Surgical ambulance referrals in sub-Saharan Africa – financial costs and coping strategies at district hospitals in Tanzania, Malawi and Zambia

BMC Health Services Research

Gerald Mwapasa¹  Eric Borgstein¹  Martilord Ifeanyichi²  Leon Bijlmakers²  Henk Broekhuizen²  Ruairi Brugha³  Adinan Juma⁴  Jakub Gajewski⁵  Chiara Pittalis⁵  Mweene Cheelo⁶  John Kachimba⁶ 

[1] College of Medicine, University of Malawi;Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre;Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland;East, Central and Southern Africa Health Community;Institute of Global Surgery, Royal College of Surgeons in Ireland;Surgical Society of Zambia, Department of Surgery, University Teaching Hospital;

关键词: Global surgery;    Referral systems;    Costs;    Sub-Saharan Africa;    District hospital;    Ambulance;   

DOI  :  10.1186/s12913-021-06709-5

来源: DOAJ

【 摘 要 】

Abstract Background An estimated nine out of ten persons in sub-Saharan Africa (SSA) are unable to access timely, safe and affordable surgery. District hospitals (DHs) which are strategically located to provide basic (non-specialist) surgical care for rural populations have in many instances been compromised by resource inadequacies, resulting in unduly frequent patient referrals to specialist hospitals. This study aimed to quantify the financial burdens of surgical ambulance referrals on DHs and explore the coping strategies employed by these facilities in navigating the challenges. Methods We employed a multi-methods descriptive case study approach, across a total of 14 purposively selected DHs; seven, three, and four in Tanzania, Malawi and Zambia, respectively. Three recurrent cost elements were identified: fuel, ambulance maintenance and staff allowances. Qualitative data related to coping mechanisms were obtained through in-depth interviews of hospital managers while quantitative data related to costs of surgical referrals were obtained from existing records (such as referral registers, ward registers, annual financial reports, and other administrative records) and expert estimates. Interview notes were analysed by manual thematic coding while referral statistics and finance data were processed and analysed using Microsoft Office Excel 2016. Results At all but one of the hospitals, respondents reported inadequacies in numbers and functional states of the ambulances: four centres indicated employing non-ambulance vehicles to convey patients occassionally. No statistically significant correlation was found between referral trip distances and total annual numbers of referral trips, but hospital managers reported considering costs in referral practices. For instance, ten of the study hospitals reported combining patients to minimize trip frequencies. The total cost of ambulance use for patient transportation ranged from I$2 k to I$58 k per year. Between 34% and 79% of all patient referrals were surgical, with total costs ranging from I$1 k to I$32 k per year. Conclusion Cost considerations strongly influence referral decisions and practices, indicating a need for increases in budgetary allocations for referral services. High volumes of potentially avoidable surgical referrals provide an economic case – besides equitable access to healthcare – for scaling up surgery capacity at the district level as savings from decreased referrals could be reinvested in referral systems strengthening.

【 授权许可】

Unknown