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1 Dear Editorial team Thank you for the opportunity to contribute this review to the BMJ South Asia issue. The review process has indeed been very useful & instructive & we are resubmitting the paper after incorporating a fair amount of the suggestions. We have also trimmed & modified the references to suit the new emphasis and also added a table. Our response to the editors & reviewers suggestions are embedded in the original message in blue colour. Suggestions for ALL articles in the South Asia collection: - We do not expect the article to be an overview of literature or to be exhaustive. - We would like authors to synthesise this information and present an analytical angle. - We suggest you have a clear central argument for what's required, challenge the status quo, provoke and stimulate. The revised draft attempts to do this. The central argument of a huge regional deficit of surgival care has been made more prominent. - Focus on solutions (as many of the issues/problems are previously documented) - what's common and what's different An effort has been made in the redraft to increase the space given to discussion on bridging the gaps. A few new ideas in this area have been added especially in the context of task sharing in underserved areas. - Focus on what's uniquely relevant to the region and give a flavour of the region's rich diversity and culture. This runs through the entire draft. - Consider cross-cutting regional approaches: what can South Asia do together? Whilst towards the end we have addressed this issue & suggested some tenatative steps we must accept that given the geopolitical situation in the region this area is currently nebulous & difficult. - A proposed standard structure might be: Introduction/regional context Methods Current trends/challenges General response to the trends/challenges Specific in country examples What this means for the future/next steps Conclusion We have tried to breakdown the review along these lines albeit with some differences.

2 Specific suggestions for this article: 1. From the outset, it is not clear what the aim of the paper is - I assume to provide an overview of the current state of surgical care in south Asia and give recommendations for how it can be improved? It would be helpful to state this early on in the introduction. We have added a line to this effect. 2. This article attempts too much rather than finding a focus for the piece and using examples of local challenges and solutions. Avoid thinking and writing in generalities simply because we've asked to take on the region. Please present an 'angle' or central argument for the piece. The central argument which has now been foregrounded is to highlight deficits & need for urgent intervention. This probably did not show through as clearly as it should have in the earlier draft & an attempt has been made to highlight it both in the introduction & the conclusion. Comments by reviewer Kataria might be helpful to frame key issues you are advocating for.some of Dr Katarias suggestions have been incorporated 3. There is a fair bit of literature cited but isnt clear if a systematic review was undertaken. There is the experience of rural surgery from the Northern areas of Pakistan from the 80s (Blanchard et al) that might have been of interest. This reference has been added. You might want to share a para on methods for this article. We have added two lines enumerating the methods. 4. The paper would have benefited from some statistics on ratio of surgeons by country and geography, gender balance. At the moment we don't get a sense of what the status is by country. Though we have mentioned some general figures, to the best of our knowledge detailed country wise data is unfortunately not available. What is the basis of calling Sri Lanka as the bench mark? sri lanka has been a benchmark in terms of health parameters. But again data on surgery is limited though the public sectors contribution & its organized nature is still the strongest in the region. We have reduced the emphasis.

3 5. We don't get a sense of what the recommendations are in terms of human resource development as well as deployment. What does South Asia need to provide optimal coverage in both urban and rural settings and by speciality? What are the implications for educational and training institutions? Regulation of practice? The private sector and medical / surgical tourism? Given the lack of baseline data, the precise deficit estimates are very difficult to estimate but the overall deficit if the region has been mentioned. We have added substantive material on how the reach of surgical services can be increased through task sharing & involvement of informal providers & trained paramedics. 6. Given the increasing contribution of trauma and emergency surgery, how should South Asia fare and prepare in this area? What is the current status and shortfall? This section has been improved upon. Again it is difficult to give a figure for the shortfall but some of he cross references do provide data. 7. Finally the whole discussion in the context of universal health care and sustainable models of financing is perfunctory and limited to one scheme in India. What are the options elsewhere or within the region that have been interrogated? Whilst we can go into details of financing models these are not strictly restricted to the surgical domain & also not our area of expertise. Emergency surgery also includes obstetric procedures including caesarean sections and the paper is largely silent on this burgeoning need and quality of care.we have added a reference on excsseive caesarian sections. 8. The article tends to focus more on the problems with surgical care in South Asia. These could be summarized succinctly and the authors delve more into action-oriented recommendations. A suggested framework: - Intro - state the paper's aims and why it's important (e.g. Lancet Commission on global surgery 2030 lists South Asia as the region with the highest deficit of estimated annual surgical unmet need in the world." We have responded to this earlier. - Setting the scene/country info - I think there are certain things that we want to know about the provision of surgical care. This might take the form of a table. As someone with very limited knowledge about it, I'd like to know some basic details for each country about: models of care (particularly private versus public); distrubution of surgical centres (e.g. rural versus urban); workforce details (e.g number of surgeons per head); surgical issues/needs specific to country/south Asia that affect the delivery of care. As stated before hard data on some of these issues is very difficult to obtain.it will have to be inferred from studies which have been quoted.

4 - Barriers to surgical care: These need to be much more clearly grouped and described. Reference 3 that they cite ( The entire range of cultural, financial and structural barriers that impede access to surgical care in Low & Middle income countries play out in their fullest in this part of the world.3 ) groups barriers as financial, cultural, or structural - this might be a useful model to follow in this paper too. Alternate suggestions could be: Equity, Access, Surgical education, Quality/ governance These have been covered albeit not neccesarily under those headings. - Briding the gap: This section again goes into some of the problem areas. Avoid repition.agreed. Repetition has been trimmed & more action oriented points enumerated. If helpful, you might also group recommendations using the same categorisation as the barriers. - The way forward: What else needs to happen, or what needs to happen next. It would be helpful if they could give a sense of priorities 9. In terms of style, it might be useful to have some boxes, and if available, data on key gaps or trends in a figure, and also key recommendations.this has been added. REVIEWERS Reviewer: 1 Recommendation: Comments: I want to thank BMJ for inviting me to review this manuscript assessing Surgery in South Asia. A group of surgeons from different specialties (GI Surgery, Pediatric Surgery, Neurosurgery, Transplantation surgery), and from different countries (India, Dubai, Bangladesh, Sri Lanka, Pakistan, India), has assessed the status of surgery in South Asia. Although well written, the manuscript would benefit from a revision. For the unknown reader, it would be beneficial to, even more, highlight the "epidemiology of surgical diseases" in South Asia. What surgical conditions are special for South Asia? This was an oversight & a section has been added Maybee a table would be informative?

5 Although the manuscript is dealing with important topics, it's my opinion that the authors try to cover too many topics at once. Example: The "Bridging the Gap" chapter are dealing with The Lancet Commission, individual health insurance, cost effective treatment algorithms, cadres of trained support staff, surgical camps, philanthropic organizations. I would suggest excluding some topics and aim to describe the success histories in greater detail. Have the use of telemedicine to, bridging the gap, been considered?. Similarly, surgical telementor solutions are easily available for instance by using Skype, mobile phones, etc. In our view whilst we may look this in the future, bridging the gap of surgical care delivery by telemedicine & telementoring in this region is challenging & perhaps not feasible. In general, although the manuscript is informative, I would suggest that you limit the number of topics. Focus on fewer topics. After i have read the manuscript I still have several questions related to: surgical education; the "epidemiology" of surgical diseases (what is special with the surgical disease panorama in South Asia?); innovative models of health care delivery (telemedicine, telementoring, surgical teams, surgical camps, health care workers trained to do surgical procedures etc),table international collaboration (what is needed, what should the focus areas be?). Additional Questions: Please enter your name: Knut Magne Augestad, MD, PhD Job Title: Surgeon, specialist in General Surgery Institution: Department of GI Surgery, Akershus University Hospital, Oslo, Norway This is a very timely review focussed on surgery for South asia as a follow up after lament commission report and explaining in details its meaning and consequences for south asian region. It is well written and has a good message. Authors have included example of srilanka as positive deviance - however a detail mention of their strategies would make this better manuscript. Secondly low cost technology and task sharing may be explained by more examples for international and regional readers Done References are adequate and relevant article may be accepted with minor revisions

6 regards Additional Questions: Please enter your name: Avinash Supe Job Title: Professor of Surgical Gastroenterology Certainly it is important as it gives a reflection of surgical care providing system revealing in current time in this area. It would be more important if statistical analysis could be added with regarding surgical manpower,the morbidities and mortalities and other benefits and pitfalls of surgical caregiving systems. In Bangladesh, as there is no structured surgical auditing system in the public health sectors which are the major surgical health care peoviders. So, inclusion of these sorts of information could definitely increase the importance of this article. We have already mentioned the almost complete lack of auditing in surgical practice in the region. This article will provide an idea in making decision for present surgical health care giving system in developing countires in South Asia. As the article mentioned the drawbacks are similar to that of Bangladesh. Majority of the districts, even in Thana/Upazilla level are started with numerous tiny private clinics and hospitals. Majority of them are established in buildings which were not intended to be used as hospitals. So the small kitchen room is being used as an operating theater with all of it's disadvantages. The present health structure in Bangladesh is such that all the upazilla health complexes are provided with the post of Surgical specialist. But, most of them are not occupied by trained manpower. Though these centers(private) are not under control of any deifinitive regulatory body but still they are providing the service for remote surgical care seekers. How to take a decision to improve the present situation, this article could give a background. Wether this article peovides enough information to add the existing knowleadge regarding this matter is not clear to me. Because, what are the articles regarding this subject submitted in BMJ is unkown to me. It can be said this article can remind the readers the burning problems of South Asia with their previous knowleadge. The style of presentation of the article, read well and made sense about the subject. Finally you can comment on the conclusions given in the

7 article. It is true that the spreading of internet connection even in the villages of Bangladesh global trends, towards increasing specialization and technology also influenced our surgeons. But lacking of monitoring system and proper governing body, any surgeon here can declare himself as a specialist in any sub speciality. For this reasons unintentional surgical trumas are increasing and these victims when reffered to public tertiary hospitals, no resulting care could be provided. From my last 35years of experice in hospitals as a surgical specialist in a developing country like Bangladesh, I can say trauma victims are the most neglected in our health care providing system. Which also came up in the article. Local low cost technology to provide primary care in trauma patients specially for fractures of the limbs could be provided with Bamboo casts. There are so many herbal medicines and conventional takes are available here in our country also. The safety and efficacy of these modalities were not tested. I think that in the article regarding the customised surgical care policy and syllabus could be advised for inclusion in the public healthcare subjects in undergrad course and curriculum which could provide awareness in the medical pesonelles regarding this. Training of the quacks for primary surgical procedures has got both pros and cons but in regarding the abuse of anti biotics and usefulness of sterility at least could save money and lives of many surgical care seekers in the remote villages.the NGO's who are working in the remote places of South asia including Bangladesh all are not strictly stuck to ethical issues when providing surgical care. For example, oophorectomy is being performed by an NGO in a district of Bangladesh which is convincing people to perform it by falsely implementing its reduction in breast cancer. What I am trying to explain here is that they are using people as guine pigs for their experiments, which is very unethical. This sort of information is lacking in the article provided. Communication with the global surgical authority and south asian coiuntries could be reciprocal so that the surgeons working here could be exposed to standard safe surgical care of the modern world as well as Western surgeons could be exposed to the problems and late presentations of surgical diseases in south asia which can provide data, information, experience and others in customizing the management client for people of this region. Additional Questions: Please enter your name: ABM Khurshid Alam Job Title: Professor of Surgery

8 Institution: Dhaka Medical College The topic is relevant and likely to be of wide interest to readers. The stark, shameful disparity in access to quality health care in general and quality surgical care in particular, in South Asia is a politically charged subject. For me personally, working with the most marginalized people in Central India over the last 17 years, this topic cannot be simply a narrative of the ills that plague the system. In that sense, my opinion herein may be 'biased'. Even as there is an entire section devoted to 'Bridging the gaps', it is very superficial and the authors do not take any firm stand. We need to clarify our position (whatever that may be) with logical reasons, on several important aspects. This could begin with introspection, as to what we as health care providers, surgeons, teachers and researchers, can and should do. And go on to suggest 'Policy-level' changes mandated to correct course and improve equity. These would be in the areas of medical education, surgical training (How, Where, and for Whom; the need for truly General Surgeons), reverse the predominance of the Private and Corporate sector and regulate it more effectively, role of National Surgical Associations and effective collaboration between Associations of the South. We agree that the provider community needs introspection & we have alluded to this. Perhaps the emphasis was not adequate in the earlier draft Also important to this discussion would be the recent discourse at the National level, further cuts in Health spending, and pushing health care further as the responsibility of individual States (Provinces). Also, the interface between the practice of Medicine and Surgery, and the law, especially the Consumer Protection Act, and the Clinical Establishments Act, need to be examined. This is especially relevant as one explores options of Task shifting and Low cost, yet effective technologies. Can the same yardsticks be applied for such widely disparate environs as a large corporate Hospital in a city and a small rural hospital? Another area that is closely entwined with access to Surgical care is the availability (or rather non-availability) of blood in Rural areas, even for emergency needs. The role of Insurance sector, whether desirable or not, and how regulation of Surgical practice could be done more effectively. Above-mentioned modifications/additions are suggested.we have incorporated a lot of the suggestions into the new draft. Additional Questions: Please enter your name: RAMAN KATARIA Job Title: Surgeon and public health physician

9 Institution: Jan Swasthya Sahyog, Bilaspur, Chattisgarh We look forward to further suggestions & feedback & apologise for the delay in resubmitting. Regards, Sanjay Nagral On behalf of all authors

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