An integrated approach to surgery and primary care systems strengthening in low- and middle-income countries: Building a platform to deliver across the spectrum of disease

  • Ashwin Vasan
    Reprint requests: Ashwin Vasan, MD, PhD, Program in Global Primary Care & Social Change, Department of Global Health & Social Medicine, Harvard Medical School, Boston, MA.
    Program in Global Primary Care and Social Change, Department of Global Health & Social Medicine, Harvard Medical School, Boston, MA

    Advancing Research on Comprehensive Health Systems (ARCHeS), Department of Population & Family Health, Mailman School of Public Health, Columbia University, New York, NY

    Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
    Search for articles by this author
  • Carly E. Hudelson
    Program in Global Primary Care and Social Change, Department of Global Health & Social Medicine, Harvard Medical School, Boston, MA
    Search for articles by this author
  • Sarah L.M. Greenberg
    Program in Global Surgery and Social Change, Department of Global Health & Social Medicine, Harvard Medical School, Boston, MA

    Department of General Surgery, Medical College of Wisconsin, Milwaukee, WI
    Search for articles by this author
  • Andrew E. Ellner
    Program in Global Primary Care and Social Change, Department of Global Health & Social Medicine, Harvard Medical School, Boston, MA

    Division of Global Health Equity, Brigham & Women's Hospital, Boston, MA

    Harvard Medical School Center for Primary Care, Boston, MA
    Search for articles by this author
Published:April 27, 2015DOI:


      Surgical services in low- and middle income countries (LMICs) must be considered within the context of a coordinated strategy for building primary care systems. Weak front-line primary care systems lead to delayed presentation and poor follow-up of patients with surgical illness, increasing the risk of poor outcomes.


      Here we propose a framework to integrating surgery and primary care, organized around basic primary care principles of access, longitudinal care, coordination, integration and equity.


      Making surgical care accessible will require frontline provider capacity to screen for and recognize common surgical conditions, as well as to deliver certain basic surgical services themselves. Making this care effective will require strengthening the capacity of interdisciplinary teams to provide longitudinal care, involving coordinated networks for referral, communication with and mentorship by more specialized providers, and postoperative follow-up. Innovative approaches to information and communication technology can help to overcome the transportation and infrastructure barriers that jeopardize both access and effectiveness. Explicit integration of surgical and primary care programs at the managerial and administrative levels, as well as at the point-of-care, will also be critical. Taking a pro-equity approach can ensure that populations with the greatest unmet needs are effectively reached.


      Utilizing the pillars of effective primary care as a guiding framework to design, implement, and scale surgical programs in LMICs offers an opportunity for strengthening and enhancing the quality of health systems as a whole.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Funk L.M.
        • Weiser T.G.
        • Berry W.R.
        • et al.
        Global operating theatre distribution and pulse oximetry supply: an estimation from reported data.
        Lancet. 2010; 376: 1055-1061
        • Weiser T.G.
        • Regenbogen S.E.
        • Thompson K.D.
        • et al.
        An estimation of the global volume of surgery: a modelling strategy based on available data.
        Lancet. 2008; 372: 139-144
        • Van Lerberghe W.
        The world health report 2008: primary health care: now more than ever.
        World Health Organization, Geneva2008
        • deVries C.R.
        • Price R.R.
        Global surgery and public health: a new paradigm.
        Jones Bartlett Learning, Sudbury, MA2012: Xi-XX
        • Youlden D.R.
        • Cramb S.M.
        • Dunn N.A.
        • Muller J.M.
        • Pyke C.M.
        • Baade P.D.
        The descriptive epidemiology of female breast cancer: an international comparison of screening, incidence, survival and mortality.
        Cancer Epidemiol. 2012; 36: 237-248
        • Jemal A.
        • Center M.M.
        • DeSantis C.
        • Ward E.M.
        Global patterns of cancer incidence and mortality rates and trends.
        Cancer Epidemiol Biomarkers Prev. 2010; 19: 1893-1907
        • Brazil MoHo
        The family health program: broadening coverage to consolidate the change in the primary care model.
        Revista Brasileira de Saude Materno-Infantil. 2003; 3: 113-125
        • Macinko J.
        • de Fátima Marinho de Souza M.
        • Guanais F.C.
        • da Silva Simoes C.C.
        Going to scale with community-based primary care: an analysis of the family health program and infant mortality in Brazil, 1999–2004.
        Soc Sci Med. 2007; 65: 2070-2080
        • Roetzheim R.G.
        • Ferrante J.M.
        • Lee J.H.
        • et al.
        Influence of primary care on breast cancer outcomes among Medicare beneficiaries.
        Ann Fam Med. 2012; 10: 401-411
        • Binagwaho A.
        • Ngabo F.
        • Wagner C.M.
        • et al.
        Integration of comprehensive women's health programmes into health systems: cervical cancer prevention, care and control in Rwanda.
        Bull World Health Organ. 2013; 91: 697-703
        • Iñiguez L.
        Overview of evolving changes in Cuba's health services.
        MEDICC Rev. 2013; 15: 45-51
        • LeBrun D.G.
        • Chackungal S.
        • Chao T.E.
        • et al.
        Prioritizing essential surgery and safe anesthesia for the Post-2015 Development Agenda: operative capacities of 78 district hospitals in 7 low- and middle-income countries.
        Surgery. 2014; 155: 365-373
        • Hoyler M.
        • Finlayson S.R.
        • McClain C.D.
        • Meara J.G.
        • Hagander L.
        Shortage of doctors, shortage of data: a review of the global surgery, obstetrics, and anesthesia workforce literature.
        World J Surg. 2014; 38: 269-280
        • Kushner A.L.
        • Cherian M.N.
        • Noel L.
        • Spiegel D.A.
        • Groth S.
        • Etienne C.
        Addressing the Millennium Development Goals from a surgical perspective: essential surgery and anesthesia in 8 low-and middle-income countries.
        Arch Surg. 2010; 145: 154-159
        • Ologunde R.
        • Maruthappu M.
        • Shanmugarajah K.
        • Shalhoub J.
        Surgical care in low and middle-income countries: Burden and barriers.
        Int J Surg. 2014; 12: 858-863
        • Mendis S.
        • Al Bashir I.
        • Dissanayake L.
        • et al.
        Gaps in capacity in primary care in low-resource settings for implementation of essential noncommunicable disease interventions.
        Int J Hypertens. 2012; 2012: 584041
        • Gakwaya A.
        • Kigula-Mugambe J.
        • Kavuma A.
        • et al.
        Cancer of the breast: 5-year survival in a tertiary hospital in Uganda.
        Br J Cancer. 2008; 99: 63-67
      1. Program NCI-SR. Cancer of the colon and rectum - SEER stat facts sheet [updated 2014; cited 2014 Aug 25]. Available from:

        • Saluja S.
        • Alatise O.I.
        • Adewale A.
        • et al.
        A comparison of colorectal cancer in Nigerian and North American patients: is the cancer biology different?.
        Surgery. 2014; 156: 305-310
        • Nkyekyer K.
        Peripartum referrals to Korle Bu teaching hospital, Ghana–a descriptive study.
        Trop Med Int Health. 2000; 5: 811-817
        • Petroze R.T.
        • Nzayisenga A.
        • Rusanganwa V.
        • Ntakiyiruta G.
        • Calland J.F.
        Comprehensive national analysis of emergency and essential surgical capacity in Rwanda.
        Br J Surg. 2012; 99: 436-443
        • Ameh E.A.
        • Chirdan L.B.
        Paediatric surgery in the rural setting: prospect and feasibility.
        West Afr J Med. 2001; 20: 52-55
        • Bickler S.
        • Kyambi J.
        • Rode H.
        Pediatric surgery in sub-Saharan Africa.
        Pediatr Surg Int. 2001; 17: 442-447
        • Chu K.
        • Rosseel P.
        • Gielis P.
        • Ford N.
        Surgical task shifting in sub-Saharan Africa.
        PLoS Med. 2009; 6: e1000078
        • Lavy C.
        • Tindall A.
        • Steinlechner C.
        • Mkandawire N.
        • Chimangeni S.
        Surgery in Malawi–a national survey of activity in rural and urban hospitals.
        Ann R Coll Surg Engl. 2007; 89: 722
      2. Federspiel FM, Milsom P, Scott J, Riesel JN, Meara JG. Global Surgical and Anaesthetic Task Shifting: a Systematic Literature Review and Survey. Conference abstract accepted by The Lancet for publication April 2015.

        • Luboga S.
        • Macfarlane S.B.
        • von Schreeb J.
        • et al.
        Increasing access to surgical services in sub-Saharan Africa: priorities for national and international agencies recommended by the Bellagio Essential Surgery Group.
        PLoS Med. 2009; 6: e1000200
      3. World Health Organization (WHO). Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines [updated 2008; cited 205 Feb 23]. Available from:

      4. World Health Organization (WHO). WHO recommendations: optimizing health worker roles to improve access to key maternal and newborn interventions through task shifting [updated 2012; cited 2015 Feb 23]. Available from:

        • Bertani A.
        • Launay F.
        • Candoni P.
        • Mathieu L.
        • Rongieras F.
        • Chauvin F.
        Teleconsultation in paediatric orthopaedics in Djibouti: evaluation of response performance.
        Orthop Traumatol Surg Res. 2012; 98: 803-807
        • Weiner J.P.
        • Yeh S.
        • Blumenthal D.
        The impact of health information technology and e-health on the future demand for physician services.
        Health Aff (Millwood). 2013; 32: 1998-2004
        • Paulus R.A.
        • Davis K.
        • Steele G.D.
        Continuous innovation in health care: implications of the Geisinger experience.
        Health Aff (Millwood). 2008; 27: 1235-1245
        • Iglehart J.K.
        A new day dawns for workforce redesign.
        Health Aff (Millwood). 2013; 32: 1870
        • Wickford J.
        • Duttine A.
        Answering global health needs in low-income countries: considering the role of physical therapists.
        World Medical & Health Policy. 2013; 5: 141-160
        • World Health Organization (WHO)
        Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations.
        World Health Organization, Geneva2010: 7 (22)
        • Patcharanarumol W.
        • Tangcharoensathien V.
        • Limwattananon S.
        • et al.
        Why and how did Thailand achieve good health at low cost. Good health at low cost 25 years on: what makes a successful health system.
        London school of Hygiene & Tropical Medicine, London, United Kingdom2011: 193-223
        • World Health Organization (WHO)
        Joint strategic action framework to accelerate the scale-up of voluntary medical male circumcision for HIV prevention in Eastern and Southern Africa (2012–2016).
        UNAIDS, Geneva2011
        • Sgaier S.K.
        • Reed J.B.
        • Thomas A.
        • Njeuhmeli E.
        Achieving the HIV prevention impact of voluntary medical male circumcision: lessons and challenges for managing programs.
        PLoS Med. 2014; 11: e1001641
        • World Health Organization (WHO)
        Considerations for implementing models for optimizing the volume and efficiency of male circumcision services.
        World Health Organization, Geneva2010
        • Rech D.
        • Bertrand J.T.
        • Thomas N.
        • et al.
        Surgical efficiencies and quality in the performance of voluntary medical male circumcision (VMMC) procedures in Kenya, South Africa, Tanzania, and Zimbabwe.
        PLoS One. 2014; 9: e84271
        • Curran K.
        • Njeuhmeli E.
        • Mirelman A.
        • et al.
        Voluntary medical male circumcision: strategies for meeting the human resource needs of scale-up in southern and eastern Africa.
        PLoS Med. 2011; 8: e1001129
        • Rosenberg Talbot J.
        • Cole C.
        • May M.
        • Weintraub R.
        GHD027: Voluntary medical male circumcision in Nyanza Province, Kenya. [Case study and teaching note].
        Harvard Business Publishing, Boston2012
        • Ferlay J.
        • Shin H.R.
        • Bray F.
        • Forman D.
        • Mathers C.
        • Parkin D.M.
        Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008.
        Int J Cancer. 2010; 127: 2893-2917
        • Sahasrabuddhe V.V.
        • Parham G.P.
        • Mwanahamuntu M.H.
        • Vermund S.H.
        Cervical cancer prevention in low-and middle-income countries: feasible, affordable, essential.
        Cancer Prev Res (Phila). 2012; 5: 11-17
        • Castro W.
        • Gage J.
        • Gaffikin L.
        • Ferreccio C.
        • Sellors J.
        Effectiveness, safety, and acceptability of cryotherapy: a systematic literature review.
        PATH, Seattle2003: 5-8
        • Denny L.
        Cervical cancer treatment in Africa.
        Curr Opin Oncol. 2011; 23: 469-474
        • Goodman A.
        • Carmen M.
        • Chuang L.
        Cervical cancer screening in the developing world and the challenge of caring for women with cancer.
        J Womens Health Issues Care. 2014; 1: 2
        • Baltussen R.
        • Sylla M.
        • Mariotti S.P.
        Cost-effectiveness analysis of cataract surgery: a global and regional analysis.
        Bull World Health Organ. 2004; 82: 338-345
        • Lam A.
        • Seck C.
        • Gueye N.N.
        • Faye M.
        • Pintart D.
        [Cataract surgery with posterior chamber lens implantation in Senegalese children less than 15 year-old].
        J Fr Ophtalmol. 2001; 24: 590-595
        • Eriksen J.R.
        • Bronsard A.
        • Mosha M.
        • Carmichael D.
        • Hall A.
        • Courtright P.
        Predictors of poor follow-up in children that had cataract surgery.
        Ophthalmic Epidemiol. 2006; 13: 237-243
        • Kishiki E.
        • Shirima S.
        • Lewallen S.
        • Courtright P.
        Improving postoperative follow-up of children receiving surgery for congenital or developmental cataracts in Africa.
        J AAPOS. 2009; 13: 280-282
        • Bailey P.
        • Lobis S.
        • Maine D.
        • Fortney J.
        Monitoring emergency obstetric care: a handbook.
        World Health Organization, Geneva2009
        • Koblinsky M.A.
        Reducing maternal mortality: learning from Bolivia, China, Egypt, Honduras, Indonesia, Jamaica, and Zimbabwe.
        World Bank Publications, Geneva2003
        • Victora C.G.
        • Rubens C.E.
        Global report on preterm birth and stillbirth (4 of 7): delivery of interventions.
        BMC Pregnancy Childbirth. 2010; 10: S4
        • Rohde J.
        • Cousens S.
        • Chopra M.
        • et al.
        30 years after Alma-Ata: has primary health care worked in countries?.
        Lancet. 2008; 372: 950-961