title: Mapping Population-Level Spatial Access to Essential Surgical Care in Ghana Using Availability of Bellwether Procedures.
abstract: Conditions that can be treated by surgery comprise more than 16% of the global disease burden. However, 5 billion people do not have access to essential surgical care. An estimated 90% of the 87 million disability-adjusted life-years incurred by surgical conditions could be averted by providing access to timely and safe surgery in low-income and middle-income countries. Population-level spatial access to essential surgery in Ghana is not known.
  
  
  
  To assess the performance of bellwether procedures (ie, open fracture repair, emergency laparotomy, and cesarean section) as a proxy for performing essential surgery more broadly, to map population-level spatial access to essential surgery, and to identify first-level referral hospitals that would most improve access to essential surgery if strengthened in Ghana.
  
  
  
  Population-based study among all households and public and private not-for-profit hospitals in Ghana. Households were represented by georeferenced census data. First-level and second-level referral hospitals managed by the Ministry of Health and all tertiary hospitals were included. Surgical data were collected from January 1 to December 31, 2014.
  
  
  
  All procedures performed at first-level referral hospitals in Ghana in 2014 were used to sort each facility into 1 of the following 3 hospital groups: those without capability to perform all 3 bellwether procedures, those that performed 1 to 11 of each procedure, and those that performed at least 12 of each procedure. Candidates for targeted capability improvement were identified by cost-distance and network analysis.
  
  
  
  Of 155 first-level referral hospitals managed by the Ghana Health Service and the Christian Health Association of Ghana, 123 (79.4%) reported surgical data. Ninety-five (77.2%) did not have the capability in 2014 to perform all 3 bellwether procedures, 24 (19.5%) performed 1 to 11 of each bellwether procedure, and 4 (3.3%) performed at least 12. The essential surgical procedure rate was greater in bellwether procedure-capable first-level referral hospitals than in noncapable hospitals (median, 638; interquartile range, 440-1418 vs 360; interquartile range, 0-896 procedures per 100 000 population; P = .03). Population-level spatial access within 2 hours to a hospital that performed 1 to 11 and at least 12 of each bellwether procedure was 83.2% (uncertainty interval [UI], 82.2%-83.4%) and 71.4% (UI, 64.4%-75.0%), respectively. Five hospitals were identified for targeted capability improvement.
  
  
  
  Almost 30% of Ghanaians cannot access essential surgery within 2 hours. Bellwether capability is a useful metric for essential surgery more broadly. Similar strategic planning exercises might be useful for other low-income and middle-income countries aiming to improve access to essential surgery.
authors.affiliation: Department of Surgery, University of Washington, Seattle2Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana3Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
authors.forename: Barclay T
authors.initials: BT
authors.lastname: Stewart
authors.affiliation: Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada5Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England.
authors.forename: Gavin
authors.initials: G
authors.lastname: Tansley
authors.affiliation: Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana3Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
authors.forename: Adam
authors.initials: A
authors.lastname: Gyedu
authors.affiliation: Information and Monitoring Unit, Ghana Health Service, Accra.
authors.forename: Anthony
authors.initials: A
authors.lastname: Ofosu
authors.affiliation: Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana3Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
authors.forename: Peter
authors.initials: P
authors.lastname: Donkor
authors.affiliation: Office of the Director General, Ghana Health Service, Accra.
authors.forename: Ebenezer
authors.initials: E
authors.lastname: Appiah-Denkyira
authors.affiliation: Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana3Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
authors.forename: Robert
authors.initials: R
authors.lastname: Quansah
authors.affiliation: Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa9Department of General Surgery, Nelson R. Mandela School of Medicine, University of Kwa-Zulu Natal, Kwa-Zulu Natal, South Africa.
authors.forename: Damian L
authors.initials: DL
authors.lastname: Clarke
authors.affiliation: Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa11Cochrane South Africa, South African Medical Research Council, Tygerberg.
authors.forename: Jimmy
authors.initials: J
authors.lastname: Volmink
authors.affiliation: Department of Surgery, University of Washington, Seattle12Harborview Injury Prevention & Research Center, Seattle, Washington13Department of Global Health, University of Washington, Seattle.
authors.forename: Charles
authors.initials: C
authors.lastname: Mock
mesh_terms: D019352:Censuses; D002585:Cesarean Section; D003906:Developing Countries; D004630:Emergencies; D005597:Fractures, Open / Q000601:surgery; D062305:Geographic Mapping; D005869:Ghana; D006297:Health Services Accessibility; D006761:Hospitals / Q000145:classification / Q000706:statistics & numerical data*; D006801:Humans; D007813:Laparotomy; D062206:Spatial Analysis; D013997:Time Factors