• Emily Bruno, Michelle C White, Linden S Baxter, Vaonandianina Agnès Ravelojaona, Hasiniaina Narindria Rakotoarison, Hery Harimanitra Andriamanjato, Kristin L Close, Alison Herbert, Nakul Raykar, Saurabh Saluja, and Mark G Shrime.
• M/V Africa Mercy, Mercy Ships, Port of Toamasina, Madagascar.
• World J Surg. 2017 May 1; 41 (5): 1218-1224.

BackgroundThe Lancet Commission on Global Surgery (LCoGS) described the lack of access to safe, affordable, timely surgical, and anesthesia care. It proposed a series of 6 indicators to measure surgery, accompanied by time-bound targets and a template for national surgical planning. To date, no sub-Saharan African country has completed and published a nationwide evaluation of its surgical system within this framework.MethodMercy Ships, in partnership with Harvard Medical School and the Madagascar Ministry of Health, collected data on the 6 indicators from 22 referral hospitals in 16 out of 22 regions of Madagascar. Data collection was by semi-structured interviews with ministerial, medical, laboratory, pharmacy, and administrative representatives in each region. Microsimulation modeling was used to calculate values for financial indicators.ResultsIn Madagascar, 29% of the population can access a surgical facility within 2 h. Surgical workforce density is 0.78 providers per 100,000 and annual surgical volume is 135-191 procedures per 100,000 with a perioperative mortality rate of 2.5-3.3%. Patients requiring surgery have a 77.4-86.3 and 78.8-95.1% risk of incurring impoverishing and catastrophic expenditure, respectively. Of the six LCoGS indicator targets, Madagascar meets one, the reporting of perioperative mortality rate.ConclusionCompared to the LCoGS targets, Madagascar has deficits in surgical access, workforce, volume, and the ability to offer financial risk protection to surgical patients. Its perioperative mortality rate, however, appears better than in comparable countries. The government is committed to improvement, and key stakeholder meetings to create a national surgical plan have begun.

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