Global Health
Barriers to Accessing Surgical Care in Pakistan: Healthcare Barrier Model and Quantitative Systematic Review

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Inadequate access to surgical services results in increased morbidity and mortality from a spectrum of conditions in Pakistan. We employed a modification of Andersen’s model of health services utilization and developed a ‘Healthcare Barrier Model,’ to characterize the barriers to accessing health care in developing countries, using surgical care in Pakistan as a case study. We performed a literature search from MEDLINE, EMBASE, CINAHL, SCOPUS, Global Health Database, and Cochrane Central Register of Controlled Trials, and selected 64 of 3113 references for analysis. Patient-related variables included age (elderly), gender (female), preferential use of alternative health providers (Hakeem, traditional healers, others), personal perceptions regarding disease and potential for treatment, poverty, personal expenses for healthcare, lack of social support, geographic constraints to accessing a health facility, and compromised general health status as it relates to the development of surgical disease. Environmental barriers include deficiencies in governance, the burden of displaced or refugee populations, and aspects of the medicolegal system, which impact treatment and referral. Barriers relating to the health system include deficiencies in capacity (infrastructure, physical resources, human resources) and organization, and inadequate monitoring. Provider-related barriers include deficiencies in knowledge and skills (and ongoing educational opportunities), delays in referral, deficient communication, and deficient numbers of female health providers for female patients. The Healthcare Barrier model addresses this broad spectrum of barriers and is designed to help formulate a framework of healthcare barriers. To overcome these barriers will require a multidisciplinary, multisectoral effort aimed at strengthening the health system.

Introduction

Despite estimates suggesting that surgical conditions account for approximately 11% of the world’s disease burden, there are enormous gaps in the provision of life saving and disability preventing surgical services both between and within low- and middle income countries (LMICs) [1]. Deficiencies in accessing essential health services are most pronounced in the rural areas of LMICs, where a sizeable percentage of the population receives their health care. Weiser et al. estimated that the poorest third of our world’s population receive only 3.5% of the total number of surgeries performed yearly [2]. In Pakistan, the rate of surgical procedures was 411 per 100,000 population (1999), versus 21,397 per 100,000 population in the United States (1996) 2, 3, 4. While recognizing that the burden of surgical diseases has yet to be quantified in Pakistan (or any other country) using existing health metrics, considerable morbidity and mortality may be averted by providing access to safe and timely surgical care for a host of emergent conditions including complications of pregnancy and injuries. For example, the incidence of injuries in the northern areas of Pakistan was estimated to be 1531/100 000 persons per year, with burns, falls, and road accidents accounting for 82% of cases [3]. The incidence of acute abdomen was 1364/100,000 persons per year in the same study, and between 39% and 47% of such cases require a surgical procedure 3, 5, 6.

Prior to suggesting a strategy to improve access to basic surgical services, it is imperative to characterize the barriers to utilization of surgical services. However, in spite of a number of papers there is no universally accepted framework for classifying barriers to care [7]. The goal of this study is to employ a ‘Healthcare Barrier Model,’ incorporating a modification of Andersen’s behavioral model of health services utilization along with the ‘health systems’ concept (WHO 2000 and 2009), to define barriers to surgical care in Pakistan as a case study 8, 9.

Section snippets

Methods

We performed a systematic literature search of peer-reviewed studies from Medline (via PubMed), EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), SCOPUS, Global Health Database, and the Cochrane Central Register of Controlled Trials. For the purpose of this paper, we define barrier as a variable that proves to be an “obstacle or hindrance or influences negatively to achieving and attainment of health and well being.” WHO defines health as a state of complete physical,

Results

Our search from MEDLINE, EMBASE, CINAHL, SCOPUS, Global Health Database, and Cochrane Central Register of Controlled Trials produced 3113 articles. Following a review of the titles and abstracts, 126 full text articles were selected for a detailed review, including 15 articles selected from reference lists. Out of these, 64 articles were selected for final inclusion in our study (Fig. 2).

The barriers are listed in Table 1. These studies represented all four provinces of Pakistan [23]; Sindh 24,

Discussion

Neglected diseases or conditions, or those in which there has been a delay in presentation, require more complex and costly solutions, and the outcomes are rarely as desirable as when patients present in an early stage of their disease process. Inadequate access to safe and timely surgical care results in increased morbidity and mortality from conditions spanning all of the surgical subspecialties. How can Pakistan reach Millennium Development Goal 4 and 5 [86], when 70% of women fail to

Conclusion and Future Directions

Deficiencies in access to surgical care lead to increased morbidity and mortality in Pakistan and other LMICs. Identifying and/or classifying the spectrum of barriers to health care (including surgery) are necessary first steps when attempting to improve surgical care in low-income and middle-income countries. Addressing the variety of barriers identified in this and other studies will require a multidisciplinary, multisectoral effort focused on strengthening the health system. There is a great

Acknowledgments

The authors acknowledge Affan B. Irfan, M.D., whose help with methodology and creating of the Healthcare Barrier Model was invaluable.

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