Barriers to Quality Perioperative Care Delivery in Low- and Middle-Income Countries: A Qualitative Rapid Appraisal Study : Anesthesia & Analgesia

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Original Research Articles: Original Clinical Research Report

Barriers to Quality Perioperative Care Delivery in Low- and Middle-Income Countries: A Qualitative Rapid Appraisal Study

Bedwell, Gillian J. MSc*; Dias, Priyanthi PhD; Hahnle, Lina MBChB*; Anaeli, Amani PhD; Baker, Tim PhD§,∥,¶; Beane, Abi PhD#; Biccard, Bruce M. PhD**; Bulamba, Fred MMed†††; Delgado-Ramirez, Martha B. MD‡‡,§§; Dullewe, Nilmini P. BSc∥∥,¶¶; Echeverri-Mallarino, Veronica MD§§; Haniffa, Rashan PhD##; Hewitt-Smith, Adam MBBS†††,***; Hoyos, Alejandra Sanin MSc§§; Mboya, Erick A. MD†††; Nanimambi, Juliana MMed††,***; Pearse, Rupert MD(Res); Pratheepan, Anton Premadas MBBS¶¶,‡‡‡; Sunguya, Bruno PhD§§§; Tolppa, Timo BMBS¶¶,##; Uruthirakumar, Powsiga BSc¶¶,∥∥∥; Vengadasalam, Sutharshan MS¶¶¶; Vindrola-Padros, Cecilia PhD###; Stephens, Timothy J. PhD

Author Information
doi: 10.1213/ANE.0000000000006113

Abstract

KEY POINTS

Question: What are the key barriers to delivering quality perioperative care for patients undergoing a Bellwether procedure in low- and middle-income countries (LMICs)?

Findings: We found 4 key barriers to the delivery of timely and safe perioperative care: fragmented care pathways, limited human and structural resources, the cost of care to patients, and the patients’ overall low expectations of care.

Meaning: To improve the quality and safety of surgical care and patient outcomes, work is required to overcome the identified barriers in perioperative care.

Provision of timely, safe, and affordable surgical care is an essential component of any health system, irrespective of the development status of a country. However, it is estimated that 9 in 10 people who live in low- and middle-income countries (LMICs) are unable to access essential surgical care.1,2 In many LMICs, the safety of surgical care is a serious concern, with surgical mortality being twice the global average,3 increasing to 50-fold higher for procedures such as cesarean delivery,4 despite this patient population being younger than the surgical populations of most high-income countries (HICs).3

Perioperative care encompasses all health system activities before, during, and after surgery to ensure safe and effective surgery, including primary, secondary, and social care (eg, care provided by families).5 The last 2 decades have seen significant attention to the inequalities in access to surgical services and the constraints of resources within the intraoperative space: limited beds, operating theater space, skilled surgeons, and anesthetic care. Internationally endorsed strategies to promote safer surgery6 and programs to build anesthesia and surgical provider capacity remain a priority globally.1 However, there is emerging evidence that improving access to surgical health care alone does not result in improved health outcomes unless it is coupled with quality perioperative care.7 An estimated 50 million deaths per year worldwide could be avoided by improving the quality of health care delivery7; the death rate within 30 days of surgery is estimated to be 4.2 million people worldwide, with half of these deaths occurring in LMICs. Multicountry research suggests that poor quality of care exists across the entire perioperative pathway, with most deaths occurring in the postoperative period.3,8 Therefore, research needs to focus on identifying barriers across the whole perioperative care pathway, rather than focusing solely on the surgical procedure itself, to maximize opportunities to improve patient outcomes.3,7 Access to facilities able to perform the 3 Bellwether procedures (emergency cesarean, emergency laparotomy, and treatment of open long-bone fracture fixations) has been identified as an indicator of the quality of essential surgical care in a country.9

Therefore, we aimed to identify key barriers to the delivery of safe, timely, and affordable perioperative care across the 3 Bellwether procedures in 5 diverse LMIC settings: 2 upper-middle income (Colombia and South Africa), 2 lower-middle income (Sri Lanka and Tanzania), and 1 lower income (Uganda).

METHODS

Study Design

We used a qualitative rapid appraisal design to explore and understand the barriers to perioperative care across the 3 Bellwether perioperative care pathways. Rapid appraisals collect and analyze data in a targeted way within limited timeframes, combining 2 or more methods of data collection and then using triangulation from different sources as a form of data validation.10,11 In this study, we utilized 3 forms of data collection: (1) perioperative pathway mapping, (2) observations of care, and (3) patient interviews. Our study group comprised investigators (clinical academics and social scientists) in each participating LMIC and in the United Kingdom. The study protocol was approved by the appropriate institutional review board (IRB) in each research center plus national research ethics committee approval when necessary. All aspects of the research were conducted in accordance with the research governance framework of each nation, including written informed consent from all participants unless a local IRB waiver was granted. All data collected were anonymized, and research participants were not identified. This article adheres to applicable Standards for Reporting Qualitative Research guidelines.12

Study Setting

Between April 2020 and March 2021, we conducted a multicenter study in 5 LMICS to represent a range of income levels and health systems: 2 upper-middle income (Colombia and South Africa), 2 lower-middle income (Sri Lanka and Tanzania), and 1 lower income (Uganda).

Sampling Strategy

Within each country, we purposefully sampled a range of health care institutions (between 1 and 3 hospitals per country), surgical clinicians, and surgical patients to reflect a diversity of local populations and health care facilities across urban and rural settings, providing different levels of surgical procedure provision. We considered the providers involved in the delivery of care across the different pathways and included hospitals for which different aspects of care would be delivered. Following a rapid appraisal design, our sampling approach was not created to be exhaustive, but to capture a “snapshot” of experiences in a short amount of time.13 Therefore, we combined the purposive sampling strategy described above with a convenience sampling strategy based on access of the research team to the health care institutions.

Data Collection

Data sources were the same in each country (unless indicated otherwise) and were categorized into the following categories: (1) pathway mapping, (2) observations of care, and (3) patient interviews.

Pathway Mapping

Led by the local research team, key clinical staff (nurses, surgeons, and anesthesiologists) participated in a pathway mapping exercise for the 3 Bellwether procedures. The mapping involved detailed descriptions of patients’ surgical journeys (prehospital, in-hospital, and posthospital), associated timelines, and the clinical care team involved. A visual representation of each pathway (ie, pathway “map”) was created as part of the main output of the exercise. The processes within these maps informed the scope, location, and timing of both the structured observations and interviews.

Observations of Care (Qualitative Data Collection)

Observations were conducted in appropriate perioperative locations, including emergency departments, surgical wards, and postoperative recovery areas, to document the patient pathway in practice for each procedure from start to finish. The purpose of these observations was to directly observe, understand, and document team and patient-care provider interactions within the perioperative environment relevant to the care processes under evaluation. Verbal consent to attend each clinical area was obtained from a senior nurse or doctor in that area. A structured observation guide (Supplemental Digital Content 1, File 1, https://links.lww.com/AA/D974) was used to record field notes and ensure consistency in the collection of data across researchers and sites. Observations were not conducted in Colombia and South Africa due to ethics committee regulations for research activities during the coronavirus disease 19 (COVID-19) pandemic. In other settings, guidance from local ethical committees pertaining to fieldwork during the pandemic was adhered to.

Interviews

Interviews were focused on understanding the perioperative pathway from staff and patients’ perspective in relation to barriers in the delivery of effective care. Participants were sampled purposively to represent experiences across the different pathways from an interprofessional range of clinical stakeholders (eg, nurses, surgeons, and anesthesiologists) and patients. Keeping in line with the rapid appraisal design, patients were only interviewed at the end of their care period so they would not feel obligated to participate or worry their care may be jeopardized. The combination of purposive sampling, focused scope of inquiry defined by process mapping, and reflexive data collection informed by pathway mapping, observations, and analysis as part of the rapid appraisal study design meant that the research aim was addressed with <10 interviews per site.

Data Processing and Analysis

Data collection and analysis occurred in parallel. A working document, in the form of a rapid appraisal procedure (RAP; Supplemental Digital Content 1, File 1, https://links.lww.com/AA/D974) sheet, summarized data originating from each source (interviews, observations, and pathway maps) for each Bellwether procedure. The RAP sheet facilitated consistency in data collection across researchers and research sites and allowed us to identify when data saturation was reached. Data were analyzed using a framework approach in which methods of qualitative content analysis are used to identify commonalities and differences in qualitative data, supporting the development of descriptive or explanatory themes to make sense of the data.14,15 The key foci set out in the RAP sheet facilitated a structured approach for using the framework approach for data analysis.13 Two researchers (T.J.S. and G.J.B.) cross-checked the coded data across all research sites. In line with best practice for the framework approach, triangulation of the findings from the data sources (pathway maps, observations, and interviews) was undertaken to initially identify commonalities and differences in the key barriers to delivery of perioperative care for each Bellwether procedure. Further analysis was performed to refine or challenge each candidate barrier as more data were added.11,16 This process was undertaken by the investigator team for each LMIC, with support from and discussion with the methodological team (C.V.-P. and T.J.S.), to identify systemic barriers in each country.

Table 1. - A Descriptive Summary of the Hospital Sites Within Each Country, and the Number of Interviews and Observations
Colombia South Africa Sri Lanka Tanzania Uganda
Number of hospitals 2 2 1 3 2
Hospital category Tertiary Tertiary Tertiary Secondary, specialized maternity hospital Tertiary Secondary, regional referral hospital Secondary, regional referral hospital Primary, district hospital Tertiary Secondary
Approximate number of inpatient beds 394 210 900 132 1314 350 365 150 400 100
Surgical specialist availability General, orthopedic, and obstetric General orthopedic, and obstetric General and orthopedic Obstetric General, orthopedic, and obstetric General, orthopedic, and obstetric General and obstetric General, orthopedic, and obstetric None
Location and populations served Urban and rural Urban Urban and rural Urban Urban and rural Rural
Theater availability 24/7 24/7 24/7 24/7 a 24/7 b
Health care fee structure Insurance-based health care Government funded with patients paying a proportion, according to income Government funded with free health care services Payments required for health care (insurance or out of pocket). Many groups can apply for payment exemptions c Government funded with free health care services d
Number of interviews and/or observations conducted Patients: 2 per pathway Patients: 2 per pathway Patients: 2 emergency cesarean deliveries; 1 emergency laparotomies; 2 long-bone fracture fixations Patients: 6 emergency cesarean deliveries; 5 emergency laparotomies; 4 long-bone fracture fixations Patients: 4 emergency cesarean deliveries; 6 emergency laparotomies; 2 long-bone fracture fixations
Clinical staff: 3 emergency laparotomy; 2 emergency cesarean; 2 long-bone fracture fixation
Clinical staff: 15 emergency laparotomies; 8 emergency cesarean deliveries; 15 long-bone fracture fixations
Observations: 16 emergency laparotomies; 13 emergency cesarean deliveries; 7 long-bone fracture fixations
Clinical staff: 28 across all pathways
Observations: 5
Observations: 2 emergency laparotomies; 8 emergency cesarean deliveries; 3 long-bone fracture fixations
Clinical staff: 1–3 per pathway
Clinical staff: ~4 per pathway and 2 patient interviews
Observations: 0
Observations: 0
aDistrict hospital does not provide orthopedic surgical services.
bEmergency laparotomy and long-bone fracture fixation: 12 pm–8 pm, Monday to Friday; 8 am–5 pm on weekends. For nonemergency fracture fixation: 2 d per week, 8 am–5 pm, Monday and Friday.
cMost patients pay out of pocket, and few have and use health insurance. Government waivers available for the elderly and for children.
dMost patients’ care should be government funded; however, in reality, there are out-of-pocket payments required for most care.

Table 2. - Summary of Emergency Cesarean Delivery Barriers to Care, Extracted From RAP Sheets, Online Team Discussions, and Review of the Pathway Maps
Barriers Colombia South Africa Sri Lanka Tanzania Uganda
Prehospital
Emergency medical services No barrier(s) identified Overwhelmed emergency medical services No barrier(s) identified No established emergency medical services. Patients required to use personal transport. No established emergency medical services. Patients required to use personal transport.
Referral and/or transfer between facilities No barrier(s) identified Inappropriate referrals No barrier(s) identified No established patient transfer services No barrier(s) identified
Overwhelmed facilities result in transfer to another facility
Overwhelmed patient transport services can result in a delay to transfer between facilities
External No barrier(s) identified Patient may present unbooked and to the incorrect facility (eg, presenting at a tertiary facility when their condition only requires a primary care facility). No barrier(s) identified No barrier(s) identified No barrier(s) identified
Preoperative
Limited resources and/or expertise No barrier(s) identified No barrier(s) identified No formal triage system for patients awaiting surgery Limited medical equipment at all levels of health care facilities Poor access to laboratory services and blood banks
Delayed access to specialist care
Financial No barrier(s) identified No barrier(s) identified No barrier(s) identified Patients are responsible for the costs of surgical care. No barrier(s) identified
Communication between health care workers and handover No barrier(s) identified No barrier(s) identified Inadequate communication between health care workers about patients’ labor progression Hiatus in theater services during nursing staff shift handover Hiatus in theater services during nursing staff shift handover
Intraoperative
Limited resources and/or expertise Overwhelmed theater services Insufficient number of theater staff Insufficient number of theater staff Insufficient number of theater staff Insufficient number of theater staff.
Most surgeries are performed by inexperienced, junior doctors. Overwhelmed theater services Most surgeries are performed by inexperienced, junior doctors.
Postoperative
Limited resources and/or expertise No barrier(s) identified Insufficient availability of ward beds No barrier(s) identified Limited medical equipment, specifically vitals monitors, and medical supplies No barrier(s) identified
Overwhelmed psychological support services
Inadequate referral to nongovernmental psychological support services
No access to intensive care units
Financial No barrier(s) identified No barrier(s) identified No barrier(s) identified Patients are responsible for costs of medication and postoperative wound care supplies. No barrier(s) identified
Medical complications Patients’ comorbidities No barrier(s) identified. No barrier(s) identified Sepsis No barrier(s) identified
Inadequate pain management
Discharge and follow-up Inadequate access to public transport to attend follow-up assessments No barrier(s) identified Administration delays with discharge No barrier(s) identified No barrier(s) identified
Inadequate communication between health care workers from which the patient is discharged and at which the patient will follow up
Patients’ needs and expectations No barrier(s) identified One patient reported having been separated from her infant for 2 days after she was transferred to another health care facility for escalated care. One patient reported experiencing inadequate explanations of their medical conditions and why surgery is required. No barrier(s) identified Patients reported experiencing inadequate explanations of their medical conditions and why surgery is required.
Patients reported that they would have preferred for their partner to be in the room during delivery.
One patient reported experiencing inadequate communication from the nursing staff about her infant’s medical condition.
Abbreviation: RAP, rapid appraisal procedure.

Table 3. - Summary of Emergency Laparotomy Barriers to Care, Extracted From the RAP Sheets, Online Team Discussions, and Review of the Pathway Maps
Barriers Colombia South Africa Sri Lanka Tanzania Uganda
Prehospital
 Emergency services Overwhelmed emergency medical services No barrier(s) identified Overwhelmed emergency medical services. Delays common specially from rural areas. No established emergency medical services. Patients required to use personal transport. No established emergency medical services. Patients required to use personal transport.
Patients are frequently located far from health care facilities.
 Referral and/or transfer between facilities No barrier(s) identified Overwhelmed patient transport services resulting in a delay to transfer between facilities, especially patients travelling from health care facilities located in rural areas. No barrier(s) identified Delays in referral to surgical disciplines Delays in referral to surgical disciplines
 External No barrier(s) identified Late presentations due to: Late presentations due to: Late presentations due to: Late presentations due to:
-Patients first seeking help from traditional healers PatPatients first seeking help from traditional healers   Patients first seeking help from traditional healers  Patients first seeking help from traditional healers
PatPatients hoping for resolution of symptoms. -Patients hoping for resolution of symptoms.  Patients hoping for resolution of symptoms  Patients hoping for resolution of symptoms
 Cost of care deterring patients from accessing health care  Cost of care deterring patients from accessing health care;
 Patients first seeking help from private clinics and/or pharmacies  Patients first seeking help from private clinics and/or pharmacies.
Preoperative
 Limited resources and/or expertise Overwhelmed radiology department Limited expertise at the primary care facilities contributes to inappropriate assessment, treatment, and/or referral. Limited expertise at the primary care facilities contributes to inappropriate assessment, treatment, and/or referral. Limited expertise at the primary care facilities contributes to inappropriate assessment, treatment, and/or referral. Limited expertise at the primary care facilities contributes to inappropriate assessment, treatment, and/or referral.
Overwhelmed radiology department
Reduced access to radiology and laboratory services—these services are located separate from the health care facility. Reduced access to radiology and laboratory services—these services are located separate from the health care facility.
Insufficient number of CT scanners, and limited expertise on appropriate referral for CT scan.
 Financial Delays with national health insurance approving surgery. No barrier(s) identified No barrier(s) identified Administration delays with the payment process. Patients are responsible for the costs of surgical care.
 Communication between health care workers and handover No barrier(s) identified. Hiatus in theater services during nursing staff shift handover. No barrier(s) identified. Hiatus in theater services during nursing staff shift handover. Inadequate communication between different departments within the health care facilities.
Intraoperative
 Limited resources and/or expertise Overwhelmed theater services. No barrier(s) identified. No barrier(s) identified. Overwhelmed theater services. Theaters are not operational at night.
Insufficient number of theater staff.
Most surgeries are performed by inexperienced, junior doctors.
Most surgeries are performed by inexperienced, junior doctors.
Postoperative
 Limited resources and/or expertise Insufficient availability of ward beds. Insufficient availability of ward beds. Insufficient availability of intensive care beds. Limited medical equipment, specifically vitals monitors, and medical supplies. No barrier(s) identified.
Insufficient availability of intensive care beds. Insufficient availability of intensive care beds.
No access to intensive care units.
Insufficient number of ward staff.
 Financial No barrier(s) identified No barrier(s) identified No barrier(s) identified Patients are responsible for costs of medication and postoperative wound. Patients are responsible for costs of medication and postoperative wound.
 Medical complications No barrier(s) identified No barrier(s) identified No barrier(s) identified Sepsis No barrier(s) identified
 Discharge and follow-up Inadequate access to public transport to attend follow-up assessments No barrier(s) identified Administration delays with discharge No barrier(s) identified No barrier(s) identified
Inadequate access to public transport to attend follow-up assessments
 Patients’ needs and expectations Patients reported experiencing delays to surgery, inadequate explanations of their medical conditions, and why surgery is required, problems with financial administration. No barrier(s) identifiedPatients reported that their needs were met, and they were satisfied with their care. Patients reported experiencing delays to surgery and inadequate pain management before surgery. Patients reported experiencing delays to surgery.Patients reported that their needs were met, and they were satisfied with their care. No barrier(s) identifiedPatients reported that their needs were met, and they were satisfied with their care.
Patients reported that their needs were met, and they were satisfied with their care.
Patients reported that their needs were met, and they were satisfied with their care.
Abbreviation: RAP, rapid appraisal procedure.

Table 4. - Summary of Long-Bone Fracture Fixation Barriers to Care, Extracted From RAP Sheets, Online Team Discussions, and Review of the Pathway Maps
Barriers Colombia South Africa Sri Lanka Tanzania Uganda
Prehospital
 Emergency services Overwhelmed emergency medical services. No barrier(s) identified Overwhelmed emergency medical services No established emergency medical services. Patients required to use personal transport. No established emergency medical services. Patients required to use personal transport.
Patients are frequently located far from health care facilities.
 Referral and/or transfer between facilities No barrier(s) identified No barrier(s) identified Overwhelmed patient transport services can result in a delay to transfer between facilities. No barrier(s) identified. No barrier(s) identified
 External No barrier(s) identified No barrier(s) identified Late presentations due to: Late presentations due to: Late presentations due to:
Patients first seeking help from traditional healers Patients first seeking help from traditional healers Patients first seeking help from traditional healers
Patients fearful of a risk of amputation at allopathic health care facilities
 Cost of care deterring patients from accessing health care.
Preoperative
 Limited resources and/or expertise Overwhelmed radiology department No barrier(s) identified Insufficient number of specialized health care workers, especially with expertise in anesthesia, orthopedic, and intensive care Poor access to radiology—services are located separate from the health care facility. No barrier(s) identified
 Financial Delays with the national traffic insurance approving surgery No barrier(s) identified No barrier(s) identified Patients are responsible for the costs of surgical care. Patients are responsible for the costs of surgical care.
Administration delays with the payment process
 Communication between health care workers and handover No barrier(s) identified No barrier(s) identified Inadequate communication between different departments within the health care facilities No barrier(s) identified No barrier(s) identified
Administration delays with referring patients to different departments
Intraoperative
 Limited resources and/or expertise Overwhelmed theater services Overwhelmed theater services Overwhelmed theater services; orthopedics only have access to theaters 2 d a week. Overwhelmed theater services Overwhelmed theater services; orthopedics only have access to theaters 2 d a week.
Long-bone fracture fixations frequently performed at night Limited medical equipment, specifically surgical implants and other medical supplies
No vascular surgeon in the province
Insufficient number of theater staff, especially with anesthesia expertise
Limited medical equipment, specifically surgical implants and other medical supplies
Long-bone fracture fixations frequently performed at night
Insufficient number of theater staff
Postoperative
 Limited resources and/or expertise Insufficient availability of ward beds No barrier(s) identified No barrier(s) identified Insufficient availability of ward beds Insufficient availability of ward beds
Limited access to rehabilitation services Limited access to rehabilitation services
Limited medical equipment, specifically vitals monitors, and medical supplies No access to radiological services in the ward, eg, C-arm
Limited access to rehabilitation services.
 Financial No barrier(s) identified Patients are responsible for costs of assistive devices (in certain provinces). Patients are responsible for costs of assistive devices. Patients are responsible for costs of medication, postoperative wound care supplies, and assistive devices. Patients are responsible for costs of medication, postoperative wound care supplies, and assistive devices.
 Medical complications No barrier(s) identified No barrier(s) identified Sepsis Sepsis No barrier(s) identified
 Discharge and follow-up Administration delays with discharge Administration delays with discharge Administration delays with discharge No barrier(s) identified No barrier(s) identified
Inadequate access to public transport to attend follow-up assessments
 Patients’ needs and expectations No barrier(s) identified Patients reported experiencing inadequate explanations of their discharge plan. Patients reported that their needs were met, and they were satisfied with their care. Patients reported experiencing delays to surgery, and needing to source cheaper medications from other health care facilities. Patients reported that their needs were met, and they were satisfied with their care.
Patients reported that their needs were met, and they were satisfied with their care.
Patients reported that their needs were met, and they were satisfied with their care.
Abbreviation: RAP, rapid appraisal procedure.

F1
Figure.:
Generic patient pathway highlighting the presence of barriers in the preoperative, intraoperative, and postoperative stages at each study setting. HDU indicates high-dependency unit; ICU, intensive care unit.

The results from each country were presented and discussed in online data meetings attended by researchers representing each LMIC and the UK-based team. At these meetings, cross-country data analysis and pattern matching were done as a group to identify similarities and variations in the barriers for each procedure across the different LMIC contexts and to ultimately identify the overarching barriers across the 5-country cohort.

RESULTS

A descriptive summary of the participating hospital sites within each country and the number of interviews and observations are shown in Table 1.

Common Barriers to Safe and Effective Perioperative Care

Mapped pathways for each procedure in each LMIC are depicted in Supplemental Digital Content 2, File 2, https://links.lww.com/AA/D975. Summary tables of barriers to care were extracted from RAP sheets, online team discussions, and review of pathways across all 5 LMICs for emergency cesarean delivery (Table 2), emergency laparotomy (Table 3), and long-bone fracture fixation (Table 4). From our data set, 4 key themes were identified as major barriers to safe and effective care: (1) the fragmented nature of the care pathways, (2) limited resources for the provision of care, (3) direct and indirect costs of care for patients, and (4) patients’ low expectations of care. The Figure is a graphic representation of the perioperative pathway, combining the key commonalities from the individual country and procedure pathway maps (in Supplemental Digital Content 2, File 2, https://links.lww.com/AA/D975). Barriers to effective care (represented in circles) are located at key points in the pathway, alongside the countries in which they were identified (represented in triangles).

The Fragmented Nature of the Care Pathways

Fragmented care was identified as the main barrier to effective perioperative care in all countries. However, the extent and nature of fragmented care varied between the 3 Bellwether procedures, between hospitals, and across the 5 LMICs. Five aspects of fragmented care were identified as key barriers to effective perioperative care. First, lack of early condition identification substantially delayed the time to surgery across all 3 Bellwether procedures. In particular, a large proportion of emergency laparotomies were delayed because of patients presenting with diffuse and nonspecific symptoms. This was especially problematic in Tanzania and Uganda, where patients often had a circuitous journey to accessing a health care setting in which definitive care could be delivered. Patients in these 2 countries frequently present at traditional healers, pharmacies or drug-dispensing outlets, private clinics, or primary health care facilities, where delays to diagnoses and misdiagnoses were frequent. The use of traditional healers was perceived by health care providers to be a complicating factor, often leading to late presentation to the hospital.

Second, limited ambulance services and/or the need to pay for transportation services (see direct and indirect costs of care for patients below) meant that transportation to and from health care facilities limited accessibility of perioperative care. Colombia and South Africa were the only settings with established ambulance services. In Sri Lanka, ambulance services were available in urban areas, but were often provided by private companies and were not freely available to all patients. At the time of data collection, there were no formally established ambulance services in Tanzania and Uganda.

Third, in all countries and for all 3 procedures, preoperative care was poorly coordinated, which substantially delayed time to surgery. Patients were often seen by several different health care providers: first for triage and then by emergency department physicians (who were often “gatekeepers” for emergency hospital admissions), after which, they were reviewed by several grades of surgeons before the decision for surgery was made. Repeated assessment from various specialties resulted in delays to diagnosis and/or surgical intervention. Furthermore, patients were often physically relocated to multiple different departments within the hospital for assessment, reassessment, and various diagnostic investigation (eg, radiology), further delaying time to surgery. Fourth, linking with poorly coordinated care, poor interdisciplinary communication was a common barrier to timely assessment and perioperative management of patients. Finally, limited postoperative care planning delayed discharge. However, given that patients in Uganda, Tanzania, and Sri Lanka are frequently unable to access postoperative care, clinicians in these settings sometimes deliberately delayed discharge to facilitate postoperative recovery and prevent complications. All 5 LMICs provided limited data from the observations and interviews on the postoperative setting.

Limited Resources for the Provision of Care

Limited resources for the provision of care were a barrier to effective perioperative care in all countries. Limitations in human resources (both in terms of skills or expertise and availability of various cadres of staff) and physical resources (including, but not limited to, theater access, surgical equipment, and postoperative monitoring equipment) were barriers in all 3 Bellwether perioperative care pathways in all 5 LMICs. Limited human resources were evident by insufficient capacity of health care providers (eg, intensivists, anesthetists, obstetricians, and rehabilitation therapists). Furthermore, levels of seniority and experience contributed to insufficient human resources. There were limited senior surgical team members in Uganda and Sri Lanka. In Uganda, junior surgeons and medical officers usually perform all emergency surgeries in the tertiary and secondary hospitals, respectively. In Sri Lanka, there were limited senior surgeons in the peripheral hospitals but sufficient senior surgeons in the tertiary hospitals. Limited human resources often led to canceled appointments (eg, antenatal), and patients being transferred to other hospitals, which delayed time to surgery. To alleviate the problems of poor staffing, care was often provided by junior, less experienced staff members, and, in some instances, students (eg, Uganda).

Besides the limited human resources and provision of ambulance services (see above), limited surgical equipment, access to operating theaters, and insufficient availability of postoperative beds were major barriers to effective perioperative care. Availability of surgical equipment was particularly problematic in Tanzania and Uganda, where clinicians reported having insufficient availability of surgical implants for internal fixation of long-bone fracture fixations. Furthermore, in Tanzania, there was a lack of equipment required to monitor patients both preoperatively and postoperatively and insufficient blood stocks for blood transfusions. Access to operating theaters was a barrier in all 5 LMICs.

Direct and Indirect Costs of Care for Patients

The direct and indirect costs of medical care for patients and their families were identified as barrier to affordable perioperative care, especially when out-of-pocket payments were required, but this cost burden varied across the 5 LMICs. Out-of-pocket payments were required for transport to health care facilities in all settings. The risk of incurring out-of-pocket costs for direct medical care was worst in Uganda and Tanzania, even though health care is ostensibly free at the point of care for everyone or through application for an exemption. In these 2 countries, costs incurred often related to a lack of stock such as medicines or dressings, which forced patients to buy these from outside the hospital to continue their care. Furthermore, patients in Uganda and Tanzania were denied long-bone fracture fixation until they could afford to cover the costs of the surgical implants. Fear of incurring substantial health care costs were reported as a cause of late presentation to hospital. In Colombia, the insurance-based system was found to contribute to substantial delays while payments were awaiting authorization. In all 5 LMICs, indirect costs in the form of lost income during hospital admission were experienced by patients.

Patients’ Low Expectations of Care

Patients’ low expectations of care were identified as barriers to effective perioperative care. Where observations of care did take place, it was noted that there was a disparity between the quality of observed care (from the researchers’ perspective) and patients’ reported satisfaction of care. Overall, patients reported being satisfied with care despite being poorly informed about their medical plan. However, while patients in Colombia, South Africa, and Sri Lanka reported being satisfied with their perioperative care, they also recognized that problems existed in their care pathways.

DISCUSSION

We identified 4 major barriers to perioperative care delivery for the Bellwether procedures across 5 LMICs perioperative health systems: (1) fragmented nature of the perioperative pathways, (2) limited resources for the provision of perioperative care, (3) direct and indirect costs of perioperative care for patients, and (4) patients’ expectations of care. The extent and severity of these barriers varied across the study cohort, but there was sufficient enough commonality that they represent 4 key areas to further the health system research focused on improving perioperative care for emergency surgical procedures in LMICs.

Fragmented care presents numerous interlinked barriers to safe and efficient perioperative care. Accessing care was frequently delayed due to patients spending time and/or money seeking assistance from traditional healers who had unestablished referral and communication channels with emergency allopathic care providers. Establishing effective referral pathways between traditional healers and allopathic health care providers, and educating the public about services offered by both traditional healers and allopathic care providers, offers an opportunity for public health interventions to reduce delays in appropriate management of Bellwether procedures. After a patient is receiving perioperative care, coordinated care could be improved through effective interdisciplinary communication. Effective planning, including establishing clear and agreed upon care management pathways using an interdisciplinary team approach, could reduce the redundancies across the perioperative period, thus reducing the time to surgery. Furthermore, inefficient interdisciplinary communication may contribute to perioperative mortality due to a delay in the identification, and possible escalation, of care needed in patients with physiological decline. There was limited preoperative monitoring for physiological deterioration. Furthermore, limited postoperative care planning was identified in all 5 LMICs. There were very limited data collected on the postoperative period from observations and interviews. This may indicate a lack of focus on postoperative care. A recent study investigating postoperative complications in surgical patients in Africa reported that 95% of deaths occurred in the postoperative period.3 Further research is needed to thoroughly investigate the drivers of, and strategies to reduce, this high mortality rate in the postoperative period, including adapting early warning scores for LMIC settings.17

The second barrier that was identified was limited resources for the provision of perioperative care. These limited resources can be defined as inequalities in access and/or availability of resources to provide perioperative care. In this study, limited resources included both insufficient human resources and physical resources (eg, surgical equipment and theater space) to conduct necessary surgical and perioperative procedures. Lack of monitoring equipment and/or access to critical care beds was a major barrier for effective preoperative and postoperative monitoring in most countries, in particular for emergency laparotomy patients, who may also be considered at highest risk of postoperative complications. Our finding of insufficient human resources is unsurprising, given that by the median number of specialist physician surgical, anesthesia, and obstetric providers is 68 (49–90) per 100,000 in HICs, 24 (11–55) per 100,000 in upper- middle-income countries, 4 (2–15) per 100,000 in lower- middle-income countries, and 0.7 (0.4–1.7) per 100,000 in low-income countries.18,19 This is substantially lower than the recommended 20–40 specialists per 100,000 providers needed to reduce perioperative mortality.1 Clearly, there is an urgent need to build human resource capacity and availability of surgical equipment and supplies in LMICs, and, in particular, those who become critically ill.20,21 Ensuring the most essential care is provided to sick surgical patients, such as that recently specified as essential emergency and critical care, could assist in prioritization decisions when resources are limited.22,23

The third barrier identified was direct and indirect costs of care for patients. All 5 LMICs included in this study have health care systems that profess to provide affordable care at the point of entry; however, we found that costs associated directly and indirectly with the perioperative care pathway were significant barriers to perioperative care. These financial barriers were particularly problematic in Uganda and Tanzania. In these 2 countries, ambulance services are nonexistent, and patients must often travel far distances to hospitals with significant out-of-pocket expenses. A further confounding factor is poverty. An extended absence from work and subsequent loss of income could have a significant impact on patients and their families, leading to delayed presentation. Furthermore, surgical procedures were delayed when patients could not fund necessary surgical supplies. For example, long-bone fracture fixation was denied until patients could cover the costs of the surgical implants. In contrast, in Colombia, where insurance funding was available, regulatory systems were slow to approve funding for long-bone fracture fixation procedures, thus delaying time to surgery. The surgical component per capita for providing 80% essential health coverage for surgery is $5.10 (US dollars) in low-income countries and 7.40 in lower- middle-income countries.24 LMICs do not spend enough on health, yet the necessary contribution for safe surgery is important and relatively small. We recommend that this be explored in future studies.

The fourth barrier was patients’ low expectations of care. Poor quality of care contributes to >8 million deaths in LMICs per year.25 In this study, patients reported being generally satisfied with their perioperative care despite being poorly informed about their medical plan, reporting poor pain management, and experiencing long wait times. There may be an expectation of poor quality care, and hence, a lack of visible dissatisfaction, as the Commission on High Quality Health Systems reported that <25% of patients in LMICs believed their health care system to work well, compared to 50% of patients in HICs.25 Importantly, quality of care has previously been reported to be worse in patients from vulnerable groups (eg, impoverished, less educated, adolescents, and those with stigmatized conditions).25 This is important, as these vulnerable groups are common in LMICs. However, more data are required to explore whether vulnerable groups report being satisfied with their care despite receiving objectively inadequate care in LMICs. Civil society needs to drive improvement in perioperative care,25 as patient outcomes will improve if the health care system is held accountable. Therefore, we recommend that public health messaging focus on improving health literacy (eg, educating populations on common conditions and surgical treatments) to facilitate patient empowerment.

Strengths and Limitations

While the barriers to effective care found in this study have been identified in other areas of health services research in LMICs, none have focused on the perioperative journey specifically. Greater worldwide access to surgical care will not necessarily result in better patient outcomes unless these procedures are nested in safe and effective perioperative care pathways. Hence, we designed this study to stimulate and focus the research agenda in this area. However, there are limitations in this work. Our study was not designed to directly investigate and/or quantify the impact of the identified barriers on patient outcomes, and further research, informed and focused by this study, will be required to do so. It is important to consider that there can be a huge difference in the care of patients in an urban/tertiary/university hospital compared to hospitals in rural areas. Where possible, local teams selected >1 study site to mitigate against this risk, but logistical considerations during the COVID-19 pandemic meant this was not always possible. The pandemic also meant that in 2 countries, observations of care could not be performed. The pragmatic nature of rapid appraisals, which develop understanding of a program from the perspectives of key stakeholders, also presents limitations, despite the RAP sheet providing a structure for data collection. For example, some details of which specific groups contributed to “staff shortages” were missed, and most teams collected only limited data about the postoperative phase. This suggests a systematic failure to appreciate the importance of good quality postoperative care, leading to complications and unnecessary mortality.

In conclusion, to improve perioperative care in these LMICs, we need to address the fragmentation of the care pathways, focus on increasing resources for the provision of perioperative care, provide strategies to prevent undue cost to patients for essential care necessary for universal health coverage, and provide education that explains how to access care and what should be expected as acceptable care.

ACKNOWLEDGMENTS

The authors thank Loreta Nandyose Sewanyana, who organized patient interviews and mapping meetings in Uganda.

DISCLOSURES

Name: Gillian J. Bedwell, MSc.

Contribution: This author made substantial contributions to data acquisition, analysis, and interpretation for the work; to drafting the work critically for important intellectual content; and gave final approval of the version to be published.

Conflicts of Interest: G. J. Bedwell receives speakers’ fees for talks on pain and rehabilitation.

Name: Priyanthi Dias, PhD.

Contribution: This author made substantial contributions to data analysis and interpretation for the work; to revising the draft manuscript for important intellectual content; and gave final approval of the version to be published.

Conflicts of Interest: None.

Name: Lina Hahnle, MBChB.

Contribution: This author made substantial contributions to data acquisition, analysis, and interpretation for the work; to revising the draft manuscript for important intellectual content; and gave final approval of the version to be published.

Conflicts of Interest: None.

Name: Amani Anaeli, PhD.

Contribution: This author made substantial contributions to data acquisition, analysis, and interpretation for the work; to revising the draft manuscript for important intellectual content; and gave final approval of the version to be published.

Conflicts of Interest: None.

Name: Tim Baker, PhD.

Contribution: This author made substantial contributions to the design of the work, revised the manuscript, and approved the final version.

Conflicts of Interest: T. Baker declares a grant and personal fees from the Wellcome Trust and personal fees from UNICEF, the World Bank, and USAID, all outside the submitted work.

Name: Abi Beane, PhD.

Contribution: This author made significant contributions to the methodology, formal analysis, and writing of the original draft; supervision and project administration; and approved the final version.

Conflicts of Interest: None.

Name: Bruce M. Biccard, PhD.

Contribution: This author made substantial contributions to the conception or design of the work; data acquisition, analysis, and interpretation for the work; drafting the work or revising it critically for important intellectual content; and gave final approval of the version to be published.

Conflicts of Interest: None.

Name: Fred Bulamba, MMed.

Contribution: This author participated in the design of the study; data acquisition, analysis, and interpretation for the work; revising the draft manuscript for important intellectual content; and gave final approval of the version to be published.

Conflicts of Interest: None.

Name: Martha B. Delgado-Ramirez, MD.

Contribution: This author helped with data acquisition, analysis, and interpretation for the work; made some additional contributions to the final draft of the manuscript; and approved the final version.

Conflicts of Interest:None.

Name: Veronica Echeverri-Mallarino, MD.

Contribution: This author helped with formal analysis, investigation, and review and editing of the manuscript; and approved the final version.

Conflicts of Interest: None.

Name: Nilmini P. Dullewe, BSc.

Contribution: This author helped with data acquisition, analysis, and interpretation for the work; made some additional contributions to the final draft of the manuscript; and approved the final version.

Conflicts of Interest: None.

Name: Rashan Haniffa, PhD.

Contribution: This author helped with review and editing of the manuscript and supervision.

Conflicts of Interest: None.

Name: Adam Hewitt-Smith, MBBS.

Contribution: This author made substantial contributions to data acquisition, analysis, and interpretation for the work; revising the draft manuscript for important intellectual content; and gave final approval of the version to be published.

Conflicts of Interest: None.

Name: Alejandra Sanin Hoyos, MSc.

Contribution: This author helped with data acquisition, analysis, and interpretation for the work; made some additional contributions to the final draft of the manuscript; and approved the final version.

Conflicts of Interest: None.

Name: Erick A. Mboya, MD.

Contribution: This author made substantial contributions to the design of the study; data acquisition, analysis, and interpretation for the work; revising the draft manuscript for important intellectual content; and gave final approval of the version to be published.

Conflicts of Interest: None.

Name: Juliana Nanimambi, MMed.

Contribution: This author participated in collection and interpretation of data for the work, and responded to regularly upcoming queries during the drafting and editing of the final version to be published.

Conflicts of Interest: None.

Name: Rupert Pearse, MD(Res).

Contribution: This author made substantial contributions to the conception and design of the work, revised the manuscript, and approved the final version.

Conflicts of Interest: R. Pearse has received research grants and/or honoraria from Edwards Lifesciences, Intersurgical, and GlaxoSmithKline. He is a member of the editorial boards of the British Journal of Anaesthesia and the British Journal of Surgery, and was previously an associate editor at BMJ Quality & Safety.

Name: Anton Premadas Pratheepan, MBBS.

Contribution: This author helped with investigation, review and editing of the manuscript, and approved the final version.

Conflicts of Interest: None.

Name: Bruno Sunguya, PhD.

Contribution: This author made substantial contributions to the design of the work; supervision in data acquisition, analysis, and interpretation for the work; revising the draft manuscript for important intellectual content; and revised the manuscript and approved the final version to be published.

Conflicts of Interest: None.

Name: Timo Tolppa, BMBS.

Contribution: This author helped with methodology, formal analysis, investigation, data curation, review, editing, and visualization of the manuscript; and approved the final version.

Conflicts of Interest: None.

Name: Powsiga Uruthirakumar, BSc.

Contribution: This author helped with investigation, review, and editing of the manuscript; and approved the final version.

Conflicts of Interest: None.

Name: Sutharshan Vengadasalam, MS.

Contribution: This author helped with formal analysis, resource provision, supervision, review and editing of the manuscript, and approved the final version.

Conflicts of Interest: None.

Name: Cecilia Vindrola-Padros, PhD.

Contribution: This author made substantial contributions to the conception and design of the work, revised the manuscript, and approved the final version.

Conflicts of Interest: None.

Contribution: This author made substantial contributions to the conception and design of the work; data acquisition, analysis, and interpretation for the work; drafting the work or revising it critically for important intellectual content; and gave final approval of the version to be published.

Conflicts of Interest: None.

This manuscript was handled by: Angela Enright, MB, FRCPC.

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