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

Authors

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

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

 

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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

Keywords

Main Subjects

References

  1. Holmer H, Lantz A, Kunjumen T, et al. Global distribution of surgeons, anaesthesiologists, and obstetricians. Lancet Glob Health. 2015;3 Suppl 2:S9-11. doi:10.1016/s2214-109x(14)70349-3
  2. Brouillette MA, Aidoo AJ, Hondras MA, et al. Anesthesia capacity in Ghana: a teaching hospital's resources, and the national workforce and education. Anesth Analg. 2017;125(6):2063-2071. doi:10.1213/ane.0000000000002487
  3. Mock CN, Donkor P, Gawande A, Jamison DT, Kruk ME, Debas HT. Essential surgery: key messages from Disease Control Priorities, 3rd edition. Lancet. 2015;385(9983):2209-2219. doi:10.1016/s0140-6736(15)60091-5
  4. Mills A, Vaughan JP, Smith DL, Tabibzadeh I. Health system decentralization: concepts, issues and country experience. World Health Organization; 1990.
  5. La Vincente S, Aldaba B, Firth S, Kraft A, Jimenez-Soto E, Clark A. Supporting local planning and budgeting for maternal, neonatal and child health in the Philippines. Health Res Policy Syst. 2013;11:3. doi:10.1186/1478-4505-11-3
  6. Cobos Munoz D, Merino Amador P, Monzon Llamas L, Martinez Hernandez D, Santos Sancho JM. Decentralization of health systems in low and middle income countries: a systematic review. Int J Public Health. 2017;62(2):219-229. doi:10.1007/s00038-016-0872-2
  7. Fayorsey RN, Saito S, Carter RJ, et al. Decentralization of pediatric HIV care and treatment in five sub-Saharan African countries. J Acquir Immune Defic Syndr. 2013;62(5):e124-130. doi:10.1097/QAI.0b013e3182869558
  8. Perks C, Toole MJ, Phouthonsy K. District health programmes and health-sector reform: case study in the Lao People's Democratic Republic. Bull World Health Organ. 2006;84(2):132-138.
  9. Sreeramareddy CT, Sathyanarayana TN. Decentralised versus centralised governance of health services. Cochrane Database Syst Rev. 2013(11). doi:10.1002/14651858.CD010830
  10. Committee on the Future of Emergency Care in the United States Health System. Emergency Medical Services: At the Crossroads. Washington, DC: The National Academies Press; 2007.
  11. Fitzsimons KJ, Mukarram S, Copley LP, Deacon SA, van der Meulen JH. Centralisation of services for children with cleft lip or palate in England: a study of hospital episode statistics. BMC Health Serv Res. 2012;12:148. doi:10.1186/1472-6963-12-148
  12. Nelen SD, Heuthorst L, Verhoeven RHA, et al. Impact of Centralizing Gastric Cancer Surgery on Treatment, Morbidity, and Mortality. J Gastrointest Surg. 2017;21(12):2000-2008. doi:10.1007/s11605-017-3531-x
  13. Colavita PD, Tsirline VB, Belyansky I, et al. Regionalization and outcomes of hepato-pancreato-biliary cancer surgery in USA. J Gastrointest Surg. 2014;18(3):532-541. doi:10.1007/s11605-014-2454-z
  14. Vali Y, Rashidian A, Jalili M, Omidvari AH, Jeddian A. Effectiveness of regionalization of trauma care services: a systematic review. Public Health. 2017;146:92-107. doi:10.1016/j.puhe.2016.12.006
  15. Rashidian A, Omidvari AH, Vali Y, et al. The effectiveness of regionalization of perinatal care services--a systematic review. Public Health. 2014;128(10):872-885. doi:10.1016/j.puhe.2014.08.005
  16. Birkmeyer JD, Siewers AE, Marth NJ, Goodman DC. Regionalization of high-risk surgery and implications for patient travel times. JAMA. 2003;290(20):2703-2708. doi:10.1001/jama.290.20.2703
  17. Stitzenberg KB, Sigurdson ER, Egleston BL, Starkey RB, Meropol NJ. Centralization of cancer surgery: implications for patient access to optimal care. J Clin Oncol. 2009;27(28):4671-4678. doi:10.1200/jco.2008.20.1715
  18. Smith ER, Vissoci JRN, Rocha TAH, et al. Geospatial analysis of unmet pediatric surgical need in Uganda. J Pediatr Surg. 2017;52(10):1691-1698. doi:10.1016/j.jpedsurg.2017.03.045
  19. Neuner JM, Gilligan MA, Sparapani R, Laud PW, Haggstrom D, Nattinger AB. Decentralization of breast cancer surgery in the United States. Cancer. 2004;101(6):1323-1329. doi:10.1002/cncr.20490
  20. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. doi:10.1371/journal.pmed.1000097
  21. Snilstveit B, Oliver S, Vojtkova M. Narrative approaches to systematic review and synthesis of evidence for international development policy and practice. J Dev Effect. 2012;4(3):409-429. doi:10.1080/19439342.2012.710641
  22. Mays N, Pope C, Popay J. Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field. J Health Serv Res Policy. 2005;10 Suppl 1:6-20. doi:10.1258/1355819054308576
  23. The WHO Health Systems Framework. Western Pacific Region Office of World Health Organization. http://www.wpro.who.int/health_services/health_systems_framework/en/.   Published 2017. Accessed January 18, 2018.
  24. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966;44(3):166-206.
  25. Kestler E, Valencia L, Del Valle V, Silva A. Scaling up post-abortion care in Guatemala: initial successes at national level. Reprod Health Matters. 2006;14(27):138-147. doi:10.1016/s0968-8080(06)27235-5
  26. Kiemtore S, Zamane H, Kain DP, et al. Effects of an intervention initiated by a national society to improve postabortion care in rural facilities in Burkina Faso. Int J Gynaecol Obstet. 2017;136(2):215-219. doi:10.1002/ijgo.12031
  27. Moon TD, Silva-Matos C, Cordoso A, Baptista AJ, Sidat M, Vermund SH. Implementation of cervical cancer screening using visual inspection with acetic acid in rural Mozambique: successes and challenges using HIV care and treatment programme investments in Zambezia Province. J Int AIDS Soc. 2012;15(2):17406. doi:10.7448/ias.15.2.17406
  28. Ramogola-Masire D, de Klerk R, Monare B, Ratshaa B, Friedman HM, Zetola NM. Cervical cancer prevention in HIV-infected women using the "see and treat" approach in Botswana. J Acquir Immune Defic Syndr. 2012;59(3):308-313. doi:10.1097/QAI.0b013e3182426227
  29. Kim YM, Lambe FM, Soetikno D, et al. Evaluation of a 5-year cervical cancer prevention project in Indonesia: opportunities, issues, and challenges. J Obstet Gynaecol Res. 2013;39(6):1190-1199. doi:10.1111/jog.12052
  30. Khozaim K, Orang'o E, Christoffersen-Deb A, et al. Successes and challenges of establishing a cervical cancer screening and treatment program in western Kenya. Int J Gynaecol Obstet. 2014;124(1):12-18. doi:10.1016/j.ijgo.2013.06.035
  31. Poli UR, Bidinger PD, Gowrishankar S. Visual inspection with acetic acid (via) screening program: 7 years experience in early detection of cervical cancer and pre-cancers in rural South India. Indian J Community Med. 2015;40(3):203-207. doi:10.4103/0970-0218.158873
  32. Mekbib T, Kassaye E, Getachew A, Tadesse T, Debebe A. The FIGO Save the Mothers Initiative: the Ethiopia-Sweden collaboration. Int J Gynaecol Obstet. 2003;81(1):93-102.
  33. Kayongo M, Rubardt M, Butera J, Abdullah M, Mboninyibuka D, Madili M. Making EmOC a reality--CARE's experiences in areas of high maternal mortality in Africa. Int J Gynaecol Obstet. 2006;92(3):308-319. doi:10.1016/j.ijgo.2005.12.003
  34. Evans CL, Maine D, McCloskey L, Feeley FG, Sanghvi H. Where there is no obstetrician--increasing capacity for emergency obstetric care in rural India: an evaluation of a pilot program to train general doctors. Int J Gynaecol Obstet. 2009;107(3):277-282. doi:10.1016/j.ijgo.2009.09.006
  35. Teklehaimanot HD, Teklehaimanot A. Human resource development for a community-based health extension program: a case study from Ethiopia. Hum Resour Health. 2013;11:39. doi:10.1186/1478-4491-11-39
  36. Nyamtema AS, Mwakatundu N, Dominico S, et al. Enhancing maternal and perinatal health in under-served remote areas in sub-Saharan Africa: a Tanzanian model. PLoS One. 2016;11(3):e0151419. doi:10.1371/journal.pone.0151419
  37. Serbanescu F, Goldberg HI, Danel I, et al. Rapid reduction of maternal mortality in Uganda and Zambia through the saving mothers, giving life initiative: results of year 1 evaluation. BMC Pregnancy Childbirth. 2017;17(1):42. doi:10.1186/s12884-017-1222-y
  38. Henry EG, Thea DM, Hamer DH, et al. The impact of a multi-level maternal health programme on facility delivery and capacity for emergency obstetric care in Zambia. Glob Public Health. 2018;13(10):1481-1494. doi:10.1080/17441692.2017.1385824
  39. Lissouba P, Taljaard D, Rech D, et al. A model for the roll-out of comprehensive adult male circumcision services in African low-income settings of high HIV incidence: the ANRS 12126 Bophelo Pele Project. PLoS Med. 2010;7(7):e1000309. doi:10.1371/journal.pmed.1000309
  40. Mwandi Z, Murphy A, Reed J, et al. Voluntary medical male circumcision: translating research into the rapid expansion of services in Kenya, 2008-2011. PLoS Med. 2011;8(11):e1001130. doi:10.1371/journal.pmed.1001130
  41. Mahler H, Searle S, Plotkin M, et al. Covering the last kilometer: using gis to scale-up voluntary medical male circumcision services in Iringa and Njombe regions, Tanzania. Glob Health Sci Pract. 2015;3(3):503-515. doi:10.9745/ghsp-d-15-00151
  42. Amuri M, Msemo G, Plotkin M, et al. Bringing early infant male circumcision information home to the family: demographic characteristics and perspectives of clients in a pilot project in Tanzania. Glob Health Sci Pract. 2016;4 Suppl 1:S29-41. doi:10.9745/ghsp-d-15-00210
  43. Galukande M, Kituuka O, Elobu E, et al. Improving surgical access in rural Africa through a surgical camp model. Surg Res Pract. 2016;2016:9021945. doi:10.1155/2016/9021945
  44. O'Flynn D, O'Flynn E, Deneke A, et al. Training surgeons as medical educators in Africa. J Surg Educ. 2017;74(3):539-542. doi:10.1016/j.jsurg.2016.10.013
  45. Washington CH, Tyler FJ, Davis J, et al. Trauma training course: innovative teaching models and methods for training health workers in active conflict zones of Eastern Myanmar. Int J Emerg Med. 2014;7(1):46. doi:10.1186/s12245-014-0046-z
  46. Tajsic NB, Sambath P, Nguon S, et al. Open Fracture Management in Low-Resource Settings: A Medical Training Experience in Cambodian Hospitals. World J Surg. 2017;41(12):2981-2989. doi:10.1007/s00268-017-4245-7
  47. Pirani S, Naddumba E, Mathias R, et al. Towards effective Ponseti clubfoot care: the Uganda Sustainable Clubfoot Care Project. Clin Orthop Relat Res. 2009;467(5):1154-1163. doi:10.1007/s11999-009-0759-0
  48. Evans AM, Chowdhury MM, Kabir MH, Rahman MF. Walk for life - the National Clubfoot Project of Bangladesh: the four-year outcomes of 150 congenital clubfoot cases following Ponseti method. J Foot Ankle Res. 2016;9:42. doi:10.1186/s13047-016-0175-0
  49. Sangameswaran RP, Verma GK, Raghavan N, Joseph J, Sivaprakasam M. Cataract surgery in mobile eye surgical unit: Safe and viable alternative. Indian J Ophthalmol. 2016;64(11):835-839. doi:10.4103/0301-4738.195599
  50. Sani R, Nameoua B, Yahaya A, et al. The impact of launching surgery at the district level in Niger. World J Surg. 2009;33(10):2063-2068. doi:10.1007/s00268-009-0160-x
  51. Bolkan HA, van Duinen A, Waalewijn B, et al. Safety, productivity and predicted contribution of a surgical task-sharing programme in Sierra Leone. Br J Surg. 2017;104(10):1315-1326. doi:10.1002/bjs.10552
  52. Delamou A, Diallo M, Beavogui AH, et al. Good clinical outcomes from a 7-year holistic programme of fistula repair in Guinea. Trop Med Int Health. 2015;20(6):813-819. doi:10.1111/tmi.12489
  53. Boschini LP, Lu-Myers Y, Msiska N, Cairns B, Charles AG. Effect of direct and indirect transfer status on trauma mortality in sub Saharan Africa. Injury. 2016;47(5):1118-1122. doi:10.1016/j.injury.2016.01.015
  54. Jenny HE, Massenburg BB, Saluja S, Meara JG, Shrime MG, Alonso N. Efficacy of facilitated capacity building in providing cleft lip and palate care in low-and middle-income countries. J Craniofac Surg. 2017;28(7):1737-1741. doi:10.1097/scs.0000000000003884
  55. Eliah E, Shayo A, Gendo C, Courtright P, Theraney M, Lewallen S. Can VISION 2020 be implemented in rural government settings? Findings from two programmes in Tanzania. Trop Med Int Health. 2008;13(10):1284-1287. doi:10.1111/j.1365-3156.2008.02140.x
  56. Pawiroredjo JC, Minderhoud J, Mans DR, et al. The cataract situation in Suriname: an effective intervention programme to increase the cataract surgical rate in a developing country. Br J Ophthalmol. 2017;101(2):89-93. doi:10.1136/bjophthalmol-2016-308659
  57. Calisti A, Belay K, Mazzoni G, Fiocca G, Retrosi G, Olivieri C. Promoting major pediatric surgical care in a low-income country: a 4-year experience in Eritrea. World J Surg. 2011;35(4):760-766. doi:10.1007/s00268-011-0992-z
  58. Wilson DA, Garrett MP, Wait SD, et al. Expanding neurosurgical care in Northwest Tanzania: the early experience of an initiative to teach neurosurgery at Bugando Medical Centre. World Neurosurg. 2012;77(1):32-38. doi:10.1016/j.wneu.2011.03.013
  59. Merceron TK, Figueroa L, Eichbaum QE. A model for delivering subspecialty pediatric surgical care in low- and middle-income countries: one organization's early experience. Springerplus. 2015;4:742. doi:10.1186/s40064-015-1528-z
  60. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Surgery. 2015;158(1):3-6. doi:10.1016/j.surg.2015.04.011
  61. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366-378. doi:10.1056/NEJMsa052049
  62. Calvello EJ, Skog AP, Tenner AG, Wallis LA. Applying the lessons of maternal mortality reduction to global emergency health. Bull World Health Organ. 2015;93(6):417-423. doi:10.2471/blt.14.146571             
  63. Boschini LP, Lu-Myers Y, Msiska N, Cairns B, Charles AG. Effect of direct and indirect transfer status on trauma mortality in sub Saharan Africa. Injury. 2016;47(5):1118-1122. doi:10.1016/j.injury.2016.01.015
  64. World Health Organization (WHO). Surgical care at the district hospital. Geneva, Switzerland: WHO; 2003.
  65. Grzybowski S, Stoll K, Kornelsen J. Distance matters: a population based study examining access to maternity services for rural women. BMC Health Serv Res. 2011;11:147. doi:10.1186/1472-6963-11-147
  66. Kornelsen J, McCartney K, Williams K. Centralized or decentralized perinatal surgical care for rural women: a realist review of the evidence on safety. BMC Health Serv Res. 2016;16(1):381. doi:10.1186/s12913-016-1629-6
  67. Grzybowski S, Stoll K, Kornelsen J. The outcomes of perinatal surgical services in rural British Columbia: a population-based study. Can J Rural Med. 2013;18(4):123-129.
  68. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346(15):1128-1137. doi:10.1056/NEJMsa012337
  69. Ou-Yang F, Hsu NC, Juan CH, et al. Breast cancer quality of care in Taiwan in relation to hospital volume: a population-based cohort study. Asia Pac J Clin Oncol. 2015;11(4):308-313. doi:10.1111/ajco.12403
  70. Lu CC, Chiu CC, Wang JJ, Chiu YH, Shi HY. Volume-outcome associations after major hepatectomy for hepatocellular carcinoma: a nationwide Taiwan study. J Gastrointest Surg. 2014;18(6):1138-1145. doi:10.1007/s11605-014-2513-5
  71. Krautz C, Nimptsch U, Weber GF, Mansky T, Grutzmann R. Effect of hospital volume on in-hospital morbidity and mortality following pancreatic surgery in Germany Ann Surg. 2018;267(3):411-417. doi:10.1097/sla.0000000000002248
  72. Huo YR, Phan K, Morris DL, Liauw W. Systematic review and a meta-analysis of hospital and surgeon volume/outcome relationships in colorectal cancer surgery. J Gastrointest Oncol. 2017;8(3):534-546. doi:10.21037/jgo.2017.01.25
  73. Colavita PD, Tsirline VB, Belyansky I, et al. Regionalization and outcomes of hepato-pancreato-biliary cancer surgery in USA. J Gastrointest Surg. 2014;18(3):532-541. doi:10.1007/s11605-014-2454-z
  74. Mesman R, Faber MJ, Berden B, Westert GP. Evaluation of minimum volume standards for surgery in the Netherlands (2003-2017): A successful policy? Health Policy. 2017;121(12):1263-1273. doi:10.1016/j.healthpol.2017.09.017
  75. Prinja S, Nandi A, Horton S, Levin C, Laxminarayan R. Costs, effectiveness, and cost-effectiveness of selected surgical procedures and platforms. Dis Control Priorities, 3rd ed. (Volume 1). 2015:317-338. doi:10.1596/978-1-4648-0346-8_ch18
  76. Menke TJ, Wray NP. When does regionalization of expensive medical care save money? Health Serv Manage Res. 2001;14(2):116-124. doi:10.1258/0951484011912618
  77. Barroy H, Vaughan K, Tapsoba Y, Dale E, Van de Maele N. Towards universal health coverage: thinking public: overview of trends in public expenditure on health (‎2000-2014)‎. Geneva: World Health Organization; 2017.
International Journal of Health Policy and Management
Volume 8, Issue 9
September 2019
Pages 521-537

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History

  • Receive Date: 19 May 2018
  • Revise Date: 27 May 2019
  • Accept Date: 28 May 2019
  • First Publish Date: 01 September 2019

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