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Original Investigation |

Mapping Population-Level Spatial Access to Essential Surgical Care in Ghana Using Availability of Bellwether Procedures Online Only

Barclay T. Stewart, MD, MScPH1,2,3; Gavin Tansley, MD4,5; Adam Gyedu, MD, MPH2,3; Anthony Ofosu, MD, MPH, MSc6; Peter Donkor, MDSc2,3; Ebenezer Appiah-Denkyira, MD7; Robert Quansah, MD, PhD2,3; Damian L. Clarke, MBBCh, PhD8,9; Jimmy Volmink, MBChB, DPhil10,11; Charles Mock, MD, PhD1,12,13
[+] Author Affiliations
1Department of Surgery, University of Washington, Seattle
2Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
3Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
4Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
5Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England
6Information and Monitoring Unit, Ghana Health Service, Accra
7Office of the Director General, Ghana Health Service, Accra
8Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa
9Department of General Surgery, Nelson R. Mandela School of Medicine, University of Kwa-Zulu Natal, Kwa-Zulu Natal, South Africa
10Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
11Cochrane South Africa, South African Medical Research Council, Tygerberg
12Harborview Injury Prevention & Research Center, Seattle, Washington
13Department of Global Health, University of Washington, Seattle
JAMA Surg. 2016;151(8):e161239. doi:10.1001/jamasurg.2016.1239.
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Importance  Conditions that can be treated by surgery comprise more than 16% of the global disease burden. However, 5 billion people do not have access to essential surgical care. An estimated 90% of the 87 million disability-adjusted life-years incurred by surgical conditions could be averted by providing access to timely and safe surgery in low-income and middle-income countries. Population-level spatial access to essential surgery in Ghana is not known.

Objectives  To assess the performance of bellwether procedures (ie, open fracture repair, emergency laparotomy, and cesarean section) as a proxy for performing essential surgery more broadly, to map population-level spatial access to essential surgery, and to identify first-level referral hospitals that would most improve access to essential surgery if strengthened in Ghana.

Design, Setting, and Participants  Population-based study among all households and public and private not-for-profit hospitals in Ghana. Households were represented by georeferenced census data. First-level and second-level referral hospitals managed by the Ministry of Health and all tertiary hospitals were included. Surgical data were collected from January 1 to December 31, 2014.

Main Outcomes and Measures  All procedures performed at first-level referral hospitals in Ghana in 2014 were used to sort each facility into 1 of the following 3 hospital groups: those without capability to perform all 3 bellwether procedures, those that performed 1 to 11 of each procedure, and those that performed at least 12 of each procedure. Candidates for targeted capability improvement were identified by cost-distance and network analysis.

Results  Of 155 first-level referral hospitals managed by the Ghana Health Service and the Christian Health Association of Ghana, 123 (79.4%) reported surgical data. Ninety-five (77.2%) did not have the capability in 2014 to perform all 3 bellwether procedures, 24 (19.5%) performed 1 to 11 of each bellwether procedure, and 4 (3.3%) performed at least 12. The essential surgical procedure rate was greater in bellwether procedure–capable first-level referral hospitals than in noncapable hospitals (median, 638; interquartile range, 440-1418 vs 360; interquartile range, 0-896 procedures per 100 000 population; P = .03). Population-level spatial access within 2 hours to a hospital that performed 1 to 11 and at least 12 of each bellwether procedure was 83.2% (uncertainty interval [UI], 82.2%-83.4%) and 71.4% (UI, 64.4%-75.0%), respectively. Five hospitals were identified for targeted capability improvement.

Conclusions and Relevance  Almost 30% of Ghanaians cannot access essential surgery within 2 hours. Bellwether capability is a useful metric for essential surgery more broadly. Similar strategic planning exercises might be useful for other low-income and middle-income countries aiming to improve access to essential surgery.

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Figure 1.
Cost-Distance Analyses of Population-Level Spatial Access to Essential Surgery in Ghana

Bellwether procedures include open fracture repair, emergency laparotomy (eg, splenectomy for trauma and repair of hollow viscous perforation), and cesarean section.

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Figure 2.
Cost-Distance Analyses of Population-Level Spatial Access to Essential Surgery With and Without First-Level Hospitals Targeted for Capability Strengthening

A location-allocation model was built to identify 5 facilities in Ghana from a candidate list of first-level hospitals that performed less than 12 of each bellwether procedure per year that would have the greatest effect on population-level spatial access to essential surgery within 1 hour if strengthened. Candidate facilities are Comboni Hospital, Hawa Memorial Savior Hospital, Oda Hospital, Wiawso Hospital, and Zebilla Hospital. Population-weighted geographic centroids of districts represented demand points in the model. A second cost-distance analysis was performed after combining the candidate facilities and facilities that performed at least 12 of each bellwether procedure per year to quantify improvements in population-level spatial access after capability strengthening. Bellwether procedures include open fracture repair, emergency laparotomy (eg, splenectomy for trauma and repair of hollow viscous perforation), and cesarean section.

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