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BMJ Open: first published as 10.1136/bmjopen-2020-042968 on 29 December 2020. Downloaded from BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay-per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email [email protected] http://bmjopen.bmj.com/ on September 27, 2021 by guest. Protected copyright. BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-042968 on 29 December 2020. Downloaded from Interpreting Lancet Surgical Indicators in Somaliland Journal: BMJ Open Manuscript ID bmjopen-2020-042968 ArticleFor Type: peerOriginal research review only Date Submitted by the 20-Jul-2020 Author: Complete List of Authors: Dahir, Shukri; Edna Adan University Hospital Cotache-Condor, Cesia; Baylor University, Department of Public Health Concepcion, Tessa; Duke University, Duke University Global Health Institute Mohamed, Mubarak; Edna Adan University Hospital Poenaru, Dan; MyungSung Christian Medical Center, Pediatric Surgery; Montreal Children\'s Hospital Research Institute, Pediatric Surgery Adan Ismail, Edna; Edna Adan Hospital Leather, Andy; King’s Health Partners and King’s College London, King’s Centre for Global Health Rice, Henry; Duke University, Global Health Institute; Duke University Medical Center, Department of Surgery Smith, Emily; Baylor University, Health, Human Performance, and Recreation; Duke University, Duke University Global Health Institute SURGERY, Health policy < HEALTH SERVICES ADMINISTRATION & http://bmjopen.bmj.com/ Keywords: MANAGEMENT, PUBLIC HEALTH on September 27, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 32 BMJ Open 1 2 3 BMJ Open: first published as 10.1136/bmjopen-2020-042968 on 29 December 2020. Downloaded from 4 5 6 7 8 9 I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined 10 in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors 11 who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance 12 with the terms applicable for US Federal Government officers or employees acting as part of their official 13 duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its 14 licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the 15 Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence. 16 17 The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to 18 the Submitting Author Forunless you peer are acting as review an employee on behalf only of your employer or a postgraduate 19 student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open 20 Access articles. Where the Submitting Author wishes to make the Work available on an Open Access basis (and 21 intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative 22 Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set 23 out in our licence referred to above. 24 25 Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been 26 accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate 27 material already published. I confirm all authors consent to publication of this Work and authorise the granting 28 of this licence. 29 30 31 32 33 34 35 36 37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44 45 on September 27, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 32 BMJ Open: first published as 10.1136/bmjopen-2020-042968 on 29 December 2020. Downloaded from 1 1 2 3 Interpreting Lancet Surgical Indicators in Somaliland 4 5 6 Shugri Dahir1, Cesia Cotache-Condor2, Tessa L Concepcion3, Mubarak Mohamed1, Dan 7 8 4 1 5 3 2,3 9 Poenaru , Edna Adan Ismail , Andrew J. M. Leather , Henry E Rice , Emily R Smith , Global 10 11 Initiative for Children’s Surgery 12 13 14 1 Edna Adan University Hospital, Hargeisa, Somaliland, 2 Department of Public Health, Baylor 15 16 University, Waco, TX,For USA; peer3 Duke Global review Health Institute, onlyDuke University, Durham, NC, 17 18 USA; 4 McGill University, Montreal, Quebec, Canada; 5 King’s Centre for Global Health and 19 20 21 Health Partnerships, King’s College London, London, UK 22 23 24 25 26 27 Shugri Dahir and Cesia Cotache-Condor contributed equally to this paper. 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 Word count: 3,099 on September 27, 2021 by guest. Protected copyright. 42 43 44 Corresponding author: 45 46 47 Emily Smith, PhD 48 49 50 Robbins College of Health and Human Sciences, Baylor University, 1621 S. 5th Street, Waco, 51 52 TX 76706 53 54 [email protected] | +1-254-710-4028 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 32 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-042968 on 29 December 2020. Downloaded from 2 1 2 3 ABSTRACT 4 5 6 7 8 Background: The unmet burden of surgical care is high in low- and middle-income countries. 9 10 The Lancet Commission on Global Surgery (LCoGS) proposed six indicators to guide the 11 12 13 development of national plans for improving and monitoring access to essential surgical care. 14 15 This study aimed to characterize the Somaliland surgical health system according to the LCoGS 16 For peer review only 17 indicators and provide recommendations for next-step interventions. 18 19 20 Methods: In this cross-sectional nationwide study, the World Health Organization’s Surgical 21 22 23 Assessment Tool – Hospital Walkthrough and geographic mapping were used for data collection 24 25 at 15 surgically-capable hospitals. LCoGS indicators for preparedness was defined as access to 26 27 timely surgery and specialist surgical workforce density (SAO), delivery was defined as surgical 28 29 30 volume, and impact was defined as protection against impoverishment and catastrophic 31 32 expenditure. Indicators were compared to the LCoGS goals and were stratified by region. 33 http://bmjopen.bmj.com/ 34 35 Results: The health care system in Somaliland does not meet any of the six LCoGS targets for 36 37 preparedness, delivery, or impact. We estimate that only 19% of the population has timely access 38 39 to essential surgery, less than the LCoGS goal of 80% coverage. The number of specialist 40 41 on September 27, 2021 by guest. Protected copyright. 42 surgical, anesthetic, and obstetric (SAO) providers is 0.8 per 100,000, compared to a LCoGS 43 44 goal of 20 SAO per 100,000. Surgical volume is 368 procedures per 100,000 people, while the 45 46 LCoGS goal is 5,000 procedures per 100,000. Protection against impoverishing expenditures was 47 48 49 only 18% and against catastrophic expenditures 1%, both far below the LCoGS goal of 100% 50 51 protection. 52 53 54 Conclusion: We found several gaps in the surgical system in Somaliland using the LCoGS 55 56 indicators and target goals. These metrics provide a broad view of current status and gaps in 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 32 BMJ Open: first published as 10.1136/bmjopen-2020-042968 on 29 December 2020. Downloaded from 3 1 2 3 surgical care, and can be used as benchmarks of progress towards universal health coverage for 4 5 6 the provision of safe, affordable, and timely surgical, obstetric, and anesthesia care in 7 8 Somaliland. 9 10 11 12 13 14 Keywords: global surgery, health policy, public health, LCoGS indicators 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 27, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 32 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-042968 on 29 December 2020.
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