Implementing surgical services in a rural, resource-limited setting: a study protocol

Abstract

Introduction

There are well-established protocols and procedures for the majority of common surgical diseases, yet surgical services remain largely inaccessible for much of the world's rural poor. Data on the process and outcome of surgical care expansion, however, are very limited, and the roll-out process of rural surgical implementation in particular has never been studied. Here, we propose the first implementation research study to assess the surgical scale-up process in the rural district of Achham, Nepal.

Methods and analysis

Based primarily on the protocols of the WHO's Integrated Management for Emergency and Essential Surgical Care (IMEESC), this study's threefold implementation strategy will include: (1) the core IMEESC surgical care program, (2) community-based follow-up via health workers, and (3) hospital-based quality improvement programs. The implementation program will employ additional emergency and surgical care protocols developed collaboratively by physicians, nurses and the authors. This strategy will be referred to as IMEESC-Plus. This study will employ both qualitative and quantitative research methodologies to collect clinical data and information on the reception and utilisation of services. The first 18 months of the implementation process will be studied and divided into an initial phase (first 6 months) and a consolidation phase (subsequent 12 months).

Discussion

This study aims to describe the logistics of the implementation process of IMEESC-Plus, and assess the quality of the resulting IMEESC-Plus services during the course of the implementation process. Using data generated from this study, larger, multi-site implementation studies can be planned that assess the scale-up of surgical services worldwide in resource-limited areas.

Article summary

Article focus

• Analysis of program results utilising the WHO's Integrated Management of Emergency and Essential Surgical Care (IMEESC) approach, which will be supplemented with additional community-based follow-up protocols, and hospital-based quality improvement mechanisms; this approach will be referred to as IMEESC-Plus.

• Study of the logistics of the implementation process of IMEESC-Plus.

• Assessment of the quality of the resulting IMEESC-Plus services during the course of the implementation process.

Key messages

• There is an acute need to study the basic operational processes by which surgical services deployment occurs in remote, resource-limited settings.

• The proposed study protocol will be the first to directly address this need.

• Using data generated from this study, larger, multi-site implementation studies can be planned that assess the scale-up of surgical services worldwide in resource-limited areas.

Strengths and limitations of this study

• As the setting of this prospective study faces many of the challenges found globally in geographically-isolated, resource-poor settings, the findings may be generalisable to other sites throughout the world.

• By utilising both quantitative data and qualitative study techniques, this protocol will enable a broad analysis of program effectiveness.