Factors influencing use of essential surgical services in North-East India: a cross-sectional study of obstetric and gynaecological surgery

Abstract

IntroductionThere continues to be a large gap between need and actual use of surgery in low-resource settings. While policy frequently focuses on expanding the supply of services, demand-side factors are at least as important in determining under utilisation and over utilisation. The aim of this study is to understand how these factors influence the use of selected essential obstetric and gynaecological surgical procedures in the underserved and remote setting of North-East India.MethodsThe study combines and makes use of data from a variety of surveys and routine systems. Descriptive analysis of variations in caesarean section, hysterectomy and sterilisation and then multivariate logit analysis of demand-side and supply-side factors on access to these services is undertaken.ResultsSurgical rates vary substantially both across and within North-East India, correlated with service capacity and socioeconomic status. Travel times to surgical facilities are associated with rates of caesarean section and hysterectomy but not sterilisation where services are much more deconcentrated. Travel is less important for surgery in private facilities where capacity is much more dispersed but dominated by the non-poor. The presence of non-doctor medical staff is associated with lower levels of surgical activity.ConclusionIn low resource, remote settings policy interventions to improve access to services must recognise that surgical rates in low-resource settings are heavily influenced by demand-side factors. As well as boosting services, mechanisms need to mitigate demand-side barriers particularly distance and influence practice to encourage surgical intervention only where clinically indicated.

How ready is the health care system in Northeast India for surgical delivery? a mixed-methods study on surgical capacity and need

“…Facility functionality and being better equipped were enablers for surgical delivery, although other considerations may also explain lower caseloads in some facilities. An accompanying paper, for example, suggests that location of facility and distance are critical factors in determining use of facilities, suggesting lower take-up by users even in cases where surgical resources may be available [ 12 ]. Results demonstrated variable workloads for surgical providers—interviewees generally reported excessive workloads, although the facility survey also revealed smaller surgical volumes at certain facilities.…”

“…Astonishingly, as many as 90% of people in rural India lack access to safe surgical care [ 10 ], and current rates of surgical procedures are far below global averages (50–499 surgeries per 100,000) [ 11 ]. Within India, the health system in the North-Eastern states is one of the most underdeveloped, with poor access and health indicators [ 12 ]. This region, consisting of eight states, comprises a substantive 3.4% of India’s population and 8% of the country’s area according to the 2011 census.…”

Hysterectomy and women’s health in India: evidence from a nationally representative, cross-sectional survey of older women

“…States with hysterectomy prevalence higher than 20%, such as Andhra Pradesh and Punjab, are ranked 2nd and 5th respectively in the national NITI Aayog health performance index, which includes both health outcomes and health systems capacity [ 28 ]. The higher prevalence of hysterectomy may reflect higher access to surgical infrastructure, while extremely low prevalence in others, such as in the Northeast, likely reflects inadequate infrastructure and unmet need for treatment for gynaecological ailments, including hysterectomy [ 29 ]. If we were to consider caesarean section rates as a proxy for access to surgical services, both states had caesarean section rates higher than the national average [ 27 ].…”

Delays in Accessing Emergency General Surgical Care in Tertiary Care Hospital during COVID-19 Pandemic in North-East India

“…1 With 4.8 billion patients lacking easy accessibility & qualitative surgical care, understanding the in uential factors associated with delay in surgery is crucial for a proper health policy proposal. 2 In India, public hospitals are underfunded and 80% of the health sector is occupied by the "For Pro t" healthcare which most Indian population can't seem to afford, bringing about a huge gap in access to proper surgical management. 3 The North Eastern part of India due to its di cult terrain and accessibility with limited resources is facing huge health care inequalities.…”