.” Journal of Health, Population, and 2819–30. Nutrition 28 (3): 264–72. Muralikrishnan, R., R. Venkatesh, N. V. Prajna, and K. D. Frick. Shillcutt, S. D., M. G. Clarke, and A. N. Kingsnorth. 2004. “Economic Cost of Cataract Surgery Procedures 2010. “Cost-Effectiveness of Groin Hernia Surgery in the in an Established Eye Care Centre in Southern India.” Western Region of Ghana.” Archives of Surgery 145 (10): Ophthalmic Epidemiology 11 (5): 369–80. 954–61. Murray, C., T. Vos, R. Lozano, M. Naghavi, A. D. Flaxman, Shillcutt, S., D. Sanders, M. Teresa Butrón-Vila, and C. Michaud, and others. 2012. “Disability-Adjusted Life A. Kingsnorth. 2013. “Cost-Effectiveness of Inguinal Hernia Years (DALYs) for 291 Diseases and Injuries in 21 Surgery in Northwestern Ecuador.” World Journal of Surgery Regions, 1990–2010: A Systematic Analysis for the Global 37 (1): 32–41. Burden of Disease Study 2010.” The Lancet 380 (9859): Singh, A. J., P. Garner, and K. Floyd. 2000. “Cost-Effectiveness 2197–223. of Public-Funded Options for Cataract Surgery in Mysore, Nathens, A. B., G. J. Jurkovich, P. Cummings, F. P. Rivara, and India.” The Lancet 355 (9199): 180–99. R. V. Maier. 2000. “The Effect of Organized Systems of Stroupe, K. T., L. M. Manheim, P. Luo, A. Giobbie-Hurder, Trauma Care on Motor Vehicle Crash Mortality.” Journal of D. M. Hynes, and others. 2006. “Tension-Free Repair the American Medical Association 283 (15): 1990–94. versus Watchful Waiting for Men with Asymptomatic NICE (National Institute for Health and Clinical Excellence). or Minimally Symptomatic Inguinal Hernias: A Cost- 2008. “Guide to the Methods of Technology Appraisal.” Effectiveness Analysis.” Journal of the American College of NICE, London. http://www.nice.org.uk/media/b52/a7 Surgeons 203 (4): 458–68. /tamethodsguideupdatedjune2008.pdf. Stylopoulos, N., G. S. Gazelle, and D. W. Rattner. 2003. PATH and M. O. H. Reproductive Health Department, “A Cost-Utility Analysis of Treatment Options for Inguinal Vietnam (Program for Appropriate Technology in Health Hernia in 1,513,008 Adult Patients.” Surgical Endoscopy and Reproductive Health Department of the Ministry of 17 (2): 180–89. Health, Vietnam). 2006. Examining the Cost of Providing Tengs, T. O., M. E. Adams, J. S. Pliskin, D. G. Safran, Medical Abortion in Vietnam. Hanoi. J. E. Siegel, and others. 1995. “Five-Hundred Life-Saving Pizzarello, L., A. Abiose, T. Ffytche, R. Duerksen, R. Thulasiraj, Interventions and Their Cost-Effectiveness.” Risk Analysis and others. 2004. “VISION 2020: The Right to Sight: 15 (3): 369–90. A Global Initiative to Eliminate Avoidable Blindness.” Thylefors, B., A. D. Negrel, R. Pararajasegaram, and Archives of Ophthalmology 122 (4): 615–20. K. Y. Dadzie. 1995. “Global Data on Blindness.” Bulletin of Quayyum, Z., M. Nadjib, T. Ensor, and P. K. Suchahya. 2010. the World Health Organization 73 (1): 115–21. “Expenditure on Obstetric Care and the Protective Effect Ungar, W. J., and M. T. Santos. 2005. “Quality Appraisal of Insurance on the Poor: Lessons from Two Indonesian of Pediatric Health Economic Evaluations.” International Districts.” Health Policy and Planning 25 (3): 237–47. Journal of Technology Assessment in Health Care 21 (2): Rausch, M., S. Lorch, K. Chung, M. Frederick, J. Zhang, and 203–10. others. 2012. “A Cost-Effectiveness Analysis of Surgical ver- van Doorslaer, E., O. O’Donnell, R. P. Rannan-Eliya, sus Medical Management of Early Pregnancy Loss.” Fertility A. Somanathan, S. R. Adhikari, and others. 2007. and Sterility 97 (2): 355–60. “Catastrophic Payments for Health Care in Asia.” Health Rehan, N. 2011. “Cost of the Treatment of Complications of Economics 16 (11): 1159–84. Unsafe Abortion in Public Hospitals.” Journal of Pakistan Vlassoff, M., T. Fetter, S. Kumbi, and S. Singh. 2012. “The Health Medical Association 61 (2): 169–72. System Cost of Postabortion Care in Ethiopia.” International Resnikoff, S., D. Pascolini, D. Etya’ale, I. Kocur, Journal of Gynecology and Obstetrics 118: S127–33. R. Pararajasegaram, and others. 2004. “Global Data on Vlassoff, M., F. Mugisha, A. Sundaram, A. Bankole, S. Singh, Visual Impairment in the Year 2002.” Bulletin of the World and others. 2014. “The Health System Cost of Post- Health Organization 82 (11): 844–51. abortion Care in Uganda.” Health Policy and Planning Richard, F., C. Ouedraogo, J. Compaore, D. Dubourg, and 29 (1): 56–66. V. De Brouwere. 2007. “Reducing Financial Barriers to Vos, T., R. Carter, J. Barendregt, C. Mihalopoulos, Emergency Obstetric Care: Experience of Cost-Sharing L. Veerman, and others. 2010. Assessing Cost-Effectiveness Mechanism in a District Hospital in Burkina Faso.” Tropical in Prevention (ACE–Prevention): Final Report. Brisbane, Medicine and International Health 12 (8): 972–81. Australia: University of Queensland; Melbourne, Rocconi, R. P., S. Chiang, H. E. Richter, and J. M. Straughn, Australia: Deakin University. http://www.sph.uq.edu.au Jr. 2005. “Management Strategies for Abnormal Early /bodce-ace-prevention. Pregnancy: A Cost-Effectiveness Analysis.” Journal of Warburton, D., and F. Fraser. 1964. “Spontaneous Abortion Reproductive Medicine 50 (7): 486–90. Risks in Man: Data from Reproductive Histories Collected Costs, Effectiveness, and Cost-Effectiveness of Selected Surgical Procedures and Platforms 337 in a Medical Genetics Unit.” American Journal of Human ———. 2006. Integrated Management for Emergency and Genetics 16 (1): 1–25. Essential Surgical Care Tool Kit. Geneva: WHO. Warf, B. C., B. C. Alkire, S. Bhai, C. Hughes, S. J. Schiff, ———. 2008. World Health Report: Primary Health Care (Now and others. 2011. “Costs and Benefits of Neurosurgical More Than Ever). Geneva: WHO. Intervention for Infant Hydrocephalus in Sub-Saharan Wilcox, A., C. Weinberg, J. O’Connor, D. Baird, J. Schlatterer, Africa.” Journal of Neurosurgery: Pediatrics 8 (5): 509–21. and others. 1988. “Incidence of Early Loss of Pregnancy.” Weiser, T. G., S. E. Regenbogen, K. D. Thompson, A. B. Haynes, New England Journal of Medicine 319 (4): 189–94. S. R. Lipsitz, and others. 2008. “An Estimation of the Wittenborn, J. S., and D. B. Rein. 2011. “Cost-Effectiveness Global Volume of Surgery: A Modelling Strategy Based on of Glaucoma Interventions in Barbados and Ghana.” Available Data.” The Lancet 372 (9633): 139–44. Optometry and Vision Science 88 (1): 155–63. WHO (World Health Organization). 2001. Macroeconomics Xia, W., S. She, and T. H. Lam. 2011. “Medical versus and Health: Investing in Health for Economic Surgical Abortion Methods for Pregnancy in China: Development. Geneva: WHO. http://whqlibdoc.who.int A Cost-Minimization Analysis.” Gynecologic and Obstetric /publications/2001/924154550x.pdf. Investigation 72 (4): 257–63. ———. 2003a. Safe Abortion: Technical and Policy Guidance for Xu, K., D. B. Evans, G. Carrin, A. M. Aguilar-Rivera, P. Musgrove, Health Systems. Geneva: WHO. and others. 2007. “Protecting Households from Catastrophic ———. 2003b. Surgical Care at the District Hospital. Geneva: Health Spending.” Health Affairs (Millwood) 26 (4): 972–83. WHO. Zimmer, Z. 2008. “Poverty, Wealth Inequality and Health ———. 2005. The World Health Report 2005: Make Every among Older Adults in Rural Cambodia.” Social Science and Mother and Child Count. Geneva: WHO. Medicine 66 (1): 57–71. 338 Essential Surgery Chapter 19 Task-Sharing or Public Finance for Expanding Surgical Access in Rural Ethiopia: An Extended Cost-Effectiveness Analysis Mark G. Shrime, Stéphane Verguet, Kjell Arne Johansson, Dawit Desalegn, Dean T. Jamison, and Margaret E. Kruk INTRODUCTION for home delivery play a role, rural women also point to the high cost of care and a lack of providers as reasons A large fraction of the disease burden is attributable for low utilization (Central Statistical Agency [Ethiopia] to conditions potentially amenable to surgical treat- and ICF International 2012; Shiferaw and others 2013). ment (Bickler and others 2015; Mock and others 2015; A patient undergoing surgery in Ethiopia would face, Shrime, Sleemi, and Thulasiraj 2014). In low- and on average, 1,125 Ethiopian birr (Br; I$204) in direct middle-income countries (LMICs), however, the utiliza- medical costs, as well as Br 1,633 to Br 3,358 (I$297 tion of surgical services is low, often because of a lack of to I$611) in direct nonmedical costs (Kifle and Nigatu surgical capacity, sociocultural factors, and cost (Chao 2010; UN 2014). Even if surgery were publicly financed, and others 2012; Hsia and others 2012; Ilbawi, Einterz, the patient would still face direct nonmedical costs, and Nkusu 2013; Knowlton and others 2013; Linden and which, in some settings, may be large enough to cause others 2012). Numerous policies have been proposed impoverishment. to improve access, including making surgery free at the The World Health Organization (WHO) has stated point of care and task-sharing (Bucagu and others 2012; that health systems have three objectives: to improve Jadidfard, Yazdani, and Khoshnevisan 2012; Kruk and health, to provide financial protection, and to advance others 2007). the equitable distribution of the two (WHO 2007). In Ethiopia, more than 80 percent of the population While health policies typically focus on the first objec- of 92 million people lives in rural areas (WHO 2012; tive, improving health may be in tension with an World Bank 2012), while surgeons are primarily located improvement in either of the other two objectives. in urban centers (Berhan 2008; Surgical Society of In addition, standard health economic evaluations of Ethiopia 2013). As a consequence, access to surgery is policies sometimes ignore their expected impact on the particularly low. For example, in 2010, 3.3 percent of private economy of households. Methods for extended women delivered their most recent child by cesarean cost-effectiveness analyses (ECEAs) have recently been section—20 percent of the women in Addis Ababa, but developed to examine all three objectives simultaneously as few as 0.5 percent of the poorest women in rural (Verguet, Laxminarayan, and Jamison 2014). Ethiopia (Central Statistical Agency [Ethiopia] and ICF This chapter studies the health and financial risk International 2012). Although traditional preferences protection benefits of policies for improving access to Corresponding author: Mark G. Shrime, MD, MPH, FACS, Harvard University, shrime@mail.harvard.edu 339 surgical care in rural Ethiopia. Using the ECEA frame- Table 19.1 Surgical Procedures and Treated Conditions work (Verguet, Gavreau, and others 2015; Verguet, Included in the Model Laxminarayan, and Jamison 2014; Verguet, Murphy, and Procedure Conditions others 2013), we compare the following: Appendectomy Acute appendicitis, complicated or • A policy of universal public financing (UPF) that uncomplicated makes surgery free at the point of care but does not Exploratory laparotomy Abdominal trauma pay for nonmedical costs Cesarean section Obstructed labor • A policy of task-sharing of surgery with nonsurgeon Other fetal indications providers • A combination of UPF and task-sharing Salpingectomy Ectopic pregnancy Hysterectomy Postpartum hemorrhage In addition, because direct nonmedical costs to Uterine rupture patients—for transportation, food, and lodging—can be Vacuum aspiration Spontaneous abortion significant drivers of both catastrophic expenditures and Postpartum sepsis decisions to avoid care (Kowalewski, Mujinja, and Jahn 2002), we examine two additional policies: Chest tube placement Thoracic trauma Amputation Gangrene • UPF with the addition of travel vouchers Traction Uncomplicated long-bone fracture • A combination of UPF, task-sharing, and travel vouchers Finally, we quantify the distribution of these benefits Model Structure, Outcomes, and Data Sources across wealth groups. Model Structure and Outcomes of Interest. We applied ECEA methodology, which is described in annex 19A METHODS (Verguet, Murphy, and others 2013; Verguet, Laxminaryan, and Jamison 2014). Selection of Interventions We followed a synthetic population of 1 million We defined a basic package of surgery to study in rural individuals similar to that in rural Ethiopia and nor- Ethiopia, comprising nine surgical procedures treating malized to identically sized wealth quintiles. The struc- 13 conditions (table 19.1). This package was chosen ture of the model is given in figure 19.1, which shows because the associated conditions have large, immediate one of the 13 surgical conditions. A patient with risks of death, and, as a result, the interventions have obstructed labor will seek care conditional on utiliza- potentially large individual benefits. For this surgical tion barriers. If she seeks care, she experiences periop- package, we looked at six scenarios: erative morbidity or mortality, with probabilities as shown in table 19.2. Total costs, patient-borne costs, • Keeping surgical delivery at the status quo direct nonmedical costs, and overall effectiveness are • Implementing UPF, in which direct medical costs for calculated. This structure is essentially identical for included procedures are fully paid by the government the other surgical conditions. The model assumes a • Task-sharing, in which nonsurgeon providers are single-event analytic horizon and, as such, assumes no trained to provide these surgeries, but the cost of discounting of costs or benefits. accessing care is unchanged from the status quo Our outcomes of interest were deaths averted, • A combination of UPF and task-sharing, in which cases of impoverishment averted, cases of cata- surgery can be provided by nonsurgeon providers strophic expenditure averted, average household cost and in which medical costs are fully funded by the savings (or “private expenditure crowded out” for public sector medical treatment), and governmental costs needed • A policy that implements UPF and provides vouchers to sustain the program. Note that ECEA methodology to patients for nonmedical costs does not explicitly calculate the economic benefits • A policy combining UPF, task-sharing, and vouchers, of better health, as would be done in a benefit-cost such that surgery can be provided by nonsurgeon pro- analysis. These benefits are addressed in sensitivity viders with no out-of-pocket (OOP) costs for patients analyses that follow. 340 Essential Surgery Figure 19.1 Basic Chance Tree Structure for Each Surgical Intervention in the Model Die Complications Die Surgeon Major complication Survive Survive Minor complication Access No complication Die Nonsurgeon Die Major complication Obstructed labor Survive Survive Minor complication No complication Die No access Survive Note: Circles represent chance nodes; triangles represent outcome nodes. Table 19.2 Condition- and Procedure-Specific Model Inputs Probability Major Minor Procedure Perioperative Mortality, complication complication cost (I$) mortality untreated rate rate Prevalence Cesarean section for obstructed labor 251.81 0.003 0.300 0.109 0.074 Obstetric Vacuum aspiration for postpartum sepsis 103.07 0.022 0.300 0.154 0.220 conditions: 0.020354 Hysterectomy for uterine rupture 441.02 0.214 0.300 0.140 0.270 Hysterectomy for postpartum hemorrhage 441.02 0.020 0.300 0.140 0.270 Salpingectomy 251.81 0.030 0.750a 0.046 0.046 Vacuum aspiration for spontaneous abortion 103.07 0.022 0.300 0.154 0.220 Cesarean section for other fetal conditions 251.81 0.003 0.300 0.109 0.074 Appendectomy 301.29 0.012 0.700 0.035 0.140 Appendicitis: 0.0003 Exploratory laparotomy 393.81 0.133 0.923 0.500 0.242 Traumatic Traction 352.43 0a 0.060 0.200 0.067 conditions: 0.06285 Chest tube placement 393.81 0.160 1.000a 0.105 0.263 Amputation 352.43 0.290 0.750 0.086 0.248 Sources: Procedure cost: Alkire and others 2012; Hu and others 2009; Kifle and Nigatu 2010; Vlassoff and others 2008, 2012. Perioperative mortality: Admasu 2004; Admasu, Haile-Mariam, and Bailey 2011; Alemayehu, Ballard, and Wright 2013; Demissie 2001; Deneke and Tadesse 2001; Gessessew and others 2011; Goyaux and others 2003; Gulam-Abbas and others 2002; Hailu 2000. Mortality, untreated: Abbas and Archibald 2005a, 2005b; Anderson and others 2007; Cobben, Otterloo, and Puylaert 2000; Gulam-Abbas and others 2002; Neilson and others 2003; Thomas and Meggitt 1981. Major complication rate: Ali 1995; Gaym 2002; Hailu 2000; Harris and others 2009; Igberase and Ebeigbe 2008; Mawalla and others 2011; Okeny, Hwang, and Ogwang 2011; Thomas and Meggitt 1981; Thonneau and others 2002. Minor complication rate: Adinma and others 2011; Ali 1995; Gaym 2002; Hailu 2000; Harris and others 2009; Hu and others 2009; Okeny, Hwang, and Ogwang 2011; Razavi and others 2005; Sohn and others 2002; Thomas and Meggitt 1981; Thonneau and others 2002. Obstetric conditions: Admasu, Haile-Mariam, and Bailey 2011; Fantu, Segni, and Alemseged 2010; Gessessew and others 2011; Singh and others 2010; Singh, Remez, and Tartaglione 2010; Thonneau and others 2002; Worku and Fantahun 2006. Appendicitis: Andersson 2007; Groen and others 2012; WHO 2008. Traumatic conditions: Groen and others 2012; Hailu 2000. a. Assumption. Task-Sharing or Public Finance for Expanding Surgical Access in Rural Ethiopia: An Extended Cost-Effectiveness Analysis 341 Data Sources. Parameter estimates (table 19.2) draw Catastrophic expenditure was assumed if patients’ on national surveys and published studies. When expenditures brought their incomes to either less possible, estimates were derived from rural Ethiopia. than zero or less than 40 percent of their initial If this was impossible, estimates were taken from nonhealth expenditure, following methods described studies performed—in order—in urban Ethiopia, previously (Habicht and others 2006; Reddy and oth- other Sub-Saharan African countries, and other ers 2013). More details are provided in annex 19A. developing countries. Finally, if no other data were Analyses were conducted using the R statistical available, estimates from high-income countries and software1 and TreeAge 2013 (TreeAge Software, upper-middle-income countries were used. Williamstown, Massachusetts). Funders had no role in study design, data collection, writing, or submis- Costs and Assumptions. All costs, including those sion for publication. from outside the Ethiopian context, are adjusted to and reported in international dollars, using pur- chasing power parity conversions and GDP deflator SENSITIVITY ANALYSIS estimates published by the United Nations and the The base-case analysis did not include the start-up World Bank (United Nations 2014; World Bank 2013). costs for a task-sharing program. These costs, based on Methodology for this conversion has been described estimates from Mozambique (Kruk and others 2007), previously (Schreyer and Koechlin 2002). were included in the sensitivity analysis. These costs Before the introduction of each program, individ- included the costs of salaries, training, library build- uals pay 34 percent of medical costs out-of-pocket, ings, books, computers, and travel. We scaled these ranging from 19 percent to 78 percent (Vlassoff and estimates linearly for differences in population size others 2012; WHO 2012). Direct nonmedical costs to and distributed the costs evenly across the population. the patient (for example, for transportation) are paid The linear scale-up results were lower than unpub- out-of-pocket under the UPF, task-sharing, and UPF + lished estimates from Ethiopia itself; therefore, these task-sharing scenarios, and shift to the public sector in unpublished estimates were also used in a separate the UPF + vouchers and UPF + task-sharing + vouchers sensitivity analysis. scenarios. Sensitivity analyses of assumptions around baseline To remain conservative, complication and mortality utilization, price elasticity of demand for care, the mag- rates for nonsurgeons were assumed to be 1.125 times nitude of direct nonmedical costs, the risk of mortality those of surgeons (Gessessew and others 2011). Similarly, from untreated disease, the cost of complications, the the costs of procedures performed by surgeons were inclusion of indirect costs, and the effects of taxation assumed to be 1.47 times higher than those performed were all performed (annex 19A). Finally, heterogeneity by nonsurgeons (Alkire and others 2012; Vlassoff and in our estimates was modeled using first-order Monte others 2008). In the base-case analysis, the cost of com- Carlo simulation. plications was set at I$25.50 (Vlassoff and others 2008) and varied in sensitivity analyses. Direct medical costs included the inpatient costs RESULTS of surgical delivery. Provider salaries are not explicitly added because this analysis is an incremental analysis Model Contextualization and Validation and, as such, provider salaries would not change with the From the 2011 Ethiopia Demographic and Health implementation of UPF or vouchers. Provider salaries in Survey (Central Statistical Agency [Ethiopia] and ICF the setting of task-sharing are addressed in a sensitivity International 2012), we calculated an overall rate of analysis below. obstetric delivery in a medical facility of 16.5 percent, Direct nonmedical costs included the costs of which is nearly identical to published estimates (Shiferaw transportation, food, and lodging; they did not include and others 2013). the costs of lost productivity due to disease. Because of The model was then validated against published likely increases in travel costs to centralized providers, mortality results from WHO, UNICEF, UNFPA, and nonmedical costs were assumed to be more expensive World Bank (2012). Because these estimates are for the when care was sought from surgeons than when sought country as a whole, and, in some cases, for low-income from nonsurgeons (I$611.66 and I$297.45, respectively) countries as a group, and because the model focuses (Kifle and Nigatu 2010). Indirect costs were not consid- solely on rural Ethiopia, we allowed the model to pre- ered in the base-case analysis, but they were considered dict slightly higher mortality than published estimates. in sensitivity analyses. Our model estimated 9,112 maternal deaths per year 342 Essential Surgery in Ethiopia, consistent with estimates of 9,000 (WHO and health benefits per I$100,000 spent are shown 2012); this translates to a predicted maternal mortality in table 19.3. Per 1 million people per year in rural ratio of 368 deaths per 100,000 live births, which is also Ethiopia, UPF averted 21 deaths, at a cost of I$895,000 consistent with World Bank estimates of 350 (World (2.4 averted deaths per I$100,000 spent, or I$42,600 per Bank 2012). Our model predicted 0.62 deaths per 1,000 death averted). Health gains from UPF varied across population from traumatic conditions and 0.012 deaths disease conditions: per I$100,000 spent, UPF was pre- per 1,000 population from appendicitis, consistent with dicted to avert 40 deaths from obstetric conditions World Bank estimates (0.61 and 0.012, respectively) (I$2,500 per death averted), 24 deaths from appendicitis (WHO 2013a). (I$4,200 per death averted), and two deaths from trauma (I$50,000 per death averted). Task-sharing was predicted to avert 250 deaths per Base-Case Analysis, without Travel Vouchers 1 million population per year in rural Ethiopia, at a Health Impacts. Nominal health benefits measured cost of I$377,200 (65 averted deaths per I$100,000; in deaths averted are shown in annex table 19A.4, or I$1,500 per death averted). As with UPF, this Table 19.3 Summary of Health Gains, Financial Risk Protection, and Costs per 1 Million Population, by Model Scenario Wealth quintile Poorest Poor Middle Rich Richest Overall Deaths averted per UPF (no vouchers) Obstetric 79 47 29 18 4 40 I$100,00 spent Appendicitis 45 25 16 11 3 24 Trauma 5 3 2 1 0 2 Total 6 3 2 1 0 3 UPF with vouchers Obstetric 27 17 11 8 2 15 Appendicitis 17 10 6 4 1 9 Trauma 2 1 1 1 0 1 Total 3 1 1 1 0 1 Task-sharing Obstetric 249 249 249 249 249 249 Appendicitis 495 495 495 495 495 495 Trauma 57 57 57 57 57 57 Total 62 64 66 68 72 65 UPF + task-sharing Obstetric 137 131 127 124 121 129 Appendicitis 128 106 90 77 64 99 Trauma 15 13 11 10 8 12 Total 17 15 13 12 11 14 UPF + task-sharing + Obstetric 42 39 37 36 35 38 vouchers Appendicitis 33 25 20 17 13 23 Trauma 4 3 3 2 2 3 Total 5 4 3 3 2 4 Cases of poverty UPF (no vouchers) Obstetric 0 −72 −91 216 0 21 averted per Appendicitis 0 −7 −24 182 0 37 I$100,000 spent Trauma 0 −24 −20 221 0 44 Total 0 −24 −21 221 0 44 table continues next page Task-Sharing or Public Finance for Expanding Surgical Access in Rural Ethiopia: An Extended Cost-Effectiveness Analysis 343 Table 19.3 Summary of Health Gains, Financial Risk Protection, and Costs per 1 Million Population, by Model Scenario (continued) Wealth quintile Poorest Poor Middle Rich Richest Overall UPF with vouchers Obstetric 0 53 96 29 0 35 Appendicitis 0 91 127 30 0 52 Trauma 0 88 124 38 0 52 Total 0 88 124 38 0 52 Task-sharing Obstetric 0 −587 −314 0 0 −178 Appendicitis 0 −531 −307 0 0 −175 Trauma 0 −454 −287 0 0 −154 Total 0 −458 −288 0 0 −155 UPF + task-sharing Obstetric 0 −307 −166 32 0 −84 Appendicitis 0 −110 −72 76 0 −20 Trauma 0 −98 −57 92 0 −10 Total 0 −101 −59 91 0 −11 UPF + task-sharing + Obstetric 0 20 34 10 0 13 vouchers Appendicitis 0 52 73 18 0 30 Trauma 0 50 71 22 0 30 Total 0 50 70 22 0 30 System cost (I$) UPF (no vouchers) Obstetric 837 866 1,025 1,213 1,581 5,522 Appendicitis 345 378 426 478 521 2,147 Trauma 142,375 155,964 175,976 197,415 215,286 887,016 Total 143,557 157,208 177,427 199,106 217,388 894,686 UPF with vouchers Obstetric 8,005 7,561 8,473 9,687 12,039 45,765 Appendicitis 2,463 2,654 2,973 3,321 3,597 15,009 Trauma 889,577 955,658 1,068,886 1,192,590 1,290,102 5,396,812 Total 900,044 965,874 1,080,332 1,205,597 1,305,738 5,457,585 Task-sharing Obstetric 1,896 2,576 3,255 3,934 5,293 16,955 Appendicitis 193 183 173 163 153 867 Trauma 80,143 76,009 71,875 67,740 63,606 359,373 Total 82,233 78,768 75,303 71,838 69,053 377,195 UPF + task-sharing Obstetric 4,047 5,296 6,696 8,131 10,990 35,160 Appendicitis 902 971 1,057 1,148 1,229 5,307 Trauma 372,217 400,402 435,985 473,213 506,330 2,188,147 Total 377,166 406,668 443,739 482,492 518,549 2,228,614 UPF + task-sharing + Obstetric 16,464 19,720 24,333 29,247 38,999 128,762 vouchers Appendicitis 4,258 4,648 5,166 5,712 6,188 25,972 Trauma 1,550,875 1,688,750 1,873,770 2,069,266 2,238,571 9,421,232 Total 1,571,597 1,713,118 1,903,268 2,104,225 2,283,758 9,575,967 Note: Health and financial risk protection benefits are measured per I$100,000 spent in the indicated quintile (or overall). Hence, the overall column is close to the average, not the total, of the quintile-specific columns. Negative numbers of cases of poverty averted represent cases of impoverishment created by the policy. Note that rows and columns do not sum directly because these reported results are ratios of benefit per dollar spent. 344 Essential Surgery prediction varies by disease condition: per I$100,000 increased because of increased demand. However, as a spent, task-sharing averted 249 deaths from obstetric result of the more expensive nature of these interven- conditions (I$400 per death averted), 495 deaths from tions, the amount of health benefit bought per dollar appendicitis (I$200 per death averted), and 57 deaths (of public money) decreased. from trauma (I$1,750 per death averted). In contrast, financial risk protection benefits increased Finally, combining task-sharing with UPF was significantly with this transfer. UPF + vouchers averted predicted to cost the system I$2,230,000 per million only 1 death per I$100,000 spent but averted 52 cases of people per year, and to avert 291 deaths, for a total of poverty (I$1,900 per case of poverty averted). Combining 14 deaths averted per I$100,000 spent (I$2,222 per death UPF, task-sharing, and vouchers averted 4 deaths and averted). Obstetric conditions accounted for 129 deaths 30 cases of poverty per I$100,000 spent (I$25,000 per per I$100,000 (I$775 per death averted), appendicitis death averted and I$3,333 per case of poverty averted). for 99 deaths per I$100,000 (I$1,000 per death averted), Distributionally, financial risk protection continued and traumatic conditions for 12 deaths per I$100,000 to accrue primarily to the rich, while health benefits (I$8,300 per death averted). accrued to the poorest. Health benefits were not equal across wealth quin- A comparison of the health benefits and the tiles. The primary beneficiaries of the health benefits financial risk protection benefits for each policy, of UPF were the poorest quintiles. Under task-sharing, on average, is provided in figure 19.2. These sum- health benefits overall were similar across wealth quin- mary statements, however, mask significant variabil- tiles, with a slightly higher benefit per dollar spent ity in outcomes across wealth quintiles, as shown in in the richest. The combination of the two policies figure 19.3. maintained a gradient similar to that seen in UPF, with additional health benefits accruing to the richest quintile. Sensitivity Analysis Adding the costs for the scaling up of task-sharing— Financial Risk Protection. Poverty Cases Averted. either published from Mozambique or unpublished Without vouchers, only UPF had financial risk from Ethiopia—decreased, by a small amount, the protection effects. Task-sharing alone and task-sharing health benefit per dollar of any policy that included + UPF both induced impoverishment on average task-sharing; it had a similarly marginal effect on the (table 19.3 and annex table 19A.4). UPF averted distributional equity of health and financial risk pro- 366 cases of poverty per million population, amount- tection outcomes. The addition of heterogeneity to ing to approximately 44 cases of poverty averted for the model is shown in figure 19.4. Other sensitivity every I$100,000 spent. Poverty was, however, created analyses—on baseline utilization, the price elasticity among the poor. Only the rich saw a financial benefit of demand, the magnitude of direct nonmedical costs, from UPF. the risk of mortality from untreated disease, the cost Task-sharing created 578 cases of poverty per of complications, the inclusion of indirect costs, and million in the population, or approximately 155 cases the impact of taxation to pay for these policies—are in created for every I$100,000 spent. No impoverishment annex 19A. was averted, and most of the impoverishment accrued to the poor. Finally, a policy that combined task-sharing with UPF DISCUSSION created 229 cases of poverty, or 11 cases per I$100,000 Using an ECEA framework (Verguet, Laxminarayan, spent. The distribution of financial risk protection, or and Jamison 2014), this chapter examines the health lack thereof, was similar to that seen in UPF. and financial risk protection benefits of five policies for Other measures of financial risk protection—cases improving access to surgical services in rural Ethiopia: of catastrophic expenditure, as well as the crowding making surgery free at the point of care (UPF); task- out of private expenditure—by policy can be found in sharing; a combination of UPF and task-sharing; UPF annex 19A. with the addition of travel vouchers; and a combination of UPF, task-sharing, and travel vouchers. Although surgical services in Addis Ababa approx- Health and Financial Benefits with Vouchers imate those offered in many higher-income countries When direct nonmedical costs of care-seeking were (Cadotte and others 2010), care in rural Ethiopia is transferred from patients, overall health benefits sparse (WHO and GHWA 2008). Because of a lack Task-Sharing or Public Finance for Expanding Surgical Access in Rural Ethiopia: An Extended Cost-Effectiveness Analysis 345 Figure 19.2 Health Protection versus Financial Risk Protection per I$100,000 Spent, by Policy a. Health vs. financial risk protection per b. Health vs. financial risk protection per 100 I$100,000 spent, overall 50 I$100,000 spent, appendicitis Cases of poverty averted Cases of poverty averted 50 0 0 –50 –50 –100 –100 –150 –150 –200 –200 0 10 20 30 40 50 60 70 0 100 200 300 400 500 600 Deaths averted Deaths averted UPF (no vouchers) UPF + vouchers UPF Task-shifting UPF + task-shifting Task-sharing UPF (no vouchers) + task-sharing UPF + task-sharing + vouchers c. Health vs. financial risk protection per d. Health vs. financial risk protection per 50 I$100,000 spent, obstetric 100 I$100,000 spent, trauma Cases of poverty averted Cases of poverty averted 0 50 0 –50 –50 –100 –100 –150 –150 –200 –200 0 50 100 150 200 250 300 0 10 20 30 40 50 60 Deaths averted Deaths averted UPF Task-shifting UPF + task-shifting UPF Task-shifting UPF + task-shifting Note: In the absence of vouchers, policies create cases of poverty, driven in large part by direct nonmedical costs. These cases of poverty are averted by the introduction of vouchers. UPF = universal public finance. of providers—most of the few surgeons in the coun- Campbell 2011) and emergency obstetric care (Ejembi try live and work in urban centers (Berhan 2008; and others 2013; Kruk and others 2007; Sitrin and Surgical Society of Ethiopia 2013)—as well as high others 2013). We examined both policies in the setting costs, many surgical conditions go untreated, con- of surgery. tributing to a large burden of surgical disease in this Unlike many global health interventions, surgery is country. Accordingly, evaluations of policy strategies a relatively nebulous service with indistinct borders. As to improve access to surgical care in this setting are a result, it is often provided by disparate, poorly orga- needed. nized platforms (Shrime, Sleemi, and Thulasiraj 2014). The provision of universal health care is a focus To facilitate analysis, a bundle of nine surgical proce- of the WHO (WHO 2013b). Thus, UPF has been dures for 13 conditions was defined and a model built proposed for interventions ranging from rotavirus based on data from nationwide surveys and the pub- vaccination (Verguet, Murphy, and others 2013) to lished literature (Central Statistical Agency [Ethiopia] dental services (Jadidfard, Yazdani, and Khoshnevisan and ICF International 2012). This model proved to be 2012) to emergency obstetric care (Bucagu and well calibrated to current health outcomes in Ethiopia others 2012). Task-sharing has also been promoted, (Shiferaw and others 2013). with nonspecialist doctors and nonphysicians increas- The results of this analysis explicitly illustrate tradeoffs ingly filling a deficit in medical services (Scott and between health and financial risk protection. We found, 346 Essential Surgery Figure 19.3 Distribution of Health Benefits and Cases of Poverty Averted, per I$100,000 Spent, across Wealth Quintiles a. Universal public finance b. Task-sharing 250 0 Poorest Rich Richest Cases of poverty averted Cases of poverty averted 200 Rich –100 150 –200 100 –300 Middle 50 Richest Poorest 0 Middle Poor –400 Poor –50 –500 0 1 2 3 4 5 6 7 60 62 64 66 68 70 72 74 Deaths averted Deaths averted c. Universal public financing + task-sharing d. Universal public financing + vouchers 150 140 120 Cases of poverty averted Cases of poverty averted 100 Middle Rich 100 Poor 50 Poorest 80 0 Richest 60 –50 Poor 40 –100 20 Rich Richest Poorest Middle –150 0 0 5 10 15 20 0 0.5 1.0 1.5 2.0 2.5 3.0 Deaths averted Deaths averted e. Universal public financing + task-sharing + vouchers 80 Middle Cases of poverty averted 60 Poor 40 20 Rich Richest Poorest 0 0 1 2 3 4 5 6 Deaths averted for example, that per I$100,000 spent, task-sharing averts the decreased magnitude of this effect when com- approximately 65 deaths while simultaneously impover- pared with task-sharing is due to a demand function ishing 155 individuals. The health benefits accrue pref- that is relatively inelastic to price, as well as to the erentially to the wealthiest, whereas the financial burden fact that UPF is a more expensive policy. Unlike with falls on the poor, in part because the rich, in this model, task-sharing, the health benefits of UPF accrue to the tended to be more sensitive to a lack of provider than poor because they are the most price sensitive; they to price. also, however, face the greatest risk of impoverishment. However, UPF averts only 3 deaths per I$100,000 Combining task-sharing with UPF buys more health spent but prevents impoverishment in 44 individuals; benefit for all quintiles than does UPF alone, but it does Task-Sharing or Public Finance for Expanding Surgical Access in Rural Ethiopia: An Extended Cost-Effectiveness Analysis 347 Figure 19.4 Heterogeneity in Results for Each of the Five Policies 100 50 Cases of impoverishment averted 0 –50 –100 –150 –200 –20 0 20 40 60 80 100 120 Deaths averted UPF Task-sharing Task-sharing + UPF + vouchers UPF + vouchers Task-sharing + UPF Note: UPF = universal public financing. so more markedly for the rich. Impoverishment contin- costs (Kruk and others 2007) decreased the amount of ues to weigh on the poor. any benefit bought per dollar by task-sharing policies Much of the impoverishment created occurs but had a minimal impact on the distributional pattern because, although demand for surgical services is for health and financial benefits. induced by their new availability, these services are This analysis has limitations. We used an often- not always free, and patients still have to pay for employed head-count approach to measuring impov- the nonmedical costs of obtaining care. For many erishment (Garg and Karan 2009; Habicht and others patients, these costs prove catastrophic (Kowalewski, 2006; Honda, Randaoharison, and Matsui 2011; Niens Mujinja, and Jahn 2002). This effect is made explicit and others 2012). Some authors, however, suggest that a when travel vouchers are included in the model. movable threshold (Ataguba 2012) or measures of depth Poverty is no longer created, but because these of poverty (Garg and Karan 2009) are more appropriate. policies are significantly more expensive, the amount We model the former in annex 19A, and the distribu- of health benefit achieved per dollar spent drops tional patterns of health and financial risk protection drastically. How such tradeoffs are to be handled is benefits remain essentially unchanged. It should be less clear and necessitates further substantial ethical noted, however, that the latter measure of poverty makes and patient-preference analyses. impoverishment in the poorest quintile much more Although the cost per quality-adjusted life year explicit. In the method presented above, individuals in cannot be calculated using the methodology employed the poorest quintile all fall below the national poverty here, a rough approximation using the median age line. No poverty can be created or averted in these in Ethiopia of 16.8 and average life expectancy, con- individuals because of that—an artifact which explains ditional on attaining that age, of 52.1 additional the fact that no cases of impoverishment occur in the years (WHO 2012) predicts that task-sharing will cost poorest in table 19.3. The impoverishing impact of each I$7,200 per life year gained; UPF + task-sharing + policy on the poorest quintile is, therefore, best seen in vouchers, the most expensive policy, will cost I$184,000 annex 19A. per life year gained. This method is also limited in that it does not mea- Although the base-case analysis did not include the sure counterfactual impoverishment well. Were a bread- start-up costs of a task-sharing program, adding these winner to suffer a catastrophic health event, that death 348 Essential Surgery may throw an entire household into poverty. This is not risk of impoverishment. Making surgery free protects explicitly addressed in our current analysis and is left to against impoverishment in the rich; health bene- future inquiry. fits and impoverishment both accrue to the poor. The strength of this analysis is in what it can show: Perhaps our most important finding is that impover- it highlights the significant tradeoffs inherent in policies ishment is not fully averted until patients no longer for increasing access to care in LMICs, which are not face nonmedical costs of accessing care. Further dissimilar from those tradeoffs seen in high-income research is warranted to refine how to choose among countries and upper-middle-income countries (Baicker these disparate policy benefits. and others 2013). In addition, the distribution of these benefits depends on the policy chosen: on the one hand, making surgery free at the point of care ANNEX appears primarily to improve financial risk protection The annex to this chapter is as follows. It is available at http:// among the richer segments of the rural Ethiopian www.dcp-3.org/surgery: population. On the other hand, the small benefits it has • Annex 19A. Extended Cost-Effectiveness Analysis on health accrue to the poorest. Conversely, task-sharing Methodology and Additional Results without vouchers creates cases of poverty while averting deaths across the entire population; the latter benefit primarily accrues to the richest, while the former harm NOTES accrues to the poorest. Because these are initially counterintuitive findings, The World Bank classifies countries according to four income the model was tested with multiple sensitivity analyses, groupings. Income is measured using gross national income (GNI) per capita, in U.S. dollars, converted from local currency including the following: allowing the demand function using the World Bank Atlas method. Classifications as of July to be more price elastic, including the costs of start-up 2014 are as follows: for a task-sharing program; increasing the probability of dying from untreated disease; decreasing the direct • Low-income countries (LICs) = US$1,045 or less in 2013 nonmedical cost; increasing the cost of complications, • Middle-income countries (MICs) are subdivided: including indirect costs in three separate ways; and • Lower-middle-income = US$1,046 to US$4,125 modeling the effect of taxation to pay for the pro- • Upper-middle-income (UMICs) = US$4,126 to US$12,745 posed policies. Although the magnitude of the ben- • High-income countries (HICs)= US$12,746 or more efits bought per dollar changes with these sensitivity analyses, the changes are often small. More important, 1. http://www.r-project.org. except in the case of taxation, the distribution of the benefits across wealth quintiles is robust to these sen- sitivity analyses. REFERENCES How to decide among the modeled policies remains Abbas, Z. G., and L. K. Archibald. 2005a. “Epidemiology a matter of further research, political debate, and ethical of Diabetic Foot in Africa.” Medical Science Monitor: analysis. Normative statements about how these choices International Medical Journal of Experimental and Clinical should be made and their potential unintended conse- Research 11 (8): 262–70. quences on income inequality are not the goal of this ———. 2005b. “Tropical Diabetic Hand Syndrome. chapter. Instead, we believe that this type of analysis can Epidemiology, Pathogenesis, and Management.” American facilitate open, fair, and well-informed deliberative pro- Journal of Clinical Dermatology 6 (1): 21–28. cesses for making these decisions. Adinma, J. I. B., E. D. Adinma, L. Ikeako, and C. Ezeama. 2011. “Abortion Treatment by Health Professionals in South-Eastern Nigeria.” Journal of Obstetrics and Gynaecology CONCLUSION 31 (6): 529–32. This chapter is the first to examine, simultane- Admasu, A. 2004. “Analysis of Ruptured Uterus in Debre Markos Hospital, Ethiopia.” East African Medical Journal ously, the health and financial benefits of policies 81 (1): 52–55. for improving access to surgical services in LMICs. Admasu, K., A. Haile-Mariam, and P. Bailey. 2011. “Indicators It highlights tensions between the two sources of for Availability, Utilization, and Quality of Emergency benefit and makes explicit their distributional pat- Obstetric Care in Ethiopia, 2008.” International Journal of terns across wealth quintiles. Task-sharing without Gynecology and Obstetrics 115 (1): 101–05. vouchers appears to improve the health of rural Alemayehu, W., K. Ballard, and J. Wright. 2013. “Primary Ethiopia but to simultaneously put the poorest at Repair of Obstetric Uterine Rupture Can Be Safely Task-Sharing or Public Finance for Expanding Surgical Access in Rural Ethiopia: An Extended Cost-Effectiveness Analysis 349 Undertaken by Non-specialist Clinicians in Rural Ethiopia: Demissie, M. 2001. “Small Intestinal Volvulus in Southern A Case Series of 386 Women.” BJOG: An International Ethiopia.” East African Medical Journal 78 (4): 208–11. Journal of Obstetrics and Gynaecology 120 (4): 505–08. Deneke, A., and B. Tadesse. 2001. “Incidence, Patterns, and Ali, Y. 1995. “Analysis of Caesarean Delivery in Jimma Hospital, Clinical Presentation of Acute Appendicitis in Adults at South-Western Ethiopia.” East African Medical Journal Zewditu Memorial Hospital (ZMH).” East and Central 72 (1): 60–63. African Journal of Surgery 6 (2): 47–50. Alkire, B., J. Vincent, C. Burns, I. Metzler, P. Farmer, and others. Ejembi, C. L., P. Norick, A. Starrs, and K. Thapa. 2013. 2012. “Obstructed Labor and Caesarean Delivery: The Cost “New Global Guidance Supports Community and Lay and Benefit of Surgical Intervention.” PLoS One 7 (4): e34595. Health Workers in Postpartum Hemorrhage Prevention.” Anderson, D. W., P. A. Goldberg, U. Algar, R. Felix, and International Journal of Gynaecology and Obstetrics 122 (3): R. S. Ramesar. 2007. “Mobile Colonoscopic Surveillance 187–89. Provides Quality Care for Hereditary Nonpolyposis Fantu, S., H. Segni, and F. Alemseged. 2010. “Incidence, Causes, Colorectal Carcinoma Families in South Africa.” Colorectal and Outcome of Obstructed Labor in Jimma University Disease 9 (6): 509–14. Specialized Hospital.” Ethiopian Journal of Health Sciences Andersson, R. 2007. “The Natural History and Traditional 20 (3): 145–51. Management of Appendicitis Revisited: Spontaneous Garg, C. C., and A. K. Karan. 2009. “Reducing Out-of-Pocket Resolution and Predominance of Prehospital Perforations Expenditures to Reduce Poverty: A Disaggregated Analysis Imply That a Correct Diagnosis Is More Important Than at Rural-Urban and State Level in India.” Health Policy and an Early Diagnosis.” World Journal of Surgery 31 (1): Planning 24 (2): 116–28. 86–92. Gaym, A. 2002. “Elective Hysterectomy at Tikur Anbessa Ataguba, J. E.-O. 2012. “Reassessing Catastrophic Health-Care Teaching Hospital, Addis Ababa.” Ethiopian Medical Journal Payments with a Nigerian Case Study.” Health, Economics, 40 (3): 217–26. Policy and Law 7: 309–26. Gessessew, A., G. A. Barnabas, N. Prata, and K. Weidert. 2011. Baicker, K., S. L. Taubman, H. L. Allen, M. Bernstein, “Task Shifting and Sharing in Tigray, Ethiopia, to Achieve J. H. Gruber, and others. 2013. “The Oregon Experiment: Comprehensive Emergency Obstetric Care.” International Effects of Medicaid on Clinical Outcomes.” New England Journal of Gynecology and Obstetrics 113 (1): 28–31. Journal of Medicine 368: 1713–22. Goyaux, N., R. Leke, N. Keita, and P. Thonneau. 2003. Berhan, Y. 2008. “Medical Doctors Profile in Ethiopia: “Ectopic Pregnancy in African Developing Countries.” Acta Production, Attrition, and Retention.” Ethiopian Medical Obstetrica et Gynecologica Scandinavica 82: 305–12. Journal 46 (S1): 1–77. Groen, R., M. Samai, K.-A. Stewart, L. D. Cassidy, T. Kamara, Bickler, S. W., T. G. Weiser, N. Kassebaum, H. Higashi, D. C. Chang, and others. 2012. “Untreated Surgical Conditions in and others. 2015. “Global Burden of Surgical Conditions.” In Sierra Leone: A Cluster Randomised, Cross-Sectional, Disease Control Priorities (third edition): Volume 1, Essential Countrywide Survey.” The Lancet 380 (9847): 1082–87. Surgery, edited by D. T. Jamison, R. Nugent, H. Gelband, Gulam-Abbas, Z., J. Lutale, S. Morbach, and L. Archibald. 2002. S. Horton, P. Jha, and R. Laxminarayan. Washington, DC: “Clincal Outcome of Diabetes Patients Hospitalized with World Bank. Foot Ulcers, Dar es Salaam, Tanzania.” Diabetic Medicine Bucagu, M., J. M. Kagubare, P. Basinga, F. Ngabo, 19: 575–79. B. K. Timmons, and others. 2012. “Impact of Health Habicht, J., K. Xu, A. Couffinhal, and J. Kutzin. 2006. “Detecting Systems Strengthening on Coverage of Maternal Health Changes in Financial Protection: Creating Evidence for Services in Rwanda, 2000–10: A Systematic Review.” Policy in Estonia.” Health Policy and Planning 21 (6): 421–31. Reproductive Health Matters 20 (39): 50–61. Hailu, S. 2000. “Paediatric Thoracic Empyema in an Ethiopian Cadotte, D. W., K. Viswanath, A. Cadotte, M. Bernstein, Referral Hospital.” East African Medical Journal 77 (11): T. Munie, and others. 2010. “The Consequence of 618–21. Delayed Neurosurgical Care at Tikur Anbessa Hospital, Harris, A. M., P. L. Althausen, J. Kellam, M. Bosse, and R. Castillo. Addis Ababa, Ethiopia.” World Neurosurgery 73 (4): 2009. “Complications Following Limb-Threatening Lower 270–75. Extremity Trauma.” Journal of Orthopedic Trauma 23 (1): 1–6. Central Statistical Agency [Ethiopia] and ICF International Honda, A., P. G. Randaoharison, and M. Matsui. 2011. (2012). Ethiopia Demographic and Health Survey, 2011. “Affordability of Emergency Obstetric and Neonatal Care Addis Ababa, Ethiopia, and Calverton, MD: Central at Public Hospitals in Madagascar.” Reproductive Health Statistical Agency and ICF International. Matters 19 (37): 10–20. Chao, T. E., M. Burdic, K. Ganjawalla, M. Derbew, C. Keshian, Hsia, R. Y., N. A. Mbembati, S. MacFarlane, and M. E. Kruk. and others. 2012. “Survey of Surgery and Anesthesia 2012. “Access to Emergency and Surgical Care in Sub- Infrastructure in Ethiopia.” World Journal of Surgery Saharan Africa: The Infrastructure Gap.” Health Policy and 36 (11): 2545–53. Planning 27 (3): 234–44. Cobben, L., A. Otterloo, and J. Puylaert. 2000. “Spontaneously Hu, D., D. Grossman, C. Levin, K. Blanchard, and S. J. Goldie. Resolving Appendicitis: Frequency and Natural History in 2009. “Cost-Effectiveness Analysis of Alternative First- 60 Patients.” Radiology 215 (2): 349–52. Trimester Pregnancy Termination Strategies in Mexico 350 Essential Surgery City.” BJOG: An International Journal of Obstetrics and Razavi, S. M., M. Ibrahimpoor, A. S. Kashani, and A. Jafarian. Gynaecology 116 (6): 768–79. 2005. “Abdominal Surgical Site Infections: Incidence Igberase, G. O., and P. N. Ebeigbe. 2008. “Exploring the Pattern and Risk Factors at an Iranian Teaching Hospital.” BMC of Complications of Induced Abortion in a Rural Mission Surgery 5: 2. Tertiary Hospital in the Niger Delta, Nigeria.” Tropical Reddy, S. R., D. Ross-Degnan, A. M. Zaslavsky, S. B. Soumerai, Doctor 38 (3): 146–48. and A. K. Wagner. 2013. “Health Care Payments in the Asia Ilbawi, A. M., E. M. Einterz, and D. Nkusu. 2013. “Obstacles Pacific: Validation of Five Survey Measures of Economic to Surgical Services in a Rural Cameroonian District Burden.” International Journal for Equity in Health 12: 49. Hospital.” World Journal of Surgery 37 (6): 1208–15. Schreyer, P., and F. Koechlin. 2002. “Purchasing Power Parity— Jadidfard, M. P., S. Yazdani, and M. H. Khoshnevisan. 2012. Measurement and Uses.” OECD Statistics Brief 3. http:// “Social Insurance for Dental Care in Iran: A Developing www.oecd.org/std/prices-ppp/2078177.pdf. Scheme for a Developing Country.” Oral Health and Dental Scott, K., and C. Campbell. 2011. “Retreat from Alma Ata? The Management 11 (4): 189–98. WHO’s Report on Task Shifting to Community Health Kifle, Y. A., and T. H. Nigatu. 2010. “Cost-Effectiveness Analysis Workers for AIDS Care in Poor Countries.” Global Public of Clinical Specialist Outreach as Compared to Referral Health 6 (2): 125–38. System in Ethiopia: An Economic Evaluation.” Cost Shiferaw, S., M. Spigt, M. Godefrooij, Y. Melkamu, and Effectiveness and Resource Allocation 8 (1): 13. M. Tekie. 2013. “Why Do Women Prefer Home Births in Knowlton, L. M., S. Chackungal, B. Dahn, D. LeBrun, Ethiopia?” BMC Pregnancy and Childbirth 13: 5. J. Nickerson, and others. 2013. “Liberian Surgical and Shrime, M. G., A. Sleemi, and R. D. Thulasiraj. 2014. “Charitable Anesthesia Infrastructure: A Survey of County Hospitals.” Platforms in Global Surgery: A Systematic Review of World Journal of Surgery 37 (4): 721–29. Their Effectiveness, Cost-Effectiveness, Sustainability, and Kowalewski, M., P. Mujinja, and A. Jahn. 2002. “Can Mothers Role in Training.” World Journal of Surgery. doi:10.1007 Afford Maternal Health Care Costs? User Costs of Maternity /s00268-014-2516-0. Services in Rural Tanzania.” African Journal of Reproductive Singh, S., T. Fetters, H. Gebreselassie, A. Abdella, Y. Gebrehiwot, Health 6 (1): 65–73. and others. 2010. “The Estimated Incidence of Induced Kruk, M. E., C. Pereira, F. Vaz, S. Bergstrom, and S. Galea. Abortion in Ethiopia, 2008.” International Perspectives on 2007. “Economic Evaluation of Surgically Trained Assistant Sexual and Reproductive Health 36 (1): 16–25. Medical Officers in Performing Major Obstetric Surgery in Singh, S., L. Remez, and A. Tartaglione 2010. Methodologies Mozambique.” BJOG: An International Journal of Obstetrics for Estimating Abortion Incidence and Abortion-Related and Gynaecology 114 (10): 1253–60. Morbidity: A Review. New York: Guttmacher Institute. Linden, A. F., F. S. Sekidde, M. Galukande, L. M. Knowlton, Sitrin, D., T. Guenther, J. Murray, N. Pilgrim, S. Rubayet, and S. Chackungal, and others. 2012. “Challenges of Surgery in others. 2013. “Reaching Mothers and Babies with Early Developing Countries: A Survey of Surgical and Anesthesia Postnatal Home Visits: The Implementation Realities of Capacity in Uganda’s Public Hospitals.” World Journal of Achieving High Coverage in Large-Scale Programs.” PLoS Surgery 36 (5): 1056–65. One 8 (7): e68930. Mawalla, B., S. E. Mshana, P. L. Chalya, C. Imirzalioglu, and Sohn, A. H., F. M. Parvez, T. Vu, H. H. Hai, N. N. Bich, and W. Mahalu. 2011. “Predictors of Surgical Site Infections others. 2002. “Prevalence of Surgical-Site Infections and among Patients Undergoing Major Surgery at Bugando Patterns of Antimicrobial Use in a Large Tertiary Care Medical Centre in Northwestern Tanzania.” BMC Surgery Hospital in Ho Chi Minh City, Vietnam.” Infection Control 11 (1): 21. and Hospital Epidemiology 23 (7): 382–87. Mock, C.N., P. Donkor, A. Gawande, D. T. Jamison, Surgical Society of Ethiopia. 2013. “List of SSE Members.” M. E. Kruk, and H. T. Debas. 2015. “Essential Surgery: Key Addis Ababa: Surgical Society of Ethiopia. Messages of This Volume.” In Disease Control Priorities Thomas, T., and B. Meggitt. 1981. “A Comparative Study of (third edition): Volume 1, Essential Surgery, edited by Methods for Treating Fractures of the Distal Half of the D. T. Jamison, R. Nugent, H. Gelband, S. Horton, P. Jha, Femur.” Journal of Bone and Joint Surgery 63B (1): 3–6. and R. Laxminarayan. Washington, DC: World Bank. Thonneau, P., Y. Hijazi, N. Goyaux, T. Calvez, and N. Keita. Neilson, J., T. Lavender, S. Quenby, and S. Wray. 2003. 2002. “Ectopic Pregnancy in Conakry, Guinea.” Bulletin of “Obstructed Labour.” British Medical Bulletin 67 (1): the World Health Organization 80: 365–70. 191–204. UN (United Nations). 2014. “Purchasing Power Parities Niens, L. M., E. Van de Poel, A. Cameron, M. Ewen, R. Laing, Conversion Factor, Local Currency Unit to International and others. 2012. “Practical Measurement of Affordability: Dollar.” United Nations Statistics Division, New York, An Application to Medicines.” Bulletin of the World Health New York. Organization 90 (3): 219–27. Verguet, S., C. Gauvreau, S. Mishra, M. MacLennan, S. Murphy, Okeny, P. K., T. G. Hwang, and D. M. Ogwang. 2011. “Acute and others. Forthcoming. “The Consequences of Raising Bowel Obstruction in a Rural Hospital in Northern Tobacco Taxes on Household Health and Finances among Uganda.” East and Central African Journal of Surgery Richer and Poorer Smokers in China: An Extended Cost- 16 (1): 65–70. effectiveness Analysis.” The Lancet Global Health. Task-Sharing or Public Finance for Expanding Surgical Access in Rural Ethiopia: An Extended Cost-Effectiveness Analysis 351 Verguet, S., R. Laxminarayan, and D. T. Jamison. 2014. ———. 2012. “World Health Statistics: Ethiopia.” http://apps “Universal Public Finance of Tuberculosis Treatment in .who.int/gho/data/view.country.8500. India: An Extended Cost-Effectiveness Analysis.” Health ———. 2013a. “Global Health Estimates Summary Tables.” Economics 24: 318–32. doi:10.1002/hec.3019. http://www.who.int/healthinfo/global_burden_disease/en/. Verguet, S., S. Murphy, B. Anderson, K. A. Johansson, R. Glass, ———. 2013b. World Health Report 2013: Research for Universal and others. 2013. “Public Finance of Rotavirus Vaccination Health Coverage. Geneva: WHO. in India and Ethiopia: An Extended Cost-Effectiveness WHO and GHWA (Global Health Workforce Alliance). 2008. Analysis.” Vaccine 31 (42): 4902–10. “Ethiopia’s Human Resources for Health Programme.” Vlassoff, M., T. Fetters, S. Kumbi, and S. Singh. 2012. “The Country Case Study. WHO and GHWA, Geneva. Health System Cost of Postabortion Care in Ethiopia.” WHO, UNICEF, UNFPA, and World Bank. 2012. Trends in International Journal of Gynaecology and Obstetrics Maternal Mortality: 1990–2010. Geneva: WHO. 118 (S2): S127–33. Worku, S., and M. Fantahun. 2006. “Unintended Pregnancy Vlassoff, M., J. Shearer, D. Walker, and H. Lucas. 2008. and Induced Abortion in a Town with Accessible Family Economic Impact of Unsafe Abortion-Related Morbidity Planning Services: The Case of Harar in Eastern Ethiopia.” and Mortality: Evidence and Estimation Challenges. Ethiopian Journal of Health Development 20 (2): 79–83. Research Report 59, Institute of Development Studies, World Bank. 2012. “Country Indicators: Ethiopia.” World Brighton, U.K. Bank, Washington, DC. WHO (World Health Organization). 2007. Everybody’s ———. 2013. “World Development Indicators, GDP Deflators.” Business: Strengthening Health Systems to Improve Health World Bank, Washington, DC. http://data.worldbank.org Outcomes. Geneva: WHO. /indicator/NY.GDP.DEFL.ZS. ———. 2008. “Global Burden of Disease 2004 Update: ———. 2014. “Maternal Mortality Ratio (modeled esti- Disability Weights for Diseases and Conditions.” WHO, mate, per 100,000 live births).” http://data.worldbank.org Geneva. /indicator/SH.STA.MMRT. 352 Essential Surgery Chapter 20 Global Surgery and Poverty William P. Schecter and Sweta Adhikari INTRODUCTION Many hospitals serving poor people charge a fee for care. Sometimes the charge is based on the belief that Surgically treated disorders represent a significant pro- uncompensated services are not valued by those who portion of the burden of the diseases associated with receive them, although no literature confirms or refutes poverty. Furthermore, surgery is a cost-effective method this hypothesis. More often, the costs of admission, of reducing suffering, prolonging life, and restoring sick medications, and food are based on the harsh economic and injured people to health and economic productivity. realities of impoverished countries. However, even a Some 2 billion people worldwide lack access to sur- nominal fee may serve as a major barrier to destitute gical care (Funk and others 2010). The maldistribution patients who need care. of surgical resources between high-income countries (HICs) and low- and middle-income countries (LMICs) is striking. HICs have an average of 14 operating rooms DISPARITIES BETWEEN LOW- AND and 45 trained surgeons per 100,000 population; LMICs have fewer than 2 operating rooms and 1 trained sur- HIGH-INCOME COUNTRIES geon per 100,000 population (MacGowan 1987). Only Surgery can have a profound impact on the lives and 3.5 percent of the estimated 234 million operations livelihood of millions of low-income patients world- performed annually occur in the poorest countries that wide. This section reviews the differential burden of spend less than US$100 per capita annually on health disease and access to surgical care between HICs and care, although these countries account for 34.8 percent LMICs, highlighting conditions with the highest burden of the global population (Weiser and others 2008). and weakest services in LMICs. The barriers to surgical access, including lack of awareness, fear, distance, and cultural beliefs, are many. However, the principal barrier appears to be the Obstetric Conditions cost of care (Malhotra and others 2005). For example, In 2011, approximately 279,000 maternal deaths occurred 91 percent of the respondents to a survey of cataract globally (WHO 2013b). The deaths were primarily due patients in Ghana cited cost as a significant barrier to to obstructed labor and peripartum hemorrhage. The treatment (Gyasi, Amoaku, and Asamany 2007). Similar burden of these deaths is born primarily by poor women barriers have been cited for hospital delivery and access in LMICs; for example, 99 percent of hemorrhage-related to obstetric services in rural Kenya (Myangome and peripartum deaths occur in LMICs (Haeri and Dildy others 2012). 2012). The key to reducing the maternal mortality ratio Corresponding author: William P. Schecter, MD, FACS, FCCM, University of California, San Francisco, bschect@sfghsurg.ucsf.edu. 353 is the presence of a trained attendant at every birth and Cherian 2008). Access to trained orthopedists, image urgent access to obstetric care (Wise and Clark 2010). intensification, internal fixation, and myocutaneous flap Although vesico-vaginal fistula due to obstructed coverage of exposed bone is extremely limited. labor is rare in HICs, as many as 3.5 million women Suboptimal quality of trauma and orthopedic care may suffer from this condition in LMICs (Wall and in LMICs leads to an excessive number of amputations, others 2008). In a recent study of 278 women with with consequent detrimental effects on mobility and genitourinary fistula in Pakistan, all of the vesico- quality of life. A Nigerian study concludes that most of vaginal fistula were repaired transvaginally, with suc- the amputations were preventable and were caused by cess rates of 85 percent, 91 percent, and 96 percent, post-fracture splintage gangrene (Yakubu, Muhammad, on the first, second, and third attempts, respectively and Mabogunje 1996). (Sachdev and others 2009). These procedures require advanced training and experience, and the demand greatly exceeds the supply of surgeons and institu- Burns tions. The ultimate solution is prevention of the initial Although few data document the epidemiology of burn damage by providing obstetric services to all pregnant injuries, little doubt exists that the global burden of women. In the interim, an organized international burns is significant, with the majority of cases occurring effort is necessary to help these women who are in Asia and Sub-Saharan Africa (Burd and Yuen 2005). socially isolated and stigmatized by incontinence and The reasons for the unequal global distribution of burns offensive odor. are unknown, but they probably include the widespread use of open fires for cooking and heating, the absence of fire codes governing building construction, and inade- Trauma quate burn prevention knowledge in adults (Olabanji In 2011, nearly 5 million people died of injuries; of these and others 2007). The problem is so significant that deaths, 88 percent occurred in LMICs (WHO 2013b). the World Health Organization (WHO) included burn Road traffic accidents were the major cause of morbidity care education as part of its course on essential emer- and mortality (Hazen and Ehiri 2006). gency surgical procedures in resource-limited facilities The vast majority of deaths in LMICs occurs in the (Cherian and others 2004). Burn care has been suggested field because of the lack of organized prehospital med- as an essential part of a context-appropriate curriculum ical care and transport systems (WHO 2004). Patients for surgical residents training in Sub-Saharan Africa with lower socioeconomic status have a greater risk of (Mutabdzic and others 2013). prehospital death (Mock and others 1998). Table 20.1 illustrates this preponderance of prehospital trauma deaths in LMICs compared with HICs. Cancer For every trauma death, many more injured patients Among the many clinical and sociodemographic factors sustain temporary or permanent disabilities (Mock contributing to disparities in cancer rates, the associa- and Cherian 2008). Musculoskeletal injuries account tion between poverty and cancer is so strong that the for the majority of the disability burden (Peden and former director of the National Cancer Institute, Samuel others 2004). In most LMICs, musculoskeletal injuries Broder, likened poverty to a carcinogen (Broder 1991; are treated by general surgeons, general practitioners, Greenlee and Howe 2009). Each year, 12.4 million cancer and nonphysician clinicians (Curci 2012; Mock and cases are newly diagnosed, and nearly 8 million patients with cancer died in 2011; more than half of these cases occurred in LMICs. The number of new cancer cases diagnosed annually Table 20.1 Proportion of Road Deaths by Setting in Three Cities is expected to increase 70 percent by 2030; the largest increases are projected to be in LMICs (Franceschi and Percent Wild 2013). A devastating and largely preventable malig- Kumasi, Monterrey, Seattle, Washington, nancy in women living in LMICs is carcinoma of the Setting Ghana Mexico United States cervix. The annual global burden is 530,000 new cases and 275,000 deaths (Sahasrabuddhe and others 2012). Prehospital 81 72 59 The human papilloma virus (HPV) causes cervical can- Emergency room 5 21 18 cer, and the development of an HPV vaccine offers the Hospital ward 14 7 23 hope of preventing this malignancy, which almost always Source: Mock and others 1998. presents as advanced disease in poor women (Woo and 354 Essential Surgery Omar 2011). However, the cultural, religious, educa- Substantial wealth-based differences in access to tional, and economic barriers to implementation of a life-saving obstetric services occur between, across, and worldwide vaccination program are major challenges, within countries. An analysis of cesarean delivery rates particularly in LMICs. over a period of 20 years in 26 countries in South Asia and Sub-Saharan Africa found that the cesarean section rate was less than 2 percent among the poorest quintile Visual Impairment in 21 out of the 25 countries, a figure well below the Approximately 285 million people are visually impaired; 5 percent to 15 percent threshold suggested by the WHO of this number, 39 million are blind, and 246 million rate in the richest quintile across countries (figure 20.1) have severe or moderate visual impairment. According (Cavallaro and others 2013). In the Sub-Saharan African to the WHO (2013a), 80 percent of the global burden countries included in the study, coverage was less than of visual impairment is preventable. Some 90 percent of 1 percent in the poorest quintile. Coverage was also visually impaired people live in LMICs (VISION 2020, higher for women living in urban areas, with the WHO 2013a), and blindness and poverty are closely urban rich faring best, followed by those from rural correlated. In a survey of blind people in Maiduguri, rich households; the rate was still higher for rural rich Nigeria, only 8.2 percent were employed, 75.3 percent women compared with urban poor women (figure 20.2) were engaged in begging, and 69 percent lived on less (Cavallaro and others 2013). than US$1 dollar a day (Ribadu and Mahmoud 2010). To promote access to care, countries have increasingly Eye surgery is a cost-effective method of treating many implemented user fee exemptions for obstetric surgery. common forms of visual impairment and blindness. These exemptions have increased utilization of cesarean Providing extracapsular cataract surgery to 95 percent sections in countries such as Mali and Senegal (Witter of those who need it would avert more than 3.5 million and others 2010). However, despite the fee exemptions, disability-adjusted life years (DALYs) per year globally. women frequently have additional costs for transpor- The integrated WHO SAFE (surgery, antibiotics, facial tation or medical supplies. In Mali, five years after the cleanliness, and environmental improvement) program abolition of user fees for cesarean section, its utilization for the treatment of trachoma would avert 11 million remained higher among women from richer households; DALYs per year globally; cost-effectiveness ranges from women in the top two quintiles received 58 percent I$13 to I$78 per DALY averted across regions (Baltussen of those surgeries, compared with 27 percent for the and others 2005).1 Outreach programs to correct refrac- bottom two quintiles (El-Khoury, Hatt, and Gandaho tive errors with inexpensive eyeglasses would greatly 2012). The lack of hospitals in rural areas and high reduce the burden of visual impairment. transportation costs continue to be significant barriers to accessing obstetric care in Mali. INEQUITIES IN SURGICAL ACCESS WITHIN COUNTRIES FINANCIAL BURDEN OF SURGICAL Substantial inequities exist in access to surgical services CONDITIONS within countries based on residence, income, and age Few poor households are able to save sufficient funds for among other social stratifiers. For example, access to surgery, particularly emergency surgery, which by defi- obstetric surgeries is inadequate in LMICs compared nition is unpredictable. The cost of emergency obstetric with HICs. Facility-based health services are less equi- care is frequently a large economic shock for families table than community-delivered services in the area and can lead to catastrophic health spending—defined of maternal, newborn, and child health interventions as spending more than 40 percent of annual nonfood (Barros and others 2012). Skilled birth attendant cov- income on health care—and impoverishment. Studies erage, an indicator of facility-based care, was found from LMICs demonstrate that a major portion of to be the most inequitable service among maternal, expenditures for obstetric care is for drugs and medical newborn, and child health interventions in 54 coun- supplies, transportation to the facility, and food and hos- tries with high maternal and child mortality—the pital stay. Patients in some LMICs seek private service Millennium Development Goals Countdown Countries. providers when third-level hospitals lack quality of care Barros and others (2012) report that households in the and have inadequate supplies; this practice significantly richest wealth quintile had 52 percent higher utilization increases patient costs (Kruk 2013). of skilled birth attendants than those in the poorest In Burkina Faso, emergency obstetric surgery imposes quintile. a major financial burden on families; 30.5 percent of Global Surgery and Poverty 355 Figure 20.1 Rate of Cesarean Sections for 25 Millennium Development Goals Countdown Countries 30 25 Cesarean sections as a percentage of deliveries 20 15 10 5 0 Poorest quintile Poor quintile Middle quintile Rich quintile Richest quintile Bangladesh Côte d’Ivoire Kenya Mozambique Rwanda Benin Ethiopia Lesotho Nepal Senegal Burkina Faso Ghana Madagascar Niger Uganda Cameroon Guinea Malawi Nigeria Zambia Chad India Mali Pakistan Zimbabwe Source: Data from Cavallaro and others 2013. Note: 2002–06 data for Cameroon, Chad, Côte d’Ivoire, India, Mali, Niger, Mozambique, and Pakistan; 2007–11 data for Bangladesh, Benin, Burkina Faso, Ethiopia, Ghana, Guinea, Kenya, Lesotho, Madagascar, Malawi, Nepal, Nigeria, Rwanda, Senegal, Uganda, Zambia, and Zimbabwe. women with severe pregnancy complications reported obstetric emergency complicated by dystocia accounted having to borrow money to pay hospital bills, compared for 34 percent of annual household cash expenditure. with 8 percent of women with normal deliveries. Nearly About 8 percent of women who received care for 33 percent of women in the poorest quintile who expe- severe obstetric complication left the hospital before the rienced severe complications sold assets to pay hospital discharge date to reduce costs, and 13 percent left the bills, whereas none of the women in the top two quin- hospital without making any payments (Borghi 2003). tiles reported selling assets to cover such costs (Storeng Evidence from Madagascar shows that out-of-pocket and others 2008). costs for cesarean section equate to catastrophic expenses In Ghana, the cost of a delivery with severe com- for poorer households (Honda, Randaoharison, and plications, including hemorrhage, was 5 percent to Matsui 2011). Women from the higher socioeconomic 8 percent of annual cash expenditure of a household, group spent 33 percent of their annual nonfood and up to 19 percent of annual household expendi- household expenditures on cesarean section, com- ture for the poorest quintile. In Benin, the total cost of pared with 105 percent for women in the medium 356 Essential Surgery socioeconomic group and 109 percent for women in Figure 20.2 Distribution of Cesarean Deliveries by Urban and Rural the lower socioeconomic group. Overall, 62 percent Households, 2002–11 of the total cost of cesarean section was for drugs 20 and medical supplies. In an Indonesian study, house- holds reported spending 23 percent to 32 percent of Cesarean sections as a percentage subsistence-level income on complicated obstetric care. Without insurance, 68 percent of the households in the 15 poorest quintile, compared with 8.8 percent in the rich- of deliveries est quintile, had catastrophic expenditures for obstetric care (Quayyum and others 2010). 10 These figures demonstrate the dual burden of pov- erty in obtaining surgical care. Poor women and men frequently cannot afford the costs of surgery, includ- 5 ing transportation to surgical facilities. When they are able to obtain emergency surgery, they suffer finan- cially from high levels of catastrophic spending and 0 impoverishment. Rural poor Urban poor Rural rich Urban rich Similar issues pertain to other conditions. For example, injuries can have a devastating effect on low-income Southern Asia households through both the actual treatment costs and Western and Central Africa the lost wages of the injured persons and family members Eastern and Southern Africa who must take time off from work or other activities to Source: Data from Cavallaro and others 2013. care for them. One study from Ghana looked at the effect Note: Figure groups data from 25 Millennium Development Goal Countdown Countries into three of a serious injury with a disability time of one month categories by geographic region. Southern Asia includes Bangladesh, India, Nepal, and Pakistan. or more on families. The majority (64 percent) reported Western and Central Africa includes Benin, Burkina Faso, Cameroon, Chad, Côte d’Ivoire, Ghana, Guinea, Mali, Niger, Nigeria, and Senegal. Eastern and Southern Africa includes Ethiopia, Kenya, a decline in family income as a result of the injury; a Lesotho, Madagascar, Malawi, Mozambique, Rwanda, Uganda, Zambia, and Zimbabwe. substantial proportion (41 percent) of families had gone into debt. A majority of rural households (54 percent) reported a decline in farm food production due to the NOTES loss of labor of the injured persons and others who had to take time off to care for them. A large number The World Bank classifies countries according to four income (41 percent) of all families, rural and urban combined, groupings. Income is measured using gross national income (GNI) per capita, in U.S. dollars, converted from local cur- reported that family food consumption declined as a rency using the World Bank Atlas method. Classifications as of result of the injuries. This finding is especially notable July 2014 are as follows: given that many of these families already had children who suffered from or were on the brink of malnutrition • Low-income countries (LICs) = US$1,045 or less in 2013 (Mock and others 2003). • Middle-income countries (MICs) are subdivided: • Lower-middle-income = US$1,046 to US$4,125 • Upper-middle-income (UMICs) = US$4,126 to US$12,745 • High-income countries (HICs)= US$12,746 or more CONCLUSIONS Poverty and infirmity are closely related. Significant 1. One I$ was the equivalent of one U.S. dollar in 2000. improvement in global health is dependent on the economic development of LMICs, a more equitable distribution of economic resources, and improved edu- REFERENCES cation. Emerging data now indicate that surgery is an Baltussen, R. M., M. Sylla, K. D. Frick, and S. P. Mariotti. 2005. essential and cost-effective method of treating a signifi- “Cost-Effectiveness of Trachoma Control in Seven World cant portion of the global burden of disease engendered Regions.” Ophthalmic Epidemiology 12 (2): 91–101. by poverty. The international surgical community has Barros, A. J., C. Ronsmans, H. Axelson, E. Loaiza, A. D. Bertoldi, a professional responsibility to address the growing and others. 2012. “Equity in Maternal, Newborn, and disparity in surgical access and standards through an Child Health Interventions in Countdown to 2015: A integrated approach of economic, educational, and Retrospective Review of Survey Data from 54 Countries.” professional development. The Lancet (9822): 1225–33. Global Surgery and Poverty 357 Borghi, J. 2003. “Costs of Near-Miss Obstetric Complications Mock, C. N., and M. N. Cherian. 2008. “The Global Burden of for Women and Their Families in Benin and Ghana.” Health Musculoskeletal Injuries: Challenges and Solutions.” Clinical Policy and Planning 18 (4): 383–90. Orthopaedics and Related Research 466 (10): 2306–16. Broder, S. 1991. “Progress and Challenges in the National Cancer Mock, C. N., S. Gloyd, S. Adjei, F. Acheampong, and O. Gish. Program.” In Origins of Human Cancer: A Comprehensive 2003. “Economic Consequences of Injury and Resulting Review, edited by J. Brugge, T. Curran, E. Harlow, and Family Coping Strategies in Ghana.” Accident Analysis and F. McCormick, 27–33. Plainview, NY: Cold Spring Harbor Prevention 35 (1): 81–90. Laboratory Press. Mock, C. N., G. J. Jurkovich, D. nii-Amon-Kotei, C. Arreola- Burd, A., and C. Yuen. 2005. “A Global Study of Hospitalized Risa, and R. V. Maier. 1998. “Trauma Mortality Patterns in Paediatric Burn Patients.” Burns 31 (4): 432–38. Three Nations at Different Economic Levels: Implications Cavallaro, F. L., J. A. Cresswell, G. V. A. Franca, C. G. Vitora, for Global Trauma System Development.” Journal of Trauma A. J. D. Barros, and others. 2013. “Trends in Caesarean 44 (5): 804–12; discussion 812–14. Delivery by Country and Wealth Quintile: Cross-Sectional Mutabdzic, D., A. G. Bedada, B. Bakanisi, J. Motsumi, and Surveys in Southern Asia and Sub-Saharan Africa.” Bulletin G. Azzie. 2013. “Designing a Contextually Appropriate of the World Health Organization 91 (12): 914–22D. Surgical Training Program in Low-Resource Settings: The doi:10.2471/BLT.13.117598. Botswana Experience.” World Journal of Surgery 37 (7): Cherian, M. N., L. Noel, Y. Buyanjargal, and G. Salik. 2004. 1486–91. doi:10.1007/s00268-012-1731–9. “Essential Emergency Surgical Procedures in Resource- Myangome, F. K., P. A. Holding, K. M. Songola, and Limited Facilities: A WHO Workshop in Mongolia.” World G. K. Bomu. 2012. “Barriers to Hospital Delivery in a Rural Hospitals and Health Services 40 (4): 24–29. Setting in Coast Province, Kenya: Community Attitude Curci, M. 2012. “Task Shifting Overcomes the Limitations and Behaviours.” Rural and Remote Health 12 (2): 1852. of Volunteerism in Developing Nations.” Bulletin of the Olabanji, J. K., A. O. Oladele, F. O. Oginni, and O. G. Oseni. American College of Surgeons 97 (10): 9–14. 2007. “Burn Safety Knowledge in Adult Nigerians.” Annals El-Khoury, M., L. Hatt, and T. Gandaho. 2012. “User Fee of Burns and Fire Disasters 20 (3): 115–20. Exemptions and Equity in Access to Caesarean Sections: Peden, M., R. Scurfield, D. Sleet, D. Mohan, A. A. Hyder, and An Analysis of Patient Survey Data in Mali.” International others. 2004. World Report on Road Traffic Injury Prevention. Journal for Equity in Health 11: 49. Geneva: World Health Organization. Franceschi, S., and C. P. Wild. 2013. “Meeting the Global Quayyum, Z., M. Nadjib, T. Ensor, and P. K. Sucahya. 2010. Demands of Epidemiologic Transition: The Indispensable “Expenditure on Obstetric Care and the Protective Effect Role of Cancer Prevention.” Molecular Oncology 7 (1): 1–13. of Insurance on the Poor: Lessons from Two Indonesian Funk, L. M., T. G. Weiser, W. R. Berry, S. R. Lipsitz, A. F. Merry, Districts.” Health Policy Plan 25 (3): 237–47. and others. 2010. “Global Operating Theatre Distribution Ribadu, D. Y., and A. O. Mahmoud. 2010. “Assessment of and Pulse Oximetry Supply: An Estimation from Reported Interrelationship between Poverty and Blindness in Data.” The Lancet 376 (9746): 1055–61. Maiduguri, Nigeria.” Nigerian Postgraduate Medical Journal Greenlee, R. T., and H. L. Howe. 2009. “County-Level Poverty 17 (4): 308–12. and Distant Stage Cancer in the United States.” Cancer Sachdev, P. S., N. Hassan, R. M. Abbasi, and C. M. Das. 2009. Causes Control 20 (6): 989–1000. “Genito-Urinary Fistula: A Major Morbidity in Developing Gyasi, M., W. Amoaku, and D. Asamany. 2007. “Barriers to Countries.” Journal of Ayub Medical College Abbottabad Cataract Surgical Uptake in the Upper East Region of 21 (2): 8–11. Ghana.” Ghana Medical Journal 41 (4): 167–70. Sahasrabuddhe, V. V., G. P. Parham, M. H. Mwanahamuntu, Haeri, S., and G. A. Dildy, 3rd. 2012. “Maternal Mortality from and S. H. Vermund. 2012. “Cervical Cancer Prevention in Hemorrhage.” Seminars in Perinatology 36 (1): 48–55. Low- and Middle-Income Countries: Feasible, Affordable, Hazen, A., and J. E. Ehiri. 2006. “Road Traffic Injuries: Hidden Essential.” Cancer Prevention Research (Phila) 5 (1): 11–17. Epidemic in Less Developed Countries.” Journal of the Storeng, K. T., R. F. Baggaley, R. Ganaba, F. Ouattara, National Medical Association 98 (1): 73–82. M. S. Akoum, and others. 2008. “Paying the Price: The Cost Honda, A., P. G. Randaoharison, and M. Matsui. 2011. and Consequences of Emergency Obstetric Care in Burkina “Affordability of Emergency Obstetric and Neonatal Care Faso.” Social Science and Medicine 66 (3): 545–57. at Public Hospitals in Madagascar.” Reproductive Health Wall, L. L., J. Wilkinson, S. D. Arrowsmith, O. Ojengbedee, Matters 19 (37): 10–20. and H. Mabeya. 2008. “A Code of Ethics for the Fistula Kruk, M. E. 2013. “Universal Health Coverage: A Policy Whose Surgeon.” International Journal of Gynecology and Obstetrics Time Has Come.” BMJ 347: f6360. 101 (1): 84–87. MacGowan, W. A. 1987. “Surgical Manpower Worldwide.” Weiser, T. G., S. E. Regenbogen, K. D. Thompson, A. B. Haynes, Bulletin of the American College of Surgeons 72 (6): 5–7, 9. S. R. Lipsitz, and others. 2008. “An Estimation of the Malhotra, R., Y. Uppal, A. Misra, D. K. Taneja, V. K. Gupta, and Global Volume of Surgery: A Modelling Strategy Based on others. 2005. “Increasing Access to Cataract Surgery in a Available Data.” The Lancet 372 (9633): 139–44. Rural Area: A Support Strategy.” Indian Journal of Public WHO (World Health Organization). 2004. World Report Health 49 (2): 63–67. on Road Traffic Injury Prevention: Summary. Geneva: 358 Essential Surgery WHO. http://www.who.int/violence_injury_prevention Witter, S., T. Dieng, D. Mbengue, I. Moreira, and V. De Brouwere. / publications/road_traffic/world_report / summary_en 2010. “The National Free Delivery and Caesarean Policy in _rev.pdf. Senegal: Evaluating Process and Outcomes.” Health Policy ———. 2013a. “Blindness: Vision 2020—The Global Initiative and Planning 25 (5): 384–92. for the Elimination of Avoidable Blindness.” Factsheet No. Woo, Y. L., and S. Z. Omar. 2011. “Human Papillomavirus 213, World Health Organization, Geneva. http://www.who Vaccination in the Resourced and Resource-Constrained .int/mediacentre/factsheets/fs213/en/. World.” Best Practice and Research Clinical Obstetrics and ———. 2013b. “Global Health Estimates for Deaths by Cause, Gynaecology 25 (5): 597–603. Age, and Sex for Years 2000–2011.” WHO, Geneva. Yakubu, A., I. Muhammad, and O. A. Mabogunje. 1996. Wise, A., and V. Clark. 2010. “Challenges of Major Obstetric “Major Limb Amputation in Adults, Zaria, Nigeria.” Haemorrhage.” Best Practice and Research: Clinical Obstetrics Journal of the Royal College of Surgeons of Edinburgh and Gynaecology 24 (3): 353–65. 41 (2): 102–04. Global Surgery and Poverty 359 Chapter 21 Benefit-Cost Analysis for Selected Surgical Interventions in Low- and Middle-Income Countries Blake C. Alkire, Jeffrey R. Vincent, and John G. Meara INTRODUCTION recently become more visible; for example, Jamison, Jha, and Bloom (2008) and Jamison and others (2012) Since surgery was first included in the second edition prominently feature BCA in their challenge papers for of Disease Control Priorities (DCP2, 2006), research the 2008 and 2012 Copenhagen Consensus (CC). examining the cost-effectiveness of surgical interven- Within the surgical cost-effectiveness literature, cleft tions in low- and middle-income countries (LMICs) lip and palate (CLP) has been the subject of at least three has expanded substantially (see chapter 18). A growing cost-effectiveness studies in LMICs; all suggest that CLP body of evidence suggests that surgical platforms can be can be repaired in LMICs in a cost-effective manner cost-effective in these countries, according to the criteria (Corlew 2010; Magee, Vander Burg, and Hatcher 2010; established by the World Health Organization (WHO) Poenaru 2013). A more thorough review of CLP can be (Grimes and others 2013). found in chapters 8 and 13 of this volume. The role of In parallel, a nascent field of study within global cesarean delivery in the context of obstructed labor, and health economics has attempted to expand the appli- its associated cost and benefit, has been previously stud- cation of benefit-cost analysis (BCA) to global health ied by the authors (Alkire and others 2012a) and is pre- interventions in these countries. In contrast with sented here with updated results. This chapter presents cost-effectiveness analysis, BCA seeks to estimate the two distinct BCAs: net economic benefit of an intervention in monetary terms. The nature of BCA allows researchers to inves- • An approach for performing BCA using CLP repair tigate the potential economic return of an investment as a model surgical intervention using primary data in global health; it also allows ministries of health and from a subspecialty hospital dedicated to CLP in finance to meaningfully compare health care projects India to investments in other governmental sectors, such • A BCA based on secondary data that model the as education and transportation, which are routinely benefit and cost of cesarean delivery for treatment of valued with BCA. The use of BCA in global health has obstructed labor in 47 LMICs. Corresponding author: Blake C. Alkire, MD, MPH, Harvard University, blake.alkire@post.harvard.edu 361 BENEFIT-COST ANALYSIS AND 1990s, the Commission on Macroeconomics and GLOBAL HEALTH Health noted that although GDP per capita remained relatively constant during this period, full income The use of BCA to assess global health interventions fell and is likely to more closely approximate the builds on the economic concept of full income, which economic performance of these countries during this reframes how a country’s economic performance is devastating era (WHO 2001). Further discussion of measured (Becker, Philipson, and Soares 2003). This full income and its potential to portray a more com- approach assumes that gross domestic product (GDP) plete economic picture than GDP per capita alone can per capita does not completely capture a country’s be found in Jamison and others (2012) and in Jamison economic welfare. In addition to the value of goods and others (2013). and services provided during a year, the full income If full income can provide a more complete picture of a country accounts for changes in life expectancy of economic performance, then valuing changes in (LE) by valuing additional years of life in monetary morbidity and mortality according to economic wel- terms (Becker, Philipson, and Soares 2003). Changes fare is a valuable exercise in itself. The analysis becomes in LE are valued using the value of a statistical life more powerful, however, if we pair potential economic (VSL) concept, which attempts to measure individ- benefits with economic cost. BCA has long been used uals’ willingness to pay for small risk reductions in by the World Bank to assess development projects mortality, and from that it extrapolates what society (World Bank 2010) and is commonplace in govern- would be willing to pay to prevent one statistical death; mental assessments of transportation or environmental this latter number is termed the value of a statistical projects (Robinson 2007). Applying BCA specifically life (Hammitt 2007). As an example, if an individual to global health interventions can allow analysts to would be willing to pay US$7 to decrease the risk of demonstrate the potential economic return on invest- mortality by 1 in 1 million, then this individual’s VSL ment to governments, nongovernmental organizations would be US$7,000,000. (NGOs), and donors; it can also allow stakeholders to Broadly, economists rely on two different methods compare health care projects with projects in other to measure VSL: revealed preference studies and stated sectors, such as transportation or education. With these preference studies. Revealed preference studies rely on concepts in mind, Jamison and others (2012) perform behavioral data, such as wage differentials of profes- a BCA for scaling up a number of interventions in sions with different mortality risk profiles, to estimate LMICs and find benefit-cost (BC) ratios that range the additional income that workers are willing to from 10:1 for essential surgical services to 35:1 for accept to be exposed to increased on-the-job mortality malaria treatment. risk; stated preference studies use surveys to ask what The BCA in this chapter builds on the CC analysis, one is willing to pay for small mortality or morbidity but it differs in a number of important ways. As in risk reductions. It is striking that among the various the CC, we also value disability-adjusted life years approaches to estimating VSL, studies in the United (DALYs) averted using the VSL methodology. This States—where the majority of VSL estimates in the process involves converting the VSL into its annualized literature have taken place—consistently find VSLs equivalent, the value of a statistical life year (VSLY). within the same order of magnitude (Viscusi and Aldy The economic benefit of an intervention, then, is as 2003). Nomenclature has unfortunately plagued VSL follows: studies because critics tend to argue that, especially when used in LMICs, the notion of differing values of Economic Benefit = DALYs Averted × VSLY. life is unethical and morally suspect. The key to resolv- ing this dilemma is to emphasize that VSL does not An important distinction between our analysis and claim that the value of one’s life is equivalent to his or the CC is that the CC chose to value the VSLY equally her VSL. VSL studies do, however, suggest that individ- across LMICs (at US$1,000 or US$5,000). The approach uals may value reductions in mortality risk differently used in this chapter differs because the seminal review based on age, income, and other demographic variables of VSL concludes that VSLY strongly correlates with (Aldy and Viscusi 2008). income (Viscusi and Aldy 2003). To be more useful Returning to the concept of full income, Jamison to the governments and NGOs in countries where the and others argue that when economic performance studied disease process occurs, our estimates of VSLY is measured in full-income terms, a more complete are country specific. We also adjust the VSLY for age assessment of economic welfare is obtained. Looking because economic data suggest that it peaks at roughly to the AIDS epidemic in Sub-Saharan Africa in the two-thirds of LE (Aldy and Viscusi 2008). To maintain 362 Essential Surgery consistency, our procedure for adjusting VSLY for age Table 21.1 Disability-Adjusted Life Years per 100,000 and Deaths uses the same functional form for age weighting as in per 10,000,000, Secondary to Cleft Lip and Palate, by World Bank the DALY literature. Region, 2011 World Bank region DALYs per 100,000 Deaths per 10,000,000 High-income countries 1.90 0.30 BENEFIT-COST ANALYSIS OF A CLEFT LIP East Asia and Pacific 7.99 4.2 AND PALATE SURGICAL SUBSPECIALTY Europe and Central Asia 6.73 3.2 HOSPITAL IN INDIA Latin America and the Caribbean 6.23 3.1 Cleft Lip and Palate Overview Middle East and North Africa 8.20 2.2 The incidence of CLP varies by ethnicity and geography. South Asia 17.85 15.0 Current estimates range from one in 300 live births to Sub-Saharan Africa 16.37 14.3 one in 1,500 live births, placing CLP among the most Source: WHO 2013. common congenital anomalies (Canfield and others 2006; Poenaru 2013; Vanderas 1987). Although the pathogenesis of CLP is complex and the Clearly, LMICs continue to have substantial unmet need subject of ongoing study, current data suggest a com- for CLP repair. plex interplay of environment and genetics (Flint and A number of studies have examined the cost- Cummings 2010). Untreated CLP results in a number effectiveness of CLP repair in LMICs. Magee, Vander of potentially life-altering sequelae, including feeding Burg, and Hatcher (2010) estimate the cost per DALY for difficulties, social stigmatization, and speech and hear- nine one-week mission trips to LMICs, which included ing developmental delays (Corlew 2010). The primary Kenya and Vietnam, to range from US$7 to US$96 treatment modality is surgery of the lip, palate, or per nondiscounted, non–age-weighted DALY averted. both within a broader multidisciplinary approach that Poenaru (2013) examines the cost-effectiveness of the includes nutrition counseling, speech therapy, audiology, extensive Smile Train network; using the organization’s otolaryngology, dentistry, orthodontics, maxillofacial reimbursement to hospitals as a proxy for cost, he esti- surgery, and possibly nasal surgery. Given that surgery mates a cost per discounted, age-weighted DALY averted can prevent the majority of the burden of disability, CLP of US$134. Finally, Corlew (2010) finds a cost per dis- has lent itself well to concentrated efforts such as mission counted, age-weighted DALY of US$70 at a Nepalese hos- trips and surgical specialty hospitals and is the focus of pital staffed primarily by local physicians. Although each multiple prominent NGOs (Hughes and others 2012). study uses a different methodology to estimate cost, and CLP has been included in estimates of the global DALYs were not calculated under uniform assumptions burden of disease (GBD) since its inception. Although (namely, discounting and age-weighting), these estimates earlier GBD studies only considered CLP’s contribution fall well within the WHO guidelines for what can be con- to morbidity, the most current iteration by the WHO, sidered a cost-effective intervention (WHO 2002). the Global Health Estimates (GHE), assumes a mortal- Finally, CLP has been the subject of at least two ity risk associated with the burden, with an estimated studies that attempt to capture the potential economic 4,992 deaths in 2011 (WHO 2013). The most current benefit of surgical repair. Both Corlew (2010) and GHE data for CLP, including the DALY mortality rate Alkire and others (2011) value DALYs averted with a by World Bank region, are shown in table 21.1. It is VSLY approach. Each study also values DALYs using important to note that the estimates for CLP are heavily the human capital approach, which assumes that people skewed to LMICs. For example, although South Asia are analogous to machines and that lost years of life and Sub-Saharan Africa make up roughly 36 percent are equivalent to lost years of productivity. With this of the global population in 2011, 62 percent of total method, gross national income (GNI) per capita is used CLP DALYs and close to 75 percent of CLP mortality as a proxy for productivity, and DALYs are valued at occurred in these two regions (WHO 2013). Of partic- a country’s GNI per capita. Corlew values the DALYs ular relevance to LMICs is the surgical backlog of CLP averted in treated patients in Nepal and finds that with a cases, defined as the total number of patients eligible for human capital approach, cleft lip and cleft palate repair CLP repair who have not received it. Poenaru (2013) result in an economic benefit per patient of US$2,500 places the global estimate of the CLP surgical backlog and US$7,000, respectively. Using a VSLY approach, the between 420,000 and 2,100,000 cases, with the majority value of cleft lip and cleft palate repair is US$57,000 of the backlog in Southeast Asia and Sub-Saharan Africa. and US$150,000, respectively (Corlew 2010). Alkire and Benefit-Cost Analysis for Selected Surgical Interventions in Low- and Middle-Income Countries 363 others (2011) ask what the potential economic benefit to (2013), and the model for valuing DALYs used in this Sub-Saharan Africa would be if all new cases of CLP in chapter is discussed in more detail in the appendix in one year were surgically repaired. With the human capital Alkire and others (2012b). Given that BCA attempts approach, the potential ranges from US$252 million to to measure economic costs and benefits, it is necessary US$441 million; with VSL, the potential economic bene- to make adjustments to the financial cost of caring for fit of the same CLP repair ranges from US$5.4 billion to patients that was provided by Operation Smile. This US$9.7 billion (Alkire and others 2011). Although these final cost includes accounting for the opportunity figures are significant, it is difficult to draw meaningful cost to patients’ families. To derive economic benefit, conclusions without the context of cost. we did not use a human capital approach; VSL is the approach favored by economists because it is more firmly rooted in actual human behavior and more Benefit-Cost Analysis of Cleft Lip and Palate Repair accurately approximates the value associated with Using cost and patient data supplied by Operation Smile health risk reduction (Belli and others 2001). and a model that converts DALYs averted to economic The cost data for surgical care at GCCCC for fis- benefit, we estimated the cost and benefit of delivering cal year 2012 (April 2012–March 2013) submitted by cleft care in a surgical specialty hospital in Guwahati, Operation Smile included the following: India, for one year. Operation Smile is a not-for-profit NGO that focuses on CLP in LMICs; from its incep- • Operating overhead, including administrative costs tion in 1982 through 2010, it has cared for more than such as printing, housekeeping and maintenance, and 120,000 children (Magee, Vander Burg, and Hatcher medical record keeping 2010). Although Operation Smile’s delivery platform • Depreciation of hospital building and equipment, has historically been short-term international missions, which were costed using standard accounting recent efforts have focused on establishing subspecialty methodology hospitals within LMICs. • Training, including American Heart Association costs The Operation Smile Guwahati Comprehensive Cleft and continuing medical education expenses Care Center (GCCCC) was founded in 2011 with the • Staff expenses (salary, travel, and food) goal of providing sustainable, high-quality subspecial- • Patient food and travel ized surgical care to the Indian state of Assam. Operation • Medicine Smile chose Guwahati after performing a needs-based • Laboratory testing. assessment and noting a substantial backlog of untreated cleft patients; GCCCC estimates that Assam has up to Water and electricity are supplied at no cost to 1,000 new cleft cases a year and a backlog of 20,000 to GCCCC by the government of Assam. To capture these 30,000 untreated cases. Furthermore, the vast majority costs, we used publicly available data on the average of Assam’s 31 million citizens live in rural settings with- tariff for electricity and water and WHO-CHOICE out access to cleft care for reasons both geographic and assumptions to estimate the cost of these resources financial; the average income is roughly US$2 per day. to society (Indian Power Market 2012; Ministry of GCCCC is funded by a combination of government, Urban Development of India and Asian Development private business, and NGO resources. In addition to Bank 2008; WHO-CHOICE 2014). In addition to the providing primary surgical CLP repair using a full-time cost of the center, we attempted to account for oppor- staff composed of more than 90 percent local medical tunity cost to the families of patients using GNI per professionals, it offers patients additional services such as capita to value days lost secondary to preoperative, dentistry, otolaryngology, speech pathology, and nutrition perioperative, and postoperative care. Finally, a cost (Campbell 2014). These services are typically offered at per patient was obtained by dividing the total cost by cleft centers in high-income countries (HICs), but they the total surgical cases for fiscal year 2012; to obtain are often missing from cleft care delivered in LMICs, espe- the cost of primary CLP repair, the total number cially when the mission model is employed. GCCCC has of primary CLP repairs was multiplied by the cost a team that educates and recruits patients; it has already per patient. visited every district within the state (Campbell 2014). To maintain consistency and facilitate comparison with economic benefits, we converted cost to U.S. dollar estimates using the purchasing-power-parity (PPP) Methods conversion factor for India in 2012 (World Bank 2013).1 The basic approach for modeling the economic impact The PPP method compares the relative price levels of of an intervention is discussed in depth by Corlew a fixed basket of goods between countries to establish 364 Essential Surgery a currency conversion rate, such that the price of the CLP is still being established. Furthermore, we did basket of goods is the same in both countries when not include DALYs averted from revision cleft surgery. stated in the reference currency. Market exchange rates These assumptions allow us to equate a broader con- are dependent upon the supply of and demand for cept (the left-hand side of the following expression) to a currency and reflect the price of money. The PPP the quantity we calculated (the right-hand side): approach results in a better, and typically more stable, cross-country comparator of the cost of goods. It is DALYs averted (Primary CLP repair) = worth noting that this approach results in cost estimates YLD averted (Primary CLP repair). that are roughly twice those obtained by using market Discounting and Age Weighting. DALYs can be calcu- exchange rates. lated under different assumptions; the two most impor- tant ones pertain to discounting and age weights. The Calculating DALYs. The DALY is a health metric that most current iteration of the GBD study has abandoned attempts to quantitatively capture the morbidity and these assumptions; however, to perform BCA that aligns mortality secondary to a disease process in a population. with empirical economic evidence, we include these One DALY is equivalent to the loss of one healthy year assumptions in this chapter. Discounting the value of of life from either early death or disability. Disability future DALYs to their present value is common practice weights (with 0 = perfect health and 1.0 = death) are and improves the economic comparability of DALYs used to calculate years lost to disability (YLD). A number that occur at different times. All of our DALY estimates of disability weights are available for accounting for CLP are therefore discounted. We used a 3 percent dis- morbidity. The original GBD study provided disability count rate, which has been used both in studies by the weights for treated and untreated CLP (Murray and architects of the DALY concept (Murray and Acharya Lopez 1996), which implies residual morbidity and is 1997) and in studies by experts on valuing mortality most consistent with the reality of CLP; surgery can risk reductions (Aldy and Viscusi 2008). The stated address a substantial portion of morbidity, but ongoing justification for age weighting in the DALY literature is challenges remain with middle ear disease, speech, and that the social value of a year of healthy life is greater other morbidities. Although there are disability weights for young adults than for children or older adults. An for isolated CL and isolated CP, there are no disability age-weighting parameter, β, determines the age at which weights for combined CLP. We therefore assigned the the DALY function peaks, with the peak occurring at CP disability weight to patients who underwent repair 1/β. The most common value of β in the DALY liter- of combined CLP. ature is 0.04, which implies a peak at age 25. However, DALYs averted for a surgical intervention rely we used an alternative, country-specific age-weighting on estimates of (1) the likelihood (0.0 to 1.0) of parameter, denoted by β , which is more consistent with disability or mortality without surgery and (2) the empirical evidence on valuation of health risks (see fur- likelihood (0.0 to 1.0) of disability or mortality to be ther discussion of β below). averted by surgery (Bickler and others 2010; Gosselin, The inclusion of discounting and age weighting Maldonado, and Elder 2010; McCord 2003). For the results in a complex DALY formula (Murray and Acharya purposes of this analysis, we assumed that CL and 1997): CP carry a value of 1.0 for likelihood of disability L without surgery, and that CL on its own has a value of 0.9 for disability to be averted by surgery. For CP, we ∫ DALYs = {[K × DW × Cxe −βx e − r ( x −a)] assumed the likelihood of disability to be averted by a surgery to be 0.7. These numbers imply that surgery + [DW × (1 − K )e − r ( x −a)]}dx (21.1) is successful at averting disability in 90 percent of CL cases and 70 percent of CP cases. These rates are in which a = age of onset of disease, L = country-specific largely consistent with the approach taken by Poenaru life-expectancy if calculating years of life lost (YLL) or (2013) and acknowledge that secondary surgery is the age at onset of a disease plus the duration of disease necessary in some cases of CLP. Our study attempts if calculating YLDs, K = an age-weighting modulation to estimate the number of DALYs averted secondary constant (0 = no age weights, 1 = full age weights), to surgical intervention for primary CLP. Although DW = disability weight (1 for death), C = age-weighting the newest iteration of the GBD study does consider correction constant, x = age integrated over the duration mortality secondary to CLP (Vos and others 2012), we of disease (YLD) or years of life lost (YLL), r = discount chose not to consider reduction in mortality because rate (3 percent in this study), and β = age-weighting the evidence base for mortality rates secondary to constant (Lopez and others 2006). Benefit-Cost Analysis for Selected Surgical Interventions in Low- and Middle-Income Countries 365 To specify which type of DALY is being considered, per capita in the desired study year, GNI p.c. (U.S.) = we rely on the notation DALYs [r, K, β]. To facili- GNI per capita in the United States in the desired study tate comparison with previous studies with regard to year, and IE-VSL = the income elasticity of VSL. cost-utility analysis, we estimated DALYs averted with The key variable in this transfer method is the no age weighting or discounting (DALYs [0,0,0]) and income elasticity of VSL (IE-VSL), which determines DALYs averted with standard GBD age weighting and the sensitivity of VSL to income. As IE-VSL increases, the discounting (DALYs [3, 1, 0.04]). estimated VSL in the lower-income country decreases. For the special case of calculating DALYs to be valued Although values of 0.55 to 1.0 are most often used in using a VSLY approach, the formula is as follows: transferring estimates of VSL, recent evidence suggests that higher values are more appropriate for transfers to L low-income countries (Hammitt and Robinson 2011). ∫ DALYs [3,1,β] = {[DW × Cxe −βx e − r ( x −a)]}dx (21.2) a We used GNI per capita estimates based on the PPP method (Viscusi and Aldy 2003), and an IE-VSL of 1.0 and 1.5. It is worth noting that formal analyses of VSL Compared with equation (21.1), the integral includes have been performed in India (Shanmugam 1996) with just one term because K = 1 (age weighting is turned a minimum VSL estimate of US$1.2 million in 2000 on because VSLY varies with age [Aldy and Viscusi U.S. dollars (Viscusi and Aldy 2003). Other studies have 2008]), which causes the second term to equal zero. found similar values (Madheswaran 2007; Shanmugam The other key differences are the presence of β and and Madheswaran 2011). These studies, however, have ~ C, where the tilde indicates that country-specific been largely performed in urban settings, and it is diffi- age-weighting parameters and correction constants were cult to compare these VSL data with a poor region such used. Evidence indicates that VSLY peaks at about two- as Assam. thirds of LE (Aldy and Viscusi 2008), so we modified To calculate the potential economic benefit of an the age-weighting factor in the DALY formula such that intervention that averts a given number of DALYs it peaks at two-thirds the LE. Therefore, DALYs [3,1,β] [3,1,β ], we multiplied DALYs [3,1, β ] by the value of a are discounted at 3 percent and are age weighted such statistical life year. VSLYx, the value of a statistical life that the maximum weight occurs at two-thirds of LE. year at age x, is given by the following expression: Because (1/β) = age at which the age-weighting factor peaks, to calculate a country-specific β, we used the fol- ~ VSLYx = V × C xe −βx (21.5) lowing expression to determine β : in which V = age-neutral (constant) value of a statisti- β = 1/[(2/3) × LE]. (21.3) cal life year (literally, a parameter that converts a single DALY unweighted for age to a monetary value), and The value of C is also country-specific because it ~ C xe −βx is the age-weighting factor found in the original varies with β according to table 5.2 in the GBD study DALY formula modified to peak at 2/3 of LE. We discuss (Lopez and others 2006). We fit a cubic polynomial to the calculation of V in the following section. Using the ~ the values in that table and used it to predict C for a DALY age-weighting factor creates internal consistency given value of β . with the age weighting of DALYs and the VSLY. The formula for estimating the economic benefit of Converting DALYs Averted to Economic Benefit. To an intervention to the individual receiving it can there- value DALYs using the VSLY approach, we first esti- fore be written as mated the VSL using the following formula (Viscusi and L Aldy 2003): VSL (Unknown) = VSL (U.S.) ∫ Economic Benefit = {[DW × VSLYx × e − r ( x −a)]}dx. a IE-VSL (21.6) ×⎡ GNIp.c.(Unknown) ⎤ ⎢ GNIp.c.(U.S.) ⎥ (21.4) Substituting the equation for VSLYx into this results in ⎣ ⎦ the following: in which VSL (Unknown) = VSL in a country where L VSL studies have not been performed, VSL (U.S.) = VSL in the United States (US$7.4 million in 2006 dollars, ∫ Economic Benefit = {[DW ×V × Cxe −βx × e − r ( x −a)]}dx. a updated to reference year),2 GNI p.c. (Unknown) = GNI (21.7) 366 Essential Surgery If the constant V is moved out of the integral, the for- Table 21.2 Economic Cost, Benefit, and DALYs Averted at the mula can be rewritten as follows: Guwahati Comprehensive Cleft Care Center for Fiscal Year 2012 L Outcome ∫ Economic Benefit = V {[DW × Cxe a −βx ×e − r ( x −a ) ]}dx, Total cost a US$2,745,000 DALYs averted b (21.8) DALYs [0,0,0] 9,600 which by equation (21.2) reduces to DALYs [3,1,0.04] 5,400 Cost per DALY averted Economic Benefit = V × DALYs (3,1,β ) (21.9) DALYs [0,0,0] $285 The DALY formula already contains the age- DALYs [3,1,0.04] $508 weighting factor (Cxe −βx ), so we need only multiply Estimated economic benefitc DALYs [3,1,β] by V, not VSLYx, which would result in IE-VSL = 1.5 US$32,000,000 double age weighting. Assuming one has already calcu- IE-VSL = 1.0 US$116,000,000 lated DALYs [3,1, β], the only variable left to define is V, the age-neutral value of a statistical life year. To solve Benefit-cost ratio c for V, set DW = 1 and a = 0, which indicates that the IE-VSL = 1.5 12 disability is equivalent to death at birth. By definition, IE-VSL = 1.0 42 the economic benefit in this case is the VSL, and L = life Note: Where dollar figures are used, they are 2012 U.S. dollars. DALY = disability-adjusted life year. expectancy (LE). Therefore, V is defined by the follow- IE-VSL = income elasticity of value of a statistical life. ing expression: a. Cost includes fixed and variable costs, along with opportunity cost to the families of patients; includes only primary cleft lip, cleft palate, and cleft lip and palate repair. b. Non–age weighted, nondiscounted disability-adjusted life years (DALYs) are represented with the LE notation DALY [0,0,0], while discounted, age-weighted DALYs are represented with the notation VSL = ∫ V × Cxe 0 −βx − r ( x −a ) e dx. (21.10) DALYs [3,1,0.04]. c. Estimates of economic benefit and consequently benefit-cost ratio rely on valuing DALYs in monetary terms. A special form of the DALY was devised to account for the fact that the VSL varies with age. We move the constants outside of the integral: LE averted of US$285 and a benefit-cost ratio (BCR) of 12. ∫ VSL = V × C xe −βx e − r ( x −a) dx. 0 (21.11) Estimates using a range of DALY and IE-VSL assump- tions are presented in table 21.2. We solve for V and integrate: Discussion and Recommendations VSL (β + r )2 V= × . (21.12) This chapter derives a BCR for CLP repair in a subspe- C 1 − e −(β+r )LE [1 + LE(β + r )] cialty surgical hospital in Guwahati, India, and finds a BCR of between 12 and 42, using the more conservative As described, multiplying V by DALYs (3,1,β) yields estimates of economic benefit. These findings suggest the economic value of averting these DALYs. that investment in CLP repair in a referral center sim- ilar to GCCCC is a good economic proposition, with a net positive return on investment. Our cost per DALY Results averted depends on assumptions regarding age weight- During the 2012 fiscal year (April 2012 through March ing and discounting and ranges from US$285 to US$508. 2013), GCCCC treated 1,498 patients with primary The WHO has provided guidelines for determining an surgical repair for cleft lip, cleft palate, or CLP, result- intervention’s cost-effectiveness by comparing the cost ing in an estimated 9,600 DALYs [0,0,0] averted. The per DALY averted to GDP per capita, with a cost per present value of the total economic benefit is sensitive DALY averted of less than GDP per capita considered to the assumed income elasticity of demand; using the to be highly cost-effective. Although our estimates fall most conservative (lower bound of VSL) parameters, well within that range (WHO 2002), they are greater the estimated economic benefit was US$32 million (in than previous estimates for CLP repair in the literature. 2012 U.S. dollars). Assuming a total economic cost of The initial investment in infrastructure and equipment US$2.75 million, this resulted in a cost per DALY [0,0,0] required at GCCCC, the broad range of services offered Benefit-Cost Analysis for Selected Surgical Interventions in Low- and Middle-Income Countries 367 to CLP patients compared with short-term international including investments in global health, education, and missions, and inclusion of the opportunity cost of lost agriculture. productivity likely explain the observed difference in estimates of cost per DALY averted. • Our BCR of between 12 and 42 is similar to the BCR of 10 for essential surgical services, as estimated by A Model for Delivery of Surgical Care. By perform- Jamison and others (2012). ing almost 1,500 primary CLP surgeries in fiscal year • BCRs have also been estimated for reducing the prev- 2012, GCCCC has demonstrated that it can begin to alence of stunting through a package of interventions address the substantial backlog of 20,000 to 30,000 that targeted malnutrition in India, and they range cases while also addressing the 1,000 new cases each between 44 and 138.6 (Hoddinott, Rosegrant, and year. Moreover, GCCCC demonstrates a number of Torero 2012). important principles for developing sustainable surgical • Estimate of BCRs for retrofitting schools in India to care. In contrast to many short-term missions, GCCCC better withstand earthquakes range from 0.04 to 5.6 provides additional services to cleft patients, including (Kunreuther and Michel-Kerjan 2012). otolaryngology, speech therapy, dentistry, and nutrition counseling. Furthermore, the large majority of medical It is difficult to directly compare a project that is care staff consists of local providers, which facilitates aimed at a single disease process, such as cleft repair, ongoing onsite training and enhances the sustainability to projects that have broader goals, such as investing in of the center. The unique public-private partnership nutrition; we present these data, however, as an example established among NGOs, private business, and the of how BCA can be used to compare investment across local government—the major funder of GCCCC—has health sectors. A BCA for essential surgical services been essential to developing and sustaining this model in LMICs would lend itself better to these broader (Campbell 2014). comparisons. In addition to providing care, it is essential that med- The economic valuation of benefits in BCA also ical organizations track and report their health-related allows for a more intuitive discussion with stakeholders outcomes. Operation Smile has an established track who are less academically oriented. For example, the cost record of publishing outcome data (McQueen and oth- per DALY averted of an intervention carries meaning ers 2009), and GCCCC has made it clear that reporting to global health academicians and is necessary for cost- and acting on outcome data are important to the center. effectiveness analysis, but donors and other stakeholders A review of the more than 8,000 surgical procedures are not always well-versed in the theory of DALYs. The performed revealed no deaths; furthermore, no surgical ability to say that an intervention will return $X for every procedures have required a blood transfusion (two units $1 dollar spent has meaning to all potential audiences, of blood are always available). Regarding cleft palate– especially those who are making decisions about alloca- specific outcomes, GCCCC reports a 3.9 percent palatal tion of funds. fistula rate for more than 700 primary repairs, which The Bellagio Essential Surgery Group, which com- compares favorably with published data from HICs prised physicians, economists, and policy makers and (Campbell 2014; Cohen and others 1991; Deshpande sought to improve access to surgical care in Sub-Saharan and others forthcoming). Cleft lip–specific outcomes Africa, made a number of recommendations regarding data for more than 1,800 cases seen in follow-up sug- essential research questions. Among these recommen- gest a total complication rate of 4 percent, largely made dations were estimating the burden of surgical disease at up of dehiscence and infection, and a revision rate of the country level, assessing the ability to access surgical only 0.4 percent. In sum, GCCCC demonstrates that care in terms of surgical capacity and patient financial high-quality, sustainable, locally supported surgical care resources, and addressing the quality and effectiveness of can be provided to an underserved population in an surgery at first-level hospitals (Luboga and others 2009). LMIC such as India. It further indicates that this care can In addition to these necessary efforts, estimates of the be provided in a highly cost-effective and economically economic cost and benefit of surgical intervention are favorable fashion. essential to developing the evidence base. Kruk and oth- ers (2010) estimate current surgical expenditure at first- Advantages of Benefit-Cost Analysis. BCA facilitates level hospitals in three Sub-Saharan hospitals and find comparison with investments not only in other med- that only 7 percent to 14 percent of the total operating ical procedures but also in government programs and cost was allocated to surgery; in addition, they find that development projects. For the 2012 CC, BCRs were the majority of surgical care was delivered by midlevel calculated for a number of development projects, providers. Quantifying current levels of expenditure 368 Essential Surgery on surgical care allows policy makers to make crucial literature with regard to age when VSLY peaks, implies funding decisions; as the burden of surgical disease is VSL curves that peak too early when compared with further delineated, these types of data will prove essen- studies in the VSL literature (Aldy and Viscusi 2008). tial as decisions are made about how to scale up surgical Consequently, our study may overestimate the VSL of care delivery. By exploring estimates of economic benefit children. The VSL of children is the subject of research; in addition to cost, policy makers can better understand however, the available evidence suggests that the VSL both current and potential returns on investments in is at least that of an adult, if not higher (Hammitt and global surgery. Haninger 2010; Roman and others 2012). Finally, a number of assumptions were used to esti- mate DALYs averted from cleft surgery. Although we Study Limitations attempted to be consistent with previous methods out- BCA as performed in this chapter has a number of lined in the surgical literature (Bickler and others 2010; limitations. One is that we have assumed that the McCord 2003), the nature of assumptions employed counterfactual in our scenario is the absence of CLP imparts a degree of uncertainty in our results that must services. This assumption may be an oversimplification be acknowledged. of the issue and would drive up our BC ratios if patients receiving CLP care at GCCCC could have received comprehensive cleft care elsewhere. It is a reasonable Future Research assumption to make, however, given that the estimated This study examines a specific platform for delivery surgical backlog of CLP in India ranges from 233,000 of surgical care—the surgical specialty hospital. As the to 544,000 cases (Poenaru 2013) and that GCCCC on global surgery community continues to consider the its own will require 40 years to 60 years to address the pros and cons of the various platforms, further eco- backlog in Assam at the current rate of CLP repair. nomic analyses should be geared toward understanding Furthermore, our results are generalizable only to cleft the benefit and cost of the mission-based model of sur- referral centers with similar characteristics to GCCCC; gical care. An extensive debate regarding the pros, cons, we are unable to draw conclusions for mission-based and possibilities for improvement has taken place in the models based on these data. literature (Dupuis 2004; Farmer and Kim 2008; Meier The current analysis focuses on an admittedly narrow 2010), yet a robust evidence base with objective out- subspecialty of surgical care, and estimating the benefits come and economic data is lacking. A recently published and costs of increasing surgical capacity in LMICs would study directly compares the mission-based model to the undoubtedly be a useful contribution to the global surgi- referral-center model (Rossell-Perry and others 2013). cal evidence base. We recognize that there is uncertainty Using outcomes data from CLP operations performed by when deriving economic benefit with a VSL methodol- a single cleft surgeon in Peru in different settings (referral ogy, but we have used the most conservative estimate of versus mission based), Rossell-Perry and others found a VSL. At the recommendation of Hammitt and Robinson statistically significant difference in palatal fistula, post- (2011), we use an IE-VSL of 1.5 to transfer estimates operative hemorrhage, and wound dehiscence, with all of VSL from the United States to poor states in LMICs occurring more frequently in the mission-based model. such as Assam, India. If the more commonly used Although one cannot draw significant conclusions from IE-VSL value of 1.0 were used, then our estimates of one study based in one setting, this study should compel benefit would increase dramatically. It could be argued further comparative research that includes economic that our approach to costing the price per surgery is less analyses in addition to outcome data. rigorous than a micro-costing approach. We are reas- sured, however, that our cost per surgery falls within the range found by a recent review of surgical cost in India Conclusions on Cleft Lip and Palate Repair (Chatterjee and Laxminarayan 2013). Our estimate sug- In summary, we find that investment in a surgical sub- gests a price of roughly 40,000 rupees per surgery, which specialty center dedicated to CLP repair can be a good compares well with Chatterjee and Laxminarayan’s study economic proposition, and that it is possible to deliver (2013), which found a range of cost for cesarean delivery high-quality, sustainable surgical care to underserved (2,500 rupees to 41,000 rupees), hernia repair (5,200 populations in LMICs. More broadly, we emphasize that rupees), endoscopic sinus surgery (53,000 rupees), and BCA serves as a useful tool for evaluating the potential coronary artery bypass grafting (177,000 rupees). economic return on investments in global health, allows The DALY age-weighting formula, although adjusted for the evaluation and discussion of projects both within in this study to be more consistent with the VSL and outside of global health academia, and facilitates Benefit-Cost Analysis for Selected Surgical Interventions in Low- and Middle-Income Countries 369 comparisons of investment in health with projects in level of funding, and international aid organizations other governmental sectors. For these reasons, BCA and governments continue to confront insufficient should be applied more broadly in global health analysis, resources to address maternal health adequately (Pitt and this chapter demonstrates one manner in which this and others 2010). could be accomplished. Although the decision-making process behind allocation of financial resources by governments and NGOs is complex, economic evaluations, including BENEFIT-COST ANALYSIS OF CESAREAN BCA, can play an important role. This section eval- DELIVERY FOR OBSTRUCTED LABOR uates the impact of treating obstructed labor with cesarean delivery across multiple regions, specifically Overview examining countries that the WHO identifies as pro- Our second analysis illustrates a higher level (that is, a viding an insufficient number of cesarean deliveries cross-country) application of the methods presented to meet current demand (Gibbons and others 2010). in the section on cleft lip and palate. Obstructed labor, We determine country-specific estimates of both the defined by the WHO as labor in which “the presenting part cost per DALY averted and the BCR for providing of the fetus cannot progress into the birth canal, despite cesarean delivery in the context of obstructed labor. strong uterine contractions” (Dolea and AbouZahr 2003, The DALYs averted refer only to the mother’s expe- 1), is among the most common causes of maternal death rience from neglected obstructed labor, not that of in LMICs (Khan and others 2006). Obstructed labor also her child. results in significant morbidity, including obstetric fistula A more comprehensive discussion of the epidemi- (Dolea and AbouZahr 2003), which is an abnormal com- ology and treatment of obstructed labor and obstetric munication between the rectum and vagina (rectovaginal fistula is provided in chapters 5 and 6 in this volume, fistula) or the bladder and vagina (vesicovaginal fistula). respectively, and in Reproductive, Maternal, Newborn, Beyond the substantial risks to physical health, victims and Child Health in this series. of obstetric fistula are known to suffer from poor mental and social health because they are often banned from their homes and turned away from their communities Methods (Wall 2006; WHO 2005). For the estimations and calculations in this section, The current morbidity and mortality posed by obstructed labor refers to cases that are neglected or left obstructed labor need not be so high, as evidenced untreated. The section of this chapter on cleft lip and by the fact that maternal death and fistula secondary palate provides a complete discussion of DALYs, VSL, to obstructed labor are rarely seen in HICs (Adler and how DALYs are valued using the VSL approach. and others 2013; Lozano and others 2012). The seque- lae of obstructed labor can be prevented by operative Estimating the Incidence and Sequelae of Obstructed delivery of the fetus, which is most commonly via Labor and Obstetric Fistula. The relevant population cesarean delivery (Dolea and AbouZahr 2003; Hofmeyr for this chapter is the estimated number of women who 2004; Neilson 2003). Timely diagnosis and treatment of incurred obstructed labor in 2010 in 47 countries noted obstructed labor with cesarean delivery requires access by the WHO as providing an insufficient number of to emergency obstetric systems, which is unfortunately cesarean deliveries (Gibbons and others 2010). unavailable to most mothers in LMICs (Paxton and others 2006; Pearson and Shoo 2005). Good evidence • To estimate the number of cases of obstructed suggests that access to emergency obstetric services labor, we used a modeling approach based on a correlates strongly with decreased maternal mortality recently performed review of the literature that esti- (Islam, Hossain, and Haque 2005; Jamisse 2004; Kayongo mates the global incidence of all cases of obstructed and others 2006). labor, including neglected and treated cases (Adler, The past two decades have seen increased invest- Ronsmans, and Filippi forthcoming). Based on these ments in global maternal health, with a consequent data, we then estimated the incidence of neglected 34 percent reduction in maternal mortality rates since obstructed labor in a country using the estimated 1990 (Lozano and others 2011; WHO and others 2010). proportion of births in a health facility as a proxy Although funding for maternal health in LMICs has for timely treatment of obstructed labor (UNICEF increased, the distribution of the funding may not be 2013); this modeling approach is based on method- appropriately aligned. Countries with the highest mater- ology previously used by the GBD study (Dolea and nal mortality ratios do not receive a commensurate AbouZahr 2003). 370 Essential Surgery • To estimate the incidence of obstetric fistula and Establishing the Cost of a Cesarean Delivery. As part mortality secondary to obstructed labor, we relied on of a background report for the 2010 World Health a recent meta-analysis that estimates the incidence of Report, the WHO estimated the unit cost of a cesarean fistula in South Asia and Sub-Saharan Africa (Adler delivery for countries that were identified as providing and others 2013). It is worth noting that the prev- an insufficient quantity to meet demand (Gibbons alence and incidence reported in Adler and others and others 2010). The inputs for estimating cost (2013) is lower than previous estimates (Wall 2006), included “initiation of labor at referral level, diagnosis likely because of a more rigorous selection criteria for of obstructed labor and referral, Caesarean delivery study inclusion. For mortality estimates, we relied on associated devices and medicines, operative facility time, estimates of mortality rates for South Asia and Sub- medical human resources time, management of shock Saharan Africa from the GBD 2010 study (Lozano and including hysterectomy and blood transfusion (assumed others 2012). For these two regions, the total number for 1% of CS performed), postoperative hospital stay for of cases of neglected obstructed labor was estimated, stabilization…program administration, training, and and then cases of maternal death and obstetric fistula the corresponding office space, electricity and other ser- secondary to obstructed labor in these regions were vices, as well as a variety of standard consumables and divided by all cases of neglected obstructed labor to equipment” (Gibbons and others 2010, 6). produce two ratios: maternal deaths per 1,000 cases It is important to note that that study did not include of neglected obstructed labor and obstetric fistula per cost associated with vaginal birth, such as clean cord 1,000 cases of neglected obstructed labor. Given that practices and the presence of a birth attendant. To maternal death and obstetric fistula should not occur account for this omission, we identified studies that if obstructed labor is treated appropriately—these estimated the cost of a vaginal delivery in a health facil- sequelae are almost never seen in HICs—we calcu- ity in countries in South Asia and Sub-Saharan Africa lated the country-specific incidence of these sequelae (Bhat and others 2009; Iyengar and others 2009; Levin based on the estimated rate of neglected obstructed and others 2003; Newlands and others 2008; Orach, labor in a country. Dubourg, and De Brouwere 2007; Quayyum and oth- ers 2010; Sarowar and others 2010). We established a We assume that if left untreated, obstetric fistula range of values for the proportion of vaginal delivery is a permanent sequela once present in survivors of cost to the WHO cesarean delivery cost, and we used obstructed labor. Probabilistic sensitivity analysis was this to adjust the WHO country-specific estimated cost employed for the following variables using Monte Carlo of cesarean section to more appropriate values. We simulation: incidence of all cases of obstructed labor employed probabilistic sensitivity analysis over a range and fistula based on Adler’s reviews (Adler and others of vaginal delivery to cesarean delivery cost proportions 2013), and incidence of maternal mortality secondary to using Monte Carlo simulation. neglected obstructed labor based on GBD 2010 (Lozano and others 2012). Estimating Disability-Adjusted Life Years. Not all We apportioned the incidence of obstructed labor cesarean deliveries are meant to address obstructed and its sequelae of maternal death and obstetric fistula labor, and not all cases of obstructed labor are treated according to seven maternal age groups: 15–19, 20–24, with cesarean delivery. We estimated that 80 percent 25–29, 30–34, 35–39, 40–44, and 45–49. This was accom- of obstructed labor cases require cesarean delivery; the plished by (1) calculating the total number of births remaining 20 percent can be addressed with instrumen- in each of these age groups for every included country tal vaginal delivery. These latter cases are excluded from in 2010; (2) dividing the number of births in each age our analysis. group by total births to calculate the relative proportion We estimated the number of DALYs that could be each age group contributes to total births; (3) calculating averted in the 47 countries included in the WHO cost the total number of cases of obstructed labor and its study if 80 percent of the obstructed labor cases were sequelae for all women ages 15–49 years; and (4) multi- prevented in a timely fashion with a cesarean delivery. plying the age-specific proportions from (2) by the total Because cesarean delivery is assigned a disability weight number of cases of obstructed labor or its sequelae from by the GBD study and carries a risk of mortality (Souza (3). An important limitation of this approach is that it and others 2010), we first calculated the gross number of does not account for the relationship between parity DALYs that would be averted by preventing 80 percent of and obstructed labor: younger women are thought to obstructed labor cases, and then subtracted the number have increased rates of obstructed labor because they are of DALYs that would be incurred secondary to cesarean more likely to be nulliparous. deliveries to arrive at the net DALYs averted. Benefit-Cost Analysis for Selected Surgical Interventions in Low- and Middle-Income Countries 371 This study used disability weights from the GBD labor was estimated to avert. To calculate the BCA, study (Lopez and others 2006) to estimate DALYs sec- we divided the country-specific economic benefit of ondary to cesarean delivery and obstetric fistula. treating obstructed labor by the total cost of providing the cesarean deliveries required to do so; the estimated Estimating the Cost per Disability-Adjusted Life Year benefit was based on valuing DALYs [3,1,β] averted Averted and the Benefit-Cost Ratio. To estimate the with the VSL approach. This section uses an IE-VSL of total cost of providing the necessary number of cesar- 1.5 to transfer VSL estimates. ean deliveries to prevent the sequelae of obstructed labor, we multiplied the country-specific unit cost of a cesarean delivery by the number of cesarean deliv- Results eries required to treat 80 percent of the cases in that Table 21.3 presents the estimated number of cesarean country. Once the total country-specific cost was cal- deliveries necessary to treat 80 percent of obstructed culated, we divided this cost by the total number of labor in each country, along with the number of cases DALYs [0,0,0] that cesarean delivery for obstructed of obstetric fistula and maternal death that would be Table 21.3 Estimated Number of Cesarean Deliveries Required to Prevent 80 Percent of Obstructed Labor, with the Total Number of Preventable Obstetric Fistulas and Maternal Mortality, 2010 Country Caesarean deliveriesa Preventable obstetric fistulas Preventable maternal mortalityb Algeria 812 (441–1,400) 6 (2–12) 9 (8–11) Bangladesh 46,429 (25,247–80,086) 362 (100–671) 533 (460–609) Benin 958 (521–1,653) 7 (2–14) 11 (9–13) Burkina Faso 4,492 (2,443–7,748) 35 (10–65) 52 (44–59) Cambodia 3,524 (1,916–6,078) 27 (8–51) 40 (35–46) Cameroon 6,274 (3,412–10,823) 49 (13–91) 72 (62–82) Central African Republic 1,466 (797–2,528) 11 (3–21) 17 (15–19) Chad 9,479 (5,154–16,351) 74 (20–137) 109 (94–124) Comoros 270 (147–466) 2 (1–4) 3 (3–4) Congo, Dem. Rep. 13,855 (7,534–23,900) 108 (30–200) 159 (137–182) Côte d’Ivoire 5,728 (3,115–9,880) 45 (12–83) 66 (57–75) Eritrea 3,306 (1,798–5,702) 26 (7–48) 38 (33–43) Ethiopia 56,534 (3,0742–97,518) 441 (121–817) 649 (560–742) Gabon 154 (84–265) 1 (0–2) 2 (2–2) Ghana 5,195 (2,825–8,961) 41 (11–75) 60 (51–68) Guinea 5,093 (2,769–8,785) 40 (11–74) 58 (50–67) Haiti 4,109 (2,234–7,087) 32 (9–59) 47 (41–54) India 276,385 (150,291–476,747) 2,157 (592–3,993) 3173 (2,737–36,28) Indonesia 43,246 (23,516–74,597) 337 (93–625) 496 (428–568) Kenya 17,442 (9,485–30,087) 136 (37–252) 200 (173–229) Lesotho 471 (256–812) 4 (1–7) 5 (5–6) Liberia 1,877 (1,021–3,237) 15 (4–27) 22 (19–25) Madagascar 9,754 (5,304–16,824) 76 (21–141) 112 (97–128) Malawi 33,04 (1,797–5,699) 26 (7–48) 38 (33–43) Mali 7,165 (3,896–12,359) 56 (15–104) 82 (71–94) Mauritania 1,315 (715–2,268) 10 (3–19) 15 (13–17) table continues next page 372 Essential Surgery Table 21.3 Estimated Number of Cesarean Deliveries Required to Prevent 80 Percent of Obstructed Labor, with the Total Number of Preventable Obstetric Fistulas and Maternal Mortality, 2010 (continued) Country Caesarean deliveriesa Preventable obstetric fistulas Preventable maternal mortalityb Mongolia 18 (10–31) 0.1 (0–0.3) 0.2 (0.2–0.3) Morocco 3,426 (1,863–5,910) 27 (7–49) 39 (34–45) Mozambique 8,194 (4,455–14,134) 64 (18–118) 94 (81–108) Nepal 8,879 (4,828–15,315) 69 (19–128) 102 (88–117) Niger 12,832 (6,978–22,134) 100 (28–185) 147 (127–168) Nigeria 85,159 (46,307–146,894) 665 (183–1,230) 978 (843–1,118) Oman 17 (9–30) 0.1 (0–0.25) 0.2 (0.2–0.2) Pakistan 57,141 (31,072–98,565) 446 (122–825) 656 (566–750) Philippines 26,402 (14,357–45,542) 206 (57–381) 303 (261–347) Rwanda 2,557 (1,391–4,411) 20 (5–37) 29 (25–34) Senegal 2,685 (1,460–4,632) 21 (6–39) 31 (27–35) Sierra Leone 2,233 (1,214–3,852) 17 (5–32) 26 (22–29) Sudan 20,044 (10,900–34,575) 156 (43–290) 230 (199–263) Swaziland 148 (81–256) 1 (0–2) 2 (1–2) Tanzania 18,198 (9,896–31,391) 142 (39–263) 209 (180–239) Togo 1,574 (856–2,715) 12 (3–23) 18 (16–21) Tunisia 394 (214–680) 3 (1–6) 5 (4–5) Uganda 13,035 (7,088–22,485) 102 (28–188) 150 (129–171) Vietnam 2,255 (1,226–3,889) 18 (5–33) 26 (22–30) Yemen, Rep. 11,957 (6,502–20,624) 93 (26–173) 137 (118–157) Zambia 5,844 (3,178–10,080) 46 (13–84) 67 (58–77) Total 811,629 6,334 9,318 Note: Table reports mean, with 95 percent uncertainty interval in parentheses. a. Necessary to prevent 80 percent of obstructed labor. b. Adjusted for mortality secondary to cesarean delivery. prevented by providing cesarean delivery for obstructed The mean total benefit across countries was estimated labor. Maternal mortality is adjusted to account for mor- to be US$1.4 billion in 2010 dollars. The last column of tality secondary to cesarean delivery. For the 47 countries, table 21.4 shows BCRs for providing cesarean deliveries an estimated 815,000 cesarean deliveries would have pre- in each country, calculated by dividing the estimated vented 6,300 cases of obstetric fistula and 9,400 maternal economic benefit by the total cost of providing cesarean deaths. Table 21.4 presents the total cost of providing the deliveries. The BCR ranges from 0.3 for the Democratic necessary number of cesarean deliveries to prevent all Republic of Congo to 75.5 for Gabon, with a median cases of obstructed labor for the included countries in value of 4.0. 2010. For each country, the total cost of providing cesar- ean deliveries for obstructed labor was then divided by the potential nondiscounted, non-age-weighted DALYs Discussion and Recommendations (notated as [0,0,0]) averted if all cases of obstructed Valuing Maternal Health Care. The analysis in this sec- labor were treated to create a cost per DALY averted. The tion elucidates the cost and benefit of treating neglected average cost per DALY averted varied by country, rang- obstructed labor with cesarean delivery across a number ing from US$243 to US$1,192 per DALY averted. The of disparate regions. We estimate that cesarean delivery median cost per DALY averted was US$416. for obstructed labor, depending on the country, costs Table 21.4 also presents the country-specific gross US$243–US$1192 per DALY [0,0,0], with a median cost economic benefit of preventing obstructed labor. of US$416 per DALY for the 47 countries included in Benefit-Cost Analysis for Selected Surgical Interventions in Low- and Middle-Income Countries 373 Table 21.4 Total Cost of Treating Obstructed Labor with Cesarean Delivery, Cost per DALY Averted, Gross Economic Benefit, and Benefit-Cost Ratio, US$, 2010 Gross economic Country Total cost (thousands)a Cost/DALY avertedb benefit (thousands)c Benefit-cost ratiod Algeria 245 (130–440) 463 (214–924) 7293 (5,400–9,300) 33.6 (14.2–64) Bangladesh 7,590 (3,890–13,620) 243 (112–484) 45,702 (34,100–58,300) 6.8 (2.9–13) Benin 207 (110–370) 349 (161–696) 677 (500–900) 3.7 (1.6–7) Burkina Faso 1,012 (520–1,820) 386 (178–770) 2,752 (2,100–3,500) 3.1 (1.3–5.9) Cambodia 812 (420–1460) 364 (168–726) 4,221 (3,100–5,400) 5.9 (2.5–11.2) Cameroon 1,325 (680–2,380) 363 (167–724) 7,759 (5,800–9,900) 6.6 (2.8–12.6) Central African Republic 356 (180–640) 551 (253–1103) 361 (300–500) 1.1 (0.5–2.2) Chad 1,967 (1,010–3,530) 350 (161–698) 5,647 (4,200–7,200) 3.2 (1.4–6.2) Comoros 61 (30–110) 407 (188–813) 118 (100–200) 2.5 (1–4.7) Congo, Dem. Rep. 4,415 (2,260–7,920) 581 (267–1159) 1,106 (800–1400) 0.3 (0.1–0.5) Côte d’Ivoire 1,314 (670–2,360) 395 (182–789) 5,773 (43,00–7,400) 5 (2.1–9.5) Eritrea 978 (500–1,760) 547 (252–1092) 435 (300–600) 0.5 (0.2–1) Ethiopia 14,214 (7,290–25,510) 452 (208–902) 21,257 (15,800–27,200) 1.7 (0.7–3.2) Gabon 80 (40–140) 901 (415–1798) 2,665 (2,000–3,400) 37.4 (15.8–71.4) Ghana 1,410 (720–2,530) 454 (209–905) 4,322 (3,200–5,500) 3.5 (1.5–6.6) Guinea 1,249 (640–2,240) 416 (192–830) 1,749 (1,300–2,200) 1.6 (0.7–3) Haiti 1,009 (520–1,810) 667 (305–1338) 1,570 (1,200–2,000) 1.8 (0.7–3.4) India 49,033 (25,150–88,000) 279 (129–557) 716,631 (534,700–914,300) 16.5 (7–31.5) Indonesia 10,777 (5,530–19,340) 395 (182–787) 150,723 (112,400–192,300) 15.8 (6.7–30.1) Kenya 3,973 (2,040–7,130) 371 (171–741) 14,498 (10,800–18,500) 4.1 (1.7–7.9) Lesotho 150 (80–270) 685 (314–1,369) 527 (400–700) 4 (1.7–7.6) Liberia 509 (260–910) 482 (222–962) 232 (200–300) 0.5 (0.2–1) Madagascar 2,198 (1,130–3,950) 381 (175–760) 3,464 (2,600–4,400) 1.8 (0.8–3.4) Malawi 752 (390–1,350) 452 (208–903) 949 (700–1,200) 1.4 (0.6–2.7) Mali 1,528 (780–2,740) 378 (174–754) 3,484 (2,600–4,500) 2.6 (1.1–4.9) Mauritania 337 (170–600) 439 (202–875) 1,814 (1,400–2,300) 6.1 (2.6–11.6) Mongolia 6 (0–10) 552 (254–1,101) 58 (0–100) 9.7 (4.1–18.5) Morocco 867 (440–1,560) 391 (180–780) 13,974 (10,400–17,800) 18.2 (7.7–34.7) Mozambique 1,900 (970–3,410) 452 (208–902) 2,587 (1,900–3,300) 1.5 (0.6–2.9) Nepal 1,684 (860–3,020) 283 (130–563) 5,765 (4,300–7,400) 3.9 (1.6–7.4) Niger 2,923 (1,500–5,250) 386 (178–770) 2,359 (1,800–3,000) 0.9 (0.4–1.7) Nigeria 20,988 (10,770–37,670) 422 (194–842) 106,203 (79,100–135,600) 5.7 (2.4–10.9) Oman 14 (10–30) 1,192 (550–2,376) 941 (700–1200) 75.7 (32–144.4) Pakistan 17,413 (8,930–31,250) 489 (225–976) 107,143 (79,900–136,700) 7 (2.9–13.3) Philippines 6,315 (3,240–11,330) 365 (168–728) 85,589 (63,900–109,200) 15.3 (6.5–29.2) Rwanda 577 (300–1040) 379 (175–756) 1,278 (1,000–1,600) 2.5 (1.1–4.8) Senegal 557 (290–1,000) 343 (158–684) 2,664 (2,000–3,400) 5.4 (2.3–10.3) Sierra Leone 525 (270–940) 416 (191–829) 978 (700–1,200) 2.1 (0.9–4) table continues next page 374 Essential Surgery Table 21.4 Total Cost of Treating Obstructed Labor with Cesarean Delivery, Cost per DALY Averted, Gross Economic Benefit, and Benefit-Cost Ratio, US$, 2010 (continued) Gross economic Country Total cost (thousands)a Cost/DALY avertedb benefit (thousands)c Benefit-cost ratiod Sudan 5,750 (2,950–10,320) 437 (202–872) 20,130 (15,000–25,700) 4 (1.7–7.5) Swaziland 52 (30–90) 796 (365–1,592) 571 (400–700) 12.5 (5.2–23.9) Tanzania 4,281 (2,200–7,680) 406 (187–810) 12,029 (9,000–15,400) 3.2 (1.3–6.1) Togo 316 (160–570) 340 (157–679) 473 (400–600) 1.7 (0.7–3.2) Tunisia 220 (110–400) 831 (383–1,657) 4,457 (3,300–5,700) 22.8 (9.6–43.6) Uganda 3,381 (1,730–6,070) 455 (209–907) 6,301 (4,700–8,000) 2.1 (0.9–4) Vietnam 587 (300–1,050) 357 (165–710) 5,172 (3,900–6,600) 9.9 (4.2–19) Yemen, Rep. 3,105 (1,590–5,570) 446 (206–891) 19,918 (14,800–25,400) 7.2 (3.1–13.8) Zambia 1,583 (810–2,840) 518 (238–1,034) 3,627 (2,700–4,600) 2.6 (1.1–4.9) Median n.a. 416 n.a. 4.0 Note: n.a = not applicable. Table reports mean, with 95 percent uncertainty interval in parentheses. a. Total cost to treat 80 percent of cases of neglected obstructed labor with cesarean delivery. b. The cost per DALY averted using [0,0,0] assumptions. See text for explanation. c. Estimated by valuing DALYs [3,1,β] with value of a statistical life year. d. Benefit-cost ratio calculated by dividing gross economic benefit by total cost. this study. These estimates compare favorably with the the relative cost-effectiveness of cesarean delivery for costs reported in chapter 18 of this volume, which summa- obstructed labor in comparison with the WHO’s per rizes the global surgery cost-effectiveness literature. Using capita income thresholds. We are not the first to suggest WHO guidelines (WHO 2002), cesarean delivery for that surgical care can be cost-effective, but our results obstructed labor is highly cost-effective in the vast major- add to the burgeoning evidence base. ity of countries, and cost-effective in all included countries. Our data further suggest that when prioritizing The BCRs in table 21.4, however, convey the main budgeting of different sectors, governments should message of this section: the BCR is greater than 1 for recognize that investment in health care can achieve nearly every country examined. The exceptions are the net-positive economic benefits, as indicated by BCRs Democratic Republic of Congo, Eritrea, Liberia, and greater than 1. Specifically, allocating appropriate levels Niger, most of which have relatively high costs per DALY of funding for providing the suggested minimum averted. These results suggest that devoting appropriate of emergency obstetric care, considered within the financial resources to cesarean delivery can combat the broader context of maternal health care, is a good catastrophic health consequences to mothers in an eco- economic proposition in the vast majority of countries nomically favorable fashion. Indeed, the median BCR for investigated. the 47 countries included in our study is 4:1, which rep- It is crucial to note that cesarean delivery is not a resents an excellent return on investment. Our headline panacea. Indeed, the overuse of the procedure in many results are also our most conservative; we used the largest HICs, along with the associated cost, has been well IE-VSL value (1.5) reported in the literature, which sig- documented (Gibbons and others 2010). This chapter nificantly reduces the estimated benefits (see the section assesses cesarean delivery in the context of obstructed of this chapter on cleft lip and palate for more detail labor, in which there is a well-defined role for operative regarding the IE-VSL). Even the four countries men- delivery. The results of this chapter do not imply that tioned above would have BCRs greater than 1 if the more cesarean delivery is always cost-effective; they do suggest, commonly used assumption of IE-VSL = 1 were used. however, that when used appropriately, the economic benefits of the procedure can outweigh the cost. Implications of Results. Our results have potentially We also emphasize that we are not advocating vertical meaningful implications for all involved stakeholders programming aimed at providing cesarean delivery or within the continuum of maternal and newborn care. emergency obstetric care in isolation; experience tells We first emphasize for potential donors and NGOs us that properly functioning health systems must be in Benefit-Cost Analysis for Selected Surgical Interventions in Low- and Middle-Income Countries 375 place for mothers to receive appropriate, high-quality CONCLUSIONS care (Maine 2007). The current focus on packages of interventions that are integrated into a functioning A case could easily be made for addressing obstructed health system are envisioned such that women in need labor from a strictly humanitarian perspective, yet some of an emergent cesarean delivery are aware of facilities continue to suggest that surgery is a luxury. This section available, are properly diagnosed, are transported to a demonstrates that investment in cesarean delivery is not referral hospital within a reasonable amount of time, only cost-effective; it can yield a net positive economic and undergo safe cesarean delivery in a capable facility return within the context of a horizontally functioning (Fournier 2009; Nyamtema, Urassa, and van Roosmalen health system. More broadly, the analyses used in this 2011). In this broader context, our argument is that cesar- chapter can be applied to other interventions and are ean delivery—as part of a larger strategy—can address crucial for better-informed investments in global health maternal mortality in an economically favorable fashion. care delivery. Study Limitations ACKNOWLEDGMENTS The analysis in this section has a number of important limitations. Our methodology rests on the overly sim- The authors acknowledge the support of the govern- plified assumption that a lack of surgical capacity is the ment of Assam, the National Rural Health Mission, the major driver of preventable morbidity and mortality. Sir Dorabji Tata Trust and Allied Trusts, Operation Smile We may have overestimated the potential benefit of International, and Operation Smile India for providing cesarean delivery given other barriers, such as a lack infrastructure and funding for the GCCCC, Assam, of timely diagnosis and poor transportation infra- India. All patients at this center are treated free of cost, structure, that are known to play a role in neglected with no commercial or financial gain to any member of obstructed labor (Chhabra, Gandhi, and Jaiswal 2000; the team. The authors wish to specifically acknowledge WHO 2005). However, our calculated BCRs suggest that Alex Campbell and William Magee for providing the surgical intervention would still be beneficial even if the data used in this analysis. number of cesarean deliveries successfully performed The section in this chapter on cesarean delivery is were far fewer than the perfect rate we have assumed. At based on a paper previously published by the authors, our median estimate of the BCR, surgical intervention entitled “Obstructed Labor and Caesarean Delivery: would still break even if only 25 percent of the poten- The Cost and Benefit of Surgical Intervention” in PLoS tially preventable DALYs were actually averted. One (Alkire and others 2012a). The methods and results A critique of the methods used for placing a dollar have been completely revised to reflect the most recent value on DALYs is presented elsewhere (Alkire and oth- data available. We wish to acknowledge the additional ers 2011; Warf and others 2011). There is uncertainty original authors for their efforts in producing the above regarding transfers of VSL estimates to low-income study: Paul Farmer, Ian Metzler, and Christy Turlington countries for which formal studies are lacking (Hammitt Burns. We also wish to thank Christopher Hughes and and Robinson 2011), but we have minimized the risk of Toni Golen for their assistance with the obstructed overvaluing a DALY by using an IE-VSL of 1.5. In fact, labor analysis. our estimates of BCRs are possibly too conservative as a result of using the lower-bound estimate of IE-VSL for valuing DALYs. Most important, our analysis does not NOTES account for the benefit of reducing perinatal mortality The World Bank classifies countries according to four income and morbidity with improved access to cesarean deliv- groupings. Income is measured using gross national income ery. The perinatal mortality rate as a result of neglected (GNI) per capita, in U.S. dollars, converted from local currency obstructed labor depends on the case series, but ranges using the World Bank Atlas method. Classifications as of July from 38 percent to 92 percent (Hofmeyr 2004; Melah and 2014 are as follows: others 2003; Neilson 2003). Finally, there is uncertainty • Low-income countries (LICs) = US$1,045 or less in 2013 regarding the true number of maternal deaths and fistula • Middle-income countries (MICs) are subdivided: worldwide and the contribution that obstructed labor • Lower-middle-income = US$1,046 to US$4,125 makes to that number; we have attempted to account • Upper-middle-income (UMICs) = US$4,126 to US$12,745 for this uncertainty with probabilistic sensitivity analysis. • High-income countries (HICs)= US$12,746 or more 376 Essential Surgery 1. The World Bank: Open Data. http://data.worldbank.org/. 1999–2001.” Birth Defects Research Part A: Clinical and 2. United States Environmental Protection Agency. “Frequently Molecular Teratology 76 (11): 747–56. Asked Questions on Mortality Risk Valuation.” http:// Chatterjee, S., and R. Laxminarayan. 2013. “Costs of Surgical yosemite .epa.gov/ee/epa/eed.nsf/webpages/mortalityrisk Procedures in Indian Hospitals.” British Medical Journal valuation.html. Open 3 (6): e002844. Chhabra, S., D. Gandhi, and M. Jaiswal. 2000. “Obstructed Labour: A Preventable Entity.” Journal of Obstetrics and Gynaecology 20 (2): 151–53. REFERENCES Cohen, S. R., J. Kalinowski, D. LaRossa, and P. Randall. 1991. “Cleft Palate Fistulas: A Multivariate Statistical Analysis of Adler, A., C. Ronsmans, C. Calvert, and V. Filippi. 2013. Prevalence, Etiology, and Surgical Management.” Plastic “Estimating the Prevalence of Obstetric Fistula: A and Reconstructive Surgery 87 (6): 1041–47. Systematic Review and Meta-Analysis.” Biomed Central Corlew, D. S. 2010. “Estimation of Impact of Surgical Disease Pregnancy and Childbirth 13 (246): 1–14. through Economic Modeling of Cleft Lip and Palate Care.” Adler, A., C. Ronsmans, and V. Filippi. Forthcoming. World Journal of Surgery 34 (3): 391–96. “Prevalence of Obstructed and Prolonged Labour: A ———. 2013. “Economic Modeling of Surgical Disease: Systematic Review.” A Measure of Public Health Interventions.” World Journal Aldy, J. E., and W. K. Viscusi. 2008. “Adjusting the Value of of Surgery 37 (7): 1478–85. a Statistical Life for Age and Cohort Effects.” Review of Deshpande, G., A. Campbell, C. Restrepo, R. Jagtap, H. Dobie, Economics and Statistics 90 (3): 573–81. and others. Forthcoming. “Early Complications after Alkire, B., C. D. Hughes, K. Nash, J. R. Vincent, and J. G. Meara. Cleft Palate Repair: A Multivariate Statistical Analysis 2011. “Potential Economic Benefit of Cleft Lip and Palate of 709 Consecutive Patients.” Journal of Craniofacial Repair in Sub-Saharan Africa.” World Journal of Surgery Surgery. 35 (6): 1194–201. Dolea, C., and C. AbouZahr. 2003. “Global Burden of Alkire, B. C., J. R. Vincent, C. T. Burns, I. S. Metzler, Obstructed Labor in the Year 2000: Version 2.” In Evidence P. E. Farmer, and others. 2012a. “Obstructed Labor and and Information for Policy. Geneva: WHO. Caesarean Delivery: The Cost and Benefit of Surgical Dupuis, C. C. 2004. “Humanitarian Missions in the Third Intervention.” PLoS One 7 (4): e34595. World: A Polite Dissent.” Plastic and Reconstructive Surgery ———. 2012b. “Obstructed Labor and Caesarean Delivery: 113 (1): 433–35. The Cost and Benefit of Surgical Intervention,” Appendix S1 Farmer, P. E., and J. Y. Kim. 2008. “Surgery and Global Health: . PLoS One 7 (4): e34595. doi:10 .1371/journal.pone.0034595 A View from beyond the OR.” World Journal of Surgery .s001. 32 (4): 533–36. Becker, G. S., T. J. Philipson, and R. R. Soares. 2003. “The Flint, P. W., and C. W. Cummings. 2010. Cummings Quantity and Quality of Life and the Evolution of World Otolaryngology: Head and Neck Surgery. 5th edition, 3 vols. Inequality.” Working Paper No. 9765, National Burea of London: Mosby. Economic Research, Cambridge, MA. http://www.nber.org Fournier, P. 2009. “Improved Access to Comprehensive /papers/w9765. Emergency Obstetric Care and Its Effect on Institutional Belli, P., J. Anderson, H. Barnum, J. Dixon, and J. P. Tan, Marternal Mortality in Rural Mali.” Bulletin of the World eds. 2001. Economic Analysis of Investment Operations: Health Organization 87 (1): 30–38. Analytical Tools and Practical Applications. Washington, DC: Gibbons, L., J. M. Belizan, J. A. Lauer, A. P. Betran, M. Merialdi, World Bank. and others. 2010. “The Global Numbers and Costs of Bhat, R., D. V. Mavalankar, P. V. Singh, and N. Singh. 2009. Additionally Needed and Unnecessary Caesarean Sections “Maternal Healthcare Financing: Gujarat’s Chiranjeevi Performed per Year: Overuse as a Barrier to Universal Scheme and Its Beneficiaries.” Journal of Health, Population Coverage.” World Health Report 2010, Background Paper and Nutrition 27 (2): 249–58. 30 for Health Systems Financing: The Path to Universal Bickler, S., D. Ozgediz, R. Gosselin, T. Weiser, D. Spiegel, and Coverage. Geneva: WHO. others. 2010. “Key Concepts for Estimating the Burden Gosselin, R. A., A. Maldonado, and G. Elder. 2010. “Comparative of Surgical Conditions and the Unmet Need for Surgical Cost-Effectiveness Analysis of Two MSF Surgical Trauma Care.” World Journal of Surgery 34 (3): 374–80. Centers.” World Journal of Surgery 34 (3): 415–19. Campbell, A. 2014. “Scalable, Sustainable Cost-Effective Grimes, C. E., J. A. Henry, J. Maraka, N. C. Mkandawire, and Surgical Care: A Model for Safety and Quality in the M. Cotton. 2013. “Cost-Effectiveness of Surgery in Low and Developing World.” Journal of Craniofacial Surgery 25 (5): Middle-Income Countries: A Systematic Review.” World 1685–89. Journal of Surgery 38 (1): 252–63. Canfield, M. A., M. A. Honein, N. Yuskiv, J. Xing, C. T. Mai, and Hammitt, J. K. 2007. “Valuing Changes in Mortality Risk: Lives others. 2006. “National Estimates and Race/Ethnic-Specific Saved versus Life Years Saved.” Review of Environmental Variation of Selected Birth Defects in the United States, Economics and Policy 1 (2): 228–40. Benefit-Cost Analysis for Selected Surgical Interventions in Low- and Middle-Income Countries 377 Hammitt, J. K., and K. Haninger. 2010. “Valuing Fatal Risks to Constraints for Essential Surgery in District Hospitals Children and Adults: Effects of Disease, Latency, and Risk in Africa: A Retrospective Cross-Sectional Survey.” PLoS Aversion.” Journal of Risk Uncertainty 40 (1): 57–83. Medicine 7 (3): e1000242. Hammitt, J. K., and L. A. Robinson. 2011. “The Income Kunreuther, H., and E. Michel-Kerjan. 2012. “Challenge Elasticity of the Value per Statistical Life: Transferring Paper: Natural Disasters.” Copenhagen Consensus 2012, Estimates between High and Low Income Populations.” Copenhagen Consensus Center, Copenhagen. Journal of Benefit-Cost Analysis 2 (1): Article 1. Levin, A., T. Dmytraczenko, M. McEuen, F. Ssengooba, Hoddinott, J., M. Rosegrant, and M. Torero. 2012. “Challenge R. Mangani, and others. 2003. “Costs of Maternal Health Paper: Hunger and Malnutrition.” Copenhagen Consensus Care Services in Three Anglophone African Countries.” 2012, Copenhagen Consensus Center, Copenhagen. International Journal of Health Planning and Management Hofmeyr, G. 2004. “Obstructed Labor: Using Better 18 (1): 3–22. Technologies to Reduce Mortality.” International Journal of Lopez, A. D., C. D. Mathers, M. Ezzati, D. T. Jamison, Gynaecology and Obstetrics 85: S62–72. C. J. L. Murray, and others. 2006. Global Burden of Disease Hughes, C. D., B. Alkire, C. Martin, N. Semer, and J. G. Meara. and Risk Factors. Washington, DC: Oxford University Press 2012. “American Plastic Surgery and Global Health: A Brief and World Bank. History.” Annals of Plastic Surgery 68 (2): 222–25. Lozano, R., M. Naghavi, K. Foreman, S. Lim, K. Shibuya, Indian Power Market. 2012. “Electricity Prices in Different States and others. 2012. “Global and Regional Mortality from of India.” http://www.indianpowermarket.com/2012/09 235 Causes of Death for 20 Age Groups in 1990 and 2010: A /electricity-prices-in-different-states.html. Systematic Analysis for the Global Burden of Disease Study Islam, M., M. Hossain, and Y. Haque. 2005. “Improvement 2010.” The Lancet 380 (9859): 2095–128. of Coverage and Utilization of EmOC Services in Lozano, R., H. Wang, K. J. Foreman, J. K. Rajaratnam, Southwestern Bangladesh.” International Journal of M. Naghavi, and others. 2011. “Progress towards Gynaecology and Obstetrics 91 (3): 298–305. Millennium Development Goals 4 and 5 on Maternal Iyengar, S. D., K. Iyengar, V. Suhalka, and K. Agarwal. 2009. and Child Mortality: An Updated Systematic Analysis.” “Comparison of Domiciliary and Institutional Delivery- The Lancet 378 (9797): 1139–65. Care Practices in Rural Rajasthan, India.” Journal of Health, Luboga, S., S. B. Macfarlane, J. von Schreeb, M. E. Kruk, Population and Nutrition 27 (2): 303–12. M. N. Cherian, and others. 2009. “Increasing Access to Jamison, D. T., J. G. Breman, A. R. Measham, G. Alleyne, Surgical Services in Sub-Saharan Africa: Priorities for M. Claeson, D. B. Evans, P. Jha, A. Mills, and P. Musgrove, National and International Agencies Recommended by the eds. 2006. Disease Control Priorities in Developing Bellagio Essential Surgery Group.” PLoS Medicine 6 (12): Countries, 2nd ed. Washington, DC: World Bank and e1000200. Oxford University Press. Madheswaran, S. 2007. “Measuring the Value of Statistical Jamison, D. T., P. Jha, and D. Bloom. 2008. “The Challenge Life: Estimating Compensating Wage Differentials among of Disease.” Copenhagen Consensus 2008, Copenhagen Workers in India.” Social Indicators Research 84 (1): Consensus Center, Copenhagen. 83–96. Jamison, D. T., P. Jha, R. Laxminarayan, and T. Ord. 2012. Magee, W. P., Jr., R. Vander Burg, and K. W. Hatcher. 2010. “Infectious Disease, Injury, and Reproductive Health.” “Cleft Lip and Palate as a Cost-Effective Health Care Copenhagan Consensus 2012, Copenhagen Consensus Treatment in the Developing World.” World Journal of Center, Copenhagen. Surgery 34 (3): 420–27. Jamison, D. T., L. H. Summers, G. Alleyne, K. J. Arrow, S. Berkley, Maine, D. 2007. “Detours and Shortcuts on the Road to and others. 2013. “Global Health 2035: A World Converging Maternal Mortality Reduction.” Lancet 370 (9595): within a Generation.” The Lancet 382 (9908): 1898–955. 1380–82. Jamisse, L. 2004. “Reducing Maternal Mortality in Mozambique: McCord, C. 2003. “A Cost Effective Small Hospital in Challenges, Failures, Successes and Lessons Learned.” Bangladesh: What It Can Mean for Emergency Obstetric International Journal of Gynaecology and Obstetrics 85 (2): Care.” International Journal of Gynaecology and Obstetrics 203–12. 81 (1): 83–92. Kayongo, M., M. Rubardt, J. Butera, M. Abdullah, McQueen, K. A., W. Magee, T. Crabtree, C. Romano, and D. Mboninyibuka, and others. 2006. “Making EmOC a F. M. Burkle, Jr. 2009. “Application of Outcome Measures Reality: CARE’s Experiences in Areas of High Maternal in International Humanitarian Aid: Comparing Indices Mortality in Africa.” International Journal of Gynaecology through Retrospective Analysis of Corrective Surgical and Obstetrics 92 (3): 308–19. Care Cases.” Prehospital and Disaster Medicine 24 (1): Khan, K. S., D. Wojdyla, L. Say, A. M. Gulmezoglu, and P. F. Van 39–46. Look. 2006. “WHO Analysis of Causes of Maternal Death: Meier, D. 2010. “Opportunities and Improvisations: A Pediatric A Systematic Review.” The Lancet 367 (9516): 1066–74. Surgeon’s Suggestions for Successful Short-Term Surgical Kruk, M. E., A. Wladis, N. Mbembati, S. K. Ndao-Brumblay, Volunteer Work in Resource-Poor Areas.” World Journal of R. Y. Hsia, and others. 2010. “Human Resource and Funding Surgery 34 (5): 941–46. 378 Essential Surgery Melah, G. S., A. U. El-Nafaty, A. A. Massa, and B. M. Audu. Roman, H. A., J. K. Hammitt, T. L. Walsh, and D. M. Stieb. 2012. 2003. “Obstructed Labour: A Public Health Problem in “Expert Elicitation of the Value per Statistical Life in an Air Gombe, Gombe State, Nigeria.” Journal of Obstetrics and Pollution Context.” Risk Analysis 32 (12): 2133–51. Gynaecology 23 (4): 369–73. Rossell-Perry, P., E. Segura, L. Salas-Bustinza, and O. Cotrina- Ministry of Urban Development of India and Asian Rabanal. 2013. “Comparison of Two Models of Surgical Development Bank. 2008. 2007 Benchmarking and Data Care for Patients with Cleft Lip and Palate in Resource- Book of Water Utilities in India. Mandaluyong City, Challenged Settings.” World Journal of Surgery. Online in Philippines: Asian Development Bank. advance of print. Murray, C. J., and A. K. Acharya. 1997. “Understanding Sarowar, M. G., E. Medin, R. Gazi, T. P. Koehlmoos, C. Rehnberg, DALYs (Disability-Adjusted Life Years).” Journal of Health and others. 2010. “Calculation of Costs of Pregnancy- and Economics 16 (6): 703–30. Puerperium-Related Care: Experience from a Hospital in Murray, C. J., and A. D. Lopez. 1996. The Global Burden of a Low-Income Country.” Journal of Health, Population and Disease: A Comprehensive Assessment of Mortality and Nutrition 28 (3): 264–72. Disability from Diseases, Injuries, and Risk Factors in Shanmugam, K. 1996. “The Value of Life: Estimates from Indian 1990 and Projected to 2020. Global Burden of Disease and Labour Market.” Indian Economic Journal 44 (4): 105–14. Injury Series. Cambridge, MA: Harvard School of Public Shanmugam, K., and S. Madheswaran. 2011. “The Value of Health on behalf of the World Health Organization and Statistical Life.” In Environmental Valuation in South Asia, the World Bank. edited by A. K. Haque, M. N. Murty, and P. Shyamsundar, Neilson, J. 2003. “Obstructed Labour.” British Medical Bulletin 412–43. New Delhi: Cambridge University Press. 67 (1): 191–204. Souza, J. P., A. Gulmezoglu, P. Lumbiganon, M. Laopaiboon, Newlands, D., D. Yugbare-Belemsaga, L. Ternent, S. Hounton, G. Carroli, and others. 2010. “Caesarean Section without and G. Chapman. 2008. “Assessing the Costs and Cost- Medical Indications Is Associated with an Increased Risk of Effectiveness of a Skilled Care Initiative in Rural Burkina Adverse Short-Term Maternal Outcomes: The 2004–2008 Faso.” Tropical Medicine and International Health 13 WHO Global Survey on Maternal and Perinatal Health.” (Suppl 1): 61–67. Biomed Central Medicine 8: 71. Nyamtema, A. S., D. P. Urassa, and J. van Roosmalen. 2011. UNICEF (United Nations Children’s Fund). 2013. The “Maternal Health Interventions in Resource Limited State of the World’s Children 2013: Children with Countries: A Systematic Review of Packages, Impacts Disabilities . New York: UNICEF. http://www.unicef and Factors for Change.” Biomed Central Pregnancy and .org/sowc2013/. Childbirth 11: 30. Vanderas, A. P. 1987. “Incidence of Cleft Lip, Cleft Palate, and Orach, C. G., D. Dubourg, and V. De Brouwere. 2007. “Costs Cleft Lip and Palate among Races: A Review.” Cleft Palate and Coverage of Reproductive Health Interventions in Journal 24 (3): 216–25. Three Rural Refugee-Affected Districts, Uganda.” Tropical Viscusi, W. K., and J. E. Aldy. 2003. “The Value of a Statistical Medicine and International Health 12 (3): 459–69. Life: A Critical Review of Market Estimates throughout the Paxton, A., P. Bailey, S. Lobis, and D. Fry. 2006. “Global Patterns World.” Journal of Risk Uncertainty 27 (1): 5–76. in Availability of Emergency Obstetric Care.” International Vos, T., A. D. Flaxman, M. Naghavi, R. Lozano, C. Michaud, Journal of Gynaecology and Obstetrics 93 (3): 300–07. and others. 2012. “Years Lived with Disability (YLDs) for Pearson, L., and R. Shoo. 2005. “Availability and Use of 1160 Sequelae of 289 Diseases and Injuries 1990–2010: Emergency Obstetric Services: Kenya, Rwanda, Southern A Systematic Analysis for the Global Burden of Disease Sudan, and Uganda.” International Journal of Gynaecology Study 2010.” The Lancet 380 (9859): 2163–96. and Obstetrics 88 (2): 208–15. Wall, L. L. 2006. “Obstetric Vesicovaginal Fistula as an Pitt, C., G. Greco, T. Powell-Jackson, and A. Mills. 2010. International Public-Health Problem.” The Lancet 368 “Countdown to 2015: Assessment of Official Development (9542): 1201–09. Assistance to Maternal, Newborn, and Child Health, Warf, B., B. C. Alkire, S. Bhai, C. D. Hughes, S. J. Schiff, 2003–08.” The Lancet 376 (9751): 1485–96. and others. 2011. “Costs and Benefits of Neurosurgical Poenaru, D. 2013. “Getting the Job Done: Analysis of the Intervention for Infant Hydrocephalus in Sub-Saharan Impact and Effectiveness of the Smiletrain Program in Africa.” Journal of Neurosurgery Pediatrics 8 (5): 509–21. Alleviating the Global Burden of Cleft Disease.” World WHO (World Health Organization). 2001. Macroeconomics Journal of Surgery 37 (7): 1562–70. and Health: Investing in Health for Economic Development. Quayyum, Z., M. Nadjib, T. Ensor, and P. K. Sucahya. 2010. Report of the Commission on Macroeconomics and Health. “Expenditure on Obstetric Care and the Protective Effect Geneva: WHO. of Insurance on the Poor: Lessons from Two Indonesian ———. 2002. The World Health Report 2002: Reducing Risks, Districts.” Health Policy and Planning 25 (3): 237–47. Promoting Healthy Life. Geneva: WHO. Robinson, L. A. 2007. “Policy Monitor: How US Government ———. 2005. The World Health Report 2005: Make Every Agencies Value Mortality Risk Reductions.” Review of Mother and Child Count. Edited by W. V. Lerberghe. Environmental Economics and Policy 1 (2): 283–99. Geneva: WHO. Benefit-Cost Analysis for Selected Surgical Interventions in Low- and Middle-Income Countries 379 ———. 2013. “Global Health Estimates for Deaths by Cause, WHO, UNICEF, UNFPA, and World Bank. 2010. Trends in Age, and Sex for Years 2000–2011.” Geneva: WHO. Maternal Mortality: 1990 to 2008: Estimates Developed http://www.who.int/healthinfo/global_ burden_disease by WHO, UNICEF, UNFPA, and the World Bank. Geneva: /en/. WHO. WHO-CHOICE. 2014. “Assumptions on Quantities of Resources World Bank. 2010. Cost-Benefit Analysis in World Bank Projects. Use.” http://www.who.int/choice/cost-effectiveness/inputs Independent Evaluation Group Report. Washington, DC: /assumptions/en/. World Bank. 380 Essential Surgery DCP3 Series Acknowledgments Disease Control Priorities, third edition (DCP3) compiles We thank the many contractors and consultants the global health knowledge of institutions and experts who provided support to specific volumes in the form of from around the world, a task that required the efforts economic analytical work, volume coordination, chap- of over 500 individuals, including volume editors, ter drafting, and meeting organization: the Center for chapter authors, peer reviewers, advisory committee Disease Dynamics, Economics, and Policy; Center for members, and research and staff assistants. For each Chronic Disease Control; Center for Global Health of these contributions we convey our acknowledge- Research; Emory University; Evidence to Policy Initiative; ment and appreciation. First and foremost, we would Public Health Foundation of India; QURE Healthcare; like to thank our 31 volume editors who provided the University of California, San Francisco; University of intellectual vision for their volumes based on years of Waterloo; University of Queensland; and the World Health professional work in their respective fields, and then Organization. dedicated long hours to reviewing each chapter, pro- We are tremendously grateful for the wisdom and viding leadership and guidance to authors, and fram- guidance provided by our advisory committee to the ing and writing the summary chapters. We also thank editors. Steered by Chair Anne Mills, the advisory com- our chapter authors who collectively volunteered their mittee assures quality and intellectual rigor of the high- time and expertise to writing over 160 comprehensive, est order for DCP3. evidence-based chapters. The U.S. Institute of Medicine, in collaboration We owe immense gratitude to the institutional spon- with the Inter-Academy Medical Panel, coordinated the sor of this effort: The Bill & Melinda Gates Foundation. peer-review process for all DCP3 chapters. Patrick Kelley, The Foundation provided sole financial support of Gillian Buckley, Megan Ginivan, and Rachel Pittluck the Disease Control Priorities Network. Many thanks managed this effort and provided critical and substan- to Program Officers Kathy Cahill, Philip Setel, Carol tive input. Medlin, and (currently) Damian Walker for their The Office of the Publisher at the World Bank pro- thoughtful interactions, guidance, and encouragement vided exceptional guidance and support throughout the over the life of the project. We also wish to thank Jaime demanding production and design process. We would Sepulveda for his longstanding support, including chair- particularly like to thank Carlos Rossel, the publisher; ing the Advisory Committee for the second edition Mary Fisk, Nancy Lammers, Devlan O’Connor, Rumit and, more recently, demonstrating his vision for DCP3 Pancholi, and Deborah Naylor for their diligence and while he was a special advisor to the Gates Foundation. expertise. Additionally, we thank Jose de Buerba, Mario We are also grateful to the University of Washington’s Trubiano, Yulia Ivanova, and Chiamaka Osuagwu of Department of Global Health and successive chairs King the World Bank for providing professional counsel on Holmes and Judy Wasserheit for providing a home-base communications and marketing strategies. for the DCP3 Secretariat, which included intellectual Several U.S. and international institutions contrib- collaboration, logistical coordination, and administra- uted to the organization and execution of meetings that tive support. supported the preparation and dissemination of DCP3. 381 We would like to express our appreciation to the follow- Reproductive and maternal health volume consulta- ing institutions: tion Nov 2013) • National Cancer Institute and Union for • University of Bergen, consultation on equity (June International Cancer Control (Cancer consultation 2011) Nov. 2013) • University of California, San Francisco, surgery volume consultations (April 2012, October 2013, Carol Levin provided outstanding governance for February 2014) cost and cost-effectiveness analysis. Stéphane Verguet • Institute of Medicine, first meeting of the Advisory added invaluable guidance in applying and improv- Committee to the Editors ACE (March 2013) ing the extended cost-effectiveness analysis method. • Harvard Global Health Institute, consultation Shane Murphy, Zachary Olson, Elizabeth Brouwer, on policy measures to reduce incidence of non- and Kristen Danforth provided exceptional research communicable diseases (July 2013) assistance and analytic assistance. Brianne Adderley • Institute of Medicine, systems strengthening meeting ably managed the budget and project processes. The (September 2013) efforts of these individuals were absolutely critical • Center for Disease Dynamics, Economics, and to producing this series and we are thankful for their Policy (Quality and Uptake meeting Sept 2013, commitment. 382 DCP3 Series Acknowledgments Series and Volume Editors SERIES EDITORS Hellen Gelband Hellen Gelband is Associate Director for Policy at the Dean T. Jamison Center for Disease Dynamics, Economics & Policy Dean Jamison is a Senior Fellow in Global Health (CDDEP). Her work spans infectious disease, particu- Sciences at the University of California, San Francisco, larly malaria and antibiotic resistance, and noncommu- and an Emeritus Professor of Global Health at the nicable disease policy, mainly in low- and middle-income University of Washington. He previously held aca- countries. Before joining CDDEP, then Resources for the demic appointments at Harvard University and the Future, she conducted policy studies at the (former) University of California, Los Angeles; he was an Congressional Office of Technology Assessment, the economist on the staff of the World Bank, where Institute of Medicine of the U.S. National Academies, he was lead author of the World Bank’s World and a number of international organizations. Development Report 1993: Investing in Health. He was lead editor of DCP2. He holds a PhD in economics Susan Horton from Harvard University and is an elected member Susan Horton is the CIGI chair in global health eco- of the Institute of Medicine of the U.S. National nomics in the Balsillie School of International Affairs at Academy of Sciences. He recently served as Co-Chair the University of Waterloo. She has worked in over 20 and Study Director of The Lancet’s Commission on low- and middle-income countries and has consulted Investing in Health. for the World Bank, the Asian Development Bank, several United Nations agencies, and the International Rachel Nugent Development Research Centre, among others. She led Rachel Nugent is a Research Associate Professor in the paper on nutrition for the Copenhagen Consensus the Department of Global Health at the University in 2008, when micronutrients were ranked as the top of Washington. She was formerly Deputy Director of development priority. She has served as associate pro- Global Health at the Center for Global Development, vost of graduate studies at the University of Waterloo, Director of Health and Economics at the Population vice-president academic at Wilfrid Laurier University in Reference Bureau, Program Director of Health and Waterloo, and interim dean at the University of Toronto Economics Programs at the Fogarty International Center at Scarborough. of the National institutes of Health, and senior econ- omist at the Food and Agriculture Organization of Prabhat Jha the United Nations. From 1991–97, she was associate Prabhat Jha is the founding director of University professor and department chair in economics at Pacific of Toronto’s Centre for Global Health Research and Lutheran University. She has advised the World Health University of Toronto Endowed Professor in Disease Organization, the U.S. government, and nonprofit orga- Control, Canada Research Chair at the Dalla Lana nizations on the economics and policy environment of School of Public Health. He is lead investigator of the noncommunicable diseases. Million Death Study in India, which quantifies the 383 causes of death and key risk factors in over two million Society; Faculty Chief Examiner, Ghana College of homes over a 14-year period. He is also Scientific Physicians and Surgeons; Council Member, West African Director of the Statistical Alliance for Vital Events, which College of Surgeons; and Chairman, Ghana Health aims to expand reliable measurement of causes of death Workforce Observatory. worldwide. He also conducts studies on epidemiology Through the Ghana Cleft Foundation, a nonprofit and economics of tobacco control worldwide. organization that he cofounded, he provides outreach cleft surgery for remote communities throughout Ramanan Laxminarayan Ghana. Ramanan Laxminarayan is Vice President for Research He was the Founding President of the Pan African and Policy at the Public Health Foundation of India, and Association for Cleft Lip and Palate and served for he directs the Center for Disease Dynamics, Economics a number of years on the International Outreach & Policy in Washington, D.C., and New Delhi. His Committee of the American Cleft Palate−Craniofacial research deals with the integration of epidemiological Association and the Advisory Board of the Center for models of infectious diseases and drug resistance into Global Health, University of Michigan. the economic analysis of public health problems. He was His research collaborations include head and one of the key architects of the Affordable Medicines neck cancer, cleft lip and palate, injury, emergency Facility for malaria, a novel financing mechanism to care, medical education, research training, and improve access and delay resistance to antimalarial global health. He is the Principal Investigator of the drugs. In 2012, he created the Immunization Technical President’s Emergency Plan for AIDS Relief/National Support Unit in India, which has been credited with Institutes of Health−funded Medical Education improving immunization coverage in the country. Partnership Initiative project on Emergency Medicine He teaches at Princeton University. at KNUST. Atul Gawande is a general and endocrine surgeon at VOLUME EDITORS Brigham and Women’s Hospital in Boston, Professor in the Department of Health Policy and Management Haile T. Debas, MD, is Director of the University of at Harvard T.H. Chan School of Public Health, and California Global Health Institute based at the University Samuel O. Thier Professor in the Department of Surgery of California, San Francisco (UCSF). His career as a at Harvard Medical School. He is Executive Director of physician, researcher, professor, and academic leader Ariadne Labs, a joint center for health systems inno- spans more than four decades and includes positions at vation, and cofounder and chairman of Lifebox, an hospitals, medical centers, and universities in Canada international not-for-profit that implements systems and the United States. At UCSF, he served as Chair and technologies to reduce surgical deaths globally. He of the Department of Surgery, Dean of the School of is also a bestselling author and staff writer for the New Medicine, Vice Chancellor, Chancellor, and Founding Yorker magazine. Executive Director of Global Health Sciences. A gas- trointestinal surgeon by training, he is the Maurice Dean T. Jamison. See the list of Series Editors. Galante Distinguished Professor of Surgery, Emeritus at UCSF. Dr. Debas served as the Founding Chair of the Margaret E. Kruk, MD, MPH, is Associate Professor Board of Directors of the Consortium of Universities of Global Health at Harvard T.H. Chan School of for Global Health. He is a member of the Institute of Public Health. Her research focuses on health care Medicine and fellow of the American Academy of Arts utilization and quality, maternal health, and popu- and Sciences. lation preferences for health services in low-income countries. Dr. Kruk is interested in the development Peter Donkor is a Professor of Oral and Maxillofacial of novel evaluation methods for assessing the effec- Surgery at the Kwame Nkrumah University of Science tiveness of complex interventions and health sys- and Technology (KNUST), Ghana. He studied at the tem reforms. She collaborates with governments University of Sydney, Australia, and the University of and academics in several African countries, most London. He has been a leader in the development of recently Ethiopia, Ghana, Liberia, Mozambique, and surgical training and provision of services in the West Tanzania. She has published more than 60 papers in African subregion as Provost, College of Health Sciences, peer-reviewed journals, was a Commissioner on the Pro-Vice Chancellor, and former Head, Department of Global Health 2035 Lancet Commission on Investing Surgery at KNUST; President, Ghana Surgical Research in Health, and serves on the Institute of Medicine 384 Series and Volume Editors Committee on Health System Strengthening. Before of Science and Technology (Kumasi). In 2005−07, joining Harvard, she was Associate Professor of Health he served as Director of the University of Washington’s Management and Policy at the Columbia University Harborview Injury Prevention and Research Center. In Mailman School of Public Health and Director of the 2007−10, he worked at the World Health Organization Better Health Systems Initiative. She was previously (WHO) headquarters in Geneva, where he was respon- Policy Advisor for Health at the Millennium Project, sible for developing the WHO’s trauma care activi- an advisory body to the UN Secretary-General on the ties. In 2010, he returned to his position as Professor Millennium Development Goals. She holds an MD of Surgery (with joint appointments as Professor of degree from McMaster University and an MPH from Epidemiology and Professor of Global Health) at the Harvard University. University of Washington. His main interests include the spectrum of injury control, especially as it pertains to Charles N. Mock, MD, PhD, FACS, has training as both low- and middle-income countries: surveillance, injury a trauma surgeon and an epidemiologist. He worked as a prevention, prehospital care, and hospital-based trauma surgeon in Ghana for four years, including at a rural hos- care. He is President (2013−15) of the International pital (Berekum) and at the Kwame Nkrumah University Association for Trauma Surgery and Intensive Care. Series and Volume Editors 385 Contributors Richard M. K. Adanu David C. Chang School of Public Health, University of Ghana, Massachusetts General Hospital and Accra, Ghana Harvard Medical School, Cambridge, Massachusetts, United States Sweta Adhikari Mailman School of Public Health, Columbia University, Anthony Charles New York, United States Gillings School of Global Public Health and School of Medicine, University of North Carolina at Asa Ahimbisibwe Chapel Hill, North Carolina, United States Department of Obstetrics and Gynecology, University of Western Ontario, London, Canada Meena Cherian World Health Organization, Geneva, Switzerland Blake C. Alkire Department of Otology and Laryngology and Thomas Coonan Department of Global Health and Social Medicine, Department of Anesthesia, Pain Management, and Harvard Medical School, Cambridge, Massachusetts, Perioperative Medicine, Dalhousie University, Halifax, United States Canada Joseph B. Babigumira Dawit Desalegn Department of Global Health, School of Public School of Medicine, College of Health Sciences, Health, University of Washington, Seattle, Washington, Addis Ababa University, Addis Ababa, Ethiopia United States Catherine R. deVries Jan J. Barendregt Department of Surgery and Department of Family School of Population Health, University of Queensland, and Preventive Medicine, School of Medicine, Brisbane, Australia University of Utah, Salt Lake City, Utah Jessica H. Beard Delanyo Dovlo Department of Surgery, University of California, Rwanda Country Office, World Health Organization, San Francisco, California, United States Kigali, Rwanda Staffan Bergström Richard P. Dutton Department of Public Health Sciences, Karolinska Institute, Anesthesia Quality Institute and University of Chicago, Stockholm, Sweden Chicago, Illinois, United States Stephen W. Bickler Mike English Department of Surgery and Rady Children’s Hospital, KEMRI-Wellcome Trust Research Programme, University of California, San Diego, California, Nairobi, Kenya and University of Oxford, Oxford, United States United Kingdom 387 Diana Farmer Katrine Lofberg UC Davis Children’s Hospital and Department of Department of Surgery, Oregon Health Sciences Surgery, University of California, Davis, California, University, Portland, Oregon, United States United States Svjetlana Lozo Magda Feres Division of Global Health and Human Rights, Dental Research Division, Department of Massachusetts General Hospital, Boston, Massachusetts, Periodontology, Guarulhos University, Sao Paulo, Brazil United States Zipporah Gathuya Jackie Mabweijano Department of Anaesthesia, Gertrude’s Children’s Mulago National Referral Hospital, Kampala, Uganda Hospital, Nairobi, Kenya Colin McCord Richard A. Gosselin Columbia University (retired) Department of Orthopedic Surgery, University of California, San Francisco, California, United States Barbara McPake School of Population and Global Health, University Hideki Higashi of Melbourne, Melbourne, Australia Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States Kelly McQueen Department of Anesthesiology, Vanderbilt Susan Horton University Medical Center, Nashville, Tennessee, School of Public Health and Health Systems, University United States of Waterloo, Waterloo, Canada John G. Meara Renee Hsia Harvard Medical School and San Francisco General Hospital and Department of Plastic and Oral Surgery, Boston Department of Emergency Medicine, University of Children’s Hospital, Boston, Massachusetts, United States California, San Francisco, California, United States Nyengo Mkandawire Kjell Arne Johansson Department of Surgery, College of Medicine, Department of Global Public Health and Primary Care, University of Malawi, Blantyre, Malawi and University of Bergen, Bergen, Norway School of Medicine, Flinders University, Adelaide, Australia Clark T. Johnson Johns Hopkins University School of Medicine, Mark A. Morgan Baltimore, Maryland, United States Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, Timothy R. B. Johnson Pennsylvania, United States Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, United States Mulu Muleta Bedane Women and Health Alliance International and Manjul Joshipura University of Gondar, Gondar, Ethiopia Academy of Traumatology, Ahmedabad, India Arindam Nandi Nicholas J. Kassebaum Center for Disease Dynamics, Economics & Policy, Seattle Children’s Hospital and Washington, DC, United States Institute for Health Metrics and Evaluation, University Richard Niederman of Washington, Seattle, Washington, United States College of Dentistry, New York University, New York, Ramanan Laxminarayan United States Center for Disease Dynamics, Economics & Policy and Emilia V. Noormahomed Public Health Foundation of India, Washington, DC, Department of Microbiology, Eduardo Mondlane United States and New Delhi, India University, Maputo, Mozambique Carol Levin Florian R. Nuevo Department of Global Health, School of Public Department of Anesthesiology, University of Santo Health, University of Washington, Seattle, Washington, Tomas Hospital and Philippine Heart Center, Manila United States and Quezon City, the Philippines 388 Contributors Eyitope Ogunbodede Nicole Sitkin Faculty of Dentistry, Obafemi Awolowo University, Department of Surgery, University of California, Davis, Ile-Ife, Nigeria California, United States Michael Ohene-Yeboah Ambereen Sleemi Komfo Anokye Teaching Hospital and Mailman School of Public Health, Columbia Department of Surgery, Kwame Nkrumah University University, New York, United States and of Science and Technology, Kumasi, Ghana Eritrean Women’s Project, Mendefera, Eritrea Andrew Ottaway David Spiegel Hobart Anaesthetic Group, Hobart, Australia Children’s Hospital of Philadelphia and Doruk Ozgediz University of Pennsylvania School of Medicine, Department of Surgery, Yale University School of Philadelphia, Pennsylvania, United States Medicine, New Haven, Connecticut, United States Sathish Srinivasan Caetano Pereira University Hospital Ayr and Ministry of Health, Mozambique and Ayrshire Eye Clinic and Laser Centre, Ayr, Scotland Department of Obstetrics and Gynecology, Central Hospital, Maputo, Mozambique Andy Stergachis School of Public Health, University of Washington, Mary Lake Polan Seattle, Washington, United States Department of Obstetrics, Gynecology, and Reproductive Medicine, Yale University School of Amardeep Thind Medicine, New Haven, Connecticut, United States Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada N. Venkatesh Prajna Aravind Eye Hospital, Madurai, India Stéphane Verguet T.H. Chan School of Public Health, Harvard University, Raymond R. Price Cambridge, Massachusetts, United States Intermountain Healthcare and Department of Surgery and Department of Family and Jeffrey R. Vincent Preventive Medicine, University of Utah, Salt Lake City, Nicholas School of the Environment, Sanford Utah, United States School of Public Policy, Duke University, Durham, Shankar Prinja North Carolina, United States Post Graduate Institute of Medical Education and Michael Vlassoff Research, Chandigarh, India Guttmacher Institute, New York, United States Thulasiraj D. Ravilla Johan von Schreeb Lions Aravind Institute of Community Ophthalmology, Department of Public Health Sciences, Karolinska Madurai, India Institute, Stockholm, Sweden Eduardo Romero Hicks Ministry of Health of Guanajuato, Guanajuato, Mexico Theo Vos Institute for Health Metrics and Evaluation, University Sarah Russell of Washington, Seattle, Washington, United States Mailman School of Public Health, Columbia University, New York, United States Thomas G. Weiser Department of Surgery, Stanford University School of William P. Schecter Medicine, Stanford, California, United States San Francisco General Hospital and Department of Surgery, University of California, Iain H. Wilson San Francisco, California, United States Royal Devon and Exeter Hospital, Exeter, United Kingdom Mark G. Shrime Interfaculty Initiative in Health Policy, Harvard Ahmed Zakariah University, Cambridge, Massachusetts, United States National Ambulance Service, Accra, Ghana Contributors 389 Advisory Committee to the Editors Anne Mills, Chair Amanda Glassman Professor, London School of Hygiene, London, Director, Global Health Policy, Center for Global United Kingdom Development, Washington, DC, United States Olusoji Adeyi Glenda Gray Director, Health, Nutrition and Population Global Executive Director, Perinatal HIV Research Unit, Practice, World Bank, Washington, DC, United States Chris Hani Baragwanath Hospital, Johannesburg, South Africa Ala Alwan Director, World Health Organization, Regional Office Demissie Habte for the Eastern Mediterranean, Cairo, Arab Republic Chair of Board of Trustees, International Clinical of Egypt Epidemiological Network, Addis Ababa, Ethiopia Rifat Atun Richard Horton Professor, Global Health Systems, Harvard University, Editor, The Lancet, London, United Kingdom Boston, Massachusetts, United States Edward Kirumira Zulfiqar Bhutta Dean, Faculty of Social Sciences, Makerere University, Chair, Division of Women and Child Health, Aga Khan Kampala, Uganda University Hospital, Karachi, Pakistan Peter Lachmann Agnes Binagwaho Professor, University of Cambridge, Cambridge, Minister of Health, Kigali, Rwanda United Kingdom Mark Blecher Senior Health Advisor, South Africa Treasury Lai Meng Looi Department, Cape Town, South Africa Professor, University of Malaya, Kuala Lumpur, Malaysia Patricia Garcia Dean, School of Public Health, Universidad Peruana Adel Mahmoud Cayetano Heredia, Lima, Peru Senior Molecular Biologist, Princeton University, Princeton, New Jersey, United States Roger Glass Director, Fogarty International Center, National Anthony Measham Institutes of Health, Bethesda, Maryland, United States World Bank (retired) 391 Carol Medlin Jaime Sepúlveda Children’s Investment Fund Foundation, London, Executive Director, Global Health Sciences, University United Kingdom of California, San Francisco, California, United States Alvaro Moncayo Richard Skolnik Researcher, Universidad de los Andes, Bogota, Lecturer, Health Policy Department, Yale School of Colombia Public Health, New Haven, Connecticut, United States Jaime Montoya Stephen Tollman Executive Director, Philippine Council for Professor, University of Witwatersrand, Johannesburg, Health Research and Development, Taguig City, South Africa the Philippines Jürgen Unutzer Ole Norheim Professor, Department of Psychiatry, University of Professor, University of Bergen, Bergen, Norway Washington, Seattle, Washington, United States Folashade Omokhodion Damian Walker Professor, University College Hospital, Ibadan, Senior Program Officer, Bill & Melinda Gates Nigeria Foundation, Seattle, Washington, United States Toby Ord Ngaire Woods President, Giving What We Can, Oxford, United Director, Global Economic Governance Program, Kingdom Oxford University, Oxford, United Kingdom K. Srinath Reddy Nopadol Wora-Urai President, Public Health Foundation of India, Professor, Department of Surgery, Phramongkutklao New Delhi, India Hospital, Bangkok, Thailand Sevkat Ruacan Kun Zhao Dean, Koc University School of Medicine, Istanbul, Researcher, China National Health Development Turkey Research Center, Beijing, China 392 Advisory Committee to the Editors Reviewers Wame Baravilala Russell Gruen United Nations Population Fund, Pacific Sub-Regional Monash University and Office, Suva, Fiji Islands The Alfred Hospital, Melbourne, Australia Chibuike Ogwuegbu Chigbu Jaymie Henry University of Nigeria Teaching Hospital, Enugu, Nigeria Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care (G4 Alliance), San Francisco, Usuf M. E. Chikte California, United States Stellenbosch University, Stellenbosch, South Africa Dhruv S. Kazi Kathryn Chu University of California, San Francisco, California, Harvard Medical School, Cambridge, Massachusetts, United States United States Robert Lane Michael Cotton International Federation of Surgical Colleges, University Hospital of Lausanne (CHUV), Lausanne, Southampton, United Kingdom Switzerland Blami Dao Andrew Leather Jhpiego, an affiliate of Johns Hopkins University, King’s College London Centre for Global Health, Baltimore, Maryland, United States London, United Kingdom Moses Galukande Jenny Löfgren Makerere University College of Health Sciences, Umeå University, Umeå, Sweden Kampala, Uganda Jane Maraka Raul Garcia East of England Deanery, Cambridge, United Kingdom Boston University, Boston, Massachusetts, United States Kelly McQueen Sarah Greenberg Vanderbilt University Medical Center, Nashville, Harvard Medical School, Cambridge, Massachusetts, Tennessee, United States United States Mahesh C. Misra John S. Greenspan All India Institute of Medical Sciences, New Delhi, India University of California, San Francisco, California, United States Sam W. Moore Stellenbosch University, Stellenbosch, South Africa Caris Grimes King’s College London Centre for Global Health, Pär Nordin London, United Kingdom Umeå University, Umeå, Sweden 393 Ebenezer Anno Nyako Samuel D. Shillcutt University of Ghana Dental School, Accra, Ghana Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States Akinyinka O. Omigbodun University of Ibadan, Ibadan, Nigeria K. M. Shyamprasad Martin Luther Christian University, Shillong, India Chris Oppong Derriford Hospital, Plymouth, United Kingdom Hugh R. Taylor University of Melbourne, Melbourne, Australia Doruk Ozgediz Yale University School of Medicine, New Haven, Nitin Verma Connecticut, United States University of Tasmania School of Medicine, Hobart, Australia Norgrove Penny The University of British Columbia, Vancouver, Canada L. Lewis Wall Washington University in St. Louis, St. Louis, Missouri, Dan Poenaru United States Queens University, Kingston, Canada Teri Reynolds Lee Wallis University of California, San Francisco, California, African Federation of Emergency Medicine, Bellville, United States South Africa Matthias Richter-Turtur Benjamin C. Warf Isar Klinikum, Munich, Germany Harvard Medical School, Cambridge, Massachusetts, United States Percy Eduardo Rossell-Perry San Martin de Porres University, Lima, Peru David Watters Deakin University and Barwon Health, Geelong, Andrés Rubiano Australia South Colombian University, Neiva, Colombia Iskender Sayek Andreas Wladis Hacettepe University Faculty of Medicine, Ankara, Karolinska Institute, Stockholm, Sweden Turkey Gavin Yamey Lawrence Sherman University of California, San Francisco, California, University of Liberia, Monrovia, Liberia United States 394 Reviewers Index Boxes, figures, maps, notes, and tables are denoted by b, f, m, n, and t respectively. A disparities between LMICs and HICs, 355 abdominal conditions emergency surgery, 73 congenital anomalies (case study), 136–37 in Ethiopia, 340. See also Ethiopia emergency surgery for acute conditions, 62–65, 222 family planning, 113, 124n10 injuries, 48 first-level hospitals, 226–28 intestinal obstructions, 63–64, 220t improving, 12–13, 14–15 mortality rate of emergency surgery, 67–68, 67t inequities in, 355 surgical intervention for, 20, 61 inguinal hernia, 155–56 abortion obstetric conditions, 88 access to surgical, 120 obstetric fistula, 101, 120 barriers to access to, 120 oral conditions, 188 consequences of unsafe, 120 poverty as barrier to, 353–57 cost-effectiveness of methods, 122, 124n13, 321–23 surgical interventions, 2, 8, 280 costs of, 331t acute adenolymphangitis (ADLA), 162, 164 effectiveness of methods, 121–22 acute lower respiratory infection, 20 in Ethiopian study, 340t Adam, T., 323 future directions of, 122–23 Adams, C., 234 global demand for, 119–20 Adanu, R. M. K., 77 incomplete, 119 Addis Ababa Fistula Hospital, 97, 103, 233, 237 induced miscarriage, 122 Adhikari, S., 353 medical vs. surgical, 121 ADLA (acute adenolymphangitis), 162, 164 methods, 121 Adler, A., 371 overview, 109 advocacy postabortion care, 109, 119–21 for congenital anomalies treatment, 143–44 surgical procedures, 109, 119–23 for contraception and family planning, 119 tubal ligation following, 114 for hernia repair, 158b academic partnerships for traumatic injury care, 41–42 congenital anomalies treatment, 139t, 140–41 affordability. See cost-effectiveness; costs; surgical obstetric fistula repairs, 103 procedures obstetric procedures, 89, 90 Africa. See also specific countries and regions access to care. See also barriers to service delivery abortion complications in, 120 abortion, 120 contraception, unmet need in, 112, 117–18 cataracts, 202–3 hernia repair complications in, 160 congenital anomalies, 130, 133, 139–40t, 139–43 lymphatic filariasis in, 162 395 Agency for Healthcare Research and Quality (AHRQ), perioperative period, 265, 266–67 21, 22 pulse oximetry, use of, 13, 292 age weighting for benefit-cost analysis, 365 quality improvement, 73, 273–74, 273b, 291–92 aging population research needs, 274 blindness and, 197, 199 safety of, 2, 13, 265, 266–68, 269t, 272, 288 cataracts and, 202 shortage of anesthesiologists, 8 changing demographics, 206 standards of practice, 291–92 oral health maladies and, 173 task-sharing, 272–73, 272t orthopedics and, 52, 53 training of providers, 270–73, 271t specialty surgical hospitals and, 237 unmet need for, 263, 264m, 265 agricultural livelihood, obstetric fistula’s effect on vigilance, defined, 265 women and, 99, 100, 103 aneurysm repair, 291t Ahimbisibwe, A., 109 Annan, Kofi, 91 AHRQ (Agency for Healthcare Research and Quality), anorectal malformations (ARMs) 21, 22 case study, 135–36 AIDS. See HIV/AIDS prevalence and mortality rates, 131t, 136 airway management during anesthesia, 266 antibiotic use Akoko, L., 154 burn care, 52 alcoholic cirrhosis of liver, 64 cataract surgery, 202 Alkire, B. C., 361, 363–64 eye infections, 201 ambulances. See prehospital and emergency care; oral disease, 179–81 transport of patients Apollo Hospital (India), 253b American Board of Surgery, 61 appendicitis/appendectomy, 23, 63, 72, 219–20t, 340t American College of Obstetrics and Gynecology, 90 mortality rate following, 283, 284–85t, 285 American Osteopathic Association, Division of State Apridec Medical Outreach Group, 158–59b Government Affairs, 309 Aravind Eye Hospital (India), 201, 203, 233, 238 American Society of Anesthesiologists, 268, 273b, 280 ARMs. See anorectal malformations AMOs (assistant medical officers). See nonphysician arteriosclerosis, 66, 225 clinicians; Tanzania arthritis, 53, 54t amputation, 46, 54, 219–20t, 291–92t, 340t, 354 Asia. See also specific countries and regions anesthesia services, 263–78 abortion complications in, 120 accredited professionals, 295t blindness in, 197 airway management, 266 burn injuries and care in, 354 anesthetist physician assistant programs, 310 contraception, unmet need in, 112 barriers to safe, 265–67 assistant medical officers (AMOs). See nonphysician burden of disease averted by, 263–66 clinicians; Tanzania cardiac perturbations, 266 associate clinicians. See nonphysician clinicians cost-effectiveness of techniques, 268–70 Association of Anaesthetists of Great Britain and costs of, 268, 269t, 270–72 Ireland, 73 data collection related to, 274 asthma, 246 definitions of terms related to technology and astigmatism, 202 patient care, 265 Australia emergency surgery, 70 anesthesia-related mortality in, 267 first-level hospitals, 220, 225 cataract-related blindness in, 198 future directions of treatment, 272–74 cataract surgery in, 199, 204 hernia repair, 157 cost-effectiveness studies in, 320 Ketamine, 225, 228n1 trauma care systems in, 43, 46 medicines essential for, 268–70, 269t autoimmune diseases, 53 mortality rate associated with, 13, 265, 267–68, 267f, 268t, 273–74, 288, 289f B nurse anesthetists, 310 Babbar Ruga Fistula Teaching Hospital (Nigeria), 232, overview, 263 237, 238 pain management, 266–67 Babigumira, J. B., 109 patient safety, 266–68, 272–74, 291–92 Babu, B. V., 164 396 Index Baek, R. M., 324 bleeding Bainbridge, D., 288 during childbirth, 77, 80, 81, 83 Baltussen, R., 327 from esophageal varices, 64 banana leaves as burn treatment, 51 traumatic injuries and, 49 Banerjee, A. V., 184 ulcers and, 64, 225 Bangladesh blindness. See also cataracts burn care in, 50 costs of, 197–98, 328 cataract surgery in, 328 disparities between LMICs and HICs, 355 DALYs averted by emergency surgery in, 68–69b expenditures to prevent, 206, 206f district (first-level) hospitals in, 215, 217, global challenge of, 197–98 217–18t, 219 prevalence of, 197, 206 costs of care, 222 risk factors for, 197 obstetric care costs in, 20 trends in reduction of, 206–7 obstetric fistula in, 99 visual acuity scale, 197, 198t trauma care system in, 45 blood transfusion, 82 Barendregt, J. J., 19 Bloom, D., 361 barriers to service delivery. See also access to care Bloom, N., 294 abortion and postabortion care, 120 Bolivia, first-level hospitals in, 217, 217–18t, 218 anesthesia, 265–66 bone fractures. See traumatic injuries cataract surgery, 202–3, 353 bone infections. See infections emergency surgeries, 73 Bradley, S., 309 family planning, 113 brain drain. See shortage of skilled surgeons first-level hospitals, 226–27 Brazil obstetric services, 353 blindness in, 197 oral health care, 183b, 188 filarial hydrocelectomy in, 165, 166 poverty, 353–57 hospital management practices in, 294 surgical care, 8–9, 287–90, 287f lymphatic filariasis in, 164 Bayalpata Hospital (Nepal), financial sustainability tooth paste fluoridation in, 179 of, 330b water fluoridation in, 177–78 BCA. See benefit-cost analysis breech birth. See cesarean delivery; obstetric conditions Beard, J. H., 61, 151, 153, 154, 155, 160 Bretlau, P., 234 Bedane, M. M., 95 Broder, S., 354 Bellagio Essential Surgery Group, 368 Brown, M. M., 206 benefit-cost analysis (BCA), 7, 361–80 Browning, A., 100, 237, 238 advantages of, 368–69 burden of disease, 20–35. See also disability-adjusted age weighting, 365–66 life years (DALYs); mortality rate cesarean delivery, 83–84, 84t, 87, 370–76, 372–73t acute abdominal conditions, 61 cleft lip and palate repair, 7, 329, 363–70, 367t anesthesia services, 263–66 discounting, 365–66 avertable burden, 6, 6–7t, 7f future directions for research, 369 calculation of, 24–25 global health interventions, 362–63 research and development on, 35–36 limitations of study, 369, 376 by scaling up subspecialty surgical care, 28–32, 33t methods for modeling, 364, 370 burn injuries, 49–50 overview, 361 cataract, 28, 30, 198–99, 198f, 355 recommendations for, 367–68 congenital anomalies, 129, 133–35, 134t, 143, 363 results, 367 definition of, 124n12 value of a statistical life (VSL), 362–63 emergency surgery, 61–62, 66–67, 221 Berger, P., 152 family planning and reduction of, 110 Bergström, S., 307 first-level hospitals and surgically treatable disease, BethanyKids, 140 23, 221 Bickler, S. W., 19, 318 “global burden of disease,” use of term, xi biopsies, 21 hernia, 153–55, 155t Birkmeyer, J. D., 290 hydrocele, 162–64 birth defects. See congenital anomalies lymphatic filariasis, 162–64, 163m Index 397 measurement of, xi prehospital treatment of trauma patients in, 253 methodology to determine estimates of, 23–25 trauma care system in, 46 limitations of, 32 Campaign to End Fistula (UNFPA), 97, 100, 103 nonavertable burden, 28 Canada calculation of, 25 anesthesia training in, 271t research and development on, 36 trauma care systems in, 43, 44b nonfatal burden, calculation of, 25 cancer obstetric conditions, 77–79, 221, 222 amputation and orthopedic surgery for, 54 obstetric fistula, 28, 30, 97–100 causing need for more surgery, 66 oral disease, 174–75, 174t cost-effectiveness of treatment, 225 population health disparities between LMICs and HICs, 354–55 subspecialty surgical care, impact on, 28–32 screening, exclusion from platform discussion, 232 surgical care, impact on, 25–28 surgical interventions for, 318 prehospital and emergency care, 245–47, 246f, 259t tumors, treatment of, 21 short-term surgical missions, 236 cardiac anomalies, congenital surgical interventions, effect on, 1–2, 6–7t, 20 avertable and nonavertable DALYs and preventable surgically treatable disease, xi–xii, xv, 1, 221, 238 deaths associated with surgical care for, 134t traumatic injuries, 23, 25, 28f, 42–43, 42f, 42t, 221 prevalence and mortality rates, 131t DALYs averted by, 25, 27t cardiac perturbations during anesthesia, 266 deaths prevented by, 25, 26t cardiac surgery, 225 Burkina Faso cost-effectiveness of, 317 catastrophic health spending in, 328, 355 short-term surgical missions, 233, 234 hernia repair in, 157 caries and periodontitis. See oral health maladies nonphysician clinicians in, 312 case study obstetric procedures in, 12, 86, 355 anorectal malformations (ARMs), 135–36 short-term surgical missions in, 233 Bayalpata Hospital (Nepal), financial sustainability burn injuries, 49–52. See also traumatic injuries of, 330b antibiotic use, 52 clubfoot, 137–38 burden of disease due to, 49–50 congenital anomalies, 136–37 cost-effectiveness of care for, 49–50 Eritrean Women’s Project, 118–19b disability-adjusted life years (DALYs) due to, 49, 52 gastroschisis, 136–37 disparities between LMICs and HICs, 354 Hirschprung’s disease, 135–36 future directions of treatment for, 52 omphalocele, 136–37 hospital management of, 50–52, 220t, 221 cataracts, 20, 198–99. See also blindness; cataract mandatory reporting, 52 surgery nutrition for healing, 52 access to care for, 202–3, 225 pain management, 51–52 burden of, 28, 30, 198–99, 198f, 355 prioritizing care of, 52 as cause of blindness, 198 rehabilitation, 52 prevalence of, 198–99, 202, 204 telemedicine to evaluate, 52 stages of, 199 triage, 51 trends in reduction of, 206–7 wound care and dressings, 51 cataract surgery, 197–212. See also blindness; cataracts astigmatism induced by, 202 C avertable and nonavertable DALYs associated with, Cambodia 30, 31t congenital anomaly repair in, 134 barriers to implementation, 202–3 costs of surgical care in, 329 complications of, 200–201 first-level hospital care, 222 consequences of delay in, 199 Essential Health Care Program (EHCP) in, 185 cost-effectiveness of, 2, 204–7, 205t, 325t, 326–27 first responder training in, 255b costs of, 204, 204t, 331t midwives, training of, 249 delivery systems for, 203 musculoskeletal (MSK) system injuries in, 49 demand-supply equation, 207 oral health care in, 183b disparities between LMICs and HICs, 355 398 Index economic benefits of, 328 Charles, A., 41 efficacy of, 201–2 Chatterjee, S., 369 endophthalmitis and, 201 checklists for surgical safety, 1, 13–14, 292–94, 293f first-level hospitals, 5t, 221 Cherian, M., 213 intervention types and procedures, 199–200 childbirth, 21, 77. See also cesarean delivery; maternal ophthalmologist productivity, 203 morbidity and mortality; obstetric conditions; outcomes of, 201–4 obstetric fistula platform for delivery of procedure, 5t birth attendants, access to, 79, 88–90, 130, 308, 355 posterior capsular opacification and, 201 stillborn child, 97, 98–99 posterior capsular rupture and, 201 training of midwives, 249 preoperative testing for, 199 children and infants. See also congenital anomalies safety of, 200–201 burns, pain management for, 51–52 short-term surgical missions, 234 Fit for School program (Philippines), 184, 185b cost-effectiveness of, 235 intussusception, emergency surgery for, 64 specialty surgical hospitals for, 5t, 236, 237 noma in, 181 sustainability of delivery systems, 203 orphaned due to maternal death, 79 types and procedures, 199–200, 225 prehospital and emergency pediatric care, 252 utility values of, 205–6 worms, emergency surgery for, 63–64 visual acuity after, 201–3 China catastrophic health spending, 3b, 285, 328, 342, 348, blindness in, 197 355–57 burn care in, 51 CBM International, 140 orthopedic surgery in, 53 cell phones, 250 trauma care system in, 45, 46 smartphones and anesthesia monitoring, 270 Chowdhury, Q., 2, 45 Central Asia. See Eastern Europe and Central Asia CinterAndes, 233 cesarean delivery Clarke, M. G., 161, 332 abnormal placentation and, 83 cleft lip and palate repair, 130 auditing, 310 benefit-cost analysis (BCA), 7, 329, 361, benefit-cost analysis for, 83–84, 84t, 87, 370–76 363–70, 363t breech presentation, 80 burden of disease, 134t, 363 challenges to safe delivery, 88 cost-effectiveness of treatment for, 324–25, 363 costs of, 331t, 356–57, 374–75t model for delivery of care, 368 delivery technique, 82 Operation Smile, 140, 233, 364, 368 disability-adjusted life years (DALYs), 370, 371–72 short-term surgical missions, 233, 234 disparities between LMICs and HICs, 285, 355 cost-effectiveness of, 235 in Ethiopian study, 339, 340t Smile Train, 140, 363 hemorrhage at time of, 83 specialty surgical hospitals for, 237 incidence of, 280, 370–71, 372–73t clubfoot, 20, 130 incision, 82 case study, 137–38 indications for, 82 cost-effectiveness of treatment for, 325 mortality rate following, 13, 283, 283–84t paramedical practitioners to treat, 141 obstructed labor requiring, 101, 370–76 Uganda Sustainable Clubfoot Care Project, 138b overview of, 82–85 Cochrane review of abortion methods, 122 preoperative preparation, 82 colectomy, 291t, 318 rate in LMICs, 280, 355, 356f College of Surgeons of East, Central, and Southern safety, 84–85 Africa, 70 urban vs. rural households, 357f Colombia Chang, D., 19 hernia repair in, 152 Chao, T. E., 320 prehospital and emergency care legislation in, 258b charitable organizations. See also nongovernmental Colombian Prehospital Care Association (ACAPH, organizations (NGOs) Asociación Colombiana de Atención congenital anomalies treatment centers, 140 Prehospitalaria), 258b platforms for surgical delivery, 231, 232–33, 238 colorectal disease, 135–36 Index 399 Commission on Investing in Health, 14 Coonan, T., 263 Commission on Macroeconomics and Health, 320, 362 Copenhagen Consensus (CC 2012), 7, 9b, 23, 361, 362 communicable diseases Corlew, D., 325, 329, 363 noncommunicable diseases superseding as leading cost-effectiveness, xii, 1, 7–8, 8f, 9b, 317–38 cause of mortality, 263 abortion methods, 122, 124n13, 321–23 treatable in prehospital and emergency care, 246 access to services impact on, 3b, 339–52 community facilities. See health centers anesthesia techniques, 268–70 Community Oriented Program for the Control of approaches to determine, 9b Rheumatic Diseases, 53 benefits of improved surgical access, 328–29 community-provided first aid. See first aid training; burn care, 49–50 first responders cataract surgery, 2, 204–7, 205t, 325t, 326–27 congenital anomalies, 129–50. See also cleft lip and cleft lip and palate repair, 324–25, 363 palate repair; neural tube defects congenital anomalies surgery, 143, 324–25, 324t abdominal wall defects, 136–37 contraception, 115–17, 116t academic partnerships for surgical care of, 139t, data uses and limitations, 318–19, 331–32 140–41 dental surgery, 318 access to surgical care for, 130, 133, 139–43 emergency surgery, 68–69, 319t, 320–21 action plan, 142–44 feasibility, importance of, 317 advocacy for, 143–44 first-level hospitals, 222–26 anorectal malformations (ARMs, case study), future priorities, 333 135–36 inguinal hernia repair, 161, 325–26 avertable and nonavertable DALYs and preventable measurement methods, 319–21 deaths associated with surgical care for, 30–32, nonemergency surgery, 323–27 31t, 134–35, 134t nonphysician clinicians, 12, 312–13 burden of, 28, 30, 133–35, 134t, 143 obstetric fistula, 100 capacity assessment for surgical care, 143 obstetric surgery, 83–85, 87–88, 321–22t, 321–23 clubfoot, 137–38 oral conditions, 186–87 colorectal disease (case study), 135–36 orthopedic procedures, 326 cost-effectiveness of surgery for, 143, 324–25, 324t overview, 317–18 data collection challenges, 130, 143 platforms for surgical delivery, 8, 238, 327–28 disability adjusted life years (DALYs), 129–30 prehospital and emergency care, 256, 256t emergency surgery, 66 reasonableness, defined, 317 first-level hospitals, 5t, 143, 221 short-term surgical missions, 235, 327–28 foreign treatment, 140t, 141 specialty surgical hospitals, 238, 327–28 future directions for treatment, 142–44 trauma care, 319t, 320–21 gastroschisis, 136–37 usefulness of data, 318–19 Hirschprung’s disease (case study), 135–36 costs implementation and surveillance priorities, 139–40t, anesthesia services, 268, 269t, 270–72 139–42 average national rate of surgery by category of models of ideal system procedures, 142–43, 142t health expenditure, 280, 281t models of treatment for, 143 as barrier to the poor’s access to services, 353. mortality rate, 130–33, 131–33t See also catastrophic health spending omphalocele, 136–37 benefit-cost analysis, 361–80. See also benefit-cost overview, 129 analysis (BCA) platform for delivery of procedure, 5t blindness, 197–98 research priorities, 143–44 cataract surgery, 204, 204t, 331t shortage of skilled surgeons, 133 catastrophic health spending, 328. See also surgical missions, 139t, 140 catastrophic health spending telemedicine use, 141, 144n6 condition-related surgical unit, 329–31 training programs for surgical providers, 141 emergency surgery, 68–69, 73 treatment centers, 139–40, 139t financial imposed on patient, 355–57 treatment delays, 130–33, 135–36, 138, 143 hospital type and, 329 contraception. See family planning and contraception labor costs, 331 400 Index obstetric procedures, 87–88, 331t, 355–56 digestive diseases oral health care, 187 burden avertable by surgery for, 23, 28, 28f patient bearing, 12. See also catastrophic health DALYs averted by, 25, 27t spending deaths prevented by, 25, 26t prehospital and emergency care, 252–54 burden nonavertable by surgical care for, 28, 29t sterilization, 116, 117t surgery for, 26–27t. See also appendicitis/ surgical interventions, 329–31, 331t appendectomy surgical unit costs, 329–31 dilation and curettage (D&C), 121. See also abortion transport of patients, 8, 214–15, 285, 288 Dimick, J. B., 290 Council on Health Research for Development, 259 disability-adjusted life years (DALYs). See also burden cultural beliefs of disease abortions and, 120 assignment to surgical procedures, 22–23 contraception use and, 111, 113 burn injuries, 49, 52 delay in seeking surgical care due to, 287 calculating for benefit-cost analysis, 9b, 365 filarial hydroceles and, 164 averted to economic benefit, 366–67 lymphatic filariasis and, 164 cataracts, 204, 355 obstetric fistula and, 97, 98, 99–100 by cause (global), 67, 67t obstetric procedures and, 88 cesarean delivery for obstructed labor, 370, 371–72 CURE network, 140 congenital anomalies, 129–30 contraceptive surgeries and abortions, 116 D converting VSL methodology into, 362 DALYs. See disability-adjusted life years definition of, 20 Das, J., 290 emergency surgery, 66–67, 67t, 68–69b data collection challenges GBD 2010 use of, 20 anesthesia services, 274 hernias, 154–55 congenital anomalies, 130, 143 hydrocele, 163 cost-effectiveness, 331–32 lymphatic filariasis, 163, 163m Debas, H. T., xvi, 1, 20, 61, 67, 215, 222 obstetric complications, 78–79, 78t de Buys Roessingh, A. S., 234 obstetric fistula, 101 delays in treatment oral disease, 174–75, 175–76t burn treatment, 50–52 prehospital and emergency care, conditions treatable cataracts, 199 in, 246–47, 247f congenital anomalies, 130–33, 135–36, 138, 143 short-term surgical missions, treatment by, 235, 239 emergency care, 259 surgical interventions, effect on, 7–8, 8f, 20, 24–25, infant mortality due to, 64, 80 27t, 28f, 221, 222–24, 281, 319 infections as result of, 54 disabled persons, rehabilitation for, 46 obstetric care, 81, 83, 88 disease burden. See burden of disease obstetric fistula, 102 Disease Control Priorities in Developing Countries, surgical care, 285, 287–88 second edition (DCP2), xi–xii, 3b, 41, 62, “demographic dividend,” 110, 123n4 213, 245 dentistry. See oral health maladies disparities between LMICs and HICs dermatological conditions. See skin anesthesia, mortality rate associated with, 13 Desalegn, D., 339 anesthesiologists, 8–9 deVries, C. R., 151 anorectal malformations (ARMs), 136 deworming, 184, 185b blindness, 355 diabetes burden of disease, 353–55 amputation and, 46 burn injuries, 50, 354 cataracts and, 199, 202 cancer, 354–55 cost-effectiveness of treatment, 225 cataract surgery, 200, 355 obstetric complications and, 80 cesarean delivery, 285, 355 oral health and, 179, 180 mortality rates, 13 treatable in prehospital and emergency care, 246 cleft lip and palate repair, 364 diaphragmatic hernia, congenital, 133t congenital anomalies, 130, 134 Index 401 emergency surgeries, 66, 67 El Salvador hernias, 152, 160f, 166 emergency obstetrical surgery in, 221 higher levels of care, 32 free health care in, 226 maternal mortality rates, 78 Emergency and Essential Surgical Care (EESC) musculoskeletal (MSK) system, 354 program, 23, 333 obstetric conditions, 353–54, 355 emergency care obstetric fistula, 354 emergency room care, 55, 56f operating room costs, 70 prehospital. See prehospital and emergency care ophthalmologists, 203 surgical emergency. See emergency surgery prehospital and emergency care, 245, 354, 354t emergency surgery, 61–76. See also obstetric conditions; surgical access, 8–9, 10m, 33, 280, 281t, 355 prehospital and emergency care; surgical surgical mortality, 283–85 procedures; traumatic injuries traumatic injuries, 42, 353–54 abdominal conditions, 61, 62–65, 222 district hospitals. See first-level hospitals appendicitis. See appendicitis/appendectomy Dominican Republic barriers to service delivery, 62, 73 cost-effectiveness of orthopedic procedures in, 326 basic systems for, 69–71 lymphatic filariasis in, 164 burden of disease, 61–62, 66–67, 221 Donkor, P., xvi, 1, 129 congenital conditions, 66 Dougherty, C., 326 cost-effectiveness of care, 68–69, 320–21 Dovlo, D., 307 costs of, 68–69, 73 Drummond, M. F., 319, 320 disability-adjusted life years (DALYS), 66–67 Duflo, E., 184 effectiveness of, 67–68 Dutton, R. P., 263 esophageal variceal bleeding, 64 first-level hospitals, 61, 66, 68–70, 72t, 222 E foreign bodies, 65 ear camps, 233, 234 future directions for, 73–74 East Asia and Pacific region gall bladder and bile duct disease, 65 anesthesia provider training in, 271 hospital care, 62t, 70 international surgical organizations in, 231 infections of the skin, muscles, bones and joints, 66 obstetric fistula in, 97 inguinal hernias, 62–63, 155–56 prehospital and emergency care, preventable deaths intestinal obstructions, 63–64 and addressable DALYs in, 247, 247f intussusception, 64 maternal and child mortality, 248 liver. See liver transport options in, 250–51 models of ideal system procedures, 71, 72t trauma care systems in, 46 mortality rate, 67, 67t Eastern Europe and Central Asia obstetric conditions, 221, 222, 323. See also cesarean blindness in, 207 delivery subsurgical specialties, avertable DALYs associated other common conditions necessitating, 66 with, 32 outcomes at first-level hospitals, 222 economic benefits of surgical intervention, 7–8, 7–8f, pelvic infections with abscesses, 64 328–29 peptic ulcer complications, 64, 72 Ecuador perforated typhoid ulcers, 64–65 cleft surgeons on short-term mission in, 234 pleural disease, 65 hernia repair in, 161 respiratory obstructions, 65 effectiveness. See also cost-effectiveness technology, 71–73 abortion, 121–22 training and distribution of skilled staff, 70–71 emergency surgical care, 67–68 types of, 62–66 prehospital and emergency care, 254–55 urinary obstructions, 65 specialty surgical hospitals, 237–38 volvulus, 63–64 trauma care systems, 43–47 worm infestation, 63–64 EHCP (Essential Health Care Program), 185 empyema, 65 Elder, G., 321, 328 endophthalmitis, 201 Elkins, T. E., 98 English, M., 213 402 Index epidemiology F impact on first-level hospitals, 225, 227 faith-based hospitals, 140, 218 inguinal hernia, 153–54, 154t Fall, B., 160 equipment and supplies. See also technology family planning and contraception, 109–28 delay in treatment due to inadequate provision, access to, 113, 123 287–88 benefits of, 110 emergency surgery, 70 burden of disease reduction and, 110 first-level hospitals, 227 contraceptive prevalence, 111–12 improved planning and logistics, 12 contraceptive security, 124n10 International Organization for Standardization cost-effectiveness of surgical contraception, (ISO) standard for equipment, 270 115–17, 116t prehospital and emergency care, 251–52 costs of surgical contraception, 116, 117t, 123n8 Eritrea future directions of, 117–19 cesarean delivery costs in, 375 importance of, 110 congenital anomalies treatment in, 141 maternal mortality reduction and, 110 obstetric fistula in, 99, 100, 103 methods, 110–11, 111t case study, 118–19b models of treatment, 118 esophageal variceal bleeding, 64 nonsurgical, 111t, 115–16, 123n5 Essential Health Care Program (EHCP), 185 obstetric care coupled with, 85 Essential National Health Research process, 259 overview, 109 Essential Trauma Care Project, 45, 45b prevalence, 111–12 Ethiopia recommendations for, 118–19 access to surgery in, 339–52 sterilization (including tubal ligation and cesarean delivery in, 339, 340t vasectomy), 110, 112–15, 123n7 costs and assumptions of study in, 342 surgical contraception, 110, 111t, 112–17 data sources of study in, 342 unmet need for, 112 Demographic and Health Survey in, 342 Farmer, D., 129 discussion of study in, 345–49 Farmer, P., xii, 2 financial risk protection in, 345 femoral hernia, 151–52 health protection vs., 346f Fentahun, W., 100 health benefits and cases of poverty averted in, 347f Feres, M., 173 hernia repair in, 160 fetal presentation abnormalities, 80 model structure and outcomes of study in, 340, FIGO (International Federation of Gynecology and 341f, 341t Obstetrics), 103 obstetric fistula in, 98, 99–100, 103, 237, 327 filarial hydrocele. See lymphatic filariasis (LF) obstetric procedures in, 86, 87 financial incentives for nonphysician clinicians, 311 results of study in, 342–45 financing. See also catastrophic health spending analysis limitations, 348–49 first-level hospitals, 226, 227 analysis without travel vouchers, 343–44t, prehospital and emergency care, 257 343–45 Finger, R. P., 329 analysis with travel vouchers, 343–44t, 345 first aid training heterogeneity in results, 348f community members, 248, 250b sensitivity analysis of study in, 342, 345 lay first responders, 8, 249, 249b, 255b task-sharing and task-shifting model, 339–49, first-level hospitals, 213–30. See also hospital care 345, 349 access to care, 226–28 universal public financing model, 340 anesthesia administration at, 220, 225 Europe. See also specific countries and regions burden of surgically treatable disease and, 23, 221 hospital management practices in, 294 capacity constraints, 215 international surgical organizations in, 231 need to provide more services, 227 mortality rates associated with surgery in, cataract surgery, 221 279–80, 280f congenital anomalies treatment, 143, 221 Everhart, J. E., 153 costs and cost-effectiveness of surgery, 8, 222–24, eye camps, 233, 234, 235 223t, 329 Index 403 obstacles to low cost and high cost-effectiveness, anesthesia services, 272–74 224–26 benefit-cost analysis, 369 disabling conditions, surgery for, 221 burn injuries, 52 emergency surgery, 61, 66, 68–70, 222 congenital anomalies, 142–44 epidemiological transition at, 225, 227 cost-effectiveness and cost-benefit analyses, 333 equipment and supplies, 227 emergency surgery, 73–74 financial support for, 226, 227 family planning, 117–19 future directions, 227–28 first-level hospitals, 227–28 hernia repairs, 155 hernia, 166 ideal vs. actual, 215–18, 216–17t hydrocele, 166 infections after surgery, 54–55, 55f, 222 obstetric conditions, 89–91 logistical systems, 228 obstetric fistula, 105–6 low utilization of, 225 oral health maladies, 188 models, 215–18 prehospital and emergency care, 256–57 monitoring of improvement, 227 surgical care, 35–37, 36f national health plans and, 228 nonphysician clinicians at, 310 G obstetrical emergencies, 221, 222 Galea, S., 328 overview, 1, 213–15 gall bladder, emergency surgery for, 65 payment issues at, 225 Garner, P., 204, 235 postsurgical treatment needs, 222 gastrointestinal diseases. See digestive diseases prehospital and emergency care provided by, 252 gastroschisis professional society support for, 228 case study, 136–37 properly functioning, 213 prevalence and mortality rates, 132t quality of service at, 225 Gathuya, Z., 263 recommended skills and services, 213 Gauvreau, C., 318 referral systems, 213–15, 221, 228 Gawande, A., xvi, 1, 279 staffing of, 228 GCCCC. See Guwahati Comprehensive Cleft Care inadequacy, 227 Center (India) personnel costs, 224 gender differences supervision of, 228 blindness and, 197 training costs, 224–25 maternal deaths, effect on girls, 79 training for, 227 general practitioners performing obstetric surgeries, type performed at, 1, 2, 4–5t, 220t, 221, procedures, 219 280–81, 318 general surgical procedures. See surgical procedures surgical outcomes at, 221–22 genital tract lacerations, 80 technology needs of, 224, 225, 227 Ghaferi, A. A., 290 trauma emergencies, 222 Ghana first responders, 8, 249, 249b abortion cost-effectiveness in, 122, 321–22 Fistula Foundation, 100 cataract surgery in, 327, 353 Fit for School program (Philippines), 184, 185b first aid training in, 249 Fitzgibbons, R. J., 152 hernia repair in, 152, 153, 157, 158–59b, 161 Floyd, K., 204, 235 household spending on health care, 357 fluoridation delivery systems, 177–79, 178t, 182, 184 infrastructure shortcomings as impediment to foreign bodies, removal by emergency surgery, 65 emergency and surgical care in, 252 foreign treatment centers for congenital anomalies, lymphatic filariasis in, 164 140t, 141 medical assistants/nonphysician clinicians in, 310 fractures. See traumatic injuries enabling environment, 313 free health care, 226, 339, 349. See also universal procedures performed by, 311 coverage of essential surgery (UCES) retention incentives, 311 Frehywot, S., 309 rural areas, 312 future directions of treatment supervision, 311–12 abortion, 122–23 obstetric fistula repair in, 327 404 Index obstetric procedures in, 87, 89–90 definition of, 151 costs, 101, 356 future directions of treatment, 166 prehospital and emergency care in, 252 mortality rate, 159–60 short-term surgical missions in, 233 overview, 151 surgical costs in, 329 reducible, 152 trauma care system in, 45, 250b repair complications, 157 prehospital mortality, 8 risk factors for, 152 vehicle accident victims, deaths of, 221 strangulated, 152 Ghana College of Physicians and Surgeons, 12 types of, 151–52 Ghana Hernia Society (GHS), 158–59b gum disease. See oral health maladies GIEESC. See Global Initiative for Emergency and Gundre, N. P., 326 Essential Surgical Care Guwahati Comprehensive Cleft Care Center (GCCCC, Gilbert, M., 249 India), 364, 367–68, 367t, 369 gingivitis. See oral health maladies GVK Emergency Management and Research Institute Glasgow Coma Score, 48 (India), 253b Global Burden of Diseases, Injuries, and Risk Factors gynecology. See obstetric conditions; obstetric fistula Study 2010 (GBD 2010), 20 on abortion-related deaths, 120 H burden estimates based on, 23–24 Haiti limitations of methodology, 32 cesarean delivery rate in, 280 distinguishing between surgical and nonsurgical costs of surgical care in, 329 conditions in, 21, 22f first-level hospital care, 222 epidemiological regions and superregions, 24, 24t filarial hydrocelectomy in, 166 on hernia-related DALYs, 154 lymphatic filariasis in, 164 on maternal mortality and morbidity, 110 trauma, young-adult deaths from, xi subspecialty surgical care, types of, 28–29 trauma care system in, 46, 328 on tooth decay, 174 cost-effectiveness of, 321 Global Competency-Based Fistula Surgery Training Haiti earthquake (2010), 28 Manual (International Federation of Gynecology Hamlin, E. C., 237 and Obstetrics et al.), 103 Hammitt, J. K., 369 Global Forum for Health Research, 259 Hanoi Health Department, 12 Global Fund to Fight AIDS, Tuberculosis and Malaria, Hatcher, K. W., 324, 363 33, 34f head injuries, 47–48, 220t Global Health 2035 targets, 37 Healing Hands for Haiti, 46 Global Initiative for Emergency and Essential Surgical health centers Care (GIEESC), 23, 45, 333 availability of, 287 Global Programme to Eliminate Lymphatic Filariasis childbirth care at, 323 (GPELF), 151, 164 prehospital and emergency care provided by, 252 Gogate, P., 201, 202 primary care, 215 Goh, J., 99, 100 surgical services provided by, 4–5t, 220–21, Goldacre, M. J., 157 226–27 Goldmann, E., 328 health insurance. See national health plans; universal Gosselin, R. A., 35, 41, 51, 321, 328 health coverage gout, 53 health workforce. See also nonphysician clinicians; GPELF (Global Programme to Eliminate Lymphatic shortage of skilled surgeons Filariasis), 151, 164 distribution of skilled personnel, 71 Greenland, 234 obstetric fistula care, 105 Grimes, C. E., 155 heart disease and heart attacks. See also cardiac groin hernia, 151–61. See also inguinal hernia surgery access to care for, 155–56 prehospital and emergency care, 246, 254 burden of disease due to, 154–55 Heitto, M., 321 clinical features of, 152–53 hemorrhage. See bleeding cost-effectiveness of repair, 161 hemothorax, 65 Index 405 hernia, 20, 151–61. See also groin hernia; inguinal emergency surgery, 70 hernia levels of services provided by, 62, 62t, 213–30, 214b costs of repair, 331t management practices, 294–95 definition of, 151 obstetric conditions, 88–89, 91 overview, 151 traumatic injuries, 44–46 short-term surgical missions, 233, 234 Hounton, S. H., 323 Hicks, E. R., 245 Howard, T., 326 Higashi, H., 19 HPV (human papilloma virus), 354–55 high-income countries (HICs). See also specific regions Hsia, R., 245 and countries Hu, D., 124n13 alcoholic cirrhosis in, 64 human papilloma virus (HPV), 354–55 amebic abscesses in, 65 Husum, H., 249 anesthesia services in, 13, 157, 292 hydroceles, 20, 161–72. See also lymphatic filariasis (LF) cataract surgery, 197, 199, 200, 204, 205 burden of disease, 162–64 cesarean delivery in, 86, 89, 375 clinical features of, 162 clubfoot in, 137, 138 communicating hydrocele, 161 congenital anomalies in, 129, 137 definition of, 161 contraception need in, 112 disability-adjusted life years (DALYs), 163 dental care, 182 elimination of, 164–65 disparities with LMICs. See disparities between future directions of treatment, 166 LMICs and HICs lymphatic filariasis and, 162 emergency surgeries in, 61, 66 noncommunicating hydrocele, 162 head injuries in, 47 overview, 151 hernias in, 153, 156, 157–59, 161 risk factors for, 162 hydrocele complications in, 165 surgical management of, 165–66 mortality rates associated with surgery in, 279, 280f types of, 161–62 musculoskeletal care in, 49, 54 hypertension, 225, 227, 246 obstetric surgery in, 77, 87 partnership with LMICs, 89 I orthopedics in, 52 incontinence. See obstetric fistula prehospital and emergency care in, 254, 259 India surgical missions from. See short-term surgical blindness in, 197 missions burn care in, 51 transfer guidelines in, 46 cataract surgery in, 199, 201, 202, 203, 207, 236, 327, trauma care system in, 43–44, 53 329 hip fractures, 53, 326. See also orthopedic procedures cleft lip and palate repair in, 7, 364, 367t, 369 Hirschprung’s disease district hospitals in, 215 case study, 135–36 emergency care training in, 253b prevalence and mortality rates, 131t eye camps in, 233, 327 HIV/AIDS, 7, 20, 21, 33, 34f, 51, 54, 78, 113, 118, 181, family planning, cost-effectiveness of, 116 308, 362 hernia repair in, 156, 157, 161, 326 Homøe, P., 234 hospital management practices in, 294 Honduras hydroceles in, 163 emergency obstetrical surgery in, 221 lymphatic filariasis in, 162, 164 free health care in, 226 physician pool in, 218 surgical safety checklist use in, 294 private health sector in, 226 honey as burn treatment, 51 surgical care standards in, 290, 290f Horton, S., 317, 318 surgical costs in, 329 hospital care. See also first-level hospitals; second-level trauma care system in, 46 hospitals; specialty surgical hospitals; third-level Indonesia hospitals Essential Health Care Program (EHCP) in, 185 burn care, 50–52 obstetric care, household spending on, 357 coordination hub, role of, 35, 36f infants. See children and infants 406 Index infections intestinal obstructions, 23, 28, 220t bloodstream, 66 emergency surgery, 63–64 eye infections, 201 intussusception, emergency surgery for, 64 Helicobacter infections, 64 Iran, trauma care system in, 46 management of surgical infections, 220t, 222 Iraq pelvic with abscesses, 64 first responder training in, 249–50, 253, 255b skin, muscles, bones, and joints, 66 prehospital treatment of trauma patients in, 253 surgical care improvement project, 288–89, 289t Israel traumatic injuries and, 54–55, 55f Jerusalem, hernia incidence in, 153 infectious diseases. See communicable diseases trauma care systems in, 43 inguinal hernia. See also hernia Iyer, S. P., 326 access to care for, 155–56 burden of disease, 154–55, 155t J clinical features of, 152–53 Jacobstein, R., 118 cost-effectiveness of repair, 161, 325–26 Jaipur prosthesis, 46 disability-adjusted life years (DALYs) due to, 154–55 Jamaica, trauma care system in, 46 emergency surgery for, 62–63, 159–60 James, M., 326 epidemiology of, 153–54, 154t Jamison, D. T., xvi, 1, 8, 339, 361, 362, 368 management of, 156–57 jaundice, 65 mesh repair, 157, 161, 225, 326 Javitt, J. C., 2 met and unmet need for repair, 155–56 Jha, P., 361 models of treatment for, 158–59 Johansson, K. A., 339 mortality rate following surgery, 159–60, 283, Johns Hopkins University, 90 285, 286t Johnson, C. T., 77 mosquito netting for, 157, 161 Johnson, T. R. B., 77 natural history of, 152 Joint Learning Initiative, 308 nonsurgical management of, 156 Joshipura, M., 41 prevalence of, 153 repair complications, 157, 160, 160f K risk factors for, 152 Kassebaum, N., 19 surgical management of, 156–57 Kasulu District Hospital (Tanzania), 215, 217–18t task shifting to improve care for, 160–61 Katmandu Model Hospital (Nepal), 325 injuries. See burn injuries; obstetric fistula; Kennedy, R. C., 237 traumatic injuries Kenya Institute of Medicine’s report Crossing the Quality anesthesia training in, 271t Chasm, 186 cataract surgery in, 328 Instituto Superior de Ciências de Saúde (Higher cleft lip and palate repair in, 363 Institute of Health Sciences, Mozambique), 313 contraception, unmet need in, 112 International Agency for the Prevention of Blindness, infrastructure shortcomings as impediment to 206, 326 emergency and surgical care in, 252 International Association for Trauma Surgery and lymphatic filariasis in, 162–63 Intensive Care, 44 obstetric fistula repair in, 100, 101 International Classification of Diseases, Version 9 obstetric services in, 353 (ICD-9) codes, 21, 22 prehospital and emergency care in, 252 International Clearinghouse for Birth Defects Kenya Orthopedic Program, 233 Surveillance and Research, 143 ketamine, 225, 228n1, 270 International Committee of the Red Cross, 232 kidneys. See renal conditions International Federation of Gynecology and Obstetrics Kim, Jim, 2 (FIGO), 103 Kingsnorth, A. N., 157, 158b, 161, 332 International Organization for Standardization (ISO) Kobusingye, O. C., 245, 253, 254, 256 standard for anesthesia equipment, 270 Kong, V., 321 International Society of Obstetric Fistula Surgeons Kruk, M. E., xvi, 1, 213, 323, 328, 339, 368 (ISOFS), 103 Kruper, L., 332 Index 407 Kuppers, B., 51 cataract surgery in. See cataracts Kurichi, J. E., 332 cesarean rates in, 79, 355. See also cesarean delivery contraception, unmet need in, 112, 118. See also L family planning and contraception The Lancet Commission on Global Surgery, 2, 9b DALYs averted by surgery in, 25, 27t, 28 land mines, 46 deaths prevented by surgery in, 25, 26t. See also Lao People’s Democratic Republic mortality rate anesthesia training in, 271t definition of, 38 Essential Health Care Program (EHCP), 185 disparities with HICs. See disparities between laparoscopy, 114 LMICs and HICs hernia repair and, 156, 161, 325–26 emergency surgery in, 19, 61–62. See also emergency Latin America and the Caribbean (LAC). See also surgery specific countries epidemiological regions and superregions in, 24, 24t abortion complications in, 120 hernia repair in, 152–53, 155. See also groin hernia; antibiotic resistance in, 180 inguinal hernia burden nonavertable by surgical care in, 28, 29t hospital care, levels of, 214b. See also first-level burn care in, 51 hospitals; second-level hospitals; third-level cesarean section mortality in, 13, 285 hospitals charitable vs. for-profit hospitals in, 218 maternal mortality, 77–78. See also maternal contraception, unmet need in, 112 morbidity and mortality emergency surgical care costs in, 68 mortality rate associated with surgery in, 282. See first-level hospitals in, 214b, 215 also mortality rate cost and cost-effectiveness, 222 obstetric fistula in. See obstetric fistula international surgical organizations in, 231 obstetric procedures in, 88–89. See also obstetric maternal and child mortality in, 248 conditions obstetric fistula in, 95 prehospital and emergency medical systems, 245. See obstetric procedures in, 219 also prehospital and emergency care physicians pool in, 218 preventive care in, 20 Latvia, mortality rates associated with surgery in, 280 public health impact of surgical care in, 23 Laxminarayan, R., 317, 369 subspecialty surgical care, avertable burden by legislation on prehospital and emergency care, 257, 258b scaling up, 32, 32f, 33t Leive, A., 328 surgical care in. See also specific types of surgery Levin, C., 317 best practices for, 37 LF. See lymphatic filariasis limitations on scope of practice, 280–81 Liberia, cesarean delivery costs in, 375 traumatic injuries in, 41, 42. See also traumatic Lifebox Foundation, 292 injuries life expectancy. See also mortality rate low back pain, 54, 54t surgical rates correlated with, 282, 282f, 282t Lozo, S., 95 liver Lundström, M., 327 alcoholic cirrhosis of, 64 lymphatic filariasis (LF). See also hydroceles amebic abscess, emergency surgery for, 65 burden of disease, 162–64 congenital anomalies (case study), 136–37 disability-adjusted life years (DALYs), 163 Lofberg, K., 129 elimination of, 164–65 logistical systems, 228 hydrocele development resulting from, 162 London School of Hygiene and Tropical Medicine, 308 mass drug administration for, 164, 165m low- and-middle-income countries (LMICs). See also lymph scrotum, 166 specific regions and countries anesthesia-related mortality in, 267 M burden avertable by scaling up surgical care in, 6, Mabweijano, J., 245 6–7t, 7f, 8, 28–32, 28f, 30f MacKenzie, E. J., 328 research and development on, 35–36 Madagascar, costs for cesarean section in, 356 burden nonavertable by scaling up surgical care in, Magee, W. P., Jr., 324, 363 30f, 33t Maine, R. G., 234 research and development on, 36 malaria, 20, 33, 34f, 246 408 Index Malawi Mestnik, M. J., 180 anesthesia-related mortality in, 267 methodology of study, 23–25. See also burden of disease cesarean delivery rate in, 280 cost-effectiveness, 319–20, 319t clubfoot program in, 138b Ethiopia basic surgery in rural areas, 340–42 contraceptive prevalence in, 118 limitations of, 32 first-level hospitals in, 214b, 215 platforms for surgical delivery, 232, 233f, 240 head injuries in, 47 metrics for surgical surveillance, 279, 296–97, 297t hernia repair in, 160 Mexico obstetric procedures in, 87 abortion cost-effectiveness in, 122, 321 transport options in, 250–51 emergency response time in, 251 Maldonado, A., 321, 328 prehospital and emergency care, effectiveness of, 255 Mali Middle East and North Africa. See also specific countries cesarean delivery in, 355 burn care in, 51 contraceptive prevalence in, 111 contraception, unmet need in, 112 obstetric care in, 89, 355 international surgical organizations in, 231 malignant hyperthermia, 270 obstetric fistula in, 97 Maputo Central Hospital (Mozambique), 310 midlevel providers. See nonphysician clinicians Marck, R., 234 midwives. See childbirth maternal health programs, 20. See also cesarean Millennium Development Goals (MDGs), 37, 78, 117, delivery; family planning and contraception; 308, 308b, 323, 355 maternal-neonatal conditions minilaparotomy, 114 valuation of, 91, 373–74 minimal annual surgical rate, 282–83 maternal morbidity and mortality, 77–79. See also miscarriage, induced, 122, 123n1 maternal-neonatal conditions Mishra, S., 164 burden of, xv, 77–78 Mkandawire, N., 41 family planning to reduce, 110 MMR (maternal mortality ratio), 77–78 impact of, 79, 87 mobile dental clinics, 184 maternal mortality ratio (MMR), xv, 77–78, 85, 221 mobile surgical platforms. See self-contained mobile obstetric fistula and, 97 surgical platforms obstetric surgery to reduce, 85, 87 Mock, C. N., xvi, 1, 41, 155, 213, 245 prehospital and emergency care, 247, 248 models of treatment prevalence and incidence of, 371 congenital anomalies, 143 maternal-neonatal conditions. See also abortion; dentistry, 182–86 obstetric conditions emergency surgery, 71 burden averted by prehospital and emergency family planning, 118 care, 248 first-level hospitals, 215–18 burden averted by surgical care for, 23, 28, 28f, 91 inguinal hernia, 158–59 DALYs averted by, 25, 27t obstetric conditions, 89–90 deaths prevented by, 25, 26t obstetric fistula, 103–5 neonatal encephalopathy, 23, 25, 28 surgical care, 35–37 neonatal resuscitation, 87 traumatic injuries, 43–46 treatable in prehospital and emergency care, 246 moist exposed burn ointment, 51 Maweni Regional Hospital (Tanzania), 215, 217–18t Moldova, surgical safety checklist use in, 13, 294 Mbembati, N., 61 Mongolia McAuliffe, E., 309 anesthesia training in, 271t McCord, C., 2, 20, 45, 61, 213 trauma care system in, 45, 54–55 McPake, B., 307 Monitoring the Building Blocks of Health Systems McQueen, K., 263 Monitoring and Evaluation Matrix (WHO), McSwain, N., 251 36–37 MDGs. See Millennium Development Goals Moon, W., 324 Meara, J. G., 361 morbidity. See disability-adjusted life years (DALYs); measles immunization, 20 maternal morbidity and mortality Médecins Sans Frontières, 46, 67, 231, 232, 233, 329 Morbidity and Mortality Conferences (M&M), 294 Mercy Ships, 233, 236 Morgan, M. A., 95 Index 409 mortality rate, 279–85, 280f. See also burden of disease Muleta, M., 237 acute abdominal conditions as cause, 61 Mullan, F., 309 anesthesia related, 13, 265, 267–68, 267f, 268t, multiple gestation, 80 273–74, 288, 289f Murad, M. K., 254 barriers to care as factor for, 287–88 Muralikrishnan, R., 203, 204 cesarean delivery, 13, 283, 283–84t musculoskeletal (MSK) system challenges to reducing, 285–87 disparities between LMICs and HICs, 354 conditions treatable in prehospital and emergency infections, 66 care to lower, 246, 247f nontraumatic conditions, 53–54, 54t congenital anomalies, 129–33, 131–33t surgical procedures performed on, 2 disparities between LMICs and HICs in, 283–85 traumatic injuries, 49, 52–53. See also traumatic emergency surgery, 67 injuries hernia and, 157, 159–60, 283, 285, 286t hip fractures and, 53 N improvements in health care practices, effect on, Nandi, A., 317 291–97 National Health and Nutrition Examination Survey increased surgical access and, 283 (NHANES), 152, 153 maternal. See maternal morbidity and mortality national health plans, xv, 228 methodology of study, 281–82 National Institute for Health and Care Excellence of noma, 181 British National Health Service, 226 postoperative care and safety, 290–91, 296t Nayak, A. N., 164 rates of, 279–85 neonatal conditions. See maternal-neonatal conditions results of study, 282–85 Nepal short-term surgical missions, 234 blindness in, 197 strategies for reducing, 291–97 cataract surgery in, 204, 327 surgically treatable conditions and, 6, 19, cleft lip and palate repair in, 327, 363 25–28, 317 financial sustainability of first-level hospital in, 330b traumatic injuries, 43 fluoridation in, 179 prehospital, 8 oral health care in, 183b young-adult deaths, xi Netherlands vehicle accident victims, 221 mortality rates in mosquito-borne parasites, 162, 164 cesarean delivery, 283 mosquito netting for hernia repair, 157 surgery, 279 mouth. See oral health maladies surgical safety checklist, use in, 293 Mozambique trauma care systems in, 43 costs of emergency surgical care in, 68 Neuhauser, D., 152 first-level hospitals in, 214b neural tube defects, 12–14, 28, 133, 134t hernia repair in, 160 neurological disabilities, 98 medical training in, 218 Nevado del Huila volcano (1985), 258b Ministry of Health human resources plan, 313 NGOs. See nongovernmental organizations obstetric procedures in, 86, 87 NHANES (National Health and Nutrition Examination shortage of skilled surgeons in, 307, 308 Survey), 152, 153 técnicos de cirurgia (TCs–nonphysician clinicians) Nicaragua in, 12, 309, 310 cost-effectiveness of orthopedic procedures in, 326 acceptability of, 311 first-level hospitals in, 218 cost-effectiveness, 312–13 Niederman, R., 173 enabling environment, 313 Niger job satisfaction, 312 cesarean delivery in procedures performed by, 310 costs of, 375 retention incentives, 311 rate of, 280 training, 37, 218 hernia repair in, 160 working and living conditions, 312 obstetric fistula in, 103 MSK. See musculoskeletal system transport options in, 251 410 Index Nigeria North America. See also specific countries abortion cost-effectiveness in, 122, 321 international surgical organizations in, 231 anesthesia-related mortality in, 267 NPCs. See nonphysician clinicians blindness in, 355 Nuevo, F. R., 263 burn care in, 50 nurse anesthetists, 310 costs of surgical care in, 329 nutrition first-level hospital care, 222 burn injuries healing and, 52 head injuries in, 47, 48 oral health and, 174 hernia repair in, 156, 160 noma in, 181 O obstetric fistula in, 97, 98, 99, 103, 327 obstetric conditions, 23, 77–94. See also obstetric fistula orthopedic services in, 354 abnormal fetal presentation, 80 prehospital and emergency care personnel training access to surgical care for, 88 in, 252 breech presentation, 80 trauma care system in, 46, 328 burden of preventable deaths and disability, 77–79, cost-effectiveness of, 321 221, 222 noma, 174–76, 181–82 cesarean delivery, 82–85, 88, 370–76 noncommunicable diseases, 3b. See also specific challenges in providing care for, 88 diseases cost-effectiveness of surgery for, 83–85, 321–22t, superseding infectious diseases as leading cause of 321–23 mortality, 263 costs of surgery for, 87–88, 331t, 355–56 nonemergency surgery. See also specific conditions disability-adjusted life years (DALYs), 78–79, 78t cost-effectiveness, 323–27 disparities between LMICs and HICs, 353–54, 355 nongovernmental organizations (NGOs) emergency surgery for, 20, 221, 222, 323 platforms for surgical delivery, 231–32 episiotomy, use of, 80 return on investment to, 362 in Ethiopian study, 339, 340t self-contained mobile surgical platforms, 233 family planning coupled with emergency services, 85 short-term surgical missions, 232–36 financial burden on the poor, 355–56 nonphysician clinicians, 12, 37, 307–16 first-level hospitals, 219–20t, 221, 222 acceptability of, 311 free emergency obstetrical care, 226 anesthesia, 271, 271t future directions of treatment, 89–91 cataracts, 203 general practitioners performing surgery, 12 congenital anomalies, 141 hospital care for, 88–89, 221, 222 cost-effectiveness of, 12, 312–13 lacerations, 80, 81 emergency surgery, 71 maternal mortality rate (MMR) due to, xv, 77–78, enabling environment, 313 85, 221 in Ethiopia, 340, 346 models of treatment for, 89–90 financial incentives, 311 multiple gestation, 80 hernia repairs, 160–61 nonphysician clinician training, 86–87, 313 job satisfaction, 312 obstructed labor, 370–76 nonfinancial incentives, 311–12 overview, 79 obstetric procedures, 86–87, 89, 219, 313 pelvic infections with abscesses, 64 oral health maladies, 184, 185–86 platform for delivery of procedure, 4t overview, 307–8 postpartum hemorrhage, 80. See also bleeding research and development, 37 quality improvement of care, 89–90 retention incentives, 311–12 retained placenta, 81 supervision, 311–12 shoulder dystocia, 80 task-shifting and task-sharing, 309–10 subsidization of care for, 85 training, 309–10, 311–12. See also training surgical intervention for, 20, 219, 219–20t working and living conditions, 312 task-shifting to increase services for, 86–87 Noormahomed, E. V., 19 technology and, 88 Nordin, P., 161 training needs, 86–87, 88–89, 91 North Africa. See Middle East and North Africa transport of patients with, 88, 89 Index 411 twins, 80 burden of disease, 174–75, 174t uterine atony, 81 caries, 174–78, 175t, 177f uterine inversion, 81–82 clinical trials, 178–80 vaginal delivery procedures, 79–80 community-based care program, 184, 186–87 obstetric fistula, 95–108 cost-effectiveness of, 318 avertable and nonavertable DALYs and preventable costs of, 187 deaths associated with surgical care for, disability-adjusted life years (DALYs), 174–76, 30–32, 31t 175–76t burden of, 28, 30, 97–100 epidemiology, 174–75 complications of, 96–97, 96f fluoridation delivery systems, 177–79, 182, 184 cost-effectiveness of surgery for, 100 future directions of treatment, 188 cost on average of surgery for, 100 implementation steps, 183–84b definition of, 95 microbiology of, 175–76 dermatological conditions due to, 98 mobile dental clinics, 184 disability-adjusted life years (DALYs) due to, 101 noma, 176, 181–82 disparities between LMICs and HICs, 354 nondentists delivering care, 184, 186 economic burden due to, 99–100 overview, 173–74 future directions of treatment for, 105–6 periodontitis, 174–76, 176t, 179–81 health system considerations related to, 103 platform for delivery of procedure, 4t health workforce requirements for care of, 105 prevention methods, 177–79, 178t, 182–88 incidence of, 370–71, 372–73t quality of care, 186 mental and emotional issues due to, 99 surgical treatment of, 176–77, 181–82, 186 models of treatment for, 103–5 tooth loss, 176t, 177f neurological disabilities due to, 98 value-based oral health care, 186–87 overview of, 95 water fluoridation to prevent, 177–79, 178t, 184 patient selection and preoperative care for, 102 Oresanya, L. B., 154 postoperative care for, 102 organization of surgical services. See platforms for postoperative training and reintegration following surgical delivery repair of, 102–3 orthopedic procedures presurgical procedure for, 101 cost-effectiveness, 326 prevention strategies and costs for, 101 short-term surgical missions, 235 renal damage due to, 98 nontraumatic conditions, 53–54, 54t reproductive organ damage due to, 97–98 platform for delivery of procedure, 5t specialty surgical hospitals for, 237–38 traumatic injuries, 52–54. See also traumatic injuries stillborn child, 97, 98–99 osteoarthritis, 53, 54t surgical repair for, 97, 100, 102 osteomyelitis, 55 obstetric palsy, 98 osteoporosis, 52–53 obstructed labor, 370–76. See also cesarean delivery otitis media, 20 Ogunbodede, E., 173 Ottaway, A., 263 Ohene-Yeboah, M., 151 Ozgediz, D., 35, 61, 129 omphalocele case study, 136–37 P prevalence and mortality rates, 132t Pacific region. See East Asia and Pacific region operating rooms, 70, 295t pain management Operation Hernia (UK), 151, 157, 158b, 161 anesthesia and, 266–67 operations. See surgical procedures burn injuries, 51–52 Operation Smile, 140, 233, 364, 368 low back pain, 54 ophthalmologists, 203 Pakistan Oppong, C., 158b district hospitals in, 215 oral health maladies, 173–96 head injuries in, 48 antimicrobial use concerns, 180–81 mortality rate from surgical emergencies in, 67 barriers to care, 183b obstetrical care costs in, 101 barriers to prevention of, 188 obstetric fistula in, 354 412 Index Pan-African Academy of Christian Surgeons, 140 population, policy, and implementation research Papua New Guinea (PPIR), 12, 13, 14 short-term surgical missions in, 233 population health paralytic ileus, 23, 28, 38n3 subspecialty surgical care, impact on, 30–32 paramedical personnel. See also nonphysician clinicians surgical care, impact on, 25–28 prehospital and emergency care, 248, 250 Portugal, prehospital treatment of trauma patients Patel, T. L., 237, 238 in, 254 patient transport. See transport of patients postabortion care, 119–21, 123 Pearse, R. M., 279 postoperative care and training, 2 pediatric surgery. See congenital anomalies complications and mortality rate, 290–91, 291–92t, pelvis 291f, 296t infections with abscesses, 64 obstetric fistula and, 102–3 traumatic injuries, 49 outcomes at first-level hospitals, 222 peptic ulcer complications, 64, 72 postpartum hemorrhage, 80 Pereira, C., 307 postpartum tubal ligation, 113–14 periodontitis, 174–76, 179–81. See also oral health poverty, 353–60. See also disparities between LMICs maladies and HICs; specific conditions and surgeries perioperative care, 263–78. See also anesthesia services access to care restricted by, 226, 355–57 safety of, 288–90 blindness and, 328–29 perioperative mortality rate (POMR), 273–74 burden of disease associated with, 353–56 Perry, H., 324 burn injuries and, 50 personnel. See also nonphysician clinicians; shortage of contraception use and, 111 skilled surgeons financial burden of disease and, 355–57 prehospital and emergency care, 248–50 oral disease and, 181 Peru overview, 353 cataract-related blindness in, 198 Prajna, N. V., 197 salt fluoridation in, 179 pregnancy. See cesarean delivery; family planning and Philippines contraception; obstetric conditions cataract surgery in, 328 prehospital and emergency care, 245–62. See also Fit for School program in, 184, 185b emergency surgery oral health care in, 183b burden of disease addressable by, 245–47, 246f, 259t platforms for surgical delivery, 3–4, 4–5t, 231–44. community-based care. See first responders See also self-contained mobile surgical platforms; cost-effectiveness of, 256 short-term surgical missions; specialty surgical costs of, 252–54 hospitals deaths due to shortcomings of, 354 classification of, 232 delivery systems for, 247–50 cost-effectiveness by type of, 235, 238–40, 327–28 disparities between LMICs and HICs, 354, 354t literature review, 232, 233f effectiveness of, 254–55 nongovernmental organizations (NGOs) as equipment and supplies, 251–52 providers of, 231–32 financing of, 257 outcomes by type of, 234, 237–38 future directions, 256–57 recommendations for, 240 health facility-based subsystems, 252 sustainability, 235–36, 238 lay first responders, 249, 249b. See also first temporary, 232–36, 238–39. See also short-term responders surgical missions legislation to address, 257, 258b training role of, 235–36, 238 notification time, 251 pleural disease surgery, 65 overview, 245 pneumonia, 65 paramedical personnel, 248, 250 pneumothorax, 65 personnel roles in, 248–50 Poenaru, D., 35, 363 research and development priorities, 257–59 Polan, M. L., 95, 118b response time, 251 POMR (perioperative mortality rate), 273–74 scene time, 251 Ponseti method, 138 systems organization, 256–57 Index 413 tiers of care, 247–48 R training for, 252, 253b, 258b Räsänen, P., 199 transportation and communication, 250–51 Ravilla, T. D., 197, 231 transport time, 251 referrals presurgical procedure first-level hospitals and, 213–15, 221, 227–28 assessment to make decision to operate, 2 of trauma patients, 46 cataract surgery, 199 registries cesarean delivery, 82 birth data, 142 noma treatment, 182 congenital anomalies, 143 obstetric fistula, 101, 102 traumatic injuries, 46 prevention rehabilitation importance of, 20 burn injuries, 52 obstetric fistula, 101 traumatic injuries, 46 oral disease, 177–79, 182–88 Rein, D. B., 327 surgery’s role in, 21 renal conditions Price, R. R., 41 kidney stones, 65 primary health care, surgical care as part of, 35, kidney transplants, 318 332–33 obstetric fistula and, 98 research and development on, 36–37 reproductive organs. See also obstetric conditions primary health centers. See health centers obstetric fistula damaging, 97–98 Primatesta, P., 157 reproductive rights, 91, 109 Prinja, S., 317 research and development professional societies’ support for first-level hospitals, anesthesia services, 274 227, 228 congenital anomalies, 143–44 public health population, policy, and implementation research surgical care’s role in, 19–20, 23, 33, 33t (PPIR), 12, 13, 14 research and development on, 35 prehospital and emergency care, 257–59 trauma care systems coordinated with, 43, 43t surgical care, 35–37 Puri, V., 152 traumatic injuries, 46 respiratory obstructions, 65. See also airway Q management during anesthesia quality-adjusted life years (QALYs), 9b retention incentives, 12, 311–12 cataract surgery, 205–6, 205t, 325t rheumatoid arthritis, 53, 54t cost-effectiveness of surgical procedures, road traffic injuries (RTIs). See traumatic injuries 319–20, 326 Robinson, L. A., 369 dental surgery, 318 Rowsell, K. V., 326 groin hernia repairs, 161 Royal Australasian College of Surgeons, 46 quality improvement. See also disability-adjusted life Royal College of Obstetrics and Gynecology, 90 years (DALYs); mortality rate RTIs (road traffic injuries). See traumatic injuries anesthesia services, 273–74, 273b Ruhl, C. E., 153 cataract surgery, 203 Ruit, S., 201, 202 first-level hospitals, 225 rural areas measurement strategies, 295–96t, 295–97 in Ethiopian study, 339. See also Ethiopia obstetric procedures, 89–90 nonphysician clinicians in, 312, 313 oral health care, 186 shortage of skilled surgeons in, 307 research and development, 37 traditional healers in, 49 surgical care, 13, 291–97 trauma care system in, 45 traumatic injury care, 46–47 Russell, S., 213 QUARITE (QUAlity of care, RIsk management and Rwanda TEchnology in obstetrics) trial, 89 abortion complications in, 119 Quebec trauma care system, 44b anesthesia training in, 271t Qureshi, J. S., 48 contraception, unmet need in, 112 414 Index infrastructure shortcomings as impediment to costs of surgical care in, 329 emergency and surgical care in, 252 first-level hospital care, 222 mortality rate from surgical emergencies in, 67 obstetric care, 20 obstetric fistula repair in, 327 head injuries in, 47–48 prehospital and emergency care in, 252 mortality rate from surgical emergencies in, 6, trauma, young-adult deaths from, xi 67, 280 SIGN (Surgical Implant Generation Network), 49 S Siim, C., 234 safety improvements, 13–14, 279–305 Singapore, hip fractures in, 53 anesthesia services, 13, 266–68, 272–74, 288 Singh, A. J., 204, 235, 327 anesthetic monitoring, 291–92 Sitkin, N., 129 checklists, 1, 13–14, 292–94 skin management practices, 294–95 infections, 66 measurement of outcomes, 295–97 obstetric fistula and dermatological conditions, 98 St. Francis Designated District Hospital (Tanzania), Sleemi, A., 95, 231 215, 217–18t smartphones and anesthesia monitoring, 270 St Leger, S., 326 Smile Train, 140, 363 Sanders, D. L., 157 Smith, A., 327 Schecter, W. P., 151, 353 social norms. See cultural beliefs Scotland, surgical safety checklist use in, 294 soft tissue infections. See infections scrotal hernia, 151 Somalia, obstetric fistula repair in, 103 second-level hospitals Sonnad, S. S., 332 congenital anomalies treatment, 143 South Africa ideal, requirements for, 216–17t abortion services in, 309 levels of care, 214b costs of medical education in, 101 properly functioning, 213 first responders in, 249 surgeries, type performed at, 4–5t, 220t, 281 head injuries in, 47, 48 self-contained mobile surgical platforms, 233, 236 mobile dental clinics in, 184 cost-effectiveness of, 8 trauma care system in, 46 outcomes, 239, 239t water fluoridation in, 178 Senegal South Asia. See also specific countries cesarean delivery in, 355 anesthesia needs in, 263 hernia repair complications in, 160 avertable burden of disease in. See also disability- obstetric care in, 89 adjusted life years (DALYs) Shillcutt, S. D., 161, 332 maternal-neonatal conditions, 28, 248 shortage of skilled surgeons, 12 prehospital and emergency care, 247, 247f anesthesiologists, 8, 265 preventable deaths, 25, 247, 247f congenital anomalies, 133, 141 subsurgical specialties, 32 emergency surgery, 71 blindness in, 207 obstetric fistula repair, 101 cataract camps in, 327 obstetric procedures, 88–89 cesarean delivery in, 355 overcoming by use of nonphysician clinicians. cesarean section mortality in, 13, 285 See nonphysician clinicians cleft lip and palate repair in, 363 reasons for, 307 contraceptive prevalence in, 111 short-term surgical missions, 232–36 first-level hospitals in, 214b cost-effectiveness of, 8, 327–28 cost and cost-effectiveness, 222 outcomes, 238–39, 239t maternal mortality in, 371 shoulder dystocia, 80 obstetric fistula in, 97 Shrime, M. G., 9b, 231, 328, 339 obstetric procedures in, 219 Sierra Leone oral disease in, 175 cesarean delivery rate in, 280 surgical costs in, 329 contraceptive prevalence in, 111 transport options in, 250–51 Index 415 Southeast Asia. See also specific countries contraceptive prevalence in, 119 blindness in, 206–7 dispensaries and health centers in, 215 burn injuries in, 50 emergency obstetrical care in, 221 cleft lip and palate repair in, 363 first-level hospitals in, 214b, 215, 217–18 contraceptive prevalence in, 111 cost and cost-effectiveness, 222–24, 223t international surgical organizations in, 231 surgeries, types performed, 219–20, 219t lymphatic filariasis in, 162 health care personnel in obstetric fistula care in, 97 nonphysician clinicians, 309 South Sudan, contraceptive prevalence in, 111 physicians, 218 Spain, hernias in, 152 shortage of skilled surgeons, 133, 307 specialty surgical hospitals, 233 training programs for surgeons, 70 cost-effectiveness of, 8, 238, 327–28 hernia prevalence in, 153–54, 154t, 155 costs of, 329 hydroelectomy need in, 165 demand and supply constraints, 236–37, 237f infrastructure shortcomings as impediment to effectiveness of, 237–38 emergency and surgical care in, 252 outcomes, 239–40, 239t lymphatic filariasis in, 162, 164 sustainability of, 238 maternal mortality in, 248, 307–8, 371 training role of, 238 medical education costs in, 101 types of, 236t obstetric fistula care in, 97 Spiegel, D., 41 obstetric procedures in, 87, 219 spillover effects from upgrading surgical care, 15 oral disease in, 175, 181 spinal cord injuries, 48 surgical costs in, 329 Sri Lanka transport options in, 250–51 emergency obstetrical care in, 221 ulcer surgery survival rates in, 64–65 free health care in, 226 subspecialty surgical care. See also cataracts; cleft lip lymphatic filariasis in, 164 and palate repair; congenital anomalies; neural trauma care system in, 44 tube defects; obstetric fistula; specialty surgical Srinivasan, S., 197 hospitals Stanford School of Medicine, 253b avertable burden by scaling up, 28–32, 31t, 32f, 33t Stephenson, B. M., 157 insufficient evidence on, 317 Stergachis, A., 109 methodology, 28–30 sterilization. See family planning and contraception population health, impact on, 30–32 stillbirths, 97, 98–99 rationale, 28 Subramaniyan, P., 326 first-level hospitals, 221 Sub-Saharan Africa. See also specific countries Sudan, obstetric fistula repair in, 103 anesthesia needs in, 263 suicide by women with obstetric fistula, 99 anesthesia-related mortality in, 267 supervision avertable burden of disease. See also burden of first-level hospital staff, 228 disease; disability-adjusted life years (DALYs) nonphysician clinicians, 311–12 injuries, 28 Surgical Care for the District Hospital (WHO), 23 maternal and child mortality, 248 surgical conditions prehospital and emergency care, 247, 247f assignment of DALYS for, 22–23, 221 preventable deaths, 25 burden estimate for, 20–35, 221 subsurgical specialties, 32 distinguishing between surgical and nonsurgical blindness in, 197 conditions, 21 burn injuries and care in, 50, 51–52, 354 surgical disability, definition of, 21b cataract-related blindness in, 198 Surgical Implant Generation Network (SIGN), 49 catastrophic health spending in, 328 surgically treatable condition, definition of, 21b cesarean delivery in, 355 surgical procedures, 19–40. See also emergency mortality related to, 285 surgery; subspecialty surgical care; specific cleft lip and palate repair in, 363, 364 type of procedure contraception acceptability of, 288 prevalence, 111 access to. See access to care unmet need in, 112 accredited surgeons, 295t 416 Index affordability of, xv, 28, 288 procedures performed by, 310 availability of, xv, 287–88, 287f research on attitudes toward, 311 barriers to service delivery. See barriers to service retention incentives, 311–12 delivery working and living conditions, 312 basic/essential, xv, 23–28, 38n2 cesarean delivery auditing in, 310 best practices for LMICs, 37 congenital anomalies treatment in, 142 burden averted value of, 22–35. See also burden of costs of emergency surgical care in, 68 disease employment freezes on health personnel, 307 checklists for safety, 1, 13–14, 292–95, 293f faith-based hospitals in, 218 definition of, 2, 20–21, 21b first-level hospitals in, 214b, 215, 217–18t, 218, 219 delays in seeking, 285, 287–88 hernia repair in, 152, 153, 155, 156t, 160 economic evaluation of, 7, 9b infrastructure shortcomings as impediment to emergencies, 61–76 emergency and surgical care in, 252 in Ethiopia study, 340, 340t lymphatic filariasis in, 162–63 future directions of treatment, 35–37, 36f obstetric fistula in, 95, 101 intervention categories, 19–20 obstetric procedures in, 86, 87, 89 low- and-middle-income countries (LMICs), need oral health care in, 183b in, 19 prehospital and emergency care in, 252 models of treatment, 35–37 shortage of skilled surgeons in, 307, 308 mortality rate associated with. See mortality rate task-sharing and task-shifting. See also nonphysician number of surgeries worldwide, 279, 317 clinicians operation, definition of, 21 anesthesia services, 272–73, 272t platform for delivery of procedure, 4t. See also cost-effectiveness of, 323 platforms for surgical delivery in Ethiopia study, 339–49 primary health care to include, 35 inguinal hernia, 160–61 research and development on, 36–37 nonphysician clinicians, 1, 309–10 priority as global health initiative, 32–33, 34f, 37 obstetric conditions, 86–87 public health impact of, xv, 19–20, 23, 33 public finance vs., 339–52 research and development, 35–37 technology. See also telemedicine role in global health, 10–11m, 19–20, 35 emergency surgery, 71–73 strategies for improving, 291–97 first-level hospitals, 224, 225, 227 subspecialty, 28, 30–32 obstetric procedures, 88 surgical sequelae, definition of, 21b técnicos de cirurgia (TCs). See Mozambique; surgical trips, 232–35, 238–39 nonphysician clinicians congenital anomalies, 140 teeth. See oral health maladies sustainability telecommunications services, 250–51 cataract surgery delivery systems, 203 telemedicine first-level hospitals, scaling up of, 330b burn injuries, evaluation of, 52 platforms for surgical delivery and, 238 congenital anomalies and, 139–40t, 141, 144n6 short-term surgical missions, 235–36 exclusion from platform discussion, 232 specialty surgical hospitals, 238 obstetric procedures and, 88 Sweden Thailand cataract surgery in, 205 mobile dental clinics in, 184 hernia repair in, 159, 161, 283 short-term surgical missions in, 234 mortality rate following cesarean delivery in, trauma care system in, 46, 47b 13, 283 quality improvement programs, 295 Swedish Hernia Register, 152 Thind, A., 20, 245 third-level hospitals T congenital anomalies treatment, 143 Tanzania ideal, requirements for, 216–17t assistant medical officers (AMOs), 12, 218, 309 levels of care, 214b cost-effectiveness, 313 properly functioning, 213 enabling environment, 313 surgeries, type performed at, 4–5t, 281 job satisfaction, 312 thorax injuries, 48 Index 417 time tradeoff (TTO) method to measure utility Essential Trauma Care Project, 45, 45b value, 205 in Ethiopian study, 340t tobacco use, 174, 225, 227 first-level hospitals, 5t, 220t, 222 Togo fractures, 53, 219–20t, 220 anesthesia-related mortality in, 267 goals of trauma care systems, 43, 43b contraception, unmet need in, 112 head, neck, face, and spine, 47–48 Tongaonkar, R. R., 157 hospital care for, 44–46 tooth decay. See oral health maladies infections related to, 54–55 tooth paste fluoridation, 179, 184 models of treatment for, 43–46 total joint replacement, 53 mortality rate of, xv traditional healers, 49, 287 prehospital, 8 training reduction, 43 anesthesia providers, 270–73, 271t musculoskeletal (MSK) system, 49, 52–54 congenital anomalies, 141 orthopedics and, 52–54 dental care, 186 outcomes at first-level hospitals, 222 emergency surgery, 70–71 platform for delivery of procedure, 5t first-level hospitals, 224–25, 227 prehospital and emergency care treating, 246, 249 first responders, community members, 248, 249, deaths in, 8 249b, 255b public health systems coordinated with trauma care midwives, 249 systems, 43, 43t obstetric fistula repair, 101, 103, 119 quality improvement (QI) programs and, 13, 46–47 obstetric procedures, 86–87, 91 registries of, 46 prehospital and emergency care personnel, 252, rehabilitation for, 46 253b, 258b research, 46 short-term surgical missions, 235–36 second-level hospitals, 5t, 220t specialty surgical hospitals, 238 systematic approach to care of, 42–44 workforce innovations, 309–10, 311–12 thorax and abdomen, 48 tranexamic acid, 49 transfer guidelines for victims of, 46 transfer of patients. See referrals; transport of patients vehicle accident victims transport of patients. See also referrals deaths of, 221, 354, 354t cataract surgery, 203 prehospital and emergency care, 249 costs of, 8, 214–15, 285, 288 travel vouchers. See transport of patients methods of, 245 triage. See prehospital and emergency care obstacles to, 287 Trinidad, prehospital treatment of trauma patients obstetric conditions requiring, 88, 89 in, 253 obstetric fistula requiring, 101 TTO (time tradeoff) method to measure utility prehospital and emergency care, 247, 250–51. See value, 205 also prehospital and emergency care tubal ligation. See family planning and contraception recommendations for, 228 tuberculosis, 33, 34f traumatic injury victims, 46 tumors. See cancer travel vouchers in Ethiopia, 340 Turaga, K., 152 traumatic brain injuries, 47 typhoid ulcers, perforated traumatic injuries, 41–60. See also burn injuries; emergency surgery, 64–65 emergency surgery; musculoskeletal (MSK) system U advocacy for improved care for, 41–42 UCES. See universal coverage of essential surgery bleeding due to, 49 Uganda body regions, 47–49 abdominal injuries in, 48 burden avertable by surgical care for, 221 abortion complications in, 119 burden nonavertable by surgical care for, 28, 29t anesthesia services in, 265 cost-effectiveness of care, 320–21 training, 271t disparities between LMICs and HICs, 42, 353–54 cesarean delivery rate in, 280 effectiveness of care systems for, 2, 43–47 congenital anomalies repair in, 134, 140 418 Index contraceptive surgery in, 113 National Inpatient Sample (NIS), 21 costs Navy’s hospital ships, 236 of emergency surgical care in, 68 number of surgeons in, 8–9 of medical education in, 101 oral health care in, 185, 186 CURE Children’s Hospital, 140 orthopedic procedures, cost-effectiveness of, 326 family planning, cost-effectiveness of, 116–17 perioperative safety in, 288 head injuries in, 47 rising health costs of, 206 hernia prevalence in, 153 surgical safety checklist, use in, 293 infrastructure shortcomings as impediment to trauma care systems in, 43 emergency and surgical care in, 252 vehicle accident victims, deaths of, 221 prehospital and emergency care in, 252, 256, 256t universal coverage of essential surgery (UCES), 1, 6, 12, spillover effects in, 15 14–15, 14f Sustainable Clubfoot Care Project, 138b universal health coverage, xv, 1, 225, 227, 259, 346. transport committees in, 228 See also universal coverage of essential surgery trauma care system in, 41, 46 (UCES) ulcers, emergency surgery for, 64–65, 72, 220t, 225 universal public financing in Ethiopia, 339–52. See also United Arab Emirates, cataract surgery in, 199 Ethiopia United Kingdom University of Michigan, 90 cataract-related blindness in, 198 unmet needs for surgery, xv–xvi, 14 cost-effectiveness studies in, 320 anesthesia services, 263, 264m, 265 eye care budget in, 206 family planning and contraception, 112 hernia repair rate in, 153 inguinal hernia, 155–56 mortality rates associated with surgery in, 280 urban areas National Health Service dental care, 185 first-level hospitals, need for, 215 National Institute for Health and Care Excellence, physicians concentrating in, 307, 312, 313 161, 226 trauma centers in, 328 oral health care in, 185 urinary obstructions, emergency surgery for, 65 orthopedic procedures, cost-effectiveness of, 326 trauma care systems in, 43 V United Nations on obstetrical emergency surgery vacuum aspiration, 121 outcomes, 222 vaginal delivery procedures, 79–80 United Nations Population Fund (UNFPA) value for global health care delivery, 186, 204–5 Campaign to End Fistula, 97, 100, 103 value of a statistical life (VSL), 362–63 fistula map prepared by, 120 Vander Burg, R., 324, 363 fistula repair, funding of, 103, 118–19b van Reenen, J., 294 survey on travel of fistula patients, 101 vasectomy. See family planning and contraception United States Vaz, F. A., 269 abortion cost-effectiveness in, 122 Venkatesh, R., 201, 203 anesthesia-related mortality in, 267 Verguet, S., 339 anesthesiologists in, 8–9 Veterans Administration hospitals (United States), 293 cataract-related blindness in, 198 Vietnam cataract surgery in, 204, 205 abortion services in, 309 charitable sector in, 231 cleft lip and palate repair in, 363 contraceptive methods, cost-effectiveness of, 117 emergency response time in, 251 cost-effectiveness studies in, 318, 320 trauma care system in, 44 Healthy People initiative, 185 Vincent, J. R., 361 hernias in, 152, 153, 325–26 VISION 2020 Right to Sight initiative, 206, 326–27 hospital management practices in, 294 visual acuity, 201–3 mortality rates in visual impairment. See blindness; cataracts; cataract surgery, 279 surgery surgical emergencies, 61, 67 vitamin A distribution, 20 National Health and Nutrition Examination Survey Vlassoff, M., 109 (NHANES), 152, 153 volvulus, emergency surgery for, 63–64 Index 419 von Schreeb, J., 213 Project, 9, 23, 333 Vos, T., 19 on first responders’ role, 249, 249b Global Alliance for Care of the Injured, 41 W Global Health Estimates, 6, 66, 133, 204, 245, 263 Waaldijk, K., 97, 98 Global Initiative for Emergency and Essential Warriner, I. K., 309 Surgical Care (GIEESC), 2, 23, 45, 333 water fluoridation, 177–80, 178t, 184 Integrated Management of Childhood Illness, 143 Weiser, T. G., 19, 279, 328 on maternal mortality, 308 Wendel, E., 327 on minimum standards for emergency and surgical West African College of Surgeons, 70 care, 12, 252, 281 West African Filariasis Program, 166 Monitoring the Building Blocks of Health Systems western diet, causing need for more surgery, 66 Monitoring and Evaluation Matrix, 36–37 WFSA. See World Federation of Societies of on nonphysician clinicians, 309 Anaesthesiologists objectives of health systems, 339 WHA. See World Health Assembly on obstetric fistula repair, 103 WHO. See World Health Organization on obstructed labor, 370 Wilhelm, T. J., 160 Patient Safety Pulse Oximetry project, 73 Wilson, I. H., 263 on properly functioning hospitals, 213 Wisborg, T., 249 on quality improvement programs for trauma Wittenborn, J. S., 327 care, 295 women. See childbirth; family planning and rheumatic disease, community-oriented program contraception; obstetric conditions; obstetric for, 53 fistula on rising health costs, 206 Women and Health Alliance International, 103 SAFE program, 355 Women’s Dignity Project and Engender Health, 95 on standardized metrics for surgical workforce innovations, 307–16. See also nonphysician surveillance, 279 clinicians Surgical Safety Checklist, 1, 13–14, 292, 293f workforce shortage. See shortage of skilled surgeons Tool for Situational Analysis to Assess Emergency working and living conditions and Essential Surgical Care, 54, 143 nonphysician clinicians, 312 on tooth decay, 174 obstetric fistula and, 99–100 trauma care guidelines, 9, 44 World Bank on universal health coverage, 346 benefit-cost analysis used by, 362 on vaginal delivery, 79 on cost-effectiveness of cataract surgery, 207 VISION 2020 Right to Sight initiative, 206, 326–27 World Development Report (1993), 3b WHO Model List of Essential Medicines, 266, 268, 270 World Federation of Societies of Anaesthesiologists, 73, World Health Report, 333 268, 273, 292 worms, 63–64, 162 World Health Assembly (WHA) on people with disabilities, 46 X Resolution 50.29 on lymphatic filariasis, 164 Xu, K., 328 Resolution 60.22, 41 on trauma and emergency care, 47 Y World Health Organization (WHO) years lived with disability (YLD) on abortion safety, 119, 321 benefit-cost analysis and, 365 on annual number of surgical operations performed conditions treatable in prehospital and emergency globally, 279 care, effect on, 246, 248f Basic Package of Oral Health Care, 174, 177, 183– DALYs and, 20 84b, 185 scaling up surgical care, impact of, 24–25, 30 on burn care education, 354 years of life lost (YLL) on cataracts and cataract surgery, 198, 201, 203 benefit-cost analysis and, 365 on cesarean delivery rates, 79, 86 conditions treatable in prehospital and emergency on congenital anomalies, 133 care, effect on, 246–47, 248f on cost-effectiveness, 367 DALYs and, 20 Emergency and Essential Surgical Care (EESC) scaling up surgical care, impact of, 24–25, 30 420 Index Z cesarean delivery rate in, 280 Zakariah, A., 245 first-level hospitals in, 214b Zambia surgical safety checklist use in, 294 anesthesia-related mortality in, 267 Zimbabwe, anesthesia-related anesthesia training in, 271t mortality in, 267 Index 421 ECO-AUDIT Environmental Benefits Statement The World Bank is committed to preserving Saved: endangered forests and natural resources. • 19 trees Essential Surgery: Disease Control Priorities, • 9 million British thermal third edition, volume 1 was printed on recy- units of total energy cled paper with 100 percent postconsumer fiber • 1,656 pounds of CO2 in accordance with the recommended standards equivalent of for paper usage set by the Green Press Initiative, greenhouse gases a nonprofit program supporting publishers • 8,980 gallons of in using fiber that is not sourced from endan- waste water gered forests. For more information, visit www • 601 pounds of solid .greenpressinitiative.org. waste I II 90000 9 781464 803468 II