Strategies for High-Quality Spine Surgery in Resource-Limited Settings: The Five-P Framework for Equitable Surgical Delivery

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.