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    The How Project: understanding contextual challenges to global surgical care provision in low-resource settings

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    Author
    Raykar, NP; Yorlets, RR; Liu, C; Goldman, R; Greenberg, SLM; Kotagal, M; Farmer, PE; Meara, JG; Roy, N; Gillies, RD
    Date
    2016-11-01
    Source Title
    BMJ Global Health
    Publisher
    BMJ PUBLISHING GROUP
    University of Melbourne Author/s
    Meara, John; Greenberg, Sally
    Affiliation
    Paediatrics (RCH)
    Medicine and Radiology
    Metadata
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    Document Type
    Journal Article
    Citations
    Raykar, N. P., Yorlets, R. R., Liu, C., Goldman, R., Greenberg, S. L. M., Kotagal, M., Farmer, P. E., Meara, J. G., Roy, N. & Gillies, R. D. (2016). The How Project: understanding contextual challenges to global surgical care provision in low-resource settings. BMJ GLOBAL HEALTH, 1 (4), https://doi.org/10.1136/bmjgh-2016-000075.
    Access Status
    Open Access
    URI
    http://hdl.handle.net/11343/256206
    DOI
    10.1136/bmjgh-2016-000075
    Abstract
    INTRODUCTION: 5 billion people around the world do not have access to safe, affordable, timely surgical care. This series of qualitative interviews was launched by The Lancet Commission on Global Surgery (LCoGS) with the aim of understanding the contextual challenges-the specific circumstances-faced by surgical care providers in low-resource settings who care for impoverished patients, and how those providers overcome these challenges. METHODS: From January 2014 to February 2015, 20 LCoGS collaborators conducted semistructured interviews with 148 surgical providers in low-resource settings in 21 countries. Stratified purposive sampling was used to include both rural and urban providers, and reputational case selection identified individuals. Interviewers were trained with an implementation manual. Following immersion into de-identified texts from completed interviews, topical coding and further analysis of coded texts was completed by an independent analyst with periodic validation from a second analyst. RESULTS: Providers described substantial financial, geographic and cultural barriers to patient access. Rural surgical teams reported a lack of a trained workforce and insufficient infrastructure, equipment, supplies and banked blood. Urban providers face overcrowding, exacerbated by minimal clinical and administrative support, and limited interhospital care coordination. Many providers across contexts identified national health policies that do not reflect the realities of resource-poor settings. Some findings were region-specific, such as weak patient-provider relationships and unreliable supply chains. In all settings, surgical teams have created workarounds to deliver care despite the challenges. DISCUSSION: While some differences exist between countries, the barriers to safe surgery and anaesthesia are overall consistent and resource-dependent. Efforts to advance and expand global surgery must address these commonalities, while local policymakers can tailor responses to key contextual differences.

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