Access to surgery in Ecuador using the enhanced 2-step floating catchment area approach

Traditional surgical access metrics are often presented at the national level, providing poor insight for local policy makers. The Enhanced Two-Step Floating Catchment Area (E2SFCA) method is an alternative to current methods with two key advantages: it provides granular estimates of access and incorporates surgical supply variables. Using this method, we calculate surgical access in Ecuador, and discuss the benefits over traditional methods.

We collected surgical supply data (number of providers, number of surgeries) from all governmental hospitals in Ecuador in 2022. Traditional global surgery indicators were calculated, including the surgical density per 100,000, surgical volume per 100,000, and two-hour access to surgery. We then performed an E2SFCA analysis, depicting the output as supply per 100,000 at the one km x one km level. Adequate access was defined as the percentage of the population meeting each of the supply indicator thresholds defined by the Lancet Commission on Global Surgery. The relationship between access to providers and surgeries was tested using robust regression. Finally, we performed a case study on expansion of supply in a single city.

Two-hour geospatial access is 89.7% in Ecuador, with 23.7 surgical providers and 2,473 surgical volume per 100,000. Using the E2SFCA method, 1.2% of the population has adequate access to all three indicators, gated by access to adequate surgical volume. There is significant geospatial variation in access to both supply variables. Robust regression revealed that one additional surgeon/anesthesiologist/obstetrician (SAO) provider is associated with 104.6 additional procedures.

Without increasing the complexity of primary data collection, the E2SFCA method estimates access to surgery at a granular scale through considering the supply of procedures and SAO providers. This more granular evaluation of surgical access gives policy makers more specific methods of targeting interventions to improve surgical access.