World Journal of Surgery

, Volume 37, Issue 7, pp 1470–1477 | Cite as

Disparities in Access to Surgical Care within a Lower Income Country: An Alarming Inequity

  • Syed Nabeel ZafarEmail author
  • Zafar Fatmi
  • Aftab Iqbal
  • Roomasa Channa
  • Adil H. Haider



Surgical care is not uniformly available worldwide. Inequities in surgical care and access may also vary within countries, and the present study aimed to explore these disparities in Pakistan.


The National Health Survey of Pakistan was analyzed. The proportion of people with a history of abdominal surgery (AS) was calculated and associated factors were determined by weighted multivariate logistic regression. Factors tested were age, gender, urban/rural residence, province, literacy, community development index (CDI), and economic status (ES). The CDI was developed for each sampling unit from select household and individual data. The ES was constructed from ownership of assets.


A total of 59 million adults were represented. Abdominal surgery had been performed in 3.2 % adults (95 % confidence interval [CI] = 2.67, 3.84), which corresponded to an annual rate of 85.9 abdominal surgeries per 100,000 population. Wide disparities were noted, with annual rates of AS varying from 37.8 to 215.6 per 100,000 population. Urban residents were independently twice as likely as rural populations to have had AS (95 % CI = 1.3, 2.8). Higher age (OR = 2.6; 95 % CI = 1.7, 4.0), female gender (OR = 1.5; 95 % CI = 1.1, 2.1), and higher ES (OR = 1.9; 95 % CI = 1.2, 2.9) were also independently associated with AS. In rural populations ES was the only factor associated with surgery, whereas in urban populations gender and CDI had important roles to play.


Access to surgical care is disparate and grossly inadequate in Pakistan. This likely contributes to significant preventable morbidity and death. Physical access to surgical facilities, especially in rural areas and for those with a low CDI, is an important concern and should be prioritized in any forthcoming national policies.


Rural Area Club Foot Surgical Care National Health Survey Perforated Appendix 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Conflicts of interest



  1. 1.
    Debas HT, Gosselin R, McCord C et al (2006) Surgery. In: Dean JGB, Jamison T, Measham AR (eds) Disease control priorities in developing countries. Oxford University Press, New York, pp 1245–1259Google Scholar
  2. 2.
    Gosselin RA, Thind A, Bellardinelli A (2006) Cost/DALY averted in a small hospital in Sierra Leone: what is the relative contribution of different services? World J Surg 30:505–511. doi: 10.1007/s00268-005-0609-5 CrossRefPubMedGoogle Scholar
  3. 3.
    McCord C, Chowdhury QA (2003) Cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care. Int J Gynaecol Obstet 81:83–92CrossRefPubMedGoogle Scholar
  4. 4.
    Weiser TG, Regenbogen SE, Thompson KD et al (2008) An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 372:139–144CrossRefPubMedGoogle Scholar
  5. 5.
    Grimes CE, Bowman KG, Dodgion CM et al (2011) Systematic review of barriers to surgical care in low-income and middle-income countries. World J Surg 35:941–950. doi: 10.1007/s00268-011-1010-1 CrossRefPubMedGoogle Scholar
  6. 6.
    Kushner AL, Cherian MN, Noel L et al (2010) Addressing the millennium development goals from a surgical perspective: essential surgery and anesthesia in 8 low- and middle-income countries. Arch Surg 145:154–159CrossRefPubMedGoogle Scholar
  7. 7.
    Contini S, Taqdeer A, Cherian M et al (2010) Emergency and essential surgical services in Afghanistan: still a missing challenge. World J Surg 34:473–479. doi: 10.1007/s00268-010-0406-7 CrossRefPubMedGoogle Scholar
  8. 8.
    Fiscella K, Franks P, Doescher MP et al (2002) Disparities in health care by race, ethnicity, and language among the insured: findings from a national sample. Med Care 40:52–59CrossRefPubMedGoogle Scholar
  9. 9.
    Hall SE, Holman CD, Sheiner H (2004) The influence of socio-economic and locational disadvantage on patterns of surgical care for lung cancer in Western Australia 1982–2001. Aust Health Rev 27:68–79CrossRefPubMedGoogle Scholar
  10. 10.
    Ronsmans C, Holtz S, Stanton C (2006) Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. Lancet 368:1516–1523CrossRefPubMedGoogle Scholar
  11. 11.
    Abdullah F, Choo S, Hesse AA et al (2011) Assessment of surgical and obstetrical care at 10 district hospitals in Ghana using on-site interviews. J Surg Res 171:461–466CrossRefPubMedGoogle Scholar
  12. 12.
    Kingham TP, Kamara TB, Cherian MN et al (2009) Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care. Arch Surg 144:122–127 (discussion 128)CrossRefPubMedGoogle Scholar
  13. 13.
    Ahmed M, Shah M, Luby S et al (1999) Survey of surgical emergencies in a rural population in the northern areas of Pakistan. Trop Med Int Health 4:846–857CrossRefPubMedGoogle Scholar
  14. 14.
    National Institute of Population Studies (NIPS) (2008) Pakistan demographic health survey, 2006–2007. National Institute of Population Studies (NIPS) [Pakistan], Macro International Inc, IslamabadGoogle Scholar
  15. 15.
    Pakistan Medical Research Council (1998) National health survey of Pakistan. Health profile of the people of Pakistan 1990–1994. Service NP, IslamabadGoogle Scholar
  16. 16.
    Fatmi Z, Hadden WC, Razzak JA et al (2007) Incidence, patterns and severity of reported unintentional injuries in Pakistan for persons five years and older: results of the national health survey of Pakistan 1990–1994. BMC Public Health 7:152CrossRefPubMedGoogle Scholar
  17. 17.
    Fatmi Z, Kazi A, Hadden WC et al (2009) Incidence and pattern of unintentional injuries and resulting disability among children under 5 years of age: results of the national health survey of Pakistan. Paediatr Perinatal Epidemiol 23:229–238CrossRefGoogle Scholar
  18. 18.
    Pappas G, Akhtar T, Gergen PJ et al (2001) Health status of the Pakistani population: a health profile and comparison with the United States. Am J Public Health 91:93–98CrossRefPubMedGoogle Scholar
  19. 19.
    Hadden WC, Pappas G, Khan AQ (2003) Social stratification, development and health in Pakistan: an empirical exploration of relationships in population-based national health examination survey data. Soc Sci Med 57:1863–1874CrossRefPubMedGoogle Scholar
  20. 20.
    Paquette IM, Zuckerman R, Finlayson SR (2011) Perforated appendicitis among rural and urban patients: implications of access to care. Ann Surg 253:534–538CrossRefPubMedGoogle Scholar
  21. 21.
    Zafar SN, McQueen KA (2011) Surgery, public health, and Pakistan. World J Surg 35:2625–2634. doi: 10.1007/s00268-011-1304-3 CrossRefPubMedGoogle Scholar
  22. 22.
    Siddiqi S, Kielmann A, Khan M et al (2001) The effectiveness of patient referral. Pak Health Policy Plan 16:193–198CrossRefGoogle Scholar
  23. 23.
    Kadir MM, Khan A, Sadruddin S et al (2000) Out-of-pocket expenses borne by the users of obstetric services at government hospitals in Karachi, Pakistan. J Pak Med Assoc 50:412–415PubMedGoogle Scholar
  24. 24.
    Shaikh BT, Hatcher J (2005) Health seeking behaviour and health service utilization in Pakistan: challenging the policy makers. J Public Health 27:49–54CrossRefGoogle Scholar
  25. 25.
    Buor D (2003) Analysing the primacy of distance in the utilization of health services in the Ahafo-Ano South district, Ghana. Int J Health Plan Manag 18:293–311CrossRefGoogle Scholar
  26. 26.
    Gabrysch S, Cousens S, Cox J et al (2011) The influence of distance and level of care on delivery place in rural Zambia: a study of linked national data in a geographic information system. PLoS Med 8:e1000394CrossRefPubMedGoogle Scholar
  27. 27.
    Penfold RB, Chisolm DJ, Nwomeh BC et al (2008) Geographic disparities in the risk of perforated appendicitis among children in Ohio: 2001–2003. Int J Health Geogr 7:56CrossRefPubMedGoogle Scholar
  28. 28.
    Hasan IJ, Khanum A (2000) Health care utilization during terminal child illness in squatter settlements of Karachi. J Pak Med Assoc 50:405–409PubMedGoogle Scholar
  29. 29.
    Yamasaki-Nakagawa M, Ozasa K, Yamada N et al (2001) Gender difference in delays to diagnosis and health care seeking behaviour in a rural area of Nepal. Int J Tuber Lung Dis 5:24–31Google Scholar
  30. 30.
    McIntyre D, Thiede M, Birch S (2009) Access as a policy-relevant concept in low- and middle-income countries. Health Econ Policy Law 4:179–193CrossRefPubMedGoogle Scholar
  31. 31.
    Akram M, Khan FJ (2007) Health care services and government spending in Pakistan. In: PIDE working papers, Pakistan Institute of Developmental Econonics, IslamabadGoogle Scholar
  32. 32.
    Federal Bureau of Statisitics Government of Pakistan Health Statistics (2011) Social statistics. Accessed 20 Jan 2011

Copyright information

© Société Internationale de Chirurgie 2012

Authors and Affiliations

  • Syed Nabeel Zafar
    • 1
    Email author
  • Zafar Fatmi
    • 2
  • Aftab Iqbal
    • 3
  • Roomasa Channa
    • 4
  • Adil H. Haider
    • 5
  1. 1.Department of SurgeryAga Khan UniversityKarachiPakistan
  2. 2.Department of Community Health SciencesAga Khan UniversityKarachiPakistan
  3. 3.Naya JeevanKarachiPakistan
  4. 4.Department of OphthalmologyJohns Hopkins Medical CenterBaltimoreUSA
  5. 5.Department of SurgeryJohns Hopkins Medical CenterBaltimoreUSA

Personalised recommendations