World J Surg DOI 10.1007/s00268-013-2317-x
Surgical Care: Addressing the Barriers to Access in Low-Income Countries Rele Ologunde • Hampus Holmer
Ó Socie´te´ Internationale de Chirurgie 2013
We read with interest, in the October 2013 issue of World Journal of Surgery, the article by Samad et al. [1], which highlighted the barriers encountered by patients trying to access surgical care in a tertiary hospital in Pakistan. These challenges are ubiquitous across the health systems of many low- and middle-income countries [2]. Samad and colleagues identified some of the reasons that these barriers to accessing surgical care exist. They characterized the barriers as contributing to first-interval delay (from the onset of symptoms to seeking initial health care) and second-interval delay (from when surgery was first advised to when it was performed). Even when patients do access care, however, they may be lost to follow-up despite having developed potentially harmful postoperative complications [3]. Thus, there may be a ‘‘third interval’’ (time from surgery to follow-up) when factors exist that further complicate the patient’s experience of accessing care. Such adverse events may influence other patients not to seek care, thus adding to the important and potentially large group of patients who never receive care for surgical illness. With surgery previously identified as a necessary component of primary care to achieve universal health coverage [4], we applaud the authors’ call to integrate general
R. Ologunde (&) Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK e-mail: [email protected] H. Holmer Faculty of Medicine, Lund University, So¨lvegatan 19, SE-221 84 Lund, Sweden e-mail: [email protected]
practitioners (GPs) into a better surgical referral network and to improve their training to be able to make surgical diagnoses. This resounds well with the Declaration of Alma Ata on Primary Health Care [5], celebrating its 35th anniversary this year. Its message of an integrated health system with primary health care as the first point of contact for patients reiterates the need for outreach initiatives in the name of primary health care to increase equitable access to specialized health care services as well. GPs are also able to act as a conduit to help patients overcome barriers to seeking specialist care as well as to follow up and maintain long-term rehabilitation. The most prominent such barrier to surgical care described in this article was the lack of knowledge about disease implications and treatment options. Interestingly, such lack of knowledge was found to be the most likely factor hindering patients from initially seeking care. Additionally, we would argue that long-standing lack of access could have led patients to become less inclined to seek care. Samad and colleagues highlighted the role of poor literacy and faulty disease perceptions. They suggested initiating a focused education campaign to address these issues. As GPs were found to be the first point of contact for up to 80 % of the study population, their potential role in educating patients about their ailments, treatment options, and disease implications should be examined further. A well-informed population is more likely to seek care when it is needed and more inclined to comply with a proposed treatment. Financial constraints remain a challenge to individuals in many low-income countries. Efforts to decrease the costs involved in treatment (including follow-up)—e.g., transportation, lost earnings, diagnosis, treatment costs—are likely to potentiate any effort to increase access to health care for underserved populations.
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World J Surg Conflicts of interest declare.
The authors have no conflict of interest to
References 1. Samad L, Jawed F, Sajun SZ et al (2013) Barriers to accessing surgical care: a cross-sectional survey conducted at a tertiary care hospital in Karachi, Pakistan. World J Surg 37:2313–2321. doi:10. 1007/s00268-013-2129-z
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2. Grimes CE, Bowman KG, Dodgion CM et al (2011) Systematic review of barriers to surgical care in low-income and middleincome countries. World J Surg 35:941–950. doi:10.1007/s00268011-1010-1 3. Ologunde R, Rufai SR (2013) Surgical follow-up in low-income and middle-income countries. Lancet Global Health 1:e132 4. World Health Organization (2008) The world health report 2008-primary health care: now more than ever. World Health Organization, Geneva 5. WHO (1978) International Conference on Primary Health Care. Declaration of Alma-Ata, Alma-Ata, U.S.S.R. Geneva, 6–12 Sept 1978
Surgical Care: Addressing the Barriers to Access in Low-Income Countries Rele Ologunde • Hampus Holmer
Ó Socie´te´ Internationale de Chirurgie 2013
We read with interest, in the October 2013 issue of World Journal of Surgery, the article by Samad et al. [1], which highlighted the barriers encountered by patients trying to access surgical care in a tertiary hospital in Pakistan. These challenges are ubiquitous across the health systems of many low- and middle-income countries [2]. Samad and colleagues identified some of the reasons that these barriers to accessing surgical care exist. They characterized the barriers as contributing to first-interval delay (from the onset of symptoms to seeking initial health care) and second-interval delay (from when surgery was first advised to when it was performed). Even when patients do access care, however, they may be lost to follow-up despite having developed potentially harmful postoperative complications [3]. Thus, there may be a ‘‘third interval’’ (time from surgery to follow-up) when factors exist that further complicate the patient’s experience of accessing care. Such adverse events may influence other patients not to seek care, thus adding to the important and potentially large group of patients who never receive care for surgical illness. With surgery previously identified as a necessary component of primary care to achieve universal health coverage [4], we applaud the authors’ call to integrate general
R. Ologunde (&) Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK e-mail: [email protected] H. Holmer Faculty of Medicine, Lund University, So¨lvegatan 19, SE-221 84 Lund, Sweden e-mail: [email protected]
practitioners (GPs) into a better surgical referral network and to improve their training to be able to make surgical diagnoses. This resounds well with the Declaration of Alma Ata on Primary Health Care [5], celebrating its 35th anniversary this year. Its message of an integrated health system with primary health care as the first point of contact for patients reiterates the need for outreach initiatives in the name of primary health care to increase equitable access to specialized health care services as well. GPs are also able to act as a conduit to help patients overcome barriers to seeking specialist care as well as to follow up and maintain long-term rehabilitation. The most prominent such barrier to surgical care described in this article was the lack of knowledge about disease implications and treatment options. Interestingly, such lack of knowledge was found to be the most likely factor hindering patients from initially seeking care. Additionally, we would argue that long-standing lack of access could have led patients to become less inclined to seek care. Samad and colleagues highlighted the role of poor literacy and faulty disease perceptions. They suggested initiating a focused education campaign to address these issues. As GPs were found to be the first point of contact for up to 80 % of the study population, their potential role in educating patients about their ailments, treatment options, and disease implications should be examined further. A well-informed population is more likely to seek care when it is needed and more inclined to comply with a proposed treatment. Financial constraints remain a challenge to individuals in many low-income countries. Efforts to decrease the costs involved in treatment (including follow-up)—e.g., transportation, lost earnings, diagnosis, treatment costs—are likely to potentiate any effort to increase access to health care for underserved populations.
123
World J Surg Conflicts of interest declare.
The authors have no conflict of interest to
References 1. Samad L, Jawed F, Sajun SZ et al (2013) Barriers to accessing surgical care: a cross-sectional survey conducted at a tertiary care hospital in Karachi, Pakistan. World J Surg 37:2313–2321. doi:10. 1007/s00268-013-2129-z
123
2. Grimes CE, Bowman KG, Dodgion CM et al (2011) Systematic review of barriers to surgical care in low-income and middleincome countries. World J Surg 35:941–950. doi:10.1007/s00268011-1010-1 3. Ologunde R, Rufai SR (2013) Surgical follow-up in low-income and middle-income countries. Lancet Global Health 1:e132 4. World Health Organization (2008) The world health report 2008-primary health care: now more than ever. World Health Organization, Geneva 5. WHO (1978) International Conference on Primary Health Care. Declaration of Alma-Ata, Alma-Ata, U.S.S.R. Geneva, 6–12 Sept 1978
