Hydrocephalus and Treatment Realities in Low-Resource Settings
Disparities in Health Systems: Workforce, Infrastructure, and Financing
Japan and Russia have surplus resources, better universal health coverage (UHC), and higher public financing for health (Table 5)—borne from deliberate policies of placing a prime value on public health [26,27]—and this becomes important given that increased expenditure on surgery can easily allow the proportional expansion of surgical capacity [1,10,22,33]. Studies that analyzed large patient databases [34,35] have examined the effect of nation-level socioeconomic factors on conditions treated by neurosurgeons. Remick and colleagues [34], after multivariate mixed-effects logistic regression, identified two nation-level variables—physician density and mean GDP growth—as significantly associated with good seizure outcomes following pediatric epilepsy surgery. Similarly, Guha and colleagues [35] identified a higher country GDP and a greater neurosurgeon-to-population density as two nation-level variables that are independent predictors of good outcome following treatment for aneurysmal subarachnoid hemorrhage. The Philippines, in contrast to the two countries, has a lower neurosurgeon workforce density (Table 5), thus expectedly restricting the breadth of access to care for children needing CSF diversion surgery.
The increased likelihood of inability to undergo an early CSF diversion surgery for the Filipino cohort of patients (Figure 1 and Table 2), especially the poor and extremely-poor subsets of Filipino patients, can be explained chiefly by financial barriers [1,5,19,24,33,36]. These barriers—direct and indirect costs relating to treatment—cause economic hardships to the household in which a patient belongs to. Families in which one of the members is a patient needing neurosurgical care are at risk for financial catastrophe and impoverishment, and this is especially true in LMICs like the Philippines [1,24,28]. Furthermore, out-of-pocket expenditures and the risks for catastrophic and impoverishing expenditures are higher in the Philippines than in Japan and in Russia (Table 5). This is particularly disadvantageous given that our results show that a higher socioeconomic status is significantly associated with an earlier time-interval of CSF diversion surgery (Table 3). Financial risk protection, therefore, is important for the acceptability and accessibility of any surgical intervention [33], especially in countries where a significant proportion of the population are poverty-stricken [1,21,24,37]. This necessitates countrywide UHC for health insurance in any form or combination—precisely the kind of social structure that Japan excels at [21,27]—that would subsidize the treatment-related costs incurred by the patients’ families. While all patients from the three centers in this study have some form of health insurance coverage, those from the Japanese and Russian neurosurgical centers receive the broad range of inpatient and outpatient services with negligible out-of-pocket expenses after substantial subsidies by public insurance and government funding. These institutional features improve health-seeking behavior and make consultations during initial presentation of disease more likely. Furthermore, Japan leads in having a high UHC Effective Coverage Index (Table 5), in what could be considered as having an effective social safety net that offsets household expenditures against costly neurosurgical management [38]. Financial risk protection is indeed important because inadequate or poor-quality health insurance coverage poses an increased likelihood of poor outcomes following CSF diversion procedures for pediatric patients [7,39].
Governance Structures and Social Determinants of Health of a Country
While a comprehensive review of the health systems of Japan [27], the Philippines [25], and the Russian Federation [26] are beyond the scope of this article, our results show that across the majority of nation-level metrics, the Philippines lags behind Japan and Russia in terms of both the Global Surgery indicators and social determinants of health (Table 5, 6). The provision of adequate standard of care is also shaped by social determinants of health within a country. Several studies have shown that a country’s economic robustness and level of resources, i.e., being a HIC, translates into better patient-level outcomes particularly when investments on perioperative care and surgical systems are made [10,22,34-36]. Perennial lack of resources in public hospitals contributes to the inability to provide safe and quality surgical services thus diminishing the capacity to rescue patients from avoidable deaths due to treatment complications. At the level of the neurosurgical centers, effective domestic resource mobilization in healthcare institutions is necessary in securing the health financing needed to achieve improved patient outcomes. Investing in surgical services is therefore paramount, but this responsibility lies beyond the sphere of influence of organized neurosurgery.
Policy Work and Resource Management Can Be The Way Forward
Policies that increase government expenditure on health appear to improve the composite metric that reflects nation-level performance of a health system [22,34]. Advocacy for more strategic policies and investments that address social determinants of health can strengthen governance and financing arrangements [14,15]. These in turn help to re-shape more responsive and equitable health and surgical systems, as certain strategies can be undertaken to reduce variation in the use of surgery [40]. LMICs have the task of providing the full range of a responsive neurosurgical system—from as simple as the availability of shunt catheter kits to more capital-intensive measures such as comprehensive facility development, progressive hospital billing, strategic purchasing, and catastrophic case packages [41]—that all in all, curbs out-of-pocket payments and helps achieve universal health coverage. A multi-level systems approach [12,40] by the involved policymakers can result in improvements in care processes of the surgical and health systems, which in turn result in better quality of care, and upon which hinges the hope of ultimately translating to better patient outcomes.
Limitations of the Study and Future Directions
The study includes patients with considerable heterogeneity in terms of etiology of hydrocephalus. Additionally, the neurosurgical centers are not entirely representative of their countries because of inherent intranational heterogeneity of institutions, especially between the public and private sectors. Selection bias and information bias may have been present because of limitations of a retrospective review. Attributing certain outcomes to a policy when they are in fact owed to unmeasurable variables runs the risk of secular trend bias as well. Due to the limited sample size, limited regression analysis, and the non-randomized and unmatched observational study design, confounding factors and their impact may not have been adequately lessened. Regardless, our study ventures into a cross-country comparison of outcomes and explores issues that are of larger socioeconomic context as related to the granularity of patient outcomes for a particular disease entity after neurosurgical intervention. If and when the Global Surgery indicator-targets are met, the outcomes of neurosurgical patients in low-resource centers of LMICs after certain policy changes can be compared using the difference-in-differences study design [42]. Finally, the authors look forward to increasing center recruitment or prospectively gathering further primary patient-level data for the next phase or form of the present study. We recommend further studies with large sample sizes that allow the inclusion of nation-level covariates into a hierarchical mixed-effects statistical analysis [34,35] that can in turn determine the magnitude of effect of those variables.