M. Bryce1, M. Bosché2, R. Benavente2, A. Chowdhury3, P. A. Bain4, L. B. Steel5, T. Le6, K. Winslow1, R. Hamzah1, S. Ilkhani7, M. Carroll1,8, G. A. Anderson1,7,9,10 1Program in Global Surgery and Social Change, Harvard Medical School, Boston, MASSACHUSETTS, USA 2Harvard Medical School, Harvard University, Boston, MASSACHUSETTS, USA 3Department of Anesthesia, Boston Children’s Hospital, Boston, MASSACHUSETTS, USA 4Countway Library, Harvard University, Boston, MASSACHUSETTS, USA 5Division of Nutritional Sciences, Cornell University, Ithaca, NEW YORK, USA 6Drexel University College Of Medicine, Philadelphia, PENNSYLVANIA, USA 7Center for Surgery and Public Health, Brigham And Women’s Hospital, Boston, MASSACHUSETTS, USA 8Department of Surgery, Yale University School Of Medicine, New Haven, CONNECTICUT, USA 9Department of Surgery, Brigham And Women’s Hospital, Boston, MASSACHUSETTS, USA 10US Air Force Reserves, 439th Aeromedical Staging Squadron, Westover Air Reserve Base, Boston, MASSACHUSETTS, USA
Introduction: Armed conflicts pose a burden on health care services in low-and-middle income countries. Available literature predominantly focuses on characterizing wartime injuries but is limited in assessing non-military, non-governmental wartime surgical capacity and response. We sought to assess the surgical capacity and strategic responses of this subset of humanitarian responders in armed conflicts through proxy indicators to identify beneficial strategies to meet surgical needs.
Methods: We searched six databases for citations from January 1st 2013 onward. We included articles detailing the surgical capacity of non-military, non-governmental organizations operating in armed conflicts. We defined surgical capacity through indicators including type and number of surgical procedures; number of operating rooms, surgical beds, surgeons, anesthesiologists, surgical equipment; and type of anesthesia employed. We defined an armed conflict as a contested incompatibility that concerns government and territory where there is use of armed force between two parties, of which at least one is the government of a state. We excluded studies from countries involved in an armed conflict without active combat within their territory or direct impact of their civilian population or refugee populations. Screening and data extraction followed standards from PRISMA-ScR guidelines.
Results: We screened 2,187 abstracts and 279 full texts, and included 30 citations. Our sample covered 23 countries (Figure 1) and 17 surgical specialties, with Afghanistan (36.7%, 11/30), and trauma, burns and acute care surgery (40%, 12/30) having the highest representation. The most cited humanitarian responder was Doctors Without Borders (46.7%, 14/30). Most publications focused on surgical capacity assessment (63.3%, 19/30), and surgical and clinical outcomes (63.3%, 19/30). Most citations reported surgical capacity indicators at the hospital or department (56.7%, 17/30), and multinational (26.7%, 8/30) levels. Number (86.7%, 26/30) and type (76.7%, 23/30) of surgical procedures performed were the most commonly reported. Over half of the articles (53.3%, 16/30) described strategies to meet surgical needs in armed conflicts. Most strategies addressed information management (68.8%, 11/16), health workforce (62.5%, 10/16), and service delivery (62.5%, 10/16).
Conclusion: This review collates common approaches for strengthening healthcare services in armed conflicts. Several articles emphasized strategies for improving information management, service delivery and workforce capacity. Governance, specific infrastructure changes, and financing of these surgical systems were less commonly discussed and remain a significant gap in the literature.
