Barriers to accessing surgical care in Pakistan: healthcare barrier model and quantitative systematic review.

Inadequate access to surgical services results in increased morbidity and mortality from a spectrum of conditions in Pakistan. We employed a modification of Andersen's model of health services utilization and developed a 'Healthcare Barrier Model,' to characterize the barriers to accessing health care in developing countries, using surgical care in Pakistan as a case study. We performed a literature search from MEDLINE, EMBASE, CINAHL, SCOPUS, Global Health Database, and Cochrane Central Register of Controlled Trials, and selected 64 of 3113 references for analysis. Patient-related variables included age (elderly), gender (female), preferential use of alternative health providers (Hakeem, traditional healers, others), personal perceptions regarding disease and potential for treatment, poverty, personal expenses for healthcare, lack of social support, geographic constraints to accessing a health facility, and compromised general health status as it relates to the development of surgical disease. Environmental barriers include deficiencies in governance, the burden of displaced or refugee populations, and aspects of the medicolegal system, which impact treatment and referral. Barriers relating to the health system include deficiencies in capacity (infrastructure, physical resources, human resources) and organization, and inadequate monitoring. Provider-related barriers include deficiencies in knowledge and skills (and ongoing educational opportunities), delays in referral, deficient communication, and deficient numbers of female health providers for female patients. The Healthcare Barrier model addresses this broad spectrum of barriers and is designed to help formulate a framework of healthcare barriers. To overcome these barriers will require a multidisciplinary, multisectoral effort aimed at strengthening the health system.