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Muhammad Ashraf,¹ Dominique Vervoort,² Syeda Rizvi,² Irum Fatima,⁴ Haitham Shoman,³ John G. Meara³ and Lubna Samad^1,4

¹Indus Health Network, Karachi, Pakistan. ²Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America. ³Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America. 4Interactive Research and Development, Pakistan. (Correspondence to: Muhammad Ashraf: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Abstract

Background: Very little is known about the state of surgical, anaesthesia and obstetric care in Pakistan.

Aims: This study aimed to assess the literature available on surgical, anaesthesia and obstetric care in Pakistan to understand the strengths and weaknesses of this care based on the domains of the framework of national surgical obstetric anaesthesia plans, namely: infrastructure, workforce, service delivery, information management, governance and service delivery.

Methods: Relevant studies in English published between 2003 and 2018 were identified by searching electronic databases including PubMed/MEDLINE, EMBASE and Scopus. Searches of the grey literature were also done for documents of various organizations. Thematic content analysis was conducted to collate, summarize and analyse the data.

Results: A total of 2347 studies were identified and screened, of which 57 articles met the inclusion criteria. While national-level surveys, reviews and policy documents provided an understanding of the existing surgical, anaesthesia and obstetric care services in the country, most of the studies were limited in their scope and therefore were not representative of the situation at the national level. In terms of surgical, anaesthesia and obstetric care, the health care infrastructure, availability of services, workforce, financial protection, information management and governance frameworks have failed to develop at the same pace as the needs of the ever-growing population in Pakistan.

Conclusions: Our findings can be used to guide future research activities as part of efforts to strengthen the surgical system in Pakistan. Recent government initiatives hold promise for future improvement in access to surgical care.

Keywords: surgery, anaesthesia, obstetrics, health services accessibility, Pakistan

Citation: Ashraf M; Vervoort D; Rizvi S; Fatima I; Shoman H; Meara J; et al. Access to safe, timely and affordable surgical, anaesthesia and obstetric care in Pakistan: a 16-year scoping review. East Mediterr Health J. 2022;28(4):302–313. https://doi.org/10.26719/emhj.22.009

Received: 20/12/20; accepted: 06/10/21

Copyright © World Health Organization (WHO) 2022. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo)

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Introduction

The Lancet Commission on Global Surgery in 2015 estimated that 5 billion people lack access to safe, timely and affordable surgical and anaesthesia care worldwide (1), including over 95% of the population in South Asia compared with only 5% of the population in Australia, North America and Western Europe (2). If this unmet need is not addressed urgently, low- and middle-income countries face a US$ 12.3 trillion loss in economic growth by 2030 (1). The Lancet Commission recommended that all countries evaluate their surgical, anaesthesia and obstetric infrastructure, workforce, service delivery, information management, governance and financing through the collection of six indicators measuring the strength of their surgical care system (1). Shortly after the Lancet Commission, the World Health Assembly unanimously adopted Resolution 68.15 in May 2015 that commits to “strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage”. The third edition of the Disease Control Priorities (DCP-3) published its first volume on essential surgery in the same year, corroborating the need to invest in cost-effective, emergency and essential surgical services as part of universal health coverage (3,4).

The updated six-domain national surgical, obstetric, and anaesthesia care plan and framework, a modification of the original five-domain framework recommended by the Lancet Commission, is being widely used to analyse and strengthen surgical care systems within a country. The framework includes domains for infrastructure, workforce, service delivery, information systems, governance and financing, which comprehensively captures all inputs, processes, outputs and outcomes of the delivery of surgical services. Based on data from the Lancet Commission, low- and middle-income countries had wider gaps in the five original domains and poorer availability of timely surgical care.

Pakistan is the sixth most populous country in the world with a population of 207.8 million. The country ranks 152 out of 189 countries according to the Human Poverty Index with two thirds of its population living in rural areas (5,6). The country is divided into four provinces (Balochistan, Khyber Pakhtunkhwa, Punjab and Sindh), two autonomous territories (Azad Kashmir and Gilgit Baltistan) and a Federal Capital Territory (Islamabad). Similar to other low- and middle-income countries, Pakistan faces a large burden of communicable diseases, road traffic injuries, and maternal, neonatal and child health issues (7). In addition, Pakistan has one of the lowest per capita health care budgets in the world (8).

Based on data from other low- and middle-income countries and poor national health indicators, the availability of surgical, anaesthesia and obstetric care in Pakistan is likely to be suboptimal. As a result, in a national stakeholder’s meeting for Pakistan’s National Vision for Surgical Care in November 2018, public and private stakeholders committed to improve surgical, anaesthesia and obstetric care in Pakistan. To inform future policy and strategy development around surgical, anaesthesia and obstetric care, we conducted a 16-year scoping review of the literature from 2003 to 2018 relevant to surgical, anaesthesia and obstetric care in Pakistan. Our aims were to understand the nature and extent of the literature available, and identify the status of surgical, anaesthesia and obstetric care in Pakistan according to the domains of the national surgical obstetric and anaesthesia plan and framework: infrastructure, workforce, service delivery, information management, governance and service delivery.

Methods

Given the wide breadth of the topic and to include different study designs, research and literature, we used a scoping review approach as opposed to a systematic review approach. This scoping review was based on the Arksey and O’Malley methodological framework (9), which has been widely used for reviews that aim to capture literature regardless of their study design and quality. This methodological framework includes six stages: i) identifying the research question; ii) identifying relevant studies; iii) selecting studies; iv) charting the data; v) collating, summarizing and reporting the results; and vi) consulting with relevant stakeholders, although this last stage was not applied in our scoping review. We chose a time span of 16 years because very little literature on gaps in surgical care delivery in Pakistan is available before 2003. Extending the time to earlier years would have provided very little additional value to this review.

Identifying the question

After thorough discussions between the research teams at the authors’ institutes and becoming familiar with the literature, the following research question was identified: What is the status of surgical, anaesthesia and obstetric care in Pakistan across health system domains of infrastructure, workforce, service delivery, information management, governance and financing?

Identifying relevant studies

Relevant studies to evaluate the current state of access to surgical, anaesthesia and obstetric care in Pakistan were identified by searching electronic databases of published literature including PubMed/MEDLINE, EMBASE and Scopus. To ensure that the maximum amount of relevant information was captured, grey literature searches were conducted across various organizations (e.g. World Health Organization, and federal and provincial health departments) and Google Scholar to include unpublished reports and policy documents. The search strategy was limited to articles published in English only. Reference lists of the articles selected were manually reviewed for other relevant sources.

The search terms “Pakistan”’ and “surgical procedures” were combined with appropriate MeSH terms and wildcards of the following terms: operative, surgeon, surgery, surgical, anaesthesia, anaesthesia, obstetric, obstetrics, caesarean, caesarean, urology, urological, neurosurgery, neurosurgical, orthopaedic, orthopaedics, orthopaedic, orthopaedics and trauma.

Studies were included in the final synthesis if they covered any of the six domains of the national surgical obstetric and anaesthesia plan. Studies that primarily focused on other related concepts (e.g. articles unrelated to the six domains) and focused on clinical interventions were excluded. Primary and secondary studies using qualitative, quantitative or mixed-method designs were included. Single-centre studies, case reports, clinical reports, abstracts and editorials were excluded.

Selection of studies

Two independent reviewers screened the title and abstract of all retrieved articles for inclusion against the set criteria. Disagreements were independently screened and resolved by the research lead. This was followed by a full-text review by the two independent reviewers who assessed the eligibility of all articles against the selection criteria. Any discordance was resolved by discussion between the three members of the review team until full consensus was reached (Figure 1).

Data collection

Information was charted on a standardized data extraction sheet on Microsoft Excel for Microsoft 365 (version 2111) for study details including title, authors’ names, journal, publication year, country of origin, study setting, study design, main findings and health care domain.

Data summary and synthesis of results

We conducted a thematic content analysis to collate, summarize and analyse the data using the six domains of the national surgical obstetric and anaesthesia plan. Each article was read by two reviewers and any concepts identified relevant to the theoretical framework were listed in our data extraction sheet. We then translated the concepts into themes and subthemes under headings of any of the six domains. The themes generated were analysed and synthesized.

Bias

Our team included senior and junior researchers, surgeons and medical trainees working in global and local delivery of and research on surgical care services. All authors are strong advocates for surgery on high-level national and international platforms. The authors’ collective experiences as researchers on health disparities and their striving for excellence as clinicians and advocates may have influenced the analysis; authors may have had a higher likelihood of identifying and documenting health system weaknesses as compared to strengths. However, aware of this bias from the start, the team searched the literature to find encouraging examples; thus, the team specifically searched and highlighted previous successful interventions and methodologically strong research outputs. The team’s aim has been to ensure that the results and discussion highlight not only the weaknesses but also the strengths in Pakistan’s surgical care system.

Results 

Articles retrieved

The search strategy identified 3050 records overall, of which 2340 remained after removing duplicates. An additional seven records were identified from the grey literature. Abstracts of all 2347 articles were reviewed, of which 2206 did not meet the inclusion criteria. The full texts of the remaining 141 articles were reviewed and 84 were excluded because they did not meet the defined criteria. Thus, 57 articles were included in the study (Figure 1). Twenty-one publications had a national focus (10–27). Among the regional literature, 19 articles provided data from Sindh (28–46), eight provided data from Punjab (47–55) and one provided data from Khyber Pakhtunkhwa (56), while three studies provided combined data for Punjab and Khyber Pakhtunkhwa provinces (57–59). Four records provided data from Islamabad (60,61), Gilgit/Baltistan (62) and Azad Jammu Kashmir (63) regions, while no records were found for Balochistan.

Type and focus of articles

Twelve of the retrieved articles were based on facility assessment surveys, which included an evaluation of the relevant workforce, equipment, supplies, infrastructure, information management system and governance at the surveyed facilities (21,34,45,49,50,52,53,57–59,64,65) (Table 1). Nine of these articles evaluated the capacity of services for emergency obstetric and neonatal care (21,49,50,53,57–59,64,65) while three articles evaluated the capacity of services for trauma and emergency care.

Eleven articles were literature reviews (10,11,13,14,26,27) or institutional experiences (28,32,35,62,66). These included comprehensive literature reviews on: the state of the surgical care system in Pakistan (11); barriers to surgical care access in the country (13); a national overview of surgical training programmes (26); considerations and performance of health policy in the devolved health system of Pakistan (10); the success of the National Eye Health Programme (14); and country-wide burden of injuries (27). Furthermore, the institutional experience of surgical care delivery included: the Aga Khan Health Services surgical care provision in the remote mountains of Gilgit Baltistan (62); the Indus Hospital provision of free-of-cost surgeries with a financial model supported by philanthropic and religious donations (35); Sindh Institute of Urology and Transplant provision of free transplant and urology surgery through a public–private partnership model (28,66); and Aga Khan University’s establishment of a trauma registry in five hospitals in Karachi (32).

The four policy documents found in the literature review were the National Health Vision 2025 (19), Human Resource for Health 2018–2030 (18), National Health Accounts 2015–2016 (67) and Minimum Service Delivery Standards (55) highlighting the federal and provincial government’s commitments and priorities in health care strategy development and health care service delivery.

Furthermore, we found a mix of patient- and community-based qualitative and quantitative studies exploring the financial, logistical and quality aspects of surgical, anaesthesia, obstetric and trauma care in Pakistan (13,15,16,23,24,29,36–39,42,43,46,51,56,60,61,63,68,69). Some of the studies explored the competencies and work-related challenges of the current workforce providing surgical, anaesthesia and obstetric care, in addition to factors that influence the choice of Pakistan’s medical students in choosing specialties related to surgical, anaesthesia and obstetric care (12,20,22,25,30,33,40,44,47,70).

Key themes and findings

The themes identified in the literature reviewed included: poor functioning of secondary-care hospitals; poor indicators for physical accessibility to surgical, anaesthesia and obstetric care facilities; lack of equipment at hospitals; varying quality of prehospital ambulance services; estimates for physician/surgical care workforce; training programmes on surgical, anaesthesia and obstetric care; specific shortages in the workforce; medical competency and professional conduct; burnout or job dissatisfaction among professionals working in surgical, anaesthesia and obstetric care; estimates for volume of surgery; rates of caesarean section; service delivery at secondary-care hospitals; dependence on tertiary-care hospitals; use of private care; safety practices related to surgical, anaesthesia and obstetric care; issues with the district health information system; management of maternal health-related data; national health examination and mortality surveys; health care financing in Pakistan; out-of-pocket expenditure; innovative financing models; national and provincial health care policy mandates; health care policy documents; and facility-level administrative monitoring and evaluation. Key findings related to these themes were categorized across the six domains of the national surgical obstetric and anaesthesia plan (Table 2).

Discussion

This comprehensive review spanning 16 years shows that a considerable amount of information on surgical care services in Pakistan is available. While national-level surveys, reviews and policy documents provided an understanding of the existing services for in the country, most of the studies were limited in their scope and therefore were not representative of the national situation. Overall, we determined that many gaps exist in the health care infrastructure, service availability, workforce, financial protection, information management and governance frameworks. 

It is clear that the development of public sector hospitals has failed to keep pace with the rate at which the country’s population and its needs have grown (5). As a result, many districts failed to meet the recommended target of one comprehensive facility for emergency obstetric and neonatal care per 500 000 population (49,53,64). Multiple reviews and facility assessments noted different deficiencies in infrastructure, workforce and financing at the secondary-level district headquarters hospitals and tehsil (subdistrict) headquarters hospitals in the rural areas, where 60% of Pakistan’s population lives (21,34,52,64). The lack of trust in rural health care facilities owing to poor quality of services results in patients travelling long distances to urban tertiary referral hospitals and selected urban district headquarters hospitals. (38,52). Consequently, many patients present to these facilities late and in a more complicated state; delays in decision-making and unavailability of transport funds compound the problem (29,71). This situation inevitably results in preventable mortality and morbidity (43).

The private sector has contributed to improving the availability of affordable or free-of-cost surgical, anaesthesia and obstetric care through independent and public–private partnership models. Prime examples are the service delivery model of the Aga Khan Health Service, Pakistan in Gilgit, various hospitals run by the Indus Hospital and Health Network and the Sindh Institute of Urology and Transplant free-of-cost renal transplant arrangement (28,35,62,66). Thus, the private sector has the potential to play a crucial role in improving universal accessibility to surgical care and hence health care. Moreover, the government can engage the private sector by supporting it in those areas where public sector service delivery is deficient. This support requires population-based mapping of surgical needs and a thorough understanding of the existing surgical infrastructure, workforce and services (72).

No comprehensive registry of the health workforce exists that provides accurate estimates of the volume and distribution of the workforce providing surgical, anaesthesia and obstetric care in Pakistan (18,26). The existing registries, which include those at the College of Physicians and Surgeons Pakistan and the Pakistan Medical and Dental Council, are not updated to reflect migration or professionals who have stopped working; as a first step, these registries need to be updated with facility-level details to allow a better understanding of workforce distribution (1,18,26). An overall figure of 0.96 physicians per 100 000 population quoted by the Ministry of National Health Services Regulation and Coordination clearly shows that Pakistan falls short of the workforce density target of 20 surgical, anaesthesia and obstetric specialists per 100 000 as recommended by the Lancet Commission (1). The need for professionals in surgical, anaesthesia and obstetric care, particularly female providers, at the secondary level needs to be specifically addressed (13,21,29,58).

Universal financial risk protection against surgical care expenditure in the population has not been achieved. With high dependence on the private sector and urban hospitals, patients from rural areas and poorer backgrounds are unable to access health care due to the high cost of travelling and high out-of-pocket expenditure on private health services (10,42). Even in the supposedly free-of-cost public sector facilities, patients pay up to 40 000 Pakistani rupees (PKR; equivalent to US$ 1066, at the current purchasing power exchange rate) for supplies, equipment or services that the government is unable to provide (60,68). Improving services at the facility level by ensuring efficient supply chain systems and the availability of standardized care would help address this barrier to timely and good-quality care. 

The Prime Minister social health insurance scheme (Sehat Sahulat Programme Pakistan) has been adopted by Azad Kashmir, Gilgit Baltistan, Khyber Pakhtunkhwa and most of Punjab (73). More than 7 000 000 families nationally are now covered for up to PKR 600 000 for inpatient expenses for all surgical procedures, maternity care, local transportation cost and provision of transport to tertiary care hospitals (74). This scheme has led to much needed relief from out-of-pocket expenditure. In addition, the ministry is working on the essential universal health benefits package using the DCP3 framework (75) with the aim of making fund allocations more equitable. Lastly, the Ehsaas cash transfer programme continues to grow and support persistently excluded and deprived families and has potential to decrease cases where health care is limited due to financial barriers (76).

Systematic health care monitoring and evaluation mechanisms are lacking in the country (10,21,55,57,65). Moreover, multiple gaps exist in the mechanism of information collection from facilities (10,21,55,57,65), and practically no system is in place to provide feedback to the end-providers. As a result, it is impossible to gauge the evolving status of health care resources and delivery of health care services in Pakistan (10,57,65), accountability is affected and well planned governance structures do not translate into practical reality (10,11). Facility-based administrative incompetence, incidents of medical neglect and unethical practices go unchecked and, not surprisingly, health outcomes deteriorate (10,21,55). 

Similar to systems in place in high-income countries, Pakistan needs a robust information management system where data on health care facility resources, services and performance are collected and uploaded on online open-access public portals promoting transparency and accountability (77,78). Such a system will allow all levels of government and society to monitor the efficiency and effectiveness of health services and resource utilization as per defined minimum standards. 

It is indeed encouraging that the government passed the Pakistan Medical Commission Act 2020 which represents the government’s commitment to regulate minimum standards within the medical profession (79). In addition, by enlisting both the public sector and private facilities to provide care to beneficiaries, the Social Health Insurance scheme has the potential to improve the monitoring of services for quality and improvement. This may eventually lead to a reduction in inefficiencies within the private and public sector by introducing market competition (73).

Overall, much more work is required to comprehensively fill the gaps in surgical care services in Pakistan. The governments of Balochistan and Sindh have yet to adopt the Prime Minister Social Health Insurance scheme (80). The question also remains as to whether the steps taken by the present government will survive the current financial crises and political changes in the future. Regardless, strong advocacy and research are needed at the national and provincial levels to ensure surgery and surgical service reforms are not overlooked during prioritization. In addition, with projected limitations in financial capacity over the next few years, international donor support may help boost progress in improving surgical care services in the country (81). It is essential to continue the momentum of strengthening the surgical care system given the cross-cutting nature of surgical services and their potential to help control the burden of communicable and non-communicable diseases, maternal and child health care, and injuries.

In our efforts to improve surgical care services, we have worked closely with the federal and provincial governments to develop the policy dialogue around surgical care improvement (82). At the National Stakeholders’ Conference for the National Vision for Surgical Care in 2018, the federal and provincial governments, along with private sector representatives, committed to improving equity in access to surgical care services in Pakistan (82) (Box 1). The importance of surgical care within the broader scope of global health has been recognized, with organizers of local medical conferences and meetings now dedicating sessions to global surgery. A dedicated journal supplement on global surgery – a first for Pakistan – is indicative of the increasing focus (83). It is hoped that this interest will translate into an increased body of high-quality research that will in turn guide interventions on strengthening the surgical care system. The timing of the Ehsaas and Sehat Sahulat Programme (76,84) initiatives, as well as the DCP-3 Essential Universal Health Benefits Package for the Islamabad Capital Territory (75), provide a unique opportunity to restructure surgical services as an essential component of health care across the country.  

Our review has some limitations. Since only literature from 2003 to 2018 was included, information from earlier studies may have been missed, although we believe that the study period provides better insight into the actual state of surgical, anaesthesia and obstetric care in Pakistan. Moreover, only articles in English were included in the review because English is the language for all medical school education, training and research and therefore no journals or articles written in the national language, Urdu, are available. While some grey literature may be published in Urdu, we believe that this literature would not substantially alter our results. Lastly, some documents quoted in this article are non-peer-reviewed local journal articles or government reports for which assumptions of validity had to be made on inclusion. 

A national household and patient survey is currently in progress to estimate the proportion of Pakistan’s population that has access to surgery within 2 hours and to document the financial and logistical challenges faced by patients in accessing care for basic surgical care procedures at the public sector hospitals of Pakistan. The survey is being conducted by Indus Hospital Network in collaboration with the Ministry of National Health Services, Regulation & Coordination and with technical support from the Program in Global Surgery and Social Change. This survey will provide the first national-level data set on surgical services in Pakistan. Furthermore, we plan to conduct a follow-up scoping review to explore changes in the nature, extent and findings of the literature on global surgery in a 5-year period after 2018.

Conclusion

Access to surgical, anaesthesia and obstetric care remains limited in Pakistan, with particular barriers in workforce, infrastructure, service delivery and financing across the country, especially in poorer provinces and territories, and rural areas. Continued political commitment and primary data are needed to better understand and address these gaps in Pakistan. The new initiatives from the Ministry of National Health Services, Regulation & Coordination have potential to fill in the gaps identified.

Funding: None.

Competing interests: None declared.

Accès à des soins chirurgicaux, anesthésiques et obstétricaux sûrs, opportuns et ayant un bon rapport coût-efficacité au Pakistan : étude exploratoire sur 16 ans

Résumé

Contexte : La situation des soins chirurgicaux, anesthésiques et obstétricaux au Pakistan est très peu connue.

Objectifs : La présente étude visait à évaluer la littérature disponible sur les soins chirurgicaux, anesthésiques et obstétricaux au Pakistan afin de comprendre les forces et les faiblesses de ces soins en fonction des domaines du cadre des plans nationaux de chirurgie, d'obstétrique et d'anesthésie, à savoir infrastructures, personnels, prestation de services, gestion de l'information et gouvernance.

Méthodes : Les études pertinentes en anglais publiées entre 2003 et 2018 ont été identifiées par une recherche dans les bases de données électroniques, y compris PubMed/MEDLINE, EMBASE et Scopus. Des recherches dans la littérature grise ont également été effectuées pour obtenir des documents de diverses organisations. Une analyse de contenu thématique a été menée pour rassembler, résumer et analyser les données.

Résultats : Au total, 2347 études ont été identifiées et examinées, parmi lesquelles 57 articles répondaient aux critères d'inclusion. Si les enquêtes, examens et documents de politique générale réalisés au niveau national ont permis de comprendre les services de chirurgie, d'anesthésie et de soins obstétricaux existant dans le pays, la plupart des études avaient une portée limitée et n'étaient donc pas représentatives de la situation au niveau national. En matière de chirurgie, d'anesthésie et de soins obstétricaux, l'infrastructure des soins de santé, la disponibilité des services, le personnel, la protection financière, la gestion de l'information et les cadres de gouvernance n'ont pas évolué au même rythme que les besoins d'une population pakistanaise toujours croissante.

Conclusions : Nos résultats peuvent servir à orienter les futures activités de recherche dans le cadre des efforts visant à renforcer le système chirurgical au Pakistan. Les récentes initiatives gouvernementales sont prometteuses pour l'amélioration future de l'accès aux soins chirurgicaux.

الحصول على الرعاية الجراحية، والتخديرية، والتوليدية في باكستان على نحو آمن، ومناسب التوقيت، وميسور التكلفة: استعراض استطلاعي مدته 16 عامًا

محمد أشرف، دومينيك فيرفورت، سيدة رزفي، إروم فاطمة، هيثم شومان، جون ميرا، لبنى صمد

الخلاصة

الخلفية: لا يُعرف الكثير عن حالة الرعاية الجراحية، والتخديرية، والتوليدية في باكستان.

الأهداف: هدفت هذه الدراسة إلى تقييم المؤلفات المتاحة بشأن الرعاية الجراحية، والتخديرية، والتوليدية في باكستان، وذلك لفهم مواطن القوة ومكامن الضعف في هذه الرعاية، استنادًا إلى المجالات المدرجة في إطار الخطط الوطنية بشأن الرعاية الجراحية، والتخديرية، والتوليدية، وهي: البنية التحتية، والقوى العاملة، وتقديم الخدمات، وإدارة المعلومات، والحوكمة وتقديم الخدمات.

طرق البحث: حُدِّدت الدراسات المهمة والمنشورة باللغة الإنجليزية بين عامي 2003 و2018 من خلال البحث في قواعد البيانات الإلكترونية: PubMed/MEDLINE، EMBASE، Scopus. وأُجريت أيضًا عمليات بحث عن المؤلفات غير المُعلنة في وثائق صادرة عن منظمات مختلفة. وأُجري تحليل مواضيعي للمحتوى بقصد جمع البيانات، وتلخيصها، وتحليلها.

النتائج: حُدِّد ما مجموعه 2347 دراسة وخضعت للفحص، واستوفت 57 دراسة منها معايير الإدراج. وفي حين أتاحت المسوح والاستعراضات ووثائق السياسات، على الصعيد الوطني، فهمًا لخدمات الرعاية الجراحية، والتخديرية، والتوليدية القائمة في البلاد، كانت معظم الدراسات محدودة في نطاقها، ومن ثَم لم تكن ممثلة للوضع على الصعيد الوطني. أما من حيث الرعاية الجراحية، والتخديرية، والتوليدية، فلم تحقق البنية الأساسية للرعاية الصحية، وتوافر الخدمات والقوى العاملة والحماية المالية وإدارة المعلومات وأطر الحوكمة، تطورًا يماثل في وتيرته تطور احتياجات السكان الذين يتزايد عددهم باستمرار في باكستان.

الاستنتاجات: يمكن استخدام النتائج التي توصلنا إليها لتوجيه الأنشطة البحثية المستقبلية في إطار الجهود الرامية إلى تعزيز النظام الجراحي في باكستان. وتُنبئ المبادرات الحكومية الأخيرة عن تحسين فرص الحصول على الرعاية الجراحية في المستقبل.

References

1. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569–624. https://doi.org/10.1016/S0140-6736(15)60160-X
2. Alkire BC, Raykar NP, Shrime MG, Weiser TG, Bickler SW, Rose JA, et al. Global access to surgical care: a modelling study. Lancet Glob Health. 2015;3(6):e316–23. https://doi.org/10.1016/S2214-109X(15)70115-4
3. A68_R15 Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. Geneva: World Health Organization; 2015 (https://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_R15-en.pdf, accessed 17 November 2019).
4. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, editors. Disease control priorities, third edition (Volume 1): essential surgery. Washington, DC: The World Bank; 2015. https://doi.org/10.1596/978-1-4648-0346-8
5. Population census [internet]. Islamabad: Pakistan Bureau of Statistics, Government of Pakistan; 2017 (http://www.pbs.gov.pk/content/population-census, accessed 31 October 2019).
6. The next frontier: human development and the anthropocene. Briefing note for countries on the 2020 Human Development Report. Pakistan [internet]. New York, NY: United Nations Development Programme; 2020 (http://hdr.undp.org/sites/all/themes/hdr_theme/country-notes/PAK.pdf, accessed 31 October 2019).
7. GHDx. GBD results tool [internet]. Seattle, WA: Institute for Health Metrics and Evaluation; 2019 (http://ghdx.healthdata.org/gbd-results-tool, accessed 20 January 2020).
8. Budget in brief [internet]. Islamabad: Ministry of Finance, Government of Pakistan; 2019 (accessed 31 October 2019).
9. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2003;8(1):19–32 https://doi.org/10.1080/1364557032000119616
10. Nishtar S, Boerma T, Amjad S, Alam A, Khalid F, ul Haq I, et al. Pakistan’s health system: Performance and prospects after the 18th Constitutional Amendment. Lancet. 2013;381(9884):2193–206. https://doi.org/10.1016/S0140-6736%2813%2960019-7
11. Zafar SN, McQueen K Surgery, public health, and Pakistan. World J Surg. 2011;35(12):2625–34. https://doi.org/10.1007/s00268-011-1304-3
12. Shamim MS, Tahir MZ, Godil SS, Kumar R, Siddiqui AA. A critical analysis of the current state of neurosurgery training in Pakistan. J Surg Neurol Int. 2011;2:183. https://doi.org/10.4103/2152-7806.91138
13. Irfan FB, Irfan BB, Spiegel DA. Barriers to accessing surgical care in Pakistan: healthcare barrier model and quantitative systematic review. J Surg Res. 2012;176(1):84–94 https://doi.org/10.1016/j.jss.2011.07.046
14. Khan AA, Khan NU, Bile KM, Awan H. Creating synergies for health systems strengthening through partnerships in Pakistan – a case study of the national eye health programme. East Mediterr Health J. 2010;16(suppl.):S61–8.
15. Mian NU, Malik MZ, Iqbal S, Alvi MA, Memon Z, Chaudhry MA, et al. Determining the potential scalability of transport interventions for improving maternal, child, and newborn health in Pakistan. Health Res Policy Syst. 2015;13(Suppl 1):57. https://doi.org/10.1186/s12961-015-0044-5
16. Zafar SN, Zafar F, Iqbal A, Channa R, Haider AH Disparities in access to surgical care within a lower income country: an alarming inequity. World J Surg. 2013;37(7):1470–7. https://doi.org/10.1007/s00268-012-1732-8
17. Nishtar S. Health and the 18th amendment. Retaining national functions in devolution. Isalmabad: Heartfile; 2011 (http://www.heartfile.org/pdf/HEALTH_18AM_FINAL.pdf, accessed 31 October 2019).
18. Pakistan: Human Resources for Health Vision (2018–30). Islamabad: Ministry of National Health Services, Regulation & Coordination, Government of Pakistan; 2018 (http://phkh.nhsrc.pk/sites/default/files/2019-06/Pakistan%20Human%20Resources%20for%20Health%20Vision%202018.pdf, accessed 31 October 2019).
19. National Health Vision Pakistan (2016–2025). Islamabad: Ministry of National Health Services, Regulation & Coordination, Government of Pakistan; 2016 (http://phkh.nhsrc.pk/sites/default/files/2020-12/National%20Health%20Vision%20Pakistan%202016-2025.pdf, accessed 31 October 2019).
20. Khan TH. Job satisfaction in Pakistani anesthesiologists. Anaesth Pain Intensive Care. 2011;15(2):93–101.
21. Health facility assessment – Pakistan National Report. Islamabad: Technical Resource Facility; 2012 (https://docplayer.net/storage/49/25154130/1640737025/e9-AQHSiFwUsC5PIchqT4g/25154130.pdf, accessed 31 October 2019).
22. Rehman A, Rehman T, Shaikh MA, Yasmin H, Asif A, Kafil H. Pakistani medical students’ specialty preference and the influencing factors. J Pak Med Assoc. 2011;61(7):713–8.
23. Mumtaz S, Bahk J, Khang Y-H. Rising trends and inequalities in cesarean section rates in Pakistan: evidence from Pakistan Demographic and Health Surveys, 1990–2013. PloS One. 2017;12(10):e0186563. https://doi.org/10.1371/journal.pone.0186563
24. Malik AM, Syed SIA. Socio-economic determinants of household out-of-pocket payments on healthcare in Pakistan. Int J Equity Health. 2012;11:51. https://doi.org/ 10.1186/1475-9276-11-51
25. Zafar S, Hafeez A, Qureshi F, Arshad N, Southall D. Structured training in the management of emergencies in mothers, babies and children in a poorly resourced health system: Logbooks to document skill use. Resuscitation. 2009;80(4):449–52. https://doi.org/10.1016/j.resuscitation.2008.11.026
26. Talati JJ, Syed NA. Surgical training programs in Pakistan. World J Surg. 2008;32(10):2156–61. https://doi.org/10.1007/s00268-008-9639-0
27. Hyder AA, Razzak JA. The challenges of injuries and trauma in Pakistan: an opportunity for concerted action. Public Health. 2013;127(8):699–703. https://doi.org/10.1016/j.puhe.2012.12.020
28. Rizvi SAH, Naqvi SAA, Zafar MN, Hussain Z, Hashmi A, Hussain M, et al. A renal transplantation model for developing countries. Am J Transplant. 2011;11(11):2302–7. https://doi.org/10.1111/j.1600-6143.2011.03712.x
29. Ansari MS, Manzoor R, Siddiqui N, Ahmed AM. Access to comprehensive emergency obstetric and newborn care facilities in three rural districts of Sindh province, Pakistan. Health Res Policy Syst. 2015;13:55. https://doi.org/10.1186/s12961-015-0042-7
30. Khan FA, Minai FN, Siddiqui S. Anaesthesia as a career choice in a developing country; effect of clinical clerkship. J Pak Med Assoc. 2011;61(11):1052–6.
31. Samad L, Jawed F, Sajun SZ, Arshad MH, Baig-Ansari N. Barriers to accessing surgical care: a cross-sectional survey conducted at a tertiary care hospital in Karachi, Pakistan. World J Surg. 2013;37(10):2313–21. https://doi.org/10.1007/s00268-013-2129-z
32. Mehmood A, Razzak JA, Kabir S, Mackenzie EJ, Hyder AA. Development and pilot implementation of a locally developed Trauma Registry: lessons learnt in a low-income country. BMC Emerg Med. 2013;13(1):4. https://doi.org/10.1186/1471-227X-13-4
33. Khan FA, Hoda MQ. Drug related critical incidents. Anaesthesia. 2005;60(1):48–52. https://doi.org/10.1111/j.1365-2044.2004.04014.x
34. Razzak JA, Baqir SM, Khan UR, Heller D, Bhatti J, Hyder AA. Emergency and trauma care in Pakistan: a cross-sectional study of healthcare levels. Emerg Med J. 2015;32(3):207–13. https://doi.org/10.1136/emermed-2013-202590
35. Samad L, Iqbal M, Tariq A, Shahzad W, Khan AJ Equitable access to comprehensive surgical care: the potential of indigenous private philanthropy in low-income settings. World J Surg. 2015;39(1):21–8. https://doi.org/10.1007/s00268-014-2852-0
36. Hussain M, Rehman R, Ikramuddin Z, Asad N, Farooq A. Inpatient satisfaction at different public sector hospitals of a metropolitan city in Pakistan: a comparative cross-sectional study. Hosp Pract (1995). 2018;46(2):88–96. https://doi.org/10.1080/21548331.2018.1427410
37. Chandran A, Ejaz K, Karani R, Baqir M, Razzak J, Hyder AA. Insights on the effects of patient perceptions and awareness on ambulance usage in Karachi, Pakistan. Emerg Med J. 2014;31(12):990–3. https://doi.org/10.1136/emermed-2013-202762
38. Khan S, Zafar H, Zafar SN, Haroon N. Inter-facility transfer of surgical emergencies in a developing country: effects on management and surgical outcomes. World J Surg. 2014;38(2):281–6. https://doi.org/10.1007/s00268-013-2308-y
39. Pasha O, Saleem S, Ali S, Goudar SS, Garces A, Esamai F, et al. Maternal and newborn outcomes in Pakistan compared to other low and middle income countries in the Global Network’s Maternal Newborn Health Registry: an active, community-based, pregnancy surveillance mechanism. Reprod Health. 2015;12(Suppl 2):S15. https://doi.org/10.1186/1742-4755-12-S2-S15
40. Siddiqui MA, Jawad A, Minhas S,Ansari A, Siddiqui A, Mehtab S. Pakistan: the new target of terrorism. Are Karachi’s emergency medical response systems adequately prepared?. J Pak Med Assoc. 2009;59(7):441–5.
41. Salam RA, Qureshi RN, Sheikh S, Khowaja AR, Sawchuck D, Vidler M, et al. Potential for task-shifting to lady health workers for identification and emergency management of pre-eclampsia and eclampsia at community level in Pakistan. Reprod Health. 2016;13(Suppl 2):107. https://doi.org/10.1186/s12978-016-0214-0
42. Agha S, Williams E. Quality of antenatal care and household wealth as determinants of institutional delivery in Pakistan: Results of a cross-sectional household survey. Reprod Health. 2016;13(1):84–4. https://doi.org/10.1186/s12978-016-0201-5
43. Shah N, Hossain N, Shoaib R, Hussain A, Gillani R, Khan NH. Socio-demographic characteristics and the three delays of maternal mortality. J Coll Physicians Surg Pak. 2009;19(2):95–8.
44. Alitoor A, Nigah-e-Mumtaz S, Syed R, Yousuf M, Syeda A. Surgical safety practices in Pakistan. J Pak Med Assoc. 2013;63(1):76–80.
45. Channa R, Jaffrani HA, Khan AJ, Hasan T, Razzak JA. Transport time to trauma facilities in Karachi: an exploratory study. Int J Emerg Med. 2008;1(3):201–4. https://doi.org/10.1007/s12245-008-0051-1
46. Jawaid M, Amin MF, Khan RA, Iqbal SA. Waiting time for emergency surgeries in a tertiary care public hospital - A performance audit. Pak J Med Sci. 2005;21(2):133–7.
47. Waheed K, Liaqat N, Khanum A, Ejaz S, Ijaz S, Butt A, et al. Burnout among gynaecological residents in lahore, Pakistan: a cross-sectional survey. J Pak Med Assoc. 2017;67(9):1318–22.
48. Faruqi NJ, Badar N, Sohail N, Tariq S, Hasan G. Unsafe abortion – a clandestine epidemic. Pak J Med Health Sci. 2011;5(3):592–4.
49. Mir AM, Gull S. Countdown to 2015: a case study of maternal and child health service delivery challenges in five districts of Punjab. J Pak Med Assoc. 2012;62(12):1308–13.
50. Ali M, Ahmed KM, Kuroiwa C. Emergency obstetric care in Punjab, Pakistan: improvement needed. Eur J Contracept Reprod Health Care. 2008;13(2):201–7. doi:10.1080/13625180701877712
51. Fatima I, Humayun A, Anwar MI, Iftikhar A, Aslam M, Shafiq M. How do patients perceive and expect quality of surgery, diagnostics, and emergency services in tertiary care hospitals? An evidence of gap analysis from Pakistan. Oman Med J. 2017;32(4):297–305. https://doi.org/10.5001/omj.2017.58
52. Ihsan A, Nadeem M, Fatima B, Ali F. Need assessment of trauma centres in Punjab. Lahore: Punjab Economic Research Institute; 2018 (https://peri.punjab.gov.pk/system/files/Health%20Trauma%20Centres%20Research%20Report.pdf, accessed 31 October 2019).
53. Fikree FF, Mir AM, Haq I.She may reach a facility but will still die! An analysis of quality of public sector maternal health services, District Multan, Pakistan. J Pak Med Assoc. 2006;56(4):156–63.
54. Utz B, Zafar S, Arshad N, Kana T, Gopalakrishnan S, Broek N. Status of emergency obstetric care in four districts of Punjab, Pakistan-results of a baseline assessment. J Pak Med Assoc. 2015;65(5):480–5.
55. Minimum service delivery standards for primary and secondary health care in Punjab. Lahore: Government of Punjab; 2008 (https://www.phc.org.pk/downloads/MSDS%20Primary%20and%20Secondary%20Healthcare-PDSSP-2008.pdf, accessed 31 October 2019).
56. Purdin S, Khan T, Saucier R. Reducing maternal mortality among Afghan refugees in Pakistan. Int J Gynecol Obstet. 2009;105(1):82–5. https://doi.org/10.1016/j.ijgo.2008.12.021
57. Ali M, Kuroiwa C. Accurate record keeping in referral hospitals in Pakistan’s north west frontier province and Punjab: a crucial step needed to improve maternal health. J Pak Med Assoc. 2007;57(9):443–6.
58. Ali M, Kuroiwa C. Challenges in access to and utilization of reproductive health care in Pakistan. J Ayub Med Coll, Abbottabad. 2008;20(4):3–7.
59. Ali M, Hotta M, Kuroiwa C, Ushijima H. Emergency obstetric care in Pakistan: potential for reduced maternal mortality through improved basic EmOC facilities, services, and access. Int J Gynecol Obstet. 2005;91(1):105–12. https://doi.org/10.1016/j.ijgo.2005.03.034
60. Khan A, Zaman S. Costs of vaginal delivery and Caesarean section at a tertiary level public hospital in Islamabad, Pakistan. BMC Pregnancy Childbirth. 2010;10:2. https://doi.org/10.1186/1471-2393-10-2
61. Khan MNA, Verstegen DML, Bhatti ABH, Bolmans DHJM, Mook WNA Factors hindering the implementation of surgical site infection control guidelines in the operating rooms of low-income countries: a mixed-method study. Eur J Clin Microbiol Infect Dis. 2018;37(10):1923–9. https://doi.org/10.1007/s10096-018-3327-2
62. Alvi AR. Experience of developing rural surgical care in a remote mountainous region of Pakistan: challenges and opportunities. Ann Trop Med Public Health. 2011;4(1):57–63. https://doi.org/10.4103/1755-6783.80541
63. Mateen A, Shaikh BT, Kumar R. Emergency obstetrics care services in District Neelum, Azad Jammu and Kashmir. J Ayub Med Coll Abbottabad. 2013;25(1):194–7.
64. Utz B, Zafar S, Arshad N, Kana T, Gopalakrishnan S, Broek N van den. Status of emergency obstetric care in four districts of Punjab, Pakistan – results of a baseline assessment. J Pak Med Assoc. 2015;65(5):480–5.
65. Jain AK, Sathar Z, Salim M, Shah ZH. The importance of public sector health facility-level data for monitoring changes in maternal mortality risks among communities: the case of Pakistan. J Biosoc Sci. 2013;45(5):601–13. https://doi.org/10.1017/S0021932013000126
66. Rizvi SA, Naqvi SA, Hussain Z, Hashmi A, Akhtar F, Hussain M, et al. Renal transplantation in developing countries. Kidney Int Suppl. 2003;(83):S96–100. https://doi.org/10.1046/j.1523-1755.63.s83.20.x
67. National Health Accounts Pakistan 2015-16. Islamabad: Pakistan Bureau of Statistics, Government of Pakistan; 2018 (https://www.pbs.gov.pk/sites/default/files//NHA-Pakistan%202015-16%20Report_0.pdf, accessed 31 October 2019).
68. Naghma-e-Rehan. Cost of the treatment of complications of unsafe abortion in public hospitals. J Pak Med Assoc. 2011;61(2):169–72.
69. Jain AK, Sathar ZA, ul Haque M. The constraints of distance and poverty on institutional deliveries in Pakistan: evidence from georeference-linked data. Stud Fam Plann. 2015;46(1):21–39. https://doi.org/10.1111/j.1728-4465.2015.00013.x
70. Salam RA, Qureshi RN, Sheikh S, Khowaja AR, Sawchuck D, Vidler M, et al. Potential for task-sharing to lady health workers for identification and emergency management of pre-eclampsia at community level in Pakistan. Reprod Health. 2016;13(Suppl 2):107. https://doi.org/10.1186/s12978-016-0214-0
71. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994;38(8):1091–1110. https://doi.org/10.1016/0277-9536(94)90226-7
72. Malik NA, Shaikh MA. Spatial distribution and accessibility to public sector tertiary care teaching hospitals: case study from Pakistan. East Mediterr Health J. 2019;25(6):431–4. https://doi.org/10.26719/emhj.18.049
73. Yusufzai A. Over 300 hospitals to be registered for Sehat Sahulat Programme. Dawn. October 9 2020 (https://www.dawn.com/news/1584003, accessed 18 April 2021).
74. Sehat Sahulat Program [website]. Islamabad: Government of Pakistan (https://www.pmhealthprogram.gov.pk/; accessed 28 May 2020).
75. Islamabad Capital Territory Health Strategy (2019–23). Islamabad: Ministry of National Health Services, Regulation & Coordination; 2018 (http://phkh.nhsrc.pk/sites/default/files/2019-06/ICT%20Health%20Strategy%20with%20monitoring%20framework%202019-23.pdf, accessed 31 October 2019).
76. Ehsaas [website]. Islamabad: Government of Pakistan (https://www.pass.gov.pk/, accessed 28 July 2020).
77. Leao BF, Bernardes MM, Levin J, Moura L, Bandarra E, Modesto LM, et al. The Brazilian National Health Informatics Strategy. Stud Health Technol Inform. 2001;84(Pt 1):38–42.
78. HealthData.gov [website]. Washington, DC: US Department of Health & Human Services (https://healthdata.gov/, accessed 28 July 2020).
79. Pakistan Medical Commission Act 2020. Islamabad: National Assembly Secretariat, Government of Pakistan; 2020 (https://www.pmc.gov.pk/Documents/law/PMC-Act,2020.pdf, accessed 18 April 2021).
80. Siddiqi S. Health coverage. Dawn. December 12 2020 (https://www.dawn.com/news/1595285, accessed 18 April 2021).
81. Policy responses to COVID-19 [internet]. Washington, DC: International Monetary Fund (https://www.imf.org/en/Topics/imf-and-covid19/Policy-Responses-to-COVID-19, accessed 18 April 2021).
82. Fatima I, Shoman H, Peters AW, Samad L, Nishtar S. Pakistan’s National Surgical, Obstetric, and Anesthesia Plan: an adapted model for a devolved federal-provincial health system. Published online 2020. Accessed May 17, 2020. https://doi.org/10.1007/s12630-020-01708-2
83. Enam SA, Khan E. Surgical care for all – much work to be done. J Pak Med Assoc. 2019;69(Suppl 1):S1.
84. Sehat Sahulat Program. About the program [internet]. Islamabad: Government of Pakistan (https://www.pmhealthprogram.gov.pk/about-us/, accessed 28 May 2020).