By: Alexi Matousek MD, MPH
An April 2015 study from the Lancet Commission on Global Surgery1 reveals that five billion people, as many as nine of ten individuals in low and middle-income countries, lack access to safe, affordable surgical care. This affects the poor, marginalized, and rural populations who have limited funds, long distances to care and poor travel infrastructure. If they do reach care, there are often no surgeons or anesthetists, medications, oxygen, or blood.
As a teen, Dr. Alexi Matousek spent summers in Haiti watching surgeons operate in austere conditions, extracting tumors, closing wounds and treating other conditions. It led him to want to be a surgeon and help countries like Haiti address easily treated illnesses before they become fatal.
According to Dr. Matousek, global surgery faces two main crises: lack of access to surgical services for vulnerable populations and an inability to measure outcomes that would enable quality improvement. He believes community health workers can be used to address both these issues.
Access to surgical services
Despite the availability of a free care program, vulnerable patients living in the mountainous areas within the service area of Hôpital Albert Schweitzer in Deschapelles, Haiti lack the literacy, social agency, relational contacts and financial means to gain access to surgical care. To improve the situation, Dr. Matousek developed a program to use community health workers to function as surgical accompagnateurs functioning as patient navigators who could link patients to care. The surgical accompagnateurs received mountain patients at the hospital, literally taking them by the hand through every necessary step and location in the hospital to be evaluated for surgery, including financial support. This simple intervention increased the elective operation rate four- fold for this vulnerable population.
Canes Sainfius, a nine-year-old boy, came to one of the screening days with a huge benign mass on his back that would have been addressed much earlier in a more developed country. His father had abandoned the family due to Canes’ disfigurement. Yet a quick 45-minute operation changed Canes’ life and reunited the family.
To encourage patients to enroll in the program, screening days were organized and widely advertised with the help of a megaphone throughout the targeted mountain regions. CHWs registered patients and physicians traveled to the mountains to identify patients needing surgery.
Long-term community-based outcome measurement is often deemed too difficult in rural areas of developing countries like Haiti. While the logistical challenges of collecting data in mountain villages are numerous, mobile health technology can enable robust data collection by community health workers. The Community Outcomes Measurement program uses a mobile application that enables CHWs to administer a questionnaire on symptoms of infection, obtain GPS data and submit a high-quality photograph of the incision three times during the 30 days after an operation. The program design will hopefully serve as a model for outcome measurement in developing countries.
Community Outcomes Measurement program design:
CHWs are trained in how to take photographs of the incision site, relay the information to the consulting surgeon via mobile phones and get immediate feedback. Integration of several best practices is key to a successful implementation of a CHW program. The program intentionally combined community-based selection of candidate CHWs with high levels of intrinsic motivation, robust training, extensive supervision, pay-for-performance incentives and written contracts to achieve excellent results.
The goal is to change the outcome measurement paradigm in developing countries. Over 100 operations have been completed and 350 people have been enrolled in the program. Five CHWs support the process; results show that 95% of patients finished 30-day follow-up; 92% of visits were performed on time; 96% of photographs were of high quality and surgeons agreed with CHWs in 84% of the cases whether there was an infection or not.
The long-term goal is to assess whether CHWs with mobile phones could replace the need for surgeons to perform outpatient follow up for patients who have no symptoms of infection, and also to evaluate whether mobile health follow up can identify infections earlier than the current standard of care, leading to reduced morbidity. Dr. Matousek also wants the approach to spread: “We hope the conversation on measuring outcomes will change from defeatism over the challenges to recognition that a well administrated community health worker program coupled with appropriate mobile technology can provide a solution.”
Dr. Matousek presented this at the Community Health Systems Initiative (CHSI), an association of global health implementers based out of the Program in Global Primary Care and Social Change at Harvard Medical School. Members come from organizations such as Partners In Health and Last Mile Health, and engage in a variety of activities, including best-practice sharing, research, advocacy, and cross-site consulting. The CHSI Roundtables are held monthly to expose participants to new ideas and influential discussion on cutting-edge community health science.
|Alexi Matousek MD, MPH
Dr. Alexi Matousek, a Brigham and Women’s Hospital surgery resident, works primarily at Hôpital Albert Schweitzer in Haiti. His projects include measuring inpatient surgical outcomes, using patient navigators to increase access to surgical care and mobile technology to enable surgical outcome measurement for a vulnerable mountain population.
1Meara, JG, Leather, AJM, Hagander, L et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015; (published online April 27.)