Can CHWs Address Access and Outcome Measurement Challenges in Surgical Care? Experience from Haiti

This article from CHW (Community Health Worker) Central describes efforts to increase access to surgical care in Haiti and across the globe. As stated by the author, Dr. Alexi Matousek, two main crises affecting surgery are: "lack of access to surgical services for vulnerable populations and an inability to measure outcomes that would enable quality improvement." Dr. Matousek sees as barriers a lack of literacy, social agency, relational contacts, and financial means to gain access to surgical care, particularly among marginalised populations. He proposes ways the CHWs can be used to address these issues.

"Dr. Matousek developed a program to use community health workers to function as surgical accompagnateurs [CHWs] functioning as patient navigators who could link patients to care.  The surgical accompagnateurs received mountain patients at the hospital, literally taking them by the hand through every necessary step and location in the hospital to be evaluated for surgery, including financial support. This simple intervention increased the elective operation rate four-fold for this vulnerable population." Screening days were also organised and advertised through a megaphone in the mountain communities throughout the region served by the hospital. "CHWs registered patients and physicians traveled to the mountains to identify patients needing surgery."

Another proposal is to collect data using mobile technology through collection by trained CHWs. "The Community Outcomes Measurement program uses a mobile application that enables CHWs to administer a questionnaire on symptoms of infection, obtain GPS [Global Positioning System] data and submit a high-quality photograph of the incision three times during the 30 days after an operation." CHWs are trained to take photographs of the incision site of patients following surgery, relay the information to the consulting physician, and get "immediate" feedback. "Integration of several best practices is key to a successful implementation of a CHW program. The program intentionally combined community-based selection of candidate CHWs with high levels of intrinsic motivation, robust training, extensive supervision, pay-for-performance incentives and written contracts to achieve excellent results."

In this trial in Haiti, over 100 surgeries were completed, with 350 people already enrolled in the programme. Five trained CHWs support the process that includes a 30-day follow-up (95% completion rate), measurement of completion of regular visits (92% performed on time), photography of the incision site (96% high-quality photos), and surgeon agreement with CHW conclusions that there was not infection (84% agreement with CHWs).

"The long-term goal is to assess whether CHWs with mobile phones could replace the need for surgeons to perform outpatient follow up for patients who have no symptoms of infection, and also to evaluate whether mobile health follow up can identify infections earlier than the current standard of care, leading to reduced morbidity."