Twenty-five sites (93%) among 27 MINSA facilities with neurosurgical services were reached and site visits performed. Facilities were in 12 of the 25 states in the country. One hospital in Lima/Callao declined to participate and in the Andean region at one of the level III hospitals we were not able to contact any neurosurgeon. Four level II hospitals from the regions, which provided basic emergency neurosurgical care were also included. Otherwise, all other facilities were tertiary care hospitals (level II) or institutes (Table 1). In all 25 hospitals the SSISEP was completed by a neurosurgeon. However, only 20 (80%) of 25 hospitals participated in an interview. The participants had practiced neurosurgery from 2 to over 15 years. No further identifying information was captured to protect the identity of the participant.
Table 1
Facilities providing neurosurgical care in Peru and facilities participating in the study
Region | Number of Total MINSA facilities by level n Level a | Number of MINSA Facilities with neurosurgical capacities n (%) b | Facilities surveyed (SISSE) c n | Total interviews d n |
Lima/Callao | 16 | II | 0 | | |
13 | III | 9 (69) | 8 | 10 |
8 | Institute | 4 (50) | 4 | 3 |
Andean | 70 | II | 1 (< 1) | 1 | 1 |
6 2 | III Institute | 6 (100) 0 | 5 | 3 |
Jungle | 20 | II | 1 (5) | 1 | 1 |
1 | III | 1 (100) | 1 | 1 |
Coastal | 36 | II | 2 (< 1) | 2 | 0 |
3 | III | 3 (100) | 3 | 1 |
Totals | 175 | 27 (15) | 25 | 20 |
Table 1 Legend: Total number of hospitals nationally compared to those staffed to provide neurosurgical care through Ministry of Health facilities, hospitals and institutes combined, throughout Peru. a Level II - small regional hospital; Level III - large general and specialized hospitals; Institutes - are larger specialized hospitals with teaching and research functions.
b Percentage of facility from MINSA established by region.
c SISSE = Survey on Surgical Infrastructure Supplies and Equipment.
d Twenty hospitals had an interview performed, at two sites multiple neurosurgeons participated resulting in 23 interviewees.
Survey on Surgical Infrastructure, Supplies, Equipment, and Procedures
Among the 25 facilities visited throughout the country, a total of 170 neurosurgeons were identified. Lima/Callao had the greatest number with 121 total. Table 2 captures the range of neurosurgeon per population insured by SIS. In aggregate, there are approximately 1 neurosurgeon to 170,000 persons insured by SIS across the country. The range in ratio was approximately 1:110,000 to 1:900,000 neurosurgeon per population insured by SIS. The complete summary of basic and essential characteristics by region is shown in Table 2. The capital had the highest concentration of resources but significant competition for utilization time of operating rooms in emergencies. Hospitals in Lima tended to have mean higher numbers of hospital beds, operating rooms, and access to post-operative recovery. Despite their resources, five hospitals (42%) in Lima/Callao reported subjectively greater than 4 hours to gain access to an operating room in the setting of neurosurgical emergency that has been evaluated and diagnosed in the hospital. The regional hospitals overall lacked access to neuroimaging compared to the Lima/Callao. Advanced three-dimensional vascular imaging was nearly inaccessible in the regions (67–100% lacked angiography capabilities). Most of the hospitals in Lima/Callao had a dedicated microscope for the neurosurgery service (75%) but the regional hospitals reported 60% either had no access or shared a common microscope with other services. All hospitals had access to at least one functional drill except one located in the Jungle. The drill in this area was owned by the local neurosurgeon and was not supplied by the hospital. All institutions reported paper charting except for one hospital in Lima.
Table 2
Summary of hospital facilities characteristics, infrastructure, and essential equipment by region
Region Hospital # | Lima/Callao n = 12 | Coast n = 5 | Andean n = 6 | Jungle n = 2 | All facilities n = 25 |
Total Number of NS* | 121 | 15 | 32 | 2 | 170 |
Mean NS a (range) | 10 (3–16) | 3 (1–5) | 5 (4–9) | 1 (n/a) | 9 (1–16) |
Ratio NS a: population insured by SIS b | 1:107,931 | 1: 275,306 | 1: 138,641 | 1: 875,705 | 1: 172,835 |
Mean Hospital Beds (range) |
| 347 (60–800) | 211 (55–320) | 246 (150–360) | 262 (224–300) | 289 (55–800) |
Do you lack access to hospital beds? (%) |
Yes, both in ICU & Floor | 11 (92) | 5 (100) | 6 (100) | 2 (100) | 24 (96) |
Is the post-operative care unit always available? (%) |
Yes | 10 (83) | 3 (60) | 1 (17) | 1 (50) | 15 (60) |
Mean number of total functional operating rooms (range) |
| 7 (2–18) | 4 (2–6) | 3 (1–5) | 5 (4–5) | 6 (1–18) |
Mean number of total nonfunctional operating rooms (range) |
| 1 (0–6) | 2 (0–3) | 1 (0–3) | 2 (0–4) | 1 (0–6) |
How long does it take to reach the operating room in the case of an emergency? (%) |
Greater than 4 hours | 5 (42) | 5 (100) | 2 (33) | 0 | 12 (48) |
Do you have a functional CT Scanner in the hospital? (%) |
No | 4 (33) | 2 (40) | 5 (50) | 1 (50) | 12 (48) |
Do you have a functional MRI Scanner in the hospital? (%) |
No | 9 (75) | 4 (80) | 5 (83) | 2 (100) | 20 (80) |
Does your service have a functional intraoperative microscope? (%) |
No | 2 (17) | 1 (20) | 4 (67) | 2 (100) | 9 (36) |
Yes, shared equipment | 1 (8) | 3 (60) | 2 (33) | 0 | 6 (24) |
Yes, dedicated to service | 9 (75) | 1 (20) | 0 | 0 | 10 (40) |
Does the hospital have access to three-dimensional angiography? (%) |
No | 2 (17) | 4 (80) | 4 (67) | 2 (100) | 12 (48) |
Total drills by type |
Manual | 17 | 6 | 8 | 2 | 28 |
Electrical | 11 | 1 | 3 | 0 | 15 |
Pneumatic | 14 | 3 | 5 | 0 | 22 |
Total Drills | 42 | 10 | 16 | 2 | 65 |
Mean number drills/hospital | 3.5 (1–10) | 2 (1–3) | 3 (2–3) | 1(n/a) | 3 (1–10) |
Table 2 Legend: Frequencies and reported ranges of the characteristics that describe the hospitals and institutes evaluated during the national evaluation. Each survey collected data on hospital infrastructure, equipment, supplies, and human resources. The percentage frequencies are estimated by column.
a NS = Neurosurgeon
b SIS = Seguro Integral de Salud, insurance provided by Ministry of Health
Neurosurgeons were asked about neurosurgical procedures they could perform at their hospitals. All reported they could perform burr holes for hematoma evacuation and shunt placement for hydrocephalus. Additionally, all reported ability to perform basic cranial decompression and fracture elevation in setting of hematoma formation. However, hospitals in the regions outside of the capital reported differing capacities to perform other, more technical procedures. Frequency of these procedures are shown in Supplemental Table 3. The next sections provide a summary of key themes identified from the second phase of the evaluation.
Qualitative Findings on Factors Influencing Access of Neurosurgical Care
Structural Factors
The neurosurgeons reported a variety of structural factors impacting their ability to provide basic neurosurgical care, with the potential to worsen patient outcomes. All but one participant described significant issues with hospital infrastructure including old facilities with limited numbers of operating rooms and hospital beds (both inpatient floor and intensive care unit beds). Many participants from the capital city commented on the aged facilities. While others in the regional hospitals often struggled with inadequate number of hospital beds without necessary critical care equipment needed to address the rising population growth.
Interviewee 15 (Lima/Callao): “The infrastructure…is inadequate. The hospital already has many years, more than 50 years old and very little has improved. You could tell that when I came to this hospital in 1988 there were in the same number of rooms than now. The population has grown by five times, if we had five rooms at that time, we should right now 25 rooms, but we do not.”
Interviewee 14 (Jungle): “The problem in the ICU is we only have 6 beds. The beds do not always have a ventilator. The connector tubes, or other equipment are missing. There are no establishments that sell that equipment here. You have to bring them from Lima. And equipping a ventilator by bringing equipment from Lima, imagine…it takes time, costs, and patients sometimes die because there is no way to treat them. That’s the big problem.”
The lack of available equipment and supplies needed to perform their daily work was pervasive across the country and impacted delivery of care. Frequently access to basic diagnostic equipment that is essential for making timely decisions, such as x-rays, CTs and MRIs, were difficult to synchronize with the clinical timely. Especially in time sensitive or emergency circumstances such as management of intracranial hypertension secondary to cerebral hemorrhages. One participant recounted his experience with management of patients presenting to hospital w large, life-threatening cerebral hemorrhage:
Interviewee 1 (Andean): “Cerebral hemorrhages are not uncommon… we do not have the ability to solve that problem… no diagnosis, no treatment for lack of equipment, no microscope, no microsurgery equipment. Those patients are left in trauma shock….”
Such patients were commonly left in the emergency room awaiting bed placement or left waiting for transfer to a more equipped hospital. It was also common for basic supplies such as gloves and hemostatic agents to be lacking. More technical equipment such as cranial drills, cautery, and microscopes were also not universally available. Delays in the local supply chains was discovered and appeared to impact hospitals outside of Lima/Callao disproportionately. Stock of basic medications, and equipment such as implants for hydrocephalus or spinal fixation were rarely available on demand and required requests and approval from MINSA administration. Neurosurgeons, frequently and privately, purchased surgical equipment and they would bring these to MINSA facilities seeking to optimize clinical outcomes, if allotted operative time. One participates describes his experience with planning an elective surgery while practicing at one of the large tertiary care hospitals in the capital city:
Interviewee 10 (Lima/Callao): “Basically what we have a tray for the brain and a tray for the spine, incomplete, but at least it allows us to perform surgery because otherwise we would not operate here…I personally bring my microsurgery and bipolar equipment...There is only one microsurgery set that belongs to the hospital but it is incomplete.”
Financial Barriers
Economic factors influencing the delivery of neurosurgical care impacted patients and neurosurgeons in a variety of ways that ultimately affected surgical safety and timeliness of interventions. Budgetary management for most hospitals occurred at regional level that subsequently relocated funds to hospitals then departments. Many neurosurgeons described deficiencies in budgetary allocation that slowed delivery of care through lack of essential equipment. The perception shared by many participants was that most hospitals lacked financial support resulting in the delays encountered in the section above. One participant discussed the difference in budgetary perceptions between hospitals and specialized institutes:
Interview 5 (Lima/Callao): “In general, institutes have an adequate financial allocation, but hospitals do not. Hospitals continue to run monetary deficits. That is why you have hospitals that do not have the necessary equipment to operate. It is even worse in the regional hospitals outside of Lima.”
Although SIS is supposed to cover services and supplies, the timeframe for approval and delivery would often be too late. Patient and families would undertake a high out-of-pocket cost in attempts to obtain timely and safe neurosurgical care. Otherwise, patients would have to wait days to months for approval for specialize supplies and testing including ventricular catheters, shunts, aneurysm clips, spinal instrumentation, or other advanced imaging such as MRIs or angiograms that sometimes never occurred. One participant commented on the risk of poor outcome while waiting for financial approval and delivery of essential equipment:
Interview 18 (Lima/Callao): “The patient who has money can buy his [aneurysm] clip and the one who does not, well, you must wait. But I can't wait, and neither can the patient. Imagine that a patient with limited resources, I have to ask the SIS to buy. When will SIS buy it for me? The patient has already died, you understand…?”
Providers without necessary equipment and supplies, would also devise alternative strategies to provide care even if the risks associated with this care would result in potential harm to the patient. These issues may result sometimes in significant neurologic sequelae for some patients. Neurosurgical practice outside of Lima/Callao more frequently experienced these issues and potentially greater delays and risks due to the lack of resources. But some providers in the capital city are reported such difficulties. One neurosurgeon improvised sterile tubing in place of specialty intracranial drains:
Interviewee 10 (Lima/Callao): “The cost of a Becker-type drain can be between $300–400 USD. Here in the hospital there are times when a family can’t buy it. So that forces us to use an artisanal system. I take a 10 or 12 nasogastric tube and place it and adapt it to a system with a collection bag…it forces us to do these things that should not be done.”
Another important issue reported by many was the inefficient and expensive patient referral process. This process often involves transport from small, distant, and less densely populated provinces to a hospital in big cities or the capital. Many patients, and family members would have to wait long periods of time to identify an accepting facility with an available bed before a transfer could be initiated. Then came the delay in the financial approval. Participants stated standard wait time for transfer were multiple days to weeks, and on occasion, months for patients requiring complex surgical intervention, especially for neurovascular conditions. One participant recounts his experience with transfer of patients to hospital in the capital city:
Interview 11 (Andean): “There are cases in which patients are waiting weeks to be transferred to Lima…the insurance must buy the tickets for the patient, an accompanying doctor and a family member. If the patient is very ill, …you must go lying down, occupying more seats or in an air ambulance. All this implies a cost…”
These issues delayed care, occupied hospital beds, increased costs, and impacted patient outcomes.
Cognitive and Institutional Barriers
We found that the prioritization of neurosurgical care and the perception that neurosurgeons are less valued human capital could be important cognitive factors influencing the working environment. At a national level, there is no clear prioritization of neurosurgical care. As a result, neurosurgeons reported they assume responsibilities for deficiencies in the healthcare system. They experience ethical pressure to intervene on a deteriorating patient. This created undue anxiety and distress for the neurosurgeon. There is severe competition to access surgical schedules, and limited efforts to prioritize deteriorating patients. Many hospitals throughout the country had one emergency operating room reserved for obstetrics and gynecology, and a second emergency room shared across all the other surgical specialties. One participants describes this issue in detail and its consequence:
Interviewee 14 (Jungle): “In the operating room, what delays care is that the room is often occupied by other emergencies, frequently gynecology and obstetrics…. Now, that can last like 4 or more hours, and often neurosurgical patients are not treated in a timely manner and the neurological sequelae increase and mortality also, logically.”
Even in neurosurgical emergencies, there were significant limitations in prioritizing the deteriorating patient. Additionally, neurosurgeons felt under supported by the institution, resulting in a poor distribution of workforce and staffing. Maintaining working contracts and salaries were inconsistent and often paid positions were backlogged by months, especially for recent graduates. This lack of support resulted in higher turnover, creating further stressors in the daily workflow. Several neurosurgeons commented on the lack of support for staff due to deficiencies in the institution/hospital’s organization and budget.
Interviewee 4, Coastal: “The government has a system implemented to license and give job stability. Contracted doctors do not have stability, they are hired for 2 months and then again for 2 months. This law has come out by the Medical College of Peru … but I have like 5 doctors who need positions and I need 3 more doctors to cover the demands of the population.”
Interviewee 14, Jungle: “Now the other big problem in the hospital is the amount of anesthesiologists is not enough to cover all the shifts or team of nurses that is needed to complements the surgical team.”
Additionally, lack of support for continuing education was also a common theme discussed by many participants. Neurosurgeons reported poor continuing education. It logistically was difficult to accomplish as no system was in place to allow for patient coverage for time away.
Interviewee 5, Lima/Callao: “One hardly leaves the private part because when you leave 15 days, they are 15 days that you are not earning. So, I hardly will go out each year to train in anything. Firstly, they will not pay me and secondly, it will be more difficult for me to do it for logistical reasons.”
Consequently, many neurosurgeons possessed a dual practice pattern in both the private and public sector. Leaving either practice resulted significant personal consequences and financial repercussions due to the lack of institutional supported. Additionally, many participants realized their role in the larger health care system and although frustrated with the limitations of the system, but also recognize it is the larger health system that should undergo improvement to address the deficiencies.
Interviewee 12, Andean: “Neurosurgery will not improve if we do not improve everything, it is a whole, we depend on everything and obviously we need human resources, and according to human resources, we will also need instrumentals to improve and perform other surgeries. We try them but we cannot complete the basics of the emergency, let alone try to do in highly complex neurosurgery.”
Interviewee 6, Lima/Callao: “When there is a larger built area, more infrastructure, more beds, everything is going to improve in that sense. We can receive more patients; we can treat a little more complex pathology. It would help a lot.”