Public Access to Surgical Care. Studies on Timeliness, Capacity, Safety and Affordability

Abstract: Background. A once commonly held belief was that surgery is too complicated, too expensive, and too ineffectively addressing a too minor proportion of the burden of disease to deserve priority in a setting of scarce healthcare resources in low- and middle-income countries. Yet, essential surgical care can be as highly cost-effective as other common public health interventions, and surgical services are increasingly considered integral to the health system strengthening necessary for reaching health-related sustainable development goals.It has been estimated that 9 out of 10 people in low and lower-middle income countries cannot access timely, safe, and affordable essential surgical care. However, little is known on the upstream determinants of access and of the downstream effects of insufficient surgical health systems.Aims and methods. The overall purpose of this thesis is to expand knowledge on public access to surgical care along the axes of timeliness, capacity, safety, and affordability. Specifically;I. To validate geographical information system (GIS) methods for calculation of geographical access, comparing patient-reported travel times to those derived by computational methods;II. To quantify the migration of surgical specialists to South Africa from other low- and middle-income countries, and from South Africa to high-income countries, using a register-based, cross-sectional study design;III. To assess the feasibility of task-shifting postoperative wound care and surgical site infections (SSI) surveillance to community health workers, analyzing under which conditions this could be beneficial, using a stochastic state transition model;IV. To estimate the burden of out-of-pocket payments for cesarean sections in the context of community-based health insurance and determine if having it reduces catastrophic health expenditure, in a prospective observational study;V. To expand measurement of catastrophic health expenditure to the postoperative period, comparing incidence at discharge to postoperative day 30, in a prospective observational study;VI. To estimate the economic consequences of neurosurgical disease in low- and middle-income countries, using value of lost output and value of lost economic welfare methods, and;VII. To quantify the relative contribution of timeliness, capacity, safety and affordability to the global lack of access to surgical careResults and conclusions. Current methods utilized to measure timeliness to surgical care were shown to be overly optimistic in at least one context (I). South Africa acts as a regional hub for migration of surgical specialists, representing an important destination for sub-Saharan emigrating surgical specialists, whilst itself acting as an even larger exporter of surgical specialists to high-income countries (II). SSI diagnosis at home via CHWs represents a potential way to reduce SSI burden, both in terms of morbidity and undue financial hardship (III). Indeed, even with robust health insurance, cesarean section patients are at high risk of catastrophic health expenditure, and often need to borrow money or sell assets in order to afford care (IV). When the postoperative follow-up after discharge is accounted for, the incidence of financial catastrophe is even larger (V). The previously unaccounted burden of neurosurgical disease will lead to profound global macroeconomic losses in the coming decades (VI). Insufficient access to surgical care is highly multidimensional, and the majority of the billions of people who lack access to surgical care do so due to a combination of two or more factors (VII). Thus, any attempt to mitigate this ongoing public health crisis will need to be as multifactorial as the problem it seeks to solve.