TY - JOUR ID - 3633 TI - Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries JO - International Journal of Health Policy and Management JA - IJHPM LA - en SN - AU - Iverson, Katherine R. AU - Svensson, Emma AU - Sonderman, Kristin AU - Barthélemy, Ernest J. AU - Citron, Isabelle AU - Vaughan, Kerry A. AU - Powell, Brittany L. AU - Meara, John G. AU - Shrime, Mark G. AD - Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA AD - Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA Y1 - 2019 PY - 2019 VL - 8 IS - 9 SP - 521 EP - 537 KW - Global Surgery KW - Service Delivery KW - Regionalization KW - Decentralization KW - Centralization KW - Low- and Middle-Income Countries (LMICs) DO - 10.15171/ijhpm.2019.43 N2 - BackgroundWhile 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. MethodsA 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. ResultsThirty-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. ConclusionInterventions 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. UR - https://www.ijhpm.com/article_3633.html L1 - https://www.ijhpm.com/article_3633_266df227ca16783afcc7b297ece288bd.pdf ER -