Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries.

Katherine R Iverson,Brittany L Powell,Emma Svensson,Ernest J Barthélemy,Isabelle Citron,John G Meara,Mark G Shrime,Kristin Sonderman,Kerry A Vaughan

doi:10.15171/ijhpm.2019.43

Abstract

Background: While recommendations for the optimal distribution of surgical services in high-income countries (HICs) exist, it is unclear how these translate to resource-limited settings. Given the significant shortage and maldistribution of surgical workforce and infrastructure in many low- and middle-income countries (LMICs), the optimal role of decentralization versus regionalization (centralization) of surgical care is unknown. The aim of this study is to review evidence around interventions aimed at redistributing surgical services in LMICs, to guide recommendations for the ideal organization of surgical services. Methods: A narrative-based literature review was conducted to answer this question. Studies published in English between 1997 and 2017 in PubMed, describing interventions to decentralize or regionalize a surgical procedure in a LMIC, were included. Procedures were selected using the Disease Control Priorities’ (DCP3) Essential Surgery Package list. Intervention themes and outcomes were analyzed using a narrative, thematic synthesis approach. Primary outcomes included mortality, complications, and patient satisfaction. Secondary outcomes included input measures: workforce and infrastructure, and process measures: facility-based care, surgical volume, and referral rates. Results: Thirty-five studies were included. Nine (33%) of the 27 studies describing decentralization showed an improvement in primary outcomes. The procedures associated with improved outcomes after decentralization included most obstetric, gynecological, and family planning services as well as some minor general surgery procedures. Out of 8 studies on regionalization (centralization), improved outcomes were shown for trauma care in one study and cataract extraction in one study. Conclusion: Interventions aimed at decentralizing obstetric care to the district hospital and health center levels have resulted in mortality benefits in several countries. However, more evidence is needed to link service distribution to patient outcomes in order to provide recommendations for the optimal organization of other surgical procedures in LMICs. Considerations for the optimal distribution of surgical procedures should include the acuity of the condition for which the procedure is indicated, anticipated case volume, and required level of technical skills, resources, and infrastructure. These attributes should be considered within the context of each country.

Highlights

Introduction there has been considerable progress in improving access to surgical, anesthetic, and obstetric care in many low- and middle-income countries (LMICs), little is known about the ideal distribution of these services
Studies published in English between January 1997 and October 2017, describing (1) decentralization and/or regionalization of one or more (2)
While this study provided a broad overview of the literature examining the optimal distribution of surgical services, this question would be better answered through large-scale population-level research

Summary

Introduction

There has been considerable progress in improving access to surgical, anesthetic, and obstetric care in many low- and middle-income countries (LMICs), little is known about the ideal distribution of these services. In 2015, the third volume of Disease Control Priorities (DCP3) published the Essential Surgery Package, consisting of 44 surgical procedures over 3 service delivery platforms that, if provided, could avert an estimated 1.5 million deaths a year.[3] These procedures were chosen as the most essential and effective in restoring health and quality of life for the greatest number of people. Providing much-needed guidance to the scale-up of surgical and obstetric care, evidence supporting the appropriate distribution of these services has not been well described. The role of decentralization versus regionalization of specific surgical services has yet to be established

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