Beyond short-term surgical missions: On the role of surgeons from high-income settings to help improve surgical care in resource-limited settings

This dissertation provides data collected during the development and implementation of an alternative approach to short-term surgical missions. These missions have been the traditional strategy for surgeons from high-income settings to help to improve surgical care in resource-limited settings. This dissertation presents an alternative approach. During the Amsterdam-based international symposium, ‘Surgery in Low Resource Settings,’ held in November 2014, the urgency for collaborative solutions became more evident. On behalf of 65 international organizations and all participants of the symposium, the “Amsterdam Declaration on Essential Surgical Care” was published in April 2015. Chapter 2 describes that the number of people dying from surgical conditions outnumbers the death toll of HIV, malaria, and tuberculosis combined. Surgery should be a part of the United Nations’ post-2015 sustainable development goals. The aim of Chapter 3 is to present baseline information on surgical burn care in sub-Saharan Africa, and establish methods of process and care improvement. A systematic review provides a critical analysis of the available literature on basic surgical care of burn injuries in sub-Saharan Africa, including timing of excision, grafting, and wound dressing techniques. The results show that essential information—such as depth of burns, TBSA, timing of grafting and wound treatment—are unreported in many of the studies. Future studies should include uniform definitions and parameters such as depth of burns, TBSA, timing of grafting, and wound treatment. The aim of Chapter 4 is to present research insights into ‘access to surgical burn care’ in LMICs. Theoretically, the study is guided by investigating timeliness, surgical capacity, and affordability. In conclusion, the study shows that patients face critical barriers to receiving timely and affordable surgical care in the catchment area of Haydom Lutheran Hospital, Tanzania. To assure timely, safe, and affordable burn care for patients in LMICs, support is also needed beyond hospital management on regional and national levels. Short-term reconstructive plastic surgical missions are a well-established routine method of addressing surgical conditions. Chapter 5 provides a systematic review that assessed the effectiveness of short- term reconstructive surgical missions in LMICs. Original studies of short- term reconstructive surgical missions were included, which reported data on patient safety measurements, health gains of individual patients, and sustainability. Studies with a low follow-up quality could potentially be under-reporting complication rates and overestimating the positive impact of missions. It was concluded that evidence on the patient outcomes of reconstructive plastic surgical missions is scarce and of limited quality. The recommendations were supported by experienced health workers in the field of surgical missions, as recorded in a survey study on surgical missions (Chapter 6). The results showed that training activities were considered most impactful, and reporting on outcome/s, along with long-term follow-up was strongly recommended. According to 94 percent of the participants, the future focus should be on establishing collaborative practices with local actors, and encouraging strategic, long-term changes, under their leadership. Chapter 7 presents insights into the effects of basic reconstructive plastic surgical training activities on participants. The study demonstrates that surgical skills of the participants can improve, and it strengthens the recommendation that training is a key strategy for the much-needed goal of sustainable solutions to meeting the global burden of surgical disease. The larger goal of training activities for health care providers is to obtain a higher standard of care for the patients in need. In the last study, the focus lies on the outcome of post-burn contracture release surgery during the trainings. Based on the results, it can be concluded that contracture release surgery performed during surgical trainings in LMICs can be safe and effective in the long-term.