Roadblocks and solutions to planning surgical care for a billion Indians
========================================================================

* Siddhesh Zadey
* Swati Sonal
* Himanshu Iyer
* Himani Baxy
* Emily R. Smith
* Catherine A. Staton
* Tamara N. Fitzgerald
* Joao Ricardo Nickenig Vissoci

*   Surgery
*   Health policies and all other topics
*   Health systems
*   Public Health

### Summary box

*   Over 90% of 1.4 billion Indians lack timely access to safe and affordable surgical care. Surgical, obstetrics and anaesthesia planning for India is arguably one of the largest undertakings in global surgery.

*   There is a paucity of granular data at the subnational level to develop an evidence-based National Surgical, Obstetric and Anesthesia Plan for India.

*   Several important data sources currently exist that could be combined to estimate the surgical care indicators.

*   Current initiatives to evaluate and scale up surgical systems in India must account for the large population percentage of children and include paediatric surgery.

India, the largest lower-middle-income country (LMIC), contributes one-fifth of the global population that lacks timely access to safe and affordable essential and emergency surgery.1 Therefore, it is critical to address surgical care in India. The Lancet Commission on Global Surgery provided two tools that could be used to improve surgical care at a systems level in India: (1) assessment of Surgical Care Indicators and (2) development of a National Surgical, Obstetric and Anesthesia Plan (NSOAP).1 Surgical care indicators evaluate timely access, workforce adequacy, delivery of care, perioperative mortality rate (POMR) and financial impact. The NSOAP identifies contextually relevant priorities and targets based on country stakeholders and conducts a cost assessment for the scale up of the surgical system.

Unfortunately, in India, the problems of incomplete, inaccessible and uncertain data limit the ability to move forward with surgical systems research and NSOAP creation.2 The Lancet Commission report and the related research for India has found that shortages of surgeons, obstetricians and anaesthetists in the health workforce, low surgical volumes and high catastrophic health expenditure risk, were among India’s major problems, with limited data on timely geographical access and POMR.1 The data presented by the Lancet Commission comes from the late 2000s and hence has limited utility for planning in 2022. The indicators initiative published updated estimates for several countries in 2015 and 2017, but contained no new data on India.3 4 While important, estimates from the Commission do not provide the subnational details necessary for NSOAP development and do not address health equity issues. Understanding the needs according to patient population demographics (age, sex, caste, religion, socioeconomic and education group, etc), health sectors (public, for-profit private, trust/non-profit private) and areas of service provision (rural, urban, tribal) is critical for the development of India’s NSOAP.

The lack of comprehensive subnational assessment of surgical care indicators across multiple dimensions—rural and urban regions, public and private healthcare providers, and paediatric and adult populations, inhibits NSOAP development. India lags behind Brazil,5 Colombia,6 7 Uganda,8 Zambia,9 Madagascar,10 Pakistan11 and Somaliland12 for mapping of surgical care indicators and is well behind Ethiopia, Nigeria, Zambia, Tanzania and Rwanda for NSOAP development.13

Surgical scaleup is dependent on several systemic factors including an ecosystem that supports local economic development, well-established surgical education pathways, robust health systems, attention to health policy and political commitment.14 In the last few years, there have been notable engagement and implementation efforts towards surgical care planning through the sign-off of the Karad Consensus Statement at the National Surgical Forum (2016). The statement was drafted by the Association of Rural Surgeons of India to propose the challenges and priorities for surgical scale up in rural areas comprising over 65% of the Indian population.15 Subsequently, the launch of Implementing Lancet Commission on Global Surgery in India (i-LCoGS-India) promoted multipartner ‘centres of excellence’ dedicated to systems strengthening.16 These two efforts have identified important challenges, such as: (1) the poor and unsafe blood supply infrastructure in the country, (2) low rural surgical workforce availability marred by limited training and unsustained partnerships and (3) lack of needs assessment, relevant targets and surgical innovations scaleup for rural India. The initiative proposed several commitments towards intersectoral solutions and established secretariats for pilot fieldwork, research and policy outreach with support from private philanthropies. In addition to these efforts, Indian and global surgery stakeholders should focus on increasing government commitment by strategically integrating surgical indicators and planning in existing national-level programmes such as National Health Mission and Pradhan Mantri Jan Arogya Yojana (PMJAY).

If India is to develop a comprehensive surgical plan, it must not overlook surgical care for children. Over 1.2 billion children, 92.3% of the LMIC paediatric population, lack access to timely, safe and affordable surgical care.17 Surgical care for children is strongly warranted given the high morbidity and mortality of many conditions,18 and the provision of children’s surgical care can protect families and economies from financial hardships.14 India needs to urgently take up paediatric surgical care in its health research and policy agenda, as it contains one of the largest paediatric populations globally with persistently high neonatal, infant and under-5 mortality rates. Notably, improving paediatric surgical care in LMICs can also impact global efforts towards achieving the sustainable development goals.19 The limited paediatric surgical workforce and training capacity currently impede surgical access in India that had 1.29 paediatric surgeons per 1 000 000 people in the last decade; 14-fold and 23-fold less than the USA and the UK, respectively.20

To inform policy change and encourage government engagement, a comprehensive subnational baseline assessment of India’s surgical system is essential. Six surgical care indicators, also included in the World Development Indicators dataset are defined as: surgical preparedness (timely access to surgical care facilities; indicator I), adequate surgical workforce (indicator II)), delivery (population-level surgical volumes rate; indicator III), POMR (indicator IV)) and impact measured by catastrophic (indicator V) and impoverishing (indicator VI) health expenditures due to surgery).1 21 This could be achieved through multiple ways that vary in required investment. First, data must be gathered for the Surgical Care Indicators across existing sources.

Timely access to surgical care (indicator I) can be obtained by building a Geographic Information Systems library detailing the locations of surgical facilities, which is an ongoing project led by our group.22 Data for surgical workforce (indicator II) can be gathered from professional societies membership lists and merged with estimates from National Sample Surveys (NSS) on employment and labour workforce, District-Level Household and Facility Surveys and government reports such as the National Health Profile and Rural Health Statistics. Data for estimating surgical volumes (indicator III) and POMR (indicator IV) can be requested from the Health Management Information System (HMIS) and PMJAY claims database. HMIS is maintained by the Ministry of Health and Family Welfare and provides monthly subnational records for health facilities, predominantly rural public facilities. While it has been reported that HMIS has missing data, studies have validated cesarean-section volumes and other maternal health variables from HMIS against other standard sources.23–25 The PMJAY claims database, currently not publicly accessible at a granular level, is maintained by the National Health Authority and includes data on several clinical outcomes for enrollees that form the socioeconomic ‘bottom 40%’. Estimates from the PMJAY data cannot be directly extrapolated to the broader society without appropriate correction for bias with regard to service utilisation and provision. For catastrophic and impoverishing health expenditures (indicators V and VI), NSS on consumer expenditure and social consumption can provide subnational estimates with additional insights from PMJAY claims data. Previously, NSS household surveys have been extensively used for general (ie, not specifically surgical) catastrophic health expenditure.26 27

Second, prospective audits supplemented by independent field studies or high-level policy groups could also be useful. Recently, the All India Institute of Medical Sciences in collaboration with the government think tank—NITI Aayog conducted a pan-India assessment of emergency and injury care at secondary and tertiary care centres and district hospitals.28 29 Similar efforts, though resource-intensive, could assist in surgical care indicators mapping. Another alternative could be the addition of surgical indicators in the next round of the Demographic and Health Survey,30 known as the National Family Health Survey in India. Third, with more investment, in the longer run, India needs to develop an open-access, integrated high-resolution surgical care indicators database with monthly data updated at the hospital level. This would be useful for implementing and updating an evidence based NSOAP.

India currently does not have an NSOAP in place. While the National Surgical Forum (2016) and other initiatives generated some momentum, the development of an NSOAP remains elusive. In the absence of subnational surgical care indicators and consensus-derived locally contextual targets for the indicators, it will be difficult to develop an evidence-based NSOAP. Given India’s large population and geography-contingent socioeconomic and cultural diversity, efforts could also be focused on state-level surgical planning. Surgical policy and planning could follow the path of India’s climate change and human health planning, where states share a common national template to device plans specific to their needs.31

Thus, the surgical care of 1.4 billion people, one-seventh of the global population, including 534 million children who reside in India, remains uncertain and undermined without definitive data and a plan. India needs urgent comprehensive baseline assessment of its Surgical Care Indicators at subnational levels and long-term investment in data monitoring. Leveraging the indicators for integrating surgical care in India’s health policy and planning is the next step that can eventually culminate in the country’s first NSOAP.

## Data availability statement

Data supporting the findings of this study are available within the article.

## Ethics statements

### Patient consent for publication

Not applicable.

## Acknowledgments

We would like to thank everyone at Duke Global Emergency Medicine Innovation Implementation (GEMINI) Research Center and Association for Socially Applicable Research (ASAR) for their support.

## Footnotes

*   Handling editor Seye Abimbola

*   Twitter @RantingSid, @ersmith2016, @CatherineStato1, @Jrvissoci

*   Contributors SZ created the original draft. SZ, SS and HI conducted the background research. All authors critically reviewed and revised the manuscript.

*   Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

*   Competing interests None declared.

*   Provenance and peer review Not commissioned; externally peer reviewed.

[http://creativecommons.org/licenses/by-nc/4.0/](http://creativecommons.org/licenses/by-nc/4.0/)
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: [http://creativecommons.org/licenses/by-nc/4.0/](http://creativecommons.org/licenses/by-nc/4.0/).

## References

1.  Meara JG, Leather AJM, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386:569–624.[doi:10.1016/S0140-6736(15)60160-X](http://dx.doi.org/10.1016/S0140-6736(15)60160-X)pmid:http://www.ncbi.nlm.nih.gov/pubmed/25924834
    
    [CrossRef](http://gh.bmj.com/lookup/external-ref?access_num=10.1016/S0140-6736(15)60160-X&link_type=DOI) 
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=25924834&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

2.  Holmer H, Bekele A, Hagander L, et al. Evaluating the collection, comparability and findings of six global surgery indicators. Br J Surg 2019;106:e138–50.[doi:10.1002/bjs.11061](http://dx.doi.org/10.1002/bjs.11061)pmid:http://www.ncbi.nlm.nih.gov/pubmed/30570764
    
    [CrossRef](http://gh.bmj.com/lookup/external-ref?access_num=10.1002/bjs.11061&link_type=DOI) 
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=30570764&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

3.  The Lancet Commission on Global Surgery. Data for the sustainable development of surgical systems: a global collaboration. The Lancet Commission on Global Surgery, 2015.
    
    

4.  The Lancet Commission on Global Surgery. Data for the sustainable development of surgical systems: a global collaboration, WDI surgical indicators data collection 2016. The Lancet Commission on Global Surgery, 2017.
    
    

5.  Massenburg BB, Saluja S, Jenny HE, et al. Assessing the Brazilian surgical system with six surgical indicators: a descriptive and modelling study. BMJ Glob Health 2017;2:e000226.[doi:10.1136/bmjgh-2016-000226](http://dx.doi.org/10.1136/bmjgh-2016-000226)pmid:http://www.ncbi.nlm.nih.gov/pubmed/28589025
    
    [CrossRef](http://gh.bmj.com/lookup/external-ref?access_num=10.1136/bmjgh-2016-000226&link_type=DOI) 
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=http://www.ncbi.nlm.nih.gov/pubmed/28589025&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

6.  Hanna JS, Herrera-Almario GE, Pinilla-Roncancio M, et al. Use of the six core surgical indicators from the Lancet Commission on global surgery in Colombia: a situational analysis. Lancet Glob Health 2020;8:e699–710.[doi:10.1016/S2214-109X(20)30090-5](http://dx.doi.org/10.1016/S2214-109X(20)30090-5)pmid:http://www.ncbi.nlm.nih.gov/pubmed/32353317
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

7.  Samper AFG, Herrera-Almario GE, Tulloch D, et al. A granular analysis of service delivery for surgical system strengthening: application of the Lancet indicators for policy development in Colombia. The Lancet Regional Health - Americas 2022;10:100217.[doi:10.1016/j.lana.2022.100217](http://dx.doi.org/10.1016/j.lana.2022.100217)
    
    

8.  Albutt K, Punchak M, Kayima P, et al. Access to safe, timely, and affordable surgical care in Uganda: a stratified randomized evaluation of nationwide public sector surgical capacity and core surgical indicators. World J Surg 2018;42:2303–13.[doi:10.1007/s00268-018-4485-1](http://dx.doi.org/10.1007/s00268-018-4485-1)pmid:http://www.ncbi.nlm.nih.gov/pubmed/29368021
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

9.  Esquivel MM, Uribe-Leitz T, Makasa E, et al. Mapping disparities in access to safe, timely, and essential surgical care in Zambia. JAMA Surg 2016;151:1064–9.[doi:10.1001/jamasurg.2016.2303](http://dx.doi.org/10.1001/jamasurg.2016.2303)pmid:http://www.ncbi.nlm.nih.gov/pubmed/27580500
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

10. Bruno E, White MC, Baxter LS, et al. An evaluation of preparedness, delivery and impact of surgical and anesthesia care in Madagascar: a framework for a national surgical plan. World J Surg 2017;41:1218–24.[doi:10.1007/s00268-016-3847-9](http://dx.doi.org/10.1007/s00268-016-3847-9)pmid:http://www.ncbi.nlm.nih.gov/pubmed/27905017
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

11. Fatima I, Shoman H, Peters A, et al. Assessment of pakistan’s surgical system by tracking the lancet global surgery indicators toward a national surgical, obstetric, and anaesthesia plan. J Am Coll Surg 2019;229:S125.[doi:10.1016/j.jamcollsurg.2019.08.278](http://dx.doi.org/10.1016/j.jamcollsurg.2019.08.278)
    
    

12. Dahir S, Cotache-Condor CF, Concepcion T, et al. Interpreting the Lancet surgical indicators in Somaliland: a cross-sectional study. BMJ Open 2020;10:e042968.[doi:10.1136/bmjopen-2020-042968](http://dx.doi.org/10.1136/bmjopen-2020-042968)pmid:http://www.ncbi.nlm.nih.gov/pubmed/33376180
    
    [Abstract/FREE Full Text](http://gh.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NzoiYm1qb3BlbiI7czo1OiJyZXNpZCI7czoxMzoiMTAvMTIvZTA0Mjk2OCI7czo0OiJhdG9tIjtzOjI0OiIvYm1qZ2gvNy8xMS9lMDEwMjkyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

13. Peters AW, Roa L, Rwamasirabo E, et al. National surgical, obstetric, and anesthesia plans supporting the vision of universal health coverage. Glob Health Sci Pract 2020;8:1–9.[doi:10.9745/GHSP-D-19-00314](http://dx.doi.org/10.9745/GHSP-D-19-00314)pmid:http://www.ncbi.nlm.nih.gov/pubmed/32234839
    
    [FREE Full Text](http://gh.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiZ2hzcCI7czo1OiJyZXNpZCI7czo1OiI4LzEvMSI7czo0OiJhdG9tIjtzOjI0OiIvYm1qZ2gvNy8xMS9lMDEwMjkyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

14. Smith ER, Concepcion TL, Niemeier KJ, et al. Is global pediatric surgery a good investment? World J Surg 2019;43:1450–5.[doi:10.1007/s00268-018-4867-4](http://dx.doi.org/10.1007/s00268-018-4867-4)pmid:http://www.ncbi.nlm.nih.gov/pubmed/30506288
    
    [CrossRef](http://gh.bmj.com/lookup/external-ref?access_num=10.1007/s00268-018-4867-4&link_type=DOI) 
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=30506288&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

15. On Behalf Of The Association Of Rural Surgeons Of India-Lancet Commission On Global Surgery Consensus Committee Arsi-LCoGS Consensus Committee. The Lancet Commission on Global Surgery - Association of Rural Surgeons of India Karad Consensus Statement on Surgical System Strengthening in Rural India. Healthc 2019;7:7–9.[doi:10.1016/j.hjdsi.2018.10.003](http://dx.doi.org/10.1016/j.hjdsi.2018.10.003)pmid:30709795
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=30709795&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

16. Raykar N, Mukhopadhyay S, Saluja S, et al. Implementation of the Lancet Commission on global surgery in India. Healthc 2019;7:4–6.[doi:10.1016/j.hjdsi.2018.11.001](http://dx.doi.org/10.1016/j.hjdsi.2018.11.001)pmid:http://www.ncbi.nlm.nih.gov/pubmed/30522905
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

17. Mullapudi B, Grabski D, Ameh E, et al. Estimates of number of children and adolescents without access to surgical care. Bull World Health Organ 2019;97:254–8.[doi:10.2471/BLT.18.216028](http://dx.doi.org/10.2471/BLT.18.216028)pmid:http://www.ncbi.nlm.nih.gov/pubmed/30940982
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

18. Butler EK, Tran TM, Nagarajan N, et al. Epidemiology of pediatric surgical needs in low-income countries. PLoS One 2017;12:e0170968.[doi:10.1371/journal.pone.0170968](http://dx.doi.org/10.1371/journal.pone.0170968)pmid:http://www.ncbi.nlm.nih.gov/pubmed/28257418
    
    [CrossRef](http://gh.bmj.com/lookup/external-ref?access_num=10.1371/journal.pone.0170968&link_type=DOI) 
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=28257418&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

19. Truche P, Smith ER, Ademuyiwa A, et al. Defining surgical workforce density targets to meet child and neonatal mortality rate targets in the age of the sustainable development goals: a global cross-sectional study. World J Surg 2022;46:2262–9.[doi:10.1007/s00268-022-06626-6](http://dx.doi.org/10.1007/s00268-022-06626-6)pmid:http://www.ncbi.nlm.nih.gov/pubmed/35752679
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

20. Lalchandani P, Dunn JCY. Global comparison of pediatric surgery workforce and training. J Pediatr Surg 2015;50:1180–3.[doi:10.1016/j.jpedsurg.2014.11.032](http://dx.doi.org/10.1016/j.jpedsurg.2014.11.032)pmid:http://www.ncbi.nlm.nih.gov/pubmed/25783299
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

21. Raykar NP, Ng-Kamstra JS, Bickler S, et al. New global surgical and anaesthesia indicators in the world development indicators dataset. BMJ Glob Health 2017;2:e000265.[doi:10.1136/bmjgh-2016-000265](http://dx.doi.org/10.1136/bmjgh-2016-000265)pmid:http://www.ncbi.nlm.nih.gov/pubmed/29225929
    
    [FREE Full Text](http://gh.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NToiYm1qZ2giO3M6NToicmVzaWQiO3M6MTE6IjIvMi9lMDAwMjY1IjtzOjQ6ImF0b20iO3M6MjQ6Ii9ibWpnaC83LzExL2UwMTAyOTIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

22. Jadhav T, Vissoci JRN, Zadey S. Measuring timely geographical access to surgical care in India: a geospatial modelling study. Lancet Glob Health 2022;10:S29.[doi:10.1016/S2214-109X(22)00158-9](http://dx.doi.org/10.1016/S2214-109X(22)00158-9)
    
    

23. Goli S, Puri P, Salve PS. Estimates and correlates of District-Level maternal mortality ratio in India. medRxiv 2021.
    
    

24. Sharma A, Rana SK, Prinja S, et al. Quality of Health Management Information System for Maternal & Child Health Care in Haryana State, India. PLoS One 2016;11:e0148449.[doi:10.1371/journal.pone.0148449](http://dx.doi.org/10.1371/journal.pone.0148449)pmid:http://www.ncbi.nlm.nih.gov/pubmed/26872353
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

25. Zadey S, Nickenig Vissoci JR. Analyzing surgical volumes, rates, and need in rural India. medRxiv 2021.
    
    

26. Pandey A, Ploubidis GB, Clarke L, et al. Trends in catastrophic health expenditure in India: 1993 to 2014. Bull World Health Organ 2018;96:18–28.[doi:10.2471/BLT.17.191759](http://dx.doi.org/10.2471/BLT.17.191759)pmid:http://www.ncbi.nlm.nih.gov/pubmed/29403097
    
    [CrossRef](http://gh.bmj.com/lookup/external-ref?access_num=10.2471/BLT.17.191759&link_type=DOI) 
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

27. Kastor A, Mohanty SK. Disease-specific out-of-pocket and catastrophic health expenditure on hospitalization in India: do Indian households face distress health financing? PLoS One 2018;13:e0196106.[doi:10.1371/journal.pone.0196106](http://dx.doi.org/10.1371/journal.pone.0196106)pmid:http://www.ncbi.nlm.nih.gov/pubmed/29746481
    
    [PubMed](http://gh.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjgh%2F7%2F11%2Fe010292.atom) 

28. Department of Emergency MedicineJPNATC, AIIMS, NITI AayogGovernment of India. Emergency and injury care at secondary and tertiary level centres in India: a report of current status on country level assessment. New Delhi: Department of Emergency Medicine, JPNATC, AIIMS, 2020.
    
    

29. Department of Emergency Medicine,JPNATC, AIIMS, NITI AayogGovernment of India. Emergency and injury care at district hospitals in India: a report of current status on country level assessment. New Delhi: Department of Emergency Medicine, JPNATC, AIIMS, 2020.
    
    

30. Juran S, Moren S, Santhirapala V, et al. The development and inclusion of questions on surgery in the 2018 Zambia demographic and health survey. Glob Health Sci Pract 2021;9:905–14.[doi:10.9745/GHSP-D-20-00619](http://dx.doi.org/10.9745/GHSP-D-20-00619)pmid:http://www.ncbi.nlm.nih.gov/pubmed/34933985
    
    [Abstract/FREE Full Text](http://gh.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiZ2hzcCI7czo1OiJyZXNpZCI7czo3OiI5LzQvOTA1IjtzOjQ6ImF0b20iO3M6MjQ6Ii9ibWpnaC83LzExL2UwMTAyOTIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

31. Nair A, Maharana A, Andhale A, et al. Heat, Dust, Fever: India’s climate adaptation plan for health should reflect regional and national needs. Think Global Health, 2022. Available: [https://www.thinkglobalhealth.org/article/heat-dust-fever](https://www.thinkglobalhealth.org/article/heat-dust-fever) [Accessed 4 May 2022].