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

Document Type : Review Article


1 Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA

2 General Surgery Department, University of California Davis Medical Center, Sacramento, CA, USA

3 Lund University, Lund, Sweden

4 Brigham and Women’s Hospital, Boston, MA, USA

5 Icahn School of Medicine at Mount Sinai, New York City, NY, USA

6 University of Pennsylvania, Philadelphia, PA, USA

7 Stanford University School of Medicine, Stanford, CA, USA

8 Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA, USA

9 Massachusetts Eye and Ear Infirmary, Boston, MA, USA


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.
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.
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.
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.



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Commentaries Published on this Paper


  • Decentralization and Regionalization of Surgical Care as a Critical Scale-up Strategy in Low- and Middle-Income Countries; Comment on “Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries”

           Abstract | PDF


  • Decentralization and Regionalization: Redesigning Health Systems for High Quality Maternity Care; Comment on “Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries”

           Abstract | PDF


  • Conceptualizing the Organization of Surgical Services; Comment on “Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries”

           Abstract | PDF


Authors' Response to the Commentaries


  • The Optimal Distribution of Surgery in Low- and Middle-Income Countries: A Proposed Matrix for Determining Country-Level Organization of Surgical Services – A Response to the Recent Commentaries

        Abstract | PDF


Main Subjects

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Volume 8, Issue 9
September 2019
Pages 521-537
  • Receive Date: 19 May 2018
  • Revise Date: 27 May 2019
  • Accept Date: 28 May 2019
  • First Publish Date: 01 September 2019