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Innovation and clinical specialities: surgery example the closed management of fractures and dislocations, skeletal traction for fractures, irrigation and debridement for open fractures and infections (osteomyelitis, septic arthritis), amputations, and manipulation and casting for clubfoot. The challenge lies in teaching safe and reliable methods that have often been displaced by higher cost technologies, while maintaining similar outcomes. Another consideration is whether some of these technological advances may be adapted through low cost production and dissemination in LMICs 26-40 . The “SIGN” intramedullary nailing system for femur and tibia fractures is one example, although the implants are currently exported free of charge to low income countries, rather than being produced locally 41 . However, surgical complications from nailing fractures that were before successfully treated conservatively by traction or other means will need to be monitored. Another example of a low cost, transferable technology is the Ponseti method for clubfoot care, which relies upon serial casting followed by a minor surgical procedure (heelcord release) and then a long-term splinting 42-45 . While the method was developed in a high-income country (USA), excellent results have been achieved in several LMICs, even in patients up to 6 years of age 42 . The treatment may be delivered by nonmedical personnel, for example by orthopaedic clinical officers in Malawi or physiotherapists in Nepal 42-44 . Establishing and maintaining adequate capacity at the facilities level must begin with a situational analysis of all district level health facilities, to obtain a baseline and inform health planners as to which improvements are required. Furthermore, a mechanism for monitoring of capacity would be invaluable to ministries of health, and would contribute to strengthening each health information system. An example is the Service Availability Mapping (SAM) technology developed by the World Health Organization (WHO) 46,48 . Both district level and facilities based questionnaires are utilized, and health workers enter information into personal digital assistants (PDAs), and also record the location with a global positioning system device (GPS). The data is then processed (digital maps, graphs, etc.) and can be disseminated to help inform decision making and the development of health care policies. Mapping has been carried out in Tanzania 48 , Uganda, Albania, Rwanda, Kenya, and Zambia. Recently, a surgical questionnaire has been incorporated into this methodology, and a pilot project has been initiated in Mongolia in collaboration with the WHO and the ministry of health. Monitoring the capacity to deliver facilities based health services such as surgery will enhance the delivery of services. There is also the need to define the unmet need for surgical services at the population level, which will require community based surveys. This additional information will help prioritize services, and guide local allocation of resources. Once the capacity to provide basic orthopaedic and surgical services is available, trained health workers must be available to deliver the services. While only 10% of the world’s burden of disease is found in the Americas, this region has 37% of the global health work force and accounts for 50% of the world’s health spending 49 . In stark contrast, Sub Saharan Africa must utilize 3% of the world’s health work force to tackle 24% of the global disease burden, and accounts for less than 1% of the world’s health spending 49 . Brain drain has been an enormous problem, with workers migrating both between and within (rural to urban) countries 49-57 . There is a critical shortage of health workers in 57 countries worldwide (36 in Africa) 49 . Common problems impacting health worker satisfaction include a lack of materials, inadequate salary, inadequate training or lack of supportive supervision, poor working conditions, inadequate living conditions, and inadequate professional recognition 50 . Other factors may include better opportunities in the private sector, with non-governmental organizations, and in other countries. A nationwide survey in Uganda demonstrated that less than 50% of health workers were satisfied, and more than 50% of physicians would prefer to emmigrate 51 . A mixture of both financial and non-financial incentives must be provided in order to retain health workers. There will never be enough surgeons to staff even the tertiary facilities in LMICs, let alone primary health care facilities, for decades to come. A recent report from Sierra Leone documented only 10 trained surgeons for a population of 5.3 million 25 . Any approach to human resources must strongly consider task shifting as a means to provide the necessary number of surgical caregivers, at least over the short term 58-75 . While there remains some controversy regarding the use of non-physician clinicians, especially for surgery, these health workers may be found in at least 25 of 47 Sub Saharan African countries 58 . While the training is shorter and less costly than for physicians (and is based on the local disease burden), the curriculum and scope of practice have not been standardized. Non-physician caregivers perform selected surgical services in Ethiopia, Angola, Ghana, Kenya, Mozambique, Tanzania, Malawi, and Uganda. Several reports have suggested that alternate cadres of health worker can safely and successfully perform caesarian section, as evidenced in Mozambique, Malawi and Tanzania 61-64 . Orthopaedic services have been shiften to non-surgeons effectively in Uganda and Malawi 65- 67 . Malawi has nine orthopaedic surgeons for a population of approximately 27 million, and Orthopaedic Clinical Officers (OCO) provide all of the district hospital level orthopaedic services for the country, under remote supervision from the few orthopaedic surgeons 65,66 . A diploma is offered after eighteen months of training, and core competencies include the treatment of musculoskeletal infections, burns, clubfoot, fractures and dislocations, and amputations 66 . Of 117 caregivers trained in this programme, only 11% have retired or relocated 66 . Uganda also utilizes 200 orthopaedic officers, as only 23 orthopaedic surgeons are available for a population of 28 million 67 . Another approach is the training of a “rural surgeon”; a pilot project has been initiated in India, and medical school graduates enroll in a 3 year training programme which focuses on competency in a finite number of common surgical procedures drawn from all of the surgical subspecialties, adapted to the local disease burden 74,75 . These individuals are typically recruited from a rural environment, and plan to practice in a rural environment. Further study will be required to evaluate the utility of this approach. Integration of surgical services in primary healthcare reforms The most recent World Health Report 23 focuses on how primary health care reforms may strengthen health systems and provide universal access to quality health services. Within this scheme, the primary care team serves to coordinate the delivery of health services, directly interfacing with communities and individuals. Despite the emphasis on primary care and preventive medicine, and the suggestion that hospital based services should be reduced, surgical care is recognized as an important component Hospital and Healthcare Innovation Book 2009/2010 113
Innovation and clinical specialities: surgery of the health system 23 . We feel that “essential” surgical care should be viewed as primary prevention of death and disability, and that the integration of surgical services at the district level in LMICs will strengthen population based health care. How can we reduce maternal mortality if access to caesarian section cannot be provided, or improve childhood survival without better care for the injured? Examples include not only the capacity to perform selected procedures such as cesaerean section, laparotomy, repair of a strangulated hernia, irrigation and debridement, or conservative management for fractures/dislocations, but also the ability to care for surgical diseases which might not require a procedure, such as closed head injury or blunt abdominal trauma. The vision of a comprehensive, horizontal approach must be emphasized, as illustrated by the WHO’s Emergency and Essential Surgical Care project (EESC) 4,6,76-79 , a diverse educational programme which has been introduced in 33 countries. In addition, the Global Initiative for Emergency and Essential Surgical Care (GIEESC) was launched in 2005, and represents the first coordinated effort to address global disparities in surgical care 79 . Integrating surgery and anaesthesia at the district level within the context of primary health care reforms will require commitment from multiple stakeholders, including governments and their ministries of health, funding agencies, non-governmental organizations, academic institutions, organizations outside the health sector, as well as community leaders and individual. Adequate resources must be allocated to upgrade and maintain capacity of the district health system (including surgery and anaesthesia), and mechanisms to train and retain health workers must be developed. Strengthening the deliver of essential surgical services will improve the capacity to deliver other hospital based services, enhance population based health care, and contribute to achieving the Millennium Development Goals. ❏ Dr David Spiegel attended Duke University for college, medical school, and his orthopaedic surgical residency. He then completed both a research and a clinical fellowship in pediatric orthopaedics at the Children's Hospital of Philadelphia. He works as a pediatric orthopaedic surgeon at the Children’s Hospital of Philadelphia, and is an Assistant Professor at the University of Pennsylvania School of Medicine. He serves as a Consultant in Orthopaedics and Rehabilitation at the Hospital & Rehabilitation Centre for Disabled Children in Banepa, Nepal. He currently serves as Chairman of the Committee on Childrens Orthopaedics in Underdeveloped Regions of the Pediatric Orthopaedic Society of North America, and has been on the Board of Orthopaedics Overseas, Global-HELP, and the Ponseti International Association. He has received the President's Call to Service Award (2006), from the President’s Council on Service and Civic Participation, for 4000 hours of community service. He has also received the Golden Apple Award by Health Volunteers Overseas (2009). He has served as a consultant to the World Health Organization, and is on the steering committee for the Global Initiative for Emergency and Essential Surgical Care (GIEESC). References 1. Debas HT, Gosselin RA, McCord C, Thind A, “Surgery” in Jamison D, Evans D, Alleyne G, Jha P, Breman J, Measham A, et al. [Eds]. Disease Control Priorities in Developing Countries (2nd Edition), ed. 2006, pp.1245-1260. New York: Oxford University Press. 2. Gosselin RA, Spiegel DA, Coughlin RR, Zirkle L. Injuries. The neglected burden in developing countries. Bull World Health Organization, 2009;87:266-247. 3. Taira BR, McQueen KA, Burkle FM Jr. Burden of surgical disease: Does the literature reflect the scope of the international crisis? World J Surg 2009;33:893-898. 4. Spiegel DA, Gosselin RA. Surgical Services in Low-income and Middle- Income Countries. Lancet 2007;370:1013-1015. 5. Ivers LC, Garfein ES, Augustin J, Raymonville M, Yang AT, Sugarbaker DS, Farmer PE. Increasing access to surgical services for the poor in Rural Haiti: Surgery as a Public good for Public Health. World Journal of Surgery 2008:32;537-542. 6. Bickler SB, Spiegel DA. Global surgery-defining a research agenda. Lancet. 2008;372:90-92. 7. Bickler SW, Sanno-Duanda B. Epidemiology of pediatric surgical admissions to a government referral hospital in the Gambia. Bull World Health Org 2000;78:1330-1336. 8. Spiegel DA. Editorial Comment. Clinical Orthpaedics and Related Research. 2008;466:2297- 2305. 9. Beveridge M, Howard A. The burden of orthopedic disease in developing countries. J Bone Joint Surg 2004; 86-A, 8: 1819-1822. 10. Lavy C, Tindall A, Steinlechner C, Mkandawire N, Chimangeni S. Surgery in Malawi - a national survey of activity in rural and urban hospitals. Ann R Coll Surg Engl. 2007;89:722- 724. 11. Mock C, Cherian MN. The global burden of musculoskeletal injuries. Challenges and solutions. Clin Orthop Rel Res 2008;466:2306-2316. 12. Spiegel DA, Gosselin RA, Coughlin RR, Joshipura M, et al. The burden of musculoskeletal injury in low and middle-income countries: challenges and opportunities. J Bone Joint Surg [Am], 2008;90:915-923. 13. Peden M, McGee K, Sharma G. The Injury Chart Book. A Graphical Overview of the Global Burden of Injuries. Geneva, World Health Organization, 2002. 14. Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Pub Health 2000;90:523-526. 15. Mock CN, Joshipura M, Goosen J. Global strengthening of care for the injured. Bull World Health Organization 2004;82:241. 16. Norton R, Hyder AA, Bishai D, Peden M. Unintentional injuries. in Jamison D, Evans D, Alleyne G, Jha P, Breman J, Measham A, et al, [Eds]. Disease Control Priorities in Developing Countries (2nd Edition), ed. 2006, pp.737-753. New York: Oxford University Press. 17. Mock C, Boland E, Acheampong F, et al. Long-term injury related disability in Ghana. Dis Rehab 2003; 25: 723-741. 18. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, et al. An estimation of the global volume of surgery: A modeling strategy based on available data. Lancet 2008;372:139-144. 19. Laxminarayanan R, Mills AJ, Breman JG, Measham AR, et al. Advancement of global health: Key messages from the disease control priorities project. Lancet 2006;367:1193-1208. 20. Gosselin RA, Amardeep Thind A, Bellardinelli A. Cost/DALY Averted in a Small Hospital in Sierra Leone: What Is the Relative Contribution of Different Services? World J Surg 2006;30. 21. Gosselin RA, Heitto M: Cost-effectiveness of a district trauma hospital in Battambang, Cambodia. World J Surg, Vol 32 (11):2450-2453, 2008 22. McCord C, Chowdhury Q. A cost effective small hospital in Bangladesh: What it can mean for emergency obstetric care. Int J Gynaecol Obstet 2003;81:83-92. 23. World Health Report. Primary Health Care: Now more than ever. World health Organization, Geneva, 2008. 24. Kingham TP, Kamara TB, Cherian MN, Gosselin RA, et al. Quantifying surgical capacity in Sierra Leone. A guide for improving surgical care. Arch Surg 2009;144:122-127. 25. Kushner AL, Cherian MN, Noel LPJ, Spiegel DA, et al. Addressing the millennium development goals from a surgical perspective: Deficiencies in the capacity to deliver safe surgery and anaesthesia in eight low and middle-income countries. Arch Surg, in Press. 26. Bewes PC. Fractures of the femur in a tropical context: A reevaluation of Perkin’s traction. Tropical Doctor 2:64-68, 1974. 27. Bach O, Hope MJ, Chaheka CV, et al. Disability can be avoided after open fractures in Africaresults from Malawi. Injury. 2004;35:846-851. 28. Gates DJ, Alms M, Cruz MM. Hinged cast and roller traction for fractured femur. A system of treatment for the Third World. J Bone Joint Surg Br. 1985;67:750-756. 29. Bassey LO. The use of P.O.P. integrated transfixation pins as an improvisation on the Hoffmann’s apparatus: contribution to open fracture management in the tropics. J Trauma. 1989;29:59-64. 30. Dagbue NA. An inexpensive and available external fixator. West Afr J Med. 2000;19:281- 282. 31. Jongen VHWM. Alternative external fixation for open fractures of the lower leg. Tropical Doctor 25:173, 1995. 32. Lourie JA. Low cost external fixator for compound tibial fractures. PNG Med J 26:62-63, 1983. 33. Noor MA. A simple and inexpensive external fixator. Injury. 1988;19:377-378. 34. Pulate A, Olivier LC, Agashe S, et al. Adaptation of Ilizarov ring fixator to the economic situation of developing countries. Arch Orthop Trauma Surg. 2001;121:79-82. 35. Udosen AM, Ogbudu S. The use of external fixators: A review of literature and experiences in a developing world. Niger J Med. 2006;15:115-118. 36. Bassey LO. Open fractures of the femur treated by the pin-in-plaster technique. Contribution 114 Hospital and Healthcare Innovation Book 2009/2010
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International Hospital Federation I
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Introduction Sterile Barrier System
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Contents Healthcare transformation
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International Hospital Federation H
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Introduction Introduction ERIC DE R
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Innovation and strategy 14 Creativi
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Innovation and strategy: creativity
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Page 119 and 120: Company Profile: Wipak Medical Wipa
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Page 141 and 142: IHF reference JAPAN JAPAN HOSPITAL
Page 143 and 144: IHF reference KENYA THE NAIROBI HOS
Page 145 and 146: IHF Corporate Member Profiles GE He
Page 147: How Can Health Organizations Get th
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