{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T08:03:01Z","timestamp":1789977781082,"version":"4.0.1"},"reference-count":58,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T00:00:00Z","timestamp":1789689600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"},{"start":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T00:00:00Z","timestamp":1789689600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Global Spine Journal"],"abstract":"<jats:sec>\n                    <jats:title>Study Design<\/jats:title>\n                    <jats:p>Narrative review with a Conceptual Framework.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>Low- and middle-income countries (LMICs), home to approximately 80\u201385% 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 &amp; Governance, Patient Selection, Perioperative Efficiency, Products &amp; Technology, and Protection (the Five-P Framework).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Five domains were identified: (1)\n                      <jats:bold>P<\/jats:bold>\n                      olicy &amp; Governance, including centralization of care, regulation of financial incentives, anti-corruption measures, and complication reduction; (2)\n                      <jats:bold>P<\/jats:bold>\n                      atient Selection, emphasizing evidence-based indications; (3)\n                      <jats:bold>P<\/jats:bold>\n                      erioperative Efficiency, including enhanced recovery pathways, ambulatory surgery, and standardized protocols; (4)\n                      <jats:bold>P<\/jats:bold>\n                      roducts &amp; Technology, focusing on resource optimization and context-appropriate technologies, including locally manufactured implants; and (5)\n                      <jats:bold>P<\/jats:bold>\n                      rotection, promoting balanced medicolegal frameworks. Together, these domains aim to maximize value, improve access, and reduce unnecessary procedures and inefficient resource utilization.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/21925682261491746","type":"journal-article","created":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T08:56:44Z","timestamp":1789721804000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Strategies for High-Quality Spine Surgery in Resource-Limited Settings: The Five-P Framework for Equitable Surgical Delivery"],"prefix":"10.1177","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2645-0483","authenticated-orcid":false,"given":"Andrei Fernandes","family":"Joaquim","sequence":"first","affiliation":[{"name":"Discipline of Neurosurgery, Department of Neurology, University of Campinas (UNICAMP), Campinas-SP, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6043-006X","authenticated-orcid":false,"given":"Shanmuganathan","family":"Rajasekaran","sequence":"additional","affiliation":[{"name":"Ganga Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,9,18]]},"reference":[{"key":"e_1_3_4_2_2","volume-title":"World Bank country and lending groups","author":"World Bank","year":"2024","unstructured":"World Bank. 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