Ensor Tim, Virk Amrit, Aruparayil Noel
Nuffield Centre for International Health and Development, University of Leeds, Leeds, West Yorkshire, UK
Nuffield Centre for International Health and Development, University of Leeds, Leeds, West Yorkshire, UK.
BMJ Open. 2020 Oct 22;10(10):e038470. doi: 10.1136/bmjopen-2020-038470.
There 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.
The 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.
Surgical 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.
In 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.
在资源匮乏地区，手术的需求与实际使用之间仍然存在很大差距。虽然政策通常侧重于扩大服务供应，但需求侧因素在确定利用不足和利用过度方面至少同样重要。本研究的目的是了解这些因素如何影响印度东北部服务不足和偏远地区某些基本妇产科手术的使用情况。
本研究结合并利用了来自各种调查和常规系统的数据。对剖宫产、子宫切除术和绝育手术的差异进行描述性分析，然后对获得这些服务的需求侧和供应侧因素进行多变量逻辑分析。
印度东北部地区之间和地区内部的手术率差异很大，与服务能力和社会经济地位相关。前往手术设施的时间与剖宫产和子宫切除术的比率有关，但与绝育手术无关，因为绝育服务的分布更为分散。在私立机构中，前往手术设施的时间对手术的影响较小，因为私立机构的服务能力分布更为分散，但主要服务于非贫困人口。非医生医务人员的存在与较低的手术活动水平相关。
在资源匮乏的偏远地区，改善服务可及性的政策干预措施必须认识到，资源匮乏地区的手术率受到需求侧因素的严重影响。除了增加服务外，还需要采取机制来减轻需求侧障碍，特别是距离障碍，并影响医疗行为，鼓励仅在临床指征明确时进行手术干预。
