Abstract
Introduction.
The Lancet Commission on Global Surgery proposed 5000 operations/100,000 people annually as a benchmark for developing countries but did not define benchmarks for different age groups. We evaluated the operation rate for elderly patients (≥65 years) in Ghana and estimated the unmet surgical need for the elderly by comparison to a high-income country benchmark.
Methods.
Data on operations performed for elderly patients over a 1-year period in 2014–5 were obtained from representative samples of 48/124 small district hospitals and 12/16 larger referral hospitals and scaled-up for nationwide estimates. Operations were categorized as essential (most cost-effective, highest population impact) vs. other according to The World Bank’s Disease Control Priority project (DCP-3). Data from New Zealand’s National Minimum Dataset were used to derive a benchmark operation rate for the elderly.
Results.
16,007 operations were performed for patients ≥65 years. The annual operation rate was 1744/100,000 (95%UI: 1440–2048), only 12% of the New Zealand benchmark of 14,103/100,000. 74% of operations for the elderly were in the essential category. The most common procedures (15%) were for urinary obstruction. 58% of operations were performed at district hospitals; 54% of these did not have fully-trained surgeons. Referral hospitals more commonly performed operations outside the essential category.
Conclusions.
The operation rate was well beneath the benchmark, indicating a potentially large unmet need for Ghana’s elderly population. Most operations for the elderly were in the essential category and delivered at district hospitals. Future global surgery benchmarking should consider specific benchmarks for different age groups.
Keywords: Enumeration, Surgical operation rate, Elderly, Ghana, LMIC, Global surgery
Introduction
The elderly population is growing at a faster rate than the general population in almost all regions of the world [1, 2]. The number of people aged 60 years or older is projected to grow from an estimated 809 million in 2012 to over 2 billion in 2050, with most of the increase in low- and middle-income countries (LMICs) where health and social protection systems are weak [1, 2]. With increased age, the burden of non-communicable diseases (NCDs) also increases, which includes many conditions that require surgery in the course of management (e.g., hernia, bowel obstruction, cancer, injury, burn).
The Lancet Commission on Global Surgery (LCoGS) recommended an annual rate for all operations of 5,000/100,000 population as a benchmark for LMICs to achieve most of the population-wide benefits of surgery [3]. The Commission did not define benchmarks for the elderly population or other age groups. Further, no nationwide assessments of surgical rates for the elderly have been performed to contextualize this metric [4, 5]. To address this gap, we aimed to estimate the annual surgical case rate for the elderly (individuals ≥65 years) in Ghana, characterized by type and hospital level to inform capacity building initiatives. We also sought to estimate the unmet surgical need for the elderly.
Methods
Setting
Ghana is a lower-middle-income country with a population of over 26 million [6]. Currently, the population of Ghana who are ≥65 years is 4.2% with an anticipated increase to 6.5% in 2050 [7]. Provision of hospital-based surgical care usually begins with district (first-level) hospitals [8, 9]. These include government-run hospitals and faith-based hospitals. They have 50–100 beds and offer some surgical services, but are often not staffed by fully-trained surgeons [10]. When necessary, patients are referred to larger regional or tertiary hospitals. Regional hospitals have 100–500 beds and are typically staffed by specialist surgical providers (e.g. general, obstetric and orthopedic surgeons). Tertiary hospitals have 500–2,000 beds and offer a broader range of surgical services. At the time of data collection, Ghana had 124 district, 11 regional, and 5 tertiary hospitals.
Study Design
The number and types of operations performed for the elderly in Ghana over a one-year period from 2014 to 2015 were determined by a retrospective review of surgical logbook data at a representative sample of all hospitals. Details of power estimation, hospital sampling, and study methodology have been previously described [11]. Briefly, all regional and tertiary hospitals and 48/124 district hospitals, selected by simple random sampling, were invited to participate in the study. Private hospitals were excluded since they do not significantly contribute to the national surgical volume [12].
The LCoGS procedure rate benchmark was established by comparing national operative volume to health outcome indicators including life expectancy and maternal mortality ratio [13]. New Zealand was selected as the standard for comparison due to its excellent health outcomes, and availability of high-quality surgical information, ensuring a high likelihood of provision of effective surgical care in an economically efficient manner [14]. Using this accepted comparator, the rate of operations performed for the elderly in New Zealand was selected as a proxy for the total surgical need of this sub-population. Considering the number of operations performed for the elderly in Ghana as the met surgical need for this sub-population, the unmet surgical need could be quantified by comparing the estimate to the respective figures from New Zealand.
Data Collection
All operations logged in operating theater and procedure area registers at sampled hospitals were transcribed into Excel (Microsoft Corp., USA). An operation was defined as a procedure performed in an operating theater or procedure area regardless of anesthesia type or surgical provider. Data captured included the date of procedure, patient demographics, operation(s) performed, and anesthesia type. No identifying information was recorded. The elderly population of Ghana (i.e., people aged ≥65 years) was extracted from The World Bank data [6].
Surgical volume for New Zealand’s elderly population was determined from the National Minimum Dataset (NMDS) [15]. The NMDS is a national collection of publicly funded hospital discharge information, organized and maintained by the New Zealand Ministry of Health. All surgical procedures performed for the elderly in 2015 were extracted from the larger dataset to obtain a proxy for surgical need.
Data Analysis
Data were described with numbers and percentages and per hospital level [i.e., district (small) and referral (large) hospitals]. Operations were also categorized into ‘essential procedures’ (i.e., most cost-effective, highest population impact) as defined by The World Bank’s Disease Control Priorities Project 3rd Edition (DCP-3) and ‘other’ (i.e., less cost-effective, lower population impact).[16]
Utilization of hospital-level probability weights to arrive at national estimates for each operation have been previously described [11]. Briefly, district- and regional-level weights were determined as the inverse of the proportion of hospitals surveyed (48/124 and 9/11, respectively). Tertiary-level weights were determined as the inverse of the proportion of surveyed hospital bed capacity (2000/4400). Bootstrap standard errors were calculated to provide 95% uncertainty intervals (UI) for the total annual national estimate of operations for the elderly. Surgical rates were expressed as operations per 100,000 elderly population using 2014 population estimates [6]. Comparison was made between the annual surgical rate for the elderly and that for the population <65 years. The unmet surgical need for the Ghanaian elderly population was estimated by comparing the annual surgical rate to that calculated using New Zealand’s NMDS. Data were analyzed with Stata v14 (StataCorp, USA).
Ethics
The study was approved by the Committee on Human Research Publications and Ethics of Kwame Nkrumah University of Science and Technology and deemed exempt by the University of Washington Institutional Review Board.
Results
National estimates
All 48 district hospitals, 9/11 regional hospitals and 3/5 tertiary hospitals agreed to participate in the study. At sampled hospitals, 7,416 operations were performed for elderly patients over the one-year period, translating to a national estimate of 16,007 (95%UI: 13,215–18,799) operations. With a 2014 elderly Ghanaian population of 917,977, the annual national rate of operations for the elderly was 1,744/100,000 (95%UI: 1,440–2,048). The estimated rates for elderly females and males were 1,278/100,000 (95%UI: 1,048–1,508) and 2,244/100,000 (95%UI: 1,846–2,642), respectively.
National procedure-type estimates
Seventy-four percent of operations performed nationally for the elderly (11,888 operations) were of the essential procedure category (i.e., most cost-effective operations with highest population impact). Essential procedures made up 83% of operations performed for the elderly at district hospitals; for referral (regional and tertiary) hospitals, they accounted for 63%. General surgical, cataract surgery and dental operations were the majority of operations performed in this category (10,091 operations; 85%) (Table 1). The largest number of operations was for urinary obstruction, which included suprapubic or urethral catheterizations (80%), prostatectomy (10%) and repair or dilatation of urethral strictures (8%).
Table 1.
National annual estimates of surgical procedures performed for the elderly (≥65 years) in Ghana 2014 – 2015
| District (small) hospitals | Referral (large) hospitals | All hospitals | ||||
|---|---|---|---|---|---|---|
| N | (%) | N | % | N | (%) | |
| Essential surgical procedures | 7,714 | (83) | 4,174 | (63) | 11,888 | (74) |
| General surgery (basic, intermediate) | 4,193 | (45) | 1,921 | (29) | 6,113 | (38) |
| Herniorrhaphy and hydrocelectomy | 1,881 | (20) | 483 | (7.2) | 2,363 | (15) |
| Superficial abscess drainage, wound debridement | 754 | (8.1) | 211 | (3.2) | 965 | (6.0) |
| Laparotomy for peritonitis (e.g., perforated viscus, appendicitis, cholecystitis) | 72 | (0.8) | 144 | (2.2) | 216 | (1.4) |
| Release of urinary obstruction | 1,431 | (15) | 985 | (15) | 2,416 | (15) |
| Male circumcision | 21 | (0.2) | 9 | (0.1) | 30 | (0.2) |
| Laparotomy for bowel obstruction | 34 | (0.4) | 71 | (1.1) | 105 | (0.7) |
| Colostomy | 0 | (0) | 19 | (0.3) | 19 | (0.1) |
| Cataract surgery | 1,374 | (15) | 735 | (11) | 2,109 | (13) |
| Dental procedures | 1,550 | (17) | 317 | (4.8) | 1,867 | (12) |
| Trauma (basic, intermediate) | 597 | (6.4) | 1,194 | (18) | 1,791 | (11) |
| Skin and soft tissue procedures | 351 | (3.8) | 143 | (2.1) | 494 | (3.1) |
| Orthopedic procedures | 217 | (2.3) | 927 | (14) | 1,144 | (7.1) |
| Tube thoracostomy | 23 | (0.2) | 29 | (0.4) | 52 | (0.3) |
| Trauma laparotomy | 3 | (0.03) | 23 | (0.3) | 26 | (0.2) |
| Burr hole | 0 | (0) | 44 | (0.7) | 44 | (0.3) |
| Surgical airway | 3 | (0.03) | 28 | (0.4) | 30 | (0.2) |
| Ob-gyn (basic, intermediate) | 0 | (0) | 8 | (0.1) | 8 | (0.1) |
| Congenital conditions (basic, intermediate) | 0 | (0) | 0 | (0) | 0 | (0) |
| Other surgical procedures | 1,630 | (17) | 2,489 | (37) | 4,119 | (26) |
| General surgical procedures | 491 | (5.3) | 614 | (9.2) | 1,104 | (6.9) |
| Excision biopsy for soft tissue masses | 220 | (2.4) | 109 | (1.6) | 329 | (2.1) |
| Procedures for breast conditions (including cancer) | 36 | (0.4) | 63 | (0.9) | 99 | (0.6) |
| Procedures for other benign general surgical conditions† | 222 | (2.4) | 333 | (5.0) | 556 | (3.5) |
| Procedures for gastrointestinal and other general surgical cancers | 13 | (0.1) | 108 | (1.6) | 121 | (0.8) |
| Head/Neck procedures | 256 | (2.7) | 752 | (11) | 1,007 | (6.3) |
| Foreign body removal | 230 | (2.5) | 661 | (9.9) | 891 | (5.6) |
| Procedures for other benign head/neck conditions‡ | 26 | (0.3) | 38 | (0.6) | 63 | (0.4) |
| Procedures for head/neck cancer | 0 | (0) | 53 | (0.8) | 53 | (0.3) |
| Miscellaneous minor procedures# | 455 | (4.9) | 108 | (1.6) | 563 | (3.5) |
| Advanced trauma and orthopedic procedures | 147 | (1.6) | 362 | (5.4) | 509 | (3.2) |
| Open reduction +/− internal fixation | 59 | (0.6) | 239 | (3.6) | 299 | (1.9) |
| horacotomy | 0 | (0) | 0 | (0) | 0 | (0) |
| Craniotomy | 0 | (0) | 7 | (0.1) | 7 | (0.04) |
| Tendon repairs/release of contractures | 3 | (0.03) | 18 | (0.3) | 20 | (0.1) |
| Other advanced orthopedic procedures | 85 | (0.9) | 98 | (1.5) | 183 | (1.1) |
| Ob-gyn procedures | 142 | (1.5) | 263 | (3.9) | 405 | (2.5) |
| Procedures for benign ob-gyn conditions | 85 | (0.9) | 138 | (2.1) | 224 | (1.4) |
| Procedures for gynecologic cancers | 57 | (0.6) | 124 | (1.9) | 181 | (1.1) |
| Urological procedures (including cancers) | 72 | (0.8) | 259 | (3.9) | 332 | (2.1) |
| Other ophthalmology procedures§ | 67 | (0.7) | 132 | (2.0) | 199 | (1.2) |
| Total | 9,344 | (100) | 6,663 | (100) | 16,007 | (100) |
includes goiter, hemorrhoids, rectal prolapse, diabetic foot and toe gangrene secondary to critical limb ischemia.
includes neck abscess, sialolithiasis, benign parotid masses, chronic sinusitis, epistaxis.
includes excision of ingrowing toenails, intra-articular injections for osteoarthritis, wound dressing under sedation, ear irrigation.
includes pterygium excisions, tarsorrhaphy, trabeculectomy and anterior chamber washouts.
Operations that were outside of the essential procedure category accounted for 26% of operations performed nationally for the elderly (4,119 operations). Majority of these (2,879; 70%) were general surgical operations (e.g., operations for goiter and benign perianal conditions, excision biopsy for soft tissue masses, and cancer operations), head and neck operations (e.g., biopsy, foreign body removal), advanced trauma and orthopedic operations (e.g., open reduction and internal fixations for fractures, osteotomies) and urological operations (e.g., nephrectomy, cystoscopy and biopsy) (Table 1).
Procedure-type estimates by hospital level
District hospitals were responsible for more than half (9,344; 58%) of all operations performed for the elderly. Over 80% (7,714 operations, 83%) of these were in the essential procedure category. These included herniorrhaphy and hydrocelectomy (1,881 operations vs 483 at referral hospitals), relief of urinary obstruction (1,431 operations vs 985 at referral hospitals), cataract surgery (1,374 operations vs 735 at referral hospitals), and dental operations (1,550 vs 317 at referral hospitals) (Table 1). Fifty-four percent of district hospitals were not staffed by fully-trained surgeons; nonetheless, these hospitals performed 39% of all operations for the elderly.
Referral hospitals contributed 42% of the total annual surgical output for the elderly. However, they performed the majority of operations classified outside of the essential procedure category (2,489; 60%)
(Table 1). Referral hospitals performed two-thirds of essential trauma surgical procedures (1,194 operations, 67%) in this age group.
Comparison to population <65 years
The estimated annual total operations performed (16,007) was much less than that estimated for the population <65 years (198,578). Yet, the annual operation rate for the elderly was 1,744 per 100,000 compared to 768 per 100,000 (95%UI: 571–965) for the population aged <65 years (Table 2). The percentage of procedures that fell into the essential category was similar for the elderly (74%) and those under 65 years (77%). However, the patterns of surgery were somewhat different, with higher rates of surgery for hernia, relief of urinary obstruction, and cataract surgery for the elderly (Figure 1). Predictably, there were higher rates of operations for basic/intermediate obstetric and gynecologic conditions, including cesarean sections, tubal ligations, and obstetric fistula repairs, for patients under 65 years (Figure 2).
Table 2:
Comparison of national annual estimated rates of surgical procedures performed in Ghana for the elderly and patients below 65 years
| Patients >65 years | Patients <65 years | |||
|---|---|---|---|---|
| N | Rate* | N | Rate** | |
| Essential surgical procedures | 11,888 | 1295 | 153,645 | 594 |
| General surgery (basic, intermediate) | 6,113 | 666 | 32,032 | 124 |
| Herniorrhaphy and hydroceiectomy | 2,363 | 257 | 14,680 | 57 |
| Superficial abscess drainage, wound debridement | 965 | 105 | 6,928 | 30 |
| Laparotomy for peritonitis (e.g., perforated viscus, appendicitis, cholecystitis) | 216 | 24 | 4,597 | 19 |
| Release of urinary obstruction | 2,416 | 263 | 1,454 | 14 |
| Male circumcision | 30 | 3 | 3,092 | 12 |
| Bowel obstruction | 105 | 11 | 943 | 4 |
| Colostomy | 19 | 2 | 336 | 1 |
| Cataract surgery | 2,109 | 230 | 1,728 | 7 |
| Dental procedures | 1,867 | 203 | 19,619 | 76 |
| Trauma (basic, intermediate) | 1,791 | 195 | 25,132 | 97 |
| Skin and soft tissue procedures | 494 | 54 | 12,278 | 49 |
| Orthopedic procedures | 1,144 | 125 | 11,481 | 48 |
| Tube thoracostomy | 52 | 6 | 473 | 2 |
| Trauma laparotomy | 26 | 3 | 624 | 2 |
| Burr hole | 44 | 5 | 198 | 1 |
| Surgical airway | 30 | 3 | 78 | 0 |
| Ob-gyn (basic, intermediate) | 8 | 1 | 74,083 | 286 |
| Congenital conditions (basic, intermediate) | 0 | 0 | 1,051 | 4 |
| Other surgical procedures | 4,119 | 449 | 44,933 | 174 |
| General Surgical procedures | 1,104 | 120 | 9,095 | 35 |
| Excision biopsy for soft tissue masses | 329 | 36 | 3,748 | 14 |
| Procedures for breast conditions (including cancer) | 99 | 11 | 1,882 | 7 |
| Procedures for other benign general surgical conditions† | 556 | 61 | 3,110 | 12 |
| Procedures for gastrointestinal and other general surgical cancers | 121 | 13 | 356 | 1 |
| Head/Neck procedures | 1,007 | 110 | 10,985 | 42 |
| Foreign body removal | 891 | 97 | 8,806 | 34 |
| Procedures for other benign head/neck conditions‡ | 63 | 7 | 2,007 | 8 |
| Procedures for head/neck cancer | 53 | 6 | 172 | 1 |
| Miscellaneous minor procedures# | 563 | 61 | 4,983 | 19 |
| Advanced trauma and orthopedic procedures | 509 | 55 | 5,102 | 20 |
| Open reduction +/− internal fixation | 299 | 33 | 3,143 | 12 |
| Thoracotomy | 0 | 0 | 15 | 0 |
| Craniotomy | 7 | 1 | 210 | 1 |
| Tendon repairs/release of contractures | 20 | 2 | 480 | 2 |
| Other advanced orthopedic procedures | 183 | 20 | 1,253 | 5 |
| Ob-gyn procedures | 405 | 44 | 11,323 | 44 |
| Procedures for benign Ob-gyn conditions | 224 | 24 | 9,728 | 38 |
| Procedures for gynecologic cancers | 181 | 20 | 1,595 | 6 |
| Urological procedures (including cancers) | 332 | 36 | 2,324 | 9 |
| Other ophthalmology procedures§ | 199 | 22 | 1,122 | 4 |
| Total | 16,007 | 1744 | 198,578 | 768 |
Rate per 100,000 patients ≥65 years;
Rate per 100,000 patients <65 years
includes goiter, hemorrhoids, rectal prolapse, diabetic foot and toe gangrene secondary to critical limb ischemia.
includes neck abscess, sialolithiasis, benign parotid masses, chronic sinusitis, epistaxis.
includes excision of ingrowing toenails, intra-articular injections for osteoarthritis, wound dressing under sedation, ear irrigation.
includes pterygium excisions, tarsorrhaphy, trabeculectomy and anterior chamber washouts.
Figure 1.
Six most commonly performed operations for the elderly in Ghana: comparison to patients below 65 years. A. Estimated numbers; B. Estimated rates.
Figure 2.
Five most commonly performed operations for patients under 65 years in Ghana: comparison to the elderly. A. Estimated numbers; B. Estimated rates
*Basic/intermediate ObGyn procedures include cesarean sections, tubal ligations, manual vacuum aspirations, dilatation and curettage and obstetric fistula repairs
Comparison to high-income country benchmark
New Zealand performed 96,327 operations in 2015 for an elderly population of 683,013; yielding an estimated annual operation rate of 14,103 per 100,000. Compared to this benchmark of total surgical need for the elderly, Ghana has an annual unmet need of 12,359 operations per 100,000 elderly population indicating that only 12% of the need for surgery in the elderly was being met in Ghana. In terms of surgical rate in the younger population, New Zealand performed 201,944 operations in 2015 for an <65 year population of 3,922,560, yielding a rate of 5,148 per 100,000. Comparison to Ghana’s rate of surgery for people <65 years of 768 per 100,000 indicates a met need for surgery of 15% for the Ghanaian population under 65 years.
Discussion
This study sought to determine the met need for surgical operations for Ghanaians aged ≥65 years to assess the current capacity and preparedness of the country to provide surgical care for the growing elderly population. The estimated annual surgical rate for the elderly was 1,744/100,000 population, only 12% of the New Zealand benchmark, indicating a potentially large unmet need for surgery for this sub-population of Ghanaians. This large unmet need was comparable to that for the Ghanaian population <65 years, suggesting a broad deficiency of surgical care services. Majority of operations for the elderly were of the essential procedure category as defined by The World Bank DCP-3 with district hospitals performing most of these operations.
The overwhelming burden of disease in elderly persons is from NCDs. However, 34% of people aged >60 years globally find it difficult to access healthcare when they need it [1]. This is likely particularly true for people trying to access surgical services, which have not been prioritized by many LMIC health systems. Although ischemic heart disease, stroke and chronic lung disease are the biggest killers, visual and hearing impairment, osteoarthritis, injuries, and surgical emergencies are among the main causes of disability and often related to causes of death [17, 18]. These conditions disproportionately affect older persons in LMICs [19]. As the Ghanaian elderly population continues to grow, the country’s healthcare system must adapt to match the demands that its rapidly growing elderly population will place on it.
Despite growing demand for elderly care, few training programs and out-migration of healthcare professionals limit the number of healthcare workers, seriously affecting adequate healthcare delivery. Further, there is a serious lack of geriatricians, surgeons, and palliative care specialists to care for the elderly in Ghana, like most LMICs. The increase in the absolute and relative numbers of older persons makes gerontological, surgical, and palliative care education urgent needs [20]. Until specific training programs are developed, existing health and social care professionals and informal caregivers need improved information and training on the needs of elderly persons, which could be integrated into current curricula [21].
The majority of older people in developing countries live in rural areas consequent to rural-to-urban migration of younger adults [22]. Surgical care needs of the rural elderly population usually fall on frontline district hospitals that typically lack fully-trained surgeons [11]. Increasing the number of surgeons at district hospitals may be a worthwhile endeavor with implications for the number and types of surgical operations available for the elderly living in rural areas. Efforts by the Ghana College of Physicians and Surgeons (GCPS) to increase the number of surgeons trained in-country and posted to rural hospitals should be applauded. Since its inception till 2016, the GCPS trained 146 surgeons who were more widely distributed, especially among district hospitals, than they were before training [23]. However, more needs to be done to narrow the gap in met need for surgery among the Ghanaian elderly. The introduction of certain high-yield aspects of gerontology (e.g., prevention and care of delirium, geriatric nutrition and pharmacotherapy, appreciation of frailty and high-risk patients, patient- and family-centered goals-of-care and end-of-life communication, aging ethics) into surgical training might be considered to equip trainees with requisite knowledge and skills to provide better services and more integrated care for the elderly.
Before drawing conclusions, several limitations should be considered. First, private hospitals were not included in the study as they provide less than 10% of the national surgical volume [12]. Therefore, excluding them is not expected to alter our estimates significantly. Second, 8% of observations in logbooks were missing age data and were excluded from the analysis. We have no reason to believe that the age distribution of missing entries is different than that seen within the complete data. Third, there are significant differences in the population demographics between New Zealand and Ghana, which likely impacts on the epidemiology of conditions requiring surgery within the two populations especially among the elderly. However, the LCoGS utilized New Zealand data to arrive at the widely accepted and utilized annual surgery rate benchmark of 5,000 operations/100,000 population. This provides good precedence and external validity for using other benchmarks derived from the New Zealand data. Nonetheless, our unmet surgical need might be over-estimated due to the fact that there might be a greater percent of very old people in New Zealand compared with Ghana. Lastly, we have noted the amount of surgery performed at district hospitals that do not have fully-trained surgeons. However, we do not have data on the quality of care at such hospitals vs. hospitals with fully-trained surgeons. Despite these limitations, these data provide a useful estimate of the annual surgical operation rate for the elderly in Ghana and allow at least a general idea of unmet need. More importantly, the study highlights current surgical care capacity for the elderly and provides data that might inform planning to better meet the surgical needs of this growing and vulnerable population.
Conclusion
The annual rate of surgical procedures for the elderly in Ghana points toward potentially large unmet surgical needs that need to be addressed. Most operations for the elderly were in the highest priority category and delivered at district hospitals, majority of which lack fully-trained surgeons. More work is required to better define geriatric surgical needs and benchmarks in LMICs and identify ways that national institutions and the global surgery community can meet the challenges of elderly population growth.
Grant support:
This study was funded by grants R25-TW009345 and D43-TW007267 from the Fogarty International Center, US National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors thank the dedicated volunteers for extracting data needed for the study and Chris Lewis of New Zealand Ministry of Health for providing us with the National Minimum Dataset.
Footnotes
Conflicts of interest: The authors declare no competing interest in any form related directly or indirectly to the subject of this article.
This manuscript was presented in part at the World Congress of Surgery 2017 (WCS 2017) at Basel, Switzerland.
Contributor Information
Adam Gyedu, Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, drgyedu@gmail.com.
Barclay Stewart, Department of Surgery, University of Washington, Seattle, WA, USA;; Department of Interdisciplinary Health Sciences, Stellenbosch University, Cape Town, South Africa, stewarb@u.washington.edu.
Cameron Gaskill, Department of Surgery, University of Washington, Seattle, WA, USA, cgaskill@uw.edu.
Emmanuella Lebasaana Salia, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, lebasaanasalia@gmail.com.
Raymond Wadie, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, wadieraymond@yahoo.com.
Peter Donkor, Department of Surgery; School of Medicine and Dentistry; Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, petadonkor@yahoo.com.
Charles Mock, Harborview Injury Prevention & Research Center, Seattle, WA, USA; Department of Surgery, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA, cmock@uw.edu.
References
- 1.United Nations Population Fund, HelpAge International Ageing in the twenty-first century: A celebration and a challenge, New York, USA, United Nations Population Fund and HelpAge International, 2012. [Google Scholar]
- 2.World Health Organization World report on ageing and health, Geneva, Switzerland, World Health Organization, 2015. [Google Scholar]
- 3.Meara JG, Leather AJ, Hagander L, et al. (2015) Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Surgery 158:3–6 [DOI] [PubMed] [Google Scholar]
- 4.Choo S, Perry H, Hesse AA, et al. (2010) Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hospitals using a WHO assessment tool. Tropical medicine & international health : TM & IH 15:1109–1115 [DOI] [PubMed] [Google Scholar]
- 5.Crompton J, Kingham TP, Kamara TB, et al. (2010) Comparison of surgical care deficiencies between US civil war hospitals and present-day hospitals in Sierra Leone. World journal of surgery 34:1743–1747 [DOI] [PubMed] [Google Scholar]
- 6.The World Bank Group World Development Indicators, 2017.
- 7.PopulationPyramids Population pyramids of the world from 1950 to 2100: Ghana - 2050, 2019.
- 8.Zakariah A, Degbotse D, Osei D, et al. Holistic Assessment of the Health Sector Programme of Work 2013, Accra, Ghana, Ghana Ministry of Health, 2014. [Google Scholar]
- 9.Gyedu A, Baah EG, Boakye G, et al. (2015) Quality of referrals for elective surgery at a tertiary care hospital in a developing country: An opportunity for improving timely access to and cost-effectiveness of surgical care. Int J Surg 15:74–78 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Stewart BT, Quansah R, Gyedu A, et al. (2015) Strategic Assessment of Trauma Care Capacity in Ghana. World journal of surgery 39:2428–2440 [DOI] [PubMed] [Google Scholar]
- 11.Gyedu A, Stewart B, Gaskill C, et al. (2017) Improving Benchmarks for Global Surgery: Nationwide Enumeration of Operations Performed in Ghana. Ann Surg 268:282–288 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Ministry of Health National Assessment for Emergency Obstetric and Newborn Care, Accra, Minstry of Health, Ghana, 2011. [Google Scholar]
- 13.Jamison DT, Summers LH, Alleyne G, et al. (2013) Global health 2035: a world converging within a generation. Lancet 382:1898–1955 [DOI] [PubMed] [Google Scholar]
- 14.Rose J, Weiser TG, Hider P, et al. (2015) Estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate. The Lancet Global health 3 Suppl 2:S13–20 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Ministry of Health New Zealand National Minimum Dataset (hospital events), Wellington. [Google Scholar]
- 16.Debas H, Donkor P, Gawande A, et al. Essential Surgery Disease Control Priorities, Washington, DC, World Bank, 2015. [PubMed] [Google Scholar]
- 17.Institute of Health Metrics and Evaluation Global burden of disease study 2016 (GBD 2016): Data compare, Seattle, United States, Institute for Health Metrics and Evaluation (IHME), 2016. [Google Scholar]
- 18.Stewart B, Khanduri P, McCord C, et al. (2014) Global disease burden of conditions requiring emergency surgery. The British journal of surgery 101:e9–22 [DOI] [PubMed] [Google Scholar]
- 19.World Health Organization Good Health Adds Life to Years: Global Brief for World Health Day 2012 Geneva, World Health Organization, 2012. [Google Scholar]
- 20.United Nations Political Declaration and Madrid International Plan of Action on Ageing (para. 82), New York, United Nations, 2002. [Google Scholar]
- 21.United Nations Political Declaration and Madrid International Plan of Action on Ageing (para. 83), New York, United Nations, 2002. [Google Scholar]
- 22.UNDESA Population Division World Population Ageing 2009, New York, 2009. [Google Scholar]
- 23.Gyedu A, Debrah S, Agbedinu K, et al. (2018) In-Country Training by the Ghana College of Physicians and Surgeons: An Initiative that has Aided Surgeon Retention and Distribution in Ghana. World journal of surgery [DOI] [PMC free article] [PubMed] [Google Scholar]