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World Journal of Surgery

, Volume 37, Issue 1, pp 24–31 | Cite as

Measuring Global Surgical Disparities: A Survey of Surgical and Anesthesia Infrastructure in Bangladesh

  • Drake G. LeBrunEmail author
  • Debashish Dhar
  • Md. Imran H. Sarkar
  • T. M. Tanzil A. Imran
  • Sayadat N. Kazi
  • K. A. Kelly McQueen
Article

Abstract

Background

Surgically treatable diseases weigh heavily on the lives of people in resource-poor countries. Though global surgical disparities are increasingly recognized as a public health priority, the extent of these disparities is unknown because of a lack of data. The present study sought to measure surgical and anesthesia infrastructure in Bangladesh as part of an international study assessing surgical and anesthesia capacity in low income nations.

Methods

A comprehensive survey tool was administered via convenience sampling at one public district hospital and one public tertiary care hospital in each of the seven administrative divisions of Bangladesh.

Results

There are an estimated 1,200 obstetricians, 2,615 general and subspecialist surgeons, and 850 anesthesiologists in Bangladesh. These numbers correspond to 0.24 surgical providers per 10,000 people and 0.05 anesthesiologists per 10,000 people. Surveyed hospitals performed a large number of operations annually despite having minimal clinical human resources and inadequate physical infrastructure. Shortages in equipment and/or essential medicines were reported at all hospitals and these shortages were particularly severe at the district hospital level.

Conclusions

In order to meet the immense demand for surgical care in Bangladesh, public hospitals must address critical shortages in skilled human resources, inadequate physical infrastructure, and low availability of equipment and essential medications. This study identified numerous areas in which the international community can play a vital role in increasing surgical and anesthesia capacity in Bangladesh and ensuring safe surgery for all in the country.

Keywords

District Hospital Clubfoot Medical College Hospital Village Doctor Equipment Availability 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Introduction

Surgically treatable conditions are a primary contributor to preventable morbidity and mortality in low income nations. Yet, because of a lack of surgical human resources, physical infrastructure, equipment, and essential medicines, approximately 2 billion people in these countries lack access to surgical services [1]. Surgical disability adjusted life years (DALYs) constitute approximately 11 % of all DALYs worldwide [2], with nearly half being found in Southeast Asia [3].

Because of the dearth of data on surgical resources in developing regions, the true extent of global surgical disparities is unknown. The present study sought to assess the surgical and anesthesia infrastructure in Bangladesh as part of a larger study by the Harvard Humanitarian Initiative measuring surgical capacity in Southeast Asia, Latin America, and sub-Saharan Africa.

Country overview

Bangladesh is a riverine country in Southeast Asia. It is bordered to the north, east, and west by India, to the southeast by Myanmar, and to the south by the Indian Ocean. Bangladesh is the seventh most populous country in the world, with an estimated population of 162,221,000 [4], making it the most densely populated large nation in the world. According to a UN estimate, the population of Bangladesh is likely to increase to 195 million by 2025 and to 222 million by 2050 [5]. Bangladesh’s capital, Dhaka, is located in the center of the country and has a metropolitan population of over 16,000,000.

The impact of such overpopulation cannot be overstated. There are only 3 physicians, 1.7 nurses, and 4 hospital beds available per 10,000 people [4, 6]. In 2006, the World Health Organization categorized Bangladesh as “one of 58 countries with a severe shortage of health workers” [7]. Bangladesh ranks 146th of 187 nations on the 2011 Human Development Index [8], and nearly 50 % of the population lives in poverty (defined as earning under $1.25 a day) [9].

Nonetheless, Bangladesh has made significant progress in its health sector. The United Nations recently rewarded Bangladesh for rapidly reducing its under-five mortality rate by over two-thirds [10]. Life expectancy in the country is age 65, and infant mortality is better than the global average at 41 deaths per 1,000 live births. Maternal mortality is 340 deaths per 100,000 live births, which is above both regional and global averages.

Healthcare in Bangladesh is provided by public and private sectors. Public hospitals serve the poorest sectors of the population and are financed by the government. The formal private sector includes hospitals run by non-governmental organizations and private facilities that provide care to patients who can afford more expensive services. The informal private sector includes village doctors, homeopathic providers, and traditional healers. The Directorate General of Health Services (DGHS), a branch of the Ministry of Health and Family Welfare (MoHFW), oversees the public healthcare system. The public healthcare structure is organized according to the 7 administrative divisions and 64 districts within the country. There is one public district hospital in each of 64 districts offering obstetric, surgical, internal medicine, and pediatric care. Eighteen public medical college hospitals act as tertiary referral centers.

Methods

A comprehensive survey tool was designed by the Harvard Humanitarian Initiative to collect and assess data involving surgical and anesthesia capacity in Bangladesh. It was adapted from the World Health Organization Tool for Situational Analysis to Assess Emergency and Essential Surgical Care (http://www.who.int/surgery/publications/QuickSitAnalysisEESCsurvey/pdf) and includes information on eight key areas of surgical care provision: Access and availability; human resources; infrastructure; outcomes recording; surgical procedures including OB/GYN, general, and specialty cases; equipment availability; non-governmental organization involvement in surgery; and pharmaceutical capacity.

The investigation consisted of two phases. First, national-level data on the Bangladeshi healthcare system were gathered from available literature and through interviews with officials in the Ministry of Health and Family Welfare and members of key medical professional societies. During the second investigative phase, individual hospital site visits were conducted by five of the authors (D.L., D.D., M.S., T.I., S.K.) in 14 public hospitals throughout the country (Fig. 1). One district hospital and one medical college hospital were surveyed in each of the seven administrative divisions. Hospitals were chosen based on convenience sampling.
Fig. 1

Map of hospitals surveyed

All hospitals were surveyed over a four-week period in January and February 2012. Hospital visits included face-to-face interviews with hospital directors, physicians, surgeons, anesthesiologists, nurses, and pharmacists. Additionally, hospital visits included tours of premises and relevant infrastructure such as operating rooms and wards. Permission to perform each visit was obtained from the district civil surgeon or hospital director.

No patients were contacted during this investigation and no data specific to individual patients were utilized. This study was approved by the Ethical Review Committee of the Bangladesh Medical Research Council. IRB exemption was obtained from the Harvard University School of Public Health, Boston, MA.

Results

National data

There are 43,537 registered physicians currently working in Bangladesh, while an additional 9,526 are registered but either not practicing or have left the country [6]. Approximately 55 % of physicians work in the public sector [11]. Throughout Bangladesh there are 18 public and 45 private medical colleges offering a total of 5,712 seats. Medical education at public medical colleges is subsidized by the government and admission is based on a national entry exam. Medical education consists of a five year curriculum plus one intern year.

Nearly one quarter (10,411) of practicing physicians are specialists [6]. Of these, 850 are anesthesiologists and an estimated 2,615 are surgical providers. Surgical providers include 1,200 OB/GYNs, 700 general surgeons, and 1,915 specialty surgeons. Specialty surgeons primarily consist of 800 ophthalmologists, 435 orthopedic surgeons, and 400 ENTs, along with smaller numbers of other types of surgeons (pediatric, urological, neurological, cardiothoracic, vascular, and plastic). Overall there are 0.05 anesthesiologists per 10,000 people and approximately 0.24 surgical providers per 10,000 people. Bangabandu Sheikh Mujib Medical University (BSMMU) is the sole medical university in Bangladesh. All postgraduate specialty training programs in Bangladesh are located at BSMMU or share an affiliation with BSMMU. A total of 20 institutes and 10 medical colleges provide post-graduate medical training in Bangladesh, and approximately 2,000 physicians are actively enrolled in specialization courses through BSMMU [11].

There are 26,889 certified nurses (officially “nurse-midwives”) in the country, with approximately 15,000 working in the public sector [6]. The nurse-to-physician ratio in Bangladesh is approximately 0.6:1. Eighty-four nursing colleges and institutes in the country offer a 3-year diploma in nursing. Annual turnout of nurses at these institutions is approximately 2,700 [6]. There are also 7,622 registered pharmacists in the country, corresponding to 0.5 pharmacists per 10,000 people [6].

Access and availability of facilities

Among surveyed district hospitals, the average catchment population was 1,879,201 (Table 1), with an average annual inpatient intake of 20,121. The average number of hospital beds at district hospitals was 140, with all hospitals reporting normal operating capacities of 150 % or more. Therefore many patients regularly stay on the ward floors or in makeshift beds in the main hospital walkways. There is a mean of 2.4 operating rooms (OR) per district hospital, corresponding to approximately 1 OR per 783,000 people within the catchment populations. However, there were approximately 4 operating tables per hospital as most hospitals use 2 operating tables in each OR. Patients travel an average of 26 km to access care at district hospitals, as reported by hospital directors.
Table 1

Healthcare accessibility at surveyed hospitals (by hospital type)

Hospital type

District hospitals

Medical college hospitals

Catchment population per hospital

1,879,201

11,100,000

Distance traveled to reach hospital, km

26

90

Inpatient admissions per annum

20,121

66,537

Number of hospital beds per hospital

140

543

Number of operating rooms per hospital

2.4

8.4

Number of operating tables per hospital

4.1

12.6

Results are reported as average values per hospital

The average catchment population of surveyed medical college hospitals was 11.1 million. These hospitals reported a mean annual inpatient capacity of 66,537, with two hospitals reporting annual inpatient intake exceeding 100,000. As with district hospitals, medical college hospitals reported operating inpatient capacities far exceeding the total number of hospital beds. A mean of 8.4 OR, or 12.6 operating tables, were found at medical college hospitals, corresponding to a rate of 1 OR per 1,321,429 people.

Access to human resources

District hospitals reported an average of 29.3 physicians on staff (Table 2). All hospitals had at least one formally trained OB/GYN, and all but one had at least one certified general surgeon. Two hospitals had to rely on anesthesiologists from nearby private hospitals for emergencies only. Overall, among the district hospitals surveyed, there was 1 physician per 64,137 people, 1 surgical provider (defined as a formally trained OB/GYN, general, or subspecialist surgeon) per 348,000 people, and 1 anesthesiologist per 1,879,201 people.
Table 2

Clinical human resources at surveyed hospitals (by hospital type)

Human resources

District hospitals

Medical college hospitals

Physicians

29.3

159.9

Anesthesiologists

1.0

6.9

OB/GYNs

1.4

11.7

General surgeons

1.6

7.4

Orthopedic surgeons

1.1

5.3

Ophthalmologists

0.7

5.0

Otolaryngologists

0.6

4.4

Urological surgeons

0

2.1

Plastic surgeons

0

0.7

Neurosurgeons

0

1.1

Pediatric surgeons

0

1.7

Nurses

49.1

205.1

Pharmacists

2.7

8.7

Pharmacy assistants

2.1

0

Midwives

1.4

0.7

Medical assistants

0.4

0

Nurse anesthetists (uncertified)

0.1

0.6

Results are reported as average numbers of providers per hospital

Medical college hospitals surveyed had a mean 159.9 physicians on staff. These included 6.9 anesthesiologists, 11.7 OB/GYNs, 7.4 general surgeons, and 20.4 subspecialty surgeons. At the medical college hospital level there was 1 physician per 69,437 people, 1 surgical provider per 280,303 people, and 1 anesthesiologist per 1,608,696 people.

Few medical officers were found at the district hospital level (Table 3). At medical college hospitals, the average numbers of surgical and anesthesia medical officers were roughly proportional to the numbers of certified specialists.
Table 3

Medical officers at surveyed hospitals (by hospital type)

Medical officers

District hospitals

Medical college hospitals

Anesthesia

0.3

5.2

OB/GYN

0.9

17.4

General surgery

0.2

13.2

Orthopedic surgery

0.2

4.4

Ophthalmology

0

3.0

Otolaryngology

0

4.0

Urology

0

2.6

Neurosurgery

0

1.2

Other surgery

0

0

Results are reported as the average number of providers per hospital

Nurses slightly outnumbered physicians at surveyed hospitals. District hospitals reported a mean of 49 nurses while medical college hospitals reported 205. These numbers correspond to 1.7 nurses per physician at district hospitals and 1.3 nurses per physician at medical college hospitals. The main providers of midwifery services are nurse-midwives, and they were considered nurses for the purposes of this study. Only two district hospitals and one medical college hospital had any midwives who were not nurse-midwives.

Infrastructure and equipment availability

All hospitals reported having an available source of electricity, though five of seven district hospitals reported a discontinuous supply of electricity, and only three reported access to a functional backup generator in case of power outages. All medical college hospitals reported a continuous supply of electricity and access to a back-up generator. All hospitals had an available source of water, in the form of tube wells, piped water, or a water tower.

Oxygen cylinders or central piped oxygen were available at all hospitals. Six district hospitals relied on oxygen cylinders, and one had a central piped system. Among the medical college hospitals, piped oxygen was available at four hospitals and cylinders were available at the remaining three. Only one medical college hospital reported routine shortages of oxygen.

At the district hospital level, blood availability varied. Two hospitals had an on-site blood bank, and the rest relied on private hospital blood banks or immediate blood donation. Blood products were available at all medical college hospitals, although blood shortages were commonly reported at all hospitals.

At both the district and the medical college hospital levels, five of seven hospitals had functional pulse oximeters in each OR (Table 4). Only one district hospital and two medical college hospitals had pulse oximeters available for postoperative monitoring. All functioning operating rooms at surveyed hospitals had an oxygen source and an anesthesia machine. All hospitals had at least one functional autoclave on site and reported that Or surface sterilization is performed after each operation.
Table 4

Equipment availability at surveyed hospitals (by hospital type)

Equipment

District hospitals (%)

Medical college hospitals (%)

Oxygen in each operating room

7 (100)

7 (100)

Pulse oximeter in each operating room

5 (71)

5 (71)

Pulse oximeter in postoperative area

1 (14)

2 (29)

Anesthesia machine in each operating room

7 (100)

7 (100)

Operative volume

A total of 146,911 procedures were performed at surveyed hospitals in the last year. These included 22,508 (15 %) procedures at district hospitals and 113,580 (85 %) at medical college hospitals (Table 5). Approximately 46 % of these operations were emergent; however, as one district hospital was unable to quantify the number of emergent procedures, this number represents an underestimate of the actual percentage.
Table 5

Annual operative volume in surveyed hospitals (by hospital type)

Parameter

District hospitals (%)

Medical college hospitals (%)

Total operations

3,215

17,772

Emergent surgeries

1,675 (52)

8,258 (46)

General surgeries

832 (26)

6,743 (38)

Pediatric surgeries

13 (<1)

512 (3)

OB/GYN surgeries (including caesarean sections)

1,077 (33)

5,771 (32)

Cesarean sections

626 (19)

3,448 (19)

Orthopedic surgeries

717 (22)

2,801 (16)

Ocular surgeries

349 (11)

1,283 (7)

Ear, nose, throat surgeries

199 (6)

574 (3)

Urological surgeries

0 (0)

153 (1)

Plastic surgeries

0 (0)

168 (1)

Neurological surgeries

0 (0)

155 (1)

Results are reported as annual mean (% of total annual operations) per hospital

District hospitals performed a mean of 3,215 operations annually. This corresponded to one operation per every 6 patients admitted and 1,340 annual operations per OR. Approximately one quarter of operations at district hospitals were general surgeries and one third were OB/GYN procedures. Pediatric surgeries, defined as operations on patients aged 0–14 years, were rare and only performed at two of the seven surveyed district hospitals.

Medical college hospitals performed an average of 17,772 operations annually, corresponding to 49 operations per day and one operation per 4 patients admitted. Approximately 2,115 annual operations were performed per OR.

Outcomes recording

All medical college hospitals had a capacity to track deaths in the OR, but no district hospital had this capacity. Similarly, no district hospital consistently investigated the cause of intraoperative death, but all but one medical college hospital investigated cause of OR death. The most common causes of surgical death at hospitals providing information were hemorrhage during cesarean section, extensive trauma from road traffic accidents or violence, complications resulting from delayed treatment, post-partum hemorrhage, and hemorrhagic and neurogenic shock from anesthesia.

Most hospitals were unwilling or unable to provide perioperative and postoperative mortality data. This is typical for hospitals in low income countries. In Bangladesh, four surveyed medical college hospitals provided mortality data (Table 6).
Table 6

Surgical mortality at surveyed hospitals reporting mortality data (by hospital type)

Mortality

Medical college hospitals

(n = 4)

Total operations

55,117

Deaths due to surgery while in the operating room

35

Deaths due to anesthesia immediately post-operation

8

Deaths due to surgery immediately post-operation

37

Deaths due to anesthesia in first 24 h post-operation

18

Deaths due to surgery in first 24 h post-operation

56

Numbers reported are sums of total deaths for hospitals that provided mortality data

Recording of post-surgical infections was inconsistent at surveyed hospitals. The two district hospitals and one medical college hospital that tracked and provided complication rates all had post-surgical infection rates between 4 and 5 %.

Pharmaceuticals

The Directorate of Drug Administration of the MoHFW maintains a List of Essential Drugs that is used in all public hospitals. This list consists of 209 medications and includes antibiotics, narcotic and non-narcotic painkillers, and anesthesia medications.

All surveyed hospitals, with the exception of one medical college hospital, had regular access to medications on this list. However, all but three hospitals reported regular shortages of these essential medications. Medications most frequently in shortage included third- and fourth-generation antibiotics, narcotic painkillers, and paracetamol.

All district hospitals and all but one medical college hospitals had regular access to antibiotics. All hospitals had access to non-narcotic pain medications. Only two district hospitals and three medical college hospitals had access to narcotic pain medicationss. Anesthesia medications were available at all hospitals except one district hospital. Refrigeration for medications was available at all hospitals except one district hospital.

Short-term surgical campaigns and NGO involvement in surgical care

Walk for Life, an international non-governmental organization (NGO) providing care for clubfoot, was present at two district hospitals, although their surgical activity was minimal. In addition, one district hospital and one medical college hospital had been visited once in the past year by short-term ophthalmology teams that primarily performed cataract repair.

Discussion

Bangladesh faces significant challenges in improving its surgical and anesthesia infrastructure. The single greatest burden weighing on the public healthcare sector is the vast patient population. Against such high demand, surgical and anesthesia human resources, physical infrastructure, equipment, and pharmaceutical supply are insufficient. And with the population set to continue growing, the weight of this burden will continue to increase.

Based on the results of this survey, surgical volume at Bangladeshi public hospitals is immense. District hospitals perform 3,215 annual operations per credentialed anesthesiologist and 595 operations per credentialed surgical provider. Medical college hospitals perform 17,772 operations annually, corresponding to 2,575 operations per credentialed anesthesiologist and 449 operations per credentialed surgical provider. The paucity of trained surgical and anesthesia specialists not only limits the capacity to carry out surgery but also puts patients at increased risk by forcing untrained providers to perform operations and anesthesia. For example, in this study one district hospital used a general practitioner to perform all emergent general surgery operations.

In order to turnover large numbers of surgical patients with insufficient operating space and equipment, hospitals may sacrifice OR sterilization, instrument sterilization, postoperative monitoring, and the isolation of a single patient in an OR. These patterns were observed in a majority of both hospital types, and they may endanger patients by compromising the OR sterile environment, increasing complications, and leaving postoperative patients unmonitored.

Safe anesthesia is a critical component of safe surgical care. Shortages of anesthesia human resources and equipment were noted at all hospitals. Some hospitals reported having unusable ORs because there are fewer anesthesia machines and oxygen sources than available ORs. Two district hospitals had no anesthesiologist but performed anesthesia with either a medical officer or a nurse. These findings coincide with reports that other district hospitals in Bangladesh are unable to perform any operations because there are no anesthesiologists on staff [12]. Such a lack of anesthesiologists limits operative volume at hospitals and puts patients at risk by delaying surgery and relying on untrained professionals to provide anesthesia. In fact, there are at least 423 physicians in Bangladesh actively practicing anesthesia without any formal training.

Providing safe preoperative, intraoperative, and postoperative surgical care in Bangladesh is further complicated by a national shortage of nearly 300,000 nursing personnel, which is reflected in the results of this study [11]. To address this shortage and reverse the problems in the nursing profession, several barriers must be overcome. These include the mass emigration of skilled nurses abroad, the negative social stigma surrounding the nursing profession in Bangladesh, an inadequate salary structure, and minimal opportunities for upward mobility [13].

Another widely acknowledged problem in Bangladeshi government hospitals is chronic absenteeism among senior physicians and surgeons, which leaves junior staff members to provide a large portion of care, including surgery [11, 14].

Certain surgical subspecialties have a clear but insufficient presence in Bangladesh. Considering that injuries, cataracts, congenital abnormalities, and other significant contributors to disability and premature death can be treated by specialized surgeons, there is an urgent need to enhance surgical specialty care in conjunction with obstetrics, general surgery, and anesthesia.

There are several limitations to this study. One district hospital (Jessore Sadar Hospital) is in the process of being incorporated into a medical college hospital, so its resources and operative capacity are greater than those of the other district hospitals. Similarly, Mitford Medical College Hospital reported significantly higher numbers of medical officers than the rest, while two medical college hospitals did not track the specialties of any medical officers. The validity of mortality data is also uncertain, as deaths may have gone underreported.

The region of Southeast Asia faces immense challenges in building up surgical and anesthesia infrastructure to meet the demand for care [3]. While numerous surgical capacity surveys have been conducted in sub-Saharan Africa, Central Asia, and the Western Pacific [15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26], this is only the second study of its kind [19] to describe the surgical infrastructure of a Southeast Asian nation, and the first to describe the situation of a low income Southeast Asian nation. Furthermore, given the unique circumstance of Bangladesh, the most densely populated large country in the world, this survey may be useful in defining future challenges faced by other nations with rapidly expanding populations.

Conclusions

Global deficiencies in surgical care have been largely neglected by the global health community [27], yet non-communicable surgical diseases, including trauma, cancer, and cardiovascular disease are significant contributors to disability and premature death in low income countries. Therefore the roles of surgical intervention and safe anesthesia are becoming increasingly important to population health, and surgical deficiencies are being increasingly acknowledged in such countries as Bangladesh.

Bangladesh faces an uphill battle in improving its surgical services to meet the needs of a vast and growing population. The public sector in particular must increase human resources, expand physical infrastructure and equipment availability, and address underlying structural deficiencies in order to provide sufficient care to the underserved communities of Bangladesh.

The role of emergency and essential surgery in population health, including emergency obstetrical interventions and safe anesthesia, cannot be underestimated. Building surgical capacity in Bangladesh and elsewhere will require a coordinated effort between donors, governments, and the global public health community. Non-governmental organizations and other international agencies can play an increased role in building surgical infrastructure globally. If such an effort comes to fruition, it will become possible to reduce disability and premature death secondary to surgical disease.

Notes

Acknowledgments

The authors are grateful to the Bangladesh Ministry of Health and Family Welfare, members of the Obstetrical and Gynaecological Society of Bangladesh, the Bangladesh Society of Anaesthesiologists, the Society of Surgeons of Bangladesh, and other professional organizations, hospital directors, physicians, and staff, without whose help and incomparable hospitality this study would never have been possible.

Conflict of interest

None.

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Copyright information

© Société Internationale de Chirurgie 2012

Authors and Affiliations

  • Drake G. LeBrun
    • 1
    • 7
    Email author
  • Debashish Dhar
    • 2
  • Md. Imran H. Sarkar
    • 3
  • T. M. Tanzil A. Imran
    • 4
  • Sayadat N. Kazi
    • 5
  • K. A. Kelly McQueen
    • 6
  1. 1.Thomas J. Watson FoundationNew YorkUSA
  2. 2.North South UniversityDhakaBangladesh
  3. 3.Dhaka Medical College HospitalRamnaBangladesh
  4. 4.Shahid Suhrawardi Medical CollegeDhakaBangladesh
  5. 5.Tejgaon CollegeFarmgateBangladesh
  6. 6.Department of AnesthesiologyVanderbilt UniversityNashvilleUSA
  7. 7.PlanoUSA

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