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Metric-Driven Surgical Care Delivery in Rural Settings of Extreme Poverty:
Prospective Implementation Science Study in Rural Nepal
ABSTRACT
Introduction
While over 11% of premature death and disability globally are due to surgically treatable conditions including
obstructed labor and traumatic injuries, human resources and funding for surgical infrastructure lags behind
nearly all other public health priorities. The World Health Organization (WHO) and other international
health agencies have recently begun to focus on building the tools, protocols and infrastructure to reduce the
global burden of surgical disease. Data on the processes and outcomes of surgical care implementation in
rural settings of extreme poverty, however, are limited. Here, we propose the first implementation research
study to assess the process of scaling up surgical capacity in a rural setting of extreme poverty, the district of
Achham, Nepal.
Methods and Analysis
The study will take place in Achham, Nepal, at a district hospital that is run as a public-private partnership
between the Nepali government and the non-profit organization Nyaya Health. Within this region, the study
will collect baseline data using community surveillance and referral mechanisms to ascertain the burden of
surgical disease in the district. This data will quantify the need for the district hospital to scale up surgical
services, as is currently being done based upon the protocols of the WHO’s Integrated Management for
Emergency and Essential Surgical Care (IMEESC). The study will assess surgeries across the three venues of
surgical care for rural patients in settings of extreme poverty: 1) surgeries conducted on-site by local staff; 2)
surgeries conducted on-site by visiting surgical camp teams; 3) surgeries conducted at distant referral sites.
Each site will be evaluated for baseline surgical capacity using the Personnel, Infrastructure, Procedures,
Equipment, Supplies (PIPES) tool. The analysis for on-site surgeries will focus on cesarean sections and softtissue injuries, since these represent the largest two categories of surgical burden: complicated labor and
traumatic injuries. The study will employ both qualitative and quantitative research methodologies to collect
clinical data and information on the utilization of services, and to assess process measures at the five key
domains of analysis: 1) emergency/pre-operative; 2) operating room/intra-operative; 3) inpatient ward/postoperative; 4) community/follow-up; and 5) facilities and supplies systems. Community health workers
(CHWs) will be tasked with ensuring follow-up of all patients. The study will be conducted over the first
eighteen months of the implementation process, and will be divided into an initial phase (first six months)
and a consolidation phase (subsequent twelve months).
Discussion
There is an acute need to fill the data gap in assessment of surgeries in rural settings of extreme poverty. In
this study, we pilot a model for metric-driven surgical care delivery and assess the feasibility, strengths,
weaknesses, and challenges of this approach for implementing and monitoring surgical services. These data
can form the basis of larger, multi-site implementation studies with a broader consortium of providers and
implementation scientists. Ultimately, data from surgical implementation science studies such as this will
provide the framework and evidence base to effectively finance and implement the expansion of surgical
services globally.
BACKGROUND
Worldwide, over 11% of death and disability are attributable to surgically curable diseases. Every year, 234
million major surgeries are performed [1][2][3], yet the distribution of these surgeries is highly inequitable.
Approximately 30% of the world’s population receives 74% of the world’s surgical procedures, with the
poorest third obtaining a meager 3% [2]. Though limited data exist, it is likely that the mortality and
morbidity rates from surgical complications are higher among the global poor [4][5]. Two billion people
worldwide, roughly a third of the global population, live in areas with less than one operating room per
100,000 people. As a result, patients in poor countries do not receive timely surgical services and suffer
significant morbidity and mortality from preventable and treatable conditions [6][7].
A large global scale-up of surgical capacity is required to close this gap in surgical access. Due to challenges
in human resources, transportation systems, and procurement of electricity and water, implementing surgical
services in settings of extreme poverty presents unique challenges. A growing literature exists on the
deployment of surgical quality initiatives within existing surgical programs, however, data examining how to
achieve this on initiation of surgical services is limited [8]. There is thus an acute need to study the core
operational processes by which surgical services deployment occurs in remote, resource-limited settings.
Furthermore while metrics have been developed for assessing the inputs and outputs of surgical care in urban
settings, there are limited data on these metrics in rural settings of extreme poverty [9].
This study will be the first to describe and assess the implementation of surgical services in rural settings of
extreme poverty. The approach we take is as follows (see Figure 1). We describe the implementation of
World Health Organization's (WHO) Integrated Management of Emergency and Essential Surgical Care
(IMEESC) program and develop a metrics system across the three primary venues that rural patients receive
care: 1) surgeries conducted on-site by local staff; 2) surgeries conducted on-site by visiting surgical camp
teams; 3) surgeries conducted by distant referral sites.
In each context, Surgeons OverSeas (SOS) Personnel, Infrastructure, Procedures, Equipment, and Supplies
(PIPES) will be used to evaluate baseline surgical capacity and document surgical readiness [21]. The metrics
system is built off of WHO’s Safe Surgery Saves Lives initiative developed in urban, specialist centers on
statistical metrics for surgery, which focused on the following: number of operating rooms; number of
accredited surgeons; number of accredited anesthesia professionals; number of surgical procedures done in an
operating room per year; day-of-surgery death ratio; post-operative in-hospital death ratio. These metrics are
appropriate and useful in tracking global surgical care, though need to be refined for rural settings of extreme
poverty where typically there are only one or at most two operating rooms, a single surgeon and a single nonphysician anesthesia professional [9].
To study this problem scientifically, we will use mixed qualitative and quantitative implementation science
methodologies. Implementation science is the study of systems and interventions aimed at establishing and
expanding empirically-supported treatments into routine care. We will conduct the research at a district-level
hospital in rural Nepal within a district of 270,000 people in a setting of extreme poverty where the nearest
reliable, comprehensive surgical services are over 16 hours away.
Overview and Specific Aims
This study will assess the delivery of surgical care in a rural setting of extreme poverty (Figure 2).
Specific Aim 1: Patient-Oriented Characteristics and Outcomes
Specific aim 1 is to describe the demographic characteristics and outcomes among surgical patients receiving
care in a rural district hospital setting of extreme poverty across the three main categories of surgical delivery:
continuous, camp-based, and referral services.
To meet specific aim 1, we will collect the following data: geographic distribution, type of surgical disease,
time from symptoms to presentation, time from presentation to surgery, successful completion of surgery,
complications, and follow-up rates at 72 hours and 30 days. We will also distribute the Surgeons OverSease
(SOS) Assessment of Surgical Need (SOSAS) to communities reached through active recruitment methods to
better understand the burden of surgical disease within the district.
Specific Aim 2: Systems-level Logistical and Clinical Processes
Specific aim 2 is to describe the logistical and clinical processes associated with providing and coordinating
care in a rural district hospital setting of extreme poverty across the three main categories of surgical delivery:
continuous, camp-based, and referral services.
To meet specific aim 2, data will include the inputs to surgical care, including: financial, staffing,
pharmaceutical, and consumable supply resources. Data will also be collected on the effective
implementation of these inputs, including: availability of surgical personnel and facilities, measures of
adherence of staff to resuscitation and operating protocols, supply chain reliability, electricity and water
reliability, and staff participation in morbidity and mortality conferences and other quality improvement
initiatives. We will additionally measure baseline surgical capacity of each site during the implementation
phase and additionally throughout the use of each site of the study using the SOS PIPES evaluation tool, an
adaptation of the WHO Tool for Situational Analysis of Emergency and Essential Care. PIPES binary system
of measurement will make it possible to index changes in surgical capacity as a trend overtime.
METHODS AND ANALYSIS
Site
This intervention will be implemented and tested in the district of Achham, located in Far Western Nepal.
Home to approximately 270,000 citizens, Achham is one of the most impoverished regions in South Asia,
and provides an excellent research site due to its remoteness, its severe and entrenched poverty, and its weak
public sector health system. The study will take place at the district-level Bayalpata Hospital, and follow-up
services will utilize its existing community health worker program. Both Bayalpata Hospital and its catchment
areas are managed through a public-private-partnership between the nongovernmental organization Nyaya
Health and the Nepali Ministry of Health.
Study Participants
The participants of this research will be patients and their families, as well as hospital staff. The main benefit
to research participants will be an improvement in accessibility, quality, and safety of surgical care delivery in
their communities.
All surgical patients who present to Bayalpata Hospital for continuous, intermittent, and referral services
during the study period will be included as participants. The anticipated surgical patients will be
predominantly women and children, who represent 75% of all patients served at Bayalpata Hospital. The
reason for this demographic predominance is because most of the region’s men travel to India as migrant
workers, and are thus absent from the district for large periods of time. Though pediatric patients represent a
large portion of the patients seen at Bayalpata Hospital [10], children are less prone to conditions amenable to
surgery, and will thus constitute fewer surgical patients. Their involvement in the study, however, will be
proportional to the burden of surgical disease among children in Achham.
Patients at this facility are all ethnic Nepalis. Owing to the geographically isolated nature of the hospital, it is
not feasible for other ethnicities to be part of the service catchment area of Bayalpata Hospital. Hence, this
study will be based on the demographics of the region’s residents.
Surgical Care Delivery Approach
The approach to surgical implementation taken here is based primarily upon the WHO’s IMEESC approach.
This strategy will be supplemented with additional community-based follow-up protocols utilizing an existing
CHW network, and hospital-based quality improvement mechanisms, one of which is the aforementioned
PIPES surgical capacity evaluation tool In this way, it will be possible to provide outreach services to improve
patient outcomes, and to establish an ongoing mechanism for institutional change. Such outreach services are
critical to continuity-of-care in rural or remote areas with poor transportation infrastructure. The primary
clinical manual utilized throughout this process will be the WHO’s Surgical Care at the District Hospital
guidelines. Protocols for operations and management policies will include the WHO’s Best Practice
Protocols: Clinical Safety Procedures, as well as emergency and surgical care protocols for physicians and
nurses developed in collaboration with the authors. Utilizing these foundations, this implementation includes
1) the core IMEESC surgical care program, 2) community-based follow-up via CHWs, and 3) tracking system
for all surgical patients.
Recruitment
For this specific study, we plan to collect active community-side surveillance of the surgical disease burden
for both planning and detection purposes. While a passive approach, which will stem mainly from contact
with both community health workers and hospital-based staff, will also serve as a basis for surgical detection,
active recruitment through referral tools, such as public radio, will also be used. A patient screening protocol
has already been initiated, in which patients that present to Bayalpata Hospital’s emergency and outpatient
departments with surgically treatable illnesses are documented and referred to either the Bayalpata Hospital
surgical program or a higher referral center.
There is a clear need for emergency surgical services due to the lack of such services in the region, although
data regarding the extent to which it is needed has not been ascertained. Given that Bayalpata Hospital serves
a dispersed catchment area of up to 500,000 people in a travel radius of over 24 hours, a community survey
may be difficult to distribute. However, through developed referral mechanisms that will look to foster
community outreach to all residents, the survey we propose to use will be able to adequately predict the
surgical volume within the district. Furthermore, we believe that understanding the burden of surgical disease
presenting for medical services provides important data that may aid health ministries, hospitals, and
nongovernmental organizations seeking to roll out surgical services in resource limited settings.
Local Continuous Services
Bayalpata Hospital currently has the capacity to conduct only minor surgical procedures, and the upcoming
expanded services will include procedures described in Table 1. During the implementation phase, PIPES
will be used to evaluate the baseline surgical capacity at Bayalpata Hospital, which will help identify needs and
plan for increases in surgery. Over time, PIPES index will be calculated, allowing us to examine the change in
capacity overtime [21]. All of these procedures will be performed by a generalist physician with post-graduate
surgical training (referred to as an “MD-GP” in Nepal). This type of practitioner is the government of
Nepal's focus for physician human resources for essential surgical care in rural areas. Surgical aspects of MDGP training focus specifically on the surgical procedures outlined in Table 1, and competency in these
procedures is required for graduation. The level of training analogous to that of MD-GP practitioners is also
the focus of the IMEESC program worldwide. The surgeon will receive additional on-site support and
training via visiting senior surgeons from among Nyaya Health colleagues in the United States and Nepal.
Utilizing
Nyaya
Health’s
existing
Mortality
and
Morbidity
programhttp://wizfolio.com/?citation=1&ver=3&ItemID=205&UserID=13252&AccessCode=7EE7EAB8
AC3A4DD980B1E07EFC4BD0A8&CitationSuffix=, email discussion and support will also be available to
the surgical staff on a non-urgent basis. This program is intended to enable enhanced learning and reflection,
rather than to provide active, real-time management.
The MD-GP will oversee an Anesthesia Assistant trained within the government’s scheme to deliver basic
anesthesia care to surgical patients in rural areas. A Staff Nurse (a specific designation within the government
of Nepal’s healthcare provider hierarchy) will assist the MD-GP and Anesthesia Assistant in providing postoperative care. In keeping with current policy, any cases that are outside the scope of practice of this modest
team will be sent via ambulance to an appropriate referral center (between 6 and 14 hours away).
Local Intermittent Surgeries (Surgical Camps)
The first phase of surgical services will be initiated with a series of surgical camps, which are anticipated to
include treatment of surgical conditions within the categories detailed in Table 1. Each will be evaluated
using PIPES during implementation. These camps will serve not only to provide surgical treatment to
patients within Bayalpata Hospital’s catchment area, but also to provide continuing medical education for
Bayalpata Hospital’s surgical staff members. All patients receiving treatment during surgical camps will be
followed-up by members of the Bayalpata Hospital CHW network.
Referral Surgeries
Patients identified through active and passive screening and who cannot be treated via local continuous or
intermittent camp services will be referred to higher centers for care. Patients who meet criteria for
enrollment into a crowdsource funding intervention in partnership with the international non-profit Watsi
will have their transportation and surgical fees paid for. Those who are not eligible for the Watsi program
will be referred as per typical practice.
Patients who present to Bayalpata Hospital with surgically-treatable illnesses that they cannot personally fund
may be selected as Watsi cases. Watsi provides an online interface through which donors can directly
contribute funding for patient surgeries, and has to-date funded numerous life-changing procedures for
patients from Achham and elsewhere. Please see Appendix 1 for the Watsi patient referral protocol and
details.
Follow-up
The existing network of CHWs at Bayalpata Hospital will follow-up with post-surgical patients to detect and
prevent complications [7]. Within each political subdivision, these health workers report to community
health advocates, who in turn report to hospital-based coordinators. This network was built off of the
government of Nepal’s existing health worker infrastructure. As such, this model should be scalable both
within Nepal and in the many countries that have government-sponsored CHW networks.
Quality Improvement
The implementation of surgical services will occur within the framework of quality management using PlanDo-Study-Act and Root Cause Analysis models. Methods will include regular data management reviews,
clinical- and operational-level checklists, and a mortality and morbidity conference program. We anticipate
that these will evolve over the course of the study, as with any quality improvement initiative. Bayalpata
Hospital maintains an active database of administrative and clinical data that integrates outcomes for its
clinical programs. In addition, quality checklists will serve as the basis for ongoing improvement, including
materials management, facilities maintenance, biomedical engineering, and provider-level clinical care.
Finally, an ongoing mortality and morbidity review program conducted at the hospital will serve as an
institutional quality improvement mechanism. The overall program aims to identify and address challenges
and action items in the spectrum of structure, process, and outcomes.
Metrics and Analysis
An implementation science approach will be used to study the deployment of surgical services in this rural,
resource-limited setting. This study will follow the first 18 months of the implementation process. Since
effective implementation hinges on quantifiable systems and human implementation as well as the reception
of such systems, a mixed qualitative and quantitative research methodology will be employed. Both
approaches are crucial, and will be used in a complimentary fashion to collect data and identify key drivers for
implementation elsewhere. Given that some changes are anticipated during the initial scale-up process, the
analysis will be broken down into an initial phase (first six months) and a consolidation phase (subsequent
twelve months.
Specific Aim 1
Nature of Surgical Disease Presenting at Bayalpata Hospital
This study will quantify the type of surgical diseases present and the treatment of these diseases using a simple
data recording instrument (draft attached). Data will be displayed in two forms: (1) a tabular form with
demographic and descriptive information, and (2) a summary form, in which information will be categorized
by types of conditions present during the initial and consolidation phases. We hypothesize that there will be a
gradual expansion over time of more complex diagnoses and surgical procedures, which can be reflected in
PIPES periodic evaluations of baseline surgical capacity. We expect that this expansion will occur rapidly
during the first 6 months and hit a plateau by 18 months. This hypothesis predicts that by the end of the
studied 18 months, the annual number of surgeries will approach 20 per 10,000 citizens.
Community-Based Follow-Up
The rate of patient improvement will be assessed by CHW patient follow-up 72 hours after surgery and again
3 weeks following discharge from the hospital using formatted checklist documents and consistent data
collection techniques. CHWs will be provided with structured training and hospital staff support, as currently
occurs within the Bayalpata CHW program [11].
Follow-up in rural Nepal is complicated by the severe lack of effective transportation infrastructure.
Furthermore, given the dearth of services in the area, it is expected that patients will be travelling long
distances to reach the hospital. In the first three months of implementation of X-Ray services at Bayalpata
Hospital, for example, 20% of patients travelled, typically by foot, more than 10 hours each way to access
services [12]. Despite these challenges, based on existing experience at the hospital, we hypothesize that this
program will be able to provide follow-up services to 95% of patients throughout the study period.
Complication Rates
Major complication rates form the basis of any surgical services monitoring and evaluation program, yet the
time course of how frequently they occur in resource-limited settings has yet to be studied. Immediate postsurgical clinical complications will be tracked as per Table 2. These data will be interpreted in light of the
qualitative analysis of Bayalpata Hospital’s existing mortality and morbidity review program and quantitative
data analysis of trends and frequency of post-operative occurrences.
Specific Aim 2
Staffing
We will describe the hiring and presence of staff, including qualifications, role, and days present on the job.
Financial Inputs
All raw financial inputs into the system will be quantified and broken down into categories for
pharmaceuticals, capital equipment, consumables, and facilities construction and maintenance inputs. These
inputs will be obtained by monthly analyses of the financial databases currently in existence at Bayalpata
Hospital. Costs will include pharmaceutical facility staffing [13], consumable materials, and capital
equipment; total monthly costs will be displayed in a histogram. Within each bar in the histogram, the
percentage of the total costs for each category of expenditures will also be displayed. Based on Bayalpata
Hospital’s costing model (available for download via references [14] and [15]), we hypothesize that the overall
construction and two-year operating costs of implementing the IMEESC-Plus model will be $0.50 USD per
capita in the district. The study will tag all costs for each component of the interventions and calculate
marginal cost effectiveness for each of the primary and secondary outcomes, using pre and post intervention
data. All costs will be assessed in 2013 United States dollars and inflation-adjusted. Cost effectiveness will be
calculated per surgery and per day of operating room availability.
Pharmaceutical and Consumable Item Utilization
The usage of pharmaceutical and consumable items during the roll-out process will be tabulated based upon
monthly analyses of the pharmaceutical and supply databases currently in existence at Bayalpata Hospital.
Assessment will be based primarily on high-volume items, including antibiotics, suture material, scalpels, and
needles. Monthly utilization patterns will be displayed by means of a histogram.
Stocking Protocols
Staff compliance to stocking protocols will be assessed by adapting existing WHO site analysis tools, and will
be displayed via monthly histograms. It is hypothesized that there will be a steady compliance to
pharmaceutical and consumable stocking protocols, with no greater than 5% missing items on a monthly
basis.
Surgical Safety and Resuscitation Protocols
Assessments will be made for adherence to the Surgical Safety Checklist, as well as novel emergency
resuscitation (pre- and post-surgical care) and hospital operations protocols developed for this project
[16]. The surgical safety checklist to be employed is well-validated and described, and has been adopted by
the WHO as the standard for surgical services globally. However, the real-world functioning of this checklist
at the outset of services in severely resource-limited settings has yet to be described (see Appendix 2 for
checklist structure). The analysis of surgical checklist adherence will occur as per Table 2. Staff adherence to
other care protocols will be determined by evaluation forms that have been adapted from the WHO model to
evaluate nursing and physician performance (see Appendix 3).
Qualitative Documentation of the Implementation Process
The deployment process will be documented qualitatively, with the primary domains of analysis being the
following: human resource management, supply chains, in-hospital work flows, and patient-level interactions.
Hospital-level analyses will be performed according to three modalities: (1) open-ended, semi-structured
interviews of staff at three-month intervals, (2) non-participant observation of planning meetings and
morbidity and mortality conferences, and (3) focus groups with staff at three-month intervals (see Appendix
4) [17]. All interviews and observations will be recorded in a journal maintained by the research coordinator.
This journal will then be translated and back-translated, and assessed using the framework analysis
methodology [18].
Comparative Cost Effectiveness Analysis
In addition to analyzing the financial inputs involved in the initial surgical scale-up process, the financial
inputs per surgical patient will be documented and presented. To accomplish this, post-scale-up financial
inputs per patient will be tabulated and compared to the average costs per surgical patient referred prior to
the availability of surgical services at Bayalpata Hospital. In the years preceding commencement of surgical
services in Achham, all patients in need of surgical services were referred to other hospitals, ranging from 236 hours of travel away. Most of these surgical referral centers operate on a fee-for-service basis, and thus
present significant costs for surgical patients (see Table 3). By analyzing the average patient costs associated
with commonly-referred conditions, and comparing them to the costs per patient of providing the same
services at Bayalpata Hospital, the decrease in financial impact on the surrounding communities will be
assessed.
For non-emergent surgeries that are conducted via surgical camps and Watsi referrals, disability adjusted life
years (DALYs) averted per patient will be calculated and compared to the costs per surgical patient accrued.
All costs will be assessed in 2013 United States dollars and inflation-adjusted. Cost effectiveness will be
calculated per surgery and per day of operating room availability.
Sample Size Considerations
Specific Aim 1
Our primary outcome for this analysis will be the rate of major complications (including death, as per Table
2) within the first 72 hours following surgery. Patients who are lost to follow-up will be considered treatment
failures, both programmatically within Bayalpata Hospital and from a research/evaluation standpoint within
the context of the study. Patients and their families may, and in our experiences oftentimes do, leave earlier
than the treatment team may suggest. However, even in these instances, we should be able to track down
patients in their home communities. Both programmatically and scientifically, we feel that it is important to
document longer-term follow-up than typical surgical care programs provide. A secondary outcome will be
the rate of major complications prior to leaving the hospital.
With 100 patients in the initial period, it will be possible to estimate the true complication rate within a +/10% interval with 95% certainty. For example, if 5 out of 100 (5%) patients have a complication in the initial
period, then the 95% exact binomial confidence interval will be approximately [1.6%,11.3%), with a width of
9.7%. With 400 patients in the consolidation period, it will be possible to estimate the true complication rate
within a +/-5% interval with 95% certainty. For example, if 20 out of 400 (5%) patients have a complication,
then the 95% exact binomial confidence interval will be approximately [3.1%,7.6%), with a width of 4.5%. In
this pilot phase, the complication rates during the initial and consolidation phases will not be directly
compared. The complication rates are expected to be too small to fit a multiple logistic regression model to
determine important predictors. However, with twenty complications in the consolidation phase, it would be
possible to fit logistic regression models with each covariate separately.
Specific Aim 2
The rates of adherence to each protocol are estimated for the initial 6 months and the subsequent 12
consolidation months. With 100 patients in the initial period, it will be possible to estimate the true
complication rate for a given process measure within (at most) a +/-10% interval with 95% certainty. For
example, for a given process measure, if the process measure is followed in 80 out of 100 (80%) patients in
the initial period, then the 95% exact binomial confidence interval will be approximately [71%,87%), with a
width of 16%. With 400 patients in the consolidation period, it will be possible to estimate the true
complication rate for a given process measure within a +/-5% interval with 95% certainty. For example, for
a given process measure, if the process measure is followed in 380 out of 400 (95%) patients, then the 95%
exact binomial confidence interval will be approximately [92%,97%), with a width of 5%. In this pilot phase,
the adherence rates during the initial and consolidation phases will not be directly compared. Secondary
logistic regression analyses will be performed to determine important predictors of complication, including
acuity of admission (elective, emergency), surgery type (orthopedic, plastic, obstetric, intra-abdominal), length
and time of operation, wound classification, and American Society of Anesthesiologists (ASA) risk index
classification.
Ethics and Dissemination
In this assessment of a surgical services intervention, the primary risk to subjects is the leaking of protected
health information. The surgical services that patients receive are part of the standard of care practices at
Bayalpata Hospital and are not research-related. Ensuring the privacy and anonymity of patient information
is essential, and measures will be employed in accordance with Health Insurance Portability and
Accountability Act [19] (HIPAA) guidelines to ensure patient confidentiality. Such measures will include
careful de-identification of patient records, use of secure servers, password-protected databases, and physical
locking of medical record storage in the clinic. No protected health information will be recorded or
transmitted electronically. Bayalpata Hospital staff members have extensive experience in ensuring the safety
of protected health information through an ongoing data management program.
An additional risk is that of psychological harm to patients who are interviewed following surgery. This will
be minimized by having sensitivity training for all staff members and by using standardized instruments. Staff
debriefing will also be conducted to identify challenges and encourage open discussion for support and
resolution.
Ethics review board proposals will be submitted to the Brigham and Women’s Hospital and to the Nepal
Health Research Council prior to starting the study. All de-identified data, protocols, and documentation
from the study will be made openly accessible to the public and disseminated via a public-access website [20].
DISCUSSION
This prospective study will be the first to describe and assess the need for and implementation of surgical
services in a setting of extreme poverty. By tracking patients within the three primary categories of rural
surgical provision: 1) continuous, 2) intermittent, and 3) referral, we can start to develop an implementation
science approach for the development and scale-up of rural surgical care.
The primary limitation of this research is that it is a single-facility study. Biases can be seen when studying the
effects of a single hospital or surgeon. It is anticipated, however, that the in-depth analysis of the process and
logistics of surgical scale-up implementation will form the necessary groundwork for a larger multi-site study.
Furthermore, the implementation of surgical services requires a broad-based team approach, and this study
will examine the entire trauma and surgical system. This system, while dependent upon individual providers,
must contain set protocols that operate effectively despite strengths and weaknesses of any given clinician.
The longitudinal data on implementation process costs, safety, and utilities that this study will provide are not
yet available. Once determined, however, these data will provide basic parameters for designing a larger
implementation research study.
TABLES AND FIGURES
Figure 1: Metric-driven Surgical Care Delivery for Rural Settings of Extreme Poverty
Delivery: IMEESC core surgical care program across continuous, camp, referral services
Quality Improvement: Use of tracking system, metrics to improve quality
Follow-up: Community-based follow-up via health workers
Figure 2: Study Overview
STUDY OVERVIEW
Logistical Processes
Flow of Patients
All Surgical Patients
Passive
Detection
(Hospital)
Passive
Detection
(CHWs)
Active
Detection
(CHWs)
Patient Evaluation
by Clinical Team
On-site
Treatment
Off-site
Treatment
Continuous
Watsi
Services
Referral
Intermittent
Non-Watsi
Services
Referral






Inputs to surgical care
-Financial inputs
-Staffing processes
-Pharmaceutical supplies
-Consumable supplies
Availability of surgical
personnel and facilities
Staff adherence to:
-Resuscitation protocols
-Operating protocols
Supply chain reliability
Electricity and water
reliability
Staff participation in:
-Morbidity and mortality
conferences
-Quality improvement
initiatives
Patient-Oriented Processes







Geographic distribution
Type of surgical disease
Time from symptoms to
presentation
Time from presentation
to surgery
Successful completion of
surgery
Complications
Follow-up rates
Table 1: List of essential surgical services provided during study period














On-Site Services
(Continuously Available)
Amputation of Digits
Casting/Splinting
Cesarean Section
Debridement
Dressing/Irrigation
Excision/Lumpectomy
Foreign Body Removal
Herniotomy/Hernioplasty
Hydrocele Reduction
Incision & Drainage
Laceration Repair
Lipoma Excision
Tubectomy
Vasectomy









Surgical Camp Services
(Intermittently Available)
Amputation of Limbs
Appendectomy
Cholecystectomy
Circumcision
Hysterectomy
Internal Fixation
Internal Open Reduction
Laparotomy
Mastoidectomy
Myringoplasty
Referral Services
(Available Outside District)
All other surgical cases,
notably:
 Cardiac surgery
 Thoracic surgery
 Plastic Surgery
 Complex intraabdominal surgery
 Pediatric surgery
Table 2: Metrics for Local (Continuous and Intermittent) Services Outcomes
Measures for Surgical Implementation
Process Measures
Community Demand, Surveillance, and Epidemiology
Geospatial mapping of cases
Demographic description of cases
Hours to reach hospital from home
Time from first symptoms to presentation
Type of surgery required
Facilities and Supplies Systems
X-ray machine in working order, with technician to operate it
Electricity present throughout duration of surgery
Number of days that the surgical theater is open^
Number of days that at least one surgeon is present
Number of days that at least one anesthesia professional is present
Suction machine verified and working pre-operatively
Oxygen source verified and working pre-operatively
Documentation of appropriate temperature strip from autoclave of surgical instruments
Emergency Room/Pre-Op
Fetal heart rate documented
Indication documented
Time from decision to incision
Pre-operative evaluation and documentation of airway
Pre-op hematocrit documented
Operating Room/Intra-Op
Time out performed prior to surgery
Pulse oximeter working throughout the case
Appropriate perioperative antibiotic use*
Appropriate size suture documented
Estimated blood loss documented
Intra-op fluids given documented
Urine output documented
Blood transfusion needed
Inpatient Unit/Post-op
Vital signs recorded within 30 minutes post-op
Postoperative exam documented by nurse within 30 minutes
Pain assessment documented immediately post-op
Length of stay in inpatient surgical ward
Length of time until ambulation
Length of time until regular diet/ oral pain meds
Community/Follow-up
Use of ambulance
Paid community health worker available in patient’s ward
Number of deliveries at hospital, cesarean and non-cesarean
Successful follow-up by community health worker within 72 hours
Successful follow-up by community health worker at 30 days
Outcomes Measures#
Mortality and major complications
Neonatal mortality
Wound dehiscence
Wound infection
*Assessed as whether or not the correct drug and dose, non-expired, was administered based upon the protocol for each surgery.
^Closures may be due to staffing shortages (including absences owing to trainings), supply chain, electricity issues
#Standard maternal and surgical morbidity and mortality, as per Table 2 obstetrics and soft tissue injury indicate scenarios in
which the metric is only applicable to those particular surgeries
Table 3: Comparative Cost Effectiveness Analysis Metrics
EMERGENT PATIENT METRICS
Pre-Implementation Post-Implementation
(Costs borne by patient)
(Costs borne by BH)
- Transportation
- Consumables
- Lodging
- Staffing
- Surgical Procedure
- Medications
- Inpatient Stay
- Medications
- Follow-up Care
NON-EMERGENT PATIENT METRICS
Cost per Patient
- Consumables
- Staffing
- Medications
DALYs Averted
-Qualitative
determination of years
of disability averted
Appendix 1: Watsi Protocol
Identification of patients
This protocol outlines the policies regarding identification, evaluation, and treatment of patients that can
receive free care via Nyaya Health’s program with WATSI. In this program, patient profiles are posted online
with the hopes to inspire donors to fund for individual patient’s treatment.
Identification of Cases
Any condition that has a significant impact on a patient’s life and has a strong possibility of cure or otherwise
improvement with a discrete intervention.
 rheumatic heart disease
 congenital heart disease
 hydrocephalus
 fractures
 contractures
 burns
 club foot
 cleft palate
 locally resectable cancer or cancer otherwise with a reasonable hope of cure
 cholecystectomy
 hernia repair
 hydrocele repair
 insulin dependent diabetes
**Please note that most of these are surgical; we have added insulin-dependent diabetes as one medical lifethreatening disease for which insulin is life-saving in the medium-term.
Cases should be emailed to [email protected] at any and all junctures. The team of clinicians can
quickly address any clinical questions or concerns.
Photography and Story
On identification of these conditions, please notify the individual within the Community Health department
who serves as the Watsi Coordinator. He/She will then take consent, a high-resolution photograph, and
story from the patient. These should be saved to dropbox Development\Dev - Partnerships
(Private)\Watsi\Patient Profiles.
Referral for Diagnostics and Evaluation
In many cases, there will be up-front costs for diagnostics and evaluation. If there is a reasonable likelihood
that the patient will require intervention, then Nyaya Health can pay for the travel and evaluation. The initial
evaluation usually will take place at Nepalgunj Medical College. These costs will be eventually paid for
through WATSI as reimbursement once the funds are raised through the website. The contact information is
provided below.
Referral for Treatment
Referral contact shall be made with an existing known excellent provider and partner of the intervention. We
maintain a list of contacts below. We should work to minimize unnecessary travel and work with surgeons to
plan ahead of time and book operating room time in advance of the patient’s visit.
Principles of Payments for Diagnostics and Treatment
We should NOT be giving money directly to the patients. There should be no possibility of our donations
being abused. For the most part, stable patients will be transported by bus. Bus tickets may be purchased
and provided to the patient. For diagnostics at Nepalgunj Medical College, patients will carry with them a
note stating that payments be billed to Bayalpata Hospital. These will then be paid by direct transfer from
Bayalpata Hospital accounts. For room and board, we will try to arrange for agreements locally that we can
likewise pay directly.
Responsibilities of Watsi Coordinator
 Check in regularly with doctors and health assistants regarding potential cases.
 Maintain at least ten print-outs of the consent form to be ready to obtain consent at any moment
 Provide consent to patient and maintain in Watsi program file
 Take high resolution picture of patient, type “watsi on boarding” response for the patient, and save to
dropbox Development\Dev - Partnerships (Private)\Watsi\Patient Profiles
 Look up in “Nepalgunj costing sheet” the approximate price of the intervention. This is found in
dropbox Development\Dev - Partnerships (Private)\Watsi\Referral Costing Sheets
 Coordinate with Nepalgunj Medical College and Nepalgunj Rotary Club for following up on patients and
getting diagnostics
 Coordinate with treating institution for timings
Responsibilities of Health Assistants and Doctors
The primary role of the HAs and doctors is to identify cases and provide all the clinical information to the
Watsi Coordinator. Also, they should assist with any contacts they have at any of the referral hospitals and
with follow-up of patients during the evaluation period and following treatment. We would like the same HA
to see their follow-up patients at every visit. This continuity in care is very important to ensure quality care
for our patients.
Potential challenges and tips for Watsi Coordinator
Identifying cases
 be an advocate for the program; keep asking any of the health assistants
Getting timely responses from referral hospitals
 go to the top grade person known at the facility first and then say their name at all lower level
communications
 if you are having trouble owing to gender bias, discrimination, or perception you are too “junior”, have a
senior physician or administrator call on your behalf
 Ask that senior leadership, whenever they are in the vicinity of referral hospitals, sign MOUs and
otherwise meet with leadership of the hospital. Example MOUs are found in dropbox for Dhulikhel and
Nepalgunj Medical College. Always prepare the MOU ready for signature prior to meeting
(Obstetrics) Caesarian
Delivery Indication (d)
Surgical Disease (c)
Tertiary Comorbidity
(ICD)
Secondary
Comorbidity (ICD)
Primary Comorbidity
(ICD)
Location (b)
Chief Complaint(a)
Contact Information
Time
Date
IP Number
Appendix 2. Surgical Implementation Checklist and Coding Chart
VITAL SIGNS
Preoperative
HR
Postoperative
HR
1hr Postoperative
HR
2hr Postoperative
HR
3hr Postoperative
HR
B/P
B/P
B/P
B/P
B/P
Resp.
Resp.
Resp.
Resp.
Resp.
O2 Sat.
O2 Sat.
O2 Sat.
O2 Sat.
O2 Sat.
Temp.
Temp.
Temp.
Temp.
Temp.
Pain
Pain
Pain
Pain
Pain
HISTORY
Past Medical History:_____________________________________________________________
Past Surgical History:_____________________________________________________________
Past Obstetric History: G____ P____ Past Obstetric Complications:________________________
Current Medications:____________________________________ Allergies:_________________
Onset of Symptoms:_________Hours/Days/Weeks (circle one) prior to presentation
Hours Traveled to Reach Hospital___________________________________________________
Referral from (circle): [1]None [2]Subhealth Post [3]Health Post [4]Nepalgunj [5]Kathmandu [6]India
PREOPERATIVE
Autoclave temperature documented
Yes No
Temp:
Fetal heart rate documented (obstetrics only)
Yes No
HR:
Preoperative airway documentation
Yes No
Difficult Airway: Yes/No
Preoperative hematocrit documentation
Yes No
Hct:
Time out performed prior to surgery
Yes No
Time from diagnosis to incision
Diagnosis:
Incision:
Pre-operative Notes
INTRAOPERATIVE
Intra-op Fluids Given
Urine Output Documented
Blood Transfusion Needed
POST-OPERATIVE
Perioperative Antibiotic Given
Suture Size Documented
Post-Operative Fluids Given
Urine Output Documented
Blood Transfusion Necessary
Yes
Yes
Yes
No
No
No
Amount:
Amount:
Amount:
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Name:
Size:
Amount:
Amount:
Blood Type:
Amount:
Amount:
a. Chief Complaint
1. Pain
2. Swelling
3. Mass
4. Bleeding
5. Penetrating Trauma
6. Blunt Trauma
7. Shortness of Breath
8. Caesarian Delivery
9. Other
b. Location
1. Head
2. Face
3. Neck
4. Upper Extremity
5. Chest
6. Abdomen
7. Pelvis
8. Spine/Back
9. Lower Extremity
h. Medical Complication
1. Cardiac Arrest
2. DVT
3. Pneumonia
4. Pulmonary Embolism
5. Sepsis
6. Septic Shock
7. Surgical Site Infection
8. UTI
9. Anesthesia Complication
10. Excessive Bleeding
11. Hypotension
12. Hypertension
13. Other
c. Surgical Disease
12. Fracture: Open Displaced
13. Fracture: Open Non-Displaced
14. Fracture: Closed Displaced
15. Fracture: Closed Non-Displaced
16. Gangrene
17. Goiter
18. Hernia
19. Hydrocele
20. Laceration
21. Mass/Tumor
22. Ovarian Torsion
e. Interventions
1. Foreign Body Removal 12. Cholecystectomy
2. Dressing/Irrigation
13. Internal Fixation
3. Casting/Splinting
14. Internal Open Reduction
4. Laceration Repair
15. Myringoplasty
5. Incision & Drainage
16. Mastoidectomy
6. Debridement
17. Herniotomy/Hernioplasty
7. Excision/Lumpectomy 18. Hysterectomy
8. Cesarean Section
19. Tubectomy
9. Laparotomy
20. Vasectomy
10. Amputation
21. Circumcision
11. Appendectomy
22. Other
i. Infrastructure Complication
1. Lack of Electricity
9. Oxygen Source Not Functioning
2. Lack of Water
10. Autoclave Not Functioning
3. Surgeon Absent
11. Pulse Oximeter Not
4. Anesthesia Staff Absent Functioning
5. Nursing Staff Absent 12. Blood Unavailable for
6. X-ray Staff Absent
Transfusion
7. X-ray Not Functioning 13. Instruments Unavailable
8. Suction Device Not
14. Medications Unavailable
Functioning
14. Other
FCVH Referral
(Yes/No)
3rd F/U Outcome (g)
3rd F/U (# days)
2nd F/U Outcome (g)
2nd F/U (# days)
1st F/U Outcome (g)
1st F/U (# days)
1. Abscess
2. Appendicitis
3. Burn
4. Cataract
5. Cholecystitis
6. Chronic Osteomyelitis
7. Cleft Lip
8. Club Foot
9. CSOM
10. Dental Abscess
11. Foreign Body
d. Caesarian Delivery Indication
1. Abnormal
11. Pre-eclampsia
Presentation
12. Eclampsia
2. Dystocia
13. Infection
3. Placental Abnormality 14. Multiple Births
4. Fetal Distress
15. Maternal HIV
5. Obstruction
16. Maternal STI
6. Pelvic Abnormality
17. Uterine Rupture
7. Acidemia
18. Previous Delivery
8. Cord Prolapse
Complications
9. Maternal Tachycardia 19. Elective Caesarian Delivery
10. Fetal Tachycardia
20. Other
g. Disposition
1. Home: Recovered
2. Home: Not Improved
3. LAMA
4. Absconded
5. Referral
6. Dead: Within 48H
7. Dead: After 48H
# of Inpatient Days
Referral (j)
Infrastructure
Complication (i)
Medical Complication
(h)
Outcome (g)
Anesthesia Type (f)
Intervention (e)
Post-Operative Notes
23. Peritonitis
24. Phimosis
25. Paraphimosis
26. Pregnancy (C/S)
27. Rectal Prolapse
28. Testicular Torsion
29. Trauma
30.Ulcer
31. Uterine Prolapse
32. Other
f. Anesthesia Type
1. None
2. Local
3. Regional Block
4. General Sedation/Analgesia
5. Ketamine
6. General Anaesthesia
j. Referral From/To
1. None
2. Subhealth Post
3. Health Post
4. Nepalgunj
5. Kathmandu
6. India
Appendix 3. Systems Checklist
SURGICAL SYSTEMS CHECKLIST
Week of______________________________
FACILITIES
METRICS
Electricity outage for
>30 minutes in past 24
hr.?
Water shortage for >30
minutes in past 24 hr.?
X-ray machine
functioning for past 24
hours?
CLINICAL METRICS
Staff adherence to
operating protocols?
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Blood available for
transfusions?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Surgeon available for the
past 24 hours?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Autoclave dysfunctional
for >30 minutes in the
past 24 hr.?
Oxygen cylinders
present in ER and at
least 50% full?
Anesthesia Assistant
available for the past 24
hours?
At least one surgical
nurse available for the
past 24 hours?
X-ray technician
available for the past 24
hours?
Suction device
functioning for the past
24 hours?
Patient monitors
functioning for the past
24 hours?
Surgical instruments
available for the past 24
hours?
Surgical medications
available for the past 24
hours?
Appendix 4. Focus Group and Individual Interviews on Quality and Patient Safety
Culture
Patient safety culture is a set a values about how individuals behave and what attitudes are appropriate to
ensure patient safety. Safety culture within a healthcare organization can be qualitatively measured with
interviews and focus groups. Interviewers will work to understand the dynamics of the way people interact
and make decisions about surgical safety. Rather than evaluating what interviewees think ought to be done,
these focus groups will examine the shared set of ideas reflected in current practice.
There are several issues to consider for patient safety culture and the team dynamics within the healthcare
setting. Patient safety involves quality improvement of current practices and thus is promoted by positive
attitudes towards innovation and risk taking. Assessments should address whether the organization
encourages new ways of doing things, or instead values traditional approaches. Team dynamics is tied with
patterns of communication. For example, participants should be asked about the degree to which
communication and reporting are restricted to formal hierarchies of authority versus informal channels.
Outcome or process orientation, or whether control and reward are focused on tasks and processes
compared with the end products and results, is also an important element of the culture and dynamics of the
group. Questions and discussions should also address whether the organization encourages and rewards
individualism, or fosters and values close teamwork.
Topics to focus on for interviews:
- Overall perceptions of safety
- Frequency of events reported
- Supervisor/manager expectations and actions promoting safety
- Teamwork within hospital
- Feedback and communication about errors
Questions to ask for interviews and focus groups:
- Is patient safety ever put at risk to get more work done?
- Are there procedures for preventing errors from happening?
- What safety issues have come up in the past?
- Does your supervisor/manager seriously consider suggestions for improving patient safety?
- What are you actively doing to improve patient safety?
- Have mistakes led to positive changes around here?
- What do you do to evaluate the effectiveness of changes?
- Do people help each other out? For example, when one area of the hospital becomes very busy?
- Do you know how to report patient safety issues?
- How often do you speak up regarding issues endangering patient safety?
- Do you feel comfortable raising concerns to supervisors/managers regarding their decisions?
- Do you feel like your mistakes will be held against you?
Appendix 5. Referred Patient Follow-Up Form
REFERRED PATIENT FOLLOW-UP
Dates Successfully Contacted:______________ Dates Unsuccessfully Contacted:_______________
Date Evaluated by Referral Doctor:_____________________________________________________
Intervention:________________________________________________________________________
Type:
 Diagnostic Only  Surgical Intervention  Nonsurgical Intervention
Date of First Intervention ________________ Date of Discharge ____________________________
Outcome:
 Recovered/Improved  Not Recovered  Dead  Unreachable
Complications:
Time after Intervention Patient Reevaluated by Doctor:_____ Hours
Appendix 6. Watsi Patient Follow-Up Form
WATSI PATIENT FOLLOW-UP
Dates Successfully Contacted:_________________
In-Person Phone  Other _____________
Dates Unsuccessfully Contacted:_______________
In-Person Phone  Other _____________
Dates Evaluated by Referral Doctor:______________________________________________________
Interventions:_________________________________________________________________________
Type:
 Diagnostic Only  Surgical Intervention  Nonsurgical Intervention
Days in Hospital (Non-ICU):__________________ Days in Hospital (ICU):____________________
Date of First Intervention:_____________________ Date of Discharge:_________________________
Total Days away from Home District: ____________________________________________________
Outcome at 3 days:
 Recovered/Improved  Not Recovered  Dead  Unreachable
Complications (see codes below):_____________________________________________________________
Outcome at 30 Days:___________________________________________________________________
Complications:________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Time after Intervention Patient Reevaluated by Doctor:_____ Hours
COMPLICATION CODES
h. Medical Complication
1. Cardiac Arrest
2. DVT
3. Pneumonia
4. Pulmonary Embolism
5. Sepsis
6. Septic Shock
7. Surgical Site Infection
8. UTI
9. Anesthesia Complication
10. Excessive Bleeding
11. Hypotension
12. Hypertension
13. Other
i. Infrastructure Complication
1. Lack of Electricity
9. Oxygen Source Not Functioning
2. Lack of Water
10. Autoclave Not Functioning
3. Surgeon Absent
11. Pulse Oximeter Not Functioning
4. Anesthesia Staff Absent
12. Blood Unavailable for Transfusion
5. Nursing Staff Absent
13. Instruments Unavailable
6. X-ray Staff Absent
14. Medications Unavailable
7. X-ray Not Functioning
14. Other
8. Suction Device Not Functioning
Appendix 7. Surgeons OverSeas PIPES Surgical Assessment
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Haynes, A.B., et al., A surgical safety checklist to reduce morbidity and mortality in a global population. The New
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2.
Funk, L.M., et al., Global operating theatre distribution and pulse oximetry supply: an estimation from reported
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3.
Weiser, S.D., W.R. Wolfe, and D.R. Bangsberg, The HIV epidemic among individuals with mental illness in
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Gawande, A.A., Thomas, E.J., Zinner, M.J., Brennan, T.A., The incidence and nature of surgical adverse
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Kable, A.K., Gibberd, R.W., Spigelman, A.D., Adverse events in surgical patients in Australia. International
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Weiser, T.G., Makary, M.A., Haynes, A.B., Dziekan, G., Berry, W.R., Gawande. A.A, Standardized
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Nyaya, H., Nyaya Health Clinical Data Page, 2012.
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Duncan, M., Following up: Update on Nyaya Health’s Community Health Worker Program, 2011.
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Nyaya, H., X-Ray Wiki Page, 2012.
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Kruk, M.E., et al., Human resource and funding constraints for essential surgery in district hospitals in Africa: a
retrospective cross-sectional survey. PLoS medicine, 2010. 7(3).
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Nyaya, H., Nyaya Health Wiki Budget Page, 2011.
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Nyaya, H., Nyaya Health Expansion Costing Sheet, 2011.
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Haynes, A.B., A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population, 2011,
NEJM.
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Marchal, B., M. Dedzo, and G. Kegels, Turning around an ailing district hospital: a realist evaluation of
strategic changes at Ho Municipal Hospital (Ghana). BMC public health, 2010. 10: p. 787.
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Nyaya, H., Data Management Wiki Page, 2012.
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