scholarly journals Economic Costs of Providing District- and Regional-Level Surgeries in Tanzania

2021 ◽  
Author(s):  
Martilord Ifeanyichi ◽  
Henk Broekhuizen ◽  
Adinan Juma ◽  
Kondo Chilonga ◽  
Edward Kataika ◽  
...  
Keyword(s):  
Economies Of Scale ◽  
Scale Up ◽  
Surgical Care ◽  
Activity Based Costing ◽  
Capital Costs ◽  
Surgical Services ◽  
Unit Costs ◽  
District Hospitals ◽  
The Individual ◽  
Arusha Region

Background: Access to surgical care is poor in Tanzania. The country is at the implementation stage of its first National Surgical, Obstetric, and Anesthesia Plan (NSOAP; 2018-2025) aiming to scale up surgery. This study aimed to calculate the costs of providing surgical care at the district and regional hospitals. Methods: Two district hospitals (DHs) and the regional referral hospital (RH) in Arusha region were selected. All the staff, buildings, equipment, and medical and non-medical supplies deployed in running the hospitals over a 12 month period were identified and quantified from interviews and hospital records. Using a combination of step-down costing (SDC) and activity-based costing (ABC), all costs attributed to surgeries were established and then distributed over the individual types of surgeries. These costs were delineated into pre-operative, intra-operative, and post-operative components. Results: The total annual costs of running the clinical cost centres ranged from $567k at Oltrumet DH to $3453k at Mt Meru RH. The total costs of surgeries ranged from $79k to $813k; amounting to 12%-22% of the total costs of running the hospitals. At least 70% of the costs were salaries. Unit costs and relative shares of capital costs were generally higher at the DHs. Two-thirds of all the procedures incurred at least 60% of their costs in the theatre. Open reduction and internal fixation (ORIF) performed at the regional hospital was cheaper ($618) than surgical debridement (plus conservative treatment) due to prolonged post-operative inpatient care associated with the latter ($1177), but was performed infrequently due mostly to unavailability of implants. Conclusion: Lower unit costs and shares of capital costs at the RH reflect an advantage of economies of scale and scope at the RH, and a possible underutilization of capacity at the DHs. Greater efficiencies make a case for concentration and scale-up of surgical services at the RHs, but there is a stronger case for scaling up district-level surgeries, not only for equitable access to services, but also to drive down unit costs there, and free up RH resources for more complex cases such as ORIF.

scholarly journals Decentralization and Regionalization of Surgical Care as a Critical Scale-up Strategy in Low- and Middle-Income Countries Comment on "Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries"

2020 ◽  
Author(s):  
Jaymie A. Henry
Keyword(s):  
Scale Up ◽  
Surgical Care ◽  
Lessons Learned ◽  
Optimal Distribution ◽  
Middle Income ◽  
Middle Income Countries ◽  
Surgical Services ◽  
Obstetric Services ◽  
Surgical Conditions ◽  
Low And Middle Income

As global attention to improve the quality, safety and access to surgical care in low- and middle-income countries (LMICs) increases, the need for evidence-based strategies to reliably scale-up the quality and quantity of surgical services becomes ever more pertinent. Iversen et al discuss the optimal distribution of surgical services, whether through decentralization or regionalization, and propose a strategy that utilizes the dimensions of acuity, complexity and prevalence of surgical conditions to inform national priorities. Proposed expansion of this strategy to encompass levels of scale-up prioritization is discussed in this commentary. The decentralization of emergency obstetric services in LMICs shows promising results and should be further explored. The dearth of evidence of regionalization in LMICs, on the other hand, limits extrapolation of lessons learned. Nevertheless, principles from the successful regionalization of certain services such as trauma care in high-income countries (HICs) can be adapted to LMIC settings and can provide the backbone for innovation in service delivery and safety.

scholarly journals Surveying and mapping breast cancer services in Ghana: a cross-sectional pilot study in the Eastern Region

BMJ Open ◽  
2021 ◽  
Vol 11 (11) ◽  
pp. e051122
Author(s):  
Moustafa Moustafa ◽  
Meghan Eileen Mali ◽  
Fidel Lopez-Verdugo ◽  
Ousman Sanyang ◽  
Jonathan Nellermoe ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Scale Up ◽  
Surgical Care ◽  
Survey Study ◽  
Eastern Region ◽  
Cross Sectional ◽  
Surgical Services ◽  
Cancer Services ◽  
Screening Services ◽  
Private Government

ObjectivesDefine the services available for the care of breast cancer at hospitals in the Eastern Region of Ghana, identify areas of the region with limited access to care through geospatial mapping, and test a novel survey instrument in anticipation of a nationwide scale up of the study.DesignA cross-sectional, facility-based survey study.SettingThis study was conducted at 33 of the 34 hospitals in the Eastern Region of Ghana from March 2020 to May 2020.ParticipantsThe 33 hospitals surveyed represented 97% of all hospitals in the region. This included private, government, quasi-government and faith-based organisation owned hospitals.ResultsSixteen hospitals (82%) surveyed provided basic screening services, 11 (33%) provided pathological diagnosis and 3 (9%) provided those services in addition to basic surgical care.53%, 64% and 78% of the population lived within 10 km, 25 km and 45 km of screening, diagnostic and treatment services respectively. Limited chemotherapy was available at two hospitals (6%), endocrine therapy at one hospital (3%) and radiotherapy was not available. Twenty-nine hospitals (88%) employed a general practitioner and 13 (39%) employed a surgeon. Oncology specialists, pathology personnel and a plastic surgeon were only available in one hospital (3%) in the Eastern Region.ConclusionsAlthough 16 hospitals (82%) provided screening, only half the population lived within reasonable distance of these services. Few hospitals offered diagnosis and surgical services, but 64% and 78% of the population lived within a reasonable distance of these hospitals. Geospatial analysis suggested two priorities to cost-effectively expand breast cancer services: (1) increase the number of health facilities providing screening services and (2) centralise basic imaging, pathological and surgical services at targeted hospitals.

scholarly journals Evaluation of Techno-Economic Studies on the bioliq® Process for Synthetic Fuels Production from Biomass

Processes ◽  
2021 ◽  
Vol 9 (4) ◽  
pp. 684
Author(s):  
Nicolaus Dahmen ◽  
Jörg Sauer
Keyword(s):  
Economies Of Scale ◽  
Biomass Energy ◽  
Production Costs ◽  
Transport Cost ◽  
Fuel Production ◽  
Case Scenario ◽  
Worst Case ◽  
Capital Costs ◽  
The Individual ◽  
Economic Studies

Techno-economic studies by various research institutions on the costs for the production of biomass to liquid (BtL) fuels using the bioliq® process were analyzed and evaluated. The bioliq® process consists of decentralized pretreatment by fast pyrolysis plants for biomass energy densification, and of a central gasification and synthesis step for synthesis of gas and synthetic fuel production. For comparison, specific material and energy flows were worked out for both process steps, and conversion efficiencies were calculated for the conversion of straw to diesel fuel via the Fischer-Tropsch synthesis. A significant variation of the overall process efficiency in the range of 33–46% was mainly a result of the different assumptions made for electricity generation at the central location. After breaking down the individual cost items to either fixed or variable costs, it turned out that the largest cost items in the production of BtL fuels were attributable to feedstock and capital costs. Comparison of the specific investments showed that, in addition to economies of scale, other factors had a significant influence leading to values between 1000 and 5000 EUR/kW. This, particularly, included the origin of the equipment purchase costs and the factors applied to them. Fuel production costs were found to range between 0.8 and 2.6 EUR/L. Possible cost reduction by learning potential was investigated, leading to an improvement by a few percent of production costs. A sensitivity analysis of the individual cost items by up to 30%, for “investments” and “biomass and transport” cost increases, led to higher manufacturing costs of up to 17% in both cases. By harmonizing the depreciation period and the chosen interest rate, the production costs changed from -16% to +17%. Similarly, effects could be shown by adjusting the costs for maintenance and servicing, and the plant operation time. A superposition of these effects in a best-case scenario led to cost reductions of 21%. The most expensive variant in the opposing worst-case scenario raised costs by up to 27%. This uncertainty contributed already fifty percent to a preliminary cost estimate based on a conceptual design.

scholarly journals Surgical ambulance referrals in sub-Saharan Africa – financial costs and coping strategies at district hospitals in Tanzania, Malawi and Zambia

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Martilord Ifeanyichi ◽  
Henk Broekhuizen ◽  
Mweene Cheelo ◽  
Adinan Juma ◽  
Gerald Mwapasa ◽  
...  
Keyword(s):  
Coping Strategies ◽  
Surgical Care ◽  
Sub Saharan Africa ◽  
Financial Reports ◽  
Study Approach ◽  
Hospital Managers ◽  
District Hospitals ◽  
Sub Saharan ◽  
Microsoft Office ◽  
Patient Referrals

Abstract Background An estimated nine out of ten persons in sub-Saharan Africa (SSA) are unable to access timely, safe and affordable surgery. District hospitals (DHs) which are strategically located to provide basic (non-specialist) surgical care for rural populations have in many instances been compromised by resource inadequacies, resulting in unduly frequent patient referrals to specialist hospitals. This study aimed to quantify the financial burdens of surgical ambulance referrals on DHs and explore the coping strategies employed by these facilities in navigating the challenges. Methods We employed a multi-methods descriptive case study approach, across a total of 14 purposively selected DHs; seven, three, and four in Tanzania, Malawi and Zambia, respectively. Three recurrent cost elements were identified: fuel, ambulance maintenance and staff allowances. Qualitative data related to coping mechanisms were obtained through in-depth interviews of hospital managers while quantitative data related to costs of surgical referrals were obtained from existing records (such as referral registers, ward registers, annual financial reports, and other administrative records) and expert estimates. Interview notes were analysed by manual thematic coding while referral statistics and finance data were processed and analysed using Microsoft Office Excel 2016. Results At all but one of the hospitals, respondents reported inadequacies in numbers and functional states of the ambulances: four centres indicated employing non-ambulance vehicles to convey patients occassionally. No statistically significant correlation was found between referral trip distances and total annual numbers of referral trips, but hospital managers reported considering costs in referral practices. For instance, ten of the study hospitals reported combining patients to minimize trip frequencies. The total cost of ambulance use for patient transportation ranged from I$2 k to I$58 k per year. Between 34% and 79% of all patient referrals were surgical, with total costs ranging from I$1 k to I$32 k per year. Conclusion Cost considerations strongly influence referral decisions and practices, indicating a need for increases in budgetary allocations for referral services. High volumes of potentially avoidable surgical referrals provide an economic case – besides equitable access to healthcare – for scaling up surgery capacity at the district level as savings from decreased referrals could be reinvested in referral systems strengthening.

scholarly journals Phenotypic plasticity of labile traits in the wild

2013 ◽  
Vol 59 (4) ◽  
pp. 485-505 ◽  
Author(s):  
Jon E. Brommer
Keyword(s):  
Life History ◽  
Phenotypic Plasticity ◽  
Statistical Approach ◽  
Scale Up ◽  
Population Level ◽  
Wild Populations ◽  
Quantitative Genetic ◽  
In The Wild ◽  
The Individual ◽  
Quantitative Genetic Parameters

Abstract Individual-based studies allow quantification of phenotypic plasticity in behavioural, life-history and other labile traits. The study of phenotypic plasticity in the wild can shed new light on the ultimate objectives (1) whether plasticity itself can evolve or is constrained by its genetic architecture, and (2) whether plasticity is associated to other traits, including fitness (selection). I describe the main statistical approach for how repeated records of individuals and a description of the environment (E) allow quantification of variation in plasticity across individuals (IxE) and genotypes (GxE) in wild populations. Based on a literature review of life-history and behavioural studies on plasticity in the wild, I discuss the present state of the two objectives listed above. Few studies have quantified GxE of labile traits in wild populations, and it is likely that power to detect statistically significant GxE is lacking. Apart from the issue of whether it is heritable, plasticity tends to correlate with average trait expression (not fully supported by the few genetic estimates available) and may thus be evolutionary constrained in this way. Individual-specific estimates of plasticity tend to be related to other traits of the individual (including fitness), but these analyses may be anti-conservative because they predominantly concern stats-on-stats. Despite the increased interest in plasticity in wild populations, the putative lack of power to detect GxE in such populations hinders achieving general insights. I discuss possible steps to invigorate the field by moving away from simply testing for presence of GxE to analyses that ‘scale up’ to population level processes and by the development of new behavioural theory to identify quantitative genetic parameters which can be estimated.

Increasing Commonalities by Designing Production-Oriented Modular Product Platforms

2014 ◽  
Vol 907 ◽  
pp. 197-210 ◽  
Author(s):  
Günther Schuh ◽  
Stefan Rudolf ◽  
Jens Arnoscht ◽  
Bastian Lüdtke
Keyword(s):  
Organizational Design ◽  
Economies Of Scale ◽  
Product Architecture ◽  
Product Range ◽  
Product Platforms ◽  
Modular Product ◽  
Product And Process ◽  
The Individual ◽  
Descriptive Framework ◽  
Architecture Development

Companies producing in high-wage countries are increasingly challenged due to the necessary differentiation and cost pressure. The modular product platform approach is more and more used by these companies for structuring their product range in order to realise and deploy commonalities. This type of product architecture enables companies to produce nearly individual products without losing economies of scale across the product range. Economies of scale due to communalities result in decreased process costs, reduced development lead-time by uncoupling the development of modules and products as well as the augmentation of the technical product robustness. However, the design of modular product platforms itself causes new challenges regarding the product structuring, the process and organizational design. Recent approaches for the development of communalities through modular product platforms are focusing only the product itself. Since costs are mainly determined in the development phase but caused later in the production phase both product and production have to be taken into account. Furthermore, modular product platforms have a higher variety and diversity of elements since they represent the components, modules and functions of the entire product program. This paradigm shift from an integral product design to a modular product structure cannot be controlled with existing models and methods. Our paper confirms commonality has to be optimized by focusing both the product and production. Therefore we have designed a descriptive framework (commonality model) to display and optimize the commonality both in the product and the process. Furthermore, a product architecture development process that is superior to the individual product development processes was developed for the systematic design of commonalities. The approach presented in this paper focusses on the interactions between product and process parameters. In our approach these interactions will first be displayed based on the graph theory and then be optimized applying sensitivity analysis. By varying relevant parameters both on the product and process side constitutive features can be derived determining product and process standards in order to enhance the overall commonality level.

Specialization Agreements under the EEC Competition Rules; A Commentary on Regulation No. 417/85

1987 ◽  
Vol 56 (4) ◽  
pp. 380-413
Author(s):  
Magnus Höög
Keyword(s):  
Individual Decision ◽  
Effective Competition ◽  
Unit Costs ◽  
Market Shares ◽  
Competition Rules ◽  
Individual Decisions ◽  
The Individual ◽  
The Right ◽  
Restrictive Clause ◽  
Considerable Size

AbstractEach case depends on its own facts. Still, the decided cases give considerable guidance to the Commission's approach to granting individual exemptions. The Commission seems to be concerned primarily with the activities of only the parties subject to the specialization agreement, not with unrelated pursuits of corporate relations of the parties94. The Commission also attributes to th especialization agreements an increase of production with a concomittent lowering of unit costs. The exclusivity will thus help to provide the necessary expanded market. The parties to the agreements discussed above are of different sizes, some have very significant shares of the markets in question. A considerable size of the parties, i.e. substantial turnover or large market shares, normally will make it more difficult to obtain an individual exemption. Still, the individual decisions make it clear that even quite substantial undertakings can obtain the benefit of an individual decision under the right circumstances. This leads to the conclusion that size per se is not a concern to the Commission. Of concern is the restrictive clauses in, to some extent, conjunction with the size. Together, the restrictive clause and the considerable size bring the agreement far within the scope of Article 85(1). That the agreement can be granted an individual exemption due to inherent advantages is another side of the coin. A significant example is Re Lightweight Papers. Once the most rigid clauses in the agreement were withdrawn, an exemption was granted no matter the huge market shares in Benelux and France (70% and 80% respectively). The existence of effective competition is the all important element. No matter the size, an exemption can be had if effective competition prevails.

scholarly journals Opposite outcomes of coinfection at individual and population scales

2018 ◽  
Vol 115 (29) ◽  
pp. 7545-7550 ◽  
Author(s):  
Erin E. Gorsich ◽  
Rampal S. Etienne ◽  
Jan Medlock ◽  
Brianna R. Beechler ◽  
Johannie M. Spaan ◽  
...  
Keyword(s):  
Reproduction Number ◽  
Negative Impact ◽  
Scale Up ◽  
Population Level ◽  
Clear Understanding ◽  
African Buffalo ◽  
Global Public Health ◽  
Individual Level ◽  
Secondary Infections ◽  
The Individual

Coinfecting parasites and pathogens remain a leading challenge for global public health due to their consequences for individual-level infection risk and disease progression. However, a clear understanding of the population-level consequences of coinfection is lacking. Here, we constructed a model that includes three individual-level effects of coinfection: mortality, fecundity, and transmission. We used the model to investigate how these individual-level consequences of coinfection scale up to produce population-level infection patterns. To parameterize this model, we conducted a 4-y cohort study in African buffalo to estimate the individual-level effects of coinfection with two bacterial pathogens, bovine tuberculosis (bTB) and brucellosis, across a range of demographic and environmental contexts. At the individual level, our empirical results identified bTB as a risk factor for acquiring brucellosis, but we found no association between brucellosis and the risk of acquiring bTB. Both infections were associated with reductions in survival and neither infection was associated with reductions in fecundity. The model reproduced coinfection patterns in the data and predicted opposite impacts of coinfection at individual and population scales: Whereas bTB facilitated brucellosis infection at the individual level, our model predicted the presence of brucellosis to have a strong negative impact on bTB at the population level. In modeled populations where brucellosis was present, the endemic prevalence and basic reproduction number (R0) of bTB were lower than in populations without brucellosis. Therefore, these results provide a data-driven example of competition between coinfecting pathogens that occurs when one pathogen facilitates secondary infections at the individual level.

Leadership development strategy: the missing links

2018 ◽  
Vol 32 (1) ◽  
pp. 11-14 ◽  
Author(s):  
Shilpa Kabra Maheshwari ◽  
Jaya Yadav
Keyword(s):  
Leadership Development ◽  
Development Strategy ◽  
Scale Up ◽  
Competitive Growth ◽  
Development Programs ◽  
Leadership Development Programs ◽  
Content Type ◽  
The Individual ◽  
Business Complexity ◽  
Practical Implications

Purpose Current volatile environments, business complexity, and leadership gaps are compelling organizations to deploy effective leadership development strategies. Fueled by competitive growth and people challenges, efforts continue to scale up but fail to create the desired leaders. This paper aims to address the missing links and calls for new ways of deploying leadership development strategy. Design/methodology/approach Qualitative data on experiential feedback have been collected from participants and stakeholders of leadership development programs in Indian organizations. Findings An integrated six-step approach to leadership development has been proposed for scholars and practitioners. Practical implications From the practitioner’s perspective, this study contributes to the field of leadership development by challenging the relevance of current approaches. It also adds to the scholarly literature on leadership development in the context of the organization and the individual. Originality/value Current studies in the area of leadership development in the Indian context are scarce.

Nonsyndromic craniosynostosis in Vietnam: initial surgical outcomes of subspecialty mentorship

2021 ◽  
pp. 1-8
Author(s):  
Dang Do Thanh Can ◽  
Jacob R. Lepard ◽  
Nguyen Minh Anh ◽  
Pham Anh Tuan ◽  
Tran Diep Tuan ◽  
...  
Keyword(s):  
Scale Up ◽  
Unmet Need ◽  
Case Series ◽  
Surgical Care ◽  
Cranial Vault ◽  
Female Ratio ◽  
Estimated Blood Loss ◽  
Common Diagnosis ◽  
Cranial Vault Remodeling

OBJECTIVE There is a global deficit of pediatric neurosurgical care, and the epidemiology and overall surgical care for craniosynostosis is not well characterized at the global level. This study serves to highlight the details and early surgical results of a neurosurgical educational partnership and subsequent local scale-up in craniosynostosis correction. METHODS A prospective case series was performed with inclusion of all patients undergoing correction of craniosynostosis by extensive cranial vault remodeling at Children’s Hospital 2, Ho Chi Minh City, Vietnam, between January 1, 2015, and December 31, 2019. RESULTS A total of 76 patients were included in the study. The group was predominantly male, with a male-to-female ratio of 3.3:1. Sagittal synostosis was the most common diagnosis (50%, 38/76), followed by unilateral coronal (11.8%, 9/76), bicoronal (11.8%, 9/76), and metopic (7.9%, 6/76). The most common corrective technique was anterior cranial vault remodeling (30/76, 39.4%) followed by frontoorbital advancement (34.2%, 26/76). The overall mean operative time was 205.8 ± 38.6 minutes, and the estimated blood loss was 176 ± 89.4 mL. Eleven procedures were complicated by intraoperative durotomy (14.5%, 11/76) without any damage of dural venous sinuses or brain tissue. Postoperatively, 4 procedures were complicated by wound infection (5.3%, 4/76), all of which required operative wound debridement. There were no neurological complications or postoperative deaths. One patient required repeat reconstruction due to delayed intracranial hypertension. There was no loss to follow-up. All patients were followed at outpatient clinic, and the mean follow-up period was 32.3 ± 18.8 months postoperatively. CONCLUSIONS Surgical care for pediatric craniosynostosis can be taught and sustained in the setting of collegial educational partnerships with early capability for high surgical volume and safe outcomes. In the setting of the significant deficit in worldwide pediatric neurosurgical care, this study provides an example of the feasibility of such relationships in addressing this unmet need.

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