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In many healthcare systems, patients abandon treatment due to poor quality care despite reaching the hospital.1 These challenges are further magnified in very low-resource settings, where public hospitals serve populations in the lowest economic strata. Increasing utilisation of existing resources is a key issue at public sector hospitals, as patients often reach the hospital only to be denied care or to abandon treatment due to poor quality, thus eroding trust in the healthcare system.1 Technically, this was more of a quantity improvement project than a quality project since the stated primary focus was on increasing surgical volume rather than enhancing quality of care. [...]outside of the dedicated QI training and teams, interventions targeted personnel, infrastructure and resources. Two task-sharing initiatives for non-specialised doctors implemented in Bihar over the past two decades, namely the Emergency Obstetric Care and the Life Saving Anesthesia Skills programmes, have impacted the availability of local skilled manpower in ways that might be immediately apparent or replicable.11 The authors also shared that the hospital which had the lowest baseline C-section rate in their intervention cohort did not improve until the later part of the collaborative after the obstetric care-related resources were infused.

In many healthcare systems, patients abandon treatment due to poor quality care despite reaching the hospital.1 These challenges are further magnified in very low-resource settings, where public hospitals serve populations in the lowest economic strata. Increasing utilisation of existing resources is a key issue at public sector hospitals, as patients often reach the hospital only to be denied care or to abandon treatment due to poor quality, thus eroding trust in the healthcare system.1 Technically, this was more of a quantity improvement project than a quality project since the stated primary focus was on increasing surgical volume rather than enhancing quality of care. [...]outside of the dedicated QI training and teams, interventions targeted personnel, infrastructure and resources. Two task-sharing initiatives for non-specialised doctors implemented in Bihar over the past two decades, namely the Emergency Obstetric Care and the Life Saving Anesthesia Skills programmes, have impacted the availability of local skilled manpower in ways that might be immediately apparent or replicable.11 The authors also shared that the hospital which had the lowest baseline C-section rate in their intervention cohort did not improve until the later part of the collaborative after the obstetric care-related resources were infused.

In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast and cervical cancer. The provision of safe and affordable surgical and anaesthesia care when needed not only reduces premature death and disability, but also boosts welfare, economic productivity, capacity, and freedoms, contributing to long-term development.

20% of COVID-19 patients become critically ill with hypoxia or respiratory failure (figure).1 Critical illness, describing any acute life-threatening condition, is receiving increased attention in global health because of its large disease burden and population impact.2 Before the COVID-19 pandemic, growing evidence suggested that the care of critical illness was overlooked in LRS—hospitals cannot, or do not, prioritise emergency and critical care.3 Most critically ill patients are cared for in emergency units and general wards and do not have access to advanced care in intensive care units (ICUs). [...]provision of essential care could prevent progression to multi-organ failure, reducing the burden on limited ICU capacity. DFM also reports personal fees from consultancy about acute respiratory disease for GlaxoSmithKline, Boehringer Ingelheim, and Bayer, unrelated to this Correspondence; in addition, DFM's institution has received funds from grants from the UK NIHR, Wellcome Trust, Innovate UK, and others, he has a patent issued to his institution for a treatment for acute respiratory distress syndrome, and he is Director of Research for the Intensive Care Society and NIHR Efficacy and Mechanism Evaluation Programme Director.

Background 11% of the global burden of disease requires surgical care or anaesthesia management or both. Some studies have estimated this burden to be as high as 30%. The Lancet Commission for Global Surgery (LCoGS) estimated that 5000 surgeries are required to meet the surgical burden of disease for 100,000 people in LMICs. Studies from LMICs, estimating surgical burden based on enumeration of surgeries, are sparse. Method We performed this study in an urban population availing employees’ heath scheme in Mumbai, India. Surgical procedures performed in 2017 and 2018, under this free and equitable health scheme, were enumerated. We estimated the surgical needs for national population, based on age and sex distribution of surgeries and age standardization from our cohort. Result A total of 4642 surgeries were performed per year for a population of 88,273. Cataract (22.8%), Caesareans (3.8%), surgeries for fractures (3.27%) and hernia (2.86%) were the commonest surgeries. 44.2% of surgeries belonged to the essential surgeries. We estimated 3646 surgeries would be required per 100,000 Indian population per year. One-third of these surgeries would be needed for the age group 30–49 years, in the Indian population. Conclusion A total of 3646 surgeries were estimated annually to meet the surgical needs of Indian population as compared to the global estimate of 5000 surgeries per 100,000 people. Caesarean section, cataract, surgeries for fractures and hernia are the major contributors to the surgical needs. More enumeration-based studies are needed for better estimates from rural as well as other urban areas.

Background Breast cancer is the commonest cancer among women in India, yet the uptake of early detection programs is poor. This leads to late presentation, advanced stage at the time of diagnosis, and high mortality. Poor accessibility and affordability are the most commonly cited barriers to screening: we analyse socio-cultural factors influencing the uptake of early detection programmes in a Universal Health Coverage (UHC) setting in India, where geographical and financial barriers were mitigated. Methods Two hundred seventy-two women engaging in an awareness-based early detection program were recruited by randomization as the participant (P) group. A further 272 women who did not participate in the early detection programme were recruited as non-participants (NP). None of the groups were previously screened for breast cancer. Interviews were conducted using a 19-point questionnaire, consisting of closed-ended questions regarding demographics and social, cultural, spiritual and trust-related barriers. Results The overall awareness about breast cancer was high among both groups. None of the groups reported accessibility-related barriers. Participants were more educated (58.09% vs 47.43%, p  = 0.02) and belonged to nuclear families (83.59% vs 76.75%, p  = 0.05). Although they reported more fear of isolation due to stigma (25% vs 14%, p  = 0.001), they had greater knowledge about breast cancer and trust in the health system compared to non-participants. Conclusions The major socio-cultural barriers identified were joint family setups, lower education and awareness, and lack of trust in healthcare professionals. As more countries progress towards UHC, recognising socio-cultural barriers to seeking breast health services is essential in order to formulate context-specific solutions to increase the uptake of early detection and screening services.

Background Mismatched surgeon-anesthesiologist ratios often exist in low-resource settings making safe emergency essential surgical care challenging. This study is an audit of emergency essential procedures performed for lower-limb (LL) musculoskeletal disorders (MSD) when an anesthesiologist was unavailable. It aims to identify strategies for safe anesthesia. Methods A 5-year retrospective audit of emergency essential LL orthopedic procedures performed at remote mission hospital in Central India was performed. Out of necessity, a regional anesthesia (RA) protocol was developed in collaboration with anesthesiologists familiar with the setting. The incidence of intraoperative surgical and perioperative anesthesia complications when RA was administered by a surgeon was evaluated. Results During this period, 766 emergency essential LL MSDs procedures were performed. An anesthesiologist was available for only 6/766. RA was administered by a surgeon for 283/766. This included spinal anesthesia (SA) for 267/283 patients, peripheral nerve blocks for 16/283. Local infiltration and/or sedation was administered to 477/766. There were 17 intraoperative surgical complications. Anesthesia-related complications included 37/267 patients who required multiple attempts to localize subarachnoid space and SA failure in 9/267 patients all of whom had successful re-administration. Additional sedation and infiltration of local anesthetic was required in 5/267 patients. Conclusion Remote pre-anesthesia consultation for high-risk patients, local surgeon-anesthesiologist networking, protocol-guided management, and dedicated short duration of training in anesthesia may be considered as an alternative for delivering RA for emergency essential surgery for LL MSDs due to unavailability of anesthesiologists.

ObjectiveTo assess the feasibility of conducting a cluster randomised controlled trial comparing the effects of Advanced Trauma Life Support (ATLS) and Primary Trauma Care (PTC) with standard care on patient outcomes.DesignThis was a pilot pragmatic three-armed parallel, cluster randomised, controlled trial conducted between April 2022 and February 2023. Patients were followed up for 30 days.SettingTertiary care hospitals across metropolitan areas in India.ParticipantsAdult trauma patients and residents managing these patients were included.InterventionsATLS or PTC training was provided for residents in the intervention arms.Main outcomes and measuresThe outcomes were the consent rate, loss to follow-up rate, missing data rates, differences in the distribution between observed data and data extracted from medical records, and the resident pass rate.ResultsTwo hospitals were randomised to the ATLS arm, two to the PTC arm and three to the standard care arm. We included 376 patients and 22 residents. The percentage of patients who consented to follow-up was 77% and the percentage of residents who consented to receive training was 100%. The loss to follow-up rate was 14%. The pass rate was 100%. Overall, the amount of missing data for key variables was low. The data collected through observations were similar to data extracted from medical records, but there were more missing values in the extracted data.ConclusionsConducting a full-scale cluster randomised controlled trial comparing the effects of ATLS, PTC and standard care on patient outcomes appears feasible, especially if such a trial would use data and outcomes available in medical records.Trial registration numberNCT05417243.