Obstacles to Surgical Services in a Rural Cameroonian District Hospital
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Obstacles to Surgical Services in a Rural Cameroonian District Hospital Andre´ M. Ilbawi • Ellen M. Einterz Daniel Nkusu
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Published online: 6 March 2013 Ó Socie´te´ Internationale de Chirurgie 2013
Abstract Background There are significant obstacles to the delivery of surgical care in low income countries. Few studies have defined or characterized these constraints. The present study aimed to identify financial and demographic factors limiting the utilization of surgical services in rural Cameroon. Methods A review was performed of all surgical records for patients presenting for surgery at the District Hospital of Kolofata in rural Cameroon over the 3-year study period (2004–2007). Disability-adjusted life years (DALYs) were calculated using disease- and patient-specific outcomes while accounting for postoperative morbidity. Univariate and multivariate analysis identified factors associated with failure to return for care. Results During the study period, 1,213 patients presented for preoperative evaluation, were informed of the cost to be paid preoperatively, and had surgery scheduled. Of these, 544 patients did not return for treatment, representing 2,163 DALYs potentially lost. Multivariate analysis revealed significant factors associated with increased likelihood of not returning for care as required preoperative payment [$US 310 (OR 0.44–0.86) and a recommended procedure for cancer (OR 0.47–0.86) or cutaneous disease (OR 0.28–0.95). Factors associated with increased odds of returning were male gender (OR 1.03–1.98), preoperative A. M. Ilbawi (&) Department of Surgery, University of Washington, School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195, USA e-mail: [email protected] E. M. Einterz D. Nkusu Hoˆpital de District de Kolofata, B.P. 111, Mora, Extreˆme-Nord, Cameroon
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payment \$US 50 (OR 2.86–16.2), and a procedure with low DALYs (OR 1.71–9.89). The average cost per DALY for all operations performed was $US 27.13. Conclusions Although surgery addresses a significant disease burden and is reported to be a cost-effective public health intervention, utilization is limited by high costs, demographic factors, and patient perceptions of surgical diseases.
Introduction The World Bank requirements for a successful public health intervention are that it is implemented on a significant scale, addresses a major problem (measured by disability-adjusted life years [DALYs]), lasts more than 5 years, proves to be cost-effective (described as \$US 100 per DALY), and produces a documented effect on outcomes [1]. Despite the recognition that an estimated one-third to one-half of the world’s population lacks basic surgical care, historically, surgery was not thought to meet these criteria because of perceived high costs and limited resource availability [2]. Recent studies have shown that surgical services can be delivered to a large population in a cost-effective manner, alleviating a substantial disease burden [3]. Significant obstacles to the implementation of surgical services remain
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