Introduction

Access to surgical care is a challenge for patients in Low-Income Countries (LIC) [1]. The Democratic Republic of Congo (DRC) is one of the sub-Saharan countries with limited access to evidencebased treatment of fractures due to weakness of the health care system, and different barriers can be identified [2,3]. According to international evaluation of essential surgery, fixation of long-bone fractures is one of the “Bellwether” procedures [4]. Surgical care has not been a priority in sub-Saharan countries, and when planning for global surgery in 2030 focus should be on the development of broad-based health-systems solutions [5]. The provision of safe and affordable surgical care will reduce disability and contribute to long-term development. However, the barriers may vary in different countries [2,6]. The surgical care of good quality must be available but also accessible and affordable with an acceptability from health care providers to assure care for all patients regardless of background. Patients must also have confidence in the care they are offered.

The access to surgical care of fractures is also influenced by the delay of admission to hospital and delay to perform the surgical procedure. However, the delay may be the consequence of a barrier to get health care due to long distances and lack of access to transport to available health institutions with trauma expertise [6-8]. Hospital care in DRC is mainly financed by the patients and their families as the governmental financial support to health institutions is very weak and about 2/3 of the population live with a daily income below the limit of “absolute poverty” [9-11]. Health care is organized in primary, secondary and tertiary level [11]. Panzi General Referral Hospital (PGRH) is a tertiary hospital, the referral hospital of the Ibanda zone of Bukavu with a population of about 500 000 people in the health zone. The urban area of Bukavu, the province capital of South-Kivu, has approximately 1.3 million inhabitants and there are two other hospitals that treat fractures operatively on a regular basis.

At PGRH there is one specialist in traumatology and 5-10 surgeons capable of treating fractures surgically. According to the routines, when patients with trauma injuries are admitted to the hospital a debridement of skin and soft tissue lesions is carried out without delay and a temporary fracture immobilization is done with a splint or cast, but the operative fracture stabilization has to wait until the patient has paid for the surgery. The price for osteosynthesis has been 365 US dollars during the period of this study. The aim was to determine barriers to access surgical treatment of fractures in the urban area of  Bukavu in South Kivu in the DRC and reasons for the delay of admission and surgical treatment.

Methods

Study Design and Setting

The present study was a sub-study of an observational prospective consecutive case series study conducted from July 1, 2021, to October 31, 2022, of patients admitted at Panzi General Referral Hospital (PGRH) with limb fractures needing surgical treatment [12]. Epidemiological and clinical data from the observational study are presented in a regional scientific journal [13]. However, the data focusing on the barriers to surgical treatment and reasons of delay have not yet been published.

Data Collection

All patients, 18 years of age or older, admitted with fractures requiring surgical treatment as determined by the attending traumatologist or surgeon, were invited to participate by answering questions about demographics, socioeconomic background and health status. The paper questionnaires were completed by one of the doctors at the Surgical Department. Clinical data from the hospitalization was collected from the medical records of the hospital. The findings were manually entered into an electronic database. Complete data was obtained from 108 patients. 7 patients with incomplete data were excluded. Written informed consent was given from all.

Data Analysis

Statistical analyses were made by using the SPSS version 23 software. The numbers and frequencies were used in the descriptive analyses of the studied variables. In the analysis of qualitative variables, and their influence on completed surgery, the chi-square test was used. For quantitative variables the student t-test was used to determine if significant differences existed between the group with completed surgery and the group discharged without having undergone surgical treatment. If the p-value was smaller than 0.05 the result was considered as statistically significant.

Ethical Considerations

The study was conducted according to the ethical principles of Helsinki declaration (14) and the regional ethical committee was consulted. All participants signed an informed consent.

Results

Data on patient characteristics are presented in Table 1. Most patients were middle-aged or young healthy men, very few were older than 60 years. About 30% came from the rural area outside the urban area. Of the fracture patients, 75% had studied at least in secondary school and 25 % had no higher education than primary school, some of them incomplete primary school. About 50 % of the patients were working with transport, most of them as drivers of motor vehicles. The monthly income was less than 100 US dollars in 63.9 % of the patients. Only 5.6 % of the patients had a monthly income of 500 US dollars or more.

Table 1: Demographics and socioeconomic patient characteristics.

The dominating trauma mechanism was road traffic accident (68.5%). More than half of the patients were admitted directly to the hospital by taxi. A large proportion of the fractures were open fractures (57.4%) mostly in the lower extremity, especially the lower leg. More information is given in Table 2.

Table 2: Trauma, Admission and Fracture characteristics

The fracture displacement was classified subjectively by the attending traumatologist or surgeon into the categories of minimal, moderate or severe displacement. One of the research questions was the influence on the access to surgical treatment, as one of the main inclusion criteria was the indication of surgical fracture treatment according to the recommendation from the traumatologist. In fact, 45 of 108 patients (41.7%) were discharged from the hospital without undergoing surgery. The reasons for not accepting surgical intervention are presented in Table 3.

Table 3: Reason for discharge from the hospital.

In addition, potential influencing factors on the access to surgery were analyzed by comparing the groups who accepted surgery and not. The Pearson’s chi-squared test was used, and p-values calculated. The results are presented in Table 4. According to this it was more likely to accept surgery if you were a male patient with severe fracture displacement from a road traffic accident. In our study patients from the rural areas were more willing to undergo surgery. Patients who reported that they had already consulted a traditional bone setter before admission were mostly negative to surgical treatment.

Table 4: Influence on the acceptance of surgical treatment.

No significant influence on the acceptance of surgery was noticed regarding income, profession, marital status, education level or comorbidity.

The delay in admission and the delay of surgery varied a lot, but about half of the patients were admitted and treated according to international recommendations. More details are given in Table 5.

Table 5: Delay of admission and delay of surgery.

Discussion

The study population in this case series was dominated by quite healthy males of young or middle age with diaphyseal fractures after road traffic accidents. The majority had open fractures (Tables 1-2). The epidemiological characteristics of fracture patients are similar to the pattern reported from other countries in the sub-Saharan area [15-17]. The majority of the population in DRC belongs to the category of people living in poverty according to international criteria, as 63.9% report a monthly income of less than 100 USD. This is an important fact as the patients and their families need to pay before the definitive surgical intervention. Only six patients of 108 reported an income monthly of 500 USD or more. 49 of the 108 patients were transferred from another health institution, where a primary assessment had been done. Even if there was a shortage of ambulances, taxis were easily available and could in most cases transport the patient to the hospital. Thus, only 10% of the patients came to PGRH by ambulance and 53% by taxi. The most striking finding was the high number of patients who chose to be discharged from the hospital without having undergone surgery (Table 3).  38 of the patients answered that the main reason was the inability to pay, as the operation could not be performed for free. Thus, they were discharged with a cast splint or without adequate stabilization of the fracture against the doctor’s advice. Six patients, who did not accept the proposed surgery, answered that the reason for their discharge was thar they preferred to consult a traditional bone setter.