Multi-level system assessment of the Ghanaian emergency, trauma, and surgical care system : a roadmap for development

Stewart, Barclay T. (2019-04)

Thesis (PhD)--Stellenbosch University, 2019.

Thesis

ENGLISH SUMMARY : This dissertation is a compilation and evolution of a multi-level assessment of emergency, trauma and surgical care in Ghana that was designed to provide benchmarking data, identify key gaps, and outline a plan for development. The work began with an assessment of surgical and trauma care capacity at district, regional and tertiary hospitals nationwide. The results demonstrated critical deficiencies in essential resources that limit the quality of care that could be provided to the sick and injured. However, when compared to a similar assessment a decade prior, there were notable improvements, which highlighted the potential for positive change, and identified existing opportunities for capacity building. While this work was being completed, three major movements in global surgery and international health policy were afoot that mandated a better understanding of access to essential surgical and trauma care and evaluation and monitoring of essential surgical and trauma care. Therefore, to stay relevant and contribute meaningfully to the meta-discussion in global surgery, we set out to pilot the collection and use of these metrics in Ghana. In addition to the assessments of capacity, piloting of the new metrics was done by: i) enumerating all operations done in the country in one year, ii) describing geospatial access to surgical care, and iii) modeling the risk of catastrophic expenditure for people who need surgery. During this phase of the work, several findings were noted. First, it seemed that surgical capacity was not directly associated to surgical output, which contrasted with the current assumptions regarding surgical capacity assessments and capacity building initiatives. Therefore, we set out to examine this relationship with data from the national capacity assessment and surgical enumeration. This study confirmed our suspicions: there was no association between capacity and output. The findings suggested that several non-measured factors were important for improving output, such as differential barriers to care, process components (e.g., protocols, policies, emotional infrastructure), and system coordination. Therefore, we sought to further characterize these components and develop a system-wide roadmap for emergency, trauma, and surgical care system development. This was done by: developing, piloting and expanding a barriers to care assessment tool; developing context-appropriate audit filters to investigate the trend of process metrics; and developing and piloting the World Health Organization (WHO) Emergency Care System Assessment Tool (ECSAT) in Ghana. The data from the entire work allowed for a rich description of the state of emergency, trauma, and surgical care in the country, identification of the key gaps, and creation of a roadmap for development. The latter was done in conjunction with the Ghana Ministry of Health and was turned over to them for implementation and monitoring by in-country partners. The work in total demonstrated the utility of multi-level assessments in planning for strategic development of the healthcare system, and contributed meaningfully to the global surgery movement with regards to tool creation and piloting of several novel metrics.

AFRIKAANSE OPSOMMING : Hierdie proefskrif is ’n samestelling en ontwikkelingsgang van ’n multivlak-assessering van nood-, trauma- en chirurgiese sorg in Ghana wat ontwerp is om normdata te verskaf, die belangrikste leemtes te identifiseer, en ’n plan vir ontwikkeling uiteen te sit. Die werk het met ’n assessering van chirurgiese en traumasorgkapasiteit by distriks-, streeks- en tersiêre hospitale landswyd begin. Die resultate het kritiese tekortkominge in noodsaaklike hulpbronne uitgewys, wat die gehalte van die voorsiene sorg aan siekes en beseerdes beperk. In vergelyking met ’n soortgelyke assessering ’n dekade vantevore, was daar egter merkbare verbeterings, wat die potensiaal vir positiewe verandering beklemtoon het en bestaande geleenthede vir kapasiteitsbou aangedui het. Terwyl hierdie werk uitgevoer is, was daar drie groot bewegings in wêreldwye chirurgie en internasionale gesondheidsbeleid aan die gang wat ’n beter begrip van toegang tot noodsaaklike chirurgiese en traumasorg, en die evaluering en monitering van noodsaaklike chirurgiese en traumasorg vereis. Om dus relevant te bly en betekenisvol tot die metabespreking in wêreldwye chirurgie by te dra, het ons met die insameling en gebruik van hierdie parameters in Ghana begin. Benewens die kapasiteitsassessering, is die loodsing van die nuwe parameters gedoen deur: i) die optelling van alle operasies wat in een jaar in die land uitgevoer is; ii) die beskrywing van die georuimtelike toegang tot chirurgiese sorg; en iii) die modellering van die risiko van katastrofiese uitgawes vir mense wat chirurgiese ingrepe benodig. Gedurende hierdie fase van die werk is verskeie bevindings aangeteken. Eerstens blyk dit dat chirurgiese kapasiteit nie direk met chirurgiese uitset verband hou nie, wat strydig is met die huidige aannames ten opsigte van chirurgiese kapasiteitassesserings en kapasiteitsbou-inisiatiewe. Daarom het ons hierdie verband met data uit die nasionale kapasiteitassessering en die chirurgiese optelling ondersoek. Hierdie studie het ons vermoedens bevestig: daar was geen verband tussen kapasiteit en uitset nie. Die bevindings suggereer dat verskeie nie-gemete faktore belangrik was om uitset te verbeter, soos differensiële hindernisse ten opsigte van sorg, proseskomponente (byvoorbeeld protokolle, beleide, emosionele infrastruktuur), en stelselkoördinasie. Daarom het ons probeer om hierdie komponente verder te karakteriseer en ’n stelselwye padkaart vir nood-, trauma- en chirurgiese sorgstelselontwikkeling te ontwikkel. Dit is gedoen deur: die ontwikkeling, loodsing en uitbreiding van ’n assesseringsinstrument om hindernisse tot sorg te bepaal; die ontwikkeling van konteks-gepaste ouditfilters om die tendens van prosesparameters te ondersoek; en die ontwikkeling en loodsing van die Wêreldgesondheidsorganisasie se Noodsorgstelselassessering-instrument in Ghana. Die data uit die werk in geheel maak voorsiening vir ’n omvangryke beskrywing van die noodtoestand-, trauma-, en chirurgiese sorg in die land; die identifisering van die belangrikste leemtes; en die skep van ’n padkaart vir ontwikkeling. Laasgenoemde is in samewerking met Ghana se Ministerie van Gesondheid gedoen en is aan hulle oorgedra vir implementering en monitering deur vennote in die land. Die werk in geheel het die nut van multivlak-assesserings in die beplanning vir die strategiese ontwikkeling van die gesondheidsorgstelsel uitgewys, en ’n betekenisvolle bydrae tot die wêreldwye chirurgiese beweging gemaak sover dit die skepping van instrumente en die loodsing van verskeie nuwe parameters betref.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/106129
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