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.
BACKGROUND
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.


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.
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. Electronic address: ashwin@post.harvard.edu.
Ashwin
A
Vasan
Program in Global Primary Care and Social Change, Department of Global Health & Social Medicine, Harvard Medical School, Boston, MA.
Carly E
CE
Hudelson
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.
Sarah L M
SL
Greenberg
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.
Andrew E
AE
Ellner
D019033:Delivery of Health Care, Integrated / Q000191:economics / Q000458:organization & administration*; D019049:Developed Countries / Q000191:economics; D003906:Developing Countries / Q000191:economics; D005260:Female; D013502:General Surgery / Q000458:organization & administration*; D014943:Global Health; D006297:Health Services Accessibility / Q000458:organization & administration*; D006801:Humans; D007182:Income; D033183:Interdisciplinary Communication; D008297:Male; D009936:Organizational Innovation; D011320:Primary Health Care / Q000458:organization & administration*; D016730:Program Development; D015397:Program Evaluation; D011787:Quality of Health Care; D012959:Socioeconomic Factors