Experience of developing rural surgical care in a remote mountainous region of Pakistan: Challenges and opportunities

Abstract

Background: Pakistan is one of the most populated countries with a population of 160 million; 67% are rural population but all the tertiary care facilities are concentrated in large cities. The Northern Areas is the most remote region with difficult terrain, harsh weather conditions and the tertiary care hospital at a distance of 600 km with traveling time of 16 h. The Aga Khan Medical Centre, Singul (AKMCS) is a secondary healthcare facility in Ghizer district with a population of 132,000. AKMCS was established in 1992 to provide emergency and common elective surgical care. It has strengthened the primary health service through training, education and referral mechanism. It also provided an opportunity for family physicians to be trained in common surgical operations with special emphasis on emergency obstetric care. In addition it offers elective rotations for the residents and medical students to see the spectrum of diseases and to understand the concept of optimal care with limited resources. Methods and Results: The clinical data was collected prospectively using international classification of diseases ICD -9 coding and the database was developed on a desktop computer. Information about the operative procedures and outcome was separately collected on an Excel worksheet. The data from January 1998 to December 2001 were retrieved and descriptive analysis was done on epi info-6. Thirty-one thousand seven hundred and eighty-two patients were seen during this period, 53% were medical, 24% surgical, 16% obstetric and 7% with psychiatric illness. Out of 1990 surgical operations 32% were general surgery, 31% orthopedic, 21% pediatric, 12% obstetric and 4% urological cases; 42% of operations were done under general anesthesia, 22% spinal, 9% intravenous (IV) ketamine, 6% IV sedation and 21% under local anesthesia. Six hundred and sixty-two were done in the main operation room including general surgery 337, obstetric 132, urological 67, pediatric 66 and orthopedic 66 cases; 64% of cases in the main operation room were done under general and 22% under spinal anesthesia. The commonest surgeries were exploratory laparotomy, caesarian sections, open prostatectomy, urological stone surgeries, appendectomy, hernia repairs and surgery for osteomyelitis. There were 21 surgical mortalities including six operative deaths, 15 non-operative deaths and 89% of the mortalities were unavoidable. The crude in-hospital mortality decreased significantly from 5.5% in 1992 to 1.1% in 2001 and the contributing factors were improved structure and process of care. Conclusion: The impact of a secondary care rural medical centre (AKMC) is very obvious from the clinical audit including accessibility, sustainability and quality of care. This could be a model of care in rural Pakistan where accessibility, affordability and quality of care is lacking.

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

“…Although most of the studies were from an urban setting, likely due to patterns of referral, studies involving the more rural [23,37,50,56] and mountainous [3,69,70,73,82,84] populations were also identified. Articles spanned the range of surgical disciplines [82,83], including General Surgery [30,31,33,51,57,61,63,65,69,70,73,77,79], Otolaryngology, [24,29,53], Urology [45,48,49,52,60,75], Neurosurgery [29,34,39,64,67,78], Plastic Surgery [74], Ophthalmology [23,25,28,56,71,84], Obstetrics and Gynecology [27, 35-38, 44, 46, 50, 59, 62, 66, 68, 72, 76, 80, 81], Cardiac Surgery …”

“…Health system level Physical resources [23,36,38,42,43,61,62,70,71,75] Lack of medicines, equipment and supplies, blood bank and lab facilities, maintenance of physical resources Human Resources and Healthcare workforce [3,25,36,37,67,70,71,75,79,82] Shortage of qualified surgeons, anesthesiologists, nurses, and paraprofessionals. Healthcare financing [28,44,51,54,58,64,75,83] Underfunded health sector, absence of medical insurance system, and social welfare structure.…”

“…These studies represented all four provinces of Pakistan [23]; Sindh , Balochistan [45][46][47][48][49][50], Punjab [51][52][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67][68], and Khyber Pukhtunkhwa [62,[69][70][71][72][73][74][75][76][77][78][79][80][81]. Two studies came from Gilgit-Baltistan, a northernmost self-governing territory [3,82], while a single study came from Kashmir [83] and from the Federally Administered Tribal Areas (FATA), an autonomous region comprising seven tribal agencies in the northwest of Pakistan [84]. Although most of the studies were from an urban setting, likely due to patterns of referral, studies involving the more rural [23,37,50,56] and mountainous …”

“…Two studies came from Gilgit-Baltistan, a northernmost self-governing territory [3,82], while a single study came from Kashmir [83] and from the Federally Administered Tribal Areas (FATA), an autonomous region comprising seven tribal agencies in the northwest of Pakistan [84]. Although most of the studies were from an urban setting, likely due to patterns of referral, studies involving the more rural [23,37,50,56] and mountainous [3,69,70,73,82,84] populations were also identified. Articles spanned the range of surgical disciplines [82,83], including General Surgery [30,31,33,51,57,61,63,65,69,70,73,77,79], Otolaryngology, [24,29,53], Urology [45,48,49,52,60,75], Neurosurgery [29,34,39,64,67,78], Plastic Surgery [74], Ophthalmology [23,…”

“…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 and2009), to define barriers to surgical care in Pakistan as a case study [8,9].…”