Interpreting the Lancet surgical indicators in Somaliland: a cross-sectional study

Shukri Dahir; Cesia F Cotache-Condor; Tessa Concepcion; Mubarak Mohamed; Dan Poenaru; Edna Adan Ismail; Andy J M Leather; Henry E Rice; Emily R Smith; Global Initiative for Children’s Surgery

doi:10.1136/bmjopen-2020-042968

Interpreting the Lancet surgical indicators in Somaliland: a cross-sectional study

BMJ Open. 2020 Dec 29;10(12):e042968. doi: 10.1136/bmjopen-2020-042968.

Authors

Affiliations

¹ Edna Adan University Hospital, Hargeisa, Somaliland.
² Department of Public Health, Baylor University, Waco, Texas, USA.
³ Global Health Institute, Duke University, Durham, North Carolina, USA.
⁴ Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, McGill University, Montreal, Québec, Canada.
⁵ King's Centre for Global Health, King's Health Partners and King's College London, London, UK.
⁶ Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
⁷ Department of Public Health, Baylor University, Waco, Texas, USA emily_r_smith@baylor.edu.

^# Contributed equally.

Abstract

Background: The unmet burden of surgical care is high in low-income and middle-income countries. The Lancet Commission on Global Surgery (LCoGS) proposed six indicators to guide the development of national plans for improving and monitoring access to essential surgical care. This study aimed to characterise the Somaliland surgical health system according to the LCoGS indicators and provide recommendations for next-step interventions.

Methods: In this cross-sectional nationwide study, the WHO's Surgical Assessment Tool-Hospital Walkthrough and geographical mapping were used for data collection at 15 surgically capable hospitals. LCoGS indicators for preparedness was defined as access to timely surgery and specialist surgical workforce density (surgeons, anaesthesiologists and obstetricians/SAO), delivery was defined as surgical volume, and impact was defined as protection against impoverishment and catastrophic expenditure. Indicators were compared with the LCoGS goals and were stratified by region.

Results: The healthcare system in Somaliland does not meet any of the six LCoGS targets for preparedness, delivery or impact. We estimate that only 19% of the population has timely access to essential surgery, less than the LCoGS goal of 80% coverage. The number of specialist SAO providers is 0.8 per 100 000, compared with an LCoGS goal of 20 SAO per 100 000. Surgical volume is 368 procedures per 100 000 people, while the LCoGS goal is 5000 procedures per 100 000. Protection against impoverishing expenditures was only 18% and against catastrophic expenditures 1%, both far below the LCoGS goal of 100% protection.

Conclusion: We found several gaps in the surgical system in Somaliland using the LCoGS indicators and target goals. These metrics provide a broad view of current status and gaps in surgical care, and can be used as benchmarks of progress towards universal health coverage for the provision of safe, affordable, and timely surgical, obstetric and anaesthesia care in Somaliland.

Keywords: health policy; international health services; public health; surgery.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Anesthesia*
Anesthesiologists
Anesthesiology*
Cross-Sectional Studies
Female
Humans
Pregnancy
Surgeons*