Kerman University of Medical Sciences International Journal of Health Policy and Management 2322-5939 8 9 2019 09 01 Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries 521 537 3633 10.15171/ijhpm.2019.43 EN Katherine R. Iverson Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA General Surgery Department, University of California Davis Medical Center, Sacramento, CA, USA 0000-0002-5261-8027 Emma Svensson Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA Lund University, Lund, Sweden Kristin Sonderman Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA Brigham and Women’s Hospital, Boston, MA, USA Ernest J. Barthélemy Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA Icahn School of Medicine at Mount Sinai, New York City, NY, USA Isabelle Citron Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA 0000-0003-4702-4926 Kerry A. Vaughan Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA University of Pennsylvania, Philadelphia, PA, USA Brittany L. Powell Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA Stanford University School of Medicine, Stanford, CA, USA John G. Meara Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA, USA Mark G. Shrime Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA Massachusetts Eye and Ear Infirmary, Boston, MA, USA Journal Article 2018 05 19 Background<br />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.<br /> <br />Methods<br />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.<br /> <br />Results<br />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.<br /> <br />Conclusion<br />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. https://www.ijhpm.com/article_3633_acf922154627f6788918f03c42b123cd.pdf