Emerging findings from health systems field research’

Over the past three years we have worked with the Kohima Institute in Nagaland (kohimainstitute.org), North East India and the College of Medicine and Allied Health Sciences in Freetown (usl.edu.sl/comahs), Sierra Leone to understand what prevents people accessing surgical services. Teams in both countries have undertaken interviews with patients, traditional providers, hospital staff and policy makers to understand factors that lead to the low rates of essential surgery we see in both contexts.

There is no doubt that health facilities in both contexts frequently lack the essential equipment and supplies to undertake safe surgery. Surgeons in Sierra Leone talk of ‘carpenters without tools’ referencing a lack of capability to undertaken diagnostics. A lack of resource means that patients must often bring their own medicines and supplies. Staff consequently have a hard job in ensuring these items are in-date and remain effective. In North East India, the availability of anaesthetics and stocks of blood often hinder the ability to provide safe surgical care.

Yet it is factors that are beyond the basic availability of services that often present the greatest obstacles preventing people accessing surgery.  In North East India, for example, the terrain is often challenging with poor roads that get worse during the rainy seasons inhibiting access to services. Rates of essential surgery fall dramatically for communities that are distant from a hospital.

How to pay for care is often a major concern for families making the decision where to take loved one for treatment. The non-government sector in North East India is much more physically accessible yet the cost of an essential operation such as caesarean section can represent more than 3 months average income. Against this background, traditional providers often seem a more viable option offering nearby services with payment in-kind or instalments.

Once a person has made up their mind to access surgery the route to obtaining care can be complex. Patients in Sierra Leone report being turned away by local facilities because of a lack of space or staff. The route to obtaining care can be a long one and with variable quality or the absence of first aid along the way, results in an injury or condition that is worsened. The eventual care can become much more invasive. Delays resulting from inadequate finance, lack of knowledge and inappropriate care can, for example, turn a wound that required basic first aid into an eventual amputation.

These barriers demonstrate the need for interventions that focus not only on what happens inside hospitals but what happens outside as well. Systems to enable communities to understand the importance of early care and where to seek services and financial mechanisms to assist people help are needed. These don’t need to be invented from scratch. There is considerable experience in other sectors such as maternal health and tuberculosis services of enabling patients to overcome these ‘demand-side’ barriers. Learning across sectors is needed in order to help families and communities access services they need and reduce the huge gap between the need and use of surgical care.