Interventions
Both population-based strategies and personal sevices provided in community clinic, district, and tertiary hospitals are considered in this section.
Population-based Strategies
Population-based approaches to the prevention of unintentional and intentional injuries are discussed in the chapters on those topics. A population-based approach to injury should not, however, be limited to injury prevention. Patients may survive their primary injuries only to become chronically disabled and a burden to their families and to society (Krug, Sharma, and Lozano 2000; Mock and others 1999; Nantulya and Reich 2002; Peden and Hyder 2002). The incidence and severity of the complications of survivable injury may be significantly lessened by the provision of adequate surgical care during pre-hospital care and initial hospitalization. No published data from developing countries are available, however, either to prove this plausible contention or to quantify the benefits of adequate initial surgical treatment. A strategy to prevent chronic disability arising from survivable injury requires well-coordinated services for resuscitation, evacuation, and early and expert operative management of the initial injury.
Many other surgical conditions that can be treated electively, such as hernias, hydroceles, and otitis media, are treated when they present with complications requiring emergency surgery. Thus, a pertinent question is whether treating such conditions electively would be more cost-effective, but no reliable data are available to answer this question positively or negatively.
Population-based strategies could also be applied to prevent or treat some musculoskeletal conditions. For example, the incidence of clubfoot is estimated at 1 or 2 per 1,000 live births, but in developing countries these children are typically brought in for orthopedic care when it is too late for effective nonsurgical conservative management (Ponseti 1999; Turco 1994). Because we have no baseline data for the burden of clubfoot and other musculoskeletal conditions, we are unable to quantify the DALYs that could be averted by comprehensive surgical care.
The following sections describe the organization of surgical services that we think would begin to provide coordinated surgical care in developing countries. The provision of surgical services in developing countries requires organizational structure and capacity at the level of community-based clinics, district hospitals, and tertiary care hospitals. Our concept of minimally adequate modules of surgical care is informed by our personal experiences, the experiences of others, and a recent World Health Organization report (WHO 2003). We recognize that to accommodate local needs and reality on the ground, any proposed plan to develop surgical services must be flexible. Table 67.4 presents our estimates of the needs for infrastructure, equipment and supplies, and workforce for the three levels of surgical care: community clinic, district hospital, and tertiary hospital.
[Table .]
Community Clinics
Table 67.4 shows resource and workforce requirements and types of surgical services a community clinic could provide for a population of around 20,000. We assume that surgical services in community clinics would be provided at no cost to patients. A cost-recovery system would be unlikely to succeed everywhere but, if implemented, should be equitable, with payments adjusted to patients' ability to pay. A mechanism for accountability and monitoring should be established to avoid the misuse of drugs and supplies. Simple patient records should be maintained, including outcomes of treatment and use of supplies. Even though the community clinic described here is what we think it should be as opposed to what we know it to be, our model may serve the needs of rural areas in developing countries and could provide a starting point for estimating costs.
District Hospitals
The next level of organization of surgical services is the district hospital, which in addition to providing primary care for the local population would also provide secondary-level surgical services and serve as a referral center for a number of community clinics in a defined region. In turn, the district hospital would ideally refer patients requiring complex surgical care to a tertiary-level hospital, but we recognize that such referral cannot always be achieved in practice because of transportation limitations, economic constraints, and prevalent social and cultural contexts. District hospitals vary in size from as small as 10 to 20 beds to as large as 200 to 300 beds and vary in their degree of sophistication in relation to diagnostic and therapeutic capabilities. For this discussion, we have arbitrarily chosen to focus on district hospitals with 100 beds or fewer.
Table 67.4 shows the infrastructure requirements for this type of hospital. Patients requiring more complex imaging studies and laboratory tests would be referred to the tertiary hospital.
To the extent possible, all equipment and supplies (table 67.4) should be standardized, and an efficient and reliable system for maintenance and replacement should be ensured. Operating room instruments and supplies should be available to enable the performance of laparotomy, thoracotomy, obstetrical and gynecological procedures, treatment of extremity fractures, skin grafting, and emergency burr hole of the skull. These instruments should be available at least in duplicate. Table 67.4 also shows workforce needs and the types of surgical procedures that may be performed in a district hospital.
The district hospital is assumed not only to serve as the referral hospital for community clinics, but also to coordinate the community clinics in its own region as a single operating unit, assuming responsibility for wireless communication, training the workforce, providing continuing medical education, and monitoring the quality and outcome of care. It would also provide primary care to its contiguous population.
Tertiary Hospitals
The tertiary hospital would function as the referral center for all complex surgical care in a region, country, or group of countries. Ideally, but depending on the country's resource constraints, it would provide the full range of care shown in table 67.4. The tertiary hospital would also provide primary surgical care for its local population and could take on the role of a teaching hospital for doctors, nurses, and other health care workers.
In the proposed organizational structure, the tertiary hospital is viewed as the top of a pyramid of surgical services, with several district hospitals referring patients requiring complex surgical care to the tertiary hospital. As such, it should also take the primary responsibility for coordinating and collaborating with all the district hospitals and community clinics in its area of responsibility to ensure that surgical care is available throughout the region and that well-functioning wireless communication and ambulance systems are available. If a regionalized system of separate ambulance services is not available, the tertiary hospital can provide the ambulance services required. Specialists in the tertiary hospital should provide telephone and electronic consultation for doctors and nurses in district hospitals. The tertiary hospital should also coordinate and monitor the quality of care in the region that serves as its referral base, undertake clinical outcome studies, and provide continuing medical education. In addition, it should be the main teaching hospital for medical students, nurses, and technicians, with the district hospitals and even the community clinics serving as clinical rotation sites for trainees. This organizational structure is ideally suited for the tertiary hospital to serve as the backbone of community-based surgical education. The extent to which this ideal function of a tertiary hospital can be implemented will depend on the financial and other resources available to the country.
Coordinated Model System for Surgical Care
The proposed system for surgical services requires the coordination and integration of the following:
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wireless communication
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continuing education programs
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regionalized supply system for equipment, essential drugs, and surgical materials
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ambulance service
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uniform data collection system
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coordinated and ongoing monitoring of quality and outcomes of care.
A wireless system of communication could render costly wired systems unnecessary and could connect community clinics, district hospitals, and tertiary hospitals in a dependable way that facilitates consultation and referral. A Web-based system of communication could be particularly important for mentoring and for providing continuing medical education. The Web can also be used to enhance contributions by volunteer surgeons, anesthesiologists, surgical specialists, nurses, and technicians from around the world. Associations such as the International Surgical Association could develop a Web portal tied to national surgical associations to ensure greater success in this regard.
A regionalized system for the purchase and delivery of equipment and supplies is highly desirable. Such a system could ensure that all equipment and supplies were standardized and made available on demand in an efficient and predictable manner.
Ground ambulance services are essential for patient transfer. In some areas, collaboration with local taxi or bus services might offer the needed support. In some more economically advanced countries, tertiary hospitals might be able to provide ambulance services using fixed-wing aircraft or helicopters.
If the proposed model for a surgical system is to be developed, systems for ongoing data acquisition and for evaluation and monitoring should be built into the model. In this way, not only could information be captured, but also the quality and outcomes of care could be monitored on an ongoing basis.
