Research and Development Agenda
The literature on surgical care in developing countries is so meager that insufficient data are available to formulate an agenda for research and development. Hence, of necessity, the research that needs to be done is extremely basic, much of it information gathering. The following are some of the areas that require investment in research and development:
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Estimates are needed of the burden of disease that requires surgical intervention along with a determination of region-specific DALYs that can be averted by means of surgical intervention. We have applied the DALYs averted from a single study in a developing country (McCord and Chowdhury 2003) to other regions, a procedure that negates regional differences in disease incidence, health care-seeking behavior, case mix, and clinical practice variations. In addition, the calculation of DALYs averted should ideally be adjusted for region-specific life expectancy and disability weights.
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Estimation of costs, both at a facility and regional level, is needed, including reducing variability in estimation methods (Adam and Koopmanschap 2003). In addition, multiple estimates of costs are needed. For example, Mulligan and others (2003) derive their operating room costs from a single study of ambulatory surgery in Colombia (Shephard and others 1993). Even though they made adjustments to reflect regional characteristics, further research is required to validate their results, especially as they apply to different settings in different countries.
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Better surgical data collection and analysis tools critical to needs assessment should be designed.
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Development of appropriate surgical care models for all levels of care based on local and regional characteristics and surgical needs would be useful.
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Cost-effectiveness and cost-benefit analyses of health systems implementation need to be determined, as do the policy implications of creating the surgical care model proposed in this chapter. The evaluation of surgery as a prevention strategy in public health should include cost-effectiveness analysis of adequate, prompt, initial surgical treatment of injury to prevent chronic disability from poorly diagnosed and treated survivable injuries and of elective treatment of hernia, hydrocele, otitis media, cataract, and clubfoot to prevent complications and disability.
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The surgical workforce in developing countries requires more in-depth study to look at the mixes of workers needed, the level of training required for the widely varying local situations of district hospitals, and the role for part-time surgical talent. The thesis is that volunteer doctors, nurses, and anesthesiologists who now contribute considerably to surgical care in developing countries in a relatively unstructured fashion could do so more effectively and in a manner that could help create sustainable local surgical workforces if a well-coordinated system with extensive information and communication support could be developed. This concept merits in-depth study. If a well-planned, Web-coordinated, global, highly integrated system could be developed, health care volunteers around the world could be organized strategically so as to deliver not only surgical care, but also training of local surgical workforces. The emphasis on training is crucial and would mitigate the complaints often heard that surgical volunteers too often contribute to the care of individual patients but fail to leave behind a mechanism for sustaining surgical care when they have left. Those volunteers who come from the high-tech world of modern surgery should realize that the latest technology is often more of a burden and diversion than a help in poor countries. Convincing demonstrations of how much can be done without recourse to CT scans, ultrasound, and video-assisted surgery could be the most useful contribution a visitor could make.
