1. HEALTH SYSTEMS STRENGTHENING
Commission on Global Surgery
Health Delivery & Management
(HDM) Working Group
HEALTH SYSTEMS STRENGTHENING
AND SURGERY
Nobhojit Roy MD MPH
Chair, LCoGS HDM Working Group
Chief of Surgery, BARC Hospital, Mumbai
RACS GLOBAL HEALTH SYMPOSIUM 26TH OCT 2015, MELBOURNE

2. The Present Situation

3. THE SURGICAL SYSTEM AND THE THREE DELAYS
The 2nd Delay
Delay in Reaching Care
The 3rd Delay
Delay in Receiving Care
The 1st Delay
Delay in Seeking Care
First delay – financial, geographic, cultural,education, disconnect, poor trust, informal network (tradiitonal healers)
Second delay – distances, poor pre-hospital, financial
Third delay – when people actually get to hospital.
C-sx 64%
laparotomy 58%
open fracture 40%
Why?
Infrastructure is poor
electricity 31%
water 22%
oxygen 24%
emergency care 31%
post op care 47%
anesthesia machine 55%
Essential medication, supplies, PPE out of stock
Equipment maintenance poor – 40% out of service
Radiology
Blood banking inadequate
Overcrowding
Elective cases get bumped for emergent cases
Poor managerial support, too busy clinicians, unable to focus on improved functionality
Care coordination lacking – referrals, NGOs, all of it
The Way Forward
1st Delay – Community outreach, Community Health Workers, BRAC
2nd Delay – Strengthening existing modes of prehospital transportation (Good Samaritan laws, trauma victim response, lay responder programs)
Explore taking care to the patient. Edgar slides – mobile surgery
3rd Delay
The Third Delay will shorten when first-level hospitals can efficiently deliver a broad range of surgical and anaesthesia services.
The First-Level Hospital – core of hospital system for DCP3, also should be able to do c-sx, laparotomy, open fracture fixation
Surgeons everywhere have devidsed meaningful workarounds, but they shouldn’t have to. Investment need to be directed towards the first-level hospital
Needs at the first-level hospital – intended for broad policy audience. Surgeons anywhere know what is needed, as do health systems planners.
We didn’t want to be too specific for obvious reasons, or be too prescriptive.
Surgeons at these sites need to be cross trained across multiple specialties, given the realities of workforce distribution.
Must celebrate them, not neglect – opportunities for continuing education, development, investment in supplies and ability to provide care, integration with tertiary and teaching roles
Maintenance – equipment failure - BMET programs – GE;
donation guidelines
Processes

4. THE THREE DELAYS The 1st Delay Financial Awareness Geographic
Poor trust
Cultural
The 1st Delay
Delay in Seeking Care
First delay – financial, geographic, cultural,education, disconnect, poor trust, informal network (tradiitonal healers)
Second delay – distances, poor pre-hospital, financial
Third delay – when people actually get to hospital.
C-sx 64%
laparotomy 58%
open fracture 40%
Why?
Infrastructure is poor
electricity 31%
water 22%
oxygen 24%
emergency care 31%
post op care 47%
anesthesia machine 55%
Essential medication, supplies, PPE out of stock
Equipment maintenance poor – 40% out of service
Radiology
Blood banking inadequate
Overcrowding
Elective cases get bumped for emergent cases
Poor managerial support, too busy clinicians, unable to focus on improved functionality
Care coordination lacking – referrals, NGOs, all of it
The Way Forward
1st Delay – Community outreach, Community Health Workers, BRAC
2nd Delay – Strengthening existing modes of prehospital transportation (Good Samaritan laws, trauma victim response, lay responder programs)
Explore taking care to the patient. Edgar slides – mobile surgery
3rd Delay
The Third Delay will shorten when first-level hospitals can efficiently deliver a broad range of surgical and anaesthesia services.
The First-Level Hospital – core of hospital system for DCP3, also should be able to do c-sx, laparotomy, open fracture fixation
Surgeons everywhere have devidsed meaningful workarounds, but they shouldn’t have to. Investment need to be directed towards the first-level hospital
Needs at the first-level hospital – intended for broad policy audience. Surgeons anywhere know what is needed, as do health systems planners.
We didn’t want to be too specific for obvious reasons, or be too prescriptive.
Surgeons at these sites need to be cross trained across multiple specialties, given the realities of workforce distribution.
Must celebrate them, not neglect – opportunities for continuing education, development, investment in supplies and ability to provide care, integration with tertiary and teaching roles
Maintenance – equipment failure - BMET programs – GE;
donation guidelines
Processes

5. THE THREE DELAYS The 2nd Delay Long distances
Delay in Reaching Care
Long distances
Poor pre-hospital transportation
Financial
First delay – financial, geographic, cultural,education, disconnect, poor trust, informal network (tradiitonal healers)
Second delay – distances, poor pre-hospital, financial
Third delay – when people actually get to hospital.
C-sx 64%
laparotomy 58%
open fracture 40%
Why?
Infrastructure is poor
electricity 31%
water 22%
oxygen 24%
emergency care 31%
post op care 47%
anesthesia machine 55%
Essential medication, supplies, PPE out of stock
Equipment maintenance poor – 40% out of service
Radiology
Blood banking inadequate
Overcrowding
Elective cases get bumped for emergent cases
Poor managerial support, too busy clinicians, unable to focus on improved functionality
Care coordination lacking – referrals, NGOs, all of it
The Way Forward
1st Delay – Community outreach, Community Health Workers, BRAC
2nd Delay – Strengthening existing modes of prehospital transportation (Good Samaritan laws, trauma victim response, lay responder programs)
Explore taking care to the patient. Edgar slides – mobile surgery
3rd Delay
The Third Delay will shorten when first-level hospitals can efficiently deliver a broad range of surgical and anaesthesia services.
The First-Level Hospital – core of hospital system for DCP3, also should be able to do c-sx, laparotomy, open fracture fixation
Surgeons everywhere have devidsed meaningful workarounds, but they shouldn’t have to. Investment need to be directed towards the first-level hospital
Needs at the first-level hospital – intended for broad policy audience. Surgeons anywhere know what is needed, as do health systems planners.
We didn’t want to be too specific for obvious reasons, or be too prescriptive.
Surgeons at these sites need to be cross trained across multiple specialties, given the realities of workforce distribution.
Must celebrate them, not neglect – opportunities for continuing education, development, investment in supplies and ability to provide care, integration with tertiary and teaching roles
Maintenance – equipment failure - BMET programs – GE;
donation guidelines
Processes

6. DISTANCE TO HOSPITAL PER INCOME GROUP
Distance to hospital by income group
First delay – financial, geographic, cultural,education, disconnect, poor trust, informal network (tradiitonal healers)
Second delay – distances, poor pre-hospital, financial
Third delay – when people actually get to hospital.
C-sx 64%
laparotomy 58%
open fracture 40%
Why?
Infrastructure is poor
electricity 31%
water 22%
oxygen 24%
emergency care 31%
post op care 47%
anesthesia machine 55%
Essential medication, supplies, PPE out of stock
Equipment maintenance poor – 40% out of service
Radiology
Blood banking inadequate
Overcrowding
Elective cases get bumped for emergent cases
Poor managerial support, too busy clinicians, unable to focus on improved functionality
Care coordination lacking – referrals, NGOs, all of it
The Way Forward
1st Delay – Community outreach, Community Health Workers, BRAC
2nd Delay – Strengthening existing modes of prehospital transportation (Good Samaritan laws, trauma victim response, lay responder programs)
Explore taking care to the patient. Edgar slides – mobile surgery
3rd Delay
The Third Delay will shorten when first-level hospitals can efficiently deliver a broad range of surgical and anaesthesia services.
The First-Level Hospital – core of hospital system for DCP3, also should be able to do c-sx, laparotomy, open fracture fixation
Surgeons everywhere have devidsed meaningful workarounds, but they shouldn’t have to. Investment need to be directed towards the first-level hospital
Needs at the first-level hospital – intended for broad policy audience. Surgeons anywhere know what is needed, as do health systems planners.
We didn’t want to be too specific for obvious reasons, or be too prescriptive.
Surgeons at these sites need to be cross trained across multiple specialties, given the realities of workforce distribution.
Must celebrate them, not neglect – opportunities for continuing education, development, investment in supplies and ability to provide care, integration with tertiary and teaching roles
Maintenance – equipment failure - BMET programs – GE;
donation guidelines
Processes

7. Delay in Receiving Care
The Three Delays
Infrastructure
Physical
Equipment & maintenance
Supply chains
Blood banks
Staffing
Processes and protocols
Isolated from system
The 3rd Delay
Delay in Receiving Care
First delay – financial, geographic, cultural,education, disconnect, poor trust, informal network (tradiitonal healers)
Second delay – distances, poor pre-hospital, financial
Third delay – when people actually get to hospital.
C-sx 64%
laparotomy 58%
open fracture 40%
Why?
Infrastructure is poor
electricity 31%
water 22%
oxygen 24%
emergency care 31%
post op care 47%
anesthesia machine 55%
Essential medication, supplies, PPE out of stock
Equipment maintenance poor – 40% out of service
Radiology
Blood banking inadequate
Overcrowding
Elective cases get bumped for emergent cases
Poor managerial support, too busy clinicians, unable to focus on improved functionality
Care coordination lacking – referrals, NGOs, all of it
The Way Forward
1st Delay – Community outreach, Community Health Workers, BRAC
2nd Delay – Strengthening existing modes of prehospital transportation (Good Samaritan laws, trauma victim response, lay responder programs)
Explore taking care to the patient. Edgar slides – mobile surgery
3rd Delay
The Third Delay will shorten when first-level hospitals can efficiently deliver a broad range of surgical and anaesthesia services.
The First-Level Hospital – core of hospital system for DCP3, also should be able to do c-sx, laparotomy, open fracture fixation
Surgeons everywhere have devidsed meaningful workarounds, but they shouldn’t have to. Investment need to be directed towards the first-level hospital
Needs at the first-level hospital – intended for broad policy audience. Surgeons anywhere know what is needed, as do health systems planners.
We didn’t want to be too specific for obvious reasons, or be too prescriptive.
Surgeons at these sites need to be cross trained across multiple specialties, given the realities of workforce distribution.
Must celebrate them, not neglect – opportunities for continuing education, development, investment in supplies and ability to provide care, integration with tertiary and teaching roles
Maintenance – equipment failure - BMET programs – GE;
donation guidelines
Processes
64%
40%
58%

8. Delay in Receiving Care
The Way Forward
Strategies for
The 1st Delay
Delay in Seeking Care
Strategies for
The 2nd Delay
Delay in Reaching Care
Strategies for
The 3rd Delay
Delay in Receiving Care
We combed the world. Got in touch with providers.
Found out where surgeons are and how long it would take to get to them
Found wide variation
Even amongst health systems “LMIC” – there were top areas and poor performing areas within the same region, same country, same state
But also widespread similarities

9. INVEST IN COMMUNITY OUTREACH
First delay – financial, geographic, cultural,education, disconnect, poor trust, informal network (tradiitonal healers)
Second delay – distances, poor pre-hospital, financial
Third delay – when people actually get to hospital.
C-sx 64%
laparotomy 58%
open fracture 40%
Why?
Infrastructure is poor
electricity 31%
water 22%
oxygen 24%
emergency care 31%
post op care 47%
anesthesia machine 55%
Essential medication, supplies, PPE out of stock
Equipment maintenance poor – 40% out of service
Radiology
Blood banking inadequate
Overcrowding
Elective cases get bumped for emergent cases
Poor managerial support, too busy clinicians, unable to focus on improved functionality
Care coordination lacking – referrals, NGOs, all of it
The Way Forward
1st Delay – Community outreach, Community Health Workers, BRAC
2nd Delay – Strengthening existing modes of prehospital transportation (Good Samaritan laws, trauma victim response, lay responder programs)
Explore taking care to the patient. Edgar slides – mobile surgery
3rd Delay
The Third Delay will shorten when first-level hospitals can efficiently deliver a broad range of surgical and anaesthesia services.
The First-Level Hospital – core of hospital system for DCP3, also should be able to do c-sx, laparotomy, open fracture fixation
Surgeons everywhere have devidsed meaningful workarounds, but they shouldn’t have to. Investment need to be directed towards the first-level hospital
Needs at the first-level hospital – intended for broad policy audience. Surgeons anywhere know what is needed, as do health systems planners.
We didn’t want to be too specific for obvious reasons, or be too prescriptive.
Surgeons at these sites need to be cross trained across multiple specialties, given the realities of workforce distribution.
Must celebrate them, not neglect – opportunities for continuing education, development, investment in supplies and ability to provide care, integration with tertiary and teaching roles
Maintenance – equipment failure - BMET programs – GE;
donation guidelines
Processes

10. SCALE LOW-COST COMPREHENSIVE REFERRAL SYSTEMS
First delay – financial, geographic, cultural,education, disconnect, poor trust, informal network (tradiitonal healers)
Second delay – distances, poor pre-hospital, financial
Third delay – when people actually get to hospital.
C-sx 64%
laparotomy 58%
open fracture 40%
Why?
Infrastructure is poor
electricity 31%
water 22%
oxygen 24%
emergency care 31%
post op care 47%
anesthesia machine 55%
Essential medication, supplies, PPE out of stock
Equipment maintenance poor – 40% out of service
Radiology
Blood banking inadequate
Overcrowding
Elective cases get bumped for emergent cases
Poor managerial support, too busy clinicians, unable to focus on improved functionality
Care coordination lacking – referrals, NGOs, all of it
The Way Forward
1st Delay – Community outreach, Community Health Workers, BRAC
2nd Delay – Strengthening existing modes of prehospital transportation (Good Samaritan laws, trauma victim response, lay responder programs)
Explore taking care to the patient. Edgar slides – mobile surgery
3rd Delay
The Third Delay will shorten when first-level hospitals can efficiently deliver a broad range of surgical and anaesthesia services.
The First-Level Hospital – core of hospital system for DCP3, also should be able to do c-sx, laparotomy, open fracture fixation
Surgeons everywhere have devidsed meaningful workarounds, but they shouldn’t have to. Investment need to be directed towards the first-level hospital
Needs at the first-level hospital – intended for broad policy audience. Surgeons anywhere know what is needed, as do health systems planners.
We didn’t want to be too specific for obvious reasons, or be too prescriptive.
Surgeons at these sites need to be cross trained across multiple specialties, given the realities of workforce distribution.
Must celebrate them, not neglect – opportunities for continuing education, development, investment in supplies and ability to provide care, integration with tertiary and teaching roles
Maintenance – equipment failure - BMET programs – GE;
donation guidelines
Processes

11. STRENGTHEN EXISTING NETWORKS OF CARE
In many settings, police, taxi and truck drivers already provide the majority of pre-hospital transportation
First delay – financial, geographic, cultural,education, disconnect, poor trust, informal network (tradiitonal healers)
Second delay – distances, poor pre-hospital, financial
Third delay – when people actually get to hospital.
C-sx 64%
laparotomy 58%
open fracture 40%
Why?
Infrastructure is poor
electricity 31%
water 22%
oxygen 24%
emergency care 31%
post op care 47%
anesthesia machine 55%
Essential medication, supplies, PPE out of stock
Equipment maintenance poor – 40% out of service
Radiology
Blood banking inadequate
Overcrowding
Elective cases get bumped for emergent cases
Poor managerial support, too busy clinicians, unable to focus on improved functionality
Care coordination lacking – referrals, NGOs, all of it
The Way Forward
1st Delay – Community outreach, Community Health Workers, BRAC
2nd Delay – Strengthening existing modes of prehospital transportation (Good Samaritan laws, trauma victim response, lay responder programs)
Explore taking care to the patient. Edgar slides – mobile surgery
3rd Delay
The Third Delay will shorten when first-level hospitals can efficiently deliver a broad range of surgical and anaesthesia services.
The First-Level Hospital – core of hospital system for DCP3, also should be able to do c-sx, laparotomy, open fracture fixation
Surgeons everywhere have devidsed meaningful workarounds, but they shouldn’t have to. Investment need to be directed towards the first-level hospital
Needs at the first-level hospital – intended for broad policy audience. Surgeons anywhere know what is needed, as do health systems planners.
We didn’t want to be too specific for obvious reasons, or be too prescriptive.
Surgeons at these sites need to be cross trained across multiple specialties, given the realities of workforce distribution.
Must celebrate them, not neglect – opportunities for continuing education, development, investment in supplies and ability to provide care, integration with tertiary and teaching roles
Maintenance – equipment failure - BMET programs – GE;
donation guidelines
Processes

12. TAKE CARE TO THE COMMUNITY – MOBILE SURGERY
First delay – financial, geographic, cultural,education, disconnect, poor trust, informal network (tradiitonal healers)
Second delay – distances, poor pre-hospital, financial
Third delay – when people actually get to hospital.
C-sx 64%
laparotomy 58%
open fracture 40%
Why?
Infrastructure is poor
electricity 31%
water 22%
oxygen 24%
emergency care 31%
post op care 47%
anesthesia machine 55%
Essential medication, supplies, PPE out of stock
Equipment maintenance poor – 40% out of service
Radiology
Blood banking inadequate
Overcrowding
Elective cases get bumped for emergent cases
Poor managerial support, too busy clinicians, unable to focus on improved functionality
Care coordination lacking – referrals, NGOs, all of it
The Way Forward
1st Delay – Community outreach, Community Health Workers, BRAC
2nd Delay – Strengthening existing modes of prehospital transportation (Good Samaritan laws, trauma victim response, lay responder programs)
Explore taking care to the patient. Edgar slides – mobile surgery
3rd Delay
The Third Delay will shorten when first-level hospitals can efficiently deliver a broad range of surgical and anaesthesia services.
The First-Level Hospital – core of hospital system for DCP3, also should be able to do c-sx, laparotomy, open fracture fixation
Surgeons everywhere have devidsed meaningful workarounds, but they shouldn’t have to. Investment need to be directed towards the first-level hospital
Needs at the first-level hospital – intended for broad policy audience. Surgeons anywhere know what is needed, as do health systems planners.
We didn’t want to be too specific for obvious reasons, or be too prescriptive.
Surgeons at these sites need to be cross trained across multiple specialties, given the realities of workforce distribution.
Must celebrate them, not neglect – opportunities for continuing education, development, investment in supplies and ability to provide care, integration with tertiary and teaching roles
Maintenance – equipment failure - BMET programs – GE;
donation guidelines
Processes

13. The 3rd Delay FOCUS ON THE FIRST-LEVEL HOSPITAL Strategies for
Delay in Receiving Care
The Core Site for Surgical Care Provision
Should be able to provide the vast majority of surgical care.
Investments should be directed towards enabling the heroic individuals who work against all odds to provide care in these settings to do their jobs
Investments should be to allow the first-level hospital to consistently provide a broad range of procedures, including emergent procedures – c-sx, laparotomy, and treatment of open fracture.
A hospital that can consistently provide these three procedures are likely staffed and equipped, and have the systems in place to provide most other surgical procedures, or very close to it. As such, we call these, the Bellwether Procedures

14. THE BELLWETHER PROCEDURES
Hospitals that can consistently provide the Bellwether Procedures are likely staffed and equipped, and function at a level of complexity that enables the delivery of other, related surgical care
Through analysis of the WHO SAT database

15. BROAD-BASED SURGICAL CARE AT THE FIRST-LEVEL

16. Through analysis of the WHO SAT database

17. Through analysis of the WHO SAT database

18. Through analysis of the WHO SAT database

19. Optimize Usage of Secondary and Tertiary System
Ancillary service coordination
Complex Radiology
Pathology
Laboratory testing
Focus on complex planned care
System-wide education, training, research
Should be able to provide the vast majority of surgical care.
Investments should be directed towards enabling the heroic individuals who work against all odds to provide care in these settings to do their jobs

20. Strengthen Blood Collection & Delivery
Target 15 donations/1000 population
Encourage and train in tranexamic acid
Ensure adequate and safe testing kits
Train providers on safe transfusion practices
Assess for well-distributed banking & delivery infrastructure
Should be able to provide the vast majority of surgical care.
Investments should be directed towards enabling the heroic individuals who work against all odds to provide care in these settings to do their jobs

21. Build Local Equipment Maintenance Capacity
BMET Training Program
Should be able to provide the vast majority of surgical care.
Investments should be directed towards enabling the heroic individuals who work against all odds to provide care in these settings to do their jobs

22. CLINICAL GUIDELINES CARE COORDINATION& REFERRALS
Invest in Professional Management
CLINICAL GUIDELINES
PROTOCOLS & EFFICIENCY
MANAGERS
QUALITY & SAFETY
CARE COORDINATION& REFERRALS
There is a lot of stuff out there that needs to be done.

23. The LCoGS HDM Working Group
Shenaaz El-Halabi (Botswana) Paul Farmer (United States) Edna Adan Ismail (Somaliland) Ganbold Lundeg (Mongolia) Edgar Rodas (Ecuador) Rowan Gillies (Australia) Facilitator Nakul Raykar (USA) Research Fellow Nobhojit Roy (India) Group Lead