Sustainable surgical resource initiative for Haiti: the SSRI-Haiti project

Figures & data

Table 1. Reproduced from [8]. Key barriers to improved access and quality of surgical care in South Africa.

Priority	Barrier
1	Lack of service provider’s knowledge, training and experience
2	Limited surgical outreach
3	Lack of and poor maintenance of equipment
4	Lack of surgical health education
5	Lack of decentralised services
6	Lack of continuity of care
7	Long waiting times
8	Complex and disjointed referral system
9	Problems with cost, time, safety, distance and comfort of transport
10	Lack of social support

Figure 1. Brochure and schedule for 2019 National Medical Conference on Critical Care Conference organized and hosted by Haitian physicians and staff at St. Luke’s Hospital in Port- au-Prince.

Figure 2. (a) Surgery log book arrived after the earthquake provided by an Italian team. (b) Example of an entry from the logbook detailing the date, patient’s name, age, medical record number, diagnosis, name of surgeon and assistant, type of anesthesia and anesthetist/anesthesiologist. For this patient on October 28th, 2016, with a breast cancer had a modified radical mastectomy with surgeon Dr Crevecouer, assisted by nurse Miss Florence with general anesthesia by Dr Edema.

Translation: “Do not forget to write down the cases in this notebook. SVP name of nurse”. This obligation was strictly enforced by the nursing director of the surgical centre and performed by the anaesthetist or anaesthesiologist.

Table 2. Types of cases performed, Aug 2012–Dec 2017 inclusive. Note that there were 1,651 known procedures performed between August 2012 and December 2018 inclusive. However, following the end of December 2017, foreign intervention shifted focus from providing surgical and anaesthesia support to critical care education. Therefore, we have excluded 145 cases, which occurred between January 2018 and December 2018, meaning analysis was only performed on the 1,506 cases from 2012 to 2017. In addition, participation in surgery, anaesthesia and education as well as data collection and analysis were hindered starting in mid-2019 and early-2020 because of national political upheaval and gang violence and travel restrictions caused by the COVID-19 pandemic, which together precluded continued participation in and analysis of the surgical program [40–43]. As of the writing of this paper, St Luke’s continues to perform surgeries with spinal, local, and general anaesthesia independently. Table 2 was composed from a descriptive statistical analysis on cases performed between Aug 2012 and Dec 2017.

Surgery type	Foreign physicians	Haitian physicians	Total
Circumcision	73 (4.8%)	36 (2.4%)	109 (7.2%)
Excision	69 (4.6%)	236 (15.7%)	305 (20.3%)
Hemorrhoidectomy	4 (0.3%)	25 (1.7%)	29 (1.9%)
Hernia	130 (8.6%)	379 (25.2%)	509 (33.8%)
Holmium laser enucleation	83 (5.5%)	0 (0%)	83 (5.5%)
Hydrocelectomy	63 (4.2%)	192 (12.7%)	255 (16.9%)
Mastectomy	19 (1.3%)	42 (2.8%)	61 (4.1%)
Miscellaneous	42 (2.8%)	27 (1.8%)	69 (4.6%)
Multiple surgeries	20 (1.3%)	66 (4.4%)	86 (5.7%)
Total	503 (33.4%)	1003 (66.6%)	1506 (100%)

Figure 3. Total number of cases at St Luke’s Hospital in Port-au-Prince on a quarterly basis, differentiated between Haitian doctors and foreign doctors.

Figure 4. Total number cases at St Luke’s Hospital on a quarterly basis. It is differentiated by the type of anesthesia applied. There are six categories of anesthesia which includes general, local, local + MAC, local + sedation, spinal, and spinal + local.

Figure 5. Types of anesthesia used by all-Haitian teams on a quarterly basis. It is differentiated by the type of anesthesia applied. There are six categories of anesthesia which includes general, local, local + MAC, local + sedation, spinal, and spinal + local.

Table 3. The SSRI three phase plan within the context of the delay framework. Each delay in the four delay framework is listed in the left column; each phase in the 3-phase plan is listed on the top row. The entries in the body of the table indicate how each phase addresses each delay.

	Phase 1 Build facility and acquire equipment	Phase 2 Train staff and perform surgeries	Phase 3 Continued Education and Expansion
Delay 1 Seeking Care	Perform proactive outreach with community leaders and medical staff	Delivery of quality care combined with local outreach encourages care-seeking by local population and “word-of-mouth” communication	Haitian-led conferences with foreign contributors; NGO peers and local churches/leaders continue spreading word.
Delay 2 Reaching Care	Creation of local satellite clinics for screening; Remote outpost in Port-Salut made possible by local competence in Port-au-Prince and volunteer trips	Deploy referral and preoperative screening protocols; Continued engagement with churches and local leaders for patient transport and awareness	Continued experiential, classroom and conference training on referral and preoperative screening protocols
Delay 3 Receiving Care	Maintain facility/equipment and continue acquisition as needed	Deploy operative protocols; Train local physicians on surgical practices; Perform surgical care with local and combined staff	Help ensure local sustainability while continuing seasonal targeted visits for volunteer care; Continued education on operative and maintenance protocols
Delay 4 Remaining In Care	See above (maintain facility/equipment)	Deploy follow-up care protocols and patient education regarding importance of follow-up and early care-seeking in the event of symptoms	Continued staff education on follow-up protocols

Mac Quene T, Smith L, Odland ML, Levine S, D’ambruoso L, Davies J, et al. Prioritising and mapping barriers to achieve equitable surgical care in South Africa: a multi-disciplinary stakeholder workshop. Global Health Action. 2022 Dec 31;15:2067395.

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