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Access to Orthopaedic Surgical Care in Northern Tanzania: A Modelling Study

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The global burden of musculoskeletal disease and resulting disability is enormous and is expected to increase over the next few decades. In the world’s poorest regions, the paucity of information defining and quantifying the current state of access to orthopaedic surgical care is a major problem in developing effective solutions. This study estimates the number of individuals in Northern Tanzania without adequate access to orthopaedic surgical services.


A chance tree was created to model the probability of access to orthopaedic surgical services in the Northern Tanzanian regions of Arusha, Kilimanjaro, Tanga, Singida, and Manyara, with respect to four dimensions: timeliness, surgical capacity, safety, and affordability. Timeliness was estimated by the proportion of people living within a 4-h driving distance from a hospital with an orthopaedic surgeon, capacity by comparing number of surgeries performed to the number of surgeries indicated, safety by applying WHO Emergency and Essential Surgical Care infrastructure and equipment checklists, and affordability by approximating the proportion of the population protected from catastrophic out-of-pocket healthcare expenditure. We accounted for uncertainty in our model with one-way and probabilistic sensitivity analyses. Data sources included the Tanzanian National Bureau of Statistics and Ministry of Finance, World Bank, World Health Organization, New Zealand Ministry of Health, Google Corporation, NASA population estimator, and 2015 hospital records from Kilimanjaro Christian Medical Center, Machame Hospital, Nkoroanga Hospital, Mt. Meru Hospital, and Arusha Lutheran Medical Center.


Under the most conservative assumptions, more than 90% of the Northern Tanzanian population does not have access to orthopaedic surgical services.


There is a near absence of access to orthopaedic surgical care in Northern Tanzania. These findings utilize more precise country and region-specific data and are consistent with prior published global trends regarding surgical access in Sub-Saharan Africa. As the global health community must develop innovative solutions to address the rising burden of musculoskeletal disease and support the advancement of universal health coverage, increasing access to orthopaedic surgical services will play a central role in improving health care in the world’s developing regions.

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  1. Weiser TG et al (2008) An estimation of the global volume of surgery: a modelling strategy based on available data. The Lancet 372:139–144

    Article  Google Scholar 

  2. Bickler SW, Spiegel D (2010) Improving surgical care in low- and middle-income countries: a pivotal role for the World Health Organization. World J Surg 34:386–390.

    Article  PubMed  Google Scholar 

  3. Alkire BC et al (2015) Global access to surgical care: a modelling study. Lancet Glob Health 3:e316–e323

    Article  PubMed  PubMed Central  Google Scholar 

  4. Spiegel DA, Gosselin RA, Coughlin RR, Kushner AL, Bickler SB (2008) Topics in global public health. Clin Orthop 466:2377–2384

    Article  PubMed  Google Scholar 

  5. Grimes CE, Bowman KG, Dodgion CM, Lavy CBD (2011) Systematic review of barriers to surgical care in low-income and middle-income countries. World J Surg 35:941–950.

    Article  PubMed  Google Scholar 

  6. Kopits E, Cropper M (2005) Traffic fatalities and economic growth. Accid Anal Prev 37:169–178

    Article  PubMed  Google Scholar 

  7. World report on road traffic injury prevention (2004)

  8. Paden M, McGee, K, Krug, E (2002) Injury: A leading cause of the global burden of disease. World Health Organization

  9. Shrime MG, Dare AJ, Alkire BC, O’Neill K, Meara JG (2015) Catastrophic expenditure to pay for surgery worldwide: a modelling study. Lancet Glob Health 3(Supplement 2):S38–S44

    Article  PubMed  PubMed Central  Google Scholar 

  10. IHME GDP profile: Tanzania

  11. WHO (2017) The global burden of disease: 2004 update, WHO. Accessed 2 Dec 2017

  12. Chao TE et al (2014) Cost-effectiveness of surgery and its policy implications for global health: a systematic review and analysis. Lancet Glob Health 2:e334–e345

    Article  PubMed  Google Scholar 

  13. Agarwal-Harding KJ, von Keudell A, Zirkle LG, Meara JG, Dyer GSM (2016) Understanding and addressing the global need for orthopaedic Trauma Care. J Bone Jt Surg Am 98:1844–1853

    Article  Google Scholar 

  14. Gosselin RA, Gialamas G, Atkin DM (2011) Comparing the cost-effectiveness of short orthopedic missions in elective and relief situations in developing countries. World J Surg 35:951–955.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Chen AT et al (2012) Volunteer orthopedic surgical trips in Nicaragua: a cost-effectiveness evaluation. World J Surg 36:2802–2808.

    Article  PubMed  Google Scholar 

  16. Laxminarayan R, Chow J, Shahid-Salles SA (2006) Intervention cost-effectiveness: overview of main messages. In: Jamison DT et al (ed) Disease control priorities in developing countries. World Bank

  17. Raykar NP et al (2015) Geospatial mapping to estimate timely access to surgical care in nine low-income and middle-income countries. The Lancet 385(2):S16

    Article  Google Scholar 

  18. Meara JG et al (2015) Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet 386:569–624

    Article  Google Scholar 

  19. How Far Can I Travel. Available at: (Accessed: 7th December 2016)

  20. Alkire BC et al (2015) Global access to surgical care: a modelling study. Lancet Glob Health 3:e316–e323

    Article  PubMed  PubMed Central  Google Scholar 

  21. Karimkhani C et al (2017) The global burden of scabies: a cross-sectional analysis from the Global Burden of Disease Study 2015. Lancet Infect Dis 17:1247–1254

    Article  PubMed  PubMed Central  Google Scholar 

  22. Berry SD, Miller R (2008) Falls: epidemiology, pathophysiology, and relationship to fracture. Curr Osteoporos Rep 6:149–154

    Article  PubMed  PubMed Central  Google Scholar 

  23. Somersalo A et al (2014) Incidence of fractures requiring inpatient care. Acta Orthop 85:525–530

    Article  PubMed  PubMed Central  Google Scholar 

  24. Hider P et al (2015) The role of facility-based surgical services in addressing the national burden of disease in New Zealand: an index of surgical incidence based on country-specific disease prevalence. Surgery 158:44–54

    Article  PubMed  Google Scholar 

  25. Pan R-H, Chang N-T, Chu D, Hsu K-F, Hsu Y-N, Hsu J-C, Tseng L-Y, Yang N-P (2014) Epidemiology of orthopedic fractures and other injuries among inpatients admitted due to traffic accidents: a 10-year nationwide survey in Taiwan. Sci World J.

    Article  Google Scholar 

  26. Kushner AL et al (2010) Addressing the millennium development goals from a surgical perspective: essential surgery and anesthesia in 8 low- and middle-income countries. Arch Surg Chic Ill 1960(145):154–159

    Article  Google Scholar 

  27. Spiegel DA, Nduaguba A, Cherian MN, Monono M, Kelley ET (2015) Deficiencies in the availability of essential musculoskeletal surgical services at 883 health facilities in 24 low- and lower-middle-income countries. World J Surg 39:1421–1432.

    Article  PubMed  CAS  Google Scholar 

  28. Kwon S et al (2012) Development of a surgical capacity index: opportunities for assessment and improvement. World J Surg 36:232–239.

    Article  PubMed  Google Scholar 

  29. Iddriss A et al (2011) Emergency, anaesthetic and essential surgical capacity in the Gambia. Bull World Health Org 89:565–572

    Article  PubMed  Google Scholar 

  30. Penoyar T et al (2012) Emergency and surgery services of primary hospitals in the United Republic of Tanzania. BMJ Open 2:e000369

    Article  PubMed  PubMed Central  Google Scholar 

  31. Premkumar A, Massawe HH, Mshabaha DJ, Foran JR, Ying X, Sheth NP (2016) The burden of orthopaedic disease presenting to a referral hospital in northern Tanzania. Glob Surg 2.

  32. National Health Accounts (NHA) Visualization|IHME Viz Hub. Accessed 11 Jan 2017

  33. PovcalNet—Detail report. Tanzania 2011—Consumption. Accessed 2 Dec 2017

  34. Funk LM et al (2010) Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet Lond Engl 376:1055–1061

    Article  Google Scholar 

  35. Roads - Paved (% of total roads) in Tanzania. Accessed 2 Dec 2017

  36. Tanzania in Figures 2012. Accessed 2 Dec 2017

  37. Spiegel DA et al (2017) Retrospective review of surgical availability and readiness in 8 African countries. BMJ Open 7:e014496

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  38. Omololu AB, Ogunlade SO, Gopaldasani VK (2008) The practice of traditional bonesetting: training algorithm. Clin Orthop 466:2392–2398

    Article  PubMed  CAS  Google Scholar 

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Sharonya L. Vadakattu, BA: Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

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Authors and Affiliations



AP (Premkumar) conceptualized the study, collected and analysed the data, and drafted the manuscript. XY, MH assisted with data collection and analysis. HM, DM FM, AP (Pallangyo), RT, GM all assisted with data collection and worked on the final manuscript. DAS worked on the final manuscript. NPS conceptualized the study with AP (Premkumar) and finalized the manuscript.

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Correspondence to Neil P. Sheth.

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The authors declare that they have no conflicts of interest.

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Premkumar, A., Ying, X., Mack Hardaker, W. et al. Access to Orthopaedic Surgical Care in Northern Tanzania: A Modelling Study. World J Surg 42, 3081–3088 (2018).

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