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

Introduction: Bellwether procedures including caesarean delivery, laparotomy, and open fracture repair are global barometers of well-functioning surgical systems. However, no study has yet mapped their geographical trends in Pakistan. We used geospatial mapping to identify district-level differences in surgical care in rural Sindh. Methods: We performed a cross-sectional, secondary analysis of patients coming to public hospitals in Sindh for bellwether procedures from the out-of-pocket expense for surgical care study. Patient origin-destination information, surgical procedure, facility type, and out-of-pocket costs were collected and analyzed. Outflows were geospatially mapped on a district level to determine high burden “exporter” districts and overburdened “hub” centers. Data were analyzed using descriptive statistics, bivariate tests (chi-squared, Wilcoxon rank-sum), and binary logistic regression. Results: Two hundred and fifteen patients with a median age of 28.5 (25-32) were included, of which 58% had surgery outside their home district. Cesarean sections were primarily in-district (45.9%), while laparotomies were more often outside the home district (31.8%). Overcrowded hubs emerged with 43% of patients treated at Jamshoro out of district as compared to Jacobabad exporting most of its patients. Demographic and socioeconomic backgrounds were similar among travelers and nontravelers suggesting interdistrict travel was influenced more by proximity of surgical facility than patient level factors. Conclusions: This geospatial mapping of essential surgical access in Pakistan provides the first empirical district-level proof of surgical inequity. Our findings underscore the urgent necessity for health system planning to synchronize surgical capacity with population requirements to provide high-quality surgical services locally, thereby discouraging the practice of bypassing nearby facilities.