Abstract
Study Design
Narrative review with a Conceptual Framework.
Objectives
Low- and middle-income countries (LMICs), home to approximately 80–85% of the global population, face a disproportionate burden of spinal disorders and limited access to timely, safe, and affordable surgical care. This review proposes a practical framework for delivering high-value spine care in LMICs by integrating evidence on health systems, value-based healthcare, and spine surgery into five strategic domains: Policy & Governance, Patient Selection, Perioperative Efficiency, Products & Technology, and Protection (the Five-P Framework).
Methods
A narrative review with a structured literature search was conducted using PubMed and gray literature. Studies on spinal care delivery, health systems, cost-effectiveness, and surgical strategies in LMICs or comparable settings were qualitatively synthesized into thematic domains.
Results
Five domains were identified: (1)
P
olicy & Governance, including centralization of care, regulation of financial incentives, anti-corruption measures, and complication reduction; (2)
P
atient Selection, emphasizing evidence-based indications; (3)
P
erioperative Efficiency, including enhanced recovery pathways, ambulatory surgery, and standardized protocols; (4)
P
roducts & Technology, focusing on resource optimization and context-appropriate technologies, including locally manufactured implants; and (5)
P
rotection, promoting balanced medicolegal frameworks. Together, these domains aim to maximize value, improve access, and reduce unnecessary procedures and inefficient resource utilization.
Conclusion
The Five-P Framework is a theoretical model that provides a system-level strategy to improve access to high-value spine care in LMICs through appropriate patient selection, efficient perioperative care, and optimal use of limited resources. Future studies to validate this proposal are necessary.