Estimates of Treatable Deaths Within the First 20 Years of Life from Scaling Up Surgical Care at First-Level Hospitals in Low- and Middle-Income Countries

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Study Justification:
This study aims to examine the potential impact of scaling up surgical care at first-level hospitals in low- and middle-income countries (LMICs) within the first 20 years of life. Surgical care is often neglected in LMICs, and improving access to surgical services can have a significant impact on reducing treatable deaths in children and adolescents.
Highlights:
– An estimated 314,609 deaths per year in the under 20-year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs.
– The majority of treatable deaths are in the under-5 year age group, with improved obstetrical care playing a significant role in reducing neonatal encephalopathy and trauma-related deaths.
– Injuries are the leading cause of treatable deaths after age 5 years.
– Sixty-one percent of treatable deaths occur in lower middle-income countries.
– Scaling up surgical care at first-level hospitals could avert 5.1% of total deaths in children and adolescents under 20 years of age in LMICs per year.
Recommendations:
– Increase the capacity of surgical services at first-level hospitals in LMICs to provide essential surgical care.
– Improve access to obstetrical care to reduce neonatal encephalopathy and birth-related trauma.
– Enhance trauma care services to address injuries as a leading cause of treatable deaths.
– Prioritize lower middle-income countries in scaling up surgical care efforts.
Key Role Players:
– Government health ministries and departments responsible for healthcare planning and implementation.
– International organizations and NGOs involved in global health and surgical care initiatives.
– Local healthcare providers, including doctors, nurses, and surgeons.
– Public health researchers and epidemiologists.
– Health policy experts and advisors.
Cost Items for Planning Recommendations:
– Infrastructure development and improvement of first-level hospitals to accommodate increased surgical capacity.
– Procurement of medical equipment and supplies necessary for surgical procedures.
– Training and capacity building programs for healthcare providers.
– Implementation of information systems and technology to support surgical care delivery.
– Monitoring and evaluation activities to assess the impact of scaling up surgical care.
– Public awareness campaigns to promote the importance of surgical care and encourage utilization.
Please note that the provided cost items are general categories and may vary depending on the specific context and needs of each LMIC.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on data from the 2019 Global Burden of Diseases Study and a counterfactual method developed for the Disease Control Priorities, 3rd Edition. The study provides estimates of the number of treatable deaths in the under 20-year age group that could be averted by scaling up surgical care at first-level hospitals in low- and middle-income countries. The methodology used is explained in detail, and adjustments for the effect of surgical care are accounted for. To improve the evidence, the abstract could include information on the sample size and demographics of the population studied, as well as any limitations or potential biases in the data collection and analysis.

Background: Surgical care is an important, yet often neglected component of child health in low- and middle-income countries (LMICs). This study examines the potential impact of scaling up surgical care at first-level hospitals in LMICs within the first 20 years of life. Methods: Epidemiological data from the global burden of disease 2019 Study and a counterfactual method developed for the disease control priorities; 3rd Edition were used to estimate the number of treatable deaths in the under 20 year age group if surgical care could be scaled up at first-level hospitals. Our model included three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries. Results: An estimated 314,609 (95% UI, 239,619–402,005) deaths per year in the under 20 year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs. Most of the treatable deaths are in the under-5 year age group (80.9%) and relates to improved obstetrical care and its effect on reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries are the leading cause of treatable deaths after age 5 years. Sixty-one percent of the treatable deaths occur in lower middle-income countries. Overall, scaling up surgical care at first-level hospitals could avert 5·1% of the total deaths in children and adolescents under 20 years of age in LMICs per year. Conclusions: Improving the capacity of surgical services at first-level hospitals in LMICs has the potential to avert many deaths within the first 20 years of life.

Data from the 2019 Global Burden of Diseases (GBD) Study [15] was used to estimate the number of deaths that could be averted in the under-20 year age group by scaling up surgical care provided at first-level hospitals. Our approach was similar to that used to estimate the number of preventable surgical deaths in Chapter 2 of Disease Control Priorities, 3rd Edition (DCP3), Volume 1: Essential Surgery [12]. This methodology assumes a basic surgical package3 with various therapeutic interventions that can be provided at first-level hospitals [16–18]. Our model included the following, with 2019 GBD cause codes shown in parenthesis: This approach recognizes that some conditions, such as maternal hemorrhage and neonatal encephalopathy, are not entirely amenable to surgical care and hence require adjustments to limit the effect of surgery [12, 19]. Adjustments for the effect of surgical care were based on information provided in Annex 2E of Chapter 2 of the Essential Surgery Volume of DCP3 [12] and are included in Additional file 1 of the supplemental information. The overall concept of our approach was to split the reported deaths from surgical conditions into surgically treatable and non-treatable deaths. Treatable deaths were calculated as follows: where DEATHScurrent denotes the deaths reported in GBD 2019, and DEATHScounterfactual represents the estimated number of deaths if delivery of surgical care had existed in a “counterfactual” state, which is described as the state in which the entire population has access to appropriate and safe surgical care deliverable at first-level hospital. To make these calculations, we downloaded age and income-specific death rates, uncertainty intervals, and population data from the Institute of Health Metrics and Evaluation using the GBD Results tool [20]. The treatable death rates for the World Bank LMIC income groups (low-income, lower-middle-income and upper middle income) were calculated by subtracting the cause-specific high-income death rates from the cause-specific rates in the low- and middle-income income groupings using the following formula: where ADRagegroupincomegroup is the cause-specific treatable death rate for each age and income group, EDRagegroupincomegroup the existing cause-specific death rates reported in GBD 2019, and CDRagegroupincomegroup the cause-specific death rates for the counterfactual state. We assumed that the lowest fatality rate to be in the high-income group and therefore representative of CDRagegroupincomegroup. The number of treatable deaths for each age and income group was determined by multiplying the cause-specific treatable death rates by the population in each category (Additional file 2). Finally, we corrected for the effect of surgical care and variability in access by multiplying the number of treatable deaths times the correction factors listed in Additional file 1.

Based on the provided information, it seems that the study focuses on estimating the number of treatable deaths in the under 20-year age group that could be averted by scaling up surgical care at first-level hospitals in low- and middle-income countries (LMICs). The study highlights the potential impact of improving access to surgical services in LMICs, particularly in relation to digestive diseases, maternal and neonatal conditions, and common traumatic injuries.

To improve access to maternal health, here are some potential innovations that could be considered:

1. Telemedicine and Teleconsultations: Implementing telemedicine services can help connect healthcare providers in remote areas with specialists in urban centers. This technology allows for remote consultations, diagnosis, and treatment recommendations, improving access to maternal health expertise.

2. Mobile Health (mHealth) Applications: Developing mobile applications that provide information, education, and reminders for pregnant women can help improve maternal health outcomes. These apps can offer guidance on prenatal care, nutrition, and postpartum care, ensuring that women have access to essential information and resources.

3. Community Health Workers: Training and deploying community health workers can enhance access to maternal health services, especially in rural and underserved areas. These workers can provide basic prenatal care, education, and referrals to healthcare facilities when necessary.

4. Transportation Solutions: Addressing transportation barriers is crucial for improving access to maternal health services. Implementing innovative transportation solutions, such as mobile clinics or community-based transportation networks, can help pregnant women reach healthcare facilities more easily.

5. Task-Shifting and Training Programs: Expanding the roles of midwives, nurses, and other healthcare professionals through task-shifting programs can increase access to maternal health services. Training programs can equip these healthcare providers with the necessary skills and knowledge to provide quality care.

6. Quality Improvement Initiatives: Implementing quality improvement initiatives in healthcare facilities can enhance the overall quality of maternal health services. This includes ensuring the availability of essential equipment, improving infection control measures, and promoting evidence-based practices.

7. Financial Innovations: Developing innovative financing models, such as microinsurance or community-based health financing schemes, can help overcome financial barriers to accessing maternal health services. These models can provide affordable and accessible healthcare coverage for pregnant women.

It is important to note that these recommendations are general and may need to be tailored to specific contexts and resource constraints. Additionally, further research and evaluation are necessary to assess the effectiveness and feasibility of these innovations in improving access to maternal health.
AI Innovations Description
Based on the provided description, the recommendation to improve access to maternal health and develop it into an innovation is to scale up surgical care at first-level hospitals in low- and middle-income countries (LMICs). This recommendation is based on the findings of the study, which estimated that scaling up surgical care at first-level hospitals in LMICs could avert an estimated 314,609 deaths per year in the under 20-year age group.

The study identified three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries as the main causes of treatable deaths in the under 20-year age group. The majority of these deaths occur in the under-5 year age group, with improved obstetrical care playing a significant role in reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries become the leading cause of treatable deaths after age 5 years.

To implement this recommendation, it is important to improve the capacity of surgical services at first-level hospitals in LMICs. This can involve providing a basic surgical package with various therapeutic interventions that can be delivered at these hospitals. Adjustments may be needed for conditions that are not entirely amenable to surgical care, such as maternal hemorrhage and neonatal encephalopathy.

To estimate the number of treatable deaths, data from the 2019 Global Burden of Diseases (GBD) Study was used. The study used a counterfactual method, comparing the existing death rates with the estimated death rates in a “counterfactual” state where the entire population has access to appropriate and safe surgical care at first-level hospitals. The treatable death rates were calculated by subtracting the cause-specific death rates in high-income countries from the rates in low- and middle-income countries.

In summary, scaling up surgical care at first-level hospitals in LMICs has the potential to significantly improve access to maternal health and reduce treatable deaths in the under 20-year age group. This can be achieved by improving the capacity of surgical services, providing a basic surgical package, and addressing specific conditions that may require adjustments in surgical care.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Strengthening First-Level Hospitals: Investing in infrastructure, equipment, and resources for first-level hospitals can improve their capacity to provide maternal health services. This includes ensuring the availability of skilled healthcare providers, essential medicines, and necessary surgical equipment.

2. Training and Capacity Building: Implementing training programs for healthcare providers in first-level hospitals can enhance their skills and knowledge in managing maternal health complications. This can include training in emergency obstetric care, neonatal resuscitation, and postpartum hemorrhage management.

3. Telemedicine and Teleconsultation: Utilizing telemedicine technologies can help overcome geographical barriers and improve access to specialized maternal health services. This enables healthcare providers in first-level hospitals to consult with specialists remotely, ensuring timely and appropriate care for pregnant women.

4. Community-Based Interventions: Implementing community-based interventions, such as mobile clinics or outreach programs, can bring maternal health services closer to remote or underserved areas. This can include antenatal care, prenatal education, and postnatal support.

To simulate the impact of these recommendations on improving access to maternal health, a methodology can be developed as follows:

1. Define the Parameters: Identify the key indicators that measure access to maternal health, such as the number of maternal deaths, the percentage of women receiving antenatal care, or the distance to the nearest healthcare facility. Determine the baseline values for these indicators.

2. Collect Data: Gather relevant data on the current status of maternal health in the target population. This can include demographic data, health facility infrastructure, healthcare provider availability, and utilization rates of maternal health services.

3. Develop a Simulation Model: Create a simulation model that incorporates the identified recommendations and their potential impact on the defined parameters. This model should consider factors such as population size, geographical distribution, healthcare infrastructure, and resource allocation.

4. Input Recommendation Scenarios: Define different scenarios based on the recommendations, such as the percentage increase in the number of trained healthcare providers, the coverage of telemedicine services, or the frequency of community-based interventions. Input these scenarios into the simulation model.

5. Run Simulations: Execute the simulation model using the defined scenarios to estimate the potential impact on the selected indicators. This can involve running multiple iterations to account for variability and uncertainty.

6. Analyze Results: Analyze the simulation results to assess the projected changes in access to maternal health services. Compare the outcomes of different scenarios to identify the most effective recommendations for improving access.

7. Refine and Validate: Continuously refine the simulation model based on feedback, additional data, or new insights. Validate the model by comparing the simulated results with real-world data, if available.

By following this methodology, policymakers and healthcare stakeholders can gain insights into the potential impact of different recommendations on improving access to maternal health. This information can guide decision-making and resource allocation to prioritize interventions that will have the greatest positive impact.

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