A taxonomy of specialized surgical platforms

The literature suggests that charitable organizations delivery surgery in two basic ways: by establishing specialty surgical hospitals, or by focusing on more temporary platforms:

Temporary surgical platforms By far the most common, this near-ubiquitous model of surgical delivery can be informatively broken down further: Short-term surgical trips This platform sends surgeons, anesthesiologists, nurses, and/or supporting staff—along with, at times, surgical instrumentation and technology—into LMIC hospitals and clinics for short periods. Often, these NGOs perform a restricted set of surgeries, relying on local physicians for followup. Organizations such as Operation Smile [19–23], numerous orthopedic organizations [24], and many others fit this model. Self-contained surgical platforms Significantly rarer, these NGOs often spend longer in-country than the short-term trips (months to years) but, importantly, carry their infrastructure with them. Self-contained on ships, airplanes, and other modes of transportation, these organizations tend not to leave behind any physical structure. Organizations such as Mercy Ships [25, 26] and CinterAndes fit this model.

Specialty surgical hospitals Another common model for surgical delivery by NGOs, these platforms establish an entire physical plant, either de novo or within an existing structure, dedicated to the treatment of one or a few related surgical conditions. Organizations such as the Addis Ababa Fistula Hospital or the Aravind Eye Hospital fit this model.

This classification scheme allows conclusions to be drawn about effectiveness, cost-effectiveness, sustainability, and the role in training of broad platforms of charitable surgical delivery in LMICs, separate from the individual conditions treated.

Temporary surgical platforms

Short-term surgical trips

Short-term, disease-specific surgical missions are myriad [27]: from “eye camps” in India [28–33] to “ear camps” in Namibia [34]; from organizations focused on facial clefting [19–23] to those focused on hernias [35], cardiac surgery [36], and endemic goiter [37]—services rendered, lengths of surgical trips, and resultant efficacies vary.

Underpinning these platforms, however, is a uniting model: surgical teams are flown into regions with high burdens of specific diseases, where they operate for short stints, often on the order of 1 to 2 weeks [38], and often in partnership with in-country physicians, to whom is left all but the most immediate of follow-up care. These missions, also called safaris [39] or blitzes [40], frequently carry their own equipment with them [38, 41], often return to the same region in subsequent years [24, 42–44], and strive toward close partnership with local hospitals and ministries of health [45, 46].

Despite the plethora of organizations that adopt this short-term model, evaluations of its effectiveness and cost-effectiveness are few. In part, this is due to a difficulty with follow-up. Of 4,100 operations for cleft lip and palate by 1 organization in 40 simultaneous sites, for example, only 703 patients (17 %) returned for a 6- to 9-month postoperative visit [19]. Similarly, in a Spanish-African cooperation program for the repair of hernias, follow-up was 21 % [16].

Effectiveness

A survey of 99 international surgical organizations found that the majority provided fewer than 500 operations per year [27]. Strong evidence exists for an association between surgical volume and outcomes in North America [47], with a stronger impact by hospital volume than by surgeon volume, especially for higher-complexity procedures [48, 49]. This seems to be maintained in the short-term platform; these organizations tend to suffer from higher mortality and complication rates while producing mixed results. In an evaluation of more than 17,000 operations performed in sub-Saharan Africa more than 114 surgical missions in two decades, an overall mortality of 3.3 % was achieved [50]. The majority of these operations were for hernias, for which a mortality as high as 1 % was observed—20 times higher than in high-income countries [51].

Both the success of an operative mission and its complication rates, however, vary by surgical procedure. Simpler procedures, such as tonsillectomy, appear safe when performed by short-term surgical missions [52]. Others less so: Maine et al [53]. Reported a rate oronasal fistula after cleft palate repair, which is more than 20-fold higher in surgical missions than in high-income countries. In their study, cases performed by experienced Ecuadorean and North American surgeons on a mission to Ecuador were compared with cases performed by similar surgeons at an American tertiary hospital. All surgeons showed this 20-fold increase in complication rates; no difference was found between Ecuadorean and North American surgeons. Although there are obviously patient-level factors that confound this increased complication rate, this finding lends further credence to an assertion that mission volume has potentially more impact than surgeon experience [53]. De Buys Roessingh et al. [42] similarly report relatively poor functional results in the repair of cleft palates on short-term surgical missions; the inherent difficulty of establishing a multidisciplinary approach in short-term surgical missions may contribute to these outcomes [54].

Results from cataract surgeries performed in eye camps are equally variable: Some report good vision outcomes [31], others poor [55]. Variability also is seen in otologic surgery; in surgical camps in Greenland [56, 57] and in mobile surgical units in Thailand [58], low complication rates and good results were found for chronic ear disease. Other authors, however, report success tied very strongly to either pathologic diagnosis [59] or the age of the surgical mission, with better results occurring a few years after the mission’s establishment [60].

Acceptable results have been found in cardiac surgery [36, 61], although some results come from very small surveys. Similar good results are reported in goiter missions, especially as they are repeated [37]. However, for the repair of burn contractures, Kim et al. found complications rates higher on surgical missions than in high-income countries [62], and, in orthopedics, Cousins et al. report success rates ranging from 28 to 75 %. Among the largest group of patients—those with lower limb trauma—47 % experienced complications [24]. Young et al. [63, 64] similarly document a not insignificant, postoperative infection rate after intramedullary nailing.

Overall, a pattern emerges in a review of the effectiveness of the short-term platform; for the condition most commonly treated by the charitable sector, the more complex the surgery, the more unsatisfactory the results. Both Marck et al [65]. and Huijing et al [66]. find this pattern, which combined with Maine’s findings above [53], leads them to recommend against short-term surgical missions for any but the simplest conditions [65, 66].

Cost-effectiveness

With a caveat to be discussed below, the few cost-effectiveness analyses that have been performed on surgical missions point to a beneficial cost-effectiveness ratio: cleft lip and palate repair costs anywhere from $52/DALY averted [67] to $1,827/DALY averted [23], or approximately $40 per patient [41], and benefit-cost analyses are similarly positive [68]. Orthopedic surgeries, at $340-$360/DALY averted, are slightly more expensive buys [38, 69].

These findings, however, must be interpreted with extreme caution, especially because they do not square with the assertion short-term surgical missions tend toward unsatisfactory outcomes. The apparent cost-effectiveness of surgical missions is an artifact of the way in which the analyses were conducted; almost all of the cited studies assume uncomplicated repairs, and all assumed that, without the mission, no surgery occurred. These assumptions will systematically result in a small cost-effectiveness ratio, biasing the analysis toward the charitable organization. As a result, an interpretation of these findings must be very narrow: only when no other platform treats the condition do these results imply that a surgical mission may be cost-effective. If the condition can be treated by other platforms—which, in many cases, it can—these cost-effectiveness results lose validity. This caveat should be combined with the fact that results of these cost-effectiveness studies depend on how the studies were conducted [70].

One cost-effectiveness analysis compared short-term platforms with other platforms for the treatment of one condition; Singh et al [55]. examined cataract surgeries performed at specialized eye camps, NGO hospitals, and the state medical college. Although not the worst value—that distinction fell to the state medical college—short-term eye camps were much less cost-effective than nongovernmental hospitals.

Sustainability and training

Many authors laud the salutary role that short-term surgical missions have in the education of surgical trainees in high-income countries [43, 71–85]. While this role is not to be dismissed, it cannot come at the cost of delivery of unsatisfactory care in LMICs [9, 86]. Besides one study, which documented an increase in laparoscopic surgeries after repeated training missions [17], no other evidence was found for the role of short-term missions in training.

Short-term surgical missions, however, have been put forward as a method to alleviate disease burden in LMICs. Unfortunately, the sustainability of this platform unclear. It is not altogether unlikely, for example, that these surgical camps treat the same conditions that are otherwise treated in local hospitals, and fragmentation in delivery contributes to an inability to meet the large burden of unmet need [87, 88]. The structure of the short-term medical mission itself may be detrimental to sustainability; patients are identified before the surgical team’s arrival, and the large volume of cases performed often disrupts local infrastructure, even after the team’s departure [40, 89].

Finally, although these platforms create awareness of surgery in the communities that they serve [90, 91], this awareness often can have counterintuitively detrimental effects on local infrastructure: when outcomes are consistently good, awareness influences positive health-seeking behavior in patients. Even the most sporadic bad outcomes, however, seem to discourage care-seeking outright [92].

Despite its ubiquity, the short-term surgical safari appears to have a relatively limited role in the delivery of surgical care. Given potentially unsatisfactory results, detrimental effects on health-seeking behavior, and stress on the local infrastructure, the short-term stand-alone surgical mission, when other options exist, is likely to be inefficient [93].

Self-contained surgical platforms

The fact that complex procedures performed by short-term missions can yield unsatisfactory results [65, 66], combined with the fact that most local hospitals also are unable to provide this care consistently [3, 5, 94], leads to an obvious question. While LMICs improve their local infrastructure, how can the interim need be best met? Are specialized surgical hospitals (to be discussed next) the most effective and efficient method, or can a different temporary model, better structured than the short-term mission, provide effective surgical care?

Few examples of an intermediate model for surgical delivery exist, but those that do are promising. Mercy Ships, for example, maintains hospital ships, carrying an entire infrastructure (including pathology and radiology [26]), allowing them to provide ophthalmologic, reconstructive, general, orthopedic, and obstetric fistula surgeries [25, 95]. The few studies on the effectiveness of surgical procedures performed by this platform indicate outcomes comparable with those seen in high-income centers [25]. Military organizations adopt a similar model: the U.S. Navy maintains two hospital ships, which report mortality and complication rates that are equivalent to, if not better than, those found in high-income, country hospitals [96–98]. In addition, complex craniofacial surgeries, for which the short-term platform appears ill-suited, appear to be successfully performed by this platform [99]. There have been no cost-effectiveness evaluations of self-contained delivery platforms to date.

Specialty surgical hospitals

Demand and supply constraints

Specialized surgical hospitals are myriad (see Box 2); many evolved from temporary surgical platforms. Cataract surgeries in India, for example, were initially performed in makeshift facilities before their care transferred to specialized hospitals. A population-based study, however, estimates that patients accessing short-term “eye camps” represent a mere 7 % of those in need [100], and current estimates put resource utilization of eye care facilities at 25 % [101].

Research by Browning and Patel, in the setting of obstetric fistula [93], similarly indicates that less than 1 % of surgical need for fistula repair is being met [93]. In Ethiopia alone, an estimated 9,000 women develop an obstetric fistula each year [102, 103]. Similar statements can be made about the unmet need for cardiac surgery, maternity services, and cancer care.

Effectiveness

Data for specialized surgical hospitals come primarily from ophthalmologic, fistula, and cancer centers [104, 105]. Although publications from specialized surgical hospitals treating other conditions exist, none include objective outcome measures [106, 107].

Evidence for the effectiveness and cost-effectiveness of specialty ophthalmologic hospitals has been presented above [55]; overall, they appear able to deliver high volumes of ophthalmologic surgery effectively [108]. A single publication from an eye hospital in Nigeria, however, reported poor postoperative vision outcomes [109]. Similarly, laparoscopic radical hysterectomy, other obstetric services, and repair of congenital anomalies can both be performed in LMIC specialized hospitals with outcomes similar to those found in the United States [105, 110–113].

Repair of obstetric fistulae is complex. Fistula surgeons are not considered expert until they have performed 300 cases, which may take years in short-term missions or local hospitals [114]. Even expert surgeons deliver closure and continence to only 85 % of patients. Both the Addis Ababa (a charitable organization) and Babbar Ruga (an initiative of the Nigerian government with some external funding) centers, however, report rates of successful fistula closure and return to continence of more than 90 % [115, 116].

Finally, complex surgical conditions, such as obstetric fistula and facial clefting, place specific design demands on the physical facility and require rehabilitative services [102]. While the local or district hospital may meet some of these needs, it must prioritize more life-threatening surgical conditions, making complex repair less likely [117]. In keeping with these findings, a recent expert elicitation study concluded that complicated obstetric fistulae are likely best repaired at high-volume, specialized surgical hospitals [118].

Cost-effectiveness

The single published, cross-platform comparison demonstrates the superior cost-effectiveness of permanent NGO hospitals in cataract surgery [55]. One other cost-effectiveness study published on surgery performed in the larger context of a mission hospital showed a beneficial cost-benefit ratio [119].

Sustainability and training

The Babbar Ruga fistula hospital reports having trained more than 600 fistula surgeons nurses worldwide [116]. Consistent with the above estimates [93], the experience of one author (AS) demonstrates the level of sustainability required for fistula training: the training of two Eritrean fistula surgeons required at least 5 years before competency levels and adequate case numbers were met. This is only possible in specialized platforms.