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Original Investigation
August 17, 2016

Mapping Population-Level Spatial Access to Essential Surgical Care in Ghana Using Availability of Bellwether Procedures

Author Affiliations
  • 1Department of Surgery, University of Washington, Seattle
  • 2Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
  • 3Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
  • 4Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
  • 5Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England
  • 6Information and Monitoring Unit, Ghana Health Service, Accra
  • 7Office of the Director General, Ghana Health Service, Accra
  • 8Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa
  • 9Department of General Surgery, Nelson R. Mandela School of Medicine, University of Kwa-Zulu Natal, Kwa-Zulu Natal, South Africa
  • 10Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
  • 11Cochrane South Africa, South African Medical Research Council, Tygerberg
  • 12Harborview Injury Prevention & Research Center, Seattle, Washington
  • 13Department of Global Health, University of Washington, Seattle
JAMA Surg. 2016;151(8):e161239. doi:10.1001/jamasurg.2016.1239

Importance  Conditions that can be treated by surgery comprise more than 16% of the global disease burden. However, 5 billion people do not have access to essential surgical care. An estimated 90% of the 87 million disability-adjusted life-years incurred by surgical conditions could be averted by providing access to timely and safe surgery in low-income and middle-income countries. Population-level spatial access to essential surgery in Ghana is not known.

Objectives  To assess the performance of bellwether procedures (ie, open fracture repair, emergency laparotomy, and cesarean section) as a proxy for performing essential surgery more broadly, to map population-level spatial access to essential surgery, and to identify first-level referral hospitals that would most improve access to essential surgery if strengthened in Ghana.

Design, Setting, and Participants  Population-based study among all households and public and private not-for-profit hospitals in Ghana. Households were represented by georeferenced census data. First-level and second-level referral hospitals managed by the Ministry of Health and all tertiary hospitals were included. Surgical data were collected from January 1 to December 31, 2014.

Main Outcomes and Measures  All procedures performed at first-level referral hospitals in Ghana in 2014 were used to sort each facility into 1 of the following 3 hospital groups: those without capability to perform all 3 bellwether procedures, those that performed 1 to 11 of each procedure, and those that performed at least 12 of each procedure. Candidates for targeted capability improvement were identified by cost-distance and network analysis.

Results  Of 155 first-level referral hospitals managed by the Ghana Health Service and the Christian Health Association of Ghana, 123 (79.4%) reported surgical data. Ninety-five (77.2%) did not have the capability in 2014 to perform all 3 bellwether procedures, 24 (19.5%) performed 1 to 11 of each bellwether procedure, and 4 (3.3%) performed at least 12. The essential surgical procedure rate was greater in bellwether procedure–capable first-level referral hospitals than in noncapable hospitals (median, 638; interquartile range, 440-1418 vs 360; interquartile range, 0-896 procedures per 100 000 population; P = .03). Population-level spatial access within 2 hours to a hospital that performed 1 to 11 and at least 12 of each bellwether procedure was 83.2% (uncertainty interval [UI], 82.2%-83.4%) and 71.4% (UI, 64.4%-75.0%), respectively. Five hospitals were identified for targeted capability improvement.

Conclusions and Relevance  Almost 30% of Ghanaians cannot access essential surgery within 2 hours. Bellwether capability is a useful metric for essential surgery more broadly. Similar strategic planning exercises might be useful for other low-income and middle-income countries aiming to improve access to essential surgery.