A hospital too far—access to surgical facilities in India

Hospitals in low-income and middle-income countries receive surgical patients late,1Alkire BC Raykar NP Shrime MG et al.Global access to surgical care: a modelling study.Lancet Glob Health. 2015; 3: e316-e323Summary Full Text Full Text PDF PubMed Scopus (348) Google Scholar and usually when they are critically ill. Consequently, high perioperative mortality and poor surgical outcomes are the unacceptable results of the provision of surgical health care in these countries. However, the larger problem of the invisible deaths in the community of those who never reached the hospital or died on the way to the hospital remains unknown. In The Lancet Global Health, Anna Dare and colleagues2Dare AJ Ng-Kamstra JS Patra J et al.for the Million Death Study CollaboratorsDeaths from acute abdominal conditions and geographical access to surgical care in India: a nationally representative spatial analysis.Lancet Glob Health. 2015; (published online Aug 14.)http://dx.doi.org/10.1016/S2214-109X(15)00079-0Google Scholar address this knowledge gap in the setting of a low-income and middle-income country in which there is no formal prehospital care or transport to the hospital. Their study overcomes the limitation of hospital-based studies, and reveals that a large proportion of patients die at home from acute abdominal conditions, as compared with those who die in the hospital. Dare and colleagues2Dare AJ Ng-Kamstra JS Patra J et al.for the Million Death Study CollaboratorsDeaths from acute abdominal conditions and geographical access to surgical care in India: a nationally representative spatial analysis.Lancet Glob Health. 2015; (published online Aug 14.)http://dx.doi.org/10.1016/S2214-109X(15)00079-0Google Scholar quantify the first delay in seeking surgical care and the second delay in reaching surgical care facilities. The 68th World Health Assembly passed a resolution on Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage on May 22, 2015. Dare and colleagues' study is well timed because it confirms the need for countries to expand access to surgical care. The authors use excellent geospatial modelling and a classification of low-mortality and high-mortality clusters for comparing surgical access within a travel distance of 20, 50, and 100 km of the hospital. However, they do not just plot the geographical distances to health facilities, but qualify this further in their analysis, to show that even if district hospitals are accessible to populations within 50 km, it is only the well-resourced and functional health facility that actually lowers mortality in acute abdominal conditions. This finding reinforces the second part of the World Health Assembly resolution that surgical access needs to include improvement of the quality of services and strengthening of the surgical workforce for optimum outcomes. Dare and colleagues2Dare AJ Ng-Kamstra JS Patra J et al.for the Million Death Study CollaboratorsDeaths from acute abdominal conditions and geographical access to surgical care in India: a nationally representative spatial analysis.Lancet Glob Health. 2015; (published online Aug 14.)http://dx.doi.org/10.1016/S2214-109X(15)00079-0Google Scholar also show that outcomes of non-acute conditions (eg, oral cancer) are unaffected by distance to the hospital. Similarly, it is acknowledged that surgical conditions such as cleft lip and palate are amenable to surgical correction in elective camp-based settings.3Magee WP Vander R Hatcher KW Richard J Burg V Cleft lip and palate as a cost-effective health care treatment in the developing world.World J Surg. 2010; 34: 420-427Crossref PubMed Scopus (75) Google Scholar Hospitals equipped and staffed for acute care surgery are able to deal better with non-acute surgical conditions too.4Aleksandrowicz L Malhotra V Dikshit R et al.Performance criteria for verbal autopsy-based systems to estimate national causes of death: development and application to the Indian Million Death Study.BMC Med. 2014; 12: 21Crossref PubMed Scopus (50) Google Scholar However, there are important factors affecting access to surgery that are beyond geographical access and transportation. These include cultural issues, alternative health-care providers (traditional doctors), lack of trust in the existing health facilities, and, most importantly, the ability to pay for the treatment.4Aleksandrowicz L Malhotra V Dikshit R et al.Performance criteria for verbal autopsy-based systems to estimate national causes of death: development and application to the Indian Million Death Study.BMC Med. 2014; 12: 21Crossref PubMed Scopus (50) Google Scholar Cost-effectiveness and out-of-pocket expenditures are important health-seeking considerations for undertaking the journey to the hospital. This area could benefit from further research. The International Classification of Diseases coding of deaths in this study reveals that gastrointestinal ulcers were the cause in 79% of deaths, and this was the single dominant acute abdominal condition in India. This finding could be a misclassification, attributable to the verbal autopsy method that forms the basis of classifying deaths in the Million Death Study.4Aleksandrowicz L Malhotra V Dikshit R et al.Performance criteria for verbal autopsy-based systems to estimate national causes of death: development and application to the Indian Million Death Study.BMC Med. 2014; 12: 21Crossref PubMed Scopus (50) Google Scholar However, the exact cause of death is not the objective of the study and the burden of these acute abdominal conditions are very well referenced in the third edition of Disease control priorities.5Jamison DT Disease Control Priorities, 3rd edition: improving health and reducing poverty.Lancet. 2015; (published online Feb 4.)http://dx.doi.org/10.1016/S0140-6736(15)60097-6Google Scholar This work makes a strong advocacy statement to complement The Lancet Commission on Global Surgery, which has a vision for universal access to safe, affordable, surgical and anaesthesia care, when needed.6Meara JG Leather AJ Hagander L et al.Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development.Lancet. 2015; 386: 569-624Summary Full Text Full Text PDF PubMed Scopus (1850) Google Scholar The recommendation for having a highly resourced district hospital within every 50 km for a country spread over 3 287 590 km2 with a population of 1·252 billion might not be immediately feasible, but does help set aspirational targets for India. Global surgery has got off to a delayed start, but basic life-saving surgery is now an accepted public health measure worthy of political attention. The enabled and accessible district hospital will be a good financial investment for the surgical burden of disease. We declare no competing interests. Deaths from acute abdominal conditions and geographical access to surgical care in India: a nationally representative spatial analysisImprovements in human and physical resources at existing government hospitals are needed to reduce deaths from acute abdominal conditions in India. Full access to well-resourced hospitals within 50 km by all of India's population could have avoided about 50 000 deaths from acute abdominal conditions, and probably more from other emergency surgical conditions.