Overcoming the barriers between resource constraints and healthcare quality

The seven pillars of healthcare quality are: efficacy, efficiency, optimality, acceptability, legitimacy, equity and cost.¹ A strong health system comprises of essential elements which can be remembered with the help of a 5S mnemonic: staff, stuff, space, systems and social support.² To this another 5S’s can be added to complete the list: surgical capacity (for workload), skills, supply (chain), suitable training for the health care workers and stewardship for coordinating complex management protocols. Healthcare quality and resource constraints are often mutually exclusive, and this is a significant challenge in the field of Global Surgery which needs to be addressed urgently so that patients receive the high-quality care that need and deserve.

The gulf between best practices and actual implementation that exists in resource-constrained circumstances has been called the ‘quality chasm’.³ The magnitude of this problem in Global Surgery has been assessed by several studies including African Surgical Outcomes and GlobalSurg Collaborative studies; both of which showed significantly worse outcome when compared with the global average. These shocking statistics include a mortality rate twice as high despite a low-risk profile after routine and cancer surgery, double the neonatal mortality and 50 times higher maternal mortality after Caesarean delivery in Africa than in high-income countries.^4–8 Causes are attributed to post-operative infection, peri-partum haemorrhage, anaesthesia complications, lack of quality post-operative care and limited capacity to rescue following the development of major complications. The potential gain of addressing quality of care in the calendar year 2020 could have led to an estimated 28% decrease in maternal deaths (86,000 lives saved; range = 77,800–92,400), 28% decrease in neonatal deaths (0.67 million lives saved; range = 0.59 million–0.75 million), and 22% fewer stillbirths (0.52 million stillbirths prevented; range = 0.48 million–0.55 million).⁹ It is not surprising that hospitals with better infrastructure and resources have better outcomes after cancer surgery, independent of country income. Moreover, across low and middle-income countries (LMICs), an improvement in hospital facilities has the potential to prevent 1–3 deaths for every 100 patients undergoing surgery for cancer.¹⁰

Poor surgical quality is a major issue in all practice settings, but can have greatest adverse impact in lower resource settings. This makes it imperative to have metrics for quality of surgical care to ensure good quality care is delivered despite low-resource settings. A beginning can be made by implementing low-cost surgical outcomes monitoring and select quality improvement systems already proven effective, such as surgical infection prevention programmes and safety checklists. Another option is employing technology and mobile health (mHealth) for patient data collection, follow-up and information sharing, to create a framework for improving care in scalable and sustainable ways.¹¹ Open online courses, open access electronic journals and textbooks, such as Primary Surgery¹² and electronic networks including burgeoning social media promise to expand access to information rapidly. But local clinical contexts and factors must be addressed to accelerate innovations in peri-operative patient safety.¹³ A flexible, comprehensive care model for delivering safe Caesarean delivery care in very low-resource settings has been suggested. It promotes a decentralized community-based care programme which allows timely transfer of care to labour and delivery including a ‘SOS’ Caesarean birth centre, together with evidence-based quality improvement programming and data collection.¹⁴

Many metrics for quality of surgical care developed in high-income settings are however resource-intensive and inappropriate in lower resource settings. This has prompted the development of an evidence-based tool to measure quality of surgical care in low-resource settings. This includes 12 indicators:The Clavien-Dindo classification of post-operative complications is a feasible standardized system appropriate for measuring surgical quality in LMICs.¹⁶

Other important suggestions include the engagement of patients themselves in the design, delivery, evaluation of health services and service delivery redesign with development of innovative solutions and optimization of networks of care.^17–19 Such will obviously influence and support quality improvement, and national surgical policies.^20,21

And finally, implementation science is especially important in low-resource settings to ensure novel solutions are translated into routine practice and benefit the largest possible number of people.²² To assist in this process, a conceptual framework for facilitating adoption of affordable surgical innovations in LMICs has been developed.²³

It is not impossible to improve the quality of surgical care with the help of low-cost affordable surgical innovations, especially when they are ‘locally developed’ by frontline health workers in search of simple, safe and ethical solutions for their unique challenges.²⁴ It is indeed well known that unless peri-operative care interventions are co-designed with local health-care staff, their sustainable adoption and successful implementation cannot be ensured and anticipated benefits may well not be seen even with the best of intentions.²⁵ To paraphrase U.S. President Abraham Lincoln’ Gettysburg Address the necessary changes have to be ‘of the people, by the people, for the people’.