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Original Investigation |

Mapping Disparities in Access to Safe, Timely, and Essential Surgical Care in Zambia ONLINE FIRST

Micaela M. Esquivel, MD1; Tarsicio Uribe-Leitz, MD1; Emmanuel Makasa, MD2; Kennedy Lishimpi, MD3; Peter Mwaba, MD3; Kendra Bowman, MD4; Thomas G. Weiser, MD1
[+] Author Affiliations
1Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
2Permanent Mission of Zambia, Geneva, Switzerland
3Zambian Ministry of Health, Lusaka, Zambia
4Division of Pediatric General and Thoracic Surgery, Department of Surgery, Children’s Hospital of Wisconsin, Milwaukee
JAMA Surg. Published online August 31, 2016. doi:10.1001/jamasurg.2016.2303
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Published online

Importance  Surgical care is widely unavailable in developing countries; advocates recommend that countries evaluate and report on access to surgical care to improve availability and aid health planners in decision making.

Objective  To analyze the infrastructure, capacity, and availability of surgical care in Zambia to inform health policy priorities.

Design, Setting, and Participants  In this observational study, all hospitals providing surgical care were identified in cooperation with the Zambian Ministry of Health. On-site data collection was conducted from February 1 through August 30, 2011, with an adapted World Health Organization Global Initiative for Emergency and Essential Surgical Care survey. Data collection at each facility included interviews with hospital personnel and assessment of material resources. Data were geocoded and analyzed in a data visualization platform from March 1 to December 1, 2015. We analyzed time and distance to surgical services, as well as the proportion of the population living within 2 hours from a facility providing surgical care.

Main Outcomes and Measures  Surgical capacity, supplies, human resources, and infrastructure at each surgical facility, as well as the population living within 2 hours from a hospital providing surgical care.

Results  Data were collected from all 103 surgical facilities identified as providing surgical care. When including all surgical facilities (regardless of human resources and supplies), 14.9% of the population (2 166 460 of 14 500 000 people) lived more than 2 hours from surgical care. However, only 17 hospitals (16.5%) met the World Health Organization minimum standards of surgical safety; when limiting the analysis to these hospitals, 65.9% of the population (9 552 780 people) lived in an area that was more than 2 hours from a surgical facility. Geographic analysis of emergency and essential surgical care, defined as access to trauma care, obstetric care, and care of common abdominal emergencies, found that 80.7% of the population (11 704 700 people) lived in an area that was more than 2 hours from these surgical facilities.

Conclusions and Relevance  A large proportion of the population in Zambia does not have access to safe and timely surgical care; this percentage would change substantially if all surgical hospitals were adequately resourced. Geospatial visualization tools assist in the evaluation of surgical infrastructure in Zambia and can identify key areas for improvement.

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Figure 1.
Population of Zambia Within a 2-Hour Travel Time of Surgical Facilities

A, Population (85.1%) within 2-hour travel time for all surgical facilities (gray dots) in Zambia. B, Population (34.1%) within 2-hour travel time for surgical facilities (gray dots) that meet the World Health Organization (WHO) minimum surgical safety standards. C, Population (19.3%) within 2-hour travel time for surgical facilities (gray dots) that provide essential surgery—trauma care, obstetric care, and care of common abdominal emergencies.

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Figure 2.
Travel Time to Types of Surgical Facilities

Differences in access to each type of facility based on travel time. Ess-Surg indicates essential surgical facilities; WHO-SS, World Health Organization safe surgical facilities.

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Figure 3.
Population Densities and Travel Time to Surgical Facilities

Partial map of Zambia depicting higher population densities (>300 people/m2) with colored dots: if they are outside of the 2-hour travel time to safe surgical facilities, the population densities are red; if they are within this travel time, the population densities are blue. The circles with a black outline indicate locations of all surgical facilities.

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