Measuring Access to Surgical Care in Rural India: Synthesis of Data and Novel Index

Abstract

Background: Globally, 5 billion people lack timely access to safe and affordable surgical care, with over a fifth of them living in India. Solving India’s surgical access issues can have high returns on investment. While healthcare access and unaffordability problems are well-known in India particularly among its rural people, research on surgical care is scant. This study attempts to fill the research gap through high-resolution nationwide estimates that have direct implications for India’s national surgical plan. Methods: Secondary data analysis with a diverse geospatial and statistical toolbox was used to create the national, state, and district-level estimates in four surgical care access dimensions. The four access dimensions were: timeliness (proportion of population within 2 hours of a surgical are facility), capacity (met surgical need for operative volumes), safety (proportion of post-operative surgical site infections), and affordability (proportion of surgery-seeking households facing catastrophic expenses). A novel composite index was introduced for assessing surgical access integrating the above dimensions. Distributional and spatial inequalities in access across Indian districts and states were measured to depict regions needing policy intervention. Correlations with Sustainable Development Goals (SDG) scores were computed. Validation and sensitivity analyses were conducted to check the robustness of the findings. Results: Timely access to surgical care was achieved by > 99% of the rural population, but only 6.81% of surgical need was met. SSI proportion was 0.19% and 60.99% of surgery-seeking households faced catastrophic health expenditure. Heterogeneities in these dimensions were observed at state and district-levels. Significant rural-urban differences were observed in surgical care access dimensions and other considered surgical care variables. The Zadey-Vissoci Access to Surgical Care Index (ZV-ASCI) depicted limited access across several states and districts. Within-state distributional inequality in ZV-ASCI was about three times that of between-states. We found limited support for spatial autocorrelations and identified the low access district clusters. For aspirational districts, whose development is high on the national agenda, ZV-ASCI was not correlated with SDG composite score. Conclusions: Our methodological workflow has high translational value for global surgery research in low-and-middle-income countries. For India, these are the first such nationwide findings that can direct the development of a National Surgical, Obstetric, and Anesthesia Plan (NSOAP). The proposed index can encourage buy-in from policymakers and raise surgical care on the global and national agenda.