You pray to your God: A qualitative analysis of challenges in the provision of safe, timely, and affordable surgical care in Uganda

Abstract

BackgroundFive billion people lack access to safe, affordable, and timely surgical and anesthesia care. Significant challenges remain in the provision of surgical care in low-resource settings. Uganda is no exception.MethodsFrom September to November 2016, we conducted a mixed-methods countrywide surgical capacity assessment at 17 randomly selected public hospitals in Uganda. Researchers conducted 35 semi-structured interviews with key stakeholders to understand factors related to the provision of surgical care. The framework approach was used for thematic and explanatory data analysis.ResultsThe Ugandan public health care sector continues to face significant challenges in the provision of safe, timely, and affordable surgical care. These challenges can be broadly grouped into preparedness and policy, service delivery, and the financial burden of surgical care. Hospital staff reported challenges including: (1) significant delays in accessing surgical care, compounded by a malfunctioning referral system; (2) critical workforce shortages; (3) operative capacity that is limited by inadequate infrastructure and overwhelmed by emergency and obstetric volume; (4) supply chain difficulties pertaining to provision of essential medications, equipment, supplies, and blood; (5) significant, variable, and sometimes catastrophic expenditures for surgical patients and their families; and (6) a lack of surgery-specific policies and priorities. Despite these challenges, innovative strategies are being used in the public to provide surgical care to those most in need.ConclusionBarriers to the provision of surgical care are cross-cutting and involve constraints in infrastructure, service delivery, workforce, and financing. Understanding current strengths and shortfalls of Uganda’s surgical system is a critical first step in developing effective, targeted policy and programming that will build and strengthen its surgical capacity.

Surgical referrals in Northern Tanzania: a prospective assessment of rates, preventability, reasons and patterns

“…This example highlights the acute shortage of anesthesia providers in Tanzania and a lack of flexibility in the system results in unpredictability of availability of services. Other studies have noted this as a major reason for self-referral to higher levels of care [5]. Currently, there are less than 50 physician anesthesia providers and about 180 nonphysician anesthesia providers for a population of 53 million people equaling 0.09 anesthesia providers per 100,000 population [34].…”

“…Interestingly, field notes indicate that all such referrals were due to the lack of x-ray film at the initiating health facility. In Uganda, one study noted that patients were often referred due to the lack of drapes, surgical blades and gowns [5]. Although seemingly mundane, such issues can lead to significant delays in delivering care to the patient.…”

“…4 President's Office, Regional Administration and Local Government, Dodoma, Tanzania. 5 GE Foundation, Boston, MA, USA. 6 Jhpiego, Baltimore, MD, USA.…”

“…As such, lower-level centers become underutilized resulting in overburdened high-level centers with inadequate resources to care for the complex conditions for which they are designed. This leads to inefficiencies at all levels within health systems with ineffective referral pathways [5,6]. Referral to distant hospitals also negatively affects patients, leading to delays in receiving care, significant direct costs for care and indirect costs with time away from work [7][8][9].…”

Surgical referral systems in low- and middle-income countries: A review of the evidence

“…Another widespread problem is the bypassing of lower level facilities by patients with simple conditions who self-refer directly to higher level hospitals for convenience, fear of delay in accessing the care they need, and belief that quality of care and more effective interventions are available at higher levels [3,9]. As a result, referral hospitals in LMICs are often congested with high volumes of patients with low-complexity conditions, and resources and staff time are absorbed by cases that could have been handled at lower levels [3,7,10,11]. This negatively impacts on costs (for patients and the health care sector) [8,12], waiting times and clinical outcomes, where appropriate management is delayed [5,13,14].…”