Martilord Ifeanyichi1,2, Henk Broekhuizen3, Mweene Cheelo4, Adinan Juma5, Gerald Mwapasa6, Eric Borgstein6, John Kachimba4, Jakub Gajewski7, Ruairi Brugha8, Chiara Pittalis7, Leon Bijlmakers3. 1. Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands. Mifeanyichi@gmail.com. 2. EMAI Health Systems and Health Services Consulting, Nijmegen, The Netherlands. Mifeanyichi@gmail.com. 3. Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands. 4. Surgical Society of Zambia, Department of Surgery, University Teaching Hospital, Lusaka, Zambia. 5. East, Central and Southern Africa Health Community, Arusha, Tanzania. 6. College of Medicine, University of Malawi, Blantyre, Malawi. 7. Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland. 8. Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland.
Abstract
BACKGROUND: An estimated nine out of ten persons in sub-Saharan Africa (SSA) are unable to access timely, safe and affordable surgery. District hospitals (DHs) which are strategically located to provide basic (non-specialist) surgical care for rural populations have in many instances been compromised by resource inadequacies, resulting in unduly frequent patient referrals to specialist hospitals. This study aimed to quantify the financial burdens of surgical ambulance referrals on DHs and explore the coping strategies employed by these facilities in navigating the challenges. METHODS: We employed a multi-methods descriptive case study approach, across a total of 14 purposively selected DHs; seven, three, and four in Tanzania, Malawi and Zambia, respectively. Three recurrent cost elements were identified: fuel, ambulance maintenance and staff allowances. Qualitative data related to coping mechanisms were obtained through in-depth interviews of hospital managers while quantitative data related to costs of surgical referrals were obtained from existing records (such as referral registers, ward registers, annual financial reports, and other administrative records) and expert estimates. Interview notes were analysed by manual thematic coding while referral statistics and finance data were processed and analysed using Microsoft Office Excel 2016. RESULTS: At all but one of the hospitals, respondents reported inadequacies in numbers and functional states of the ambulances: four centres indicated employing non-ambulance vehicles to convey patients occassionally. No statistically significant correlation was found between referral trip distances and total annual numbers of referral trips, but hospital managers reported considering costs in referral practices. For instance, ten of the study hospitals reported combining patients to minimize trip frequencies. The total cost of ambulance use for patient transportation ranged from I$2 k to I$58 k per year. Between 34% and 79% of all patient referrals were surgical, with total costs ranging from I$1 k to I$32 k per year. CONCLUSION: Cost considerations strongly influence referral decisions and practices, indicating a need for increases in budgetary allocations for referral services. High volumes of potentially avoidable surgical referrals provide an economic case - besides equitable access to healthcare - for scaling up surgery capacity at the district level as savings from decreased referrals could be reinvested in referral systems strengthening.
BACKGROUND: An estimated nine out of ten persons in sub-Saharan Africa (SSA) are unable to access timely, safe and affordable surgery. District hospitals (DHs) which are strategically located to provide basic (non-specialist) surgical care for rural populations have in many instances been compromised by resource inadequacies, resulting in unduly frequent patient referrals to specialist hospitals. This study aimed to quantify the financial burdens of surgical ambulance referrals on DHs and explore the coping strategies employed by these facilities in navigating the challenges. METHODS: We employed a multi-methods descriptive case study approach, across a total of 14 purposively selected DHs; seven, three, and four in Tanzania, Malawi and Zambia, respectively. Three recurrent cost elements were identified: fuel, ambulance maintenance and staff allowances. Qualitative data related to coping mechanisms were obtained through in-depth interviews of hospital managers while quantitative data related to costs of surgical referrals were obtained from existing records (such as referral registers, ward registers, annual financial reports, and other administrative records) and expert estimates. Interview notes were analysed by manual thematic coding while referral statistics and finance data were processed and analysed using Microsoft Office Excel 2016. RESULTS: At all but one of the hospitals, respondents reported inadequacies in numbers and functional states of the ambulances: four centres indicated employing non-ambulance vehicles to convey patients occassionally. No statistically significant correlation was found between referral trip distances and total annual numbers of referral trips, but hospital managers reported considering costs in referral practices. For instance, ten of the study hospitals reported combining patients to minimize trip frequencies. The total cost of ambulance use for patient transportation ranged from I$2 k to I$58 k per year. Between 34% and 79% of all patient referrals were surgical, with total costs ranging from I$1 k to I$32 k per year. CONCLUSION: Cost considerations strongly influence referral decisions and practices, indicating a need for increases in budgetary allocations for referral services. High volumes of potentially avoidable surgical referrals provide an economic case - besides equitable access to healthcare - for scaling up surgery capacity at the district level as savings from decreased referrals could be reinvested in referral systems strengthening.
Authors: K A Kelly McQueen; Doruk Ozgediz; Robert Riviello; Renee Y Hsia; Sudha Jayaraman; Stephen R Sullivan; John G Meara Journal: Health Hum Rights Date: 2010-06-15
Authors: Leon Bijlmakers; Dennis Cornelissen; Mweene Cheelo; Mzaza Nthele; John Kachimba; Henk Broekhuizen; Jakub Gajewski; Ruairí Brugha Journal: Health Policy Plan Date: 2018-12-01 Impact factor: 3.344
Authors: Blake C Alkire; Nakul P Raykar; Mark G Shrime; Thomas G Weiser; Stephen W Bickler; John A Rose; Cameron T Nutt; Sarah L M Greenberg; Meera Kotagal; Johanna N Riesel; Micaela Esquivel; Tarsicio Uribe-Leitz; George Molina; Nobhojit Roy; John G Meara; Paul E Farmer Journal: Lancet Glob Health Date: 2015-04-27 Impact factor: 26.763