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.