title: Challenges and Opportunities in the Provision of Surgical Care in Vanuatu: A Mixed Methods Analysis.
abstract: The Pacific island nation of Vanuatu faces a number of challenges in delivering surgical care to its population. We aimed to understand and document the barriers, opportunities and required actions to improve surgical care in the country using a mixed methods analysis which incorporated the perspectives of local health stakeholders.
  
  
  
  A baseline quantitative assessment of surgical capacity in Vanuatu was carried out using the WHO situational analysis tool. Twenty semi-structured interviews were then conducted on the two main islands (Efate and Espiritu Santo) with surgeons, allied health staff, health managers, policy-makers and other key stakeholders, using a grounded theory qualitative case study methodology. Initial informants were identified by purposive sampling followed by snowball sampling until theoretical saturation was reached. Interviews were open and axially coded with subsequent thematic analysis.
  
  
  
  Vanuatu faces deficits in surgical infrastructure, equipment and human resources, especially in the rural provinces. Geographic isolation, poverty and culture-including the use of traditional medicine and low health literacy-all act as barriers to patients accessing timely surgical care. Issues with governance, human resourcing and perioperative care were commonly identified by stakeholders as key challenges facing surgical services. Increasing outreach clinics, developing efficient referral systems, building provincial surgical capacity and undertaking locally led research were identified as key actions that can improve surgical care.
  
  
  
  Documenting locally identified challenges and opportunities for surgical care in Vanuatu is an important first step towards developing formal strategies for improving surgical services at the country level.
authors.affiliation: Global Surgery Group, Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland Mail Centre, 1142, Auckland, New Zealand. syou467@aucklanduni.ac.nz.
authors.forename: S
authors.initials: S
authors.lastname: Young
authors.affiliation: Global Surgery Group, Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland Mail Centre, 1142, Auckland, New Zealand.
authors.forename: W R G
authors.initials: WR
authors.lastname: Perry
authors.affiliation: Northern Provincial Hospital, Espiritu Santo, Vanuatu.
authors.forename: B
authors.initials: B
authors.lastname: Leodoro
authors.affiliation: Pacific Health Section, School of Population Health, University of Auckland, Auckland, New Zealand.
authors.forename: V
authors.initials: V
authors.lastname: Nosa
authors.affiliation: Global Surgery Group, Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland Mail Centre, 1142, Auckland, New Zealand.
authors.forename: I
authors.initials: I
authors.lastname: Bissett
authors.affiliation: Global Surgery Group, Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland Mail Centre, 1142, Auckland, New Zealand.
authors.forename: J A
authors.initials: JA
authors.lastname: Windsor
authors.affiliation: Global Surgery Group, Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland Mail Centre, 1142, Auckland, New Zealand.
authors.forename: A J
authors.initials: AJ
authors.lastname: Dare
mesh_terms: D003695:Delivery of Health Care / Q000458:organization & administration*; D004630:Emergencies; D013502:General Surgery / Q000458:organization & administration*; D006297:Health Services Accessibility; D006801:Humans; D036301:Qualitative Research; D019035:Rural Health Services / Q000458:organization & administration; D009514:Vanuatu; D014944:World Health Organization