title: Charitable platforms in global surgery: a systematic review of their effectiveness, cost-effectiveness, sustainability, and role training.
abstract: OBJECTIVE
  This study was designed to propose a classification scheme for platforms of surgical delivery in low- and middle-income countries (LMICs) and to review the literature documenting their effectiveness, cost-effectiveness, sustainability, and role in training. Approximately 28 % of the global burden of disease is surgical. In LMICs, much of this burden is borne by a rapidly growing international charitable sector, in fragmented platforms ranging from short-term trips to specialized hospitals. Systematic reviews of these platforms, across regions and across disease conditions, have not been performed.
  
  
  METHODS
  A systematic review of MEDLINE and EMBASE databases was performed from 1960 to 2013. Inclusion and exclusion criteria were defined a priori. Bibliographies of retrieved studies were searched by hand. Of the 8,854 publications retrieved, 104 were included.
  
  
  RESULTS
  Surgery by international charitable organizations is delivered under two, specialized hospitals and temporary platforms. Among the latter, short-term surgical missions were the most common and appeared beneficial when no other option was available. Compared to other platforms, however, worse results and a lack of cost-effectiveness curtailed their role. Self-contained temporary platforms that did not rely on local infrastructure showed promise, based on very few studies. Specialized hospitals provided effective treatment and appeared sustainable; cost-effectiveness evidence was limited.
  
  
  CONCLUSIONS
  Because the charitable sector delivers surgery in vastly divergent ways, systematic review of these platforms has been difficult. This paper provides a framework from which to study these platforms for surgery in LMICs. Given the available evidence, self-contained temporary platforms and specialized surgical centers appear to provide more effective and cost-effective care than short-term surgical mission trips, except when no other delivery platform exists.
authors.affiliation: Harvard Interfaculty Initiative in Health Policy, 14 Story Street, 4th Floor, Cambridge, MA, 02138, USA, shrime@gmail.com.
authors.forename: Mark G
authors.initials: MG
authors.lastname: Shrime
authors.forename: Ambereen
authors.initials: A
authors.lastname: Sleemi
authors.forename: Thulasiraj D
authors.initials: TD
authors.lastname: Ravilla
mesh_terms: D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care / Q000191:economics / Q000458:organization & administration; D013502:General Surgery / Q000191:economics / Q000458:organization & administration*; D014943:Global Health; D006801:Humans; D007391:International Cooperation; D008493:Medical Missions / Q000191:economics / Q000458:organization & administration; D016896:Treatment Outcome