A. G. Ramirez1,2, A. E. Giles2,3, M. G. Shrime4,5 1University Of Virginia,Charlottesville, VA, USA 2Harvard School Of Public Health,Boston, MA, USA 3McMaster University,Hamilton, ONTARIO, Canada 4Harvard School Of Medicin, Program In Global Surgery And Social Change,Boston, MA, USA 5Massachusetts Eye And Ear Infirmary,Otolaryngology,Boston, MA, USA
Introduction:
Access to essential surgical services is receiving increased recognition in global health with the WHO recognition of surgical provision as integral to universal health care. Using available data, a composite measure of commonly measured inputs was developed that estimates likelihood of surgical availability at a facility level, allowing for assessment of current surgical provision and progress over time using geospatial methods.
Methods:
Geospatial analysis was used to model the current percentage of the population with access to a surgically capable hospital in Malawi, the expansion of all Malawian hospitals to surgery-ready capacity, and the access gain upon optimization of five select hospitals. Data sources include the Demographic and Health Surveys Program Service Provision Assessment, a facility-based survey completed in 2013-2014 in Malawi containing geocoded data on all health facilities in the country, gadm.org for national and subnational district administrative boundaries, and WorldPoP for population density based on 2015 projections. Distance to facility was varied between 10, 20, and 30 kilometers to account for different modes of available transportation. For the optimization scenario, the hospitals were selected based on largest predicted catchment population after accounting for existing surgically capable hospitals.
Results:
48 of the 116 hospitals in Malawi were identified as capable of providing surgery: 4 Central Hospitals, 22 District Hospitals, and 22 Community/Other Hospitals. The present population covered by surgical services in Malawi is 5,129,191 (31.7%), 9,802,621 (60.6%), and 12,847,661 (79.4%) at 10, 20, and 30 kilometers, respectively. Enhancing surgical capacity to all hospitals would increase surgical provision to 7,510,353 (46.4%), 13,013,934 (80.4%), and 15,282,611 (94.5%) of the population at 10, 20 and 30 kilometers, respectively, an increase of 14.7-19.8% of the population. Targeted optimization of five select hospitals showed a summative population coverage size increase of 1,530,660 (3.4%) and 1,947,799 (4.9%) of the population at 20 and 30 kilometers, respectively. All five hospitals were urban community or rural community hospitals located in the southern half of the country.
Conclusion:
Current coverage of surgical availability in Malawi is inadequate. Given resource constraints, it is prudent to select hospitals to optimally maximize surgical services based on population coverage added. Our model provides an optimization algorithm that demonstrates that the addition of surgical capability to only five targeted facilities would expand surgical access for up to 2 million people. Improvement of additional facilities could be conducted on this same strategic basis.