Facilitating access to surgical care through a decentralised case-finding strategy: experience in Madagascar

The need

Globally, 5 billion people lack access to safe, affordable and timely surgical care,1 and an estimated 143 million more procedures are needed each year to meet that need.2 Challenges to accessing surgical care are multifactorial and involve complex interactions between cultural, geographical, social and economic factors. The cost of surgery in low-income and middle-income countries (LMICs) is near prohibitive, with 81 million people facing catastrophic expenditure due to the costs of surgery per year.3 4 The direct medical cost of the surgery itself is often not the largest portion of a patient’s financial burden3: patients’ travel costs are the most commonly reported barrier to accessing cleft lip and palate surgery in sub-Saharan Africa,5 and gender disparities in access are also known to exist.6–10 Other documented barriers to care in LMICs include a lack of available surgeons, inadequate facilities, poor roads and low levels of education and health literacy.6 9–17 These barriers fall heaviest on the poor and those living in remote areas.

Non-governmental organisations (NGOs) play a significant role in providing surgical care in LMICs. In some countries, over 50% of the total surgical care is provided by NGOs.18 Lack of surgeon availability, inadequate facilities and surgical costs may be overcome by NGOs offering free surgical care, but other barriers still exist, such as distance, transport costs and health literacy. Deliberate patient selection strategies aimed to target the financially poor, those living in remote areas and to overcome gender disparities are needed, but it is unclear whether such strategies are sufficient to overcome these barriers.

Mercy Ships is a surgical NGO that operates the world’s largest civilian hospital ship, the Africa Mercy. The Africa Mercy visits coastal sub-Saharan African countries at the invitation of the head of state, typically spending 10 months in one country docked in the major port city. Working closely with the Ministry of Health free surgeries, training and quality improvement initiatives are provided. The ship has 84 beds and 5 operating rooms providing a range of elective maxillofacial, plastics, general, gynaecological and orthopaedic procedures. Typical surgeries include cleft lip and palate surgery including pharyngoplasty; excision of soft tissue and bony tumours of the head and neck including those requiring mandibulectomy and maxillectomy; reconstructive surgery after noma or after burns to the head, neck and limbs and hands; excision of large soft tissue tumours such as neurofibroma; goitre surgery, obstetric fistula and hernia repair; and correction of neglected clubfoot, valgus and varus deformities of the lower limbs. Outpatient and rehabilitation services are provided during the 10-month period. Any patients needing further care after Mercy Ships departure are handed over to the care of the local hospitals usually to doctors who have participated in the Mercy Ships training programmes and a Memorandum of Understanding for costs arranged with the hospital director. Data on patient’s socioeconomic status and self-reported barriers to surgical care are routinely collected, and Mercy Ships has previously examined the relationship between poverty, barriers to surgical care and health outcomes in the Republic of Congo.14

For two consecutive field services, from October 2014 to June 2015 and from August 2015  to June 2016, Mercy Ships was based in Madagascar, a low-income country off the east coast of Africa. Madagascar has a population of 24 million, a surgical workforce density of 0.78 providers per 100 000 population, annual surgical volume of 135–191 procedures per 100 000 population and a perioperative mortality rate of 2.5%–3.3%.19 Only 20% of the population can access surgical services within 2 hours, and up to 95% would face financial ruin if they required surgery.19 Most hospitals lack reliable electricity and oxygen supplies, basic monitoring required for safe anaesthesia and paediatric-appropriate equipment for surgery and anaesthesia.20

This analysis paper describes how Mercy Ships changed from a centralised to a decentralised patient selection strategy with the aim of recruiting a greater proportion of underserved patients. We report the impact of our changes with respect to patient’s wealth index and self-reported barriers to care. Recommendations to other NGOs, policymakers and funders are given with respect to targeting patients in greatest need.

The patient selection programme

Mercy Ships’ patient selection process

Initial assessment and design

The patient selection programme begins before the ship’s arrival. Initial assessments are made to design a surgical schedule that meets host country needs. Assessments consist of interviews with key government personnel; representatives from the WHO, aid agencies and other NGOs, local hospital staff and community leaders. The assessment informs a collaborative decision-making process between Mercy Ships and the Ministry of Health concerning surgical programme design and consequent patient selection.

Historically, 70%–80% of Mercy Ships patients are selected at the beginning of a field service at a field site in the major port or capital city. Potential patients are expected to travel to this city to be seen. The remaining 20%–30% of the surgical capacity is reserved for patients travelling to two or three smaller screening events in remote areas identified by the Ministry of Health. Billboard, radio and television advertisements detail dates and locations of selection events and the types of conditions treated. Local hospital contacts, community leaders and other NGOs also help spread the word.

Change in selection strategy

In Madagascar, the Africa Mercy was docked in the eastern port city, Toamasina, which is 8 hours by road from the capital city, Antananarivo. In the first field service (October 2014–June 2015), Mercy Ships used a centralised selection strategy, aiming to find 70% of patients from Toamasina and 30% from the capital (Antananarivo) and two remote cities (Mahajanga and Toliara). From August 2015 to June 2016, a decentralised selection strategy was used, aiming to find only 30% of patients from Toamasina and 70% from the capital and 10 remote locations. For the decentralised screening strategy, the 10 remote sites were identified in collaboration with the Ministry of Health as sufficient to cover the majority of the country’s population: Tolagnaro, Manakara, Mahajanga, Antsiranana, Mandritsara, Andapa, Toliara, Fortadrevo, Antsirabe and Morondava (see figure 1). In general, these 10 key cities were at least 1 day’s travel from the capital city and at least 2 days’ travel from Toamasina. Patients still had to reach the key city but, thereafter, surgery, patient transport, accommodation and food were provided free of charge. All cities remote from the port city were visited at least twice: once to perform an initial assessment including crowd security and plan the selection process with the Regional Minister of Health, local hospital leadership, community leaders, police and media and later to undertake the patient selection process.

Figure 1

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Map of Madagascar showing location of cities used in centralised and decentralised selection strategies.

The decentralisation strategy was initiated at the request of the Ministry of Health who wanted the rural populations to have equal opportunity to access Mercy Ships’ specialised surgical services.

The evaluation

The impact

The change in selection strategy from centralised to decentralised selection resulted in proportionally more patients in the lower wealth quintiles undergoing surgery. Figur e 2 shows the proportion of patients in the five quintiles for the two selection methods. Patients in the richest, rich and middle quintiles were 4.6, 2.6 and 2.0 times, respectively, more likely to have been selected in the centralised selection strategy (table 1).

Patients ranged in age from 3 months to 73 years; the centralised group had a median age of 24 years (IQR: 7–42 years), and decentralised group had a median age of 21 years (IQR: 6–39 years). Patients in the decentralised group were younger than those in the centralised group, although this difference did not quite achieve statistical significance (p=0.056). There were significantly more females than males (52% vs 47.4%, p=0.022) in the decentralised group. However, in collaboration with the government of Madagascar, we increased the numbers of obstetric fistula surgeries during the second field service and when this increase is controlled for, the effect of gender disappears.

The type of surgery and number of patients per specialty was consistent across the two field services with two exceptions. Due to a later than usual start to the first field service (October instead of August), the orthopaedic programme was reduced in the first field service (centralised group), and in the second field service (decentralised group), obstetric fistula surgery was increased at the request of the government. Average numbers of patients per specialty per month were maxillofacial: 39 and 41, plastic surgery: 11 and 10, general surgery: 40 and 45, orthopaedic surgery: 6 and 10 and obstetric fistula: 1 and 4 for the centralised and decentralised groups, respectively.

All reported barriers to prior care, except for lack of transportation (p=0.95), were statistically significantly more likely to have been identified by patients in the decentralised group compared with centralised group. More patients in the centralised selection group compared with the decentralised group reported no barriers to accessing care (38.6% vs 8.1%, p<0.001) (table 2).

Patients who identified multiple barriers to prior surgical care were more likely to have presented in the decentralised group (p=0.046) and less likely to be in the richest quintile (p=0.037). Age and gender were not predictive of facing multiple barriers to care (table 3).

Overcoming barriers to surgical access for the most underserved

This data-driven analysis demonstrates that a decentralised patient selection strategy that actively targets poor and remote areas can increase access to the most underserved, especially the poor and patients facing multiple barriers to care.

There are various models for expanding access to surgical care that include task-shifting,22 use of mobile platforms23 and impact of government policy,24 but little is known regarding case-finding strategy. We sequentially evaluated two selection strategies: a centralised selection strategy that focused on the larger population centres in Madagascar and a decentralised strategy that deliberately targeted remote areas of Madagascar, where access to surgical care was limited. The decentralised strategy aimed to gain widespread coverage of the whole country so that surgery was available to as many people as possible. Given that travel costs are the single most common barrier to accessing free cleft lip and palate surgery in sub-Saharan Africa,5 our findings suggest that NGOs should consider case-finding by travelling to patient’s rural locations, rather than expecting the patient to bear the brunt of transport costs. This will require a change in strategy and higher upfront costs for many NGOs, but the return on this investment is the ability to reach a greater proportion of the rural population. However, in the poorest of countries, even richer urban patients may lack access to surgical care due to lack of trained surgeons, so a decentralised case finding strategy may just shift the population treated.

Fear of surgery and mistrust of service providers are also known barriers to care,11 13 15 17 25 and women are more than three times as likely as men to experience such fears.16 The results presented here suggest that active case-finding in the poorest communities, in collaboration with the community and its religious leaders, may work to overcome some of this fear and mistrust, leading to an increase in access to surgery by parent’s willingness to present children for surgery. As the number of surgical NGOs grows, collaboration between NGOs and Ministries of Health is also likely to be important. Collaboration to avoid duplication of services, share patient details and facilities (eg, CT scanning) and provision of ongoing care are also likely to be important in overcoming barriers to care.

That patients in the decentralised group did not more readily identify lack of transportation is surprising given the remoteness of this population. A possible explanation for this may be that in this context due to the overwhelming barriers being surgical cost and lack of surgeons, the issue of transport was perceived as irrelevant unless the other barriers were overcome.

This analysis has a number of limitations. The barriers-to-care questionnaire retrospectively asked patients if they had previously experienced barriers to care and so is subject to recall bias. There is no recent DHS programme data available for Madagascar, so we had to create a simulation model to allow weights to be given to the demographic and asset-related questionnaire that could have introduced errors. However, when the simulation model was applied to the original DHS data, the correlation between predicted wealth and actual wealth was 91%. Our experience is based in a single country with a predominantly rural population, therefore distance and transportation costs maybe over-represented. Despite these limitations, the data presented have a number of strengths: large sample size, broad specialty mix and thorough demographic and barrier assessments all demonstrate how changing from a centralised to decentralised selection strategy can improve access to care for the poorest patients and those who experience multiple barriers to care.

Conclusion and recommendations

Barriers to surgical care are multifactorial and involve complex geographical and socioeconomic factors. NGOs and surgical providers in LMICs cannot simply offer free surgery and expect to reach those in need. Our data show that country-specific patient selection strategies can be developed to overcome principle barriers and allow patients in greatest need to access surgical care. Therefore, we make the following recommendations to NGOs and other stakeholders involved n the provision of surgical care in LMICs:

1. consider case-finding by travelling to patient’s rural locations, rather than expecting the patient to travel to access care

2. design decentralised active case-finding strategies to reach the poorest communities, in collaboration with the community and its religious leaders

3. routine collection of demographic, wealth and prior barriers to care data (see online appendix file) can help determine patient profiles to assess if stakeholders are achieving their aims of improving access to surgical care to those who need it.