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Background: Surgery is among the most neglected parts of healthcare systems in low‐ and middle‐income countries. Ethiopia has launched a national strategic plan to address challenges in the surgical system. This study aimed to assess surgical capacity in two Ethiopian regions to inform priority areas for improvement. Methods: A mixed‐methods study was conducted using two tools adapted from the Lancet Commission's Surgical Assessment Tools: a quantitative Hospital Assessment Tool and a qualitative semistructured interview tool. Fifteen hospitals selected by the Federal Ministry of Health were surveyed in the Tigray and Amhara regions to assess the surgical system across five domains: service delivery, infrastructure, workforce, information management and financing. Results: Service delivery was low across hospitals with a mean(s.d.) of 5(6) surgical cases per week and a narrow range of procedures performed. Hospitals reported varying availability of basic infrastructure, including constant availability of electricity (9 of 15) and running water (5 of 15). Unavailable or broken diagnostic equipment was also common. The majority of surgical and anaesthesia services were provided by non‐physician clinicians, with little continuing education available. All hospitals tracked patient‐level data regularly and eight of 15 hospitals reported surgical volume data during the assessment, but research activities were limited. Hospital financing specified for surgery was rare and the majority of patients must pay out of pocket for care. Conclusion: Results from this study will inform programmes to simultaneously improve each of the health system domains in Ethiopia; this is required if better access to and quality of surgery, anaesthesia and obstetric services are to be achieved. Much to be done still [ABSTRACT FROM AUTHOR]

Acellular dermal matrix (ADM) implant-based reconstructions have transformed direct-to-implant breast reconstruction (DTI). But like all surgery, it is not deplete of complications such as seroma, infections and wound healing problems. These are cited with varying frequencies in the literature. With increased experience and through a series of measures instituted to minimize complications, we have been able to improve outcomes for our patients. We report our technical refinements for prevention of ADM reconstruction associated complications including patient selection, implant selection, drains, dressing and our post operative antibiotic regime. We also outline our protocol for the management of ADM associated complications including seroma, simple and complex infection and red breast syndrome, such that the sequelae of complications are minimized and patients achieve a better long-term outcome.

Aims: To share experiences and learning curve of the introduction of profunda artery perforator (PAP) flaps in breast reconstruction. The secondary aim was to share techniques to improve outcomes., Methods: Case series reviewing outcomes of 56 consecutive PAP flaps performed by a single surgeon across five institutions between March 2021 and May 2023 were reported. The senior author's preference is to routinely stack and bury the flaps to optimise cosmetic outcomes., Results: Fifty-six PAP flaps were performed in 30 patients. The majority of the PAPs were stacked (n = 43, 77%). The mean age at surgery was 46 years (SD 8.44 years) and mean body mass index was 23.86 (SD 3.59). The mean flap weight was 198.83 g (SD 82.86 g) and the mean combined weight for stacked flaps was 369.57 g (SD 98.65 g). Mean ischaemia time was 56.59 min (SD 17.83 min). There was one flap loss (2%). Of the immediate flaps, 90% were buried and monitored using flow couplers., Conclusion: The routine use of PAPs, in particular stacked PAPs, allows for adequate volume and height for breast reconstruction in patients who may have otherwise been deemed unsuitable for autologous breast reconstruction. The PAP flap has replaced the transverse upper gracilis and superior gluteal artery perforator flaps as the second line flap choice in our practice., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The purpose of this study is to compare outcomes in patients undergoing buried and non-buried free flaps for breast reconstruction, in addition to evaluating the safety and reliability of venous flow couplers. A retrospective review was performed of all patients undergoing free flap breast reconstruction between 2013 and 2023. The primary outcomes were free flap failure, complications and the number of procedures required to complete the reconstructive journey. A total of 322 flaps were performed in 254 consecutive patients, with 47.5% ( n = 153) being buried and 52.0% ( n = 169) being non-buried reconstructions. The most common flap of choice being deep inferior epigastric artery perforator flaps (81.9%) followed by profunda artery perforator flaps (14.3%). There was no significant difference between the two groups in complications, including flap failure (buried 2.0% vs. non-buried 1.8% p = 0.902). There was a significant reduction in the number of procedures required to complete the reconstructive journey, with 52.2% ( n = 59) of patients undergoing single-stage breast reconstruction in the buried group compared with only 25.5% ( n = 36) in the non-buried group ( p < 0.001). Two (0.6%) patients experienced a false negative in which the signal of the flow coupler was lost but the flap was perfused during re-exploration. No flap losses occurred without being identified in advance by a loss of audible venous flow signal. Buried free flap breast reconstruction is safe and requires fewer operations to complete patients' reconstructive journey. Flow couplers are a safe and effective method of monitoring buried free flaps in breast reconstruction.

Competing Interests: Declaration of Competing Interest None declared.

Aim: To assess the effect of cosmetic rhinoplasty on PROMS using the FACE-Q™ tool., Methods: Between July 2020 and February 2022 all patients undergoing rhinoplasty by a single surgeon were approached pre-operatively and 6 months post-operatively to complete the Face-Q™ "Satisfaction with Nose" module. Post-operative patients were asked to complete the FACE-Q™ "Satisfaction with Outcome" module., Results: One hundred and sixty-five patients underwent rhinoplasty (147 primary, 18 revisions). Eighty two percent (n = 135) completed a pre-operative "Satisfaction with Nose" module. Thirty three percent (n = 54) completed the full pre and post- operative dataset. The mean pre-operative "Satisfaction with Nose" score was 32.88 (± 8.40). The mean post-operative "Satisfaction with Nose" score was 77.45 (SD17.26) and "Satisfaction with Outcome" score was 75.27(SD 21.88). The mean change in score 133% (SD 63%). Seventy-seven percent of patients were "very satisfied" or "somewhat satisfied" across all 10 aspects of the nose. The tip had the lowest post-operative satisfaction with 19% of patients somewhat or very dissatisfied., Conclusion: Rhinoplasty generates significant improvements in PROMS and satisfaction is high, an important positive finding for patients considering surgery. Routine collection of PROMS for rhinoplasty can inform practice and guide expectations as to its psychological impact., Competing Interests: Conflicts of interest None declared., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

This commentary discusses an article by Broekhuizen et al which assesses policy options for scaling up the SURG-Africa surgical team mentoring program in Malawi to increase access to surgical care. In modeling these scenarios, the authors assess the cost of scaling up surgical teams mentoring and the impacts of scaling the program on district hospitals (DHs) and central hospitals (CHs). The additional costs borne by DHs when increasing surgical volume remains a significant issue identified by the authors and could ultimately determine the success of the program. The piece indirectly advocates for an increased role for task-shifting. The Ministry of Health of Malawi will have to ensure the appropriate governance and regulatory processes are in place to maintain quality and accountability., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Objective: Brazil is a country with universal health coverage, yet access to surgery among remote rural populations remains understudied. This study assesses surgical care capacity among hospitals providing care for the rural populations in the Amazonas state of Brazil through in-depth facility assessments., Methods: a stratified randomized cross-sectional evaluation of hospitals that self-report providing surgical care in Amazonas was conducted from July 2016 to March 2017. The Surgical Assessment Tool (SAT) developed by the World Health Organization and the Program in Global Surgery and Social Change at Harvard Medical School was administered at remote hospitals, including a retrospective review of medical records and operative logbooks., Results: 18 hospitals were surveyed. Three hospitals (16.6%) had no operating rooms and 12 (66%) had 1-2 operating rooms. 14 hospitals (77.8%) reported monitoring by pulse oximetry was always present and six hospitals (33%) never have a professional anesthesiologist available. Inhaled general anesthesia was available in 12 hospitals (66.7%), but 77.8% did not have any mechanical ventilation device. An average of 257 procedures per 100,000 were performed. 10 hospitals (55.6%) do not have a specific post-anesthesia care unit. For the regions covered by the 18 hospitals, with a population of 497,492 inhabitants, the average surgeon, anesthetist, obstetric workforce density was 6.4., Conclusion: populations living in rural areas in Brazil face significant disparities in access to surgical care, despite the presence of universal health coverage. Development of a state plan for the implementation of surgery is necessary to ensure access to surgical care for rural populations.

Background: Motor overflow refers to involuntary movements that accompany voluntary movements in healthy individuals. This may have a role in synkinesis. Objective: To describe the frequency and magnitude of facial motor overflow in a healthy population. Methodology: Healthy participants performed unilateral facial movements: brow elevation, wink, snarl, and closed smile. Two reviewers analyzed the magnitude of each movement and cocontraction. Patterns of movements are described. Univariate analysis was used to assess the relationship between efficacy of unilateral facial control and the frequency and magnitude of cocontractions. Results: Eighty-nine participants completed the videos. Consensual mirror movements occurred in 96% of participants during unilateral eye closure and 86% during brow elevation. The most common associated movement was ipsilateral eye constriction occurring during snarl (90.1%). Improved unilateral facial control was associated with a decrease in frequency and magnitude of associated movements during brow elevation, wink, and snarl. Conclusion: This study showed stereotyped patterns of motor overflow in facial muscles that resemble those in synkinesis and become more evident as unilateral control of the face decreases.

Introduction: Many patients worldwide are unable to access timely primary repair of cleft lip and palate. The aim of this study was to assess patient-perceived barriers to accessing timely cleft lip and palate repair across Brazil., Methods: A 29-item questionnaire was applied to patients undergoing surgery for cleft lip and/or palate across five contrasting sites in Brazil from February 2016 to November 2017. Differences in patient timelines, demographics, and patient-reported barriers were compared by region. A multivariate logistic regression was used to determine predictors of delayed care., Results: Of 181 patients, 42% of patients received timely primary surgical repair. The age of the patient at the interview was 82 months (standard deviation [SD] 107) and 52% were male. The majority of delays occurred between diagnosis and primary surgical repair. The mean number of barriers to accessing timely surgical care cited by each patient was 3.77. The most common barrier was perceived "lack of hospitals that provided the surgery in my area" (48% (n = 86)). Univariate logistic regression showed increased odds of receiving late care in the state of Amazonas (odds ratio [OR] 2.91; 95% confidence interval [CI] 1.07-7.96; P = 0.037) or Para (OR 4.46; 95% CI 1.09-19.70; P = 0.037). Multivariate logistic regression determined predictors of delayed care to be female sex (OR = 2.05; 95% CI 1.05-3.99; P = 0.035) and perceived poor availability of care (OR = 0.045; 95% CI 1.02-4.37; P = 0.045)., Conclusion: The majority of patients in Brazil are not receiving timely primary repair of their clefts. Improvements in the coordination of care, patient education and patient empowerment are required., Competing Interests: Declaration of Competing Interest None declared, (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Evidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. We explored factors driving performance in the Safe Surgery 2020 intervention in Tanzania's Lake Zone to distil implementation lessons for low-resource settings., Methods: We identified higher (n=3) and lower (n=3) performers from quantitative data on improvement from 14 safety and teamwork and communication indicators at 0 and 12 months from 10 intervention facilities, using a positive deviance framework. From 72 key informant interviews with surgical providers across facilities at 1, 6 and 12 months, we used a grounded theory approach to identify practices of higher and lower performers., Results: Performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum., Conclusion: Future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions., Competing Interests: Competing interests: SA, SSA, EB, MC, PC, IC, ADM, EE, LF, GCG, MG, AH, DTJ, AK, LK, StK, SaK, TNL, EM, SM, AM, GM, ChaR, CheR, HS, DS, VS, CS, MS, LT, AT, JV, TW and NZ had financial support from GE Foundation for the submitted work. EE, AH, GCG, AK, LF, SM, DS, LT, AT and JV declare financial support from ELMA Philanthropies. DB is employed by GE Foundation, which funded this work. NAK reports that he is the Director of Health, Social Welfare and Nutrition Services at PO-RALG in Tanzania. SM reports that she is the Acting Assistant Director NCDs, at the Ministry of Health, Community Development, Gender, Elderly and Children in Tanzania. Both institutions are party to the MoU under which the Safe Surgery 2020 intervention (the subject of the study/assessment) is implemented., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Evidence-based strategies for improving surgical quality and patient outcomes in low-resource settings are a priority., Objective: To evaluate the impact of a multicomponent safe surgery intervention (Safe Surgery 2020) on (1) adherence to safety practices, teamwork and communication, and documentation in patient files, and (2) incidence of maternal sepsis, postoperative sepsis, and surgical site infection., Methods: We conducted a prospective, longitudinal study in 10 intervention and 10 control facilities in Tanzania's Lake Zone, across a 3-month pre-intervention period in 2018 and 3-month post-intervention period in 2019. SS2020 is a multicomponent intervention to support four surgical quality areas: (i) leadership and teamwork, (ii) evidence-based surgery, anesthesia and equipment sterilization practices, (iii) data completeness and (iv) infrastructure. Surgical team members received training and mentorship, and each facility received up to a $10 000 infrastructure grant. Inpatients undergoing major surgery and postpartum women were followed during their stay up to 30 days. We assessed adherence to 14 safety and teamwork and communication measures through direct observation in the operating room. We identified maternal sepsis (vaginal or cesarean delivery), postoperative sepsis and SSIs prospectively through daily surveillance and assessed medical record completeness retrospectively through chart review. We compared changes in surgical quality outcomes between intervention and control facilities using difference-in-differences analyses to determine areas of impact., Results: Safety practices improved significantly by an additional 20.5% (95% confidence interval (CI), 7.2-33.7%; P = 0.003) and teamwork and communication conversations by 33.3% (95% CI, 5.7-60.8%; P = 0.02) in intervention facilities compared to control facilities. Maternal sepsis rates reduced significantly by 1% (95% CI, 0.1-1.9%; P = 0.02). Documentation completeness improved by 41.8% (95% CI, 27.4-56.1%; P < 0.001) for sepsis and 22.3% (95% CI, 4.7-39.8%; P = 0.01) for SSIs., Conclusion: Our findings demonstrate the benefit of the SS2020 approach. Improvement was observed in adherence to safety practices, teamwork and communication, and data quality, and there was a reduction in maternal sepsis rates. Our results support the emerging evidence that improving surgical quality in a low-resource setting requires a focus on the surgical system and culture. Investigation in diverse contexts is necessary to confirm and generalize our results and to understand how to adapt the intervention for different settings. Further work is also necessary to assess the long-term effect and sustainability of such interventions., (© The Author(s) 2021. Published by Oxford University Press on behalf of International Society for Quality in Health Care.)

Background: Postoperative mortality rate is one of six surgical indicators identified by the Lancet Commission on Global Surgery for monitoring access to high-quality surgical care. The primary aim of this study was to measure the postoperative mortality rate in Tanzania's Lake Zone to provide a baseline for surgical strengthening efforts. The secondary aim was to measure the effect of Safe Surgery 2020, a multi-component intervention to improve surgical quality, on postoperative mortality after 10 months., Methods: We prospectively collected data on postoperative mortality from 20 health centers, district hospitals, and regional hospitals in Tanzania's Lake Zone over two time periods: pre-intervention (February to April 2018) and post-intervention (March to May 2019). We analyzed postoperative mortality rates by procedure type. We used logistic regression to determine the impact of Safe Surgery 2020 on postoperative mortality., Results: The overall average in-hospital non-obstetric postoperative mortality rate for all surgery procedures was 2.62%. The postoperative mortality rates for laparotomy were 3.92% and for cesarean delivery was 0.24%. Logistic regression demonstrated no difference in the postoperative mortality rate after the Safe Surgery 2020 intervention., Conclusions: Our results inform national surgical planning in Tanzania by providing a sub-national baseline estimate of postoperative mortality rates for multiple surgical procedures and serve as a basis from which to measure the impact of future surgical quality interventions. Our study showed no improvement in postoperative mortality after implementation of Safe Surgery 2020, possibly due to low power to detect change.

Background: All-cause perioperative mortality rate (POMR) is a commonly reported metric to assess surgical quality. Benchmarking POMR remains difficult due to differences in surgical volume and case mix combined with the burden of reporting and leveraging this complex and high-volume data. We seek to determine whether the pooled and individual procedure POMR of each bellwether (cesarean section, laparotomy, management of open fracture) correlate with state-level all-cause POMR in the interest of identifying benchmark procedures that can be used to make standardized regional comparisons of surgical quality., Methods: The Brazilian National Healthcare Database (DATASUS) was queried to identify unadjusted all-cause POMR for all patient admissions among public hospitals in Brazil in 2018. Bellwether procedures were identified as any procedure involving laparotomy, cesarean section, or treatment of open long bone fracture and then classified as emergent or elective. The pooled POMR of all bellwether procedures as well as for each individual bellwether procedure was compared with the all-cause POMR in each of the 26 states, and one federal district and correlations were calculated. Funnel plots were used to compare surgical volume to perioperative mortality for each bellwether procedure., Results: 4,756,642 surgical procedures were reported to DATASUS in 2018: 237,727 emergent procedures requiring laparotomy, 852,821 emergent cesarean sections, and 210,657 open, long bone fracture repairs. Pooled perioperative mortality for all of the bellwether procedures was correlated with all-procedure POMR among states (r = 0.77, p < 0.001). POMR for emergency procedures (2.4%) correlated with the all-procedure (emergent and elective) POMR (1.6%, r = 0.93, p < .001), while POMR for elective procedures (0.4%) did not (p = .247). POMR for emergency laparotomy (4.4%) correlated with all-procedure POMR (1.6%, r = 0.52, p = .005), as did the POMR for open, long bone fractures (0.8%, r = 0.61, p < .001). POMR for emergency cesarean section (0.05%) did not correlate with all-procedure POMR (p = 0.400). There was a correlation between surgical volume and emergency laparotomy POMR (r = - 0.53, p = .004), but not for emergency cesarean section or open, long bone fractures POMR., Conclusion: Procedure-specific POMR for laparotomy and open long bone fracture correlates modestly with all-procedure POMR among Brazilian states which is primarily driven by emergency procedure POMR. Selective reporting of emergency laparotomy and open fracture POMR may be a useful surrogate to guide subnational surgical policy decisions.

Background: An effective referral system is essential for a high-quality health system that provides safe surgical care while optimizing patient outcomes and ensuring efficiency. The role of referral systems in countries with under-resourced health systems is poorly understood. The aim of this study was to examine the rates, preventability, reasons and patterns of outward referrals of surgical patients across three levels of the healthcare system in Northern Tanzania., Methods: Referrals from surgical and obstetric wards were assessed at 20 health facilities in five rural regions prospectively over 3 months. Trained physician data collectors used data collection forms to capture referral details daily from hospital referral letters and through discussions with clinicians and nurses. Referrals were deemed preventable if the presenting condition was one that should be managed at the referring facility level per the national surgical, obstetric and anaesthesia plan but was referred., Results: Seven hundred forty-three total outward referrals were recorded during the study period. The referral rate was highest at regional hospitals (2.9%), followed by district hospitals (1.9%) and health centers (1.5%). About 35% of all referrals were preventable, with the highest rate from regional hospitals (70%). The most common reasons for referrals were staff-related (76%), followed by equipment (55%) and drugs or supplies (21%). Patient preference accounted for 1% of referrals. Three quarters of referrals (77%) were to the zonal hospital, followed by the regional hospitals (17%) and district hospitals (12%). The most common reason for referral to zonal (84%) and regional level (66%) hospitals was need for specialist care while the most common reason for referral to district level hospitals was non-functional imaging diagnostic equipment (28%)., Conclusions: Improving the referral system in Tanzania, in order to improve quality and efficiency of patient care, will require significant investments in human resources and equipment to meet the recommended standards at each level of care. Specifically, improving access to specialists at regional referral and district hospitals is likely to reduce the number of preventable referrals to higher level hospitals, thereby reducing overcrowding at higher-level hospitals and improving the efficiency of the health system.

Objective: Patients with cleft lip and palate (CLP) are more likely to have sinusitis. The purpose of this study is to determine whether patients with CLP have thickening of the Schneiderian membrane. Specific aims were to (1) compare Schneiderian membrane thickness in patients with CLP to noncleft controls, (2) evaluate whether membrane thickening is associated with cleft side in patients with unilateral cleft lip and palate (UCLP), and (3) evaluate if age and sex are predictors of mucosal thickening., Design: Case-control study., Setting: Tertiary care center., Patients: Patients with CLP and controls., Main Outcome Measure: The primary outcome variable was maximum Schneiderian membrane thickness measured on cone beam computed tomography. The primary predictor variable was the presence of a cleft. Additional variables were cleft phenotype, age, and sex., Results: There were 225 patients with CLP and 93 controls. Median mucosal thickness was 2.4 mm in cleft group and 0.0 mm in controls ( P = .006). In cleft group, 56.7% of sinuses had mucosal thickness >2.0 mm compared to 38.2% in controls ( P = < .004). Pathologic membrane thickening (>4.0 mm) was significantly higher in cleft group ( P = .005). No statistically significant difference in mucosal thickness between cleft and noncleft sides in patients with UCLP. Linear regression showed no association between age or sex and Schneiderian membrane thickness., Conclusion: Schneiderian membrane thickening is more common in patients with CLP and is not associated with the side of the cleft in patients with UCLP.

Background: Adverse events from surgical care are a major cause of death and disability, particularly in low-and-middle-income countries. Metrics for quality of surgical care developed in high-income settings are resource-intensive and inappropriate in most lower resource settings. The purpose of this study was to apply and assess the feasibility of a new tool to measure surgical quality in resource-constrained settings., Methods: This is a cross-sectional study of surgical quality using a novel evidence-based tool for quality measurement in low-resource settings. The tool was adapted for use at a tertiary hospital in Amazonas, Brazil resulting in 14 metrics of quality of care. Nine metrics were collected prospectively during a 4-week period, while five were collected retrospectively from the hospital administrative data and operating room logbooks., Results: 183 surgeries were observed, 125 patient questionnaires were administered and patient charts for 1 year were reviewed. All metrics were successfully collected. The study site met the proposed targets for timely process (7 hours from admission to surgery) and effective outcome (3% readmission rate). Other indicators results were equitable structure (1.1 median patient income to catchment population) and equitable outcome (2.5% at risk of catastrophic expenditure), safe outcome (2.6% perioperative mortality rate) and effective structure (fully qualified surgeon present 98% of cases)., Conclusion: It is feasible to apply a novel surgical quality measurement tool in resource-limited settings. Prospective collection of all metrics integrated within existing hospital structures is recommended. Further applications of the tool will allow the metrics and targets to be refined and weighted to better guide surgical quality improvement measures., Competing Interests: Competing interests: LR, IC and JAR received generous support from the Ronda Stryker and William Johnston Global Surgery Fellowship Fund. None of the authors declare any conflict of interest., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: While recommendations for the optimal distribution of surgical services in high-income countries (HICs) exist, it is unclear how these translate to resource-limited settings. Given the significant shortage and maldistribution of surgical workforce and infrastructure in many low- and middle-income countries (LMICs), the optimal role of decentralization versus regionalization (centralization) of surgical care is unknown. The aim of this study is to review evidence around interventions aimed at redistributing surgical services in LMICs, to guide recommendations for the ideal organization of surgical services., Methods: A narrative-based literature review was conducted to answer this question. Studies published in English between 1997 and 2017 in PubMed, describing interventions to decentralize or regionalize a surgical procedure in a LMIC, were included. Procedures were selected using the Disease Control Priorities' (DCP3) Essential Surgery Package list. Intervention themes and outcomes were analyzed using a narrative, thematic synthesis approach. Primary outcomes included mortality, complications, and patient satisfaction. Secondary outcomes included input measures: workforce and infrastructure, and process measures: facility-based care, surgical volume, and referral rates., Results: Thirty-five studies were included. Nine (33%) of the 27 studies describing decentralization showed an improvement in primary outcomes. The procedures associated with improved outcomes after decentralization included most obstetric, gynecological, and family planning services as well as some minor general surgery procedures. Out of 8 studies on regionalization (centralization), improved outcomes were shown for trauma care in one study and cataract extraction in one study., Conclusion: Interventions aimed at decentralizing obstetric care to the district hospital and health center levels have resulted in mortality benefits in several countries. However, more evidence is needed to link service distribution to patient outcomes in order to provide recommendations for the optimal organization of other surgical procedures in LMICs. Considerations for the optimal distribution of surgical procedures should include the acuity of the condition for which the procedure is indicated, anticipated case volume, and required level of technical skills, resources, and infrastructure. These attributes should be considered within the context of each country., (© 2019 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: Lack of providers in surgery, anesthesia, and obstetrics (SAO) is a primary driver of limited surgical capacity worldwide. We aimed to identify predictors of entry into Surgery, Anesthesia, and Obstetrics and Gynecology (SAO) fields and preference of working in the public sector in Brazil which may help in profiling medical students for recruitment into these needed areas., Methods: A questionnaire was applied to all Brazilian medical graduates registered with a Board of Medicine from 2014 to 2015. Twenty-three characteristics were analyzed. Logistic regression was used to determine predictors' influence on outcome., Results: There were 4601 (28.2%) responders to the survey, of which 40.5% (CI 34.7-46.5%) plan to enter SAO careers. Of the 23 characteristics analyzed, eight differed significantly between those who planned to work in SAO and those who did not. Of those eight characteristics, just three were significant predictors in the regression model: preference for working in the hospital setting, having spent more than 70% of their clinical years in practical activities, and valuing the substantial earning potential. These three factors explained only 6.3% of the variance in SAO preference. Within the graduates who preferred SAO careers, there were only two predictors for working in the public sector ("preparatory time before medical school" and valuing "prestige/status")., Conclusions: Factors affecting specialty and sector choice are multifaceted and difficult to predict. Future programs to fill provider gaps should identify methods other than medical student profiling to assure specialty and sector needs are met.

Background: In low- and middle-income countries, poor access to care can result in delayed surgical repair of orofacial clefts leading to poor functional outcomes. Even in Brazil, an upper middle-income country with free comprehensive cleft care, delayed repair of orofacial clefts commonly occurs. This study aims to assess patient-perceived barriers to cleft care at a referral center in São Paulo., Methods: A 29-item questionnaire assessing the barriers to care was administered to 101 consecutive patients (or their guardians) undergoing orofacial cleft surgery in the Plastic Surgery Department in Hospital das Clínicas, in São Paulo, Brazil, between February 2016 and January 2017., Results: A total of 54.4% of patients had their first surgery beyond the recommended time frame of 6 months for a cleft lip or cleft lip and palate and 18 months for a cleft palate. There was a greater proportion of isolated cleft palates in the delayed group (66.7% vs 33.3%). Almost all patients had a timely diagnosis, but delays occurred from diagnosis to repair. The mean number of barriers reported for each patient was 3.8. The most frequently cited barriers related to lack of access to care include (1) lack of hospitals available to perform the surgery (54%) and (2) lack of availability of doctors (51%)., Conclusion: Delays from diagnosis to treatment result in patients receiving delayed primary repairs. The commonest patient-perceived barriers are related to a lack of access to cleft care, which may represent a lack of awareness of available services.

Despite emergency and essential surgery and anaesthesia care being recognised as a part of Universal Health Coverage, 5 billion people worldwide lack access to safe, timely and affordable surgery and anaesthesia care. In Tanzania, 19% of all deaths and 17 % of disability-adjusted life years are attributable to conditions amenable to surgery. It is recommended that countries develop and implement National Surgical, Obstetric and Anesthesia Plans (NSOAPs) to systematically improve quality and access to surgical, obstetric and anaesthesia (SOA) care across six domains of the health system including (1) service delivery, (2) infrastructure, including equipment and supplies, (3) workforce, (4) information management, (5) finance and (6) Governance. This paper describes the NSOAP development, recommendations and lessons learnt from undertaking NSOAP development in Tanzania. The NSOAP development driven by the Ministry of Health Community Development Gender Elderly and Children involved broad consultation with over 200 stakeholders from across government, professional associations, clinicians, ancillary staff, civil society and patient organisations. The NSOAP describes time-bound, costed strategic objectives, outputs, activities and targets to improve each domain of the SOA system. The final NSOAP is ambitious but attainable, reflects on-the-ground priorities, aligns with existing health policy and costs an additional 3% of current healthcare expenditure. Tanzania is the third country to complete such a plan and the first to report on the NSOAP development in such detail. The NSOAP development in Tanzania provides a roadmap for other countries wishing to undertake a similar NSOAP development to strengthen their SOA system., Competing Interests: Competing interests: None declared.

Objective: We endeavored to create a comprehensive course in global surgery involving multinational exchange., Design: The course involved 2 weeks of didactics, 2 weeks of clinical rotations in a low-resource setting and 1 week for a capstone project. We evaluated our success through knowledge tests, surveys of the students, and surveys of our Zimbabwean hosts., Setting: The didactic portions were held in Sweden, and the clinical portion was primarily in Harare with hospitals affiliated with the University of Zimbabwe., Participants: Final year medical students from Lund University in Sweden, Harvard Medical School in the USA and the University of Zimbabwe all participated in didactics in Sweden. The Swedish and American students then traveled to Zimbabwe for clinical work. The Zimbabwean students remained in Sweden for a clinical experience., Results: The course has been taught for 3 consecutive years and is an established part of the curriculum at Lund University, with regular participation from Harvard Medical School and the University of Zimbabwe. Participants report significant improvements in their physical exam skills and their appreciation of the needs of underserved populations, as well as confidence with global surgical concepts. Our Zimbabwean hosts thought the visitors integrated well into the clinical teams, added value to their own students' experience and believe that the exchange should continue despite the burden associated with hosting visiting students., Conclusions: Here we detail the development of a course in global surgery for medical students that integrates didactic as well as clinical experiences in a low-resource setting. The course includes a true multilateral exchange with students from Sweden, the United States and Zimbabwe participating regularly. We hope that this course might serve as a model for other medical schools looking to establish courses in this burgeoning field., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Worldwide, five billion people lack access to safe, affordable surgical, obstetric, and anaesthesia (SOA) care when needed. In many countries, a growing commitment to SOA care is culminating in the development of national surgical, obstetric, and anaesthesia plans (NSOAPs) that are fully embedded in the National Health Strategic Plan. This manuscript highlights the content and outputs from a World Health Organization (WHO) lead workshop that supported country-led plans for improving SOA care as a component of health system strengthening., Methods: In March 2018, a group of 79 high-level global SOA stakeholders from 25 countries in the WHO AFRO and EMRO regions gathered in Dubai to provide technical and strategic guidance for the creation and expansion of NSOAPs., Results: Drawing on the experience and expertise of represented countries that are at different stages of the NSOAP process, topics covered included (1) the global burden of surgical, obstetric, and anaesthetic conditions; (2) the key principles and components of NSOAP development; (3) the critical evaluation and feasibility of different models of NSOAP implementation; and (4) innovative financing mechanisms to fund NSOAPs., Conclusions: Lessons learned include: (1) there is unmet need for the establishment of an NSOAP community in order to provide technical support, expertise, and mentorship at a regional level; (2) data should be used to inform future priorities, for monitoring and evaluation and to showcase advances in care following NSOAP implementation; and (3) SOA health system strengthening must be uniquely prioritized and not hidden within other health strategies.

Background: Improvement in the surgical system requires intersectoral coordination. To achieve this, the development of National Surgical, Obstetric, and Anaesthesia Plans (NSOAPS) has been recommended. One of the first steps of NSOAP development is situational analysis. On the ground situational analyses can be resource intensive and often duplicative. In 2016, the Ministry of Health of Tanzania issued a directive for the creation of an NSOAP. This systematic review aimed to assess if a comprehensive situational analysis could be achieved with existing data. These data would be used for evidence-based priority setting for NSOAP development and streamline any additional data collection needed., Methods: A systematic literature review of scientific literature, grey literature, and policy documents was performed as per PRISMA. Extraction was performed for all articles relating to the five NSOAPS domains: infrastructure, service delivery, workforce, information management, and financing., Results: 1819 unique articles were generated. Full-text screening produced 135 eligible articles; 46 were relevant to surgical infrastructure, 53 to workforce, 81 to service delivery, 11 to finance, and 15 to information management. Rich qualitative and quantitative data were available for each domain., Conclusions: Despite little systematic data collection around SOA, a thorough literature review provides significant evidence which often have a broader scope, longer timeline and better coverage than can be achieved through snapshot-stratified samples of directed on the ground assessments. Evidence from the review was used during stakeholder discussion to directly inform the NSOAP priorities in Tanzania.

Background: Worldwide efforts to improve access to surgical care must be accompanied by improvements in the quality of surgical care; however, these efforts are contingent on the ability to measure quality. This report describes a novel, evidence-based tool to measure quality of surgical care in low-resource settings., Methods: We defined a widely applicable, multidimensional conceptual framework for quality. The suitability of currently available quality metrics to low-resource settings was evaluated. Then we developed new indicators with sufficient supportive evidence to complete the framework. The complete set of metrics was condensed into four collection sources and tools., Results: The following 15 final evidence-based indicators were defined: (1) Safe structure: morbidity and mortality conference; (2) safe process: use of the safe surgery checklist; (3) (4) safe outcomes: perioperative mortality rate and proportion of cases with complications graded >2 on the Clavien-Dindo scale; (5) effective structure: provider density; (6) effective process: procedure rate; (7) effective outcome: rate of caesarean sections; (8) patient-centered process: use of informed consent; (9) patient-centered outcome: patient hospital satisfaction questionnaire; (10) timely structure: travel time to hospital; (11) timely process: time from emergency department presentation to non-elective abdominal surgery; (12) timely outcome: patient follow-up plan; (13) efficient process: daily operating room usage; (14) equitable outcome: comparative income of patients compared with population; and (15) proportion of patients facing catastrophic expenditure because of surgical care., Conclusion: This tool provides an evidence-based conceptual tool to assess the quality of surgical care in diverse low-resource settings., (Copyright © 2018 Elsevier Inc. All rights reserved.)