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Open Access 01-12-2021 | Research article

Surgical ambulance referrals in sub-Saharan Africa – financial costs and coping strategies at district hospitals in Tanzania, Malawi and Zambia

Authors: Martilord Ifeanyichi, Henk Broekhuizen, Mweene Cheelo, Adinan Juma, Gerald Mwapasa, Eric Borgstein, John Kachimba, Jakub Gajewski, Ruairi Brugha, Chiara Pittalis, Leon Bijlmakers

Published in: BMC Health Services Research | Issue 1/2021

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.

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PPP conversion factor, GDP (LCU per international $). 2020;https://data.worldbank.org/indicator/PA.NUS.PPP?view=map. Accessed 15th May 2020.

Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg. 2008;32(4):533–6. https://doi.org/10.1007/s00268-008-9525-9.CrossRefPubMedPubMedCentral

McIntyre T, Zenilman ME. Globalization of surgery: Let's get serious. Arch Surg. 2010;145(8):715–6. https://doi.org/10.1001/archsurg.2010.145.CrossRefPubMed

McQueen K, Ozgediz D, Riviello R, Hsia RY, Jayaraman S, Sullivan SR, et al. Essential surgery: integral to the right to health. Health Hum Rights. 2010;12(1):137–52.PubMed

Grimes CE, Henry JA, Maraka J, Mkandawire NC, Cotton M. Cost-effectiveness of surgery in low-and middle-income countries: a systematic review. World J Surg. 2014;38(1):252–63. https://doi.org/10.1007/s00268-013-2243-y.CrossRefPubMed

Meara JG, Greenberg SL. The lancet commission on global surgery global surgery 2030: evidence and solutions for achieving health, welfare and economic development. Surgery. 2015;157(5):834–5. https://doi.org/10.1016/j.surg.2015.02.009.CrossRefPubMed

Alkire BC, Vincent JR, Meara JG. Benefit-cost analysis for selected surgical interventions in low-and middle-income countries. Essential Surgery. Disease Control Priorities. 3rd edn (volume 1). Washington DC: World Bank; 2015. p. 361-77.

Alkire BC, Raykar NP, Shrime MG, Weiser TG, Bickler SW, Rose JA, et al. Global access to surgical care: a modelling study. Lancet Glob Health. 2015;3(6):e316–e23. https://doi.org/10.1016/S2214-109X(15)70115-4.CrossRefPubMedPubMedCentral

Bickler SN, Weiser TG, Kassebaum N, Higashi H, Chang DC, Barendregt JJ, Noormahomed EV, Vos T. Global Burden of Surgical Conditions. In: Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, editors. Essential Surgery: Disease Control Priorities, Third Edition (Volume 1). Washington DC: The World Bank Group; 2015.

Ndihokubwayo J, Coulibaly S, Cherian M, Ekeke M, Nabyonga J, Musango L, et al. Strengthening surgical and anaesthetic services at district level in the African region: issues, challenges and proposed actions. East Central African J Surg. 2017;22(1):21–7. https://doi.org/10.4314/ecajs.v22i1.3.CrossRef

10.

Rajbhandari R, McMahon DE, Rhatigan JJ, Farmer PE. The neglected hospital-the district hospital's central role in global health care delivery. N Engl J Med. 2020;382(5):397–400. https://doi.org/10.1056/NEJMp1911298.CrossRefPubMed

11.

Bijlmakers L, Wientjes M, Mwapasa G, Cornelissen D, Borgstein E, Broekhuizen H, et al. Out-of-pocket payments and catastrophic household expenditure to access essential surgery in Malawi-a cross-sectional patient survey. Ann Med Surg. 2019;43:85–90. https://doi.org/10.1016/j.amsu.2019.06.003.CrossRef

12.

Bijlmakers L, Cornelissen D, Cheelo M, Nthele M, Kachimba J, Broekhuizen H, et al. The cost of providing and scaling up surgery: a comparison of a district hospital and a referral hospital in Zambia. Health Policy Plan. 2018;33(10):1055–64. https://doi.org/10.1093/heapol/czy086.CrossRefPubMed

13.

Albutt K, Yorlets RR, Punchak M, Kayima P, Namanya DB, Anderson GA, et al. You pray to your God: A qualitative analysis of challenges in the provision of safe, timely, and affordable surgical care in Uganda. PloS one. 2018;13(4):e0195986.

14.

Gajewski J, Bijlmakers L, Mwapasa G, Borgstein E, Pittalis C, Brugha R. ‘I think we are going to leave these cases’. Obstacles to surgery in rural Malawi: a qualitative study of provider perspectives. Tropical Med Int Health. 2018;23(10):1141–7. https://doi.org/10.1111/tmi.13135.CrossRef

15.

Simba DO, Mbembati NA, Museru LM, Lema LE. Referral pattern of patients received at the national referral hospital: challenges in low income countries. East Afr J Public Health. 2008;5(1):6–9. https://doi.org/10.4314/eajph.v5i1.38969.CrossRefPubMed

16.

English M, Lanata CF, Ngugi I, Smith PC. District hospitals. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al., editors. Disease control priorities in developing countries. Washington (DC): The World Bank Group; 2006.

17.

Pittalis C, Brugha R, Bijlmakers L, Mwapasa G, Borgstein E, Gajewski J. Patterns, quality and appropriateness of surgical referrals in Malawi. Tropical Med Int Health. 2020;25(7):824–33. https://doi.org/10.1111/tmi.13406.CrossRef

18.

Paxton A, Maine D, Freedman L, Fry D, Lobis S. The evidence for emergency obstetric care. Int J Gynecol Obstet. 2005;88(2):181–93. https://doi.org/10.1016/j.ijgo.2004.11.026.CrossRef

19.

Soe-Lin S, Kim TM, Thomas M, Schweitzer J, Hecht R, Adeyi O, et al. How to close the gap on MDGs 4 & 5 in Africa. Washington, DC: Results for Development Institute; 2014.

20.

Dennis R, Pullen K. Improving access to emergency healthcare in sub Saharan Africa. World Transp Policy Pract. 2015;21(2):8–20.

21.

Campbell OM, Graham WJ. Group LMSSs. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006;368(9543):1284–99. https://doi.org/10.1016/S0140-6736(06)69381-1.CrossRefPubMed

22.

Tayler-Smith K, Zachariah R, Manzi M, Van den Boogaard W, Nyandwi G, Reid T, et al. An ambulance referral network improves access to emergency obstetric and neonatal care in a district of rural Burundi with high maternal mortality. Tropical Med Int Health. 2013;18(8):993–1001. https://doi.org/10.1111/tmi.12121.CrossRef

23.

Tsegaye A, Somigliana E, Alemayehu T, Calia F, Maroli M, Barban P, et al. Ambulance referral for emergency obstetric care in remote settings. Int J Gynecol Obstet. 2016;133(3):316–9. https://doi.org/10.1016/j.ijgo.2015.11.012.CrossRef

24.

Accorsi S, Somigliana E, Solomon H, Ademe T, Woldegebriel J, Almaz B, et al. Cost-effectiveness of an ambulance-based referral system for emergency obstetrical and neonatal care in rural Ethiopia. BMC pregnancy and childbirth. 2017;17(1):220. https://doi.org/10.1186/s12884-017-1403-8.CrossRefPubMedPubMedCentral

25.

Hofman JJ, Dzimadzi C, Lungu K, Ratsma EY, Hussein J. Motorcycle ambulances for referral of obstetric emergencies in rural Malawi: do they reduce delay and what do they cost? Int J Gynecol Obstet. 2008;102(2):191–7. https://doi.org/10.1016/j.ijgo.2008.04.001.CrossRef

26.

Somigliana E, Sabino A, Nkurunziza R, Okello E, Quaglio G, Lochoro P, et al. Ambulance service within a comprehensive intervention for reproductive health in remote settings: a cost-effective intervention. Tropical Med Int Health. 2011;16(9):1151–8. https://doi.org/10.1111/j.1365-3156.2011.02819.x.CrossRef

27.

Muchiri F, Kariuki J, Otundo D, Mwagandi L, Karanja S. Cost-efficient evaluation of ambulance services for community critical care transport needs in Machakos County. Kenya East African Medical Journal. 2017;94(1):12–9.

28.

Lungu K, Kamfose V, Chilwa B, Hussein J. Are bicycle ambulances and community transport plans effective in strengthening obstetric referral systems in Southern Mulawi? Int J Gynecol Obstet. 2000;70:B86.CrossRef

29.

Bhopal SS, Halpin SJ, Gerein N. Emergency obstetric referral in rural Sierra Leone: what can motorbike ambulances contribute? A mixed-methods study. Matern Child Health J. 2013;17(6):1038–43. https://doi.org/10.1007/s10995-012-1086-8.CrossRefPubMed

30.

Silva AL. Maternal health and transport: Implementing an emergency transport scheme in northern Nigeria. first African Community Access Programme (AFCAP) Practitioners Conference; 2011.

31.

den Hollander D, Albert M, Strand A, Hardcastle TC. Epidemiology and referral patterns of burns admitted to the burns Centre at Inkosi Albert Luthuli Central Hospital, Durban. Burns. 2014;40(6):1201–8. https://doi.org/10.1016/j.burns.2013.12.018.CrossRef

32.

Nkurunziza T, Toma G, Odhiambo J, Maine R, Riviello R, Gupta N, et al. Referral patterns and predictors of referral delays for patients with traumatic injuries in rural Rwanda. Surgery. 2016;160(6):1636–44. https://doi.org/10.1016/j.surg.2016.08.006.CrossRefPubMed

33.

Gyedu A, Baah EG, Boakye G, Ohene-Yeboah M, Otupiri E, Stewart BT. Quality of referrals for elective surgery at a tertiary care hospital in a developing country: an opportunity for improving timely access to and cost-effectiveness of surgical care. Int J Surg. 2015;15:74–8. https://doi.org/10.1016/j.ijsu.2015.01.033.CrossRefPubMedPubMedCentral

34.

Pittalis C, Brugha R, Gajewski J. Surgical referral systems in low-and middle-income countries: A review of the evidence. PloS one. 2019;14(9):e0223328.

35.

Cornelissen D, Mwapasa G, Gajewski J, McCauley T, Borgstein E, Brugha R, et al. The cost of providing district-level surgery in Malawi. World J Surg. 2018;42(1):46–53. https://doi.org/10.1007/s00268-017-4166-5.CrossRefPubMed

36.

Pittalis C, Brugha R, Crispino G, Bijlmakers L, Mwapasa G, Lavy C, et al. Evaluation of a surgical supervision model in three African countries—protocol for a prospective mixed-methods controlled pilot trial. Pilot and feasibility studies. 2019;5(1):25. https://doi.org/10.1186/s40814-019-0409-6.CrossRefPubMedPubMedCentral

37.

Government of Republic of Zambia. Zambia National Maternal and neonatal services referral guidelines. Lusaka: Ministry of Health of Zambia; 2018.

38.

Chitsa B. Factors affecting the provision of referral Services at the Primary Level of health Care in Zomba District in Malawi. Texila Int J Public Health. 2019. https://doi.org/10.21522/TIJPH.2013.SE.19.01.Art023.

39.

Schmitz MM, Serbanescu F, Arnott GE, Dynes M, Chaote P, Msuya AA, et al. Referral transit time between sending and first-line receiving health facilities: a geographical analysis in Tanzania. BMJ Glob Health. 2019;4(Suppl 5):e001568. https://doi.org/10.1136/bmjgh-2019-001568.CrossRefPubMedPubMedCentral

40.

Gajewski J, Mweemba C, Cheelo M, McCauley T, Kachimba J, Borgstein E, et al. Non-physician clinicians in rural Africa: lessons from the medical licentiate programme in Zambia. Hum Resour Health. 2017;15(1):53. https://doi.org/10.1186/s12960-017-0233-0.CrossRefPubMedPubMedCentral

41.

Sani R, Nameoua B, Yahaya A, Hassane I, Adamou R, Hsia RY, et al. The impact of launching surgery at the district level in Niger. World J Surg. 2009;33(10):2063–8. https://doi.org/10.1007/s00268-009-0160-x.CrossRefPubMedPubMedCentral

42.

Gajewski J, Borgstein E, Bijlmakers L, Mwapasa G, Aljohani Z, Pittalis C, et al. Evaluation of a surgical training programme for clinical officers in Malawi. Br J Surg. 2019;106(2):e156–e65. https://doi.org/10.1002/bjs.11065.CrossRefPubMed

43.

Broekhuizen H, Lansu M, Gajewski J, Pittalis C, Ifeanyichi M, Juma A, et al. Using group model building to capture the complex dynamics of scaling up district-level surgery in Arusha region. Tanzania: International Journal of Health Policy and Management; 2020.

44.

Government of Tanzania. National Surgical, Obstetrics and Anaesthesia Plan (NSOAP) 2018–2025. Dodoma: Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) of Tanzania; 2018.

45.

Government of Republic of Zambia. National Surgical, Obstetrics, and Anaesthesia Strategic Plan (NSOASP) 2017–2021. Lusaka: Ministry of Health of Zambia; 2017.

46.

Chikowe I, Mwapasa V, Kengne AP. Analysis of rural health centres preparedness for the management of diabetic patients in Malawi. BMC Res Notes. 2018;11(1):267. https://doi.org/10.1186/s13104-018-3369-7.CrossRefPubMedPubMedCentral

47.

Kamau KJ, Osuga BO, Njuguna S. Challenges facing implementation of referral system for quality health care services in Kiambu county, Kenya. Health Syst Policy Res. 2017;4(1):1–8.CrossRef

48.

Government of Republic of Zambia. National Health Policy. Lusaka: Ministry of Health of Zambia; 2012.

49.

Madinah N. Challenges and barriers to the health service delivery system in Uganda. IOSR J Nurs Health Sci. 2016;5(2):30–8.

50.

Afari H, Hirschhorn LR, Michaelis A, Barker P, Sodzi-Tettey S. Quality improvement in emergency obstetric referrals: qualitative study of provider perspectives in Assin north district, Ghana. BMJ open. 2014;4(5):e005052. https://doi.org/10.1136/bmjopen-2014-005052.CrossRefPubMedPubMedCentral

51.

Crandon IW, Harding HE, Williams EW, Cawich SO. Inter-hospital transfer of trauma patients in a developing country: a prospective descriptive study. Int J Surg. 2008;6(5):387–91. https://doi.org/10.1016/j.ijsu.2008.07.004.CrossRefPubMed

52.

Murray SF, Pearson SC. Maternity referral systems in developing countries: current knowledge and future research needs. Soc Sci Med. 2006;62(9):2205–15. https://doi.org/10.1016/j.socscimed.2005.10.025.CrossRefPubMed

53.

Hope KR. Corruption and development in Africa. Corruption and development in Africa: Springer; 2000. p. 17–39.CrossRef

54.

Carlson C, Chirwa W, Hall N, Cammack D. Study of health sector efficiency in Malawi. Lilongwe: Ministry of Health; 2014.

55.

Government of Tanzania. Comprehensive Council Health Planning (CCHP) Guidelines. 4th ed. Dodoma: Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) of Tanzania; 2011.

56.

Manthalu G, Nkhoma D, Kuyeli S. Simple versus composite indicators of socioeconomic status in resource allocation formulae: the case of the district resource allocation formula in Malawi. BMC Health Serv Res. 2010;10(1):6. https://doi.org/10.1186/1472-6963-10-6.CrossRefPubMedPubMedCentral

Title: Surgical ambulance referrals in sub-Saharan Africa – financial costs and coping strategies at district hospitals in Tanzania, Malawi and Zambia
Authors: Martilord Ifeanyichi
Henk Broekhuizen
Mweene Cheelo
Adinan Juma
Gerald Mwapasa
Eric Borgstein
John Kachimba
Jakub Gajewski
Ruairi Brugha
Chiara Pittalis
Leon Bijlmakers
Publication date: 01-12-2021
Publisher: BioMed Central
Published in: BMC Health Services Research / Issue 1/2021
Electronic ISSN: 1472-6963
DOI: https://doi.org/10.1186/s12913-021-06709-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Surgical ambulance referrals in sub-Saharan Africa – financial costs and coping strategies at district hospitals in Tanzania, Malawi and Zambia

Abstract

Background

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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