title: Systematic review of barriers to surgical care in low-income and middle-income countries.
abstract: BACKGROUND
  There is increasing evidence that lack of facilities, equipment, and expertise in district hospitals across many low- and middle-income countries constitutes a major barrier to accessing surgical care. However, what is less clear, is the extent to which people perceive barriers when trying to access surgical care.
  
  
  METHODS
  PubMed and EMBASE were searched using key words ("access" and "surgery," "barrier" and "surgery," "barrier" and "access"), MeSH headings ("health services availability," "developing countries," "rural population"), and the subject heading "health care access." Articles were included if they were qualitative and applied to illnesses where the treatment is primarily surgical.
  
  
  RESULTS
  Key barriers included difficulty accessing surgical services due to distance, poor roads, and lack of suitable transport; lack of local resources and expertise; direct and indirect costs related to surgical care; and fear of undergoing surgery and anesthesia.
  
  
  CONCLUSIONS
  The significance of cultural, financial, and structural barriers pertinent to surgery and their role in wider health care issues are discussed. Immediate action to improve financial and geographic accessibility along with investment in district hospitals is likely to make a significant impact on overcoming access and barrier issues. Further research is needed to identify issues that need to be addressed to close the gap between the care needed and that provided.
authors.affiliation: Department of General Surgery, Epsom & St. Helier Hospitals NHS Trust, Wrythe Lane, Carshalton, Surrey, SM5 1AA, UK. carisgrimes@doctors.org.uk
authors.forename: Caris E
authors.initials: CE
authors.lastname: Grimes
authors.forename: Kendra G
authors.initials: KG
authors.lastname: Bowman
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Dodgion
authors.forename: Christopher B D
authors.initials: CB
authors.lastname: Lavy
mesh_terms: D003469:Culture; D005190:Family; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data*; D006767:Hospitals, District; D006801:Humans; D007182:Income; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D011203:Poverty; D012944:Social Support; D013514:Surgical Procedures, Operative / Q000191:economics / Q000706:statistics & numerical data*