title: Disparities in access to surgical care within a lower income country: an alarming inequity.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Surgery, Aga Khan University, Karachi, Pakistan. zafar.nabeel@gmail.com
authors.forename: Syed Nabeel
authors.initials: SN
authors.lastname: Zafar
authors.forename: Zafar
authors.initials: Z
authors.lastname: Fatmi
authors.forename: Aftab
authors.initials: A
authors.lastname: Iqbal
authors.forename: Roomasa
authors.initials: R
authors.lastname: Channa
authors.forename: Adil H
authors.initials: AH
authors.lastname: Haider
mesh_terms: D000005:Abdomen / Q000601:surgery; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003906:Developing Countries; D005260:Female; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data*; D006306:Health Surveys; D054625:Healthcare Disparities / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010154:Pakistan; D012959:Socioeconomic Factors; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*; D055815:Young Adult