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An Evaluation of Preparedness, Delivery and Impact of Surgical and Anesthesia Care in Madagascar: A Framework for a National Surgical Plan

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Abstract

Background

The Lancet Commission on Global Surgery (LCoGS) described the lack of access to safe, affordable, timely surgical, and anesthesia care. It proposed a series of 6 indicators to measure surgery, accompanied by time-bound targets and a template for national surgical planning. To date, no sub-Saharan African country has completed and published a nationwide evaluation of its surgical system within this framework.

Method

Mercy Ships, in partnership with Harvard Medical School and the Madagascar Ministry of Health, collected data on the 6 indicators from 22 referral hospitals in 16 out of 22 regions of Madagascar. Data collection was by semi-structured interviews with ministerial, medical, laboratory, pharmacy, and administrative representatives in each region. Microsimulation modeling was used to calculate values for financial indicators.

Results

In Madagascar, 29% of the population can access a surgical facility within 2 h. Surgical workforce density is 0.78 providers per 100,000 and annual surgical volume is 135–191 procedures per 100,000 with a perioperative mortality rate of 2.5–3.3%. Patients requiring surgery have a 77.4–86.3 and 78.8–95.1% risk of incurring impoverishing and catastrophic expenditure, respectively. Of the six LCoGS indicator targets, Madagascar meets one, the reporting of perioperative mortality rate.

Conclusion

Compared to the LCoGS targets, Madagascar has deficits in surgical access, workforce, volume, and the ability to offer financial risk protection to surgical patients. Its perioperative mortality rate, however, appears better than in comparable countries. The government is committed to improvement, and key stakeholder meetings to create a national surgical plan have begun.

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Acknowledgements

E. Bruno received funding for International travel by Boston Children’s Hospital, Boston, MA, USA, and from the Mark Allen McConkey, M.D., Medical Student Public Service Fund. L. S. Baxter received a travel and education Grant from the National Institute for Academic Anaesthesia, UK. M. G. Shrime receives funding from the GE foundation for its Safe Surgery 2020 initiative.

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Authors and Affiliations

  1. M/V Africa Mercy, Mercy Ships, Port of Toamasina, Madagascar

    Emily Bruno, Michelle C. White, Linden S. Baxter, Vaonandianina Agnès Ravelojaona, Hasiniaina Narindria Rakotoarison, Kristin L. Close & Alison Herbert

  2. University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA

    Emily Bruno

  3. Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA

    Emily Bruno, Nakul Raykar, Saurabh Saluja & Mark G. Shrime

  4. Ministère de la Santé Publique, Antananarivo, Madagascar

    Hery Harimanitra Andriamanjato

  5. Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Nakul Raykar

  6. Department of Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA

    Saurabh Saluja

  7. Department of Otolaryngology, Harvard Medical School, Boston, MA, USA

    Mark G. Shrime

  8. Office of Global Surgery and Health, Massachusetts Eye and Ear Infirmary, Boston, MA, USA

    Mark G. Shrime

  9. M/V Africa Mercy, Mercy Ships, Port of Cotonou, Benin

    Michelle C. White & Kristin L. Close

Authors
  1. Emily Bruno
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  2. Michelle C. White
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  3. Linden S. Baxter
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  4. Vaonandianina Agnès Ravelojaona
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  9. Nakul Raykar
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  10. Saurabh Saluja
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Corresponding author

Correspondence to Michelle C. White.

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Conflict of interest

M. C. White, V. A. Ravelojaona, H. N. Rakotoarison, H. H. Andriamanjato, K. L. Close, A. Herbert, N. Raykar and S. Saluja have no conflicts of interest to declare.

Additional information

Emily Bruno and Michelle C. White serve as the lead authors of this article.

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Bruno, E., White, M.C., Baxter, L.S. et al. An Evaluation of Preparedness, Delivery and Impact of Surgical and Anesthesia Care in Madagascar: A Framework for a National Surgical Plan. World J Surg 41, 1218–1224 (2017). https://doi.org/10.1007/s00268-016-3847-9

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  • DOI: https://doi.org/10.1007/s00268-016-3847-9

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