Geospatial Analysis of Out-of-pocket Expenditure for Essential Surgical Care in Rural Sindh

Area of Science:

• Global Health
• Surgical Systems Analysis
• Geospatial Health Mapping

Background:

• Bellwether procedures like C-sections, laparotomies, and open fracture repair are key indicators of surgical system functionality.
• No prior studies have geographically mapped these essential surgical procedures in Pakistan.
• This study focuses on rural Sindh to identify district-level disparities in surgical care access.

Purpose of the Study:

• To conduct geospatial mapping of bellwether surgical procedures in rural Sindh, Pakistan.
• To identify district-level differences and geographical trends in surgical care access.
• To provide empirical evidence of surgical inequity in Pakistan.

Main Methods:

• Cross-sectional, secondary analysis of patients undergoing bellwether procedures in public hospitals in Sindh.
• Collected and analyzed patient origin-destination data, procedure type, facility type, and out-of-pocket costs.
• Geospatial mapping of patient outflows to identify "exporter" districts and overburdened "hub" centers, using descriptive statistics and bivariate tests.

Main Results:

• 58% of 215 patients traveled outside their home district for surgery.
• Cesarean deliveries were mostly in-district (45.9%), while laparotomies were more frequently performed out-of-district (31.8%).
• Jamshoro emerged as a major hub (43% out-of-district patients), while Jacobabad was a significant exporter district; travel appeared driven by facility proximity rather than patient demographics.

Conclusions:

• This study provides the first district-level empirical evidence of surgical inequity in Pakistan through geospatial mapping.
• Findings emphasize the critical need for health system planning to align surgical capacity with population needs.
• Improving local surgical services is essential to reduce the bypass of nearby facilities and ensure equitable access.